Conservative Hip Surgery Case Title: Bilateral Symptomatic Hip Dysplasia

Demographics

1.  

   Age: 47 years Sex: Female BMI: 20.5

    

2. Relevant Past Medical History

    

   Principal pathologies: Leiden Factor 5 thrombo-philia, heterozygote

   Previous surgical procedures: 2005, appendicitis acuta; 2001, 1998, and 1995, child birth; 1987, arthroscopy right knee, Osteochondritis Dissecans; 1986, re-arthroscopy left shoulder; 1985, re-arthroscopy right shoulder; 1985, z-plasty left iliotibial band; 1985, z-plasty right iliotibial band; 1984, arthroscopy left shoulder; 1984, arthroscopy right knee, osteochondritis dissecans; 1983, arthroscopy right shoulder; 1982, arthroscopy right knee, cartilage defects on the patella; 1973, fracture of the right patella

   Medication: Tablet omega-3 1000 mg × 1, capsule morphine 10 mg × 2, tablet ibuprofen 600 mg × 3, capsule tramadol 50 mg PN, tablet paracetamol 1000 mg PN

   History of presenting complaint: Increasing bilateral activity-related hip pain during several years. The pain is localized in the groin, pointed out with C-sign, and radiating down in the anterior aspect of the femur. Pain is described the same way on both sides, but it is worst on the left side. The patient rides bike 25 km every day without any significant worsening of the pain. Walking, standing, and running worsen the pain, and the patient scores VAS 8 (0–10) after 15 min walk. At rest she scores VAS 2 and often sleeping is impaired since falling asleep can be difficult, and she also often wakes up with pain in the groin because of rotational movements while sleeping.

3. Clinical Examination

    

   Symptoms: Bilateral activity-related groin pain. Impaired sleeping

   Range of motion: left hip: 0/140, 45/35, and 45/45; right hip: 0/140, 45/35, and 45/45

   Specific tests: Left side, impingement test: positive; FABERS test: positive; Ober’s test: negative; Lasegue test: negative; Trendelenburg test: positive. Right side: impingement test: positive; FABERS test: positive; Ober’s test: negative; Lasegue test: negative; Trendelenburg test: negative.

   Neurovascular evaluation: Sensation, force, and reflexes were found normal and equal on both sides. Pulses were felt in a. dorsalis pedis, a. popliteal, and a. femoralis.

    

4. Preoperative Radiological Assessment/Imaging (Figs. 1.38, 1.39, and 1.40)

    

    

    

   Fig. 1.38 Preoperative standing pelvis X-ray. CE angle left:

   17. AI angle left: 12. CE angle right: 19. AI angle rigth: 11

    

    

    

    

   Fig. 1.39 Preoperative evaluation of the cartilage in a T2 MR scan shown in a transversal section

    

    

    

    

    

   Fig. 1.40 Preoperative evaluation of the cartilage in a T2 MR scan shown in a coronal section

    

5. Preoperative Planning

    

   Diagnosis: Developmental dysplasia of the hip (DDH) (Figs. 1.38, 1.39, and 1.40).

   Possible treatment options: Total hip arthroplasty or periacetabular osteotomy.

   Chosen treatment method: Periacetabular osteotomy.

    

6. Surgical Note

    

   Patient’s position: The patient is placed supine on a radiolucent table.

   Type of anesthesia: Spinal anesthesia is induced at the L2–L3 levels with a dose of 3 mL bupivacaine (5 mg/mL).

   Surgical approach: The minimally invasive transsartorial approach is used. The skin is incised from the anterior superior iliac spine and distally 7 cm along the sartorius muscle. The lateral cutaneous nerve is isolated and carefully retracted. The inguinal ligament is cut at the insertion of the anterior superior iliac spine. The ilium is approached subperiosteally with the iliacus and psoas major muscles protecting the femoral neurovascular bundle.

   Main steps: The first of the five osteotomies is the ramus superior ossis pubis cut; then a 1 cm anterior-posterior cut is made in the ischium 1 cm distal the joint. The third cut is also in the ischium and is made from the inside of the pelvis and outward. The fourth cut is made on the ilium at the level of the spina iliaca anterior. The fifth and last

   cut is connecting the fourth ilial cut with the third ischial cut.

   Reconstruction techniques: Redirection of the acetabular fragment is done primarily by medial-izing the ischial part but also lateralizing the ilium. Care should be taken not to unintendedly rotate the fragment which can be easily be observed with the nonparallel alignment of the ilium cut. Internal rotation of the fragment will antevert the acetabulum and external rotation will retrovert the acetabulum (Figs. 1.41 and 1.42).

    

7. Intraoperative Challenges

    

   Challenges and solutions: Fluoroscopic evaluation is necessary throughout the operation, and therefore the pelvis is kept in a neutral position to avoid excessive tilting or rotation. The fluoroscopy equipment is positioned to facilitate the attainment of anteroposterior and 60 degrees (false profile) views. After the fifth cut, a pointy forceps is used to reorientate the fragment; sometimes this can be challenging but can be aided with a Schantz screw. Finally, inserting a 30 degree angled osteotome in the third ischial cut and apply rotating movements can further help the reorientation by ensuring that the fragment is entirely free of any bone or soft tissue adhesions.

    

8. Postoperative Radiographs

   (Figs. 1.41 and 1.42)

    

    

    

   Fig. 1.41 Standing X-ray after left side PAO

    

    

    

    

    

   Fig. 1.42 Standing X-ray after right side PAO. A, B, and C marks solid bony healing of ramus superior os pubis, os ischium, and os ilium

    

9. Postoperative Management

    

   Chemoprophylaxis and anticoagulant treatment period: Before anesthesia, 1.5 g of cefuroxime is administered, and to reduce blood loss, tranexamic acid is administered; 10 mg/kg is given at the beginning of the surgery. For thromboprophylaxis, a tablet of 10 mg rivaroxaban is administered 6 h postoperative and then every day until mobilized.

   Gait/limb loading until full loading: 30 kg partial weight bearing for six weeks is recommended for patients <40 years and eight weeks for patients >40 years of age.

    

10. Follow-Up

    and Complications

     

    Report of postoperative complications and their management (i.e., recurrent dislocation): femoral nerve palsy, peroneal nerve plasty, obturator nerve palsy, femoral artery and vein lesion/thrombosis, intra-articular osteotomy, secondary displacement, malposition of acetabulum, nonunion, infection, and DVT. Nerve palsy is due to neurapraxia and will normalize during 6 weeks to 3 month. Extremely rare permanent neurological deficiencies will reside. Damage to the vessels can also occur, and vascularization should always be evaluated immediately postoperative. Secondary

    displacement and malposition can be addressed by either re-PAO or a total hip replacement if contraindications exist. Nonunion of ramus superior is quite often seen and is correlated with large correction and age. It rarely causes any problems but is known to give rise to stress fractures in ramus inferior ossis pubis close to the symphyses. Infection is a very rare event and can often be handled with a simple soft tissue revision.

     

11. Discussion

     

    Advantages of the applied method: The benefit of joint sparing procedure periacetabular osteotomy is obvious since it spares the joint but offers an everyday life with less pain and the chance of high-intensity sporting. Furthermore, the minimally invasive approach offers a surgical procedure with few complications, minimal surgical trauma, and no compromise in long-term results. Disadvantages of the method: The risk of complications, reoperation with hip arthroscopy, or conversion to a total hip arthroplasty is present. Furthermore, using the minimal invasive approach offers no direct visualization of the ischial cut

    which some surgeons feel discomfortable.

    Alternative evidence-based techniques for the case: Total hip replacement is also a validated treatment for acetabular dysplasia especially in this case with a patient above 45 years. The negative consequence of a total hip arthroplasty will diminish with increasing age when comparing with a periacetabular osteotomy.

    Why is the chosen technique better for this case? This patient is very active with a desire for high-intensity sporting/recreation activity. No signs of arthrosis were present before surgery.

    Indications and contraindications for your technique: If patients suffer from persistent hip pain (groin, C-sign) with a center-edge angle of Wiberg <25 degrees, pelvic bone maturity, internal rotation >15 degrees, and hip flexion <110 degrees without any signs of arthrosis, they can be considered for joint preserving surgery. Furthermore, we consider age > 45 years and BMI > 30 a relative contraindication. If any contraindications, we suggest surgery with an unce-

     

    mented total hip replacement. We prefer to operative only one side at the time due to challenges with mobilization.

    Learning curve and how to manage complications: The learning curve is steep, and a high volume is necessary to sustain expertise. Furthermore, to handle the potential complications safely, the surgeon must establish a collaboration with vascular surgeons and experienced pelvic surgeons [43–45].

    Level of evidence concerning the superiority of this method against others: CEMB Oxford level 3-4.