CLOSED OR OPEN REDUCTION

Abstract

Introduction: The incidence of DDH has decreased dramatically during the last thirty years. The first reason was the introduction of targeted examination of all newborn babies (in the Czech Republic since 1977) and then our system was adopted by all of the other European countries. In the 1960s about 15% of all children were treated for different stages of hip dysplasia and there were 3% of true dislocations. These very high numbers of less serious grades of DDH are partially due to over-diagnosis and over-treatment. In the 1980s, the numbers had been reduced to 5% of dysplasias and 0.8% of dislocations. The introduction of ultrasound examination according to Graf within the first week of life has contributed to further reduction of DDH cases.

Material and Methods: Open reduction is indicated only for congenitally dislocated hip joints in which tender, conservative reduction cannot be done. As a tender reduction, this can only be made by continuous overhead traction with a gradual increase of hip abduction from 10 to 60 degrees. When reduction cannot be considered as harmless, the surgical procedure consisting of open reduction and derotational osteotomy should be performed before the age of one year. In children older than the age of eighteen months a pelvic osteotomy must be added

Results: From 1980 to the end of 2000 (a period of 21 years), 147 dislocated hip joints in 128 children were operatively treated. The average follow-up was 11 years (2 – 21). In the age group of up to 15 months of age, 68 hip joints (62 patients) had open reduction and a derotational osteotomy was added in 32 cases (47%).

An additional pelvic osteotomy in cases of simple open reduction was performed on 17 hips (47%) and on 10 hips (31%) in cases of open reduction and derotation.

Aseptic necrosis developed in 5 cases (7.3%), but it is difficult to distinguish between pre-existing necrosis after conservative treatment and postoperative necrosis.

In the age group of 15 months to 36 months, there were 47 hip joints in 42 children. The surgery consisted of open reduction, varus and derotational osteotomy plus Salter (exceptionally Pemberton) osteotomy. The rate of necrosis was 12.8% (6 cases).

The open reduction in children older than the age of 3 was performed in 24 children (32 hip joints). The open reduction, varus and derotational osteotomy of the femur were performed in all cases. The Salter osteotomy was performed in 12 hips, Pemberton in 5, triple pelvic osteotomy in 6 cases, and Chiari was used in primary reduction in 9 cases.

The necrosis rate was 6.2% (2 cases).

In the targeted study regarding the effectivity of overhead traction, we had 90 hip joints in 76 patients. In the group of primary treatment in our institution (57 hip joints), successful reduction was reached in 80.1% of cases, but in the group of 33 hip joints where primary treatment had failed, conservative treatment was successful in only 30% and open reduction was performed in 23 cases.

We used the radiological classification according to Severin and clinical score according to Merle D’Aubigne: Severin I - excellent results − 12%, Severin II – good – 63%, Severin III – fair – 15%, Severin IV – poor – 6%, Severin V – re-dislocation, 6 cases – 4%. The necrosis rate was 9%.

Conclusion: Conservative and operative treatment of DDH are not two competing methods. The treatment of each dislocation starts conservatively. Only when there is no chance for harmless, tender reduction of the femoral head into the acetabular socket, the open reduction should be indicated and performed by experienced specialists. Early open reduction with femoral derotation gives statistically significant better results in comparison with only open reduction. The percentage of excellent results seems to be low, but it must be kept in mind that a hip joint which was operated and had an open reduction heals, in the majority of cases, at least radiologically. Functional results do not correspond in childhood with the radiology. Despite that, the children in the time period of FU do not complain, and the patients with operated DDH in the natural history must be considered as a high risk for the development of secondary coxarthrosis.