Factors associated with an unfavourable outcome after Salter innominate osteotomy in patients with unilateral developmental dysplasia of the hip: does occult dysplasia of the contralateral hip affect the outcome?

A cross-sectional study evaluating patients' preferences for Salter innominate osteotomy

BACKGROUND

Residual acetabular dysplasia in children after reduction of hip dislocation is often treated using Salter innominate osteotomy to prevent future osteoarthritis. Preventive surgery for asymptomatic patients, which could result in overtreatment, should be carefully applied with consideration of patients' opinions. In this study, we aimed to describe opinions on Salter innominate osteotomy as preventive surgery for children among adult patients who had undergone periacetabular osteotomy for hip pain due to hip dysplasia.

METHODS

A mail-in questionnaire survey was conducted with 77 patients who underwent periacetabular osteotomy. Participants responded whether they would recommend Salter innominate osteotomy as preventive surgery for children and the reason for their opinion. We also performed a patient-based evaluation using the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire and assessed clinical outcome measures with the Japanese Orthopedic Association score. Their recommendations and reasons were evaluated, and associations between their opinions and demographic and clinical characteristics were analyzed.

RESULTS

Forty-three patients (56%) responded to the questionnaire. Of these, 10 (23%) patients recommended undergoing Salter innominate osteotomy, 28 (65%) patients did not, and 5 (12%) patients responded they were undecided. No significant association was observed between their opinions and demographic/clinical characteristics evaluated in the survey. The most frequent reason for why they do not recommend Salter innominate osteotomy was related to uncertainty about future hip pain.

CONCLUSIONS

In total, 65% of the study participants did not recommend Salter innominate osteotomy for children with risk of dysplasia in the future. Participants' preferences regarding preventive surgery were not influenced by demographic and clinical characteristics.

Salter pelvic osteotomy for the treatment of Developmental Dysplasia of the Hip: assessment of postoperative results and risk factors

BACKGROUND

If non-surgical treatment of Developmental Dysplasia of the Hip (DDH) fails or if DDH is late-detected, surgery is necessary. Salter pelvic osteotomy (SPO) is an effective surgical option for such cases.

OBJECTIVES

To study the results after SPO; to evaluate risk factors; to reveal radiological parameters that may correlate with results.

METHODS

Results analysis in 17 patients (22 hips). Risk factors included those that do not depend on the surgeon (patient's age, value of the acetabular index (AI) preoperatively, DDH Tonnis grade) and those that depend on the surgeon (amount of AI correction). To radiological parameters which may correlate with the amount of AI correction we referred distance "d" and the lateral rotation angle.

RESULTS

SPO allows performing AI correction in ranges 24.1 ± 6.5°. Excellent and good clinical results were obtained in 95.5% of patients; excellent and good radiological results in 86.4% of patients. Risk factors that do not depend on the surgeon were older patient's age and higher preoperative AI values (p <0.05). The risk factor that depends on the surgeon was the amount of AI correction (p <0.05). The distance "d" was recognized as a radiological parameter that may indicate sufficient AI correction (p <0.05).

CONCLUSION

In older patients with a higher preoperative AI value the results will be predictably worse. The surgeon may influence the result with a greater amount of AI correction (which may also be indicated radiologically by the distance "d" values).

LEVEL OF EVIDENCE

IV, therapeutic, case series.

Angulated Salter osteotomy in the treatment of developmental dysplasia of the hip

Salter osteotomy is widely used to improve acetabular coverage in the treatment of developmental dysplasia of the hip. Herein we describe angulated Salter osteotomy (ASO) as the modified Salter osteotomy, which creates a two-point contact between the proximal and distal fragments and better stabilizes the fixation of the fragments. We reported our results of ASO and compared it with that of Salter osteotomy performed previously by us. We retrospectively reviewed 41 unilateral hips that underwent ASO, with no other accompanying procedures, between 2012 and 2018. We investigated the radiographic measurements included the preoperative values of the acetabular index and center-edge angle (CEA), immediate postoperative values of distance d (lateral displacement of the distal fragment), lateral rotation angle (LRA), the ratio of the obturator height (ROH), pelvic height increase percentage (PHIP) and the values of acetabular index and CEA during the last follow-up. Measurements were compared with 20 unilateral hips that underwent Salter osteotomy. The mean age at the time of surgery was 5.4 years, and the mean follow-up duration was 3.3 years. Immediately after surgery, the mean distance d, LRA, ROH and PHIP were 8 mm, 19°, 70 and 1%, respectively. The last follow-up values of acetabular index and CEA significantly improved from the preoperative values by 18° and 21°, respectively. Patients treated with ASO showed significantly larger distance d, more improvement in CEA, and lesser PHIP than those treated with Salter osteotomy. The short-term outcomes of ASO are favorable. ASO was as effective as or better than Salter osteotomy in pulling out and stabilizing the distal fragment anterolaterally. ASO prevents elongation of the ilium, which causes pelvic obliquity.

Residual Acetabular Dysplasia in the Reduced Hip

BACKGROUND

Residual acetabular dysplasia occurs in up to a third of patients treated successfully for developmental dysplasia of the hip (DDH) and has been found to be a significant risk factor for early hip osteoarthritis (OA).

DISCUSSION

Age at the time of initial reduction and the initial severity of DDH have been linked to residual acetabular dysplasia. An anteroposterior pelvic radiograph is the main diagnostic modality, but MRI also provides valuable information, particularly in equivocal cases. The literature supports intervening when significant residual acetabular dysplasia persists at 4-5 years of age, and common surgical indications include acetabular index (AI) > 25°-30°, lateral center-edge angle (LCEA) < 8°-10°, and a broken Shenton's line on radiographs; and a cartilaginous acetabular angle (CAI) > 18°, cartilaginous center-edge angle (CCE) < 13°, and/or the presence of high-signal intensity areas on MRI. Surgical options include redirectional pelvic osteotomies and reshaping acetabuloplasties, which provide comparable radiographic and clinical results.

CONCLUSION

RAD is common after treatment of DDH and requires regular follow-up for diagnosis and appropriate management to decrease the long-term risk of OA. Long-term outcomes of patients treated with pelvic osteotomies are generally favorable, and the risk of OA can be decreased, although the risk of total hip replacement in the long-term remains.

Docking phenomenon and subsequent acetabular development after gradual reduction using overhead traction for developmental dysplasia of the hip over six months of age

PURPOSE

This study aimed to explore the docking of the femoral head into the acetabulum after gradual reduction (GR) using traction for developmental dysplasia of the hip (DDH) and the impact on subsequent acetabular development.

METHODS

A total of 40 patients with DDH (42 hips) undergoing GR using overhead traction and spica casting were retrospectively reviewed. The presence of inverted labrum and the coronal and axial femoral-acetabular distances (FADs) were compared between MRI immediately and five weeks after spica casting. The change in the acetabular index on anteroposterior pelvic radiographs were compared between hips with inverted labrum (residual group) and with normally-shaped labrum (normalized group) on follow-up MRI.

RESULTS

The mean age at reduction was 13.1 months (7 to 33) and the mean follow-up duration was 7.7 years (4 to 11). The rate of inverted labrum and the FADs significantly decreased between the MRI scans (all p-values < 0.001), and previous Pavlik harness failure had no negative effect on these decreases. The acetabular indices at the ages of three and five years in the residual group were significantly larger than those in the normalized group (both p-values < 0.001). Residual acetabular dysplasia was seen in 84.2% of the residual group compared with 34.8% of the normalized group (p = 0.002).

CONCLUSION

The docking phenomenon can occur during spica casting following GR using traction in children with DDH between the ages of six months and three years. The remaining inverted labrum at the cast removal may negatively affect subsequent acetabular development.

LEVEL OF EVIDENCE

III - retrospective comparative study.

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.

Outcomes and complications of patients undergoing Salter's innominate osteotomies for hip dysplasia: a systematic review of comparative studies

The purpose of this systematic review is to assess outcomes and complications of patients undergoing Salter's innominate osteotomies (SIOs) for the correction of hip dysplasia along with patient and technical factors that can be optimized to improve outcomes after SIO. MEDLINE and EMBASE were searched from data inception to 9 October 2018. Data were presented descriptively. Twenty-seven studies were identified including 1818 hips (87.1%) treated with SIO (mean age of 2.1 ± 2.5 years and mean follow-up of 3.5 ± 5.0 years). Patients undergoing SIO had a post-operative center-edge angle (CEA) of 31.3° ± 5.3° and an acetabular index (AI) angle of 16.1° ± 5.2°. Patients undergoing SIO with pre-operative traction had significantly lower (P = 0.049) post-operative McKay criteria scores compared to patients without pre-operative traction. Patients undergoing SIO between the ages of 1.5-2 years had significantly better (P < 0.05) post-operative McKay criteria scores compared to patients aged 4-6 years. The complication rate was 9.4% with avascular necrosis (2.5%) being most common. This review found that SIO for developmental dysplasia of the hip produces generally good post-operative clinical outcomes. The CEA and AI can be corrected to normal range after SIO. Patients may have superior outcomes if they have SIO at a younger age, were not treated with pre-operative traction and did not have untreated contralateral hip dysplasia. Outcomes appear to be similar between one-stage bilateral SIO and a two-stage procedure in the setting of bilateral hip dysplasia; however, more multicentered studies are needed to confirm these results.

Preoperative incipient osteoarthritis predicts failure after periacetabular osteotomy: 69 hips operated through the anterior intrapelvic approach

BACKGROUND

Untreated developmental hip dysplasia may result in pain, loss of function and is a common cause of osteoarthritis (OA). The periacetabular osteotomy (PAO) was developed to relieve symptoms and postpone further degeneration of the hip. We aimed to assess preoperative clinical and radiographic prognostic factors and evaluate survivorship of PAO after medium-term follow-up of 7.4 (2-15) years.

METHODS

59 patients (69 hips) operated with a PAO through an anterior intrapelvic approach from 1999 to 2011 were retrospectively identified. The patients were evaluated radiographically and clinically with Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index and 15D quality of life questionnaires. Survival analyses identified native hip joint survival predictors.

RESULTS

9 hips (9 patients) were converted to a total hip arthroplasty (THA). Of the 50 remaining patients (60 hips), 44 patients (54 hips) were examined at medium-term follow-up. 3 patients were lost to follow-up or declined participation and 3 were interviewed by telephone. Patient age at time of surgery was 32 (14-44) years. Survival analyses showed 84.3% (95% confidence interval [CI], 68.7-92.5%) survival of the native hip at 8 years follow-up (number at risk 32) (worst case scenario 80% survival at 8 years, 95% CI, 63.9-89.2%, number at risk 32). Cox regression with presence of preoperative OA (Tönnis ⩾1), showed a crude hazard ratio for conversion to THA with preoperative OA of 13.73, p < 0.001.

CONCLUSIONS

Periacetabular osteotomy through the anterior intrapelvic approach can be performed safely and with satisfactory results at medium-term follow-up. The presence of preoperative incipient OA (Tönnis ⩾1) is the most important predictor for poor hip joint survival.

Proposal of a New Type of Innominate Osteotomy without the Use of Bone Graft in Children: A Preliminary Study

Good long-term outcomes have been reported for the Salter innominate osteotomy (SIO), which is widely used to correct developmental dysplasia of the hip (DDH) in children. In this study, we describe the procedure and early outcomes of a new pelvic osteotomy termed "angulated innominate osteotomy" (AIO).

METHODS

Twenty-one patients (22 hips) underwent AIO. We evaluated age at the time of surgery, operative time, blood loss, and time to bone union. Several radiographic parameters were assessed preoperatively, immediately postoperatively, and at the time of the latest examination. Measurements were compared with those of 20 previous patients who underwent SIO. The AIO is made to form an isosceles triangle. This enables 2 points of contact between the proximal and distal bone fragments, eliminating the need for a bone graft.

RESULTS

Mean age at the time of surgery was 5.9 years, and the mean duration of follow-up was 30.8 months. The mean operative time was 103 minutes, mean blood loss was 33 mL, and mean time to bone union was 9.8 weeks. Immediately postoperatively, the mean "distance d" (lateral displacement of the distal fragment), mean ratio of the obturator heights (ROH), and mean lateral rotation angle (LRA) were 7.2 mm, 70.4%, and 19.3°, respectively. At the latest examination, the mean acetabular index (AI), center-edge angle (CEA), and acetabular head index (AHI) were 16.4°, 23.7°, and 85.5%, respectively, each of which were significantly improved compared with the preoperative values. Moreover, the mean postoperative iliac length difference (ILD) between the operative and contralateral sides was only 0.1 mm. Those treated with AIO had a significantly shorter operative time and time to bone union, and less blood loss, than those treated with SIO. The mean distance d, ROH, and LRA did not differ significantly from SIO results, while the mean ILD was significantly less.

CONCLUSIONS

AIO is a less-invasive procedure that does not require a bone graft, and the short-term outcomes were favorable. Sufficient coverage of the acetabulum with displacement of the distal bone fragment to an extent similar to SIO can be achieved; we consider AIO a worthy surgical procedure that has the potential to provide good long-term outcomes similar to those seen with SIO.

LEVEL OF EVIDENCE

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

Clinical evaluation of ultrasound screening in follow-up visits of infants with cerebral palsy at high risk for developmental dysplasia of the hip

The aim of the study was to assess the clinical value of ultrasound screenings for the developmental dysplasia of the hip (DDH) and explore its etiology in high-risk infants with cerebral palsy in follow-up visits. A group of 98 cases of infants at high-risk of cerebral palsy who received rehabilitation treatment between July, 2009 and July, 2010 were selected. Infants included 58 men and 40 women, aged <6 months and not lost to follow-up visits. Ultrasound (using Graf static inspection) screening of hips was performed and the infants with abnormalities were given clinical intervention, and 1- to 2-year-old infants were given outpatient follow-ups. The results were analyzed and there were 40 abnormal cases among the 98 cases of infants at high risk of cerebral palsy, including 18 cases of unstable hip joint, and 22 cases of DDH (12 cases of hip dysplasia, 3 cases of hip subluxation and 7 cases of hip dislocation). Early clinical intervention for infants with hip dysplasia and outpatient follow up for infants aged 1–2 years was carried out and had ischemic necrosis of femoral head, with the exception of 1 case of femoral detorsion that was poorly restored. In conclusion, the probability of DDH was higher in infants at high-risk of cerebral palsy compared to the normal infants. Hip ultrasound is a safe, simple, and effective screening method for these infants, which is of great clinical significance for an earlier diagnosis and treatment of DDH in infants with cerebral palsy.