Journal of Hip Preservation Surgery Vol. 5, No. 1, pp.

34–38
doi: 10.1093/jhps/hnx045
Advance Access Publication 11 January 2018
Technical Tips

Capsular augmentation in Colonna arthroplasty for

the management of chronic hip dislocation
Matthew Sloan and Atul F. Kamath*
Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
*Correspondence to: A. F. Kamath. Department of Orthopedic Surgery, Center for Hip Preservation, Penn Medicine, 800 Spruce Street, Pennsylvania
Hospital, 8th Floor Preston, Philadelphia, PA 19107, USA. E-mail: [email protected]
Submitted 1 March 2017; Revised 12 November 2017; revised version accepted 12 December 2017

ABSTRACT
Colonna capsular arthroplasty represents an option for the management of chronic hip dislocation in young
patients with dysplasia. In the appropriate patient, modern capsular arthroplasty procedures may provide an
opportunity for hip preservation in patients with preserved femoral head cartilage and not appropriate for total
hip arthroplasty. Here, we review our experience with surgical dislocation of the hip and capsular arthroplasty in a
27-year-old female with congenital hip dysplasia and chronic superior hip dislocation. Due to inadequate native
capsular tissue, a decellularized dermal allograft was used for interposition and capsular arthroplasty augmenta-
tion. The femoral head with preserved articular cartilage was reduced into the enlarged native acetabulum using a
parachute technique to hold the allograft in position. Post-operatively, the patient was placed in a hip abduction
brace and made non-weight bearing for six weeks. A conservative physical therapy protocol was implemented to
allow gradual increase in weight bearing and range of motion over the first 12 weeks post-operatively.

I N T RO D U C T I O N Other series have reported promising outcomes in selected

Capsular arthroplasty has been performed for over patients [2, 3].
100 years as a treatment for complete hip dislocation in Here, we review our experience with surgical dislocation
children and young adults. It was first described by of the hip and capsular arthroplasty for congenital hip dys-
Codivilla in 1901, then later reported by Hey Groves in plasia and chronic superior hip dislocation. This technical
1926 and Colonna in 1932. The technique involves wrap- note describes the use of a decellularized dermal allograft
ping the femoral head within the hip capsule prior to per- for interposition and capsular arthroplasty augmentation,
forming hip reduction into the true acetabulum. due to inadequate native capsular tissue volume. The fem-
This procedure was historically complicated by high rates oral head with preserved articular cartilage was reduced
of osteonecrosis and need for further procedures. into the enlarged native acetabulum using a parachute
Improved outcomes with total hip arthroplasty (THA) technique to hold the allograft in position.
additionally diminished enthusiasm for the capsular arthro-
plasty technique. Ganz et al. reviewed a contemporary S U R G I CA L T E C HN I Q U E
one-stage procedure with safe surgical hip dislocation and This is a 27-year-old female who presented with left hip
capsular arthroplasty in nine patients with chronic hip dis- pain and chronic high femoral head dislocation. She pre-
locations. The authors found a mean Harris Hip Score sented to clinic with a limp, pelvic obliquity, and leg length
(HHS) of 84 at a mean of 7.5 years follow-up, with one pa- discrepancy. She had no prior hip surgery. Her pain was
tient proceeding to THA after 27 years [1]. The patients located in the groin and buttocks. The patient had a 2 cm
did require repeat surgery 18–30% of the time to address leg length discrepancy, with the left leg shorter. The left
persistent mechanical issues or for repeated hip reduction. hip ranged from 10 of extension to 110 of flexion. Hip

C The Author(s) 2018. Published by Oxford University Press.

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 34
 Capsular augmentation in Colonna arthroplasty  35

internal rotation was 50 , and external rotation was 40 . Intra-operative templated head size in our patient, for
Hip abduction was 40 , and hip adduction was 20 . Her example, was 40 mm. Lactated ringer irrigation is used to
abductor muscle strength was intact when tested in the bathe the cartilage to avoid cartilage desiccation during
standing and lateral decubitus positions. exposure.
From preoperative planning, it was clear that the pa- After the cartilage is evaluated and deemed adequate for
tient’s capsular volume was low and stretched superiorly preservation, attention is turned to identification of the native
due to chronic dislocation. Due to the nature of the patient’s acetabulum. Chronic dislocation leads to scar formation and
chronic superior dislocation position, we had an Arthrex capsular attenuation. Careful dissection inferiorly toward the
R
ArthroflexV Dermal Allograft (Naples, FL, USA) available as native acetabulum is performed and tactile feel is used to
an alternative capsular arthroplasty material. This graft is identify the dysplastic acetabular rim. A radio-opaque instru-
made from human donor dermal tissue that undergoes a ment is placed in the inferior border and a fluoroscopic image
decellularizing process, which removes >97% of donor is taken to confirm alignment relative to the teardrop. The
DNA (less than 1 viable particle per million). The tissue is native acetabulum is then reamed and compared in volume
stored at room temperature and retains the biomechanical with the templated native femoral head size. Preliminary re-
properties of the dermis without detriment to the elastin duction is performed with a moistened lap sponge covering
and collagen structure. The graft provides a collagen scaffold the femoral head cartilage. If the head is too large for the na-
for vascular and fibrous tissue ingrowth [4]. tive acetabulum, head reduction is performed.
For treatment of leg length discrepancy and potential sci- In our presented case, the sciatic nerve was not under
atic nerve traction injury, we considered femoral shortening excessive tension with the hip reduced and knee fully ex-
osteotomy. If this procedure were performed, the osteotom- tended, and the soft tissues appeared appropriately ten-
ized bone could be used for the shelf autograft. Alternatively sioned. With adequate femoral head reduction, the decision
graft would be drawn from the iliac crest if no femoral was made to forego femoral shortening osteotomy and per-
shortening osteotomy was performed. A straight plate can form iliac crest bone graft harvest for shelf autograft aceta-
affix a shortening osteotomy (usually up to 3 cm), with or buloplasty to supplement the dysplastic superior rim [7].
without derotation to accommodate abnormal femoral ver- The graft was sized at the superior acetabular rim for ad-
sion. Finally, a varusization proximal femoral osteotomy with equate coverage and extracted en bloc from the iliac crest.
blade plate fixation was considered in the event that reduc- The shelf graft was fashioned, and excess bone was saved
tion into the native acetabulum was complicated by instability for autograft packing about the shelf. The shelf was then
or extra-articular impingement. Trochanteric advancement secured in place with two cannulated screws.
can also reduce any residual extra-articular impingement, and The patient’s native anatomy afforded a low-volume
improve abductor functional length. Pre-operative imaging socket. At this time, with the shelf in place, the acetabulum
and planning diagrams are shown in Fig. 1. was reamed to form a concentric socket, starting with a
The approach for surgical dislocation of the hip has 36-mm reamer centrally to clear the remnant pulvinar tis-
been described previously [5]. During the Gibson ap- sue. Serially reaming was performed to expand the socket
proach in our case patient, the abductor musculature dem- orifice, up to one millimeter larger than the femoral head
onstrated no signs of atrophy. Capsulotomy is performed measurement. Reaming continued sequentially to medial-
carefully to avoid injury to the medial femoral circumflex ize and optimize abduction and anteversion of the native
artery that runs posterosuperiorly to the lesser trochanter acetabulum with the new shelf. Frequent assessment of the
and provides the main blood supply to the femoral head thickness of the anterior and posterior walls of the acetabu-
[6]. Long anterior- and posterior-based leaflets of native lum was performed, in order to avoid iatrogenic thinning
capsule were fashioned from the existing capsular sleeve. In out of the walls. Several millimeters of cortical wall thick-
our case, there was attenuation in both volume and thick- ness remained after reaming. The shelf graft was used to
ness of the capsule, so that complete coverage of the fem- augment the total acetabular volume.
oral head was not possible. We also sought to increase the Next, the capsule is assessed for capsular arthroplasty, to
volume of capsule that would serve as the final capsular provide interposed tissue and prevent adhesion between the
interposition arthroplasty surface. Therefore, the dermal reamed native acetabulum (now devoid of articular cartilage)
graft was chosen to augment the central and superior as- and the femoral head. Native capsule may not always be suffi-
pects of the femoral head. cient, and capsular adequacy must be carefully evaluated to
The articular cartilage of the femoral head can be as- determine if augmentation is necessary. In some instances of
sessed circumferentially (Fig. 2). A sizing template is laid chronic high dislocation the capsule may be stretched, but
over the femoral head to estimate appropriate cup size. not attenuated and, thus, viable for this purpose. In our case,
36  M. Sloan and A. F. Kamath

Fig. 1. Pre-operative imaging: (A) anteroposterior (AP) pelvis X-ray. (B) Left hip AP and lateral X-ray. (C) Right and left hip false
profile views. (D) Bilateral leg-length scanogram. (E) Pelvis CT axial cuts. The calculated femoral anteversion was 9 . (F) Left hip
CT 3D reconstructions. (G) Left hip MRI arthrogram demonstrating low hip capsule volume despite high dislocation. (H) AP pelvis
with preoperative template for native acetabulum location, trochanteric osteotomy, and possible femoral shortening osteotomy.

the capsule was too attenuated over the length of the chronic
dislocation area to cover the femoral head adequately and of
insufficient thickness to provide a durable interposition bear-
ing surface. Therefore, a dermal allograft of 40 mm  70 mm
in size, and 3.0 mm in thickness, was used to augment cover-
age of the femoral head. We placed stay sutures in each cor-
ner of the allograft to effect a parachute technique into the
acetabulum and to hold the graft in place during the reduc-
tion maneuver (Fig. 3). The dermal side [4] of the graft ap-
poses the femoral head to provide a soft, gliding interposed
surface intra-articularly. With the allograft draped over the
acetabulum, the stay sutures attached anteriorly were used to
hold the graft in place. The posterior stay sutures were pos-
itioned with one inferior to the femoral neck and one super-
ior to the femoral neck to provide tension that keeps the
Fig. 2. Exposure of the intact articular cartilage of the femoral head. graft from bunching underneath the femoral head. In this
 Capsular augmentation in Colonna arthroplasty  37

with the head in the reduced position and capsule secured.

Deep closure was then performed, and the trochanteric flip
osteotomy was repaired with two cortical screws. On-table
range of motion in our patient demonstrated hip stability in
full extension, extension and external rotation, as well as com-
bined hip flexion to 90 and internal rotation to 50 .

POST-OPERATIVE PROTOCOL
Fig. 3. Stay sutures placed in each corner of the dermal allograft After sterile closure and dressing, the patient is immediately
to allow appropriate tensioning and positioning within the acet- placed in a hip abduction brace and post-operative imaging
abulum during the final femoral head reduction maneuver. is performed (Fig. 5A and B). The patient is made non-
weight bearing for at least 6 weeks. We prefer a regimen
with serial decreases in degree of abduction over the first few
weeks as healing progresses to prevent dislocation/sublux-
ation. The patient is maintained in an abduction brace for
3 months post-operatively. The patient’s weight bearing was
progressed to weight-bearing as tolerated by 4 months post-
operatively. A detailed post-operative physical therapy pro-
gram has been previously described [1] and found useful in
our practice for this augmentation procedure as well as the
‘standard’ Colonna procedure. We choose to use a hip ab-
duction brace, instead of spica casting, in compliant patients
to aid with hygiene and wound care needs. Increase of ab-
ductor strengthening is developed throughout the rehabilita-
tion period. We do not use a continuous passive motion
machine in our protocol, though one could consider this an
Fig. 4. Femoral head reduced via a parachute of interposed dermal option to improve hip range of motion after the passage of
allograft. The superior rim shelf autograft affixed with two screws is adequate time for healing.
also visible. Cranial side of body is to the right of the image. The patient continues to do well at 8 months post-
operatively, with maintenance of reduction and the femoral
manner, we could control the tension and coverage over the head centered under the stable, healed shelf osteotomy
articulating surface of the femoral head during delivery into (Fig. 5C). The patient’s most recent hip range of motion is
the native socket. The native anterior and posterior capsular from 10 of extension to 100 of flexion, and she currently
leaflets were secured to the dermal graft. Graft thickness ob- walks without any assistive device and no limp.
tained was 2 mm in thickness after preparation (saline
soak, serial stretching, and gentle tensioning over the femoral DISCUSSION
head). The graft is pliable and has the ability to conform to The practice of capsular arthroplasty has long been
the acetabular cavity created. We sought to place the thick described, with variable results in the historical literature.
graft material in the superior weight-bearing zone instead of Recent series, however, have reported promising outcomes
the attenuated host capsule for durability of the articulation. in selected patients. Chung et al. reported satisfactory HHS
The femoral head is then reduced as described earlier into in over half of Colonna’s patients at 17 years follow-up [2].
this interposed allograft parachute. Due to the compressible Pozo et al. found that nearly three-quarters of patients had
nature of the graft, it conformed snugly to the acetabulum an HHS over 80 at 20-year follow-up [3]. As THA has
and allowed for femoral head reduction. The stay sutures can demonstrated an increased failure rate in patients under 50
then be tied down to remnant capsule using a free needle years old [8, 9], continued development of hip preservation
with interrupted sutures in circumferential fashion about the techniques in the young patient, with adequate femoral
femoral head and neck. Supplemental 0-vicryl partial-thick- head cartilage despite hip dislocation, is needed.
ness sutures allow for full integration of host capsule to the Capsular arthroplasty, in conjunction with modern hip
allograft tissue, to engulf the femoral head in the capsular preservation techniques, may offer a viable option for
arthroplasty (Fig. 4). A final assessment of tension on the sci- chronic hip dislocation, and allograft capsular augmentation
atic nerve is made, as well as length and rotation of the limb, may help to address capsular deficiency. In order for this to
38  M. Sloan and A. F. Kamath

Fig. 5. Post-operative X-rays. (A) Intra-operative left hip AP fluoroscopic view demonstrating adequate femoral head reduction.
(B) Post-operative AP pelvis X-ray in hip abduction brace. (C) 8-Month post-operative AP pelvis X-ray.

be a viable option, the candidate must have functional ab- R E F E R EN C E S

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