Progressive lateralization and constant hip geometry in children with DDH, NDH, and LCPD following hip reconstructive surgery: a cohort study of 73 patients with a mean follow-up of 4.9 years

BACKGROUND

Pelvic and femoral osteotomies have been effective methods to treat developmental dysplasia of the hip (DDH), neurogenic dislocation of the hip (NDH), and Legg-Calvé-Perthes disease (LCPD). The aim of this study was to evaluate the mid-term results after hip reconstruction in children with DDH, NDH, and LCPD.

METHODS

In a retrospective study, X-rays of 73 children (2-19 years) with DDH, NDH, and LCPD were measured before, 3 months, and at final follow-up (FU) after hip reconstructive surgery (open reduction, and femoral and/or pelvic osteotomy ± soft-tissue procedures between 2008 and 2018). Measurement of hip geometry included acetabular index (AI), center-edge angle (CE), and Reimers migration index (RMI). Mean follow-up time at final FU was 4.9 years. P value was set P < 0.05.

RESULTS

After surgery (femoral osteotomy: 84 hips, Salter innominate osteotomy: 21 hips, Pemberton osteotomy: 30 hips, open reduction: 28 hips, Chiari osteotomy: 4 hips, and soft-tissue release: 24 hips), hip geometry parameters improved significantly. Nevertheless, at final FU, there was deterioration in hip geometry with femoral head lateralization (RMI) compared to the data at 3 months after surgery (RMI: preop/3 months/final FU: 40.6 ± 16.1%/6.1 ± 9.0/15.4 ± 16.0%; CE: 11.3° ± 20.0°/30.2° ± 9.5°/27.9 ± 15.4°; AI: 28.8° ± 9.6°/19.1° ± 7.6°/18.3 ± 7.6°). Sub-group analysis did not show differences concerning the progression of RMI in DDH, NDH, and LCPD at final FU. Regardless of basic disease, the lateralization was observed in all three groups (DDH, NDH, and LCPD) and statistically significant comparing X-rays 3 months postoperatively to maximum follow-up (DDH; NDH; LCPD: 2.7 ± 6.8%/7.6 ± 10.1%; 13.7 ± 15.3%/22.8 ± 19.8%; 1.7 ± 4.1%/14.9 ± 11.3%). Additional soft-tissue release techniques in patients with DDH or NDH did not show postoperative differences with statistical significance. Concerning surgical techniques, a connection between the lower RMI and the procedure of osteotomy of the ilium was found. In 25 patients, (34%) complications were observed: superficial skin lesions in 8, deep skin lesions in 3, contraction of adductors in 3, subluxation in 2, dislocations of the cast in 2, osteonecrosis of the femoral head in 2 cases, reluxation in 1, infection of the implanted plate in 1, compliance problem in 1, delayed bone healing in 1, and contraction of knee flexors in 1 case.

DISCUSSION

The basic results of this study show a significant improvement of hip geometry at a follow-up of 4.9 years and prove findings of previously published literature. Moreover, the study was able to show a progression of RMI in all patient groups, which have undergone reconstructive surgery, despite basic hip geometry data (AI, CE angle) did not change. Those findings were independent from underlying pathology. Complications were counted in 34% of the patients and involved all known adverse events after hip reconstructive surgery. This makes clear why annual follow-up checks are needed not to miss the right indication for revision surgery.

CLINICAL RELEVANCE

Evidence level: Level IV, case series.

TRIAL REGISTRATION

This manuscript is part of a prospective randomized clinical trial, registered in the German Clinical Trials Register DRKS-ID: DRKS00016861.

Modified Pemberton Pelvic Osteotomy Through Inner Ilium Approach for Treatment of Developmental Dysplasia of the Hip in Children

INTRODUCTION

Pemberton osteotomy is a widely used operation in developmental dysplasia of the hip (DDH). The traditional pelvic osteotomy was through outside of the ilium. However, in this study, we performed the pelvic osteotomy through the inner ilium approach.

PATIENTS AND METHODS

We retrospectively analyzed 79 patients diagnosed with DDH with open surgery in our hospital from March 2016 to May 2018. There were 39 patients who underwent outside ilium Pemberton osteotomy (PO) and 40 patients who underwent inner "L shaped" ilium Pemberton osteotomy (ILSO). Acetabular index (AI), center-edge angle of Wiberg (CE angle), Severin grading scoring system, postoperative avascular necrosis (AVN) by Kalamchi and McEwen classification, and McKay grading scoring system were used for evaluation.

RESULTS

There was no significant difference between the PO group and ILSO group on AI (p = 0.476), CE angles (p = 0.225), avascular necrosis (Kalamchi and McEwen, p = 0.854), and hip function (McKay's, p = 0.444) on the final follow-up. There were significant differences in X-ray radiation (p < 0.001), blood loss (p = 0.011) and surgery time (p < 0.001).

CONCLUSION

Inner side ilium is a viable approach for Pemberton osteotomy of DDH in children with less X-ray radiation, and less blood loss and shorter surgery time.

LEVEL OF EVIDENCE

III.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00676-7.

Short Term Radiological Outcome of Combined Femoral and Ilium Osteotomy in Pelvic Reconstruction of the Child

Background and Objectives: Reconstruction of the pelvic joint is a common way to address developmental dysplasia of the hip (DDH), as well as neurogenic dislocation of the hip (NDH) and Legg−Calvé−Perthes disease (LCPD) in children. The purpose of this study was to analyze the short-term radiologic outcome after hip reconstructive surgery either treated with sole osteotomy of the femur or in combination with iliac osteotomy in patients with DDH, NDH and LCPD. Materials and Methods: X-rays of 73 children, aged 2−18 years, with DDH, NDH and LCPD after hip reconstructive surgery were measured retrospectively and compared to the preoperative x-rays concerning various parameters to define hip geometry. The surgical procedures were femoral osteotomy (74), Salter innominate osteotomy (27), Pemberton osteotomy (27), open reduction (37), Chiari osteotomy (4). The pre-/postoperative acetabular index (AI), center-edge angle (CE) and Reimers migration index (RMI) were evaluated before and 3 months after surgery. Results: Hip geometry parameters improved significantly (RMI: preop/postop: 62.23% ± 31.63%/6.30% ± 11.51%, p < 0.001; CE: 11.53° ± 20.16°/30.58 ± 8.81°, p < 0.001; AI: 28.67° ± 9.2°/19.17 ± 7.65°, p < 0.001). Sub-group analysis showed a superior RMI in DDH compared with NDH 3 months after surgery (DDH/NDH: 2.77% ± 6.9%/12.94% ± 13.5%; p = 0.011). Osteotomy of the iliac bone (Salter innominate, Pemberton, Chiari) resulted in a significant improvement of the postoperative RMI compared to cases without osteotomy of the ilium (7.02 ± 11.1% vs. 16.85 ± 4.71%; p = 0.035). Conclusions: Femoral and pelvic osteotomies are effective to improve the radiological pelvic parameters in infants and adolescents with DDH, NDH and LCPD. In addition, the study found that the combination of femoral and pelvic osteotomy led to a better RMI than femoral osteotomy alone. Using the combined ilium and femoral osteotomy, it was possible to show the highest effect on correction of the hip geometry with respect to residual RMI.

Clinicoradiological outcomes following pembersal acetabular osteotomy for developmental dysplasia of hip in young children: A series of 16 cases followed minimum 2 years

PURPOSE

Pembersal acetabular osteotomy is a relatively less practised procedure for developmental dysplasia of hip in young children. We retrospectively studied the acetabular correction and clinico-radiological outcome with this osteotomy in 16 children (16 hips) aged less than 4 years.

METHODS

Postoperative correction of acetabular dysplasia was measured by acetabular index (AI). At follow up, following radiological parameters were documented: Centre edge angle (CEA), Reimer's index (RI) and acetabular depth to width ratio (D/W ratio). Avascular necrosis of hip, stability, and premature fusion of triradiate cartilage (TRC) were also recorded. Overall containment was assessed by modified Severin classification and function by Mckay clinical grade.

RESULTS

The mean age at time of surgery was 25 months. Mean follow up was 54 months. The postoperative AI (17.6 ± 5.6°) improved significantly from preoperative values (37.5 ± 5.0°) (p < 0.0001). Mean follow up AI on the operated side was 15.3 ± 6.9° as compared to 14.7 ± 4.4° on the normal side (p = 0.78). Follow up CEA (24.9 ± 11.3°), Reimer's index (14.3%), D/W ratio (40.9%) did not differ significantly from the normal side. Early closure of TRC was not found in any of hips. All hips were clinically stable. As per modified Severin's classification, 7 hips were Type Ia, 7 Type IIa and 2 had residual dysplasia. Twelve (75%) hips had excellent clinical outcome, 2 (12.5%) good outcome and 2 (12.5%) had fair outcome.

CONCLUSIONS

Pembersal osteotomy is a safe and effective option for correction of acetabular dysplasia during open reduction of DDH in young children. It improves the AI and femoral head coverage, and promotes formation of a congruent and stable hip joint.

Mid- and long-term outcome of Salter's, Pemberton's and Dega's osteotomy for treatment of developmental dysplasia of the hip: a systematic review and meta-analysis

INTRODUCTION

Early diagnosis and early treatment have become the gold standard for management of developmental dysplasia of the hip. Surgery is required in case of failed initial treatment. Innominate pelvic osteotomy of Salter (SIO), Pemberton's pericapsular osteotomy (PPO) and Dega's acetabuloplasty (DA) are among the most used procedures.We performed a systematic review and meta-analysis of the past 57 years in order to assess the mid- and long-term outcome of these techniques.

METHODS

Studies met inclusion criteria if they: (1) reported at least 5 cases treated by 1 of the abovementioned surgical techniques; (2) included children aged between 1 and 8 years; (3) surgical indication was late detected DDH or a failed initial treatment; (4) presented a minimal follow-up of 24 months; (5) reported the radiological score of Severin and/or the clinical score of McKay.Clinical and radiological outcomes were dichotomised into favourable and unfavourable outcome and weighted summary rates were determined using meta-analysis models.

RESULTS

From a total of 7391 articles, 48 level of evidence grade IV articles were included in our review. A total of 2143 cases with a mean follow up of 112.4 months were included.Pooled Severin score indicated a statistically better outcome for PPO and DA compared to SIO (p = 0.0003 and p = 0.002, respectively). By dichotomising the results in favourable and unfavourable outcome, PPO showed the best results (p = 0.0002 vs. SIO, p = 0.01 vs. DA).Pooled McKay score showed a statistically better outcome for PPO and DA compared to SIO (p < 0.0001 and p = 0.03, respectively) as well as better outcomes for PPO compared to DA (p = 0.01). By dichotomising the results in favourable and unfavourable, PPO showed the best results.

CONCLUSIONS

Even if our review demonstrates slightly better radiological and clinical results with the PPO, the currently available and limited data do not allow for clear recommendation towards one of these techniques.

MRI-based assessment of acetabular version and coverage after previous Pemberton osteotomy in skeletally mature patients

PURPOSE

In hip dysplasia the Pemberton osteotomy can modify the shape of the acetabulum and is indicated for children aged between two and 12 when the triradiate cartilage is still open. However, there have been concerns about acetabular retroversion following this type of osteotomy. The studies, however, have been based on plain radiographs. The aim of our investigation was to assess the 3D acetabular orientation in patients with previous Pemberton osteotomy after skeletal maturation.

METHODS

Ten patients with 12 operated hips were included who received Pemberton osteotomy for hip dysplasia between January 3, 2005 and March 25, 2011. Mean age at surgery and at follow-up were 7.2 years (sd 3.7) and 19.2 years (sd 3.7), respectively. MRIs were conducted with 1.5 T. Besides the measurement of acetabular version, the analysis included alpha angles, acetabular sector angles (ASAs) as well as modified ASAs (cartilage covered area angles). Furthermore, the presence of osteoarthritis (OA) as well as acetabular retroversion was determined on plain radiographs. Patient-related outcome measures included the international Hip Outcome Tool (iHOT) and EuroQol-5-Dimensions (EQ5D) scores.

RESULTS

In comparison with the contralateral native and healthy hips the operated hips showed similar version (19.5° (sd 4.6°) versus 18.6° (sd 7.0°); p = 0.974). Also, there were no differences in terms of femoral head sphericity (alpha angles) and acetabular coverage (ASA angles). Five of 12 Pemberton hips showed signs of beginning OA (Kellgren-Lawrence classification I or II) while none of the non-operated hips did. Patients who received surgery before the age of six years had similar functional and radiological results when compared with patients who were older than six years at surgery. Among all patients, iHOT was 91.9 (sd 10.0) and EQ5D was 90.3 (sd 7.3)).

CONCLUSION

The Pemberton osteotomy provides good long-term radiographic and functional results without compromising acetabular version or coverage.

LEVEL OF EVIDENCE

Level III: retrospective comparative study.

Correction of the acetabular index is more crucial than the type of acetabuloplasty in developmental dysplasia

BACKGROUND

Acetabular remodeling may not be predictable after open reduction in developmental dysplasia of the hip (DDH) in older children. Several acetabuloplasties have been developed, and all are aimed at correcting the dysplastic acetabulum. The goal of this study is to evaluate if the type of pelvic acetabuloplasty and the corrected (postoperative) acetabular index (AI) affect early follow-up femoral head coverage.

METHODS

A retrospective review of single-surgeon consecutive acetabuloplasties (Dega or Pemberton) from December 2012 to December 2015 was conducted. The inclusion criteria were a diagnosis of DDH, undergoing simultaneous primary open reduction, and follow-up of at least 18 months. Univariable analysis was based on the type of acetabuloplasty. The correlation between AI and final center edge angle (CEA) was tested. Multiple regression was performed.

RESULTS

Of the total 58 hips in 39 patients included, 41 underwent Dega acetabuloplasty, and 17 had Pemberton acetabuloplasty. The median follow-up was 40.50 months (interquartile range 27.25-57). Pemberton acetabuloplasty produced a lower corrected AI, but the difference was not significant in follow-up measurements. Corrected AI was significantly correlated with final CEA (R = - 0.31, P = 0.018). In the multiple regression, only corrected AI was independently associated with final CEA (B = - 0.29, SE = 0.15, P = 0.06), whereas the type of acetabuloplasty, age, and preoperative severity of the dislocation were not.

CONCLUSION

The correction obtained during acetabuloplasty affects early follow-up femoral head coverage. Ensuring proper sizing and placement of the grafted bone is probably more important than the type of acetabuloplasty chosen.

LEVEL OF EVIDENCE

Level III.