Capsular augmentation in Colonna arthroplasty for the management of chronic hip dislocation

Capsular augmentation in Colonna arthroplasty for the management of chronic hip dislocation Journal of Hip Preservation Surgery Vol. 5, No. 1, pp. 34–38 doi: 10.1093/jhps/hnx045 Advance Access Publication 11 January 2018 Technical Tips Capsular augmentation in Colonna arthroplasty for the management of chronic hip dislocation Matthew Sloan and Atul F. Kamath* Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA *Correspondence to: A. F. Kamath. Department of Orthopedic Surgery, Center for Hip Preservation, Penn Medicine, 800 Spruce Street, Pennsylvania Hospital, 8th Floor Preston, Philadelphia, PA 19107, USA. E-mail: akamath@post.harvard.edu Submitted 1 March 2017; Revised 12 November 2017; revised version accepted 12 December 2017 ABSTRACT Colonna capsular arthroplasty represents an option for the management of chronic hip dislocation in young patients with dysplasia. In the appropriate patient, modern capsular arthroplasty procedures may provide an opportunity for hip preservation in patients with preserved femoral head cartilage and not appropriate for total hip arthroplasty. Here, we review our experience with surgical dislocation of the hip and capsular arthroplasty in a 27-year-old female with congenital hip dysplasia and chronic superior hip dislocation. Due to inadequate native capsular tissue, a decellularized dermal allograft was used for interposition and capsular arthroplasty augmenta- tion. The femoral head with preserved articular cartilage was reduced into the enlarged native acetabulum using a parachute technique to hold the allograft in position. Post-operatively, the patient was placed in a hip abduction brace and made non-weight bearing for six weeks. A conservative physical therapy protocol was implemented to allow gradual increase in weight bearing and range of motion over the first 12 weeks post-operatively. Other series have reported promising outcomes in selected INTRODUCTION patients [2, 3]. Capsular arthroplasty has been performed for over Here, we review our experience with surgical dislocation 100 years as a treatment for complete hip dislocation in of the hip and capsular arthroplasty for congenital hip dys- children and young adults. It was first described by plasia and chronic superior hip dislocation. This technical Codivilla in 1901, then later reported by Hey Groves in note describes the use of a decellularized dermal allograft 1926 and Colonna in 1932. The technique involves wrap- for interposition and capsular arthroplasty augmentation, ping the femoral head within the hip capsule prior to per- due to inadequate native capsular tissue volume. The fem- forming hip reduction into the true acetabulum. oral head with preserved articular cartilage was reduced This procedure was historically complicated by high rates into the enlarged native acetabulum using a parachute of osteonecrosis and need for further procedures. technique to hold the allograft in position. Improved outcomes with total hip arthroplasty (THA) additionally diminished enthusiasm for the capsular arthro- plasty technique. Ganz et al. reviewed a contemporary SURGICAL TECHNIQUE one-stage procedure with safe surgical hip dislocation and This is a 27-year-old female who presented with left hip capsular arthroplasty in nine patients with chronic hip dis- pain and chronic high femoral head dislocation. She pre- locations. The authors found a mean Harris Hip Score sented to clinic with a limp, pelvic obliquity, and leg length (HHS) of 84 at a mean of 7.5 years follow-up, with one pa- discrepancy. She had no prior hip surgery. Her pain was tient proceeding to THA after 27 years [1]. The patients located in the groin and buttocks. The patient had a 2 cm did require repeat surgery 18–30% of the time to address leg length discrepancy, with the left leg shorter. The left persistent mechanical issues or for repeated hip reduction. hip ranged from 10 of extension to 110 of flexion. Hip V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Capsular augmentation in Colonna arthroplasty  35 internal rotation was 50 , and external rotation was 40 . Intra-operative templated head size in our patient, for Hip abduction was 40 , and hip adduction was 20 .Her example, was 40 mm. Lactated ringer irrigation is used to abductor muscle strength was intact when tested in the bathe the cartilage to avoid cartilage desiccation during standing and lateral decubitus positions. exposure. From preoperative planning, it was clear that the pa- After the cartilage is evaluated and deemed adequate for tient’s capsular volume was low and stretched superiorly preservation, attention is turned to identification of the native due to chronic dislocation. Due to the nature of the patient’s acetabulum. Chronic dislocation leads to scar formation and chronic superior dislocation position, we had an Arthrex capsular attenuation. Careful dissection inferiorly toward the Arthroflex Dermal Allograft (Naples, FL, USA) available as native acetabulum is performed and tactile feel is used to an alternative capsular arthroplasty material. This graft is identify the dysplastic acetabular rim. A radio-opaque instru- made from human donor dermal tissue that undergoes a ment is placed in the inferior border and a fluoroscopic image decellularizing process, which removes>97% of donor is taken to confirm alignment relative to the teardrop. The DNA (less than 1 viable particle per million). The tissue is native acetabulum is then reamed and compared in volume stored at room temperature and retains the biomechanical with the templated native femoral head size. Preliminary re- properties of the dermis without detriment to the elastin duction is performed with a moistened lap sponge covering and collagen structure. The graft provides a collagen scaffold the femoral head cartilage. If the head is too large for the na- for vascular and fibrous tissue ingrowth [4]. tive acetabulum, head reduction is performed. For treatment of leg length discrepancy and potential sci- In our presented case, the sciatic nerve was not under atic nerve traction injury, we considered femoral shortening excessive tension with the hip reduced and knee fully ex- osteotomy. If this procedure were performed, the osteotom- tended, and the soft tissues appeared appropriately ten- ized bone could be used for the shelf autograft. Alternatively sioned. With adequate femoral head reduction, the decision graft would be drawn from the iliac crest if no femoral was made to forego femoral shortening osteotomy and per- shortening osteotomy was performed. A straight plate can form iliac crest bone graft harvest for shelf autograft aceta- affix a shortening osteotomy (usually up to 3 cm), with or buloplasty to supplement the dysplastic superior rim [7]. without derotation to accommodate abnormal femoral ver- The graft was sized at the superior acetabular rim for ad- sion. Finally, a varusization proximal femoral osteotomy with equate coverage and extracted en bloc from the iliac crest. blade plate fixation was considered in the event that reduc- The shelf graft was fashioned, and excess bone was saved tion into the native acetabulum was complicated by instability for autograft packing about the shelf. The shelf was then or extra-articular impingement. Trochanteric advancement secured in place with two cannulated screws. can also reduce any residual extra-articular impingement, and The patient’s native anatomy afforded a low-volume improve abductor functional length. Pre-operative imaging socket. At this time, with the shelf in place, the acetabulum and planning diagrams are shown in Fig. 1. was reamed to form a concentric socket, starting with a The approach for surgical dislocation of the hip has 36-mm reamer centrally to clear the remnant pulvinar tis- been described previously [5]. During the Gibson ap- sue. Serially reaming was performed to expand the socket proach in our case patient, the abductor musculature dem- orifice, up to one millimeter larger than the femoral head onstrated no signs of atrophy. Capsulotomy is performed measurement. Reaming continued sequentially to medial- carefully to avoid injury to the medial femoral circumflex ize and optimize abduction and anteversion of the native artery that runs posterosuperiorly to the lesser trochanter acetabulum with the new shelf. Frequent assessment of the and provides the main blood supply to the femoral head thickness of the anterior and posterior walls of the acetabu- [6]. Long anterior- and posterior-based leaflets of native lum was performed, in order to avoid iatrogenic thinning capsule were fashioned from the existing capsular sleeve. In out of the walls. Several millimeters of cortical wall thick- our case, there was attenuation in both volume and thick- ness remained after reaming. The shelf graft was used to ness of the capsule, so that complete coverage of the fem- augment the total acetabular volume. oral head was not possible. We also sought to increase the Next, the capsule is assessed for capsular arthroplasty, to volume of capsule that would serve as the final capsular provide interposed tissue and prevent adhesion between the interposition arthroplasty surface. Therefore, the dermal reamed native acetabulum (now devoid of articular cartilage) graft was chosen to augment the central and superior as- and the femoral head. Native capsule may not always be suffi- pects of the femoral head. cient, and capsular adequacy must be carefully evaluated to The articular cartilage of the femoral head can be as- determine if augmentation is necessary. In some instances of sessed circumferentially (Fig. 2). A sizing template is laid chronic high dislocation the capsule may be stretched, but over the femoral head to estimate appropriate cup size. not attenuated and, thus, viable for this purpose. In our case, Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 36  M. Sloan and A. F. Kamath Fig. 1. Pre-operative imaging: (A) anteroposterior (AP) pelvis X-ray. (B) Left hip AP and lateral X-ray. (C) Right and left hip false profile views. (D) Bilateral leg-length scanogram. (E) Pelvis CT axial cuts. The calculated femoral anteversion was 9 .(F) Left hip CT 3D reconstructions. (G) Left hip MRI arthrogram demonstrating low hip capsule volume despite high dislocation. (H) AP pelvis with preoperative template for native acetabulum location, trochanteric osteotomy, and possible femoral shortening osteotomy. the capsule was too attenuated over the length of the chronic dislocation area to cover the femoral head adequately and of insufficient thickness to provide a durable interposition bear- ing surface. Therefore, a dermal allograft of 40 mm 70 mm in size, and 3.0 mm in thickness, was used to augment cover- age of the femoral head. We placed stay sutures in each cor- ner of the allograft to effect a parachute technique into the acetabulum and to hold the graft in place during the reduc- tion maneuver (Fig. 3). The dermal side [4] of the graft ap- poses the femoral head to provide a soft, gliding interposed surface intra-articularly. With the allograft draped over the acetabulum, the stay sutures attached anteriorly were used to hold the graft in place. The posterior stay sutures were pos- itioned with one inferior to the femoral neck and one super- iortothe femoralnecktoprovide tension thatkeeps the Fig. 2. Exposure of the intact articular cartilage of the femoral head. graft from bunching underneath the femoral head. In this Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Capsular augmentation in Colonna arthroplasty  37 with the head in the reduced position and capsule secured. Deep closure was then performed, and the trochanteric flip osteotomy was repaired with two cortical screws. On-table range of motion in our patient demonstrated hip stability in full extension, extension and external rotation, as well as com- bined hip flexion to 90 and internal rotation to 50 . POST-OPERATIVE PROTOCOL After sterile closure and dressing, the patient is immediately Fig. 3. Stay sutures placed in each corner of the dermal allograft to allow appropriate tensioning and positioning within the acet- placed in a hip abduction brace and post-operative imaging abulum during the final femoral head reduction maneuver. is performed (Fig. 5A and B). The patient is made non- weight bearing for at least 6 weeks. We prefer a regimen with serial decreases in degree of abduction over the first few weeksashealing progresses to prevent dislocation/sublux- ation. The patient is maintained in an abduction brace for 3 months post-operatively. The patient’s weight bearing was progressed to weight-bearing as tolerated by 4 months post- operatively. A detailed post-operative physical therapy pro- gram has been previously described [1] and found useful in our practice for this augmentation procedure as well as the ‘standard’ Colonna procedure. We choose to use a hip ab- duction brace, instead of spica casting, in compliant patients to aidwithhygiene and wound care needs. Increase of ab- ductor strengthening is developed throughout the rehabilita- tion period. We do not use a continuous passive motion machine in our protocol, though one could consider this an option to improve hip range of motion after the passage of Fig. 4. Femoral head reduced via a parachute of interposed dermal adequate time for healing. allograft. The superior rim shelf autograft affixed with two screws is also visible. Cranial side of body is to the right of the image. The patient continues to do well at 8 months post- operatively, with maintenance of reduction and the femoral manner, we could control the tension and coverage over the head centered under the stable, healed shelf osteotomy articulating surface of the femoral head during delivery into (Fig. 5C). The patient’s most recent hip range of motion is the native socket. The native anterior and posterior capsular from 10 of extension to 100 of flexion, and she currently leaflets were secured to the dermal graft. Graft thickness ob- walks without any assistive device and no limp. tained was 2 mm in thickness after preparation (saline soak, serial stretching, and gentle tensioning over the femoral DISCUSSION head). The graft is pliable and has the ability to conform to The practice of capsular arthroplasty has long been the acetabular cavity created. We sought to place the thick described, with variable results in the historical literature. graft material in the superior weight-bearing zone instead of Recent series, however, have reported promising outcomes the attenuated host capsule for durability of the articulation. in selected patients. Chung et al. reported satisfactory HHS The femoral head is then reduced as described earlier into in over half of Colonna’s patients at 17 years follow-up [2]. this interposed allograft parachute. Due to the compressible Pozo et al. found that nearly three-quarters of patients had nature of the graft, it conformed snugly to the acetabulum an HHS over 80 at 20-year follow-up [3]. As THA has and allowed for femoral head reduction. The stay sutures can demonstrated an increased failure rate in patients under 50 then be tied down to remnant capsule using a free needle years old [8, 9], continued development of hip preservation with interrupted sutures in circumferential fashion about the techniques in the young patient, with adequate femoral femoral head and neck. Supplemental 0-vicryl partial-thick- head cartilage despite hip dislocation, is needed. ness sutures allow for full integration of host capsule to the Capsular arthroplasty, in conjunction with modern hip allograft tissue, to engulf the femoral head in the capsular preservation techniques, may offer a viable option for arthroplasty (Fig. 4). A final assessment of tension on the sci- chronic hip dislocation, and allograft capsular augmentation atic nerve is made, as well as length and rotation of the limb, may help to address capsular deficiency. In order for this to Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 38  M. Sloan and A. F. Kamath Fig. 5. Post-operative X-rays. (A) Intra-operative left hip AP fluoroscopic view demonstrating adequate femoral head reduction. (B) Post-operative AP pelvis X-ray in hip abduction brace. (C) 8-Month post-operative AP pelvis X-ray. be a viable option, the candidate must have functional ab- REFERENCES ductor musculature and preferably no prior surgery to the 1. Ganz R, Slongo T, Siebenrock KA et al. Surgical technique: The hip or abductors, which could interfere with hip biomech- capsular arthroplasty: a useful but abandoned procedure for young anics upon hip reduction. When performing this procedure, patients with developmental dysplasia of the hip. Clin Orthop Relat it is imperative to evaluate preoperative advanced imaging Res 2012; 470: 2957–67. 2. Chung SM, Scholl HW, Ralston EL, Pendergrass EP. The Colonna for capsular deficiency and repeat intraoperative evaluation capsular arthroplasty. A long-term follow-up study of fifty-six pa- to determine whether capsular arthroplasty without aug- tients. J Bone Joint Surg Am 1971; 53: 1511–27. mentation is feasible. For such cases where there is concern 3. Pozo JL, Cannon SR, Catterall A. The Colonna–Hey Groves for deficient capsular tissue, we recommend having an allo- arthroplasty in the late treatment of congenital dislocation of the graft available to provide augmentation for femoral head hip. A long-term review. J Bone Joint Surg Br 1987; 69: 220–8. coverage if necessary. Other interposition options for cap- 4. Achilles Tendon Reinforcement with ArthroFlex Decellularized sular augmentation could include autograft or allograft fa- Dermis. Package Insert 2015. 5. Ganz R, Gill TJ, Gautier E et al. Surgical dislocation of the adult scia lata, though one must select these materials carefully as hip a technique with full access to the femoral head and acetabu- volume and thickness can be donor dependent. We have lum without the risk of avascular necrosis. J Bone Joint Surg Br described the dermal allograft augmentation parachute 2001; 83: 1119–24. technique as one way to maneuver the allograft around the 6. Kalhor M, Beck M, Huff TW, Ganz R. Capsular and pericapsular femoral head during the reduction maneuver, and to com- contributions to acetabular and femoral head perfusion. J Bone pletely encompass the femoral head when native tissue is Joint Surg Am 2009; 91: 409–18. deficient. 7. Nishimatsu H, Iida H, Kawanabe K et al. The modified Spitzy shelf operation for patients with dysplasia of the hip. A 24-year follow- up study. J Bone Joint Surg Br 2002; 84: 647–52. FUNDING 8. Siebenrock KA, Scho¨ll E, Lottenbach M, Ganz R. Bernese periace- This work was not supported by any outside funding source. tabular osteotomy. Clin Orthop Relat Res 1999; 363: 9–20. 9. Ramiah RD, Ashmore AM, Whitley E, Bannister GC. Ten-year life CONFLICT OF INTEREST STATEMENT expectancy after primary total hip replacement. J Bone Joint Surg Br None declared. 2007; 89: 1299–302. Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Hip Preservation Surgery Oxford University Press

Capsular augmentation in Colonna arthroplasty for the management of chronic hip dislocation

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Journal of Hip Preservation Surgery Vol. 5, No. 1, pp. 34–38 doi: 10.1093/jhps/hnx045 Advance Access Publication 11 January 2018 Technical Tips Capsular augmentation in Colonna arthroplasty for the management of chronic hip dislocation Matthew Sloan and Atul F. Kamath* Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA *Correspondence to: A. F. Kamath. Department of Orthopedic Surgery, Center for Hip Preservation, Penn Medicine, 800 Spruce Street, Pennsylvania Hospital, 8th Floor Preston, Philadelphia, PA 19107, USA. E-mail: akamath@post.harvard.edu Submitted 1 March 2017; Revised 12 November 2017; revised version accepted 12 December 2017 ABSTRACT Colonna capsular arthroplasty represents an option for the management of chronic hip dislocation in young patients with dysplasia. In the appropriate patient, modern capsular arthroplasty procedures may provide an opportunity for hip preservation in patients with preserved femoral head cartilage and not appropriate for total hip arthroplasty. Here, we review our experience with surgical dislocation of the hip and capsular arthroplasty in a 27-year-old female with congenital hip dysplasia and chronic superior hip dislocation. Due to inadequate native capsular tissue, a decellularized dermal allograft was used for interposition and capsular arthroplasty augmenta- tion. The femoral head with preserved articular cartilage was reduced into the enlarged native acetabulum using a parachute technique to hold the allograft in position. Post-operatively, the patient was placed in a hip abduction brace and made non-weight bearing for six weeks. A conservative physical therapy protocol was implemented to allow gradual increase in weight bearing and range of motion over the first 12 weeks post-operatively. Other series have reported promising outcomes in selected INTRODUCTION patients [2, 3]. Capsular arthroplasty has been performed for over Here, we review our experience with surgical dislocation 100 years as a treatment for complete hip dislocation in of the hip and capsular arthroplasty for congenital hip dys- children and young adults. It was first described by plasia and chronic superior hip dislocation. This technical Codivilla in 1901, then later reported by Hey Groves in note describes the use of a decellularized dermal allograft 1926 and Colonna in 1932. The technique involves wrap- for interposition and capsular arthroplasty augmentation, ping the femoral head within the hip capsule prior to per- due to inadequate native capsular tissue volume. The fem- forming hip reduction into the true acetabulum. oral head with preserved articular cartilage was reduced This procedure was historically complicated by high rates into the enlarged native acetabulum using a parachute of osteonecrosis and need for further procedures. technique to hold the allograft in position. Improved outcomes with total hip arthroplasty (THA) additionally diminished enthusiasm for the capsular arthro- plasty technique. Ganz et al. reviewed a contemporary SURGICAL TECHNIQUE one-stage procedure with safe surgical hip dislocation and This is a 27-year-old female who presented with left hip capsular arthroplasty in nine patients with chronic hip dis- pain and chronic high femoral head dislocation. She pre- locations. The authors found a mean Harris Hip Score sented to clinic with a limp, pelvic obliquity, and leg length (HHS) of 84 at a mean of 7.5 years follow-up, with one pa- discrepancy. She had no prior hip surgery. Her pain was tient proceeding to THA after 27 years [1]. The patients located in the groin and buttocks. The patient had a 2 cm did require repeat surgery 18–30% of the time to address leg length discrepancy, with the left leg shorter. The left persistent mechanical issues or for repeated hip reduction. hip ranged from 10 of extension to 110 of flexion. Hip V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Capsular augmentation in Colonna arthroplasty  35 internal rotation was 50 , and external rotation was 40 . Intra-operative templated head size in our patient, for Hip abduction was 40 , and hip adduction was 20 .Her example, was 40 mm. Lactated ringer irrigation is used to abductor muscle strength was intact when tested in the bathe the cartilage to avoid cartilage desiccation during standing and lateral decubitus positions. exposure. From preoperative planning, it was clear that the pa- After the cartilage is evaluated and deemed adequate for tient’s capsular volume was low and stretched superiorly preservation, attention is turned to identification of the native due to chronic dislocation. Due to the nature of the patient’s acetabulum. Chronic dislocation leads to scar formation and chronic superior dislocation position, we had an Arthrex capsular attenuation. Careful dissection inferiorly toward the Arthroflex Dermal Allograft (Naples, FL, USA) available as native acetabulum is performed and tactile feel is used to an alternative capsular arthroplasty material. This graft is identify the dysplastic acetabular rim. A radio-opaque instru- made from human donor dermal tissue that undergoes a ment is placed in the inferior border and a fluoroscopic image decellularizing process, which removes>97% of donor is taken to confirm alignment relative to the teardrop. The DNA (less than 1 viable particle per million). The tissue is native acetabulum is then reamed and compared in volume stored at room temperature and retains the biomechanical with the templated native femoral head size. Preliminary re- properties of the dermis without detriment to the elastin duction is performed with a moistened lap sponge covering and collagen structure. The graft provides a collagen scaffold the femoral head cartilage. If the head is too large for the na- for vascular and fibrous tissue ingrowth [4]. tive acetabulum, head reduction is performed. For treatment of leg length discrepancy and potential sci- In our presented case, the sciatic nerve was not under atic nerve traction injury, we considered femoral shortening excessive tension with the hip reduced and knee fully ex- osteotomy. If this procedure were performed, the osteotom- tended, and the soft tissues appeared appropriately ten- ized bone could be used for the shelf autograft. Alternatively sioned. With adequate femoral head reduction, the decision graft would be drawn from the iliac crest if no femoral was made to forego femoral shortening osteotomy and per- shortening osteotomy was performed. A straight plate can form iliac crest bone graft harvest for shelf autograft aceta- affix a shortening osteotomy (usually up to 3 cm), with or buloplasty to supplement the dysplastic superior rim [7]. without derotation to accommodate abnormal femoral ver- The graft was sized at the superior acetabular rim for ad- sion. Finally, a varusization proximal femoral osteotomy with equate coverage and extracted en bloc from the iliac crest. blade plate fixation was considered in the event that reduc- The shelf graft was fashioned, and excess bone was saved tion into the native acetabulum was complicated by instability for autograft packing about the shelf. The shelf was then or extra-articular impingement. Trochanteric advancement secured in place with two cannulated screws. can also reduce any residual extra-articular impingement, and The patient’s native anatomy afforded a low-volume improve abductor functional length. Pre-operative imaging socket. At this time, with the shelf in place, the acetabulum and planning diagrams are shown in Fig. 1. was reamed to form a concentric socket, starting with a The approach for surgical dislocation of the hip has 36-mm reamer centrally to clear the remnant pulvinar tis- been described previously [5]. During the Gibson ap- sue. Serially reaming was performed to expand the socket proach in our case patient, the abductor musculature dem- orifice, up to one millimeter larger than the femoral head onstrated no signs of atrophy. Capsulotomy is performed measurement. Reaming continued sequentially to medial- carefully to avoid injury to the medial femoral circumflex ize and optimize abduction and anteversion of the native artery that runs posterosuperiorly to the lesser trochanter acetabulum with the new shelf. Frequent assessment of the and provides the main blood supply to the femoral head thickness of the anterior and posterior walls of the acetabu- [6]. Long anterior- and posterior-based leaflets of native lum was performed, in order to avoid iatrogenic thinning capsule were fashioned from the existing capsular sleeve. In out of the walls. Several millimeters of cortical wall thick- our case, there was attenuation in both volume and thick- ness remained after reaming. The shelf graft was used to ness of the capsule, so that complete coverage of the fem- augment the total acetabular volume. oral head was not possible. We also sought to increase the Next, the capsule is assessed for capsular arthroplasty, to volume of capsule that would serve as the final capsular provide interposed tissue and prevent adhesion between the interposition arthroplasty surface. Therefore, the dermal reamed native acetabulum (now devoid of articular cartilage) graft was chosen to augment the central and superior as- and the femoral head. Native capsule may not always be suffi- pects of the femoral head. cient, and capsular adequacy must be carefully evaluated to The articular cartilage of the femoral head can be as- determine if augmentation is necessary. In some instances of sessed circumferentially (Fig. 2). A sizing template is laid chronic high dislocation the capsule may be stretched, but over the femoral head to estimate appropriate cup size. not attenuated and, thus, viable for this purpose. In our case, Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 36  M. Sloan and A. F. Kamath Fig. 1. Pre-operative imaging: (A) anteroposterior (AP) pelvis X-ray. (B) Left hip AP and lateral X-ray. (C) Right and left hip false profile views. (D) Bilateral leg-length scanogram. (E) Pelvis CT axial cuts. The calculated femoral anteversion was 9 .(F) Left hip CT 3D reconstructions. (G) Left hip MRI arthrogram demonstrating low hip capsule volume despite high dislocation. (H) AP pelvis with preoperative template for native acetabulum location, trochanteric osteotomy, and possible femoral shortening osteotomy. the capsule was too attenuated over the length of the chronic dislocation area to cover the femoral head adequately and of insufficient thickness to provide a durable interposition bear- ing surface. Therefore, a dermal allograft of 40 mm 70 mm in size, and 3.0 mm in thickness, was used to augment cover- age of the femoral head. We placed stay sutures in each cor- ner of the allograft to effect a parachute technique into the acetabulum and to hold the graft in place during the reduc- tion maneuver (Fig. 3). The dermal side [4] of the graft ap- poses the femoral head to provide a soft, gliding interposed surface intra-articularly. With the allograft draped over the acetabulum, the stay sutures attached anteriorly were used to hold the graft in place. The posterior stay sutures were pos- itioned with one inferior to the femoral neck and one super- iortothe femoralnecktoprovide tension thatkeeps the Fig. 2. Exposure of the intact articular cartilage of the femoral head. graft from bunching underneath the femoral head. In this Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Capsular augmentation in Colonna arthroplasty  37 with the head in the reduced position and capsule secured. Deep closure was then performed, and the trochanteric flip osteotomy was repaired with two cortical screws. On-table range of motion in our patient demonstrated hip stability in full extension, extension and external rotation, as well as com- bined hip flexion to 90 and internal rotation to 50 . POST-OPERATIVE PROTOCOL After sterile closure and dressing, the patient is immediately Fig. 3. Stay sutures placed in each corner of the dermal allograft to allow appropriate tensioning and positioning within the acet- placed in a hip abduction brace and post-operative imaging abulum during the final femoral head reduction maneuver. is performed (Fig. 5A and B). The patient is made non- weight bearing for at least 6 weeks. We prefer a regimen with serial decreases in degree of abduction over the first few weeksashealing progresses to prevent dislocation/sublux- ation. The patient is maintained in an abduction brace for 3 months post-operatively. The patient’s weight bearing was progressed to weight-bearing as tolerated by 4 months post- operatively. A detailed post-operative physical therapy pro- gram has been previously described [1] and found useful in our practice for this augmentation procedure as well as the ‘standard’ Colonna procedure. We choose to use a hip ab- duction brace, instead of spica casting, in compliant patients to aidwithhygiene and wound care needs. Increase of ab- ductor strengthening is developed throughout the rehabilita- tion period. We do not use a continuous passive motion machine in our protocol, though one could consider this an option to improve hip range of motion after the passage of Fig. 4. Femoral head reduced via a parachute of interposed dermal adequate time for healing. allograft. The superior rim shelf autograft affixed with two screws is also visible. Cranial side of body is to the right of the image. The patient continues to do well at 8 months post- operatively, with maintenance of reduction and the femoral manner, we could control the tension and coverage over the head centered under the stable, healed shelf osteotomy articulating surface of the femoral head during delivery into (Fig. 5C). The patient’s most recent hip range of motion is the native socket. The native anterior and posterior capsular from 10 of extension to 100 of flexion, and she currently leaflets were secured to the dermal graft. Graft thickness ob- walks without any assistive device and no limp. tained was 2 mm in thickness after preparation (saline soak, serial stretching, and gentle tensioning over the femoral DISCUSSION head). The graft is pliable and has the ability to conform to The practice of capsular arthroplasty has long been the acetabular cavity created. We sought to place the thick described, with variable results in the historical literature. graft material in the superior weight-bearing zone instead of Recent series, however, have reported promising outcomes the attenuated host capsule for durability of the articulation. in selected patients. Chung et al. reported satisfactory HHS The femoral head is then reduced as described earlier into in over half of Colonna’s patients at 17 years follow-up [2]. this interposed allograft parachute. Due to the compressible Pozo et al. found that nearly three-quarters of patients had nature of the graft, it conformed snugly to the acetabulum an HHS over 80 at 20-year follow-up [3]. As THA has and allowed for femoral head reduction. The stay sutures can demonstrated an increased failure rate in patients under 50 then be tied down to remnant capsule using a free needle years old [8, 9], continued development of hip preservation with interrupted sutures in circumferential fashion about the techniques in the young patient, with adequate femoral femoral head and neck. Supplemental 0-vicryl partial-thick- head cartilage despite hip dislocation, is needed. ness sutures allow for full integration of host capsule to the Capsular arthroplasty, in conjunction with modern hip allograft tissue, to engulf the femoral head in the capsular preservation techniques, may offer a viable option for arthroplasty (Fig. 4). A final assessment of tension on the sci- chronic hip dislocation, and allograft capsular augmentation atic nerve is made, as well as length and rotation of the limb, may help to address capsular deficiency. In order for this to Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018 38  M. Sloan and A. F. Kamath Fig. 5. Post-operative X-rays. (A) Intra-operative left hip AP fluoroscopic view demonstrating adequate femoral head reduction. (B) Post-operative AP pelvis X-ray in hip abduction brace. (C) 8-Month post-operative AP pelvis X-ray. be a viable option, the candidate must have functional ab- REFERENCES ductor musculature and preferably no prior surgery to the 1. Ganz R, Slongo T, Siebenrock KA et al. Surgical technique: The hip or abductors, which could interfere with hip biomech- capsular arthroplasty: a useful but abandoned procedure for young anics upon hip reduction. When performing this procedure, patients with developmental dysplasia of the hip. Clin Orthop Relat it is imperative to evaluate preoperative advanced imaging Res 2012; 470: 2957–67. 2. Chung SM, Scholl HW, Ralston EL, Pendergrass EP. The Colonna for capsular deficiency and repeat intraoperative evaluation capsular arthroplasty. A long-term follow-up study of fifty-six pa- to determine whether capsular arthroplasty without aug- tients. J Bone Joint Surg Am 1971; 53: 1511–27. mentation is feasible. For such cases where there is concern 3. Pozo JL, Cannon SR, Catterall A. The Colonna–Hey Groves for deficient capsular tissue, we recommend having an allo- arthroplasty in the late treatment of congenital dislocation of the graft available to provide augmentation for femoral head hip. A long-term review. J Bone Joint Surg Br 1987; 69: 220–8. coverage if necessary. Other interposition options for cap- 4. Achilles Tendon Reinforcement with ArthroFlex Decellularized sular augmentation could include autograft or allograft fa- Dermis. Package Insert 2015. 5. Ganz R, Gill TJ, Gautier E et al. Surgical dislocation of the adult scia lata, though one must select these materials carefully as hip a technique with full access to the femoral head and acetabu- volume and thickness can be donor dependent. We have lum without the risk of avascular necrosis. J Bone Joint Surg Br described the dermal allograft augmentation parachute 2001; 83: 1119–24. technique as one way to maneuver the allograft around the 6. Kalhor M, Beck M, Huff TW, Ganz R. Capsular and pericapsular femoral head during the reduction maneuver, and to com- contributions to acetabular and femoral head perfusion. J Bone pletely encompass the femoral head when native tissue is Joint Surg Am 2009; 91: 409–18. deficient. 7. Nishimatsu H, Iida H, Kawanabe K et al. The modified Spitzy shelf operation for patients with dysplasia of the hip. A 24-year follow- up study. J Bone Joint Surg Br 2002; 84: 647–52. FUNDING 8. Siebenrock KA, Scho¨ll E, Lottenbach M, Ganz R. Bernese periace- This work was not supported by any outside funding source. tabular osteotomy. Clin Orthop Relat Res 1999; 363: 9–20. 9. Ramiah RD, Ashmore AM, Whitley E, Bannister GC. Ten-year life CONFLICT OF INTEREST STATEMENT expectancy after primary total hip replacement. J Bone Joint Surg Br None declared. 2007; 89: 1299–302. Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/34/4799056 by Ed 'DeepDyve' Gillespie user on 16 March 2018

Journal

Journal of Hip Preservation SurgeryOxford University Press

Published: Jan 1, 2018

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