Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Outcome at Forty-five Years After Open Reduction and Innominate Osteotomy for Late-Presenting Developmental Dislocation of the Hip"
by Simon R. Thomas, MA, FRCS(Tr&Orth), et al.

Commentary & Perspective by
Michael B. Millis, MD*,
Children's Hospital, Boston, Massachusetts

Posted November 2007

Developmental dysplasia of the hip remains the single most common cause of osteoarthritis of the hip in North America1, Japan2, and many other parts of the world. Various screening measures have reduced the prevalence of late-presenting dislocation, but the clinical problem is unlikely to disappear in the foreseeable future.

Of the many ground-breaking achievements of Robert Salter, his now classic technique of single-stage open reduction and innominate osteotomy to treat children with late-presenting hip dislocation is among the most enduring3. The technique has endured because it is it extremely effective. While certain details of the perioperative care of these patients have changed in the past forty years, the basic technique of anterior-approach open reduction with capsulorrhaphy and innominate osteotomy has truly stood the test of time.

Many elements in this work3 are remarkable, but a few must be mentioned. Although a follow-up rate of "only" 79% might be questioned in some reports, given the distance from which many of these children were referred to Toronto and the minimum follow-up time of forty years from the time of the index operation, the authors should be congratulated.

The patients in this memorable series of cases were operated on by a true master who literally invented the osteotomy technique employed. The results reported for these patients, while extremely impressive, are still sobering. The overall complication rate of 25% is humbling, particularly when one considers the skill and attention to detail of the surgeon. The rate of conversion to total hip replacement of 31% in the patients who survived more than forty years beyond the index procedure is also a reminder that, even with optimal treatment, osteoarthritis will still be a frequent outcome of the late-diagnosed dislocated hip.

Although nearly one-third of the hips had been replaced by the time of the final follow-up evaluation, the survival rates of 99% at thirty years, 86% at forty years, and 54% at forty-five years after reduction are better than the results achieved in any other reported series of such patients4,5.

The authors identified bilaterality as a strong risk factor for a subsequent hip replacement; however, another expected risk factor for poor result, older mean age at the time of the index surgery, did not reach significance (mean age at index surgery for the patients with surviving hips was 2.65 years; mean age at index operation for patients who required total hip replacement was 3.05 years; p = 0.07).

All patients in this consecutive series were treated with preliminary traction for a minimum of two weeks before surgery, followed by a single-stage open reduction, standard capsulorrhaphy, and innominate osteotomy with plaster immobilization for a minimum of ten weeks postoperatively. Today, as the authors noted, many of the older patients would be treated with a slightly different protocol, with preliminary traction replaced by intraoperative femoral shortening to reduce soft-tissue tension. Additionally, some surgeons would now prefer to perform a slightly different pelvic osteotomy or capsulorrhaphy. It is unlikely, however, that any contemporary surgeon could expect any better results at a minimum follow-up time of forty years than those achieved by Dr. Salter. In fact, except for hip replacement, no secondary procedure was necessary later in childhood or during the early stages of maturity in any patient in this group, and, in the minority of patients who did need hip replacement, the procedure was not necessary until thirty or more years after the index procedure.

Indeed, this article may well become a classic—the latest chapter in a fascinating sequence of articles documenting the evolution in function of a group of 101 dislocated hips over as much as nearly five decades since index surgery in very early childhood. We should view these results as the gold standard in treatment, only to be improved upon if we can universally diagnosis and institute treatment of a developmentally dislocated hip well before a child begins to walk.

*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. Aronson J. Osteoarthritis of the young adult hip: etiology and treatment. Instr Course Lect. 1986;35:119-28.
2. Nakamura S, Ninomiya S, Nakamura T. Primary osteoarthritis of the hip joint in Japan. Clin Orthop Relat Res. 1989;241:190-6.
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.
4. 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.
5. 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.