Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Michael B. Millis, MD*,
Children's Hospital, Boston, Massachusetts
Posted November 2007
Developmental dysplasia of the hip remains the single most
common cause of osteoarthritis of the hip in North America1, Japan2,
and many other parts of the world. Various screening measures have reduced the prevalence
of late-presenting dislocation, but the clinical problem is unlikely to
disappear in the foreseeable future.
Of the many ground-breaking achievements of Robert Salter,
his now classic technique of single-stage open reduction and innominate
osteotomy to treat children with late-presenting hip dislocation is among the
most enduring3. The technique has endured because it is it extremely
effective. While certain details of the perioperative care of these patients
have changed in the past forty years, the basic technique of anterior-approach
open reduction with capsulorrhaphy and innominate osteotomy has truly stood the
test of time.
Many elements in this work3 are remarkable, but a
few must be mentioned. Although a follow-up rate of "only" 79% might be questioned
in some reports, given the distance from which many of these children were
referred to Toronto and the minimum follow-up time of forty years from the
time of the index operation, the authors should be congratulated.
The patients in this memorable series of cases were operated
on by a true master who literally invented the osteotomy technique employed. The
results reported for these patients, while extremely impressive, are still
sobering. The overall complication rate of 25% is humbling, particularly when one
considers the skill and attention to detail of the surgeon. The rate of
conversion to total hip replacement of 31% in the patients who survived more
than forty years beyond the index procedure is also a reminder that, even with
optimal treatment, osteoarthritis will still be a frequent outcome of the
late-diagnosed dislocated hip.
Although nearly one-third of the hips had been replaced by
the time of the final follow-up evaluation, the survival rates of 99% at thirty
years, 86% at forty years, and 54% at forty-five years after reduction are
better than the results achieved in any other reported series of such patients4,5.
The authors identified bilaterality as a strong risk factor
for a subsequent hip replacement; however, another expected risk factor for poor
result, older mean age at the time of the index surgery, did not reach
significance (mean age at index surgery for the patients with surviving hips
was 2.65 years; mean age at index operation for patients who required total hip
replacement was 3.05 years; p = 0.07).
All patients in this consecutive series were treated with preliminary
traction for a minimum of two weeks before surgery, followed by a single-stage
open reduction, standard capsulorrhaphy, and innominate osteotomy with plaster
immobilization for a minimum of ten weeks postoperatively. Today, as the
authors noted, many of the older patients would be treated with a slightly
different protocol, with preliminary traction replaced by intraoperative
femoral shortening to reduce soft-tissue tension. Additionally, some surgeons
would now prefer to perform a slightly different pelvic osteotomy or capsulorrhaphy.
It is unlikely, however, that any contemporary surgeon could expect any better
results at a minimum follow-up time of forty years than those achieved by Dr.
Salter. In fact, except for hip replacement, no secondary procedure was
necessary later in childhood or during the early stages of maturity in any
patient in this group, and, in the minority of patients who did need hip
replacement, the procedure was not necessary until thirty or more years after
the index procedure.
Indeed, this article may well become a classic—the latest
chapter in a fascinating sequence of articles documenting the evolution in
function of a group of 101 dislocated hips over as much as nearly five decades
since index surgery in very early childhood. We should view these results as
the gold standard in treatment, only to be improved upon if we can universally
diagnosis and institute treatment of a developmentally dislocated hip well before
a child begins to walk.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
References
1. Aronson J. Osteoarthritis of the young adult hip: etiology and treatment. Instr Course Lect. 1986;35:119-28.
2. Nakamura S, Ninomiya S, Nakamura T. Primary osteoarthritis of the hip joint in Japan. Clin Orthop Relat Res. 1989;241:190-6.
3. Salter RB. Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip. J Bone Joint Surg Br. 1961;43:518-39.
4. Angliss R, Fujii G, Pickvance E, Wainwright AM, Benson MK. Surgical treatment of late developmental displacement of the hip. Results after 33 years. J Bone Joint Surg Br. 2005;87:384-94.
5. Malvitz TA, Weinstein SL. Closed reduction for congenital dysplasia of the hip. Functional and radiographic results after an average of thirty years. J Bone Joint Surg Am. 1994;12:1777-92.
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