Fig. 1 In this Orthopaedic Video Theater video, Brett A. Shannon, MD, and Mihir Thacker, MD, demonstrate a positive Galeazzi sign with the dislocated left hip during a physical examination to determine knee symmetry and hip dislocation.

AAOS Now

Published 12/20/2023
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Selina Poon, MD, FAAOS

Adductor Tenotomy, Open Reduction, and Pelvic Osteotomy of Late-presenting Developmental Dysplasia of the Hip

Editor’s note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now will routinely review “OVT Plus” videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.

Frank dislocation of the hip represents the most severe form of developmental dysplasia of the hip (DDH). Early diagnosis and treatment of DDH are important to provide optimal clinical outcomes for patients. The incidence of DDH is approximately one in 1,000 live births. Risk factors for DDH include being of female sex, being the first-born child, having breech position, and having a positive family history of hip dysplasia. Breech presentation is the most important single risk factor. Depending on the age of the patient at presentation, the treatment for DDH changes. Late presentation of DDH or dislocation often requires surgical open reduction and pelvic osteotomy for the best outcome.

Fig. 1 In this Orthopaedic Video Theater video, Brett A. Shannon, MD, and Mihir Thacker, MD, demonstrate a positive Galeazzi sign with the dislocated left hip during a physical examination to determine knee symmetry and hip dislocation.
Fig. 2 An arthrogram of the left hip shows the superior dye pool, inverted labrum, and inadequate coverage of the femoral head.
Fig. 3 Considerable improvement in the shape of the acetabulum after osteotomy and graft placement.

In a recent OVT Plus video, Brett A. Shannon, MD, and Mihir Thacker, MD, show the physical exam and surgical technique for an adductor tenotomy, anterior open reduction, and San Diego–style iliac osteotomy for treatment of late-presenting DDH in a patient aged 18 months. The video provides the step-by-step surgical technique as well as the indication for each portion of the procedure in detail.

The video starts by showing the patient walking in the office with a perceived leg length discrepancy as well as a limp. Other physical exam findings include the positive Galleazi sign, asymmetrical popliteal creases, and limited hip abduction (Fig. 1). Notably, the video shows the limited arc where the hip remains located in the acetabulum and a visible “clunk” can be seen as the hip dislocates in adduction.

During the surgical portion of the case, the surgeons start with an adductor tenotomy and arthrogram of the affected hip. Presenting the inverted labrum, superior dye pooling, and inadequate coverage of the femoral head with the arthrogram is helpful for a viewer who may not be an expert in pediatric hip anatomy and radiographs (Fig. 2). The video then shows each step of the open reduction, capsulorrhaphy, and iliac osteotomy, with expert tips and tricks for successful completion of each step of the case. Recommendations for specific instruments to use are appreciated as well. Although the authors stated that they determined that a tenotomy of the iliopsoas tendon was necessary based on palpation of the tension, they do not provide the viewers with how that decision was made. The expert tip to not only isolate the iliopsoas tendon but also visualize the insertion of muscle fibers onto the tendon and stimulate the tendon with electrocautery will help the viewers from inadvertently injuring the nerve.

When performing this procedure, the surgeon may not be able to visualize certain steps, such as the cutting of the transverse ligament after removal of the pulvinar and ligamentum teres. The video is able to showcase these steps well to offer clarity. The removal of the inner table at the far posterior and anterior aspect of the osteotomy allows for considerable correction of the shape of the acetabulum (Fig. 3).

Overall, this video presents a clear approach to performing an open reduction of the hip safely and successfully. Young surgeons and surgeons who are not familiar with this technique will gain insight into performing this procedure.

Selina Poon, MD, MPH, FAAOS, is a pediatric orthopaedic surgeon and director of research at Shriners Children’s Southern California in Pasadena, Cali f. She is also a member of the AAOS Now Editorial Board.

Video details

Title: Late-presenting Developmental Dysplasia of the Hip: Adductor Tenotomy, Arthrography, Open Reduction, and Pelvic Osteotomy
Authors: Brett A Shannon, MD, and Mihir Thacker, MD
Published: Feb. 27, 2023
Time: 10:01
CME: 0.75 credits
Tags: Pediatrics, Lower Extremity, Fracture

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