One-stage treatment of developmental dysplasia of the hip in untreated children from two to five years old. A comparative study.

Abstract

A total of 38 children (49 hips) were retrospectively investigated to assess the efficacy and safety of one-stage treatment of developmental dysplasia of the hip (DDH) in untreated children from two to five years of age. Our method consisted of open reduction, Salter innominate osteotomy, femoral shortening and derotation osteotomy. The patients were distributed into two groups according to the age at which they were operated: Group I included 19 patients aged < 3 years (24 hips) and Group II included 19 patients aged > or = 3 years (25 hips). Mean follow-up was 5.08 years for Group I and 5.76 years for group II. Clinical and radiological assessment at final followup showed that the outcome was not significantly different between the two groups. Furthermore, after this follow-up period, the rates of avascular necrosis were similar. Children with DDH between two and five years of age were treated successfully with one-stage treatment.

Full text

Page 1

A total of 38 children (49 hips) were retrospectively
investigated to assess the efficacy and safety of one-
stage treatment of developmental dysplasia of the hip
(DDH) in untreated children from two to five years of
age. Our method consisted of open reduction, Salter
innominate osteotomy, femoral shortening and dero-
tation osteotomy. The patients were distributed into
two groups according to the age at which they were
operated : Group I included 19 patients aged
< 3 years (24 hips) and Group II included 19 patients
aged ≥ 3 years (25 hips). Mean follow-up was
5.08 years for Group I and 5.76 years for group II.
Clinical and radiological assessment at final follow-
up showed that the outcome was not significantly
different between the two groups. Furthermore, after
this follow-up period, the rates of avascular necrosis
were similar. Children with DDH between two and
five years of age were treated successfully with one-
stage treatment.
Keywords : developmental dislocation of the hip ; one-
stage surgical treatment ; older children.
INTRODUCTION
The primary goal of correction of developmental
dysplasia of the hip (DDH) is the concentric reduc-
tion of the hip. The principles of the treatment of
DDH for a child over two years are different from
those for a newborn (2,10,14,20). no consensus exists
regarding the best management after walking age
for DDH (9,20,22). This condition can result in soft-
tissue contractures of the muscles, tendons and cap-
sule around the hip, which prevent reduction and
can put pressure on the developing femoral head
during or after reduction, leading to ischemia (9,11,
22,26). Closed or open reduction without osseous
realignment has been associated with residual dys-
plasia (17,20). Femoral shortening has been shown to
facilitate reduction and does not appear to increase
the prevalence of avascular necrosis (AVn) of the
femoral head (8,19,22,25). Many authors have recom-
mended a one-stage procedure for hip reconstruc-
tion consisting of open reduction, femoral shorten-
ing with or without varus derotational osteotomy
Acta Orthopædica Belgica, Vol. 77 - 4 - 2011No benefits or funds were received in support of this study
Acta Orthop. Belg., 2011, 77, 464-471
One-stage treatment of developmental dysplasia of the hip
in untreated children from two to five years old
A comparative study
Cemil ERTüRK, Mehmet Akif AlTAY, Raci YARIMPAPUç, Ibrahim KORUK, U. Erdem IS ¸IKAn
From the Faculty of Medicine of Harran University, Sanliurfa, Turkey
ORIGINAL STUDY
I Cemil Ertürk, MD, Assistant Professor.
I Mehmet Akif Altay, MD, Assistant Professor.
I U. Erdem Is ¸ıkan, MD, Professor.
Harran University Faculty of Medicine, Department of
Orthopaedic Surgery, Sanliurfa, Turkey.
I Raci Yarımpapuç, MD, Orthopaedic Surgeon.
25 Aralık State Hospital, Department of Orthopaedic
Surgery, Gaziantep, Turkey.
I Ibrahim Koruk, MD, Assistant Professor.
Harran University Faculty of Medicine, Department of
Public Health, Sanliurfa, Turkey.
Correspondence : Cemil Ertürk, Harran University Faculty
of Medicine, Department of Orthopaedic Surgery, Yenisehir,
63100 Sanliurfa, Turkey. E-mail : erturkc@yahoo.com
© 2011, Acta Orthopædica Belgica.

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and pelvic osteotomy in children older than three
years of age (4,6,12,13,19,20,22,26,27). However, there
is limited information available on the comparison
of one-stage treatment before and after the age of
three years.
despite neonatal screening and early treatment
of ddH in newborns and infants, it is not rare to see
an older child with untreated or neglected
ddH (6,26). due to economical and educational
disparities, we often see these types of cases in the
Southeastern region of our country.
In this study we present our functional and radio -
graphic findings in children aged from two to five
years with previously untreated ddH. The aim of
this study was to compare the results of a one-stage
operative procedure in patients with ddH before
the age of 3 years versus after that age.
MATERIAL AND METHODS
Written informed consent was obtained from all par-
ents, and approval to use their medical records and re-
evaluate each patient was given by the local research
Ethics Committee. We retrospectively reviewed the med-
ical records of 54 consecutive patients (age range : 2 to
5 years) with ddH who were treated between 1998 and
2008 by a single-stage combined procedure by the same
surgeon (ry). We excluded 15 patients who had an
associated muscular or teratologic dislocation (n = 2)
or previously treated ddH (n = 9) or who did not have
follow -up (n = 4). Thus, we evaluated 38 previously
untreated consecutive patients (49 hips). The operative
treatment consisted of open reduction, Salter innominate
osteotomy (SIO), femoral shortening, and derotation
osteotomy. A minimum postoperative follow-up period
of two years was required for inclusion in this study.
The patients were distributed into two groups accord-
ing to the age at which they were operated : Group I
included 19 patients aged < 3 years of age (24 hips) and
Group II 19 patients aged ≥ 3 years of age (25 hips).
The average age was 2.6 years at the time of surgery :
2.15 ± 0.17 years (range 2.0 to 2.6) in Group I, and
3.39 ± 0.48 years (range 3.0 to 4.8) in Group II. There
were 35 girls (44 hips) and 3 boys (5 hips). Twenty three
patients had a dislocation of the left hip, 26 of the right
hip, and 11 had bilateral dislocation. Preoperative trac-
tion was not attempted. We evaluated the initial radio -
graphs using the method of Tönnis (28). In Group I there
were 8 Tönnis type III and 16 Tönnis type IV hips ; in
Acta Orthopædica Belgica, Vol. 77 - 4 - 2011
ONE-STAGE TrEATMENT OF dEVElOPMENTAl dySPlASIA OF THE HIP
465
Group II there were 8 Tönnis type III and 17 Tönnis type
IV hips.
The follow-up ranged from two to 10 years. The mean
follow-up period was 5.08 years (range 2-10 years) for
Group I and 5.76 years (range 3-10 years) for Group II.
Surgical technique
The operation started with percutaneous adductor
tenotomy. The surgical approach combined two inci-
sions : a Smith-Petersen approach to expose the innomi-
nate bone, and a lateral incision for the subtrochanteric
derotational shortening osteotomy procedure (15). SIO
was performed precisely as described by Salter in his
first report (21). The capsule was opened and the socket
defined and cleaned. The transverse ligament and inferi-
or capsule were divided and the ligamentum teres was
excised. The amount of correction of the derotation or
femoral shortening was decided intraoperatively under
direct visualization. Femoral shortening ranging between
1 to 2 cm in length was performed in all hips. Excess
anteversion (more than 40°) of the proximal femoral
segment was found in many cases, and derotation of the
proximal segment of the femoral osteotomy was per-
formed in all hips. However, varus position was not
added to decrease the neck shaft angle. The osteotomy
was fixed with a small dynamic compression plate. None
of the femoral heads were fixed to the acetabulum by a
Kirshner wire for maintenance of reduction. Capsule
excision and capsulography were performed after reduc-
tion. A spica cast was worn for six weeks, followed by
full time abduction bracing for six weeks and night-time
only bracing for an additional six weeks. Patients were
encouraged to move in an abduction brace. In bilateral
cases, in order to reduce the stiffness on the operated side
and to prevent the graft and bone collapsing at the
osteotomy site related to immobilization osteoporosis,
operation of the other hip was delayed four or six weeks
after removal of the splint and the patient was rehabili-
tated during this time interval.
A conventional anterior-posterior (AP) pelvic radio -
graph was taken immediately after surgery and at six
weeks and an AP and frog leg lateral, at three, six and
12 months. Final clinical and radiological evaluations
were performed using the medical records and radio -
graphs prepared or taken at the time of the most recent
follow-up visit (Figs. 1, 2). Evaluations and measure-
ments were performed by the orthopedic surgeon (MAA)
who was not involved in the care of the patients. The
same surgeon also assessed the radiographs at diagnosis,
immediately postoperatively and at the most recent

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C. ERTüRK, M. A. AlTAY, R. YARIMPAPUC ¸, I. KORUK, U. E. IS ¸IKAn
Acta Orthopædica Belgica, Vol. 77 - 4 - 2011
follow-up. All patients were followed up clinically and
radiologically in accordance with the modified McKay
criteria (16) and Severin classification (23) (Table I and
II). Excellent and good results were considered as satis-
factory, fair and poor as unsatisfactory. Sharp’s acetabu-
lar index (AI) angle (24) and Wiberg’s center-edge (CE)
angle (30) were measured. The grade of AVn of the
femoral head was evaluated according to the system of
Kalamchi and Mac Ewen (11) : Grade I, changes affecting
the ossific nucleus ; Grade II , lateral physeal damage ;
Grade III , central physeal damage and Grade IV, total
damage to the femoral head and physis. We measured the
limb length clinically from the antero superior iliac spine
to the medial malleolus.
A modified scoring system of Trevor et al (29) was
used for clinical and radiological evaluation of the
results. According to this evaluation scheme the total
score is 20 and the 18-20 range is accepted as excellent,
15-17 as good, 12-14 as moderate, and below 12 as poor
(Table III).
Statistical analysis
All statistical analyses were conducted using the
SPSS 11.5 computer program. The Mann-Whitney U test
was used to determine differences in the parametric
values (preoperative AI and last follow-up AI, the CE
angle and the scoring system of Trevor) between the
groups. The chi-square (χ2) test was used to evaluate the
nonparametric values, such as the preoperative Tönnis
grade, and the follow-up Severin and McKay criteria.
P values < 0.05 were considered significant.
RESULTS
none of the patients had any intraoperative or
immediate postoperative complications such as
infection or graft displacement.
Excellent clinical results were obtained in
37 hips (75.6%), good results in eight hips (16.3%),
fair results in three hips (6.1%), and poor result in
Fig. 1b. — Six months after one-stage combined surgery
Fig. 1a. — Preoperative radiograph of a 3-year-old child with
developmental dysplasia of the left hip.
Fig. 1c. — Three years after operation, good clinical result

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Acta Orthopædica Belgica, Vol. 77 - 4 - 2011
OnE-STAGE TREATMEnT OF DEVElOPMEnTAl DYSPlASIA OF THE HIP
467
Fig. 2a. — Preoperative radiograph of a 2-year-old child with
bilateral developmental dislocation of the hip.
Fig. 2b. — One-stage combined surgery on the right side and
on the contralateral side 3 months later.
Fig. 2c. — The 7-year postoperative radiograph
Fig. 2d. — nine years after operation. note type II avascular
necrosis of the left hip.
Table I. — Modified McKay criteria
GradeCriteria
ExcellentStable, painless hip, no limp, negative Trendelenburg sign, and a full range of movement
GoodStable, painless hip, slight limp, negative Trendelenburg sign, and a slight decrease in range of movement
FairStable, painless hip, limp, positive Trendelenburg sign, and limitation of movement
Poor Unstable or painful hip, or both ; positive Trendelenburg sign

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C. ERTüRK, M. A. AlTAY, R. YARIMPAPUC ¸, I. KORUK, U. E. IS ¸IKAn
Acta Orthopædica Belgica, Vol. 77 - 4 - 2011
one hip (2.0%). Radiological results were excellent
in 33 hips (67.4%), good in eight hips (16.3%), fair
in seven hips (14.3%), and poor in one hip
(2.0%). We found satisfactory results, clinically in
45 hips (85%) and radiographically in 41 (75%)
(Table IV).
In Group I, clinical results were excellent in
16 hips (66.6%), good in five hips (20.8%), fair in
two hips (8.3%), and poor in one hip (4.1%). In
Group II, 21 hips (84%) were rated excellent, three
hips (12%) good, and in one hip fair (4%). Twenty-
one hips (87.5%) in Group I and 24 hips (96%) in
Group II yielded sat isfactory results, whereas three
hips (12.5%) in Group I and one hip (4%) in Group
II yielded unsatis factory results. However, there
was no significant difference between the two
groups according to McKay's clinical criteria at
final follow-up (p > 0,05).
Table II. — Severin’s table
Grade Criteria
Excellent IACE angle > 19°, age 6-13 years ; CE angle > 25°, age > 14 years
Good IBCE angle 15-19°, age 6-13 years ; CE angle 20-25°, age > 14 years
IIModerate deformity of femoral head, femoral neck, or acetabulum, but otherwise the same as grade IA or IB
Fair IIIDysplastic hip, no subluxation ; CE angle < 15°, age 6-13 years ; CE angle < 20°, age > 14 years
Poor IVSubluxation
VFemoral head in false acetabulum
VIRedislocation
Table III. — Method of assessment using the modified scoring system of Trevor et al (29)
Symptoms and signsSeverity Points
Painnone
Occasional
Persistent
Full
Slight limitation but no fixed deformity
More than half the normal range
less than half the normal range
little
Absent
Present
3
2
1
5
4
3
2
1
1
0
Movement
limp
Function as described by the patient and assesed in
the follow-up clinic
Full
Slightly limited
Severely limited
Age < 14 years Age ≥ 14 years
3
2
1
Radiological feature
The CE of Wiberg ≥ 20° ≥ 25°
15°-19° 20°-24°
10°-14° 15°-19°
< 10° < 15°
normal
Partial coxa plana or coxa magna
Complete coxa plana or other severe deformity
Intact
Broken
4
3
2
1
3
2
1
1
0
Appearance of the femoral head
Shenton’s line