Combined Malrotation, Short Leg & Dysplasia
A 22-year old young man was referred to Dr. Santore for complex hip preservation surgery. A few years prior he noticed his right knee acting up after completing 20 to 30 mile runs, but with no trace of hip pain. The patient had become an avid physical fitness enthusiast during his college years, participating in running and weightlifting. In the Fall of 2017, he noticed it was becoming difficult to maintain proper form when lifting. The following year he had a brief incident of hip pain that resolved before experiencing intermittent knee pain again and an abnormal gait. As the year continued, painless popping of the hip during lifting became common but was manageable until he felt what he described as “a pulled a muscle” while sprinting. Shortly thereafter the symptoms progressed to severe pain leading to an x-ray series that revealed quite abnormal hip morphology (see Pre-Operation X-ray below). Inquiry into his family history revealed scoliosis and hypermobility from both sides of his family.
The radiographic exam determined that the while the patient's femur was severely malrotated in its resting position, the anatomy of the upper femur looked normal on x-ray when the leg was rotated internally. He tested negative for many of the classic manifestations of hypermobility but did have a history of myopia and constipation, some less common indicators for hypermobility, as well as a significant degree of hyperextension in both knees, a trait shared with both parents. To finish the long list of anatomical abnormalities our patient also had a leg length discrepancy, with his right leg being 5/8 of an inch shorter than the left.
The surgical plan was a double osteotomy to simultaneously correct the acetabular dysplasia in the pelvis, and a derotation valgus osteotomy of the femur to achieve normal foot alignment and equal leg lengths. The results of the dual PAO and ITO can be seen below (see Post-Operation X-ray). Despite the complexity of the surgery, he had a near pain-free and uneventful recovery. His pre-op hip pain is gone, and he can walk normally with no limp and leg lengths are equal.
Here we see a bizarre appearance of the right hip with superposition of the greater trochanter over the femoral head. This is an extreme example of femoral malrotation that is paired with hip dysplasia.
The post-op image demonstrates the results of a dual PAO, ITO procedure. The major corrections resulted in an image that resembles a normal hip.