Pelvic Osteotomies in the Child and Young Adult Hip: Indications and Surgical Technique

Risk of Venous Thromboembolism in Adolescents Undergoing Pelvic Osteotomy: Insights From a Propensity-matched Retrospective Cohort Study

BACKGROUND

Pelvic osteotomies are surgical procedures that are commonly performed in adolescents and young adults to improve stability or correct various deformities. Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), are dreaded complications of any major procedure including pelvic osteotomies. Unlike adults, the incidence of DVT and need for prophylactic measures are not well understood in the adolescents. The purpose of this study is to understand the need for VTE prophylaxis in adolescents and determine if their risk profile aligns with adults, who have more established VTE prophylactic guidelines in place for these surgeries.

METHODS

This retrospective cohort study utilized data from the TriNetX Research Network, which includes records from over 80 healthcare organizations and more than 120 million patients. De-identified patient data from January 1, 2003, to March 1, 2024, were extracted using relevant ICD-9 and ICD-10 procedural codes. The study included 2 cohorts: patients aged 13 to 17 years (adolescents) and patients 18 years and older (adults) who underwent pelvic osteotomies. To control for confounding variables, propensity score matching was employed based on sex and relevant comorbidities, including diabetes mellitus, tobacco use, and overweight/obesity. Statistical significance was set at P<0.01.

RESULTS

A total of 2374 patients successfully matched in each cohort. Within 90 days following surgical intervention, adult patients had overall risks of 4.5%, 1.9%, and 5.9%, whereas adolescent patients had overall risks of 1.3%, 0.5%, and 1.4% for DVT (RR: 3.419), PE (RR: 4.182), and either DVT or PE (RR: 4.118), respectively.

CONCLUSIONS

This study examines the rate of VTE in a large cohort of adolescents undergoing pelvic osteotomies. Although we found the rates to be lower in adolescents compared with adults, the high absolute risk in adolescents-above 1%, the threshold established in the literature for considering prophylaxis-underscores the need for tailored risk stratification strategies and targeted thromboprophylaxis protocols for this population.

LEVELS OF EVIDENCE

Level III: case-control study or retrospective cohort study.

Shelf acetabuloplasty may inhibit range of motion: A computer simulation analysis

Shelf acetabuloplasty has been performed in patients with developmental dysplasia of the hip (DDH); however, the appropriate position of the shelf has not been determined, particularly with respect to avoiding range of motion (ROM) loss. The aim of this study was to investigate the frequency of ROM inhibition and the influence of 3D position of the shelf following actual shelf acetabuloplasty and virtual surgery using computer simulation analysis. Computed tomography data from 15 patients with DDH who underwent shelf acetabuloplasty were collected between August 2019 and February 2022. The three-dimensional models of a hip joint were constructed using Zed Hip®. Maximal internal rotation (MIR) at 45° and 90° flexion was measured in each patient. The frequency and position of ROM inhibition was determined in a real postoperative model virtually. In addition, a second analysis using virtual acetabuloplasty was performed. Upon placing the shelf, three patterns were provided for the following four parameters: height, coronal inclination, center-edge angle (CEA), and anteroposterior position. The predictors for ROM inhibition were analyzed using a logistic regression model. In the actual postoperative model, a limitation of MIR at 90° and 45° of flexion occurred in 60% and 66.7% of patients, respectively. A higher CEA and anterior position are major factors limiting MIR. The analysis of the virtual shelf acetabuloplasty model revealed that anterior position and CEA were significant factors causing ROM inhibition. As for clinical significance, the results of the current study indicated the optimal location of the shelf to avoid iatrogenic impingement after shelf acetabuloplasty.

Twelve to Twenty-year Follow-up of Dega Acetabuloplasty in Patients With Developmental Dysplasia of the Hip: Is it as Effective as Expected?

BACKGROUND

Although Dega acetabuloplasty is widely used for the treatment of developmental dysplasia of the hip, there is a paucity of data on long-term outcomes. The purpose of the study was to evaluate the rate of residual acetabular dysplasia after Dega acetabuloplasty.

METHODS

Patients of a previously reported consecutive series of 35 patients (43 hips) operated by a single surgeon were recontacted for long-term follow-up. Of these, 25 patients (32 hips) consented, with a follow-up rate of 71% (74% of hips). The mean age at the time of surgery was 35 (18 to 65) months. The presence of residual dysplasia was noted according to the lateral center-edge angle of Wiberg, femoral head extrusion index, and Tönnis angle. The latest radiographic outcome was evaluated according to the Severin classification and patients were clinically evaluated according to the modified McKay criteria.

RESULTS

The mean follow-up duration of 16.5 (12 to 20) years yielded an average age of 19.2 (14 to 23) years at the time of analysis. According to lateral center-edge angle, femoral head extrusion index, and Tönnis angle, 5 (15.6%) hips were dysplastic and 2 (6.3%) hips were reoperated for resubluxation. Thus, a total of 7 hips (21.9%) were considered to have residual dysplasia. With the exception of 2 hips that underwent further osteotomies, no other hips were re-subluxated or redislocated. Overcoverage was noted in 6 (18.7%) hips. There were 26 Severin group I and II (81.3%), 4 Severin group III (12.5%), and 2 Severin group IV (6.2%) hips. According to modified McKay criteria, 20 (62.5%) hips were excellent, 7 (21.9%) hips were good, and 5 (15.6%) were fair. Severin classification and modified McKay criteria were correlated with dysplasia ( P < 0.05).

CONCLUSIONS

Seventy-eight percent of the hips treated by Dega acetabuloplasty for developmental dysplasia of the hip did not have acetabular dysplasia at a mean follow-up of 16 years. Even in well-treated asymptomatic hips, patients should be followed regularly, especially for residual dysplasia.

LEVEL OF EVIDENCE

Level IV.

Effects of different pelvic osteotomy surgeries on acetabular center and pelvic morphology

OBJECTIVE

To compare the effects of Salter pelvic osteotomy, Pemberton pelvic osteotomy, and triple pelvic osteotomy on the center of acetabulum and pelvic morphology in children with hip joint disease.

METHODS

The data of children treated with Salter pelvic osteotomy (2 males and 14 females with an average age of 2.49 years), Pemberton pelvic osteotomy (4 males and 11 females with an average age of 6.11 years), and triple pelvic osteotomy(4 males and 8 females with an average age of 9.59 years) between January 2011 and December 2020 were collected. After discharge, the outpatient review was followed up for at least 1 year. All patients underwent anterior-posterior pelvic X-ray scanning before surgery, three months after surgery in the first year and every six months after the first year. The following X-ray features were analyzed: bilateral pelvic height (PH), iliac crest inclination (ICI), a horizontal distance of the acetabulum center (HD), and vertical distance of the acetabulum center (VD).

RESULTS

The mean follow-up time was 16.9 ± 4.9 months in the Salter group, 20.7 ± 5.1 months in the Pemberton group, and 18.0 ± 5.4 months in the triple group (all P > 0.05). No significant differences between PH, HD, and VD of both sides on the preoperative AP pelvic x-ray were found. However, at the last follow-up, PH, HD,VD, and ICI increased in the Salter group (all P < 0.05), PH and VD increased in the Pemberton group (all P < 0.05), and VD decreased in the Triple group (P < 0.05).

CONCLUSION

Salter pelvic osteotomy may cause pelvic height to increase and the center of acetabulum to move outward and downward. In contrast, Pemberton pelvic osteotomy may cause pelvic height to increase and the center of acetabulum to move downward. Triple pelvic osteotomy only causes the center of acetabulum to move downward.

Effects of different pelvic osteotomies on acetabular morphology in developmental dysplasia of hip in children

Developmental dysplasia of hip seriously affects the health of children, and pelvic osteotomy is an important part of surgical treatment. Improving the shape of the acetabulum, preventing or delaying the progression of osteoarthritis is the ultimate goal of pelvic osteotomies. Re-directional osteotomies, reshaping osteotomies and salvage osteotomies are the three most common types of pelvic osteotomy. The influence of different pelvic osteotomy on acetabular morphology is different, and the acetabular morphology after osteotomy is closely related to the prognosis of the patients. But there lacks comparison of acetabular morphology between different pelvic osteotomies, on the basis of retrospective analysis and measurable imaging indicators, this study predicted the acetabular shape after developmental dysplasia of the hip pelvic osteotomy in order to help clinicians make reasonable and correct decisions and improve the planning and performance of pelvic osteotomy.

Fifty percent of patients undergoing periacetabular osteotomy for hip dysplasia showed normal findings upon neonatal ultrasound screening : Symptomatic hip dysplasia in adulthood despite inconspicuous neonatal hip ultrasound

Developmental dysplasia of the hip (DDH) is characterized by the pathomorphology of inadequate acetabular coverage of the femoral head leading to increased loading of the articular surface and acetabular rim. If left untreated, this ultimately leads to osteoarthritis. Germany introduced a nationwide universal ultrasound screening program for all newborn infants in 1996. Subsequently, the incidence of undiagnosed hip dislocation was significantly reduced. In this consecutive series of patients who underwent periacetabular osteotomy for the treatment of symptomatic dysplasia of the hip between October 2014 and October 2022 data regarding the U3 screening examination were analyzed. The data included whether the examination was performed, whether the findings were positive or negative, whether the patients underwent any form of treatment in the case of a positive finding and whether a control X‑ray was performed. This study provides evidence that acetabular undercoverage cannot be ruled out based on a normal finding in ultrasonography screening. Furthermore, the study also shows that residual dysplasia may persist despite attempts of conservative treatment.

3-D acetabular morphology of the neuromuscular hip: implications for preoperative planning

The importance of precisely understanding the pathoanatomy of acetabular dysplasia prior to surgical treatment has long been recognized. Acetabuloplasties for neuromuscular hip dysplasia have typically aimed to improve the acetabulum by increasing posterior-superior coverage, as previous three-dimensional (3-D) computed tomography (CT) studies have shown that acetabular dysplasia in neuromuscular hips is primarily in the direction of posterior-superior subluxation or dislocation. The purpose of this study was to identify differences in 3-D morphology between normal hips and dysplastic neuromuscular hips, specifically to identify areas of acetabular deficiency to guide preoperative decision-making. Patients treated for neuromuscular hip dysplasia at a single institution between 2009 and 2017 with a preoperative high-resolution pelvic CT scan (28 hips) were evaluated with custom software to measure acetabular morphology. Acetabuli were divided into equal octants; coverage angles were measured for each octant of interest. Variables were compared with age- and sex-matched normal controls (56 hips). We found a wide range of hip pathology in our study cohort. Five hips had no sectors with abnormal coverage. One hip (4%) was overcovered anteriorly. The remaining pathology was undercoverage located anteriorly [n = 7 (25%)], superiorly [n = 6 (21%)], posteriorly [n = 4 (14%)] or globally [n = 5 (18%)]. Our findings indicate that individual patients with neuromuscular acetabular dysplasia have unique deformities that do not uniformly conform to a specific area of acetabular deficiency. It is imperative to define the specific 3-D acetabular deficiency location and magnitude for accurate preoperative planning. Level of evidence: Level III.

MRI-based assessment of acetabular version and coverage after previous Pemberton osteotomy in skeletally mature patients

PURPOSE

In hip dysplasia the Pemberton osteotomy can modify the shape of the acetabulum and is indicated for children aged between two and 12 when the triradiate cartilage is still open. However, there have been concerns about acetabular retroversion following this type of osteotomy. The studies, however, have been based on plain radiographs. The aim of our investigation was to assess the 3D acetabular orientation in patients with previous Pemberton osteotomy after skeletal maturation.

METHODS

Ten patients with 12 operated hips were included who received Pemberton osteotomy for hip dysplasia between January 3, 2005 and March 25, 2011. Mean age at surgery and at follow-up were 7.2 years (sd 3.7) and 19.2 years (sd 3.7), respectively. MRIs were conducted with 1.5 T. Besides the measurement of acetabular version, the analysis included alpha angles, acetabular sector angles (ASAs) as well as modified ASAs (cartilage covered area angles). Furthermore, the presence of osteoarthritis (OA) as well as acetabular retroversion was determined on plain radiographs. Patient-related outcome measures included the international Hip Outcome Tool (iHOT) and EuroQol-5-Dimensions (EQ5D) scores.

RESULTS

In comparison with the contralateral native and healthy hips the operated hips showed similar version (19.5° (sd 4.6°) versus 18.6° (sd 7.0°); p = 0.974). Also, there were no differences in terms of femoral head sphericity (alpha angles) and acetabular coverage (ASA angles). Five of 12 Pemberton hips showed signs of beginning OA (Kellgren-Lawrence classification I or II) while none of the non-operated hips did. Patients who received surgery before the age of six years had similar functional and radiological results when compared with patients who were older than six years at surgery. Among all patients, iHOT was 91.9 (sd 10.0) and EQ5D was 90.3 (sd 7.3)).

CONCLUSION

The Pemberton osteotomy provides good long-term radiographic and functional results without compromising acetabular version or coverage.

LEVEL OF EVIDENCE

Level III: retrospective comparative study.