results of medial open reduction of developmental.7

Results of medial open reduction of developmental dysplasiaof the hip with regard to walking ageMurat Altay, Ismail Demirkale, Ferhat Senturk, Ahmet Firat and Safa Kapicioglu

This study aimed to evaluate the outcome of medial open

reduction for developmental dysplasia of the hip (DDH)

in patients before and after walking age. A minimum

5-year radiographic and clinical follow-up compared

29 patients (group 1) before walking age with 38 patients

(group 2) after walking age for DDH. The correction

ratio of acetabular index was similar in both groups

postoperatively (41.8% for group 1 and 44.9% for group 2),

and it was statistically not significant (P > 0.05).

The Kalamchi–MacEwen classification showed no

correlation between operative age and the rate of

avascular necrosis (P > 0.05). This report presents

similar complication rates as that of the Severin criteria

for medial open reduction of the hip and challenges the

conventional belief that a medial open reduction for

the treatment of DDH in a walking-age child at

short-term to mid-term follow-up has comparable

results. J Pediatr Orthop B 22:36–41 �c 2012 Wolters

Kluwer Health | Lippincott Williams & Wilkins.

Journal of Pediatric Orthopaedics B 2013, 22:36–41

Keywords: developmental dysplasia of the hip, medial open reduction,walking age

Department of Orthopaedics and Traumatology, Kecioren Education andResearch Hospital, Ankara, Turkey

Correspondence to Ismail Demirkale, MD, Department of Orthopaedics andTraumatology, Kecioren Education and Research Hospital, 06280 Ankara, TurkeyTel/fax: + 90 505 400 2679; e-mail: [email protected]

IntroductionThe goal of achieving a stable and durable anatomic

reduction has been sought by orthopedic surgeons for many

years. In 1908 and 1973, Ludloff [1] and Ferguson [2],

respectively, reported on an operative technique in which

the main obstacles against the concentric reduction of the

femoral head into the acetabulum were targeted. They

stated that if this operation was performed relatively early

in the course of developmental dysplasia of the hip

(DDH), stimulation of acetabular development and pre-

vention of secondary dysplasias may be more evident.

Previous studies have reported failure in achieving a

nondysplasic hip joint without the need of secondary

procedures and sustaining a stable relationship between

the acetabular and femoral head after medial open

reduction [3–5]. Okano et al. [6] obtained unacceptable

results when the operation was performed on patients aged

over 17 months. Nevertheless, recent studies on acetabular

development and prediction of hip dysplasia in patients

with DDH have shown that a swift remodeling of the

acetabulum occurs within the first year of reduction and

continues slowly until 7 or 8 years of age [7]. Also Kitoh

et al. [8] demonstrated the acetabular index angle (AI) at

4 years and center-edge angle (CEA) at 5 years to be the

most important predictors of acetabular development and

these can be the most reliable predictors of future

acetabular dysplasia. Although they used a patient group

with an average age of 9.3 months at the time of reduction,

controversy still exists about the upper age limit for medial

open reduction.

The purpose of the present study was to evaluate the

short-term to mid-term results of medial open reduction

in the treatment of DDH in a larger study. We also aimed

to determine the safe upper age limit for medial open

reduction by comparing two groups of patients in conjunc-

tion with certain criteria, such as weight-for-age percentile

and the presence of ossific nucleus. In addition, potential

prognostic factors for functional outcome and correction

ratio of the acetabular index, which implies acetabular

development, were analyzed and compared with radiologi-

cal findings with regard to the ambulation pattern of the

patient at the time of the operation.

Materials and methodsInstitutional review board approval was obtained for this

retrospective study. Using our comprehensive prospective

database, we retrospectively carried out a radiographic

and clinical evaluation of patients treated for DDH. From

February 2003 to September 2005, the senior author

(M.A.) performed 152 (116 patients) consecutive medial

open reductions for DDH. Our indications to perform a

medial open reduction were older age (> 6 months) and

intraoperative grade 2 or grade 3 arthrographic reductions.

Of these, two patients had undergone an additional

unilateral proximal femoral derotation osteotomy at the

time of the initial operation. Five patients had a history of

traction, followed by closed reduction (all bilateral).

A Pavlik harness was applied to 21 hips (n = 16; five

bilateral, 11 unilateral). Twenty-six patients (36 hips)

were lost to follow-up or their charts and radiographs were

not available for review. To obtain a homogenous case

series for the treatment of DDH by medial approach and

to determine its clear effect on DDH, whether the

patient is ambulatory or not, the selected patients for this

36 Original article

1060-152X �c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/BPB.0b013e3283587631

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

mailto:[email protected]

study must not have had any of the above interventions,

for either the pelvis or proximal femur. Finally, 49 patients

(69 hips) were excluded from the study, leaving a total of

83 hips of 67 patients (16 bilateral and 51 unilateral

involvement) for evaluation. The average age of the

patients at the time of surgery was 13.97±3.13 months

(range, 7–23 months). There were 17 male and 50 female

patients (Table 1).

The patients were assigned to two groups on the basis of

whether the patient was able to walk or not at the time of

the operation; group 1, before walking age (n = 29); group

2, after walking age (n = 38). Both groups were compar-

able in respect of all of the above-mentioned variables.

Surgical technique

The operative procedure utilized a standard Ferguson

medial approach. The decision to perform an adjunctive

capsulotomy was based on intraoperative arthrographic

assessment of the hip. In case of grade 2 or grade 3

arthrographic reductions, the dissection was carried out

posterior to the adductor brevis, and after division of the

iliopsoas tendon, capsulotomy was performed; ligamentum

teres was excised and the inferior transverse acetabular

ligament was sectioned. Bilateral involvements were

operated on in the same session. After closure of the

incision, a hip spica cast was applied to all patients at 901

flexion and 601 abduction and they were removed at the

end of 3 months. A full-time abduction brace was then

worn for a further 1.5 months. The patient underwent a

period of physical therapy to regain motion of the hip and

no further treatment was given.

Radiographic evaluation

Radiological assessment of the hips was made according

to the Severin classification [9]. While Severin groups I

and II were defined as acceptable, III, IV, and V were

defined as unacceptable. Once the radiological evaluation

of the hip joint had acceptable intraobserver and

interobserver reliability, preoperative and periodic post-

operative radiographic analysis was carried out in an

unblinded manner for all patients by one senior-level

orthopedic resident (I.D.) [10]. Supine anteroposterior

radiographs of the hips were taken preoperatively to

measure the AI of Hilgenreiner [11]. At the last visit,

standing anteroposterior and false-profile radiographs were

taken to evaluate the AI of Hilgenreiner, CEA of Wiberg

[12], the anterior center-edge angle (ACEA) of Lequesne

[13], and the collodiaphyseal angle (CDA) of the femur.

The preoperative and postoperative values were compared

to assess deformity correction. The Kalamchi–MacEwen

classification system was used to determine the rate of

avascular necrosis (AVN) [14]. The medical records and

radiographs of the patients were also reviewed to assess the

radiographic appearance of nucleus of the femoral head and

the weight-for-age percentiles both for males and females.

Clinical evaluation

Clinical hip function was graded according to the McKay

criteria. All patients returned for a follow-up clinic visit

and radiographic examination at a minimum of 5.6 years.

Parent-reported overall satisfaction with the surgical

procedure was also ascertained at the most recent

follow-up visit.

Statistical analysis

The correction ratio of AI, ACEA, CEA, and CDA were

compared using Student’s t-test. The preoperative and

postoperative values of AI, the correlation between the

correction ratio of AI and the follow-up period, and the

correction ratio of AI, ACEA, CEA, and CDA were

compared using Pearson’s correlation test. Significance

was determined at a P value of less than 0.05.

ResultsThe average follow-up period was 6.6 years (range, 5.6–8.8

years). At the time of the operation the mean age was

13.9 months (range, 7–23 months). Radiographic analysis

demonstrated consistent acetabular correction and signifi-

cant improvement in the AI (mean, 22.61; P < 0.001).

Overall treatment results including radiological measure-

ments are summarized in Table 2. The Pearson correlation

test revealed no significant difference between the

correction ratio of AI and the follow-up period for surgically

treated patients (r = 0.02; P > 0.05). There were no

statistically significant differences between the correction

ratio of AI and the operative age (r = 0.19; P > 0.05),

operative side (r = 0.19; P > 0.05 and r = – 0.19; P > 0.05,

for right and left sides, respectively), presence or absence

of ossific nucleus (r = 0.07; P > 0.05) and sex of the

patients (r = 0.08; P > 0.05). The effects of the ambulation

pattern of the patient at the time of the operation on

radiological parameters are shown in Table 3.

Although, 44 (65.6%) patients obtained excellent or good

results, the functional outcome in patients and parents

was rated as very favorable because 51 parents who

provided feedback reported that they were satisfied with

the procedure. Of them, four parents could not be

reached at the time of this review but were satisfied

when last seen. According to the modified McKay criteria,

Table 1 Patient demographics

Group 1 Group 2

SexBoys 11 6Girls 18 32

InvolvementUnilateral 19 32Bilateral 10 6

Weight-for-age percentileZ50 11 13< 50 20 23

Ossific nucleus appearancePresent 20 50Absent 12 1

Results of open reduction of hip after walking age Altay et al. 37


24 patients (35.8%) had excellent results, 20 (29.9%)

good, 16 (23.9%) fair, and 7 (10.4%) poor. A separate

evaluation was made to elicit the effect of the operative

age on the modified McKay criteria. Excellent and good

results were obtained for 17 (58.6%) group 1 patients and

27 (71.1%) group 2 (Fig. 1a–d) patients (Table 4).

A final evaluation of the hips using the Kalamchi–

MacEwen classification showed 20 (24.1%) AVN changes.

Further evaluation of AVN showed no correlation

between the operative age and the rate of AVN

(P > 0.05). In addition, 11 Kalamchi changes (13.3%) in

group 1 and nine (10.8%) in group 2 were noted (Fig. 2a–d).

Although statistically not significant, with regard to the

weight-for-age percentile, 14 of 20 Kalamchi changes were

noted in patients at 50 percentile or more. There were no

short-term complications other than reduction loss in eight

patients, six of whom had a high weight-for-age percentile.

All eight were treated by closed reduction and cast

reapplication.

DiscussionTo date, the management of a child after walking age with

developmental hip dysplasia remains controversial

[15–20]. Perhaps the most challenging clinical scenario

occurs when the proximal part of the femur of a weight-

bearing child compresses the posterosuperior part of the

acetabulum leading to adhesion and contractures with

shortening of the external rotators. Numerous studies are

available analyzing the outcomes after open reduction of

DDH by anterolateral or medial approaches [21–23].

Table 2 Radiographic measurement results at the last visit

Mean P

AIPreoperative 41.78±5.671 (range, 33–571)Last visit 23.46±5.311 (range, 14–311) < 0.001

CEA at the last visit 16.85±10.231 < 0.001CDA 145.32±8.541 NSACEA 27.76±11.651 NS

ACEA, anterior center-edge angle; AI, acetabular index angle; CDA, collodia-physeal angle; CEA, center-edge angle.

Table 3 Summary of radiographic correction obtained at the lastvisit of patients before and after walking age

Radiographic findings

Group 1 Group 2 P

Acetabular index 24.05±5.311 22.96±5.311 > 0.05CEA 15.80±12.181 17.83±10.311 > 0.05CDA 142.60±9.211 145.04±9.991 > 0.05ACEA 26.84±12.211 29.16±10.661 > 0.05

ACEA, anterior center-edge angle; CDA, collodiaphyseal angle; CEA, center-edge angle.

Fig. 1

The preoperative anteroposterior (AP) pelvis (a), frog views (b), and initial postoperative AP pelvis view (c) of an 11-month-old female patient whowas at the walking age at the time of the operation. The acetabular index angle is 441 and the femoral head is in the subluxated position. (d) Thepostoperative third year AP pelvis view demonstrates a good acetabular development without avascular necrosis changes.

38 Journal of Pediatric Orthopaedics B 2013, Vol 22 No 1


Sener et al. [24], Okano et al. [6,25], and Mardam-Bey

et al. [26] reported high failure and complication rates of

the medial open reduction when done after walking age.

Apart from these studies, however, Chmielewski

et al. [27] stated that a medial approach, which is simple

and effective, goes directly to the area where main

obstacles of an anatomic reduction exists.

The current standard of practice for managing DDH is to

perform and maintain an anatomic reduction for acet-

abular development. Most orthopedic surgeons prefer the

anterolateral approach for the treatment of DDH after

walking age. The anterolateral approach allows capsulor-

rhaphy, simultaneous pelvic osteotomy, and eversion of

the limbus. A review of failed open reductions showed

the anteromedial area to be the area of failure [21,22].

Mankey et al. [28] has stated the importance of effective

capsulorrhaphy in the first postoperative week and

O’Hara et al. [29] has reported the adverse effects of

limbectomy on acetabular development. Keeping these

considerations in mind, a medial approach was chosen for

the treatment of DDH at walking age as having

advantages compared with an anterolateral approach with

Table 4 Comparison of two groups in the clinical outcome scoresand radiological outcome measurements at the last visit

Variables Group 1 Group 2 P

McKay criteriaExcellent 11 13 NSGood 10 10 NSFair 11 5 NSPoor 3 4 NS

Kalamchi changesType 2 6 7 NSType 3 4 0 NSType 4 1 2 NS

Severin classificationExcellent 23 40 NSGood 6 6 NSFair 2 3 NSPoor 1 2 NS

n, number of patients calculated; NS, not significant (P > 0.05).

Fig. 2

A 7-month-old female patient with unilateral involvement. The preoperative AP pelvis view (a) demonstrates bilateral ossific nucleus, a dislocated right-sided hip and 341 of acetabular index angle (AI). A medial open reduction was performed (b). After removing the cast, the patient was followed up inan abduction brace for an additional 1.5 months. Although there is type 3 Kalamchi changes, AP pelvis (c) and frog views (d) of the patient atpostoperative third year shows marked acetabular development with Severin grade 3 hip.



respect to minor bleeding risk, shorter operation time,

and smaller exposure, with reduced damage to tissues.

According to the modified McKay criteria, our results

(65.6% with excellent or good results) were similar to

previous studies [3,16,17,19,20]. The mean correction of

the AI (22.61) and CEA (17.41) and Severin classification

(65% at acceptable range) also corresponded to those in

the literature [4,16–18,30,31]. The most favorable result

of this study was that although the radiological grade and

femoral head involvement of the patients remained in the

moderate-to-good zone, 55 of 67 parents provided

positive feedback for the procedure at a mean follow-up

of 6.6 years.

We also observed a relatively high risk for AVN and

moderate subluxation in patients with a high weight-for-

age percentile. This may be due to several factors that

may increase the likelihood of cast complications or

complexity of the disease. First and most importantly,

many of these patients may have been followed up

inexpertly in the early stages. Second, many of these

patients with a high weight-for-age percentile may have

had advanced or delayed bone age, both of which may

have contributed to a higher risk of postoperative

radiographic moderate results.

Our surgical indications for a medial approach for DDH

have expanded over time. Careful preoperative assess-

ment is necessary to determine whether a high-grade

dislocated hip can be reduced with a less invasive surgical

approach, such as the Ferguson technique. Surgical

treatment is then tailored to reduce the hip. In a high-

grade dislocation in a walking child or a child with

proximal femur or acetabular deformities, a combination

of techniques may be used, including anterior approach,

proximal femoral varus, and derotation osteotomy or

innominate osteotomy. Currently, when acetabular dys-

plasia is present in a child with a low acetabular growth

potential, the accepted management should be focused

on acetabular correction [7,32]. However, it must be

emphasized that normalizing the acetabular inclination

by acetabular reorientation needs large surgical exposures

with relatively high complication rates. This is of specific

concern because of the potential growth potential of the

acetabulum. For this reason, we remain reluctant to

perform a medial approach unless the child does not have

a high-grade dislocation. Thus, independent of whether

the child is walking or not, anatomical acetabular

reduction and maintenance of this anatomic reduction

without any associated complications may result in

continuous acetabular development. Eight of our patients

on whom the medial approach was used early in our

experience suffered loss of reduction in the initial

postoperative period, and they required reapplication of

the cast. These two instances heightened our awareness

of this problem and prompted us to be more aggressive in

releasing the medial capsule and to make a more effective

cast application with the goal of optimizing the main-

tenance of anatomic reduction. Currently, we always

perform inferior transverse acetabular ligament resection

to ensure anatomic reduction. The safe zones of the hip

joint are then evaluated, and if found not to be suitable so

that additional femoral correction is required, our

rationale is to perform a proximal femur varus-producing

osteotomy and/or a derotation osteotomy. Two patients

who had undergone proximal femur osteotomy at the

time of medial approach were excluded from the study.

There are certain limitations of this study. This is a

retrospective review that analyzes the results of the

medial approach in children up to 23 months of age. It is

likely that our clinical results, complication rates, and

advanced reoperation rates for degenerative changes may

be more favorable in the future as the follow-up period

broadens. While all patients in this homogenous series

received a medial approach, long-term results may help

determine the exact consequences of this approach.

Finally, identifying an appropriate control group for this

patient cohort is difficult. Even historical cohorts

followed in natural history studies are of limited value

because of the substantial heterogenity of DDH in terms

of the pathoanatomy, associated acetabular abnormalities,

age of the patient, and clinical manifestations of a

subluxated hip. The cohort we analyzed is unique in

that it represents a consecutive series of patients, none of

whom had received any previous intervention or sequen-

tial or postoperative additional surgeries.

Conclusion

We emphasize that surgical treatment of a dislocated hip in

a walking-age child can be performed with a medial

approach, which is safe and reliable. Our results suggest

that appropriately applied medial open reduction is

associated with good clinical results at short-term to mid-

term follow-up regardless of the ambulation pattern of the

patient. Continued clinical and radiographic evaluation is

essential to assess the efficacy of this surgical strategy.

AcknowledgementsConflicts of interest

There are no conflicts of interest.

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