Ilizarov Hip Reconstruction
Children, adolescents, and young adults with late sequelae of neonatal hip sepsis or chronic hip dislocation from dysplasia often present with the clinical problems of pain, Trendelenburg gait, lower extremity length discrepancy, and hip instability, all related to absence of part or all of the femoral head and neck and proximal migration of the femur.
Reconstructive procedures for this difficult problem including trochanteric arthroplasty, hip arthrodesis, pelvic osteotomy, and femoral osteotomy have not been satisfactory.
A proximal femoral subtrochanteric osteotomy (pelvic support osteotomy) has also been described. Support is achieved by valgus osteotomy of the proximal femur, placing the upper end of the femur against the lateral aspect of the pelvis. In addition, the vulgus angulation improves hip biomechanics by improving the mechanical efficiency of the abductor musculature.
Proximal femoral osteotomy
Proximal femoral osteotomy and realignment found popularity in adult patients for the treatment of hip osteoarthritis. In more recent times, this procedure has been reserved for young patients with symptomatic hip disease in whom total joint arthroplasty has offered an inadequate solution. Proximal femoral osteotomy finds great utility for adults in the treatment of hip deformities. Common deformities include a varus or valgus neck shaft angle, rotational malalignments, bone defects, and leg length discrepancy. These deformities can be acquired as in the case of proximal femur fracture malunions and non-unions, or congenital (developmental) as in the cases of fibrous dysplasia, coxa vara, and developmental dysplasia.
Articulated Hinged Distraction of the Hip
Articulated hinged distraction (AHD) utilizes external fixation to reduce joint forces and allows for the repair of articular cartilage. AHD takes advantage of the intrinsic capacity of cartilage cells to regenerate in young individuals. AHD has been used successfully in the elbow and knee in human subjects. Several series have shown successful use of AHD, especially in young individuals. AHD provides an ideal environment for self-healing does not prevent le future use of less conservative such as arthrodesis or total joint arthroplasty.
Treatment of Disorders of the Hip
01.Fractures of the Femoral Neck
Internal fixation of transcervical hip fractures does not ensure union: surgical intervention may reduce an already compromised blood supply. Moreover. a number of factors are known to retard healing of hip fractures. including suboptimal contact and immobilization of the fragments. the presence of synovial fluid at the fracture site. and the lack of periosteum around the femoral neck. The goal osteosynthesis of femoral neck fractures must he adequate reduction of the fracture followed by interfragmentary compression until union is achieved.
02.Pseudarthrosis of the Femoral Neck
Treatment tactics designed to overcome pseudarthroses of the fem-oral neck must take into account not only the problem of obtaining bone union. but also, the following considerations. The position of the greater trochanter relative to the pelvis and acetabulum must be the same as on the uninjured side to nor-malize the abductor moment arm. The height of the apex of the trochanter should be sufficient to maintain tension on the abductor muscles. The femoral neck axis should form the proper angle with the femoral shaft axis.
The difficulties encountered when treating hip dislocations in older children. teenagers and adults by conventional methods are well known. The traumatic nature of the surgical intervention and the high proportion of poor results with some procedures demand a more satisfactory approach to the problem. We have worked out some new techniques for treating chronic hip dislocations using the apparatus developed by the author. Our approach permits us to achieve good locomotor function of the affected limb, eliminate shortening and the Trendelenburg sign, and preserve some hip motion. Furthermore, we gain these objectives with a one-stage operation that entails minimal surgical intervention.
The techniques we have developed for correcting femoral neck varus deformities allow us to achieve all these goals simultaneously while customizing the treatment to the patient’s pathology. In all cases, reconstruction of the femoral neck is performed after a hinge osteotomy in the sagittal or frontal plane.
Deforming in coxarthrosis is widespread throughout the world. A large number of surgical procedures have been developed to deal with the hip pathology, yet the problem is far from being solved. Our methods of proximal femoral reconstruction are based upon the author’s concepts on the influence of blood supply and loading upon the shape and volume of bone. When the blood supply to the femoral head diminishes and the load remains unchanged, or when the load increases without a concomitant enhancement of blood supply, the rate of reparative osteogenesis declines, leading to degenerative, dystrophic, and destructive changes within the joint. When the blood supply is diminished, decreasing the load on the femoral head and acetabulum will bring the rate of reparative osteogenesis into proper relationship to the blood supply. With this objective in mind we, have designed a proximal femoral reconstruction that achieves tin loading of the femoral head by abutting the proximal end of the femoral shaft under either the acetabular rim. the acetabular or the horizontal portion of the pubic bone.
05.Coxa Vara with Congenital Pseudarthrosis
When coxa vara is combined with congenital pseudarthrosis, the goals described in chapter 17 must be combined with the objective of achieving bone union. With our methods, we can stimulate osseous healing without direct intervention at the pseudarthrosis. The technique of wire insertion and frame application when a pseudarthrosis is present differs slightly from that in the case of marked coxa vara. As a rule. a wire is inserted through the proximal fragment above the level of the pseudarthrosis: this wire is curved and attached to the arch of the frame for side-to-side compression.