ONE STAGE COMBINED SURGICAL TREATMENT FOR DEVELOPMENTAL DISLOCATION OF THE HIP IN OLDER CHILDREN INCLUDING FEMORAL SHORTENING

The treatment of developmental dislocation of the hip (DDH) in older children is a challenge because they have high displacement of the hip, contracted soft tissues, insufficiency of the acetabulum and increased anteversion of the femoral head. In such patients it is difficult to reduce the femoral head into the acetabulum, maintain the concentric reduction and obtain a satisfactory functional hip joint. The aim of this study is to assess the advantage and disadvantage of one stage combined surgery with femoral shortening in treatment of DDH in children above 2 years old. This is a prospective study done in Al-Basrah General Hospital between (June 2008-June 2010), thirty patients were treated (35 hips), 28 females and 2 males. Five hips were right hip dislocation, 20 hips were left and 5 patients were bilateral. Femoral shortening done for all the hips and, in 28 hips pelvic osteotomy were performed at the time of open reduction. At the most recent follow-up (4 months-2 years) According to the radiographic criteria of Severin, 5 hips were excellent, 15 hips good and 10 hips have fair results, 5 end up hips had poor outcome. Avascular necrosis developed in 5 of the 35 hips. All patients were followed with respect to range of motion and recovery from limb-length discrepancy. Different complications were recorded per or postoperatively. Some complications like pelvic fracture (1 hip), subluxation and instability (3 hips), dislocation (2 hips) and stiffness (7 hips). According to the rating system of Mckay's clinical criteria, there were 7 hips excellent, 11 hips good, 12 hips fair results and 5 hips had a poor result. It is concluded that children who are two years or older and have DDH, can safely be treated with an extensive one-stage operation consisting of open reduction combined with femoral shortening and pelvic osteotomy, without increasing the risk of avascular necrosis. The limb length discrepancy that is produced by the shortening does not appear to cause a clinical problem. Introduction he treatment of DDH is challenge in older children. Those patients have high displacement of the hip, contracted soft tissues, insufficiency of the acetabulum and increased anteversion of the femoral head 1,2 . The problem lie in reducing the femoral head into the acetabulum maintaining the concentric reduction and obtaining a satisfactory functional hip joint 3 . Ombredanne 4 reported an operation that included open reduction with femoral shortening in 1932. Combined operation of open reduction with femoral shortening, iliac osteotomy and reorientation of the femoral head & neck, have been used since 1963. An osteotomy of the proximal part of the femur to shorten the femur has been recommended to avoid the complication of avascular necrosis, this operation allows the tight structures that cross the level of the osteotomy to function as if they were lengthened and does so more T One stage combined surgical treatment for developmental dislocation of the hip Ali A Al-Iedan Bas J Surg, 17, March, 2011 59 effectively than a soft-tissue release. Patients and Methods This is prospective study of the clinical and radiological outcome of children who were (2.4/12-6.6/12 years) and had DDH that were treated at Al-Basrah General Hospital from (June 2008-June 2010). All of them were grade 3 or 4 according to the Tonnis 5 radiological classification. Children who had a neuromuscular condition or who had received previous treatment for the dislocation were excluded. There were 35 involved hips in 30 patients, 28 females and 2 males. Five hips were right and 20 hips were left and 5 cases were bilateral. Postoperatively, patients were evaluated for range of motion of the hip, limb length discrepancy and gait. Anteroposterior radiographs of the pelvis were done. Operative Technique All patients had open reduction through an anterior hip approach, after capsulotomy and excision of the hypertrophied ligamentum teres, gentle traction was applied to the extremity to assess the degree of contracture of the muscles that cross the hip joint. Due to the soft-tissue contracture, the femoral head still was not reducible without applying excessive pressure even with adductor tenotomy. Through a separate lateral approach, a transverse osteotomy was made in the subtrochanteric region. The two femoral fragments were allowed to overlap and reduction was obtained quite easily. A segment of femur that was 1-3 centimeters long, sufficient to relieve the muscular tension across the hip joint was then excised. If, at the time of the trial reduction of the hip, internal rotation of the femur seemed to contribute to stability of the joint, derotation was achieved by externally rotating the distal femoral fragment in relation to the proximal fragment before applying the plate. The hip was reduced concentrically and fixed by k-wire in most of the patients if coverage was inadequate a Salter or Dega pelvic osteotomy was performed. Postoperatively, the child wears a spica cast for six weeks. Fifteen patients needed blood transfusion during or after surgery, all patients were given third generation cephalosporin parenteraly for the first 3 days. The spica and any pins that were used for fixation removed after 6 weeks under general anesthesia, then started physiotherapy but the weight bearing is not allowed till 12 weeks postoperatively.


Introduction
he treatment of DDH is challenge in older children.Those patients have high displacement of the hip, contracted soft tissues, insufficiency of the acetabulum and increased anteversion of the femoral head 1,2 .The problem lie in reducing the femoral head into the acetabulum maintaining the concentric reduction and obtaining a satisfactory functional hip joint 3 .Ombredanne 4  An osteotomy of the proximal part of the femur to shorten the femur has been recommended to avoid the complication of avascular necrosis, this operation allows the tight structures that cross the level of the osteotomy to function as if they were lengthened and does so more T effectively than a soft-tissue release.

Patients and Methods
This is prospective study of the clinical and radiological outcome of children who were (2.4/12-6.6/12years) and had DDH that were treated at Al-Basrah General Hospital from (June 2008-June 2010).All of them were grade 3 or 4 according to the Tonnis 5 radiological classification.Children who had a neuromuscular condition or who had received previous treatment for the dislocation were excluded.There were 35 involved hips in 30 patients, 28 females and 2 males.Five hips were right and 20 hips were left and 5 cases were bilateral.Postoperatively, patients were evaluated for range of motion of the hip, limb length discrepancy and gait.Anteroposterior radiographs of the pelvis were done.

Operative Technique
All patients had open reduction through an anterior hip approach, after capsulotomy and excision of the hypertrophied ligamentum teres, gentle traction was applied to the extremity to assess the degree of contracture of the muscles that cross the hip joint.Due to the soft-tissue contracture, the femoral head still was not reducible without applying excessive pressure even with adductor tenotomy.Through a separate lateral approach, a transverse osteotomy was made in the subtrochanteric region.The two femoral fragments were allowed to overlap and reduction was obtained quite easily.A segment of femur that was 1-3 centimeters long, sufficient to relieve the muscular tension across the hip joint was then excised.If, at the time of the trial reduction of the hip, internal rotation of the femur seemed to contribute to stability of the joint, derotation was achieved by externally rotating the distal femoral fragment in relation to the proximal fragment before applying the plate.The hip was reduced concentrically and fixed by k-wire in most of the patients if coverage was inadequate a Salter or Dega pelvic osteotomy was performed.Postoperatively, the child wears a spica cast for six weeks.Fifteen patients needed blood transfusion during or after surgery, all patients were given third generation cephalosporin parenteraly for the first 3 days.The spica and any pins that were used for fixation removed after 6 weeks under general anesthesia, then started physiotherapy but the weight bearing is not allowed till 12 weeks postoperatively.

Results
Of the 30 patients, the extent of shortening (limb length discrepancy) of the lower limb immediately postoperatively averaged 1.5 centimeters (0.5-3 centimeters).A pelvic osteotomy was necessary to stabilize the reduction in 28 of the thirty-five hips, 10 of these procedures (28.57%) were Salter innominate osteotomies and the remaining 18 (51.42%)were Dega.All hips were classified using the criteria of Severin 6 .The range of motion for our patients who returned for review was recorded and a score was assigned using the Mckay's rating criteria 6 , 35 hips were rated; excellent (7 hips, 20%), good (11 hips, 31.4%), fair (12 hips, 34.28), poor (5 hips, 14. 8%).  ) combined with open reduction, capsulorrhaphy and possibly pelvic osteotomy, has been considered by some to be a more extensive procedure than can safely be undertaken in one stage.Although we agree that it is a complicated procedure that should only be attempted by a surgeon with extensive experience, it can clearly be accomplished safely without a major increase in morbidity compared with open reduction alone.A satisfactory result (excellent or good) was achieved clinically in approximately 51.40% and radiographically in 57% of the hips in this series.This is a reflection of the fact that congenital dislocation of the hip in older children is a complex problem that has no easy solution.Many studies suggested that the treatment of choice in older children was a one-stage combined surgical treatment with femoral shortening 4,5,[7][8][9][10][11][12][13][14][15][16] 6,[17][18][19] .Avascular necrosis (AVN) is a serious complication in the treatment of DDH 3,10,20,21 .The two major causes of AVN are excessive pressure on the cartilaginous femoral head, and occlusion of vessels of the femoral head 10 .Particularly in older children, the presence of high displacement of the hip, contracted soft tissues and increased anteversion of the femoral head may complicate the reduction and encourage AVN of the femoral head 9,11,22,14

Conclusion
In a child two years or older, the treatment of congenital dislocation of the hip with one stage femoral shortening, open reduction, capsulorrhaphy, and, if necessary, pelvic osteotomy, is a difficult procedure, but its advantages include the avoidance of prolonged traction.We have shown that this procedure can be done safely, with reliable results without increasing the risk of avascular necrosis.The limb length discrepancy that is produced by the shortening does not appear to cause a clinical problem.There is no doubt that these patients should be followed further, to find out whether degenerative arthritis or additional AVN will develop.The definitive number of AVN in this small series remains uncertain, owing to the relatively short follow-up, considering that AVN may become apparent after as long as 10 years so it is so difficult to compare puplished results of various series of cases for they are evaluate differently and also have different periods of follow up.

Recommendation
Because of the less complications as compared with other studies, avoidance of prolonged time of hospitalization, the correction of associated femoral & acetabular deformities and without an increase in risk of avascular necrosis.So we recommend the use of one stage combined surgery for treatment of DDH in children above 2 years old.

Figure1: A anteroposterior radiography of 3
Figure1: A anteroposterior radiography of 3 years child with bilateral DDH.B: after treatment with open reduction pelvic osteotomy and femoral shortening of the left hip.

Figure 4 :
Figure 4: Our results according to Mckay's criteria 7 for clinical evaluation.