Developmental Dysplasia Of The Hip At Five Years Of Age Treated With Open Reduction And Femoral Osteotomy: A Case Report

摘要

Developmental dysplasia of the hip when presenting late is always a great challenge for orthopaedicians. Once the diagnosis is made by A.P. & lateral view radiographs; operative treatment should preferably include osteotomy on pelvic side with open reduction and femoral shortening. We describe 3 cases who presented late and were treated with open reduction, femoral shortening and pemberton osteotomy. Salter and Pemberton osteotomy are the commonly done procedures on pelvic side in these cases. In our centre earlier we were using Salter osteotomy. The present case report details the usage of the Pemberton osteotomy in 3 cases of developmental dysplasia of the hip who presented late, when treated with Pemberton osteotomy resulted in a good reduction of the acetabular head. We thus strongly recommend Pemberton osteotomy over Salter osteotomy. Introduction Normal hip development depends on proportionate growth of the acetabular triradiate cartilages and the presence of a concentrically located femoral head. Various genetic factors, hormonal factors, intrauterine mal-positioning and postnatal factors play a role in etiology of the developmental dysplasia of the hip (DDH). A child may be born with acetabular dysplasia without dislocation of the hip, and the latter may develop weeks or months later.Westin et al. reported the late development of dislocation of the hip in children with normal neonatal clinical and radiographic examinations; they termed this developmental dysplasia as opposed to congenital dysplasia of the hip. Diagnosis based on clinical suspicion that is limitation of abduction, asymmetrical skin folds, positive Galezzi sign, waddling or Trendelenburg gait and followed by radiographs taken in anteroposterior (AP) view and lateral view (frog leg position). In AP view approximate position of cartilaginous head is ascertained by following the ossified femoral neck. Lateral view gives idea regarding the anteversion of the neck. DDH when diagnosed at birth and treated at earliest results in normal development of the hip without any surgical intervention, but for delayed presentation surgery is required. Treatment options start with conservative treatment to keep the head within the acetabulum for plastic modulation in position of abduction and flexion. If detection is late various surgical options available are reduction of the head with femoral or innominate or acetabular surgeries. There is no doubt that open reduction and femoral shortening with capsulorraphy can relocate the head but there is always the scope of reorientation of the acetabulum to improve head coverage and acetabular index1, 2, 3.Salter and Pemberton osteotomy are the commonly done procedures on the pelvic side2, 3. The present case report details the usage of Pemberton osteotomy in 3 cases of developmental dysplasia of the hip who presented late. When treated with Pemberton osteotomy they resulted in a good reduction of the acetabular head. Case report 3 females (2.5, 3, and 3.5 year old) presented to our institution with a limp of the affected side. After history, clinical examination and necessary investigation, they were diagnosed having developemental dysplasia of the hip with the head either subluxated or dislocated and with a high riding head. [Figure-1] The patients were taken up for surgical reduction and Pemberton type osteotomy was done in each one.In all the 3 cases reduction of the femoral head was done through anterior approach through bikini incision. After incision along the iliac crest, sub-perisoteal dissection of the gluteal muscle followed by retraction the rectus femoris, the capsule was opened. Femoral shortening in the sub-trochantric region was done through another incision and reduction of the femoral head into the acetabulum was done. A femur bone segment equal to overlapping of fragments was removed and fixation of femoral fragments with plating was done and graft removed from pelvic osteotomy was put at the shortening site. T