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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 29  |  Issue : 2  |  Page : 109-112

A case of late sequela of infantile hip infection treated by Ilizarov hip reconstruction using monolateral fixator


1 Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal University, Karnataka, India
2 Department of Orthopaedics, Silchar Medical College and Hospital, Silchar, India
3 Department of Orthopaedics, Tezpur Medical College and Hospital, Tezpur, Assam, India

Date of Web Publication20-Aug-2015

Correspondence Address:
Srikanth Mudiganty
Flat CIII 10, KMC Staff Quarters, Mangalore, Karnataka, 575001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.163203

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  Abstract 

A 13-year-old female presented with chronic instability of her left hip due to late sequela of infantile hip infection. Instability of hip causes significant problems due to pain, limp, and shortening. Such a case is rare and difficult to treat. We performed a subtrochanteric valgus extension pelvic support osteotomy, along with distal varization and lengthening osteotomy utilizing a monolateral fixator. The patient was clinically and radiologically followed up for 24 months after her operation. The fixator was removed after 12 months once radiological union and adequate lengthening was achieved. Pre- and postoperative assessments were done using the Harris Hip Score, which showed a significant improvement. Long duration of usage of the fixator, knee stiffness, and pin tract infections are a few of the limitations observed.

Keywords: Monolateral fixator, Pelvic support osteotomy, Unstable hip


How to cite this article:
Mudiganty S, Sipani AK, Das SK. A case of late sequela of infantile hip infection treated by Ilizarov hip reconstruction using monolateral fixator. J Med Soc 2015;29:109-12

How to cite this URL:
Mudiganty S, Sipani AK, Das SK. A case of late sequela of infantile hip infection treated by Ilizarov hip reconstruction using monolateral fixator. J Med Soc [serial online] 2015 [cited 2020 Oct 20];29:109-12. Available from: https://www.jmedsoc.org/text.asp?2015/29/2/109/163203


  Introduction Top


Instability of the hip in an adolescent can be due to different causes including untreated developmental dysplasia of the hip, sequelae of neonatal septic arthritis, and paralytic conditions like poliomyelitis. Irrespective of the cause, this condition leads to significant disability due to pain, instability, limp, and shortening. The patient develops a Trendelenburg gait and an energy-inefficient gait. [1] The aim of surgery is to achieve a pain-free, stable hip with no limb length discrepancy.

The two main treatment modalities available include total joint replacement and pelvic support osteotomy. Total joint replacement is the treatment modality of choice, especially with the advances in metallurgy. But in young patients, joint replacement prosthesis is exposed to high mechanical stresses and has an increased risk of failure. Over a period of time, pelvic support osteotomy has become the treatment of choice for the treatment of chronic unstable hips in children and adolescents. [2]

Ilizarov hip reconstruction (IHR) refers to the combination of pelvic support valgus osteotomy with the distal femoral osteotomy for lengthening and varus correction. [3] However, the method of IHR is associated with complications like pin tract infections, discomfort of the patient, and decreased knee range of motion. [4] To overcome these disadvantages, modifications applying the same principles have been tried using monolateral fixators, [5] hybrid fixators, [6] or intramedullary devices. [7]

We report a case of chronic unstable hip in a 13-year-old female patient treated by pelvic support osteotomy and femoral lengthening using monolateral fixator.


  Case report Top


A 13-year-old girl presented to us with pain, limp, and shortening of her left extremity, suggestive of an unstable hip most probably as a sequela of infantile hip infection. Trendelenburg test was positive [Figure 1] and preoperative limb length discrepancy was 6.5 cm [Figure 2]. Her lumbar lordosis was not exaggerated, suggesting no fixed flexion deformity. Her preoperative Harris Hip Score was 71. X-ray evaluation confirmed the diagnosis as a Hunka stage IVB sequela of infantile hip infection [Figure 3].
Figure 1 : Clinical photograph showing pelvic drop

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Figure 2 : Clinical photograph showing limb length discrepancy

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Figure 3 : Preoperative x-ray

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Before the operation, anteroposterior radiograph with the extremity in maximum adduction was taken. The first osteotomy was planned where the femoral shaft crossed the ischium in this radiograph. The amount of valgus at this osteotomy is determined by adding 15° to the femoropelvic adduction angle. Overcorrection of 15° is done to compensate for the remodeling and abductor muscle fatigue. The second osteotomy was performed to correct the limb length discrepancy and to realign the limb. The level of distal osteotomy was planned with the help of a paper tracing. A line called the proximal mechanical axis (PMA) was drawn perpendicular to the horizontal axis of the pelvis and was distally extended so as to pass through the proximal osteotomy. The distal mechanical axis (DMA) was drawn from the center of the ankle joint to the center of the knee joint and extended proximally. Distal osteotomy was performed at the intersection of these two lines. The angle between the PMA and DMA determines the amount of varus at the second osteotomy.

During the operation, the patient was placed on a radiolucent table and her limb was held in maximal adduction by an assistant. Two Schanz screws (S. H. Pitkar Orthotools) were placed in the proximal fragment and two in the middle fragment. Proximal osteotomy was done and the pins were connected to the rail with the help of swivel clamps. Three Schanz screws were placed in the distal fragment and distal osteotomy was done, and the screws were connected to the rail with a swivel clamp (S. H. Pitkar Orthotools) [Figure 4].
Figure 4 : Immediate postoperative x-ray

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After the operation, the patient was allowed partial weight-bearing by the third day with the help of axillary crutches. Distraction was started on the 10 th postoperative day at 1 mm/day. Full weight-bearing was encouraged as per the comfort of the patient and weaning from the axillary crutches was encouraged. Distraction was done till there was no limb length discrepancy, which was for a period of 60 days. Regular pin tract dressing was done by the patient with boiled water.

The patient was followed up every month with clinical assessment and x-rays [Figure 5].
Figure 5 : 1-year postoperative x-ray before removal of the frame

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The frame was removed after 1 year of the operation and the patient was followed up for 1 year thereafter. She had no shortening, no limp, and a good range of motion of the hip joint. Her postoperative Harris Hip Score was 93 as against the preoperative score of 71. Pin tract infections were noted, which subsided with regular dressings and oral administration of antibiotics. However, stiffness of her knee was noted but it gradually improved with physiotherapy with knee range of motion at the final follow-up being 0-90°.


  Discussion Top


Hunka described the following five types of sequelae from neonatal septic arthritis: 1- minimal or no femoral head changes; 2A- femoral head deformity but the physis remains intact, 2B- femoral head deformity with the physis closed; 3- femoral neck pseudarthrosis; 4A- complete destruction of the femoral head but stable neck segment, 4B- complete destruction of the femoral head but unstable neck segment; and 5- complete destruction of the head and the neck with dislocation [Figure 6]. Hunka stage 4 and stage 5 hips are unstable hip joints and are indications for pelvic support osteotomy. [8]

The aim of treating an unstable hip joint as a sequela to infantile hip infection is to correct the gait abnormality by improving the abductor efficiency, correcting the limb length discrepancy, and improving the hip biomechanics. Pelvic support osteotomy and total hip arthroplasty are the two treatment modalities available for treatment. However, hip arthroplasty is associated with many complications and is best avoided in patients less than 15 years of age. [9]
Figure 6 : Hunka classification of sequelae from neonatal hip arthritis

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Unstable hip joint due to a neglected congenital hip dislocation in children more than 5 years of age and who do not meet the criteria for a cartilage-preserving surgery may be treated using a Colonna capsular arthroplasty that involves preoperative traction, capsular interposition, and subsequent femoral rotational osteotomy. [10] Congenital femoral deficiency is treated using the superhip procedure described by Paley et al. [11] "SUPER" is an acronym for Systematic Utilitarian Procedure for Extremity Reconstruction. The superhip procedure involves a pelvic osteotomy and a proximal femoral osteotomy to correct the deformity.

Pelvic support osteotomy initially showed good results but was associated with drawbacks like knee valgus and failure to correct limb length discrepancy till the introduction of second distal osteotomy by Ilizarov. [12] Paley et al. have performed IHR using the conventional frame in eight patients with unstable hips as a sequela of septic arthritis who had a mean of 11.2 years. [13]

Knee stiffness and recurrent pin tract infections are complications of the conventional IHR. Transfixion of the large muscle groups and tightening of the quadriceps muscle due to femoral lengthening lead to knee stiffness. [4] Aggressive postoperative physical therapy is mandatory to achieve functional knee range of motion. Physiotherapy is continued even after removal of the frame. The use of transosseous wires that pass through the large muscle groups significantly increase the risk of pin tract infections; the use of multiple wires causes pain and difficulty in pin tract dressing. [14] The use of monolateral fixators significantly decreases the risk of these complications.

Results of the monolateral fixator in comparison to the conventional Ilizarov frame are similar in terms of healing, duration, and angular deformities but the incidence and severity of complications like pin tract infections and knee stiffness are much less in the former. [15] In addition, a significant number of patients tend to experience extreme discomfort with the use of the Ilizarov frame. However, with the use of monolateral fixator, difficulty is experienced in the insertion of three uniplanar Schanz pins in the proximal fragment that is already deformed as a sequela of septic arthritis.

To summarize, IHR is an excellent treatment option for young patients with hip instability as a sequela to septic arthritis. There is a significant improvement in hip biomechanics and gait mechanism. Use of monolateral fixator decreases the number of complications and ensures the patient's comfort. However, pin tract infections, knee stiffness, and relatively long period of usage of the fixator are limitations of this procedure.

Acknowlegdements

We are extremely thankful to our colleagues and the staff of the Department of Orthopaedics, Silchar Medical College & Hospital, Silchar, Assam, India. We are extremely grateful to Dr. Mangal Parihar, Mumbai, Maharashtra, India for his invaluable guidance during the entire treatment. We would like to thank the patient and her guardians for having faith in us.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pafilas D, Nayagam S. The pelvic support osteotomy: Indications and pre-operative planning. Strategies Trauma Limb Reconstr 2008;3: 83-92.  Back to cited text no. 1
    
2.
Rozbruch SR, Paley D, Behave A, Herzenberg JE. Ilizarov hip reconstruction for the late sequelae of infantile hip infection. J Bone Joint Surg Am 2005;87:1007-18.  Back to cited text no. 2
    
3.
Paley D. Hip joint considerations, the pelvic support osteotomy. In: Principles of Deformity Correction. Berlin: Springer; 2002. p. 647-94.  Back to cited text no. 3
    
4.
Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res 1990;250:81-104.  Back to cited text no. 4
    
5.
Inan M, Bowen RJ. A pelvic support osteotomy and femoral lengthening with monolateral fixator. Clin Orthop Relat Res 2005;440:192-8.  Back to cited text no. 5
    
6.
Shetty GM, Song HR, Lee SH, Kim TY. Bilateral valgus-extension osteotomy of hip using hybrid external fixator in spondyloepiphyseal dysplasia: Early results of a salvage procedure. J Pediatr Orthop B 2008;17:21-5.  Back to cited text no. 6
    
7.
Krieg AH, Lenze U, Hasler CC. Ilizarov hip reconstruction without external fixation: A new technique. J Child Orthop 2010;4:259-66.  Back to cited text no. 7
    
8.
Hunka L, Said SE, MacKenzie DA, Rogala EJ, Cruess RL. Classification and surgical management of the severe sequelae of septic hips in children. Clin Orthop Relat Res 1982;30-6.  Back to cited text no. 8
    
9.
Dudkiewicz I, Salai M, Israeli A, Amit Y, Chechick A. Total hip arthroplasty in patients younger than 30 years of age. Isr Med Assoc J 2003;5:709-12.  Back to cited text no. 9
    
10.
Colonna PC. Capsular arthroplasty for congenital dislocation of the hip: Indications and technique; Some long-term results. J Bone Joint Surg Am 1965;47:437-49.  Back to cited text no. 10
    
11.
Paley D, Standard SC. Treatment of congenital femoral deficiency. In: Flynn JM, editor. Operative Techniques in Orthopaedic Paediatric Surgery. Philadelphia: Lippincott Williams & Wilkins; 2011. p. 177-98.  Back to cited text no. 11
    
12.
Paley D. Principles of Deformity Correction. New York: Springer; 2002. p. 689-94.  Back to cited text no. 12
    
13.
Rozbruch SR, Paley D, Bhave A, Herzenber JE. Ilizarov hip reconstruction for the late sequelae of infantile hip infection. J Bone Joint Surg Am 2005;87:1007-18.  Back to cited text no. 13
    
14.
Inan M, Alkan A, Harma A, Ertem K. Evaluation of the gluteus medius muscle after a pelvic support osteotomy to treat congenital dislocation of the hip. J Bone Joint Surg Am. 2005;87:2246-52.  Back to cited text no. 14
    
15.
Inan M, Bomar JD, Küçükkaya M, Harma A. A comparison between the use of a monolateral external fixator and the Ilizarov technique for pelvic support osteotomies. Acta Orthop Traumatol Turc 2004;38: 252-60.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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