- Email: [email protected]
The operative management of congenital dislocation of the hip
The Operative Management of Congenital Dislocation of the Hip
S h e r m a n S. C o l e m a n
When any one of these circumstances exists, there is a positive indication for open reduction. In nearly all instances, the determination of the need for open reduction must be made by examining and manipulating the hip under general anesthesia. Only then can one accurately assess which, if any, of the above indications obtain.
Even in this modern so-called enlightened age, the need for operative treatment of congenital dislocation of the hip and its sequelae remains a very important discipline. Early recognition of an abnormal hip in the newborn or neonate does not necessarily eliminate the need for subsequent surgical procedures on the hip. However, the magnitude as well as the type of surgery required for the best treatment of the dislocated hip are clearly related to the time of diagnosis. 1
Technique There are two well accepted surgical approaches for open reduction of the congenitally dislocated hip. These are the medial 'adductor' approach and the anterior 'iliofemoral' or inguinal approach. Over the past 15 years the relative advantages and disadvantages of each have been assessed in considerable depth, and the indications for which approach to use have been clarified. The medial adductor approach. This was originally developed by Ludloff in 1908. 2 This procedure has had substantial periods of popularity and rejection, but it currently enjoys a rather respected and defensible place in the surgeon's armamentarium. It is generally agreed that the procedure should be reserved for those children under eighteen months of age :
Open Reduction of Congenital Dislocation of the Hip Indications What precisely is meant by failure of closed reduction ? There are at least four criteria, which are of course indications for open reduction. If closed reduction fails by whatever means have been implemented, then open reduction becomes mandatory. These include the following : 1. Inability to achieve concentric reduction by closed efforts. In these instances there is an unacceptable (greater than 2.0 mm) increase in the space between the femoral head and the acetabulum as compared to the opposite normal side, with the hip reduced. 2. Inability to achieve and maintain reduction without placing the affected limb in an unphysiological position (greater than 60 ° of abduction). 3. Inability to place the femoral head in the acetabulum at all (an irreducible hip). 4. An unstable reduction, wherein the hip can be reduced, but it is unstable in any position.
1. Whose hips are reducible, but unstable. 2. Whose hips cannot be congruently reduced. 3. Who require an unphysiologic position in order to hold the hip stable.I, 4 In any of these three instances, a carefully performed medial adductor approach to the hip can predictably achieve a very satisfactory reduction. Via in incision parallel to the adductor crease, the adductor longus is sectioned, and the interval anterior to the adductor brevis is developed. The lesser
ShermanS. ColemanMD, Shriners Hospitals for crippled children, Intermountain Unit, Fairfax Avenueand Virginia Street, Salt Lake City, Utah 84103-4399,USA. Current Orthopaedics(1987) 1, 275-283 © 1987 Longman Group UK Ltd
275
276
THE OPERATIVE MANAGEMENT
O F C O N G E N I T A L D I S L O C A T I O N OF T I l E HIP
trochanter and iliopsoas are exposed. The soft tissue can be teased away from the tendon and the large medial femoral circumflex artery is identified and protected. The iliopsoas tendon is sectioned and reflected, thus exposing the hip joint capsule which is incised to expose the entire anterior, superior and inferior aspects of the joint. A substantial exploration of the joint can be carried out and all structures that prevent reduction can be carefully removed. These include the iliopsoas tendon, the contracted c/apsule, the enlarged and hypertrophic ligamentum te~es, the transverse acetabular ligament, and an//infolded limbus. This approach, however, does not allow a capsulorrhaphy to be accomplished; thus there is some residual instability to the reduction. However, with a properly applied cast the reduction can nearly always be rendered stable. In the absence of capsulorrhaphy a more prolonged period of cast immobilisation is needed. An anteroposterior X-ray film is taken when the cast is applied, and it is essential that another pelvic film is taken 1 week later to verify continued stable reduction (Fig. 1). Customarily the cast is changed under anesthesia at 6 weeks. At 12 weeks post-operatively the patient is placed in a removable plastic abduction splint which is kept on for at least 6 weeks to 3 months, being removed only for bathing. Clinical judgement, based on physical examination of stability and progressive
radiological improvement, determines when the splintage is eliminated completely. The anterior approach. This is more versatile than the medial approach and lends itself to additional operative procedures, as well as allowing a more thorough joint exploration. A capsulorrhaphy can also be accomplished which greatly enhances joint stability. Thus in addition to the indications for the medial approach it should definitely be employed whenever the hip is irreducible; the patient is over 18 months of age; or if there is any doubt about the problem. Radiological evaluation prior to splintage in the operating room is essential and should be repeated following the application of a one and one-half spica cast. A further pelvic film should be taken a week later to ensure reduction is being maintained (Fig. 2). Because of the capsulorrhaphy, a second spica cast is not usually necessary and 'broomstick plasters' (Fig. 3) can be used after 6 weeks provided both physical evaluation and X-rays confirm a stable reduction. 18 m o, 'i_
_
11-16-81
Fig. 1--Pelvic film of 3-month-old male showing obvious dislocation of the left hip (A). The hip remained unstable following closed reduction; therefore an open reduction through the medial adductor approach was done. The pelvic radiograph 5 months post-op (B). Three years later the femoral head and acetabulum are developing well (C). Ten years after reduction the hip is indistinguishable from normal (D).
Fig. 2--Pelvic film of an 18-month-old female with obvious bilaterally dislocated hips. Note the apparently shallow acetabulae (A). The hips were irreducible and therefore bilateral open reductions through an anterior approach were accomplished 1 week apart. The high riding right hip required femoral shortening, and the result 9 months later is seen (B). Three years later the acetabulae have developed well (C), 6 years following open reduction only, the hips appear normal (D). No pelvic reconstructive procedure was entertained at any time since the initial reduction was stable and congruent.
CURRENT ORTHOPAEDICS 277
Fig. 3 - - D r a w i n g to illustrate the use of cylinder casts that permit flexion and extension, but allow no rotation, abduction or adduction. It is essential that the knees are bent and the casts are held with crossbars in order to control rotation and adduction-abduction.
These casts extend from ankle to groin and are applied with the knee slightly flexed and the thighs in neutral rotation with 30-45 ° abduction. They are connected by two cross-bars. This allows controlled flexion and extension, but does not permit rotation or abduction or adduction of the hips. These are kept on for a minimum of 6 weeks, and thereafter if good radiographic stability is evident, the same sptintage program is implemented as was done following the medial adductor approach. If the above therapeutic plan is carried out with meticulous attention to detail, the majority of patients under 3 years of age will demonstrate very satisfactory remodeling and development of the acetabulum with
growth. The follow-up program however is extremely important and the following features of acetabular development should be closely monitored: 1) progressive improvement (lowering) of the acetabular index; 2) normal development and more clear delineation of the 'tear-drop' shadow medially; 3) an improvement in Shenton's line; 4) improved configuration and clear delineation of the surcile; 5) progressive overall improvement of the acetabular femoral head relationships (Fig. 2). It is important to emphasise that steady improvement in these radiologic parameters can and often does occur steadily up through ages 9 and 10. 3 This may extend into the second decade so long as the triradiate cartilage remains open and the hip remains concentrically reduced and stable (Figs 2 & 4). If any of these radiologic parameters fail to improve or especially if there is evidence of progressive extrapelvic protrusion of the femoral head with the development of a 'V' shaped teardrop, then one must assess the need for a stabilising procedure, either on the acetabular side, the femoral side, or both. Open reduction with femoral shortening. A subtrochanteric femoral shortening, 5 sometimes called a 'decompression' osteotomy (Figs 2 & 4), is indicated in children over 18 months when an open reduction through the anterior approach fails despite all efforts to release the soft tissues. The ease with which the femoral head can be reduced into the acetabulum following femoral shortening, despite its totally irreducible state without shortening, is impressive. Properly done, not only can the reduction be rendered easier, but any pressure on the femoral head is relieved, thus reducing the likelihood of osseous necrosis. In addition angular or torsional deformities of the proximal femur can be corrected simultaneously. When done in children under 10 years of' age surgical shortening by resection is compensated for by stimulation of growth. 6 This procedure has been an
Fig. 4 - - A 5-year-old girl with a dislocated left hip (A). Note the seemingly shallow and poorly developed acetabulum. The appearance four and one-half months following open reduction and femoral shortening done through an anterior approach (B). Two years later the hip remains congruently stable and the acetabulum is improving (C). Eight and ½years later the hip is indistinguishable from normal (D). No reconstructive procedure on the pelvis was ever done. This illustrates the great ability of the acetabulum to remodel when the reduction is stable and congruent.
278
T H E O P E R A T I V E M A N A G E M E N T OF C O N G E N I T A L D I S L O C A T I O N OF THE HIP
invaluable addition to our surgical armamentarium in dealing with difficult high-riding dislocated hips. Combined Procedures at time o f Open Reduction. Stability cannot always be achieved at the time of open reduction, and a simultaneous stabilising procedure must be carried out in a small number of instances on children between 18 months and 3 years of age. Whether this is done on the pelvic or the femoral side must be governed by the surgeon's appraisal of where the principal abnormality of the hip lies. The different stabilising operative techniques each have their advantages and disadvantages and are discussed below.
simple, but necessarily demanding requirement, the operation will likely succeed if properly done. Operations on the Femoral Side
These procedures are much less commonly done in the United States in comparison with Europe. It is difficult to explain the reasons for this dichotomy of thought and concept. Nevertheless, the proximal femoral varus or varus rotational osteotomy holds a firm place in the treatment of congenital dislocation of the hip, either at the time of open reduction or subsequently as a reconstructive procedure. 1°,11 It is believed that a degree of varus (or more correctly stated, less valgus
Stabilising (Reconstructive) Procedures in the Younger Child Operations on the Pelvis
In the young child under 3 or 4 years of age the two most popular procedures on the pelvic side are the redirectional innominate osteotomy (Salter) 7 and the pericapsular innominate osteotomy (Pemberton). s Both were developed at about the same time, with the aim of obtaining an open reduction and stabilisation of the hip at the same operation. The enthusiasm that greeted these combined procedures led to many unfortunate failures and catastrophics. Orthopaedic surgeons somehow failed to recognise that the prime purpose in treating a dislocated hip was to obtain reduction of the dislocation. A pelvic osteotomy does not compensate for poorly or inadequately done open reduction. Another misunderstanding that gained wide acceptance was that these reconstructive procedures must be routinely done at the time of open reduction in children 18 months of age and older, because of the inability of the acetabulum to develop normally after that age. This concept still has its disciples despite the fact that it has been proven to be incorrect. Currently, there are only three defensible indications to perform either of these procedures. The first is the inability of the surgeon to obtain hip joint stability at the time of open reduction; the second is failure of the acetabulum to remodel with growth as discussed previously (Fig. 5); and the third is the development of progressive extra-pelvic protrusion following open reduction (Fig. 5). In all three of these situations there is a clearly identifiable indication for a stabilising procedure. Needless to say, for all operations there should be an indication. If there is not an indication, then there is a contraindication to performing the operation. Furthermore, as Salter has said, the ability to do an operation is not an indication to do it. 9 The most crucial prerequisite to performing either the innominate (Salter) osteotomy or the pericapsular (Pemberton) osteotomy is a concentrically reduced or reducible hip that has a satisfactory range of motion, especially in abduction, inward rotation, and flexion (Fig. 6). If one adheres to this
Fig. 5--Pelvic film of an 18-month-old girl with a dislocated right hip (A). An open reduction and femoral shortening was accomplished. Six months later (B). Note subtle evidence of development of the medial acetabular articular cortex with a "V" appearance. At age 7 years the teardrop has retained its "V" shape (C) and this, along with a persistently positive Trendelenburg sign prompted the performance of a Pemberton osteotomy. The result is seen in (D). A film taken 2½ years later shows a stable hip with normal range of motion and a negative Trendelenburg sign (E).
CURRENT ORTHOPAEDICS
279
Fig. 7--Pelvic film of an 18-month-old girl who underwent closed reduction of bilaterally dislocated hips 6 months earlier (A). Because of excessive anteversion and slightly subluxated hips, bilateral proximal femoral varus rotational osteotomies were performed (B). The result 9 years later (C). The acetabulae are well developed, but the varus of the upper femur has not yet been corrected.
Reconstructive Procedures in the Older Child and Adolescent Operations on the Pelvis Fig. 6--Pelvic film of a 2½-year-old girl who had undergone a closed reduction of the left hip 6 months earlier (A). Note slight subluxation and 'V" shaped teardrop, two pathognomonic signs of instability. Film taken six weeks postoperatively following a re-directional (Salter) osteotomy (B). The appearance nine months later (C). Twelve years later (D). Note the reversal of the teardrop to normal.
than normal), together with the correction of excessive femoral anteversion, produces greater stability of the hip joint, 12 which in turn encourages acetabular development. The major critics of this approach are concerned with the fact that there is not always a significant deformity of the proximal femur, and thus a deformity is being produced on one side of the joint in an effort to correct a deformity on the other side. It has been voiced that for the 'occasional' hip surgeon this is a safer procedure than a pelvic osteotomy, and that correction of a poorly done proximal femoral osteotomy is easier to achieve than correction of a poorly done pelvic osteotomy, a3 Without question this operation has much to offer and when a substantial deformity of the proximal femur exists it should be corrected (Figs. 7 & 8). In some situations both acetabular and femoral reconstructive procedures may be indicated at the same time. The indications and requirements for the proximal femoral operation are essentially identical to the pelvic procedures and must be rigidly adhered to for a successful surgical venture.
Fortunately, older children and adolescents rarely pose the problem of the need for reduction of a complete dislocation. Rather, the major problem consists of correction of newly identified or residual abnormalities of the hip, either on the pelvic or the femoral side or both. The reason for separating this group of patients from the younger child is based upon two concepts: 1) these older individuals have more firmly established and clearly identifiable hip abnormalities which require extensive and often more complicated surgery; 2) they have hips that are difficult if not impossible to'normalise' by surgery. Nonetheless a substantially long lasting hip can be created by a properly done reconstructive procedure even at this age. The effectiveness of any surgery will be governed by how carefully the pre-operative indications and requirements are adh, red to and how precisely and effectively the operat" ~n is accomplished technically. The indications for a reconstructive acetabular procedure in an older child or adolescent are: 1) disabling hip pain either with activity or rest; 2) positive Trendelenburg gait or test; 3) radiological evidence of a dysplastic acetabulum. The latter includes first, a substantially abnormally elevated acetabular index; second, a C-E angle below 20 °; and third, a 'V' shaped teardrop figure, indicating hip joint instability; and finally, progressive subluxation of the femoral head from the acetabulum (Fig. 9). The pre-operative
280
THE O P E R A T I V E M A N A G E M E N T OF C O N G E N I T A L D I S L O C A T I O N OF THE HIP
Fig. 8--Pelvic film of a 9-year-old boy who had undergone closed reduction of congenitally dislocated hips during infancy (A). Note excessive coxa valga and excessive anteversion (proven by inward rotation films). A proximal femoral varus rotational osteotomy was done because of a painfully positive Trendelenburg gait (B). The appearance 18 months later (C). The patient was pain free and had reversed his Trendelenburg sign to normal.
requirements include 1) a reasonably concentric relationship of the femoral head to the acetabulum with the thigh held in abduction, inward rotation and slight flexion; 2) a satisfactory range of hip motion; 3) a satisfactory joint space; 4) minimal evidence of degenerative joint disease. The term 'satisfactory' is difficult to quantify, but any substantial lack of hip motion or fixed contracture would be a contraindication. The two most commonly employed pelvic reconstructive procedures in the United States are the single redirectional innominate osteotomy (Salter) 7 (Fig. 6), and the triple innominate osteotomy (Steel) 14 (Fig. 9). The Salter procedure effectively treats older children and very young adolescents with a mild to moderate acetabular dysplasia, who have a flexible symphysis pubis, and require minimal lateral coverage of the acetabulum. In those adolescents and young adults with more advanced dysplasia, a rather rigid symphysis pubis, and who need mostly lateral coverage of the femoral head, the Steel procedure is more effective. The double innominate osteotomy described by Sutherland 15 attempts to add some degree of medialisation of the acetabulum by resecting a segment of the superior and inferior pubic ramus just lateral to the symphysis, in addition to the iliac osteotomy. Though conceptually attractive, it has not yet achieved the popularity of the Salter or Steel procedures. The pericapsular acetabular rotation operation of Wagner 16 (the spherical osteotomy) and the Eppright 17 (dial) osteotomy are technically very demanding procedures. They are designed to rotate the entire acetabulum, including about 1 cm of subarticular bone and hyaline articular cartilage over
Fig. 9--Pelvic film of a 16-year-old boy who was having progressively increasing right hip pain with activities (A), He had a positive Trendelenburg sign. The X-ray film shows subluxation and a "V' shaped teardrop, evidence of an unstable hip. An abduction inward rotation film showed improvement in the femoral head-acetabular relationships (B). Six months following a triple innominate osteotomy (Steel) the femoral head is well covered and the acetabular roof is horizontal (C), The appearance 1 year post-operative
(D).
CURRENT ORTHOPAEDICS 281 the femoral head and represent the most ideal form of reconstructive acetabular procedure. To be accurately done they must be accomplished under image intensification, and considerable experience and technical skill are required for their safe and effective execution. Neither procedure is recommended for the 'occasional' child's or adolescent's hip surgeon. Operations on the Femur
Deformities of the proximal femur are not uncommon in the older child and adolescent, and they often require surgical correction. The major abnormalities include angular (excessive varus or valgus) and torsional (usually excessive anteversion) deformities (Fig. 8) causing poor hip biomechanics resulting in a limp, inadequate acetabular development, and instability in the hip joint. It is essential these deformities are accurately assessed by appropriate hip biplane radiography and any deformity of the upper femur is corrected fully. It is important, however, that they are not over-corrected otherwise an opposite deformity is produced. A third proximal femoral deformity, resulting from femoral head necrosis, is called 'trochanteric overgrowth '18 in which there is relative overgrowth of the trochanter secondary to ratardation of the capital femoral physis (Fig. 10). In most instances the osteonecrosis of the femoral head is the result of treatment at the time of original reduction. The trochanteric 'overgrowth' produces a biomechanically incompetent hip abductor mechanism, leading to a progressively increasing gluteal lurch or 'sway', and an unstable hip joint that may become painful due to the deleterious effect of the instability upon the articular cartilage. On examination, the patient will exhibit either a positive Trendelenburg sign or gait, or will manifest a 'fatigue' positive Trendelenburg sign.
This sign is elicited by having the patient stand on the affected side with the weight removed from the opposite limb for a minimum of 30 s. If the opposite pelvis slowly drops downward, the test is positive. Radiographically, a standing anteroposterior view of the hip will show uncovering of the femoral head, and frequently the 'teardrop' will exhibit a 'V' shape, indicating a subluxating hip. In more advanced cases, early joint narrowing may be seen along with other early signs of degenerative joint disease. The most striking radiographic abnormality is shortening of the femoral neck, varying degrees of varus or valgus of the neck-shaft angle, and substantial upward projection of the greater trochanter as compared to the femoral head (Fig. 11). Treatment for angular or torsional abnormalities of the proximal femur are managed by osteotomy at the intertrochanteric region. The overgrown greater trochanter is most effectively treated by its distal and sometimes lateral transfer so that its proximal tip lies directly opposite the center of the femoral head (Fig. 12). Occasionally a reconstructive pelvic osteotomy and corrective femoral osteotomy must be accomplished. With appropriate internal fixation no external splintage is required, and both procedures can be done simultaneously.
Fig. 11--Pelvic film of a 15-year-old girl (A). She had Fig. 10--Pelvic radiograph of an 1 1 -year-old girl (A). She had been treated previously by closed reduction and at age 4 years a pericapsular (Pemberton) pelvic osteotomy. Femoral head necrosis lead to a prominent "overgrown" greater trochanter, resulting in a positive Trendelenburg gait. The result of distal transfer of the greater trochanter 2 years later (B).
undergone open reduction and redirectional (Salter) osteotomy at age 2 years. Because of a painful hip on activity and a substantially positive Trendelenburg gait and test, she underwent a triple innominate (Steel) osteotomy and a simultaneous distal transfer of the greater trochanter (B). The appearance 2 years post-operatively (C). Her Trendelenburg gait has not reversed, but she no longer has pain on activity.
282
THE O P E R A T I V E M A N A G E M E N T O F C O N G E N I T A L D I S L O C A T I O N OF THE HIP
Fig. 12--Pelvic film of a 16-year-old boy having had progressively increasing pain in the right hip with activities (A). Note obliquity of acetabular roof, excessive valgus of the femoral neck-shaft angle, and subluxation of the femoral head. Nine months following surgery he is fully active without pain (B). Note correction of the acetabular obliquity and the femoral neck-shaft angle.
Salvage Procedures on the Acetabulum in Later Childhood and Adolescence In some instances a hip joint may not fulfil the requirements for a reconstructive procedure, and as a consequence the surgeon must resort to operations that do not have the predictability or potential lasting quality of a reconstructive procedure. These operations all have one thing in common. In one way or another the capsule of the hip joint is utilised as all or part of the weight-bearing surface of the acetabulum. The three currently employed 'salvage' procedures are the Chiari osteotomy, 19 the 'shelf' augmentation procedure, 2° and the Colonna 21 capsular arthroplasty, of which the Chiari is by far the most commonly done (Fig. 13). The Colonna capsular arthroplasty is reserved for the rare case of the multiply operated hip that is badly scarred and yet still dislocated (Fig. 14). (The author also used it effectively in an untreated dislocation in a young adolescent when no other procedure seemed capable of providing the appropriate reduction and stability of the hip.) Post-operative stiffness has been substantially reduced by a simultaneous subtrochanteric femoral shortening. The indications and pre-operative requirements for the Chiari osteotomy and 'shelf' augmentation procedures are a painful hip that is subluxated and irreducible because of scarring or incongruency of the femoral head and acetabulum. Thus, a reconstructive procedure is contraindicated. The pre-operative requirements for either operation include the following: 1) a satisfactory range of motion, especially in flexion and extension; 2) a satisfactory cartilage or joint
Fig. 13--Pelvic X-ray film of a 15-year-old girl with moderately severe right hip pain, with a very complicated but poorly documented treatment history for dislocation of the hip (A). A Chiari osteotomy and distal transfer of the greater trochanter was accomplished simultaneously, The appearance 9 months post-operatively (B). Following removal of internal fixation 3 months later (C). Her pain has been relieved substantially, but the Trendelenburg test remains positive.
space; 3) minimal evidence of degenerative joint disease; 4) a femoral head that is not subluxated so high that a Chiari osteotomy will enter the sacroiliac joint; or will provide too little additional coverage of the femoral head. Clearly this latter requirement does not have to be met in the 'shelf' augmentation procedure.
Arthrodesis of the Hip in Later Childhood and Adolescence This is a viable and highly satisfactory procedure for the totally destroyed hip that does not fulfil the preoperative requirements for either a reconstructive or salvage procedure. It can provide lasting durability for many years and there are no irreversible bridges burned if an implant arthroplasty ultimately is desired. The only indication is a hip that is painfully disabling and cannot be effectively treated by a reconstructive or a salvage procedure (Fig. 15). The essential preoperative requirements include a normal opposite hip, a normal ipsilateral knee and a normal lumbar spine. The foregoing discussion attempts to put into perspective the current most commonly used biological
CURRENT ORTHOPAEDICS
283
Fig. 1 4 ~ N i n e - y e a r - o l d girl who in earlier childhood underwent two failed efforts at open reduction and was lost to follow-up. The radiograph shows a dislocated hip with a false acetabulum and a virtually non-existent true acetabulum (A). A Colonna arthroplasty was accomplished as seen in the film taken 2 months post-operatively (B). Five years later she has a painless hip, a normal gait and normal range of motion (C).
procedures in the treatment of congenital dislocation of the hip and its sequelae through older childhood and adolescence. At the present time there appears to be no place in the otherwise healthy patient for implant arthroplasty in this age group. Undoubtedly with intelligent analysis of the long-term results of these operations the future will bring greater sophistication and will identify the indications more specifically. References 1. ColemanS S 1978 Congenitaldysplasia and dislocation of the hip. C V Mosby, St Louis 2. LudloffK 1908 Zur blutigeneinrenkungder angeboren huftluxation. Z. Ortho. Chir. 22:272 3. Ponseti I V 1978 Growth and development of the acetabulum in the normal child. Journal of Bone and Joint Surgery 60-A : 575 585
Fig. 15--Pelvic radiograph of an 18-year-old woman who had a long history of treatment for dislocation of the left hip (A). The hip was painful, had a poor range of motion and was progressively disabling. A hip fusion was accomplished. Eighteen months later (B).
4. Staheli L T 1985 T r e a t m e n t of hip dislocation in children with arthrogryposis. Journal of Pediatric Orthopaedics 5 : 751-752 5. Ashley R K, Larsen L J, James P M 1972 Reduction of dislocation of the hip in older children: a preliminary report. Journal of Bone and Joint Surgery 54-A : 545 550 6. King H A, Coleman S S 1980 Open reduction and femoral shortening in congenital dislocation of the hip. Orthopaedic Transactions 4-3 : 30~303 7. Salter R B 1961 Innominate Osteotomy in the treatment of congenital dislocation and subluxation of the hip joint. Journal of Bone and Joint Surgery 43-B : 518 539 8. Pemberton P A 1965 Pericapsular osteotomy of the ilium for treatment of congenital subluxation and dislocation of the hip. Journal of Bone and Joint Surgery 47-A : 65-86 9. Salter R B 1979 Personal communication. Pediatric Orthopaedic International Seminar, Chicago 10. Somerville E W 1978 A long term follow-up of congenital dislocation of the hip. Journal of Bone and Joint Surgery 60B(I): 25-30 11. Chuinard E G 1972 Femoral osteotomy in the treatment of congenital dysplasia of the hip. Orthopaedic Clinics of North America 3:157 12. Kasser J R, Bowen J R, M a c E w e n G D 1985 Varus derotation osteotomy in the treatment of persistent dysplasia in congenital dislocation of the hip. Journal of Bone and Joint Surgery 67-A: 195 202 13. Tachdjian M O 1980 Personal communication. Pediatric Orthopaedics International Seminar, San Francisco 14. Steel H H 1973 Triple osteotomy of the innominate bone. Journal of Bone and Joint Surgery 55-A: 343-350 15. Sutherland D H, Greenfield R 1977 Double innominate osteotomy. Journal of Bone and Joint Surgery 59-A: 1082 1090 16. Wagner H 1978 Experiences with spherical acetabular osteotomy for the correction of the dysplastic acetabulum. Progress in Orthopaedic Surgery 2: 131 17. Eppright R 1977 From motion picture presentation at the American A c a d e m y of Orthopaedic Surgeons annual meeting, Las Vegas, N e v a d a 18. Stevens P M, Coleman S S 1985 Coxa Breva: Its pathogenesis and rationale for its m a n a g e m e n t . Journal of Pediatric Orthopaedics 5 : 515-521 19. Chiari K 1955 Ergebnisse mit der beckenosteotomie als pfannendach-plastik. Z. Ortho. Chir. 87:14 20. Staheli L T 1981 Slotted acetabular augmentation. Journal of Pediatric Orthopaedics 1 : 321 21. Colonna P C 1965 Capsular arthroplasty for congenital dislocation of the hip; indications and technique. Journal of Bone and Joint Surgery 47-A: 437 449
S h e r m a n S. C o l e m a n
When any one of these circumstances exists, there is a positive indication for open reduction. In nearly all instances, the determination of the need for open reduction must be made by examining and manipulating the hip under general anesthesia. Only then can one accurately assess which, if any, of the above indications obtain.
Even in this modern so-called enlightened age, the need for operative treatment of congenital dislocation of the hip and its sequelae remains a very important discipline. Early recognition of an abnormal hip in the newborn or neonate does not necessarily eliminate the need for subsequent surgical procedures on the hip. However, the magnitude as well as the type of surgery required for the best treatment of the dislocated hip are clearly related to the time of diagnosis. 1
Technique There are two well accepted surgical approaches for open reduction of the congenitally dislocated hip. These are the medial 'adductor' approach and the anterior 'iliofemoral' or inguinal approach. Over the past 15 years the relative advantages and disadvantages of each have been assessed in considerable depth, and the indications for which approach to use have been clarified. The medial adductor approach. This was originally developed by Ludloff in 1908. 2 This procedure has had substantial periods of popularity and rejection, but it currently enjoys a rather respected and defensible place in the surgeon's armamentarium. It is generally agreed that the procedure should be reserved for those children under eighteen months of age :
Open Reduction of Congenital Dislocation of the Hip Indications What precisely is meant by failure of closed reduction ? There are at least four criteria, which are of course indications for open reduction. If closed reduction fails by whatever means have been implemented, then open reduction becomes mandatory. These include the following : 1. Inability to achieve concentric reduction by closed efforts. In these instances there is an unacceptable (greater than 2.0 mm) increase in the space between the femoral head and the acetabulum as compared to the opposite normal side, with the hip reduced. 2. Inability to achieve and maintain reduction without placing the affected limb in an unphysiological position (greater than 60 ° of abduction). 3. Inability to place the femoral head in the acetabulum at all (an irreducible hip). 4. An unstable reduction, wherein the hip can be reduced, but it is unstable in any position.
1. Whose hips are reducible, but unstable. 2. Whose hips cannot be congruently reduced. 3. Who require an unphysiologic position in order to hold the hip stable.I, 4 In any of these three instances, a carefully performed medial adductor approach to the hip can predictably achieve a very satisfactory reduction. Via in incision parallel to the adductor crease, the adductor longus is sectioned, and the interval anterior to the adductor brevis is developed. The lesser
ShermanS. ColemanMD, Shriners Hospitals for crippled children, Intermountain Unit, Fairfax Avenueand Virginia Street, Salt Lake City, Utah 84103-4399,USA. Current Orthopaedics(1987) 1, 275-283 © 1987 Longman Group UK Ltd
275
276
THE OPERATIVE MANAGEMENT
O F C O N G E N I T A L D I S L O C A T I O N OF T I l E HIP
trochanter and iliopsoas are exposed. The soft tissue can be teased away from the tendon and the large medial femoral circumflex artery is identified and protected. The iliopsoas tendon is sectioned and reflected, thus exposing the hip joint capsule which is incised to expose the entire anterior, superior and inferior aspects of the joint. A substantial exploration of the joint can be carried out and all structures that prevent reduction can be carefully removed. These include the iliopsoas tendon, the contracted c/apsule, the enlarged and hypertrophic ligamentum te~es, the transverse acetabular ligament, and an//infolded limbus. This approach, however, does not allow a capsulorrhaphy to be accomplished; thus there is some residual instability to the reduction. However, with a properly applied cast the reduction can nearly always be rendered stable. In the absence of capsulorrhaphy a more prolonged period of cast immobilisation is needed. An anteroposterior X-ray film is taken when the cast is applied, and it is essential that another pelvic film is taken 1 week later to verify continued stable reduction (Fig. 1). Customarily the cast is changed under anesthesia at 6 weeks. At 12 weeks post-operatively the patient is placed in a removable plastic abduction splint which is kept on for at least 6 weeks to 3 months, being removed only for bathing. Clinical judgement, based on physical examination of stability and progressive
radiological improvement, determines when the splintage is eliminated completely. The anterior approach. This is more versatile than the medial approach and lends itself to additional operative procedures, as well as allowing a more thorough joint exploration. A capsulorrhaphy can also be accomplished which greatly enhances joint stability. Thus in addition to the indications for the medial approach it should definitely be employed whenever the hip is irreducible; the patient is over 18 months of age; or if there is any doubt about the problem. Radiological evaluation prior to splintage in the operating room is essential and should be repeated following the application of a one and one-half spica cast. A further pelvic film should be taken a week later to ensure reduction is being maintained (Fig. 2). Because of the capsulorrhaphy, a second spica cast is not usually necessary and 'broomstick plasters' (Fig. 3) can be used after 6 weeks provided both physical evaluation and X-rays confirm a stable reduction. 18 m o, 'i_
_
11-16-81
Fig. 1--Pelvic film of 3-month-old male showing obvious dislocation of the left hip (A). The hip remained unstable following closed reduction; therefore an open reduction through the medial adductor approach was done. The pelvic radiograph 5 months post-op (B). Three years later the femoral head and acetabulum are developing well (C). Ten years after reduction the hip is indistinguishable from normal (D).
Fig. 2--Pelvic film of an 18-month-old female with obvious bilaterally dislocated hips. Note the apparently shallow acetabulae (A). The hips were irreducible and therefore bilateral open reductions through an anterior approach were accomplished 1 week apart. The high riding right hip required femoral shortening, and the result 9 months later is seen (B). Three years later the acetabulae have developed well (C), 6 years following open reduction only, the hips appear normal (D). No pelvic reconstructive procedure was entertained at any time since the initial reduction was stable and congruent.
CURRENT ORTHOPAEDICS 277
Fig. 3 - - D r a w i n g to illustrate the use of cylinder casts that permit flexion and extension, but allow no rotation, abduction or adduction. It is essential that the knees are bent and the casts are held with crossbars in order to control rotation and adduction-abduction.
These casts extend from ankle to groin and are applied with the knee slightly flexed and the thighs in neutral rotation with 30-45 ° abduction. They are connected by two cross-bars. This allows controlled flexion and extension, but does not permit rotation or abduction or adduction of the hips. These are kept on for a minimum of 6 weeks, and thereafter if good radiographic stability is evident, the same sptintage program is implemented as was done following the medial adductor approach. If the above therapeutic plan is carried out with meticulous attention to detail, the majority of patients under 3 years of age will demonstrate very satisfactory remodeling and development of the acetabulum with
growth. The follow-up program however is extremely important and the following features of acetabular development should be closely monitored: 1) progressive improvement (lowering) of the acetabular index; 2) normal development and more clear delineation of the 'tear-drop' shadow medially; 3) an improvement in Shenton's line; 4) improved configuration and clear delineation of the surcile; 5) progressive overall improvement of the acetabular femoral head relationships (Fig. 2). It is important to emphasise that steady improvement in these radiologic parameters can and often does occur steadily up through ages 9 and 10. 3 This may extend into the second decade so long as the triradiate cartilage remains open and the hip remains concentrically reduced and stable (Figs 2 & 4). If any of these radiologic parameters fail to improve or especially if there is evidence of progressive extrapelvic protrusion of the femoral head with the development of a 'V' shaped teardrop, then one must assess the need for a stabilising procedure, either on the acetabular side, the femoral side, or both. Open reduction with femoral shortening. A subtrochanteric femoral shortening, 5 sometimes called a 'decompression' osteotomy (Figs 2 & 4), is indicated in children over 18 months when an open reduction through the anterior approach fails despite all efforts to release the soft tissues. The ease with which the femoral head can be reduced into the acetabulum following femoral shortening, despite its totally irreducible state without shortening, is impressive. Properly done, not only can the reduction be rendered easier, but any pressure on the femoral head is relieved, thus reducing the likelihood of osseous necrosis. In addition angular or torsional deformities of the proximal femur can be corrected simultaneously. When done in children under 10 years of' age surgical shortening by resection is compensated for by stimulation of growth. 6 This procedure has been an
Fig. 4 - - A 5-year-old girl with a dislocated left hip (A). Note the seemingly shallow and poorly developed acetabulum. The appearance four and one-half months following open reduction and femoral shortening done through an anterior approach (B). Two years later the hip remains congruently stable and the acetabulum is improving (C). Eight and ½years later the hip is indistinguishable from normal (D). No reconstructive procedure on the pelvis was ever done. This illustrates the great ability of the acetabulum to remodel when the reduction is stable and congruent.
278
T H E O P E R A T I V E M A N A G E M E N T OF C O N G E N I T A L D I S L O C A T I O N OF THE HIP
invaluable addition to our surgical armamentarium in dealing with difficult high-riding dislocated hips. Combined Procedures at time o f Open Reduction. Stability cannot always be achieved at the time of open reduction, and a simultaneous stabilising procedure must be carried out in a small number of instances on children between 18 months and 3 years of age. Whether this is done on the pelvic or the femoral side must be governed by the surgeon's appraisal of where the principal abnormality of the hip lies. The different stabilising operative techniques each have their advantages and disadvantages and are discussed below.
simple, but necessarily demanding requirement, the operation will likely succeed if properly done. Operations on the Femoral Side
These procedures are much less commonly done in the United States in comparison with Europe. It is difficult to explain the reasons for this dichotomy of thought and concept. Nevertheless, the proximal femoral varus or varus rotational osteotomy holds a firm place in the treatment of congenital dislocation of the hip, either at the time of open reduction or subsequently as a reconstructive procedure. 1°,11 It is believed that a degree of varus (or more correctly stated, less valgus
Stabilising (Reconstructive) Procedures in the Younger Child Operations on the Pelvis
In the young child under 3 or 4 years of age the two most popular procedures on the pelvic side are the redirectional innominate osteotomy (Salter) 7 and the pericapsular innominate osteotomy (Pemberton). s Both were developed at about the same time, with the aim of obtaining an open reduction and stabilisation of the hip at the same operation. The enthusiasm that greeted these combined procedures led to many unfortunate failures and catastrophics. Orthopaedic surgeons somehow failed to recognise that the prime purpose in treating a dislocated hip was to obtain reduction of the dislocation. A pelvic osteotomy does not compensate for poorly or inadequately done open reduction. Another misunderstanding that gained wide acceptance was that these reconstructive procedures must be routinely done at the time of open reduction in children 18 months of age and older, because of the inability of the acetabulum to develop normally after that age. This concept still has its disciples despite the fact that it has been proven to be incorrect. Currently, there are only three defensible indications to perform either of these procedures. The first is the inability of the surgeon to obtain hip joint stability at the time of open reduction; the second is failure of the acetabulum to remodel with growth as discussed previously (Fig. 5); and the third is the development of progressive extra-pelvic protrusion following open reduction (Fig. 5). In all three of these situations there is a clearly identifiable indication for a stabilising procedure. Needless to say, for all operations there should be an indication. If there is not an indication, then there is a contraindication to performing the operation. Furthermore, as Salter has said, the ability to do an operation is not an indication to do it. 9 The most crucial prerequisite to performing either the innominate (Salter) osteotomy or the pericapsular (Pemberton) osteotomy is a concentrically reduced or reducible hip that has a satisfactory range of motion, especially in abduction, inward rotation, and flexion (Fig. 6). If one adheres to this
Fig. 5--Pelvic film of an 18-month-old girl with a dislocated right hip (A). An open reduction and femoral shortening was accomplished. Six months later (B). Note subtle evidence of development of the medial acetabular articular cortex with a "V" appearance. At age 7 years the teardrop has retained its "V" shape (C) and this, along with a persistently positive Trendelenburg sign prompted the performance of a Pemberton osteotomy. The result is seen in (D). A film taken 2½ years later shows a stable hip with normal range of motion and a negative Trendelenburg sign (E).
CURRENT ORTHOPAEDICS
279
Fig. 7--Pelvic film of an 18-month-old girl who underwent closed reduction of bilaterally dislocated hips 6 months earlier (A). Because of excessive anteversion and slightly subluxated hips, bilateral proximal femoral varus rotational osteotomies were performed (B). The result 9 years later (C). The acetabulae are well developed, but the varus of the upper femur has not yet been corrected.
Reconstructive Procedures in the Older Child and Adolescent Operations on the Pelvis Fig. 6--Pelvic film of a 2½-year-old girl who had undergone a closed reduction of the left hip 6 months earlier (A). Note slight subluxation and 'V" shaped teardrop, two pathognomonic signs of instability. Film taken six weeks postoperatively following a re-directional (Salter) osteotomy (B). The appearance nine months later (C). Twelve years later (D). Note the reversal of the teardrop to normal.
than normal), together with the correction of excessive femoral anteversion, produces greater stability of the hip joint, 12 which in turn encourages acetabular development. The major critics of this approach are concerned with the fact that there is not always a significant deformity of the proximal femur, and thus a deformity is being produced on one side of the joint in an effort to correct a deformity on the other side. It has been voiced that for the 'occasional' hip surgeon this is a safer procedure than a pelvic osteotomy, and that correction of a poorly done proximal femoral osteotomy is easier to achieve than correction of a poorly done pelvic osteotomy, a3 Without question this operation has much to offer and when a substantial deformity of the proximal femur exists it should be corrected (Figs. 7 & 8). In some situations both acetabular and femoral reconstructive procedures may be indicated at the same time. The indications and requirements for the proximal femoral operation are essentially identical to the pelvic procedures and must be rigidly adhered to for a successful surgical venture.
Fortunately, older children and adolescents rarely pose the problem of the need for reduction of a complete dislocation. Rather, the major problem consists of correction of newly identified or residual abnormalities of the hip, either on the pelvic or the femoral side or both. The reason for separating this group of patients from the younger child is based upon two concepts: 1) these older individuals have more firmly established and clearly identifiable hip abnormalities which require extensive and often more complicated surgery; 2) they have hips that are difficult if not impossible to'normalise' by surgery. Nonetheless a substantially long lasting hip can be created by a properly done reconstructive procedure even at this age. The effectiveness of any surgery will be governed by how carefully the pre-operative indications and requirements are adh, red to and how precisely and effectively the operat" ~n is accomplished technically. The indications for a reconstructive acetabular procedure in an older child or adolescent are: 1) disabling hip pain either with activity or rest; 2) positive Trendelenburg gait or test; 3) radiological evidence of a dysplastic acetabulum. The latter includes first, a substantially abnormally elevated acetabular index; second, a C-E angle below 20 °; and third, a 'V' shaped teardrop figure, indicating hip joint instability; and finally, progressive subluxation of the femoral head from the acetabulum (Fig. 9). The pre-operative
280
THE O P E R A T I V E M A N A G E M E N T OF C O N G E N I T A L D I S L O C A T I O N OF THE HIP
Fig. 8--Pelvic film of a 9-year-old boy who had undergone closed reduction of congenitally dislocated hips during infancy (A). Note excessive coxa valga and excessive anteversion (proven by inward rotation films). A proximal femoral varus rotational osteotomy was done because of a painfully positive Trendelenburg gait (B). The appearance 18 months later (C). The patient was pain free and had reversed his Trendelenburg sign to normal.
requirements include 1) a reasonably concentric relationship of the femoral head to the acetabulum with the thigh held in abduction, inward rotation and slight flexion; 2) a satisfactory range of hip motion; 3) a satisfactory joint space; 4) minimal evidence of degenerative joint disease. The term 'satisfactory' is difficult to quantify, but any substantial lack of hip motion or fixed contracture would be a contraindication. The two most commonly employed pelvic reconstructive procedures in the United States are the single redirectional innominate osteotomy (Salter) 7 (Fig. 6), and the triple innominate osteotomy (Steel) 14 (Fig. 9). The Salter procedure effectively treats older children and very young adolescents with a mild to moderate acetabular dysplasia, who have a flexible symphysis pubis, and require minimal lateral coverage of the acetabulum. In those adolescents and young adults with more advanced dysplasia, a rather rigid symphysis pubis, and who need mostly lateral coverage of the femoral head, the Steel procedure is more effective. The double innominate osteotomy described by Sutherland 15 attempts to add some degree of medialisation of the acetabulum by resecting a segment of the superior and inferior pubic ramus just lateral to the symphysis, in addition to the iliac osteotomy. Though conceptually attractive, it has not yet achieved the popularity of the Salter or Steel procedures. The pericapsular acetabular rotation operation of Wagner 16 (the spherical osteotomy) and the Eppright 17 (dial) osteotomy are technically very demanding procedures. They are designed to rotate the entire acetabulum, including about 1 cm of subarticular bone and hyaline articular cartilage over
Fig. 9--Pelvic film of a 16-year-old boy who was having progressively increasing right hip pain with activities (A), He had a positive Trendelenburg sign. The X-ray film shows subluxation and a "V' shaped teardrop, evidence of an unstable hip. An abduction inward rotation film showed improvement in the femoral head-acetabular relationships (B). Six months following a triple innominate osteotomy (Steel) the femoral head is well covered and the acetabular roof is horizontal (C), The appearance 1 year post-operative
(D).
CURRENT ORTHOPAEDICS 281 the femoral head and represent the most ideal form of reconstructive acetabular procedure. To be accurately done they must be accomplished under image intensification, and considerable experience and technical skill are required for their safe and effective execution. Neither procedure is recommended for the 'occasional' child's or adolescent's hip surgeon. Operations on the Femur
Deformities of the proximal femur are not uncommon in the older child and adolescent, and they often require surgical correction. The major abnormalities include angular (excessive varus or valgus) and torsional (usually excessive anteversion) deformities (Fig. 8) causing poor hip biomechanics resulting in a limp, inadequate acetabular development, and instability in the hip joint. It is essential these deformities are accurately assessed by appropriate hip biplane radiography and any deformity of the upper femur is corrected fully. It is important, however, that they are not over-corrected otherwise an opposite deformity is produced. A third proximal femoral deformity, resulting from femoral head necrosis, is called 'trochanteric overgrowth '18 in which there is relative overgrowth of the trochanter secondary to ratardation of the capital femoral physis (Fig. 10). In most instances the osteonecrosis of the femoral head is the result of treatment at the time of original reduction. The trochanteric 'overgrowth' produces a biomechanically incompetent hip abductor mechanism, leading to a progressively increasing gluteal lurch or 'sway', and an unstable hip joint that may become painful due to the deleterious effect of the instability upon the articular cartilage. On examination, the patient will exhibit either a positive Trendelenburg sign or gait, or will manifest a 'fatigue' positive Trendelenburg sign.
This sign is elicited by having the patient stand on the affected side with the weight removed from the opposite limb for a minimum of 30 s. If the opposite pelvis slowly drops downward, the test is positive. Radiographically, a standing anteroposterior view of the hip will show uncovering of the femoral head, and frequently the 'teardrop' will exhibit a 'V' shape, indicating a subluxating hip. In more advanced cases, early joint narrowing may be seen along with other early signs of degenerative joint disease. The most striking radiographic abnormality is shortening of the femoral neck, varying degrees of varus or valgus of the neck-shaft angle, and substantial upward projection of the greater trochanter as compared to the femoral head (Fig. 11). Treatment for angular or torsional abnormalities of the proximal femur are managed by osteotomy at the intertrochanteric region. The overgrown greater trochanter is most effectively treated by its distal and sometimes lateral transfer so that its proximal tip lies directly opposite the center of the femoral head (Fig. 12). Occasionally a reconstructive pelvic osteotomy and corrective femoral osteotomy must be accomplished. With appropriate internal fixation no external splintage is required, and both procedures can be done simultaneously.
Fig. 11--Pelvic film of a 15-year-old girl (A). She had Fig. 10--Pelvic radiograph of an 1 1 -year-old girl (A). She had been treated previously by closed reduction and at age 4 years a pericapsular (Pemberton) pelvic osteotomy. Femoral head necrosis lead to a prominent "overgrown" greater trochanter, resulting in a positive Trendelenburg gait. The result of distal transfer of the greater trochanter 2 years later (B).
undergone open reduction and redirectional (Salter) osteotomy at age 2 years. Because of a painful hip on activity and a substantially positive Trendelenburg gait and test, she underwent a triple innominate (Steel) osteotomy and a simultaneous distal transfer of the greater trochanter (B). The appearance 2 years post-operatively (C). Her Trendelenburg gait has not reversed, but she no longer has pain on activity.
282
THE O P E R A T I V E M A N A G E M E N T O F C O N G E N I T A L D I S L O C A T I O N OF THE HIP
Fig. 12--Pelvic film of a 16-year-old boy having had progressively increasing pain in the right hip with activities (A). Note obliquity of acetabular roof, excessive valgus of the femoral neck-shaft angle, and subluxation of the femoral head. Nine months following surgery he is fully active without pain (B). Note correction of the acetabular obliquity and the femoral neck-shaft angle.
Salvage Procedures on the Acetabulum in Later Childhood and Adolescence In some instances a hip joint may not fulfil the requirements for a reconstructive procedure, and as a consequence the surgeon must resort to operations that do not have the predictability or potential lasting quality of a reconstructive procedure. These operations all have one thing in common. In one way or another the capsule of the hip joint is utilised as all or part of the weight-bearing surface of the acetabulum. The three currently employed 'salvage' procedures are the Chiari osteotomy, 19 the 'shelf' augmentation procedure, 2° and the Colonna 21 capsular arthroplasty, of which the Chiari is by far the most commonly done (Fig. 13). The Colonna capsular arthroplasty is reserved for the rare case of the multiply operated hip that is badly scarred and yet still dislocated (Fig. 14). (The author also used it effectively in an untreated dislocation in a young adolescent when no other procedure seemed capable of providing the appropriate reduction and stability of the hip.) Post-operative stiffness has been substantially reduced by a simultaneous subtrochanteric femoral shortening. The indications and pre-operative requirements for the Chiari osteotomy and 'shelf' augmentation procedures are a painful hip that is subluxated and irreducible because of scarring or incongruency of the femoral head and acetabulum. Thus, a reconstructive procedure is contraindicated. The pre-operative requirements for either operation include the following: 1) a satisfactory range of motion, especially in flexion and extension; 2) a satisfactory cartilage or joint
Fig. 13--Pelvic X-ray film of a 15-year-old girl with moderately severe right hip pain, with a very complicated but poorly documented treatment history for dislocation of the hip (A). A Chiari osteotomy and distal transfer of the greater trochanter was accomplished simultaneously, The appearance 9 months post-operatively (B). Following removal of internal fixation 3 months later (C). Her pain has been relieved substantially, but the Trendelenburg test remains positive.
space; 3) minimal evidence of degenerative joint disease; 4) a femoral head that is not subluxated so high that a Chiari osteotomy will enter the sacroiliac joint; or will provide too little additional coverage of the femoral head. Clearly this latter requirement does not have to be met in the 'shelf' augmentation procedure.
Arthrodesis of the Hip in Later Childhood and Adolescence This is a viable and highly satisfactory procedure for the totally destroyed hip that does not fulfil the preoperative requirements for either a reconstructive or salvage procedure. It can provide lasting durability for many years and there are no irreversible bridges burned if an implant arthroplasty ultimately is desired. The only indication is a hip that is painfully disabling and cannot be effectively treated by a reconstructive or a salvage procedure (Fig. 15). The essential preoperative requirements include a normal opposite hip, a normal ipsilateral knee and a normal lumbar spine. The foregoing discussion attempts to put into perspective the current most commonly used biological
CURRENT ORTHOPAEDICS
283
Fig. 1 4 ~ N i n e - y e a r - o l d girl who in earlier childhood underwent two failed efforts at open reduction and was lost to follow-up. The radiograph shows a dislocated hip with a false acetabulum and a virtually non-existent true acetabulum (A). A Colonna arthroplasty was accomplished as seen in the film taken 2 months post-operatively (B). Five years later she has a painless hip, a normal gait and normal range of motion (C).
procedures in the treatment of congenital dislocation of the hip and its sequelae through older childhood and adolescence. At the present time there appears to be no place in the otherwise healthy patient for implant arthroplasty in this age group. Undoubtedly with intelligent analysis of the long-term results of these operations the future will bring greater sophistication and will identify the indications more specifically. References 1. ColemanS S 1978 Congenitaldysplasia and dislocation of the hip. C V Mosby, St Louis 2. LudloffK 1908 Zur blutigeneinrenkungder angeboren huftluxation. Z. Ortho. Chir. 22:272 3. Ponseti I V 1978 Growth and development of the acetabulum in the normal child. Journal of Bone and Joint Surgery 60-A : 575 585
Fig. 15--Pelvic radiograph of an 18-year-old woman who had a long history of treatment for dislocation of the left hip (A). The hip was painful, had a poor range of motion and was progressively disabling. A hip fusion was accomplished. Eighteen months later (B).
4. Staheli L T 1985 T r e a t m e n t of hip dislocation in children with arthrogryposis. Journal of Pediatric Orthopaedics 5 : 751-752 5. Ashley R K, Larsen L J, James P M 1972 Reduction of dislocation of the hip in older children: a preliminary report. Journal of Bone and Joint Surgery 54-A : 545 550 6. King H A, Coleman S S 1980 Open reduction and femoral shortening in congenital dislocation of the hip. Orthopaedic Transactions 4-3 : 30~303 7. Salter R B 1961 Innominate Osteotomy in the treatment of congenital dislocation and subluxation of the hip joint. Journal of Bone and Joint Surgery 43-B : 518 539 8. Pemberton P A 1965 Pericapsular osteotomy of the ilium for treatment of congenital subluxation and dislocation of the hip. Journal of Bone and Joint Surgery 47-A : 65-86 9. Salter R B 1979 Personal communication. Pediatric Orthopaedic International Seminar, Chicago 10. Somerville E W 1978 A long term follow-up of congenital dislocation of the hip. Journal of Bone and Joint Surgery 60B(I): 25-30 11. Chuinard E G 1972 Femoral osteotomy in the treatment of congenital dysplasia of the hip. Orthopaedic Clinics of North America 3:157 12. Kasser J R, Bowen J R, M a c E w e n G D 1985 Varus derotation osteotomy in the treatment of persistent dysplasia in congenital dislocation of the hip. Journal of Bone and Joint Surgery 67-A: 195 202 13. Tachdjian M O 1980 Personal communication. Pediatric Orthopaedics International Seminar, San Francisco 14. Steel H H 1973 Triple osteotomy of the innominate bone. Journal of Bone and Joint Surgery 55-A: 343-350 15. Sutherland D H, Greenfield R 1977 Double innominate osteotomy. Journal of Bone and Joint Surgery 59-A: 1082 1090 16. Wagner H 1978 Experiences with spherical acetabular osteotomy for the correction of the dysplastic acetabulum. Progress in Orthopaedic Surgery 2: 131 17. Eppright R 1977 From motion picture presentation at the American A c a d e m y of Orthopaedic Surgeons annual meeting, Las Vegas, N e v a d a 18. Stevens P M, Coleman S S 1985 Coxa Breva: Its pathogenesis and rationale for its m a n a g e m e n t . Journal of Pediatric Orthopaedics 5 : 515-521 19. Chiari K 1955 Ergebnisse mit der beckenosteotomie als pfannendach-plastik. Z. Ortho. Chir. 87:14 20. Staheli L T 1981 Slotted acetabular augmentation. Journal of Pediatric Orthopaedics 1 : 321 21. Colonna P C 1965 Capsular arthroplasty for congenital dislocation of the hip; indications and technique. Journal of Bone and Joint Surgery 47-A: 437 449