Surgical technique: The capsular arthroplasty: a useful but abandoned procedure for young patients with developmental dysplasia of the hip

Abstract

Background: Codivilla in 1901, Hey Groves in 1926, and Colonna in 1932 described similar capsular arthroplasties--wrapping the capsule around the femoral head and reducing into the true acetabulum--to treat completely dislocated hips in children with dysplastic hips. However, these procedures were associated with relatively high rates of necrosis, joint stiffness, and subsequent revision procedures, and with the introduction of THA, the procedure vanished despite some hips with high functional scores over periods of up to 20 years. Dislocated or subluxated hips nonetheless continue to be seen in adolescents and young adults, and survival curves of THA decrease faster for young patients than for patients older than 60 years. Therefore, joint preservation with capsular arthroplasty may be preferable if function can be restored and complication rates reduced.

Description of technique: We describe a one-stage procedure performed with a surgical hip dislocation and capsular arthroplasty. Various additional joint preservation procedures included relative neck lengthening for improved motion clearance and head size reduction, roof augmentation, and femoral shortening/derotation for containment and congruency.

Methods: We retrospectively reviewed nine patients (one male, eight female; age range, 13-25 years) who had such procedures between 1977 and 2010. Function was assessed by the Harris hip score (HHS). Minimum followup was 1 year (median, 2 years; mean, 7.5 years; range, 1-27 years).

Results: At latest followup, the mean HHS was 84 (n = 7) (range, 78-94). One patient underwent THA after 27 years. Complications included one deep vein thrombosis and one successfully treated neck fracture.

Conclusions: Our data in these nine patients suggest capsular arthroplasty performed with a surgical hip dislocation and other appropriate adjunctive procedures is useful to treat dislocated hips in young patients with few complications. It may postpone THA.

Level of evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1A–D

Diagrams illustrate capsular incision. (A) The first incision of the capsule runs from the anterosuperior edge of the trochanteric osteotomy to the most superior point of the anterior rim. The incision is extended as close as possible to the anterior osseous rim down to the transverse ligament. With traction on the leg, the correct level of superior capsulotomy can be determined. (B) To inspect the joint, the elongated round ligament is excised. The femoral head is dislocated from the capsular cavity and held distally with the use of a Hohmann retractor hooked around the acetabular notch. Posterior capsulotomy can be executed from outside or inside. (C) After all capsular connections with the acetabular rim are sectioned, the leg is extended and the neck is lifted anteriorly using a bone hook. This allows approximation of the posterior capsular margins B to B′ and suture from caudad to cephalad. It is followed by the anterior suture A to A′. (D) Closure of the capsule over the head must be executed firmly but without tissue overlapping.

Fig. 2A–C

Images illustrate the case of Patient 2, a female patient who at 13 years old had low congenital dislocation of the left hip; she suffered from a substantial limp and moderate pain. (A) Pre- and (B) postoperative radiographs show the hips before and after the patient underwent capsular arthroplasty with a subtrochanteric shortening and derotational osteotomy and autologous bone augmentation of a small defect of the acetabular roof. (C) A long-term followup radiograph at 17 years postoperatively shows the head is well centered and the joint space is large and congruent. Clinically, the hip is nearly normal.

Fig. 3A–C

Images illustrate the case of Patient 4, a 21-year-old woman with arthrogryposis and a left hip dislocation. The patient previously had one attempt at reduction in early childhood. On presentation, there was a severe limp and constant pain. (A) Pre- and (B) postoperative radiographs show the hip before and after the patient underwent capsular arthroplasty, relative femoral neck lengthening, femoral head reduction osteotomy, bone grafting of the acetabular roof, and subtrochanteric shortening and derotational osteotomy. (C) A most recent followup radiograph taken 4 years postoperatively shows the femoral head is vital and the joint space is large and well maintained. The functional performance is represented by an HHS of 78 and limitations of ROM are due mainly to the patient’s underlying arthrogryposis.