Hip Arthrogram
Technique
- under II
- 10 mls contrast mixed with 10 mls saline
- prime the line
- spinal needle
- do not spill contrast over front of hip as will obstruct view
A. Lateral approach
- 45° angle with thigh
- insert just inferior & anterior to the greater trochanter
- advance 5-10 cm
- enter joint medially
B. Anterior approach
- preferred technique
- palpate femoral artery just below inguinal ligament
- femoral head is halfway between ASIS and pubic tubercle
- insert needle 2.5 cm below ASIS, aim to go behind NV bundle
- at 45° angle to skin
- aim for anterior neck
C. Medial approach
- MUA & arthrogram in young child
- excess extra-articular contrast will pool inferior & medial to joint so not to obstruct view of joint
- flex & abduct leg
- insert needle inferior to adductor longus tendon
- use II
- advance below femoral artery to head or neck
- generally inferior aspect of neck just below head
Open reduction via Smith-Peterson approach
Disadvantage
- damage LFCN
- stiffness (large dissection)
- access to inferior capsule and transverse ligament difficult
Advantage
- reduced risk of AVN
- can perform pelvic osteotomy through approach
Technique
Incision
- use bikini incision modification
- start 3cm below ASIS
- parallel to inguinal ligament 7cm
- longitudinal causes excess scarring, especially in young girl
Superficial dissection
- interval between sartorius & TFL
- LFCN retracted medially on top of sartorius
- ascending branch LCFA tied off in interval
- superior plane continued proximally by splitting apophysis
- if needed to perform pelvic osteotomy
- peel glutei off llium to expose supra-acetabular region
Deep dissection
- between G medius and RF
- both heads rectus divided
- reflected head blends with capsule and superior rim acetabulum
- straight head to AIIS
Release
- psoas released under iliacus
- careful capsulotomy at acetabular edge
- remove capsule off lateral acetabulum
- to medial corner under direct vision
- any blocks to reduction removed
- excision of ligamentum teres
- transverse ligament division
- pulvinar removed
- evert inverted labrum
Gentle reduction of head
Tight capsulorrhaphy performed
- especially superiorly to remove lax capsule
Pelvic osteotomy
- if over 1 year of age with dysplasia
- redirectional or reshaping
Femoral osteotomy
- performed if excessive traction at time of reduction
- avoid AVN
Spica cast applied
Medial Open Reduction
Disadvantage
- risk of AVN via MCFA damage
- only < 1 year as no access to periacetabular region
- unable to perform capsulorraphy
Advantage
- easy access to blocks to reduction
- especially psoas / inferior capsule
- reduced blood loss
Technique
Position
- supine
- hip abducted & flexed / frog legs
Landmarks
- adductor longus & pubic tubercle
Incision
- parallel to & 1cm below groin crease
- over adductor longus
Superficial dissection
- between gracilis / posterior & adductor longus / anterior
Deep dissection
- between adductor magnus & adductor brevis
- protect anterior branch obturator nerve on brevis
- protect posterior branch obturator nerve on magnus
- retract adductor brevis anteriorly
- will expose lesser tuberosity with psoas tendon inserting onto it
- isolate psoas tendon before division
Dangers
- protect MCFA as it passes between adductor brevis & psoas at LT
- runs around the medial side of psoas / anterior to psoas tendon
- fully isolate psoas before dividing
Release
- release psoas at LT
- T Capsulotomy
- divide transverse Lligament
- ligamentum teres can be used to pull head into acetabulum
- suture to anteromedial capsule
- may need to place radial splits in limbus
Salter Osteotomy
Redirectional
- corrects anterior and superolateral acetabular deficiency
- less than 5 years but > 18/12
- mild - moderate dysplasia
- need concentric reduction
Technique
- Smith Peterson approach
- iliac apophysis split
- subperiosteal dissection to sciatic notch reflecting gluteals
- Gigli saw - osteotomy through GS notch
- emerge anteriorly between ASIS and AIIS
- acetabulum rotated anteriorly and laterally
- triangular graft from crest
- K wire fixation
Complication
- 25% leg lengthening
Periacetabular osteotomy
Dega
- leaves posterior wall intact
- relies on plasticity of superior acetabulum
Pemberton
- osteotomy includes posterior column
- bend through tri-radiate cartilage
Smith - Petersen approach
- split apophysis
- curved osteotome
- parallel superior dome of acetabulum
- 15 mm above
- can leave posterior column intact
- bone graft +/- K wires
Femoral Derotaton and Varising Osteotomy
Technique Antero-lateral
Open reduction as above
Separate lateral approach
- elevate vas lateralis
- 2 x K wires centrally in neck, short of physis
- check II
- open and protect periosteum with homans
- mark distal and proximal femur with drill holes to check rotation later
- osteotomy with microsagittal saw 1 cm below LT
- don't need to resect wedge with Synthes offset locking plate
- may need to shorten
- decrease anteversion by IR distal fragment
- check range of ER of hip / should be reduced
Osteotomy fixed Synthes Offset Locking Plate
- 125o for some varus