Surgical treatment of the congenital dislocation of the hip after walking age: open reduction and Salter's osteotomy

Tratamento cirúrgico da luxação congênita do quadril pós marcha: redução aberta e osteotomia de Salter

Abstracts

A luxação congênita do quadril (LCQ), após a marcha, requer o tratamento cirúrgico, sendo uma das opções a redução aberta associada a osteotomia do osso inominado (tipo Salter). Neste estudo foram avaliados 18 pacientes, 22 quadris, que apresentavam LCQ tratados cirurgicamente, entre 1989 e 1995, utilizando a osteotomia do osso inominado, pela técnica de Salter, pós redução aberta. A idade dos pacientes, na época da cirurgia, variou de 12 a 30 meses, com média de 19 meses, sendo 15 do sexo feminino e 3 do masculino, 4 pacientes tinham acometimento bilateral, sendo que nos demais, 8 tinham o quadril esquerdo acometido e 6 o lado direito. Os resultados foram avaliados segundo critérios clínicos de Dutoit et al.(3) e radiográficos de Severin(12), após um seguimento médio de 48 meses. Clinicamente foram obtidos 18% de resultados excelentes (4); 54% resultados bons (12); 14% regulares (3); e 14% ruins (3). Quanto aos critérios radiográficos, encontramos 36% dos quadris classificados como excelentes (8); 45% bons (10); 5% regulares (1); e 14% ruins(3). Como complicações foram constatados 3 casos de reluxação, tratados com outra técnica cirúrgica. Não foi observado nenhum caso de infecção, fratura do enxerto e lesão vascular ou nervosa.

Luxação congênita do quadril; Osteotomia de Salter; Marcha

ORIGINAL ARTICLE

Surgical treatment of the congenital dislocation of the hip after walking age: open reduction and Salter's osteotomy

Guaracy Carvalho Filho^I; Alceu Gomes Chueire^II; Helencar Ignácio^III; Márcio de Oliveira Carneiro^IV; João Francese Neto^IV; Augusto César Canesin^IV

^IPhD in Orthopedics and Head of the Orthopedics and Traumatology Discipline

^IIPhD in Orthopedics and Head of the Orthopedics and Traumatology Department

^IIIPhD in Orthopedics and Residents' Preceptor

^IVFormer Resident Doctors

^{Correspondence}

SUMMARY

The congenital dislocation of the hip, after the function of weight bearing begins or walking phase requires surgical treatment, and one of the options is the open reduction combined to innominate osteotomy (Salter). In this study, the results of 18 patients, 22 surgically treated hips with congenital dislocation, were evaluated from 1989 and 1995, using innominate osteotomy, by Salter's technique after open reduction. The age of the patients at the time of surgery ranged from 12 to 30 months (age after march), mean age of 19 months. Fifteen were female and 3 were male, 4 patients had bilateral dislocation and in the remaining, 8 had their left hip dislocated and 6 had their right hip dislocated. The results were evaluated according to Dutoit et al.⁽³⁾ clinical criteria and to Severin⁽¹²⁾ radiological criteria, after a mean follow-up of 48 months. Eighteen percent of excellent clinical results (4); 54% of good results (12); 14% of regular results (3) and 14% of bad results(3) were obtained. As to the radiologic criteria, 36% of the hips were classified as excellent (8); 45% as good (10); 5% regular (1) and 14% bad (3). There were 3 cases of re-dislocation which were treated by a different surgical technique. No cases of infection, graft fracture and vascular or nervous injury were reported.

Key Words: Hip dislocation congenital; Salter osteotomy; March.

INTRODUCTION

Hip development dysplasia involves several abnormalities ranging from simple hip instabilities with capsule looseness to complete dislocation of the femoral head relating to an abnormal acetabulum cavity. In these cases, the acetabulum is in an antero-superior position as a consequence of the excessive anteversion, this way becoming progressively flat and oblique. This occurs as a consequence of lack of contact between the acetabulum and the femoral head, which is generally in a 15º anteversion. The femoral head may be spherical or posteromedially flattened⁽¹³⁾.

Hip development dysplasia may be divided into teratologic and typical, and this last one subdivides into: dislocated hip, dislocable hip, sub-dislocated and unstable, which can be dislocable or sub-dislocable. The treatment directly depends on age and the degree of acetabulum and proximal femur dysplasia.

In the dislocated hip, treatment consists in reduction and atraumatic and concentric maintenance of the femoral epiphysis, until joint stability is achieved, and before walking age it may be conservative⁽²⁾. After the walking age it is necessary an open reduction due to hip structures interposing (round ligament, capsular labrum and fibrocartilage). Once reduction is obtained, stability can be achieved by acting over the acetabulum and/or the proximal femur⁽¹³⁾.

Salter⁽¹¹⁾ described the innominate bone osteotomy for treating congenital hip dislocation and sub-dislocation, repositioning the acetabulum aiming to get a ceiling in order to support the femoral head after the reduction. Since then, this surgical technique has been used and analyzed by several authors.

Walters et al⁽¹⁴⁾ analyzed Salter's innominate osteotomy performed in 29 hips of 24 patients, reporting good and excellent results in all cases, with an average follow up of 9 years and 3 months, using Severin's⁽¹²⁾ radiographic rating, with low complication rates.

Mariambourg et al.⁽⁹⁾ analyzed Salter's osteotomy for treatment of congenital hip dislocation, with excellent acetabular dysplasia correction and reduction of the acetabular index, with an average follow-up of 6 years and 2 months.

Kershaw et al.⁽⁸⁾ analyzed hip dysplasia treatment failures concluding that, once re-dislocation after primary open reduction takes place, a new reduction or even a pelvian or femoral osteotomy would be necessary.

Saleh et al.⁽¹⁰⁾ performed a study evaluating pelvian remodeling after innominate bone osteotomy, evaluated by means of obturator foramen symmetry and concluded that in patients with mature skeleton there was no bone remodeling. In the same year, Volpon et al.⁽¹⁶⁾ evaluated the influence of post Salter osteotomy iliac bone longitudinal growth, finding that there is not any change in relation to local growth derangements.

Haidar et al.⁽⁶⁾ performed a retrospective study of patients who were surgically treated by open reduction and Salter's osteotomy, evaluating clinical and radiographic results as well as complications. They report that 97.3% of the patients were clinically rated as good and excellent results, and radiographcally, 83.3% were equally rated. In three hips (8%), it was diagnosed signs of avascular necrosis, however symptomatic in only one. It was concluded that open reduction plus Salter's osteotomy is an excellent therapeutic option, with low complication index for CHD patients diagnosed at the age of walking start.

This study aimed to evaluate mid term clinical and radiographic results of surgical treatment of CHD after starting to walk, with a combination of open reduction and Salter's osteotomy.

CASES AND METHOD

This study was accomplished at the Orthopedics and Traumatology Department of Faculdade de Medicina de São José do Rio Preto and at the Hospital de Base.

Eighteen non-treated congenital hip dislocation patients, who were at walking age, underwent surgical treatment from 1989 to 1995, and were three boys and fifteen girls. From the 18, 4 patients had bilateral dislocation, 8 at the left side and 6 at the right side, in a total of 22 treated hips.

The age at the time of the surgery ranged from 12 to 30 months, with an average of 19 months. Time of cast immobilization was in average 7 months. After this it was allowed total load walking and light physiotherapic exercises. Bone graft fixating Kirschner wires were removed during the first change of the cast model, between 8 and 12 weeks after surgery.

Post-operative follow-up ranged from 36 to 96 months, averaging 48 months.

All patients underwent open reduction followed by Salter's osteotomy according to description ⁽¹³⁾. In bilateral cases, osteotomies were performed at the same surgical time.

It was not performed previous traction in any case, due to nursery care technical difficulties.

Evaluation criteria

Clinical and radiographic aspects were evaluated. For clinical evaluation, Dutoit's et al.⁽³⁾ criteria were used (Table 1). Radiographic evaluation was based on Severin's⁽¹²⁾ rating (Table 2).

RESULTS

CE Wiberg's ⁽¹⁵⁾ angle (Figure 1), that averages 36º with a normal range from 20 to 46º, was evaluated in post-operative radiograph (AP pelvis radiograph) only in the treated side in 19 located hips from 16 patients, with 18º average, ranging from 15 to 40º (Table 3).

It was also evaluated the AC angle (Figure 2), that averages 30º, pre and post-operatively at the treated side of the same 16 patients (19 hips), averaging 39º, range from 31 to 47º pre-operatively and averaging 22º (range 18º to 33º) post-operatively. A mean reduction of 17º was observed, maximum 25º and minimum 7º. By means of the radiographic criteria were found 8 excellent hips (36%), 10 good (45%), 1 fair (5%), 3 bad (14%) (Table 3).

In clinical evaluation it was found 4 hips rated as excellent (18%), 12 as good (54%), 3 as fair (14%) and 3 as bad (14%) – that presented early pos-operative re-dislocation (up to 8 weeks), and needed a new surgical procedure (Table 4).

There was no case of superficial or deep infection, no vascular complication, no significant lower limb dysmetria, no nervous injury, and no lost correction due to graft compression and necrosis.

The only complication found was post-operative re-dislocation inside the cast in three hips, re-operated with a femoral osteotomy, one of them bilateral in a male and one case undergoing surgery at 16 months of age, stressing that the patient walked early, disregarding medical instructions.

Complete radiographic documentation of one case is in Figures 3 (A, ^B), ⁴ and ⁵ (^A,^B).

DISCUSSION

Surgical treatment of congenital hip dysplasia is progressively becoming less frequent due to current early and preventive diagnosis methods as routine ultrasonography.

Deformities that take place in cases lacking early reduction lead to an aggressive treatment that can be performed at the femur or the acetabulum.

One of the most important methods for acetabulum repositioning is the surgery proposed by Salter ⁽¹¹⁾ in 1961, who observed 92% of excellent and good results treating 25 hips (18 patients). This technique has been performed with a satisfactory success degree by several authors from different countries. In order to perform medium and long term results evaluation, these authors ^(6,9) used radiographic Severin's⁽¹²⁾ criteria, which takes into consideration acetabular (AC) and CE Wiberg's⁽¹⁵⁾ angles, femoral head sphericity, hip dislocation and sub-dislocation and presence or absence of arthrosis. Another evaluation method is according to clinical criteria by Dutoit et al.⁽³⁾ that are based on hip stability and mobility, pain, limping and Trendelenbourg test.

Waters et al.⁽¹⁴⁾ evaluated 29 hips that underwent innominate bone osteotomy, with good and excellent results in all cases. Later, other authors (6,9) found similar results. In our revision were found 82% results among good and excellent in radiographic criteria according to Severin's⁽¹²⁾ method, and 73% by Dutoit's et al.⁽³⁾ clinical criteria.

On the other hand literature demonstrates ⁽⁶⁾ that Salter's osteotomy is not free of complications such as superficial and deep infection, osteocondritis, sub-dislocation, re-dislocation, chondrolysis, sciatic nerve praxis, avascular necrosis. In our series we had as complication three re-dislocated hips, with diagnosis only confirmed by CT since radiographic evaluation was compromised due to the cast model. These patients needed new surgery with femoral complementation with a de-rotational subtraction osteotomy after a new open reduction, as indicated by Kershaw et al.⁽⁸⁾.

Some authors as Galpin et al.⁽⁴⁾, Browne et al.⁽¹⁾ and Gibson et al.⁽⁵⁾ prefer femoral osteotomy as a complement for open reduction. Others, as Karakas et al.⁽⁷⁾ and Williamson et al. ⁽¹⁷⁾ add femoral and Salter's osteotomy after open reduction. However, in our study, Salter's osteotomy was shown to be sufficient for femoral head retention, leaving valgus or varus femur osteotomy as a back-up for complementing in cases of failure (re-dislocation).

Saleh et al.⁽¹⁰⁾ demonstrated that pelvian remodeling after Salter's osteotomy was not found in patients with mature skeleton. In our study it was performed in patients from 12 to 30 months of age (after walking age), who have a high bone remodeling potential, however not influencing mid term clinical and radiographic results as described by Volpon et al.⁽¹⁶⁾

CONCLUSION

Even though not complication-free, it can be concluded that open HCD reduction complemented by Salter's osteotomy (of the innominate bone) was shown to be an efficacious treatment method for congenital hip dislocation after walking age, however needing to keep under evaluation and whenever possible compared to other treatment methods and techniques.

Trabalho recebido em 21/08/2002

Aprovado em 20/12/2002

• 1. Browne RS. The management of late diagnosed congenital dislocation and subluxation of the hip-with special reference to femoral shortening. J Bone Joint Surg Br 61:7-12, 1979.
• 2. Churgay CA, Caruthers BS. Diagnosis and treatment of congenital dislocation of the hip. Am Family Phys 45:1217-28, 1992.
• 3. Dutoit M, Moulin P, Morseher E. Salter's innominate osteotomy. 20 years after. Chir Pediatr 30:277-283, 1989.
• 4. Galpin RD, Roach JW, Wenger DR, Herring JA, Birch JG. One-stage treatment of congenital dislocation of the hip in older children, incluing femoral shortening. J Bone Joint Surg Am 71:734-741, 1989.
• 5. Gibson PH, Benson MK. Congenital dislocation of the hip. Review at maturity of 147 hips treated by excision of the limbus and derotation osteotomy. J Bone Joint Surg Br 64:169-175, 1982.
• 6. Haidar RK, Jones RS, Vergroesen DA, Evans GA. Simultaneous open reduction and Salter innominate osteotomy for developmental dysplasia of the hip. J Bone Joint Surg Br 78:471-476, 1996.
• 7. Karakas ES, Baktir, A, Argun M, Turk CY. One-stage treatment of congenital dislocation of the hip in older children. J Pediatr Orthop 15:330-336, 1995.
• 8. Kershaw CJ, Ware RE, Pattinson R, Fixsen JA. Revision of failed open reduction of congenital dislocation of the hip. J Bone Joint Surg Br 75:744-749, 1993.
• 9. Mariambourg G, Pouliquen JC, Beneux J. Salter's innominate osteotomy for congenital dislocation of the hip. A 129 cases report. Rev Chir Orthop 77:406-411, 1991.
• 10. Saleh JM, O'Sullivan ME, O'Brien TM. Pelvic remodeling after Salter osteotomy. J Pediatr Orthop 15: 342-345, 1995.
• 11. Salter RB. Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip. J Bone Joint Surg Br 43:518-539, 1961.
• 12. Severin F. Contribution to the knowledge of congenital dislocation of the hip joint. Late results of closed reduction and artrographic studies of recent cases. Acta Chir Scand 84 (suppl 63):1-142, 1941.
• 13. Tachdjian MO. Dysplasia congenital of the hip. In: Pediatric Orthopedics. 2nd ed. Philadelphia: Saunders,1990. p.297-306.
• 14. Waters P, Kurica K, Hall J, Micheli LJ. Salter innominate osteotomies in congenital dislocation of the hip. J Pediatr Orthop 8:650-655, 1988.
• 15. Wiberg G. Studies on dysplastic acetabula and congenital subluxation of hip joint. Acta Chir Scand 83(suppl):58, 1939.
• 16. Volpon JB, Cury Filho M, Tierno GOH. Efeito da osteotomia de Salter no crescimento do osso ilíaco do coelho. Rev Bras Ortop 30:57-60, 1995.
• 17. Williamson DM, Glover SD, Benson MK. Congenital dislocation of the hip presenting after the age of three years. A long term review. J Bone Joint Surg Br 71:745-751, 1989.

Publication Dates

• Publication in this collection
  16 Apr 2003
• Date of issue
  Jan 2003

History

• Accepted
  20 Oct 2002
• Received
  21 Aug 2002