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2008BacheCE_TorodeIP

 

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Abstract of the article: Bache CE et al. Ligamentum teres tenodesis in medial approach open reduction for developmental dislocation of the hip (2008). The article describes a method for transposition of the proximal attachment of the ligamentum capitis femoris (LCF) in congenital hip dislocation. The text in Russian is available at the following link: 2008BacheCE_TorodeIP.


Abstract

Background:

When closed reduction of a developmental dislocation of the hip fails, some form of open reduction is required. In recent years, the many advantages of the medial approach open reduction have been emphasized. However, there have been suggestions that the rate of growth disturbance in the proximal femur and the requirement for secondary surgical procedures may be higher with this route than with others. The purpose of this study was to investigate the efficacy and safety of a modified medial approach open reduction, in which the stability of the reduction is enhanced by resection of the redundant ligamentum teres and suturing of the stump of the tendon to the anteromedial capsule.

Methods:

The hospital records and radiographs of 92 infants and children with 109 dislocated hips were reviewed retrospectively. Key demographic and pretreatment data were collected by the first author and compared with the outcome at the most recent follow-up. In addition, 69 children returned for a clinical evaluation by the first author. The outcome at the most recent follow-up was graded according to Severin, and associations were sought between pretreatment grade of dislocation according to Tonnis, the presence of ossific nucleus, changes in the acetabular index, the requirements for secondary surgery, associations with previous treatment, and the position of abduction in the postoperative cast.

Results:

At a mean follow-up of 9 years, 89% of hips were classified as Severin grade 1 or 2. Avascular necrosis (AVN) was classified according to the system of Kalamchi and MacEwen. The incidence of AVN was 41%, but two thirds of these were grade 1 (temporary irregular ossification), and the Severin grading in these hips was not compromised. The presence of ossification in the capital epiphysis and a range of abduction of less than 60 degrees in the hip spica were noted to be protective against the development of AVN. Three hips redislocated and required additional treatment. Thirty-eight hips required a total of 44 additional surgical procedures.

Conclusions:

We have demonstrated that it is possible to use a medial approach for open reduction of the congenitally dislocated hip in combination with tenodesis of the ligamentum teres to the anteromedial joint capsule. The incidence of growth disturbance in the proximal femur is high and cumulative with long-term follow-up. However, in this large series, the rate of hip stability, growth disturbance, and need for secondary surgery are comparable to other series. We conclude that the many advantages of open reduction by the medial approach outweigh the disadvantages.


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Bache CE, Graham HK, Dickens DRV, Donnan L, Johnson MB, Nattrass G, O'Sullivan M, Torode IP. Ligamentum teres tenodesis in medial approach open reduction for developmental dislocation of the hip. Journal of Pediatric Orthopaedics. 2008;28(6)607-13. DOI: 10.1097/BPO.0b013e318184202c  pubmed.ncbi.nlm.nih.gov  ,  journals.lww.com


Surgical Technique

The approach is similar to that described by Weinstein and Ponseti.1 A 3- to 4-cm incision is made parallel to and 1 cm distal to the groin crease, centered on adductor longus (Fig. 1). The tendon of adductor longus is divided, close to the pubic tubercle, and allowed to retract. The anterior branch of the obturator nerve is then identified and traced between adductor brevis and pectineus. When this interval is developed, the medial circumflex vessels can be identified and protected by gentle retraction. The psoas tendon is divided at its insertion to the lesser trochanter, and the capsule is opened in a T fashion. Care is taken to ensure that the long limb of the T is continued beneath the vessels as far as the synovial reflection. The transverse acetabular ligament is divided (Fig. 2), the bulk of the pulvinar is cleared, and the limbus is everted if necessary. The ligamentum teres is retracted and explored to determine how much should be resected to permit a concentric reduction, with preservation of a 5- to 10-mm stump attached to the fovea. The femoral head is then delivered into the acetabulum and the shortened ligamentum teres is reattached to the medial capsule, in the region of the divided transverse acetabular ligament, by one or two 1.00 Vicryl sutures. The incision is closed in layers without a drain and sealed with a waterproof dressing. A double hip spica is applied with the hips flexed 100 degrees and abducted 40 to 60 degrees, for 6 to 8 weeks.


Christopher Edward Bache – Birmingham Childrens Hospital, Birmingham, United Kingdom. edsarahbache@btinternet.com

H Kerr Graham

D Robert V Dickens

Leo Donnan

Michael B Johnson

Gary Nattrass

Mark O'Sullivan

Ian P Torode


ligamentum capitis femoris, ligamentum teres, ligament of head of femur, pathology, congenital dislocation, dislocation, plastic surgery, reconstruction, open plastic surgery


NB! Fair practice / use: copied for the purposes of criticism, review, comment, research and private study in accordance with Copyright Laws of the US: 17 U.S.C. §107; Copyright Law of the EU: Dir. 2001/29/EC, art.5/3a,d; Copyright Law of the RU: ГК РФ ст.1274/1.1-2,7

                                                                   

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