Aims. Brace treatment is the cornerstone of managing developmental dysplasia of the hip (DDH), yet there is a lack of evidence-based treatment protocols, which results in wide variations in practice. To resolve this, we have developed a comprehensive nonoperative treatment protocol conforming to published consensus principles, with well-defined a priori criteria for inclusion and successful treatment. Methods. This was a single-centre, prospective, longitudinal cohort study of a consecutive series of infants with ultrasound-confirmed DDH who underwent a comprehensive nonoperative brace management protocol in a unified multidisciplinary clinic between January 2012 and December 2016 with five-year follow-up radiographs. The radiological outcomes were acetabular index-lateral edge (AI-L), acetabular index-sourcil (AI-S), centre-edge angle (CEA), acetabular depth ratio (ADR), International Hip Dysplasia Institute (IHDI) grade, and evidence of avascular necrosis (AVN). At five years, each hip was classified as normal (< 1 SD), borderline dysplastic (1 to 2 SDs), or dysplastic (> 2 SDs) based on validated radiological norm-referenced values. Results. Of 993 infants assessed clinically and sonographically, 21% (212 infants, 354 abnormal hips) had DDH and were included. Of these, 95% (202 infants, 335 hips) successfully completed bracing, and 5% (ten infants, 19 hips) failed bracing due to irreducible hip(s). The success rate of bracing for unilateral dislocations was 88% (45/51 infants) and for bilateral dislocations 83% (20/24 infants). The femoral nerve palsy rate was 1% (2/212 infants). At five-year follow-up (mean 63 months (SD 5.9; 49 to 83)) the prevalence of residual dysplasia after successful brace treatment was 1.6% (5/312 hips). All hips were IHDI grade I and none had AVN. Four children (4/186; 2%) subsequently underwent surgery for residual dysplasia. Conclusion. Our comprehensive protocol for nonoperative treatment of infant DDH has shown high rates of success and extremely low rates of residual dysplasia at a mean age of five years. Cite this article: Bone Joint J 2023;105-B(8):935–942

Reorientation of the dysplastic acetabulum can be achieved with a simple Salter or Dega osteotomy. While this may be beneficial in children, it is usually insufficient in more severe adolescent or adult dysplasias. Improvement in coverage with double and triple oste-otomies is limited by the size of the acetabular fragment and the ligaments connected to the sacrum. Correction is achieved with the notable asymmetry of the pelvis. The development of these osteotomies results in making the acetabular fragment smaller and smaller and without ligamentous connection between sacrum and sciatic bone. The periacetabular Ganz osteotomy (PAO) is a compromise of the size of acetabular fragment between triple and dial (spherical) osteotomies. The acetabular fragment as in triple Carlioz and Tonnis osteotomies has no connection with the sacrum, what results in enormous possibilities for correction . Finally, the pelvic ring is left untouched.

The aim of the study is to present our experience and early results in using this technique in the treatment of dysplasia with subluxation in adolescent and young adults.

Our material consists of 42 hips in 35 patients (29 females and 6 males) operated in years 1998 – 2001. In 7 cases there was bilateral involvement, the rest were unilateral. The age at operation was between 11 and 39 years, mean 17,5 years. The indication for the PAO in all cases was acetabular dysplasia with different degree of subluxation. In 10 hips there was severe subluxation with CE below 0°, in 4 hips the signs of osteoarthritis were found. The follow-up ranged from 1 to 4 years. Methods. The PAO as a single procedure was done in 39 hips. In only 3 hips the subtrochanteric DVO was done simultaneously. In clinical pre-op. and post-op. examination the following factors were regarded: pain, limping, Trendelenburg sign, range of motion, leg length discrepancy. Radiographic pre-op. and post-op. examination consisted of AP view of the pelvis, false profile and AP view with leg in abduction. Classic and anterior CE angles were measured.

Results. Flexion slightly decreased from pre-op. 90-140° (av.118°) to 80-130° (av.104°) post-op., abduction left unchanged 15-80° (av.40°) and 15-80° (40°) respectively, adduction slightly increased 15-50° (av.31°) and 20-50° (av. 33°). The range of rotation did not change after operation. The sign of Trendelenburg was found in 27 hips pre-op. and in 8 hips post-op. Pain was found in 29 hips before operation and in 4 after surgery. Either classic or anterior CE angle increased after surgery to the normal value in almost all cases from −14° to 34° and from −10° to 35° respectively. We had a rather low complication rate. In our group 35 operations were done without any complications. In 7 hips the following complications were found: in 1 hip overcorrection and in 2 others insufficient correction, 2 urinary infections, ectopic bone formation in 1 hip, local soft tissue infection in 1 hip and in 1 bad scar formation. We did not find any signs of AVN in our series.

Aims. Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing. Methods. This was a single-centre, prospective longitudinal cohort study of infants with DDH managed using a published, standardized Pavlik harness protocol between January 2012 and December 2016. RAD was measured at two years’ mean follow-up using acetabular index-lateral edge (AI-L) and acetabular index-sourcil (AI-S), and at five years using AI-L, AI-S, centre-edge angle (CEA), and acetabular depth ratio (ADR). Each hip was classified based on published normative values for normal, borderline (1 to 2 standard deviations (SDs)), or dysplastic (> 2 SDs) based on sex, age, and laterality. Results. Of 202 infants who completed the protocol, 181 (90%) had two and five years’ follow-up radiographs. At two years, in 304 initially pathological hips, the prevalence of RAD (dysplastic) was 10% and RAD (borderline) was 30%. At five years, RAD (dysplastic) decreased to 1% to 3% and RAD (borderline) decreased to < 1% to 2%. On logistic regression, no variables were predictive of RAD at two years. Only AI-L at two years was predictive of RAD at five years (p < 0.001). If both hips were normal at two years’ follow-up (n = 96), all remained normal at five years. In those with bilateral borderline hips at two years (n = 21), only two were borderline at five years, none were dysplastic. In those with either borderline-dysplastic or bilateral dysplasia at two years (n = 26), three (12%) were dysplastic at five years. Conclusion. The majority of patients with RAD at two years post-brace treatment, spontaneously resolved by five years. Therefore, children with normal radiographs at two years post-brace treatment can be discharged. Targeted follow-up for those with abnormal AI-L at two years will identify the few who may benefit from surgical correction at five years’ follow-up. Cite this article: Bone Joint J 2024;106-B(7):744–750

Management of symptomatic residual acetabular dysplasia in adolescence and early adulthood remains a major therapeutic challenge. At our unit the two senior authors review all patients preoperatively and simultaneously perform each procedure. In the four years from 1998 forty-three Bernese osteotomies were performed in 40 patients with residual acetabular dysplasia. The mean average age at surgery was 21 years (range 12 – 43 years) and there were 34 female patients. The indication for surgery was symptomatic hip dysplasia (all idiopathic but for one male with a history of slipped capital femoral epiphysis) presenting with pain and restricted ambulation. 4 patients had previous surgery on the affected hip (2 Salter’s osteotomy, one Shelf procedure and one proximal femoral osteotomy). 27.5% of patients had symptomatic bilateral disease. 42% of patients had Severin class IV or V dysplasia at presentation. 100% of patients had preservation of the hip joint at last follow-up evaluation (mean 2.4 years), with excellent results in 82%, an average post-operative Harris hip score of 96, and an average d’Aubigne hip score of 16.1. The mean post-operative improvements in radiographic measures were as follows: Anterior centre edge angle +19.4°, Lateral centre angle +25.8°, Acetabular Index – 10.7°. Head to Ischial distance – 7.3mm. Surgical operative time decreased from 128 minutes to 43 minutes from the first to the most recent case. Average blood loss has reduced from 1850mls to 420mls over the four years experience. Predonation of 2 units of blood requested from all patients with baseline hemoglobin of > 12g/dl. When combined with intraoperative cell salvage the need for transfusion of homologous blood has been eliminated. All complications occurred in the first 9 patients: (one major – iliac vein injury requiring no further treatment; four moderate – lateral cutaneous nerve injuries; four minor – asymptomatic heterotopic ossification). Our experience confirms that the Ganz peri-acetabular osteotomy is an efficacious procedure for the treatment of the residually dysplastic hip, providing excellent clinical results, where early intervention is the key to improved outcome. It is a technically demanding procedure with a significant early learning curve and we believe that a two-surgeon approach is invaluable to the management of these difficult cases

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

The purpose of this study was to evaluate the long-term clinical and radiological results of patients with hip dysplasia who underwent spherical acetabular osteotomy. The surgical technique used was that described by Wagner.

The first 26 unilateral spherical osteotomies performed by one surgeon at one institution were reviewed at a minimum clinical follow-up of 20 years (median 23.9, maximum 29 years). One patient had died 5 years after the index operation unrelated to the procedure. Three patients (3 hips, 11 %) could not be traced. Preoperative and follow-up radiographic measurements included lateral and anterior centre-edge angle, acetabular index angle, and acetabulum-head index of Heyman and Herndon. Antero-posterior radiographs of the pelvis were evaluated for the presence of joint congruency, joint space narrowing, increased sclerosis of the subchondral bone, and bone cysts.

Osteotomy improved the mean lateral centre-edge angle from −20 to +130, and the acetabular head index from 52% to 72%. The mean postoperative anterior centre-edge angle of Lequesne and de Seze was 23 (range: −10 to 62). Seven of 22 hips (32%) needed conversion to total hip replacement. The average Harris hip score at latest follow-up of the remaining 15 hips was rated 86 points (range: 50 to 100 points). Overall, 11 of the 15 hips were clinically rated good or excellent. On latest follow-up severity of osteoarthritis was unchanged in 13 of 15 hips. Only 3 of 9 hips requiring conversion to total hip replacement or showing progressive osteoarthritis were rated congruent after the index operation. On the other hand, 10 of 13 hips not requiring conversion to total hip replacement or progressive osteoarthritis were congruent. The 20-year-follow-up Kaplan-Meier survival estimates based on conversion to total hip replacement as an end point was 86.4%. (95% confidence interval: 63.4% to 95.4%). The 25-year-follow-up survivorship was 65.1 % (95% confidence interval: 35.6% to 83.7%).

The long-term results of the spherical osteotomy are satisfactory from the standpoint of both improvement in clinical condition and the radiological appearance of the joint. The Wagner spherical osteotomy had prevented progression of degenerative changes in 13 out of 22 hips (59%) after a median 23.9 year follow-up. Congruency of the joint seems to be a major factor predicting long-term outcome.

Purpose. To investigate the effect of soft tissue release (STR) and the length of postoperative immobilisation on the long term outcomes of closed reduction (CR) of the hip for developmental dysplasia of the hip. Materials. 77 hips (72 patients) who had undergone closed reduction (CR) between 1977-2005 were studied retrospectively to review their outcome (Severin grade), identify the reasons for failure and to assess factors associated with residual dysplasia. Particular attention was paid to the use of a STR at the time of CR (to improve initial hip stability) and the duration of postoperative immobilisation. Results. The mean age at CR was 10.5 months (5-24months) and mean follow up 97 months. A STR (adductor ± psoas tenotomies) was performed in 65%. Post-operative immobilisation time varied between 3-12 months (mean 6.3 months). 6 hips (all Tonnis grade 3) failed CR within 2-6 weeks. In the remaining 49 hips, 85% were Severin Grade 1 at age 5yrs. Acetabular index (AI) decreased in all patients over time: 80% hips had an AI <20. 0. at age 5yrs. Neither a STR, nor the time of post-operative immobilisation conferred any additional benefit on the final AI. 2/55 hips required a pelvic osteotomy for residual dysplasia. This was not related to initial Tonnis grade, age at reduction or use of STR. Conclusion. A STR is often required for initial hip stability. Once a stable hip is achieved, an excellent long term outcome from CR in infants <24months old can be expected with remodelling of the acetabular dysplasia in ≥95%. Significance. Hip stability is the key to a good outcome. The optimal length of post-operative bracing has not been determined from this study but 3-6months immobilisation of the stable hip is adequate

This retrospective matched cohort study tested the hypothesis that an incomplete periacetabular acetabuloplasty, as an added step to delayed open reduction, diminishes the risk of developing acetabular dysplasia. 29 hips from 23 patients with idiopathic DDH that underwent intentionally delayed open reduction and acetabuloplasty at our institution from 2003 to 2010 were matched for age at presentation and bilaterality to historic controls. These were 29 hips from 26 patients, treated with open reduction alone from 1989 to 2003. Residual dysplasia treated with pelvic osteotomy, AVN grade II-IV, and rate of re-intervention were the outcome measures. The mean ages at diagnosis and at surgery were 8.62 weeks and 12.97 months, respectively. At latest follow-up, 27 hips in the acetabuloplasty group and 22 in the open reduction alone group had satisfactory radiographic outcome (Severin class Ia, Ib or II) (p=0.16). 18 of the 58 hips (31.0%) had AVN, 7 (24.14%) in the case group and 11(37.93%) in the control group. Further surgery was required in 15 of the 29 hips in the open reduction alone group. These included 2 revision of open reductions, 5 pelvic osteotomies, 3 varus derotation osteotomies, and 5 apo or epiphysiodesis whilst only one patient in the acetabuloplasty group required a medial screw epiphysiodesis for late lateral growth arrest. There is a positive association between the need for further surgery and open reductions alone: the odds ratio is 14.00 and the 95% confidence interval (1.97, 99.63), p=0.0017. The five hips in the open reduction alone group that required a pelvic osteotomy were intervened at an average of 31.45 (±9.07) months. The addition of an incomplete periacetabular periacetabuloplasty to all hips undergoing open reduction eliminated residual acetabular dysplasia in this cohort whilst it does not appear to have deleterious effects, as evidenced by the similar Severin and McKay scores

Reduction therapy in developmental dysplasia of the hip (DDH) is initialized in the newborn period. Harness treatment is continued until normal ultrasound-values are reached. Above the age of one year the assessment of DDH relies mainly on interpretation of plain radiographs of the pelvis. In order to rule out residual dysplasia after ultrasound controlled treatment radiological control is advised to the time children start walking. The purpose of this study is to evaluate the early radiological outcome after ultrasound controlled treatment of DDH and to examine whether there is a correlation between the initial severitiy of DDH, measured by ultrasound, and the severity of residual DDH on the radiograph at the time of the first follow-up. A. p. pelvic radiographs of 90 children (72 girls, 18 boys, 180 hips) with DDH (29 unilateral, 61 bilateral) were reviewed retrospectively. To the beginning of the ultrasound surveilled therapy (mean age 7,2 weeks) the morphologic findings were staged according to the Graf classification. Ultrasound surveilled abduction treatment was continued until normal ultrasound findings were reached. To the time children started walking (mean age 14,8 months) an a. p. radiograph of the pelvis was performed. The acetabular index (AI) was measured and classified according to the normal values of the hip joint described by Tönnis. The initial ultrasound findings expressed by the Graf classification were compared with the AI in the radiographic follow-up and Tönnis’ normal values. To simplify matters the 180 Graf-classified hips were distributed into 4 categories: Graf Ia/b=category 1, Graf IIa-D=category 2, Graf IIIa/b=category 3, Graf IV=category 4. The initially normal contralateral hips in ultrasound (n=29, category 1) presented in 37,9% a normal AI, in 41,4% with a mild dysplasia (between 1SD and 2SD) and in 20,7% with a severe dysplasia (beyond 2SD). The Graf type IIa-D hips (n=81, category 2) presented in 37% a normal AI, 32,1% showed a mild dysplasia and 30,9% a severe dysplasia. The Graf type III a/b hips (n=60, category 3) showed 35%, 30% and 35%, Graf type IV hips (n=10, category 4) 60%, 30% and 10%, respectively. The mean AI in all four categories differed only marginally. In our setting of patients different conclusions can be drawn:. Even after successful ultrasound guided therapy with a sonographically normal hip at the time bracing is finished there is a risk for residual dysplasia. Therefore radiological follow-up of every once treated hip is necessary. To reduce the number of radiographs the time for the first radiographic follow up may be delayed to the age of two. We only see a minimal risk to miss a dislocated hip in time. In very rare cases the indication for an acetabuloplasty is generally seen before the age of two, in our patient population we saw no immediate indication for surgery

The dual mobility (DM) bearing concept was introduced to reduce the risk of dislocation in total hip arthroplasty (THA). Our aim was to evaluate the early outcomes following the utilisation of DM in primary and revision THA in our unit. Prospectively collected data on all patients undergoing a DM bearing at was reviewed between July 2012and December 2015. The primary outcome assessed was dislocation, with a secondary outcome revision for any reasons. All data was gathered from patient clinical records and the digital picture archiving and communication system (PACS). 30 primary THA were undertaken and 54 revision THAin the time period described. 11 of the procedures involved a proximal femoral endoprosthesis. The mean age in the primary setting was 65 and 73 in the revision population. The main indications for using DM bearing in the primary setting were; trauma (40%), residual dysplasia (40%) and malignancy (17%). There were no dislocations in the primary THA category. Indications in the revision THA cohort included 33% for aseptic loosening, 11% for instability, 18% for ALVAL reactions, 20% for infection, 18% for fracture. 1 out of the 54 revision THA had one large bearing dislocation requiring closed reduction. Subsequent analysis confirmed that implant alignment was satisfactory and this was a patient compliance issue due to mental health concerns. To date no patient in either cohort required revision surgery. Overall dislocation rate was 1.2%. Our early experience with DM bearings has been positive with no evidence of early failure or loosening. The dislocation rate overall has been low and matches the current large series in the literature

Purpose. To determine (i) the relationship between osteonecrosis and hip function, physical function and quality of life in adolescents and young adults treated for DDH; and (ii) how affected children change over 10 years. Methods. We included 109 patients (mean age 19.2 ± 3.8 years) with osteonecrosis and 30 age-matched patients without osteonecrosis following DDH treatment between 1992–2005. All completed valid patient-reported outcome measures to quantify their hip function (maximum score 100); physical function (maximum score 100); and quality of life (maximum score 1). Of these, 39 patients had been followed prospectively since 2006, allowing quantification of within-person changes over time. We graded all radiographs for severity of osteonecrosis, residual dysplasia, subluxation and osteoarthritis. We determined the association between patient-reported outcomes and radiographic severity of osteonecrosis using mixed-effects regression analysis; and repeated-measures analysis of variance to quantify person changes over time. We adjusted for age, prior operations and acetabular dysplasia. Results. In 135 patients (168 hips) with and without osteonecrosis, mean differences (95% confidence interval) in hip function, physical function and quality of life were 0.75 (−6.67, 8.17), −1.97 (−17.58, 13.60) and −0.05 (−0.91, 0.36), respectively. Adjusted analysis showed no difference in these outcomes based on radiographic severity of osteonecrosis (p> 0.05). Of 39 patients followed over 10 years, 4 had undergone hip arthroplasty. For the remainder, mean changes (95% confidence interval) in hip function, physical function and quality of life from baseline to current assessment were 7.18 (−2.11, 12.26), −2.11 (−15.47, 11.25), −0.03 (−0.11, 0.05), respectively. Radiographic severity of osteonecrosis was not correlated with changes in patient-reported outcomes over time. Conclusion. Osteonecrosis secondary to DDH remains relatively benign even in young adulthood. Overall, patients demonstrated good hip function, physical function and normal quality of life. Equally, children maintained such high levels over the course of 10 years if their hip survived

To evaluate the safety and efficacy of treating patients with Graf IIa developmental hip dysplasia. The management of the developmentally immature Graf Type IIa dysplastic hip is controversial. Some authors advocate early treatment with an abduction harness whilst others adopt watchful waiting. At our institution selective sonographic assessment for developmental dysplasia of the hip (DDH) was established in 1997 with prospective data collection. All infants diagnosed with Graf Type IIa hip(s) were treated with either a Pavlik harness or double nappies, with clinical and sonographic follow up until normalisation. Pelvic radiographs were routinely performed at 8 and 18 months follow up for assessment of residual dysplasia and/or complications of treatment. We evaluated the safety and efficacy of all treated patients between 2005 and 2013. Complete clinical and radiological follow up (mean 2.1 years, 0.7–6.5) was available for 103 of 118 infants. 69 were treated with a Pavlik harness and 49 with double nappies. The chosen treatment was successful in 110 hips with no documented complications, well developed ossific nuclei on follow up radiographs, and no further treatments undertaken. In the double nappy group 4 infants deteriorated sonographically so were changed to a Pavlik harness with subsequent normalisation and successful treatment. 3 patients required VDRO at age 18 months (17–20) and 1 patient required closed reduction and spica cast treatment at age 11 months. No further complications arose in this group. The 15 patients lost to follow up had successful initial treatment but failed to attend for radiographic review. Both Pavlik harness and double nappies are safe treatment modalities for Type IIa hip dysplasia. However, sonographic deterioration was observed in both groups with surgical intervention required in the minority, supporting the ongoing treatment of these immature hips

In this paper operations are discussed that improve the dysplastic acetabular roof in developmental dislocation of the hip (DDH) of children up to 10 years. In the first year of life acetabular dysplasia can be treated successfully by flexion-abduction splints and plaster casts in „human position“. From the second year on, only slight dysplasias can heal spontaneously or be treated conservatively. Then the steep acetabular roof has to be osteotomized and levered down to a normal angle and coverage to avoid redislocation or residual dysplasia. Different procedures have been described in the course of time. Two osteotomies are chiseling in the anterior to posterior direction. Salters innominate osteotomy levers the whole acetabulum with the lower part of the pelvis in an anterolateral direction around an axis passing through the pubic symphysis and the posterior part of the osteotomy. In Pembertons osteotomy the hinge for turning down the acetabular roof is the last, posterior, transverse cortical segment over the tri-radiate cartilage, short before the sciatic notch. Osteotomies chiseling from lateral in medial direction have been described already by Albee (1915) and Jones (1920). Lance (1925) propagated this technique in Europe. Here the acetabular roof is partially osteotomized in a thickness of 5–7 mm. Only the lateral part of the acetabulum is brought into the horizontal position. Wiberg in 1939 used this technique, but in 1953 he was the first to publish a full osteotomy what Dega called 1973 a transiliac osteotomy. Dega had originally learned the technique of Lance, but in 1963 when he reduced high dislocations after the technique of Colonna, he performed also a full transiliac osteotomy. After the Symposium of Chapchal in Basel 1965 we started in Berlin also with the complete acetabular osteotomy. With the control of an image intensifier the blade of the osteotome is driven toward the posterior rim of the tri-radiate cartilage leaving only a small bony rim above. Anteriorly the blade passes through the ant. inf. iliac spine. Posteriorly it just enters the sciatic notch. Here we check the blade position by direct palpation. The acetabulum is bent down partly in the small rim of bone left and mainly in the triradiate cartilage. Angles up to 50° have been achieved, which you cannot reach by other techniques. In the beginning we have combined after Mittelmeier and Witt this acetabuloplasty with a varus osteotomy of the femur. In our long-time follow-up (Brüning et al. 1988,1990) however, we found in almost 50% a subcapital coxa valga or a so-called head-in-neck-position of the femoral head. Then we avoided varusosteotomies and had good results without it (Pothmann). To keep the acetabular roof in the new position we used first bone wedges from the varus osteotomy, then deproteinized bone wedges from animals, and today deep frozen wedges of human femoral heads of the bone bank, sterilized at 121 degrees C for 20 min. (Ekkernkamp, Katthagen). A firm layer of cortical bone laterally is necessary. Reinvestigations have proven the stability of this material too ( Pothmann). This type of acetabular osteotomy in our and other authors opinion is the best. Salters osteotomy is not as efficient in severe dysplasia. And in older children it produces a decrease in anteversion of the acetabulum, which may limit internal rotation of the hip and cause osteoarthritis if it does not improve. In Pembertons osteotomy one cannot use the image intensifier, which is of great help to perform the osteotomy exactly and also the levering of the acetabulum to the optimal coverage. Our first long-time follow-up of children with additional varus-osteotomies (Brüning et al.) reviewed 90 hip joints in 67 children. The age at operation was in average 3.6 years, the age at follow-up 15 years. Clinical results. 98% of the patients had no pain or only occasional, no limitation of movement and normal or almost normal gait. The Trendelenburg sign was negative in 71% of the cases, grade 1 in 15.5% and grade 3 in 13.5%. Radiological evaluation. The mean value of the AC-angle (acetabular index) preoperatively was 33.8°, postoperatively normal with 16.3°. The acetabular angle of the weightbearing zone was at follow-up 9.7°, which is normal too. At the age of less than 18 years the CE angle of 25,9° was normal too, as well the instability (protrusion) index of Reimers of 12.3 % and the distance femoral head to teardrop figure with 8.8 mm. In our study group of hip dysplasia we introduced a score of normal values of hip measurements and 3 grades of deviation from normal, slightly pathological, severely pathological and extremely. When we counted normal values and slightly pathological ones together as a good result, we found for the different measurements of the acetabulum percentages mainly between 82 and 93 %. Remarkable were two measurements of the femoral neck, the epiphyseal index with only 50 % of normal and slightly pathological angles and the head-neck index with 47.7% respectively. This was due to the head-in-neck position of the femoral neck after varus osteotomy as we have mentioned already. Acetabular coverage is achieved best in transiliac osteotomies up to 10 years. Then, only by triple pelvic osteotomies the acetabulum in total can be redirected to a normal coverage. But this operation is more difficult. Residual dysplasias therefore should be treated as early as possible in the way demonstrated here

Aims

Eccentric reductions may become concentric through femoral head ‘docking’ (FHD) following closed reduction (CR) for developmental dysplasia of the hip (DDH). However, changes regarding position and morphology through FHD are not well understood. We aimed to assess these changes using serial MRI.

Background. Several risk factors for the development of osteonecrosis following treatment of developmental dislocated hip have been reported. The need for further research with a large-enough sample size including statistical adjustment of confounders was demanded. The purpose of the present study was to find reliable predictors of osteonecrosis in patients managed for developmental dislocation of the hip. Methods. A retrospective cohort study of children, who have been hospitalized at our department between January 1998 and February 2007 with a developmental dislocation of the hip, was completed. Sixty-four patients satisfied the criteria for inclusion. Three groups according to age and treatment were identified. Group A and B included patients treated with closed or open reductions aged less than twelve months. Patients of group C were past walking age at the time of reduction and were treated by open reduction combined with concomitant pelvic and femoral osteotomies. The average duration of follow-up for all patients was 6.8 years. Logistic regression analysis was conducted to identify predictors for the development of osteonecrosis. Results. The overall rate of osteonecrosis in group A and B was 27.4% compared to 88.2% in patients of group C. After pooling of all data, no protective effect of the ossific nucleus of the femoral head on the development of osteonecrosis was found (p = 0.14). Additionally, an increase of surgical procedures in children of group C could not be demonstrated (p = 0.17). By using logistic regression analysis the type of reduction and secondary reconstructive procedure due to residual acetabular dysplasia could be identified as predictors for the development of osteonecrosis. Conclusions. Open reduction combined with concomitant osteotomies and secondary reconstructive interventions due to residual acetabular dysplasia increase the risk for osteonecrosis in the treatment of the developmental dislocated hip. Therefore, we advocate early reduction of the dislocated hip in the first year of life to avoid the need for concomitant osteotomies combined with open reduction. Level of Evidence. Prognostic study, level II-1 (retrospective study)

Background: Deformity of the femoral head after open reduction for developmental dislocation of the hip (DDH) influences the outcome of pelvic osteotomy as a final correction for residual dysplasia to prevent secondary osteoarthritis. The purpose of this study was to review long-term outcomes after open reduction using a medial approach for DDH. The correlation between age at the time of operation and femoral head deformity at skeletal maturity was specifically evaluated. Methods: Forty-two hips in 40 patients with more than 10 years of follow-up were assessed radiologically. The mean age at the time of surgery was 14.3 (range, 6–31) months, and the postoperative follow-up period ranged from 10 to 27 (mean, 15.8) years. The round and enlargement indices of the femoral head were measured on follow-up radiographs to evaluate deformity and enlargement of the femoral head at skeletal maturity. Results: Severin classification was I and II in 16 hips; III, IV, and V in 23; and II at the final follow-up in the 3 hips treated by osteotomy less than 10 years after open reduction. Mean round index at follow-up was 58.3 ± 8.3 (range, 47–79); it showed correlation with age at the time of operation (r = 0.68, p < 0.001). Mean enlargement index at follow-up was 113.4 ± 11.8 (range, 93–137) and showed no correlation with age at the time of operation (r = 0.009, p = 0.96). Conclusions: At more than 10 years’ follow-up, the occurrence of deformity of the femoral head correlated with increased age at the time of operation. Indications for use of a medial approach in the correction of DDH in older patients must take into account the risk of subsequent femoral head deformity at skeletal maturity

Management of symptomatic residual acetabular dysplasia in adolescence and early adulthood remains a major therapeutic challenge. At our unit the two senior authors review all patients preoperatively and simultaneously perform each procedure. In the four years from 1998 forty-three Bernese osteotomies were performed in 40 patients with residual acetabular dysplasia. The mean average age at surgery was 21 years (range 12 – 43 years) and there were 34 female patients. The indication for surgery was symptomatic hip dysplasia (all idiopathic but for one male with a history of slipped capital femoral epiphysis) presenting with pain and restricted ambulation. 4 patients had previous surgery on the affected hip (2 Salter’s osteotomy, one Shelf procedure and one proximal femoral osteotomy). 27.5% of patients had symptomatic bilateral disease. 42% of patients had Severin class IV or V dysplasia at presentation. 100% of patients had preservation of the hip joint at last follow-up evaluation (mean 2.4 years), with excellent results in 82%, an average post-operative Harris hip score of 96, and an average d’Aubigne hip score of 16.1. The mean post-operative improvements in radiographic measures were as follows: Anterior centre edge angle +19.4°, Lateral centre angle +25.8°, Acetabular Index – 10.7°. Head to Ischial distance – 7.3mm. Surgical operative time decreased from 128 minutes to 43 minutes from the first to the most recent case. Average blood loss has reduced from 1850mls to 420mls over the four years experience. Predonation of 2 units of blood requested from all patients with baseline hemoglobin of > 12g/dl. When combined with intraopera-tive cell salvage the need for transfusion of homologous blood has been eliminated. All complications occurred in the first 9 patients: (one major – iliac vein injury requiring no further treatment; four moderate – lateral cutaneous nerve injuries; four minor – asymptomatic heterotopic ossification). Our experience confirms that the Ganz periacetabular osteotomy is an efficacious procedure for the treatment of the residually dysplastic hip, providing excellent clinical results, where early intervention is the key to improved outcome. It is a technically demanding procedure with a significant early learning curve and we believe that a two

Aims

When the present study was initiated, we changed the treatment for late-detected developmental dislocation of the hip (DDH) from several weeks of skin traction to markedly shorter traction time. The aim of this prospective study was to evaluate this change, with special emphasis on the rate of stable closed reduction according to patient age, the development of the acetabulum, and the outcome at skeletal maturity.

DDH with or without previous treatment is the most frequent source of early hip OA in adolescents. Others are hip joint deformation following Legg-Calve-Perthes disease, slipped capital epiphysis or trauma. Secondary OA after rheumatoid arthritis, bacterial infection or as result of an hemophilic hip joint are relatively infrequent. The choice of treatment depends on the type of the deformity and the severity of osteoarthritic changes. Osteotomies are favorably performed in adolescents. Arthrodesis is rarely accepted in this age group. In selected individuals THR is the matter of choice. Pain, limping gait, restricted joint motion and sometimes clicking phemomena are the usual complains. Pain is usually aggravated by running and other sports activities. Residual dysplasia of the hip with a spherical femoral head is best treated by a triple periacetabular osteotomy. The Bernese ostetomy of Ganz (. 3. ) and the triple osteotomy of Tönnis (. 9. ) are popular procedures. They mobilise an acetabular fragment, then reorient and stabilise the fragment in an optimal position. Internal fixation with screws provides stability and allows early mobilisation with partial weight bearing. Chiari’s osteotomy is a supracetabular rotatory displacement osteotomy. Femoral head and joint capsule are medialised and covered by the osteomised iliac bone. The joint capsule in the weight bearing zone is transformed into fibrous cartilage by time. Congruent remodelling of the acetabular roof and fibrous tissue transformation into cartilage are biased by inproper height and orientation of the osteotomy (. 5. ). There is still an indication in severe DDH with subluxation of the femoral head and those with a severely deformed femoral head. In pathomorphologies with aspherical femoral heads femoral osteotomies, usually valgus osteotomies, are required additionally in order to optimize the joint congruency. A dysplastic hip in a high dislocation and moderate to severe OA are contraindications. Radiographic work up includes pelvic ap view and faux profil view. Assessment of the anterior and posterior acetabular rim indicate orientation of the acetabulum in terms of anteversion / retroversion. Orientation of the subchondral sclerosis over the femoral head is an indicator of femoral head coverage as CE-angle and AC-angle. 20°–30° abduction view in neutral rotation mimikes the postoperative acetabulum / femoral head relation. From CT-scans acetabular orientation ( ante-version / retroversion ), degenerative bone cysts, posteroinferior joint space and femoral head deformities and femoral neck osteophytes are depicted. Labrum pathology is dedectable by MRT and MRT-arthrography. After treatment of DDH deformation of the femoral head and neck due to ischaemic necrosis develop in an incidence up to 20 %, depending on the method. Premature closure of the epiphyseal plate can also follow trauma, septic arthritis and Legg-Calve-Perthes disease. Most often an combination of acetabular dysplasia and coxa magna with short femoral neck and a high-standing greater trochanter are typical deformities. Specchiulli’s classification (. 8. ) is very helpful for deformations after avascular necrosis in DDH. Limping gait due to femoral shortening and insufficient strength of the abductor muscels are the major complains of adolescents. Symptoms exacerbate during walking of longer distances and restrict sports activities. Valgus osteotomy, Y-osteotomy, transfer of the greater trochanter alone or in combination with valgus osteotomy are appropiate methods to restore a better function and improve alignment of the mechanical axis to the knee joint. Femoral neck lengthening osteotomies (. 1. ,. 4. ) with distal-lateral transfer of the greater trochanter are advocated by several authors. Restoration of almost normal anatomy muscle function of the hip joint are realistic aims of these methods. If the abductor muscel deficit is dominant and only a minor leg length discrepancy is in slight deformities, e.g. some Specchiulli’s type B2, we do not always need such complex procedures. Isolated transfer of the greater trochanter also improves the lever arm of the abductor muscles and therefore joint function, but does not influence leg length discrepancy. Disappearance of the Tren-delenburg-type gait is the most visible improvement of this procedure (. 7. ). Total hip replacement (=THR) is rarely indicated in adolescents, but sometimes necessary for restoration of a almost normal quality of life. Especially in severe symptomatic OA after septic arthritis or trauma in some individuals remain only two options : arthrodesis or arthroplasty. Arthrodesis is a permanent solution for many years or even life time. Gait function is compromised remarkable (. 6. ) and specific compensatory mechanisms are adopted when walking. Excessive motion in the lumbar spine and ipsilateral knee provokes back and knee pain as well as osteoarthritic changes on the long run. THR in young patients includes the risk of several revisions over life time , due to wear problems particularly in physically active individuals. A deficient acetabular bone stock as usual in severe acetabular dysplasia or poor bone quality after trauma or septic arthritis may compromize primary stability and secondary osteointegration. Nevertheless functional results and outcome (. 2. ) in terms of life quality are superior compared with various non-substituting procedures

The D.D.H screening programme until the second half of ’80 was based on the clinical Ortolani-Barlow’s manoeuvre at newborn age and by xray examination of the pelvis at three – four month old to discover hip joint anomalies that could be address at a future dislocation. Never less the so-called Dislocation of the Hip was a quite common pathology around Europe. The close reduction of a dislocated hip has been the treatment of choice in order to attempt to reduce a dislocated hip without surgical operation. Close reduction was preferred to be obtained after a period of skin traction on bed, at which a special frame were added, to perform a progressive gentle reduction gaining, in an average of three weeks time, complete abduction before applying a spica cast. Two main methods were used: reduction with the hips extended, abducted and internal rotated according to Sommerville- Petit and reduction in over head position with the hips flexed, abducted and external rotated. These two systems were designed to decrease the Avascular Necrosis of the femoral head that often occurs if the reduction was obtained during a sudden manoeuvre under general anaesthesia. Generally the correct position of the femoral head into the acetabular socket, at the moment to apply the plaster, was assessed by an arthrogram, to avoid the bad surprise of further dislocation due to false reduction after the traction period. The child so treated had to be followed during her/his growth to assess the development of acetabular roof and the position of the femoral head linked at the antiversion of the femoral neck. Any hip joint, in which acetabular index do not improve during growth, needs acetabular and femoral osteotomies to overcome these anatomical defects as cause of a persisting genetic defect. At the end of ’80, a deep change of the natural history of D.D.H. in Italy is related to the introduction of screening programme based on accurate clinical examination of the hip of the babies at the nursery, selection of babies with risk signs of D:D.H. such as clinical anomalies, instability of the hip at Ortolani-Barlow’s, familiarity for D.D.H. and breech delivery. The hips of those babies are immediately assessed by ultrasonographic examination according to Graf’s method. The general population, on the contrary, is examined by US between the second and the third months of age. The National Health Service encourages the US screening paying its cost. In this way the incidence of late-D.D.H. and late-dislocation is enormously decreased and the outcome of the pathology has been improved. The conservative treatment of the hip affected by different grade of anomalies early discovered trough US examination, in fact, are treated by simple harness in abduction for mild dyspalsia to plaster spica cast in human position if the hip is severely unstable and Ortolani positive. There are same rare cases of true Congenital Dislocation at birth that can not be conservatively reduced and it will be necessary to perform a open reduction generally when the ossified nucleus of femoral head appeares. Our experience:. From 1975, when our Children Orthopaedic Department was created in the Medical School of “Federico II” University of Naples and the first authors become the Chief, we admitted 374 patients affected by dislocation of the hip (F=308 – M= 66 F:M= 5:1) with a mean age of 7 and half months (min.4 mths.– max 20 mths). All these patients were put in traction on the Morel’s bed in order to attempt a close reduction in extended, abducted and internal rotated position according to Sommerville- Petit method. Average time of traction was 25 days (min. 7 max 38). 120 patients were undergone at an arthrographic examination in general anaesthesia. 46 patients did not achieve the reduction and were operated on. A spica cast were applied for 60 days followed by an harness in abduction. Total amount of time of treatment was a mean of 7 months (min 110 days max. 12 months). Residual dysplasia was observed in 48 patients that needed a further surgical procedure. The number of inpatient affected by D.D.H. were an average of 21 per year until 1990 to drop dramatically at 3 per year in the last decade. On the other hand the D.D.H. outpatient clinic increased. The selected babies examined were 6930 at an average age of 4 months old. All the babies were undergone to clinical and Us examination and classified according to Graf. Hip anomalies were seen in 630 babies. The treatment was related to clinical and Us observation. Simple abduction pillow or simple harness in abduction were used in hip clinically negative at Ortolani-Barlow’s manoeuvre and 2c or 2b type according to Graf.’s classification. Milgram harness or Coxaflex harness (Thamert –Burgwedel –Germany) or plaster spica cast in “human position” were applied in instable hip type D or worse and clinically positive at Ortolani-Barlow manoeuvre. 25 patients were hospitalised because affected by irreducible hip. Conclusion:. The experience that we have done over decades in treatment of D.D.H. confirms the assumption of Treadwell and Bell (1981) that claimed that D.D.H. screening deeply changed the natural history of D.D.H. The problem was to find a good screening test helpful to diagnose as soon as possible a pathological hip. Graf’s method, after a decade of scientific criticism, can be elected at a worth method to screen an infant hip. Screening program based on ultrasound and clinical examination decreases hospitalisation, cost and sequels of D.D.H. in term of surgical operation and degenerative arthritis of hip joint at least at a medium follow up. The hip that need to be hospitalised are the true congenital dislocated hip for which early diagnosis probably should not effect their clinical history. A danger is hidden in US screening. Ultrasonography has to be performed by a skill examiner and it has to be implemented by careful clinical examination with anamnestic recording of the data in order to obtain the best result of the D.D.H. screening program