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Colonna Arthroplasty with Concomitant Femoral Shortening and Rotational Osteotomy. Long-Term Results*

ANTHONY A. STANS, M.D. and SHERMAN S. COLEMAN, M.D., SALT LAKE CITY, UTAH

Investigation performed at the Shriner's Hospital for Crippled Children, Intermountain Unit, and the Department of Orthopedic Surgery, University of Utah School of Medicine, Salt Lake City

	Abstract

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The results of Colonna capsular arthroplasty in twenty-two hips in twenty patients were reviewed. All twenty patients were at least five years old at the time of the operation, which was performed for either complete dislocation or marked subluxation of the hip. None were candidates for reconstructive procedures designed to preserve articular cartilage. The mean age at the time of the Colonna arthroplasty was nine years and three months (range, five years to fifteen years and two months), and the mean duration of follow-up was sixteen years (range, six to thirty-two years). At the most recent follow-up examination, the mean Harris hip score, for the twenty-one hips for which it was available, was 82 points (range, 52 to 98 points), the patients had improved gait, and there was marked improvement in the radiographic appearance of the hip according to the classification system of Severin. Thirteen hips in twelve patients had concomitant femoral shortening and rotational osteotomy at the time of the Colonna arthroplasty, and none of these patients who did not have evidence of avascular necrosis of the capital femoral epiphysis preoperatively had it postoperatively. Three hips that did not have concomitant femoral shortening had evidence of new-onset avascular necrosis after the Colonna arthroplasty. Concomitant femoral shortening and rotational osteotomy allowed the operation to be performed without preoperative traction, dramatically reduced the need for a subsequent rotational femoral osteotomy, and reduced the prevalence of postoperative avascular necrosis of the capital femoral epiphysis.

	Introduction

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Because of early detection and treatment, dislocation of the hip and severe, painful subluxation currently are rare in children who are more than five years old. However, when present in such children, these conditions are extremely difficult to treat. While the natural history of untreated bilateral congenital dislocation of the hip in children who are older than the age of five years has been considered acceptable, patients who have untreated unilateral congenital dislocation often are seen as adults for debilitating symptoms about the hip. Furthermore, reconstructive procedures in adults for residua of untreated congenital dislocation are difficult because of shortening of the muscles of the thigh, soft-tissue contracture, and the smaller dimensions of the dysplastic proximal aspect of the femur and the acetabulum⁷. The management of patients who have an unsuccessfully treated dislocation or severe subluxation of the hip presents additional major therapeutic challenges. Such a patient often has had several previous operations but still has limited function of the hip because of pain, restriction of motion, limb-length discrepancy, inefficient biomechanics of the hip, or degenerative joint disease. Scarring from previous operations and abnormal development of the acetabulum and the femur often preclude reconstructive procedures on the hip that preserve acetabular articular cartilage.

In 1936, Colonna described capsular arthroplasty, which eliminates the hyaline cartilage of the acetabulum, as primary treatment for congenital dislocation of the hip⁵. Since then, procedures that preserve the articular cartilage of the acetabulum have replaced the Colonna arthroplasty except in children who are more than five years old and do not meet the criteria for a cartilage-preserving procedure. Colonna used preoperative traction, interpositioning of the capsule, and subsequent femoral rotational osteotomy. Patients had three sessions of anesthesia, needed prolonged hospitalization and lengthy periods of immobilization, and frequently had postoperative avascular necrosis of the capital femoral epiphysis^3-5.

In 1955, Bertrand described femoral shortening performed concomitantly with a Colonna arthroplasty as an alternative to preoperative traction. In 1978, Coleman described femoral shortening and rotational osteotomy performed concomitantly with a Colonna arthroplasty. This procedure was designed to correct torsional deformity, to facilitate reduction, and to eliminate excessive postoperative pressure on the capital femoral epiphysis⁴. However, as far as we know, no long-term results of this procedure have been published. Our purpose was to determine if Colonna capsular arthroplasty with concomitant femoral shortening and rotational osteotomy can improve function of the hip and coverage of the femoral head by the acetabulum as well as produce a high level of patient satisfaction.

	Materials and Methods

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One of us (S. S. C.) performed twenty-nine Colonna arthroplasties in twenty-seven patients between 1962 and 1988. Three patients (three hips) did not have a clinical or radiographic examination at the time of our review, but they were contacted by telephone or letter a mean of nine years postoperatively. No subsequent operative procedure had been done in any of the three patients. Four patients were lost to follow-up. A complete clinical and radiographic follow-up assessment, which included a physical examination and an anteroposterior radiograph of the pelvis, was performed for twenty patients (twenty-two hips) (Table I), and these patients form the basis of this study. The patients' charts were reviewed, and data regarding pain and limitation of activity as well as the results of the physical examination were recorded. The range of motion of the hip, gait, and the Trendelenburg sign were specifically noted. A minimum of five years of follow-up was required.

Assessment of the preoperative and follow-up radiographs included measurement of the center-edge angle of Wiberg and the acetabular angle of Sharp. All of the measurements were performed with a digitizing tablet (Ortho-Graphics, Salt Lake City, Utah) by the one of us (A.A.S.) who had not performed the operations. This method of radiographic measurement is more accurate than manual measurement¹⁰. The preoperative and postoperative radiographs were examined for evidence of avascular necrosis of the capital femoral epiphysis. The degree of dislocation or dysplasia of the hip was graded on the preoperative and postoperative radiographs according to the method proposed by Severin, which assigns a grade of I (a spherical femoral head congruent with the acetabulum and concentrically reduced) to VI (a completely dislocated hip).

The indications and prerequisites for Colonna arthroplasty were discussed in detail by Coleman. The indication for the procedure in the present study was a severe limp or pain caused by persistent dislocation despite at least one previous operation on the hip for seventeen patients (eighteen hips), pain and a limp caused by severe bilateral subluxation despite several previous operations on the hip for one patient (two hips), and a severe limp and limb-length discrepancy due to untreated unilateral dislocation of the hip for two patients (two hips). No patient who had untreated bilateral dislocation was managed with a Colonna arthroplasty. All patients were at least five years old at the time of the Colonna arthroplasty. Reconstructive procedures that preserve articular cartilage were contraindicated in all patients because concentric reduction of the femoral head could not be achieved, the range of motion of the hip was markedly limited secondary to scarring from previous operations, or there was radiographic evidence of severe degenerative changes of the hip joint. Less extensive salvage procedures were contraindicated because of complete dislocation or severe subluxation of the hip.

The first nine Colonna arthroplasties (eight patients) in this series were performed according to the method initially proposed by Colonna, which included preoperative traction and adductor tenotomy^5,6. All nine hips had a supracondylar femoral rotational osteotomy a mean of three weeks after the capsular arthroplasty. The remaining thirteen hips (twelve patients) had femoral shortening and a rotational osteotomy in the subtrochanteric region performed concomitantly with the arthroplasty instead of preoperative traction. This allowed for comparison of the results of the two techniques.

The Colonna arthroplasty with concomitant femoral shortening and rotational osteotomy was well described and illustrated by Coleman. We currently perform the procedure with use of a two-incision technique. An anterior Smith-Petersen approach to the hip is made through a bikini incision. The hip abductors are elevated off the hip capsule, and the capsule is elevated off the ilium, where it is often very adherent at the site of a pseudoacetabulum. The hip capsule is divided anteriorly in a line paralleling its fibers from the acetabulum to the base of the femoral neck. The capsule is then completely and circumferentially incised at its attachment to the acetabular rim, and the psoas tendon is divided. One patient (Case 4) (two hips) did not have adequate capsule to cover the femoral heads completely because the femoral heads were subluxated, not dislocated completely. To provide adequate capsular coverage for each femoral head, the thickened and hypertrophic capsule was divided tangentially to one-half of its thickness, thus doubling its area.

At this juncture, exposure of the acetabulum is markedly improved if the osteotomy for femoral shortening and rotation is performed through a direct lateral approach to the femur. After exposure of the femur, the femoral cortex is scored longitudinally to maintain orientation of the two segments after the osteotomy. After the transverse femoral osteotomy is completed at the level of the lesser trochanter, the proximal femoral segment may be carefully retracted posteriorly through the anterior incision to allow exceptional exposure of the acetabulum. Articular cartilage and all soft tissue are removed from the acetabulum, and very small acetabular reamers are used to enlarge and deepen the acetabulum symmetrically to the inner table of the pelvis, providing adequate coverage of the femoral head. After the femoral osteotomy and the appropriate soft-tissue release, the proximal femoral segment can easily be brought down to the level of the acetabulum. The capsule is then trimmed and fashioned so that it can be sewn over the femoral head with the portion of the capsule thickened from previous weight-bearing positioned over the weight-bearing cartilage of the femoral head. The capsule-covered head is then placed gently within the enlarged and deepened acetabulum without pressure on the capital femoral epiphysis.

The distal segment of the femur is allowed to overlap the proximal segment in its newly reduced position, and the overlapping portion is resected from the distal segment. In this series of patients, a mean of 1.6 centimeters (range, 1.0 to 2.5 centimeters) was resected from the distal femoral segment. The rotational deformity is corrected by fixation of the plate to the proximal femoral segment with screws and fixation of the distal femoral segment to the plate with a clamp. Movement through the range of inward and outward rotation is performed, and the rotation of the distal femoral segment relative to the proximal segment is adjusted to achieve a stable reduction of the hip at neutral rotation and to allow approximately 30 degrees of inward rotation at the hip. Outward rotation of the distal segment relative to the proximal segment ranged from approximately 20 to 40 degrees. Screws are then applied to secure the distal femoral segment in place and to maintain appropriate rotational alignment. The incisions are closed, and a radiograph is made to confirm concentric reduction and the position of the hardware.

After the Colonna arthroplasty, the hips were immobilized in a one and one-half hip-spica cast for six weeks. After six weeks, the spica cast was changed to a bilateral above-the-knee cylinder cast with a crossbar to control rotation, and range-of-motion exercises of the hip were begun. Walking with crutches without bearing weight was begun at approximately twelve weeks postoperatively, and full weight-bearing was not permitted until six months postoperatively. For the two patients who had a bilateral Colonna arthroplasty, the procedure on the second hip was performed three and four months after the first procedure, after full extension and flexion of the first hip was achieved.

	Results

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All nine hips that had been treated with preoperative traction and a Colonna arthroplasty without concomitant femoral shortening and rotational osteotomy needed a subsequent supracondylar femoral rotational osteotomy to correct excessive femoral anteversion. However, only one of the thirteen hips that had been treated with concomitant femoral shortening and rotational osteotomy needed such a procedure. Six hips (three that had traction and three that had shortening) had had evidence of avascular necrosis of the capital femoral epiphysis before the Colonna arthroplasty. Of the six hips that had had traction and no preoperative evidence of avascular necrosis, three had avascular necrosis postoperatively. In contrast, none of the ten hips that had shortening without preoperative evidence of avascular necrosis had evidence of avascular necrosis postoperatively. Thus, there was a higher prevalence of new-onset avascular necrosis of the capital femoral epiphysis in the hips that had had preoperative traction than in those that had had concomitant femoral shortening and rotational osteotomy. This observation provides strong support for the value of femoral shortening, as has been shown by Schoenecker and Strecker.

The hips that had had femoral shortening and rotational osteotomy had greater improvement in the Severin grade than those that had had preoperative traction; the mean postoperative grade was 1.8 for the former group and 2.3 for the latter. However, the ultimate functional result did not always differ substantially between the hips that had had preoperative traction and those that had had concomitant femoral shortening. There were no detectable differences between the two groups postoperatively with regard to patient satisfaction, limb-length discrepancy, range of motion, improvement in the Trendelenburg sign, or limp.

With the numbers available for study, we could not detect a significant difference between the Harris hip scores of the two groups. At the most recent follow-up examination, the mean Harris hip score for the hips that had had preoperative traction was 79 points (range, 52 to 98 points), compared with 84 points (range, 58 to 96 points) for the twelve hips that had had concomitant shortening and rotational osteotomy and for which a Harris hip score was available. With the use of regression analysis, the Harris hip scores were plotted against the duration of follow-up, and both groups demonstrated a trend toward decreasing function with time (Fig. 1). Extrapolation analysis suggested that one patient (Case 9) was a statistical outlier, and thus this patient was not included in the data for the line representing the hips that had had preoperative traction. The results for the two groups were noted to be similar, so the two groups were combined and analyzed as a whole. This created a larger set of patients that could be compared more easily with series treated with other salvage procedures reported in the literature.

View larger version (20K): [in this window] [in a new window]   Fig. 1 Graph of the Harris hip scores plotted against the duration of follow-up. Regression analysis was used to create the best straight line for the patients who had had preoperative traction (represented by squares) and for those who had had concomitant femoral shortening and rotational osteotomy (represented by circles). The two lines are not significantly different, and their negative slope illustrates a decrease in the Harris hip scores with an increasing duration of follow-up. Harris hip score = 107.783 - 1.962 x duration of follow-up (r2 = 0.757) for the group managed with concomitant femoral shortening and rotational osteotomy. Harris hip score = 97.882 - 1.1 x duration of follow-up (r2 = 0.185) for the group managed with preoperative traction.

Gait improved for most patients. Before the Colonna arthroplasty, five patients had a moderate limp, fourteen had a severe limp, and one was unable to walk. Postoperatively, three patients had no limp, twelve had a mild limp, three had a moderate limp, one had a severe limp, and the patient who could not walk preoperatively remained unable to do so postoperatively.

Similarly, there was a marked improvement in the Trendelenburg sign postoperatively. All twenty-one of the hips in patients who were able to walk had a positive sign preoperatively. Postoperatively, seven hips had a negative Trendelenburg sign, six had a positive sign only with fatigue, and eight had a positive sign at rest.

There was little improvement in the range of motion after the operation (Table II). Extension and abduction were poor preoperatively (-11 and 21 degrees, respectively) but improved after the operation (to -1.5 and 26 degrees, respectively). At the most recent follow-up examination, there was a decrease in inward and outward rotation, flexion, and adduction from 36, 37, 95, and 26 degrees, respectively, preoperatively to 14, 25, 81, and 21 degrees, respectively, postoperatively, but no patient reported that the range of motion markedly limited their activities of daily living. One woman had delivered four children by cesarean section because of limited abduction of both hips, but four other women had delivered a total of fourteen children by vaginal delivery without problems.

Four patients had had a total hip arthroplasty by the time of the most recent follow-up examination. Three of these patients had had traction before the Colonna arthroplasty, and the other had had concomitant femoral shortening and rotational osteotomy. Pain secondary to degenerative hip disease was the indication for the total hip arthroplasty in three patients, one of whom had had concomitant femoral shortening. The total hip arthroplasty for these three patients was performed a mean of twenty years after the Colonna arthroplasty. The Harris hip scores for these three patients were 58, 56, and 52 points (mean, 55 points) immediately before the total hip arthroplasty. The remaining patient had the total hip arthroplasty after sustaining a traumatic fracture of the femoral neck while playing soccer in a recreational league seven years after the Colonna arthroplasty. All of the total hip arthroplasties were performed without complication and without the need for concomitant femoral shortening.

There were four complications (Table I), including compression of the lateral femoral cutaneous nerve, recurrent dislocation of the hip, persistent acetabular dysplasia, and a deep wound infection. In addition to the four total hip arthroplasties, several additional procedures were performed on the ipsilateral hip: two patients had trochanteric advancement, one had decompression of the lateral femoral cutaneous nerve, one had a proximal femoral valgus osteotomy, one had a Pemberton osteotomy and a Salter osteotomy, and one had a revision of the Colonna arthroplasty.

	Illustrative Case Reports

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CASE 10. A nine-year-old girl was seen for persistent dislocation of the left hip and acetabular dysplasia of the right hip (Fig. 2-A). The patient had been diagnosed with bilateral congenital dislocation of the hip when she was two years old. A bilateral adductor tenotomy and bilateral closed reduction was performed immediately at that time at an outside facility, and a spica cast was applied postoperatively. The right hip remained reduced, but the left hip redislocated. When she was three years old, the patient had been managed with skeletal traction for four weeks, followed by repeat closed reduction and application of a spica cast. The left hip dislocated again, and an open reduction, capsulorrhaphy, and Pemberton osteotomy was performed at the age of four years.

View larger version (120K): [in this window] [in a new window]   Fig. 2-A Figs. 2-A, 2-B, and 2-C: Case 10. A nine-year-old girl who had bilateral congenital dislocation of the hip. The patient had had three procedures on the left hip and one procedure on the right hip before the reduction was successfully maintained with a Colonna arthroplasty on the left and a Salter osteotomy on the right. The case of this patient allows comparison of the long-term radiographic results of these procedures. Fig. 2-A: Preoperative anteroposterior radiograph of the pelvis, demonstrating persistent Severin grade-VI dislocation of the left hip and Severin grade-III dysplasia of the right hip.

View larger version (107K): [in this window] [in a new window]   Fig. 2-B Anteroposterior radiograph made five years after the Colonna arthroplasty on the left and the Salter osteotomy on the right. The patient had improvement in the center-edge angles16 and a normal range of motion bilaterally.

View larger version (119K): [in this window] [in a new window]   Fig. 2-C Anteroposterior radiograph made twenty-four years postoperatively. The patient had Severin grade-I dysplasia on the left, with moderate discomfort in the hip after walking approximately one mile (1.6 kilometers).

View larger version (114K): [in this window] [in a new window]   Figs. 3-A, 3-B, and 3-C: Case 4. A thirteen-year-old girl in whom severe, painful subluxation of both hips was treated with a bilateral Colonna arthroplasty, which necessitated splitting of the capsule to provide adequate coverage of the femoral heads. The patient had had four previous operations on each hip, resulting in painful limited motion bilaterally. Fig. 3-A: Preoperative anteroposterior radiograph. The dysplasia was classified as Severin grade V on the right and Severin grade III on the left.

View larger version (104K): [in this window] [in a new window]   Fig. 3-B Anteroposterior radiograph made three years after the bilateral Colonna arthroplasty. The dysplasia was classified as Severin grade II bilaterally.

View larger version (117K): [in this window] [in a new window]   Fig. 3-C Anteroposterior radiograph made twenty-three years after the bilateral Colonna arthroplasty. The coverage of the femoral head had been maintained, but there were radiographic changes consistent with degenerative hip disease.

View larger version (119K): [in this window] [in a new window]   Figs. 4-A, 4-B, and 4-C: Case 9. A five-year and seven-month-old boy who was seen for persistent Severin grade-VI dislocation of the right hip, Severin grade-III dysplasia of the left hip, and evidence of avascular necrosis of the left femoral head. The patient had had three previous procedures on both hips. The case of this patient demonstrates the results of Colonna arthroplasty after the longest follow-up in our series (thirty-two years). It also provides the opportunity for comparison of the radiographic results of a Colonna arthroplasty with those of a shelf procedure. Fig. 4-A: Anteroposterior radiograph made when the patient was first seen by the senior one of us (S. S. C.).

View larger version (119K): [in this window] [in a new window]   Fig. 4-B Anteroposterior radiograph made five years postoperatively. Both hips remained reduced. The dysplasia was Severin grade III on the right and Severin grade II on the left.

View larger version (105K): [in this window] [in a new window]   Fig. 4-C Anteroposterior radiograph, made thirty-two years postoperatively, showing increased dysplasia and degenerative changes in the right hip as compared with the left hip.

	Discussion

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We seldom see complete dislocation or severe, painful subluxation of the hip in children who are more than five years old. The treatment of such children is extremely difficult because of the inability to achieve concentric reduction of the hip, the limited motion of the hip due to scarring from previous operations, or degenerative changes of the hip joint that preclude reconstructive procedures designed to preserve articular cartilage. Traditional salvage procedures that preserve motion include the Chiari osteotomy and the shelf procedure. Both procedures are less extensive than the Colonna arthroplasty and should be performed when possible. However, it is technically impossible to perform a Chiari osteotomy cephalad to the level of a dislocated femoral head as the osteotomy would be performed cephalad to the sciatic notch, entering the sacro-iliac joint. Similarly, a shelf procedure performed in a severely subluxated or dislocated hip may not provide adequate coverage of the femoral head, and it does not shift the femoral head medially. Conversely, in a hip that is slightly subluxated, there is not enough capsule to cover the femoral head completely, even if the capsule is tangentially split to double its area. Therefore, Colonna arthroplasty is contraindicated for patients who have slight subluxation of the hip.

A review of the literature reveals few reports of the results of treatment of congenital dislocation of the hip in children who are more than five years old. Browne reported the results for thirty hips with congenital dislocation or subluxation that had been treated with open reduction accompanied by femoral shortening, femoral rotation, or a shelf procedure, as needed, in patients who were five to fifteen years old. Eight patients had had previous operations on the hip. At a mean of 4.5 years, the results, which were graded according to the system proposed by Trevor et al., were satisfactory for seven of the sixteen hips that had been treated with open reduction without a shelf procedure and for six of the fourteen hips that had been treated with a concomitant shelf procedure. Femoral shortening did not affect the prevalence of avascular necrosis².

The long-term results of Colonna arthroplasty compare favorably with those of a shelf procedure and Chiari osteotomy. Hamanishi et al. reported the results for 124 hips at a mean of ten years after an acetabular shelf procedure performed as treatment for acetabular dysplasia, subluxation of the hip, or dislocation of the hip. Eight patients had had a previous operation. At the time of the operation, the patients ranged in age from ten to fifty-three years (mean, twenty-four years). According to the 100-point grading system of the Japanese Orthopedic Association⁸, the mean score for all 124 hips was 86 points at the most recent follow-up examination. Windhager et al. reported the results of 236 Chiari osteotomies. Twenty-one hips (9 per cent) had a reoperation for degenerative osteoarthrosis at a mean of 15.4 years postoperatively. The remaining 215 hips were followed for a mean of 24.8 years (range, twenty to thirty-four years). The clinical result was satisfactory for 112 (52 per cent) of the 215 hips.

Several authors have reported the long-term results of Colonna arthroplasty. Ritter and Wilson described the results for forty patients (forty hips) who had had the procedure performed at a mean age of six years and were followed for a mean of 9.5 years (range, three to twenty-nine years). Twenty-six patients had a congenital dislocation, ten had a dislocation secondary to neuromuscular disease, and four had a unilateral dislocation associated with infection. Thirty-three patients had had preoperative traction, and seven hips were spontaneously reducible at the time of the operation. Fifteen patients (38 per cent) had a staged supracondylar rotational femoral osteotomy after the capsular arthroplasty. All hips were graded with the Harris hip score, and twenty-two (55 per cent) had a satisfactory result. Four hips had postoperative avascular necrosis of the capital femoral epiphysis¹¹.

Chung et al. reported the long-term results for sixty-three hips (fifty-six patients) in which Colonna had performed a capsular arthroplasty. Thirty-seven (59 per cent) of the sixty-three hips had a staged rotational femoral osteotomy. The mean duration of follow-up was seventeen years (range, six to thirty-seven years). Thirty-one patients had a satisfactory result, according to the Harris hip score. Forty-one hips (65 per cent) had some evidence of avascular necrosis of the capital femoral epiphysis, ranging from mild flattening to severe distortion of the femoral head.

In the present series, the result was satisfactory for fourteen hips (64 per cent), which compares favorably with the results of the previously mentioned series of salvage procedures, including the two largest series of patients managed with Colonna arthroplasty^3,11. Neither Ritter and Wilson nor Chung et al. performed concomitant femoral shortening and rotational osteotomy. This is the most important difference in operative technique between those studies and the current study. In our series, the hips treated with concomitant femoral shortening and rotational osteotomy had a lower prevalence of new-onset avascular necrosis of the capital femoral epiphysis and a greater improvement in Severin grade postoperatively compared with the hips that had had preoperative traction. Schoenecker and Strecker demonstrated the value of femoral shortening in the prevention of avascular necrosis of the capital femoral epiphysis. Increased femoral anteversion is a constant finding in congenital dislocation of the hip. Correction of this pathological anteversion proximally in the subtrochanteric region at the time of the Colonna arthroplasty may improve reduction of the femoral head into the reamed acetabulum. This explains the greater improvement in Severin grade compared with that in patients who were managed with a distal femoral rotational osteotomy six weeks after the Colonna arthroplasty. Concomitant femoral shortening and rotational osteotomy eliminated the need for an additional session of anesthesia for adductor tenotomy and application of traction, eliminated the three-week period of preoperative traction, and dramatically reduced the number of patients who needed a staged femoral rotational osteotomy after the capsular arthroplasty.

As in the long-term study by Chung et al., symptoms of degenerative hip disease tended to develop in our patients approximately fifteen years after the Colonna arthroplasty. The seven hips (32 per cent) that had an unsatisfactory result had been followed for a mean of twenty years; this reflects the natural history of hips after a Colonna arthroplasty. As noted previously, three patients had a total hip arthroplasty to treat degenerative hip disease a mean of twenty years after the Colonna arthroplasty. The total hip arthroplasty was facilitated by the capsular arthroplasty, in contrast to the technical difficulty encountered when total hip arthroplasty is performed in untreated congenitally dislocated hips⁷. Therefore, because it simplifies a later procedure, Colonna arthroplasty can be considered a preparatory stage for total hip arthroplasty.

One of our patients (Case 4) was the exception to the rule that subluxation is a contraindication to Colonna arthroplasty. A less extensive procedure, such as a Chiari osteotomy, might have been done on the left hip, and radiographs correctly portended inadequate capsule to cover the femoral head completely. However, this patient had had four previous operations on each hip, which resulted in bilateral painful near-ankylosis. Bilateral hip disease precluded operative arthrodesis, as it did in half of the patients in our series. It was decided that a less extensive salvage procedure would not decrease the severe pain or improve the range of motion adequately. Therefore, despite subluxation of the hip, bilateral Colonna arthroplasty was thought to be indicated. To solve the problem of inadequate capsule to cover the femoral head, the capsule was split tangentially to one-half of its thickness, which doubled its area. Splitting of the capsule markedly increased the difficulty of the procedure but provided adequate capsule to cover the femoral head. We have no experience with the use of fascia from a distant site (such as fascia lata) to augment inadequate coverage by the hip capsule, but this may provide an alternative to splitting of the capsule. In our patient (Case 4), the split capsule functioned well and the Harris hip score at the latest follow-up examination was 89 points on the left and 88 points on the right. The satisfaction of the patient was rated 10 points.

In conclusion, Colonna arthroplasty with concomitant femoral shortening and rotational osteotomy is an effective treatment for the difficult therapeutic problem presented by a dislocation or severe, painful subluxation of the hip in a patient who is at least five years old. In the present series, the Colonna arthroplasty resulted in improvements in the gait, the Trendelenburg sign, and the radiographic appearance as well as a high degree of patient satisfaction. When compared with Colonna arthroplasty as originally described, Colonna arthroplasty with concomitant femoral shortening and rotational osteotomy allowed the operation to be performed without preoperative traction, reduced the need for a subsequent rotational femoral osteotomy, resulted in improved coverage of the femoral head by the acetabulum, and reduced the prevalence of avascular necrosis of the capital femoral epiphysis. However, increasing symptoms and decreased function related to degenerative hip disease may occur fifteen to twenty years after the Colonna arthroplasty.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Division of Pediatric Orthopedic Surgery, Mayo Clinic, 200 First Street, S.W., Rochester, Minnesota 55905.

Department of Orthopedic Surgery, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132.

	References

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