Can Salter osteotomy correct late diagnosed hip dysplasia: A retrospective evaluation of 49 hips after 6.7 years?

Current Surgical Techniques in the Treatment of Adult Developmental Dysplasia of the Hip

The surgical protocols currently used for the treatment of developmental dysplasia of the hip (DDH) are varied, with sufficient differences in clinical outcomes that warrant a review of the role of practicing orthopedic surgeons. This paper aims to summarize the current novel techniques within the realm of surgical treatment for adult DDH, thus serving as a guide to surgeons looking to quickly familiarize themselves with available techniques. We performed computer systematic literature searches of the Embase and PubMed databases from 2010 to 2 April 2022. Study parameters as well as their respective patient reported outcomes (PROMs) were described in detail and compiled into diagrams. Two novel techniques were identified for the treatment of borderline or low-grade DDH. Six techniques which included modifications to the Bernese periacetabular osteotomy (PAO) were identified for the treatment of symptomatic DDH. Three techniques which include combinations of arthroscopy and osteotomy were identified for the treatment of DDH with concomitant hip pathologies such as cam deformities. Finally, six techniques, all of which are modifications to total hip arthroplasty (THA), were identified for the treatment of high-grade DDH. The techniques detailed in this review therefore equip surgeons with the necessary knowledge to improve outcomes in patients with varying degrees of DDH.

Appropriate Surgical Timing of Salter Innominate Osteotomy for Residual Acetabular Dysplasia in Children

BACKGROUND

Salter innominate osteotomy (SIO) provides favorable results for treating residual acetabular dysplasia in young children. In this study, we examined the midterm results of SIO according to the age at surgery to determine the optimal timing of this procedure.

METHODS

We retrospectively examined 50 hips of 42 patients (8 boys and 34 girls) with acetabular dysplasia who underwent SIO and were followed up until skeletal maturity. The center-edge angle (CEA) was measured based on the anteroposterior radiographs of the hip obtained before surgery, 5 weeks after surgery, and at the latest follow-up. Severin classification was evaluated at the latest follow-up. Patients were categorized into 3 groups according to age at surgery: younger than 7 years of age (group A), 7 to 8 years of age (group B), and 9 years of age or older (group C).

RESULTS

The mean preoperative CEA level of 0.9 degrees improved to 17.1 degrees postoperatively, which was increased to 28.1 degrees at the latest examination. Overall, 45 hips (90%) were classified as Severin I or II, with 96% in group A, 94% in group B, and 57% in group C. In group C, postoperative acetabular coverage was similar to that in the other groups (16.6 degrees in group A, 14.8 degrees in group B, and 18.1 degrees in group C), although the final outcome was unsatisfactory. The average improvement in CEA from postoperative to skeletal maturity was significantly smaller in group C than in the other groups (12.7 degrees in group A, 11.3 degrees in group B, and 3.0 degrees in group C).

CONCLUSIONS

SIO showed favorable outcomes with satisfactory acetabular coverage at skeletal maturity. However, satisfactory acetabular coverage could not be obtained in some older patients because of limited postoperative remodeling capacity and smaller secondary improvement of CEA. We recommend that SIO should be performed in patients aged 8 years or younger.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Application of 3D navigation for osteotomy of DDH in children: A systematic review and meta-analysis

OBJECTIVE

To systematically review the current articles to compare the efficacy and safety of 3D navigation-assisted osteotomy of DDH with conventional osteotomy of DDH in children. Study design Databases such as PubMed, Embase, Cochrane Library were searched, from inception to April, 2022, for studies applying 3D navigation-assisted osteotomy in DDH children.

METHODS

There were 626 articles identified. According to the search strategy and inclusion criteria, 7 studies were finally included, with a total of 288 cases. Study screening, data extraction, and quality assessment were conducted by two reviewers independently. Data analyses were performed using RevMan 5.4 software.

RESULTS

There were 7 retrospective cohort studies included. Meta-analysis showed that 3D navigation-assisted DDH osteotomy resulted in shorter duration of surgery [I ² = 88%, REM, MD = 22.86, 95%CI (-27.29, -18.43), p < 0.00001], less radiation exposure during surgery [I ² = 53%, REM, MD = 2.76, 95%CI (-3.15, -2.37), p < 0.00001], and less intraoperative bleeding [I ² = 94%, REM, MD = 26.83, 95%CI (-39.24, -14.41), p < 0.0001], compared with conventional DDH osteotomy. There was a significant difference in the number of patients with McKay clinical function graded as poor between the two groups [I ² = 0%, FEM, RR = 0.20, 95%CI (0.05, 0.74), p = 0.02], whereas there were no significantly statistical differences in the corrected acetabular index angle, postoperative leg length discrepancy, and number of patients with Severin x-ray graded as poor between the two groups (p > 0.05).

CONCLUSION

3D navigation-assisted pelvis and thighbone osteotomy for DDH children could shorten duration of surgery and reduce intraoperative bleeding and x-ray exposure, presenting definite therapeutic effect.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier: CRD42022333767.

Bone union status of all osteotomy sites one year after curved periacetabular osteotomy based on computed tomography

BACKGROUND

Curved periacetabular osteotomy (CPO) is a joint-preservation surgery to treat acetabular dysplasia. It is performed via an anterior approach with the osteotomy of the anterosuperior iliac spine (ASIS). One of the complications associated with CPO includes non-union of the osteotomy sites. However, all osteotomy sites including the ASIS have not been simultaneously evaluated. Therefore, we investigated: (1) the bone union status of all osteotomy sites; and (2) the predictors of non-union at one year after CPO based on computed tomography (CT).

HYPOTHESIS

The bone union status may be different in each osteotomy site.

PATIENTS AND METHODS

This retrospective review included 147 hips of 124 patients with symptomatic acetabular dysplasia who underwent CPO from 2011 to 2018. At one year postoperatively, we evaluated the bone union status of all osteotomy sites: the ASIS, ischium, pubis, and ilium using CT and investigated the predictors for achieving bone union.

RESULTS

Bone union was confirmed in both the ASIS and ilium in all cases. In contrast, ischial and pubic non-union was confirmed 15/147 hips (10.2%) and 42/147 hips (28.5%), respectively. The multivariate analysis revealed that the predictors of ischial non-union were both large width of the gap at the pubic osteotomy site and small postoperative acetabular roof obliquity, and that the predictor of pubic non-union was large width of the gap at the pubic osteotomy site.

DISCUSSION

At one year after CPO, both the ASIS and ilium obtained complete bone union, while ischial and pubic non-union were observed. Large width of the gap at the pubic osteotomy site was the predictor of both ischial and pubic non-union. In CPO, sufficient bone union can be achieved at the ASIS and the ilium, while it is necessary to reduce the width of the gap at the pubic osteotomy site to prevent ischial and pubic non-union.

LEVEL OF EVIDENCE

IV; retrospective study.

Risk factors associated with unsatisfactory hip function in children with late-diagnosed developmental dislocation of the hip treated by open reduction

BACKGROUND

Open reduction with or without pelvic and femoral osteotomy is the accepted treatment option for children older than 18 months with developmental dislocation of the hip (DDH). However, few studies have investigated hip function in children with late DDH treated by open reduction. Therefore, we performed a retrospective study investigating the risk factors potentially associated with unsatisfactory hip function.

HYPOTHESIS

We hypothesized that some risk factors can be associated with unsatisfactory hip function in patients with late DDH treated by open reduction.

PATIENTS AND METHODS

We retrospectively reviewed the clinical and radiographic data of 79 children (98 hips, mean age 39.7±18.6 months; range, 19-95.3) with late-detected DDH treated by open reduction. Acetabular index (AI), Tönnis grade, Center Edge Angle (CEA), avascular necrosis of the femoral epiphysis (AVN), and Severin radiographic grade were evaluated on radiographs. Hip function was rated according to modified Outcome Evaluation Standard for Congenital Dislocation of the Hip with a maximum score of 15. According to type of surgery, patients were divided into four groups: open reduction alone (Group A), open reduction in conjunction with pelvic osteotomy (Group B), and open reduction in conjunction with femoral osteotomy and Pemberton/Salter (Group C) or Bernese-type triple pelvic osteotomy (Group D). Analysis of variance (ANOVA), t-test, chi-square test, and multivariate regression analysis were used to evaluate the independent risk factors of unsatisfactory hip function.

RESULTS

The mean hip function score was 10.8±2.8 (4.5-15); 61 hips (62.2%) had satisfactory function (23 [23.5%] excellent and 38 [38.8%] good), while 37 hips (37.8%) had unsatisfactory function (16 [16.3%] fair and 21 [21.4%] poor). Spearman correlation analysis indicated that age at surgery was negatively correlated with function score (r=-0.326, p=0.001). The age of patients with satisfactory hip function (34.5±14.2 months; range, 19.4-74.8) was significantly lower than those with unsatisfactory function (43.7±21 months; range, 20.6-95.3) (p=0.011). The hip function score in Group A (14.2±0.8; range, 12.8-15) was significantly higher than in the other three groups (p<0.001). Hip function score in patients with type III or IV AVN was significantly lower than those without AVN, or with type II AVN (p=0.001). Multivariate regression analysis confirmed age at surgery, type of surgery and AVN were negatively correlated with hip function score. Logistic regression analysis and chi-square test confirmed age and type of surgery, and AVN were independent risk factors of unsatisfactory hip function. Multivariate regression analysis found ability to squat and amount of hip flexion and abduction, significantly decreased with age at surgery; while presence of limping, amount of hip flexion, abduction, adduction and external rotation significantly decreased with type of surgery.

DISCUSSION

Age at surgery, type of surgery and severe AVN are independent risk factors for unsatisfactory hip function in patients with late-detected DDH treated by open reduction. The ability to squat, the amount of hip flexion and abduction are the main functional parameters affected by age and surgery.

LEVEL OF EVIDENCE

IV, case series.

Biomechanical investigation of pelvic stability in developmental dysplasia of the hip: unilateral salter osteotomy versus one-stage bilateral salter osteotomy

Background

Developmental dysplasia of the hip (DDH) is a common disease in infants and children, and the treatment of bilateral DDH remains controversial. This study aimed to evaluate the stability of one-stage bilateral Salter pelvic osteotomy for bilateral DDH in patients of walking age.

Methods

In total, nine child cadavers aged 2–6 years were included. A universal mechanical testing machine was used for stability test. We performed two different surgical procedures on the specimens: nine child cadavers underwent unilateral Salter pelvic osteotomy, and six child cadavers were randomly selected to undergo Salter pelvic osteotomy again to simulate one-stage bilateral Salter pelvic osteotomy. The stability of the bilateral sacroiliac joints, local stability of the operation area, ultimate load test, and axial stiffness were evaluated.

Results

Both unilateral and bilateral Salter osteotomy could destroy the integrity of the pelvic ring and increase the risk of pelvic instability. In this study, compared with unilateral Salter osteotomy, bilateral Salter osteotomy had similar pelvic stability, and there was no significant difference between unilateral and bilateral Salter osteotomy in sacroiliac joint stability (p > 0.05), local stability (p = 0.763), ultimate load (p = 0.328), and axial stiffness (p = 0.480).

Conclusions

One-stage bilateral Salter pelvic osteotomy as a potential surgical method is viable and stable for children with bilateral DDH.

[Modified Salter innominate osteotomy in adults]

OBJECTIVE

The dysplastic acetabulum is shifted three-dimensionally outwards and forwards.

INDICATIONS

Symptomatic residual hip dysplasias and hip subluxations in skeletally mature patients up to the age of 50 years. Sharp's acetabular up to 60°, as an exception above 60°.

CONTRAINDICATIONS

Acetabular retroversion. Radiographic joint space at the lateral acetabular edge that is less than half the normal thickness for the patient's age. Relative contraindication: Elongated leg on the affected side.

SURGICAL TECHNIQUE

Ilioinguinal approach in a supine position. Division of the innominate bone. Pivoting the distal osteotomy fragment outwards and forwards with the aid of the Salter maneuver. Fixing the fragments with a guide wire. Final correction of the osteotomy fragments. Force fitting of a dovetail grooved, wedge-shaped bone graft. Insertion of a cannulated compression screw and two further threaded rods. Wound closure.

POSTOPERATIVE MANAGEMENT

Unloaded 3‑point walking for 4 weeks. Increasing weight bearing from week 4. Full weight bearing from week 10-12.

RESULTS

A total of 45 consecutive patients (7 men, 38 women, 49 hips) underwent surgery. Average age at surgery was 27.6 years. The Sharp acetabular angle improved from preoperatively 45.7° ± 4.2° by 13.8° to 32.0° ± 6.4°; the Wiberg (LCE) angle increased from 15.4° ± 9.3° by 19.5° to 34.9° ± 10° postoperatively. The anterior center edge (ACE) angle increased from 28.9° ± 10.4° by 8.6° ± 2.3° to 37.5° ± 8.1°. Complications requiring surgical intervention occurred in 7 patients.