Open reduction and Salter innominate osteotomy combined with femoral osteotomy in the treatment of developmental dysplasia of the hip: Comparison of results before and after the age of 4 years

[Study on Salter osteotomy combined with subtrochanteric shortening and derotational osteotomy in treatment of Tönnis type and developmental dysplasia of the hip in children]

Objective

To investigate the effectiveness of Salter osteotomy combined with subtrochanteric shortening and derotational osteotomy in treating Tönnis type Ⅲ and Ⅳ developmental dysplasia of the hip (DDH) in children and explore the urgical timing.

Methods

A retrospective collection was performed for 74 children with Tönnis type Ⅲ and Ⅳ DDH who were admitted between January 2018 and January 2020 and met the selection criteria, all of whom were treated with Salter osteotomy combined with subtrochanteric shortening and derotational osteotomy. Among them, there were 38 cases in the toddler group (age, 18-36 months) and 36 cases in the preschool group (age, 36-72 months). There was a significant difference in age between the two groups ( P<0.05), and there was no significant difference in gender, side, Tönnis typing, and preoperative acetabular index (AI) ( P>0.05). During follow-up, hip function was assessed according to the Mckay grade criteria; X-ray films were taken to observe the healing of osteotomy, measure the AI, evaluate the hip imaging morphology according to Severin classification, and assess the occurrence of osteonecrosis of the femoral head (ONFH) according to Kalamchi-MacEwen (K&M) classification criteria.

Results

All operations of both groups were successfully completed, and the incisions healed by first intention. All children were followed up 14-53 months, with an average of 27.9 months. There was no significant difference in the follow-up time between the two groups ( P>0.05). At last follow-up, the excellent and good rates according to the Mckay grading were 94.73% (36/38) in the toddler group and 83.33% (30/36) in the preschool group, and the difference between the two groups was significant ( P<0.05). The imaging reexamination showed that all osteotomies healed with no significant difference in the healing time between the two groups ( P>0.05). There was no significant difference in AI between the two groups at each time point after operation ( P>0.05), and the AI in the two groups showed a significant decreasing trend with time extension ( P<0.05). The result of Severin classification in the toddler group was better than that in the preschool group at last follow-up ( P<0.05). There was no significant difference in the incidence of ONFH between the two groups ( P>0.05). In the toddler group, 2 cases were K&M type Ⅰ; in the preschool group, 3 were type Ⅰ, and 1 type Ⅱ. There was no dislocation after operation.

Conclusion

Salter osteotomy combined with subtrochanteric shortening and derotational osteotomy is an effective way to treat Tönnis type Ⅲ and Ⅳ DDH in children, and surgical interventions for children aged 18-36 months can achieve better results.

Outcomes of Open Reduction in Children With Developmental Hip Dislocation: A Multicenter Experience Over a Decade

BACKGROUND

Open reduction of the hip is commonly performed in children with severe developmental dysplasia of the hip, or in cases that are refractory to nonoperative forms of treatment. The open reduction has been associated with numerous complications including avascular necrosis (AVN) of the femoral head, the need for reoperation, and residual radiographic dysplasia. This study seeks to determine the effects of preoperative severity of dysplasia, associated procedures (femoral and acetabular osteotomies), age on AVN, and the need for reoperation.

METHODS

Children with developmental dysplasia of the hip and a minimum of 2 years of follow-up who underwent open reduction were identified. The following data points were recorded: sex, laterality of hip involvement, simultaneous procedures, surgical approach used, age, acetabular index, and International Hip Dysplasia Institute grade. We analyzed the effects of preoperative International Hip Dysplasia Institute, age, surgical approach (anterior/medial), bilateral reduction, and simultaneous femoral shortening or pelvic osteotomy on the outcomes of AVN and reoperation.

RESULTS

One hundred eighty-five hips in 149 patients were included in this study with an average follow-up of 4 years (range: 2 to 5 y). The average age at index surgery was 23 months (range: 1 to 121 mo). Overall, 60 hips (32.4%) required secondary surgical procedures at an average age of 58.5 months. High-grade AVN was noted in 24 hips (13.0%) and was found to be associated with the severity of the hip dislocation ( P = 0.02). A higher rate of reoperation was found in children over 18 months at the time of open reduction who did not receive an acetabular osteotomy ( P = 0.012).

CONCLUSION

Approximately 1/3 of patients require another operative intervention within the first 4 years after open reduction of the hip. We found the severity of hip dislocation to be associated with a higher risk of AVN development. These findings support performing an acetabular osteotomy in children over 18 months of age at the time of open reduction to decrease the likelihood of requiring future reoperation during the first 4 years after the index procedure.

LEVEL OF EVIDENCE

Level III.