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Original article
Introduction
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Table 1
Patient demographics
Sex
Boys
Girls
Involvement
Unilateral
Bilateral
Weight-for-age percentile
Z 50
< 50
Ossific nucleus appearance
Present
Absent
Group 1
Group 2
11
18
6
32
19
10
32
6
11
20
13
23
20
12
50
1
Results
The average follow-up period was 6.6 years (range, 5.68.8
years). At the time of the operation the mean age was
13.9 months (range, 723 months). Radiographic analysis
demonstrated consistent acetabular correction and significant improvement in the AI (mean, 22.61; P < 0.001).
Overall treatment results including radiological measurements are summarized in Table 2. The Pearson correlation
test revealed no significant difference between the
correction ratio of AI and the follow-up period for surgically
treated patients (r = 0.02; P > 0.05). There were no
statistically significant differences between the correction
ratio of AI and the operative age (r = 0.19; P > 0.05),
operative side (r = 0.19; P > 0.05 and r = 0.19; P > 0.05,
for right and left sides, respectively), presence or absence
of ossific nucleus (r = 0.07; P > 0.05) and sex of the
patients (r = 0.08; P > 0.05). The effects of the ambulation
pattern of the patient at the time of the operation on
radiological parameters are shown in Table 3.
Although, 44 (65.6%) patients obtained excellent or good
results, the functional outcome in patients and parents
was rated as very favorable because 51 parents who
provided feedback reported that they were satisfied with
the procedure. Of them, four parents could not be
reached at the time of this review but were satisfied
when last seen. According to the modified McKay criteria,
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38
< 0.001
< 0.001
NS
NS
AI
Preoperative
Last visit
CEA at the last visit
CDA
ACEA
ACEA, anterior center-edge angle; AI, acetabular index angle; CDA, collodiaphyseal angle; CEA, center-edge angle.
Acetabular index
CEA
CDA
ACEA
Group 1
Group 2
24.055.311
15.8012.181
142.609.211
26.8412.211
22.965.311
17.8310.311
145.049.991
29.1610.661
> 0.05
> 0.05
> 0.05
> 0.05
ACEA, anterior center-edge angle; CDA, collodiaphyseal angle; CEA, centeredge angle.
Discussion
To date, the management of a child after walking age with
developmental hip dysplasia remains controversial
[1520]. Perhaps the most challenging clinical scenario
occurs when the proximal part of the femur of a weightbearing child compresses the posterosuperior part of the
acetabulum leading to adhesion and contractures with
shortening of the external rotators. Numerous studies are
available analyzing the outcomes after open reduction of
DDH by anterolateral or medial approaches [2123].
Fig. 1
The preoperative anteroposterior (AP) pelvis (a), frog views (b), and initial postoperative AP pelvis view (c) of an 11-month-old female patient who
was at the walking age at the time of the operation. The acetabular index angle is 441 and the femoral head is in the subluxated position. (d) The
postoperative third year AP pelvis view demonstrates a good acetabular development without avascular necrosis changes.
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Variables
McKay criteria
Excellent
Good
Fair
Poor
Kalamchi changes
Type 2
Type 3
Type 4
Severin classification
Excellent
Good
Fair
Poor
Group 1
Group 2
11
10
11
3
13
10
5
4
NS
NS
NS
NS
6
4
1
7
0
2
NS
NS
NS
23
6
2
1
40
6
3
2
NS
NS
NS
NS
Fig. 2
A 7-month-old female patient with unilateral involvement. The preoperative AP pelvis view (a) demonstrates bilateral ossific nucleus, a dislocated rightsided hip and 341 of acetabular index angle (AI). A medial open reduction was performed (b). After removing the cast, the patient was followed up in
an abduction brace for an additional 1.5 months. Although there is type 3 Kalamchi changes, AP pelvis (c) and frog views (d) of the patient at
postoperative third year shows marked acetabular development with Severin grade 3 hip.
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40
cast application with the goal of optimizing the maintenance of anatomic reduction. Currently, we always
perform inferior transverse acetabular ligament resection
to ensure anatomic reduction. The safe zones of the hip
joint are then evaluated, and if found not to be suitable so
that additional femoral correction is required, our
rationale is to perform a proximal femur varus-producing
osteotomy and/or a derotation osteotomy. Two patients
who had undergone proximal femur osteotomy at the
time of medial approach were excluded from the study.
There are certain limitations of this study. This is a
retrospective review that analyzes the results of the
medial approach in children up to 23 months of age. It is
likely that our clinical results, complication rates, and
advanced reoperation rates for degenerative changes may
be more favorable in the future as the follow-up period
broadens. While all patients in this homogenous series
received a medial approach, long-term results may help
determine the exact consequences of this approach.
Finally, identifying an appropriate control group for this
patient cohort is difficult. Even historical cohorts
followed in natural history studies are of limited value
because of the substantial heterogenity of DDH in terms
of the pathoanatomy, associated acetabular abnormalities,
age of the patient, and clinical manifestations of a
subluxated hip. The cohort we analyzed is unique in
that it represents a consecutive series of patients, none of
whom had received any previous intervention or sequential or postoperative additional surgeries.
Conclusion
Acknowledgements
Conflicts of interest
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