Radiological results of modified Dega osteotomy in Tönnis grade 3 and 4 developmental dysplasia of the hip

Salter osteotomy has lower fluoroscopy exposure time compared to Tonnis lateral acetabuloplasty

Salter osteotomy and Tonnis lateral acetabuloplasty (TLA) are pelvic osteotomies with similar indications and clinical results used in the treatment of developmental dysplasia of the hip (DDH). The aim of our study was to compare the intraoperative fluoroscopy exposure time (FET) in patients with DDH treated with the Salter osteotomy and TLA. In this study, data were collected prospectively and compared after the study was completed. The patients were evaluated in three groups: pelvic osteotomy (group 1), open reduction with pelvic osteotomy (group 2) and open reduction + pelvic osteotomy + femoral shortening (group 3). Pelvic osteotomy techniques in each group were further analyzed in two subgroups as Salter osteotomy and TLA. Age, sex, surgery side, degree of dysplasia according to the Tönnis classification, duration of anesthesia and intraoperative FET (seconds) were recorded. A total of 109 patients (93 girls and 16 boys) were included in the study; 29 patients in group 1, 50 in group 2 and 30 in group 3. Although the patients who underwent Salter osteotomy and TLA were similar in all three groups in terms of age, sex, surgery side, Tönnis classification and duration of anesthesia, FET was longer in the patients who underwent TLA (group 1, P  < 0.001; group 2, P  < 0.001; group 3, P  = 0.005). The use of the Salter osteotomy technique in the treatment of acetabular dysplasia in patients with DDH seems to be more advantageous in terms of FET than TLA osteotomy. It would be beneficial to consider this result in terms of radiation safety. Level of Evidence: II.

Femoral osteotomy is not recommended for children aged 2-3 years with Tönnis grade III developmental dysplasia of the hip

The objective of this study was to compare outcomes following open reduction with and without femoral shortening when treating patients aged 2-3 years with Tönnis grade III developmental dysplasia of the hip (DDH). In this prospective study, 78 patients (6 boys and 72 girls; mean age: 27.8 months; age range: 24-35 months) with Tönnis grade III DDH at our hospital from January 2014 to August 2017 were included. There were 34 hips in the without femoral shortening group and 44 hips in the femoral shortening group. Clinical outcomes were rated using the modified McKay criteria, and the hips were graded using the Severin score. Avascular necrosis (AVN) and redislocation were assessed. Mean follow-up was 26.5 months (range 17-32 months). In the without femoral shortening group (n = 34), there were five patients with AVN (14.7%), and 30 scored excellent and 4 scored good results per the modified McKay criteria. Further, 28 excellent and six good results were obtained using the Severin scale; no patient had redislocation. In the femoral shortening group(n = 44), there were seven patients with AVN (15.9%), and 38 scored excellent and six scored good results per the modified McKay criteria. Further, 31 excellent and 13 good results were obtained using the Severin scale; no patient had redislocation. Additionally, there were no statistically significant differences based on Modified McKay criteria, Severin score and AVN rate. Femoral shortening is not required for children aged 2-3 years with Tönnis grade III DDH.

Collagen I in the Hip Capsule Plays a Role in Postoperative Clinical Function in Patients With Developmental Dysplasia of the Hip

The aims of the present study is to evaluate the roles of collagen I and III in the hip capsule in the postoperative clinical function of patients with developmental dysplasia of the hip (DDH). Hip capsules from 155 hips of 120 patients were collected during surgery. The patients were divided into three groups according to age: I: 2-3.5 years; II: 3.5-5 years; and III: 5-6 years. Patient clinical function and radiographic outcomes were evaluated with the McKay scores and Severin classification. The expression of collagen I and III was detected through immunohistochemistry and quantitative reverse transcription polymerase chain reaction (RT-PCR) and analyzed according to age, sex, degree of dislocation and McKay classification. All patients received open reduction and pelvic osteotomy and/or femoral shortening osteotomy and achieved good results on the basis of postoperative X-ray imaging. The average follow-up time was 3.4 years (range 2-4.3 years). There were no changes in the expression of collagen III in the different groups. The expression of collagen I according to age and sex was not significantly different. Lower expression of collagen I was observed in DDH patients with a higher degree of dislocation according to the Tonnis grade. The highest expression of collagen I was detected in the group with poor clinical function according to the McKay classification. Collagen I is correlated with the degree of dislocation and is a risk factor for poor clinical function in DDH patients. Collagen I is correlated with the degree of hip dislocation and poor clinical function in DDH patients.

Assessment of irreducible aspects in developmental hip dysplasia by magnetic resonance imaging

BACKGROUND

The developmental dysplasia of the hip (DDH) can cause a wide range of pathological changes, and often requires surgical treatment. Preoperative evaluation is very important for DDH. We aimed to assess the diagnostic capability of magnetic resonance imaging (MRI) for irreducible aspects preventing hip reduction in DDH.

METHODS

A total of 39 pediatric patients who received DDH evaluation in pediatric orthopedics from January 2015 to December 2019 were included. The samples included 4 cases of bilateral DDH and 35 cases of unilateral DDH, a total of 43 hip joint samples. All patients underwent surgical treatment, pathological examination and MRI of hip joint.

RESULTS

With pathological results or intraoperative findings as the gold standard, the sensitivity and specificity of MRI were 90.3% and 83.3% for the affected labrum, 92% and 83.3% for thickening of the round ligament, 90.0% and 91.3% for atrophy of the iliopsoas muscle, and 100% and 100% for fibrofatty pulvinar tissue and joint effusion, respectively.

CONCLUTIONS

The MRI showed an extraordinary capability of detecting these irreducible factors and helped surgeon choose the appropriate treatment strategies.

The Paley ilioischial limb modification of the Dega osteotomy

Background

We aim to describe a modified Dega osteotomy technique in detail, emphasizing its eventual advantages in comparison to the original Dega osteotomy and ‘San Diego’ modification. We also present our related literature review on various osteotomy techniques.

Methods

We reviewed the radiological indices of 27 dysplastic hips in 25 children with cerebral palsy and developmental dislocation of the hips (9 boys, 16 girls; mean age, 5 years) who underwent a modified Dega osteotomy according to Paley.

Results

Comparing the radiological indices results between our patients and those reported by the various authors in the literature, the data are almost identical.

Conclusions

The modified Dega osteotomy is the only technique wherein all two limbs of the triradiate cartilage are true, which becomes a single hinge where the osteotomy turns. Despite the similar results in the radiological indices between our patients and those in the literature, we still consider that the entire triradiate cartilage is a better hinge point for the iliac osteotomy. The difference between the osteotomy adopted in our institution and the modality described by most authors in the literature is that the latter mostly ignore or miss the ischial limb of the triradiate cartilage.

Predictors of femoral shortening for pediatric developmental hip dysplasia surgery: an observational study in 435 patients

Background

Open reduction of the congenitally dislocated hip may not be possible without femoral shortening. The goal of this study is to develop a prognostic prediction model for the need of femoral shortening in children undergoing anterior open reduction for the treatment of developmental dysplasia of the hip (DDH). The secondary objective was to determine if femoral shortening influences the risk of adverse events.

Methods

A cohort from February 1, 2008 thru July 31, 2017 was studied retrospectively at a single centre. Patients between the age of 1 and 8 years, having international hip dysplasia institute (IHDI) grade 3 and 4, undergoing primary anterior open reduction for DDH were included in the study. The outcome of interest was femoral shortening, and the potential predictors were age, sex, side, body mass index and IHDI grade. Logistic regression was employed to identify the independent predictors and was followed by internal validation using bootstrapping. In addition, complications encountered were recorded and analysed.

Results

A total of 548 hips in 435 patients were included. Median follow-up (interquartile range) was 27 (13–48.25) months. Femoral shortening was needed on 119 hips. Factors that increased the probability of femoral shortening in the reduced model were age, male gender, and IHDI grade 4. Adjusting for IHDI and the addition of pelvic osteotomy, the probability of recurrence was lower when femoral shortening is included and higher with increased patient age. There were more deep infections when femoral shortening is added. Femoral shortening did not affect the occurrence of avascular necrosis.

Conclusion

In addition to age and superior displacement of the femoral head, male gender is considered to be an independent predictor for needing femoral shortening. Studying the probability of femoral shortening in DDH surgery may optimize family education, operating room preparation, and operative time utilization. Moreover, there appears to be less risk of recurrence when femoral shortening is performed at the cost of higher probability of deep surgical site infection.

Use of iliac crest allograft for Dega pelvic osteotomy in patients with cerebral palsy

Background

Dega pelvic osteotomy is commonly performed procedure in patients with cerebral palsy (CP) undergoing hip reconstructive surgery for hip displacement. However, there has been no study investigating the outcomes after Dega pelvic osteotomy using allograft in patients with CP. This study investigated the outcomes of Dega pelvic osteotomy using iliac crest allograft in CP with hip displacement and the factors affecting allograft incorporation.

Methods

This study included 110 patients (150 hips; mean age 8y7mo; 68 males, 42 females) who underwent hip reconstructive surgeries including Dega pelvic osteotomy using iliac crest allograft. To evaluate the time of allograft incorporation, Goldberg score was evaluated according to the follow-up period on all postoperative hip radiographs. The acetabular index, migration percentage, and neck-shaft angle were also measured on the preoperative and postoperative follow-up radiographs.

Results

The mean estimated time for allograft incorporation (Goldberg score ≥ 6) was 1.1 years postoperatively. All hips showed radiographic union at the final follow-up and there was no case of graft-related complications. Patients with Gross Motor Function Classification System (GMFCS) level V had 6.9 times higher risk of radiographic delayed union than those with GMFCS level III and IV. Acetabular index did not increase during the follow-up period (p = 0.316).

Conclusions

Dega pelvic osteotomy using iliac crest allograft was effective in correcting acetabular dysplasia, without graft-related complications in patients with CP. Furthermore, the correction of acetabular dysplasia remained stable during the follow-up period.

The early radiological effects of Dega and Pemberton osteotomies on hip development in children aged 4-8 years with developmental dysplasia of the hip

We aimed to investigate the early radiological effects of Dega and Pemberton iliac osteotomies that were performed in patients aged 4-8 years with developmental dysplasia of the hip on development of hip joint. Dega osteotomy or Pemberton osteotomy was performed in 76 hips of 58 patients because of developmental dysplasia of the hip between September 2011 and June 2015 and were evaluated retrospectively. Of a total of 76 hips, Pemberton osteotomy was performed on 39 (19 unilateral) and Dega osteotomy was performed on 37 (21 unilateral). In all hips, the acetabular index, acetabular depth ratio, centre-edge angle of Wiberg, and Reimer's index values were recorded preoperatively and at the final follow-up. We measured the surface areas of the femoral head ossific nucleus in patients with unilateral dysplastic hips and compared results before both osteotomy procedures and at the final follow-up. There were no statistically significant differences between the groups in terms of the acetabular index and acetabular depth ratio values (P>0.05) preoperatively and at the final follow-up, but the mean centre-edge angle of Wiberg and Reimer's index values showed significant statistical differences in favor of the Dega procedure (P<0.05). There was a statistically significant difference in favor of the Pemberton procedure when the mean ratio of the surface area of the femoral head ossific nucleus on the dysplastic side in relation to the normal side was compared preoperatively (P=0.042) and at the final follow-up (P=0.027) in unilateral hips. Although Dega and Pemberton osteotomies produce satisfactory radiological outcomes at early stages in children aged 4-8 years with developmental dysplasia of the hip, a higher rate in the surface area of the femoral head ossific nucleus was observed in the Pemberton osteotomy group, which also had a lower mean age than the Dega osteotomy group.

Analyses of outcomes of one-stage operation for treatment of late-diagnosed developmental dislocation of the hip: 864 hips followed for 3.2 to 8.9 years

Background

The one-stage procedure for treatment of older developmental dislocation of the hip (DDH) is used widely. However, the best age group for this operation is still unknown. The aims of our study were to evaluate middle-term outcomes of one-stage surgical treatment of a large number of patients with late-diagnosed DDH, and to explore the best age group for treatment.

Methods

We retrospectively reviewed 652 patients with a total of 864 hip joints with DDH, all aged >18 months. All the hip joints were treated with one-stage procedures including open reduction, pelvic osteotomy, and femoral shortening. The patients were divided into three groups according to age at surgery: Group I: 1.5–2.5 years; Group II: 2.5–8 years; and Group III: >8 years. The latest clinical and radiographic outcomes, complications and avascular necrosis (AVN) of the femoral head were evaluated and compared among the three groups.

Results

The mean age at surgery was 5.8 years (range: 1.5–13.2 years). The average time of follow-up was 6.2 years (range: 3.2–8.9 years). A total of 79.4% of good or excellent outcomes were obtained for clinical functional evaluation according to the McKay classification. For radiographic outcomes, 732 hips (84.7%) were classified as good or excellent according to the Severin classification. A total of 27.4% of all hips had a poor outcome according to the Kalamchi and MacEwen classification for AVN. The poorest outcomes were observed for clinical, radiographic and AVN results in Group III (p < 0.001). Compared with Group I, the better results for clinical and AVN outcomes were found in Group II (p < 0.001). However, similar clinical outcomes were observed between Groups I and II (p > 0.05). A significantly higher incidence of redislocation and residual acetabular dysplasia was observed in Tonnis grade II and III hip dislocation (p < 0.001).

Conclusions

One-stage treatment of late-diagnosed DDH had a good outcome in young and middle group. Younger patients achieved better results than older patients. However, the best age group was 2.5–8 years. Tonnis grade II and III DDH is a risk factor for redislocation and residual acetabular dysplasia after the one-stage operation.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-401) contains supplementary material, which is available to authorized users.