Surgical Treatment of Developmental Hip Dislocation in Children Aged 1 to 3 Years: A Mean 18-Year, 9-Month Follow-up Study

Posted on March 11, 2010

by Kevin E. Varner, MD; Stephen J. Incavo, MD; Richard J. Haynes, MD; Jesse A. Dickson, MD

Abstract

Forty-six consecutive patients with 57 congenitally dislocated hips were treated with open reduction and femoral or acetabular procedures as indicated. Patient age ranged from 12 to 36 months at the time of surgery. We evaluated the outcome of 38 of the 46 patients (83%) with 47 hips (83%) at a mean follow-up of 18 years, 9 months (range, 13 years, 7 months to 24 years, 7 months) after all patients had reached skeletal maturity.

Using Severin’s radiographic classification, 24 hips (52%) were rated as class I, 12 (26%) as class II, 8 (17%) as class III, 2 (4%) as class IV, and 0 as class V. The mean Iowa Hip Score was 92 points. One patient had significant abductor weakness and a Trendelenburg gait. The mean leg-length discrepancy was <1 cm. Disturbance in growth of the proximal aspect of the femur occurred in 10 hips (22%).

In our experience, open reduction of the congenitally dislocated hip in children aged 1 to 3 years, combined with femoral or acetabular procedures, leads to successful clinical and radiographic results in most cases. These patients have an opportunity for normal hip function during childhood and the potential for a straightforward reconstructive procedure should they develop severe degenerative hip arthrosis.

Congenital hip dislocation in children younger than 1 year can be successfully treated nonoperatively in most instances,1-5 whereas operative treatment is usually necessary in children older than 3 years. There is no general agreement for the treatment of a child aged 1 to 3 years with congenital hip dislocation. Since a variety of treatments have been recommended for hip dysplasia in children with varying results, long-term follow-up data are important.3,5-16

Previously, we reported the 6-year follow-up data of surgical treatment for congenital hip dislocation in children aged 1 to 3 years.6 At that time, comprehensive 1-stage surgical treatment for the dislocated hip was undertaken in the hope that normal hip anatomy could be restored, further surgery could be avoided, and results would sustain long-term follow-up. Our initial results were encouraging at an average 6-year follow-up, and no patients had a significant limp, Trendelenburg gait, or avascular necrosis.

This article presents a concise update of our 6-year results at longer-term follow-up in this patient population.

Materials and Methods

This study is a retrospective analysis of consecutive cases of all patients treated with a comprehensive surgical approach for a dislocated hip. All patients ranged from 1 to 3 years of age at the time of their initial surgery. In the original patient cohort, 57 cases (46 consecutive patients) were initially treated. Fifty-one hips in 41 patients were the basis for the original, previously reported study.6 All procedures were performed at the Houston Shriners Hospitals for Crippled Children between 1969 and 1981 by the resident staff. The senior author (K.E.V.) was in attendance.

The original patient cohort of 57 hips in 46 patients was re-evaluated after skeletal maturity. Six patients (8 hips) were unavailable for follow-up despite extensive effort, and 2 patients (2 hips) declined to return for re-evaluation, although both reported no difficulty with their hips. For these reasons, 47 hips in 38 patients make up this study, with a mean follow-up of 18.8 years (range, 13.6-24.6 years). The patient population included 33 girls and 5 boys, with 29 unilateral dislocations (13 right, 16 left) and 9 bilateral dislocations.

An anterior Smith-Peterson approach to the hip joint was used with wide capsular exposure to detach the inferomedial portion of the capsule from the inferior acetabular rim.17 The ligamentum teres was detached from the femoral head, and any fibrocartilaginous membrane was removed prior to incision of the labrum so that the femoral head could be easily positioned into the acetabulum. The portion of the labrum that was infolded was incised radially and a small portion was excised.

Any femoral head reduction that could not be accomplished easily was treated with 2 to 3 cm of shortening of the femur at the level of the lesser trochanter and fixed with a 4-hole bone plate. If femoral anteversion was in excess of 60°, the proximal femur was derotated (also at the subtrochanteric level). The coverage of the femoral head was performed visually at the time of the open reduction. After these maneuvers, if the anterolateral aspect of the femoral head remained uncovered after the femur had been internally rotated to correct for anteversion, a pericapsular osteotomy (stabilized with threaded pins) was performed as described by Pemberton.18 In all cases, an advancing capsulorrhaphy was performed for additional soft tissue stabilization of the femoral head into the acetabulum. A Pemberton osteotomy was performed without a femoral osteotomy in 11 patients. When a femoral osteotomy was performed, it preceded the Pemberton osteotomy.

Postoperative treatment included 12 weeks in a spica cast followed by 6 weeks of abduction bracing. All hardware was removed between 1 and 3 years after the index procedure.

In the original cohort, in addition to the open reduction, 29 hips (62%) required a Pemberton osteotomy, 2 hips (4%) required femoral shortening, and 34 (72%) required a derotational osteotomy. Early in our surgical experience, 3 patients (6%) were treated between 1 and 2 years later with an innominate osteotomy as described by Salter19 and Salter and Dubos20 to improve acetabular coverage. Ideally, these cases would have been treated with a Pemberton osteotomy at the time of the open reduction procedure. There have been no other subsequent surgical procedures in any of these patients.

Patient evaluation at last follow-up included a standard history and physical examination with particular attention to the patient’s hip function. A complete radiographic evaluation was performed, and a functional evaluation was made using the Iowa hip rating system. For this updated report, radiographic appearance of each hip was graded according to the Severin radiographic classification system21 and compared to the 6-year results. Additionally, the development of any proximal femoral growth disturbances or deformities were noted, as these have been described as possible occurrences long after the original surgery is performed. All radiographic measurements were made by a single observer and reviewed by another (K.E.V.).

Statistical evaluation of the data included chi-square analysis, unpaired t test, and Fisher’s exact test. The level of statistical significance was P<.05.

Results

All patients had reached skeletal maturity, as defined by closure of the tri-radiate cartilage and the proximal femoral epiphysis, at follow-up.5 Mean patient age at follow-up was 18.8 years (range, 14.9-26.2 years).

The final mean Iowa hip rating was 92 points (range, 64-100 points). Of the 38 patients, 31 (82%) were rated as excellent, 1 (3%) as good, 4 (10%) as fair, and 2 (5%) as poor, corresponding to an overall incidence of 85% good and excellent based on the Iowa rating system. The patients had a leg-length discrepancy with a mean of 1 cm (range, 0-2 cm).

Radiographic evaluation according to the criteria of Severin were classified as 52% (24 hips) class I (excellent), 26% (12 hips) class II (good), 17% (8 hips) class III (fair), and 4% (2 hips) class IV (poor). There were no class V results (Figures 1, 2). One patient was not evaluated radiographically since she was early in her first trimester of pregnancy. It should be noted that 3 of the class III hips had excellent clinical scores (97, 92, and 95 points on the Iowa rating system), and radiographs were remarkable for only minimal deformity, with the center-edge angles of 12°, 14°, and 15°, respectively.

Of the 10 hips that were Severin class III or IV, 3 had mild coxa magna and well-developed acetabuli. Of the remaining five, 4 had significant femoral head deformities and 1 had insufficient lateral acetabular development with an increased center-edge angle of 60° (normal angle is <20°).

Of 28 hips treated with Pemberton osteotomies, 13 hips (45%) were class I, 8 (29%) were class II, 6 (25%) were class III, and 1 (2%) was class IV. There were no significant differences in Severin grades of hips that were treated with Pemberton osteotomies and those that were not (P=.99). Of the 3 hips that had an innominate osteotomy, there was 1 Severin class I, 1 class III, and 1 class IV.

The presence of a proximal growth disturbance of the proximal femur was evident in 10 hips. Those patients with growth disturbance had statistically worse outcomes as measured by Iowa score (P=.0001) and by Severin score (P=.0001). Also, there was a significantly higher percentage in boys (4 of 6) compared to girls (6 of 41) (P=.014). Of those 10 hips, 3 were considered to have near complete head involvement and 7 had only partial head involvement.

Comparing the 18.8-year results to the 6.1-year results, 9 additional cases of proximal femoral growth disturbance were identified (P<.05). Comparing the Severin classification, in our initial report 92% were rated as good or excellent, and at 18.8-year follow-up, 78% had a good or excellent result (Figure 3).

Discussion

This study, representing long-term follow-up of surgical treatment for dysplastic hips in children between ages 1 and 3 years, reveals that our reported 6-year results hold up well at a mean 18-year follow-up. When the senior author initially began treating hips with this comprehensive 1-stage approach, there were proponents of both closed and operative treatment.5,9,10-13,16,22 Nonoperative treatment, however, often required prolonged traction, subsequent surgical intervention, and residual subluxation. The intended goal of a 1-stage comprehensive treatment for hip dysplasia in children of walking age was the restoration of normal hip joint development while minimizing the number of surgical procedures.

The use of the Severin classification system as a basis for comparison is appropriate. While this system suffers from poor interobserver reliability, it demonstrates acceptable intraobserver reliability.23 Albinana et al24 reported that residual hip dysplasia as measured by the Severin system resulted in a higher risk of early degenerative joint disease in patients who were followed up at a mean age of 44 years. Furthermore, residual dysplasia was related to the need for hip replacement surgery.24 This finding was also noted by Malvitz and Weinstein,9 who reported a strong concurrent association between the Severin classification, the Iowa Hip Rating, and degenerative joint disease, while noting some discrepancy believed to be related to the use of the functional scoring system for children and its possible inadequacy in reflecting their future clinical outcome. Collectively, these studies provide evidence to support the use of the Severin classification at maturity as a surrogate for long-term radiographic and functional outcomes.

Several other long-term studies are available on surgical treatment of the dislocated hip. Subasi et al,25 similarly using a 1-stage approach, demonstrated that surgery performed earlier in a child’s life had improved results at a mean 4-year follow-up.8,9,26-28 Other surgical approaches to the dislocated hip have been used in the past, most notably a medial approach to the hip joint.29,30 In a similar age group, Kiely et al31 reported a 14% rate of avascular necrosis and a 6% redislocation rate using a Ferguson approach.32 Okano et al33 reported an increased risk for femoral head deformity using a Ludloff approach in this patient age group. Biçimoglu et al30 reported on a medial approach and noted a 2% redislocation rate, 6% reoperation rate for secondary procedures, and 20% osteonecrosis rate.

The development of a normal acetabulum is beneficial to patients even if they develop later degenerative hip changes. Hip dysplasia can result in alterations of anatomy on both the femoral and acetabular sides.34,35 However, residual acetabular dysplasia makes future treatment with hip arthroplasty difficult and may provide less durable results.24,26.28,36-39 Potential newer developments in hip arthroplasty, such as hip resurfacing, require normal or near-normal acetabular anatomy.40,41 Removal of hardware used for fixation is a controversial issue. However, future reconstructive surgery can be complicated by retained or broken hardware. This is especially true if plates or screws are located in the femoral medullary canal or in the ilium.42

Conclusion

Our initial 6-year study concluded that “this aggressive approach is justified, since the results are at least as good as those of any reported series.” After 18 years of follow-up, we believe the data still support a 1-stage, combined procedure to address both the acetabular and femoral sides of the dysplastic hip joint. We expect these good results in early adulthood to slowly deteriorate with time, but these patients have an opportunity for normal hip function during childhood and the potential for a straightforward reconstructive procedure of the hip should they develop severe degenerative hip arthrosis.

References

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Authors

Drs Varner and Incavo are from the Department of Orthopedic Surgery and Sports Medicine, The Methodist Hospital System, and Drs Haynes and Dickson are from Baylor College of Medicine, Houston, Texas.

Drs Varner, Incavo, Haynes, and Dickson have no relevant financial relationships to diclose.

Correspondence should be addressed to: Kevin E. Varner, MD, Department of Orthopedic Surgery and Sports Medicine, The Methodist Hospital System, 6550 Fannin, Ste 2500, Houston, TX 77030 (kevarner@tmhs.org).

doi: 10.3928/01477447-20100129-05

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