Introduction & Discussion: From an experience of over 250 Salter osteotomies, 148 of which have been reviewed at skeletal maturity, certain technical tips merit discussion:-

Preoperative positioning and the incision

Psoas tenotomy, capsular exposure and the capsulotomy

Facilitation of the Gigli saw osteotomy

Sizing and procurement of the graft

Displacement and fixation of the osteotomy

Application of the hip spica

Some questions are worthy of debate:-

Can the osteotomy be safely combined with open reduction of the high dislocation?

Should the osteotomy be fixed before reducing the femoral head?

Are there alternatives to autogenous bone graft and K-wire fixation?

Is minimally invasive surgery an option?

Are the contraindications and alternatives to the Salter osteotomy fully appreciated?

Treatment of residual acetabular dysplasia is still controversial regarding the timing of Surgery, and the type of surgical procedur. Material and Methods: We analyzed 70 patients (83 hips) operated between 1980–1988 year, in which Salter innominate osteotomy was performed in the treatment of residual acetabular dysplasia in DDH. Patients were divided in two different age groups: from 2–4 (53 hips) and 4–6 (30 hips) years. The average follow up was 7 years (from 2 to 10 years). Acetabular remodeling was radiographically assessed by measuring of the Acetabular Index (AI) at the beginning and after the 5 years of age subsequently by measuring the CE angle of Wiberg. All preoperative hips were dysplastic according to Tonnis (+2SD) criteria. Results were statistically analyzed by using the Student’s T test, and One Way Repeated Measures ANOVA, with the correction for the different age groups. Results: We found that there were no statistically significant differences in AI and CE angle between these two age groups and between these groups and normal values. Conclusion: We recommend Salter innominate osteotomy as a procedure of choice in the treatment of acetabular dysplasia in DDH, provided the patient is younger than 6 years of age

Salter’s innominate osteotomy predisposes the hip to acetabular retroversion as it hinges upon the symphysis pubis. Retroversion is a recognised cause of osteoarthritis, hip pain and clinical signs of impingement, but there is uncertainty as to whether this over cover persists with growth and development. We reviewed the long-term follow up of twenty patients that had undergone a Salter’s osteotomy between 1985 to 1993 at The Royal Orthopaedic Hospital Birmingham or New Cross Hospital Wolverhampton. Sixteen skeletally mature patients were available for review that had previously had the pelvic osteotomy performed at a mean five years of age with a contralateral normal hip. Salter’s osteotomy had been performed for developmental dysplasia of the hip in 13 patients and for Perthes’ disease in three patients. Follow up was performed at an average age of 20 years. Outcome was assessed using the Harris Hip Score and a clinical examination for signs of impingement and by a measurement of acetabular version, on well centered pelvic radiograph. Acetabular version was evaluated by the relationship between anterior and posterior walls of both the normal and Salter acetabulum, using radiographic templates as described by Hefti. Mean acetabular version averaged 16.9 degrees (95% CI 7.6 to 26.1) of anteversion on the Salter side and 17.6 degrees (95% CI 10.4 to 24.8) anteversion on the contralateral normal hip. There was no statistical difference between the version on operated and normal hips, paired t test (p = 0.83). Harris Hip Score averaged 85, indicating a good outcome at long-term follow up. Two patients (12%) demonstrated retroversion, however neither of these had signs of impingement on clinical examination. After a Salter innominate osteotomy in childhood, we believe there is remodelling of acetabular version by skeletal maturity

Clinical and radiographic data on 47 hips in 45 patients with Developmental Hip Dysplasia who underwent either a Salters Innominate Osteotomy or a Femoral Derotation Varus Osteotomy by a single operator were reviewed. The average age of patients at the time of osteotomy was 21 months (range 12–108 months). Clinical evaluation was performed with use of the lowa hip rating score and the Harris hip score. Radiographs were evaluated pre=operatively, post-operatively and at final review. The mean duration of follow-up was 15 years 9 months (range 10–21 years). Thirty-five patients had a Salter innominate osteotomy, 11 a derotation varus osteotomies and one a Klisic. Al last follow-up examination the Iowa hip rating averaged 96.6 (range 62 to 100) and the modified Harris Hip Score averaged 96.8 (range 48 to 100). Forty seven percent of patients reported abductor fatigue after sport. Forty-one patients had excellent result with a Severin class I hip on radiographic evaluation. All of these patients had an Iowa index > 95 and a mean Centre-Edge angle of 35.5 (range 25–40). Six patients had a poor radiological outcome with 5 Severin class IV hips and one class V. Clinical outcome scores did not correlate with poor radiological outcome; Iowa hip score 92 (range 62–100). One patient required a Ganz periactabular osteotomy. The age at which primary osteotomy was performed was significantly higher in the poor outcome group with a mean of 50.8 months. When the anatomy of the hip is restored to normality at an early age with out the development of avascular necrosis excellent long-term results can be expected

The vertical configuration open MRI Scanner (Signa SPIO, General Electric) has been used to assess the place of interventional MR in the management of developmental dysplasia of the hip over the last four years. Twenty-six patients have been studied. In static mode, coronal and axial T1 – weighted spin echo images are initially obtained to assess the anatomy of the hip, followed by dynamic imaging in near-real time. In all cases, dynamic imaging was very good for assessing and demonstrating stability. The best position for containment can be assessed and a hip spica applied. Scanning in two planes gives more information and allows more accurate positioning than an arthrogram. Confirmation of location of the hip after application of the spica can be easily demonstrated. Adductor tenotomies have been performed within the imaging volume, and in two cases, this enabled planning of femoral osteotomies. All patients have had a satisfactory outcome, but five have required open reduction and a Salter innominate osteotomy. In ten cases, the opportunity has also arisen to alternative perform an arthrogram, either because of the complexity of the cases, or at a later date as an alternative to a repeat MRI, or because of difficulty with access to the machine. The place of interventional MRI in DDH is not yet defined. As machines get better and the definition improves, the amount of information about the nature of dislocation, the relative size of the acetabulum to the femoral head, the state of the limbus, the best position for containment and stability, and the potential for growth of the acetabulum, particularly posteriorly will be increased. It follows that the potential for more accurate definition of each hip and the outcome is better – and safer – than by arthrography, which remains the ‘gold standard’ but involves radiation and is only one-dimensional

Over the last several years, triple pelvic osteotomy has become our preferred method for surgical containment in Perthes disease. Since 1995, seventeen patients with Perthes disease have been treated with triple pelvic oste-otomy at our institution. Fourteen of seventeen patients (82%) had a good or excellent clinical result at latest follow-up. According to Sundt’s criteria, radiographic outcome was rated as good in fourteen patients (82%), fair in one patient and poor in two patients. Experience with the technical aspects of the procedure is necessary to avoid pseudarthrosis and iatrogenic external rotation of the acetabular fragment. To evaluate the efficacy of triple pelvic osteotomy as a method of surgical containment in Perthes disease. Recent trends point to surgery as the method of choice for containment in older children with Perthes disease. Over the last several years, triple pelvic osteotomy has become our preferred method for surgical containment in Perthes disease. Since 1995, seventeen patients (seventeen hips) with Perthes disease classified as either lateral pillar B or C have been treated with triple pelvic osteotomy at our institution. The average age at surgery was 8.5 years with an average follow-up of 4.3 years. Outcome was assessed using clinical as well as multiple radiographic criteria. Fourteen of seventeen patients (82%) had a good or excellent clinical result at latest follow-up. No patients had a residual limp or limb length inequality. Two patients had a minor postoperative complication (transient peroneal nerve palsy, meralgia paresthetica). According to Sundt’s criteria, radiographic outcome was rated as good in fourteen patients (82%), fair in one patient and poor in two patients. Triple pelvic osteotomy minimizes potential complications associated with other surgical methods such as Trendelenberg gait and shortening with proximal femoral osteotomy or hinge abduction following a Salter innominate osteotomy. Experience with the technical aspects of the procedure is necessary to avoid pseudarthrosis and iatrogenic external rotation of the acetabular fragment. Triple pelvic osteotomy is now our procedure of choice for containment in the older child with Perthes disease

We compared the clinical and radiological effects of the Salter and the Chiari pelvic osteotomy on congruent dysplastic adolescent hips with mild symptoms and free of degenerative changes. The Salter innominate osteotomy has a significant role in the surgery of paediatric hips with significant elasticity of triradiate cartilage, while the Chiari procedure is reserved for incongruent dysplasia with mild or moderate arthrosis in adolescents or young adults. Neither of these operative procedures is an ideal indication for congruent dysplastic adolescent hips free of arthrosis. Hypothetically, the residual remodelling potentials of immature congruent dysplastic adolescent hips can be sufficient to overcome the disadvantages of the Salter and the Chiari osteotomy and give good, long-lasting results. The effects of these quite different procedures in two homologous groups were compared. There were 30 hips treated with Chiari and 25 hips corrected by Salter osteotomy. All hips were congruently dysplastic according to the distance between the centres of the femoral head and the acetabulum (Klaue et al., classification). Groups were homologous considering mean age (14.5 years), follow-up period (8.5 years), presence of preoperative pain, Trendelenburg sign, and degenerative changes. Assessment for pain and Trendelenburg sign was made at follow-up. Radiological measurement was made of the central-edge angle of Wiberg (CE), acetabular angle of Sharp (AAS), and the femoral head coverage index of Heyman and Herndon (FHC). Progression of degenerative changes was analysed according to the criteria of Kellgren and Lawrence. At follow-up in the Chiari group, presence of pain was reduced from 54% to 6.6%, and from 35% to 12% in the Salter group. The presence of Trendelenburg sign was reduced 3% in the Chiari group and remained the same in the Salter group. At control, mean values of radiological parameters were normal in both groups (Salter: CE-27.8°, AIS-36.8°, ING-82.8%; Chiari: CE-36.8°; AIS-39.7°; ING-90.8%). Individual analysis showed 16% of dysplastic hips in the Salter group, and none in the Chiari group. Only one hip (4%) had grade 1 arthrosis after Salter osteotomy. There were five grade 1 hips (17%) in the Chiari group and one (3%) grade 2 arthrotic hip. At follow-up (mean 8.5 years) greater reduction of pain was found in the Chiari group than in the Salter group, but the presence of Trendelenburg sign remained almost unchanged in both groups. There was normalisation of the mean values of radiological parameters in both groups, but the Salter osteotomy was unable to correct dysplasia in 16% of the adolescent hips. Progression of degenerative changes was more rapid in the Chiari group