Certainly. The AP pelvic radiograph reveals a dislocated left hip and dysplastic acetabulum. Shenton’s line, which is a line drawn along the inferior border of the superior pubic ramus and the medial border of the femoral neck, is broken. The femoral head is located laterally and superiorly to the inferiomedial quadrant formed by the intersection of Perkin’s and Hilgenreiner’s lines.
My initial approach would involve taking a comprehensive history and performing a thorough physical examination. I would specifically look for risk factors associated with developmental dysplasia of the hip (DDH), such as a positive family history and factors related to decreased intrauterine space such as being a first-born, breech presentation, or oligohydramnios.
Additionally, I would evaluate the patient for any underlying neuromuscular conditions that could contribute to the hip dislocation, such as spina bifida, arthrogryposis, or cerebral palsy. During the examination, I would assess for signs such as a Trendelenburg gain, leg length discrepancy, fixed flexion deformity, and reduced abduction of the left hip, which is a reliable clinical sign of DDH.
If indicated, I will proceed with an examination under anesthesia (EUA) and arthrogram. This procedure would allow for a detailed assessment of the acetabulum, soft tissues, and proximal femur. It is unlikely that the dislocated hip would reduce closed, and several factors may impede reduction, including an inverted limb, elongated ligamentum teres, hour-glass constriction of the capsule, psoas tendon, and pulvinar.
Indications for open reduction would include failure of closed reduction, an unstable reducible hip, or soft tissue interposition hindering a congruent reduction.
Certainly. I would utilize a modified anterior (ilio-femoral) approach to the hip. To initiate the approach, I would make a skin incision parallel and distal to the iliac crest, extending approximately 2 cm distal to the anterior superior iliac spine (ASIS) and medially within the groin skin crease.
Once the incision is made, I would identify and protect the lateral cutaneous nerve of the thigh. Then, I would proceed distally and develop the internervous plane between the tensor fascia lata (innervated by the superior gluteal nerve) and the sartorius muscle (innervated by the femoral nerve).
Continuing the dissection, I would split the iliac crest apophysis and elevate the muscles en masse on both sides of the pelvis, extending down to the sciatic notch and the superior border of the acetabulum. I would divide the straight head of the rectus femoris and create a T-shaped capsular incision to gain access to the hip joint.
Within the joint, I would clear the acetabulum of any pulvinar and redundant ligamentum teres, taking care not to disturb the labrum. If there is an inverted labrum, it would need to be everted, and radial cuts may be necessary to facilitate this process. The inferior capsule may also require release, ensuring the preservation of the blood supply to the femoral head. Additionally, the tightness in the iliopsoas muscle may necessitate a release to achieve reduction of the hip.
Following the reduction, I would assess the need for a shortening femoral osteotomy and/or a pelvic osteotomy, such as the Salter osteotomy, to provide adequate coverage for the hip.
To conclude the procedure, I would perform a double-breasted capsular repair, close the incisions in layers, and immobilize the hip with a hip spica cast. The cast would be applied with the hip in approximately 30° of abduction and internal rotation. The patient would require a cast change at 6 weeks, and the total duration of casting would be 3 months. Post-operatively, close monitoring for spica syndrome would be essential, and an MRI scan would be organized to confirm the maintenance of hip reduction.
Long-term follow-up would be necessary to ensure normal hip development in the patient.
Certainly. The open reduction of a dislocated hip, although effective in achieving reduction, is not without potential complications. Some complications that may arise include avascular necrosis (AVN) of the femoral head, which can occur due to disruption of the blood supply during the surgical procedure. Other complications include infection, neurovascular injury, damage to the growth plate, residual hip instability, leg length discrepancy, and stiffness or limitation of hip motion.
Additionally, there is a risk of iatrogenic injury to surrounding structures such as nerves, blood vessels, or the labrum during the surgical dissection or reduction of manoeuvres. Close attention to surgical technique, careful handling of tissues, and meticulous closure can help minimize the occurrence of these complications.
Certainly. Following the surgery, the patient would require close post-operative monitoring. This would involve assessing the stability of the reduction, monitoring for complications such as spica syndrome, and ensuring appropriate cast care.
During the initial 3-month period of casting, the patient would require regular follow-up visits to evaluate the hip’s progress and monitor for any signs of AVN, infection, or other complications. After the cast removal, the patient would undergo further assessment of hip stability, range of motion, and gait.
Long-term follow-up would be necessary to monitor the patient’s hip development, assess for any residual deformities, and ensure appropriate growth and function of the hip joint. Regular clinical examinations, radiographic evaluations, and functional assessments would be conducted at predetermined intervals based on the patient’s progress and the surgeon’s judgment