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

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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: Surgical reduction of congenital hip dislocation is technically challenging. In our practice, surgical reduc-
Received 17 February 2017 tion is usually reserved for patients who have failed non-operative treatment, which is the first-line
Accepted 4 April 2017 strategy. However, primary surgery may be indicated if the dislocation is diagnosed late and can be
performed until 8 years of age. The reduction step is crucial. It starts with painstaking exposure of the
Keywords: capsule. Identifying the lower part of the acetabulum is the key to accurate repositioning of the epi-
Congenital dislocation of the hip physis. The main intra-articular procedures are resection of the ligament teres, adipose tissue within
Surgical reduction
the acetabular cavity, and transverse acetabular ligament; and eversion of the radially incised limbus.
Femoral shortening osteotomy
Innominate osteotomy
In patients younger than 1 year of age, surgical reduction can be performed via the anterior approach
Acetabuloplasty or, in some cases, the obturator approach. No complementary steps are needed. If the diagnosis is made
Avascular necrosis 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 this

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
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.
S148 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
Magnetic resonance imaging (MRI) is not performed routinely
before surgical reduction of congenital hip dislocation, 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 muscle. The
pectineus should be displaced anteriorly and the adductor brevis
and gracilis posteriorly to expose the iliopsoas tendon, which is
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-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.
 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
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
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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 be accessible if
an additional procedure on the pelvis is performed. Four needles
S150 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.
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 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
 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
by aligning the two femoral segments, with moderate tension on
the muscles. The length of the overlap is equal to the length of femur
that should be removed from the distal segment, using a Gigli saw.
The femoral cylinder is kept in a cup for use during 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, and helping to position small double-
angled retractors. A bone nibbler is used to remove 5 to 10 mm of
each ramus and the fragmented bone is then reinserted to ensure
haemostasis and bone healing. The approach to the superior pubic
ramus involves a horizontal incision of the periosteum at the lower
S151
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. Acetabuloplasty
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 graft can be
harvested as described for the innominate osteotomy.
S152 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
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].
Between 6 and 12 month of age, simple reduction via the ante-
rior approach is the technique of choice. In our experience, 50%
 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
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.
S153
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. Causes
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.
When achieving joint congruence and femoral head stability
is not feasible, even by performing pelvic osteotomies, a Colonna
arthroplasty may be the only solution.
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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.
 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
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 [25,26].
The procedure is performed through the lateral Gibson
approach. The gluteal muscles are identified and lifted, leaving
the gluteus medius tendon intact. A circumferential incision is
made in the capsule flush with the acetabulum. This step requires
painstaking exposure of the capsule. The femoral head is thus com-
pletely dislocated. Great care is needed posteriorly to avoid injuring
the blood vessels. The femoral head should be sealed within the
capsule, which should be wrapped evenly around it. It may be
necessary to thin the capsule and to create a capsule flap to facili-
tate closure if the amount of tissue is insufficient. The lower edge
of the acetabulum is identified and a double-angled retractor is
placed in the obturator foramen. The acetabular cavity is then deep-
ened cautiously, in the inferior to superior direction, using a sharp,
straight, rigid curette. Deepening is stopped when the vertical and
horizontal parts of the triradiate cartilage are visible (Fig. 15). The
containment capacity of the anterior and posterior walls and of the
roof is assessed to determine which adjustments are needed. The
size of the acetabular cavity should then be compared to that of
the head wrapped in the capsule. The reduction should give a feel-
ing of stability, with the femur in the functional rotation position,
i.e., with about 15 ◦ of anteversion. If the amount of anteversion
is excessive, the femoral head is stable only when the lower limb
is in internal rotation. In this situation, lateral femoral derotation
should be performed, if needed combined with femoral shortening
(Fig. 16).
The hip is placed in abduction to stabilise the head in the acetab-
ular cavity before closing the incisions. The gluteal muscles are easy
to suture if properly identified.
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Fig. 15. Colonna procedure: approach, wrapping of the femoral head, and deepening
of the acetabular cavity.
Fig. 16. Colonna procedure: reduction, with femoral derotation osteotomy when
necessary.
The postoperative care programme is crucial. There are three
main steps.
The hip is placed in traction in abduction for 6 weeks, during
which the patient is cautiously placed in the prone position and
the hip mobilised, with a gradual increase in motion range from
20 ◦ to 60 ◦ .
During the next 6 weeks, the lower limb is gradually brought
closer to the anatomical position and maximal range of motion is
recovered.
The patient is then gradually brought to the erect position.
When the hip has recovered satisfactory mobility, weight-bearing
is started on an incline. After about 4 months, if the patient is bear-
ing weight and has good hip mobility, assisted walking is started
then continued for 2 months. Walking contributes to strengthen
the muscles. Then, provided the hips are mobile and stable weight-
bearing has been achieved, unassisted walking can be started.
This postoperative programme requires management in a reha-
bilitation centre for 5–6 months.
A good outcome consists in a reduced hip, a satisfactory joint
line, and stable painless gait (Fig. 17). At about 30 years of age, the
patient can be expected to developed symptoms due to joint space
narrowing. Total hip arthroplasty may then be indicated.
6.1.2.3. Abstention. Abstention may be indicated in patients with
bilateral recurrent dislocation or severe damage to the femoral
S156 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157

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 compli-

cation if it causes a severe deformity of the proximal 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 Fig. 18. Severe avascular necrosis of the femoral epiphysis after surgical reduction
effective measure that has no adverse effects. The femur can cor- without femoral shortening.
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
before performing the capsulorrhaphy. These additional bony pro-
epiphysis vary. However, the risk of early osteoarthritis is high [30].
cedures ensure optimal hip stability and minimise the risk of
residual dysplasia. Femoral shortening and derotation osteotomy
7. Conclusion (classically reserved in the past for patients older than 3 years)
is a useful and prudent measure that lessens the pressure on
Ideally, the treatment of congenital hip dislocation is non- the femoral epiphysis, facilitates reduction, and decreases the
operative. If this method fails, surgical reduction is required. risk of recurrent dislocation and avascular necrosis. We there-
In patients aged 6 to 12 months, surgical reduction can be fore recommend combining this osteotomy with the surgical
achieved via the anterior or obturator approach. No additional pro- reduction.
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 Disclosure of interest
addition to hip reduction, correction of the femoral and acetabu-
lar abnormalities is needed to ensure that the reduction is stable The author declares that he has no competing interest.
 C. Glorion / Orthopaedics & Traumatology: Surgery & Research 104 (2018) S147–S157
Acknowledgements
Remi Kohler, Nejib Khouri, and Georges Finidori for their help
in drafting this lecture.
References
[1] Wicart P, Ghanem I, Seringe R. Réduction chirurgicale pour échec du traitement
orthopédique de la luxation congénitale de hanche entrepris avant l’âge de 6
mois [Open reduction after failure of conservative treatment for congenital
dislocation of the hip initiated before the age of six months]. Rev Chir Orthop
Reparatrice Appar Mot 2003;89:115–24.
[2] Kahle WK, Anderson MB, Alpert J, Stevens PM, Coleman SS. The value of pre-
liminary traction in the treatment of congenital dislocation of the hip. J Bone
Joint Surg Am 1990;72:1043–7.
[3] Schoenecker PL, Strecker WB. Congenital dislocation of the hip in children:
comparison of the effects of femoral shortening and of skeletal traction in
treatment. J Bone Joint Surg Am 1984;66:21–7.
[4] Landa J, Benke M, Feldman DS. The limbus and the neolimbus in developmental
dysplasia of the hip. Clin Orthop Relat Res 2008;466:776–81.
[5] Atsumi T, Kuroki Y. Role of impairment of blood supply of the femoral
head in the pathogenesis of idiopathic osteonecrosis. Clin Orthop Relat Res
1992;277:22–30.
[6] Ludloff K. The open reduction of the congenital hip dislocation by an anterior
incision. Am J Orthop Surg 1913;10:438–54.
[7] Mankey MG, Arntz GT, Staheli LT. Open reduction through a medial approach
for congenital dislocation of the hip: a critical review of the Ludloff approach
in sixty-six hips. J Bone Joint Surg Am 1993;75:1334–45.
[8] Ferguson Jr AB. Primary open reduction of congenital dislocation of the hip
using a median adductor approach. J Bone Joint Surg Am 1973;55:671–89.
[9] Diepstraten AF. Open reduction of congenital hip dislocation: advantages of the
Ferguson medial approach. Acta Orthop Scand 1985;56:32–5.
[10] Tumer Y, Ward WT, Grudziak J. Medial open reduction in the treatment of
developmental dislocation of the hip. J Pediatr Orthop 1997;17:176–80.
[11] Konigsberg DE, Karol LA, Colby S, O’Brien S. Results of medial open reduction of
the hip in infants with developmental dislocation of the hip. J Pediatr Orthop
2003;23:1–9.
[12] Klisic P, Jankovic L. Combined procedure of open reduction and shortening of
the femur in treatment of congenital dislocation of the hips in older children.
Clin Orthop Relat Res 1976;119:60–9.
[13] Galpin RD, Roach JW, Wenger DR, Herring JA, Birch JG. One-stage treatment of
congenital dislocation of the hip in older children, including femoral shorten-
ing. J Bone Joint Surg Am 1989;71:734–74.
S157
[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:
65–86.
[15] Wenger DR. Surgical treatment of developmental dysplasia of the hip. Instr
Course Lect 2014;63:313–23.
[16] Thomas S, Wedge J, Salter R. Outcome at forty-five years after open reduction
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
la SOFCOT, 7. Paris: Expansion scientifique française; 1977. p. 157–76.
[18] Kim HW, Morcuende JA, Dolan LA, Weinstein SL. Acetabular development in
developmental dysplasia of the hip complicated by lateral growth disturbance
of the capital femoral epiphysis. J Bone Joint Surg Am 2000;82:1692–700.
[19] Luhmann SJ, Schoenecker PL, Anderson AM, Bassett GS. The prognostic impor-
tance of the ossific nucleus in the treatment of congenital dysplasia of the hip.
J Bone Joint Surg Am 1998;80:1719–27.
[20] Roposch A, Stöhr KK, Dobson M. The effect of the femoral head ossific nucleus
in the treatment of developmental dysplasia of the hip: a meta-analysis. J Bone
Joint Surg Am 2009;91:911–8.
[21] Roposch A, Wedge JH, Krahn MD. The role of the ossific nucleus in the treatment
of established hip dislocation. Clin Orthop Relat Res 2006;449:295–302.
[22] Sankar WN, Tang EY, Moseley CF. Predictors of the need for femoral shortening
osteotomy during open treatment of developmental dislocation of the hip. J
Pediatr Orthop 2009;29:868–71.
[23] Sankar WN, Young CR, Lin AG, et al. Risk factors for failure after open reduction
for DDH: a matched cohort analysis. J Pediatr Orthop 2011;31:232–9.
[24] Renshaw TS. Inadequate reduction of congenital dislocation of the hip. J Bone
Joint Surg Am 1981;63:1114–21.
[25] Lagrange J, Rigault P, Pouliquen JC. Résultats de l’arthroplastie de Colonna. Rev
Chir Orthop 1973;59:353–73.
[26] Boardman DL, Moseley CF. Finding patients after 40 years: a very long-
term follow-up study of the Colonna arthroplasty. J Pediatr Orthop 1999;19:
169–76.
[27] Salter RB, Kostuik J, Dallas S. Avascular necrosis of the femoral head as a com-
plication of treatment for congenital dislocation of the hip in young children:
a clinical and experimental investigation. Can J Surg 1969;12:44–61.
[28] Kalamchi A, MacEwen GD. Avascular necrosis following treatment of congenital
dislocation of the hip. J Bone Joint Surg Am 1980;62:876–88.
[29] Aguş H, Omeroğlu H, Uçar H, Biçimoglu A, Türmer Y. Evaluation of the risk
factors of avascular necrosis of the femoral head in developmental dysplasia of
the hip in infants younger than 18 months of age. J Pediatr Orthop B 2002;11:
41–6.
[30] Roposch A, Liu L, Amaka C, Wedge J. Functional outcomes in children with
osteonecrosis secondary to treatment of developmental dysplasia of the hip. J
Bone Joint Surg Am 2011;93:145–50.