Volume 04 / Issue 04 / December 2016
Page 26
boa.ac.uk
JTO Features
Operations we no longer do: Posterior Iliopsoas transfer (Sharrard Procedure) Mike Bell
When I was appointed to Sheffield Children’s Hospital in 1986, spina bifida was still prevalent. My predecessor, John Sharrard, had worked extensively with these children. He was concerned that many children with spina bifida developed hip dislocation and following the study of a large group of patients he came to the conclusion that the cause was muscle imbalance around the hips. He found that many children with hip dislocation were innervated to L3 and, as a result, the hip flexors and adductors were active, in the absence of opposing muscles. He designed a modification of the Mustard procedure to rebalance the hips. He transferred the psoas to the posterior aspect of the greater trochanter, via a hole in
the iliac wing. His rationale was to remove the deforming force and provide active hip extension and abduction. The procedure involved an anterior approach to the hip between the femoral artery and femoral nerve. This is not for the faint hearted! The psoas and the lesser trochanter are identified and psoas is detached from the lesser trochanter with a small piece of cartilage. The iliacus is also mobilised from its femoral attachment. The complete muscle mass of iliopsoas is then mobilised and passed into the pelvis under the inguinal ligament.
successful in containing the hips. Follow-up also showed that the hole in the pelvis increased in size as the child grew.
Why do I no longer do it? The incidence of high level spina bifida has decreased significantly, as a result of screening with alphafetoprotein and the realisation of the importance of folic acid supplements in women who are planning to get pregnant.
Evidence from Australia identified that many children with spina bifida who had dislocated hips had a much higher level of neurological impairment with no muscle activity around the hips. They also found that in cases of bilateral hip dislocation the children functioned very well, in spite of the fact that the hips were dislocated. It was also noted that if surgery was unsuccessful on one side, the overall outcome was much worse as one hip would be enlocated, whilst the other remained dislocated. The resulting leg length inequality gives significant imbalance. Therefore, the Sharrard procedure’s place is very limited and should only be performed in children who have a unilateral hip dislocation with innervation to L3 - now a very rare situation. n
The abdominal muscles and iliacus are mobilised from the iliac wing. A hole is then made in the posterior aspect of the iliac wing. The iliopsoas tendon is passed through the hole in the pelvis and the abductor muscle mass and attached to the posterior aspect of the greater trochanter. Access to the greater trochanter is via a lateral approach.
Did it work?
Mike Bell
There was doubt as to whether the transfer functioned as an active transfer or merely as a tenodesis. It was by and large
Figure 1: Pictorial representation of Sharrard’s operation