3D Pre-Operative Planning and Patient-Specific Guides for Re-Directional Peri-Acetabular Osteotomy in Children and Adolescents

Surgical procedures to correct hip dysplasia associated with subluxation or dislocation of the femoral head are complex. The 3D geometric abnormalities of the acetabulum and proximal femur vary across patients. We, therefore, suggest a patient-specific surgical treatment involving computer-assisted 3D planning of the peri-acetabular osteotomies, taking into account the femoral head position; 3D printing of patient-specific guides for the cuts, repositioning, and fixation; and intra-operative application of the simulated displacements with their fixation. Level of evidence: IV.

Open reduction after failed closed reduction following failed Pavlik harness treatment in developmental dysplasia of the hip: One- or two-stage?

INTRODUCTION

The current published evidence for the treatment of developmental dysplasia of the hip (DDH) with failed closed reduction (CR) following failed Pavlik harness (PH) treatment is still limited. This study aimed to determine whether an one-stage open reduction (OR) would lead to a similar outcome to a two-stage OR in these patients. Meanwhile, the occurrence of femoral head avascular necrosis (AVN) and further surgery (pelvic osteotomy, PO) within the follow-up period was investigated.

MATERIALS AND METHODS

A consecutive series of DDH patients who failed CR following failed PH treatment and received OR finally between January 2008 and December 2020 were studied. The patients were divided into two groups. One group of which received OR immediately after failed CR (one-stage OR group, Group A), and the other received a delayed OR (two-stage OR group, Group B). The McKay's criteria, acetabular index (AI) and the degree of dislocation of the hips were evaluated for the final outcomes.

RESULTS

At the last follow-up, 54 (84.4%) of the 64 hips in Group A and 26 (83.9%) of 31 hips in Group B were in excellent or good condition. Comparison between the two groups revealed that there were no differences in terms of McKay grading (P = 0.950), AI (P = 0.783), incidence of AVN (P = 0.745), and also incidence of PO (P = 1.000). However, a significant lower mean AI was found in Group A, when the OR was performed in Group B (31.06 ± 4.45° vs. 33.87 ± 4.12°, P = 0.004).

CONCLUSION

Both of the one- and two-stage OR may acheive favorable outcomes. Moreover, one-stage OR is of without the general anesthesia risk associated with two-stage OR. We therefore advocate that an OR should be performed in appropriate DDH patients during the same session once a failed CR is detected.

Functional outcome and athletic level after arthroscopic repair followed by triple pelvic osteotomy in patients with labral tears resulting from acetabular dysplasia

BACKGROUND

Patients with acetabular dysplasia are at a higher risk of developing symptomatic labral tears. Isolated treatments that address these pathologies are well established. Combined treatment with hip reorientation osteotomy using Bernese periacetabular osteotomy in addition to arthroscopic labral repair show good results. Studies that report the outcome in patients who received both arthroscopic labral repair and a triple pelvic osteotomy (TPO) are lacking. The aim of this study is to investigate the short to midterm functional outcome and activity level in these patients.

METHODS

This case series retrospectively included 8 patients (2 male, 6 female) with acetabular dysplasia (lateral center-edge angle [LCEA] ≤ 25°) and a labral tear on magnetic resonance arthrography (MRA). All patients underwent arthroscopic labral repair followed by TPO after an average period of 3 months (range 2-6). Average age at the time of surgery was 25 years (range 15-37). Patients were followed up and the following main parameters were assessed: LCEA, modified Harris hip score (mHSS), Tegner score, UCLA score, patient satisfaction on a scale of 1-4.

RESULTS

The mean follow-up was 19 months (range 15-25). The mean LCEA increased from 18° to 37° (p < 0.0001). The mHSS improved from a mean of 79 to 94 on final follow-up (p = 0.00123). The Tegner and UCLA scores had a median of 4 and 5, respectively. The mean LCEA increased from 18° to 37° (p < 0.0001). The mean patient satisfaction was 3.6.

CONCLUSION

Patients with evidence of a labral tear resulting from acetabular dysplasia benefit from arthroscopic repair followed by a TPO. The literature still lacks evidence that labral repair and reorientation osteotomy produce superior outcome compared to osteotomy alone. Treatment should consider clinical presentation in addition to radiological findings with emphasis on MRA.

A long-term outcome (up to 29 years) of bilateral iliac wings "bayonet osteotomies" for closure of bladder exstrophy

BACKGROUND

Several types of pelvic osteotomy techniques have been reported and employed by orthopedic surgeons to enhance the approximation of symphyseal diastasis in bladder exstrophy patients. However, there is limited evidence on a long-term follow-up to confirm which osteotomy techniques provide the most suitable and effective outcomes for correcting pelvic deformities. This study aimed to describe the surgical technique of bilateral iliac bayonet osteotomies for correcting pelvic bone without using fixation in bladder exstrophy and to report on the long-term clinical and radiographic outcomes following the bayonet osteotomies.

METHODS

We retrospectively reviewed patients with bladder exstrophy who underwent bilateral iliac bayonet osteotomies with the closure of bladder exstrophy between 1993 and 2022. Clinical outcomes and radiographic pubic symphyseal diastasis measurements were evaluated. From a total of 28 operated cases, eleven were able to attend a special follow-up clinic or were interviewed by telephone by one of the authors with completed charts and recorded data.

RESULTS

A total of 11 patients (9 female and 2 male) with an average age at operation of 9.14 ± 11.57 months. The average followed-up time was 14.67 ± 9.24 years (0.75-29), with the average modified Harris Hip score being 90.45 ± 1.21. All patients demonstrated decreased pubic symphyseal diastasis distance (2.05 ± 1.13 cm) compared to preoperative (4.58 ± 1.37 cm) without any evidence of nonunion. At the latest follow-up, the average foot progression angle was externally rotated 6.25° ± 4.79° with full hips ROM, and no patients reported abnormal gait, hip pain, limping, or leg length discrepancy.

CONCLUSIONS

Bilateral iliac wings bayonet osteotomies technique demonstrated a safe and successful pubic symphyseal diastasis closure with an improvement both clinically and radiographically. Moreover, it showed good long-term results and excellent patient's reported outcome scores. Therefore, it would be another effective option for pelvic osteotomy in treating bladder exstrophy patients.

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.

Avascular necrosis of the femoral head in patients with cerebral palsy after hip surgery-incidence and impact on quality of life

PURPOSE

This study investigated the incidence of AVN in patients with cerebral palsy who underwent a hip reconstruction surgery (soft tissue release, femur and pelvic osteotomies) and its impact on quality of life.

METHODS

Retrospective study, with clinical and radiographic analysis of 104 patients (128 hips) GMFCS IV and V with a minimum two year follow-up. Reimers migration percentage, the amount of abduction, acetabular index, and the neck-shaft angle were collected before and after surgery. Modified Tönnis classification was used to analyze the hips before surgery, and the Bucholz and Ogden classification was used to identify hips with AVN. Function and quality of life were investigated with the CPCHILD questionnaire after surgery.

RESULTS

The mean age of participants at surgery was 120.1 months (72-184), and it was not related with AVN (p = 0.946). AVN signs were observed in 62 hips (48.5%). The mean pre-op Reimers value was 68.7% (16-100) in normal hips and 83.1% (0-100) in hips with AVN (p = 0.003). All hips considered as Tönnis IV before surgery developed AVN (p = 0.006). The amount of abduction did not differ between hips that developed AVN and those that did not (p = 0.313). Patients who developed AVN had lower scores of quality of life (p = 0.023) and comfort (p = 0.025) according to the CPCHILD questionnaire.

CONCLUSION

We observed a relationship between the greater pre-operative severity according to the Reimers index and the modified Tonnis classification and the development of AVN.

Modified Pemberton Pelvic Osteotomy Through Inner Ilium Approach for Treatment of Developmental Dysplasia of the Hip in Children

INTRODUCTION

Pemberton osteotomy is a widely used operation in developmental dysplasia of the hip (DDH). The traditional pelvic osteotomy was through outside of the ilium. However, in this study, we performed the pelvic osteotomy through the inner ilium approach.

PATIENTS AND METHODS

We retrospectively analyzed 79 patients diagnosed with DDH with open surgery in our hospital from March 2016 to May 2018. There were 39 patients who underwent outside ilium Pemberton osteotomy (PO) and 40 patients who underwent inner "L shaped" ilium Pemberton osteotomy (ILSO). Acetabular index (AI), center-edge angle of Wiberg (CE angle), Severin grading scoring system, postoperative avascular necrosis (AVN) by Kalamchi and McEwen classification, and McKay grading scoring system were used for evaluation.

RESULTS

There was no significant difference between the PO group and ILSO group on AI (p = 0.476), CE angles (p = 0.225), avascular necrosis (Kalamchi and McEwen, p = 0.854), and hip function (McKay's, p = 0.444) on the final follow-up. There were significant differences in X-ray radiation (p < 0.001), blood loss (p = 0.011) and surgery time (p < 0.001).

CONCLUSION

Inner side ilium is a viable approach for Pemberton osteotomy of DDH in children with less X-ray radiation, and less blood loss and shorter surgery time.

LEVEL OF EVIDENCE

III.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00676-7.

Impact of Failed Pavlik Harness Treatment on the Outcomes Following Closed or Open Reduction in Developmental Dysplasia of the Hip

PURPOSE

To investigate the impact of failed Pavlik harness (PH) treatment on the outcomes following closed reduction (CR) or open reduction (OR) in developmental dysplasia of the hip (DDH).

METHODS

Ninety-three DDH patients treated with CR or OR were enrolled. One group of which received previous PH treatment (F group) and the other (L group) not. The clinical outcomes were evaluated according to McKay's criteria. Radiographs were evaluated for acetabular index (AI) and the degree of dislocation of the hips.

RESULTS

A higher rate of CR was found in F group (P = 0.034). Before CR/OR, the mean AI in F group was significantly lower than that in L group (P = 0.000), while at the last follow-up, the AIs in both groups were all improved. In F group, there were 7 (16.67%), 18 (42.86%) and 17 (40.48%) hips were classified as Graf type II, III and IV pathologic changes, respectively, when PH treatment started, while the corresponding data were 17 (40.48%), 17 (40.48%) and 8 (19.05%) after PH treatment (P = 0.024). At the last follow-up, no significant difference was found concerning the complications between the two groups (P > 0.05).

CONCLUSIONS

PH treatment, even if failed, may have the ability of accelerating the development of the acetabulum and increasing the rate of successful CR. Thus we advocate a trial of PH treatment for all DDH patients less than 6 months of age. Meanwhile, a close monitoring by dynamic ultrasonography is required due to the risk of AVN.

[Minimally invasive periacetabular osteotomy for adult hip dysplasia]

OBJECTIVE

Performance of a periacetabular osteotomy (PAO) using a minimally invasive approach for three-dimensional correction of the acetabular position.

INDICATIONS

Symptomatic developmental dysplasia of the hip in adolescents and adults.

CONTRAINDICATIONS

Advanced osteoarthritis of the hip, incongruence of the hip joint surfaces.

SURGICAL TECHNIQUE

A periacetabular osteotomy is performed via a minimally invasive approach.

RESULTS

In total, 39 patients were followed up for 3.5 (3-4.5) years. The lateral center-edge angle of Wiberg increased significantly from 16.1° (7-24°) to 30.5° (25-37°) (p < 0.0001), the acetabular index changed from 13.2° (2-25.3°) to 2.8° (-3-13°; p < 0.0001). Mean duration of surgery was 88 (57-142) minutes. No major complications occurred.

The "true" acetabular anteversion angle (AV angle): 2D CT versus 3D model

INTRODUCTION

Different factors can lead to inconsistencies in measurement for the acetabular version using 2D axial CT-cuts. We have defined a "true" anteversion angle (AV angle) in the physiological position of the pelvis in 3D with the largest European population measured to our knowledge.

MATERIAL AND METHODS

We analyzed 258 hemipelvises and created 3D models. We compared the results of our AV angle 3D method with the cross-sectional cuts of the same acetabula. We included factors like side, sex, body mass index, and patient positioning.

RESULTS

Overall, the mean (SD) AV angle was 16.1 (5.9)° as measured with the 3D method and 22.0 (6.0)° as measured with the 2D method (p < 0.0001). Measured with both the 3D and the 2D method, the AV angle was significantly larger in female than in male individuals (p < 0.0001). In the 2D method, the AV angle estimation was influenced by the pelvic tilt.

CONCLUSION

We propose a more accurate method for the measurement of the AV angle of the acetabulum in a 3D model that is not influenced by patient positioning or pelvic tilt. We provide a computational model that will facilitate operative decisions and improve preoperative planning. We confirm that 3D measurement should be the gold standard in measuring the acetabular anteversion.

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.

Role of Chiari osteotomy in treating degenerative hip arthritis: A review

Chiari pelvic osteotomy (CPO) or medial displacement pelvic osteotomy is a surgical procedure of making a congruent shelf above intact hip joint by using the cancellous bone of ilium along with capsular interpositioning to contain the femoral head and bear weight. CPO is usually considered a salvage procedure indicated in patients with dysplastic acetabular sockets as a part of developmental hip dysplasia. It has been widely performed for several decades but since 1990s number of CPO procedures has decreased because of use of other pelvic osteotomies, total hip arthroplasty (THA), ultrasound screening and narrowing indications for this procedure. However, CPO is not a historical procedure and it has viable indications in modern orthopaedic surgery, especially in patients who prefer joint-conservating procedure or in situations when THA is not feasible. Moreover, keeping the native hip as long as possible should be preferred modern orthopaedic approach. The Chiari osteotomy can produce excellent results in patients who have right indications and when other procedures are not suitable. On the other hand, there are several disadvantages of this procedure such as narrowing of the pelvis, shortening of the limb and risk of sciatic nerve palsy. With in-depth analysis of literature, we discuss indications for CPO, surgical technique of CPO, THA conversion rate after CPO, the interval from the CPO to THA and CPO survival rate.

Osteotomy in the newborn classic bladder exstrophy patient: A comparative study

INTRODUCTION

Pelvic osteotomy is indicated in classic bladder exstrophy (CBE) patients with a wide pubic diastasis or non-malleable pelvis. While the safety of pelvic osteotomy in delayed and failed closures is established, there remains less clarity on their safety in newborns. The authors herein sought to present their experience with CBE patients who underwent pelvic osteotomy for assistance with bladder closure during both the newborn and delayed time periods.

OBJECTIVE

The authors hypothesize that pelvic osteotomy during exstrophy closure may be performed safely in newborns with few perioperative or post-operative negative sequelae.

STUDY DESIGN

A prospectively maintained IRB-approved database was reviewed for CBE patients who underwent osteotomy during primary closure. Patient demographics, performing institution (authors' or outside), closure outcome, diastasis width, and post-operative complications were noted. Patient subgroups included newborn and delayed (>28 days of life) closures. Failure was defined as bladder dehiscence, prolapse, outlet obstruction, or vesicocutaneous fistula requiring reoperation. Orthopedic complications included nerve palsies, superficial pin-site infection, and bladder neck erosion by orthopedic hardware. Analyses were performed using a Chi-square test.

RESULTS

286 patients were included: 186 newborn and 100 delayed closures. The authors' institution performed 109 cases (44 newborn and 65 delayed). Within the overall newborn closure cohort, no significant differences were found in outcomes among the osteotomy types with success rates of 80%, 60.8%, and 71.4% in the combined, posterior iliac, and anterior innominate groups, respectively (p = 0.24). In the delayed group, success rates were significantly different with rates of 100%, 72.4%, and 93.8% in the combined, posterior iliac, and anterior innominate groups, respectively (p < 0.001). Febrile urinary tract infection (UTI) was the most common complication at 8% (23/286). Only 1.7% (5/286) of patients had orthopedic complications with 3 patients in the newborn cohort, 2 patients in the delayed cohort, and only one patient requiring reoperation.

DISCUSSION

Orthopedic complications are rare in CBE patients who undergo osteotomies regardless of the closure period. No clinically significant difference in orthopedic complication rate was found between newborn and delayed closure periods.

CONCLUSIONS

While current trends have moved toward delayed primary closures, there remains a role for osteotomy during exstrophy closure in select newborn patients and can be performed safely with few complications.

Total hip arthroplasty after pelvic osteotomy for acetabular dysplasia: A systematic review

The purposes were (1) to investigate and compare the findings of patients undergoing total hip arthroplasty (THA) following a corrective pelvic osteotomy (PO), to a control group of patients who underwent THA but not PO and (2) to evaluate the outcomes and complications for secondary THA after PO. Three studies recorded reduced cup anteversion in the osteotomy group. Two studies reported higher PROs for the control group. The most common complication after failed PAO was dislocations. PO may entail challenges on a subsequent THA, illustrated by higher intraoperative blood loss, lower consistency in cup positioning and compromised patients reported outcomes.

Comparison of the inner side and two-sided approaches for iliac crest bone graft harvesting for pediatric pelvic osteotomy

Background

The iliac crest is one of the most used bone graft sources. In this study, we aimed to identify the effects of inner side and two-sided approaches for iliac crest bone harvesting on post-surgery ilium growth in children.

Materials and methods

We retrospectively analyzed 47 patients who underwent pelvic osteotomy and iliac crest bone graft (ICBG) procedures from January 2015 to September 2018. The patients were divided into an inner table ilium exposure group (group A) and the inner-outer table ilium exposure group (group B) and were followed up with radiography in postoperative months 1, 3, 6, and 12, and the growth areas were measured using PACS software. Complications such as damage to the arteries or nerves, ureteral injury, gastrointestinal hernia, ileus, abnormal cosmetic appearance, sensory disturbances, and functional limitations were recorded based on clinical records.

Results

There were 22 patients aged 5.3±1.5 years in group A and 25 patients aged 5.9±1.8 years in group B. There were no significant differences in demographics between the two groups, or in growth in the first month. However, bone graft growth at months 3, 6, and 12 was significantly better in group A than in group B. There was no significant difference in complications between the two groups.

Conclusion

Exposure of only the inner table of the ilium resulted in faster recovery of the bone defect than two-sided exposure in pelvic osteotomy. Therefore, we suggest protecting the outer side of the ilium during surgery.

Level of evidence

Level III

3D - Printed Patient Specific Instrumentation in Corrective Osteotomy of the Femur and Pelvis: A Review of the Literature

Background

The paediatric patient population has considerable variation in anatomy. The use of Computed Tomography (CT)-based digital models to design three-dimensionally printed patient specific instrumentation (PSI) has recently been applied for correction of deformity in orthopedic surgery. This review sought to determine the existing application of this technology currently in use within paediatric orthopaedics, and assess the potential benefits that this may provide to patients and surgeons.

Methods

A review was performed of MEDLINE, EMBASE, and CENTRAL for published literature, as well as Web of Science and clinicaltrials.gov for grey literature. The search strategy revolved around the research question: “What is the clinical impact of using 3D printed PSI for proximal femoral or pelvic osteotomy in paediatric orthopaedics?” Two reviewers, using predetermined inclusion criteria, independently performed title and abstract review in order to select articles for full text review. Data extracted included effect on operating time and intraoperative image use, as well as osteotomy and screw positioning accuracy. Data were combined in a narrative synthesis; meta-analysis was not performed given the diversity of study designs and interventions.

Results

In total, ten studies were included: six case control studies, three case series and a case report. Five studies directly compared operating time using PSI to conventional techniques, with two showing a significant decrease in the number of intraoperative images and operative time. Eight studies reported improved accuracy in executing the surgical plan compared to conventional methods.

Conclusion

Compared to conventional methods of performing femoral or pelvic osteotomy, use of PSI has led to improved accuracy and precision, decreased procedure times, and decreased intra-operative imaging requirements. Additionally, the technology has become more cost effective and accessible since its initial inception and use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41205-020-00087-0.

Risk factors associated with unsatisfactory hip function in children with late-diagnosed developmental dislocation of the hip treated by open reduction

BACKGROUND

Open reduction with or without pelvic and femoral osteotomy is the accepted treatment option for children older than 18 months with developmental dislocation of the hip (DDH). However, few studies have investigated hip function in children with late DDH treated by open reduction. Therefore, we performed a retrospective study investigating the risk factors potentially associated with unsatisfactory hip function.

HYPOTHESIS

We hypothesized that some risk factors can be associated with unsatisfactory hip function in patients with late DDH treated by open reduction.

PATIENTS AND METHODS

We retrospectively reviewed the clinical and radiographic data of 79 children (98 hips, mean age 39.7±18.6 months; range, 19-95.3) with late-detected DDH treated by open reduction. Acetabular index (AI), Tönnis grade, Center Edge Angle (CEA), avascular necrosis of the femoral epiphysis (AVN), and Severin radiographic grade were evaluated on radiographs. Hip function was rated according to modified Outcome Evaluation Standard for Congenital Dislocation of the Hip with a maximum score of 15. According to type of surgery, patients were divided into four groups: open reduction alone (Group A), open reduction in conjunction with pelvic osteotomy (Group B), and open reduction in conjunction with femoral osteotomy and Pemberton/Salter (Group C) or Bernese-type triple pelvic osteotomy (Group D). Analysis of variance (ANOVA), t-test, chi-square test, and multivariate regression analysis were used to evaluate the independent risk factors of unsatisfactory hip function.

RESULTS

The mean hip function score was 10.8±2.8 (4.5-15); 61 hips (62.2%) had satisfactory function (23 [23.5%] excellent and 38 [38.8%] good), while 37 hips (37.8%) had unsatisfactory function (16 [16.3%] fair and 21 [21.4%] poor). Spearman correlation analysis indicated that age at surgery was negatively correlated with function score (r=-0.326, p=0.001). The age of patients with satisfactory hip function (34.5±14.2 months; range, 19.4-74.8) was significantly lower than those with unsatisfactory function (43.7±21 months; range, 20.6-95.3) (p=0.011). The hip function score in Group A (14.2±0.8; range, 12.8-15) was significantly higher than in the other three groups (p<0.001). Hip function score in patients with type III or IV AVN was significantly lower than those without AVN, or with type II AVN (p=0.001). Multivariate regression analysis confirmed age at surgery, type of surgery and AVN were negatively correlated with hip function score. Logistic regression analysis and chi-square test confirmed age and type of surgery, and AVN were independent risk factors of unsatisfactory hip function. Multivariate regression analysis found ability to squat and amount of hip flexion and abduction, significantly decreased with age at surgery; while presence of limping, amount of hip flexion, abduction, adduction and external rotation significantly decreased with type of surgery.

DISCUSSION

Age at surgery, type of surgery and severe AVN are independent risk factors for unsatisfactory hip function in patients with late-detected DDH treated by open reduction. The ability to squat, the amount of hip flexion and abduction are the main functional parameters affected by age and surgery.

LEVEL OF EVIDENCE

IV, case series.

Iliac Pedicle Wedge Graft as a New Modification for Iliac Osteotomies in Young Adolescents: A Single-blind Randomized Clinical Trial

BACKGROUND

Iliac osteotomies in adolescent patients may accompany graft related difficulties such as graft absorption and delayed union. A new modification of iliac osteotomies has been proposed to address these difficulties.

METHODS

A total of 24 consecutive hip joints in 21 juvenile or adolescent patients who were candidate for salter or triple pelvic osteotomy were included. A modification was performed to harvest a wedged bone graft based on a muscle pedicle of Tensor Fascia Lata and inserted at pelvic osteotomy site instead of a traditional graft technique. The hips were randomized into two groups. The traditional wedge graft was used in group 1, while the new modification was performed in group 2. The primary outcome of this study was duration of union. The secondary outcomes were Center Edge Angle (CE) Angle on pre-operation, immediately post-operation and at the end of follow-up.

RESULTS

Both groups were similar statistically regarding their age, gender , estimated blood loss and the duration of follow-up. However, significant differences were found in the time to complete union between the two groups (P=0.03). CE angle decreased in both groups when comparing its last follow-up to its right postoperative values, but the decrease was significant only in group 1(P=0.03). The type of surgery (Salter or TPO) had no significant effect on the average time to union. That shows faster union in pedicle graft group and less coverage loss during follow-up period than conventional graft patients.

CONCLUSION

With the modification proposed , the healing at the osteotomy site was faster and the loss of correction, owing to the graft resorption, decreased. Using this pedicle wedge graft technique may improve the results of pelvic osteotomies in adolescent.

Rotational acetabular osteotomy for symptomatic hip dysplasia in patients younger than 21 years of age: seven- to 30-year survival outcomes

AIMS

The aim of this study was to report the long-term results of rotational acetabular osteotomy (RAO) for symptomatic hip dysplasia in patients aged younger than 21 years at the time of surgery.

PATIENTS AND METHODS

We evaluated 31 patients (37 hips) aged younger than 21 years at the time of surgery retrospectively. There were 29 female and two male patients. Their mean age at the time of surgery was 17.4 years (12 to 21). The mean follow-up was 17.9 years (7 to 30). The RAO was combined with a varus or valgus femoral osteotomy or a greater trochanteric displacement in eight hips, as instability or congruence of the hip could not be corrected adequately using RAO alone.

RESULTS

The mean Merle d'Aubigné clinical score improved significantly from 15.4 to 17.2 (p < 0.0001). The mean centre-edge (CE) angle improved from -2.6° to 26°, the mean acetabular roof angle improved from 3.0° to 5.2°, and the mean head lateralization index improved from 0.68 to 0.62. Progression of radiological osteoarthritis (OA) was seen in seven hips, but no patient underwent total hip arthroplasty.

CONCLUSION

RAO is an effective form of correction for a severely dysplastic hip in adolescent and young adult patients. Cite this article: Bone Joint J 2019;101-B:390-395.

Postoperative redislocation of the hip in a patient with congenital insensitivity to pain with anhidrosis: A case report and review of literature

Pelvic osteotomy is commonly used to adjust acetabula dysplasia for congenital dislocation of the hip, whereas congenital insensitivity to pain with anhidrosis (CIPA) is a rare hereditary disease that often has the characteristics of joint development deformity and easy fracture. This article reports the case involving a CIPA patient who was surgically treated by Chiari pelvic osteotomy and proximal femoral rotation osteotomy for congenital dislocation of the left hip joint and was provided long-term follow-up for redislocation and bilateral femoral head absorption.

Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children

INTRODUCTION

Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction.

METHODS

The authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy-epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction.

RESULTS

Out of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5-29.1). There were 37 closures performed at the authors' institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2%) of all closures, and in 36 (97.3%) of closures at the authors' institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9%) closures, external fixation and skin traction in 43 (45.7%), and spica cast and external fixation in 5 (5.3%) closures. For all closures, there were 33 failures (71.7%) among those immobilized with spica cast alone versus 4 failures (9.3%) for those immobilized with external fixation and skin traction (p<0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0% and 9.3% respectively (p=0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7% versus 23.3%, p=0.059).

CONCLUSION

Failure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8% failure rate) for postoperative management in an older child (1-2 years).

LEVEL OF EVIDENCE

Level III, Retrospective comparative study STUDY TYPE: Therapeutic study.

Total hip arthroplasty after a previous pelvic osteotomy: A systematic review and meta-analysis

BACKGROUND

There are several reports regarding total hip arthroplasty (THA) after a previous pelvic osteotomy (PO). However, to our knowledge, until now there has been no formal systematic review and meta-analysis published to summarize the clinical results of THA after a previous PO. Therefore, we conducted a systematic review and meta-analysis of results of THA after a previous PO. We focus on these questions as follows: does a previous PO affect the results of subsequent THA, such as clinical outcomes, operative time, operative blood loss, and radiological parameters.

METHODS

Using PubMed, Web of Science, and Cochrane Library, we searched for relevant original papers. The pooling of data was performed using RevMan software (version 5.3, Cochrane Collaboration, Oxford, UK). A p-value<0.05 was judged as significant. Standardized mean differences (SMD) were calculated for continuous data with a 95% confidence interval (CI) was reported. Statistical heterogeneity was assessed based on I² using standard χ² test. When I²>50%, significant heterogeneity was assumed and a random-effects model was applied for the meta-analysis. A fixed-effects model was applied in the absence of significant heterogeneity.

RESULTS

Eleven studies were included in this meta-analysis. The pooled results indicated that there was no significant difference in postoperative Merle D'Aubigne-Postel score (I²=0%, SMD=-0.15, 95% CI: -0.36 to 0.06, p=0.17), postoperative Harris hip score (I²=60%, SMD=-0.23, 95% CI: -0.50 to 0.05, p=0.10), operative time (I²=86%, SMD=0.37, 95% CI: -0.09 to 0.82, p=0.11), operative blood loss (I²=82%, SMD=0.23, 95% CI: -0.17 to 0.63, p=0.25), and cup abduction angle (I²=43%, SMD=-0.08, 95% CI: -0.25 to 0.09, p=0.38) between THA with and without a previous PO. However, cup anteversion angle of THA with a previous PO was significantly smaller than that of without a previous PO (I²=77%, SMD=-0.63, 95% CI: -1.13 to -0.13, p=0.01).

CONCLUSION

Systematic review and meta-analysis of results of THA after a previous PO was performed. A previous PO did not affect the results of subsequent THA, except for cup anteversion. Because of the low quality evidence currently available, high-quality randomized controlled trials are required.

LEVEL OF EVIDENCE

Level III, meta-analysis of case-control studies.

Pelvic modelling and the comparison between plate position for double pelvic osteotomy using artificial cancellous bone and finite element analysis

BACKGROUND

Finite element analysis was used to compare fixation methods for double pelvic osteotomy (DPO). Using 3D scanning a stereolithography (stl) image was produced of a canine pelvis and this was subsequently refined in computer aided design (CAD). Using the CAD files, the images were imported in MSC Marc software to produce a working finite element (FE) model with 3 dimensional tetrahedral elements with linear shaped functions. The dimensions of a precontoured pelvic osteotomy plate with eight screws and a twisted seven screw straight plate were used to build the 2 fixations implants for the FE models. An equivalent load of 300 N was applied progressively on all FE models in order to facilitate its convergence. The load was applied in a distributed manner on the femur-hip joint contact area in order to simulate the actual behavior of the joint. The aim of the present study was to analyze the difference in stiffness and behavior under loading between a lateral vs ventral plate fixation, with unlocked screws and different gap scenarios, for stabilization of a pelvic osteotomy using finite element analysis.

RESULTS

From both configurations the maximum displacement of the ventral plate with 7 screws without gap had a value of 1.988 mm, while in the DPO plate had a maximum displacement of 2.191 mm. The load applied for each of the different configurations studied when a gap of 1° was considered and also when a condition of no gap was considered. The ventral plate was stiffer than the lateral plate when a gap was not present. When the gap was closed in the ventral plate, the stiffness increased until a point that remained constant.

CONCLUSIONS

Ventral plate fixation can be as or more stiff as lateral plate fixation and provides flexible fixation. This behavior should reduce screw loosening. Using ventral plate fixation is recommended to reduce screw loosening or failure.

Postoperative Immobilization and Pain Management After Repair of Bladder Exstrophy

Surgical repair of bladder exstrophy is an ongoing challenge for pediatric urologists. Postoperative immobilization is a mainstay of care to decrease tension on the repair site and is often utilized in conjunction with pelvic osteotomies performed in the same operative setting by pediatric orthopedic surgeons. Multiple pelvic immobilization techniques have been developed in conjunction with repair techniques including special techniques for neonates. The most commonly utilized techniques for pelvic immobilization are Buck's and Bryant's traction and spica casting. A multimodal pain management approach is critical with pelvic immobilization to minimize postoperative pain and anxiety associated with reconstructive surgery at a young age.

Rotational Acetabular Osteotomy

Hip dysplasia is the most common cause of secondary osteoarthritis (OA). To prevent the early onset of secondary OA, Nishio's transposition osteotomy, Steel's triple osteotomy, Eppright's dial osteotomy, Wagner's spherical acetabular osteotomy, Tagawa's rotational acetabular osteotomy (RAO), and Ganz' periacetabular osteotomy (PAO) have been proposed. PAO and RAO are now commonly used in surgical treatment of symptomatic acetabular dysplasia in Europe, North America, and Asia. The aim of this paper is to present the followings: the patient selection criteria for RAO; the surgical technique of RAO; the long-term outcome of RAO; and the future perspectives.

[Analysis of outcomes of one-stage operation for treatment of late-diagnosed developmental dysplasia of hip]

Objective: To evaluate and identify the middle-term results of one-stage open reduction of patients in late-diagnosed developmental dysplasia of the hip, and to explore the best age group for treatment. Methods: A total number of 311 patients (390 hips) with LDDH in Department of Pediatric Orthopaedic of Anhui Provincial Children's Hospital from June 2006 to December 2010 were retrospectively reviewed. The patients were divided into 3 groups according to age at the start of surgical treatment: 1.5-2.5 years, 2.5-7.0 years and >7.0 years. There were 11 males and 71 females in group of 1.5-2.5 years with average age of (2.1±0.3) years; There were 29 males and 165 females in group of 2.5-7.0 years with average age of (4.4±0.4) years; There were 8 males and 33 females in group >7.0 years with average age of (9.2±1.4) years. The last clinical and radiographic outcomes, complications and avascular necrosis (AVN) of the femoral head were evaluated and compared among the three groups. ANOVA and Pearson's χ(2) statistic were used to analyze data. Results: Among the three groups, there were no statistically differences in gender, acetabular index, different sides and follow-up time(all P>0.05), there was significant difference in Tönnis grade(χ(2)=21.410, P<0.01). There were 77.4% of patients showed an excellent or good result according to McKay's clinical classification and 82.6%(390 hips) according to Severin's radiological classification. A total of 28.5% of all hips had a poor outcome according to the Kalamchi and MacEwen classification (grade Ⅱ to Ⅳ) for AVN. Radiographic(χ(2)=78.860, P<0.01) and AVN(χ(2)=14.756, P=0.001) results (poorest in group of >7.0 years and best in group of 2.5-7.0 years) between three groups had statistically differences. Furthermore, clinical outcomes in group of >7.0 years was significantly lowest than groups of 1.5-2.5 years or 2.5-7.0 years, there was no significant differences between groups of 1.5-2.5 years and 2.5-7.0 years(χ(2)=1.503, P=0.682). The incidence of redislocation and residual acetabular dysplasia in Tönnis grade Ⅱ or Ⅲ hip dislocation(85.0%, 17 hips) was significantly higher (χ(2)=4.440, P=0.035). Conclusion: One-stage treatment of LDDH had good outcome in 1.5 to 7.0 years patients, the best age are 2.5-7.0 years.

A balanced approach for stable hips in children with cerebral palsy: a combination of moderate VDRO and pelvic osteotomy

BACKGROUND

Hip reconstructive surgery in cerebral palsy (CP) patients necessitates either femoral varus derotational osteotomy (VDRO) or pelvic osteotomy, or both. The purpose of this study is to review the results of a moderate varisation [planned neck shaft angle (NSA) of 130°] in combination with pelvic osteotomy for a consecutive series of patients.

METHODS

Patients with CP who had been treated at our institution for hip dysplasia, subluxation or dislocation with VDRO in combination with pelvic osteotomy between 2005 and 2010 were reviewed.

RESULTS

Forty patients with a mean follow-up of 5.4 years were included. The mean age at the time of operation was 8.9 years. The majority were non-ambulant children [GMFCS I-III: n = 11 (27.5 %); GMFCS IV-V: n = 29 (72.5 %)]. In total, 57 hips were treated with both femoral and pelvic osteotomy. The mean pre-operative NSA angle of 152.3° was reduced to 132.6° post-operatively. Additional adductor tenotomy was performed in nine hips (16 %) at initial operation. Reimers' migration percentage (MP) was improved from 63.6 % pre-operatively to 2.7 % post-operatively and showed a mean of 9.7 % at the final review. The results were good in 96.5 % (n = 55) with centred, stable hips (MP <33 %), fair in one with a subluxated hip (MP 42 %) and poor in one requiring revision pelvic osteotomy for ventral instability.

CONCLUSIONS

This approach maintains good hip abduction and reduces soft-tissue surgery. Moderate varisation in VDRO in combination with pelvic osteotomy leads to good mid-term results with stable, pain-free hips, even in patients with severe spastic quadriplegia.

Newborn exstrophy closure without osteotomy: Is there a role?

INTRODUCTION

Recent articles document successful classic bladder exstrophy (CBE) closure without osteotomy. Still, many patients require osteotomy if they have a large bladder template and pubic diastasis, or non-malleable pelvis.

OBJECTIVE

To understand the indications and outcomes of bladder closure with and without pelvic osteotomy in patients younger than 1 month of age.

METHODS

An institutional database of 1217 exstrophy-epispadias patients was reviewed for CBE patients closed at the authors' institution within the first month of life. Patient demographics, closure history, pubic diastasis distance, bladder capacity, and outcomes were recorded and compared using chi-square tests between osteotomy and non-osteotomy patients. Failure was defined as bladder dehiscence, prolapse, vesicocutaneous fistula, or bladder outlet obstruction requiring reoperation. Bladder capacity >100 mL was deemed sufficient for bladder neck reconstruction (BNR).

RESULTS

One hundred CBE patients were included for analysis: 38 closed with osteotomy (26 male, 12 female), and 62 closed without osteotomy (42 male, 20 female). There were four failed closures in the osteotomy group (2 dehiscence, 2 prolapse) and four failed closures in the non-osteotomy group (2 dehiscence, 2 prolapse). This corresponded to statistically equivalent rates of failure between the osteotomy and non-osteotomy groups (10.5% vs. 6.5%, p = 0.466). There was no statistically significant difference between the groups' ability to achieve bladder capacity sufficient for BNR (82% vs. 71%, p = 0.234).

DISCUSSION

A successful primary bladder closure, regardless of the use of osteotomy, has been shown to be the single most important predictor of eventual continence. Because of the complexity of exstrophy manifestations, a multidisciplinary team approach is of the utmost importance. Based on our institutional experience, closure without osteotomy is considered when patients are <72 h of life, have a pubic diastasis <4 cm, malleable pelvis, and pubic apposition without difficulty. Rates of successful closure and attaining sufficient capacity for BNR were both statistically equivalent across groups. This retrospective study is limited by selection bias and the significant difference in follow-up time between groups. Nevertheless, as a high-volume exstrophy center this study draws from one of the largest cohorts available.

CONCLUSIONS

Regardless of the type of closure undertaken, there clearly is a role for newborn CBE closure without pelvic osteotomy in patients considered suitable for closure by both the pediatric urologist and orthopedic consultant. However, if there is any doubt concerning pubic diastasis width, pelvic malleability, or ease of pubic apposition, an osteotomy is highly recommended.

Retrospective analysis of the radiographic indicators for peri-acetabular osteotomy of developmental dysplasia in children

PURPOSE

Open surgery, nonsurgical positioning device and casting are mainstay treatments of developmental dysplasia of the hip (DDH). The optimal indicators for surgical interventions remain unclear. In this study, we aim to establish empirical, sensitive radiographic indicators for peri-acetabular osteotomy intervention in developmental dysplasia in Chinese children.

METHODS

One hundred and three DDH patients treated in The Soochow University Children's Hospital between 2006 and 2012 were assessed; patients with known causes of neuron muscular and abnormal hip joint origin were excluded. Fifty-four suitable patients, demonstrating 71 dysplasia hips with complete clinical record and adequate X-ray films, were enrolled in this study. Patients were divided into group A (conservative interventions failed, followed by salvage peri-acetabular osteotomy) and group B (conservative treatment only); a total of 16 quantitative parameters were measured on each pelvic X-ray film.

RESULTS

Among 71 hip joints measured, 29 hips of group A underwent salvage peri-acetabular osteotomy (40.8 %,) showed higher X2, Y, h, and Smith c/b (Vh) (p < 0.05). The age, c, HT, b, A2 in the group A salvage operation were statistically significantly different compared to group B patients (without salvage operations) (p < 0.05).

CONCLUSIONS

Pre-operative pelvic X-ray film assessment of acetabulum lateralization markers (X2, c, HT, c/b ratio) and the superior migration measurements (Y, h, h/b ratio) are potentially valuable radiographic indicators for determining which DDH patients will require peri-acetabular osteotomy.

Safety and efficacy of staged pelvic osteotomies in the modern treatment of cloacal exstrophy

INTRODUCTION AND OBJECTIVE

Staged pelvic osteotomy (SPO) prior to bladder closure has been shown to be a safe and effective method for achieving pubic approximation in cloacal exstrophy (CE) patients with extreme diastasis. However, SPO outcomes have never been compared to those for combined pelvic osteotomy (CPO) at the time of closure in CE patients.

METHODS

A prospectively maintained database of 1208 exstrophy-epispadias complex patients was reviewed for CE patients treated with pelvic osteotomies. Inclusion criteria were osteotomy at the authors' institution and closure within two months of osteotomy. After inclusion, patients were separated into four groups depending on osteotomy procedure (SPO vs. CPO) and whether their osteotomy occurred with primary closure or re-closure. Patient demographics, closure history, pre-operative diastasis measurement, most recent post-operative diastasis measurement, and outcomes were recorded and compared by chi-squared tests and ANOVA.

RESULTS

Among 116 CE patients reviewed, 46 met inclusion criteria. With primary closure or re-closure, 27 had SPO and 19 had CPO. No SPO re-closure patients had previous osteotomy; 4 CPO re-closure patients had a previous osteotomy with closure. Median time between osteotomy and closure in SPO patients was 14 days. Median follow-up after SPO and CPO were 4 and 11 years, respectively. SPO significantly reduced the pre-operative diastasis compared to CPO on most recent diastasis measurement (3.5 cm vs. 0.4 cm, p=0.003). There were no significant differences in the overall complication rate, or the rates of each specific complication, between the SPO and CPO groups. No patients had wound dehiscence or prolapse. One CPO patient was able to intermittently catheterize per urethra while all other patients required continent urinary diversion to achieve continence.

CONCLUSIONS

To the authors' knowledge, this is the first study comparing SPO and CPO outcomes in CE patients. SPO reduces pre-operative diastasis more than CPO, and does not appear to incur increased rates of complication, closure failure, or incontinence. Due to its apparent safety and greater efficacy, SPO should be considered in all CE patients with extreme diastases undergoing primary closure or re-closure.

Impact of pelvic osteotomy on the incidence of inguinal hernias in classic bladder exstrophy

BACKGROUND/PURPOSE

The high prevalence of inguinal hernias in the bladder exstrophy population is well documented. The authors' aim is to determine whether pelvic osteotomy reduces the incidence of primary and recurrent inguinal hernias in patients with classic bladder exstrophy.

METHODS

Using an institutionally-approved database, patients who underwent immediate or delayed primary bladder closure between 1974 and 2012 were identified and stratified by the use of pelvic osteotomy at the time of closure. Data were analyzed using Fisher's exact test and multivariate logistic regression analysis.

RESULTS

One hundred thirty-six patients were identified with a median follow up of 8years. The incidence of inguinal hernias following closure was 25% in the osteotomy group versus 46% in the non-osteotomy group (p=0.017). Osteotomy was associated with a significant decrease in recurrence of inguinal hernias amongst patients who underwent previous repair (17% versus 47%, osteotomy versus non-osteotomy, p=0.027) and the development of primary inguinal hernias in whom initial groin exploration was negative (20% versus 39%, p=0.029). Osteotomy and female sex were associated with a decreased rate of inguinal hernia development after bladder closure while age at closure was not.

CONCLUSIONS

Pelvic osteotomy at the time of exstrophy closure decreases the likelihood of primary or recurrent inguinal hernia development.

Major surgical procedures in children with cerebral palsy

There are 3 surgical procedures that patients with cerebral palsy (CP) undergo that may be considered major procedures: femoral osteotomies combined with pelvic osteotomies, spine fusion, and intrathecal baclofen pump implant for the treatment of spasticity. Many complications are known to occur at a higher rate in this population, and some may be avoided with prior awareness of the preoperative pathophysiology of the patient with CP.

Triple pelvic osteotomy: Report of our mid-term results and review of literature

A wide variety of pelvic osteotomies have been developed for the treatment of developmental dysplasia of the hip (DDH). In the present paper, we present a detailed review of previous studies of triple osteotomy as an alternative treatment for DDH. We also report our experience treating 6 adult cases of DDH by triple osteotomy in order to highlight the various aspects of this procedure.The mean age of our patients was 31.2 years with a mean follow-up period of 6 years. We assessed range of motion, center-edge angle, acetabular index angle, Sharp angle, acetabulum head index, head lateralization index, Japanese Orthopedic Association score, Harris hip score, patient satisfaction, and the difference between lower limb lengths before and after the procedure. At final follow-up, clinical scores were significantly improved and radiographic parameters also showed good correction of acetabulum.

Developmental dysplasia of the hip in the newborn: A systematic review

Developmental dysplasia of the hip (DDH) denotes a wide spectrum of conditions ranging from subtle acetabular dysplasia to irreducible hip dislocations. Clinical diagnostic tests complement ultrasound imaging in allowing diagnosis, classification and monitoring of this condition. Classification systems relate to the alpha and beta angles in addition to the dynamic coverage index (DCI). Screening programmes for DDH show considerable geographic variation; certain risk factors have been identified which necessitate ultrasound assessment of the newborn. The treatment of DDH has undergone significant evolution, but the current gold standard is still the Pavlik harness. Duration of Pavlik harness treatment has been reported to range from 3 to 9.3 mo. The beta angle, DCI and the superior/lateral femoral head displacement can be assessed via ultrasound to estimate the likelihood of success. Success rates of between 7% and 99% have been reported when using the harness to treat DDH. Avascular necrosis remains the most devastating complication of harness usage with a reported rate of between 0% and 28%. Alternative non-surgical treatment methods used for DDH include devices proposed by LeDamany, Frejka, Lorenz and Ortolani. The Rosen splint and Wagner stocking have also been used for DDH treatment. Surgical treatment for DDH comprises open reduction alongside a combination of femoral or pelvic osteotomies. Femoral osteotomies are carried out in cases of excessive anteversion or valgus deformity of the femoral neck. The two principal pelvic osteotomies most commonly performed are the Salter osteotomy and Pemberton acetabuloplasty. Serious surgical complications include epiphyseal damage, sciatic nerve damage and femoral neck fracture.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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