Surgical Treatment of Developmental Dysplasia of the Hip in Children Three to Five Years of Age


Mohammed AbdelFattah Sebae*

Citation: Surgical Treatment of Developmental Dysplasia of the Hip in Children Three to Five Years of Age. American Research Journal of Orthopedics and Traumatology. 2017; 2(1): 1-8.

Copyright This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract:

Background: The neglected DDH with adaptive changes in bone and soft tissue is difficult to treat and can lead to permanent disability. The aim of treatment of these cases to establish normal anatomy of the femur and acetabulum to promote normal development of the hip.

Aim of the Work: The aim of this study is to evaluate of the results of one–stage surgical treatment of DDH in children between 3-5 years of age.

Patients and Methods: A prospective study on 36 children (40 hips) presented by DDH at age between 3-5 years old, 16 hips were Tonnis grade III and 24 hips were grade IV. Open reduction, derotation femoral osteotomy with shortening was done for all hips, Varusangulation for excessive valgus was add to the osteotomy in 16 hips (40%), and Degapel vicosteotomy was added to femoral osteotomy in 24 hips (60%). Post operatively hip spica was done for all the patients for twelve weeks.

Results: The mean follow- up period was 40 months (range 24 - 60 months). Clinically, according to Mc Kay system, the outcome was excellent for 20 hips (50%) were, good in 14 hips (35%), fair in 4(10%), and poor in 2 h i p s (5%). Radiologically, the Severin’s classification criteria for 22 hips (55%) were excellent, in 12 hips (30%) were good, fair in 4 (10%), and were poor in 2 (5 %).

Conclusion: One stage hip reconstruction operation is a good approach to treat the cases with late presented developmental dysplasia of hip (DDH). A stable concentric reduction can be achieved which help in remodeling of the acetabulum and stable concentric reduction of the dislocated hip. Tonnis grade III dislocation of DDH is risky for residual acetabular dysplasia and subluxation after one stage hip reconstruction.

Keywords: surgical, treatment, developmental, dysplasia, hip,


Description:

INTRODUCTION

The neglected DDH with adaptive changes in bone and soft tissue is difficult to treat and can lead to permanent disability. [1]. Residual acetabulardy splasia and hip subluxation in children result in premature arthritis of hip in young adults [2]. The aim of treatment of these cases is to establish normal anatomy of the femur and acetabulum to promote normal development of the hip [3]. Treatment with one–stage procedure (open reduction, capsulorrhaphy, and femoral osteotomy with or without shortening) is preferred by many authors. In those late presenting children, a pelvic osteotomy is needed to achieve a stable concentric reduction [4-6]. The Dega osteotomy is one of the commonly used osteotomies in the management of DDH. Dega described two different types of incomplete trans-iliac osteotomies [7,8].

The purpose of this study is evaluation of the results of one–stage hip operation in DDH presented between 3-5 years of age.

PATIENTS AND METHODS

A prospective study on 36 children (40 hips) presented by DDH at age between 3-5 years old, 16 hips were Tonnis [9] grade III and 24 hips were grade IV. Open reduction, derotation femoral osteotomy with shortening was done for all hips, Varus angulation for excessive valgus was add to the osteotomy in 16 hips (40%), and Dega pelvic osteotomy was added to femoral osteotomy in 24 hips (60 %). Postoperatively hip spica was done for all the patients for twelve weeks.

There were 22 girls (28 hips) and 14 boys (12 hips). Dislocation of the left hip in 20 patients; 12 patients had dislocation of the right and 4 girls had bilateral dislocation. Open reduction with shortening and derotation of the femur was done for all hips, Varusangulation for excessive valgus was add to the osteotomyin 16 hips (40%), and Degapel vicosteotomy was performed in 24 hips (60%). Post operatively hip spica was done for all the patients for twelve weeks.

PREOPERATIVE EVALUATION

According to Tonnis classification system [9], there were eighteen hips Tonnis grade III and 22 hips were grade IV [Table 1]. Radiological evaluation of reduction included the acetabular index (AI) [10], the center-edge angle of Wiberg (CEA) [11], the migration percentage of Reimers (MI) [12], Shenton line disruption, the femoral neck shaft angle, and evaluation of the grade of the femoral head avascular necrosis (AVN) according to Bucholz-Ogden classification system [13]. 

OPERATIVE PROCEDURE

The mean operative time was 120±18 min. range (90-145).The mean operative blood loss was 250 ± 49 (range 150–350) ml. The mean follow –up period was 40 months (range 24 – 60 months after surgery.

Immediately after surgery, a double spica cast was applied in 30° of flexion and 30° of abduction with 20° internal rotation of the hips. Plain x-rays were done to evaluate reduction of the femoral head into the true acetabulum. Three months postoperative, an abduction orthosis was used at night for 2 months. Follow up radiographs were taken every month for the first 3 months after spica followed by every 3 months until the end of the first year, and every 6 months later.
Statistical Analysis

The Statistical Package for the Social Sciences (SPSS version 20.0) software was used for analysis. According to the type of data qualitative represent as number and percentage, quantitative continues group represent by mean ± SD, comparison between paired quantitative parametric data by Paired t test.

RESULTS

The mean follow- up period was 40 months (range 24 - 60 months). Clinically, according to McKay system [14], the outcome was excellent (achieving Stable painless hip)for 20 hips (50 %) were, good (there was a slight limp, and limitation of last degrees of movement) in 14 hips (35 %), fair (with limp, positive trendelenburg sign limited abduction (10° -25°) and internal rotation in flexion (0-10), exhibit radiological coxa plana due to AVN of the femoral head) in 4(10 %), and poor (unstable, and had residual subluxation at latest follow-up radiographs) in 2 hips (5 %). 

RADIOGRAPHIC RESULTS

The preoperative, the early postoperative and latest follow-up radiographs were used to measure the acetabular index (AI), the center-edge angle of Wiberg (CEA), the migration percentage of Reimers (MI), Shenton line disrupation, and the femoral neck shaft angle. In all hips but two, the acetabular index was improved at the latest follow-up examination, in those two hips, the femoral head was subluxed. The mean preoperative AI was 43°±8.5, and at the end of follow –up it was reduced to an average 22°±5.6 [range 20°- 30°]. 

The preoperative CEA was negative in all patients. In all hips except two, the mean postoperative center- edge angle was improved with average 29°±8.6 [range 20°-50°] at the end of follow–up period. In two hips with poor results the CEA was [10°] and the femoral head was subluxed. The mean postoperative migration percentage described by Reimers [- 0.22±0.06], and at the end of follow –up the mean MI was [-0.19±0.04]. The Shenton line was intact in 38 hips. The neck shaft angle was increased from an average of 118°±12.8 postoperatively to 126°±14.4 at the latest follow-up examination [Fig. 1, 2, 3]. The Severin’s classification [15] criteria for 22 hips (55 %) were excellent, in 12 hips (30 %) were good, fair in 4 (10%), and were poor in 2 hips (5 %), both patients had Tonnis grade III hip dislocation.