0 pen Reduction

of a Congenital
Dislocated Hip
and Salter
Innominate
Osteotomy
Colin F. Moseley
INDICATIONS/CONTRAINDICATIONS
Open reduction is the treal.ment of choice for congenital hip dislocation after the age of 18 months.
Because it is better to leave a hip dislocated than to produce a reduced but dysplastic hip, the sur-
geon must conclude that there is an age after which the operation is not indicated. probably around
4 or 5 years for bilateral hip dislocation and 8 years for unilateral hip dislocation. '!'he Salter
innominate osteotomy should be a routine component of open reduction of congenital hip disloca-
tion, because it redistributes forces and promotes modeling of the acetabulum.

PREOPERATIVE PlANNING
After induction of anesthesia, examination under fluoroscopy is perfOI'IIled to determine the amount
of femoral anteversion. '!'he femur is rotated until the femoral neck and the femoral head ossific
nucleus line up with the femoral shaft. Femoral anteversion is calculated by subtracting the amount
121
122 SECTION III Hips

of external rotation required from 90 degrees to obtain this fluoroscope view. Arthrogram prior to
open reduction is useless. The acetabulum cannot be visualized because it is filled with pulvinar, and
the femoral head is always somewhat out of round. The need for femoral shortening cannot be
determined in advance and is not related to the x-ray appearance. Derotation osteotomy is performed
when there is more than 50 degrees of femoral anteversion or when the stability of the hip reduction
demands it.

SURGICAL PROCEDURE
Setup
The patient is positioned supine oo a radiolucent table, with the hip elevated on a bump. The bump
should be placed under the iliac crest but not under the buttock to avoid pushing the gluteal muscles up
against the hip and limiting exposure of the sciatic notch. The radiolucent table is used to permit
examination before surgeey and for a later x-ray to check the lengths of the pins used for the Salter
osteotomy.

Technique
The surgical procedure will be described as if being performed as the first procedure on the hip of a
2 year old. It should be recognized that secondary procedures are substantially more difficult,
because few of the anatomicallandmm:ks are easily identified. The dimensions J:tlelltioned must be
increased for larger children.
The incision is made 1 em below the iliac crest and inguinal ligament and should extend about
5 em (Fig. 1~1) posterior to the anterior superior iliac spine (ASIS) and 3 em medially to this. The
best approach is to think of the superficial exposure in three stages: F'trSt, the iliac crest; second, the
interval between sartorius and tensor fascia femoris muscles; and third, the middle portion and
the lateral femoral cutaneous nerve.
The incision is extended to the iliac crest, retracting the ovemanging external oblique muscle if
necessary. Some fibers may have to be released from the iliac crest to expose its cartilaginous cen-
ter. Using the thumb and forefinger as guides, the surgeon incises the iliac apophysis exactly in the
middle (Fig. 1~2). Each half of the iliac apophysis can be popped off cleanly with pressure of the
thumb in a sponge. The ilium is exposed subperiosteally, and a sponge is packed back into the sci-
atic notch on each side.
The interval between the sartorius and the tensor fascia lath muscles lies on a straight line
between the ASIS and the patella. The deep fascia is incised on that line, starting 15 mm distal to the
ASIS (Fig. 1~3). The interval can be recognized by fat around the lateral femoral cutaneous nerve.
The nerve passes distally and laterally beneath the still intact part of the deep fascia. The fascia is
then incised carefully and the nerve identified, mobilized, and retracted medially (Fig. 10-4).
The bony ridge between the ASIS and anterior inferior iliac spine (AilS) is now exposed.
Unlike the iliac crest, this ridge is sharp and narrow and does not provide an easy target. The
experienced surgeon can accomplish this exposure by palpating the AilS and making one cut from

FIGURE 10·1
The incision.
I0 Open Reduction of a Congenital Dislocated Hip and Salter Innominate Osteotomy 123

FIGURE 10·2
Exposure of the ilium.

FIGURE 10·3
Developing the distal
interval.

FIGURE 10·4
Exposure of the lateral
femoral cutaneous
nerve.
124 SECTION III Hips

FIGURE 10·!1
Exposure of the
interspinous ridge.

the ADS to the ASIS, but most will prefer to make small2- to 3-mm. cuts along the ridge, starting
superiorly and elevating the periosteum progressively until the AilS is reached. The ADS is rec-
ognized as the cartilaginous apophysis of origin of the straight or direct head of the rectus femoris
muscle (Fig. 10..5).
The tendon of the straight head of the rectus femoris is immediately obvious in the depth of the
interval extending distally from the ADS. Its medial and lateral borders are identified and the tendon
transected as far proximally as possible, preferably at the takeoff of the rectus femoris reflected head,
which may not be easily identified because it is incorporated into the false acetabulum. The straight
head of the rectus femoris tendon does not need to be tagged, because it does not retract out of the
wound.
The iliopsoas muscle comprises the medial wall of the surgical interval, emerging from behind the
medial periosteum of the iliac crest Its tendon lies on the posterior aspect; however, it only begins
at the level of the pubis, so the smgeon must look for it rather distally at the pelvic rim. It is identi-
fied by rolling the muscle medially on itself to identify the posterior aspect of the muscle and the
tendon. When the tendon is visualized, a right-angle clamp can be inserted into the muscle just
anterior to the tendon (Fig. 10-6), separating the tendon from the muscle, and can be used to deliver
the tendon into the wound, where it can be transected.

FIGURE 10·8
Releasing the psoas
tendon.
 10 Open Reduction of a Congenital Dislocated Hip and Salter Innominate Osteotomy 125

FICURE 10·7
Exposing the hip
capsule.
The hip capsule now constitutes the base of the exposed interval and can be cleaned with an ele-
vator. The goal is to develop two intervals that almost meet medially (Fig. 10-7).
The hip capsule is visible as a smooth, shiny, white layer (Fig. 10-8). Frequently some fibers of
the iliopsoas originate from the anterior capsule (the capsulopsoas muscle) and can be cleared off
the hip capsule with the elevator.
It is important to develop the superior pe:ri.capsul.ar interval and to extend that exposme as far
medially as poss:ible, right to the bone at the superior aspect of the false acetabulum. This interval is
not easily visualized, particularly with very high-riding femoral heads; therefore, the exposme is
done largely by palpation. This layer can be joined to the lateral iliac subperiosteal layer by cutting
the intervening tissue with heavy scissors from anterior to posterior (Fig. 10-9).
Attention can then be turned to the anterior and inferior capsule. Exposure is extended as far
medially as possible along the pubic ramus, thereby exposing the anterior origin of the hip capsule.
This step is extremely important to allow the initial release and later repair of the capsule.
The capsule incision is begun with a scalpel. Once entered, heavy scissors are used to avoid dam-
aging the articular cartilage of the head. The incision is T -shaped, with the stem of the T horizontal
(not in line with the neck) and extending from the margin of the acetabulum to a point laterally that
will lie at the acetabulum margin once the hip is reduced. The umbrella of theTis immediately along
the margin of the acetabulum, extending posteriorly and as far distally as possible.

FICURE 10·8
Developing the
pericapsular interval.
128 SECTION III Hips

FIGURE 10·9
Exposing the capsule.

In making the superior limb of the incision, the smgeon should inspect the cut edge to be sure that
the labrum has not been splayed out beneath the capsule instead of being in its usual location within
the acetabulum.
The distal extension of this incision medially is important, as that part of the capsule can consti-
tute a bmie:r to reduction. It is exposed by balancing the tip of a right-angle retractor on the pubic
ramus as far medially as possible (Fig. 10-10), without letting it slip superiorly or inferiorly.
The ligamentum teres ligament is usually the first anatomized structure seen upon opening the hip
capsule. It can be hooked with a right-angle clamp and is transected at its insertion on the femoral
head, producing a relatively spherical femoral head surface without a prominence (Fig. 10-11). This
ligament should then be cleared of peripheral attachments, t:ransected at its origin in the depth of the
acetabulum, and removed.
The transverse acetabular ligament is palpated and then tnmsected with scissors while palpating this
area. This ligament must be completely released to allow the labrum, to which it is attached at each end,
to retract, thereby allowing the acetabulwn's entrance to widen for full reduction of the femoraL
Once the transverse acetabular ligament has been released, the labrum needs no further attention.
It is a very soft structure and will be extruded out of the way by the reduced femoral head. Some
have suggested making radial cuts, but this is not only unnecessary but also ineffective, because the
labrum usually has a very wide base and cannot be ''folded" out.

FIGURE 10-10
Opening the capsule.
 10 Open Reduction of a Congenital Dislocated Hip and Salter Innominate Osteotomy 127

FIGURE 10·11
Excising the ligamentum
teres.
The pulvinar is not considered a real obstruction by those who say that it will simply extrude out
of the acetabulum when the head is reduced. Others prefer to remove the pulvinar tissue with a
rongeur in order to expose the acetabulum's articular cartilage.
Redundant portions of the hip capsule can be trimmed. First the triangular superior flap formed
by the T incision can be excised. Second, now that the extent of the false acetabulum can be visual-
ized, the capsule can be elevated from the l.a.temJ. iliac wing down to the superior margin of the true
acetabulum, where the capsule is excised, taking care to avoid the labrum.
The femoral head can now be reduced, usually with a satisfying clUDk:. The reduction can then be
assessed for stability by adducting and extending the hip. The surgeon must take note of the muscu-
lar tension generated by the reduction. Because the Salter osteotomy will further increase the ten-
sion across the hip joint, a decision must be made about the need for a shortening osteotomy of the
femur. Although this will almost never be necessary in the 2-year-old child, the likelihood does
increase with older children. The adductor longus tendon can be palpated at this point and, if too
tight, can be released percutaneously.
Reference should also be made to the preoperative assessment of femoral anteversion. If this is
more than 50 degrees, a derotation femoral osteotomy should be performed, whether or not femoral
shortening is required.
In anticipation of the capsulorrhaphy, three heavy, nonabsorbable sutmes are placed but not tied
(Fig. 10-12A). On the femoral side, they are inserted 2 to 3 mm apart along the superior cut edge of
the inferior capsular, with the most lateral suture placed right at the apex, at the most lateral part of
the cut edge. On the acetabular side, the su~ are placed a few millimet:ers apart, with the medial

FIGURE 10·12 A, B. Capsule sutures.

128 SECTION III Hips

FIGURE 10·13
Preparing for the Salter
osteotomy.

one being placed as far medially as possible (Fig. 10..12B). Placement of this medial suture requires
superior rettaction along the pubic ramus.
To prepare for the Salter innominate osteotomy, a channel for passing a Gigli saw is developed, us-
ing a periosteal elevator into the sciatic notch from both the medial and lateral aspects (Fig. 10-13).
Chandler retractors are placed in the sci.atk: notch. To the surgeon, the notch appears farthe£ away on
the lateral aspect than on the medial (Fig. 10-14). This is because on the medial side, the surgeon is look-
ing at the pelvic brim and not at the actual notch. Remembering this will facilitate passage of the saw.
Twisting the Chandler retractors provides a space for the Gigli saw (Fig. 1()..15). The best strat-
egy is to start on the medial aspect and aim the tip of the saw at the lateral retractor so that it strikes
and then rides up its blade. Alternatively, one can use special channeled retractors designed by Mer-
cer Rang that, when placed in the notch, facilitate passage of the saw. When the Gigli saw appears
laterally, it can be grasped and pulled through (Fig. 10-16).
Before beginning the cut, the limbs of the saw should be oriented transversely so that the plane
between the limbs intersects the pelvis at the desired point of anterior exit of the cut, just at the top
of the ADS (Fig. 10-17). This should be a straight cut to facilitate fitting the bone wedge.
A wedge of bone is cut from the anterior part of the iliac crest that includes the ASIS and the
interspinous ridge (Fig. 10-18). A triangular wedge of about 30 degrees with straight sides is fash-
ioned from this bone (Fig. 10-19).

FIGURE 10-14
Providing access to the
sciatic notch.
FIGURE 10-UI
Passing the Gigli saw.

FIGURE 10·18
Delivering the Gigli
saw.

FIGURE 10·17
Making the pelvic cut.
129
130 SECTION III Hips

FIGURE 10-18
Gutting the wedge.

FIGURE 10·11
Shaping the wedge.

FIGURE 10·20
Opening the pelvic
osteotomy.
 10 Open Reduction of a Congenital Dislocated Hip and Salter Innominate Osteotomy 131

FIGURE 10·21
Inserting the wedge.

Two sharp towel clips are applied to the pelvis. The uppec clip can be applied so that its croll:h
impinges on the crest, allowing it to function as a lever. The lower clip is placed deep to the ADS on
the inferior hemipelvis (Fig. 10..20). Care should be taken to place the inferior towel clip through
bone and not just through the apophysis to avoid separation from the underlying bone when traction
is applied. The wedge is opened by exerting traction on the lower clip and leverage on the upper one.
Forward displacement of the lower segment improves the axis of rotation and thereby the coverage
achieved by the redirection.
The bone wedge should be gently placed into the gap (Fig. 10..21). Forcing it in only serves to sep-
arate the fragments without gaining the necessary rotational correction. The cut surface of the pelvis
is much broader than the graft. Therefore, the graft should be placed as far medially as possible to
minimi:re the chance that the pins used for fixation will intrude into the acetabulum. Lengthening at
the medial margin of the osteotomy should be avoided.
The graft is fixed in place by two threaded pins. The first pin engages only the very tip of the
superior pelvic segment but passes through the middle of the graft. The second, more superior pin
achieves better purchase of the pelvic segment but passes near the tip of the wedge (Fig. 10-22). Both
pins pass into the distal pelvis medially and posteriorly to the acetabulum.

FIGURE 10·22
Pin fixation.
132 SECTION III Hips

FIGURE 10-23
A, B. Ensuring correct
pin depth.

The desired depth of pin penetration is to, but not through, the triradiate carti.l.age. In the 2-year-old
child, this depth is about 12 to 13 mm into the distal segment. Determining how far the pin has pen-
etrated into the distal segment is a simple, quick procedure: Use pins that have a smooth, unthreaded
butt end (Fig. 10-23A). Mount the pin so that the shoulder (the transition between the threaded and
nonthreaded portions) is visible. Aftec insertion of the first pin, place a similar pin alongside the first,
with the tip at the level of the cut surface of the distal segment (Fig. 10-23B). The relative displace-
ment of the shoulders of the two pins shows the depth of penetration into the distal segment An x-ray
is taken to assess depth of penetration, and the pins are adjusted accordingly. The pins are the.o. cutoff
at the bone. The capsularritaphy is then completed by tying the previously placed capsule sutures.
The iliac crest is closed using a vertical double throw stitch to ensure good apposition of the cut
surfaces. The deep fascia is closed with care to avoid entrapping any fibers of the lateral femoral
cutaneous nerve.

POSTOPERATIVE MANAGEMENT
A one-and-half hip spica is applied with the leg in about 20 degrees of flexion, 30 degrees of
abduction, and neutral oc slight internal rotation. Care is taken to produce a good cast mold posterioc
and superior to the greater ttochanter. The spica is worn for 3 months.
 10 Open Reduction of a Congenital Dislocated Hip and Salter Innominate Osteotomy 133

FICURE 10·24
The x-ray shows a
shallow acetabulum, an
absent teardrop, a blunt
acetabular lip, and a
small femoral ossific
nucleus.

COMPLICATIONS TO AVOID
The most serious complication is redislocation of the femoral head. This risk can be minimized by
careful application of the spica cast, achieving the mold with plaster instead of ftbe.rglass. The
patient is maintained in a supine position and never in a prone, sitting, or vertical position. This pre-
vents the child's weight from being born by the thighs on the legs of the cast, which can push the
hips up and out, risking dislocation. For younger patients who are not toilet trained, parents must
make a supreme effort to keep the cast clean and dry. Not doing so can lead to severe skin problems
and could necessitate anesthesia to replace the cast.

ILLUSTRATIVE CASE
A girl presented at the age of 31h years with a dislocated left hip (Fig. 10-24). It was evident when
she first began to walk that her gait was abnormal, but she had received no prior treatment.
She underwent an open reduction, Salter osteotomy, and shortening osteotomy of the femur
(Figs. 10-25 and 10-26).

FIGURE 10·2!1
This x-ray was taken 1
year after the procedure,
at the age of 41 / 2 years.
The femoral head is
deeply reduced and well
covered. In the usual
course of events, the
femoral plate would
have been removed at
about this time.
134 SECTION III Hips

FIGURE 10-28
This is the follow-up
x-ray at the age of 6
years, 21h years after
the open reduction.
Note that the femoral
head, although deeply
reduced in the
acetabulum, is
somewhat lateralized
with respect to the
pelvis due to the
widened teardrop, which
represents the thickened
medial wall of the
acetabulum.

At the age of 11 years, she was functioDing no.rmally with no limp, pain, or disability. The hip
looks excellent radiologically (Fig. 1()..27).

PEARLS AND PITFALLS

• The lateral femoral cutaneous nerve must be retracted medially. Because it exits the pelvis
beneath the inguinal ligament and the origin of that ligament has been moved medially, the nerve
should also be retracted medially.
• The stem of the T -shaped incision into the capsule must be superior enough, because the inferior
flap is used in the repair.
• Careful attention should be paid to the release of the anteroinferior capsule. Although this can
be difficult to access, failure to adequately release the capsule can leave an obstruction to
reduction.

FIGURE 10-27
The ossific nucleus
has formed well, with
no evidence of
avascular necrosis,
and the head appears
spherical and
congruent. The center
edge angle measures
30 degrees.
 lO Open Reduction of a Congenital Dislocated Hip and Salter Innominate Osteotomy 135
• At the time of the trial reduction, the surgeon must assess the need for femoral shortening.
Some tension is required to maintain the reduction, but excessive tension can lead to avascu-
lar necrosis.
• Because the Salter osteotomy moves the capsular origin from the pubic ramus more distal and
makes it harder to access, the sutures for the capsulorrhaphy should be placed before the innom-
inate osteotomy is done.

REFERENCES
1. Akagi S, Tanabe T, Ogawa R, et aL AcetaOOlar development after open reduction for developmental dislocation of the hip.
15-year follow-up of 22 hips without additional surgery. Acta Orthop Scand. 1998;69(1 ): 17-20.
2. Albinana J, Dolan LA, Spratt KF, et al Acetabular dysplasia after treatment for developmental dysplasia of the hip:
implications for secondary procedures. J Bone Joint Surg Br. 2004;86(6): 876--886.
3. Crawford AH, Mehlman Cf, Slover RW, et al. The fate of untreated developmental dislocation of the hip: long-term
follow-up of eleven patients. J Pediatr Orthop. 1999;19(5):641-6t4.
4. Galpin RD, Roach JW, Wenger DR, et aLOne-stage treatment of congenital dislocation of the hip in older children,
including femoral shortening. J Bone Joint Surg Am. 1989;71(5):734-741.
5. Haidar RK, Jones RS, Vergroesen DA. et al. Simultaneous open reduc1ion and Saller innominate osteotomy for develop-
mental dysplasia of the hip. J Bone Joint Surg Br. 1996;78(3):471-476.
6. Salter RB. Role of innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip in the older
child. J Bone Joint Surg. 1966;48A: 1413.
7. Zionts LE, MacEwen GD. Treatment of congenital dislocation of the hip in children between the ages of one and three
years. J Bone Joint Surg Am. 1986;68(6):829-846.