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Open reduction and varus-detorsion osteotomy with femoral shortening in treatment of congenital dislocation of the hip
J304 Orthop Sci (1998) 3:304–309
H. Ohsako et al.: Operative treatment of CDH
Open reduction and varus-detorsion osteotomy with femoral shortening in treatment of congenital dislocation of the hip Hirofumi Ohsako, Takashi Sakou, and Shunji Matsunaga Department of Orthopaedic Surgery, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
Abstract: In this study, we clinically and radiographically evaluated open reduction with shortening of the femur in children more than 1 year old with refractory congenital dislocation of the hip. In 19 children (aged 1–4 years), 22 joints were operated on. The patients were followed-up for an average of 8.7 years (range, 2–13 years). Functional results were satisfactory in all joints, and differences in limb length were not significant. Radiographically, good results (grades I and II) were obtained in 16 of the 22 joints, according to Severin’s criteria. This surgical procedure may be indispensable for treating refractory congenital dislocation of the hip in children over 1 year old. Key words: congenital dislocation of the hip, open reduction, varus detorsion osteotomy, shortening of the femur
Introduction When appropriately instituted, conservative therapies for dysplasia in newborns, involving the use of flexible abduction devices including a Pavlik harness, have produced beneficial results, greatly reducing the incidence of complete congenital dislocation of the hip (CDH) and residual dysplasia.9 If CDH cannot be reduced conservatively, open reduction of CDH is indicated, with or without varus derotational osteotomy of the femur,10,12,13 but the results with this procedure have been disappointing because of the frequent occurrence of avascular necrosis of the femoral epiphysis, redislocation, and joint contracture.3,10,12 Thus, finding a satisfactory surgical treatment for CDH remains an unsolved problem.
Offprint requests to: S. Matsunaga Received for publication on May 2, 1997; accepted June 3, 1998
Ombrédanne14 and Hey Groves8 first advocated decompression of the femoral head by shortening of the femur as a means to decrease the complications associated with reduction in the treatment of older children. Subsequent reports1,5,11,15 showed that this surgical procedure was very effective in preventing avascular necrosis of the femoral head and redislocation of the hip in children older than 2 years. The indications for this surgery for children under 3 years old remain controversial, however, and this treatment is limited to selected cases because it demands highly specialized surgical techniques. Since 1982, we have performed open reduction with shortening of the femur in cases of irreducible dislocation in children more than 1 year old. In this study, we evaluated 2- to 13-year follow-up results of this operation clinically and radiographically, leading to a discussion of the appropriate indication for this surgery.
Patients and methods We studied 22 hip joints of 19 patients (2 boys and 17 girls) with irreducible CDH, treated with open reduction with shortening of the femur in our hospital. The patients were all over 6 years of age at final follow-up, and had been followed-up for more than 2 years after surgery. The average age at surgery was 1.9 years (range, 1–4 years), and the average follow-up period was 8.7 years (range, 2–13 years). Four of the patients had been previously treated by manipulative reduction, 5 had been treated with a Pavlik harness, and 4 with overhead traction. The remaining 6 patients had not previously been treated. Preoperative skeletal traction was not used in any of the patients. The hip joints were approached by Smith-Peterson’s anterolateral incision. The rectus femoris and sartorius muscles were separated from their attachment to the ilium, and the articular capsule was exposed. The
H. Ohsako et al.: Operative treatment of CDH
305
iliopsoas was separated at the lesser trochanter, and the articular capsule was incised to open the hip joint. The resisting tissues for reduction, most likely thickened ligamentum capitis femoris, adipose tissue in the acetabulum, and inverted acetabular limbus, were resected. The anterior and inferior portions of the capsule, as well as the transverse acetabular ligament, were also released to facilitate reduction. The femur was osteomized at a level just below the lesser trochanter, and shortened by 1–2 cm. The increased anteversion of the femoral head was reduced to 0 degrees, and the neck-shaft angle of the femur was reduced to 90
degrees, in which position it was fixed with plating. A hip-spica cast was applied and remained in place for 6–8 weeks after the operation. In 9 joints that showed residual acetabular dysplasia, Salter’s innnominate osteotomy was performed, from 6 months to 3 years after the first operation. The characteristics of the patients are summarized in Table 1. Clinical results of the procedure were determined using the assessment system of Gibson and Benson6 in patients over 14 years old at the final follow-up (n 5 5) (Table 2). Results were regarded as satisfactory when a patient was classified as grade I or II. The range of
Table 1. Surgical and follow-up data
Case number
Earlier treatment
Age at operation (years)
Follow-up period (years)
Age at Salter’s operation (years)
Radiological evaluation (Severin18)
Acetabular angle pre-op/ post-op (degrees)
Avascular necrosis pre-op/ post-op
Leg length discrepancy at final follow-up (cm)
IIb
38/44a
1/1
11
Sex
Operation side
1
F
L
PH, 2 months; MR and FP, 2 months
1.8
12.4
2
F
R
PH, 4 months
1
13
Ia
26/47a
2/2
0
3
M
L
PH, 4 months; OHT, 1 month
1
13
IIa
38/43a
2/2
0
4
F
L
None
2.5
12.5
III
35/46a
2/2
0
5
F
L
PH, 1 month; OHT, 1 month
1.7
11.3
2.2
IIa
47/36a
2/1
12
6
F
L
PH, 2 months
1.5
11.5
5
Ib
40/48a
2/2
21
7
F
R
PH, 2 months
1.5
8.5
IIb
38/48a
2/2
11.5
a
5
8
F
L
4
9
III
31/52
2/2
0
9
M
L
PH, 3 months; MR and FP, 2 months
1.5
8.5
IVb
36/56a
1/1
0
10
F
R
PH, 3 months
1.7
7.5
Ib
43/47a
1/1
0
11
F
R
PH, 2 months; OHT, 1 month
1.1
5.5
IIb
35/15
1/1
0
12
F
L
None
3.8
6.5
5
Ia
40/40a
2/2
12
13
F
L
PH, 4 months; MR and FP, 2 months
4
2
5.5
IIa
34/18
1/1
0
14
F
R
PH, 3 months; OHT, 1 month; MR and PH, 2 months
1.3
5
IIb
30/20
1/1
0
15
F
L
None
1.5
5
Ia
39/20
2/2
10.5
16
F
L
None
1.2
5
III
40/23
2/2
0
17
F F
R L
OHT, 1 month OHT, 1 month
2.8 3
13.2 13
Ia III
29/43a 34/47a
2/2 1/1
18
F F
L R
None None
1.5 1.6
11.5 11.4
4.7 5.4
IIb IIb
44/51a 42/49a
2/2 2/2
19
F F
L R
PH, 3 months PH, 3 months
1.3 1.9
5.2 4.6
4.4
III Ib
55/18 48/25
1/1 1/2
4
PH, Pavlik harness; OHT, overhead traction; MR, manual reduction; FP, frog plaster immobilization a Sharp angle
306
H. Ohsako et al.: Operative treatment of CDH
Table 2. Clinical assessment of five patients aged .14 years at final follow-up (Gibson and Benson6) Grade I Grade II Grade III Grade IV
No pain, no limp, unlimited endurance No pain, slight limp, slight restriction of endurance Occasional pain, noticeable limp, endurance moderately restricted Regular pain, marked limp, severe restriction of endurance
motion of the joint was assessed using the method of Ferguson and Howorth.4 Radiographic assessment was done according to Severin’s method.18 Grades I or II were judged as satisfactory and grades III or IV were considered unsatisfactory.
Results The clinical results, evaluated in the five patients who were more than 14 years old at final follow-up, were satisfactory; four were evaluated as grade I and one as grade II. In the follow-up of the entire group of 19 patients, the range of motion was excellent in 17 of 22 hip joints (77%) and good in 5 hip joints (23%). Internal rotation was slightly restricted in 7 of 22 hips (32%). Trendelenburg’s sign was noted in 3 (16%) of the 19 patients, and external rotation gait was observed in 1 (5%). The leg length on the surgical side at the final follow-up was, in most patients, the same as that on the unaffected side, but 6 legs showed a discrepancy in length (less than 2 cm in all 6). The acetabular angle ranged between 25 and 55 degrees (means, 38.0 degrees) before surgery, and was significantly decreased in 8 hips after the surgical reduction, while acetabular dysplasia was not improved in 14 hips. Salter’s innominate osteotomy was performed additionally in 9 of these 14 hips 6 months to 3 years after the initial surgery. Concentric reduction was achieved surgically in all the joints, with the center edge (CE) angle between 0 and 30 degrees (mean, 18 degrees) at the final follow-up. The neck-shaft angle of the femur averaged 140.1 degrees (range, 123–162 degrees) at the final follow-up. Radiographic evidence of avascular necrosis in the femoral head was evaluated according to the criteria of Salter et al.16 Avascular necrosis of the femoral head was judged to have occurred in 9 hip joints in 9 different patients before the operation, all of whom had been treated with closed manipulative procedures and had been held in the frog-leg position by a plaster cast, or treated with a Pavlik harness or overhead traction. Avascular necrosis of the femoral head was not found postoperatively in 6 hip joints of the 5 patients who had not had any previous treatments. According to Severin’s18 classification, the radiographic results were:
Fig. 1. Radiographic assessment according to Severin.18 Grades I and II, satisfactory; grades III, IV, V, and VI, unsatisfactory. The gray areas show joints in which Salter’s osteotomy was also performed. n 5 22 joints
grade I in 7 joints (32%), grade II in 9 joints (40%), grade III in 5 joints (23%), and grade IV in 1 joint (5%). Thus, the results were satisfactory in 72% of the joints (Fig. 1). Satisfactory results were obtained in 6 (67%) of the 9 joints which had avascular necrosis of the femoral head preoperatively, and in 10 (77%) of the 13 joints which did not have avascular necrosis of the femoral head preoperatively.
Case presentation Case 11. Girl (aged 6.6 years at final follow-up) CDH of the right hip was diagnosed in this patient 1 month after birth. A Pavlik harness was applied when she was aged 10 months and its use continued for 2 months, but reduction was not achieved (Fig. 2a). In addition, reduction was not achieved after 4 weeks of overhead traction. The preoperative acetabular angle was 35 degrees. Open reduction was performed, with shortening of the femur, when she was aged 13 months (Fig. 2b). When she was followed up 5.5 years after the operation, the girl’s condition was determined radiographically to be Severin’s grade II. At 6.6 years of age, the acetabular angle had improved to 15 degrees (Fig. 2c).
H. Ohsako et al.: Operative treatment of CDH
307
Case 12. Girl (aged 10 years at final follow-up) Diagnosis of CDH of the left hip was made when this patient was 3 years old (Fig. 3a). Open reduction was performed, with shortening of the femur. Nine months after the initial surgery, Salter’s innominate osteotomy was performed (Fig. 3b). Ten years after the initial operation, the patient’s condition was radiographically determined as grade I (Fig. 3c), which was considered a satisfactory outcome.
Discussion
a
b
In children under 18 months of age with CDH in whom concentric reduction cannot be achieved by appropriate conservative treatments, an open reduction is usually indicated. However, open reduction has frequent serious complications involving redislocation and avascular necrosis of the femoral head.10,12 Avascular necrosis of the femoral head occurred in 11%–67% of patients treated with open reduction, and the radiographic results were acceptable in 46%–96% of patients at 10or 20-year follow-up.10,13 Derotational femoral shortening was first performed by Ombrédanne14 and Hey Groves8 to treat children aged between 24 months and 4 years with so-called high-riding hip. Several subsequent reports5,11 emphasized that this procedure was effective in preventing avascular necrosis of the femoral head in children over 2 years of age. Wenger et al.21 treated 15 children younger than 2 years of age who had irreducible CDH by performing an open reduction combined with femoral shortening. In that series, this procedure produced a high rate of stable reduction and satisfactory clinical and radiographic results. Partial femoral head necrosis was noted in only two patients. In other reports,5,11,21 the incidence of avascular necrosis was also markedly reduced in patients treated with shortening of the femur compared to results in those treated without the shortening. In our series, avascular necrosis of the femoral head was not found in any of the children with CDH who had been treated primarily with derotational femoral shortening. This finding confirmed that decompression of the femoral head by shortening of the femur helps to prevent avascular necrosis of the femoral head. However, an extremely proximally placed femoral osteotomy may predispose patients to avascular necrosis in rare cases.20
b
c
Fig. 2a–c. Case 11. Girl (aged 6.6 years at follow-up). a Preoperative radiogram of the hip joint; b Two months after femoral derotational varus osteotomy with shortening; c Radiogram 5.5 years after operation
308
H. Ohsako et al.: Operative treatment of CDH
children aged as young as 5 months. However, we do not recommend this procedure for children less than 12 months of age because surgical procedures in such young patients may be extremely difficult. The performance and fixation of derotational femoral shortening must be precise. Most authors advise that a 1- to 2-cm-long bone segment be removed from the proximal femur near the lesser trochanter1,5,21 in children aged less than 2 years. About 90 degrees of derotation1 and a 115-degree neck-shaft angle11 are generally recommended to achieve a stable reduction. We performed derotational varus osteotomy to the same degree specifications. This technique provides a pressure-free reduction. Earlier studies found that limb-length inequality corrected spontaneously, probably because the femoral osteotomy stimulated growth,5,17,19,21 and we achieved similar results in our study. Acetabular dysplasia appeared likely to resolve spontaneously after surgical reduction in patients under 2 years of age, and subsequently some of our patients did not require an acetabuloplasty. Salter’s innominate osteotomy shoud generally be performed as a supplementary procedure if acetabular dysplasia is not improved in children over 5 years of age.7 In children aged over 3 years, a one-stage operation of derotational femoral shortening combined with innominate osteotomy may be indicated.5,21 A major goal in treating patients with CDH is to minimize the iatrogenic complication of avascular necrosis of the femoral head. This study showed that derotational femoral shortening was very effective in preventing avascular necrosis of the femoral head in irreducible CDH. We also emphasize that abnormalities in bony and soft tissues, which hinder concentric reduction of the femoral head in the acetabulum, should be evaluated radiographically before surgery. The simultaneous correction of these associated abnormalities is also important for obtaining a stable hip.
a
b
References c Fig. 3a–c. Case 12. Girl (aged 10 years at follow-up). a Preoperative radiogram of the hip joint; b Salter’s osteotomy was done 14 months after femoral derotational varus osteotomy with shortening; c radiogram 6.5 years after operation
Derotational femoral shortening is generally considered to be a standard surgical procedure for children aged over 2 years with CDH.2 Wenger et al.21 have mentioned that this procedure can be indicated for
1. Browne RS. The management of late diagnosed congenital dislocation and subluxation of the hip. J Bone Joint Surg Br 1979;61: 7–12. 2. Coleman SS. Congenital dysplasia and dislocation of the hip. St Louis: Mosby, 1978:72–154. 3. Doudoulakis JK, Cavadias A. Open reduction of CDH before 1 year of age. 69 hips followed for 13 (10–19) years. Acta Orthop Scand 1993;64:188–192. 4. Ferguson AB, Howorth MB. Slipping of the upper femoral epiphysis. A study of 70 cases. JAMA 1931;97:1867–72. 5. Galpin RD, Roach JW, Wenger DR, et al. One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening. J Bone Joint Surg Am 1989:71:734–41. 6. Gibson PH, Benson MKD. Congenital dislocation of the hip: Review at maturity of 147 hips treated by excision of the limbus
H. Ohsako et al.: Operative treatment of CDH
7.
8.
9.
10.
11.
12.
13.
and derotation osteotomy. J Bone Joint Surg Br 1982;64:169– 75. Gulman B, Tuncay IC, Dabak N, et al. Salter’s innominate osteotomy in the treatment of congenital hip dislocation: A longterm review. J Pediatr Orthop 1994;14:662–6. Hey Groves EW. The treatment of congenital dislocation of the hip-joint, with special reference to open operative reduction. In: Milford H, editor. The Robert Jones birthday volume. London: Oxford University Press, 1928:73–96. Inao S, Ando M, Gotoh E. Present appearances of congenital dislocation of the hip in various countries. Seikeigeka (Orthopedic Surgery) 1993;44:570–6 (in Japanese). Kalamchi A, Schmidt TL, MacEwen GD. Congenital dislocation of the hip. Open reduction by the medial approach. Clin Orthop 1982;169:127–32. Klisic P, Jankovic L. Combined procedure of open reduction and shortening of the femur in treatment of congenital dislocation of the hips in older children. Clin Orthop 1976;119:60–9. Koizumi W, Moriya H, Tsuchiya K, et al. Ludloff’s medial approach for open reduction of congenital dislocation of the hip. A 20-year follow-up. J Bone Joint Surg Br 1996;78:924–9. Mankey MG, Arntz CT, Staheli LT. Open reduction through a medial approach for congenital dislocation of the hip. A critical review of the Ludloff approach in 66 hips. J Bone Joint Surg Am 1993;75:1334–44.
309 14. Ombrédanne L. Précis clinique et opératoire de chirurgie infantile. Paris: Masson, 1923. 15. Potasz P, Bandyra A, Saraste H. Double osteotomy for congenital dislocation of the hip: 55 hips followed for 3–8 years. Orthop Int 1993;1:341–4. 16. Salter RB, Kostuik J, Dallas S. Avascular necrosis of the femoral head as a complication of treatment for congenital dislocation of the hip in young children: A clinical and experimental investigation. Can J Surg 1969:12:44–61. 17. Schoenecker PL, Strecker WB. Congenital dislocation of the hip in children. Comparison of the effects of femoral shortening and of skeletal traction in treatment. J Bone Joint Surg Am 1984:66:21–7. 18. Severin E. Contribution to the knowledge of congenital dislocation of the hip joint. Late results of closed reduction and arthrographic studies of recent cases. Acta Chir Scand 1941;84:1–142. 19. Shee B-W, Huang S-C, Liu T-K. One-stage correction of neglected congenital dislocation of the hip without preoperative traction. J Formos Med Assoc 1993;92:729–36. 20. Tönnis D. Congenital dysplasia and dislocation of the hip in children and adults. Berlin: Springer, 1987. 21. Wenger DR, Lee C-S, Kolman B. Derotational femoral shortening for developmental dislocation of the hip: Special indications and results in the child younger than 2 years. J Pediatr Orthop 1995;15:768–79.
H. Ohsako et al.: Operative treatment of CDH
Open reduction and varus-detorsion osteotomy with femoral shortening in treatment of congenital dislocation of the hip Hirofumi Ohsako, Takashi Sakou, and Shunji Matsunaga Department of Orthopaedic Surgery, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
Abstract: In this study, we clinically and radiographically evaluated open reduction with shortening of the femur in children more than 1 year old with refractory congenital dislocation of the hip. In 19 children (aged 1–4 years), 22 joints were operated on. The patients were followed-up for an average of 8.7 years (range, 2–13 years). Functional results were satisfactory in all joints, and differences in limb length were not significant. Radiographically, good results (grades I and II) were obtained in 16 of the 22 joints, according to Severin’s criteria. This surgical procedure may be indispensable for treating refractory congenital dislocation of the hip in children over 1 year old. Key words: congenital dislocation of the hip, open reduction, varus detorsion osteotomy, shortening of the femur
Introduction When appropriately instituted, conservative therapies for dysplasia in newborns, involving the use of flexible abduction devices including a Pavlik harness, have produced beneficial results, greatly reducing the incidence of complete congenital dislocation of the hip (CDH) and residual dysplasia.9 If CDH cannot be reduced conservatively, open reduction of CDH is indicated, with or without varus derotational osteotomy of the femur,10,12,13 but the results with this procedure have been disappointing because of the frequent occurrence of avascular necrosis of the femoral epiphysis, redislocation, and joint contracture.3,10,12 Thus, finding a satisfactory surgical treatment for CDH remains an unsolved problem.
Offprint requests to: S. Matsunaga Received for publication on May 2, 1997; accepted June 3, 1998
Ombrédanne14 and Hey Groves8 first advocated decompression of the femoral head by shortening of the femur as a means to decrease the complications associated with reduction in the treatment of older children. Subsequent reports1,5,11,15 showed that this surgical procedure was very effective in preventing avascular necrosis of the femoral head and redislocation of the hip in children older than 2 years. The indications for this surgery for children under 3 years old remain controversial, however, and this treatment is limited to selected cases because it demands highly specialized surgical techniques. Since 1982, we have performed open reduction with shortening of the femur in cases of irreducible dislocation in children more than 1 year old. In this study, we evaluated 2- to 13-year follow-up results of this operation clinically and radiographically, leading to a discussion of the appropriate indication for this surgery.
Patients and methods We studied 22 hip joints of 19 patients (2 boys and 17 girls) with irreducible CDH, treated with open reduction with shortening of the femur in our hospital. The patients were all over 6 years of age at final follow-up, and had been followed-up for more than 2 years after surgery. The average age at surgery was 1.9 years (range, 1–4 years), and the average follow-up period was 8.7 years (range, 2–13 years). Four of the patients had been previously treated by manipulative reduction, 5 had been treated with a Pavlik harness, and 4 with overhead traction. The remaining 6 patients had not previously been treated. Preoperative skeletal traction was not used in any of the patients. The hip joints were approached by Smith-Peterson’s anterolateral incision. The rectus femoris and sartorius muscles were separated from their attachment to the ilium, and the articular capsule was exposed. The
H. Ohsako et al.: Operative treatment of CDH
305
iliopsoas was separated at the lesser trochanter, and the articular capsule was incised to open the hip joint. The resisting tissues for reduction, most likely thickened ligamentum capitis femoris, adipose tissue in the acetabulum, and inverted acetabular limbus, were resected. The anterior and inferior portions of the capsule, as well as the transverse acetabular ligament, were also released to facilitate reduction. The femur was osteomized at a level just below the lesser trochanter, and shortened by 1–2 cm. The increased anteversion of the femoral head was reduced to 0 degrees, and the neck-shaft angle of the femur was reduced to 90
degrees, in which position it was fixed with plating. A hip-spica cast was applied and remained in place for 6–8 weeks after the operation. In 9 joints that showed residual acetabular dysplasia, Salter’s innnominate osteotomy was performed, from 6 months to 3 years after the first operation. The characteristics of the patients are summarized in Table 1. Clinical results of the procedure were determined using the assessment system of Gibson and Benson6 in patients over 14 years old at the final follow-up (n 5 5) (Table 2). Results were regarded as satisfactory when a patient was classified as grade I or II. The range of
Table 1. Surgical and follow-up data
Case number
Earlier treatment
Age at operation (years)
Follow-up period (years)
Age at Salter’s operation (years)
Radiological evaluation (Severin18)
Acetabular angle pre-op/ post-op (degrees)
Avascular necrosis pre-op/ post-op
Leg length discrepancy at final follow-up (cm)
IIb
38/44a
1/1
11
Sex
Operation side
1
F
L
PH, 2 months; MR and FP, 2 months
1.8
12.4
2
F
R
PH, 4 months
1
13
Ia
26/47a
2/2
0
3
M
L
PH, 4 months; OHT, 1 month
1
13
IIa
38/43a
2/2
0
4
F
L
None
2.5
12.5
III
35/46a
2/2
0
5
F
L
PH, 1 month; OHT, 1 month
1.7
11.3
2.2
IIa
47/36a
2/1
12
6
F
L
PH, 2 months
1.5
11.5
5
Ib
40/48a
2/2
21
7
F
R
PH, 2 months
1.5
8.5
IIb
38/48a
2/2
11.5
a
5
8
F
L
4
9
III
31/52
2/2
0
9
M
L
PH, 3 months; MR and FP, 2 months
1.5
8.5
IVb
36/56a
1/1
0
10
F
R
PH, 3 months
1.7
7.5
Ib
43/47a
1/1
0
11
F
R
PH, 2 months; OHT, 1 month
1.1
5.5
IIb
35/15
1/1
0
12
F
L
None
3.8
6.5
5
Ia
40/40a
2/2
12
13
F
L
PH, 4 months; MR and FP, 2 months
4
2
5.5
IIa
34/18
1/1
0
14
F
R
PH, 3 months; OHT, 1 month; MR and PH, 2 months
1.3
5
IIb
30/20
1/1
0
15
F
L
None
1.5
5
Ia
39/20
2/2
10.5
16
F
L
None
1.2
5
III
40/23
2/2
0
17
F F
R L
OHT, 1 month OHT, 1 month
2.8 3
13.2 13
Ia III
29/43a 34/47a
2/2 1/1
18
F F
L R
None None
1.5 1.6
11.5 11.4
4.7 5.4
IIb IIb
44/51a 42/49a
2/2 2/2
19
F F
L R
PH, 3 months PH, 3 months
1.3 1.9
5.2 4.6
4.4
III Ib
55/18 48/25
1/1 1/2
4
PH, Pavlik harness; OHT, overhead traction; MR, manual reduction; FP, frog plaster immobilization a Sharp angle
306
H. Ohsako et al.: Operative treatment of CDH
Table 2. Clinical assessment of five patients aged .14 years at final follow-up (Gibson and Benson6) Grade I Grade II Grade III Grade IV
No pain, no limp, unlimited endurance No pain, slight limp, slight restriction of endurance Occasional pain, noticeable limp, endurance moderately restricted Regular pain, marked limp, severe restriction of endurance
motion of the joint was assessed using the method of Ferguson and Howorth.4 Radiographic assessment was done according to Severin’s method.18 Grades I or II were judged as satisfactory and grades III or IV were considered unsatisfactory.
Results The clinical results, evaluated in the five patients who were more than 14 years old at final follow-up, were satisfactory; four were evaluated as grade I and one as grade II. In the follow-up of the entire group of 19 patients, the range of motion was excellent in 17 of 22 hip joints (77%) and good in 5 hip joints (23%). Internal rotation was slightly restricted in 7 of 22 hips (32%). Trendelenburg’s sign was noted in 3 (16%) of the 19 patients, and external rotation gait was observed in 1 (5%). The leg length on the surgical side at the final follow-up was, in most patients, the same as that on the unaffected side, but 6 legs showed a discrepancy in length (less than 2 cm in all 6). The acetabular angle ranged between 25 and 55 degrees (means, 38.0 degrees) before surgery, and was significantly decreased in 8 hips after the surgical reduction, while acetabular dysplasia was not improved in 14 hips. Salter’s innominate osteotomy was performed additionally in 9 of these 14 hips 6 months to 3 years after the initial surgery. Concentric reduction was achieved surgically in all the joints, with the center edge (CE) angle between 0 and 30 degrees (mean, 18 degrees) at the final follow-up. The neck-shaft angle of the femur averaged 140.1 degrees (range, 123–162 degrees) at the final follow-up. Radiographic evidence of avascular necrosis in the femoral head was evaluated according to the criteria of Salter et al.16 Avascular necrosis of the femoral head was judged to have occurred in 9 hip joints in 9 different patients before the operation, all of whom had been treated with closed manipulative procedures and had been held in the frog-leg position by a plaster cast, or treated with a Pavlik harness or overhead traction. Avascular necrosis of the femoral head was not found postoperatively in 6 hip joints of the 5 patients who had not had any previous treatments. According to Severin’s18 classification, the radiographic results were:
Fig. 1. Radiographic assessment according to Severin.18 Grades I and II, satisfactory; grades III, IV, V, and VI, unsatisfactory. The gray areas show joints in which Salter’s osteotomy was also performed. n 5 22 joints
grade I in 7 joints (32%), grade II in 9 joints (40%), grade III in 5 joints (23%), and grade IV in 1 joint (5%). Thus, the results were satisfactory in 72% of the joints (Fig. 1). Satisfactory results were obtained in 6 (67%) of the 9 joints which had avascular necrosis of the femoral head preoperatively, and in 10 (77%) of the 13 joints which did not have avascular necrosis of the femoral head preoperatively.
Case presentation Case 11. Girl (aged 6.6 years at final follow-up) CDH of the right hip was diagnosed in this patient 1 month after birth. A Pavlik harness was applied when she was aged 10 months and its use continued for 2 months, but reduction was not achieved (Fig. 2a). In addition, reduction was not achieved after 4 weeks of overhead traction. The preoperative acetabular angle was 35 degrees. Open reduction was performed, with shortening of the femur, when she was aged 13 months (Fig. 2b). When she was followed up 5.5 years after the operation, the girl’s condition was determined radiographically to be Severin’s grade II. At 6.6 years of age, the acetabular angle had improved to 15 degrees (Fig. 2c).
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Case 12. Girl (aged 10 years at final follow-up) Diagnosis of CDH of the left hip was made when this patient was 3 years old (Fig. 3a). Open reduction was performed, with shortening of the femur. Nine months after the initial surgery, Salter’s innominate osteotomy was performed (Fig. 3b). Ten years after the initial operation, the patient’s condition was radiographically determined as grade I (Fig. 3c), which was considered a satisfactory outcome.
Discussion
a
b
In children under 18 months of age with CDH in whom concentric reduction cannot be achieved by appropriate conservative treatments, an open reduction is usually indicated. However, open reduction has frequent serious complications involving redislocation and avascular necrosis of the femoral head.10,12 Avascular necrosis of the femoral head occurred in 11%–67% of patients treated with open reduction, and the radiographic results were acceptable in 46%–96% of patients at 10or 20-year follow-up.10,13 Derotational femoral shortening was first performed by Ombrédanne14 and Hey Groves8 to treat children aged between 24 months and 4 years with so-called high-riding hip. Several subsequent reports5,11 emphasized that this procedure was effective in preventing avascular necrosis of the femoral head in children over 2 years of age. Wenger et al.21 treated 15 children younger than 2 years of age who had irreducible CDH by performing an open reduction combined with femoral shortening. In that series, this procedure produced a high rate of stable reduction and satisfactory clinical and radiographic results. Partial femoral head necrosis was noted in only two patients. In other reports,5,11,21 the incidence of avascular necrosis was also markedly reduced in patients treated with shortening of the femur compared to results in those treated without the shortening. In our series, avascular necrosis of the femoral head was not found in any of the children with CDH who had been treated primarily with derotational femoral shortening. This finding confirmed that decompression of the femoral head by shortening of the femur helps to prevent avascular necrosis of the femoral head. However, an extremely proximally placed femoral osteotomy may predispose patients to avascular necrosis in rare cases.20
b
c
Fig. 2a–c. Case 11. Girl (aged 6.6 years at follow-up). a Preoperative radiogram of the hip joint; b Two months after femoral derotational varus osteotomy with shortening; c Radiogram 5.5 years after operation
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children aged as young as 5 months. However, we do not recommend this procedure for children less than 12 months of age because surgical procedures in such young patients may be extremely difficult. The performance and fixation of derotational femoral shortening must be precise. Most authors advise that a 1- to 2-cm-long bone segment be removed from the proximal femur near the lesser trochanter1,5,21 in children aged less than 2 years. About 90 degrees of derotation1 and a 115-degree neck-shaft angle11 are generally recommended to achieve a stable reduction. We performed derotational varus osteotomy to the same degree specifications. This technique provides a pressure-free reduction. Earlier studies found that limb-length inequality corrected spontaneously, probably because the femoral osteotomy stimulated growth,5,17,19,21 and we achieved similar results in our study. Acetabular dysplasia appeared likely to resolve spontaneously after surgical reduction in patients under 2 years of age, and subsequently some of our patients did not require an acetabuloplasty. Salter’s innominate osteotomy shoud generally be performed as a supplementary procedure if acetabular dysplasia is not improved in children over 5 years of age.7 In children aged over 3 years, a one-stage operation of derotational femoral shortening combined with innominate osteotomy may be indicated.5,21 A major goal in treating patients with CDH is to minimize the iatrogenic complication of avascular necrosis of the femoral head. This study showed that derotational femoral shortening was very effective in preventing avascular necrosis of the femoral head in irreducible CDH. We also emphasize that abnormalities in bony and soft tissues, which hinder concentric reduction of the femoral head in the acetabulum, should be evaluated radiographically before surgery. The simultaneous correction of these associated abnormalities is also important for obtaining a stable hip.
a
b
References c Fig. 3a–c. Case 12. Girl (aged 10 years at follow-up). a Preoperative radiogram of the hip joint; b Salter’s osteotomy was done 14 months after femoral derotational varus osteotomy with shortening; c radiogram 6.5 years after operation
Derotational femoral shortening is generally considered to be a standard surgical procedure for children aged over 2 years with CDH.2 Wenger et al.21 have mentioned that this procedure can be indicated for
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