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Children's Orthopaedics

FEMORAL VARUS DEROTATION OSTEOTOMY FOR THE TREATMENT OF HABITUAL HIP SUBLUXATION AND DISLOCATION IN CHILDREN WITH TRISOMY 21

Stanmore, England, 25 June 2010



Abstract

Purpose

Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21 and we describe long-term outcomes following the precise use of femoral varus derotation osteotomy.

Methods

16 consecutive hips, 9 children, with Trisomy 21 aged =10 years, were identified from hospital databases. Clinical notes and radiographs from presentation to final follow-up were reviewed.

Results

Mean age at first known hip dislocation was 4.1 years (range 3, 7 years). All had a femoral varus derotation osteotomy (VDRO). In 2 hips, significant intraoperative instability persisted and a periacetabular osteotomy and capsulorraphy were required.

Mean Femoral neck shaft angle (NSA) fell from 166.7° (+/-6.9°) to 106.0° (+/-5.4°). Mean follow-up was 5.9 years (+/-2.9). 1 hip (6.2%) developed painful arthritis. 14 hips developed peri-trochanteric varus deformities. 2 (12.5%) developed periprosthetic fractures 4 and 8 years post-operatively.

Conclusion

Prevention of long term disabling pain from habitually dislocating or recurrently subluxed hips, in patients with Trisomy 21, requires surgical intervention to increase hip containment.

In those aged =9 who have not developed hip incongruency, a VDRO with adequate varisation and minimal derotation was sufficient. Reducing the femoral NSA to approximately 100°, intraoperatively stabilised most hips. If instability persisted, a periacetabular osteotomy and capsulorraphy were performed. The 2 hips requiring additional procedures had the least corrected NSAs (115° and 122°) in our series. These patients were also older, aged 7 and 10, a factor that may have also contributed to the need for acetabular correction.

We believe surgical management of habitually subluxed or dislocated Trisomy 21 hips allows for a predictable result. We recommend a varus producing proximal femoral osteotomy to correct the NSA to 100-110°. This should be performed before either the age of 8 years or teardrop development. In our experience this has been effective in maintaining hip stability.