Salter's innominate osteotomy for hip dysplasia in adolescents and young adults

The Importance of Monitoring and Factors That May Influence Leg Length Difference in Developmental Dysplasia of the Hip

In unilateral Developmental Dysplasia of the Hip (DDH), avascular necrosis (AVN), femoral or pelvic osteotomy, and residual dysplasia causing subluxation of the proximal femur may influence Leg Length Discrepancy (LLD). This can lead to gait compensation, pelvic obliquity, and spinal curvature. The aim of this study is to determine the prevalence of LLD, establish which limb segment contributes to the discrepancy, describe how AVN influences LLD, and ascertain variables that may influence the need for LLD corrective procedures.

METHODOLOGY

This study assessed long-leg radiographs at skeletal maturity. Radiographs were assessed for the articulo-trochanteric distance (ATD) and femoral and tibial length. AVN was classified according to Kalamchi-MacEwen.

RESULTS

109 patients were included. The affected/DDH leg was longer in 72/109 (66%) patients. The length difference was mainly in the subtrochanteric segment of the femur. AVN negatively influenced leg length. Older (≥three years) patients with multiple procedures were more likely to have AVN. LLD interventions were performed in 30 (27.5%) patients. AVN grade or type of DDH surgery did not influence the odds of needing a procedure to correct LLD.

CONCLUSIONS

Procedures to correct LLD were performed irrespective of previous DDH surgery or AVN grades. In most patients, the affected/DDH leg was longer, mainly in the subtrochanteric segment of the femur, largely influenced by femoral osteotomy in patients with multiple operative procedures for DDH. We recommend careful monitoring of LLD in DDH.

Mid- and long-term outcome of Salter's, Pemberton's and Dega's osteotomy for treatment of developmental dysplasia of the hip: a systematic review and meta-analysis

INTRODUCTION

Early diagnosis and early treatment have become the gold standard for management of developmental dysplasia of the hip. Surgery is required in case of failed initial treatment. Innominate pelvic osteotomy of Salter (SIO), Pemberton's pericapsular osteotomy (PPO) and Dega's acetabuloplasty (DA) are among the most used procedures.We performed a systematic review and meta-analysis of the past 57 years in order to assess the mid- and long-term outcome of these techniques.

METHODS

Studies met inclusion criteria if they: (1) reported at least 5 cases treated by 1 of the abovementioned surgical techniques; (2) included children aged between 1 and 8 years; (3) surgical indication was late detected DDH or a failed initial treatment; (4) presented a minimal follow-up of 24 months; (5) reported the radiological score of Severin and/or the clinical score of McKay.Clinical and radiological outcomes were dichotomised into favourable and unfavourable outcome and weighted summary rates were determined using meta-analysis models.

RESULTS

From a total of 7391 articles, 48 level of evidence grade IV articles were included in our review. A total of 2143 cases with a mean follow up of 112.4 months were included.Pooled Severin score indicated a statistically better outcome for PPO and DA compared to SIO (p = 0.0003 and p = 0.002, respectively). By dichotomising the results in favourable and unfavourable outcome, PPO showed the best results (p = 0.0002 vs. SIO, p = 0.01 vs. DA).Pooled McKay score showed a statistically better outcome for PPO and DA compared to SIO (p < 0.0001 and p = 0.03, respectively) as well as better outcomes for PPO compared to DA (p = 0.01). By dichotomising the results in favourable and unfavourable, PPO showed the best results.

CONCLUSIONS

Even if our review demonstrates slightly better radiological and clinical results with the PPO, the currently available and limited data do not allow for clear recommendation towards one of these techniques.

[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.

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

BACKGROUND

Surgical treatment of late diagnosed development dysplasia of the hip (DDH) remains challenging with several methods being described. We therefore retrospectively evaluated the outcome of Salter innominate osteotomy (SIO) in patients with fully-grown bone, to evaluate whether this surgical procedure allows sufficient acetabular correction.

MATERIAL AND METHODS

Between 2004-2012 SIO had been performed in 45 patients (49 hips) with late diagnosed DDH. The evaluation included pre- and postoperative radiographs (n=49), the complication rate (n=49) and the clinical outcome (WOMAC, HHS, UCLA) (n=34).

RESULTS

Mean age at surgery was 27.6 (16-51) with a follow-up of 6.7±2.7 (0.9-11.0) years. Radiologically, a good acetabular correction with a significant improvement of the Center Edge angle (15.4° to 34.9°), sharps angle (45.7° to 32.0°) and migration percentage (33.2% to 14.4%) (p<0.001) was found. Clinical results revealed a WOMAC of 13.9±13.3, UCLA of 7.8±2.1 and HHS of 85.0±11.8. Complications were noted for 10 patients (20%) with 7 (14%) requiring revision.

CONCLUSION

The results demonstrated that SIO achieved a satisfying acetabular correction and good clinical results in late diagnosed DDH. It therefore might be an option in some cases, although periacetabular osteotomy techniques are currently preferable used as they allow a wider range of acetabular correction.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Dega osteotomy for the management of developmental dysplasia of the hip in children aged 2-8 years: results of 58 consecutive osteotomies after 13-25 years of follow-up

PURPOSE

Developmental dysplasia of the hip (DDH) is a term used to cover a broad spectrum of anomalies ranging from mild dysplasia to high-riding dislocations. We report the management of DDH in children using the Dega osteotomy and their long-term follow-up.

METHODS

Fifty-eight hips from 48 children younger than 8 years treated using the Dega osteotomy between January 1988 and October 2000 were included in this multcenter study. Both prospective (41 hips) and retrospective (17 hips) cases were included, and follow-up was for a minimum of 13 years. Radiographs were made preoperatively, immediately postoperatively, after 6 weeks or at removal of the spica cast if any, at 6-month intervals and/or as indicated for 3 years postoperatively and then on annual basis until the last follow-up. A single-cut computed tomographic scan was performed for all prospective patients. Special attention was paid to the predictive measures of hip arthrosis and the survival of the hip after Dega osteotomy.

RESULTS

The final clinical outcome was favorable in 44 hips (75.9 %). Eleven hips needed a second surgery (acetabuloplasty and/or arthroplasty) during the follow-up period.

CONCLUSIONS

In our pediatric patient population the Dega osteotomy proved to be an adequate measure for the management of this complex condition. The worst complication was avascular necrosis, and all of the affected hips ended with failure (pain, another surgery, or both).

The effect of Dega acetabuloplasty and Salter innominate osteotomy on acetabular remodeling monitored by the acetabular index in walking DDH patients between 2 and 6 years of age: Short- to middle-term follow-up

Introduction

The surgical management of neglected developmental dysplasia of the hip (DDH) in walking children has always been a challenge to orthopedic surgeons. The aim of this study was to evaluate the short- to middle-term clinical and radiographic results of the management of DDH.

Patients and methods

Patients less than 6 years old using two of the most commonly used osteotomies, namely, Salter innominate osteotomy and the Dega acetabuloplasty. Special attention was paid to acetabular remodeling after concentric reduction, which was monitored by the acetabular index, that, in turn, was measured preoperatively, immediately postoperatively, every 6 months, and at the final follow-up examination.

Results

The final overall clinical end results were favorable (excellent or good) in 93 hips (85.3 %). There was a marked improvement of the acetabular coverage during the follow-up period, which proved the good remodeling potential of the acetabulum for this particular age group after concentric reduction was achieved and maintained.

Conclusion

Both osteotomy types were found to be adequate for the management of neglected walking DDH patients under the age of 6 years.

The effect of Dega acetabuloplasty and Salter innominate osteotomy on acetabular remodeling monitored by the acetabular index in walking DDH patients between 2 and 6 years of age: short- to middle-term follow-up

INTRODUCTION

The surgical management of neglected developmental dysplasia of the hip (DDH) in walking children has always been a challenge to orthopedic surgeons. The aim of this study was to evaluate the short- to middle-term clinical and radiographic results of the management of DDH.

PATIENTS AND METHODS

Patients less than 6 years old using two of the most commonly used osteotomies, namely, Salter innominate osteotomy and the Dega acetabuloplasty. Special attention was paid to acetabular remodeling after concentric reduction, which was monitored by the acetabular index, that, in turn, was measured preoperatively, immediately postoperatively, every 6 months, and at the final follow-up examination.

RESULTS

The final overall clinical end results were favorable (excellent or good) in 93 hips (85.3 %). There was a marked improvement of the acetabular coverage during the follow-up period, which proved the good remodeling potential of the acetabulum for this particular age group after concentric reduction was achieved and maintained.

CONCLUSION

Both osteotomy types were found to be adequate for the management of neglected walking DDH patients under the age of 6 years.

In vitro investigation of biomechanical changes of the hip after Salter pelvic osteotomy

BACKGROUND

Salter innominate osteotomy of the pelvis is widely used to improve the coverage of the femoral head in developmental dysplasia of the hip, but the biomechanical and geometric changes after this osteotomy are not well understood.

METHODS

A CT dataset of an 8-year-old child with severe dysplasia of both hips was used to create a polyamide model of the left hemipelvis and proximal femur. The hemipelvis was mounted to a holding device and the proximal femur attached to a sensor guided industrial robot. The robot was programmed to apply joint forces and torques based on single-leg stance. Two major muscles were represented by wires connected to hydraulic cylinders; muscle forces were adjusted to balance the joint moments. Resulting joint forces were measured using a pressure measuring sensor before and after Salter osteotomy of the hip. Geometric changes were recorded using a three-dimensional ultrasound measurement system.

FINDINGS

The preoperative hip joint resultant force was 583N (270% body weight), while after the operation a mean force of 266N (120% body weight) was measured. Postoperative muscle forces were roughly half the preoperative values. The hip joint was translated medially and caudally. Postoperatively, the length of gluteus medius and maximus muscles increased.

INTERPRETATION

The preoperative value of the resultant hip joint force is comparable to values reported in the literature. The results suggest that Salter innominate osteotomy leads to a reduction of hip joint and muscle forces in addition to increasing joint contact area.

Triple pelvic osteotomy for the management of painful developmental hip dysplasia in the young adult

We present a consecutive series of 24 adolescent and young adult patients who have undergone a triple pelvic osteotomy as treatment for symptomatic developmental dysplasia of the hip. With a mean duration of follow-up of 6.5 years (range 2 -16 years) we report good improvements with regard to pain and function in 22 of the 24 patients. Radiological improvements were consistently demonstrated in the centre edge angle and the acetabular index. There were no major complications. When dealing with this difficult problem in young patients we maintain that a redirectional pelvic osteotomy is an appropriate means of treatment in symptomatic patients with a congruent joint.

The role of acetabular and femoral osteotomies in reconstructive surgery of the hip: 2005 and beyond

Femoral and acetabular osteotomies have enduring and useful roles in the ongoing surgical treatment of patients with various hip conditions. The classic indication for intertrochanteric valgus osteotomy is to induce healing of femoral neck nonunions. Additional indications include posttraumatic deformity, limb-length inequality, certain cases of osteonecrosis, and adult sequelae of Legg-Calve-Perthes disease, and slipped capital femoral epiphysis. Isolated intertrochanteric osteotomy is only occasionally indicated for the treatment of arthritis secondary to dysplasia. Rotational osteotomies of the pelvis have overtaken the role once historically played by intertrochanteric osteotomy in the treatment of dysplasia-related hip anomalies. Ideal candidates have prearthritic, activity-related pain associated with radiographic dysplasia. It is imperative that the hip joint be congruous, free of fixed subluxation, and located in the natural acetabulum. Surgical treatment of associated acetabular labral tears and/or detachments and impingement lesions can be done at the same time through antecedent hip arthroscopy (same anesthetic) or open arthrotomy. The direction and magnitude of correction need to be customized to fit the nature of the dysplasia. A standard method of correction likely is to result in unwanted iatrogenic retroversion in some cases. Intertrochanteric osteotomy now is used as a complement to rotational osteotomy for the indications outlined above.