SYMPOSIUM: DEVELOPMENTAL DYSPLASIA OF THE HIP
How Are Outcomes Affected by Combining the Pemberton
and Salter Osteotomies?
Aysegul Bursalı MD, Murat Tonbul MD
? The Association of Bone and Joint Surgeons 2008
the Pemberton and Salter osteotomies. Results have usually
been reported in patients with dysplasia but without frank
dislocation. We asked if the following factors influence the
outcome of the Pembersal operation in patients with dis-
located hips: triradiate cartilage damage causing early
closure; the acetabular index improvement; and the age of
the patient at time of operation. We assessed triradiate
cartilage damage, a modified McKay clinical classification,
acetabular index, center-edge angles, Reimers index, ace-
tabular depth-to-width ratios, Severin classification and
To ¨nnis grading of 33 patients (44 hips) have been evalu-
ated in this retrospective study. The mean age at surgery
was 5 years (range, 1.5–14 years). The minimum followup
was 5 years (mean, 10.5 years; range, 5–17 years). Pre-
operatively, three (7%) hips were To ¨nnis Grade 2, 10
The Pembersal operation combines features of
(23%) were Grade 3, and 31 (70%) were Grade 4. Eight
(18%) hips were Severin Class 1, 32 (73%) Class 2, and
four (9%) were Class 3. According to McKay’s criteria
satisfactory results with a rate of 76% were obtained.
Premature closure of the triradiate cartilage occurred in
eight (18%) hips and postoperative avascular necrosis of
the femoral head in three (6%) hips. Satisfactory clinical
and radiographic improvements in the aforementioned
parameters can be obtained by Pembersal osteotomy.
Level of Evidence: Level IV, therapeutic case series. See
the Guidelines for Authors for a complete description of
levels of evidence.
Developmental dysplasia of the hip is one of the most
common orthopaedic problems seen during childhood with
reported incidences of 1 per 1,000 to 3.4 per 100 [8, 21].
[5, 6, 23, 30]. Most surgeons are familiar with procedures
described by Salter  in 1961 and by Pemberton  in
1965. Salter and Dubos [22, 23] described a transiliac
innominate osteotomy in which the lower quarter of the
pelvis is rotated forward, downward, and outward, that
reoriented the acetabulum anterolaterally, thereby increas-
ing the coverage of the femoral head. Pemberton 
described an acetabuloplasty in which the ilial osteotomy
ends at the posterior limb of the triradiate cartilage and the
anterolateral rim of the acetabulum is hinged downward and
should be within the acetabulum’’ and apparently not at the
edge (i.e., the center of the triradiate cartilage. The asym-
metry of the obturator foramina, as seen in both procedures,
suggests rotation of the inferior quadrant of the pelvis.
Each author certifies that he or she has no commercial associations
(eg, consultancies, stock ownership, equity interest, patent/licensing
arrangements, etc) that might pose a conflict of interest in connection
with the submitted article.
Each author certifies that his or her institution either has waived or
does not require approval for the human protocol for this investigation
and that all investigations were conducted in conformity with ethical
principles of research.
MH Metin Sabanci Baltalimani Hospital for Research and
Education, Istanbul, Turkey
A. Bursalı (&)
Yildiz Posta Cad. Cigdem Ap. No:11/9 Gayrettepe, Istanbul,
e-mail: email@example.com; firstname.lastname@example.org
MH Okmeydani Hospital for Research and Education, Istanbul,
Clin Orthop Relat Res (2008) 466:837–846
A combined pelvic osteotomy (‘‘Pembersal’’) was
described in 1985 by Perlik et al. . The osteotomy
combines key aspects of the Pemberton (pericapsular) and
the Salter (innominate) osteotomies. The osteotomy avoids
the center of the triradiate cartilage and is directed from the
ilium extending into the ischial body across the posterior
ilioischial limb of the triradiate cartilage, allowing the
rotation of the lower part of the pelvis in addition to bending
the acetabular roof at the triradiate cartilage . Since
1989 we have been performing this so-called Pembersal
operation. In contrast to some previously described series,
93% of the hips on which we have operated were frankly
dislocated at the time of the initial surgery rather than
We asked whether: (1) there was any triradiate cartilage
damage causing early closure; (2) the acetabular index
could be substantially improved via the combined osteot-
omy; and (3) the age at surgery influenced various
radiographic features ostensibly reflecting outcomes (ace-
tabular index, the center-edge angles, the Reimers index,
the acetabular depth-to-width ratios, the Severin classifi-
cation, the To ¨nnis grading and the McKay’s criteria).
Materials and Methods
We retrospectively reviewed the records of 90 consecutive
patients (115 hips) who underwent Pembersal pelvic oste-
otomy for DDH between 1989 and 1997. We excluded
patients with inadequate records and short followup
(n = 18), neuromuscular disorders (n = 2), connective
tissue disorders (n = 3), or patients with previous hip
surgery (n = 7). We were able to locate 33 patients (44
hips) (37% of the patients) with full documentation who
could be contacted for followup. The mean age at the time
of surgery was 5 years (range, 1.5–14 years). We separated
our patients into two groups according to the age at which
they were operated: younger (Group 1) and older (Group 2)
than 4 years. There were 29 female and four male patients.
Nineteen hips were on the right side and 25 were on the
left. Eleven patients had bilateral dysplasia. The minimum
followup time for the 37 patients included was 5 years
(mean, 10.5 years; range, 5–17 years).
Preoperatively the patients were examined by the
operating surgeon (AB). Clinical parameters such as pain,
range of motion of the affected and the contralateral hips,
instability, limp and Trendelenburg sign were collected.
Anteroposterior (AP) radiographs of the pelvis were taken
and the hips classified according to To ¨nnis . According
to this classification, Grade 1 means the cartilaginous head
of the femur is laterally displaced by no more than2
width (relative to the superior bony rim of the acetabulum).
In Grade 2, the femoral head is laterally displaced by more
3 of its
upward by more than1
laginous rim of the acetabulum, it is Grade 3. In Grade 4,
the femoral head is completely dislocated and is separated
from the acetabulum by the labrum or the constricted
capsule. Preoperatively, according to To ¨nnis classification,
three (7%) of the hips were Grade 2, 10 (23%) were Grade
3, and 31 (70%) were Grade 4.; thus 93% of the hips were
dislocated at the time of the index operation. We further
measured the acetabular index. The acetabular index of
Hilgenreiner is formed by a line drawn from a point at the
lower lateral edge of the ilium on the triradiate cartilage
connected to the horizontal line of Hilgenreiner, and a
second line drawn from the point on the ilium to the
superior acetabular rim .
The surgical technique used was originally described by
Perlik et al.  (Pembersal). All procedures were per-
formed by the same surgeon (AB). The ilium was exposed
subperiosteally through an anterior iliofemoral approach.
Then the iliopsoas tenotomy was performed through its
tendinous portion at the level of the triradiate cartilage, and
an arthrotomy to inspect the joint cavity for the need of
de ´bridement of the pulvinar and assessment of the reduc-
tion was routinely performed. Neither excision nor radial
incision of the labrum was performed. Subtrochanteric
femoral shortening was performed via a lateral proximal
femoral incision when the hips were classified as grade 3
and 4 according to To ¨nnis . Thirty-one femurs (70%)
were shortened an average of 2.5 cm (range, 1.5–7 cm).
Pelvic osteotomy was performed 10 to 15 mm above the
anterior inferior iliac spine to the body of the ischium,
following the attachment of the joint capsule and paral-
leling the acetabular dome. To avoid entering the joint, an
index finger was introduced into the acetabulum during the
osteotomy. This osteotomy differs from the Pemberton
procedure in that it continues through the ilioischial limb of
the triradiate cartilage but not through the distal cortex.
Opening the osteotomy creates a greenstick fracture
through the remaining part of the ischial body. The lower
quarter of the body was displaced forward and downward,
resulting in anterolateral rotation of the acetabulum about
an axis that passes through the ischial fracture and the
symphysis pubis. And also, the acetabular roof was rotated
downward and laterally with the triradiate cartilage acting
like a hinge. As a result, the acetabulum was reoriented as
in the Salter procedure, and deepened as in the Pemberton
osteotomy. A triangular, curved bone graft was taken from
the patient’s ipsilateral iliac crest and wedged into the
osteotomy site. Because the osteotomy and the interposed
graft are adequately stable we used no internal fixation.
Patients were kept in a 1½ spica cast for 6 weeks
postoperatively. After removal of the cast, an abduction
orthosis was applied for an additional 6 weeks. Range of
3 of its width. If the femoral head is displaced
3 of its height relative to the carti-
838 Bursalı et al.Clinical Orthopaedics and Related Research
motion exercises then began and weight bearing resumed
as tolerated without any assisting device, such as crutches
We (AB, MT) performed radiographic examinations just
after the first intervention at the 6th and 12th weeks and
1 year after the operation. Additionally, after cast removal,
clinical examinations were performed at the 6th and 12th
weeks and 1 year after the operation. At the last followup
all the patients were reevaluated clinically and radio-
graphically by the same surgeon (AB). The patients were
clinically evaluated according to the modified McKay’s
criteria which consist of pain, range of motion of the
affected and the contralateral hips, instability, limp and
Trendelenburg sign (Table 1) . We evaluated patients
radiographically according to Severin’s criteria (Table 2)
. At the last followup the acetabular roof obliquity
angle, the center-edge angle of Wiberg, the Reimers index
and the acetabular depth-to-width ratios were also mea-
sured as radiographic parameters [7, 9, 12, 16, 20].
The acetabular index of Hilgenreiner is formed by a line
drawn from a point at the lower lateral edge of the ilium on
the triradiate cartilage connected to the horizontal line of
Hilgenreiner, and a second line drawn from the point on the
ilium to the superior acetabular rim . The acetabular roof
obliquity is used instead of acetabular index at the last fol-
lowup as the patients were skeletally mature. This was the
angle subtended by the line connecting the inferior-most
the acetabulum with a parallel horizontal line . The
center-edge angle of Wiberg is formed by a line parallel to
the longitudinal body axis and by the line connecting the
center of the femoral head (C) with the edge (E) of the
acetabular roof . The width of the femoral head parallel
to Hilgenreiner’s line is measured as line (b), and the dis-
tance (a) from the lateral border of the femoral head to the
Ombre ´danne-Perkins line. The ratio (a/b)*100 assigns a
percentage value to the degree of centering of the femoral
head. This is the ‘‘Instability Index of Reimers’’ . The
acetabular depth-to-width ratios are measured in the fol-
lowing manner: the width of the acetabulum is measured
from the most lateral point of the superior acetabular rim to
the lower margin of the acetabulum (b), the depth of the
acetabulum is measured on the perpendicular bisector of the
width line (a); (a/b)*100 gives the ratio  (Fig. 1).
We used the Wilcoxon test to determine differences
between the mean preoperative and last followup acetabular
index. The Mann-Whitney U test was used to determine
index and followup acetabular roof obliquity angle, the
center-edge angle, the Reimers index, and the acetabular
depth-to-width ratio) between the groups. The chi-square
test was used to evaluate the nonparametric values, such as
Table 1. Modified criteria of McKay for clinical evaluation of results 
IExcellent Painless, stable hip; no limp, more than 15 degrees of internal rotation;
negative Trendelenburg sign
II GoodPainless, stable hip; slight limp, slight decrease in hip motion;
negative Trendelenburg sign
IIIFairMinimum pain; moderate stiffness;
positive Trendelenburg sign
IV PoorSignificant pain
Table 2. Severin’s criteria for radiographic evaluation of results 
Class DescriptionCenter-edge angle
INormal appearanceC 15 (5–13 yrs.)
C 20 ([14 yrs.)
C 15 (5–13 yrs.)
C 20 ([14 yrs.)
\15 (5–13 yrs.)
\20 ([14 yrs.)
IIMild deformity of the femoral head and neck or the acetabulum
IIIDysplasia or moderate deformity of the femoral head
and neck or the acetabulum, or both
IVSubluxation of the femoral head
VArticulation of the femoral head with a false acetabulum
Volume 466, Number 4, April 2008The Pembersal Pelvic Osteotomy for DDH839
thepreoperativeTo ¨nnisgrade,andthe followupSeverinand
McKay criteria between the groups. All values were recor-
ded on a Microsoft Excel spreadsheet. Analyses were made
using Statistical Package for the Social Sciences (Windows
2000; SPSS Version 13, Chicago, Ill.). A p value of\0.05
was considered significant.
According to modified McKay’s clinical criteria at the last
followup 17 (38%) hips were excellent (Grade I), 17 (38%)
good (Grade II), nine (20%) fair (Grade III), and one (4%)
poor (Grade IV), (Table 3). Using Severin radiographic
classification at the last followup, there were eight (18%)
Class 1 hips, 32 (73%) Class 2 hips, and four (9%) Class 3
Premature closure of the triradiate cartilage occurred in
eight (18%) hips. These eight hips were in patients on
whom we had operated early in our series.
The average acetabular index had decreased (t = 5.16,
p\0.05) from 37.6? (range, 25?-60?) preoperatively to
12.5? (range, 10?-32?) at the last followup.
The clinical outcomes as rated by McKay’s criteria,
were similar (p[0.05) in both groups. However, younger
patient age at operation resulted in better radiological
outcomes. The averages of the preoperative and followup
acetabular index/roof obliquity angle, the followup center-
edge angles were greater (p\0.05) in group 1 than group
2, whereas the Reimers index, and the acetabular depth-to-
width ratios were lesser in group 1 than in group 2
(p\0.05 and, p = 0.0475, respectively) (Table 4). The
preoperative and last followup Severin classifications and
To ¨nnis grading between age groups improved (15 mild to
moderate deformities according to Severin classification in
group 1, and 21 in group 2; p\0.05, 10 complete dislo-
cation in group 1 versus 21 in group 2; p\0.01) (Table 4).
The patients illustrate these differences (Figs. 2–4).
Complications occurred in 11 hips (10 patients): post-
operative avascular necrosis of the femoral head in three
(6%) hips and premature closure of the triradiate cartilage
in eight (18%) hips. There were no redislocations, graft
displacements, or infections. In one patient the osteotomy
entered the joint, which was detected postoperatively by
radiographs. At the last followup the hip radiographically
was Severin Class 3 and clinically Grade II (good)
according to modified McKay’s criteria (Fig. 5).
Fig. 1 The five morphological
dysplasia are (A) center-edge
angle, (B) acetabular index of
Hilgenreiner, (C) the acetabular
depth-to-width ratio, (D) insta-
bility index of Reimers, and (E)
acetabular roof obliquity.
Table 3. Clinical and radiological results of patients preoperatively and at last followup
To ¨nnis grade
Followup RI Followup
D/W ratio (%)
31 hips; G 4
10 hips; G 3
3 hips; G 2
37.6?(25–60?)12.5?(10–32?)8 hips; C 1
32 hips; C 2
4 hips; C 3
17 hips; G I
17 hips; G II
9 hips; G III
1 hip; G IV
29.1? (11–48?)0.18 (0–0.46)42.3 (25–59)
AI = acetabular index; AO = acetabular roof obliquity angle; C-E = center-edge angle; RI = Reimers index; D/W = acetabular depth-to-
840Bursalı et al.Clinical Orthopaedics and Related Research
The Pembersal procedure combines features of the Salter
osteotomy and the Pemberton acetabuloplasty. By per-
forming this procedure, we asked if acetabular remodeling
would be improved, thus promoting congruous and
concentric normal hip development. Iatrogenic damage of
of the Pembersal procedure,which may lead tounsuccessful
results. We asked whether (1) there was any triradiate
Table 4. Clinical and radiological results of patients according to age at operation preoperatively and at last followup
Preop AI (range)Followup AO
38.77? ? (25–60? ?)10.27? ? (0–26? ?)7? 1
30.54? ? (11–46? ?) 0.16 (0–0.33)42.14% (31–55)
36? (24–50?)15.23? (0–32?) 28.54? (14–48?) 0.20 (0–0.46)42.36 (25–59)
U = 292,
U = 335,
U = 285,
U = 315,
U = 265,
p = 0.0475
AI = acetabular index; AO = acetabular roof obliquity angle; C-E = center-edge angle; RI = Reimers index; D/W = acetabular depth-to-
width ratio; Bold = Group 1 (22 hips), age range, 1.5–4 years; Italic = Group 2 (22 hips), age range, 5–14 years; E = excellent; G = good;
F = fair; P = poor).
Fig. 2A–C A female patient was operated bilaterally (right hip at age
7 years and left at 8 years). Femoral shortening was performed
bilaterally (2 cm at the right femur and 2.5 cm at the left). (A) At
initial presentation both hips were To ¨nnis Grade 4. Preoperative
acetabular index was 46? at the right site and 40? at the left. (B) An
early followup radiograph is shown. She was followed for 17 years.
(C) At the last followup, she was pain-free, had no limping, and was
able to perform all daily activities with no limitation. Radiograph-
ically, the acetabular indices were 15? and 8?, the center-edge angles
were 23? and 32?, the Reimers indices were 0.15 and 0.13, and the
acetabular depth-to-width ratios were 46% at both the right and left
hips. Both hips were Severin Class 2, excellent according to modified
Volume 466, Number 4, April 2008The Pembersal Pelvic Osteotomy for DDH 841
Fig. 3A–C A male patient was
operated bilaterally at age 6.
was performed on the right side.
(A) At initial presentation both
hips were To ¨nnis Grade 4. Pre-
were 40? on the right side and
36? on the left. (B) An early
followup radiograph is shown.
He was followed for 15 years.
(C) At the last control, he was
pain-free. Radiographically, the
angles were 25? and 35?, the
Reimers indices were 0.24 and
0.16, and the acetabular depth-
to-width ratios were 59% and
43% at the right and left hips,
respectively. Both hips were
Class 2 according to Severin,
and excellent according to mod-
ified McKay’s criteria.
Fig. 4A–C The left hip of this female patient was operated at age
1.5 years. (A) In this preoperative radiograph, her hip was To ¨nnis
Grade 3 initially. Preoperative acetabular index was 42?. (B) A
radiograph immediately postoperative is shown. She was followed for
9 years. (C) At the last followup, she was pain-free with no limitation
of hip range of motion. Radiographically, the acetabular index was
13?, the center-edge angle was 30?, the Reimers index was 0.16, and
the acetabular depth-to-width ratio was 50%. The hip was Class 2
according to Severin, and excellent according to modified McKay’s
842Bursalı et al. Clinical Orthopaedics and Related Research
cartilage damage causing early closure; (2) the acetabular
index could be substantially improved via the combined
osteotomy; and (3) the age at surgery influenced various
clinical and radiographic outcomes.
The major limitation of this study is the loss of patients to
followup. This is due to the social security insurance system
in our country. Most of our patients join this system only for
a short period, during which time they address their health
problems. However, they quit paying for insurance after
surgery and lose their rights for further followup. This
33 of 90 (37%) patients in our series. Although only one-
third of the patients overall were evaluated, we presume
those who maintain insurance and followup are similar to
those who for primarily financial reasons do not.
Several authors have reported 71% to 94% major
improvement in parameters such as the acetabular index,
the center-edge angles, the Reimers index, the acetabular
depth-to-width ratios, the Severin classification, the To ¨nnis
grading and the McKay’s criteria of a Salter osteotomy
with a mean followup of 5.5 to 30.9 years [1, 3, 6, 11, 23,
30] (Table 5). Complication rates, including bone graft
displacement, migration of the K-wire, redislocation, hip
flexion and abduction contractures, and avascular necrosis
of the femoral head, were reported as an overall 30% by
Bohm and Brzuske  63.3% by Gulman et al. , and 6%
by Hosny and Fattah .
Pemberton and several others [17, 27, 28, 31] reported
major improvements in parameters such as the acetabular
index, the center-edge angles, the Reimers index, the ace-
tabular depth-to-width ratios, the Severin classification, the
To ¨nnis grading and the McKay’s criteria using Pemberton
acetabuloplasty with rates of 83% to 96% with a mean
followup of 5.3 to 14.6 years (Table 2). Complication rates
were reported as an overall 0 to 5.5% in different series [4,
27], and complications included iliac bone fracture over the
osteotomy, bone graft displacement, and mild paresis due
to sciatic nerve injury.
Perlik et al.  reviewed their series of 50 hips in 44
children, 62% of whom had prior surgery. The patients
underwent the Pembersal operation at a mean age of
7.3 years and had a mean followup of 6 years. They
reported 54% satisfactory improvements in radiological
parameters such as the acetabular index, the center-edge
angle, the Reimers index, the acetabular depth-to-width
ratios and clinically in McKay’s criteria and To ¨nnis grad-
ing and a 6% complication rate, including one graft
displacement and two mild infections.
Fig. 5A–C The left hip of this male patient was operated at age
10 years. (A) In this preoperative radiograph, his hip was To ¨nnis
grade 4 initially. Preoperative acetabular index was 26?. Femoral
shortening of 2.5 cm was performed. (B) An early followup
radiograph is shown (note the obvious premature closure of the left
triradiate cartilage compared to the right). He was followed for
15 years. (C) At the last control, he was pain-free. Radiographically,
the acetabular index was 20?, the center-edge angle was 30?, the
Reimer’s index was 0.20, and the acetabular depth-to-width ratio was
45%. The hip was Class 2 according to Severin, and excellent
according to modified McKay’s criteria.
Volume 466, Number 4, April 2008The Pembersal Pelvic Osteotomy for DDH 843
The recommended ages for Salter and Pemberton oste-
otomies are 1.5–6 and 1.5–14 years, respectively [17, 23].
Perlik et al. reported their range for combined pelvic
osteotomy as 3 years and 8 months to 12 years and
8 months . In our series the range for the Pembersal
operation was 1 year and 6 months to 14 years. Our series
differs from those in previous studies (Table 5) because we
have performed the procedure as a primary attempt and
93% of the hips were dislocated, in contrast with the pre-
vious series in which all of the hips were dysplastic.
Premature closure secondary to injury of the triradiate
cartilage results in a shallow dysplastic acetabulum .
The extent of the deformity depends on the patient’s age at
injury and the specific area involved. Several authors
types of pelvic osteotomies with satisfactory clinical results
[13, 14, 19, 26]. They concluded acetabuloplasties per-
formed adjacent to the triradiate cartilage typically do not
have an adverse effect on its functions, but despite the low-
risk injury long-term followup was recommended. They
graft used to maintain the fragment displacement crossed
the triradiate cartilage. The graft may cause a fusion effect.
Special attention to the ilioischial limb is of great impor-
tance because this portion has the greatest potential of
growth of the triradiate cartilage and its injury may cause
deformation and subluxation of the hip joint . The eight
on whom we had operated early in our series. As we grad-
carefully in order not to harm the triradiate cartilage.
However, this combined pelvic osteotomy is potentially
harmful to the cartilage and therefore the younger patients
(B 4 years) tolerated it better than the older group.
Perlik et al., however, could not demonstrate premature
closure of the posterior limb of the triradiate cartilage in his
series and noted it was difficult to identify in the followup
roentgenograms . After physiological closure of the tri-
radiate cartilage, the acetabular roof is less flexible, and
presumably the Pemberton component of the procedure
contributes lessto thecorrection.Additionally,violation
of the growth center might be expected to cause premature
closure; as Pemberton suggested, it does not appear to cause
substantial problems and alter the final results .
The mean preoperative acetabular index and the mean
followup acetabular roof obliquity angle, the center-edge
angle of Wiberg, were greater in group 1 than group 2,
whereas Reimers index and acetabular depth-to-width ratios
obtain good clinical and radiographic results. Although the
clinical results were similar in both age groups.
Table 5. Comparison of techniques
Minimum followup (years)
Age at surgery (years)
% Severin’s I + II
Gulman et al. 
8 years (mean, 13; range, 8–25)
Majority 1.5 to 4 years
Karakas et al. 
2 years (mean, 7.5; range, 2–16)
Morin et al. 
3 years (mean, 12; range, 3–27)
Bohm and Brzuske 
26.2 years (mean, 30.9; range, 26.2–35.4)
Szepesi et al. 
1 year (mean, 5.3; range, 1–15)
Wada et al. 
5 years (mean, 9.4; range, 5–17.4)
Thielemann et al. 
10.4 years (mean, 14.7; range, 10.4–19.5)
Perlik et al. 
2 years (mean, 6; range, 2–18.8)
5 years (mean, 10.5; range, 5–17 years)
Shortening (in 70%)
844Bursalı et al.Clinical Orthopaedics and Related Research
In our series at the last followup, we detected radio-
graphic dysplasia in 18% of the hips (six patients, eight
hips) perhaps due to premature closure of the triradiate
cartilage and likely reflecting iatrogenic damage. This
damage may be because of the wide exposure of the iliac
bone affecting the remodeling capacity of the triradiate
cartilage or forced correction may be damaging the trira-
diate physis. Also, the graft crossing the triradiate cartilage
may cause a fusion effect, as previously mentioned. One of
these patients was 1.5 years old at the time of surgery, and
the mean age of the other five patients was 8.8 years
(range, 6–11 years). This implies the main cause for further
dysplasia may not only be the iatrogenic damage to the
triradiate cartilage, but also that, after age 4, wide exposure
is needed to visualize the field and manipulate the osteo-
tome, the flexibility of the iliac bone is decreased, and the
remodeling capacity is already diminished, as mentioned
by Bohm and Brzuske . Theoretically, the earlier the
damage to the triradiate cartilage, the worse the acetabular
dysplasia would be expected, whereas the femoral head
may further induce the acetabulum to reshape and mold.
Murphy et al.  reported the acetabular index of
depth-to-width in patients with hips that did not develop
severe arthritis by the age of 65 had a mean value of 48%,
whereas dysplastic acetabula in which secondary osteoar-
thritis was more likely to develop had an average depth-to-
width ratio of 31%. In our series, the mean acetabular
depth-to-width ratio, the Reimers index, and the center-
edge angle in the younger age group was 42.1%, 0.16, and
30.5?, respectively. The same values in the elderly group
were 42.4%, 0.20 and 28.5?, respectively. These data
suggest the younger the patient at the time of operation, the
better the radiological outcomes will be. However, fol-
lowup until the later decades of life is required to ascertain
whether the age at the operation influences the risk of OA.
Considering 93% of the hips were dislocated initially
and more than 50% of the patients in our series were older
than 5 years, we believe our clinical and radiographic
results are satisfactory. However, the relatively high rate of
triradiate cartilage damage may be avoided by skilled
1. Barrett WP, Staheli LT, Chew DE. The effectiveness of the Salter
innominate osteotomy in the treatment of congenital dislocation
of the hip. J Bone Joint Surg Am. 1986;68:79–87.
2. Berkeley ME, Dickson JH, Cain TE, Donovan MM. Surgical
therapy for congenital dislocation of the hip in patients who are
twelve to thirty-six months old. J Bone Joint Surg Am.
3. Bohm P, Brzuske A. Salter innominate osteotomy for the treat-
ment of developmental dysplasia of the hip in children: results of
seventy-three consecutive osteotomies after twenty-six to thirty-
five years of follow-up. J Bone Joint Surg Am. 2002;84:178–186.
4. Faciszewski T, Kiefer G, Coleman SS. Pemberton osteotomy for
residual acetabular dysplasia in children who have congenital
dislocation of the hip. J Bone Joint Surg Am. 1993;75:643–649.
5. Gulman B, Tuncay IC, Dabak N, Karaismailoglu N. Salter’s
innominate osteotomy in the treatment of congenital hip dislo-
cation: a long-term review. J Pediatr Orthop. 1994;14:662–666.
Operative Orthopaedics, 10th ed. Philadelphia, PA: Mosby;
7. Heyman CH, Herndon CH. Legg-Perthes disease: a method for
the measurement of the roentgenographic results. J Bone Joint
Surg Am. 1950;32:767–778.
8. Hiertonn T, James U. Congenital dislocation of the hip: experi-
ences of early diagnosis and treatment. J Bone Joint Surg Br.
9. Hilgenreiner WH. Classic. Translation: Hilgenreiner on congen-
ital hip dislocation. J Pediatr Orthop. 1986;6:202–214.
10. Hosny GA, Fattah HA. Salter’s innominate osteotomy: the bio-
logic stimulating effect. J Pediatr Orthop B. 1998;7:150–153.
11. Karakas ES, Baktir A, Argun M, Turk CY. One-stage treatment
of congenital dislocation of the hip in older children. J Pediatr
12. Massie WK, Howorth MB. Congenital dislocation of the hip. Part
I. Methods of grading results. J Bone Joint Surg Am. 1950;32:
13. McKay DW. Pemberton’s innominate osteotomy: indications,
technique, results, pitfalls, complications. In: Tachdjian MO, ed.
Congenital Dislocation of the Hip. New York, NY: Churchill
14. Morin C, Rabay G, Morel G. Retrospective review at skeletal
maturity of the factors affecting the efficacy of Salter’s innomi-
nate osteotomy in congenital dislocated, subluxed and dysplastic
hips. J Pediatr Orthop. 1998;18:246–253.
15. Murphy SB, Ganz R, Muller ME. The prognosis in untreated
dysplasia of the hip: a study of radiographic factors that predict
the outcome. J Bone Joint Surg Am. 1995;77:985–989.
16. O¨meroglu H, Bicimoglu A, Agus H, Tumer Y. Measurement of
center-edge angle in developmental dysplasia of the hip: a
comparison of two methods in patients under 20 years of age.
Skeletal Radiol. 2002;31:25–29.
17. Pemberton PA. Pericapsular osteotomy of the ilium for treatment
of congenital subluxation and dislocation of the hip. J Bone Joint
Surg Am. 1965;47:65–86.
18. Perlik PC, Westin GW, Marafioti RL. A combination pelvic
osteotomy for acetabular dysplasia in children. J Bone Joint Surg
19. Plaster RL, Schoenecker PL, Capelli AM. Premature closure of
the triradiate cartilage: a potential complication of pericapsular
acetabuloplasty: case report. J Pediatr Orthop. 1991;11:676–678.
20. Reimers J. The stability of the hip in children: a radiological
study of the results of muscle surgery in cerebral palsy. Acta
Orthop Scand Suppl. 1980;184:1–100.
21. Rosendahl K, Markestad T, Lie R. Developmental dysplasia of
the hip: a population-based comparison of ultrasound and clinical
findings. Acta Paediatr. 1996;85:64–69.
22. Salter RB. The classic: innominate osteotomy in the treatment of
congenital dislocation, subluxation of the hip by Robert B. Salter
J Bone Joint Surg (Brit) 43B:3:518, 1961. Clin Orthop Relat Res.
23. Salter RB, Dubos JP. The first fifteen years’ personal experience
with innominate osteotomy in the treatment of congenital dislo-
cation and subluxation of the hip. Clin Orthop Relat Res.
Volume 466, Number 4, April 2008The Pembersal Pelvic Osteotomy for DDH 845
24. Scuderi G, Bronson MJ. Triradiate cartilage injury: report of two
cases and review of the literature. Clin Orthop Relat Res.
25. Severin E. Congenital dislocation of the hip: development of the
hip after reduction. J Bone Joint Surg Am. 1950;32:507–518.
acetabulum in young rabbits. Acta Orthop Scand. 1984;55:14–17.
27. Szepesi K, Rigo J, Biro B, Fazekas K, Poti L. Pemberton’s per-
icapsular osteotomy for the treatment of acetabular dysplasia.
J Pediatr Orthop B. 1996;5:252–258.
28. Thielemann F, Schneider A, Ko ¨hler T, Du ¨rrschmidt V, Gu ¨nther
KP. The pericapsular osteotomy of the ilium (Pemberton) in
combination with a derotation and varisation osteotomy of the
proximal femur: results after the end of the maturity process.
Z Orthop. 2003;141:459–464.
29. To ¨nnis D. An evaluation of conservative and operative methods
in the treatment of congenital hip dislocation. Clin Orthop Relat
30. Utterback TD, MacEwen GD. Comparison of pelvic osteotomies
for the surgical correction of the congenital hip. Clin Orthop
Relat Res. 1974;98:104–110.
31. Wada A, Fujii T, Takamura K, Yanagida H, Taketa M, Nakamura
T. Pemberton osteotomy for developmental dysplasia of the hip
in older children. J Pediatr Orthop. 2003;23:508–513.
846 Bursalı et al.Clinical Orthopaedics and Related Research