Practical Guidelines to Correct Acetabular Dysplasia in Children and Adolescents

Salter innominate osteotomy (SIO) provides favorable results for treating residual acetabular dysplasia in young children. In this study, we examined the midterm results of SIO according to the age at surgery to determine the optimal timing of this procedure. We retrospectively examined 50 hips of 42 patients (8 boys and 34 girls) with acetabular dysplasia who underwent SIO and were followed up until skeletal maturity. The center-edge angle (CEA) was measured based on the anteroposterior radiographs of the hip obtained before surgery, 5 weeks after surgery, and at the latest follow-up. Severin classification was evaluated at the latest follow-up. Patients were categorized into 3 groups according to age at surgery: younger than 7 years of age (group A), 7 to 8 years of age (group B), and 9 years of age or older (group C). The mean preoperative CEA level of 0.9 degrees improved to 17.1 degrees postoperatively, which was increased to 28.1 degrees at the latest examination. Overall, 45 hips (90%) were classified as Severin I or II, with 96% in group A, 94% in group B, and 57% in group C. In group C, postoperative acetabular coverage was similar to that in the other groups (16.6 degrees in group A, 14.8 degrees in group B, and 18.1 degrees in group C), although the final outcome was unsatisfactory. The average improvement in CEA from postoperative to skeletal maturity was significantly smaller in group C than in the other groups (12.7 degrees in group A, 11.3 degrees in group B, and 3.0 degrees in group C). SIO showed favorable outcomes with satisfactory acetabular coverage at skeletal maturity. However, satisfactory acetabular coverage could not be obtained in some older patients because of limited postoperative remodeling capacity and smaller secondary improvement of CEA. We recommend that SIO should be performed in patients aged 8 years or younger. Level III-retrospective comparative study.

Acetabular dysplasia is one of the most common causes of early hip osteoarthritis and hip replacement surgery. Recent literature suggests that acetabular dysplasia does not always originate at infancy, but can also develop later during childhood. This systematic review aims to appraise the literature on prevalence numbers of acetabular dysplasia in children after the age of 2 years. A systematic search was performed in several scientific databases. Publications were considered eligible for inclusion if they presented prevalence numbers on acetabular dysplasia in a general population of healthy children aged 2-18 years with description of the radiological examination. Quality assessment was done using the Newcastle-Ottawa score. Acetabular dysplasia was defined mild when: the center-edge angle of Wiberg (CEA-W) measured 15-20°, the CEA-W ranged between -1 to -2SD for age, or based on the acetabular index using thresholds from the Tönnis table. Severe dysplasia was defined by a CEA-W < 15°, <-2SD for age, or acetabular index according to Tönnis. Of the 1837 screened articles, four were included for review. Depending on radiological measurement, age and reference values used, prevalence numbers for mild acetabular dysplasia vary from 13.4 to 25.6% and for severe acetabular dysplasia from 2.2 to 10.9%. Limited literature is available on prevalence of acetabular dysplasia in children after the age of 2 years. Prevalence numbers suggest that acetabular dysplasia is not only a condition in infants but also highly prevalent later in childhood.

Backgrounds: Dega pelvic osteotomy is commonly used to correct acetabular dysplasia in children with open triradiate cartilage. The use of bovine xenogeneic bone graft (Tutobone®) for Dega osteotomy has not been reported so far. This study aimed to determine the clinical and radiological outcome in a large series of children with hip dysplasia who were treated by Dega osteotomy using a bovine xenogeneic block for stabilisation. Methods: A retrospective, single-centre study was conducted including 101 patients (147 hips) with different underlying diseases. The acetabular angle of Hilgenreiner (AA) and the lateral center-edge angle (LCA) were analysed to quantify the correction of acetabular indices. Graft incorporation was assessed using the Goldberg scoring system. Results: the mean preoperative AA improved from 28.1 (SD: 6.7) to 14.7 (SD: 5.1) after surgery (p < 0.001). The mean preoperative LCA improved from 9.9 (SD: 6.7) to 21.8 (SD: 6.8) postoperatively (p < 0.001). Both indices remained stable at the one-year follow-up examination. Graft incorporation was excellent with a mean Goldberg score of 6.6. Heterotopic ossification occurred in one hip without clinical relevance. Graft-related complications were not noted. Conclusions: Dega osteotomy using Tutobone® is safe and effective in the treatment of acetabular dysplasia in children independent of the underlying disease.

Acetabular dysplasia is an important pre-disposing factor for osteoarthritis of the hip. However, it is not completely known how acetabular dysplasia develops during childhood. To study the prevalence of acetabular dysplasia and its association with body mass index (BMI) and physical activity in 9 year old children. The population for this cross-sectional study was drawn from the ongoing prospective cohort study: Generation R. 9,778 mothers with a delivery date from March 2002 until January 2006 were enrolled. In a random subgroup of these children Dual-energy X-ray absorptiometry (DXA) scanning was performed at age 9. BMI, standardized for the Dutch population and categorized in four groups based on extended international Obesity Task Force cut-offs: underweight, normal, overweight and obesity. Physical activity was based on time spent on playing outdoors, playing sports and walking/cycling to school. The degree of acetabular dysplasia was determined with the centre-edge angle (CEA) and acetabular depth-width ratio (ADR) in DXA images of the hip. 1,188 DXA images of children's hips were available for analysis. The median age of the children was 9.86 years. Prevalence of dysplasia and mild dysplasia was respectively 6.3%; 25.6% with CEA and 4.8%; 25.0% with ADR. BMI was negatively associated with mild dysplasia (OR 0.80 CI 0.71-0.90). Obese children showed less mild dysplasia compared to normal children (OR 0.48 CI 0.24-0.97) in unadjusted analysis. Physical activity represented by walking to school showed a statistically significant negative association with mild dysplasia (OR 0.87 CI 0.76-0.99). After adjustment for age, ethnicity, sex, first born, breech presentation, birthweight, gestational age and Caesarean section, the patterns of association with dysplasia remained for both BMI and physical activity. In this study, being overweight and light physical activity were negatively associated with the development of (mild) acetabular dysplasia at the age of 9 years.

Purpose: Several studies have shown that the morphology of the hip strongly influences the development of osteoarthritis of the hip. Especially the evidence for cam morphology and acetabular dysplasia is strong. Both morphological variants develop during childhood. In order to potentially prevent development of these morphologies and thus to prevent hip OA in later life, it is crucial to understand how these morphologies develop during childhood. Especially little is known on the natural course of primary dysplasia in the developing hip in children. In this study we focused on the association of hip dysplasia with overweight and physical activity in 9 year old children. Methods: The population for this cross-sectional study was drawn from the ongoing prospective pregnancy cohort: Generation R. 9,778 mothers with a delivery date from March 2002 until January 2006 were enrolled. In a random subgroup of children DXA scanning was performed of the left hip and whole body at age 9. Body mass index, standardized for the Dutch population was divided in four categories based on extended international Obesity Task Force cut-offs: underweight, normal BMI, overweight and obesity. Physical activity was based on self-reported data and defined in 3 areas: time spent on playing outdoors, playing sports and walking to school. The amount of acetabular dysplasia was determined with the center-edge angle (CEA) in DXA images of the (left) hip. Mild and severe dysplasia were defined as CEA<20 and CEA<15 respectively. Associations were tested using logistic regression, adjusting for age, ethnicity, sex, first born, breech birth, gestational weight, gestational age and caesarean section. Results: 1,026 DXA images of the children’s hip were available for analysis. The median age of the children was 9.7 years (range: 9.2 - 12.0 years). Mean prevalence of mild and severe dysplasia was 25.6% and 6.3% respectively (table1). Weight was negatively associated with dysplasia. Obese children showed less dysplasia compared to normal children, while underweight children showed more dysplasia. This was significant only for the unadjusted association between being overweight and mild dysplasia, although the pattern was present for both crude and adjusted associations in both mild and severe dysplasia. Physical activity showed a negative association with dysplasia for playing outside and walking/cycling to school, not for sport activity. Meaning the children who play more outside or walk or cycle to school showed a lower prevalence of dysplasia. This association was significant especially for mild dysplasia after adjustment. Stratification for sex revealed no sex-specificity: all associations were similar for boys and girls. Conclusions: The results of this study suggest that being overweight and mild physical activity might be protective against developing (mild) dysplasia of the hip. The cross-sectional nature of this study prevents making conclusions on causality. For instance, the negative association between dysplasia and mild physical activity could point to a reverse causality as well. Obesity is a known risk factor for many types of OA, though not for hip OA. The current result might provide a possible explanation. The direct (positive) effect of obesity on hip OA could be attenuated by the indirect (negative) effect that is mediated by dysplasia, which is one of the strongest risk-factors for hip OA. These results warrant further investigation of developing hip dysplasia using the 14-year time point of this prospective cohort. In conclusion, obesity and mild physical activity were negatively associated with acetabular dysplasia of the hip in 9 year old children.Tabled 1Associations between dysplasia and weight/physical activityMild dysplasia (CEA<20) n=263 out of 1026Severe dysplasia (CEA<15) n=65 out of 1026crude ORadjusted ORcrude ORadjusted ORWeight (normal=ref)Underweight1.14 (0.65 to 0.20)0.99 (0.51 to 1.92)1.51 (0.62 to 3.68)1.75 (0.64 to 4.82)Overweight0.72 (0.48 to 1.08)0.82 (0.52 to 1.28)0.84 (0.40 to 1.74)1.07 (0.50 to 2.31)Obese0.39 (0.17 to 0.94)0.54 (0.22 to 1.33)0.65 (0.15 to 2.76)0.91 (0.21 to 3.96)Physical activity (hours per week)Sport activity1.00 (0.91 to 1.10)1.00 (0.89 to 1.11)1.05 (0.88 to 1.251.02 (0.84 to 1.25)Playing outside0.98 (0.95 to 1.00)0.97 (0.94 to 1.00)0.95 (0.88 to 1.02)0.92 (0.83 to 1.02)Walking/cycling to school0.87 (0.76 to 0.99)0.86 (0.74 to 0.99)0.82 (0.63 to 1.08)0.76 (0.54 to 1.06) Open table in a new tab

Several surgical procedures have been devised to increase acetabular coverage of the femoral head in children with dysplasia of the hip. In this report we describe an acetabuloplasty that combines the key aspects of the Pemberton and Salter osteotomies. It has been used at the Los Angeles Unit of the Shriners Hospital for Crippled Children since the late 1960's. To assess the results of this combination procedure, fifty hips in forty-four children were evaluated at an average of six years postoperatively. The average age at operation was 7.3 years, and 62 per cent of the patients had had prior surgery. Clinically, thirty-two hips in which there had been no or slight symptoms preoperatively remained unchanged, twelve that had had preoperative limitations improved, and six showed some deterioration in terms of slight loss of motion, mild pain, and a limp. Roentgenographically, acetabular dysplasia (as measured by the acetabular index and by the center-edge angle of Wiberg) improved in more than 90 per cent of the hips. The roentgenographic results were comparable with those obtained by innominate or pericapsular osteotomy. The combination osteotomy has the advantages of both the Pemberton procedure and the Salter operation and proved to be an excellent surgical procedure for older children whose acetabular development did not progress as well as was expected.

We reviewed the results for fifty-two hips in forty-two patients who had had a Pemberton pericapsular osteotomy between 1968 and 1984 as treatment for residual acetabular dysplasia of the hip. The average age of the patients at the time of the osteotomy was four years. The average duration of follow-up was ten years. At the time of the most recent follow-up, forty-two of the fifty-two hips had a rating of Severin class IA, an essentially normally developed hip. The results of the Pemberton osteotomy were unpredictable if there had been necrosis of the femoral head (without infection) preoperatively. We believe that the Pemberton osteotomy is a safe, effective procedure for the treatment of acetabular dysplasia in patients who have congenital dislocation of the hip.

Background:While perinatal risk factors are widely used to help identify those at risk for developmental dysplasia of the hip (DDH) within the first 6 to 8 weeks of life, limited data exist about their association with radiographic evidence of dysplasia in childhood. The purpose of this study was to determine which perinatal risk factors are associated with acetabular dysplasia in children who are ≥2 years of age.Methods:Pelvic radiographs were made in 1,053 children (mean age, 4.4 years [range, 2 to 7 years]) who had been assessed prospectively as having at least 1 of 9 widely accepted perinatal risk factors for DDH. Two radiologists who were blinded to patient risk factors, history, and age determined the acetabular index (AI). The primary outcome was defined as an AI >2 standard deviations from the Tönnis reference values (“severe” dysplasia). The secondary outcome was an AI of >20° at >2 years of age. The association between risk factors and outcomes was assessed using logistic regression. The effect of treatment in infancy was adjusted for in 37 hips.Results:Twenty-seven participants (3%) showed “severe” hip dysplasia; 3 of these had received treatment for DDH in infancy. Girls were more likely to experience this outcome (odds ratio [OR] = 2.59; 95% confidence interval [CI] = 1.04 to 6.46; p = 0.04); no other examined risk factors were significant. The secondary outcome appeared in 146 participants (14%), 12 of whom had received treatment in infancy. We observed the following predictors for this outcome: female sex (OR = 1.77; 95% CI = 1.21 to 2.59; p = 0.003), breech presentation (OR = 1.74; 95% CI = 1.08 to 2.79; p = 0.02), and being a firstborn child, which had a protective effect (OR = 0.67; 95% CI = 0.46 to 0.96; p = 0.03).Conclusions:We identified a substantial number of cases that will require at least radiographic surveillance for mild and severe hip dysplasia; 92% had no prior diagnosis of DDH. Those who had been born breech were affected by this outcome even if ultrasonography of the hip had been normal at 6 to 8 weeks, suggesting a benefit from additional radiographic testing.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The acetabulum interacts with the femoral head in daily activities and may exhibit structural changes in the presence of hip disorders. This study aims to redefine hip disorders in children with cerebral palsy by structural characteristics of the acetabulum in relation to the degree of the migration percentage. The clinical and radiographic data of 70 patients (36 males, 34 females; mean age 8.2 years) with spastic cerebral palsy were retrospectively analyzed. The acetabular structure was measured by the acetabular index on reconstructed three-dimensional computerized tomography for precision of measurement. Any significant change in acetabular index measured on the reconstructive computerized tomography related to every 10% increment of migration percentage was regarded as clinically significant in hip disorders. The acetabular index measured on the reconstructive computerized tomography showed an increasing trend with the increment of migration percentage. The most significant acetabular index measured on the reconstructive computerized tomography change occurred between the 20%-29% and 30%-39% migration percentage groups (p < 0.001), suggesting that a migration percentage of 30% is the starting point of hip disorder. A significant increase in the posterolateral acetabular index measured on the reconstructive computerized tomography occurred in migration percentages >50%, indicating posterolateral acetabular dysplasia. Hips with migration percentages from 80% to 100% had consistent acetabular indexes measured on the reconstructive computerized tomography values, suggesting complete dislocation and no more contact and interaction between the femoral head and acetabular fossa. Structural characteristics in the acetabulum reflect hip dysfunction and potentially classify hip disorders. Results suggest the migration percentage 30% as a starting point of hip disorder and 80% as a turning point of hip dislocation in children with cerebral palsy. level IV, diagnostic study.

BackgroundAcetabular dysplasia is the most common cause of secondary arthritis of the hip joint. Achieving maximum restoration of the acetabular coverage and medialization of the femoral head remains difficult with the original Steel triple pelvic osteotomy for acetabular dysplasia in children and adults. This study intended to answer the following questions: (1) Are the midterm functional results of our modified procedure favorable, particularly in relation to Harris scores? and (2) On the basis of the Tönnis grade, does this procedure has a different effect on radiographic parameters and functional results at midterm follow-up?MethodsThis study included 26 consecutive adult patients with symptomatic acetabular dysplasia (28 hips) who underwent modified triple pelvic osteotomy through two incisions between July 2005 and June 2012. According to the preoperative Tönnis grade, the patients were divided into T0 (Tönnis grade 0), T1 (Tönnis grade 1), and T2 (Tönnis grade 2) groups. Wiberg center-edge (CE) angle, Sharp acetabular angle, lateralization, and Harris scores were analyzed to assess the radiographic and clinical outcomes.ResultsThe mean CE angle (28.43° [± 3.58°], p < 0.05), Sharp acetabular angle (36.39° [± 3.26°], p < 0.05), lateralization (16.82 mm [± 3.10 mm], p < 0.05), and Harris scores (89.07 [± 4.97], p < 0.05) at the last follow-up significantly improved compared to those preoperatively. Multiple comparisons of radiographic outcomes among the three groups indicated no significant difference (p < 0.05). Harris scores in group T2 were significantly lower than those in groups T0 (p < 0.05) and T1 (p < 0.05). No major complication was observed.ConclusionsOur modified triple pelvic osteotomy for adult symptomatic acetabular dysplasia with early-stage osteoarthritis could lead to excellent radiographic outcomes, good clinical results, and lower complication rates.

There are a variety of described osteotomies to address acetabular dysplasia in children with Developmental Dysplasia of The Hip (DDH). This study will analyze the radiographic outcome of cases diagnosed with DDH and treated with a Salter innominate osteotomy. A retrospective review of all patients who underwent Salter innominate osteotomy between January 2017 and January 2019 at our institution was performed. 48 procedures (44 patients were evaluated for acetabular index (AI) and center edge angle (CEA) based on the preoperative, immediate postoperative, and the most recent pelvic x-ray. 48 procedures (44 patients) were radiologically evaluated. The AI improved from 34° preoperatively to 19.9° on the final follow up radiograph and the CEA improved from -2.4° preoperatively to 24.6° on the final follow up radiograph. In our hands, use of Salter innominate osteotomy for acetabular dysplasia in patients with DDH was associated with good radiological outcomes. The Salter innominate osteotomy was able to improve lateral acetabular coverage of the hip to almost near-normal radiographic values. Therapeutic IV.

Purpose: The remodeling potential of the dysplastic acetabulum in children with neuromuscular disorders is not clear and how to address residual acetabular dysplasia after femoral osteotomy in children with cerebral palsy remains unknown. The purpose of this study is to 1) quantify acetabular remodeling in patients with CP who received a femoral osteotomy without an acetabular osteotomy and 2) to determine the impact of age and Gross Motor Function …

Introduction: DDH is the most common congenital anomaly of the musculoskeletal system in newborns. The disease ranges from a simple flattening of the acetabular cavity to the complete dislocation of the femoral head. Most developed countries report an incidence of 1.5 to 20 cases of DDH per 1000 births, depending in part on the methods of screening used. It includes a wide spectrum of hip alterations: neonatal instability; acetabular dysplasia; hip subluxation; and true dislocation of the hip. Aim of the Study: The aim of this study was to evaluate the management of the Developmental Dysplasia of Hip (DDH) in children. Methods: This retrospective study was conducted in the Department of Pediatric Surgery, Bangladesh Shishu Hospital &amp; Institute, Dhaka, Bangladesh during the period from January2018 to December 2021. Result: In total 54 neonates completed the study. In our study we found majority (53.70%) of children were aged less than 4 months old. Followed by 25.93% &amp; 20.37% were aged 1-2 months &amp; 3-4 months respectively. Majority of neonates were girls (61.11%) compared to boys (38.89%). The highest risk factors of DDH was breech presentation (19%).We found that majority of neonates (70.37%) had dysplasia on left side and 7.41% had dysplasia on right side respectively. The prevalence of bilateral condition was 12(22.22%). Conclusion: DDH a common congenital anomaly that can be successfully treated non-operatively if detected early. For older individuals with dislocated or unstable hips, surgery is necessary. Surgery's function in treating acetabular dysplasia in children is changing and largely determined by symptoms. Expanding therapy choices for DDH and improved anatomical patient assessment skills among doctors will result in the proper intervention at the right time.

Purpose: The remodeling potential of the dysplastic acetabulum in children with neuromuscular disorders is not clear and how to address residual acetabular dysplasia after femoral osteotomy in children with cerebral palsy remains unknown. The purpose of this study is to 1) quantify acetabular remodeling in patients with CP who received a femoral osteotomy without an acetabular osteotomy and 2) to determine the impact of age and Gross Motor Function Classification System (GMFCS) on remodeling over time. Methods: Medical records and radiographs of patients aged 1-18 with a diagnosis of cerebral palsy, who have undergone isolated femoral osteotomy at our Children’s hospital over an 8-year period (2010-2018) with at least one year follow up were reviewed. Age at time of surgery, gender, GMFCS, procedure(s) performed at the time of the procedure, preoperative acetabular index (AI) as well as subsequent AI at follow-up visits yearly for four years if applicable were recorded. Univariate analysis was used to quantify the characteristics of this cohort over time. Results: A total of 50 patients (26M, 24F) with an average age at the time of surgery of 8.2 ± 4.4 years, were identified who met our inclusion criteria demonstrating appropriate follow-up and operative procedure(s). The cohort consisted of GMFCS I: 1 (2%), GMFCS II: 3 (6%), GMFCS III: 5 (10%), GMFCS IV: 6 (12%), and GMFCS V: 32 (64%). The average acetabular index was as follows: preoperative AI (21.0° ± 7.1°), postoperative (21.3° ± 7.5°), 1 year (19.8° ± 6.2°), 2 year (20.3° ± 7.1°), 3 year (18.3° ± 6.6°), and 4 year (16.5° ± 6.0°). Over the four years of follow-up, the average hip’s acetabular index changed just -4.4°. Age and GMFCS were not significant contributors. Conclusion: This retrospective case-series investigated the change in acetabular dysplasia in cerebral palsy patients after receiving isolated femoral osteotomies. On average, these children had a 4.4 degree decrease in their AI over four years which is not a significant change in correcting their dysplasia. We suggest that acetabular dysplasia should be addressed at the time of femoral correction to provide complete correction.

A new modified technique of triple osteotomy of the innominate bone has been devised and implemented for the treatment of residual acetabular dysplasia in children with developmental dysplasia of the hip. The procedure is done through a two-incision approach. The ischium, pubis, and iliac bones are osteotomized, with resection of a triangular wedge of bone from the outer cortex of the proximal part of the ilium. The resection of the triangular wedge of bone from the outer cortex alone creates a slot with the intact inner cortex serving as a stabilizing abutment where the distal posterior aspect of the ilium fits. This osteotomy allows for extensive coverage of the femoral head with greater stability. The stable construct of the osteotomy and pelvic fixation facilitates early weight bearing and obviates the need for hip spica cast immobilization. Since its conception the new triple osteotomy has been done in 11 children (13 hips). The preoperative vertical center edge angle of Weiberg was 8.9 degrees (range, 5 degrees -17 degrees ). The postoperative vertical center edge angle was a mean of 45.6 degrees (range, 31 degrees -58 degrees ). The last followup vertical center edge angle was a mean of 44.9 degrees (range, 29 degrees -58 degrees ). The mean preoperative acetabular angle of Sharp was 53 degrees (range, 48 degrees -61 degrees ). The postoperative acetabular angle was a mean of 25.4 degrees (range, 19 degrees -40 degrees ). The last followup acetabular angle was a mean of 28 degrees (range, 18 degrees -41 degrees ). All patients went on to have bony unions on their innominate bone. We describe the technique for the osteotomy and presents preliminary results of all patients who had the procedure.