A retrospective analysis of the effects of femoral shortening osteotomy on clinical and radiologic outcomes in open reduction and Pemberton pericapsular osteotomy for Tonnis type 4 dysplasia of the hip

Femoral shortening in open reduction and Pemberton



developmental dislocation of the hip, femoral shortening, avascular necrosis, Pemberton’s acetabuloplasty


Background/Aim: Open reduction (OR) and Pemberton’s periacetabular osteotomy (PPO) are efficient and reliable methods for treating late-diagnosed developmental dysplasia of the hip. However, various studies have reported an avascular necrosis (AVN) rate of up to 80% with this technique, which is increased in Tönnis type 4 hips. In this study, we hypothesized that femoral shortening osteotomy (FSO) would reduce the rates of AVN by decreasing the post-reduction pressure on the femoral head.

Methods: In this retrospective cohort study, we reviewed patients who had undergone OR and PPO between 2006 and 2016. Only hips with Tönnis type 4 dislocation were included. The subjects were divided into two groups: Group 1, who had undergone OR+PPO, and Group 2, who had undergone OR+PPO+FSO. The Kalamchi-MacEwen system was used for AVN classification. The groups were compared regarding the pre- and postoperative acetabular indices and the rate of AVN and other complications.

Results: We included 76 hips of 50 patients who met the inclusion criteria in the study. Group 1 consisted of 46 hips of 32 patients, and Group 2 consisted of 30 hips of 18 patients. The mean age of the patients was 31.5 months, and Group 1 (30 months) had a significantly lower mean age than Group 2 (34 months) (P=0.019). There were no statistically significant differences regarding the pre- and postoperative acetabular indices. In Group 1, 27 (58%) out of 46 hips had AVN, whereas the rate of AVN was ten (30%) out of 30 hips in Group 2. Out of the 27 hips with AVN in Group 1, 12 were type 1, five were type 2, and ten were type 3. Out of the 10 hips with AVN in Group 2, seven were type 1, two were type 2, and one was type 4. There was a statistically significant difference between the groups regarding the rates of AVN, with Group 2 having better outcomes not only in comparison to the rate of all AVNs (P=0.031) but also in comparison to high-grade AVNs (P=0.042) (Grade 3 and Grade 4).

Conclusion: Performing FSO with OR and PPO provides a significant decrease in the rate of AVN without altering acetabular development after surgery.


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Patel H, Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ. 2001 Jun 12;164(12):1669-77. PMID: 11450209; PMCID: PMC81153.

Chen Q, Deng Y, Fang B. Outcome of one-stage surgical treatment of developmental dysplasia of the hip in children from 1.5 to 6 years old. A retrospective study. Acta Orthop Belg. 2015 Sep;81(3):375-83. PMID: 26435230.

Danielsson L. Late-diagnosed DDH: a prospective 11-year follow-up of 71 consecutive patients (75 hips). Acta Orthop Scand. 2000 Jun;71(3):232-42. doi: 10.1080/000164700317411816. PMID: 10919293. DOI: https://doi.org/10.1080/000164700317411816

Wang TM, Wu KW, Shih SF, Huang SC, Kuo KN. Outcomes of open reduction for developmental dysplasia of the hip: does bilateral dysplasia have a poorer outcome? J Bone Joint Surg Am. 2013 Jun 19;95(12):1081-6. doi: 10.2106/JBJS.K.01324. PMID: 23783204. DOI: https://doi.org/10.2106/JBJS.K.01324

Yagmurlu MF, Bayhan IA, Tuhanioglu U, Kilinc AS, Karakas ES. Clinical and radiological outcomes are correlated with the age of the child in single-stage surgical treatment of developmental dysplasia of the hip. Acta Orthop Belg. 2013 Apr;79(2):159-65. PMID: 23821967.

Herold HZ, Daniel D. Reduction of neglected congenital dislocation of the hip in children over the age of six years. J Bone Joint Surg Br. 1979 Feb;61(1):1-6. doi: 10.1302/0301-620X.61B1.422627. PMID: 422627. DOI: https://doi.org/10.1302/0301-620X.61B1.422627

Schoenecker PL, Strecker WB. Congenital dislocation of the hip in children. Comparison of the effects of femoral shortening and of skeletal traction in treatment. J Bone Joint Surg Am. 1984 Jan;66(1):21-7. PMID: 6690440. DOI: https://doi.org/10.2106/00004623-198466010-00003

Groves EH. The treatment of congenital dislocation of the hip-joint, with special reference to open operative reduction. The Robert Jones birthday volume: Oxford University Press, London; 1928. p. 73-96.

Ombrédanne L, Fèvre DM. Précis clinique et opératoire de chirurgie infantile: par L. Ombrédanne,... 5e édition... avec la collaboration de Marcel Fèvre: Masson; 1949.

Galpin RD, Roach JW, Wenger DR, Herring JA, Birch JG. One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening. J Bone Joint Surg Am. 1989 Jun;71(5):734-41. PMID: 2732262. DOI: https://doi.org/10.2106/00004623-198971050-00015

Ning B, Yuan Y, Yao J, Zhang S, Sun J. Analyses of outcomes of one-stage operation for treatment of late-diagnosed developmental dislocation of the hip: 864 hips followed for 3.2 to 8.9 years. BMC Musculoskelet Disord. 2014 Nov 28;15:401. doi: 10.1186/1471-2474-15-401. PMID: 25432778; PMCID: PMC4289045. DOI: https://doi.org/10.1186/1471-2474-15-401

Wenger DR, Lee CS, Kolman B. Derotational femoral shortening for developmental dislocation of the hip: special indications and results in the child younger than 2 years. J Pediatr Orthop. 1995 Nov-Dec;15(6):768-79. doi: 10.1097/01241398-199511000-00009. PMID: 8543606. DOI: https://doi.org/10.1097/01241398-199511000-00009

Akgül T, Bora Göksan S, Bilgili F, Valiyev N, Hürmeydan OM. Radiological results of modified Dega osteotomy in Tönnis grade 3 and 4 developmental dysplasia of the hip. J Pediatr Orthop B. 2014 Jul;23(4):333-8. doi: 10.1097/BPB.0000000000000059. PMID: 24769776. DOI: https://doi.org/10.1097/BPB.0000000000000059

Alassaf N. Predictors of femoral shortening for pediatric developmental hip dysplasia surgery: an observational study in 435 patients. Patient Saf Surg. 2018 Oct 19;12:29. doi: 10.1186/s13037-018-0176-y. PMID: 30377448; PMCID: PMC6194737. DOI: https://doi.org/10.1186/s13037-018-0176-y

Sankar WN, Tang EY, Moseley CF. Predictors of the need for femoral shortening osteotomy during open treatment of developmental dislocation of the hip. J Pediatr Orthop. 2009 Dec;29(8):868-71. doi: 10.1097/BPO.0b013e3181c29cb2. PMID: 19934701. DOI: https://doi.org/10.1097/BPO.0b013e3181c29cb2

Gholve PA, Flynn JM, Garner MR, Millis MB, Kim YJ. Predictors for secondary procedures in walking DDH. J Pediatr Orthop. 2012 Apr-May;32(3):282-9. doi: 10.1097/BPO.0b013e31824b21a6. PMID: 22411335. DOI: https://doi.org/10.1097/BPO.0b013e31824b21a6

Mootha AK, Saini R, Dhillon M, Aggarwal S, Wardak E, Kumar V. Do we need femoral derotation osteotomy in DDH of early walking age group? A clinico-radiological correlation study. Arch Orthop Trauma Surg. 2010 Jul;130(7):853-8. doi: 10.1007/s00402-009-1020-8. Epub 2009 Dec 11. PMID: 20012070. DOI: https://doi.org/10.1007/s00402-009-1020-8

Tönnis D. Indikation und Zeitplanung für operative Eingriffe bei Hüftdysplasie im Kindes- und Erwachsenenalter [Indications and time planning for operative interventions in hip dysplasia in child and adulthood]. Z Orthop Ihre Grenzgeb. 1985 Jul-Aug;123(4):458-61. German. PMID: 4072348.

Pemberton Pa. Pericapsular Osteotomy of the Ilium for Treatment Of Congenital Subluxation and Dislocation of the Hip. J Bone Joint Surg Am. 1965 Jan;47:65-86. PMID: 14256975. DOI: https://doi.org/10.2106/00004623-196547010-00004

Kalamchi A, MacEwen GD. Avascular necrosis following treatment of congenital dislocation of the hip. J Bone Joint Surg Am. 1980 Sep;62(6):876-88. PMID: 7430175. DOI: https://doi.org/10.2106/00004623-198062060-00002

Cordier W, Tönnis D, Kalchschmidt K, Storch KJ, Katthagen BD. Long-term results after open reduction of developmental hip dislocation by an anterior approach lateral and medial of the iliopsoas muscle. J Pediatr Orthop B. 2005 Mar;14(2):79-87. doi: 10.1097/01202412-200503000-00004. PMID: 15703515. DOI: https://doi.org/10.1097/01202412-200503000-00004

El-Sayed M, Ahmed T, Fathy S, Zyton H. The effect of Dega acetabuloplasty and Salter innominate osteotomy on acetabular remodeling monitored by the acetabular index in walking DDH patients between 2 and 6 years of age: short- to middle-term follow-up. J Child Orthop. 2012 Dec;6(6):471-7. doi: 10.1007/s11832-012-0451-x. Epub 2012 Nov 28. PMID: 24294309; PMCID: PMC3511692. DOI: https://doi.org/10.1007/s11832-012-0451-x






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Köse M, Topal M, Yılar S, Engin M Çağatay, Yıldırım Ömer S, Zeynel A. A retrospective analysis of the effects of femoral shortening osteotomy on clinical and radiologic outcomes in open reduction and Pemberton pericapsular osteotomy for Tonnis type 4 dysplasia of the hip: Femoral shortening in open reduction and Pemberton. J Surg Med [Internet]. 2023 Mar. 20 [cited 2024 Jun. 19];7(3):225-8. Available from: https://jsurgmed.com/article/view/7745