Surgical Treatment

Types of operation

Surgery is usually undertaken either

• when other methods have not been successful or
• when DDH is diagnosed relatively late and when non-operative methods are unlikely to work.

The type of surgery required depends very much on each individual case so it would not be wise here to outline any possible course of treatment. In some cases, one operation may be all that's required or a series may be undertaken to correct the hip(s) in stages. But some descriptions of the more common surgical procedures will help you to understand your child's operation.

This is not a comprehensive list. Your child's surgeon is the person to ask for any detailed information.

Closed reduction and Plaster Fixation

In a closed reduction the surgeon manipulates the thighbone (femur) so that the ball (femoral head) is placed in the socket. Sometimes a tendon in the groin area, the adductor tendon, needs to be lengthened to ensure that the femoral head is placed in the socket correctly. The child is put in a plaster cast to keep everything stable whilst the tendons and ligaments grow. The plasters usually remain on for 6 weeks and then the child is admitted for another EUA,(examination under anaesthetic - see below for more details) and if the hip is still unstable, a reapplication of the plaster cast. It is now unusual to be kept in plaster for over 6 months.

Plaster is applied in many different ways to suit the needs of the child. The aim is to put the head of the femur into the socket in the optimum position to encourage correct growth. The cast is often called a Hip Spica. There are three basic variations and both legs, or one and a half legs, or only one leg may be fully enclosed. The most popular shapes are:

The 'frog plaster' or double hip spica.

This is the most common type of plaster after a closed reduction.

The 'hurdling plaster' or single hip spica.

This is more common after an open reduction.

The 'A' shape plaster is also known as the broomstick plaster because of the bar between the legs.

This is most common after a femoral osteotomy.

Traditional plaster of paris may be used over wadding, or a combination of plaster of paris and fibreglass material or all fibreglass. Plaster of paris is always white, but the fibreglass plasters can be coloured or even patterned.

Tenotomy

The surgical lengthening of a tendon.

Open reduction

Surgery undertaken to bring the head of the femur (the ball) opposite the hip socket (acetabulum). This will include the division and lengthening of tendons and joint capsules. The leg is placed in a position where the hip joint is most stable. This means that the leg may be set at an odd angle in the plaster cast. This type of open procedure is not done until the ossific nucleus appears. (The ball at the head of femur shows that it is maturing by changing from cartilage to bone.)

Femoral Osteotomy

This is sometimes called a rotation osteotomy or derotation osteotomy. The top end of the femur (the thigh bone) is realigned to give better stability to the hip. The femur is broken just below the femoral head and rotated to the best position. Small metal plates are placed across the "break" to hold the bone in position. The child is then put in a plaster cast, from waist to toe for approximately six weeks. The plates are usually left in place for about a year, when the child has another more minor operation to remove them.

Acetabulum reconstruction/pelvic osteotomy

This is a general heading for operations to reconstruct and deepen the hip socket. Such operations are generally not needed in young babies, and it is usually only undertaken when dislocation continually recurs because the socket is very shallow or when the socket remains shallow and might cause problems in later life.

There are many different approaches to this operation and some of the more common ones are called, Salter's Innominate Osteotomy, Chiari Osteotomy, Pemberton Acetabuloplasty and Colonna Arthroplasty. All involve realigning the pelvis to deepen the socket and may involve pins and bone grafts. Most young children are immobilised in a hip spica. But older children and teens are allowed to mobilise on crutches.

Going to Theatre

It is normal to feel very anxious about your child having an anaesthetic. Anaesthesia is a very safe procedure, but do talk to the doctors and nurses on the ward about any specific concerns you have. Tell them if your child has been unwell, as in certain circumstances, it is better to delay the operation and wait until the child is better. Most hospitals allow parents in the anaesthetic room so that you can reassure your child whilst they are going to sleep. The nurses on the ward will tell you what to expect.

Examination Under Anaesthetic and Arthrogram

Examination Under Anaesthetic is sometimes referred to as an EUA. This is usually done if treatment in splints has not worked or the child had been diagnosed at an age when splints would not be effective. He or she is given a light anaesthetic so that the surgeon can examine the hips when all the muscles are relaxed. The procedure is often combined with a special x-ray called an arthrogram . This type of examination allows the surgeon to decide whether a closed reduction and plaster is likely to be successful or whether an open reduction is needed.

Returning from Theatre

Waiting for your child to come back from theatre is very stressful. You will be told when your child is ready to return to the ward. In some hospitals you will be allowed in the recovery room to be with your child when he/she wakes up. Remember your child will still be heavily sedated from the anaesthetic, so won't remember much. Try to be calm and reassuring. The sound of your voice will help him/her to settle.

After bigger operations your child may come back from theatre with a drip in the arm or foot. This is used to deliver medicines, such as painkillers and also stops your child from becoming dehydrated. Some children also have a tube coming out from the wound. This stops fluid from collecting at the site of the wound and helps healing.

Most children recover very quickly. They will only be allowed to sip small amounts of water to begin with, but as soon as they are fully awake they will be able to feed normally. After a simple procedure like EUA and application of plaster you may be able to leave the hospital the same day. After a bigger operation you may be in hospital a few days.