Long-term result of combination of open reduction and femoral derotation varus osteotomy with shortening for developmental dislocation of the hip

What Is the Impact of a Previous Femoral Osteotomy on THA? A Systematic Review

BACKGROUND

Femoral osteotomies have been widely used to treat a wide range of developmental and degenerative hip diseases. For this purpose, different types of proximal femur osteotomies were developed: at the neck as well as at the trochanteric, intertrochanteric, or subtrochanteric levels. Few studies have evaluated the impact of a previous femoral osteotomy on a THA; thus, whether and how a previous femoral osteotomy affects the outcome of THA remains controversial.

QUESTIONS/PURPOSES

In this systematic review, we asked: (1) What are the most common complications after THA in patients who have undergone femoral osteotomy, and how frequently do those complications occur? (2) What is the survival of THA after previous femoral osteotomy? (3) Is the timing of hardware removal associated with THA complications and survivorship?

METHODS

A systematic review was carried out on PubMed, the Cochrane Systematic Reviews Database, Scopus, and Embase databases with the following keywords: "THA", "total hip arthroplasty", and "total hip replacement" combined with at least one of "femoral osteotomy" or "intertrochanteric osteotomy" to achieve the maximum sensitivity of the search strategy. Identified studies were included if they met the following criteria: (1) reported data on THAs performed after femoral osteotomy; (2) recorded THA followup; (3) patients who underwent THA after femoral osteotomy constituted either the experimental group or a control group; (4) described the surgical and clinical complications and survivorship of the THA. The database search retrieved 383 studies, on which we performed a primary evaluation. After removing duplicates and completing a full-text evaluation for the inclusion criteria, 15 studies (seven historically controlled, eight case series) were included in the final review. Specific information was retrieved from each study included in the final analysis. The quality of each study was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. The mean MINORS score for the historically controlled studies was 14 of 24 (range, 10-17), whereas for the case series, it was 8.1 of 16 (range, 5-10).

RESULTS

The proportion of patients who experienced intraoperative complications during THA ranged from 0% to 17%. The most common intraoperative complication was femoral fracture; other intraoperative complications were difficulties in hardware removal and nerve palsy; 15 studies reported on complications. The survivorship of THA after femoral osteotomy in the 13 studies that answered this question ranged from 43.7% to 100% in studies that had a range of followup from 2 to 20 years. The timing of hardware removal was described in five studies, three of which detailed more complications with hardware removal at the time of THA.

CONCLUSIONS

This systematic review demonstrated that THA after femoral osteotomy is technically more demanding and may carry a higher risk of complications than one might expect after straightforward THA. Staged hardware removal may reduce the higher risk of intraoperative fracture and infection, but there is no clear evidence in support of this contention. Although survivorship of THA after femoral osteotomy was generally high, the studies that evaluated it were generally retrospective case series, with substantial biases, including selection bias and transfer bias (loss to followup), and so it is possible that survivorship of THA in the setting of prior femoral osteotomy may be lower than reported.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Reduction by Pelvic External Fixator Followed by Innominate and Derotational Femoral Osteotomies for Late Presenting Bilateral Developmental Dysplasia of the Hip

Introduction

Bilateral developmental dysplasia of the hip is a challenging situation, closed and open reduction with or without pelvic and femoral osteotomies are all proposed.

Methods

We investigated the feasibility of closed ilizarov reduction combined with Salter and femoral osteotomy to provide stable concentric hips.

Results

We retrospectively reviewed 19 patients (38 hips). Tonnis Criteria, acetabular index and Center-edge angle were measured preoperatively and postoperatively. Acetabular index changed significantly (P<0,001), 80% were excellent or good according to Mckay, 25% were Ia and 69% were IIa Severin's criteria with at least three years follow-up.

Conclusion

The midterm overall results are favorable for application of this technique.

[Dysplasia in the development of the hip]

Developmental dysplasia of the hip (DDH) causes anatomical changes that cause early coxarthrosis. Although risf factors have been determined, the aetiology and physiopathology remains exactly unknown. Neonatal screening with physical examination and ultrasound have been stablished in order to diagnose this disease early in life. A diagnosis in the first months of life is essential as it enables a normal hip to form and prevent the appearance of early coxarthrosis. Treatment principles are to be able to reduce the hip without provoking avascular necrosis of the femoral head, and to normalize the acetabular development. Knowledge of the orthopaedic and surgical options is essential in order to achieve success in the treatment.

Do we need femoral derotation osteotomy in DDH of early walking age group? A clinico-radiological correlation study

INTRODUCTION

The occurrence of exaggerated femoral anteversion and the role of femoral derotation osteotomy in developmental dysplasia of hip, especially early walking age group are controversial.

METHOD

We evaluated femoral anteversion, acetabular anteversion, acetabular index in 15 dislocated hips and 11 normal hips in cases of unilateral dislocation of hip in DDH of age group 12-48 months. We correlated this femoral anteversion with the intra operative "test of stability" which is described by Zadeh et al. We found that there was no statistically significant difference in femoral anteversion between dislocated and normal hips. In all the 15 cases we did open reduction by anterior approach (Somerville approach) and evaluated the position for maximum stability. In 3 cases we were unable to perform test of stability as they needed femoral shortening for reduction of joint.

RESULTS

In the rest 12 hips, 10 were stable in flexion and abduction while 2 were stable in flexion. None of the hips required internal rotation for stability. Hence we did salters osteotomy in all the hips and femoral shortening through lateral approach in 3 cases. At a minimum follow up of 18 months all the hips were clinically stable and none of them dislocated till final follow up. The mean correction of acetabular index was 15.4 degrees and the outcome was excellent in 8 hips and good in 7 hips as per modified McKay's criteria. Hence we recommend that femoral derotation osteotomy is not needed in DDH of early walking age group.

CONCLUSION

As the surgical treatment of DDH involves complex osteotomies around the hip and these surgeries have effect on long term outcome, MRI evaluation of femoral anteversion as a part of pre operative evaluation is advised. Also, as the intra operative evaluation needs enough clinical experience and it can not be performed in cases requiring femoral shortening for reduction, we consider pre operative evaluation of femoral anteversion by MRI as essential rather than adjunctive.

Long-term results after two-stage operative treatment of late developmental displacement of the hip

The purpose of this study was to evaluate the long-term results of 43 patients who underwent two-stage operative treatment of late developmental displacement of the hip (LDH). The average age at the time of open reduction was 20.7 months. An intertrochanteric osteotomy was performed after an average of 6.7 weeks. The mean clinical and radiological follow-up was 32.75 years. Degenerative changes were documented according to Kellgren. For assessment of outcome we used Severin's classification and score according to Merle d'Aubigné. One patient required a total hip replacement. Complications included one superficial infection and three recurrent dislocations. One patient developed coxa magna and two additional avascular necrosis of the hip. The score according to Merle d'Aubigné was 16.1. At the latest follow-up 35 hips had degenerative changes grade 0 or 1 and 7 grade 2. Using the Severin classification 13 hips had a satisfactory result (class I), 14 were rated as class II, 7 as class III, 5 as class IV and 2 as class V. The two-stage procedure seems to be a successful principle in the operative treatment of LDH.

Treatment of developmental dysplasia of the hip after walking age with open reduction, femoral shortening, and acetabular osteotomy

The one-stage surgical treatment for developmental dysplasia of the hip-consisting of open reduction, femoral shortening, and pelvic osteotomy-is a demanding procedure, one that is more challenging, technically, than a staged procedure. It can, however, be done safely and effectively, providing good conditions for proper development of the hip joint in the older child who has untreated developmental dysplasia of the hip.

Successful treatment of high congenital dislocated hips in older children by open reduction, pelvic and femoral osteotomy with external fixator stabilization (average 8.2 years of age)

A new technique using a hinged external fixator to stabilize an open reduction with pelvic and femoral osteotomies has been developed for treating high-dislocated hips in older children with developmental dislocated hip (DDH). This technique was performed in 11 patients (12 hips) at a mean age of 8.2 years. At follow up, radiographic results showed no redislocation/subluxation and clinical results demonstrated 11 hips as excellent/good and only one hip as poor from persistent stiffness. In conclusion, this new technique produces acceptable results in the treatment of older children with high dislocation of the hip from DDH.