Adolescent and Young Adult Hip Dysplasia

Young-Jo Kim

I. Periacetabular Osteotomy

Abductor-sparing surgical approach
Rectus-sparing anterior approach
Ischial osteotomy
Superior ramus osteotomy
Iliac osteotomy and posterior column split
Acetabular fragment reduction
Intraoperative range of motion assessment
Anterior arthrotomy and femoral osteoplasty

Operative Indications

Significant symptoms affecting daily life
Classic acetabular dysplasia deformity
- Lateral center-edge angle of Wiberg less than 20°
- Tönnis angle greater than 10°
- Anterior center-edge angle less than 20°
Relative indications
- Microinstability due to ligamentous laxity, capsular deficiency, and excessive femoral anteversion
- Pincer impingement due to global acetabular overcoverage or acetabular retroversion

Examination Under Anesthesia

Maximal hip flexion of the affected hip
Hip internal rotation in 90° of flexion of the affected hip
Flexion and internal rotation will decrease when anterior and lateral coverage is increased in classic acetabular dysplasia correction
Need range of motion prior to surgery to determine the extent of decrease

Figure 21-1 ▪ The tendency for the pelvis to go into lordosis when supine is counteracted by placing a blanket underneath the contralateral leg. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Figure 21.2 ▪ The surgical incision is marked starting about 1 cm below the iliac crest, proximally. Distally, the center of the hip is estimated by flexing the hip and palpating the tensor-sartorius interval. The incision is carried just medial to the tensor-sartorius interval over the center of the hip joint. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Positioning

Patient is positioned supine with the affected hip draped free
Decrease the lumbar lordosis as much as possible. If needed, place a blanket roll under the contralateral limb if a flexion contracture exists in order to minimize pelvic tilt (Figure 21.1)

Surgical Approach

Bikini skin incision is marked: start 1 cm below iliac crest to 1 to 2 cm past the anterior line over the hip joint (Figure 21.2)
Skin is incised and dissection carried down sharply through the Scarpa fascia
External oblique fascial is incised laterally, and the muscle is cleared off the iliac crest periosteum (Figure 21.3)
Tensor fascial is incised from the anterior superior iliac spine (ASIS) going distal and lateral at approximately 30° angle (Figure 21.4)
Dissection is carried down to the rectus tendon through the tensor fascia envelope (Figure 21.5)
The iliacus muscle is elevated off the ilium subperiosteally

The superior iliac spine is osteotomized using an osteotome (Figure 21.6)

Figure 21-3 ▪ The external oblique abdominal muscle is cleared off the iliac crest without taking off the periosteum. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Figure 21-4 ▪ The tensor fascial is opened, and through this interval, dissection is carried down to the rectus fascia. This approach protects the lateral femoral cutaneous nerve. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Figure 21-5 ▪ The tensor is retracted laterally, and after clearing the fatty layer on top of the rectus, the fascia is seen. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Figure 21-6 ▪ The anterior superior iliac spine is osteotomized using an osteotome. Approximately, 5-mm thickness wafer of bone will allow retraction of the inguinal ligament and sartorius muscle medially. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

The interval just medial to the direct head of the rectus is opened, and the iliocapsularis is detached off the inferior iliac spine down to the capsule (Figure 21.7). This is not an internervous plane, so do not carry the dissection distal to the lateral femoral circumflex vessels
The psoas tendon sheath is identified from inside the pelvis and following this down to the capsule by gently dividing the iliocapsularis muscle (Figure 21.8)
Develop the interval between the psoas tendon and the capsule using meniscus scissors and pass the scissors down to the ischium (Figure 21.9)

Techniques in Steps

Ischial Osteotomy

Pass a Lane retractor through the psoas capsule interval and feel the ischium
Bring the fluoroscope into the anteroposterior (AP) position and may check to verify the Lane retractor is in the infracotyloid groove
You may slide the narrow Ganz osteotome down to the ischium by lifting the Lane retractor anteriorly and place the osteotome underneath

Verify the position of the Ganz osteotome using fluoroscope in the AP position (Figure 21.10)

Figure 21-7 ▪ When performing the rectus-sparing approach, the iliopsoas is detached off the medial aspect of the rectus attachment (held by the forcep). The iliocapsularis attaches to the distal aspect of the inferior iliac spine. Detaching this will allow retracting the iliocapsularis off the anterior hip capsule. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Figure 21-8 ▪ The psoas tendon is retracted medially, and the interval between the psoas and capsule can be seen. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Figure 21-9 ▪ The meniscus scissors are used to dissect between the capsule and the psoas tendon. This interval will be used to osteotomize the ischium. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

Figure 21-10 ▪ Fluoroscopy is used to verify the location of the Ganz osteotome on the ischium. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

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