Literature suggest that capsulorrhaphy will take care of it but I have normally seen otherwise in few cases. What may be the evidence for going for bony surgery at this age?
Dear Ajai
The treatment is directly related to the age of the child. However , at any age the goal of treatment is to obtain a concentric reduction of the femoral head in the acetabulum , thereby allowing better development of the joint.
In children over six months of age and around a year, the treatment is by reduction under general anesthesia and plaster . The plaster should be kept for 6 weeks , when the child should be anesthetized and the exchange of plaster be made . At this stage it is a clinical and radiological evaluation . New plaster is made the child should stay with it for six weeks for a total of three months in detention .
In children between one and three years of age it is sometimes possible to obtain a closed reduction of the dislocated hip, but the incidence of failure is higher . In children where closed reduction is not successful surgical treatment is indicated , which may vary from femoral osteotomy , acetabular or both , depending on the radiographic appearance of the hip joint
thanksElias. in India these patients present quite late with large head and very small acetabulum. femoral shortening may bring head down but problem is how to put back in socket without pelvic surgery at this age.
Dear Ajai
In inveterate dislocations may be necessary femoral osteotomy associated with pelvic osteotomy ( Salter, shelf or Chiari - depending on age)
Unfortunately, in inveterate congenital dislocations and rediclocations (when there is a manifest discrepancy between head and acetabulum with failed acetabuloplasty) one should have to rediscover the clasic open reduction with widening of the acetabulum. It gives a very good stability and good early results. But the late results (after 15-20 years) are such that THR should be considered. Here is the place for resurfacing arthroplasty in younf adults.
thanks Tanchev. but to widen the acetabulum, can u through some light or can give your technique
Dear Dr. Singh, the link below may be useful for you. This is a large article by Scaglietti and Calandriello, published in JBJS 44B, 2, (1962) " Open reduction of congenital dislocation of the hip". Please, pay attention to p. 270, where the obstacles in the acetabulum are tackled. Of course, today the early detection of DDH has made many of the techniques described obsolete.
www.boneandjoint.org.uk/.../field.../257.full-text.pdf
Dr. Singh, you may also consider the technique of Colonna (1932) who uses reamer or curette to enlarge the acetabulum (Campbell's operative orthopaedics).Unfortunately, the late results are connected with stiffness and even ankylosis. In the cases you tackle, this could be an option too, although today rarely used because of the early detection and adequate treatment of DDH.
sorry Panayot, i strongly discourage it as it may lead to stiffnes. this will lose whole advantage of the surgery
You are right but sometimes we have to chose the lesser evil. I said above, we are lucky today with the early detection and treatment of DDH. Unfortunately, in lately diagnosed cases, repeated redislocations followed by renewed close reductions will certainly lead to avascular necrosis of the femoral head.
In the walking age group, children will require a open reduction with capsulorrhaphy and femoral shortening (to reduce risk of AVN). For the slightly mis shaped heads I have found it worthwhile to cut the transverse acetabular ligament to accomodate the femoral head at the time of reduction. If after reduction some amount of head remains uncovered I susally proceed to an Acetabular procedure to improve head coverage as also recommended by various other athors.
I am agree that in some cases we are facing with very difficult situation, specially in coxa magna and breve with proximalization of great trochanter. Short femoral neck can't give you possibility for concentric reduction. Proximalization of great trochanter is also an obstacle. The other obstacle that is more easy to solve are: Iliopsoas tendon, capsular constriction, transverse acetabular ligament, pulvinar etc. Preop. assessment in 3D is very important. Clinical assessment, Dynamic ultrasound evaluation, Arthrography and MRI are very important in preop planning. I have long time experience in this pathology in different age and sometimes there are discordancy between preop planning and intraop. finding.
Yes but 3d CT is very important in preop planning for older children.
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