Rev. bras. ortop. vol.49 número1

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

Original

Article

Clinical

and

radiographic

medium-term

evaluation

on

patients

with

developmental

dysplasia

of

the

hip,

who

were

submitted

to

open

reduction,

capsuloplasty

and

Salter

osteotomy

夽

,

夽夽

Válney

Luiz

da

Rocha,

Guilherme

Lima

Marques,

Leonardo

Jorge

da

Silva,

Tiago

Augusto

di

Macedo

Bernardes,

Frederico

Barra

de

Moraes

∗

DepartamentodeOrtopediaeTraumatologia,HospitaldasClínicas,UniversidadeFederaldeGoiás,Goiânia,GO,Brazil

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Articlehistory:

Received12October2012 Accepted22March2013

Keywords:

Congenitalhipdislocation/surgery Surgicalprocedures

Operative/methods Bonediseases Developmental

Hip/growthanddevelopment

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b

s

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t

Objective:toevaluatetheclinicalandradiographicmedium-termresultsfromsurgical treat-ment ofdevelopmentaldysplasia throughopenreduction,Salteretal.’sosteotomyand capsuloplasty.

Methods:13patientswereevaluated,13hipstreatedsurgicallybytheproposedtechnique between2004and2011.AclinicalandradiographicevaluationwasconductedbyDutoit etal.andSeverinetal.criteria,respectively.

Results:theacetabularpreoperativeindexforthe13surgicallytreatedhipsrangedfrom27◦

to50◦_(average_of_36),_and_after_surgical_correction_to_18.5◦_(10–28◦_),_so_that_the_evaluations_of

preoperativeandpostoperativeacetabularindexesshowedupsignificantstatisticreduction (p<0.05).Regardingthepostoperativeclinicalevaluation,itwasfound:nineexcellenthips (69.2%),threegoodones(23.1%),nofairhips(0%)andapoorone(7.7%).Inradiographic evaluation,itwasfound:sixexcellenthips(46.1%),threegoodones(23.1%),nofairhips (0%)andfourpoorones(30.8%).Therefore,favorableresultswereobtained(92.3%),with groupedhipswithexcellentandgoodratingsassatisfactoryandwithfairandbadratingsas unsatisfactory.Itisalsoimportanttonoticethattherewasnosignificanceamongoccurrence ofcomplications,thepatient’sage,thetimeofsurgeryandthepreoperativeacetabularindex (p>0.05).Ascomplicationsoccurred,itwasfoundthatthreesubluxationsandasubluxation associatedwithavascularnecrosisofthefemoralhead.

Conclusion: openreduction,Salteretal.’sosteotomyandcapsuloplastyareseentobeaviable optionforthetreatmentofdevelopmentaldysplasiaofthehip,accordingtoclinicaland radiologicalmedium-termevaluations.

夽_Please_cite_this_article_as:_da_Rocha_VL,_Marques_GL,_da_Silva_LJ,_di_Macedo_Bernardes_TA,_de_Moraes_FB._Avaliac¸ão_clínica_e_radiológica emmédioprazodospacientesportadoresdedisplasiadodesenvolvimentodoquadrilsubmetidosareduc¸ãoaberta,capsuloplastiae osteotomiadeSalter.RevBrasOrtop.2014;49:51–55.

夽夽

StudyconductedatPediatricOrthopediaService,DepartmentofOrthopediaandTraumatology,HospitaldasClínicas,Universidade FederaldeGoiás,Goiânia,GO,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](F.B.deMoraes).

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capsuloplastia

e

osteotomia

de

Salter

Palavras-chave: Luxac¸ãocongênitado quadril/cirurgia

Procedimentoscirúrgicos operatórios/métodos Doenc¸asdodesenvolvimento ósseo

Quadril/crescimentoe desenvolvimento

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o

Objetivo: avaliaroresultadoclínicoeradiológicodotratamentocirúrgicodadisplasiado desenvolvimentodoquadrilemmédioprazo,pormeiodareduc¸ãoaberta,dacapsuloplastia edaosteotomiadeSalteretal.

Métodos: foramavaliados13pacientes,13quadris,entre2004e2011,tratados cirurgica-mentepelatécnicaproposta.Umaavaliac¸ãoclínicaeradiológicafoifeitapeloscritériosde Dutoitetal.eSeverinetal.,respectivamente.

Resultados: nos13quadrisacometidosoíndiceacetabularpré-operatóriovarioude27◦_a

50◦_(média_de₃₆₎_e,_após_correc¸ão_cirúrgica,_para_18,5◦_em_média,_com_variac¸ão_de₁₀◦_a₂₈◦_,

demodoqueasavaliaçõesdosíndicesacetabularespréepós-operatóriosapresentaram reduçãocomsignificânciaestatística(p<0,05).Quantoàavaliaçãoclínicapós-operatória, foramencontrados:novequadrisótimos(69,2%),trêsbons(23,1%),nenhumregular(0%)e umruim(7,7%).Naavaliaçãoradiológica,foramencontradosseisquadrisótimos(46,1%), trêsbons(23,1%),nenhumregular(0%)equatroruins(30,8%).Portanto,obtiveram-se result-ados favoráveis em 92,3%, pois agrupam-sequadris comavaliação ótima e boa como satisfatórioseoscomavaliaçãoregulareruimcomoinsatisfatórios.Atente-sequenão houvesignificânciaentreaocorrênciadecomplicações,aidadedopaciente,omomentoda cirurgiaeoíndiceacetabularpré-operatório(p>0,05).Comocomplicaçõesocorridas, têm-setrêssubluxaçõesisoladaseumasubluxaçãoassociadaànecroseavasculardacabeça femoral.

Conclusão:areduc¸ãoaberta,acapsuloplastiaeaosteotomiadeSalteretal.sãoconsideradas umaopc¸ãoviáveldopontodevistaclínicoeradiológicoemmédioprazoparaotratamento dadisplasiadodesenvolvimentodoquadril.

Introduction

Developmentaldysplasiaofthe hip (DDH)involves a spec-trumofdevelopmentaldisordersofthehip,whichpresentin differentformsandages,fromaligamentlaxitytocomplete dislocationofthefemoralhead.Insuchcases,theacetabulum issituatedinananterosuperiorpositionasaresultof exces-siveanteversion,whichmakesitincreasinglyshallow,thick and oblique.DDHis classifiedinto two types:typical (sub-divided intodislocable, subluxated anddislocated hip)and teratologic.

Theetiology of DDH remains unknown, but ethnic and geneticfactorsareimportant.Geneticfactorsmaydetermine theacetabulardysplasia,ligamentlaxityorboth,asreported by Wynne-Davies.1 _In _addition _to _the _preexisting _factors, mechanicalfactorssuchasintrauterinepositionand postna-talhabitscanalsointerferewiththeprocess.

Inseveralpapers,theincidenceofDDHrangedfrom2to17 per1000.InBrazil,VolponandCarvalhoFilho2_demonstrated anincidenceof2.31per1000.

The treatment depends on the patient’s age, degree of acetabularandproximalfemurdysplasia.Itisconsideredthat, afterthestartofthewalking,asurgicaloptionforthe treat-mentofDDHconsistsofopenreduction,Salter’sosteotomy, andcapsuloplasty.3_This_technique_promotes_acetabular repo-sitioning,aimingtoincreasethecoverageofthefemoralhead, whichwillbesurgicallyreducedintotheacetabulum.

The aim ofthis study was to evaluate the clinical and radiologicaloutcomeinthemediumtermsurgicaltreatment ofDDHbyopenreduction,Salter’sosteotomy,and capsulo-plasty.

Materials

and

methods

Thirteenpatients who remained withDDH aftertheystart walking,whetherbyfailureofmedicaltreatmentinthefirst yearoflifeorbyreferralofthechildwithadelayed diagno-sis,wereevaluated.Allweretreatedsurgicallybetween2004 and2011,bythetechniquesofopenreduction,capsuloplasty, andSalter’sosteotomy.ThestudywasapprovedbytheEthics andResearchCommitteeofthehospital,wheretheworkwas done.

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Fig.1–Surgicaltechnique:openreduction,capsuloplastyandSalter’sinnominateosteotomy.

underanaverageoutpatientfollow-upof5.3years(1.4–14.1 years).

Toevaluatetheresults,radiographicandclinicalcriteria wereemployed.Theradiographswereevaluatedbythe crite-riaofSeverin,5_which_take_into_account_the_Wiberg_acetabular (AC)andCEangles,thesphericityofthefemoralhead,the dis-locationandsubluxationofthehip,andoccurrence(ornot) ofarthrosis.Withrespecttotheclinicalsituation,the anal-ysiswasperformed inconformity toDutoitet al.criteria,6 basedonhipstabilityandmobility,pain,lamenessandonthe Trendelenburgtest.

Thestatistical analysiswasperformeddescriptivelyand analytically, with the methods of McNemar, Friedman, Wilcoxon and Univariate Logistic Regression Analysis, in

ordertoestablishstatisticalsignificancebetweentheclinical and radiologicalparameters,withasignificancelevelof5% (p<0.05).

Results

Thehipswerepooledforanalysisregardlessoftheinvolved side.Inthe13affectedhips,thepreoperativeacetabularindex rangedfrom 27◦ _to₅₀◦ _(average,₃₆◦₎_and _after_the_surgical

correction,theaveragewas18.5◦ _(10–28◦_)._For_this_estimate,

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Fig.2–RadiologicalevolutionofafemalepatientwithDDHtreatedwithSalteretal.’sosteotomy.Excellentradiologicresult with53months’follow-up.

AccordingtoDutoitet al.,6 _in_the_clinical _evaluation_we couldobservenineverygood(69.2%),threegood(23.1%),0fair (0%),and1poor(7.7%)hip.Therefore,wegroupedhipswith goodandverygoodevaluationassatisfactory,andthosewith poorandfairevaluationasunsatisfactory.Hence,weobtained 92.3%satisfactoryresults(Table1).

Intheradiologicalstudy,sixverygood(46.1%)(Fig.2),three good(23.1%),0fair(0%),andfourpoor(30.8%)hipswerefound. Therefore,wegroupedhipswithgoodandverygood evalua-tionassatisfactory,andthosewithpoorandfairevaluationas unsatisfactory.Hence,weobtained69.2%offavorableresults

(Table2).

ToevaluatetheinfluenceofDutoitetal.6_and_of_Severin5 inrelationtopre-andpost-surgicaltreatment,consideringthe techniquesofopenreductionandcapsuloplastyandSalter’s osteotomy,McNemartestandFisheretal.’sexacttestwere applied,and noother correlationswere observed,i.e., only thesurgeryinterferedwiththeclinicalandradiological out-come.

Withregard tocomplications, twoisolated subluxations andoneosteonecrosisofthefemoralheadwithsubluxation

Table1–ResultsofclinicalevaluationaccordingDutoit.6

Treatment Pre Post

n % % Nutrition % %

Dutoit

1–excellent 0 0.0 9 69.2 92.3

2–good 0 0.0 3 23.1

3–regular 0 0.0 100.0 0 0.0 7.7

4–poor 13 100.0 1 7.7

Table2–Resultsofradiologicalevaluationaccording Severin5

Treatment Pre Post

n % % n % %

Severin

1–excellent 0 0.0 6 46.1 69.2

2–good 0 0.0 3 23.1

3–regular 2 15.4 100.0 0 0.0 30.8

4–poor 9 69.2 4 30.8

5–poor 1 7.7 0 0.0

6–poor 1 7.7 0 0.0

anddislocationoccurred.Thiswasoneofthecasesofisolated

subluxationtreatedwithanother surgicalprocedure. There

were nocases ofinfection, fracture, significant lower limb

dysmetria,orneurovascularinjury.

Discussion

Thesurgicaltreatmentofdevelopmentaldysplasiaofthehip

isbecominganincreasinglylessfrequentchallenge,thanksto

currentmethodsforearlydiagnosisandprevention,for

exam-ple,thephysicalexaminationofthenewbornandroutineuse

ofultrasonographyforsuspectedcases.Physicalexamination

toidentifycasesofDDHshouldbedoneroutinelyonall

new-borns.

The Ortolani maneuver, described in 1948 by Marino

OrtolaniapudTachdjian,4_when_positive,_allows_the_diagnosis

ofDDH;however,thenegativity doesnotexcludethe diag-nosis, because some hips are unstable,but not dislocated. TheBarlowprovocativemaneuverallowsthediagnosisofhip instability.Moreover,inchildrenolderthanthreemonths,the Ortolanimaneuvermaybenegative,becauseevenifthehip remainsdislocated,itwillbenolongerpossibletoreplacethe femoralheadinto theacetabulum.Withrespecttothe Bar-lowmaneuver,itmustbeemphasizedthatmanynewborns testedpositiveinthefirsttestbecomenegativeaftertwoor threeweeks.

Inthedislocatedhipthetreatmentconsistsconcentricand atraumaticreductionoffemoralheadwithintheacetabulum. Beforethestartofwalking,thistreatmentmaybe conserva-tive,however,afterthechildbeginstowalkthereisatendency ofinterpositionofsofttissues,suchastheroundligament, labrum and capsuleofthis joint.Hence,it isnecessaryan openreduction.Onceachieved,thisreductioncanbe main-tainedbymeansofproceduresontheacetabulum,softtissue, orboth.Lindstrometal.7_showed_that_if_the_concentric reduc-tionisachievedandmaintained,therewillberemodelingof theacetabulumthatwillbemorepronounceduptofouryears, andmayoccuruptoeightyears.

Basedonthejointmobilityandstabilityinthepresence ofpainand/orlameness,Dutoitetal.6_developed_a_system_of post-surgicalclinicalclassification.

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of the head/neck and acetabulum, with reference to the CEangle ofWiberg and presence ofpost-surgical subluxa-tion/dislocation.

Salteretal.3 _described_an_innominate_osteotomy_for_the treatmentofcongenitalhipdislocationandsubluxationand promoted acetabularrepositioningwiththe formationof a rooftosupportthefemoralheadafterreduction.Intheirfirst report,Salteretal.evaluated25hipsafterfollow-upofone tothreeyears,andreportedthatalltheirpatientsachieveda goodorexcellentresult.

Bohm et al.8 _studied ₆₃ _hips _treated _with _innominate osteotomy,withamedianfollow-upof30.9years;in88.8%of cases,theyachievedsatisfactoryradiologicalresults, accord-ingtoSeverinindex.

Tukenmez et al.9 _evaluated ₆₁ _hips _treated _with_Salter osteotomyand obtainedsatisfactory clinical and radiologi-calresults in 82% (Dutoit) and 94.5% (Severin) procedures, respectively,withanincidenceof21.5%ofpost-operative com-plications.

Carvalho Filho et al.10 _evaluated ₁₈ _patients _with _DDH treatedwithSalteretal.’sosteotomyandobtained72% satis-factoryclinicalresults(Dutoit)and81%favorableradiological outcomes (Severin); 16.6% of patients had post-operative redislocationinsidethecast.

Ofthe13hips includedinthisstudy,weobtained satis-factoryclinicalandradiologicalresultsin92.3%(Dutoit)and 69.2%(Severin),respectively.Thus,ourfindingsagreewiththe resultsofotherseries.

Salehetal.11_have_demonstrated_absence_of_pelvic remod-elingafter innominateosteotomyin patients withskeletal maturity. In this study, the osteotomy was performed in patientsbetween1.9and6years(agepost-march),yetthere wasnoinfluenceontheclinicalandradiographicresultsin themediumterm,accordingtothatdescribedbyCarvalhoand VolponFilho.2

Frequency,degreeofdisability,durationofsymptomsand morbidityweretakenintoaccount.However,osteonecrosisis themostfearedcomplicationoftreatmentofDDH,andoccurs onlyinpatientswhoreceivedsomeformofbloodyorbloodless treatment,being regardedasa commoncause ofhip posi-tioninginabduction>70◦ _or_in_forced_medial_rotation. _This

canoccureveninthenormalhipoppositetothatwhichis beingtreated.Therefore,hipimmobilizationsinanadequate positionandacarefulbloodlessorbloodyreductionin accor-dancewiththebasicprinciples,maydecreasetheriskofthis seriouscomplication.Itshouldbeborneinmindthat,inthis study,therewerecomplications,suchastwocasesofisolated

subluxation,acaseofosteonecrosisassociatedwith subluxa-tion,andonedislocation.

Conclusion

TheassociationofSalter’sosteotomywithopenreductionand capsuloplastybecomesaviableoptionforthetreatmentof DDHafterthechildbeginstowalk,withsatisfactoryclinical andradiologicalresults.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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