Diagnosis and therapy of hip dysplasia in the older child

Diagnosis of congenital hip dysplasia is based on normal values of the acetabulum, but also criteria such as deficiency of the acetabular rim and an increased distance from the tear drop figure. Instability of the hip joint is seen in arthography. Acetabuloplasty is the way to treat it. Unstable joints will deteriorate, stable ones are frequently improving spontaneously. The technique of open reduction from an inguinal approach medial of the psoas muscle is described. There are many advantages. Simultaneous shortening osteotomy and acetabuloplasty to permit immediate movements out of the hip spica are recommended to avoid stiffening and contractures. Hip dysplasia is corrected by a lateral acetabuloplasty that levers down the acetabular roof in the triradiate cartilage. After consolidation of the cartilage triple pelvic osteotomy for acetabular rotation is the method to correct dysplasia in adolescents and adults. The closer the osteotomies are performed to the hip joint, the better rotation is possible. Our technique has proved successful now in 12 years.     

髋臼成形截骨治疗成人髋臼发育不良

目的　探讨治疗成人髋臼发育不良的新方法。方法　沿髋臼上缘截骨 ,截骨后将骨瓣尽量向下翻转以加大髋臼对股骨头的包容。截骨间隙采用髂骨植骨填充并用克氏针固定。结果　 18例平均随访 3 5年 ,根据Gordon标准评定疗效 ,优 9例 ,良 7例 ,中 2例。结论　该方法是治疗成人髋臼发育不良的有效方法     

One-stage correction of the dysplastic hip in cerebral palsy with the San Diego acetabuloplasty: results and complications in 104 hips

Ninety-two patients with cerebral palsy underwent a special type of pericapsular acetabuloplasty designed to correct the hip dysplasia that occurs in cerebral palsy. The osteotomy was performed as part of a combined procedure (including femoral osteotomy and soft-tissue releases). Retrospective analysis was performed on 75 of the children (104 hips from 1982 through 1995) with a mean follow-up of 6.9 years. Ninety-nine (95%) of the 104 hips remained well reduced at follow-up. There were no redislocations. If the preoperative migration percentage was >70% (severe subluxation), improved results were noted in hips that had an open reduction with capsulorrhaphy. There were 13 complications including intraarticular extension of the acetabuloplasty (one) and avascular necrosis of the femoral head (eight hips, 8%). Indications for addition of a pericapsular acetabuloplasty include an open triradiate cartilage, acetabular dysplasia (acetabular index >25 degrees), and subluxation or dislocation with a migration percentage of >40%. Even hips with relative incongruity and some deformity of the femoral head can be successfully treated with this combined approach.     

Surgical treatment of congenital dislocation of the hip

The results of two collective studies on congenital dislocation of the hip (CDH) from a number of hospitals are reported here, including general trends in the Federal Republic of Germany and the author's personal methods and preferences. In the first collective study group, the rate of ischemic necrosis in open reductions was 8.2% for anterolateral approaches, 9.6% for inguinal, 16.7% for Ludloff's operation, and only 5.5% when shortening osteotomy was combined with open reduction. A simultaneous Salter osteotomy or acetabuloplasty increased the rate to 10.3% and a concomitant varus osteotomy to 22.2%. The author prefers an inguinal approach to the hip joint, first laterally and then medially of the iliopsoas muscle and femoral nerve, for optimal visualization of the acetabulum. Stability of the joint is increased by a girdle-like flap from the dorsolateral capsule, which is drawn anteriorly and prevents dorsal redislocation. Acetabuloplasty should also be used, even during the first year of life, in joints in which stability may only be guaranteed by extreme abduction and internal rotation. Salter's and Pemberton's osteotomies are used in Germany with good results. However, the author prefers a lateral Albee-Lance acetabuloplasty modified to a complete osteotomy for lateral levering of the acetabular roof. Long-term results show measurements between 82% and 93% of normal and slightly pathologic values. Simultaneous or single varus osteotomies lead to subcapital coxa valga and should no longer be used routinely. In adolescents and adults up to 45 years of age, as long as osteoarthritis is not too advanced and the femoral head is not too deformed, triple pelvic osteotomy with the author's type of modification has a number of advantages.     

Pemberton髋臼成形术治疗发育性髋关节脱位

目的：探讨分析Pemberton髋臼成形术在发育性髋脱位的治疗上具有哪些优势。方法：采用Pemberton髋臼成形术治疗儿童发育性髋脱位106例116髋,男19例29髋,女87例87髋。左侧46髋,右侧50髋,双侧20髋。年龄18个月～13岁,平均7岁3个月,其中18个月～6岁99髋,7～13岁17髋。116髋均采用Pemberton髋臼成形术或内收肌、髂腰肌切断加Pemberton髋臼成形术加转子下股骨短缩、旋转截骨术。95髋单纯行Pemberton髋臼成形术,余21髋行全套手术。双侧髋脱位患儿均先做一侧,1年后再做另一侧,同时将第1次手术股骨内固定钢板取除。结果：病例随访时间2～10年,平均6年。按照Mullerh和Seddon标准进行功能评定,优67髋,良34髋,可10髋,差5髋,优良率87%。结论：Pemberton髋臼成形术适用于多个年龄段的儿童发育性髋脱位患者,疗效肯定,在发育性髋脱位的治疗中占有重要地位。     

Pemberton's acetabuloplasty for congenital dislocation or subluxation of the hip

The results obtained in a consecutive series of thirty-seven Pemberton operations for congenital dislocation or subluxation of the hip are reported. Over the period under review, 1967 to 1973, it was the only type of acetabuloplasty employed at Winford. Unless the mandatory concentric reduction could be obtained with ease, preliminary open reduction was favoured, especially in cases of primary care. Femoral rotation osteotomy was added for marked anteversion. The programme was designed to be complete inside fourteen weeks, and was so for eighteen hips. Secondary acetabuloplasty was performed on hips with instability or dislocation persisting despite previous treatment. The operations were performed from eighteen months to thirteen years of age. One initial failure required a repeat operation which was successful, but one severely dysplastic hip remained so. The average follow-up was six years.     

Growth disorders of the acetabular roof after acetabuloplasty in congenital hip dysplasia

PURPOSE: The aim of this long-term study was to evaluate whether the Lance acetabuloplasty for congenital dysplasia of the hip causes a growth disturbance of the acetabular roof during or after puberty. METHOD: 71 hips of 58 patients were followed clinically and radiologically over a maximum time of 16 years after the operative procedure of a Lance acetabuloplasty. The average age of the patients at the time of operation was 2.8 years (1-6 years). In order to assess the growth of the acetabulum in the early and long-term postoperative phase quantitative parameters (acetabular index of Hilgenreiner, CE angle of Wiberg, ACM angle of Idelberger) as well as qualitative parameters (disturbance of the ossification of the acetabulum and the femoral head) were determined in standardized X-rays of the pelvis, done routinely 6 months, 3 years, 5 years, 8 years and at an average of 11 years as the last follow-up examination after the operation. The assessment of these metrical parameters were carried out in accordance to the classification of the study-group "hip dysplasia" of the DGOT (normal--slight pathological--serious pathological) respecting the different age-groups and degrees of dysplasia. RESULTS: Although in the early postoperative phase the acetabular roof showed a positive development (65% of the CE angles could be considered normal 3 years after operation), the further growth of the acetabulum was disturbed in the period of puberty (8 years after operation only 33% of the CE angles could be considered normal, 51% were extremely pathological). And also in the last X-ray control after an average follow-up time of 11 years a significant retardation of the acetabular roof was seen in 51% of all cases. CONCLUSION: The Lance acetabuloplasty seems to damage the Ossa acetabuli, which are as centers of ossification the essential anatomic structures for the growth of the acetabular rim in adolescence. CLINICAL RELEVANCE: Other procedures such as the Salter osteotomy are to be preferred for the therapy of hip dysplasia.     

The surgical treatment of inveterate hip dislocation in children affected with cerebral palsy: a preliminary report

The incidence of hip dislocation in patients affected with cerebral palsy is directly correlated with the degree of neurologic deficit. Surgical treatment aimed at stabilization of the coxofemoral joint relieves pain and avoids the occurrence of changes in the static of the pelvis and vertebral column. The authors report their experience with procedures for the recovery of joint congruency (release of the adductors and psoas, surgical reduction of the dislocated epiphysis, femoral shortening associated with varus-derotation at the osteotomy level, acetabuloplasty) performed in one or more surgical stages, and operations with a purely anthalgic purpose (innominate osteotomy according to Chiari), specifying relative indications in relation to age.     

Ipsilateral teratologic high hip dislocation, femoral hypoplasia and below-knee hemimelia associated with contralateral fibular hemimelia: report of a case with functional result

In this case report, we present a patient with right teratologic high hip dislocation, femoral hypoplasia and below-knee hemimelia associated with left fibular hemimelia. Combined open reduction, proximal femoral osteotomy and a Dega acetabuloplasty were performed in the right hip. Closed tibial wedge osteotomy and centralization of the foot with lateral release and Achilles tendon lengthening were performed for the left side. The patient was able to walk with her prosthesis successfully within the first six postoperative months.     

Modified Pemberton acetabuloplasty for the treatment of congenital hip dysplasia

Since 1986, the author has been performing a modified Pemberton acetabuloplasty (MPA) with the deliberate aim of producing a greenstick fracture at the sciatic notch. This procedure was performed in 16 girls representing 17 hips. Nine hips (eight patients) were dislocated. Eight hips (eight patients) had residual or primary acetabular dysplasia. In all dislocated hips and in a teratologic sub-luxation, the MPA osteotomy was performed concomitantly with an open reduction and a femoral shortening. All femoral heads remained well covered, with one exception. One hip had a type III avascular necrosis of the femoral head. Two other hips had evidence of premature growth arrest at maturity without previous signs of avascular necrosis. Two hips had arrest of the triradiate cartilage. The contour of the obturator foramen changed in 10 of the 17 hips. This osteotomy is easier to perform than either a Salter or a Pemberton osteotomy. There was no difficulty in obtaining the desired coverage of the femoral head.     

先天性髋关节脱位手术治疗的探讨

目的 探讨先天性髋关节脱位手术治疗的有效方法。方法 采用开放复位、骨盆旋转截骨、髋臼成形或加盖、股骨上段旋转或短缩截骨的联合术式治疗先天性髋关节脱位106例，158髋。结果 全部病例经2～14年的随访，按照临床疗效评定标准，优良率达95．6％。结论 该方法根据病变的不同情况，采用联合的手术方式进行治疗，术后不用石膏固定，而采用牵引的方法，有利于髋关节功能的恢复；该手术方法可灵活运用，且并发症少。疗效满意。     

A modification on osteotomy of the pelvis (Chiari) for treatment in case of severe dysplastic acetabulum]

The paper presents a report on a modified osteotomy of the pelvis for surgical treatment in case of severe dysplastic acetabulum. This procedure combines the technique of acetabuloplasty and that one of Chiari's osteotomy of the pelvis.     

Early loss of hip containment in a child with dysplasia epiphysealis hemimelica

Progressive loss of hip containment attributable to dysplasia epiphysealis hemimelica of the right proximal femur and macrodactyly of the right second toe was diagnosed and monitored by radiographs and magnetic resonance imaging in a 7-year-old boy. The patient had early surgical correction including shortening osteotomy of the hypertrophic toe and partial resection of the involved superolateral femoral head-neck junction combined with a Pemberton-like acetabuloplasty. This treatment restored containment and function. At 4 years followup, the femoral head remained contained and the patient was participating fully in the activities of daily life for his age-group. A review of the literature suggests monitoring the hip with magnetic resonance imaging may allow early identification of a hip at risk for loss of containment. This treatment may save the hip from severe deformity and early secondary osteoarthritis.     

One-stage hip reconstruction in children with cerebral palsy: long-term results at skeletal maturity

Purpose

Hip subluxation is common in children with cerebral palsy (CP). Surgery is indicated in case of pain or progressive increase of Reimers index on radiographs. Peri-iliac osteotomy combined with femoral osteotomy is one of the numerous operative techniques available, but results at skeletal maturity remain unclear. The purpose of this radiological study was to report the long-term results of this procedure.

Materials and methods

Twenty hips in 20 children were retrospectively evaluated at skeletal maturity. Mean age at surgery was 8.1 years and follow-up averaged 9.1 years. All patients underwent Dega acetabuloplasty, soft-tissue release and femoral-shortening varus derotation osteotomy without open reduction. Reimers index, acetabular angle (AA) and neck-shaft angle (NSA) were compared on preoperative, postoperative and latest follow-up radiographs.

Results

Dega osteotomy significantly improved the AA and the correction remained stable at maturity. The NSA significantly decreased postoperatively (153°–115°), but recurrence of the valgus deformity (130°) of the proximal femur was observed at maturity. Consequently, Reimers index followed the same evolution. No case of osteonecrosis was reported but one hip dislocated and one subluxated during follow-up.

Conclusion

Progressive recurrence of the valgus deformity of the proximal femur, attributable to adductors spasticity and gluteus medius weakness, led to a significant increase in the Reimers index. However, hip coverage remained >70 % at maturity in 90 % of the hips. This one-stage procedure without hip dislocation efficaciously corrected acetabulum dysplasia and successfully treated neurological hips in CP patients.

Level of evidence

IV: retrospective study.     

Premature closure of the triradiate cartilage: a potential complication of pericapsular acetabuloplasty

A case of premature triradiate cartilage closure secondary to a Gill acetabuloplasty performed at age 14 months is reported. The deficiency in acetabular development and failure of the pelvis to grow to its anticipated height is documented. A proximal femoral redirectional osteotomy and an innominate osteotomy performed near maturity improved femoral head coverage and hip biomechanics. Acetabuloplasties performed adjacent to the triradiate cartilage typically do not have any adverse effect on its function. Despite this low risk of injury to the triradiate cartilage after a Gill or Pemberton acetabuloplasty, long-term follow-up is recommended to observe acetabular development. Premature closure is most likely to occur if the bone graft used to maintain fragment displacement crosses the triradiate cartilage.     

Evaluation and compensation of lower limb length discrepancy after surgical treatment of developmental hip dysplasia

Summary The aim of this study was to find a solution for lower limb length discrepancy following surgical treatment of developmental hip dysplasia (DDH) in neglected cases. For this purpose, radiographic examination of 49 hips of 33 children with DDH was made. They were surgically treated by one-stage combined procedure that consisted of open reduction, modified innominate osteotomy and proximal femoral osteotomy. Mean age was 3.5 years and mean follow-up was 34.3 months. In bilateral cases this procedure did not cause notable lower limb length discrepancy. In unilateral cases, it was seen that limb length could be balanced by performing a modified innominate osteotomy producing transiliac lengthening in children older than 4 years. In children younger than 4 years there was no need to perform an acetabuloplasty producing transiliac lengthening because extensive femoral shortening was not needed and femoral overgrowth was sufficient to balance the length of lower limbs. Also avascular necrosis of the femoral head was observed as one of the important factors producing limb length discrepancy in variable degrees.This study was presented in part at the 20th World Congress of SICOT in Amsterdam, The Netherlands, 18–23 August 1996.     

Incomplete periacetabular acetabuloplasty: A one-stop procedure for developmental dysplasia of the hip

Background

Residual acetabular dysplasia is one of the most common complications after treatment for developmental dysplasia of the hip. The acetabular growth response after reduction of a dislocated hip varies. The options are to wait and add a redirectional osteotomy as a secondary procedure at an older age, or to perform a primary acetabuloplasty at the time of the open reduction to stimulate acetabular development. We present the early results of such a procedure—open reduction and an incomplete periacetabular acetabuloplasty—as a one-stop procedure for developmental dysplasia of the hip.

Patients and methods

We retrospectively reviewed the results obtained with 55 hips (in 48 patients, 43 of them girls) treated between September 2004 and February 2011. This cohort included late presentations and failures of nonoperative treatment and excluded unsuccessful previous surgical treatment (including closed reductions), neuromuscular disease, and other teratological conditions. Patients were treated once the ossific nucleus was present or when they reached one year of age. 31 cases were late presentations while 17 represented failures of nonoperative treatment. The mean age of the patients at surgery was 1.3 (0.6–2.6) years. The mean follow-up period was 4 (2–8) years. According to the IHDI classification, 1 was grade I, 9 were grade II, 13 were grade III, and 32 were grade IV.

Results

The mean acetabular index fell from 38 (23–49) preoperatively to 21 (10–27) at the last follow-up. There were no infections, nerve palsies, or graft extrusions. None of the cases required secondary surgery for residual acetabular dysplasia. 8 patients developed avascular necrosis (AVN) of grade II or more. The incidence of AVN was significantly associated with previous, failed nonoperative treatment. 1 patient developed coxa magna requiring shelf arthroplasty 4 years after the index procedure and 1 patient with lateral growth arrest required medial screw epiphysiodesis.

Interpretation

This incomplete periacetabular acetabuloplasty is a reliable adjunct to open reductions, and it is followed by a rapid acetabular growth response that avoids secondary pelvic procedures. It is a one-stop surgery with predictable outcome that can be performed in 0.5- to 2.5-year-old children.The treatment of children with developmental dysplasia of the hip (DDH) between 6–24 months of age is controversial. Many authors have advocated closed reduction, provided arthrographic concentricity is achieved. However, the prevalence of residual acetabular dysplasia in this age group ranges from 38% to over 80% (Roose et al. 1979, Luhmann et al. 2003, Albinana et al. 2003). Many of these children will need secondary procedures at a later date, mainly a pelvic osteotomy, to prevent degenerative disease (Wedge and Wasylenko 1979). Some surgeons favor open reduction, which provides an opportunity to address acetabular dysplasia at the same time. Intentional late open reduction (delayed until the appearance of the ossific nucleus or by 1 year of age) is considered to be safe, as it is associated with a lower rate of subsequent pelvic osteotomy and a reduced incidence of avascular necrosis (Bolland et al. 2010).We present the early results of a novel but possibly reinvented acetabular intervention. The incomplete periacetabular acetabuloplasty (IPA) is performed simultaneously with open reduction and capsulorrhaphy. The aim of the procedure is to “ignite” acetabular growth following concentric reduction of the femoral head rather than to completely correct acetabular deficiency or to perform a redirectional procedure. We believe that the addition of less aggressive acetabular growth stimulation surgery may restore a more normal femoral head/acetabular development in a shorter period by precipitating a remodeling cascade. Such a process would obviate the need for further and more interventional secondary reconstructive pelvic surgery to address residual acetabular dysplasia.     

Treatment of dysplastic and congenitally dislocated hips with the Zweymueller total hip prosthesis

Uncemented Zweymueller total hip prostheses were implanted in 35 dysplastic or dislocated hips in 33 patients. Sixteen hips were dislocated and 19 hips were dysplastic; in 12 hips, an intertrochanteric or pelvic osteotomy was performed in early childhood. In all cases, the titanium screw socket was implanted at the level of the original cotyloid cavity. Osteotomy of the greater trochanter, shortening osteotomy, or roof acetabuloplasty were not performed. In cases in which the femoral cavity was too narrow for the Zweymueller stem, an anterolateral longitudinal window-shaped osteotomy was performed. In cases of severe dysplasia, cotyloid cavity bone grafts from the resected femoral head were placed medially to reinforce the acetabular bottom. Clinical and radiographic follow-up ranged from 3-8 years. Average Harris hip score improved from 47 points preoperatively to 86.2 points postoperatively. Complications included two primary anterior dislocations, two temporary femoral nerve pareses, and two deep vein thromboses. At longest follow-up evaluation, no revision was indicated in any of the hips. Satisfactory results in this series were attributed to careful patient selection, precise preoperative radiographic planning, and an operative technique that included implantation of the socket at the primary acetabulum and achievement of primary stability using press-fit fixation.     

Pelvic osteotomies in children and adolescents

The main types of pelvic osteotomies in children and adolescents are reviewed. Osteotomies in the first group aim at reorienting the acetabulum: Salter's innominate osteotomy is widely used; its technique, possible drawbacks and indications are analyzed; double and triple osteotomies are then reviewed (Sutherland, Le Coeur, Steel, T?nnis and Trousseau) with their prerequisites, drawbacks and specific indications. A second group of osteotomies do not involve complete transsection of the hemipelvis; they are acetabuloplasties following the techniques described by Dega and by Pemberton, the indications of which are also presented together with their prerequisites. Last comes Chiari's osteotomy: it appears as a palliative operation, with limited indications in children and adolescents. Finally, the indications for pelvic osteotomies are reviewed, according to patient's age, anatomical status of the hip and underlying pathology. Unstable and dysplastic DDH hips may be treated by Salter's osteotomy, Pemberton's acetabuloplasty of triple pelvic osteotomy if the hip is mobile, well centered and congruous. The more simple Salter and Pemberton operations are to be preferred to triple osteotomy as long as they are indicated, i.e. until the age of 5 to 8 years. Established congenital dislocations may be treated using Chiari's osteotomy in cases where a reorientation osteotomy or acetabuloplasty is no longer indicated, provided the hip remains mobile. The indications for pelvic osteotomy in Perthes disease are analyzed, and the arguments for a pelvic rather than femoral osteotomy in some cases are presented. Pelvic osteotomies with the numerous techniques developed over the years, have been a major advance in the treatment of hip anomalies in children. In older adolescents, their indication must be balanced against those of hip reconstruction; they must anyway never make subsequent arthroplasty in adult age difficult or impossible.