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Post-reduction avascular necrosis in congenital dislocation of the hip

DR Cooperman, R Wallensten and SD Stulberg
J Bone Joint Surg Am. 1980;62:247-258.

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Post-Reduction Avascular Necrosis in Congenital

Dislocation of the Hip
LONG-TERM FOLLOW-UP STUDY OF TWENTY-FIVE PATIENTS

BY DANIEL R. COOPERMAN, M.D.*, CHICAGO, RICHARD WALLENSTEN, MED. LIC.t, STOCKHOLM, SWEDEN,
AND S. DAVID STULBERG, M.D.*, CHICAGO, ILLINOIS

From the Orthopaedic Unit, Karolinska Institute, Stockholm, Sweden

ABSTRACT: Twenty-five patients with thirty con- Recently Buchholz and Ogden, as well as Kalamchi,
genitally dislocated hips in which avascular necrosis described various patterns of avascular necrosis that can
developed after closed reduction were followed for an occur after reduction of a congenital dislocation of the hip.
average of thirty-nine years from the time of reduction. They described an association between the early pattern of
Twenty-four of the thirty hips had moderate or severe involvement in the proximal part of the femur and the pat-
osteoarthritis and twenty-two of the twenty-five pa- tern of deformity seen there at maturity. These two
tients had significant pain or loss of function, or both, studies, as well as the ones mentioned earlier, warned of
by the time they were forty-two years old. the likelihood that the deformities following avascular
The deformities produced by avascular necrosis necrosis are likely to lead to early, painful degenerative ar-
that were related to osteoarthritis included: (1) loss of thritis. However, none of the studies have contained
sphericity of the femoral head, (2) persistent lateral sufficiently long follow-up information on the patients to
and proximal subluxation, (3) irregularity of the me- reveal how often the arthritis supervenes, how severe it is,
dial part of the femoral head, and (4) acetabular or how long a time it takes to become manifest.
dysplasia. In our report we describe the course of twenty-five pa-
The study suggests that if avascular necrosis de- tients in whom avascular necrosis developed following
velops following closed reduction of a congenitally dis- treatment for congenital dislocation of the hip, all of the
located hip, attempts should be made to prevent lateral patients having been treated by closed reduction and im-
and proximal subluxation of the femoral head and to mobilization in a plaster cast. The patterns of avascular
correct these abnormalities, if possible, once they oc- necrosis are described, as are the final deformities and the
cur. significance of these deformities in relation to the de-
velopment of degenerative arthritis.
Avascular necrosis is a complication of treatment of
Materials and Methods
congenital hip dislocation which frequently results in sig-
nificant deformity of the hip joint. Although the reported Between 1927 and 1943, 184 children who were
incidence of avascular necrosis varies, there is general younger than four years old were treated for congenital dis-
agreement that it occurs primarily in hips that are treated location of the hip at the Norrbacka Orthopaedic Hospital
and that its incidence is dependent on the age of the patient of the Karolinska Institute in Stockholm, Sweden. Roent-
at the time of reduction and on the methods used to obtain genograms and records were available for 109 of the chil-
and hold the reduction15 Crego and Schwartzman had no dren. Avascular necrosis of the femoral head developed
patients with the complication after they used skeletal trac- following closed reduction and plaster-cast immobilization
tion to achieve closed reduction, while Esteve observed an in fifty-four (50 per cent) of those patients. Fourteen of the
incidence of 68 .6 per cent after performing closed manipu- fifty-four had had subsequent acetabuloplasties and there-
lation to obtain reduction. The recorded incidence of avas- fore were includednot in this study. Ofthe remaining forty
cular necrosis after closed reduction in other studies fell patients, twenty-five could be located for follow-up. In
between those extremes: 5 1 per cent6, 46.2 per cent 45 this group of twenty-five patients, there were thirty-five
per cent9, and 10.2 per cent4. There also has been a high dislocated hips; that is, ten patients had bilateral disloca-
incidence of avascular necrosis after open reduction: 30 tions.
per cent9 and 22 per cent6, for example. Of the ten patients with bilateral dislocation, five had
one hip eliminated from the study. One femoral head never
* Section of Orthopaedics, University of Chicago, 950 East 59th manifested avascular necrosis; one hip had not been ade-
Street, Chicago, Illinois 60637.
quately reduced; one hip was followed for too short a
t Orthopaedic Unit, Karolinska Institute, 104 01 Stockholm 60,
Sweden. period of time after reduction to determine whether os-

VOL. 62-A, NO. 2, MARCH 1980 247

248 D. R. COOPERMAN, RICHARD WALLENSTEN, AND S. D. STULBERG

FIG. 1-A
Figs. 1-A through 1-E: A patient with involvement of the posteromedial part of the femoral head by avascular necrosis.
Fig. 1-A: Moderately dislocated left hip of a one and one-half-year-old girl, immediately prior to reduction.

FIG. 1-B
At three years old, one and one-half years after reduction, the patient has involvement of the medial femoral epiphysis and metaphysis, with delayed
ossification.

teoarthritis would develop; and two hips had acetabulo- thirteen months and seventeen months old; eleven, be-
plasties during the patients’ youth, thus altering the natural tween eighteen and twenty-three months; nine, between
course of the disease. This left thirty hips in twenty-five twenty-four and twenty-nine months; one, thirty-two
patients for our study. months; and four patients were between thirty-six and
All thirty hips initially were completely dislocated. In forty-seven months old.
all of the patients, the most medial aspect of the proximal The treatment used in the vast majority of the patients
end of the femur was lateral to Perkins’ line. In all of the was that standardized by Severin, whose monograph ap-
femoral heads in which the ossific nucleus was visualized peared at the end of the period during which most of the
pre-reduction (twenty-seven of thirty hips), it was above children were treated. Closed reduction was carried out by
Hilgenreiner’s line; in the three in which it was not a manipulation that emphasized the avoidance of force.
visualized, the medial beak of the femur was at or above Adequacy of reduction was usually assessed with roent-
Hilgenreiner’s line. The amount of superior displacement genograms and, in addition, an arthrogram. None of the
ranged from slight (Fig. 2-A), to moderate (Fig. 1-A), to hips in this series redislocated after the initial closed re-
marked (Fig. 3-A), with a comparable number of hips in duction was performed. The hips were immobilized in
each group. double spica casts in approximately 90 degrees of flexion
None of the patients in this study had been treated and 70 degrees of abduction. These were bilateral short
prior to being seen at our institution. The average age of spicas , allowing free motion of the knees . The duration of
the patients at the time that the diagnosis was made was plaster-cast immobilization ranged from two to five
23.7 months. At diagnosis, five patients were between months. Following discontinuation of the cast treatment,

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 AVASCULAR NECROSIS IN CONGENITAL DISLOCATION OF THE HIP 249

FIG. 1-C
At five years old (left), the medial epiphysis and metaphysis are still ossifying and there is mottling of the involved area. Six years later (right), the
mottled appearance is still present in the metaphysis and there is a scalloped area in the medial epiphysis. The femoral head, as a whole, is slightly
enlarged, but is round and well reduced. The acetabulum appears to be developing normally.

FIG. 1-D FIG. l-E

Fig. 1-D: At forty years old, the patient has a normal right hip without symptoms of osteoarthnitis. The left hip has moderate osteoarthnitis (with
more than 50 per cent narrowing ofthe superiorjoint space), marginal femoral osteophytes, and small osteophytes and cysts on the acetabular lip. The
femoral head is not subluxated and the acetabulum is not dysplastic.
Fig. 1-E: At fifty years old, the patient still has a normal right hip but there is severe osteoarthnitis in the left hip, with almost complete loss of joint
space superiorly, a large femoral foveal osteophyte, and a medial acetabular osteophyte. An osteotomy was performed when she was forty-seven
years old.

abduction splints were used for two hours during the day one and fifty-six years old. All but three hips were fol-
and all night. The splints were used for six to eighteen lowed for at least thirty-six years from the time of reduc-
months. No further treatment was prescribed. tion. Those three patients were followed until they were
The patients were re-examined at an average of seventeen, eighteen, and twenty-four years old, and they
thirty-nine years following closed reduction. At final were included in this study because the ultimate fate of
follow-up, three patients were between seventeen and their hips could be determined; that is, in all three patients
twenty-four years old; seven, between thirty-eight and significant osteoarthritis had developed at the time of
forty; ten, between forty-one and forty-four; five, between follow-up. Two of the patients had surgical hip fusions for
forty-five and fifty; and five patients were between fifty- relief of pain and the third had severe osteoarthritis with

VOL. 62-A, NO. 2, MARCH 1980

250 D. R. COOPERMAN, RICHARD WALLENSTEN, AND S. D. STULBERG

FIG. 2-A

Figs. 2-A through 2-E: A patient with involvement of the whole femoral head by avascular necrosis.
Fig. 2-A: Slightly dislocated night hip and subluxated left hip of a one year and one-month-old girl, immediately prior to reduction.

-
FIG. 2-B FIG. 2-C
Fig.
2-B: Three years later there is a gradual ossification of the femoral head, all of which has been involved by avascular necrosis. The femoral
neck is flattened superiorly. There is persistent lateral, but not superior, subluxation.
Fig. 2-C: At twelve years old, the patient is seen with a large, deformed femoral head with incomplete ossification, premature closure of the
epiphyseal plate, proximal and lateral subluxation, and early osteoarthnitis.

TABLE I
complete loss of joint space in the superior aspect of the

CRITERIA FOR THE DIAGNOSIS OF AVA5CULAR NECROSIS

hip joint as well as significant osteophyte formation, both
FOLLOWING REDUCTION OF A CONGENITALLY DISLOCATED HIP* femoral and acetabular, at final follow-up.
Thirteen patients were personally interviewed and ex-
Total Necrosis of Partial Necrosis of
the Femoral Head the Femoral Head
amined. The remaining twelve were interviewed by tele-
phone. All twenty-five patients had follow-up anteropos-
Failure of appearance of the Failure of ossification of
tenor and frog-leg lateral roentgenograms.
ossific nucleus ofthe femoral the nucleus in a specific
head for one year or longer area of the femoral head At the follow-up interview, the patient’s history was
following reduction for one year or longer after carefully reviewed to determine if other conditions existed
reduction
that might have complicated the congenital dislocation. No
Failure of growth in an existing Roentgenographic evidence of patients had a history of a fracture or traumatic dislocation
ossific nucleus for one year viability of the remainder
or longer after reduction of the femoral head
of the hip, Legg-Perthes disease, septic arthritis, juvenile
rheumatoid arthritis, paralytic disease, or spastic disor-
Increased roentgenographic Abnormalities in a specific
density of the entire area of the epiphysis which ders. Adequate information was obtained to allow us to
femoral head followed by can progress to fragmenta- evaluate the current status of the patients using the Iowa
the roentgenographic tion of the epiphysis in
hip-rating scale for pain and function5.
appearance of fragmentation that area
The criteria that we used to diagnose avascular ne-
a Adapted from the studies of Salter et al . and of Gage and Winter. crosis are included in Table I. Once it was determined that

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 AVASCULAR NECROSIS IN CONGENITAL DISLOCATION OF THE HIP 251

avascular necrosis had developed, each patient’s roent- duction, sex distribution, method of treatment, and ade-
genograms were examined for its extent and location. The quacy of reduction.
quality of reduction was assessed, as were the sequences
Results
of development of the femoral head, femoral neck, and
acetabulum. The age at onset of osteoarthritis and the final At final follow-up, twenty-nine of thirty hips in the
extent and characteristics of the osteoarthritis were evalu- avascular necrosis group had roentgenographic evidence
ated. of osteoarthritis. We measured the severity of osteoar-
In order to determine whether the results seen at thritis in terms of the extent that the joint space was nar-
follow-up were attributable to avascular necrosis spe- rowed. Severe osteoarthritis was considered to exist if the
cifically or to the treatment regimen in general, we as- joint space was completely obliterated. There was
sembled a control population consisting of thirty patients moderate osteoarthritis if the joint space had narrowed 50
with unilateral congenital dislocation of the hip. The ages per cent or more, and mild osteoarthritis meant that the
at the time of treatment and the sex distribution of these joint space had narrowed but not by more than half of the
patients were essentially identical to those in the group normal space. Twenty-four hips (nineteen patients) had

FIG. 2-D FIG. 2-E

Fig. 2-D: Four years later, advanced osteoarthritis and progressive secondary subluxation are present.
Fig. 2-E: At eighteen years old, the patient has severe osteoarthnitis.

with avascular necrosis, and the patients also had been moderate to severe osteoarthritis. In addition to the nar-
treated at the Norrbacka Clinic between 1927 and 1943 by rowing of the joint space, all of the hips demonstrated os-
the method of treatment described. All of these patients teophyte formation medially on either the femoral head or
were followed at least until skeletal maturity and fifteen the foveal aspect of the acetabulum, or both. One-half of
were followed for an average of forty years. them had osteophytes on the lateral roof of the
The degree of displacement that had to be overcome acetabulum. Fifty per cent demonstrated cystic changes in
to obtain reduction was comparable in the avascular ne- the femoral head and 25 per cent had degenerative cysts in
crosis group and the control group. It did not appear to be a the lateral roof of the acetabulum. Sclerosis of the roof of
factor in the development of avascular necrosis. In fact, the acetabulum was common, being seen in 75 per cent of
some of the worst results were seen in patients who had the patients.
had minimum superior dislocation (Fig. 2-A). Seven patients had had surgery prior to the initiation
The accuracy of reduction was assessed using a trans- of this study, which was performed after osteoarthritis had
parent grid, a method suggested by Smith et al. (Fig. 7). developed and had become sufficiently symptomatic for
The measurements of the adequacy of reduction were the patient to seek medical attention. Two had hip fusions
made on the hips immediately after they had been re- in late adolescence, fifteen and sixteen years after reduc-
duced and during the first year after reduction. All of the tion. The rest had femoral osteotomies, both varus and
hips were reduced perfectly with regard to residual valgus, in an effort to palliate their symptoms thirty-three
superior displacement. The lateral displacements were and one-half, thirty-four, thirty-four and one-half, forty-
measured using the c/b ratio (Fig. 6) and the ratio averaged three, and forty-five years after reduction. All five of the
0.75 (range, 0.59 to 0.92) in the avascular necrosis group patients who had osteotomies had good relief of pain for
and 0.74 (range, 0.65 to 1 .0) in the control group. We at least eighteen months after the procedure; three were
concluded that the control group and the avascular necrosis still quite satisfied three to five years after osteotomy.
group were comparably matched with regard to age at re- Of the other twelve, all had pain ranging from

VOL. 62-A, NO. 2, MARCH 1980

252 D. R. COOPERMAN, RICHARD WALLENSTEN, AND S. D. STULBERG

FIG. 3-A
Figs. 3-A through 3-D: A patient in whom coxa magna has developed.
Fig. 3-A: Markedly bilaterally dislocated hips of a two-year-old girl, immediately prior to closed reduction.

. .

.1

FIG. 3-B
Four years later, the right femoral head is enlarged. There is apparent bilateral flattening of the medial epiphysis and metaphysis, with persistent
lateral, but not superior, subluxation bilaterally.

moderate to disabling and six had enough functional im- either a grossly irregular contour (Fig. 2-C) or a finely ir-
pairment to prohibit their working at jobs requiring pro- regular surface (Fig. 1-C). Twenty-five hips demonstrated
longed weight-bearing. mild to marked acetabular dysplasia. This was in marked
Five hips in five patients had mild osteoarthritis. In contrast to the hips in the control group, none of which had
addition to up to 50 per cent narrowing of the joint space, deformed femoral heads and only five of which had
two patients had small, marginal osteophytes on the dysplastic acetabula at maturity. Four of the five hips with
femoral head; two others had cystic changes in the femoral dysplastic acetabula were followed for an average of forty
head; and the fifth patient had cystic changes in the years and in all moderate to severe osteoarthritis de-
acetabulum. veloped, similar in pattern to that seen in the group with
Three of the five patients had mild pain and none had avascular necrosis. Eleven hips that were normal at
significant functional impairment. skeletal maturity were available for follow-up. All were
One hip was roentgenographically free of osteoar- essentially normal at follow-up, an average of forty years
thritis. The patient was pain-free and functionally normal later.
at follow-up. It appeared that two factors led to the development of
Our findings confirm the commonly held belief that osteoarthritis in the avascular necrosis group: deformity of
the development of avascular necrosis following reduction the femoral head and acetabular dysplasia.
of congenital dislocation of the hip is associated with
early , painful degenerative arthritis. Deformity of the Femoral Head
These patients were followed closely during adoles- Nine (30 per cent) of the femoral heads were de-
cence. At skeletal maturity, a vast majority of the hips formed at maturity. The pattern of avascular necrosis was
were abnormal . Nine had a deformed femoral head with studied to determine if the deformity was associated with

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 AVASCULAR NECROSIS IN CONGENITAL DISLOCATION OF THE HIP 253

FIG. 3-C
When the patient is ten years old the right femoral head is uncovered, in contrast with the left. There is an apparent bilateral break in Shenton’s line,
although it is greater on the right side than on the left. There is somewhat more lateral subluxation on the night side than on the left.

FIG. 3-D
Three years later, there is progressive lateral and superior subluxation of the enlarged right femoral head. The left hip is no longer subluxated
laterally or superiorly and is developing quite well.

certain patterns of involvement of the ossific nucleus. Deformity of the femoral head was not necessarily as-
There were two hips with involvement of the whole head sociated with irregularity of the surface of the head, but
and twenty-eight with partial involvement of the head. The it too caused osteoarthritis. If the lateral aspect of the
hips with partial involvement of the head were evenly dis- epiphysis was damaged, asymmetrical growth was noted
tributed in medial, lateral, and posterior localizations. and the femoral head appeared to grow out of the
With one exception there was no correlation between the acetabulum while the femoral head became flattened (Fig.
pattern of localization of avascular necrosis within the 4-C). This was occasionally noted in spite of what had
epiphysis and the deformity. The exception was that been an adequate initial reduction. Also, if the femoral
partial involvement of the medial half of the epiphysis head gradually became subluxated during the first few
with sparing of the lateral half produced a subtle type of years after reduction, to the extent that the Shenton’s line
irregularity of the surface of the femoral head which, was broken, marked deformity of the femoral head was
although it was essentially spherical, had a mottled, noted (Figs. 2-B and 2-C). All nine hips with deformed
cystic, and slightly flattened area on its medial aspect femoral heads had moderate to severe osteoarthritis at
which persisted even after revascularization was complete follow-up.
(Fig. 1-C).
/4 cetabular Dysplasia
All irregularities of the surface were associated with
the development of osteoarthritis, even when the de- Acetabular dysplasia was a common deformity seen
velopment of the hip appeared quite satisfactory at matur- in patients in whom avascular necrosis of the femoral head
ity. developed following closed reduction (twenty-five hips).

VOL. 62-A, NO. 2, MARCH 1980

254 D. R. COOPERMAN, RICHARD WALLENSTEN, AND 5. D. STULBERG

Figs. 4-A, 4-B, and 4-C: A patient with progressive valgus deformity from premature closure of the lateral epiphyseal plate.
Fig. 4-A: Bilaterally dislocated hips of a one and one-half-year-old girl, immediately prior to reduction.

When the patient is three years old (left), resolving avascular necrosis with lateral extrusion of the epiphysis is seen. There is no break in Shenton’s
line and the femoral head is slightly subluxated laterally. Three years later (right), there is a break in Shenton’s line and valgus deformity is develop-
ing.

The dysplasia was measured by the adult acetabular angle than 42 degrees at maturity.
described by Sharp and by the percentage of the femoral In the avascular necrosis group, only six of the
head covered by the acetabulum. To measure the adult femoral heads were at least 75 per cent covered by the
acetabular angle, first a baseline is drawn between the dis- acetabulum, as measured on an anteroposterior roentgen-
tal margins of the left and right teardrop figures . Two ogram using the following method. First a reference line is
additional lines are drawn: one from the lateral end of the drawn through the centers of both femoral heads . A per-
inner teardrop line to the lateral edge of the acetabulum and pendicular line is drawn from the lateral lip of the
the other perpendicular to the inner teardrop baseline. acetabulum to this line. The percentage of coverage is cal-
These two lines form the angle, which in the group with culated by dividing the amount of the femoral head that is
avascular necrosis averaged 46 degrees (range, 40 to 50 under the acetabulum by the diameter of the head as repre-
degrees). Nineteen of the thirty hips had an angle greater sented on the reference line. The average coverage in the
than 45 degrees (the maximum in a normal hip at maturity group with avascular necrosis was 66 per cent (range, 38
is 42 degrees), and five had an angle of 42 degrees or less. to 100 per cent). Only six femoral heads were more than
In the control group, only five hips had an angle greater 75 per cent covered. In the control group, twenty-five

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 AVASCULAR NECROSIS IN CONGENITAL DISLOCATION OF THE HIP 255

FIG. 4-C
When the patient is three years old (left), resolving avascular necrosis with lateral extrusion ofthe epiphysis is seen. There is no break in Shenton’s
line and the femoral head is slightly subluxated laterally. Three years later (right). there is a break in Shenton’s line and valgus deformity is
developing.

heads were at least 75 per cent covered. In all of the In five of the control hips acetabular dysplasia developed.
femoral heads in the avascular necrosis group that were Two patients in this study had treatment for acetabu-
less than 75 per cent covered, moderate to severe osteoar- lar dysplasia. Each patient had bilateral avascular necrosis
thritis had developed at final follow-up. and bilateral acetabular dysplasia developed. In each, an
The development of acetabular dysplasia in the hips acetabular roof was formed over one hip using turned-out
with avascular necrosis appeared to be related to two fac- ipsilateral iliac bone. These procedures were done when
tors: (1) coxa magna with persistent lateral subluxation of one child was eight years old and the other, thirteen. These
the femoral head, and (2) progressive valgus deformity re- two hips were eliminated from the study results, as men-
lated to an epiphyseal arrest in the lateral aspect of the tioned in Material and Methods, but they are of interest
proximal femoral epiphysis. because they offer an opportunity to compare the de-
Coxa magna was noted in twenty-one hips. In eigh- velopment of a hip that was operated on with the virtually
teen, it was associated with persistent lateral subluxation identical contralateral hip on which no operation was per-
of the femoral head. A transient lateral subluxation fol- formed (Figs. 5-A through 5-D). Both hips on which an
lowing reduction was seen in both the avascular necrosis acetabuloplasty had been performed did considerably bet-
and the control groups and was comparable in degree and ter clinically and roentgenographically than the contralat-
incidence. In the control group, in twenty-five hips this eral hips.
lateral subluxation resolved within four years of reduction,
and those hips were essentially normal at skeletal matur- Discussion
ity. In contrast, so-called medialization of the femoral Our results support the widely held belief that the de-
head rarely occurred in the avascular necrosis group. In velopment of avascular necrosis following the reduction of
eighteen of the twenty-one hips in which coxa magna de- a congenitally dislocated hip is usually associated with the
veloped, there was persistent lateral subluxation and early development of a significant osteoarthritis. Of the
acetabular dysplasia. In three hips, coxa magna developed thirty hips followed in this study, twenty-four (80 per cent)
associated with an unusually deep reduction and acetabular had moderate or severe osteoarthritis at the time of
coverage of 75 per cent or more of the femoral head. In follow-up, and only one hip was free of any signs of ar-
these three hips only mild degenerative arthritis devel- thritis. These results emphasize the importance of avoid-
oped. ing, if possible, this complication of treatment of a con-
In two hips, a growth arrest of the lateral aspect of genitally dislocated hip. But severe osteoarthritis need not
the proximal femoral epiphysis appeared to result in a pro- inevitably follow avascuiar necrosis. In six hips significant
gressive valgus deformity, which resulted in acetabular arthritis did not occur. In these hips the femoral heads re-
dysplasia (Fig. 4-C). In five hips, acetabular dysplasia re- mained spherical and smooth following the development
suited although there was neither coxa magna nor a growth of avascular necrosis and were at least 75 per cent covered
arrest at the lateral epiphysis. The cause was not apparent. within the acetabulum.

VOL. 62-A, NO. 2, MARCH 1980

256 D. R. COOPERMAN, RICHARD WALLENSTEN, AND S. D. STULBERG

HG. 5-A
Figs. 5-A through 5-D: A patient treated with acetabuloplasty for persistent subluxation.
Fig. 5-A: Bilaterally dislocated hips of a three-year-old girl, immediately prior to reduction.

Two years later she is seen with bilateral avascular necrosis. Both hips are subluxated laterally, but Shenton’s line is intact.

FIG. 5-C
At the age of thirteen. it was thought that the left hip was more subluxated than the right one. Therefore. an acetahuloplasty was performed. At the
age oftwenty. bilateral valgus deformities of Ihe femoral head and neck and associated acetahular dysplasia are present. However, the left hip is less
subluxated than the right hip.

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 AVASCULAR NECROSIS IN CONGENITAL DISLOCATION OF THE HIP 257

,, - .

FIG. 5-D
Twenty-nine years later, there is advanced arthritis in the right hip. A femoral osteotomy has been performed to relieve pain. The left hip remains
asymptomatic. There are mild osteoarthnitic changes present on the left side, but the hip is well reduced and covered.

There was an increased tendency for hips that had sified. Persistent lateral subluxation with lack of coverage
undergone avascular necrosis to remain subluxated lateral- of the femoral head may lead to further deformity and
ly for several years following reduction. This persistent acetabular dysplasia, both of which are associated with the
lateral subluxation leads to the development of acetabular development of osteoarthritis . The asymmetrical closure
dysplasia and the occurrence, when the patient is relatively of the epiphyseal plate and the subsequent development of
young, of significant osteoarthritis. Thus, achieving and a valgus deformity of the proximal end of the femur may
maintaining a deep concentric reduction appears most im- result in an increasingly dysplastic acetabulum and flat-
portant to avoid the complications associated with avascu- tened femoral head. It is important to be aware that these
lar necrosis. events associated with poor results may not be obvious for
four to eight years after reduction.
NORMAL
HIP Acetabular dysplasia was a major contributing factor
Center Line Perkins’ Line to the development of osteoarthritis in the majority of our
patients. In two patients with bilateral acetabular dysplasia
following avascular necrosis, an acetabuloplasty improved
the long-term result (Figs. 5-A through 5-D). The cases of
these two patients suggest that it is possible to treat the

IC)
TRANSPARENT GRID
ne
C
huT lP LEFT lIP
I
3 2 1 0 1 2 3

Lot.rol Position

Sup.nior sit,on
-1 -1
FIG. 6
Drawing of pelvis showing Hilgenreiner’s line (a line through the cen- I
tens of the tniradiate cartilages), Perkins’ line (a perpendicular erected on
Hilgenreiner’s line, passing through the outermost border of the acetabu-
lar roof), center line, distance from center line to Perkins’ line (h), dis-
tance from center line to the medialmost portion of the femoral neck (c),
and distance from the supenionmost part of the femoral neck to Hilgen-
reiner’s line (h). (Reprinted from Correlation of Postreduction Roent-
genognams and Thirty-One-Year Follow-up in Congenital Dislocation of
the Hip, by W. S. Smith, C. E. Badgley, J. B. Orwig, and J. M. Harper.
J. Bone and Joint Sung. , 50-A: 1082, Sept. 1968).
FIG. 7

Our study emphasizes the importance of long-term Transparent grid superimposed on a drawing of the pelvis showing
method of obtaining measurements b, c, and h. CL. , P.L. , and ilL.
follow-up of hips that have undergone avascular necrosis
refer to center line, Perkins’ line, and Hilgenreiner’s line, respectively.
following reduction of a congenitally dislocated hip. De- (Reprinted from Correlation of Postreduction Roentgenograms and
Thirty-One-Year Follow-up in Congenital Dislocation of the Hip, by
formity of the femoral head may not be completely evident
w. S. Smith, C. E. Badgley, J. B. Orwig, and J. M. Harper. J. Bone
until the femoral head and acetabulum are completely os- and Joint Sung. , 50-A: 1082, Sept. 1968.)

VOL. 62-A, NO. 2, MARCH 1980

258 D. R. COOPERMAN, RICHARD WALLENSTEN, AND S. D. STULBERG

acetabular dysplasia that results in association with avas- avascular necrosis. Our study does point out the impor-
cular necrosis. As our experience with treatment is limited tance of achieving and maintaining a concentric, well seat-
to these two patients, our study cannot serve as a guide to ed reduction and establishing good acetabular coverage.
recommendations of specific treatment and certainly does The role of acetabuloplasty and of pelvic and femoral os-
not suggest the need for the routine performance of an teotomy in achieving these objectives is certainly worthy
acetabuloplasty in hips that have undergone post-reduction of critical study.

References
I . BUCHHOLz, R. W., and OGDEN, I. A.: Patterns of Ischemic Necrosis of the Proximal Femur - Non-Operatively Treated Congenital Disease. In
The Hip: Proceedings of the Sixth Open Scientific Meeting of The Hip Society. St. Louis, C. V. Mosby, 1978.
2. CREGO, C. H., JR., and SCHWARTZMAN, J. R.: Follow-up Study ofthe Early Treatment ofCongenital Dislocation ofthe Hip. J. Bone and Joint
Sung. , 30-A: 428-442, April 1948.
3. ESTEVE, RAFAEL: Congenital Dislocation of the Hip. A Review and Assessment of Results of Treatment with Special Reference to Frame Re-
duction as Compared with Manipulative Reduction. J. Bone and Joint Sung. , 42-B: 253-263, May 1960.
4. FARRELL, B. P., and H0w0RTH, M. B.: Open Reduction in Congenital Dislocation of the Hip. J. Bone and Joint Surg., 17: 35-42, Jan. 1935.
5. GAGE, J. R., and WINTER, R. B.: Avascular Necrosis of the Capital Femoral Epiphysis as a Complication of Closed Reduction of Congenital
Dislocation of the Hip. J. Bone and Joint Sung. , 54-A: 373-388, March 1972.
6. JUDET, J.: L’avenir des luxations cong#{233}nitales de la hanche r#{233}duites. Correction chirurgicale pr#{233}cocede leurs d#{233}fautsanatomiques. Rev.
chir. orthop., 44: 152-175, 1958.
7. KALAMCHI, Au: Natural History ofAvascular Necrosis Following Treatment ofCongenital Dysplasia ofthe Hip. Orthop. Trans., 2: 209, 1978.
8. LARSON, C. B.: Rating Scale for Hip Disabilities. Clin. Orthop. , 31: 85-93, 1963.
9. MASSIE, W. K.: Vascular Epiphyseal Changes in Congenital Dislocation ofthe Hip. Results in Adults Compared with Results in Coxa Plana and
in Congenital Dislocation without Vascular Change. J. Bone and Joint Sung., 33-A: 284-306, April 1951.
10. P0NSETI, IGNACI0: Causes of Failure in the Treatment of Congenital Dislocation of the Hip. J. Bone and Joint Sung. , 26: 775-792, Oct. 1944.
I 1. SALTER, R . B .; K0STUIK, J . ; and DALLAS, S .: Vascular Necrosis of the Femoral Head as a Complication of Treatment of Congenital Dislocation
of the Hip in Young Children: A Clinical and Experimental Investigation. Canadian J. Surg. , 12: 44-62, 1969.
12. SEVERIN, ERIK: Contribution to the Knowledge of Congenital Dislocation of the Hip Joint. Late Results of Closed Reduction and Arthrognaphic
Studies of Recent Cases. Acta Chin. Scandinavica, Supplementum 63, 1941.
13. SHARP, I. K.: Acetabular Dysplasia. The Acetabular Angle. J. Bone and Joint Surg., 43-B: 268-272, May 1961.
14. SMITH. W. S.; BADGLEY. C. E.; ORwIG, J. B.; and HARPER, J. M.: Correlation of Postreduction Roentgenograms and Thirty-One-Year Fol-
low-up in Congenital Dislocation of the Hip. J. Bone and Joint Surg., 50-A: 1081-1088, Sept. 1968.
15. WEINER, D. S.; HOYT, W. A.; and O’DELL, H. W.: Congenital Dislocationofthe Hip. The RelationshipofPremanipulationTractionand Age to
Avascular Necrosis of the Femoral Head. J. Bone and Joint Sung., 59-A: 306-31 1, April 1977.

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