Idiopathic hypertonicity as a cause of stiffness after surgery for developmental dysplasia of the hip

Abstract

Introduction: There are various complications reported with surgical treatment of DDH. Most studied complication is avascular necrosis of the femoral head and hip stiffness. The purpose of this report was to describe a case with severe stiffness of the hip due to hypertonicity in periarticular muscles after it was treated for developmental dysplasia of the hip (DDH).

Presentation of case: Three-year-old patient referred to our institution with bilateral DDH. Two hips were operated separately in one year with anterior open reduction, femoral shortening osteotomy. Third month after last surgery, limited right hip range of motion and limb length discrepency identified. Clinical examination revealed that patient had limited range of motion (ROM) in the right hip and compensated this with pelvis obliquity. Gluteus medius, sartorius and iliofemoral band release performed after examination under general anesthesia. Symptoms were persisted at 3rd week control and examination of the patient in general anesthesia revealed full ROM without increased tension. For the identified hypertonicity, ultrasound guided 100IU botulinum toxin A injection performed to abductor group and iliopsoas muscles. Fifth month later, no flexor or abductor tension observed, and there was no pelvic obliquity.

Discussion: Stiffness as a complication is rare and is usually resolved without treatment or simple physical therapy. Usually it is related with immobilization or surgery associated joint contracture, and spontaneous recovery reported. Presented case is diagnosed as hip stiffness due to underlying local hypertonicity. That is resolved with anesthesia and it was treated after using botulinum toxin A injection.

Conclusion: Hypertonicity with hip stiffness after surgical treatment of DDH differ from spontaneous recovering hip range of motion limitation and treatment can only be achieved by reduction of the muscle hypertonicity by neuromuscular junction blockage.

Keywords: Hip dysplasia; Hip stiffness; Idiopathic hypertonicity.

Fig. 1

Three-year-old patient referred to our institution with bilateral DDH (according to Tönnis classification, left hip is grade 4 and right hip is grade 3).

Fig. 2

Early postoperative X-ray after anterior open reduction, femoral shortening osteotomy and Dega acetabuloplasty of right hip.

Fig. 3

X-ray at postoperative 3rd month, limited right hip range of motion and limb length discrepancy identified.

Fig. 4

Fifth month after Botulinum injection, no flexor or abductor tension observed, and there was no pelvic obliquity.

Fig. 5

Two years later after Botulinum injection. Left hip operated with Dega acetabuloplasty for acetabular dysplasia. Patient had no complaint with hips.