Open Reduction Of Congenital Dislocation Research Articles

Low rate of clinically important avascular necrosis of the femoral head after Ludloff's procedure.

Ludloff's procedure for open reduction of congenital dislocation of the hip (CDH) is recommended for its minimal tissue damage, but is criticised for the risk of late avascular necrosis (AVN) of the femoral head. The aim of present study was primarily to assess the risk of late AVN of the femoral head and secondly the range of motion (ROM) of the hip and the quality of life in children following Ludloff's procedure. 13 hips in 11 children after Ludloff's procedure due to CDH were included retrospectively from 1997 to 2005 at Aarhus University Hospital. Radiographs were evaluated for the presence of AVN of the femoral head and classified according to the Bucholz and Ogden classification, with type 2-4 having clinical relevance. A clinical examination included range of motion (ROM) and leg length discrepancy (LLD) measurements. The HAGOS hip questionnaire evaluated activity, participation and quality of life. No severe type 3-4 AVN was observed. 2 type 2 and 5 type 1 were observed. AVN was observed in 7 of the 13 operated hips (54%). An 8.6° difference in flexion for unilaterally treated hips was observed (p<0.02). 8 of 11 patients had minor LLD (range 0.5-2 cm). Only minor AVN of clinical importance was seen after Ludloff's procedure.

Ludloff approach for osteochondroma in the lesser trochanter in a young middle-distance runner

Ludloff's approach was described for open reduction of congenital dislocation of the hip. We describe the preoperative planning and the surgical procedure for removing an osteochondroma in the lesser trochanter performed by an anteromedial approach. At follow-up, the patient was asymptomatic and had no limitations in his hip motion, with no radiological relapse. This approach can be used without complications, avoiding more aggressive approaches that force to dislocate the hip and lead to sacrifice more soft tissues.

Open reduction of congenital dislocation of the knee: a report on two cases

Congenital dislocation of the knee (CDK) is not a common condition, and in most cases, reduction is performed by closed methods. We present two children with CDK who were refractory to conservative treatment. Surgical reduction was performed, and quadriceps lengthening was done by VY plasty in one and Z plasty in the other. At operation, it was difficult to identify the different muscle groups. Abnormal fibrous tissue was present in both the cases beneath the contracted quadriceps, which required complete excision. The child with Z plasty to lengthen the quadriceps had better range of motion in the knee than did the one with VY plasty.

Open reduction for congenital dislocation of the hip: comparison of the long-term results of the wide exposure method and Ludloff’s method

We compared the long-term clinical and radiographic results of two methods of open reduction for congenital dislocation of the hip; a wide exposure method (360-degree circumferential capsulotomy) versus Ludloff’s method (limited capsulotomy via the medial approach). Thirty-one hips in 24 patients assigned to group A received the wide exposure method and 32 hips in 27 patients assigned to group B had the Ludloff reduction. All patients were surgically reduced at less than 3 years of age. The follow-up averaged 16 years. None of the hips in group A required additional operations; however, 34.4% of the hips in group B did. At the latest review, 26 (83.9%) of the hips in group A were rated as Severin class I or II. Except for one patient, none had pain or a limp. Of the hips in group B, 18 (56.3%) were rated as Severin class I or II. Three patients had pain or Trendelenburg gait. Avascular necrosis occurred in 3.2% of hips in group A and in 21.9% of hips in group B. The wide exposure method is capable of completely releasing the posterosuperior tightness resulting from capsular adhesion to the ilium and the contracted short external rotators. Releasing the posterosuperior tightness from these structures seemed to provide a better chance of achieving an anatomically and functionally satisfactory hip.

Severin Classification System for Evaluation of the Results of Operative Treatment of Congenital Dislocation of the Hip. A Study of Intraobserver and Interobserver Reliability*

The Severin classification system frequently is used to evaluate the radiographic results of operations performed for the treatment of congenital dislocation of the hip. However, the reliability of this classification scheme has not been established, to our knowledge. Ideally, a classification system should be validated before it is used to promote therapeutic guidelines or to compare results of treatment; the purpose of the present study was to establish the intraobserver and interobserver reliability of the Severin classification system. Four blinded raters and the operating surgeon independently used the Severin system to evaluate the most recent radiographs of thirty-seven children (fifty-six hips) who had been managed, an average of nine years previously, with a medial open reduction for congenital dislocation of the hip. Three of the raters evaluated the same radiographs again under similar testing circumstances eight weeks later. Ten paired interobserver and three intraobserver comparisons then were analyzed with use of the Cohen kappa coefficient (kappa). The average kappa coefficient for the six pairwise comparisons between the four blinded raters was 0.15 (range, -0.05 to 0.42) when all Severin classes were analyzed independently. The average kappa coefficient for the four pairwise comparisons between the blinded raters and the operating surgeon was even lower (0.02). The kappa coefficients for the three intraobserver comparisons were 0.20, 0.38, and 0.44 (average, 0.34). Kappa analysis demonstrated variable and low levels of agreement when the Severin system was used to rate the results of operations performed for the treatment of congenital dislocation of the hip. We believe that the unadjusted kappa coefficient should indicate excellent agreement (kappa > 0.75) for all comparisons if this system is to be used for the evaluation of clinical results. The unacceptably low levels of intraobserver and interobserver reliability call into question the clinical conclusions of reports in which the Severin system has been used as the basis of proof.

Ludloff's medial approach for open reduction of congenital dislocation of the hip. A 20-year follow-up.

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff's medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi. At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented. We conclude that Ludloff's medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations.

LUDLOFF’S MEDIAL APPROACH FOR OPEN REDUCTION OF CONGENITAL DISLOCATION OF THE HIP

We reviewed 33 patients (35 hips) after open reduction of congenital dislocation of the hip using Ludloff’s medial approach. The mean age at the time of operation was 14 months (5 to 29) and at the time of final follow-up 20.1 years (15 to 24) giving a mean duration of follow-up of 19.4 years (14 to 23). We evaluated the radiological results by the Severin classification and the extent of avascular necrosis using the criteria of Kalamchi. At the latest review 16 hips (45.7%) were in Severin groups I or II (acceptable results) and 19 (54.3%) in Severin groups III, IV or V (unacceptable results). There was evidence of avascular necrosis in 15 hips (42.9%). The radiological results began to become worse at about the age of ten years when type-II avascular changes presented. We conclude that Ludloff’s medial approach for open reduction is unsatisfactory for the treatment of congenital dislocation since about half of our patients required additional operations.

Revision of failed open reduction of congenital dislocation of the hip

We report a review of 33 hips (32 patients) which had required repeat open reduction for congenital dislocation of the hip. They were followed up for a mean of 76 months (36 to 132). Factors predisposing to failure of the initial open reduction were simultaneous femoral or pelvic osteotomy, inadequate inferior capsular release, and inadequate capsulorrhaphy. Avascular necrosis had developed in more than half the hips, usually before the final open reduction. At review, 11 of the hips (one-third) were in Severin grade 3 or worse; five had significant symptoms and only ten were asymptomatic and radiographically normal. Once redisplacement has occurred after primary open reduction, attempts to reduce the head by closed means or by pelvic or femoral osteotomy are usually unsuccessful and a further open reduction is necessary.

Open reduction of CDH before one year of age. 69 hips followed for 13 (10-19) years.

50 children (69 hips) had open reduction of congenital dislocation of the hip (CDH) at the age of 7 (2-12) months. 4 hips had a poor result from severe necrosis of the femoral head. Another 5 hips with less severe necrosis had a fair result. 7 of the 9 hips with avascular necrosis were below the age of 6 months at the time of operation. 13 hips (9 children) required complementary operations to establish congruous reduction of the hip. The follow-up period was 13 (10-19) years, and the results were successful in 53 hips. No difference was found in the unilaterally and bilaterally operated on hips. Anteversion corrected itself in due time in most of the hips, and coxa magna had disappeared in hips that had reached maturity. Good hips remained good and poor hips became progressively worse.

Open Reduction of Congenital Dislocation of the Hip

s from the European Paediatric Orthopaedics Society, March 25–27, 1992, Jerusalem, Israel: PDF Only

Medial Approach Open Reduction in Congenital Dislocation of the Hip Without Preliminary Traction

Medial Approach Open Reduction in Congenital Dislocation of the Hip Without Preliminary Traction

Medial approach open reduction for congenital dislocation of the hip using the Ferguson procedure

Between January 1979 and October 1984, 31 congenitally dislocated hips in 19 patients were treated using open reduction via the medial approach, as described by Ferguson, at the Ankara University Faculty of Medicine. Patient age at operation ranged from 3 to 33 months (mean 12.1 months). The average follow-up was 94.7 months. All hips were evaluated both radiographically and clinically. Avascular necrosis of the femoral head was observed in 9.7% and slight, transient ischaemic radiographic changes of the femoral head in 22.6% of the hips; 25.8% of the hips have already undergone or are due to undergo subsequent surgery due to an insufficient radiographic result. The medial approach was found to be a reliable procedure for infants who have not had extensive previous conservative treatment and who are between 7 and 18 months of age.

Medial Adductor Open Reduction for Congenital Dislocation of the Hip

Twenty-two consecutive patients with 26 dislocated hips were evaluated for a mean of 7 years after open reduction through a medial adductor approach. Severin classification of grade I or II and center-edge angles greater than 20 degrees were present in 73% of hips and 88% of patients treated between the ages of 5 and 14 months. Avascular necrosis (AVN) with partial head involvement occurred in 15% of hips and correlated positively with increased age at surgery, but did not preclude a satisfactory Severin classification. Best results were obtained in children treated between the ages of 5 and 14 months.

Early open reduction for congenital dislocation of the hip

We have reviewed 82 children with congenital dislocation of the hip, after treatment by anterior open reduction followed by derotation femoral osteotomy. The clinical and radiological results were significantly better in the group that had open reduction before the appearance of the capital femoral epiphysis; this group also had a lower incidence of avascular necrosis. We conclude that, when it is clearly indicated, the earlier an open reduction is carried out the better the results.

Muscle plasty in surgical treatment of congenital dislocation of the hip in children

Active development of extra-articular, low-traumatic methods of surgical treatment of congenital dislocation of the femur has reduced the number of such postoperative complications as relaxation, decentration, and aseptic necrosis of the femoral head by now. As a rule, the main focus of research is on surgeries with correction of the pelvic and femoral components. But it is not uncommon that even correctly performed open reduction of congenital dislocation of the femur and restoration of proper coaptation of the articular surfaces end in failure. Lateroposition, decentration, or even reluxation occur either immediately after removal of the plaster immobilization or in the course of active physical and mechanical therapy. One of the main reasons for such failures is the imbalance between the internal and external rotators of the femur that occurs after correction of the anteversion angle.

Treatment of failed open reduction for congenital dislocation of the hip.

Twenty-three patients with 25 involved hips underwent repeat open reduction after previous unsuccessful attempts at open reduction for congenital dislocation of the hip (CDH). All hips ultimately were reduced at a mean age of 2 years 10 months (range 10 months to 7 years 3 months). On review, we noted that 15 of the hips were never concentrically reduced at the first procedure, and seven of these hips had undergone simultaneous Salter osteotomy. The most common cause of failure was improper exposure and release of the tight inferior capsule and transverse acetabular ligament, which blocked complete reduction. A vascular necrosis was documented in 44% of the hips, with a lateral physeal growth disturbance in four hips, a central physeal growth arrest in four hips, and complete femoral head necrosis in three hips.

Avascular necrosis after open reduction for congenital dislocation of the hip: analysis of causative factors and natural history.

We analysed the causative factors and natural history of avascular necrosis (AVN) after open reduction of 87 dislocated hips. AVN was observed in 37% of the hips, yet open reduction did not appear to contribute to the development of AVN and its prevalence was similar in hips treated by open or closed reduction in our institution. Only 45% of hips with AVN had a good late result. More containment procedures were required if AVN had occurred. Premature physeal closure was one late manifestation of this complication, which occurred following apparent partial AVN changes.

Early results of medial approach open reduction in congenital dislocation of the hip: use before walking age.

The operative findings and results in our first 40 consecutive open reductions of the congenitally dislocated hip by the medial approach are presented. These were all performed by one surgeon before walking age and, with one exception, all patients were aged less than 11 months at operation. Follow-up was from 2 to 7 years (mean 4.6 years). A vascular necrosis did not occur, but coxa magna and significant acetabular dysplasia were each present in one case. We have not performed any secondary operations.

Medial Approach Open Reduction in Congenital Dislocation of the Hip

Medial Approach Open Reduction in Congenital Dislocation of the Hip

Follow-up Study of Open Reduction in Congenital Dislocation of the Hip

We presented the follow-up study of fifteen hips of thirteen patients of CDH treated surgically. The follow-up period was 3.8 years in average. Open reduction was performed in two hips, open reduction with derotation varus osteotomy in five and open reduction with femoral shortening in eight. Saltor or Chiari operation was added in four. The postoperative results were excellent on the whole showing less deformity of the femoral head and a good stabilization of the hip. We stress that each factor obstructing a stable reduction should be evaluated and removed at surgery and, if overriding dislocation of the femoral head, decompression of femoral shortening is important to prevent necrosis of the femoral head.