Scientific Article   |    
Salter Innominate Osteotomy for the Treatment of Developmental Dysplasia of the Hip in Children Results of Seventy-three Consecutive Osteotomies After Twenty-six to Thirty-five Years of Follow-up
Paul Böhm, MD; Annemarie Brzuske, MD
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Investigation performed at the Department of Orthopedic Surgery, Eberhard-Karls-Universität Tübingen, Tübingen, Germany

Paul Böhm, MD
Orthopädische Universitätsklinik, Eberhard-Karls-Universität Tübingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany. E-mail address: paul.boehm@med.uni-tuebingen.de

Annemarie Brzuske, MD
Kantonsspital, Abteilung Orthopädie, 6000 Luzern 16, Switzerland

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

J Bone Joint Surg Am, 2002 Feb 01;84(2):178-186
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Background: Reorientation of the acetabulum may be necessary in the treatment of an unstable hip in children with developmental dysplasia of the hip. In 1961, Salter described the innominate osteotomy for stabilizing the reduced hip in the position of function by redirection of the acetabulum as one piece. In the present study, we describe our long-term results with this procedure.

Methods: We reviewed the cases of sixty-one patients who had seventy-three Salter innominate osteotomies. At the time of the operation, the mean age of the patients was 4.1 years (range, 1.3 to 8.8 years). Radiographs made preoperatively, postoperatively, and at the time of the most recent follow-up visit were evaluated. Clinical evaluation was performed with use of the Merle d’Aubigné and Postel system as well as the Harris hip score.

Results: The mean duration of follow-up was 30.9 years (range, 26.2 to 35.4 years). There were seven true revisions (one acetabuloplasty, one triple osteotomy, and five total hip arthroplasties). With true revision as the end point, the cumulative survival rate at 35.3 years was 0.90. Fifteen of the seventy-three hips were considered a failure, which was defined as a revision or a Harris hip score of <70 points and/or a Merle d’Aubigné and Postel score of <13 points. The long-term clinical outcome was significantly influenced by the grade of dislocation on the radiographs made at the first examination (p = 0.0388) and on those made immediately preoperatively (p < 0.0001), the postoperative summarized hip factor (the radiographic grade of dysplasia) (p = 0.0002), the preoperative (p = 0.0392) and postoperative (p = 0.0072) grades of avascular necrosis of the femoral head, and the technique of reduction (p < 0.0001).

Conclusions: When an acetabulum can be most closely restored to a normal configuration without the development of avascular necrosis, good long-term results (lasting for more than thirty years) can be expected. When open reduction is necessary, it is preferable to perform it separately prior to the Salter innominate osteotomy. The grade of dislocation at the time of the first examination and immediately preoperatively, the grade of avascular necrosis of the femoral head, and the adequacy of surgical correction are important prognostic factors for the long-term clinical result.

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    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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    Paul Böhm
    Posted on May 10, 2002
    Re: avascular necrosis after treatment of DDH
    Department of Orthopedic surgery, University Tübingen

    We appreciate Dr. Ucar’s comments regarding our study. He is right, when he criticizes the sentence “No hip without preoperative radiographic signs of avascular necrosis at six months postoperatively”. This sentence should read “No hip without preoperative radiographic signs of AVN (grade 0) had six months postoperatively radiographic signs of AVN grade 2, 3, or 4.” This was the original text of the manuscript. When reading the proofs, we did not realize that the words “grade 2, 3, or 4” were omitted. We apologize for this mistake.

    There were 2 hips with preoperative AVN grade 1 which were 6 months postoperatively assessed grade 0, and 7 hips deteriorated from preoperatively grade 0 to postoperatively grade 1. In one of these 7 hips the postoperative dislocation was grade 2 and because of a poor outcome, a triple osteotomy was necessary. Obviously, the poor outcome was a result of the poor reduction rather than of the AVN grade 1.

    In our series, there were only 5 patients with AVN grade 4 indicating involvement of the growth plate. We do not think that using the classification of Kalamchi and Mc Ewen (1980) for further differentiation of these 5 cases (in type II, III, and IV) would be very helpful. Kim et al. (2000) emphasize the importance of monitoring acetabular development rather than searching for radiographic changes of physeal arrest, which are difficult to detect in young children.

    References: Kalamchi A, MacEwen GD. Avascular necrosis following treatment of congenital dislocation of the hip. J Bone Joint Surg Am. 1980 Sep;62(6):876-88. Kim HW, Morcuende JA, Dolan LA, Weinstein SL.Acetabular development in developmental dysplasia of the hip complicated by lateral growth disturbance of the capital femoral epiphysis. J Bone Joint Surg Am. 2000 Dec;82-A(12):1692-700.

    derya hakan uçar
    Posted on May 09, 2002
    avascular necrosis after treatment of DDH
    ortopaedic treatment center, ankara, turkey

    To The Editor,

    We read with interest the paper entitled " Salter Innominate Osteotomy For The Treatment Of Developmental Dysplasia Of The Hip In Children" (2002 ; 84-A:178-187)by Böhm et all..We appreciate the fact that this is a remarkable paper in regards to the number of patients followed and the duration of follow up. However we have few comments on the interpretation of results and methods used in this study.

    Preoperative avascular necrosis of the hip was reported in 53%(39 hips)and it was stated that " no hip without radiographic signs of avascular necrosis preoperatively had radiographic signs of avascular necrosis at six months postoperatively ". However, six months postoperatively avascular necrosis was reported in 60 % (44 hips).Thus, the 7% (5 hips) difference between preoperative and postoperative results conflicts with the statement above.

    Evaluation and grading of avascular necrosis of the hip was done according to the system of Tönnis(1). In this system,Grade 1,2, or 3 avascular necrosis affects only the epiphysis and because the physis is not compromised, it has no adverse effects on final clinical results. Only grade 4 avascular necrosis compromises the physeal plate and causes significant growth disturbance of the hip with severe long term clinical consequences.

    The most serious iatrogenic complication during and following treatment of developmental dysplasia of the hip is avascular necrosis and the most commonly used and accepted system which predicts the complications and clinical outcome is the system described by Kalamchi and Mc Ewen(1980)(2). In this classification system, Type I affects only the ossific nucleus of the femoral head and even if the patient is not followed closely during the first few years, it is unlikely that there will be a long term adverse outcome. However, type II, III, IV avascular necrosis affects the physeal growth plate and may be associated with permanent damage which adversely influences the long term clinical and radilogical results.

    The radiographic tell tale signs of Type II avascular necrosis which affects the lateral physeal plate can fully appreciated around age of 10 years (4-14 years) (3) and when observed in early stages of acetebular developement ,it has deleterious effects on the long term outcome.In such an important series reported by the authors it is unfortunate that avascular necrosis was only assessed at 6 months postoperatively (at the mean age of 5 years).

    We would like to ask the authors whether they assessed the postoperative radiographs following skeletal maturity in regards to the incidence of AVN and the incidence of Type II (Kalamchi) avascular necrosis at the time of maturity or completion of acetabular growth.

    References: 1. Tönnis D. Congenital dysplasia and dislocation of the hip in children and adults. chapter 18 P.275 ,New York: Springer ;1987. 2. Kalamchi A., Mac Ewen GD.Avasculer necrosis following treatment of congenital dislocation of the hip J.Bone and Joint Surg. 62 - Am.1980:876 - 88. 3. KIM HW , MORCUENDE JA, DOLAN LA ,WEINSTEIN SL. Acetebular developmental dysplasia of the hip comlicated by lateral growth disturbance of the capital femoral epiphysis .J. Bone Joint Surgery Am. 2000 ; 82 :1692 - 1699.

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