Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157

Available online at

ScienceDirect
www.sciencedirect.com

Review article

Surgical reduction of congenital hip dislocation

C. Glorion
Service d’orthopédie et traumatologie pédiatrique, hôpital Necker–Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France

a r t i c l e i n f o a b s t r a c t

Article history:
Received 17 February 2017 Surgical reduction of congenital hip dislocation is technically challenging. In our practice, surgical
Accepted 4 April 2017 reduc- tion is usually reserved for patients who have failed non-operative treatment, which is the
first-line strategy. However, primary surgery may be indicated if the dislocation is diagnosed late
Keywords:
and can be performed until 8 years of age. The reduction step is crucial. It starts with painstaking
Congenital dislocation of the hip exposure of the capsule. Identifying the lower part of the acetabulum is the key to accurate
Surgical reduction repositioning of the epi- physis. The main intra-articular procedures are resection of the ligament
Femoral shortening osteotomy teres, adipose tissue within the acetabular cavity, and transverse acetabular ligament; and eversion of
Innominate osteotomy the radially incised limbus. In patients younger than 1 year of age, surgical reduction can be
Acetabuloplasty performed via the anterior approach or, in some cases, the obturator approach. No complementary
Avascular necrosis steps are needed. If the diagnosis is made late, in contrast, reduction of the hip must be combined
with corrective procedures on the femur and acetabulum designed to stabilise the reduction before
the capsulorrhaphy, with the goal of optimising hip stability and minimising the risk of residual
dysplasia. Femoral shortening and derotation osteotomy was classically reserved for children older
than 3 years but has now been shown to be a useful and pru- dent procedure in younger patients.
This osteotomy decreases pressure on the epiphysis, facilitates the reduction, and diminishes the risk
of recurrence and avascular necrosis of the femoral head, which are the two dreaded complications.
The outcome depends on the care directed to the procedure and on the quality of postoperative
management.
© 2017 Elsevier Masson SAS. All rights reserved.

1. Introduction and stabilisation). Surgical reduction is reserved for failures of

Surgical reduction of congenital hip dislocation is a
challenging procedure whose outcome depends on two factors:
the ability of the surgeon to develop the optimal operative plan
and the degree of gentleness and accuracy with which the
surgery is performed. The two main complications are recurrent
dislocation, which is chiefly due to faulty operative technique;
and avascular necrosis of the femoral head, which may be
related to poorly-controlled and excessively aggressive surgical
gestures. Another cause of avascular necrosis is failed non-
operative treatment responsible for damage to the tissues and
blood vessels.
Learning the surgical technique described in this article is
there- fore of the utmost importance.
Surgery is rarely indicated. The management of congenital
hip dislocation relies chiefly on non-operative techniques, which
include early, ambulatory methods (double- or triple-diapering to
abduct the hips, abduction pad, Pavlik harness) and later treat-
ments applied in the hospital (traction and non-operative
reduction
E-mail addresses: christophe.glorion@aphp.fr, christophe.glorion@gmail.com
this first-line treatment [1], when the obstacles to reduction
cannot be overcome and the hip remains irreducible or unstable.
Finally, sur- gical reduction may be indicated as the first-line
treatment if the dislocation is diagnosed late; the most widely-
accepted age thresh- old of 4 years is open to question.
This article focuses solely on congenital hip dislocation. The
management of residual dysplasia is not discussed.
2. Surgical technique for hip
reduction
2.1. Preoperative
work-up
A preoperative work-up is mandatory to visualise and under-
stand the obstacles to hip reduction. It should include a
radiograph of both hips in internal rotation to ensure an accurate
assessment of the neck-shaft angle, which is usually normal.
In addition to the pelvic radiograph, arthrography is a good
investigation for visualising the isthmus of the capsule, interposi-
tion tissue deep within the acetabulum, and inversion of the
limbus. If non-operative treatment fails to achieve reduction or
stabilisa- tion, arthrography is usually performed to look for
explanations. Arthrography has the advantage of being a
dynamic investigation.
https://doi.org/10.1016/j.otsr.2017.04.021
1877-0568/© 2017 Elsevier Masson SAS. All rights reserved.
 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157 S149
muscle. The pectineus should be displaced anteriorly and the
Magnetic resonance imaging (MRI) is not performed adductor brevis and gracilis posteriorly to expose the iliopsoas
routinely before surgical reduction of congenital hip dislocation, tendon, which is
as the infor- mation it provides does not help to choose the
operative technique.
Computed tomography (CT) may help to understand the acetab-
ular defects and to analyse the acetabular fossa, particularly before
revision surgery for failed reduction. In the youngest patients,
however, incomplete ossification and radiation exposure limit the
usefulness of CT.

2.2. Preparing for surgery

Preoperative traction for 1 week can be used to lower the

femoral head down to the level of the acetabulum and may
prepare the blood vessels for the reduction. Traction is part of
our standard practice, although no definitive proof of efficacy is
available [2,3].

2.3. Principles of surgery: reduction and stabilisation

Surgical reduction is the main goal. The femoral head must

be repositioned within the acetabulum. The main extra-articular
obstacle to reduction is the iliopsoas muscle, which curves in
front of the joint capsule. The intra-articular obstacles consist
of the capsular isthmus, further narrowed by the iliopsoas
muscle; the ligament teres; the transverse ligament; fibro-fatty
tissue filling the acetabular fossa (pulvinar); and the inverted
limbus that cov- ers the joint surface. The surgical limbus is
defined as a pathologic structure composed of the inverted
labrum subjected to excessive pressures and of the adjacent
capsular tissue [4] (the word “limbus” means border and is now
used to designate the bony edge of the acetabulum).
The femoral epiphysis receives terminal vascularisation from
the posterior circumflex artery [5], which can be viewed as an
obstacle to reduction, given its vulnerability to injury by
excessive traction during lowering of the femur, by surgical
trauma, or by extreme hip abduction during immobilisation.
Stabilisation is achieved using a reduction position to comple-
ment the capsulorrhaphy and, in many cases, correction of bony
abnormalities such as excessive femoral anteversion or length
and acetabular dysplasia. Correction of bone deformities, when
per- formed, should ideally be sufficient to ensure stabilisation,
with the capsulorraphy simply closing the joint cavity. If
needed, any redundant capsular tissue is removed.

2.4. Surgical approaches

Several approaches are available. Each approach has

distinctive characteristics in terms of hip joint exposure.

2.4.1. Medial or obturator approach

With the child supine, the skin incision is performed in the
genito-femoral fold. There are three approaches:

• the Ludloff approach [6,7] is the most widely-used and is

located between the pectineus muscle anteriorly and the
adductor longus and adductor brevis posteriorly;
• the Ferguson approach [8,9] is between the adductor longus
and
adductor brevis anteriorly and between the adductor magnus
and gracilis posteriorly;
• the Weinstein and Ponseti approach is between the neurovascu-
lar bundle anteriorly and the pectineus muscle posteriorly.

When creating these medial approaches, the adductor longus

is divided near its insertion on the pubic bone, and the anterior
branch of the obturator nerve is identified under the pectineus
S148 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
inferior capsule can be fully exposed. This step is mandatory
before the capsulotomy. Careful exposure of the capsule is best
achieved using a rasp and, in some cases, a scalpel.

Fig. 1. Sandbag under the buttock and gel pad under the back to tilt the
pelvis in a three-quarter oblique position. Bikini incision, approach to the
tensor fasciae latae–sartorius gap and to the iliac crest. The rectus femoris is
exposed.

detached from the lesser trochanter. The capsule is exposed

and opened by performing a T-shaped incision with one branch
along the axis of the neck and the other along the lower
edge of the acetabulum. The transverse ligament is then
exposed. Division of this ligament at both ends is a crucial
step. The fibro-fatty tissue filling the acetabular fossa can then
be removed. The interposed limbus is incised radially to allow
its eversion, which exposes the acetabular cartilage. This places
the femur in its normal position. The hip is then placed in the
reduction position of 90 ◦ flexion, 30 ◦ abduction, and 10 ◦
internal rotation.
The capsule cannot be closed. A spica cast is worn for
3 weeks then replaced by a Petit abduction splint, which
allows flexion–extension of the hip, until the acetabular
dysplasia is fully corrected [10,11]. With medial approaches,
great care is in order to avoid injuring the medial circumflex
artery.

2.4.2. Anterior
approach
The child is supine with a large sandbag under the buttock
and a gel pad under the back to turn the pelvis in a three-quarter
oblique position. The bikini skin incision runs 1 cm below the
crest then crosses under the antero-superior iliac spine and
courses medially over a further 2 cm. The Smith–Petersen
approach is then per- formed: the gap between the tensor
fasciae latae and sartorius is identified, and the incision is kept
within the fascia of the tensor fasciae latae (Fig. 1). The lateral
femoral cutaneous nerve should not be identified, as it is within
a protective sheath. This gap leads to the rectus femoris and is
temporarily packed with a gauze pad. The wing of the ilium
(lateral iliac fossa) is exposed subperiosteally after detaching
the tensor fasciae latae anteriorly. The capsule is exposed
gradually by retracting the gluteal muscles (Fig. 2). This step is
challenging as the approach should be extended posteriorly
along a sufficient distance to ensure full exposure of the
capsule, in order to facilitate its re-tensioning. The rectus
femoris tendon is dissected, divided, and gently retracted
downwards. The iliopsoas muscle, which then becomes visible
outside the field, is isolated circumferentially and divided as
distally as possible, ideally at the white/red junction. Caution
requires that the femoral nerve be visu- alised. Thus, the antero-
Fig. 2. The gluteal muscles are detached to expose the iliac wing. The rectus
femoris tendon is divided and the capsule exposed.
2.4.3. Lateral approach
This is the Gibson approach. The child is lying on the side.
The skin incision is lateral, nearly rectilinear, with two-third of
the length above the greater trochanter. The tensor fasciae latae
is opened longitudinally and the gluteus muscle fibres are spread
proximally. The fan-shaped gluteal muscles are then exposed.
The posterior edge of the gluteus medius is identified by a suture
near its insertion and the muscle is detached gradually, moving
upwards to its tendon, which is left intact. The gluteus minimus
is identified in the same way and lifted. It is difficult to separate
from the capsule, to which it adheres closely. The capsule is
exposed as described for the anterior approach. The rectus
femoris tendon, which is then visible medially, is divided. The
iliopsoas muscle is identified and divided at the white/red
junction. Flexing the hip facilitates this step.
2.5. Criteria for selecting the approach
The obturator approach is reserved for early reductions with
no additional procedures.
The anterior approach, which has my preference, can be used
in all situations. It has the advantages of clearly identifying all
the extra-articular obstacles and of providing good exposure of
the acetabulum. This is undoubtedly the most appropriate
approach for all concomitant procedures.
The lateral approach provides the best exposure of the acetab-
ulum but is further from the anterior obstacles and is not readily
combined with concomitant procedures on the acetabulum. We
reserve this approach for early reductions, as an alternative to the
obturator approach, and for revision procedures requiring
deepen- ing of the acetabulum (Colonna procedure) combined, if
needed, with a femoral osteotomy.
2.6. Capsulotomy
This is a crucial step and should be performed only after the
capsule is fully exposed. It is described above in the section on
the obturator approach.
With the other two approaches, the anterior insertion of the
cap- sule must be exposed by extending downwards to the upper
edge of the obturator foramen. Laterally, the incision should be
extended to 1 cm of the greater trochanter, cautiously to avoid
damaging the
Fig. 3. T-shaped incision in the capsule and exposure of the acetabulum. The upper
edge of the obturator foramen should be clearly visible. A double-angled retractor
is placed in the foramen. The ligament teres and transverse ligament become
visible and are resected. Radial incisions are made in the limbus, which is then
everted.
blood supply to the head via the circumflex artery. Posteriorly,
the incision should extend far along the acetabular insertion in
order to fully expose the dislocation pouch.
The capsular incision is performed using a cold blade. The
inci- sion is T-shaped, with the vertical branch parallel to the axis
of the neck and the horizontal branch 5 mm from the iliac
insertion of the capsule, from anterior and downward to posterior
and upward (Fig. 3). Two flaps are thus obtained.
2.7. Intra-articular
steps
The acetabulum can then be exposed (Fig. 3). First, the
ligament teres should be cut flush with the head, which can then
be displaced upwards and posteriorly using a Lambotte bone
hook. The ligament teres is followed to the acetabular fossa,
where it is cut flush with the bone, where its insertion is a
reliable landmark. The insertions of the transverse ligament on
the horns of the acetabulum are iden- tified and the ligament
resected. The lower part of the acetabulum with its smooth
cortex resembling the Niagara Falls is then visi- ble. A spatula
or scissors can then be inserted into the upper part of the
obturator foramen, where a double-angled retractor is inserted.
This step is key to exposure of the acetabulum and to the success
of the procedure.
A curette can then be used to gently detach the fibro-fatty tis-
sue, which adheres loosely to the acetabular cavity. Eversion of
the limbus then exposes the acetabular cartilage. Radial incisions
are made in the limbus at 15 mm intervals and the limbus
segments are then everted using a small Trelat hook or a small
curette. Leaving the limbus in place improves the ability of the
acetabulum to retain the femoral head. The head can then be
reduced, if needed after a procedure on the femur (Fig. 4).
2.8. Capsulorrhaphy
technique
Capsular resection, if needed, should remove part of the
inferior flap. The superior flap should be left intact and advanced
to elim- inate the dislocation pouch. Strong absorbable suture
should be used, with shallow-curved needles. The sutures are
prepared and identified after being threaded through the superior
flap (Fig. 5). The anterior part of the acetabulum will no longer performed. Four needles
be accessible if an additional procedure on the pelvis is
 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
Fig. 4. The femoral head can then be reduced. However, reduction is facilitated by
performing a femoral shortening and external derotation osteotomy.
Fig. 5. After internal fixation of the femoral osteotomy and reduction of the
femoral head, the capsulorrhaphy is prepared by threading interrupted sutures in
order to tighten the capsular pouch.
prepared with suture are sufficient. The sutures are knotted at the
end over the reduced and stable head.
Capsulorrhaphy has a stabilising effect in simple early reduc-
tion. In more extensive procedures including correction of
femoral and acetabular deformities, the head must be stable
without cap- sulorrhaphy. Closure of the capsule must then be
achieved without tension to close the joint.
In the event of persistent intra-operative instability, stabilisa-
tion of the head by inserting a pin into the acetabulum is not a
good solution, as the dislocation is likely to recur when the pin is
removed. A better method consists in resecting the posterior part
of the superior flap of the capsule.
S151
Fig. 6. A single S-shaped incision ensure good visibility for both the hip reduction
and the femoral osteotomy.
3. Additional procedures
Except when reduction is performed early, surgical reduction
should always be combined with additional procedures on the
femur and/or pelvis [12]. The objective is three-fold: to prevent
avascular necrosis [3], to facilitate the reduction, and to correct
the excessive femoral anteversion and acetabular dysplasia.
3.1. The
femur
When there is major proximal migration of the femur, and in
children older than 18 months, a femoral osteotomy is advisable
to improve the ease and safety of the reduction by shortening the
femur [13]. The osteotomy also corrects the excessive
anteversion, which is nearly always present, thus ensuring that
the head remains reduced without exaggerated medial rotation of
the femur.
The approach can be distinct from the bikini incision. The
inci- sion is then lateral and centered on the proximal fourth
of the femur.
Another option, which has my preference, consists in
perform- ing a single S-shaped skin incision that starts under the
iliac wing, where it is curved, then straightens along the femur
(Fig. 6). This approach offers the same possibilities for surgical
reduction (and has the advantage of leaving the gluteus
medius–tensor fasciae latae gap intact for future hip surgery if
needed) and pelvic pro- cedures. Within a single field, this
approach provides easy access to the hip joint, femur, and
ilium for correction of acetabular abnormalities. Another
advantage is greater ease in evaluating the reduction and in
determining the amount of shortening and dero- tation. Finally,
this incision facilitates teaching of the procedure. It is not
associated with any specific morbidity and provides a rather
pleasing cosmetic result, despite being longer than the sum of the
two separate incisions (bikini plus lateral along the thigh).
The femoral metaphysis and diaphysis should be approached
after a longitudinal incision in the tensor fasciae latae and
inverted L-shaped division of the proximal insertion of the vastus
lateralis. The exposure must be sufficient to allow the
implantation of a four- holed radius plate (3.5 screws). The first
step consists in evaluating the amount of femoral anteversion,
which is often increased (from
30 ◦ to 70 ◦ ), by measuring the angle between the axis of the
neck
and the femoral condyles. The result dictates the amount of dero-
tation needed. Simple derotation of the diaphysis is sufficient, as
there is usually no coxa valga in congenital hip dislocation.
The plate is secured by the proximal screws in the femur
turned in internal rotation. Two small pins can be used to
S150 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
quantify the derotation. The osteotomy is performed using a
Gigli saw in the middle of the plate. The head is then reduced.
Shortening is assessed
 and helping to position small double- angled retractors. A bone
by aligning the two femoral segments, with moderate tension on nibbler is used to remove 5 to 10 mm of each ramus and the
the muscles. The length of the overlap is equal to the length of fragmented bone is then reinserted to ensure haemostasis and
femur that should be removed from the distal segment, using a bone healing. The approach to the superior pubic ramus involves a
Gigli saw. The femoral cylinder is kept in a cup for use during horizontal incision of the periosteum at the lower
the pelvic step. The femur is then reduced while providing the
desired amount of anteversion, with external derotation of the
distal segment until the patella faces directly anteriorly. Fixation
is completed by inserting the distal screws. A compression effect
is achieved by drilling at the distal end of the distal hole.
The epiphysis is positioned within the acetabulum. The lower
limb is then in the anatomical position. At this point, the
acetabular dysplasia can be evaluated.

3.2. The
pelvis

Correcting the acetabular dysplasia is nearly always

indispens- able, both to ensure the stability of the epiphysis
and to create optimal anatomical and mechanical conditions for
growth.

3.2.1. Iliac crest

cartilage
Acetabuloplasty (Pemberton or Dega) does not affect the iliac
crest cartilage (Fig. 2). If innominate osteotomy is performed, in
contrast, a surgical approach to the iliac fossa is needed. One option
is to perform an incision in the cartilage of the iliac crest cartilage,
following the line of the iliac crest. The medial part of the cartilage
can then be detached. We prefer to leave the iliac crest cartilage
intact. This can be achieved by performing an iliac wing osteotomy
5 mm below the cartilage then displacing the strip of bone and car-
tilage medially. This method minimises the risk of iliac wing
growth disturbances.

3.2.2. Innominate
osteotomy
After an approach to the iliac wing (internal and external
iliac fossae), the greater sciatic notch is cautiously exposed and
a Gigli saw is inserted through it. The osteotomy is performed in
the posterior-to-anterior direction with the cut ending above the
antero-inferior iliac spine. The acetabulum is redirected using a
small Müller toothed forceps. The acetabulum is tilted anteriorly
and laterally in the plane of the iliac wing. Care should be taken
to translate the distal segment anteriorly over 1 cm, to promote
its stabilisation on the proximal cut in the iliac wing. Ideally,
fixation is achieved by positioning threaded pins or screws in an
X configu- ration. Another widely-used option consists in
superior-to-inferior fixation using a row of three pins. A
bicortical iliac graft is harvested from the iliac wing posterior to
the pins or screw to avoid modifying the anterior iliac bone
contour (Fig. 7). The graft is used to fill the defect created by the
osteotomy. If a femoral shortening osteotomy was performed, the
removed femoral segment can be used as the graft. When pins
are used for fixation, the first pin is inserted under visual
guidance into the iliac wing in the direction of the posterior
column (with great care to avoid the joint) to allow implantation
of the triangular graft. One or two additional pins are then
inserted for definitive fixation of the osteotomy and stabilisation
of the graft.
In older children, when major redirection of the distal
fragment is required, a triple osteotomy technique is used. Our
preference goes to the Pol-Le-Coeur method as updated by Jean-
Paul Padovani. The approach is through the genito-femoral fold.
The inferior pubic ramus is exposed subperiosteally after
identification of the pos- terior attachment of the gracilis
muscle. The ramus is directed obliquely, downwards, laterally,
and posteriorly. A spatula is the best instrument for skirting the
ramus, identifying the medial edge of the obturator foramen,
 graft can be harvested as described for the innominate
osteotomy.

Fig. 7. Salter innominate osteotomy with redirection of the acetabulum to

improve lateral and anterior coverage.

edge of the rectus muscle and, ideally, at the upper edge of

the pectineus muscle. Similarly, the spatula is used to identify
the cor- rect site by palpating the medial edge of the obturator
foramen. Double-angled retractors are put in place and the
osteotomy is performed as described above. Care should be
taken to avoid bleed- ing, which can make these steps difficult.
Closure is achieved by approximating the muscles over the two
osteotomies, suturing the fascia superficialis, and finally
performing a continuous intrader- mal suture.

3.2.3. Acetabulopl
asty
Acetabuloplasty to correct the acetabular dysplasia is
extremely useful in young children between 18 months and 3
years of age. The method described by Pemberton [14]
provides lateral and anterior correction and that described by
Dega lateral, posterior and, to a lesser degree, anterior
correction.
The sandbag under the buttock and gel pad under the back
of the patient are removed. Fluoroscopy is essential at this
point to identify the medial portion of the horizontal branch of
the triradi- ate cartilage, which indicates the proper orientation
of the chisel. On the fluoroscopy view, the axis of acetabular
fragment rotation needed to redirect the roof is determined. The
first step consists in determining the height at which the
osteotomy should start on the lateral table of the iliac wing.
The beginning of the cut should be at a sufficient height to
avoid necrosis of the acetabular fragment. A straight chisel is
used first to mark the line then a curved chisel to ensure a safe
distance from the acetabular roof and to reach the medial part
of the horizontal branch of the triradiate cartilage.
For the Pemberton acetabuloplasty, the osteotomy is
performed from anterior to posterior and from lateral to medial.
The hinge is medial and posterior and coverage is therefore
lateral and anterior (Fig. 8). For the Dega acetabuloplasty, the
hinge is medial. A Keris- son forceps is used to cut the
posterior column, which can then be redirected. This ensures
better posterior coverage. The graft is composed of femoral or
iliac bone (Fig. 9).
A segment of femur is inserted to maintain the opening
needed to correct the dysplasia. Alternatively, an iliac bone
 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
Fig. 8. Pemberton acetabuloplasty, which improves anterior and lateral coverage.
Fig. 9. Dega acetabuloplasty, which improves lateral and posterior coverage.
During closure, the crucial step is repositioning of the iliac
crest apophasis, which is then directly sutured to the gluteus
muscles using wide stitches.
4. Postoperative care
The hip is immobilised in a spica cast. After surgical
reduction alone in infants, the contralateral thigh should be
immobilised in the cast. A duration of 3 weeks is sufficient when
surgical reduction was performed alone. Ideally, upon removal
of the cast, traction should be used, initially with the hip in the
same position as in the cast. The hip is then gradually mobilised
and straightened. After the period of traction, the patient wears
a Petit abduction splint allowing flexion–extension of the hip, to
ensure a gentle transition.
When procedures are performed on the bone in addition to the
reduction, the spica cast should be worn for 5 weeks, after which
traction is preferably used, for 1 week. When the hip has
recovered
S1
Fig. 10. Surgical hip reduction with femoral and pelvic osteotomies. Redundant
capsule should be excised from the inferior flap when necessary.
range of motion, the patient can assume the erect position. If the
acetabular dysplasia was corrected, the Petit abduction splint is
unnecessary.
Rehabilitation therapy is not required. Walking is sufficient.
The family should receive instruction about maintaining and
monitor- ing good hip mobility.
5. Strategy
The surgical strategy depends on the local sanitary and eco-
nomic resources for children [15]. In countries lacking the
resources needed for non-operative reduction by gradual
traction, surgical reduction is the method of choice.
In Scandinavian countries and in a few French centres, early
sur- gical reduction via the anterior or obturator approach is
standard practice in infants who have not yet started to walk.
However, this strategy carries a risk of residual acetabular
dysplasia.
When the dislocation is diagnosed in a child who has learned
to walk, or after failure of non-operative reduction by
Somerville- Petit-Morel traction, surgical reduction via the
anterior approach with the additional bony procedures (Fig. 10)
is the best solution. Low morbidity rates can be achieved by
complying scrupulously with all the surgical principles and steps.
Long-term outcomes are good [16] in the absence of severe
complications.
Economic and public health reasons may warrant broadening
the indications of this procedure, which must therefore continue
to be taught. Furthermore, surgeons who go on missions to
countries with limited healthcare resources must be thoroughly
familiar with this procedure and its technical variants.
The age of the patient is the main factor in determining the
surgical strategy.
5.1. Infants younger than 1 year of
age
When surgery is deemed necessary either as the first-line
treat- ment or after failure of non-operative reduction, the
obturator approach can be used in patients younger than 6
months of age. We have no experience with this approach [7,9–
11].
S2 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
Between 6 and 12 month of age, simple reduction via the experience, 50%
ante- rior approach is the technique of choice. In our
Fig. 11. Mary, aged 6 months at surgery: bilateral hip dislocation diagnosed at birth. At 2 weeks of age, no improvement despite triple-diapering. A. Traction failed to
achieve reduction. B. Bilateral surgical reduction via the anterior approach, in two separate procedures 1 month apart. C. Outcome at 15 years of age: in the Postel-
Merle d’Aubigné scoring system, mobility was 6, pain 6, and stability 6. No change at 17 years of age.
of patients have residual dysplasia (Fig. 11). Residual acetabular
dysplasia is defined as no change in, or loss of, correction of the
acetabular angle. Surgical correction should be offered in this
situ- ation. Guillaumat showed that acetabular growth usually
proceeds at a steady pace during the first few years then
accelerates at 5 years of age [17], which would therefore seem to
be a good time to per- form the correction [18].
5.2. From 18 months to 4
years
This is the period of choice for a combined procedure that
cor- rects all the bone abnormalities, as described by Klisic and
Jankovic [12]. Presence of the femoral head ossification centre
has been reported to be associated with a lower risk of
vascular compli- cations [19–21]. We recommend waiting until
18 months of age for this combined procedure, and the femoral
osteotomy improves safety. Sankar et al. [22] demonstrated that
femoral shortening was usually required if the vertical
displacement of the femoral head was greater than 30% of the
acetabular width, as well as in patients older than 3 years of age.
For the acetabuloplasty, the Pemberton procedure is probably
preferable over the Dega procedure, as it provides better
coverage laterally and anteriorly, where the defi- ciency is
greatest (Fig. 12). In older children, the Salter innominate
osteotomy is simple and effective [15]. This osteotomy is always
feasible, even without fluoroscopy.
5.3. After 4 years of
age
The procedure remains feasible, at least until 8 years of
age (Fig. 13). A femoral osteotomy is mandatory. For the
acetabulum, the best method is often a triple pelvic osteotomy to
ensure opti- mal correction of the severe acetabular dysplasia. In
older children, if possible, postoperative traction can be used to
mobilise the hips and decrease the risk of stiffness.
6. Complications
Two complications can occur after surgical reduction of hip
dislocation: recurrent dislocation and avascular necrosis of the
femoral epiphysis.
6.1. Recurrent
dislocation
6.1.1. Caus
es
The dislocation may recur immediately if some obstacles to
reduction were left in place and the bony abnormalities were
insufficiently corrected. Another cause of recurrent dislocation
is inappropriate hip position during the period of postoperative
immobilisation [23,24]. In every case, the cause of the
recurrence must be identified and revision surgery performed
immediately.
The recurrence may become apparent upon removal of the
cast. The situation should be analysed in detail. Early recurrences
usually require the same treatment as immediate recurrences.
Delayed recurrences are more challenging. The most common
causes are presence within the acetabulum of soft tissue or bone,
exaggerated anteversion or retroversion due to excessive derota-
tion, and insufficient acetabular correction resulting in
inadequate containment of the femoral head.
6.1.2. Treatment decisions based on time to
recurrence
6.1.2.1. Repeated reduction. The reduction can be
repeated if the time since surgery is sufficiently short (Fig. 14).
After longer inter- vals, the dysplasia may become severe, with
abnormal thickening of the acetabulum responsible for
diminished containment capacity. In this situation, CT with 3D
reconstructions provides important information for guiding the
treatment decision. If the conditions allow reduction, this
procedure should be performed and can provide a good
outcome. stability is not feasible, even by performing pelvic osteotomies, a
When achieving joint congruence and femoral head Colonna arthroplasty may be the only solution.
Fig. 12. Youssef, 4 years of age at surgery. A. Dislocation with upward migration. B. Reduction with femoral osteotomy and Pemberton acetabuloplasty. C. Outcome at 7
years of age: no pain, excellent motion range.

Fig. 13. Samir, 8 years of age at surgery. A. Bilateral dislocation. Treatment was started at 8 years of age. B. Bilateral surgical reduction with femoral osteotomy and triple
pelvic osteotomy, in two separate procedures 2 months apart. C. Outcome at 26 years of age. D. Excellent range of motion, pain with prolonged standing.
 Fig. 15. Colonna procedure: approach, wrapping of the femoral head, and
deepening of the acetabular cavity.

Fig. 14. A. Recurrent dislocation after surgery with no femoral osteotomy. B. Repeat
surgical reduction.

6.1.2.2. Colonna arthroplasty. When the acetabular

cavity is oblit- erated by major thickening of the acetabulum or
by ossifications, a Colonna arthroplasty can be performed. The
acetabulum is deep- ened. The capsule is wrapped around the
femoral epiphysis, which is then reduced into the deepened
acetabular cavity. Under the effect of hip movements, the
interposed capsular tissue undergoes cartilaginous metaplasia Fig. 16. Colonna procedure: reduction, with femoral derotation osteotomy when
[25,26]. necessary.
The procedure is performed through the lateral Gibson
approach. The gluteal muscles are identified and lifted, leaving
The postoperative care programme is crucial. There are three
the gluteus medius tendon intact. A circumferential incision is
main steps.
made in the capsule flush with the acetabulum. This step requires
The hip is placed in traction in abduction for 6 weeks, during
painstaking exposure of the capsule. The femoral head is thus
which the patient is cautiously placed in the prone position and
com- pletely dislocated. Great care is needed posteriorly to avoid the hip mobilised, with a gradual increase in motion range from
injuring the blood vessels. The femoral head should be sealed
20 ◦ to 60 ◦ .
within the capsule, which should be wrapped evenly around it.
During the next 6 weeks, the lower limb is gradually brought
It may be necessary to thin the capsule and to create a capsule
closer to the anatomical position and maximal range of motion is
flap to facili- tate closure if the amount of tissue is insufficient.
recovered.
The lower edge of the acetabulum is identified and a double-
The patient is then gradually brought to the erect position.
angled retractor is placed in the obturator foramen. The
When the hip has recovered satisfactory mobility, weight-bearing
acetabular cavity is then deep- ened cautiously, in the inferior to
is started on an incline. After about 4 months, if the patient is
superior direction, using a sharp, straight, rigid curette.
bear- ing weight and has good hip mobility, assisted walking is
Deepening is stopped when the vertical and horizontal parts of
started then continued for 2 months. Walking contributes to
the triradiate cartilage are visible (Fig. 15). The containment
strengthen the muscles. Then, provided the hips are mobile and
capacity of the anterior and posterior walls and of the roof is
stable weight- bearing has been achieved, unassisted walking can
assessed to determine which adjustments are needed. The size of
be started.
the acetabular cavity should then be compared to that of the
This postoperative programme requires management in a
head wrapped in the capsule. The reduction should give a feel-
reha- bilitation centre for 5–6 months.
ing of stability, with the femur in the functional rotation position,
A good outcome consists in a reduced hip, a satisfactory joint
i.e., with about 15 ◦ of anteversion. If the amount of anteversion
line, and stable painless gait (Fig. 17). At about 30 years of age,
is excessive, the femoral head is stable only when the lower limb
the patient can be expected to developed symptoms due to joint
is in internal rotation. In this situation, lateral femoral derotation
space narrowing. Total hip arthroplasty may then be indicated.
should be performed, if needed combined with femoral
shortening (Fig. 16).
The hip is placed in abduction to stabilise the head in the 6.1.2.3. Abstention. Abstention may be indicated in
acetab- ular cavity before closing the incisions. The gluteal patients with bilateral recurrent dislocation or severe damage
muscles are easy to suture if properly identified. to the femoral
Fig. 17. Sarah, 5 years of age at failure of non-operative treatment. A. Second recurrence of the dislocation after surgical reduction. B. Acetabular cavity filled with bone
tissue.
C. Colonna procedure: after 5 years, the hip is mobile and
painless.

head with avascular necrosis. Early total hip arthroplasty may

then be indicated. With the prostheses currently on the market,
long survival times with good functional outcomes are possible.

6.2. Avascular necrosis

Avascular necrosis of the femoral epiphysis is a dreaded addition to hip reduction, correction of the femoral and acetabu-
compli- cation if it causes a severe deformity of the proximal lar abnormalities is needed to ensure that the reduction is stable
femur [27,28]. This complication is iatrogenic: it does not occur
in untreated con- genital hip dislocation. Severity varies from a
minor disturbance in epiphyseal growth, occasionally with coxa
magna of good progno- sis, to complete necrosis with deformity
of the femoral head and shortening or a change in orientation of
the femoral neck.
Avascular necrosis may be due to excessive traction or direct
surgical injury to the posterior blood vessels [29]. Another cause
is excessive hip abduction during the period of immobilisation.
Finally, when the femur is not shortened, excessive pressure on
the femoral head may result in avascular necrosis (Fig. 18).
The prevention of avascular necrosis relies on preoperative
trac- tion and, above all, shortening of the femur, which is a
simple and effective measure that has no adverse effects. The
femur can cor- rect the length discrepancy by a growth spurt due
to deperiostation during the osteotomy and to removal of the
fixation material.
The adverse consequences of avascular necrosis of the
femoral epiphysis vary. However, the risk of early osteoarthritis
is high [30].

7. Conclusion
Ideally, the treatment of congenital hip dislocation is non-
operative. If this method fails, surgical reduction is required.
In patients aged 6 to 12 months, surgical reduction can be
achieved via the anterior or obturator approach. No additional
pro- cedures are needed. In our experience, about half of the
patients subsequently require treatment for residual dysplasia.
In patients older than 4 years of age who require surgery, in
 before performing the capsulorrhaphy. These additional bony
pro- cedures ensure optimal hip stability and minimise the
risk of residual dysplasia. Femoral shortening and derotation
osteotomy (classically reserved in the past for patients older
than 3 years) is a useful and prudent measure that lessens
the pressure on the femoral epiphysis, facilitates reduction,
and decreases the risk of recurrent dislocation and avascular
necrosis. We there- fore recommend combining this osteotomy
with the surgical reduction.

Disclosure of
interest
Fig. 18. Severe avascular necrosis of the femoral epiphysis after surgical
reduction without femoral shortening.
The author declares that he has no competing interest.
Acknowledgements [14] Pemberton PA. Pericapsular osteotomy of the ilium for treatment of congen-
ital subluxation and dislocation of the hip. J Bone Joint Surg Am 1965;47:
Remi Kohler, Nejib Khouri, and Georges Finidori for their 65–86.
[15] Wenger DR. Surgical treatment of developmental dysplasia of the hip. Instr
help in drafting this lecture.
Course Lect 2014;63:313–23.
[16] Thomas S, Wedge J, Salter R. Outcome at forty-five years after open reduction
References and innominate osteotomy for late-presenting developmental dislocation of
the hip. Bone Joint Surg Am 2007;89:2341–50.
[17] Guillaumat M. La croissance de la hanche normale. Cahiers d’enseignement de
[1] Wicart P, Ghanem I, Seringe R. Réduction chirurgicale pour échec du
la SOFCOT, 7. Paris: Expansion scientifique franc¸ aise; 1977. p. 157–76.
traitement orthopédique de la luxation congénitale de hanche entrepris avant
[18] Kim HW, Morcuende JA, Dolan LA, Weinstein SL. Acetabular development in
l’âge de 6 mois [Open reduction after failure of conservative treatment for
developmental dysplasia of the hip complicated by lateral growth disturbance
congenital dislocation of the hip initiated before the age of six months]. Rev
of the capital femoral epiphysis. J Bone Joint Surg Am 2000;82:1692–700.
Chir Orthop Reparatrice Appar Mot 2003;89:115–24.
[19] Luhmann SJ, Schoenecker PL, Anderson AM, Bassett GS. The prognostic impor-
[2] Kahle WK, Anderson MB, Alpert J, Stevens PM, Coleman SS. The value of pre-
tance of the ossific nucleus in the treatment of congenital dysplasia of the hip.
liminary traction in the treatment of congenital dislocation of the hip. J Bone
J Bone Joint Surg Am 1998;80:1719–27.
Joint Surg Am 1990;72:1043–7.
[20] Roposch A, Stöhr KK, Dobson M. The effect of the femoral head ossific nucleus
[3] Schoenecker PL, Strecker WB. Congenital dislocation of the hip in children:
in the treatment of developmental dysplasia of the hip: a meta-analysis. J Bone
comparison of the effects of femoral shortening and of skeletal traction in
Joint Surg Am 2009;91:911–8.
treatment. J Bone Joint Surg Am 1984;66:21–7.
[21] Roposch A, Wedge JH, Krahn MD. The role of the ossific nucleus in the
[4] Landa J, Benke M, Feldman DS. The limbus and the neolimbus in developmental
treatment of established hip dislocation. Clin Orthop Relat Res 2006;449:295–
dysplasia of the hip. Clin Orthop Relat Res 2008;466:776–81.
302.
[5] Atsumi T, Kuroki Y. Role of impairment of blood supply of the femoral
[22] Sankar WN, Tang EY, Moseley CF. Predictors of the need for femoral shortening
head in the pathogenesis of idiopathic osteonecrosis. Clin Orthop Relat Res
osteotomy during open treatment of developmental dislocation of the hip. J
1992;277:22–30.
Pediatr Orthop 2009;29:868–71.
[6] Ludloff K. The open reduction of the congenital hip dislocation by an anterior
[23] Sankar WN, Young CR, Lin AG, et al. Risk factors for failure after open reduction
incision. Am J Orthop Surg 1913;10:438–54.
for DDH: a matched cohort analysis. J Pediatr Orthop 2011;31:232–9.
[7] Mankey MG, Arntz GT, Staheli LT. Open reduction through a medial approach
[24] Renshaw TS. Inadequate reduction of congenital dislocation of the hip. J Bone
for congenital dislocation of the hip: a critical review of the Ludloff approach
Joint Surg Am 1981;63:1114–21.
in sixty-six hips. J Bone Joint Surg Am 1993;75:1334–45.
[25] Lagrange J, Rigault P, Pouliquen JC. Résultats de l’arthroplastie de Colonna. Rev
[8] Ferguson Jr AB. Primary open reduction of congenital dislocation of the hip
Chir Orthop 1973;59:353–73.
using a median adductor approach. J Bone Joint Surg Am 1973;55:671–89.
[26] Boardman DL, Moseley CF. Finding patients after 40 years: a very long-
[9] Diepstraten AF. Open reduction of congenital hip dislocation: advantages
term follow-up study of the Colonna arthroplasty. J Pediatr Orthop 1999;19:
of the Ferguson medial approach. Acta Orthop Scand 1985;56:32–5.
169–76.
[10] Tumer Y, Ward WT, Grudziak J. Medial open reduction in the treatment of
[27] Salter RB, Kostuik J, Dallas S. Avascular necrosis of the femoral head as a com-
developmental dislocation of the hip. J Pediatr Orthop 1997;17:176–80.
plication of treatment for congenital dislocation of the hip in young children:
[11] Konigsberg DE, Karol LA, Colby S, O’Brien S. Results of medial open reduction
a clinical and experimental investigation. Can J Surg 1969;12:44–61.
of the hip in infants with developmental dislocation of the hip. J Pediatr
[28] Kalamchi A, MacEwen GD. Avascular necrosis following treatment of congenital
Orthop 2003;23:1–9.
dislocation of the hip. J Bone Joint Surg Am 1980;62:876–88.
[12] Klisic P, Jankovic L. Combined procedure of open reduction and shortening of
[29] Agus¸ H, Omerog˘ lu H, Uc¸ ar H, Bic¸ imoglu A, Türmer Y. Evaluation of the
the femur in treatment of congenital dislocation of the hips in older children.
risk factors of avascular necrosis of the femoral head in developmental
Clin Orthop Relat Res 1976;119:60–9.
dysplasia of the hip in infants younger than 18 months of age. J Pediatr Orthop
[13] Galpin RD, Roach JW, Wenger DR, Herring JA, Birch JG. One-stage treatment of
B 2002;11: 41–6.
congenital dislocation of the hip in older children, including femoral shorten-
[30] Roposch A, Liu L, Amaka C, Wedge J. Functional outcomes in children with
ing. J Bone Joint Surg Am 1989;71:734–74.
osteonecrosis secondary to treatment of developmental dysplasia of the hip. J
Bone Joint Surg Am 2011;93:145–50.