Rev. bras. ortop. vol.49 número4

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w w w . r b o . o r g . b r

Original

Article

Bilateral

developmental

dysplasia

of

the

hip

treated

with

open

reduction

and

Salter

osteotomy:

analysis

on

the

radiographic

results

夽

,

夽夽

Anastácio

Kotzias

Neto

∗

_,

_Adriana

_Ferraz,

_Franco

_Bayer

_Foresti,

Rafael

Barreiros

Hoffmann

HospitalInfantilJoanadeGusmão,Florianópolis,SC,Brazil

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t

i

c

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e

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n

f

o

Articlehistory:

Received10March2013 Accepted10October2013 Availableonline5April2014

Keywords: Hipdislocation, congenital/pathology

Hipdislocation,congenital/etiology Hipdislocation,congenital/surgery Hipdislocation,congenital/therapy

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b

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Objectives:toevaluatetheradiographicresultsfrompatientswithbilateraldevelopmental dysplasiaofthehip(DDH)whounderwentsurgicaltreatmentbymeansofopen reduc-tionandSalterosteotomy,withorwithoutassociatedfemoralshorteningasdescribedby Ombrédanne.

Methods:thiswasaretrospectivedescriptivestudyinwhich21patientswithbilateralDDH (42hips)wereanalyzed.TheyweretreatedatHospitalInfantilJoanadeGusmão(HIJG),with operationsbetweenAugust1997andOctober2009.Toevaluatetheradiographicresults, theacetabularindexandtheWibergcenter-edgeangleweremeasured,andtheSeverin andKalamchi–MacEwenclassificationswereused.Descriptiveandparametricstatistical analyseswereusedtoevaluatethedata.

Results:wedidnotobserveanystatisticallysignificantdifferenceinanalyzingthe radio-graphicparameters, makingcomparisonsregarding the side affected,the order ofthe proceduresandwhetherfemoralshorteningwasperformed,althoughtherewasa signifi-cantdifferencebetweenthemfrombeforetoaftertheoperation.

Conclusion:openreductioninassociationwithiliacosteotomyasdescribedbySalter pre-sented significant improvements in the radiographic parameters analyzed, comparing thepre-andpostoperativevalues.Thisimprovementoccurredindependentlyofwhether Ombrédannefemoralshorteningwasperformed.Themostprevalentcomplicationinthe studygroupwasavascularnecrosisofthefemoralhead.

Displasia

do

desenvolvimento

do

quadril

bilateral

tratada

com

reduc¸ão

cruenta

e

osteotomia

de

Salter:

análise

dos

resultados

radiográficos

Palavras-chave: Luxac¸ãocongênitade quadril/patologia

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e

s

u

m

o

Objetivos:avaliarosresultadosradiográficosdepacientesportadoresdedisplasiado desen-volvimentodoquadril(DDQ)bilateral, submetidosaotratamentocirúrgicopormeioda

夽

Pleasecitethisarticleas:KotziasNetoA,FerrazA,BayerForestiF,BarreirosHoffmannR.Displasiadodesenvolvimentodoquadril bilateraltratadacomreduc¸ãocruentaeosteotomiadeSalter:análisedosresultadosradiográficos.RevBrasOrtop.2014;49:350–358. 夽夽

WorkperformedattheOrthopedicsandTraumatologyService,HospitalInfantilJoanadeGusmão,Florianópolis,SC,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](A.KotziasNeto).

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rev bras ortop.2014;49(4):350–358

351

Luxaçãocongênitade quadril/etiologia Luxaçãocongênitade quadril/cirurgia Luxaçãocongênitade quadril/terapia

reduc¸ãocruentaeosteotomiadeSalterassociadaounãoaoencurtamentofemoraldescrito

porOmbrédanne.

Métodos: trata-sedeestudodescritivoretrospectivocomanálisede21pacientescomDDQ bilateral(42quadris),tratadosnoHospitalInfantilJoanadeGusmão(HIJG)eoperadosentre agostode1997eoutubrode2009.Paraavaliaçãodosresultadosradiográficos,forammedidos oíndiceacetabulareoângulocenter-edge(CÊ)deWibergeusadasasclassificaçõesdeSeverin edeKalamchieMacEwen.Análisesestatísticasdescritivaseparamétricasforamusadas paraavaliaçãodosdados.

Resultados:nãoobservamosdiferenc¸aestatisticamentesignificantenaanálisedos parâmet-rosradiográficoscomparando-osquantoaoladoacometido,àordemdosprocedimentose àfeituradeencurtamentofemoralounão,emboraexistadiferenc¸asignificativaentreeles nosperíodospréepós-operatório.

Conclusão: reduçãocruentaassociadaàosteotomiadoilíacodescritaporSalterapresentou melhoriasignificativadosparâmetrosradiográficosanalisadosnacomparaçãodosvalores prée pós-operatórios.Essamelhoriaocorreuindependentementeda feituraounãodo encurtamentofemoraldeOmbrédanne.Acomplicaçãomaisprevalentenogrupoestudado foianecroseavasculardacabeçafemoral.

Introduction

Developmental dysplasia of the hip (DDH) comprises a

spectrumof abnormalities during the development ofthis

joint that vary according to the patient’s age and go from self-limitingdefectswithoutlong-termconsequencesto dis-locationthatmayleadtopermanentdeficiency.1_In_cases_in

whichdislocationofthehipoccurs,theacetabulumpresents adeficiencyinitsanterosuperioraspectandisshowntobe thick,shallowandoblique.2_The_etiology_is_{multifactorial,}_with

genetic,hormonalandenvironmentalcauses,butitisbelieved thattheprimarycauseisrestrictionofthemovementsofthe fetusorhyperelasticityofthejointcapsuleofthehip.3

TheincidenceofDDHwithdislocationisaroundonein

every thousandlivebirths.Itismoreprevalent inchildren withpelvicpresentation,femalesandchildrenwithapositive familyhistory(12%to33%).3–6

TheprognosisforDDHisdirectlylinkedtoearly diagno-sis,whichenablestreatmentthatismoreeffectiveandless aggressivetowardthepatient.7_However,_a_considerable

num-ber ofcases are diagnosed after the child starts towalk.8

Thetreatment hasthe aim ofrecovering joint congruence

andstability,soastopromoteitsphysiologicaldevelopment. When instituted within the first days of life, a high

suc-cess rate and reduced complication rate are achieved. As

thechildgrows,the anatomicalalterationsincrease,which makesthe treatmentmoredifficult.9,10 _In_smaller_children,

the treatmentbegins withclosed reductionbymeans of a

Pavlikharness,whichiseffectiveinupto95%ofthecases.3

Afterthe age of sixmonths, the harnessloses its efficacy

andtherecommendedtreatmentbecomesclosedreduction

with plaster-cast immobilization. In children over the age

of18 months, the treatment varies from closed reduction

withplaster-castimmobilizationtoopenreductionin

asso-ciation with osteotomy. Thetreatment described bySalter

isthe preferred procedure and itmay or may notbeused

in association with the femoral shortening described by

Ombrédanne.3,11–13

Theimportanceofearlyidentificationandadequate

treat-ment for this disease is to prevent its sequelae, such as

deformity ofthe femoralhead, anteversion ofthe femoral

neck,valgusthighanddysplasticacetabulum,whichevolve tohiparthrosis.14,15

Theobjectiveofthisstudywastoevaluatetheradiographic resultsfrompatientswhounderwentsurgicaltreatmentfor

bilateral dislocation, with open reduction combined with

Salter’sosteotomy,inassociationwithOmbrédanne’sfemoral

shorteningwhennecessary.

Material

and

methods

Thiswasaretrospectivedescriptivestudy.Themedicalfiles ofallthepatientswithDDHattendedattheJoanadeGusmão Children’sHospital(HIJG)betweenAugust1997andOctober 2009werereviewed.Treatmentwasprovidedfor296patients: 70 (23.65%) using Pavlik’s harness, 93 (31.42%) with closed

reduction that was maintained using a plaster case from

thepelvistothefoot,21(7.09%)withopenreductionalone

and 112 (37.84%) with open reduction in association with

osteotomy.Amongtheosteotomycases,11patients(9.82%)

underwenttheDegaprocedure,four(3.57%)Pemberton,two

(1.79%)Chiari,two(1.79%)Steel,one(0.89%)Kalamchiandone (0.89%)Shelf.Amongtheremaining91patients(81.25%),the Salterprocedurewasused.Inthepresentstudy,onlythecases withbilateralinvolvementtreatedbymeansofopen

reduc-tion andSalter’sosteotomy,withorwithout Ombrédanne’s

femoralshortening,wereanalyzed.

Weanalyzed21patientswithbilateralDDH(42hips oper-ated).Ofthese,19(90.5%)were femaleandtwo(9.5%)were male.Themeanageatthetimeofdiagnosiswas2.3years; theearliestwasattheageofonemonthandthelatestwasat 4.6years.Themeanlengthoffollow-upwas5.8years,witha rangefromtwoyearsto13yearsandninemonths.

Thelengthofpostoperativeimmobilizationwassixweeks.

The patients were treated by two surgeons. In two cases

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Table1–Acetabularindex(AI)valuesbeforeandaftertheoperation(indegrees)inrelationtothesideaffected.

Patient PreoperativeAI AIsixweeksafteroperation LatepostoperativeAI

Rightside Leftside Rightside Leftside Rightside Leftside

1 47 44 26 30 18 20

2 30 45 26 28 9 14

3 35 40 15 10 16 10

4 42 42 19 22 27 12

5 35 42 36 26 40 18

6 33 38 19 18 11 12

7 40 38 26 16 12 10

8 40 40 18 18 20 22

9 38 40 26 25 30 19

10 40 42 21 16 20 21

11 38 34 23 17 12 18

12 50 45 10 20 10 8

13 31 31 27 23 19 18

14 37 50 23 18 16 25

15 37 32 20 17 23 20

16 32 33 18 16 17 16

17 41 45 32 26 21 23

18 36 29 32 23 24 23

19 35 40 18 20 22 21

20 25 24 18 16 21 11

21 34 46 27 32 23 15

Mean 36.9

SD5.6

39

SD6.5

22.8

SD6.2

20.8

DP5.5

19.6

DP7.3

16.9

DP5.0

38

SD6.1(p=0.2)

21.8a

SD5.9(p=0.16)

18.2b

SD6.3(p=0.16)

AI,acetabularindex;SD,standarddeviation.

a _Significant_difference_between_preoperative_AI_and_AI_of_six_weeks_after_operation₍_p_<_0.000001).

b _Significant_difference_between_preoperative_AI_and_late_{postoperative}_AI₍_p₌_0.001).

reduction. The other patients (90.5%) had not previously

undergoneanytypeoftreatment.

In one patient, the osteosynthesis material was not

removedbecauseoftechnicaldifficulties.Inalltheothers,the materialwasremoved.Themeanlengthoftimeafterthe oper-ationforthisproceduretobeperformedwas21.5monthsfor theleftsideand22.45monthsfortherightside.

Toevaluatetheradiographicresults,weusedthe acetab-ular index(AI),the center-edge angle(CÊ)ofWiberg,16 _the

classificationofSeverin17_and_the_type_of_avascular_necrosis

ofthefemoralhead,accordingtotheclassificationof Kalam-chiandMacEwen.18_The_statistical_analysis_was_performed_in

descriptiveandanalyticalformbymeansofthechi-square, pairedWilcoxon,Student’standpairedStudent’stmethods, withtheaimofestablishingwhetherstatisticalsignificance existedbetweentheparametersevaluated.Weusedthe Ses-tatnetsoftware19_to_analyze_the_data_and_the_significance_level

wasfoundtobe0.05.

ThisstudywasapprovedbytheResearchEthicsCommittee (CEP-HIJG)andwasregisteredunderprotocol027/2011.

Results

ThemeanpreoperativeAIwas38◦₍_±_6.1◦_):_the_right_side pre-sentedamean of36.9◦ ₍_±_5.6◦₎_and_the_left _side,₃₉◦₍_±_6.5◦_). Therewasnostatisticaldifferenceinrelationtothisfinding, whichindicatedthatthesamplewashomogenous(Table1).

ThemeanAIsixweeksaftertheoperationwas21.8◦₍_±_5.9◦₎

amongthe 42 hips.The mean forthe rightside was 22.8◦

(±6.2◦₎_and_for_the_left_side,_20.8◦ ₍_±_5.5◦_)._There_was_no sig-nificant difference(Table1). Thegeneralmeanforthe late postoperative AI was 18.2◦ ₍_±_6.3◦_): _for _the _right _side, _19.6◦ (±7.3◦₎_and_for_the_left_side,_16.9◦ ₍_±_5.0◦_)._There_was_no sta-tistically significant difference, but there was a significant differenceincomparingthepreoperativeAIwiththeAIsix weekaftertheoperationandwiththelatepostoperativeAI (Table1).

Thedegreeoffemoralheadnecrosiswasevaluated.There was nonecrosisin eightpatients,whiletwo were affected bilaterallyandelevenpresentedunilateralnecrosis.Outofthe 42hipsoperated,27didnotpresentnecrosis(64.29%),type1 necrosisoccurredinthreepatients(7.4%),type2infive(11.9%), type3infour(9.52%)andtype4inthree(7.14%).Inrelationto thesideaffected,wedidnotfindanystatisticallysignificant difference(Table2)(Figs.1A–Cand2A–C).

InrelationtotheCÊofWiberg,16_the_mean_{postoperative}

valuewas19.4◦₍_±_11.6◦_):_for_the_right_side,_18.1◦₍_±_11.7◦_),_and fortheleftside,19.7◦₍_±_12.3◦_)._There_was_no_significant differ-encebetweenthesides(Table2).

Outofthetotalnumberofhips,accordingtothe classifi-cationofSeverin17₍_Table₂_),₂₈_(66.67%)_presented_good_and

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Table2–Evaluationofpostoperativeparameters,withcomparisonbetweenthesides.

Patient KalamchiandMacEwenclassification18

foravascularnecrosisofthefemoralhead

Center-edgeangle(CÊ)of

Wiberg16_(in_degrees)

Severinclassification17

Rightsidea _Left_sidea _Right_side _Left_side _Right_sideb _Left_sideb

1 – – 18 22 1B 1A

2 – – 37 28 1A 1A

3 – 2 17 12 1B 3

4 1 – 20 18 1B 2A

5 3 – <0 11 4B 3

6 – – 31 40 1A 1A

7 2 – 34 40 1A 2A

8 2 – 13 8 3 3

9 2 – <0 16 4B 3

10 – – 15 24 2B 1A

11 – 4 32 40 1A 2A

12 4 2 35 17 2B 2B

13 – – 19 19 1A 1A

14 – – 15 16 2B 1B

15 – 3 10 0 3 4A

16 – – 10 30 3 1A

17 3 3 19 10 1A 3

18 – 1 18 8 1B 3

19 – 4 33 <0 2A 5

20 – – 16 30 1B 1A

21 1 – 8 24 3 1A

Mean 18.1

SD11.7

19.7

SD12.3

19.4

SD11.6(p=0.41)

SD,standarddeviation.

a _{Non-significant}_difference_between_the_sides_affected₍_p₌_0.18).

b _{Non-significant}_difference_between_the_sides_affected₍_p₌_0.08).

Thehipsdealtwithinthefirstsurgicalprocedurepresented resultssimilartothosedealtwithinthesecondprocedure, sincetherewasnostatisticaldifferenceinrelationtotheAI sixweeksafterthe operation,latepostoperativeAI,Wiberg CÊ(p=0.28),degreeofavascularnecrosisofthefemoralhead andSeverinclassification(p=0.09).Thepatients’ meanage atthetimeofthefirstsurgicalprocedurewas3.7years(1.9 to6.8years)and atthe timeofthe second surgical proce-dure,4.3years(2.5toeightyears),withameanintervalof7.2 months(3to15months)betweentheinterventions(Table3 andFig.3A–C).

Anothercriterionanalyzedwasinrelationtothepatients

who required femoral shortening. The femoral osteotomy

describedbyOmbrédanne12_was_performed_on₁₃_patients₍₂₄

hips;57.14%).Therewasnostatisticallysignificantdifference inanyofthecriteriaanalyzed:AIsixweeksaftertheoperation (p=0.25),latepostoperativeAI(p=0.06),avascularnecrosisof thefemoralhead(p=0.08),Wiberg CÊ(p=0.18)and Severin classification(p=0.39).

Surgicalrevisionwasnecessaryforfourhips(9.52%)and thepatientsdidnotpresentpostoperativeinfection.

Discussion

Thetreatment forDDH hasthe basic premise ofattaining

stable concentric reduction of the hip into the functional

weight-bearingposition.Instabilityofthereductionoriginates frompoorpositioningoftheacetabulumintheanteriorand lateraldirections.OpenreductioninassociationwithSalter’s osteotomyoftheiliacboneinordertoredirecttheacetabulum istodayaclassicaltreatmentmethod.20

Intheliterature,wefoundfewstudiesshowingresultsfrom patientswhoweretreatedforbilateralDDHatalatestage,who underwentsurgicaltreatmentbymeansofopenreductionand Salter’sosteotomy,withorwithoutassociatedfemoral

short-eningasdescribedbyOmbrédanne.

Manyauthorshaverecommendedthatopenreductionin

associationwithosteotomyoftheinnominatebonefor correc-tionofacetabulardysplasiashouldbeperformedonchildren

ata minimumage of18 months21 _and _that_the _technique

describedbySalter22_should_be_applied_to_patients_at_a

max-imum age of six years.Several studies have clinically and radiographicallyevaluatedthepre-andpostoperative

condi-tions ofchildrenwithDDH whounderwentopenreduction

and Salter’s osteotomy,2,11,20,21,23–34 _but _none_of_them _used

samplesconsistingonlyofpatientsaffectedbilaterally. Inthepresentstudy,21patientswithbilateralDDHwith

ameanintervalof7.2monthsbetweentheprocedureswere

evaluated.Thevariationinthetimebetweentheprocedures wasduetotherecoveryofmobilityinthehipthatwas oper-atedfirst.

Prado et al.21 _studied ₃₂ _patients₍₄₂ _hips,_i.e., ₁₀

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Table3–Evaluationofpostoperativeparametersinrelationtothesideaffectedearlierandlateron.

Patient Age(inmonths) AIsixweeks

afteroperation

(indegrees)

Late

postoperativeAI

(indegrees)

KalamchiandMacEwen

classification18_for

avascularnecrosisofthe

femoralheada

Center-edge

angle(CÊ)of

Wiberg16_(in

degrees)

Severin

classification17 b

1stS 2ndS 1stS 2ndS 1stS 2ndS 1stS 2ndS 1stS 2ndS 1stS 2ndS

1 42 46 26 30 18 20 – – 18 22 1B 1A

2 27 33 26 28 9 14 – – 37 28 1A 1A

3 59 65 15 10 16 10 – 2 17 12 1B 3

4 31 35 22 19 12 27 – 1 18 20 2 1B

5 82 86 36 26 40 18 3 – <0 11 4B 3

6 23 30 18 19 12 11 – – 40 31 1A 1A

7 31 39 26 16 12 10 2 – 34 40 1A 2A

8 28 38 18 18 20 22 2 – 13 8 3 3

9 43 46 26 25 30 19 2 – <0 16 4B 3

10 45 52 21 16 20 21 – – 15 24 2B 1A

11 40 44 23 17 12 18 – 4 32 40 1A 2A

12 81 96 20 10 8 10 2 4 17 35 2B 2B

13 35 40 27 23 19 18 – – 19 19 1A 1A

14 48 54 23 18 16 25 – – 15 16 2B 1B

15 57 64 17 20 20 23 3 – 0 10 4A 3

16 35 42 16 18 16 17 – – 30 10 1A 3

17 23 33 32 26 21 23 3 3 19 10 1A 3

18 60 71 32 23 24 23 – 1 18 8 1B 3

19 66 79 18 20 22 21 – 4 33 <0 2A 5

20 35 41 18 16 21 11 – – 16 30 1B 1A

21 35 43 27 32 23 15 1 – 8 24 3 1A

Mean 44.1

SD17.4

51.3

SD18.6

23.2

SD5.7

20.4

SD5.9

18.6

SD7.3

17.9

SD5.3

21.2

DP10.7

20.7

DP10.8

47.7

SD18.2

21.8

SD5.9(p=0.1)

18.2

SD6.3(p=0.39)

20.9

SD10.7(p=0.28)

S,surgery;AI,acetabularindex;SD,standarddeviation.

a _{Non-significant}_difference_in_relation_to_the_earliness_of_the_intervention₍_p₌_0.7).

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rev bras ortop.2014;49(4):350–358

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Fig.1–Femalepatientagedfouryearsandonemonth: preoperativeX-rayinAugust2007(A).X-rayonAugust16, 2009,twoyearsandfivemonthsafteroperationonright hipandoneyearandsixmonthsafteroperationonlefthip (B).X-rayonOctober2,2010,threeyearsandthreemonths afteroperationonrighthipandtwoyearsandeight monthsafteroperationonlefthip,presentingtypeI necrosisofthefemoralhead(C).

osteotomy.Amongthe10patientswithbilateralinvolvement, 10jointswereoperatedbetweentheagesoftwoandfouryears andtheothertenjointsbetweenfourandsevenyearsofage,

withamean interval offour monthsbetween thesurgical

procedures.

Bertoletal.20_evaluated₁₀₃_hips_of_eight_boys_and₈₅_girls

(10bilateralcases).Allofthemunderwentopenreductionand Salter’sosteotomy,withorwithoutassociatedrotationaland varusosteotomyofthefemur.Inoursample,wedidnot per-formvaruscorrection.

CarvalhoFilhoetal.2_evaluated_three_boys_and₁₅_girls_(four

bilateralcases)whohadalreadystartedtowalk,withDDHthat hadnotbeentreatedpreviously.Thesurgerywasperformedin asingleprocedureandthepatients’meanagewas19months. Rochaetal.23_analyzed₁₈_female_hips_that_underwent_open

reduction,Salter’sosteotomyandOmbrédanne’sprocedureat

Fig.2–Femalepatientagedthreeyearsandthreemonths: preoperativeX-rayinJune2004(A).X-rayinJanuary2005, threemonthsafteroperationonlefthipandsixmonths afteroperationonrighthip(B).X-rayinOctober2011,inthe latepostoperativeperiod,sevenyearsafteroperationon righthipandsixyearsandninemonthsafteroperationon lefthip,presentingtype4necrosisofthefemoralhead(C).

agesbetweentwoandeightmonths,inwhichfourcaseswere bilateral.Inthesebilateralcases,themeantimebetweenthe surgicalprocedureswassixmonths.

El-Sayedetal.24_treated₈₇_patients_with_DDH_by_means_of

openreductionandSalter’sosteotomy.Therewere22 bilat-eralcases,whichwereoperatedwithanintervalofsixweeks. Bhuyan25_waited_three_to_six_months_to_perform_the_procedure

onthecontralateralhip.

Regardingthepostoperativefollow-uponthepatientsof thepresentstudy,themeandurationwas5.8years.Carvalho Filhoetal.2_followed_up_their_patients_for_a_mean_of_four_years,

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Fig.3–Femalepatientagedtwoyears:preoperativeX-ray inMarch1998(A).X-rayinJuly2007:postoperative

radiographiccontrolproducednineyearsandeightmonths afteroperationonrighthipandnineyearsandtwomonths afteroperationonlefthip(B).X-rayinAugust2011,atthe ageof15yearsand11months:13yearsandeightmonths afteroperationonrightsideand13yearsandtwomonths afteroperationonleftside(C).

Manyauthorshavedescribedfollow-upsontreatedpatients rangingfromoneyearto24yearsandsixmonths.11,20,21,23–32

Regardingradiographicevaluations,themeanpreoperative AIamongthecasesstudiedherewas38◦_,_with_a_mean_value fortherightsideof36.9◦_and_for_the_left_side_of₃₉◦_._Regarding theAIsixweeksaftertheoperation,themeanvaluewasfound tobe21.8◦_,_the_right_side_22.8◦_and_the_left_side_20.8◦_._The_mean forthelatepostoperativeAIwas18.2◦_._There_was_a_{statistically} significantdifferencebetweenthepre-andpostoperativeAIs (p<0.05).

CarvalhoFilhoetal.2_found_a_preoperative_angle_of₃₉◦_and ameanpostoperativeangleof22◦_.

Rochaetal.23_found_preoperative_mean_values_of_43.3◦_on therightsideand42.1◦_on_the_left_side_and_{postoperative} val-uesof31.57◦_and_30.36◦_,_{respectively.}_Although_the_values_were higher,theyalsoobservedasignificantdifferencefrombefore toaftertheoperation(p<0.001).

Yagmurluetal.26_performed_Salter_or_Steel_osteotomy_on

six patients.Themean preoperativeAIwas 37.8◦_, _and _this improvedto21.2◦_after_the_operation.

El-Sayedetal.24_found_a_{statistically}_significant_difference

betweenthepre-andpostoperativeAIvalues,which dimin-ishedfrom41.56◦_to_20.41◦_in_children_younger_than_four_years. Bhuyan26_reduced_the_AI_from₄₂◦ ₍_±₅₎_to₂₁◦₍_±_2)._Abdullah etal.27_obtained_a_significant_improvement_in_AI_in_all_the₄₂

hips treated,thus decreasingit from 44◦ ₍_±_2.5)_to₂₃◦ ₍_±_3). Among63children,Changetal.11_found_a_mean_preoperative

AIof35.4◦_;_the_AI_six_months_after_the_operation_was₁₇◦_and_it was12.6◦_ten_years_after_the_operation._In_our_study,_there_was adecreasingtrendinAIvalueswithpassageoftime, chang-ingto18.2◦_,_but_without_any_{statistically}_significant_difference inrelationtothevaluesfromsixweeksaftertheoperation (p=0.06).

ThepostoperativeWibergCEangleobtainedinour

anal-ysiswas19.4◦_, _i.e.,_smaller_than_the_angles_of₂₈◦ _found_by CarvalhoFilhoetal.,2 ₃₁◦ ₍_±₉₎_and_32.3◦ ₍_±_11.9)_by_El-Sayed etal.24_and_32.3◦₍_±_11.9)_in_patients_with_Salter’s_osteotomy and36.9◦₍_±_10.5)_in_cases_with_associated_femoral_shortening treatedbyTezerenetal.28

TheradiographicclassificationdescribedbySeverinmakes itpossibletoassesstheresultsfromSalter’sosteotomyover themediumandlongterms.Inourstudy,wefoundthat65%of thehipshadasatisfactoryradiographicresult.Betterresults were foundby CarvalhoFilhoet al.,2 _with_81% _of_the _hips

in classificationsIand II; Prado etal.,21 _with_92.8%;_Rocha

etal.,23_with_88.9%;_El-Sayed_et_al.,24_with_88%_(types_I_and_II);

Bhuyan,25_with_83.3%;_and_Yagmurlu_et_al.,26_with_74%_showing

satisfactoryresults.

Femoralshorteningwasperformedon24hips,withoutany difference inthe radiographic evaluationinrelationto the caseswithout shortening. Bertolet al.20 _found_that _75%_of

the resultswere goodinthe caseswithout shorteningand

64.4% inthe caseswith femoral shortening. Prado et al.21

performed femoralshorteningon alloftheir patientswith

bilateral involvement. They suggested that femoral

short-ening should be used as an auxiliary surgical treatment

methodforDDH,sincethefinalresultdependsonthe pro-ceduresusedinaddressingthejointproblem.Theyreported that,becauseofthediminishedorevenabsentpotentialfor recoveryofacetabulardevelopment,simplereplacement pro-ceduresinchildrenoverthe ageofthreeyears giveriseto unsatisfactorymediumandlong-termresults.Asheyetal.34

indicatedfemoralshorteninginassociationwithsimpleopen reduction,forchildrenovertheageofthreeyears.Tezeren et al.28 _evaluated _their _results_and _found _Severin_I _in _75%

and SeverinIIin18.7% ofthecasestreated without

short-ening and SeverinI in 76.9% and Severin IIin 23% of the

patientswhounderwentfemoralshorteningandconcluded

thattherewasnosignificantdifferencebetweenthe proce-dures.

InthestudybySalterandDubos,22_among_the_patients_who

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rev bras ortop.2014;49(4):350–358

357

In relation to the duration of immobilization after the

operation,Rochaetal.24_kept_their_patients_in_plaster_casts

fromthepelvistothe footfor2.5months,El-Sayedet al.25

fortwomonthsand Sadeghpour et al.35 _for_three_months,

i.e.,longerperiodsthanthesixweeksrecommendedinthe presentstudy.

Thetimeintervaluntilremovalofthesynthesismaterial rangedfromthreemonthstofiveyearsandtenmonths,with

a mean of21.63 months. Carvalho Filho et al.2 _performed

removalofthesynthesismaterialbetweeneightandtwelve weeksaftertheoperation,whileRochaetal.24 _did_this _one

yearaftertheoperation.

Somecomplications from Salter’sosteotomy have been

described,such assuperficial and deep infection, subluxa-tion,renewed dislocation,chondrolysis, neuropraxia ofthe sciaticnerve andavascularnecrosis.22 _In _the_present

sam-ple,therewere 15casesofavascularnecrosis, withoutany significantdifferencebetweenthesides.Wedidnotfindany casesofsuperficialordeepinfection.Therewerethreecases

ofreneweddislocation,whichwereresolvedthroughanew

surgicalprocedure.

Wenotedthat in thecases ofavascularnecrosis,

espe-cially those of types 3 and 4, seven (16.66%) occurred in

patientsofmoreadvancedageandwithhigherdislocation.

These required greater capsule release because of

adher-encesandtheconsequentresection,giventhatthecapsule iselongated,whichisprobablythereasonforthisincidence (p>0.08).

Bertoletal.20_found_a_greater_rate_of_growth_plate_injury_in

thegroupinwhichassociatedfemoralshorteningwas

per-formed(p<0.05), aswell asmorecasesofsubluxationand dislocation.Pradoetal.21_reported_four_cases_of_subluxation

(9.5%). Rocha et al.23 _had _one _case _of _subluxation, _one _of

osteonecrosisandoneotherofosteonecrosisassociatedwith subluxation.

Changetal.11 _operated_on₆₃_children_between_the_ages

of one and three years, using the technique described by

Salter, and found 30 cases ofavascular necrosis: 16 cases withearlysigns ofthis,withinthefirst twoyears afterthe operation,and14 withsignsseen lateronafterthe opera-tion.

Yagmurlu et al.26 _described _four _cases _with _avascular

necrosisamong27hipsthatwere operated(14%).They did

not cite the classification used, or the likely cause of the event.

Roposchetal.36_found_that_73%_of_their_cases_presented

avascularnecrosis(86/118)overameanfollow-upperiodof eightyears(oneto19years),accordingtothecriteriaofOgden andBucholz,amongthepatientstreatedwithopenandclosed reduction,andtheyconcludedthattherewasnorelationship withperformingfemoralshortening.

Weconsideredthatreneweddislocationandbone

necro-sispredisposedpatientstopoorfunctionalandradiographic results.Amongthepatientsstudied,thegradeencountered rangedfromtypesItoIVofKalamchiandMacEwen,andwas mostfrequentlytypeII,with11.9%(5/42),followedbytypeIII, with9.52%(4/42).Theseresultswereconcordantwiththoseof Holmanetal.,37_who_found₁₀_cases_of_necrosis,_all_classified

asSeverinIVorworse,amongtheirresultsfromtreatments usingdifferenttechniqueson179hips.

Conclusions

Open reductionin association with osteotomy ofthe iliac

boneas describedbySalter presenteda statistically

signif-icantimprovementintheangularparametersmeasuredon

thepatients’radiographs,frombeforetoaftertheoperation.

This improvement did not have any relationship with

whetherfemoralshorteningasdescribedbyOmbrédannewas

performed.

Therewasnosignificantdifferenceregardingtheresults betweenthesidesoperated.

Avascular necrosis of the femoral head was the most

prevalent complication in the group studied and this had

arelationshipwithhigherdislocationandpatientsofmore advancedage.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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