Triple Osteotomy of the Innominant Bone in a 14 year old girl

1
Triple Osteotomy of the Innominant Bone in a 14
year old girl

• Janet Trethewey, EdD, ATC
• BSSMC 2006

2
Hip Dysplasia

• Google Search for Hip Dysplasia
• Very Common in large breed dogs

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DDH

• Developmental Dislocation (Dysplasia) of the Hip
  (DDH)
• Abnormal formation of the hip joint
• The femoral head is not stable in the acetabulum
  due to improper alignment
• May or may not dislocate
• Usually detected at birth but not always1-4

4
DDH Risk Factors

• Girls1,2
• 40-60 Left Hip1,9
• 20 Bilateral9
• First Born1
• Breech Babies1
• Family History2
• European origin2

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DDH-Screening

• Screening at Birth1-3,6
• Physical exam dislocation or click
• Radiography
• Well-baby checks
• Usually detected within first 6 months of life
  poorer outcomes the later detected
• Most literature up to age 3

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DDH-Treatment

• Initially if mild or moderate1-2
• Triple diapering
• If sever or non-responsive1-2
• Pavlik harness up to 6 months
• Older than 6 months1-2
• Hip spica cast
• surgery

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DDH-Prognosis

• With successful treatment no further
  problems1-3
• Rare cases leg length discrepancy due to
  brace/spica1
• Unsuccessful or non-treatment
• Osteoarthritis leading to hip replacement1-5

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Case Study

• 14 Year old Female
• Youngest of 4 girls
• Older sister had mild click as an infant and
  was triple diapered
• No S S at birth or during prenatal follow-up
  visits

9
Cont.

• Became very active at age 12 upon entering Jr.
  High athletics
• Began complaining of Right knee pain with
  activity
• No swelling
• Family physician Dx Growing Pains
• Rx activity as tolerated, OTC-NSAID, ice
• Resolved over summer with decreased activity

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Cont.

• Upon second year of activity, knee pain more
  intense
• Unable to climb stairs
• Unable to participate
• No swelling
• Referred to Orthopedist
• Growing pains
• Cont. original Tx

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Cont.

• Age 14 Frosh. Year
• VB season some discomfort
• BB season sever pain/disability
• Unable to climb stairs
• Interfering with sleep
• Unable to participate
• Began feeling pop in hip

12
Cont.

• Referred to second orthopedist
• Mother requested radiographs of entire lower
  extremity
• Dx Developmental Dysplasia of Hip
• Knee Pain referred pain from Hip
• Allowed to continue participation within limits
  pain and re-eval. at end of season

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Cont.

• January, 2005
• Hip fully dislocated during practice
• Referred to specialist for triple osteotomy to
  reconstruct acetabulum
• Surgery Jan. 23, 2005

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Pre-Op Radiograph
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Post-op Radiograph
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Cont.

• Patient non-weight bearing for 6 weeks
• Limited weight bearing additional 14 weeks
• Full weight bearing 5 months post-op.
• Physical therapy first 12 weeks post-op

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Follow-up Radiograph
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Cont.

• Released for activity approximately June 1, 2005
• Continued exercising on own over summer
• Began VB August, 2005
• Knee pain resumed September, 2005
• Has grown almost 2 since surgery
• Restricted from BB season-returned to PT

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Conclusions

• Referred Pain
• Remember to examine entire extremity
• Follow up
• No ATC available
• Physician unfamiliar with activity level
• Poor communication between physician PT

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Cont.

• Growth should not hurt
• Pain a symptom of injury
• Listen to Parents
• Intuition know child best
• Listen to Patient
• Allow to talk/explain

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References

• American Academy of Orthopaedic Surgeons. (2204)
  Developmental Dislocation (Dysplasia) of the Hip
  (DDH). Retrieved 11/23/2005 http//orthoinfo.aaos
  .org/fact/printer_page.cfm?topcategoryhipThread_
  ID153.
• French, L and Dietz, F. (1999) Screening for
  Developmental Dysplasia of the Hip. American
  Family Physician. Retrieved 11/23/2005
  http//www.aafp.org/afp/990700ap/177.html.
• Aronsson, D, Goldberg M, Kling, T and Roy, D.
  (1994) Developmental dysplasia of the hip.
  Pediatrics. Retrieved 11/23/2005
  http//www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
  RetrievedbpubmeddoptAbstr...
• McCarthy, J, et al. (1996) Innominate Osteotomy
  in Adolescents and Adults who have Acetabular
  Dysplasia. The Journal of Bone and Joint Surgery,
  78-A.No 10. 1455-1461.
• Hsin, J, Saluja, R, Eilert, R, and Wiedel, J.
  (1996) Evaluation of the Biomechanics of the Hip
  following a Triple Osteotomy of the Innominate
  Bone. The Journal of Bone and Joint Surgery,78-A,
  No. 6. 855-862.
• Complete Human Anatomy, Interactive Series CD.
  Primal 3D Pictures Ltd.

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Thank You

• Robin Linda
• Christian Oberquell, ATC
• Tom Welch
• Jack Trethewey