Abstract
Background: A consecutive series of seventy-six patients (101 hips)
underwent primary open reduction, capsulorrhaphy, and innominate osteotomy for
late-presenting developmental dislocation of the hip. They were between 1.5
and five years old at the time of surgery, which was done between 1958 and
1965. The present study was designed to review the outcome of these patients
into middle age.
Methods: We located and reviewed the cases of sixty patients (eighty
hips), which represents a 79% rate of follow-up at forty to forty-eight years
postoperatively. Nineteen patients (twenty-four hips) had undergone total hip
replacement, and three (three hips) had died of unrelated causes. The
remaining thirty-eight patients (fifty-three hips) were assessed by the WOMAC
(Western Ontario and McMaster Universities Osteoarthritis Index) and Oxford
hip score questionnaires, physical examination, and a standing anteroposterior
pelvic radiograph. The radiographs were analyzed to determine the minimum
joint space width and the Kellgren and Lawrence score. Accepted indices of hip
dysplasia were measured.
Results: With use of Kaplan-Meier survival analysis and with the end
point defined as total hip replacement, the survival rates at thirty, forty,
and forty-five years after the reduction were 99% (95% confidence interval,
±2.4%), 86% (95% confidence interval, ±6.9%), and 54% (95%
confidence interval, ±16.4%), respectively. The average Oxford hip
score and WOMAC score for the surviving hips were 16.8 (range, 0 to 82) and
16.7 (range, 0 to 71), respectively. Of the fifty-one hips for which
radiographs were available, thirty-eight demonstrated a minimum joint space
width of >2.0 mm and thirteen demonstrated definite osteoarthritis on the
basis of this criterion. Osteoarthritis, according to the system of Kellgren
and Lawrence, was grade 0 or 1 in twenty-nine hips, grade 2 in seven hips, and
grade 3 or 4 in fifteen hips. The average center-edge and acetabular angles
were 40° (range, 0° to 61°) and 32° (range, 20° to
43°), respectively. With the numbers studied, no significant association
was detected between outcome and the modifiable risk factors of body mass
index or age at the time of surgery. Hips in patients with bilateral
involvement were at significantly greater risk of failure (p = 0.02).
Conclusions: This method of treatment achieves a 54% rate of
survival of the hip at forty-five years. Two-thirds of the surviving hips have
an excellent prognosis forty to forty-eight years after the index procedure
according to the Kellgren and Lawrence score.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
The success rate of nonoperative treatment for neonatal instability and
dislocation of the hip is excellent up to six months of
age1, with the
potential for a normal hip in adult life. A dislocation that presents late
needs more invasive treatment and has a less predictable outcome. Screening
for hip dysplasia has yet to eliminate completely the burden of this
disorder2-5.
The clinical course of untreateddevelopmental dislocation of the hip is not
well characterized. A small series of nine patients has been reported with
apparently satisfactory function at an average age of forty-six
years6, despite
substantial gait
abnormalities7 and
hyperlordosis secondary to fixed flexion contractures of the hip. In a larger
series of forty-two hips in patients who were between sixteen and eighty-six
years old with untreated dislocations, more than half were rated as only fair
or poor according to the Harris hip score with a modified weighting for
function8. There
were signs of moderate or well-developed osteoarthritis, particularly when a
false acetabulum was well formed. Backache was not obviously increased, but
symptomatic, ipsilateral genu valgum was common in patients with unilateral
involvement. Hartofilakidis et al. reported the onset of pain early in the
fourth decade in 100 untreated
dislocations9.
Intervention for a late dislocation that achieves a concentric, stable
reduction of the hip joint may improve this outlook, but it is associated with
a risk of osteonecrosis of the femoral head that does not occur in the
untreated hip. The results of any treatment, with its attendant complications,
must be followed carefully as subtle forms of residual dysplasia may cause
rapidly progressive osteoarthritis many years after an apparently good
result10,11.
Acetabular shape is probably largely determined by about the age of eight
years12. Natural
remodeling after a late reduction in childhood is difficult to predict and may
cease to be effective at an earlier age with increasing severity of residual
dysplasia13.
For children seen with developmental dislocation of the hip after the age
of eighteen months, the senior author (R.B.S.) devised, in 1957, a protocol of
preoperative traction, open reduction, and capsulorrhaphy combined with a new
procedure of innominate osteotomy to redirect the deficient
acetabulum14,15.
Good results were reported for this group at ten to fifteen years
postoperatively16
and again at fifteen to thirty-three
years17. Others
have reported improved results with innominate osteotomy for this
indication18-20.
This study was designed to establish the outcome of this protocol for
late-presenting developmental dislocation of the hip in patients followed into
middle age with use of validated clinical and radiographic outcome measures.
Since the results were expected to be neither uniformly perfect nor
definitively poor, we used additional assessment measures for comparison with
published series of other techniques and untreated cases.
The present study is a retrospective review of a prospectively assembled
cohort. Institutional review board approval was obtained prior to the
initiation of this study.
The senior author had collected data prospectively on all patients
undergoing innominate osteotomy between the years 1957 and
196817. Details of
the index procedure and postoperative course up to 1972 were meticulously
cataloged with a summary of any prior intervention. We also obtained the
complete microfiche charts, covering up to and sometimes beyond the age of
eighteen years, for all but two of these patients.
Three hundred and twenty-five innominate osteotomies were performed or
supervised by the senior author in 250 patients during this period. We applied
the following criteria to this group. Patients were included if they had a
primary open reduction performed for developmental dislocation of the hip, the
surgery was performed at this institution by or under the supervision of the
senior author according to the protocol described in this paper, the age at
presentation was between eighteen and sixty months, and a minimum of forty
years had elapsed since surgery. Patients were excluded if they had any
previous hip operation, such as an attempted closed reduction at another
institution prior to referral or an open procedure with a different protocol,
or if they had an intervention for developmental subluxation or dysplasia
(rather than dislocation) of the hip.
Thus, 101 hips with late-presenting developmental dislocation in
seventy-six patients (sixty-one female and fifteen male) were included in this
study. The mean age at the time of open reduction was 2.8 years (range, 1.5 to
4.7 years). Three patients were excluded because of a previous procedure
outside this protocol.
Operative Protocol
The underlying principle of an innominate osteotomy in a hip with
developmental dislocation is to correct the misdirected acetabulum so that
after reduction, the hip, which was previously stable only in the position of
flexion, abduction, and internal rotation, is made stable in the functional
position of weight-bearing.
Preoperatively, patients were managed in the hospital with unilateral
traction applied to the affected side(s) as they lay supine. In children under
the age of three years, skin tape traction for two weeks was usually
sufficient to bring the femoral head opposite the acetabulum (as confirmed
radiographically). In older children, skeletal traction was usually necessary
for up to three weeks to achieve the same end point. After percutaneous
adductor tenotomy, an anterior approach to the hip by means of an oblique skin
incision was used to explore the interval between the sartorius and tensor
fasciae latae and to split the iliac apophysis. The psoas tendon was
lengthened at the pelvic brim, and the capsule was exposed in the plane deep
to the reflected head of the rectus femoris tendon. A capsulotomy was made
parallel to and 1 cm distal to the acetabulum, taking care to preserve the
underlying labrum. The transverse acetabular ligament was cut, and the
ligamentum teres was excised. The femoral head was reduced by gentle flexion
of the hip with slight abduction and internal rotation. The distal flap of the
capsule was then incised perpendicular to the first incision, and the
redundant inferolateral portion of the T shape thus created was excised.
Sutures were placed for capsulorrhaphy but were left untied at this point.
An innominate osteotomy was then performed with a Gigli saw and bone graft
from the iliac crest. This was fixed with two threaded Kirschner wires.
Finally, hip reduction was confirmed before the capsulorrhaphy sutures were
tied. No patient underwent a femoral osteotomy.
The child was managed with a single-leg hip spica cast for six weeks with
the hip in approximately 30° of flexion, slight abduction, and internal
rotation (depending on the amount of femoral neck anteversion). This was
followed by bilateral long-leg abduction casts for an additional four weeks to
protect the capsulorrhaphy.
In patients with bilateral dislocation, the operation on the second hip was
done two or three weeks after the first. The single hip-spica cast was then
replaced by a double hip-spica cast.
Locating Patients
Tracing patients many years after surgery that they had had as children is
a challenge21. We
commissioned a public records search with a private agency that had access to
data that included birthdates and premarital surnames. An advertisement was
placed in the national and provincial press. We contacted regional health
services, local nursing stations, and community elders in rural North American
aboriginal communities from which some children had been referred. We reviewed
this group at a special clinic in the northern part of Ontario, Canada, where
the patients were transported by light aircraft. Radiographs were made
digitally and uploaded onto our own system (Centricity PACS; GE Medical
Systems, Slough, United Kingdom).
Two patients had moved to British Columbia, Canada; two had moved to the
United States; and one had returned to her native Australia. These patients
were evaluated by means of a questionnaire completed over the telephone or on
the Internet. Radiographs made locally were uploaded onto our system. One
patient declined to take part in the study but informed us that the treated
hip had not been replaced, and another declined radiographic examination but
completed the questionnaires.
All other patients returned for an evaluation at The Hospital for Sick
Children in Toronto. We measured body mass index in every patient by dividing
weight in kilograms by the square of the height in meters. For those who had
undergone total joint replacement of the involved hip(s), we recorded the time
from the index procedure to this event. For the remaining patients, we
performed a clinical, outcome, and radiographic assessment.
Clinical Assessment
The first author performed a clinical examination that was based on the
original and modified Harris hip
scores8,22.
Outcome Assessment
Patients completed the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC)
questionnaire23 for
hips and the Oxford hip
score24
questionnaire, as modified by Pynsent et al., to generate a percentage figure
with differentiation of symptoms according to
side25. Both are
patient-based scoring systems of proven validity, reliability, and
sensitivity, with 0 representing a perfect score and 100, the worst possible
score. Age and sex-matched individuals who were parents of children attending
our fracture clinic completed both questionnaires and acted as a local control
group.
Radiographic Assessment
An anteroposterior standing radiograph of the pelvis, centered on the hips
and with both feet in 15° of internal rotation, was made at 75 kV, 25 to
40 mA, and a focus-to-film distance of 130 cm on a digital imaging system
(Centricity PACS; GE Medical Systems).
The radiographs were graded by comparison with the atlas standards of the
Kellgren and Lawrence classification
system26. All
identifying features on the radiographs were removed, and the iliac crests,
which would indicate a previous innominate osteotomy, were cut from the
frames. They were coded and mixed, in an electronic slide format (PowerPoint;
Microsoft, Redmond, Washington), with fifteen radiographs of age-matched
osteoarthritic hips as a confusion step. Since the classification is most
reliable with a single observer performing the comparisons, the first author,
blinded to other parts of the assessment, scored all of the
radiographs27.
We also measured the minimum joint space width with a cutoff of 2.0 mm to
indicate definite
osteoarthritis28,29.
The acetabular angle of Sharp and the center-edge angle of Wiberg were
measured to identify and quantify acetabular
dysplasia30,31.
All measurements were made electronically, with use of magnified views and
contrast control (Centricity PACS, GE Medical Systems), where necessary.
The radiographs were also classified, with the confusion step, according to
the classification system of
Severin32. Class I
indicated a perfect hip with a normal center-edge angle; Class II, some
deformity of the femoral head but a normal center edge angle; Class III,
residual hip dysplasia without subluxation but a reduced center-edge angle;
Class IV, some degree of subluxation with the center-edge angle near 0°;
Class V, so-called secondary acetabulum on the edge of or proximal to the true
acetabulum; and Class VI, complete dislocation.
Statistical Methods
A trained statistician performed survival analysis and statistical testing
independently.
For the survival analysis, a hip was censored if, by the end of the study,
it had not been replaced or there had been less than forty-eight years of
follow-up. Since much of the data were censored, the analysis for the most
part used Kaplan-Meier curves and Cox proportional-hazards techniques.
Survival time was calculated from the date of the index operation to the end
of the study or last follow-up evaluation for the censored hips and to the
date of hip replacement for those that had been replaced. Some patients had a
bilateral index procedure; observing multiple events in the same patient that
may not be independent can lead to biased estimates. The robust sandwich
estimate was used to adjust for such dependence.
For a comparison of independent measures, such as body mass index, age at
the time of the index operation, and the Oxford and WOMAC scores, the Student
t test was used to compare group means.
Sixty of the seventy-six patients in the original cohort were traced, and
the cases of these patients were reviewed, for a follow-up rate of 79%. There
were sixty-three hips in forty-seven women and seventeen hips in thirteen men.
The average length of follow-up for patients surviving to the end of the study
was 43.3 years (range, forty to forty-eight years) from the time of the index
operation. The average age of the patients was 2.8 years (range, 1.5 to five
years) at the time of the index operation and 45.8 years (range, forty-two to
fifty-one years) at the time of the latest follow-up.
Twenty-four hips in nineteen patients (eighteen female and one male) had
undergone a total joint replacement (see Appendix). Three patients had died of
unrelated causes without a hip replacement during the study. They were
included in the survival analysis only. Thus, the rate of joint replacement
was 31% in the seventy-seven hips of patients surviving beyond forty years
from the index procedure. The rate of postoperative complications had been 46%
in the hips that had a joint replacement compared with 15% in the hips that
had not been replaced (see Appendix). The postoperative complications included
recurrent dislocation requiring revision open reduction, residual subluxation
requiring abduction casting or revision innominate osteotomy, and
supracondylar femoral shaft fracture. Overall, the complication rate for the
entire study group was 25%.
The occurrence and the description of osteonecrosis were poorly documented
in the patient records. Most archived radiographs from that period had been
destroyed so that contemporary classifications could not be applied
retrospectively. This study group forms the greater part of 110 dislocations
that had the operation as a primary procedure and were reviewed at an average
of 5.5 years
postoperatively16.
The additional nine dislocations included then were managed operatively after
1965. The rate of osteonecrosis at that time was 5.7%, on the basis of the
delayed appearance or mottling of the ossific nucleus and subsequent
flattening of the femoral head or coxa
magna33.
Of the sixteen patients (twenty-one hips) lost to followup, five had
bilateral involvement. The average age at the time of the index operation was
2.7 years (range, 1.9 to 4.6 years), and the postoperative complication rate
was 33%. These figures are similar to those of the study group.
Clinical Outcomes
Fifty-three hips (69% of all hips in the surviving patients) in
thirty-eight patients (twenty-seven female and eleven male) had not been
replaced at the end of the study. The average Oxford hip score was 16.4
(range, 0 to 82), and the average WOMAC score was 16.3 (range, 0 to 71).
The control group comprised seventy-five hips in fifty women and
twenty-five men whose average age was 45.4 years (range, forty-two to fifty
years). Chosen at random, thirty-eight patients were asked to complete the
questionnaires for their right hip and thirty-seven for their left. They had
an average Oxford hip score of 2.9 (range, 0 to 26) and an average WOMAC score
of 4.1 (range, 0 to 49). The differences in scores between the study and
control groups were highly significant (p < 0.0001). In studies of patients
who had a hip replacement, the average preoperative scores were 67.7 with the
Oxford hip-scoring
system34 and 59
with the WOMAC35
system.
The original22
and modified8 Harris
hip scores were an average of 88 points (range, 30 to 100 points) and 89
points (range, 27 to 100 points), respectively, for the study group.
Radiographic Outcomes
Fifty-one of the fifty-three surviving patients who had not had a hip
replacement had radiographs made for this study (Figs.
1-A,
1-B,
1-C,
2-A,
2-B,
2-C and
2-D). Thirty-eight of them had
a minimum joint space width of >2.0 mm, and thirteen had definite
osteoarthritis on the basis of thiscriterion. Twenty-nine hips had no or
doubtful signs of osteoarthritis (grade 0 or 1) according to the Kellgren and
Lawrence score (Figs. 2-A,
2-B,
2-C and
2-D). Seven hips had mild
osteoarthritis (grade 2), but only two of them had substantial symptoms on the
pain domain of the WOMAC questionnaire. The remaining fifteen hips had
moderate or severe osteoarthritis (grade 3 or 4, respectively), although two
patients with hips categorized as grade 3 had a minimum joint space width of
>2.0 mm.
The average center-edge and acetabular angles were 40° (range, 0°
to 61°) and 32° (range, 20° to 43°), respectively. Nine hips
had a center-edge angle of =30°, while six had an acetabular angle of
>38°. Nine hips were graded as Severin Class I, thirty-three, as Class
II; eight, as Class III; and one, as Class IV.
Two female patients (three hips) had rheumatoid arthritis develop. All
three hips were involved. One hip had been replaced; one had severe,
symptomatic arthritis; and one had mild signs with no symptoms.
Survival Analysis
The survival rates for all hips are plotted in
Figure 3. The first failure
occurred thirty years after the index procedure. The data become unreliable
after forty-five years, when there are fewer than ten patients in the tail of
the survival
curve36. Until that
time, the survival rates at thirty, forty, and forty-five years after
reduction are 99% (95% confidence interval, ±2.4%), 86% (95% confidence
interval, ±6.9%), and 54% (95% confidence interval, ±16.4%),
respectively.
Association of Risk Factors for a Poor Outcome
The patients who had a hip replacement or had definite development of
osteoarthritis, according to joint space width, by the end of the study and
those who had not were compared with respect to their mean age at the time of
the index surgery. The mean ages were 3.05 and 2.65 years, respectively, and
the difference was four months, which failed to reach significance (p = 0.07).
Body mass indices in these same groups were almost identical (28.59 and 28.57,
respectively).
With use of the Cox proportional-hazards regression model, the hips in the
patients who had undergone surgery bilaterally were at 2.9 times greater risk
of a subsequent hip replacement compared with the hips in patients with
unilateral involvement (p = 0.02)
The present investigation is a retrospective study without controls, either
untreated or managed with isolated steps of the protocol. The data cannot
therefore identify whether, for example,
capsulorrhaphy37
was important in the outcome or whether innominate osteotomy was required in
every patient within this age-range. The timing of and indications for
intervention to improve acetabular dysplasia in all forms of developmental
dysplasia of the hip are highly
controversial13,20.
The senior author believed that the normal osseous development of the
acetabulum could no longer be ensured even after successful reduction beyond
the age of eighteen months, and so all children with late-presenting
developmental dislocation of the hip underwent innominate osteotomy with open
reduction after this age. Our data can be used to predict the outcome of
children managed in this way.
The Severin classification of developmental dysplasia of the hip is
historically popular despite concerns for its
reliability38. At
an average of 5.5 years after the index operation, 96% of the hips in this
group were Class I or II. However, at the time of the latest follow-up,
twenty-four hips (31%) had undergone joint replacement and thirteen (17%) had
definite osteoarthritis. Thus, a good Severin grade approaching skeletal
maturity did not guarantee a good outcome into middle age.
Perhaps uniquely in a series with this duration of followup, the operative
technique has not been altered. The main change in protocol concerns
preoperative traction, which is generally no longer practical. All of the
children in this study had a minimum period of two weeks of traction, to
stretch the soft tissues and decrease joint pressure after reduction, but our
subsequent experience has shown that this may not be essential for a safe
reduction in younger children. In older children, instead of prolonged
traction in the hospital, we currently recommend femoral shortening, which we
believe may decrease the rate of osteonecrosis. Radiographic archives for this
group, for the period from the time of the operation to adolescence, had been
destroyed, and the rate of osteonecrosis quoted in the present study is from a
study that predates contemporary
classifications39,40.
This invalidates any comparison of the rates of osteonecrosis after traction
in the present study with those in more recent series of femoral
shortening.
Otherwise the methodology is robust and was designed to eliminate potential
bias in the interpretation of outcomes. Survival analysis was based on the
objective end point of total hip replacement, and we used validated,
self-administered outcome questionnaires. The WOMAC index assesses three
domains—pain, disability, and joint stiffness—in patients with
arthritis of the hip. The Oxford hip score is similar but is designed
specifically to assess patients undergoing hip replacement. Both demonstrate a
ceiling effect for patients without arthritis, manifested in a relatively high
prevalence of hips with a score of 0. We included the Oxford score to
establish what proportion of the surviving hips had scores close to those of
patients requiring replacement. This identifies the patients who satisfy the
criteria for this intervention but do not reach the end point for survival
analysis, perhaps because they are on a waiting list or are delaying surgery
because of their relatively young age. In the series, two surviving hips
reached the age-matched reference value of the Oxford
score35 for joint
replacement and four more were within 10 points of it. This indicates failure,
impending or actual, in 39% of the hips at the end of the study.
Our definition of osteoarthritis as radiographic evidence of a minimum
joint space width is objective and
validated28,29.
We included the Kellgren and Lawrence
score26 although it
is more subjective. A recent longitudinal cohort study followed 1904 men and
women with osteoarthritis of the hip who were fifty-five years of age or older
at baseline for five
years41. The
Kellgren and Lawrence score was by far the strongest predictor of all
determinants studied for progression of hip arthritis. We can use it to
examine the decrease in survival from 86% at forty years to 54% at forty-five
years, which could be an anomaly of the low numbers in the tail of the
curve36. At the end
of the study, fifty-one of the fifty-three surviving hips had radiographs,
which demonstrated a low risk for the development or progression of
osteoarthritis (a Kellgren and Lawrence grade of 0 or 1 or grade 2 without
pain) within the next five years in thirty-four hips (67%) and a high risk of
progression or joint replacement (grade 3 or 4 or grade 2 with pain) in
seventeen hips (33%). Thus, 55% of all seventy-five surviving hips with
radiographs available had either been replaced or were likely to progress to
this step within five years, while the remaining 45% had an excellent
radiographic outcome and were at low risk for deterioration. These figures are
similar to those in the tail of the survival curve.
There are few studies of intervention for this condition with comparable
follow-up. Angliss et al. reported the results of the so-called direct method
of treatment for late-presenting developmental dislocation of the
hip42,43.
The majority of 191 hips underwent preoperative traction with progressive
abduction followed by open reduction with
limbusectomy44,45
and staged femoral derotation osteotomy. The median age at the time of the
index operation was two years (range, 0.75 to 7.9 years) with follow-up to a
median of thirty-three years (range, twenty-five to forty-eight years). Forty
percent had moderate or severe arthritis (50% in the open reduction group),
and there was a 14% rate of hip replacement or arthrodesis. Twenty-six percent
remained in Severin Class I or II at the time of the final follow-up. The
replacement rate in our group at thirty-three years was 3.8% (95% confidence
interval, ±4.2%). Eighty-two percent (forty-two) of the fifty-one
surviving hips (or 53% of the original cohort of hips) were Severin Class I or
II with additional years of follow-up at the end of our study.
Malvitz and Weinstein reported on 152 hips in patients who were an average
of 1.75 years old (range, 0.8 to eight years) at the time of closed
reduction46. They
were followed for an average of thirty years (range, fifteen to fifty-three
years). The Harris hip score was an average of 90 points for the surviving
hips (compared with an average of 88 points in our series with an additional
ten to eighteen years of follow-up), and there was an 11% rate of joint
replacement (compared with 1.2% [95% confidence interval, ±2.4] in our
series at thirty years).
Comparison of retrospective case series is inherently unsatisfactory.
Nonetheless, we feel justified in recommending this operative protocol for
late-presenting developmental dislocation of the hip on the basis of these
results. We accept that preoperative traction can probably be safely omitted
in younger children, in whom the dislocated femoral head has not migrated a
substantial distance proximally, or traction can be replaced with femoral
shortening osteotomy in older children.
Even in this series, however, the rate of hip replacement, prevalence of
osteoarthritis47,
and functional outcomes compared with those for age-matched controls
demonstrate that some of the involved hips have residual abnormalities.
Bilateral hip dislocation and postoperative complications are poor prognostic
factors, but it is otherwise unclear why some hips fare better than others
into middle age. Given the association between obesity and
osteoarthritis48,
it is surprising that body mass was not related to outcome and this may simply
be a Type-II statistical error. The failure to detect a significant
association between the age at the time of surgery and the outcome could have
the same explanation. Albinana et al. demonstrated a substantial increase in
the prevalence of residual acetabular dysplasia with increasing age at the
time of
reduction13. From
two to seven years after reduction in their series, an increased acetabular
index was the strongest indicator for failure to achieve a satisfactory
Severin grade at maturity. An alternative explanation, therefore, is that the
addition of innominate osteotomy in all late presentations brings the risk
profile for subsequent failure toward that associated with a dislocation that
is treated earlier. If this inference (that redirecting the acetabulum in
older children with reduced remodeling capacity ameliorates the negative
effect of increased age) is correct, then it would seem appropriate to perform
the innominate osteotomy at the time of open reduction.
In summary, this method of open reduction and innominate osteotomy for
developmental dislocation of the hip presenting after eighteen months of age
can be expected to result, on the basis of data derived from validated and
reliable measures, in the following outcomes at forty-five years after the
index procedure. The failure rate (with joint replacement as the end point) is
46% (95% confidence interval, ±16.4), with definite osteoarthritis in
25% of the surviving hips. Two-thirds of the surviving hips are able to
function at a high level up to and well beyond forty-five years, on the basis
of predictive data from well-designed population studies. The potentially
modifiable risk factors of body mass and age at the time of index surgery do
not appear to affect outcome for children between eighteen and sixty months
old, but bilateral dislocation of the hip is a poor prognostic factor. Even in
the face of postoperative complications, failure after the use of this
procedure to treat late-presenting dislocation of the hip is unlikely for the
first thirty years after surgery.
Tables showing clinical details on all study patients are available with
the electronic versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?
Note: The authors thank Dr. James Wright, Dr. Andrew Howard, and
Dr. William Cole for their peer review throughout this study and Derek
Stephens for performing the statistical analyses. They are also grateful to
their research assistants Laura Sutton and Mauro Barillas and to Sam Donaldson
for her advice and assistance during this project.
Grill F, Bensahel H, Canadell J, Dungl
P, Matasovic T, Vizkelety T. The Pavlik harness in the treatment of congenital
dislocating hip: report on a multicenter study of the European Paediatric
Orthopaedic Society. J Pediatr Orthop.
1988;8:
1-8.81
1988
[PubMed][CrossRef]
Wirth T, Stratmann L, Hinrichs F.
Evolution of late presenting developmental dysplasia of the hip and associated
surgical procedures after 14 years of neonatal ultrasound screening. J
Bone Joint Surg Br. 2004;86:
585-9.86585
2004
Paton RW, Srinivasan MS, Shah B, Hollis
S. Ultrasound screening for hips at risk in developmental dysplasia: is it
worth it? J Bone Joint Surg Br.
1999;81:
255-8.81255
1999
[PubMed][CrossRef]
Tredwell SJ, Bell MH. Efficacy of
neonatal hip examination. J Pediatr Orthop.
1981;1:
61-5.161
1981
[PubMed][CrossRef]
Rosendahl K, Markestad T, Lie RT.
Ultrasound screening for developmental dysplasia of the hip in the neonate:
the effect on treatment rate and prevalence of late cases.
Pediatrics. 1994;94:
47-52.9447
1994
[PubMed]
Crawford AH, Mehlman CT, Slovek RW. The
fate of untreated developmental dislocation of the hip: long-term follow-up of
eleven patients. J Pediatr Orthop.
1999;19:
641-4.19641
1999
[PubMed][CrossRef]
Lai KA, Lin CJ, Su FC. Gait analysis of
adult patients with complete congenital dislocation of the hip. J
Formos Med Assoc. 1997;96:
740-4.96740
1997
Wedge JH, Wasylenko, MJ. The natural
history of congenital disease of the hip. J Bone Joint Surg Br.
1979;3:
334-8.3334
1979
Hartofilakidis G, Karachalios T, Stamos
KG. Epidemiology, demographics, and natural history of congenital hip disease
in adults. Orthopedics.
2000;23:
823-7.23823
2000
[PubMed]
Cooperman DR, Wallensten R, Stulberg SD.
Acetabular dysplasia in the adult. Clin Orthop Relat Res.
1983;175:
79-85.17579
1983
[PubMed]
Harris WH. Etiology of osteoarthritis of
the hip. Clin Orthop Relat Res.
1986;213:
20-33.21320
1986
[PubMed]
Weinstein SL, Mubarak SJ, Wenger DR.
Developmental hip dysplasia and dislocation: Part I. J Bone Joint Surg
Am. 2003;85:
1824-32.851824
2003
Albinana J, Dolan LA, Spratt KF,
Morcuende J, Meyer MD, Weinstein SL. Acetabular dysplasia after treatment for
developmental dysplasia of the hip. Implications for secondary procedures.
J Bone Joint Surg Br.
2004;86:
876-86.86876
2004
[PubMed][CrossRef]
Salter RB. Innominate osteotomy in the
treatment of congenital dislocation and subluxation of the hip. J Bone
Joint Surg Br. 1961;43:
518-39.43518
1961
Salter RB. Role of innominate osteotomy
in the treatment of congenital dislocation and subluxation of the hip in the
older child. J Bone Joint Surg Am.
1966;48:
1413-39.481413
1966
[PubMed]
Salter RB, Dubos JP. The first fifteen
years' personal experience with innominate osteotomy in the treatment of
congenital dislocation and subluxation of the hip. Clin Orthop Relat
Res. 1974;98:
72-103.9872
1974
[CrossRef]
O'Brien TM, Reynolds RAK, Salter RB,
Wedge JH, Wray AR. The long-term (15 to 33 years) results of innominate
osteotomy as primary treatment of congenital dislocation and subluxation of
the hip for children aged 1.5 to 4 years. J Bone Joint Surg Br.
1992;74(Supp III):
S285.74S285
1992
Barrett WP, Staheli LT, Chew DE. The
effectiveness of the Salter innominate osteotomy in the treatment of
congenital dislocation of the hip. J Bone Joint Surg Am.
1986;68:
79-87.6879
1986
[PubMed]
Roth A, Gibson DA, Hall JE. The
experience of five orthopaedic surgeons with innominate osteotomy in the
treatment of congenital dislocation and subluxation of the hip. Clin
Orthop Relat Res. 1974;98:
178-82.98178
1974
[CrossRef]
Macnicol MF, Bertol P. The Salter
innominate osteotomy: should it be combined with concurrent open reduction?
J Pediatr Orthop B.
2005;14:
415-21.14415
2005
[PubMed][CrossRef]
Boardman DL, Moseley CF. Finding
patients after 40 years: a very long term follow-up study of the Colonna
arthroplasty. J Pediatr Orthop.
1999;19:
169-76.19169
1999
[PubMed]
Harris WH. Traumatic arthritis of the
hip after dislocation and acetabular fractures: treatment by mold
arthroplasty. An end-result study using a new method of result evaluation.
J Bone Joint Surg Am.
1969;51:
737-55.51737
1969
[PubMed]
Bellamy N, Buchanan WW, Goldsmith CH,
Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument
for measuring clinically important patient relevant outcomes to antirheumatic
drug therapy in patients with osteoarthritis of the hip or knee. J
Rheumatol. 1988;15:
1833-40.151833
1988
Dawson J, Fitzpatrick R, Carr A, Murray
D. Questionnaire on the perceptions of patients about total hip replacement.
J Bone Joint Surg Br.
1996;78:
185-90.78185
1996
[PubMed]
Pynsent PB, Adams DJ, Disney SP. The
Oxford hip and knee outcome questionnaires for arthroplasty. J Bone
Joint Surg Br. 2005;87:
241-8. Erratum in: J Bone Joint Surg Br.
2005;87:1166.87241
2005
[CrossRef]
Kellgren JH, Lawrence JS. Radiological
assessment of osteo-arthrosis. Ann Rheum Dis.
1957;16: 494
-502.16494
1957
[PubMed][CrossRef]
Croft P. An introduction to the Atlas of
Standard Radiographs of Arthritis. Rheumatology (Oxford).
2005;44Suppl 4:
iv42.44iv42
2005
[PubMed][CrossRef]
Jacobsen S, Sonne-Holm S, Soballe K,
Gebuhr P, Lund B. Radiographic case definitions and prevalence of
osteoarthrosis of the hip: a survey of 4151 subjects in the Osteoarthritis
Substudy of the Copenhagen City Heart Study. Acta Orthop Scand.
2004;75:
713-20.75713
2004
[PubMed][CrossRef]
Croft P, Cooper C, Wickham C, Coggon D.
Defining osteoarthritis of the hip for epidemiologic studies. Am J
Epidemiol. 1990;132:
514-22.132514
1990
Sharp IK. Acetabular dysplasia. The
acetabular angle. J Bone Joint Surg Br.
1961;43:
268-72.43268
1961
Wiberg G. Studies on dysplastic
acetabula and congenital subluxation of the hip joint. With special reference
to the complication of osteoarthritis. Acta Chir Scand Suppl.
1939;58:
7-38.587
1939
Severin E. Contribution to the knowledge
of congenital dislocation of the hip. Late results of closed reduction and
arthrographic studies of recent cases. Acta Chir Scand.
1941;84 (Suppl 63):
37.8437
1941
Salter RB, Kostuik J, Dallas S.
Avascular necrosis of the femoral head as a complication of treatment for
congenital dislocation of the hip in young children: a clinical and
experimental investigation. Can J Surg.
1969;12:
44-61.1244
1969
[PubMed]
Fitzpatrick R, Morris R, Hajat S, Reeves
B, Murray DW, Hannen D, Rigge M, Williams O, Gregg P. The value of short and
simple measures to assess outcomes for patients of total hip replacement
surgery. Qual Health Care.
2000;9:
146-50.9146
2000
[PubMed][CrossRef]
Lieberman JR, Hawker G, Wright JG. Hip
function in patients >55 years old: population reference values. J
Arthroplasty. 2001;16:
901-4.16901
2001
[CrossRef]
Murray DW, Carr AJ, Bulstrode C.
Survival analysis of joint replacements. J Bone Joint Surg Br.
1993;75:
697-704.75697
1993
[PubMed]
Lejman T, Strong M, Michno P.
Capsulorrhaphy versus capsulectomy in open reduction of the hip for
developmental dysplasia. J Pediatr Orthop.
1995;15:
98-100.1598
1995
[PubMed][CrossRef]
Ward WT, Vogt, M, Grudziak JS, Tumer Y,
Cook PC, Fitch RD. Severin classification system for evaluation of the results
of operative treatment of congenital dislocation of the hip. A study of
intraobserver and interobserver reliability. J Bone Joint Surg
Am. 1997;79:
656-63.79656
1997
Kalamchi A, MacEwen GD. Avascular
necrosis following treatment of congenital dislocation of the hip. J
Bone Joint Surg Am. 1980;6:
876-88.6876
1980
Bucholz RW, Ogden JA. Patterns of
ischemic necrosis of the proximal femur in nonoperatively treated congenital
hip disease. In: The hip: proceedings of the Sixth Open Scientific
Meeting of the Hip Society. St. Louis: CV Mosby; 1978. p
43-63.43
1978
Reijman M, Hazes JM, Pols HA, Bernsen
RM, Koes BW, Bierma-Zeinstra SM. Role of radiography in predicting progression
of osteoarthritis of the hip: prospective cohort study. BMJ.
2005;330:
1183.3301183
2005
[PubMed][CrossRef]
Somerville EW, Scott JC. The direct
approach to congenital dislocation of the hip. J Bone Joint Surg
Br. 1957;39:
623-40.39623
1957
Angliss R, Fujii G, Pickvance E,
Wainwright AM, Benson MK. Surgical treatment of late developmental
displacement of the hip. Results after 33 years. J Bone Joint Surg
Br. 2005;87:
384-94.87384
2005
[CrossRef]
Ponseti IV. Growth and development of
the acetabulum in the normal child. Anatomical, histological, and
roentgenographic studies. J Bone Joint Surg Am.
1978;60:
575-85.60575
1978
[PubMed]
Carlioz H, Filipe G. The natural history
of the limbus in congenital dislocation of the hip. In: Congenital
dislocation of the hip. Tachdjian MO, editor. New York: Churchill
Livingstone; 1982. p 242-62.242
1982
Malvitz TA, Weinstein SL. Closed
reduction for congenital dysplasia of the hip. Functional and radiographic
results after an average of thirty years. J Bone Joint Surg Am.
1994;12:
1777-92.121777
1994
Danielsson L, Lindberg H. Prevalence of
coxarthrosis in an urban population during four decades. Clin Orthop
Relat Res. 1997;342:
106-10.342106
1997
Felson DT, Lawrence RC, Dieppe PA,
Hirsch R, Helmick CG, Jordan JM, Kington RS, Lane NE, Nevitt MC, Zhang Y,
Sowers M, McAlindon T, Spector TD, Poole AR, Yanovski SZ, Ateshian G, Sharma
L, Buckwalter JA, Brandt KD, Fries JF. Osteoarthritis: new insights. Part 1:
the disease and its risk factors. Ann Intern Med.
2000;133:
635-46.133635
2000
[PubMed]