Late-diagnosed DDH: a prospective 11-year follow-up of 71 consecutive patients (75 hips)

I have prospectively studied 71 consecutive patients (75 hips) with late-diagnosed DDH (developmental dysplasia of the hip) treated uniformly with special reference to the development of the femoral head and the acetabulum. The age at the start of treatment was 10 (2-64) months. The follow-up time was 11 (6-18) years. After tenotomy and traction, closed reduction failed in 7 hips. These cases were treated by open reduction with or without Salter innominate osteotomy-in 2 hips femoral osteotomy was also done (shortening, varus and derotation). 1 hip subluxated and 1 re-dislocated after closed reduction. Avascular necrosis occurred in 4 hips and additional surgery was required in 12 hips--11 Salter osteotomies, 1 varus femoral osteotomy. In the first year after reduction, the acetabular angle improved rapidly--faster in the younger children. When treatment started between 12 and 22 months, the improvement was slower and the final outcome more unpredictable. The femoral head continued to grow irrespective of the age at reduction and became normal in almost all cases. Salter's innominate osteotomy stabilized hips after open reduction and gave excellent results in cases with an increasing acetabular angle. At the last re-examination, all but 2 patients were asymptomatic. Radiographically, 65 hips were rated Severin group I, 9 group II and 1 group III.     

Late-diagnosed DDH: A prospective 11-year follow-up of 71 consecutive patients (75 hips)

I have prospectively studied 71 consecutive patients (75 hips) with late-diagnosed DDH (developmental dysplasia of the hip) treated uniformly with special reference to the development of the femoral head and the acetabulum. The age at the start of treatment was 10 (2-64) months. The follow-up time was 11 (6-18) years. After tenotomy and traction, closed reduction failed in 7 hips. These cases were treated by open reduction with or without Salter innominate osteotomy - in 2 hips femoral osteotomy was also done (shortening, varus and derotation). 1 hip subluxated and 1 re-dislocated after closed reduction. Avascular necrosis occurred in 4 hips and additional surgery was required in 12 hips - 11 Salter osteotomies, 1 varus femoral osteotomy. In the first year after reduction, the acetabular angle improved rapidly - faster in the younger children. When treatment started between 12 and 22 months, the improvement was slower and the final outcome more unpredictable. The femoral head continued to grow irrespective of the age at reduction and became normal in almost all cases. Salter's innominate osteotomy stabilized hips after open reduction and gave excellent results in cases with an increasing acetabular angle. At the last re-examination, all but 2 patients were asymptomatic. Radiographically, 65 hips were rated Severin group I, 9 group II and 1 group III.     

Which is a better method for Perthes' disease: femoral varus or Salter osteotomy?

The optimum surgical treatment of patients with Perthes' disease has not been decided. We compared the clinical and radiographic results at skeletal maturity of the femoral varus osteotomy and the Salter innominate osteotomy for treatment of patients with Perthes' disease. Treatment in 46 patients was by femoral varus osteotomy and in 30 patients by Salter innominate osteotomy. There were no significant differences between the two groups. The clinical results were similar in the two groups except for scarring after surgery, which was more prominent in the femoral varus osteotomy group. There was no significant difference in the sphericity of the femoral head and congruity of the hip between the two groups. However, coverage of the femoral head by the acetabulum, the neck-shaft angle, and the articular-trochanteric distance were closer to normal in the Salter innominate osteotomy group. We think that the Salter innominate osteotomy is the better treatment for patients with Perthes' disease to decrease residual problems such as coxa vara, trochanteric prominence, poor acetabular coverage, and the surgical scar.Level of Evidence: Therapeutic study, Level IV (case series-no, or historical control group).     

Treatment of Tönnis type II hip dysplasia with or without open reduction in children older than 18 months: a preliminary report

Purpose

In this study, we aim to investigate whether the hip with Tönnis type II dysplasia in children older than 18 months can be treated without open reduction.

Methods

In our study, 47 hips (47 patients) with type II developmental dysplasia of the hip according to the Tönnis classification were treated by a combination of open reduction through an anterolateral approach with iliopsoas tenotomy followed by innominate osteotomy and capsulorrhaphy or iliopsoas tenotomy followed by innominate osteotomy. The patients with open reduction constitute the open Salter group (32 hips), while the rest of the patients with innominate osteotomy alone constitute the closed Salter group (15 hips). The acetabular index (AI) and Smith’s c–b and h–b index were assessed on the preoperative, immediate postoperative and final follow-up hip X-rays.

Results

There were no statistically significant differences related to sex distribution, age and postoperative follow-up time between the patients of each group. There was also no statistically significant difference between the preoperative AI of the open and closed Salter osteotomy groups. Overall, 80% of hips with open reduction had Smith’s c–b ratio greater than the value of 1 and h–b ratio lower than the value of 0.05.

Conclusion

The preoperative c–b index of the open osteotomy group was statistically greater than the c–b index of the closed osteotomy group and the preoperative h–b index of the open Salter group was statistically smaller than the h–b index of the closed Salter group, which means that most of the hips in the open osteotomy group are more in a lateralised and superior position compared to the closed osteotomy group. To us, there exists a subgroup of hips with less lateralisation and superior displacement according to the Smith’s c–b and h–b ratio in Tönnis type II hip dysplasia. These hips might be less amenable to capsulorrhaphy because of the lower capsular instability and treatment may be done with closed reduction after iliopsoas tenotomy with Salter osteotomy in this select group of patients.     

Management of post septic hip dislocations when the capital femoral epiphysis is present

Delayed or missed diagnosis of septic arthritis of hip in children results in various sequelae. The group of post septic hip dislocations when the capital femoral epiphysis (CFE) is present has not been described in the commonly used classifications. This is a retrospective series of 21 hips in 18 children. The presence of the CFE was confirmed radiologically or at the time of intervention. The mean follow-up after intervention was 6.3 years. Interventions for dislocations included closed reduction ± adductor tenotomy, open reduction ± supplementary femoral procedures, and acetabular procedures. Results were evaluated clinically with Ponseti hip scoring and radiologically with the modified Severin grading. Closed reduction was successful in seven of 20 hips (35%) and open reduction in 13 of 14 hips. At follow-up, good clinical result was seen in nine of 18 cases (50%). The mean neck shaft angle was 129° in all hips and 124° after femoral varus osteotomy. There was one redislocation and three subluxations. The modified Severin classification was class 2 in five hips (good), class 3 in 12 hips (fair), class 4 in three hips (poor), and class 6 in one hip (failure). Septic hip dislocation with CFE present is a distinct entity. MRI is helpful for planning treatment. A significant number of patients need open reduction with other procedures. Femoral varus osteotomy may contribute to coxa vara. In the short term, intervention results in a stable, functional, and mobile hip.     

Middle-term results of Salter innominate osteotomy

This study evaluated middle-term clinical and radiographic results of Salter innominate osteotomy for treatment of dysplastic, subluxated, or congenitally dislocated hips. Thirty-five hips in 33 patients with a mean age at index surgery of 4 years 7 months were followed up for an average of 16.5 years. Radiographic center-edge angle of Wiberg, acetabular index, and regularity of the femoral head were evaluated. Fifteen (43%) hips were in Group I, 11 (31%) hips were in Group II, six (17%) hips were in Group III, and three (9%) hips were in Group IV according to the Severin classification. Significant differences were found in the preoperative and recent center-edge angle (average, 1.1 degrees and 28.8 degrees in the excellent and good groups versus -5.3 degrees and 15.0 degrees in the fair and poor groups) and regularity of the femoral head (very irregular versus others). The current results indicate that after middle-term followup, Salter innominate osteotomy is an effective treatment. The authors conclude this procedure is indicated in patients who meet the criteria proposed by Salter.     

The surgical treatment of developmental dislocation of the hip in older children: a comparative study

The aim of this retrospective study was to compare simultaneous open reduction and Salter innominate osteotomy versus one-stage combined surgical treatment including femoral shortening. A total of 24 patients were studied. Group 1 included 16 hips in 14 patients treated by simultaneous open reduction and Salter innominate osteotomy; Group 2 included 13 hips in 10 patients treated by one-stage open reduction, Salter innominate osteotomy and femoral shortening. The average age at the time of operation was 4.1 years (range: 3.3 to 5.1). Average follow-up was 5.3 years (range: 2.7 to 9.0). Clinical and radiological assessment at final follow-up showed that the outcome was not significantly different between the two groups. The duration of operation, however, was significant different between the groups. Patients with DDH between 3 and 5 years of age were treated successfully with either simultaneous open reduction and Salter innominate osteotomy or a one-stage combined surgical procedure including femoral shortening. Clinical and radiological outcomes were similar. Nevertheless, after this follow-up period, the rate of avascular necrosis was slightly higher in Group 1; on the other hand, one-stage combined surgical treatment including femoral shortening significantly prolonged the operative time.     

Modified triple innominate osteotomy for acetabular dysplasia: for better femoral head medialization and coverage

Steel's triple innominate osteotomy was created for correcting dysplastic acetabulum in adolescents and young adults. We modified Steel's triple innominate osteotomy with two anterior incisions and ramus cuts close to the acetabulum to improve the mobility of the fragment for better coverage of the hip. The purpose of this study was to compare these two techniques with respect to acetabular morphology, femoral head coverage, and medialization. From 1989 to 2007, 22 hips from 19 adolescents and young adults underwent triple innominate osteotomy for symptomatic acetabular dysplasia with Tonnis grades 1 or 2. We divided patients into group A (11 hips from 10 patients), comprising patients who underwent classical Steel's osteotomy, and group B (11 hips from nine patients), comprising patients who underwent modified Steel's osteotomy, with a minimum follow-up of 2 years. Preoperative and postoperative radiographs of pelvis in the standing position were available for comparison. We used Sharp's angle, center-edge angle, femoral head extrusion index, and center-head distance discrepancy to evaluate hip morphology, femoral head coverage, and medialization, respectively. The paired t-test was used for statistical calculation with P-value less than 0.05 considered significant. The postoperative Sharp's angle, center-edge angle, femoral head extrusion index, and center-head distance discrepancy all had better results in group B with statistical significance. Other variants such as age, sex, and operation side did not have any significance. No postoperative complication was encountered. Our modified technique provided a better mobility of the rotated fragment in correcting acetabular dysplasia with a short learning curve. Most importantly, we provided greater coverage and medialization of the femoral head for better long-term results. Level of evidence: level III, retrospective comparative study.     

Operative treatment of bilateral hip dislocation in children with arthrogryposis multiplex congenita

PURPOSE: Arthrogryposis multiplex congenita (AMC) is a rare syndrome with multiple joint contractures. It is commonly believed that bilaterally dislocated hips associated with joint contractures should not be reduced, because movement is satisfactory, while open reduction leads to poor results. This report presents our experience with surgical management of bilateral dislocation of hips in children with AMC. METHODS: During the period 1990 to 2000, we performed open reduction on 8 hips of 4 children with AMC. The mean age at surgery was 23 months (range, 5-48 months). Open reduction and capsular plication without any bony procedure were performed in 4 hips (2 patients). De-rotation and varus osteotomy of the femur was performed in 4 hips, and Salter osteotomy of the innominate bone in 2 hips. The average acetabular index was 44 degrees, and the mean centreedge angle was -41 degrees preoperatively. RESULTS: The average follow-up period was 4 years (range, 2-9 years). The average acetabular index and centre-edge angle were 19 and 18 degrees, respectively at the time of last follow-up. All children could walk without support. One child required re-opening for redislocation of hip joint. The clinical results were good in 6 hips and fair in 2 hips, according to Severin's and McKay's classifications. CONCLUSION: Our experience shows that open reduction for bilateral dislocation of hips in children with AMC is a suitable option with generally good results. Surgery performed at earlier age gives the best functional outcome.     

The Salter innominate osteotomy: should it be combined with concurrent open reduction?

The timing of surgical realignment of the acetabulum after reduction of the dysplastic hip is controversial since a delay in correction may allow the joint to sublux again. The radiographic outcome after 188 Salter osteotomies was reviewed 5-25 years postoperatively using a comprehensive rating scale; 139 hips (69%) developed satisfactorily, 49 hips (26%) remained dysplastic but stable and nine hips (5%) were unsatisfactory. The best results occurred in children under the age of 30 months treated by combined open reduction and Salter osteotomy, when no further operation was required. The staged procedure yielded a slightly smaller proportion of satisfactory results, which were independent of the age of the child (and the incidence of redisplacement and avascular change was reduced). If the innominate osteotomy reduced the acetabular inclination by approximately 15 degrees the hip joint usually stabilized and a normal acetabular (Sharp) angle was present at maturity. When 132 patients were assessed clinically at maturity (between the ages of 16 and 35 years), clinical, functional and radiographic review revealed that 121 of 148 hips were graded in Severin groups I and II. The clinical outcome was determined by the degree to which the acetabular dysplasia was corrected.     

Combined salter innominate osteotomy with femoral shortening versus other methods of treatment for Legg-Calvé-Perthes disease

The results of treatment of Legg-Calvé-Perthes disease in 357 patients at the Institute for Orthopaedic Surgery "Banjica," Belgrade, from January 1963 to December 1987 with > or = 10 years of follow-up are summarized. The advantages of combined Salter innominate osteotomy with femoral shortening, as a one-step operation, are emphasized. Male predominance was found in a ratio of 4.75:1, and bilateral involvement was present in 21% of the patients. Disease onset was usually between ages 4 and 7 years (mean 6.5 years). Catterall criteria for the classification of the disease were used; patients in groups I and II were treated nonsurgically and those in groups III and IV were treated surgically. Most of the surgically treated patients (64.4%) had one or more head risk factors. The most frequently used surgical procedure was a Salter innominate osteotomy with or without femoral shortening. Assessment of treatment was made by measuring the final center-edge angle and by using criteria developed by Catterall, Mose, Harrison, and Stulberg. Final functional status of the operated hips was recorded as well. The greatest final center-edge angle of 34.27 degrees was found in the patients treated with combined Salter innominate osteotomy and femoral shortening, showing improvement of 14.98 degrees. Surgical treatment, except for revascularization procedures, showed good and fair results in > 90% of patients. The range of hip motion was improved in most patients. The earliest weight-bearing allowance was found in patients who underwent Salter innominate osteotomy and femoral shortening; it averaged 3.1 months. The duration of immobilization was also the shortest in this group. The average femoral shortening was 1.38 cm (range 0.9-1.9 cm). The proposed combined Salter osteotomy with femoral shortening is recommended for the treatment of more severe cases of Legg-Calvé-Perthes disease, thus preventing establishment of early secondary hip arthrosis.     

Posterior acetabular wall deficiency in Down syndrome

Trisomy 21 or Down syndrome is the most common chromosomal anomaly and is associated with musculoskeletal abnormalities related to a generalized ligamentous laxity. Approximately 1% to 7% of Down syndrome patients have hip instability. Prior studies on the topic recommend Salter innominate osteotomy, capsular plication, and a varus derotational osteotomy of the proximal femur, which typically is in an anteverted and valgus position. The authors present a previously unreported bilateral finding in two patients noted on three-dimensional reconstruction computed tomography: deficiency of the posterior acetabular wall. Each was treated using a modification of the Pemberton osteotomy in which a wedge of iliac crest graft is placed posteriorly to hinge the posterior wall into a position of better posterior coverage of the femoral head. Both patients' hips have remained stable more than 10 years postoperatively. Follow-up imaging demonstrates well-remodeled osteotomy sites and excellent posterior coverage of the femoral heads.     

Surgical treatment of hip dislocation in Kabuki syndrome: use of incomplete periacetabular osteotomy for posterior acetabular wall deficiency

Purpose

Kabuki syndrome is characterized by distinctive facial features, skeletal anomalies, persisting fingertip pads with dermatoglyphic abnormalities, postnatal growth deficiency and mental retardation. This report reviews our results in the operative treatment of hip dislocations in patients with Kabuki syndrome.

Methods

Between 2001 and 2009, seven dislocated hips (three unilateral and two bilateral hips) in five patients (all girls) were operatively treated at our institution. The operative treatment consists of open reduction, femoral derotation varus osteotomy, pelvic osteotomy (Salter in one and incomplete periacetabular osteotomy in six hips) and capsular plication. The age of the patients at the time of surgery ranged from 2.4 to 5.7 years, with an average of 3.6 years.

Results

The follow-up postoperative period ranged from 3.2 to 6.3 years, with an average of 5.0 years. At the final follow-up, all patients reported no click and no pain, and showed well-contained hips by radiographs. All seven hips were graded as Severin class I-II. One patient presented as having habitual dislocation of the hip 4.4 years after surgery. Computed tomographic (CT) scans revealed posterior acetabular wall deficiency, which was not corrected by the anterolaterally directed Salter osteotomy. The incomplete periacetabular osteotomy provided sufficient posterolateral coverage of the acetabulum.

Conclusion

Operative treatment combining open reduction, femoral derotation varus and incomplete periacetabular osteotomies, and capsular plication provided successful results in patients with Kabuki syndrome who had the characteristics of hip instability such as ligamentous laxity, muscular hypotonia and posterior acetabular wall deficiency.     

Results of the Kalamchi modification of salter osteotomy in the treatment of developmental dysplasia of the hip.

The results of the Kalamchi osteotomy for acetabular dysplasia or subluxation secondary to developmental dysplasia of the hip are reported. In 16 hips, the modified innominate osteotomy was the sole procedure, whereas 10 hips had a concomitant shelf procedure and four hips had a concomitant femoral varus osteotomy. Using a modification of Severin's classification for radiographic evaluation, 97% of hips were classified as excellent (class I and II). Using McKay's criteria for clinical results, 93% of hips were classified as excellent or good. The advantages of this procedure are avoidance of limb lengthening, better stability of the osteotomy, no need for graft, and theoretically a decrease in pressure across the femoral head.     

Double innominate osteotomy

We performed double innominate osteotomy in twenty-five patients with acetabular insufficiency resulting from congenital dislocation of the hip and other lesions. Following iliac (Salter) osteotomy, the second osteotomy was carried out medial to the obturator foramen in the interval between the symphysis pubis and the pubic tubercle. In children more than six years old, adolescents, and adults, addition of the pubic osteotomy increased the amount of acetabular rotation and coverage of the femoral head that could be achieved. An additional benefit was that the femoral head could be shifted medially, decreasing the length of the femoral lever arm. The improvement in center-edge angle in the twenty-five patients averaged 27 degrees, and the acetabular index decreased an average of 19.5 degrees. The center of the head shifted medially an average of 1.5 centimeters. Hip stability was achieved in twenty-three of the patients.     

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.     

Acetabular coverage after innominate osteotomy

A criticism of innominate osteotomy is that it may cause relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address that hypothesis. We had access to standing hip radiographs of 30 patients (36 hips) who had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation at least 40 years earlier. A single independent investigator used the validated method of Hefti (1995) to measure anterior and posterior acetabular coverage, contact area, and version. Ten operated hips had advanced osteoarthritis obscuring acetabular landmarks. Twenty-six operated hips were readable despite some radiographs showing signs of mild-to-moderate osteoarthritis. Twenty contralateral hips without developmental hip dysplasia formed a comparison group and 21 age-matched and sex-matched "normal hips" were used as a control. A significant difference between the groups was found for contact area (P < 0.001). There was no significant difference between the other 3 outcomes: anterior coverage (P = 0.509), posterior coverage (P = 0.135), and anteversion (P = 0.845). Anteversion in hips with a good outcome after innominate osteotomy and open reduction was not different to a control group of radiographically normal hips. The early osteoarthritic changes seen in these hips may relate to decreased contact area compared with the normal population. In this series, innominate osteotomy before the age of 5 years did not consistently cause acetabular retroversion that persisted into adulthood. Apparently unaffected hips contralateral to the dislocated side display reduced contact area relative to controls indicating probable occult dysplasia.     

A combination pelvic osteotomy for acetabular dysplasia in children

Several surgical procedures have been devised to increase acetabular coverage of the femoral head in children with dysplasia of the hip. In this report we describe an acetabuloplasty that combines the key aspects of the Pemberton and Salter osteotomies. It has been used at the Los Angeles Unit of the Shriners Hospital for Crippled Children since the late 1960's. To assess the results of this combination procedure, fifty hips in forty-four children were evaluated at an average of six years postoperatively. The average age at operation was 7.3 years, and 62 per cent of the patients had had prior surgery. Clinically, thirty-two hips in which there had been no or slight symptoms preoperatively remained unchanged, twelve that had had preoperative limitations improved, and six showed some deterioration in terms of slight loss of motion, mild pain, and a limp. Roentgenographically, acetabular dysplasia (as measured by the acetabular index and by the center-edge angle of Wiberg) improved in more than 90 per cent of the hips. The roentgenographic results were comparable with those obtained by innominate or pericapsular osteotomy. The combination osteotomy has the advantages of both the Pemberton procedure and the Salter operation and proved to be an excellent surgical procedure for older children whose acetabular development did not progress as well as was expected.     

Treatment of failed open reduction for congenital dislocation of the hip

Twenty-three patients with 25 involved hips underwent repeat open reduction after previous unsuccessful attempts at open reduction for congenital dislocation of the hip (CDH). All hips ultimately were reduced at a mean age of 2 years 10 months (range 10 months to 7 years 3 months). On review, we noted that 15 of the hips were never concentrically reduced at the first procedure, and seven of these hips had undergone simultaneous Salter osteotomy. The most common cause of failure was improper exposure and release of the tight inferior capsule and transverse acetabular ligament, which blocked complete reduction. A vascular necrosis was documented in 44% of the hips, with a lateral physeal growth disturbance in four hips, a central physeal growth arrest in four hips, and complete femoral head necrosis in three hips.     

髋臼重建手术在儿童髋关节病理性脱位的应用

目的总结髋臼重建手术在儿童髋关节病理性脱位中的应用及临床疗效。方法 2006年1月-2011年1月,共收治59例(59髋)儿童髋关节病理性脱位,采用髋关节切开复位联合髋臼重建手术治疗。男22例,女37例;年龄1～15岁,平均4.9岁。化脓性髋关节炎后遗病理性脱位33例,髋关节结核26例;病程1个月～10年。髋关节半脱位9例,髋关节全脱位50例。术前Harris髋关节功能评分为43～78分,平均61分。14例髋臼指数基本正常,32例轻度增大,13例明显增大。合并髋臼破坏28例;股骨头缺血性坏死25例,股骨头部分缺失12例,股骨头完全缺失6例,股骨头颈同时缺失3例;前倾角增大25例;髋内翻畸形9例。结果术后即刻摄X线片示所有髋关节均达中心性复位。55例切口Ⅰ期愈合,4例切口延期愈合。53例获随访,随访时间2～5年,平均3年。随访期间无髋关节再脱位。38例髋臼指数基本正常,15例轻度增大。前倾角15～25°,平均20°;颈干角110～140°,平均125°,头颈解剖关系基本恢复正常。术后2年髋关节活动度完全恢复正常18例,屈曲及旋转轻度受限30例,纤维强直5例;Harris髋关节功能评分为62～95分,平均87分。结论儿童髋关节病理性脱位常合并严重的髋臼及股骨头颈部骨质破坏及后遗畸形,治疗上应严格遵循个体化原则,根据患髋主要病理改变选择适当的髋臼重建术式,并结合股骨头颈重建处理,可获得满意疗效。