Acetabular morphology and orientation differs from ethnic group to another. Thus, investigating the natural history of the parameters that are used to assess both was a matter of essence. Nevertheless, clarification the picture of normal value in our society was the main aim of this study. However, Acetabular head index (AHI) and center edge angle (CEA) were the most sensitive indicative parameters for acetabular dysplasia. Hence, they were the main variables used in evaluation of acetabular development. A cross-sectional retrospective study that had been done in a tertiary center. Computed tomography abdomen scouts’ radiographs of non-orthopedics patients were included. They had no history of pelvic or hips’ related symptoms or fractures in femur or pelvis. Images’ reports were reviewed to exclude those with tumors in the femur or pelvic bones. A total of 81 patients was included with 51% of them were males. The mean of age was 10.38± 3.96. CEA was measured using Wiberg technique, means of CEA were 33.71±6.53 and 36.50±7.39 for males and females, respectively. Nonetheless, AHI means were 83.81±6.10 and 84.66±4.17 for males and females, respectively. On the other hand, CEA was increasing by a factor 0.26 for each year (3-18, range). In addition, positive significant correlation was detected between CEA and age as found by linear regression r 2 0.460 (f(df1,79) =21.232, P ≤0.0001). Also, Body mass index (BMI) was positively correlated with CEA r 0.410, P 0.004). This study shows that obesity and aging are linked to increased CEA. Each ethnic group has its own normal values that must be studied to avoid premature diagnosis

The Bernese periacetabular osteotomy (PAO) is not indicated for growing hips as it crosses the triradiate cartilage in its posterior branch, and experimental work has shown this can induce substantial deformations, similar to posttraumatic dysplasia, which is observed after pelvis crash injuries in childhood.

Upon examination, all injuries in the 19 cases of posttraumatic dysplasia described in literature plus 16 hips of our personal collection took place before the age of 6, which is striking as pelvic injuries in children increase with age.

Based on this observation, we started to extend the PAO indication to severe dysplasias in children with open growth plate, initially aged 9 years and older. Following the positive results, it was extended further, our youngest patient being 5 years old.

We retrospectively examined radiographic outcomes of 23 hips (20 patients), aged 10.6±1.8 years [range 5.0 – 13.2], operated by us in four centers. Pre- and 3-months postoperative, and the latest FUP radiograph at growth plate closure were measured. We evaluated the acetabular index (AI), lateral center-edge (LCE), ACM-value and compared them with reference values adjusted for age. The age at triradiate cartilage closure was compared with the non-operated side.

The follow-up time was 5.4±3.7 years [0.8 - 12.7]. In 5 hips, growth plate closure was delayed by a few months. All angles significantly normalized after PAO (LCE: 14±8° → 38±11°, AI: 20±8° → 7±4°, ACM: 53±5° → 48±4°), with >80% of them severe pathological pre-PAO, none afterwards. Acetabular molding was normal. Only few complications occurred; one had signs of coxarthosis, one sciatic nerve pain, one interfering osteosynthesis material that was removed, one had an additional valgus osteotomy, and all resolved.

Based on 20 cases with follow-up until complete triradiate cartilage closure, we believe to have sufficient information to extend the PAO indication to growing hips of 9 years and older.

Aims

When the present study was initiated, we changed the treatment for late-detected developmental dislocation of the hip (DDH) from several weeks of skin traction to markedly shorter traction time. The aim of this prospective study was to evaluate this change, with special emphasis on the rate of stable closed reduction according to patient age, the development of the acetabulum, and the outcome at skeletal maturity.

Treatment of residual acetabular dysplasia is still controversial regarding the timing of Surgery, and the type of surgical procedur

Material and Methods: We analyzed 70 patients (83 hips) operated between 1980–1988 year, in which Salter innominate osteotomy was performed in the treatment of residual acetabular dysplasia in DDH. Patients were divided in two different age groups: from 2–4 (53 hips) and 4–6 (30 hips) years. The average follow up was 7 years (from 2 to 10 years). Acetabular remodeling was radiographically assessed by measuring of the Acetabular Index (AI) at the beginning and after the 5 years of age subsequently by measuring the CE angle of Wiberg. All preoperative hips were dysplastic according to Tonnis (+2SD) criteria. Results were statistically analyzed by using the Student’s T test, and One Way Repeated Measures ANOVA, with the correction for the different age groups.

Results: We found that there were no statistically significant differences in AI and CE angle between these two age groups and between these groups and normal values.

Conclusion: We recommend Salter innominate osteotomy as a procedure of choice in the treatment of acetabular dysplasia in DDH, provided the patient is younger than 6 years of age.

The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. Variability exists in the duration of brace treatment after successful reduction of the dislocated hip. In this study we evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database. We retrospectively studied prospectively enrolled infants with at least one dislocated hip that were initially treated with a PH and had a recorded AI at two-year follow-up. Subjects were treated at one of two institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured 12-week brace treatment protocol. Hip dislocation was defined as less than 30% femoral head coverage at rest on the pre-treatment ultrasound or IHDI grade III or IV on the pre-treatment radiograph. Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace 3x longer than hips from institution 2 (adjusted mean 8.9±1.3 months vs 2.6±0.2 months)(p < 0 .001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (p=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9˚) compared to Institution 2 (adjusted mean 23.5±0.8˚) (p=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age- and sex- matched AI normal data (p=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia, compared to a 22% (6/27) from Institution 2 (p=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (p=0.071). Our findings suggest that prolonged brace treatment does not result in improved acetabular index at age two years. Hips treated at Institution 1 had the same AI at age two years as hips treated at Institution 2, while spending about 1/3 the amount of time in a brace. We recommend close follow-up for all children treated for dislocated hips, as ~1/4 of infants had acetabular index measurements at or above the 90th percentile of normal. Continued follow-up of this prospective cohort will be critical to determine how many children require acetabular procedures during childhood. The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at two-year follow-up

Aim. To compare the rate and severity of avascular necrosis following medial open and closed reduction in developmental hip dysplasia and the resulting influence on femoral and acetabular development. Method. The radiographs and hospital records of 118 patients with dislocation of the hip were reviewed. 57 patients (66 hips) underwent medial open reduction and 61 patients (75 hips) underwent closed reduction. Mean follow-up was 10.9 years (5 years to 17.4 years). Avascular necrosis (AVN) was recorded according to the Bucholz and Ogden classification. The acetabular index was measured pre-operatively, at 1 and 4 years following surgery. The final radiograph was assigned a Severin grade. Sharp and centre-edge angles were recorded at final follow-up. A Severin grade I or II was considered a satisfactory result and a grade III to V an unsatisfactory result. Initial non-operative measures, such as Pavlik harness treatment and traction were documented. Additional surgical interventions were noted. Results. The rate of clinically significant AVN (types 2, 3, 4) following medial open reduction was 28.7% versus 17.3% following closed reduction. The rate of Type 2 AVN was 22.7% versus 10.6% respectively. Early acetabular development was similar in both groups. Long-term follow-up showed an unsatisfactory outcome (Severin grade III-V) following medial open reduction in 32% versus 8% in the closed reduction group. Conclusion. Our findings suggest that medial open reduction is associated with a higher rate of AVN than closed reduction. Type 2 AVN was twice as common in the medial open reduction group. More unsatisfactory results were seen in the medial open reduction group at long term follow up

Aim: To compare acetabular development and hip stability over time in patients treated for developmental dysplasia of the hip (DDH) by open reduction combined with either varusderotation (VDRO) or innominate (IO) osteotomies. Method: Patients who underwent open reduction for DDH, combined with either VDRO (38 patients) or IO (33 patients), between 15 months and 4 years of age were reviewed. Both groups comprised a single surgeon consecutive series, differing only in the type of osteotomy performed. A total of 490 postoperative radiographs over a maximum follow-up period of 13.6 years were analyzed. We used repeated measures analysis of variance to compare the change in acetabular index (AI) as well as several other radiographic indices of acetabular development and hip stability over time. Results: After osteotomy, the AI decreased in both groups but the magnitude of the decrease was significantly different between groups over time (p< 0.0001). The AI of patients undergoing VDRO never decreased as much as that of patients undergoing IO, with a mean difference of 10.4 degrees after 4 years (p< 0.0001). Similarly the IO group demonstrated more favourable acetabular architecture and hip stability over time compared to the VDRO group, as quantified by change in the acetabular floor thickness (p< 0.03), lateral centring ratio (p< 0.0001) and superior centring ratio (p < 0.0001). Conclusions: Acetabular remodelling after IO was more effective at reversing acetabular dysplasia and maintaining hip stability than VDRO. Long-term follow-up of VDRO will be necessary to determine if late improvement occurs. IO may be preferable over VDRO in the treatment of hip dislocation after walking age

Introduction: A criticism of innominate osteotomy is that it causes relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address this hypothesis. Materials and Methods: We had access to radiographs of 30 patients that had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation. The patients are now middle-aged and formed part of a previously reported study on the long term outcome of this protocol. Standardised, well-centered anteroposterior standing hip radiographs had been obtained. We used the validated method of Hefti (1995) to measure anterior and posterior acetabular coverage and contact area. All measurements were made by a single independent investigator. Results: 10 operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks. 26 hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B. Discussion: We were unable to assess operated hips which had gone on to replacement or severe osteoarthritis. This is a flaw as those hips with better radiographs have been selected out for study. Nonetheless this was a unique opportunity to assess the effect of innominate osteotomy on acetabular development in good numbers of hips with a variety of evolved outcomes. Conclusion: Acetabular coverage and load area in hips with a good outcome after innominate osteotomy with open reduction were not different to a control group of radiographically normal hips without previous DDH. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version

Normal acetabular development in developmental dysplasia of the hip (DDH) depends upon early and maintained congruent reduction. Computed tomography is an accepted method for evaluating this and attempts to quantify hip reduction, by various angular and linear measurements, have been reported. The aim of this study was to assess initial CT scans, following open reduction in the older child with DDH, with comparison of outcome to evaluate prognostic value. Method: Thirty consecutive patients underwent open reduction for DDH, with a mean age of 25.9 months at the time of operation. Acetabular morphology and the position of the femoral head were evaluated on the initial CT scan, taken on the first postoperative day, and AP pelvic radiograph taken at the latest follow-up. Results: The acetabulae of the dislocated hips were found to be significantly more anteverted than the normal. The dislocated hips also had significantly increased lateral displacement both initially and at latest follow-up. Posterior displacement of the proximal femoral metaphysis should raise concern due to an association with the need for further surgical intervention. These results did not however correlate with outcome. In conclusion, despite the significant differences noted between DDH and normal hips they did not predict acetabular development or persistent acetabular dysplasia

Purpose: The aim of this prospective controlled study was to assess the natural history of acetabular development in D.D.H. treated under 18 months of age. Method: For this purpose, patients who were treated using a posteromedial approach soft tissue surgical procedure due to unilateral D.D.H., had intraoperative radiographic anatomic reductions, had neither any type of avascular necrosis of the femoral head nor breakage of the Shenton’s line during the follow-up period, had complete follow-up till at least 10 years of age and had normal center-edge angles at the latest follow-up were selected from a prospective series that started in December 1993. Unaffected contrlateral hips were used as controls. Fourteen hips of 14 patients (13 females and 1 male) met the above mentioned strict criteriae and included the study. Acetabular angle of Sharp (AA) was measured to assess the acetabular slope in the frontal plane preoperatively and during follow-up. A paired t-test was used for the statistical analysis of the data and a P value less than 0.05 was considered significant. Conclusion: In anatomically reduced and uncomplicated dysplastic hips which have been treated under 18 months of age, acetabular slope in the frontal plane tends to improve continuosly till at least 10 years of age and reaches to similar angular values as in the unaffected hips at nearly 7 years of age. In such hips, it may not be appropriate to make a final decision on whether the acetabular development is sufficient or not before 7 years of age

Aims

Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing.

Aims

Eccentric reductions may become concentric through femoral head ‘docking’ (FHD) following closed reduction (CR) for developmental dysplasia of the hip (DDH). However, changes regarding position and morphology through FHD are not well understood. We aimed to assess these changes using serial MRI.

Aims

To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures.

Introduction: A criticism of innominate osteotomy (IO) is that it causes relative acetabular retroversion, predisposing to OA. This study was designed to address this hypothesis. Materials and Methods: We had access to radiographs of 30 patients 45 years after they had undergone open reduction and innominate osteotomy for late presenting DDH. Using the validated method of Hefti (1995) we measured anterior and posterior acetabular coverage, contact area and version. Results: Group 1 – 26 Post-op hips, Group 2 – 20 Contralateral hips, Group 3 – 21 Normal hips. Anterior coverage was 10.8% in group 1, 11.0% in group 2 and 12.0% in group 3. Posterior coverage was 18.8% in group 1, 18.9% in group 2 and 21.0% in group 3. Contact area was 16.1 cm2 in group 1, 13.9 cm2 in group 2, and 22.1 cm2 in group 3. Version was 7.20 in group 1, 7.10 in group 2, and 7.70 in group 3. A significant difference was found for contact area (p< 0.001). There was no significant difference in version (p = 0.845). Conclusion: Early OA may be related to contact area. Any abnormal (retro)version grows out. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version

AIMS. We present a retrospective study of bilateral CDH. We analysed the correlation of complications to the confounding factors. MATERIAL AND METHODS. We reviewed all bilateral CDH patients treated by the same surgeon at Southampton between 1988-2006. The patient recruitment was carried out as follows: . Group A – failed Pavlik harness;. Group B – late presentations not treated in Pavlik harness. RESULTS. The series included 50 patients (5 males; 45 females). The average age at presentation was 21 weeks (1-160). The average age at reduction was 15 months (4-45). The average follow-up was 6.7 years (4-15). 4 hips required revision due to loss of reduction. The number of surgical interventions throughout the treatment course ranged 4-12 (average – 7.3). AVN occurred in 17 hips (17%). Previous Pavlik harness treatment, CR and higher height of dislocation (HD) were associated with an increased rate of AVN. 42 pelvic (PO) and 12 femoral (FO) osteotomies (54%) were performed. CR and greater HD increased the pelvic osteotomy rate, while Pavlik harness treatment failure did not affect it. The mean AI demonstrated a gradual decline following reduction. While there was no difference between OR vs CR, and Group A vs B, the HD≥3 was associated with a significant acetabular development delay when compared to HD≤2. CONCLUSIONS. Despite the complexity of CDH cases, it is possible to achieve an acceptable level of inevitable complication (AVN – 17%, PO – 42%, FO – 12%, revision reduction – 4%). The rate of AVN was independently negatively affected by CR and prolonged immobilisation. Only the hips with initial HD of ≤2 had their acetabular index return to normal (<21°) before the age of 4 years. This is the first comprehensive analysis of bilateral CDH cases, emphasising the difficulty of treatment of this condition and providing the foundation for an outcomes-predicting system

Introduction: A criticism of innominate osteotomy is that it causes relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address this hypothesis. Materials and Methods: We had access to radiographs of 30 patients that had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation. The patients are now middle-aged and formed part of a previously reported study. Standardised, well-centered anteroposterior standing hip radiographs were obtained and using the validated method of Hefti (1995), anterior and posterior acetabular coverage and contact area were measured. From this we were able to extrapalate the acetabular version. Ten operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks. Twenty-six hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B. 21 further age and sex matched AP pelvis radiographs were taken from the PACS system at random. All of which had been reported as normal by a consultant musculoskeletal radiologist, these formed group C. The Kruskal Wallis test was used to compare the 4 outcomes, in the 3 groups. A significant difference between the groups was found for contact area (p< 0.001). There was no significant difference between the other 3 outcomes. Anterior coverage (p=0.509), posterior coverage (p = 0.135) and antirversion (p= 0.845). Conclusion: Acetabular coverage and anteversion in hips with a good outcome after innominate osteotomy with open reduction were not different to a control group of radiographically normal hips without previous DDH. The early osteoarthritic changes seen in these hips may be related to a decreased contact area compared to the normal population. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version

Introduction: The use of a trans-physeal, trans-articular suture anchor across a joint as a means of internal stabilisation has not previously been described. This study assesses the damage caused by the procedure to the immature porcine hip. Methods: Six twelve week old pigs underwent unilateral hip surgery. Anteroposterior pelvic radiographs were taken preoperatively and six weeks post-operatively. The acetabular index and diameter of the femoral head ossific nucleus of both hips were measured and compared. Specimens were analysed macroscopically for femoral head diameter, acetabular dimensions and for evidence of gross chondrolysis. Histological analysis was performed to assess the presence of articular chondrolysis and proximal femoral physeal arrest. Results: In four out of six specimens the rate of change of the acetabular index slowed as compared to the unoperated side, though none worsened. The diameter of the femoral ossific nucleus continued to increase in size at a similar rate to the unoperated side on radiological examination. Similar findings were seen with the macroscopic analysis. Gross and histological analysis of the articular cartilage showed only local areas of chondrolysis, related to the drilling. Metaphyseal growth at the proximal femoral physis was unaffected by the procedure. Discussion: The use of a trans-articular suture-anchor across the hip appears to cause marginal retardation of acetabular development in the normal hip. The trans-physeal approach to the hip does not appear to affect proximal femoral physeal or epiphyseal growth in the short-term, and the presence of a bioabsorbable suture within the joint did not result in chondrolysis

Between 1982 and 1997, twenty-six children between the age of 2 and 15 (mean age 10. 6 years) underwent proximal femoral replacement. Twenty have survived and all but three have reached skeletal maturity. Sequential radiographs have been reviewed with particular reference to acetabular development and fixation of the prostheses. Initially a cemented acetabular component was inserted, but recently uncemented implants and unipolar femoral heads that exactly fit the acetabulum have been used. In older children the acetabulum develops normally and the components remain well fixed. One of nine children over thirteen years with a cemented acetabulum needed revision for loosening and one suffered recurrent dislocations. In younger children the acetabulum continues to develop at the triradiate cartilage, so a cemented acetabulum grows away from the ischiopubic bar. As the component is fixed proximally, it becomes increasingly vertical and will almost inevitably loosen. In our study six of eight children under 13 years of age with a cemented acetabulum needed revision for loosening. Unipolar replacements in younger children tend to erode the superior acetabular margin. Femoral head cover is difficult to maintain, and of four unipolar implants in children under thirteen, two required acetabular augmentation. Cemented cups may be unsuitable for children under thirteen years but our results are not statistically significant. In this age group, unipolar implants may be more appropriate but they have serious potential complications. In children over thirteen, cemented implants survive longer. The number of uncemented implants in our study is too small to comment on long-term survival

Purpose: The use of a bioabsorbable suture anchor across a joint as a means of internal stabilization has not previously been described. This study assesses the iatrogenic damage caused by such a procedure in the normal immature porcine hip. Materials and Methods: Six twelve week old pigs underwent unilateral transarticular suture anchorage of the hip using a Panalok® RC Quick Anchor® Plus with Panacryl® suture. (Mitek® Products Johnson and Johnson). Anteroposterior pelvic radiographs were taken pre-operatively and six weeks post-operatively. Acetabular index, diameter of the femoral head ossific nucleus of both hips on both occasions were measured and compared. Pigs were sacrificed six weeks post-operatively. Specimens were analysed macroscopically for femoral head diameter, acetabular dimensions, and presence of gross chondrolysis. Histological analysis was performed to assess the presence of articular chondrolysis, and proximal femoral physeal arrest. Results: In four out of six hips the rate of change of the acetabular index slowed as compared to the unoperated side though none worsened. The diameter of the femoral ossific nucleus on the operated side continued to increase in size at a similar rate as the unoperated side, despite the surgical procedure according to radiographic comparison. Similar findings were made in the macroscopic analysis of the hip geometry. Gross and histological analysis of the articular cartilage show only local areas of chondrolysis related to the drill holes, and in one hip where a second hole was drilled, cartilage regeneration was noted. Metaphyseal growth at the proximal femoral physis was unaffected by the procedure. Conclusions: The use of a trans-articular suture anchor across the hip appears to cause marginal retardation of acetabular development in the normal hip. The procedure does not appear to affect proximal femoral physeal or epiphyseal growth and the presence of a bioabsorbable suture within the joint did not result in chondrolysis

Background The ossific nucleus of the femoral head is usually present ultrasonographically around 12 weeks of age. It has been considered that the presence of an ossific nucleus in the femoral head is an indication of hip stability. In the ultrasound scan clinic for the assessment of developmental dysplasia of the hip at Sheffield Children’s Hospital, we have identified unstable hips with ossific nuclei, as well as, the appearance of ossific nuclei at as early as 2 weeks of age. These observations suggested the need to clarify the initial considerations that the ossific nucleus appeared ultrasonographically around 12 weeks of age and was an indicator of hip stability. Aim To determine the relationship, if any, between the presence of the ossific nucleus of the femoral head ultrasonographically and stability of the hip. Patient selection We have included in our study all the children who have had an ultrasound scan of their hips from 1996 to 1999 at Sheffield Children’s Hospital for suspected developmental dysplasia. Methodology We have retrospectively reviewed reports of ultrasound scans performed for developmental dysplasia of the hip between 1996 and 1999. We have looked at the report for both the hips of each child. We have collected and analyzed data with regard to the age of the child at the time of the scan, the depth of the acetabulum, the shape of the femoral head, the presence or absence of an ossific nucleus, the dynamic stability of the hips and the congruity of the joint as reported on the ultrasound report. We report the findings in the first 318 hips of the 627 available patients in the study period. Results The ossific nucleus can appear as early as 2 weeks and yet may not be visible until 24 weeks. In the 318 hips examined the ossific nucleus was present in 46 (14.47%). The age range for these scans was 1–40 weeks after birth. Of the 318 hips 252 (79.24%) were stable on dynamic screening, 274 (86.16%) had a normal(spherical) appearance of the femoral head, 209 (65.72%) had normal acetabular development and 263 (82.7%) demonstrated congruence of the hip joint. These data have been analyzed using Microsoft excel at confidence intervals of 0.8, which suggest no relationship between the presence of the ossific nucleus and hip stability. Conclusion The limited early results of this study have shown that the ossific nucleus of the femoral head can appear from a very early age, may not appear until well after 12 weeks of age and is not an indicator of hip stability. Its presence on ultrasound scan does not exclude developmental dysplasia of the hip