The shelf operation for hip dysplasia in adolescence

Developmental Dysplasia of the Hip: Controversies in Management

PURPOSE OF REVIEW

Many aspects of developmental hip dysplasia (DDH) care and evaluation are still active areas of debate. Recent studies have provided more insight into these topics such as strategies for reducing osteonecrosis, assessing hip reduction after closed and open reduction, and the management of residual acetabular dysplasia.

RECENT FINDINGS

The presence of the ossific nucleus at the time of reduction does not alter the risk of osteonecrosis. The risk of osteonecrosis may be higher when hips are immobilized in excessive abduction. Limited sequence MRI may be the best choice for assessing hip reduction after closed and open reduction; however, new technologies are emerging such as 3D fluoroscopy and perfusion MRI. The treatment of residual acetabular dysplasia with bracing has been shown to be effective and the decision to perform a pelvic osteotomy is based on patient-specific factors. The spectrum of DDH treatment has evolved over the past several decades. Recent studies have provided insights into strategies for osteonecrosis prevention, hip evaluation during after reduction, and the management of residual acetabular dysplasia. However, there is ample room for additional and more rigorous studies guiding advanced imaging for assessing hip reduction such as 3D fluoroscopy and perfusion MRI, as well as the management of residual acetabular dysplasia.

Radiological results of Shelf acetabuloplasty in adolescent hip dysplasia with aspherical femoral head: how to get an ideal placement of the Shelf graft

Shelf acetabuloplasty continues to be effective in the prevention or delay of osteoarthritis in adolescent dysplastic hips. We aimed to evaluate the efficacy and to determine the correct level of the bone graft objectively. We retrospectively analyzed 16 hips underwent Shelf acetabuloplasty originated by Spitzy. The mean age at surgery was 15.3 years old with the mean caput index at 39.7%. The average follow-up was 11 years. The radiological evaluation was based on acetabular-head index (AHI) at preoperative and latest radiographs, acetabular-Shelf distance (ASD) and Shelf-head ratio at immediate postoperative and latest radiographs. The cutoff value for the ideal ASD was determined by receiver operating characteristic (ROC) and the Pearson correlation test used in statistical analysis to assess the relationship between ASD and Shelf graft resorption. Clinical evaluation was performed using Harris Hip Score (HHS) at the latest follow-up. The AHI was improved in all cases, from mean 56.9 to 91.0% (P < 0.001). The mean of ASD was 7 mm. In nine of the 16 cases, the Shelf graft was well united at the same level of the existing acetabulum with good continuity. The ROC curve showed the cutoff value for the ideal ASD was 6 mm. The Pearson correlation test also showed a positive relationship between ASD and Shelf graft resorption (P = 0.001). The average of HHS scores was 98.1 points. Both radiological and clinical results were acceptable. The ideal placement that keeps the shelf sufficient to bear the mechanical stress without bone resorption over time was at the level of 6 mm from the joint space. Level III - therapeutic study.

Pelvic Osteotomies in the Child and Young Adult Hip: Indications and Surgical Technique

Pelvic osteotomies are used for hip preservation in children and young adults to improve femoral head coverage and stabilize the hip joint. Redirectional osteotomies aim to reduce the overall volume and redirect the acetabulum. These include Salter, Pemberton, Dega, and San Diego osteotomies. Reorientation osteotomies aim to reorient the acetabulum and include periacetabular and triple osteotomies. Salvage osteotomies aim to enlarge the acetabulum and medialize the hip center. These include shelf and Chiari osteotomies. The standard anterior approach and surgical technique for the eight pelvic osteotomies used by hip preservation surgeons are described along with each osteotomy's history, indications, and outcomes.

Open treatment of dysplasia-other than PAO: does it have to be a PAO?

Hip dysplasia is a developmental disorder that results in anatomic abnormalities in which the acetabular coverage is insufficient. In the absence of severe degenerative changes, younger active patients with these symptomatic structural abnormalities are increasingly managed with joint-preserving operations. Historically there have been numerous reconstructive pelvic osteotomies. In recent years, the Bernese periacetabular osteotomy (PAO) has become the preferred osteotomy by many surgeons. Even so, as our understanding of the hip advances and new diagnostic and treatment techniques are developed, we sought to put a focus on the long-term results of augmental osteotomies and pelvic osteotomies other than the PAO, to see if any of these surgeries still have a place in the current algorithm of treatment for the dysplastic hip. As the longevity of the treatment is the focal point for joint preservation surgeries for the dysplastic hip, these authors have searched databases for articles in the English literature that reported results of long-term follow-up with a minimum of 11-year survivorship after surgical treatment of developmental dysplasia of the hip. Reconstruction osteotomies for the dysplastic hip are intended to restore normal hip anatomy and biomechanics, improve symptoms and prevent degenerative changes, in this manuscript each procedure is independently assessed on the ability to achieve these important characteristics.

Treatment of adolescents with a periacetabular osteotomy after previous pelvic surgery

BACKGROUND

Although the success of the Bernese periacetabular osteotomy (PAO) has been reported for primary dysplasia, there is no study analyzing the radiographic, functional, and gait results of the PAO to correct residual hip dysplasia after previous pelvic surgery.

QUESTIONS/PURPOSES

We assessed (1) radiographic and (2) functional and gait outcomes of patients treated with a PAO after previous pelvic surgery (PPSx) and compared their results with results of patients with no previous surgery (NPSx) to determine whether the PAO was equally effective in patients with revision pelvic surgery.

METHODS

Twenty-nine dysplastic hips in 26 patients (average age, 16.3 years) were included: 13 in the PPSx group and 13 in the NPSx group. Radiographic parameters included the lateral center-edge angle, acetabular index, and femoral head extrusion index measured preoperatively and at 6 months and 1 year. We assessed preoperative and postoperative function using the Harris hip score (HHS). Preoperative and postoperative gait analysis included the hip abductor impulse.

RESULTS

Improvements in groups were seen from preoperatively to 1 year postoperatively for the lateral center-edge angle, acetabular index, and femoral head extrusion index without differences between groups. The modified HHSs improved at 6 months and were maintained at 1 year for patients in both groups without differences between groups. The hip abductor impulse returned to preoperative values at 6 months in the NPSx group but not until 1 year in the PPSx group.

CONCLUSIONS

The Bernese PAO is effective in providing similar final radiographic and functional results, however, a trend toward decreased hip flexion and abduction power at 1 year was seen with previous pelvic surgery.

A shelf procedure at a follow-up of 75 years

Developmental dysplasia of the hip predisposes to premature degenerative hip disease. A number of operations have been described to improve acetabular cover and have achieved varying degrees of success. We present the case of an 84-year-old woman, who underwent a shelf procedure to reconstruct a dysplastic hip 75 years ago. To date, the shelf remains intact and the hip is asymptomatic. We believe this represents the longest documented outcome of any procedure to stabilise the hip.

Long-term results after closed reduction of latedetected hip dislocation: 60 patients followed up to skeletal maturity

BACKGROUND

This retrospective study was undertaken because there is limited knowledge about the long-term results after closed reduction of late-detected hip dislocation. The aims were to evaluate the outcome after skeletal maturity and to find predictive factors for good and poor results.

PATIENTS AND METHODS

The material included 60 patients (78 hips, 53 girls) treated during the period 1958-62. The primary treatment was skin traction for 36 (16-76) days. Closed reduction was performed in all hips except 4 that needed open reduction. The mean age at reduction was 20 (4-65) months. Hip spica plaster was worn for 9 (6-20) months. Within 3 years of the start of treatment, derotation femoral osteotomy was performed because of increased femoral anteversion in 35 patients. Later, 28 patients underwent additional surgery on the femur or acetabulum to improve femoral head coverage. Radiographs at the time of diagnosis and during follow-up to skeletal maturity were assessed. The average age of the patients at the most recent follow-up was 26 (15-42) years.

RESULTS

The femoral head coverage normalized during the primary treatment and then decreased somewhat during the remaining growth period. The dysplasia of the acetabulum improved markedly during the first year after reduction. It continued to improve, but to a much lesser degree, until 8-10 years of age. A satisfactory radiographic outcome at skeletal maturity (Severin grades I and II) was obtained in 63% of the hips. Early derotation osteotomy of the femur did not improve the outcome. Avascular necrosis of the femoral head occurred in 14% of the hips. Risk factors for unsatisfactory outcome at skeletal maturity were high initial dislocation, steep acetabulum 1 year after reduction, reduced femoral head coverage at age 8-10 years, and avascular necrosis.

INTERPRETATION

The specific risk factors and the radiographic outcome--with satisfactory long-term results in nearly two-thirds of the patients--would be valuable for comparison with outcome studies after more modern treatment regimes.

Is there a place for shelf acetabuloplasty in the management of adult acetabular dysplasia?

We followed up 76 consecutive hips with symptomatic acetabular dysplasia treated by acetabular shelf augmentation for a mean period of 11 years. Survival analysis using conversion to hip replacement as an end-point was 86% at five years and 46% at ten years. Forty-four hips with slight or no narrowing of the joint space pre-operatively had a survival of 97% at five and 75% at ten years. This was significantly higher (p = 0.0007) than that of the 32 hips with moderate or severe narrowing of the joint-space, which was 76% at five and 22% at ten years. There was no significant relationship between survival and age (p = 0.37) or the pre- and post-operative centre-edge (p = 0.39) and acetabular angles (p = 0.85).

Shelf acetabuloplasty is a reliable, safe procedure offering medium-term symptomatic relief for adults with acetabular dysplasia. The best results were achieved in patients with mild and moderate dysplasia of the hip with little arthritis.

Comparison between Salter's innominate osteotomy and augmented acetabuloplasty in the treatment of patients with severe Legg-Calvé-Perthes disease. Analysis of 90 hips with special reference to roentgenographic sphericity and coverage of the femoral head

This is a roentgenographic and retrospective study comparing the results of two different operative procedures used in the treatment of Legg-Calvé-Perthes disease: Salter innominate osteotomy, and Augmented Acetabuloplasty. Group I comprised 43 patients (50 hips) who underwent Salter osteotomy. Another 40 patients (40 hips) were treated by Augmented Acetabuloplasty and formed Group 2. In Group 1, 11 (25.58%) patients were girls and 32 (74.42%) were boys. In Group 2, there were 4 (10%) girl and 36 (90%) boy patients. The average age was 6.62 years in Group 1 and 6.35 years in Group 2. Follow-up varied from 2 years to 10 years in both Groups 1 and 2. In Group 1, 18 (36%) hips were in the stage of necrosis, 28 (56%) in fragmentation, and 4 (8%) in reossification; in Group 2, 16 (40%) hips were in necrosis, 23 (57.5%) in fragmentation, and only 1 (2.5%) in reossification. All hips in necrosis were included in Salter and Thompson group B; all hips in fragmentation were classed as Catterall group 3 or 4. Preoperative arthrographs of the 50 hips in Group I were graded according to Laredo: 29 (58%) in group III, 18 (36%) in group IV, and 3 (6%) in group V. Only 23 of the 43 hips of Group 2 had preoperative arthrographs; there were 14 (60.87%) in group III, 8 (34.78%) in group IV, and 1 (4.35%) in group V. The preoperative Wiberg's Center-Edge (CE) angle of Group 2 (19.4 degrees) was significantly greater than that of Group 1 (16.7 degrees). The percentage difference (A%) between immediate postoperative and preoperative CE angle was significantly greater in Group 2. The delta% between final and immediate postoperative CE angle was significantly greater in Group 1, and within Group 1 it was significantly greater at age 4 years to 6 years. The A% between final and preoperative CE angle was statistically the same in both Group I and Group 2. The distribution of good, fair and poor Mose ratings did not differ in Group 1 and Group 2, but there was a tendency of better results after Augmented Acetabuloplasty in children older than 6 years. Younger patients of Group 1 (4-6 years) ended up with good results at a significantly higher frequency than the older ones. Group 1 children with preoperative Laredo III arthrography had good results in a significantly greater number of cases, as compared with Laredo grade IV. The delta% between final and immediate postoperative CE angle was greater in those hips with good Mose rating.

Relief from pain after Bombelli's valgus-extension osteotomy, and effectiveness of the combined shelf operation

Between 1979 and 1993, we treated 67 hips in 58 patients with severe osteoarthritis caused by congenital dislocation of the hip, employing Bombelli's valgus-extension osteotomy. The mean age of the patients was 43.6 years (range, 23-59 years). The mean follow-up period was 9.7 years (range, 5-16 years). Thirty-three of the 67 joints were followed-up for more than 10 years after the operation. Of the 67 joints, 31 were operated on by Bombelli's valgus-extension osteotomy combined with a shelf operation (combined group), and 36 by Bombelli's valgus-extension osteotomy alone (single group). Clinical evaluation was made according to the Japanese Orthopaedic Association (JOA) hip score system (JOA hip score). In order to assess the effectiveness of this operation in regard to sustained relief from pain after the operation, Kaplan-Meier survivor analysis was performed on the basis of pain score on the JOA hip score. The end-point of the Kaplan-Meier analysis was defined as a score of less than 20 points on the pain score at the time of follow-up or conversion to total hip arthroplasty. In order to analyze the factors that exacerbated pain and to assess the effectiveness of the combined shelf operation, the degree of superior displacement of the femoral head (measured from roentgenograms) after the operation was examined in relation to the pain score. The mean JOA hip score improved, from 56.1+/-11.0 before the operation to 77.0+/-16.1 at the latest follow-up. Kaplan-Meier analysis showed a survival rate of 79.4% 10 years after the operation. Superior displacement of the femoral head had gradually progressed with time after the operation in patients with and without the combined shelf operation. Displacement of the femoral head was positively correlated with the acetabular angle of the weight-bearing surface (WBS angle) (sourcil) preoperation. The mean pain score in the combined group was significantly higher than that in the single group 6 to 9 years after the operation. The results of our assessments led us to conclude that Bombelli's valgus-extention osteotomy is satisfactory as far as clinical and radiological evaluations are concerned, as relief from the pain has continued for more than 10 years after the operation. The combined shelf operation is effective for relieving pain in severe osteoarthritis caused by congenital dislocation of the hip.

Results of periacetabular osteotomy in patients with previous surgery for hip dysplasia

The results of 19 periacetabular osteotomies in 18 patients who had undergone prior bony surgical procedures for hip dysplasia were evaluated. There were 10 females and eight males with an average age of 30.9 years. Previous surgical interventions included 18 intertrochanteric osteotomies, nine pelvic osteotomies, and two shelf acetabuloplasties. The average clinical followup for this group was 45 months. Harris hip score averages improved from 60 to 90 points. Merle d'Aubigne scores showed similar elevations from 13.1 to 16.4 points. Radiographic assessment documented increased coverage and lower Tönnis secondary arthrosis grades in a significant number of hips. No significant differences in outcome were found between this group and a reference group of patients undergoing periacetabular osteotomy who had no previous hip surgery. These intermediate term results are encouraging and seem to discount anticipated problems of prior scarring and distorted pelvic and proximal femoral anatomy.

Innominate osteotomy in adolescents and adults who have acetabular dysplasia

The results were evaluated for twenty-eight adolescents and adults (thirty-one hips) who had had a Salter innominate osteotomy because of acetabular dysplasia and pain in the hip. The mean age at the time of the index operation was twenty-two years, and the mean duration of radiographic follow-up was seventy-one months. Radiographs were available for twenty-five patients (twenty-eight hips) at the most recent follow-up evaluation. The radiographic evaluation included determination of the acetabular angle, the center-edge angle, the coverage of the femoral head, the height of the joint space, and the Shenton line. Compared with the preoperative measurements, the acetabular angle had decreased by a mean of 10.0 degrees, the center-edge angle had increased by a mean of 13.2 degrees, and the coverage of the femoral head had increased by a mean of 15 per cent (p < 0.001 for all three values). The height of the joint space had decreased but, with the numbers available, this change was not significant. The Harris hip scores, determined for twenty patients (twenty-one hips), improved from a mean of 71.2 points preoperatively to a mean of 88.3 points at the latest follow-up evaluation (p < 0.001). A questionnaire, completed by twenty-seven patients (thirty hips), revealed that twenty-one patients (78 per cent) were satisfied with the result of the operation; twenty-two patients (81 per cent) said that they would recommend this procedure to others who had a similar condition. The pain score (with 1 point indicating mild pain and 5 points indicating severe pain) improved from a mean of 3.7 points preoperatively to a mean of 2.5 points at the latest follow-up evaluation (p < 0.001). There were six postoperative complications. One patient had a non-union; one, an infection; one, heterotopic bone; and three, numbness. Two of these patients subsequently had a total hip arthroplasty at ninety-eight and 150 months, and one patient had a Chiari osteotomy at twenty-two months. Our findings demonstrate that the Salter innominate osteotomy provides notable clinical improvement as well as improvements in the radiographic measurements of the hip in patients who have acetabular dysplasia.

The Spitzy shelf operation for the dysplastic hip. Retrospective 10 (5-25) year study of 124 cases

Since 1961 we have used the Spitzy shelf operation combined with a vertical flap osteotomy of the outer cortex of the ilium for early arthrosis secondary to acetabular dysplasia, subluxation, and dislocation. In 124 hips, followed for 10 (5-25) years, clinical improvement was maintained in 67/85 of patients who were operated on under the age of 30 and in 22/39 of patients treated after 30. However, less than half of the hips in the younger group and only one out of ten in the older group were symptom-free.

Glass-ceramic implant in acetabular bone defect: an experimental study

Extensive acetabular defects produced surgically in 25 dogs were repaired using A-W glass-ceramic blocks. No dislocation of the femoral head, and no displacement or breakdown of the blocks was seen 1 year after surgery. All dogs were able to run normally shortly after surgery, except for one that limped for a short time. The failure load between the blocks and the bone had increased markedly 2 months after implantation. The failure load/unit area was 33.2 kgw/cm 2 1 year after implantation. We conclude that glass-ceramic supplementation of the acetabulum is successful experimentally, and that this may be a promising method for repair of large acetabular bone defects.

Modified rotational acetabular osteotomy (RAO) for advanced osteoarthritis of the hip joint in the middle-aged person. First report

Classical methods for pelvic osteotomy, such as those of Salter, Pemberton, Chiari, and Wagner, have been developed for reconstruction of the subluxed hip joint in children and young adults. Regarding pelvic osteotomy involving a middle-aged patient, however, there are not as many operation methods to consider, and it is difficult to choose the most suitable technique for alleviating advanced osteoarthritis. Based on current practice, total hip replacement (THR) seems the accepted method, though it presents problems such as loosening, sinking, and infections; because of these factors physicians hesitate to recommend THR surgery, particularly if the patient is otherwise healthy and appears to have many good years ahead of him. As an alternative, we have been developing and improving the acetabular osteotomy, based on Tagawa's rotational acetabular osteotomy (RAO) and Wagner's acetabular osteotomy (type II). In this paper we present the results of a modified RAO operation performed on 50 middle-aged patients with an average age of 42 years and 2 months (31-61). The average follow-up was 3 years and 3 months (1-9 years). In 82% of patients the result was satisfactory (41 of 50 cases). A similar osteotomy technique has been used by Eppright and Wagner. We feel that our method achieves a more favorable result for an older patient with severe osteoarthritis, since both the surgery and the follow-up rehabilitation are more comprehensive. A modified acetabular osteotomy should not be regarded as merely an alternative to total hip replacement, but as the preferred choice for hip-joint reconstruction.

[The shelf operation for painful hip dysplasia in adults. Apropos of a continuous series of 230 cases]

230 shelf operations were carried out between 1961 and 1985 for painful acetabular dysplasia or subluxation of the hip. 208 patients have been followed up for more than one year, with 79 for between 10 and 24 years. Substantial relief of pain was obtained in 88%. The benefits of operation usually continue for many years. Factors which may lead to a poor result are advanced age, dislocation of the hip and the presence of marked osteoarthritic changes. The results have been compared with those obtained for Chiari's osteotomy, and the relative indications for the two procedures are discussed.