[Indications and results of corrective pelvic osteotomies in developmental dysplasia of the hip]. Orthopade. 2008;37:556-570, 572-574, 576. [PMID: 18493740 DOI: 10.1007/s00132-008-1240-6]

Finite Element Analysis of Various Osteotomies Used in the Treatment of Developmental Hip Dysplasia in Children

Late-discovered developmental hip dysplasia deformities often necessitate complex surgical treatments and meticulous preoperative planning. The selection of osteotomies is contingent upon the patient's age and the specific structural deformity of the hip. In our anatomical hip model, derived from the data of a 12-year-old patient, we performed virtual osteotomies that are commonly recommended for such cases. We precisely constructed geometric models for various osteotomies, including the Dega, Pemberton, Tönnis, Ganz, Chiari pelvic, and Pauwels femoral osteotomies. We employed Autodesk Inventor for the finite element analysis of the hip joint and the corrective osteotomies. In comparing one-stage osteotomies, we noted that the Dega and Ganz pelvic osteotomies, especially when combined with the Pauwels femoral osteotomy, yielded the most favorable outcomes. These combinations led to enhanced femoral head coverage and reduced intra-articular pressure. Furthermore, we calculated the femoral head-to-acetabulum volume ratio for both the Dega and Pauwels osteotomies. The encouraging results we obtained advocate for the integration of finite element analysis in virtual osteotomies of the pelvis and femur as a preoperative tool in the management of developmental hip dysplasia.

Residual hip dysplasia in children: osseous and cartilaginous acetabular angles to guide further treatment-a pilot study

PURPOSE

In case of residual hip dysplasia (RHD) in children, pelvic radiographs are sometimes insufficient to precisely evaluate the entire coverage of the femoral head, when trying to decide on the need for further reconstructive procedures.

METHODS

This study retrospectively compares the bony and the cartilaginous acetabular angle of Hilgenreiner (HTE) of 60 paediatric hips on pelvic MRI separated in two groups. Group 1 included 31 hips with RHD defined by a bony HTE > 20°. Group 2 included 27 hips with a HTE < 20°. They were compared by introducing a new ratio calculated from the square of cartilaginous HTE above the bony HTE on frontal MRI. The normal upper limit for this acetabular angle ratio was extrapolated from the published normal values of cartilaginous HTE and bony HTE in children.

RESULTS

The acetabular angle ratio was statistically significantly increased in the hips with RHD with a mean value of 7.1 ± 4.7 compared to the hips in the control group presenting a mean value of 2.1 ± 1.9 (p < 0.00001).

CONCLUSIONS

This newly introduced ratio seems to be a helpful tool to orientate the further treatment in children presenting borderline RHD.

Bernese periacetabular osteotomy through a double approach : Simplification of a surgical technique

OBJECTIVE

Reorientation of the acetabulum to normalize load transfer or avert femoroacetabular pincer impingement to prevent osteoarthritis of the hip.

INDICATIONS

Persisting acetabular dysplasia after closure of growth plates or acetabular malrotation.

CONTRAINDICATIONS

High dislocation of hip, secondary acetabulum, increased misalignment on functional X‑ray, high-grade mobility restriction. Relative: degenerative changes, advanced age.

SURGICAL TECHNIQUE

Bernese periacetabular osteotomy through two incisions; all bone cuts are carried out under direct vision. The osteotomies are equivalent to the classic Ganz method. In a slightly tilted forward lateral decubitus position, a posterior incision is applied for the ischium osteotomy and the caudal portion of the retroacetabular osteotomy. The pubis and ilium osteotomies are performed in a supine position through an anterior approach with subsequent reorientation and screw fixation. The rectus femoris is not dissected unless joint exposure is required.

POSTOPERATIVE MANAGEMENT

Partial weight bearing with 20 kg for the first 6 weeks postoperatively, followed by stepwise transition to full loads after radiological control.

RESULTS

In total, 34 patients (37 hips) were followed up for 20.4 ± 10.3 months. Tönnis osteoarthritis scale levels remained constant. The center-edge angle of Wiberg increased from 13.2 ± 7.5° to 26.5 ± 6.7°, the Tönnis angle (acetabular index) changed from 13.8 ± 6.5° to 3.4 ± 4.4°. At follow-up, the Merle d'Aubigné and Postel score was 16.5 ± 1.4; the modified Harris hip score 87.6 ± 13.9 and the International hip outcome tool (iHOT)-12 78.2 ± 20.3 points. The mean surgical time was 213 ± 29 min. Severe complications were not observed.

[Acetabuloplasty - The Dega and Pemberton technique]

BACKGROUND

Hip dysplasia is the most common congenital deformity requiring surgical correction osteotomy in order to prevent early onset of secondary hip arthrosis. The shape of the acetabulum can be modified by Dega or Pemberton osteotomy and is indicated for hip dysplasia and luxation with irregularities of the socket for children aged between 2 and 12 when the y‑physis is still open.

METHOD

We will describe indication, contra-indication, preoperative planning as well as details of the Pemberton technique. In addition, we will provide practical advice based on our long-standing experience.

RESULTS

We present long-term results from the literature and also from our department. In addition, we will explain and critically discuss our own experiences and the risks and complications of surgical techniques. Good long-term results are reported for acetabuloplasties and Salter osteotomy which are preferred for surgical treatment of hip dysplasia in early life. Advantages and disadvantages of both surgical techniques will be compared in the discussion section.

CONCLUSION

Dega and Pemberton acetabuloplasty shows good long-term results regarding prevention of a secondary coxarthrosis. However, correct indication is crucial since this surgical technique is more difficult compared to Salter osteotomy but is also associated with a higher correction potential and a lower complication rate.

[Intertrochanteric femoral osteotomy : Indications, surgical technique, results]

BACKGROUND

Intertrochanteric osteotomies are part of joint-preserving hip surgery. Indications involve not only the mature but also the growing skeleton. After identification of the causative pathologies multidimensional corrections with the aim of a better joint situation and prevention of early osteoarthritis are possible.

METHODS

The surgical technique of intertrochanteric osteotomies is presented. Potential indications are discussed on the basis of results in the literature.

RESULTS

In the surgical treatment of developmental dysplasia of the hip intertrochanteric osteotomies are used as additional surgery. In Perthes disease the containment is improved while the onset of osteoarthritis in epiphysis capitis femoris can be decelerated. Treatment of torsion pathologies is reliable. Avascular necrosis of the femoral head and beginning osteoarthritis are critical indications.

CONCLUSION

For appropriate indications intertrochanteric osteotomies are a valuable element in joint-preserving surgery with very good long-term results.

[Congenital hip dysplasia, screening and therapy]

Congenital hip dysplasia and hip dislocation are relatively common pathological conditions of the musculoskeletal system in infants. An early and certain diagnosis can now be achieved by sonographic hip screening within the framework of screening examination programs. This early diagnostic procedure in infants is essential particularly for a conservative treatment strategy. Therefore, apart from possessing in-depth knowledge, training of the examiner in specialist courses is of central importance. This article presents an overview of the entity of congenital hip dysplasia and hip dislocation, the diagnostics and treatment with special emphasis on recent developments.

[Complications after hip osteotomy]

Complex deformities of the acetabulum are one of the most common reasons for secondary pelvic osteoarthritis. One option of treatment is osteotomy of the acetabulum close to the joint. The correction of the spatially reduced roof of the femoral head resulting from pelvic dysplasia can minimize the risk of developing secondary osteoarthritis or reduce the progression of an already existing osteoarthritis. The Ganz periacetabular osteotomy (PAO) and Tönnis triple osteotomy procedures are the predominant methods used to correct hip dysplasia in adolescents. Both are complex procedures which bear specific risks and complications, thus requiring very experienced surgeons.

[Combined Salter-Pemberton pelvic osteotomy]

OBJECTIVE

In simple pelvic osteotomy in childhood the aim is for better lateral roofing, a safe centering of the femoral head and tuning between the volumes of the acetabulum and the femoral head. By the combination of anterior modified Pemberton osteotomy with dorsal osteotomy according to Salter these objectives can be achieved.

INDICATIONS

Dysplasia of the acetabulum in patients between 2 years old and adolescence, subluxation and dislocation of the femoral head, also in neurological diseases as cerebral palsy and hypercontainment in Legg-Calvé-Perthes disease.

CONTRAINDICATIONS

Critically small pelvic bones in toddlers younger than 18 months, children with a delay in skeletal formation. In patients aged more than 15 years if the symphysis is too taut for an effectual pivoting of the acetabulum and the acetabulum has no potential for future maturing.

SURGICAL TECHNIQUE

Surgery is carried out by making a skin incision by the iliac crest ending in the middle of the groin, the cartilaginous iliac apophysis is split and the periosteum is elevated from the medial and lateral wall of the ilium to the inner pelvic ring. A K-wire is used to mark the level and the center of the osteotomy and dorsal to the K-wire a straight osteotomy is performed with a Gigli saw and anteriorly an arc-shaped and tilted cut is made with a chisel. The distal iliac fragment is rotated widely outwards and forwards and a triangular bone graft is removed from the anterior part of the iliac crest. The graft is inserted into the opened up osteotomy, three K-wires are used to fix the desired position of the iliac fragments and the two halves of the iliac apophysis are sutured together.

POSTOPERATIVE MANAGEMENT

After the operation uncooperative children receive a scotch cast for 4 weeks. Cooperative children are mobilized after 3 weeks of bed rest. Partial weight-bearing is allowed after 6 weeks and full weight-bearing after 8-10 weeks.

RESULTS

A total of 56 combined Salter-Pemberton pelvic osteotomies were performed in 49 patients from 1999 to 2008. The results of these studies demonstrate that this osteotomy is a safe and effective procedure which enables not only sufficient correction in classical dysplasia of the hip joint but also in high grade dislocation of the hip joint caused by cerebral palsy.

Developmental dysplasia of the hip in the newborn: A systematic review

Developmental dysplasia of the hip (DDH) denotes a wide spectrum of conditions ranging from subtle acetabular dysplasia to irreducible hip dislocations. Clinical diagnostic tests complement ultrasound imaging in allowing diagnosis, classification and monitoring of this condition. Classification systems relate to the alpha and beta angles in addition to the dynamic coverage index (DCI). Screening programmes for DDH show considerable geographic variation; certain risk factors have been identified which necessitate ultrasound assessment of the newborn. The treatment of DDH has undergone significant evolution, but the current gold standard is still the Pavlik harness. Duration of Pavlik harness treatment has been reported to range from 3 to 9.3 mo. The beta angle, DCI and the superior/lateral femoral head displacement can be assessed via ultrasound to estimate the likelihood of success. Success rates of between 7% and 99% have been reported when using the harness to treat DDH. Avascular necrosis remains the most devastating complication of harness usage with a reported rate of between 0% and 28%. Alternative non-surgical treatment methods used for DDH include devices proposed by LeDamany, Frejka, Lorenz and Ortolani. The Rosen splint and Wagner stocking have also been used for DDH treatment. Surgical treatment for DDH comprises open reduction alongside a combination of femoral or pelvic osteotomies. Femoral osteotomies are carried out in cases of excessive anteversion or valgus deformity of the femoral neck. The two principal pelvic osteotomies most commonly performed are the Salter osteotomy and Pemberton acetabuloplasty. Serious surgical complications include epiphyseal damage, sciatic nerve damage and femoral neck fracture.

[Total hip replacement in developmental dysplasia: anatomical features and technical pitfalls]

Total hip arthroplasty is the procedure of choice for most patients with advanced, symptomatic osteoarthritis due to congenital dysplasia of the hip. However, the complexity of arthroplasty is significantly increased because of anatomic abnormalities associated with dysplasia of the hip. In addition the relatively young age of patients may affect survival of the implant. From a biomechanical standpoint the primary surgical objective is reconstruction of the anatomical center of rotation. Independent of the pelvic bone stock the socket should be located as near as possible to the anatomical acetabular location. There are various operative strategies to ascertain sufficient stability of the socket. The anterolateral deficiency of the acetabulum can be reconstructed by bulk femoral autografting or bone impaction grafting. Furthermore controlled perforation of the medial wall or implantation of reinforcement rings and oval sockets have been described. Cementless, biological socket fixation shows superior long-term results compared to cemented cups, especially in these young patients. The location of the reconstructed acetabulum and the desired leg length influence the type of femoral reconstruction and in some cases femoral shortening is required. In this article endoprosthetic reconstructive options for developmental dysplasia of the hip are discussed depending on the femoral and acetabular deformity.

Triple pelvic osteotomy for the treatment of residual hip dysplasia. Analysis of complications

The aim of the paper was to present the results achieved with triple pelvic osteotomy in the treatment of residual hip dysplasia, with special interest in identifying recurrences and complications and how to avoid them. 60 patients (76 hips) with developmental dysplasia of the hip (DDH), treated by the triple pelvic osteotomy according to Tönnis and modified by Vladimirov, were included in the study. Hips were evaluated radiologically with the center-edge (CE) angle, break of the Shenton-Menard arch and index of acetabular depth by Heyman-Herndon, and functionally using the Harris Hip Score (HHS). The postoperative results showed an average increase of the CE angle by a mean of 23.5+/-9.28 degrees, with a highly significant difference between the preoperative and final postoperative findings (t-test, t=-20.85, p<0.01). The mean HHS significantly improved (p<0.01). Total complication rate was 13,1%, divided in: 1,3% (one case) of triple nonunion of iliac, pubic and ischial bones, 7,9% (six cases) of double nonunion of pubic and ischial bones, 2,6% (two cases) of peroneal palsy and 1,3% (one case) of infection. In this study the triple pelvic osteotomy showed to be reliable for acetabular dysplasia in adolescent and young adult, alone or in association with proximal femoral osteotomy and/or great trochanter distal advancement.