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Effect of Innominate and Femoral Varus Derotation Osteotomy on Acetabular Development in Developmental Dysplasia of the Hip
Gavin Spence, MD, FRCS(Orth)1; Richard Hocking, BSc(Med), MBBS(Hons), FRACS(Orth)2; John H. Wedge, MD, FRCS(C)2; Andreas Roposch, MD, MSc, FRCS1
1 Department of Orthopaedic Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, United Kingdom. E-mail address for A. Roposch: a.roposch@ich.ucl.ac.uk
2 Department of Orthopaedic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Arthritis Research Campaign. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Great Ormond Street Hospital for Children, London; Institute of Child Health, University College London, London, England; and Hospital for Sick Children, Toronto, Ontario, Canada

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Nov 01;91(11):2622-2636. doi: 10.2106/JBJS.H.01392
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Abstract

Background: Open reduction for the treatment of hip dislocation due to developmental dysplasia of the hip in children of walking age is frequently combined with either a femoral varus derotation osteotomy or an innominate osteotomy; however, it remains unclear which of these procedures is preferable in terms of subsequent hip development. The purpose of the present study was to compare acetabular development in patients managed for dislocation of the hip with open reduction combined with one of the two osteotomies.

Methods: Patients between fifteen months and four years of age with hip dislocations that were treated at two different centers were compared. At one center, open reduction combined with a femoral varus derotation osteotomy was performed (thirty-eight patients), and at the other, open reduction combined with an innominate osteotomy was performed (thirty-three patients). In each group, one surgeon performed all of the operations. A total of 490 postoperative radiographs that were made over a mean follow-up period of 6.2 years were analyzed. We compared the change in acetabular index as well as several other radiographic criteria of acetabular development and hip stability over time.

Results: After osteotomy, the acetabular index improved in both groups; however, the acetabular index in patients who underwent a varus derotation osteotomy never improved as much as that in patients who underwent an innominate osteotomy, with a mean difference of 9.5 after four years (p < 0.0001). Similarly, the innominate osteotomy group demonstrated better acetabular architecture and hip stability over time as quantified by the change in the acetabular floor thickness (p = 0.03), lateral centering ratio (p < 0.0001), and superior centering ratio (p < 0.0001).

Conclusions: In the present series, acetabular remodeling after open hip reduction and innominate osteotomy was more effective for reversing acetabular dysplasia and maintaining hip stability than open reduction combined with a femoral varus derotation osteotomy was. Long-term follow-up is necessary to determine whether the more favorable hip development following innominate osteotomy is associated with a lower incidence of premature degenerative hip disease.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Andreas Roposch, MD, MSc, FRCS
    Posted on November 21, 2009
    Mr. Roposch and Dr. Wedge respond to Dr. Vukasinovic
    Great Ormond Street Hospital for Children, London, United Kingdom

    We would like to thank Professor Vukasinovic and colleagues for their comments on our recent paper. We are well aware of the work of this group from Serbia and have been following their results with great interest.

    It seems that their first comment is the only one relevant to the research question of our recently published study. Although we routinely perform a Salter innominate osteotomy in patients aged 18 months or older, we do not routinely perform a femoral shortening-derotation osteotomy in addition to the open reduction. We make this decision intra-operatively and, as a general rule, accept up to 20 degrees of internal rotation to stabilize the hip. If more rotation is required, we do the osteotomy. However, we agree that the likelihood of such a shortening-derotation osteotomy increases with the age of the patient. One of us (JHW) visited Professor Klisic in 1975 and was greatly influenced by his approach. Thereafter he combined both Salter and femoral osteotomy with open reduction for those patients between 3 and 4 years of age and older. The published long term results (1) support the practice of open reduction and innominate osteotomy up until at least 3 years of age because superior results up to 48 years post-operatively have not been published to date. We do not recommend reduction of complete dislocations in bilateral DDH after age 7 or a unilateral dislocation after age 10 as the results do not compare favorably with those in untreated individuals but we agree with most of their other comments. However, we do perform a modified periacetabular osteotomy as opposed to the Chiari osteotomy in cases where a salvage procedure is warranted when post-operative congruency of the hip is not likely to be predicted or achieved.

    Reference

    1. Thomas SR, Wedge JH, Salter RB. Outcome at forty-five years after open reduction and innominate osteotomy for late-presenting developmental dislocation of the hip. J Bone Joint Surg Am. 2007;89:2341-50.

    Basil Grogono
    Posted on November 19, 2009
    Effect of Innominate and Femoral Varus Derotation Osteotomy on Acetabular Development...
    Dalhousie University, Halifax, Nova Scotia, Canada

    To the Editor:

    I enjoyed the article by Spence et al. on CDH very much (1). It seems that that innominate pelvic osteotomy is likely to produce more rapid and effective correction of acetabular dysplasia than femoral varus and rotational osteotomy. However, I was surprised I could find no reference to Mr. Edgar Somerville's life long work (2). He published many papers on his concept of limbus excision and femoral varus osteotomy. In his paper, "The results of treatment of 100 congenitally dislocated hips", he relates the CE angle to the end results and noted that open reduction and removal of an obstructing limbus combined with a femoral rotational osteotomy was followed by gradual development of the dislocated hips into normal hips. Bad results were due to inadequate seating of the femoral head, a retained limbus, or inadequate rotation of the femur. It is more than 50 years since I first saw Mr. Somerville's early embarkation on this valuable work. On coming to Canada in 1959, I was then exposed to Mr. Salter's remarkable work on innominate osteotomy (3).

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Spence G, Hocking R, Wedge JH, Roposch A. Effect of innominate and femoral varus derotation osteotomy on acetabular development in developmental dysplasia of the hip. J Bone Joint Surg Am. 2009;91:2622-36.

    2. Somerville EW. Results of treatment of 100 congenitally dislocated hips. J Bone Joint Surg Br. 1967;49:258-67.

    3. Salter RB. Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip. J Bone Joint Surg Br. 1961;43:518-39.

    Zoran S. Vukasinovic
    Posted on November 04, 2009
    Surgical Treatment of Developmental Dysplasia of the Hip - Our Experience
    Institute for Orthopaedic Surgery "Banjica" Belgrade, Serbia

    To the Editor:

    We read the paper by Spence et al. (1) with great interest. Living in Serbia, a country with a high incidence of developmental dysplasia of the hip (DDH) (2.4%), and working in the country's biggest orthopaedic hospital, we have acquired great experience in the surgical treatment of this disease. We started forty years ago, in a study conducted by Predrag Klisic (2). Our first treatment option was open hip reduction combined with a Chiari pelvic osteotomy and a femoral varus derotation osteotomy. Later on, the Chiari osteotomy was replaced by the Salter innominate osteotomy, and the femoral varus derotation osteotomy was replaced by femoral derotation with shortening.

    Currently, our treatment protocol is as follows (3,4):

    1. Open reduction with a Salter innominate osteotomy and femoral derotation shortening osteotomy in all patients, aged 2 to 8 years with a hip dislocation.

    2. In older children, 8-12 years of age, the combination of procedures is similar, but the Salter osteotomy is replaced by triple pelvic osteotomy.

    3. In cases with femoral head deformities due to postreduction osteonecrosis (such as coxa plana) where postoperative spherical congruence cannot be achieved, a Chiari pelvic osteotomy is performed.

    4. We do not perform surgical reduction of a dislocated hip in children over 12 years of age.

    5. In less serious cases, hip dysplasia and subluxation, we perform an isolated pelvic osteotomy or a combination of pelvic and femoral osteotomies without opening the hip joint. This treatment option can be used even in adolescents.

    Using this protocol, acetabular development is very good in younger children and much better than it was previously when we performed isolated pelvic or femoral osteotomies.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Spence G, Hocking R, Wedge JH, Roposch A. Effect of innominate and femoral varus derotation osteotomy on acetabular development in developmental dysplasia of the hip. J Bone Joint Surg Am. 2009;91:2622-36.

    2. Klisic P, Jankovic LJ, Basara V. [Open reduction with pelvic osteotomy and femoral shortening]. Acta Orthop Belg. 1990;56:269-74. French.

    3. Gavrankapetanovic I, Vukasinovic Z. Surgical treatment of late developmental displacement of the hip. J Bone Joint Surg Br. 2005;87:1307.

    4. Vukasinović Z, Vucetić C, Cobeljić G, Bascarević Z, Slavković N. [Developmental dislocation of the hip is still important problem--therapeutic guidelines]. Acta Chir Iugosl. 2006;53:17-9. Serbian.

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