Transposition of the acetabulum after iliac ischial osteotomy in the treatment of hip dysplasia in infants

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Abstract


Background. Transposition of the acetabulum after pelvic osteotomy is the most effective surgical method to treat dysplastic hip joint disorders in patients of different ages. According to Salter, iliac osteotomy of the pelvis is the main surgical method used to correct dysplastic acetabulum in 7- and 8-year-old children. In older patients, the pubic symphysis and pelvic ligaments become more rigid, which significantly limits the degree of rotation of the acetabulum. In these cases, a triple pelvic osteotomy is performed to enhance the mobility of the acetabular fragment. This pubic bone osteotomy is performed near the femoral neurovascular bundle, which may be damaged during the procedure.

Aim. To describe a technique for transposition of the acetabulum after iliac and ischial osteotomy of the pelvis, which was developed to reduce trauma, prevent vascular complications, and increase postoperative stability of the pelvic ring.

Materials and methods. A method developed by the authors for transposition of the acetabulum after iliac and sciatic pelvic osteotomy is described in detail. The surgical method was performed 99 times on 89 children with dysplastic hip joint disorders, and the results are presented.

Conclusion. Transposition of the acetabulum after iliac and ischial pelvic osteotomy is an effective treatment for dysplastic instability of the acetabulum in children aged 9–16 years. The procedure is indicated when it is necessary to rotate the acetabular fragment by more than 25°, and there is no need for hip medialization.

Introduction

Transposition of the acetabulum is a common method for the surgical treatment of dysplastic hip joint pathology. Iliac pelvic osteotomy, proposed by R.B. Salter in 1957, is the principal method for surgical correction of dysplastic acetabulum in children aged younger than 7-8 years [1-4]. In older patients, the pubic symphysis and pelvic ligaments have become rigid, which significantly limits the degree of rotation of the acetabular fragment. To improve the mobility of the acetabulum in such cases, a double (iliac-pubic) [5] or triple (iliac-pubic-sciatic) pelvic osteotomy is performed.

The basic principle of this intervention is to change the position of the acetabulum to increase the area of full cartilage contact between the femoral head and acetabulum. There are several known methods for performing a triple pelvic osteotomy, including a number of approaches to the innominate bone, choice of location, direction, and number of incisions [6-13].

Pubic bone osteotomy is an obligatory element of triple and periacetabular (Bernese) pelvic osteotomy. Such surgeries are performed in close proximity to the femoral neurovascular bundle, which is easy to damage. This procedure prevents the widespread adoption of pelvic osteotomies into routine practice in domestic orthopedic clinics and hospitals [14-16].

The motivation to develop the method of transposition of the acetabulum after ilio-ischial pelvic osteotomy is to reduce trauma, prevent intraoperative vascular complications, and increase the postoperative stability of the pelvic girdle [17, 18].

Materials and methods

From 2007 to 2013, a total of 99 acetabular transpositions after ilio-ischial pelvic osteotomy were performed in 89 patients with dysplastic pathology of the hip joint at the Department of Hip Pathology of the Turner Scientific and Research Institute for Children’s Orthopedics, and in pediatric wards of the Federal Centers of Traumatology, Orthopedics and Endoprosthetics, in the cities of Cheboksary, Smolensk, and Barnaul. Patients were aged between 9 and 16 years. In 10 patients with bilateral pathology, surgery was performed in stages, with an interval between 3 and 4 months between surgeries. The follow-up period was up to 7 years. All patients, their parents, or legal guardians signed a voluntary informed consent for examination and treatment.

The patient selection criteria were:

  • Dysplasia of the acetabulum that required correction of more than 25°
  • Patient age over 9 years.

Depending on the type of pathology, acetabular transposition surgery was performed in isolation or in combination with open reduction and corrective osteotomy of the hip (Table 1).

The choice of corrective hip osteotomy was determined by the type of deformity of the proximal femur. The following surgeries were performed: detorsion osteotomy (18 cases), varus detorsion osteotomy (24 cases), and valgus detorsion (20).

Clinical tests were conducted according to the standard protocol for patients with hip problems. Assessments included range of movement examination, limb length difference, degree of muscle group atrophy, severity of the Trendelenburg sign, and impingement test.

Results of X-ray and computed tomography imaging were used for morphometric assessment of common indicators of spatial hip joint pathology, including Wiberg’s angle, Sharp’s angle, acetabular frontal inclination, collo-diaphyseal angle, and antetorsion; the degree of lateral and cranial displacement of the femoral head; femoral head extrusion index (FHEI); and the severity and dynamics of degenerative changes (DC; cysts, sclerotic changes, and osteochondrosis). During surgery, correction of spatial relationships at the hip joint was performed to achieve the closest approximation that is the norm for the patient’s age group.

Stages of DC were classified according to the deforming coxarthrosis scale (DCA) for children and adolescents, developed at the Turner Scientific and Research Institute for Children’s Orthopedics [2].

Stage 1: Sclerotic changes, blurred contours of the superolateral rim of the acetabulum, increased bone density in subchondral sections of the acetabular arch (subchondral sclerosis), and trabecular structure along the tension groups is intact.

Stage 2a: Trabecular structure is distorted, appears blurred, and trabecular orientation is altered; initial signs of bone cyst formation (decreased bone density inside the cyst cavity with increased bone density rim around the cyst) in the part of the acetabulum that bears the most weight load; and areas of sclerosis are spread to the central areas of the acetabulum.

Stage 2b: Joint space is uneven in the areas of maximal weight load on the femoral head and acetabulum, bone cysts have reached full maturity (the cavity and sclerotic rim are fully formed) and rupture into the joint space, and narrowing of the joint space is most pronounced at the sites of cyst rupture.

Stage 3: Joint space is narrowed along all surfaces and bone growth is present along the rim.

Surgical technique

The patient is placed in the lateral position. Using the anterolateral Watson-Jones approach, an angular incision is made through the skin and subcutaneous tissue in the upper third of the thigh from the anterior superior iliac spine toward the greater trochanter and further down along the shaft of the femur. The fascia lata incision repeats the skin incision and is enhanced by transverse dissection over the greater trochanter of the femur. The anterior inferior iliac spine is approached between the tensor fascia lata and gluteus medius muscles. The external oblique muscle is elevated subperiosteally from the iliac crest, and a 4-5 cm long longitudinal incision is made at the iliac apophysis, continued over the anterior superior iliac spine until the section reaches the anterior inferior spine. Using elevators, the iliac wing is released subperiosteally to the greater sciatic notch, and a gigli wire saw is positioned around the iliac isthmus.

Arthrotomy and intertrochanteric osteotomy are performed as indicated.

The next step is to isolate the ischium. If osteotomy of the femur is not indicated, one assistant pulls the greater trochanter ventrally with a bone hook to facilitate access, while another assistant extends the lower limb at the hip joint.

The sciatic nerve is isolated using blunt dissection for the length necessary to achieve its mobility. The nerve block is applied by injection of a local anesthetic [2-5 mL of 2% novocaine or 0.5% ropivacaine HCl (Naropine)]. At the cranial end of the sacrospinal and sacrotuberal ligaments, an H-shaped incision is made through the periosteum. The body of the ischium should be isolated strictly subperiosteally, under constant visual control over the sciatic nerve. Elevators are then inserted around the ischial bone, until the surgeon is positive they touch one another.

The bones are cut consecutively; the ischium with a chisel or oscillating saw, and the ilium with the previously inserted Gigli saw.

The direction of the ischial cut is important. The cut must go from the bottom up, and from front to back at a 45° angle, to eliminate the stabilizing action of the sacrospinal and sacrotuberal ligaments.

Transposition is performed with a single hook retractor or Ollier rake retractor. The acetabular fragment is rotated laterally, anteriorly, and downward.

The pivot point is the pubic symphysis. Sufficient leverage and disengagement of the pelvic ligaments allows for transposition of the acetabulum. Pelvic bone fragments are fixed into place with needles or cancellous screws. In femoral osteotomy, the diastasis can be filled with autoharvested femoral fragments, but if no osteotomy is performed, the fragments are fixed with just needles and screws. For osteosynthesis of the femur (in the case of corrective osteotomy), angular plates and screws are used. Prior to fixation, the necessity of additional femoral shortening osteotomy to avoid compression in the joint is determined by evaluating for overlap of femoral fragments. The wound is sutured in layers and a Redon drain is inserted at the osteotomy site.

The limb is immobilized with a foam pillow. In the case of corrective femoral osteotomy, additional immobilization with an anti-rotation boot up to one-third of the calf is applied. A plaster cast is applied only in cases of acetabular transposition in combination with corrective osteotomy and arthrotomy.

The stability of the hip joint is examined by rotation and flexion of the hip.

Surgery schematics are presented in Fig. 1.

Results and discussion

During triple pelvic osteotomy surgery, we compared the degree of mobility of the acetabular fragment after consecutive cuts of the pelvic bones in different combinations, including the ilium and ischium, ilium and pubic, and ilium and ischium and pubic. Intraoperatively, mobility was evaluated visually and subjectively by the surgeon. The resulting degree of acetabular fragment rotation was determined by comparing pre- and postoperative radiograms. In some cases, ilio-ischial osteotomy achieves the same degree of acetabular fragment rotation as triple pelvic osteotomy, but to achieve adequate acetabular rotation, it is essential to perform ischial osteotomy as close to the acetabulum as possible from the bottom up, front to back, and at a 45° angle. If these requirements are met, the section line goes above the attachment site of the sacrotuberal and sacrospinal ligaments, which eliminates their stabilizing effect on the pelvic ring.

All patients were followed up for 3-7 years postoperatively.

Before treatment, 63% and 48% of patients complained of pain in the affected joint and lameness, respectively. Moreover, by age 14-15 years, all patients noted a change in lifestyle (inability to participate in active sports, aerobics, fitness exercises, dancing), which caused psychological distress.

Positive changes were observed in all cases after treatment, including the disappearance of pain and ability to walk longer distances without rest. Lameness disappeared in 43% of patients and was noted only by the end of the day, during instances of serious deviations from routine.

Preoperatively, a positive impingement test was observed in 89% of patients, but this dropped to 19% in the long-term after treatment. This can be explained by the “resolution” of conflict between the acetabular labrum and femoral head because of significantly increased FHEI postoperatively.

The main focus of this study was on study of data regarding the dynamics of degenerative symptoms.

Out of 42 joints, there was complete regression of degenerative symptoms in 22 cases (52%) with Stage 1 DCA. These results are excellent when considered together with the clinical picture. Moreover, long-term remission of DC was achieved in 20 cases (48%).

Good results were achieved in 38 cases with Stage 2a DCA. Improvement to Stage 1 DCA was observed in 28 cases (74%), and long-term remission of DC was seen in 10 cases (26%).

A similar pattern was noted in 19 cases with Stage 2b DCA. There was a decrease in the severity of DCA, as 14 cases (75%) improved to Stage 2a and five cases (25%) improved to Stage 1.

These results can be explained by a combination of factors, including the regenerative abilities of joint components with incomplete endochondral ossification, reduced pressure on the femoral head because of increased FHEI, and a stimulating effect of the periacetabular osteotomy on joint trophism.

Case Study

Patient B, an 11-year-old female, was diagnosed with congenital subluxation of the right hip. She was admitted to the Turner Scientific and Research Institute for Children’s Orthopedics with complaints of pain in the right hip joint and lameness after prolonged physical load. Her growth and development had been normal. The discomfort and pain started when she was 10 years old, and progressed with age. Her radiologic diagnosis on admission was congenital subluxation of the right hip, Stage 2a DCA. She underwent corrective osteotomy of the right femur and acetabular transposition after ilio-ischial osteotomy. Two years postoperatively the patient has no complaints, and her current radiologic diagnosis is DCA Stage 1 (Fig. 2).

Complications

In two cases (2%) there were neurological complications, specifically neuropathy of the sciatic nerve. After integrated treatment, however, full sensitivity and leg function were recovered. There were no wound infection complications or bone nonunion complications at the osteotomy sites.

Conclusion

Ilio-ischial osteotomy is an effective technique for the treatment of dysplastic and DC of the hip and other related pathologies, in children and adolescents aged 9-16 years. Ilio-ischial osteotomy is indicated when more than 25° of rotation of the acetabular fragment is required, but there is no need for hip joint medialization.

Ilio-ischial osteotomy maintains a high corrective potential. Important advantages of this type of surgery include reduced tissue trauma, shorter duration of surgery, and prevention of damage to neurovascular bundle.

Funding information and conflict of interest

This work was supported by the Turner Scientific and Research Institute for Children’s Orthopedics, Saint Petersburg, Russian Federation. The authors declare no explicit or potential conflicts of interest associated with the publication of this paper. The study was conducted in accordance with ethical guidelines of IRB of The Turner Scientific and Research Institute for Children’s Orthopedics.

Vladimir E Baskov

The Turner Scientific and Research Institute for Children’s Orthopedics

Author for correspondence.
Email: dr.baskov@mail.ru

Russian Federation MD, PhD, head of the department of hip pathology. The Turner Scientific and Research Institute for Children’s Orthopedics

Mikhail M Kamosko

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: fake@eco-vector.com

Russian Federation MD, PhD, professor, head of the department of hip pathology. The Turner Scientific and Research Institute for Children’s Orthopedics

Dmitry B Barsukov

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: dbbarsukov@gmail.com

Russian Federation MD, Ph.D, senior research associate of the department of hip pathology. The Turner Scientific and Research Institute for Children’s Orthopedics

Ivan Yu Pozdnikin

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: pozdnikin@gmail.com

Russian Federation MD, Ph.D, research associate of the department of hip pathology. The Turner Scientific and Research Institute for Children’s Orthopedics

Vadim V Kozhevnikov

Federal Center of traumatology, orthopedics and endoprosthesic replacement

Email: fake@eco-vector.com

Russian Federation vadim-barnaul@bk.ru

Igor V Grigoriev

The Turner Scientific and Research Institute for Children’s Orthopedics

Email: fake@eco-vector.com

Russian Federation MD, chief of the department of pediatric traumatology and orthopedics. Federal Center of traumatology, orthopedics and endoprosthesic replacement, Cheboksari

Pavel I Bortulev

Federal Center of traumatology, orthopedics and endoprosthesic replacement

Email: pavel.bortulev@yandex.ru

Russian Federation MD, research associate of the department of pediatric traumatology and orthopedics. The Turner Scientific and Research Institute for Children’s Orthopedics.

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Copyright (c) 2016 Baskov V.E., Kamosko M.M., Barsukov D.B., Pozdnikin I.Y., Kozhevnikov V.V., Grigoriev I.V., Bortulev P.I.

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