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Case report
Successful closed reduction after adductor tenotomy in a 14-year-old boy with chronic hip dislocation in Down syndrome Aidin Sadeghilara,b, Abdul Halim A. Rashida and Sharaf Ibrahima Dislocation or subluxation of the hip is considered as the most common hip problem in patients with Down syndrome. Recommended treatment of chronic dislocation treatment is open reduction combined with femoral and/or pelvis osteotomies. We report a Down syndrome child with chronic hip dislocation who was successfully treated with adductor tenotomy and closed reduction, which has not been reported previously. J Pediatr Orthop B c 2014 Wolters Kluwer Health | Lippincott 23:244–246 Williams & Wilkins.
Introduction Dislocation or subluxation of the hip is considered as the most common hip problem in patients with Down syndrome. The aetiology of hip instability is multifactorial, including ligamentous laxity and changes in the shape of the pelvis and the alignment of the acetabulum [1]. However, the main causes of hip instability are capsular laxity and hypotonia rather than acetabular dysplasia [2]. In most of the patients, symptoms of hip instability occur between the ages of 2 and 10 years and are uncommon at birth. In most cases, patients present with hip pain, limping or inability to walk. Untreated dislocation of the hip in Down syndrome may lead to permanent subluxation or dislocation, progressive dysplasia, poor gait and painful arthritis. The approach for
Journal of Pediatric Orthopaedics B 2014, 23:244–246 Keywords: closed reduction, Down syndrome, hip dislocation a
Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur and bDepartment of Orthopaedics, International Medical Schools, Management and Science University, Shah Alam, Malaysia Correspondence to Aidin Sadeghilar, MD, Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Kuala Lumpur, Malaysia Tel/fax: + 60 3 55216914; e-mail: [email protected]
hip dislocation includes operative and nonoperative treatments. However, for chronic dislocation, treatment recommendations have varied from open reduction combined with femoral and/or pelvis osteotomies to leaving the patient untreated. We report on a Down syndrome child with chronic hip dislocation who was treated with adductor tenotomy and closed reduction. To the best of our knowledge, there is no previous report of a successful closed reduction after adductor tenotomy in older children with a chronic hip dislocation in Down syndrome.
Case report An 11-year-old boy with Down syndrome initially presented to our clinic with gradual and progressive Fig. 2
Fig. 1
Normal hips at the age of 11 years.
c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
Radiograph of the pelvis at the age of 14 years showing the dislocated right hip.
DOI: 10.1097/BPB.0000000000000033
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Closed reduction of hip dislocation Sadeghilar et al. 245
Fig. 3
difficulty in walking without any history of trauma or fall. This was due to atlantoaxial instability, and he was treated with posterior instrumentation and fusion from the occiput to the C2 vertebra. The pelvic radiograph at the age of 11 years was normal (Fig. 1). At 14 years of age, his mother noticed shortening of the right lower limb and limited abduction of the right hip. Physical examination revealed limitation of right hip abduction to only 301. The affected limb was shorter by 3 cm. The radiograph of the pelvis showed posterior dislocation of the right hip with a dysplastic acetabulum and flattened head of the femur, indicating a chronic dislocation (Fig. 2). He was treated with an adductor tenotomy followed by a closed reduction. The hip was easily reducible (Fig. 3). He was immobilized in a single hip spica for 6 weeks. The follow-up of 20 months after the procedure showed features of avascular necrosis (AVN) of the reduced right hip. The patient remains asymptomatic (Fig. 4). The patient was followed up for 32 months after closed reduction. Radiographs showed healing of the AVN, but with flattening and lateral extrusion of the femoral head. The child has no pain and the hip is stable (Fig. 5). Written consent has been obtained from parents for publication purposes.
Discussion Right hip reduced after adductor tenotomy and closed reduction.
The successful closed reduction of the hip after adductor tenotomy in a 14-year-old boy with Down syndrome with
Fig. 4
Radiograph 20 months after adductor tenotomy and closed reduction showing features of avascular necrosis.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
246
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
Fig. 5
Open or percutaneous adductor tenotomy in chronic hip dislocation is often necessary because of secondary adduction contracture and for increasing the safe zone of adduction and abduction in which the hip remains reduced [1]. Subcutaneous adductor tenotomy in hip dislocation and subluxation is a safe procedure that can treat and prevent hip dislocation/subluxation [5]. Down syndrome patients have generalized ligament laxity and muscle hypotonia, which may lead to hip dislocation. However, the generalized ligament laxity has also facilitated the closed reduction in this patient. We did not have an MRI to determine the vascularity of the femoral head before the closed reduction. After adductor tenotomy, the head was easily reducible. The AVN was most likely due to the dislocation rather than the reduction as the femoral head could be reduced without difficulty in this child who has generalized ligament laxity. Despite various surgical treatments of this condition, postoperative recurrent instability is a common problem and parents must be informed of this complication [6]. Conclusion
We have shown that in a child with Down syndrome who has a chronic hip dislocation, closed reduction after an adductor tenotomy is possible and should be attempted. Radiograph 32 months after adductor tenotomy and closed reduction.
Acknowledgements This work was supported by ‘Universiti Kebangsaan Malaysia Medical Center’ internal grants.
chronic dislocation of the hip prompted a literature search to compare our experience with previously reported methods of treatment. Most authors reported that sequelae from recurrent subluxation or dislocation of the hips in Down syndrome may require surgery to prevent eventual disability. Although there are reports of closed reduction of hip dislocation in patients with Down syndrome [3], there is little consensus on how best to deal with these patients, particularly when they present late. Greene [4] reported nonoperative management of three hip dislocations in two patients with closed reduction, hip spica and prolonged immobilization. However, both of the cases were under 6 years of age and the dislocations were either acute or habitual.
Conflicts of interest
There are no conflicts of interest.
References 1 2 3 4 5
6
Lovell WW, Morrissy RT, Weinstein SL. Lovell and Winter’s pediatric orthopaedics. Philadelphia: Lippincott Williams & Wilkins; 2006. Mik G, Gholve PA, Scher DM, Widmann RF, Green DW. Down syndrome: orthopedic issues. Curr Opin Pediatr 2008; 20:30–36. Bennet GC, Rang M, Roye DP, Aprin H. Dislocation of the hip in trisomy 21. J Bone Joint Surg Br 1982; 64:289–294. Greene WB. Closed treatment of hip dislocation in Down syndrome. J Pediatr Orthop 1998; 18:643–647. Rolauffs B, Stuby F, Barth S, Ochs B, Aurich M, Weise K, et al. Prophylaxis and therapy for hip dislocations in patients with infantile cerebral palsy (ICP): motor functional, radiological and clinical results after subcutaneous adductor tenotomy. Z Orthop Unfall 2007; 145:505–510. Hresko MT, McCarthy JC, Goldberg MJ. Hip disease in adults with Down syndrome. J Bone Joint Surg Br 1993; 75:604–607.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Case report
Successful closed reduction after adductor tenotomy in a 14-year-old boy with chronic hip dislocation in Down syndrome Aidin Sadeghilara,b, Abdul Halim A. Rashida and Sharaf Ibrahima Dislocation or subluxation of the hip is considered as the most common hip problem in patients with Down syndrome. Recommended treatment of chronic dislocation treatment is open reduction combined with femoral and/or pelvis osteotomies. We report a Down syndrome child with chronic hip dislocation who was successfully treated with adductor tenotomy and closed reduction, which has not been reported previously. J Pediatr Orthop B c 2014 Wolters Kluwer Health | Lippincott 23:244–246 Williams & Wilkins.
Introduction Dislocation or subluxation of the hip is considered as the most common hip problem in patients with Down syndrome. The aetiology of hip instability is multifactorial, including ligamentous laxity and changes in the shape of the pelvis and the alignment of the acetabulum [1]. However, the main causes of hip instability are capsular laxity and hypotonia rather than acetabular dysplasia [2]. In most of the patients, symptoms of hip instability occur between the ages of 2 and 10 years and are uncommon at birth. In most cases, patients present with hip pain, limping or inability to walk. Untreated dislocation of the hip in Down syndrome may lead to permanent subluxation or dislocation, progressive dysplasia, poor gait and painful arthritis. The approach for
Journal of Pediatric Orthopaedics B 2014, 23:244–246 Keywords: closed reduction, Down syndrome, hip dislocation a
Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur and bDepartment of Orthopaedics, International Medical Schools, Management and Science University, Shah Alam, Malaysia Correspondence to Aidin Sadeghilar, MD, Department of Orthopaedics and Traumatology, Faculty of Medicine, Universiti Kebangsaan Malaysia, 56000 Kuala Lumpur, Malaysia Tel/fax: + 60 3 55216914; e-mail: [email protected]
hip dislocation includes operative and nonoperative treatments. However, for chronic dislocation, treatment recommendations have varied from open reduction combined with femoral and/or pelvis osteotomies to leaving the patient untreated. We report on a Down syndrome child with chronic hip dislocation who was treated with adductor tenotomy and closed reduction. To the best of our knowledge, there is no previous report of a successful closed reduction after adductor tenotomy in older children with a chronic hip dislocation in Down syndrome.
Case report An 11-year-old boy with Down syndrome initially presented to our clinic with gradual and progressive Fig. 2
Fig. 1
Normal hips at the age of 11 years.
c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 1060-152X
Radiograph of the pelvis at the age of 14 years showing the dislocated right hip.
DOI: 10.1097/BPB.0000000000000033
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Closed reduction of hip dislocation Sadeghilar et al. 245
Fig. 3
difficulty in walking without any history of trauma or fall. This was due to atlantoaxial instability, and he was treated with posterior instrumentation and fusion from the occiput to the C2 vertebra. The pelvic radiograph at the age of 11 years was normal (Fig. 1). At 14 years of age, his mother noticed shortening of the right lower limb and limited abduction of the right hip. Physical examination revealed limitation of right hip abduction to only 301. The affected limb was shorter by 3 cm. The radiograph of the pelvis showed posterior dislocation of the right hip with a dysplastic acetabulum and flattened head of the femur, indicating a chronic dislocation (Fig. 2). He was treated with an adductor tenotomy followed by a closed reduction. The hip was easily reducible (Fig. 3). He was immobilized in a single hip spica for 6 weeks. The follow-up of 20 months after the procedure showed features of avascular necrosis (AVN) of the reduced right hip. The patient remains asymptomatic (Fig. 4). The patient was followed up for 32 months after closed reduction. Radiographs showed healing of the AVN, but with flattening and lateral extrusion of the femoral head. The child has no pain and the hip is stable (Fig. 5). Written consent has been obtained from parents for publication purposes.
Discussion Right hip reduced after adductor tenotomy and closed reduction.
The successful closed reduction of the hip after adductor tenotomy in a 14-year-old boy with Down syndrome with
Fig. 4
Radiograph 20 months after adductor tenotomy and closed reduction showing features of avascular necrosis.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
246
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 3
Fig. 5
Open or percutaneous adductor tenotomy in chronic hip dislocation is often necessary because of secondary adduction contracture and for increasing the safe zone of adduction and abduction in which the hip remains reduced [1]. Subcutaneous adductor tenotomy in hip dislocation and subluxation is a safe procedure that can treat and prevent hip dislocation/subluxation [5]. Down syndrome patients have generalized ligament laxity and muscle hypotonia, which may lead to hip dislocation. However, the generalized ligament laxity has also facilitated the closed reduction in this patient. We did not have an MRI to determine the vascularity of the femoral head before the closed reduction. After adductor tenotomy, the head was easily reducible. The AVN was most likely due to the dislocation rather than the reduction as the femoral head could be reduced without difficulty in this child who has generalized ligament laxity. Despite various surgical treatments of this condition, postoperative recurrent instability is a common problem and parents must be informed of this complication [6]. Conclusion
We have shown that in a child with Down syndrome who has a chronic hip dislocation, closed reduction after an adductor tenotomy is possible and should be attempted. Radiograph 32 months after adductor tenotomy and closed reduction.
Acknowledgements This work was supported by ‘Universiti Kebangsaan Malaysia Medical Center’ internal grants.
chronic dislocation of the hip prompted a literature search to compare our experience with previously reported methods of treatment. Most authors reported that sequelae from recurrent subluxation or dislocation of the hips in Down syndrome may require surgery to prevent eventual disability. Although there are reports of closed reduction of hip dislocation in patients with Down syndrome [3], there is little consensus on how best to deal with these patients, particularly when they present late. Greene [4] reported nonoperative management of three hip dislocations in two patients with closed reduction, hip spica and prolonged immobilization. However, both of the cases were under 6 years of age and the dislocations were either acute or habitual.
Conflicts of interest
There are no conflicts of interest.
References 1 2 3 4 5
6
Lovell WW, Morrissy RT, Weinstein SL. Lovell and Winter’s pediatric orthopaedics. Philadelphia: Lippincott Williams & Wilkins; 2006. Mik G, Gholve PA, Scher DM, Widmann RF, Green DW. Down syndrome: orthopedic issues. Curr Opin Pediatr 2008; 20:30–36. Bennet GC, Rang M, Roye DP, Aprin H. Dislocation of the hip in trisomy 21. J Bone Joint Surg Br 1982; 64:289–294. Greene WB. Closed treatment of hip dislocation in Down syndrome. J Pediatr Orthop 1998; 18:643–647. Rolauffs B, Stuby F, Barth S, Ochs B, Aurich M, Weise K, et al. Prophylaxis and therapy for hip dislocations in patients with infantile cerebral palsy (ICP): motor functional, radiological and clinical results after subcutaneous adductor tenotomy. Z Orthop Unfall 2007; 145:505–510. Hresko MT, McCarthy JC, Goldberg MJ. Hip disease in adults with Down syndrome. J Bone Joint Surg Br 1993; 75:604–607.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
