Derotational femoral shortening for developmental dislocation of the hip: special indications and results in the child younger than 2 years

Modified Capsulorrhaphy Technique in Open Reduction of Developmental Dysplasia of the Hip

BACKGROUND

Neglected patients with developmental dysplasia of the hip (DDH) are not uncommon. Various treatment modalities have been used. Capsulorrhaphy is one of the most critical steps during the process of open reduction of DDH. Inadequate capsulorrhaphy technique can increase the failure rate of open reduction procedures. This study presented the clinical and radiographic results of using a new capsulorrhaphy technique.

METHODS

Between November 2005 and March 2018, 540 DDH in 462 patients were retrospectively reviewed. The mean age at surgery was 31 months. All patients underwent a modified capsulorrhaphy technique developed by the main author (with or without additional pelvic or femoral procedures). Postoperative patient assessment during the follow-up period was performed both clinically and radiologically.

RESULTS

Follow-up period ranged between 36 months and 12 years. Based on the modified McKay score, good and excellent outcomes were obtained in 90.3%. Functional results were better in younger age (less than 39 mo). Both acetabular index and lateral center edge angle showed significant improvement at 3 years follow-ups. Proximal femoral growth disturbance (PFGD) was encountered in 92 hips. Classes 2 and 3 did not affect the functional results, whereas patients with PFGD classes 4 and 5 had fair to poor functional outcomes. There were 12 hips with redislocation. Revision was done using the same capsulorrhaphy technique.

CONCLUSION

Using the index technique of capsulorrhaphy in DDH surgery is safe, reliable, and yields good functional and radiologic outcomes with a relatively low complication rate.

LEVEL OF EVIDENCE

Level IV-therapeutic retrospective case series.

The fate of inverted limbus in children with developmental dysplasia of the hip: Clinical observation

In this study, we observed the fate of the inverted limbus after closed reduction for the treatment of developmental dysplasia of the hip (DDH) and its impact on acetabular development. Clinical data were reviewed for 26 DDH patients with an inverted or overriding limbus after closed reduction for hip dysplasia. Patients were divided into a residual inversion group (19 cases, 22 hips) and a spontaneous resolution group (7 cases, 7 hips) according to the limbus status at the last follow-up. Differences in the osseous acetabular index (AI) and cartilaginous AI (CAI), the magnitude of limbus inversion, center-edge angle (CEA), height-to-width index (HWI) of the femoral head epiphysis, and avascular necrosis (AVN) at last follow-up were compared. There were no statistically significant differences in the preoperative AI and CAI between groups. The magnitude of limbus inversion after reduction and the AI at the final follow-up in the residual inversion group were both larger than those in the spontaneous resolution group. The CAI, CEA, and HWI were not significantly different between groups. The magnitude of limbus inversion in the residual inversion group did not significantly decrease over time. AVN occurred in five hips in the residual inversion group. No cases of AVN occurred in the spontaneous resolution group. After closed reduction, the inverted limbus was not absorbed in the majority of cases; instead, it evolved into a thin layer of fibrous tissue embedded between the femoral head and acetabulum. This may delay the endochondral ossification of the acetabulum.

Patient-reported outcomes in young adults with osteonecrosis secondary to developmental dysplasia of the hip - a longitudinal and cross-sectional evaluation

Background

Osteonecrosis of the femoral head is a common complication in the treatment of developmental dysplasia of the hip (DDH). While functional outcomes of affected patients are good in childhood, it is not clear how they change during the transition to young adulthood. This study determined the relationship between osteonecrosis and hip function, physical function and health status in adolescents and young adults.

Methods

We performed a cross-sectional study of 169 patients with a mean age of 19.7 ± 3.8 years with and without osteonecrosis following an open or closed reduction (1995–2005). We also performed a separate longitudinal evaluation of an historical cohort of 54 patients with osteonecrosis, embedded in this sample. All completed patient-reported outcome measures in 2015/2016 to quantify hip function (maximum score 100); physical function (maximum score 100); and general health status (maximum score 1). We graded all radiographs for subtype of osteonecrosis (Bucholz-Ogden); acetabular dysplasia (centre-edge angle); subluxation (Shenton’s line); and osteoarthritis (Kellgren-Lawrence). Analyses were adjusted for the number of previous surgical procedures on the hip and for the severity of residual hip dysplasia.

Results

In 149 patients (186 hips) with and without osteonecrosis, the mean differences (95% confidence interval) in hip function, physical function and quality of life were − 4.7 (− 10.26, 0.81), − 1.03 (− 9.29, 7.23) and 0.10 (− 1.15, 1.18), respectively. Adjusted analyses stratified across types of osteonecrosis showed that only patients with Bucholz-Odgen grade III had reduced hip function (p < 0.01) and physical function (p < 0.05) but no difference in health-related quality of life when compared to no osteonecrosis.

Conclusion

Osteonecrosis secondary to DDH is a relatively benign disorder in adolescents and young adulthood. Affected patients demonstrated minimal physical disability, a normal quality of life but reduced hip function.

Efficacy and safety of a novel personalized navigation template in proximal femoral corrective osteotomy for the treatment of DDH

Background

This present study is aimed to retrospectively evaluate the efficacy and safety of a novel personalized navigation template in proximal femoral corrective osteotomy for the treatment of DDH.

Methods

Twenty-nine consecutive patients with DDH who underwent proximal femoral corrective osteotomy were evaluated between August 2013 and June 2017. Based on the different surgical methods, they were divided into the conventional group (n = 14) and navigation template group (n = 15). The osteotomy degrees, radiation exposure, and operation time were compared between the two groups.

Results

No major complications relating to osteotomy surgery such as redislocation or avascular necrosis occurred in the navigation template group, which had more accurate osteotomy degrees, less radiation exposure, and shorter operation time when compared with the conventional group (P < 0.05). Moreover, there was significant difference according to the McKay criteria between the two groups (P = 0.0362).

Conclusions

The novel personalized navigation template in proximal femoral corrective osteotomy is effective and safe, which could improve the femoral osteotomy accuracy, reduce radiation exposure, and shorten operation time.

A Comparative Study of Clinical and Radiological Outcomes of Open Reduction Using the Anterior and Medial Approaches for the Management of Developmental Dysplasia of the Hip

BACKGROUND

The literature is scanty on reports directly comparing the outcomes of anterior open reduction (AOR) and medial open reduction (MOR) in the management of developmental dysplasia of the hip (DDH).

PURPOSE OF THE STUDY

To compare clinical and radiographic outcomes of surgical treatment using either AOR or MOR in children with DDH aged < 24 months and to evaluate the procedure-inherent risks of avascular necrosis of the femoral head (AVN) and need for further corrective surgery (FCS).

METHODS

61 children who underwent surgical treatment for DDH were categorized into two groups: AOR (31 hips of 28 patients) and MOR (39 hips of 33 patients). The mean age was 17 ± 5.85 (range 7-24) months in group AOR and 13 ± 5.31 (range 6-24) months in group MOR. The mean follow-up was 118 ± 41.2 (range 24-192) months and 132 ± 36.7 (range 24-209) months in group AOR and MOR. At the final follow-up, mid- to long-term clinical and radiographic outcomes were assessed. FCS was recorded.

RESULTS

Regarding McKay's clinical criteria, both groups exhibited similar results (p = 0.761). No significant differences were observed between the groups in both the center-edge-angle (p = 0.112) and the Severin score (p = 0.275). The AVN rate was 32% in the AOR group and 20% in the MOR group (p = 0.264). The FCS rate was 22% in the AOR group and 12% in the MOR group (p = 0.464).

CONCLUSIONS

This study showed similar clinical and radiological outcomes with AOR and MOR with no significant relation to AVN and FCS.

LEVEL OF EVIDENCE

Level III.

Arthrodiastasis followed by open reduction associated with pelvic and femoral osteotomies for the treatment of high inveterate congenital hip dislocation

Our purpose is to analyze results, following the use of arthrodiastasis for the treatment of inveterate congenital hip dislocations. The study included eight patients. The mean age was 6 years. Three (37.5%) were male patients, and five (62.5%) were female patients. The patients were followed-up for 46 months. Teratologic, neurologic, rheumatic, and syndrome-associated dislocations were excluded. The following scores were used: Harris Hip Score, displacement of femoral head with respect to Hilgenreiner's line, Acetabular index, Wiberg angle, Reimer's extrusion index, and leg length discrepancy. Statistical analysis was carried out using Wilcoxon's test and Fisher's test. P values less than 0.05 were considered significant. We performed surgical technique in two stages. First, arthrogram and an adductor and a psoas tenotomy through an inguinal approach were performed; two 3.2 mm hydroxiapatite-coated screws were positioned in the supra-acetabular region and femoral shaft, joined using monolateral LRS fixator with a proximal locking T clamp. Distraction began the day after the procedure at a rate of 1 mm/day until restoration of Shenton's arc. Second, we performedan arthrogram intraoperatively, which included the anterior approach to the hip with open reduction, capsulorrhaphy and Salter osteotomy, and proximal femoral varus derotational osteotomy. Harris Hip Score improved significantly. Acetabular index and Wiberg angle decreased significantly in an average time of 14 months. Reimer's index showed no difference with respect to a healthy hip. Final leg length discrepancy was 14.9 mm. The complications that occurred were superficial pin tract infections: 25% of patients. We believe that arthrodiastasis, compounded by monolateral external fixation and an adductor and psoas tenotomy, combined with open reduction and pelvic and femoral osteotomies, is an optional tool to resolve the treatment approach to high inveterate congenital dislocation of the hip.

Relationship between femoral anteversion and tibial torsion: CT evaluation of 38 unilateral developmental dysplasia of the hip patients

INTRODUCTION

Patients with developmental dysplasia of the hip (DDH) present with a wide spectrum of deformities. Few studies have assessed the relationship between femoral anteversion (FA) and rotational profile. The aim of this study is to evaluate the influence of FA on the lower extremity rotational profile by comparing tibial torsion (TT) between the extremities on both sides in patients with unilateral DDH, using computed tomography (CT).

PATIENTS AND METHODS

Thirty eight patients with unilateral developmental dysplasia of the hip, who underwent a preoperative rotational profile CT scan at our institution, were evaluated. 3D rotational profile CT was performed, and FA and TT of the extremities on both sides were measured.

RESULTS

On individual comparison of the rotational profile, mean FA of the affected extremity showed a significantly higher value ( p = 0.006). But, there was no significant difference in mean TT between the 2 extremities. On group analysis, the excessive FA group (group B) showed significantly higher values of tibial torsion and tibial torsion side-to-side difference compared to the normal FA group (group A) ( p = 0.000, p = 0.011, respectively).

CONCLUSIONS

Our study suggests that patients with DDH can present with excessive FA. Therefore, while treating patients who show excessive FA, surgeons must consider the possibility of a higher rotational profile of the affected extremity, before performing surgical treatments for DDH.

Bernese-type triple pelvic osteotomy through a single incision in children over five years: a retrospective study of twenty eight cases

INTRODUCTION

Bernese-type triple pelvic osteotomy (BTPO) combines periacetabular and triple innominate osteotomy techniques. However, studies that evaluate the clinical and radiographic outcomes of BTPO are scarce. The aim of this study is to report on the clinical and radiographic outcomes of ambulatory children with developmental dysplasia of the hip (DDH) or Legg-Calvé-Perthes disease (LCPD) managed with BTPO that were older than five years of age at the time of surgery.

MATERIALS AND METHODS

We retrospectively reviewed the records of 27 consecutive patients with DDH or LCPD (mean age 7.6 ± 1.8; 28 hips) who were treated with the reported technique. All patients had regular clinical and radiographic follow-up. Post-operatively, changes in the acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured in all patients. The presence/absence of avascular necrosis of the femoral epiphysis was also noted in patients with DDH. Final radiographic results were evaluated with the Severin and Stulberg classifications. The Harris hip score was used in the functional evaluation of all patients.

RESULTS

In patients with DDH, the mean age at the time of surgery was 7.5 ± 1.8 years and the mean follow-up time was 22.2 ± 10.7 months. Prior to surgery, the mean AI was 37.9° ± 7.6°. At their final follow-up visit, the mean AI and CEA were 10.8° ± 5.4° and 40.9° ± 8.6°, respectively. Moreover, 66.7% of hips (14/21) were graded as Severin type I, and 33.3% (7/21) were graded as type II. The overall AVN rate was 14.3% (3/21). The mean Harris score was 92.1 ± 7.7. In patients with LCPD, the mean age at the time of surgery was 7.9 ± 1.8 years, and the mean follow-up time was 18.4 ± 6.1 months. Prior to surgery, 85.7% of hips were graded as Herring C, and 14.3% were graded as grade B. Prior to surgery, the mean AI and CEA were 19.4° ± 5.3° and 19.1° ± 12.6°, respectively. At the final follow-up visit, the mean AI and CEA were 5.8° ± 3.4° and 50.3° ± 12.0°, respectively, and 57.1% of hips were graded as Stulberg II. The mean Harris score was 94 ± 5.4. Ischial osteotomy non-unions were recorded in three patients (10.7%).

CONCLUSIONS

BTPO through a modified anterior Smith-Peterson approach is an alternative treatment for DDH and LCPD in older children who are skeletally immature. It not only provides for a large acetabular correction but also achieves good biomechanical stability.

Acetabular Remodeling and Role of Osteotomy After Closed Reduction of Developmental Dysplasia of the Hip

BACKGROUND

The purposes of this study were to evaluate acetabular remodeling after closed reduction of developmental dysplasia of the hip (DDH) and to delineate the role of osteotomy.

METHODS

Eighty-four hips with DDH treated with closed reduction and followed until the patient was 8 years of age or older were included in this study. The mean age at closed reduction was 14.0 months (range, 3 to 30 months) and that at the latest follow-up visit was 12.7 years (range, 8.0 to 24.7 years). Osteotomy was performed in 26 hips (31%) during the follow-up period, at an average age of 2.8 years (range, 2.0 to 5.8 years). The acetabular index (AI) and center-edge angle (CEA) were measured, and osteonecrosis was graded. The treatment outcome was evaluated as satisfactory (Severin grade I or II) or unsatisfactory (III or IV). We retrospectively analyzed the associations among radiographic parameters, performance of osteotomy, grade of osteonecrosis, and final outcome.

RESULTS

A satisfactory outcome was observed in 67 (80%) of the 84 hips. An osteotomy was not performed in 30 of 34 hips with an AI of <32° and a CEA of >14° at the age of 3 years, and 28 (93%) of these 30 hips showed a satisfactory outcome. Of the 33 hips with an AI of ≥32° and a CEA of ≤14° at the age of 3 years, the 20 that had undergone an osteotomy showed a higher proportion of satisfactory outcomes than the 13 hips that had not (p = 0.01). Three of the 4 hips that showed an unsatisfactory outcome following an osteotomy had an AI of ≥34° at 1 year post-osteotomy. Grade-II, III, or IV osteonecrosis, according to the Bucholz-Ogden classification, developed in 10 of the 84 hips, and these 10 hips had a higher proportion of unsatisfactory outcomes than did those that developed no or grade-I osteonecrosis (p = 0.004).

CONCLUSIONS

Hips with DDH showing poor acetabular remodeling after closed reduction may benefit from osteotomy. The AI and CEA at the age of 3 years can serve as one of the guidelines for osteotomy. Continued surveillance for acetabular remodeling is required even after osteotomy.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Developmental dysplasia of the hip: What has changed in the last 20 years?

Developmental dysplasia of the hip (DDH) describes the spectrum of structural abnormalities that involve the growing hip. Early diagnosis and treatment is critical to provide the best possible functional outcome. Persistence of hip dysplasia into adolescence and adulthood may result in abnormal gait, decreased strength and increased rate of degenerative hip and knee joint disease. Despite efforts to recognize and treat all cases of DDH soon after birth, diagnosis is delayed in some children, and outcomes deteriorate with increasing delay of presentation. Different screening programs for DDH were implicated. The suspicion is raised based on a physical examination soon after birth. Radiography and ultrasonography are used to confirm the diagnosis. The role of other imaging modalities, such as magnetic resonance imaging, is still undetermined; however, extensive research is underway on this subject. Treatment depends on the age of the patient and the reducibility of the hip joint. At an early age and up to 6 mo, the main treatment is an abduction brace like the Pavlik harness. If this fails, closed reduction and spica casting is usually done. After the age of 18 mo, treatment usually consists of open reduction and hip reconstruction surgery. Various treatment protocols have been proposed. We summarize the current practice for detection and treatment of DDH, emphasizing updates in screening and treatment during the last two decades.

Medial versus anterior open reduction for developmental hip dislocation in age-matched patients

BACKGROUND

The difference between medial (MAOR) and anterior (AAOR) approaches for open reduction of developmental hip dysplasia in terms of risk for avascular necrosis (AVN) and need for further corrective surgery (FCS, femoral and/or acetabular osteotomy) is unclear. This study compared age-matched cohorts undergoing either MAOR or AAOR in terms of these 2 primary outcomes. Prognostic impact of presence of ossific nucleus at time of open reduction was also investigated.

METHODS

Institutional review board approval was obtained. Nineteen hips (14 patients) managed by MAOR were matched with 19 hips (18 patients) managed by AAOR based on age at operation (mean 6.0; range, 1.4 to 14.9 mo). Patients with neuromuscular conditions and known connective tissue disorders were excluded. Primary outcomes assessed at minimum 2 years' follow-up included radiographic evidence of AVN (Kalamchi and MacEwen) or requiring FCS.

RESULTS

MAOR and AAOR cohorts were similar regarding age at open reduction, sex, laterality, and follow-up duration. One hip in each group had AVN before open reduction thus were excluded from AVN analysis. At minimum 2 years postoperatively (mean 6.2; range, 1.8 to 11.7 y), 4/18 (22%) MAOR and 5/18 (28%) AAOR met the same criteria for AVN (P=1.0). No predictors of AVN could be identified by regression analysis. Presence of an ossific nucleus preoperatively was not a protective factor from AVN (P=0.27). FCS was required in 4/19 (21%) MAOR and 7/19 (37%) AAOR hips (P=0.48). However, 7/12 (54%) hips failing closed reduction required FCS compared with 4/26 (16%) hips without prior failed closed reduction (P=0.024). Cox regression analysis showed that patients who failed closed reduction had an annual risk of requiring FCS approximately 6 times that of patients without a history of failed closed reduction (hazard ratio=6.1; 95% CI, 1.5-24.4; P=0.009), independent of surgical approach (P=0.55) or length of follow-up (P=0.78).

CONCLUSIONS

In this study of age-matched patients undergoing either MAOR or AAOR, we found no association between surgical approach and risk of AVN or FCS. In addition, we identified no protective benefit of a preoperative ossific nucleus in terms of development of AVN. However, failing closed reduction was associated with a 6-fold increased annual risk of requiring FCS.

SIGNIFICANCE

To the best of our knowledge, this is the first study comparing these 2 surgical techniques in an age-matched manner. It further corroborates previous studies stating that there may be no difference in risk of AVN based on surgical approach or presence of ossific nucleus preoperatively.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Mid term results of Pemberton pericapsular osteotomy

BACKGROUND

Treatment for developmental dysplasia of the hip (DDH) varies according to the age of the patient. For children under 3 months, the preferred treatment is Pavlik bandaging and/or dynamic hip orthosis;for children of 3-18 months (with/without arthrography), closed and open reductions (ORs) are most common; and for children 18 months and older, pelvic osteotomies are used. Radiological and functional outcomes of patients between 16 months and 7 years of age who underwent Pemberton pericapsular osteotomy (PPO) were evaluated.

MATERIALS AND METHODS

Twelve patients with developmental dysplasia of the hip (DDH) received treatment on 14 hips between 2001 and 2006. All patients with DDH had PPO as pelvic osteotomy. PPO was done solely in 3 hips, PPO and open reduction (OR) in and OR + PPO + femoral shortening in 6. The average age was 39.85 months (range 16-83 months). All had 1-stage surgery. Acetabular index (AI) and the grade of displacement were determined according to Tönnis'. Center-edge (CE) angle was evaluated. Clinical evaluations were made as described by McKay, radiological assessments by Severin's criteria and femoral head avascular necrosis measurements by Kalamchi-MacEwen's criteria. Average followup periods were 83.35 months (range 48-115 months).

RESULTS

Preoperative and postoperative average AI levels were 41.92° (range 30-50°) and 19,5° (range 5-34°), respectively (P < 0.001). According to Severin's classification, 11 (78.57%) patients were Ia, 1 (7.14%) was Ib, 1 (7.14%) was II and 1 (7.14%) was III. According to Kalamchi-McEven criteria, 12 (85.71%) patients were type I, 2 (14.28%) patients were type II. CE postoperatively was measured as 24.24° (range 12-41°). Clinically (McKay), the functional results in 13 (92.85%) patients were very good (I) and in 1 (7.14%) was good (II).

CONCLUSIONS

Functional and radiological mid term outcomes were found to be comparable in most of the patients with DDH undergoing PPO between the ages of 16 months and 7 years.

A Combined Procedure for High Dislocation in Patients with Developmental Dysplasia of the Hip

INTRODUCTION

A combined procedure including open reduction, femoral shortening osteotomy, and an acetabular procedure is often necessary to obtain a desirable result in children of walking age who have a high-riding hip dislocation.

STEP 1 SURGICAL APPROACH

A careful approach to the femoral head and acetabulum is required to avoid injury to nerves, vessels, and cartilage.

STEP 2 EXPLORE THE HIP JOINT

Make sure to find the true acetabulum and remove all obstacles to femoral head reduction.

STEP 3 FEMORAL HEAD REDUCIBILITY

Check the reducibility of the femoral head in different positions through a full range of hip motion.

STEP 4 FIRST FEMORAL OSTEOTOMY

Expose the proximal part of the femur subperiosteally and make necessary markers for determining the amount of shortening and rotation at the time of osteotomy.

STEP 5 HIP JOINT STABILITY

Check femoral head reduction stability with the proximal end of the osteotomized femur.

STEP 6 FEMORAL SHORTENING

Decide the amount of shortening and rotation for the best femoral head reduction.

STEP 7 PEMBERTON ACETABULOPLASTY

In cases with a dysplastic acetabulum and inadequate femoral head coverage after reduction, perform a Pemberton osteotomy.

STEP 8 POSTOPERATIVE MANAGEMENT

Apply a hip spica cast, which the patient wears for six weeks; then switch to a hip abduction brace.

RESULTS

The patient shown in Figures 26 through 29 and Video 5 was a three-year and six-month-old girl with bilateral developmental dysplasia of the hip that was discovered late (Figs. 26 and 27).IndicationsContraindicationsPitfalls & Challenges.

Arthroscopic reduction and acetabuloplasty for the treatment of dislocated hips in children of walking age: a preliminary report

INTRODUCTION

This paper presents our initial findings on the use of arthroscopic hip reduction in conjunction with acetabuloplasty to treat patients of walking age who had congenital dislocation of the hip.

MATERIALS AND METHODS

Arthroscopic reduction with acetabuloplasty was performed on nine children of walking age with nine dislocated hips. The average age of the patients was 21.4 months (14-41 months). Arthroscopic reduction was performed using a two-portal method with a 2.7-mm mini cannulated arthroscopic instrument. We used a subadductor portal and a high anterolateral portal. The obstacles preventing reduction-hypertrophic teres ligament, pulvinar, capsular constriction, hypertrophic transverse ligament-were eliminated.

RESULTS

We treated one grade 4 hip, four grade 3 hips and four grade 2 hips, as classified by Tönnis. We were able to perform arthroscopic reduction on all of the hips. The main obstacles preventing reduction were a capsular constriction and a hypertrophic teres ligament. During the investigation period, which averaged 15.4 months (6-29 months), no repeat dislocation occurred. According to the Tönnis classification system for avascular necrosis, there were two cases of a grade 2 necrosis of the femoral head. The average preoperative AC angle was 40° (34°-47°). The average AC angle at the follow-up examination was 18.7° (11°-27°).

CONCLUSIONS

We can conclude that the standardized arthroscopic surgical technique presented here can also be used to safely perform arthroscopic reduction in toddlers. The new arthroscopic method is an alternative to open reduction for selective hip dislocations. We believe this approach can be used to treat dislocated hips that are classified as grades 2 and 3 dislocations according Tönnis. Early results are promising. Medium-term results are needed to make a definitive statement on the rates of necrosis of the femoral head.

An Unusual Complication Seen in a Six-Year-Old Girl Treated with Open Reduction and Pemberton Osteotomy for Neglected Developmental Dysplasia of the Hip: A Femoral Neck Fracture Sustained during Passive Motion under General Anesthesia

Despite the screening programs for newborn children with hip ultrasonography, neglected developmental dysplasia of the hip (DDH) is still continuing to be a problem in the east and southeast parts of our country. The main complications are redislocation, avascular necrosis, and joint stiffness. We present an unusual complication, femoral neck fracture during passive motion under general anesthesia, of a six-year-old girl with neglected DDH treated by open reduction and Pemberton osteotomy without femoral shortening. The fracture was treated by open reduction and internal fixation combined with proximal femoral shortening. After 5 years the patient had excellent clinical results, no avascular necrosis was seen, and the radiologic appearance was type IA according to modified Severin classification. In conclusion older children with neglected DDH are more likely to have joint stiffness after open reduction. If there is even a little doubt about joint stiffness after open reduction, one should not refrain from femoral shortening. Also passive motion under general anesthesia should be applied very carefully with fluoroscopic control.

The outcome of paediatric LCP hip plate use in children with and without neuromuscular disease

BACKGROUND

The relatively new paediatric LCP hip plate (Synthes GmBH Eimattstrasse 3 CH-4436 Oberdorff) is used in children, both with and without neuromuscular disease, for fixation of proximal femoral osteotomy for a variety of indications.

MATERIALS AND METHODS

We retrospectively reviewed the notes and radiographs of all those children who have had paediatric LCP device for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution (Royal Manchester Children's Hospital), between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications.

RESULTS

Forty-three paediatric LCP hip plates were used in 40 patients (27 males and 13 females) for the fixation of 40 proximal femoral osteotomies and three proximal femur fractures. This included 13 children with underlying neuromuscular pathology and 27 children without neuromuscular disease. All osteotomies and fractures radiologically healed within 6 months [majority (n = 40) within 3 months]. There was no statistically significant difference (p = 0.45) in the neck shaft angle between the immediately post-operative and final X-rays after completion of bone healing. There were no implant-related complications both in patients with and without neuromuscular disease. No metalwork loosening was observed and no plate revisions were required. Three post-operative fractures occurred in patients with neuromuscular pathology treated with post-operative plaster immobilisation.

CONCLUSION

The paediatric LCP hip plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric orthopaedic conditions.

Results of Tönnis-type acetabuloplasty in patients with developmental hip dysplasia

AIM

The aim of this prospective study was to evaluate the outcome of open reduction and Tönnis acetabuloplasty as the first method of treating developmental dysplasia of the hip (DDH) in children in early childhood at walking age.

MATERIALS AND METHODS

Between 2005 and 2009, 34 hips of 34 children were operated on with the aforementioned method. Mean age was 25.6 (range 12-44) months, and mean follow-up was 3.6 years. During the follow-up period ,the hips were evaluated using the acetabular index and for development of avascular necrosis and redislocation. Functional evaluation was also conducted.

RESULTS

Clinically, 97.3 % of patients had excellent and good results. The acetabular angle decreased from 45° preoperatively to 21° early postoperatively and at the last follow-up had improved to 18°. In two hips, type 2 avascular necrosis developed. Hip instability was not observed, and no additional surgery was performed.

CONCLUSION

Tönnis acetabuloplasty is a powerful tool to increase primary stability of the hip when acetabular coverage is inadequate in DDH. Besides its acute correction ability, when performed properly, it has no unwanted effects on acetabular growth. As an isolated procedure or as a part of combined open reduction and/or femoral osteotomy, Tönnis type acetabuloplasty is a safe and effective method.

Osteonecrosis and femoro-acetabular impingement: sequelae of developmental dysplasia of the hip

A 2-year-old girl with developmental dysplasia of the right hip underwent open reduction and capsulorrhaphy via the anterior approach with hip spica casting in an internally rotated position. During her 26 years of follow-up, she was found to have osteonecrosis and subsequently cam-type femoro-acetabular impingement at 28 years of age. She was treated with surgical dislocation of the hip and osteochondroplasty to recreate the normal contour of the head and neck offset.

Three dimensional-CT evaluation of femoral neck anteversion, acetabular anteversion and combined anteversion in unilateral DDH in an early walking age group

PURPOSE

At present, the indications for femoral derotational osteotomy remain controversial due to the inconsistent findings in femoral neck anteversion in developmental dysplasia of the hip (DDH). Moreover, combined anteversion is not assessed in unilateral DDH using three dimensional-CT. Therefore, the purposes of our study were to observe whether the femoral neck anteversion (FA), acetabular anteversion (AA) and combined anteversion (CA) on the dislocated hips were universally presented in unilateral DDH according to the classification system of Tönnis.

METHODS

Sixty-two patients with unilateral dislocation of hip were involved in the study, including 54 females and eight males with a mean age of 21.63 months (range, 18-48 months). The FA, AA and CA were measured and compared between the dislocated hips and the unaffected hips.

RESULTS

Although no significant difference was observed in FA between the dislocated hips and the unaffected hips (P = 0.067, 0.132, respectively) in Tönnis II and III type, FA was obviously increased on the dislocated hips compared with the unaffected hips in Tönnis IV type. Increased AA on the dislocated hips was a universal finding in Tönnis II, III and IV types. Meanwhile, a wide safe range of CA from 24° to 62° was demonstrated on the unaffected hips.

CONCLUSION

Femoral derotational osteotomy seems not to be necessary in Tönnis II and III types in unilateral DDH. Femoral derotational osteotomy should be considered in DDH, especially in Tönnis IV type, if the CA is still above 62° and the hip joints present instability in operation after abnormal acetabular anteversion, acetabular index and acetabular coverage of the femoral head are recovered to normal range through pelvic osteotomy.

Developmental dysplasia of the hip: open reduction as a risk factor for substantial osteonecrosis

BACKGROUND

Kalamchi and MacEwen (K&M) described a four-group scheme for classifying osteonecrosis (ON) following treatment for developmental dysplasia of the hip (DDH). However, the four groups can overlap in radiographic appearance, making assessment difficult.

QUESTIONS/PURPOSES

We (1) describe a simplified K&M classification; (2) determined whether the simplified classification was reliable; and (3) assessed whether differences in the type of reduction or age at reduction resulted in different degrees of ON.

PATIENTS AND METHODS

We retrospectively reviewed 300 patients with DDH treated with either open or closed reduction. We included 101 of these patients (133 involved hips). Intraobserver and interobserver reliability testing of the original and our simplified classification was performed. ON occurred in 64 hips (48%). Of these, 22 had original K&M Group I disease (classified as simplified Group A), and 42 had original K&M Groups II, III, or IV disease (classified as simplified Group B). The mean age of the patients at final followup was 12.4 years (range, 6-26.3 years).

RESULTS

The interobserver reliability of the simplified classification was greater than that of the K&M classification (0.51 vs 0.33, respectively). Closed reduction after skin traction resulted in a lower incidence of Group B ON than open reduction, regardless of age at reduction.

CONCLUSIONS

We propose a simplified and more reliable classification of ON after DDH. With the new classification we found type of reduction (closed with traction versus open without femoral shortening) but not age influenced the risk of ON.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The evaluation of hip muscles in patients treated with one-stage combined procedure for unilateral developmental dysplasia of the hip: part II: isokinetic muscle strength evaluation

BACKGROUND

To assess the isokinetic muscle strength (IMS) of hip flexor and extensor muscles in patients treated with one-stage combined procedure for developmental dysplasia of the hip and analyze the effect of the status of hip muscles on IMS.

METHODS

Twenty-two patients were included in the study. The mean age was 154.4+/-34.6 (110-216) months and the mean follow-up was 112.6+/-32.0 (68-159) months. All patients underwent complete tenotomy of the iliopsoas muscle to ease open reduction and had excellent results according to the modified McKay criteria of Barrett and type I hips according to the radiologic criteria of Severin. All patients had earlier magnetic resonance imaging examination that revealed reattachment of the iliopsoas in 7 (32%) patients. IMS measurements were performed at 120 degrees/s and 240 degrees/s. The peak torque (PT), PT angle, total work (TW), and average power (AP) values of operated and nonoperated hips were recorded separately for flexors and extensors.

RESULTS

For flexors, TW and AP values were lower at the operated hip when compared with the nonoperated hip at both angular velocities. PT was only lower at the operated hip at 120 degrees/s. For extensor muscles, PT, TW, AP, and PT angle showed no statistically significant difference at either angular velocity. For flexors, the PT deficit between the operated and nonoperated hips at 120 degrees/s and 240 degrees/s was measured as 15.3% and 8.0%, respectively. There was no difference between the flexor muscles of operated and nonoperated hips considering PT, TW, and AP at both angular velocities in patients with reattachment. The IMS deficit of flexor muscles at 120 degrees/s was significantly higher in patients without reattachment of iliopsoas when compared with those with reattachment, and correlated to the widths of the iliopsoas muscle at levels II and III.

CONCLUSIONS

Assessing the results of surgical treatment of DDH with conventional radiologic and functional criteria might be misleading in some patients with excellent results because some of these patients, particularly those without reattachment of the iliopsoas muscle, experience significant weakness in hip flexion.

Análise radiográfica dos fatores prognósticos no tratamento do quadril displásico inveterado

OBJETIVO: Avaliar os resultados do tratamento cirúrgico da Displasia do Desenvolvimento do Quadril na idade da marcha. MÉTODOS: Avaliamos 33 quadris operados entre novembro de 1992 e setembro de 1997. A média de idade foi 4 anos e 5 meses na ocasião da cirurgia e 11 anos e 7 meses quando avaliamos os resultados. O seguimento médio foi de 10 anos e 2 meses. Realizamos o encurtamento femoral, redução cruenta e osteotomia pélvica (Salter ou Chiari). Radiograficamente avaliamos: grau da luxação, índice acetabular; ângulo acetabular; arco de Shenton; linha de Hilgenheiner; coeficientes c/b, c/h, centro-acetábulo e cabeça-acetábulo; largura da cartilagem trirradiada; relação cabeça trocânter; esfericidade da epífise femoral; ângulo de Wiberg; necrose avascular e anisomelia. Os parâmetros radiográficos foram avaliados nos períodos pré-operatório, pós-operatório imediato e tardio. RESULTADOS: Verificamos estatisticamente melhora significante destes no momento pré-operatório para o pós-operatório imediato (p=0,0001) porém não houve variação significante entre o pós-operatório imediato e o tardio (p=0.5958). CONCLUSÃO: Pela classificação utilizada para avaliação dos resultados observamos 23 (69,70%) bons, 5 (15,15%) regulares e 5 (15,15%) maus resultados.

Femoral anteversion in developmental dysplasia of the hip

BACKGROUND

Limited data exist in the literature with regard to the amount of femoral anteversion in children with developmental dysplasia of the hip (DDH). The data that do exist are variable: certain studies cite increased version in DDH compared with normal while others have found no significant difference. The purpose of our study was to quantify the degree of femoral anteversion in a large, consecutive series of children with DDH.

METHODS

We performed a prospective study on 37 consecutive hips (30 patients) that were undergoing surgical procedures for DDH. After induction with general anesthesia (before the planned procedure), arthrograms were performed to allow accurate localization of the center of the femoral head. An anteroposterior radiograph was taken with the patient positioned supine and the knee flexed 90 degrees over the end of the operating table and the leg held perpendicular to the plane of the table. The limb was then rotated 90 degrees for the lateral radiograph. The offset of the center of the femoral head to the midline of the femoral shaft was measured in each view and a simple trigonometric relationship was used to calculate the femoral version.

RESULTS

The mean age of the children in our series was 33.5 months (range: 6 to 79 mo). There were 4 boys and 26 girls; 7 patients had bilateral involvement. The mean femoral anteversion was 50.3 degrees+/-17.9 degrees. Significant variability was found: the lowest femoral version measured 0 degrees and the highest measured 95.7 degrees.

CONCLUSIONS

In most of our children with DDH, femoral anteversion was increased compared with published norms; however, significant variation existed. Given the variability of femoral anteversion, we believe that an individualized surgical approach is warranted, including preoperative assessment of the femoral version followed by derotational femoral osteotomy only if indicated by the patient's specific torsional profile.

LEVEL OF EVIDENCE

Anatomic study.

The evaluation of hip muscles in patients treated with one-stage combined procedure for unilateral developmental dysplasia of the hip: part I: MRI evaluation

BACKGROUND

To assess the status of hip flexor and extensor muscles with MRI in patients with unilateral developmental dysplasia of the hip (DDH) after walking age who were treated with one-stage combined procedure.

METHODS

Twenty-two patients operated upon with one-stage combined procedure for unilateral DDH were included in this study. All patients underwent complete tenotomy of the iliopsoas muscle hindering open reduction. All patients showed excellent results according to the modified McKay criteria of Barrett and type 1 hips according to radiologic criteria of Severin at the latest follow-up. MRI assessment of iliopsoas, rectus femoris, tensor fasia lata, sartorius, and gluteus maximus muscles was performed and muscles of the hip that was operated upon were compared with the hip that was not. In addition, the iliopsoas muscle was examined for reattachment and the effect of reattachment was evaluated.

RESULTS

Mean age was 154.4+/-34.6 (110 to 216) months. Mean follow-up was 112.6+/-32.0 (68 to 159) months. Reattachment of the iliopsoas was observed in 7 (32%) patients, with no significance in terms of age, postoperative follow-up period, or the duration of the postoperative period. Atrophy in the hip that was operated upon was significant in iliopsoas, rectus femoris, tensor fasia lata, and gluteus maximus muscles when compared with the hip that was not. No significance was detected in the sartorius muscle between hips that were operated upon and those that were not. Cross-sectional areas of tensor fascia lata, rectus femoris, sartorius, and gluteus maximus muscles were not significantly different between patients with and without reattachment of iliopsoas. The width of the iliopsoas muscle was significantly lowered in patients without reattachment.

CONCLUSIONS

Patients with DDH treated with combined procedures including complete iliopsoas tenotomy do not have hip muscles similar to hip muscles that have not been operated upon, despite excellent radiologic and clinical results. These patients can be affected by muscular changes in the long term. Follow-up by conventional radiologic and clinical criteria alone may not be enough, and patients may have problems, as in our series, that cannot be detected by conventional radiologic and clinical assessments.

LEVEL OF EVIDENCE

Level IV, Therapeutic case series.

Predictors of the need for femoral shortening osteotomy during open treatment of developmental dislocation of the hip

BACKGROUND

It is well accepted that femoral shortening osteotomy can reduce the risk of complications after open reduction of developmental dislocation of the hip (DDH), especially in older children and "high" dislocations. It remains unclear, however, at what age a child needs a femoral shortening osteotomy and what exactly constitutes a "high" dislocation. The purpose of our study was to evaluate age and femoral displacement as predictors of the need for a femoral shortening osteotomy during the open treatment of DDH.

METHODS

A retrospective study was performed on all hips that underwent open treatment for DDH between 2005 and 2008. In our algorithm, femoral shortening osteotomy was performed only if it was necessary to ease femoral head reduction (independent of patient age and radiographic displacement). Preoperative anteroposterior radiographs of the pelvis were used to measure the normalized superior and lateral displacement of the proximal femoral metaphysis relative to Hilgenreiner's line and the lateral edge of the triradiate cartilage, respectively. Operative reports were reviewed to determine age at the time of surgery and whether or not a femoral shortening osteotomy was performed.

RESULTS

Our series consisted of 72 consecutive hips; mean patient age was 35.6 months (range: 16.4 to 76.0 mo). Overall, 25 of 72 hips (35%) underwent a femoral shortening osteotomy. When the proximal femur was vertically displaced greater than 30% of the pelvic width, the child was significantly more likely to need a femoral shortening osteotomy (P<0.0001, relative risk 3.6). Children older than 36 months of age were also more likely to require a shortening compared with younger children (P=0.001, relative risk 3.2). When both factors were present, the relative risk of needing a femoral shortening was 3.8 (P<0.00002).

CONCLUSIONS

As expected, older patients (>36 mo of age) and high dislocations (superior displacement of the proximal femur >30% of pelvic width) were more likely to require a femoral shortening osteotomy. Our results may help frame expectations for both the family and the surgeon when anticipating surgical treatment for DDH.

LEVEL OF EVIDENCE

3 (case-control study).

Residual axial plane deformities after hip reconstruction for developmental dysplasia of the hip after walking age

Children with developmental dysplasia of the hip after walking age can be treated with one-stage combined operations. In these procedures, complex deformity corrections at both frontal and axial planes are performed in the guidance of intraoperative stability tests. The reports about the results of these procedures focus on frontal plane assessments but neglect to assess axial plane corrections. We aimed to find out whether hips with unilateral developmental dysplasia of the hip, treated by one-stage combined procedures after walking age and which had good frontal plane containment at the last follow-up, had any axial plane deformities. Twenty-one patients were included in this study according to our described criteria. Mean age at the operation time was 38.04 months (range: 20-86 months), mean follow-up time was 55.54 months (range: 24-117 months) and mean age at latest follow-up was 93.46 months (range: 52-150 months). Femoral anteversions, acetabular anteversions and acetabular sector angles were measured bilaterally in the computed tomography examination. Operated hip measurements were compared with the contralateral hips. One-way variance analysis was used for statistical analysis. Femoral anteversion, acetabular anteversion and posterior acetabular sector angle values of the operated hips were found to be statistically lower than those of the contralateral hips. Our findings suggest that using the intraoperative stability test alone for planning osteotomies may lead to unsuitable femoral head coverage in axial plane although successful frontal plane containment can be obtained. We believe that strict preoperative planning that can be accomplished by a preoperative computed tomography examination should be performed in order to decide innominate osteotomy type and correction amounts.

One-stage combined surgery with or without preoperative traction for developmental dislocation of the hip in older children

PURPOSE

To compare one-stage combined surgery with and without preoperative traction, in older children with developmental dislocation of the hip (DDH).

METHODS

Records of 9 children who underwent combined surgery for DDH with preoperative traction in 12 hips (group 1) and 12 undergoing the same procedure without preoperative traction in 16 hips (group 2) were retrospectively reviewed. The surgery consisted of open reduction, Salter's innominate osteotomy and femoral shortening with derotation varus osteotomy. The mean age of the patients at the time of operation was 5.8 years. The mean follow-up period was 5.9 years.

RESULTS

At final follow-up, clinical outcome in group 1 was worse than that in group 2, though radiographic assessment demonstrated no significant difference between the groups.

CONCLUSION

One-stage combined surgery without preoperative traction is effective in the treatment of DDH in older children, and has a lower complication rate, but radiographically the groups did not differ.

Long-term result of combination of open reduction and femoral derotation varus osteotomy with shortening for developmental dislocation of the hip

This study examined femoral derotation varus osteotomy with shortening performed on children with developmental dislocation of the hip. Each patient reached 14 years of age. Surgical outcomes were evaluated clinically and roentgenographically. We studied nine patients with 11 joints undergoing surgical repair. Age at the time of operation averaged 2 years and 1 month; the period of observation averaged 15 years and 7 months; and age at final investigation averaged 17 years and 8 months. Each patient underwent the study operation as an initial treatment. Salter pelvic osteotomy was reserved as a second treatment for those patients whose acetabular development proved inadequate during post-surgical observation. The evaluation method established by McKay was utilized to determine clinical results at the time of final investigation; 73% of the study group were established as having good results. Severin's evaluation method was used to assess roentgenographical results; 45% of the study group were determined to have good results. Kalamchi's evaluation method allowed six joints to be diagnosed with avascular necrosis of the femoral head; however, in all cases but one, necrosis had been present prior to surgery. Those six joints that did not have necrosis of the femoral head prior to surgery developed only one mild necrosis subsequent to surgery. Achieving a stable reduced position by femoral derotation varus osteotomy, as well as sufficient decompression of the femoral head by shortening osteotomy, are considered to have played very important roles in preventing the femoral head from developing necrosis.

Open reduction and varus-detorsion osteotomy with femoral shortening in treatment of congenital dislocation of the hip

In this study, we clinically and radiographically evaluated open reduction with shortening of the femur in children more than 1 year old with refractory congenital dislocation of the hip. In 19 children (aged 1-4 years), 22 joints were operated on. The patients were followed-up for an average of 8.7 years (range, 2-13 years). Functional results were satisfactory in all joints, and differences in limb length were not significant. Radiographically, good results (grades I and II) were obtained in 16 of the 22 joints, according to Severin's criteria. This surgical procedure may be indispensable for treating refractory congenital dislocation of the hip in children over 1 year old.