Long-term results after open reduction of developmental hip dislocation by an anterior approach lateral and medial of the iliopsoas muscle

Abstract

The technique of and especially the approach to open reduction of developmental dislocation of the hip are still a matter of discussion. The anterior approach, first lateral and then medial to the iliopsoas muscle, was described by Tonnis in 1978. A follow-up investigation to adulthood has now been performed. Eighty-seven children (118 hips) out of 105 children (83%) who underwent open reduction of developmental dislocation of the hip before the age of 4 years were reinvestigated 10-21 years after the operation. An anterior approach first lateral, then medial to the iliopsoas muscle was chosen, because this offers the best access to the joint. Additional operations including transiliac osteotomy for acetabuloplasty, shortening osteotomy, and femoral osteotomies were performed as necessary. In 92 (78%) of the 118 hips studied the CE angle exceeded 25 degrees and in 98 hips (83%) the VCA angle exceeded 25 degrees. Critical CE angles between 20 and 25 degrees were found in 14% of the hips, and critical VCA angles in 4%. Residual dysplasia (<20 degrees) was found in 8 and 13% of the hips, respectively. Avascular necrosis according to Hirohashi was observed after operation in grade 1 in 5.9% and grade 2 in 1.7%. No necrosis was found following shortening osteotomy of the proximal femur. The anterior approach, first lateral, then medial to the iliopsoas muscle, offers an optimal access to the medial parts of the joint with control of reduction, protects the vasculature of the femoral neck, and allows simultaneous postero-lateral capsulorrhaphy and pelvic osteotomies.

Developmental Dislocation of the Hip Successfully Treated by Preoperative Traction and Medial Open Reduction: A 22-year Mean Followup

“…The effect of preoperative traction has been questioned for surgical treatment of DDH since all the anatomic obstacles to hip reduction are surgically eliminated [35,59,64,82]. Although the percentage of our excellent and good long-term radiographic results, according to the Severin classification, is higher than in other series in which traction was not used [18,30,33,39,50,71,[78][79][80], it is difficult to determine whether preoperative traction served to decrease the complication rate. Inpatient traction is costly [35,59,82]; however, more than 1/2 of our patients successfully completed home traction before surgery.…”

“…Early hip subluxation after open reduction and/or redislocation while wearing the plaster cast has been reported in a range of 0% to 11% with a mean of 2.4% for anterior and medial open reductions [7,10,11,16,18,20,21,23,31,37,40,46,50,52,69,70,[77][78][79]88]. Our patients had a redislocation rate of 2.8%.…”

“…Although we were aware of this general trend in favor of anterior open reduction that provides capsulorrhaphy and avoids medial circumflex vessels, the good preliminary results we obtained in children older than 24 months encouraged us to increase the upper age limit for medial open reduction to 36 months. Moreover, according to the literature, even open reduction by the anterior approach may provide unsatisfactory results in children older than 24 months [17,18,25,30,33,47,58,73,79,80]. Schoenecker and Strecker [64] reported two series of patients older than 24 months who had open reduction by the anterior approach.…”

“…It is known that the final result of DDH after open reduction can be evaluated only when musculoskeletal growth is completed [81], but to our knowledge, there is a paucity of studies including skeletally mature patients [5,18,30,33,39,52,71,[78][79][80].…”

“…During the last 36 years, the anterior approach has been reported less frequently [1,10,17,18,20,23,25,30,31,47,58,70,71,73,79,80] than the medial approach [4, 6, 7, 11, 16, 21, 22, 33, 36, 37, 39, 40, 46, 48-50, 52-54, 60, 69, 77, 78, 85, 88], especially in younger children.…”