36

Original article

Results of medial open reduction of developmental dysplasia

of the hip with regard to walking age
Murat Altay, Ismail Demirkale, Ferhat Senturk, Ahmet Firat and Safa Kapicioglu
This study aimed to evaluate the outcome of medial open
reduction for developmental dysplasia of the hip (DDH)
in patients before and after walking age. A minimum
5-year radiographic and clinical follow-up compared
29 patients (group 1) before walking age with 38 patients
(group 2) after walking age for DDH. The correction
ratio of acetabular index was similar in both groups
postoperatively (41.8% for group 1 and 44.9% for group 2),
and it was statistically not significant (P > 0.05).
The KalamchiMacEwen classification showed no
correlation between operative age and the rate of
avascular necrosis (P > 0.05). This report presents
similar complication rates as that of the Severin criteria
for medial open reduction of the hip and challenges the

conventional belief that a medial open reduction for

the treatment of DDH in a walking-age child at
short-term to mid-term follow-up has comparable
c 2012 Wolters
results. J Pediatr Orthop B 22:3641
Kluwer Health | Lippincott Williams & Wilkins.

Introduction

in the treatment of DDH in a larger study. We also aimed

to determine the safe upper age limit for medial open
reduction by comparing two groups of patients in conjunction with certain criteria, such as weight-for-age percentile
and the presence of ossific nucleus. In addition, potential
prognostic factors for functional outcome and correction
ratio of the acetabular index, which implies acetabular
development, were analyzed and compared with radiological findings with regard to the ambulation pattern of the
patient at the time of the operation.

The goal of achieving a stable and durable anatomic

reduction has been sought by orthopedic surgeons for many
years. In 1908 and 1973, Ludloff [1] and Ferguson [2],
respectively, reported on an operative technique in which
the main obstacles against the concentric reduction of the
femoral head into the acetabulum were targeted. They
stated that if this operation was performed relatively early
in the course of developmental dysplasia of the hip
(DDH), stimulation of acetabular development and prevention of secondary dysplasias may be more evident.
Previous studies have reported failure in achieving a
nondysplasic hip joint without the need of secondary
procedures and sustaining a stable relationship between
the acetabular and femoral head after medial open
reduction [35]. Okano et al. [6] obtained unacceptable
results when the operation was performed on patients aged
over 17 months. Nevertheless, recent studies on acetabular
development and prediction of hip dysplasia in patients
with DDH have shown that a swift remodeling of the
acetabulum occurs within the first year of reduction and
continues slowly until 7 or 8 years of age [7]. Also Kitoh
et al. [8] demonstrated the acetabular index angle (AI) at
4 years and center-edge angle (CEA) at 5 years to be the
most important predictors of acetabular development and
these can be the most reliable predictors of future
acetabular dysplasia. Although they used a patient group
with an average age of 9.3 months at the time of reduction,
controversy still exists about the upper age limit for medial
open reduction.
The purpose of the present study was to evaluate the
short-term to mid-term results of medial open reduction
c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
1060-152X

Journal of Pediatric Orthopaedics B 2013, 22:3641

Keywords: developmental dysplasia of the hip, medial open reduction,
walking age
Department of Orthopaedics and Traumatology, Kecioren Education and
Research Hospital, Ankara, Turkey
Correspondence to Ismail Demirkale, MD, Department of Orthopaedics and
Traumatology, Kecioren Education and Research Hospital, 06280 Ankara, Turkey
Tel/fax: + 90 505 400 2679; e-mail: drismail@yahoo.com

Materials and methods

Institutional review board approval was obtained for this
retrospective study. Using our comprehensive prospective
database, we retrospectively carried out a radiographic
and clinical evaluation of patients treated for DDH. From
February 2003 to September 2005, the senior author
(M.A.) performed 152 (116 patients) consecutive medial
open reductions for DDH. Our indications to perform a
medial open reduction were older age (> 6 months) and
intraoperative grade 2 or grade 3 arthrographic reductions.
Of these, two patients had undergone an additional
unilateral proximal femoral derotation osteotomy at the
time of the initial operation. Five patients had a history of
traction, followed by closed reduction (all bilateral).
A Pavlik harness was applied to 21 hips (n = 16; five
bilateral, 11 unilateral). Twenty-six patients (36 hips)
were lost to follow-up or their charts and radiographs were
not available for review. To obtain a homogenous case
series for the treatment of DDH by medial approach and
to determine its clear effect on DDH, whether the
patient is ambulatory or not, the selected patients for this
DOI: 10.1097/BPB.0b013e3283587631

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Results of open reduction of hip after walking age Altay et al. 37

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

measure the AI of Hilgenreiner [11]. At the last visit,

standing anteroposterior and false-profile radiographs were
taken to evaluate the AI of Hilgenreiner, CEA of Wiberg
[12], the anterior center-edge angle (ACEA) of Lequesne
[13], and the collodiaphyseal angle (CDA) of the femur.
The preoperative and postoperative values were compared
to assess deformity correction. The KalamchiMacEwen
classification system was used to determine the rate of
avascular necrosis (AVN) [14]. The medical records and
radiographs of the patients were also reviewed to assess the
radiographic appearance of nucleus of the femoral head and
the weight-for-age percentiles both for males and females.
Clinical evaluation

study must not have had any of the above interventions,

for either the pelvis or proximal femur. Finally, 49 patients
(69 hips) were excluded from the study, leaving a total of
83 hips of 67 patients (16 bilateral and 51 unilateral
involvement) for evaluation. The average age of the
patients at the time of surgery was 13.973.13 months
(range, 723 months). There were 17 male and 50 female
patients (Table 1).
The patients were assigned to two groups on the basis of
whether the patient was able to walk or not at the time of
the operation; group 1, before walking age (n = 29); group
2, after walking age (n = 38). Both groups were comparable in respect of all of the above-mentioned variables.
Surgical technique

The operative procedure utilized a standard Ferguson

medial approach. The decision to perform an adjunctive
capsulotomy was based on intraoperative arthrographic
assessment of the hip. In case of grade 2 or grade 3
arthrographic reductions, the dissection was carried out
posterior to the adductor brevis, and after division of the
iliopsoas tendon, capsulotomy was performed; ligamentum
teres was excised and the inferior transverse acetabular
ligament was sectioned. Bilateral involvements were
operated on in the same session. After closure of the
incision, a hip spica cast was applied to all patients at 901
flexion and 601 abduction and they were removed at the
end of 3 months. A full-time abduction brace was then
worn for a further 1.5 months. The patient underwent a
period of physical therapy to regain motion of the hip and
no further treatment was given.
Radiographic evaluation

Radiological assessment of the hips was made according

to the Severin classification [9]. While Severin groups I
and II were defined as acceptable, III, IV, and V were
defined as unacceptable. Once the radiological evaluation
of the hip joint had acceptable intraobserver and
interobserver reliability, preoperative and periodic postoperative radiographic analysis was carried out in an
unblinded manner for all patients by one senior-level
orthopedic resident (I.D.) [10]. Supine anteroposterior
radiographs of the hips were taken preoperatively to

Clinical hip function was graded according to the McKay

criteria. All patients returned for a follow-up clinic visit
and radiographic examination at a minimum of 5.6 years.
Parent-reported overall satisfaction with the surgical
procedure was also ascertained at the most recent
follow-up visit.
Statistical analysis

The correction ratio of AI, ACEA, CEA, and CDA were

compared using Students t-test. The preoperative and
postoperative values of AI, the correlation between the
correction ratio of AI and the follow-up period, and the
correction ratio of AI, ACEA, CEA, and CDA were
compared using Pearsons correlation test. Significance
was determined at a P value of less than 0.05.

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

Journal of Pediatric Orthopaedics B 2013, Vol 22 No 1

24 patients (35.8%) had excellent results, 20 (29.9%)

good, 16 (23.9%) fair, and 7 (10.4%) poor. A separate
evaluation was made to elicit the effect of the operative
age on the modified McKay criteria. Excellent and good
Table 2

Radiographic measurement results at the last visit

Mean

41.785.671 (range, 33571)

23.465.311 (range, 14311)
16.8510.231
145.328.541
27.7611.651

< 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.

Table 3 Summary of radiographic correction obtained at the last

visit of patients before and after walking age
Radiographic findings

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.

results were obtained for 17 (58.6%) group 1 patients and

27 (71.1%) group 2 (Fig. 1ad) patients (Table 4).
A final evaluation of the hips using the Kalamchi
MacEwen classification showed 20 (24.1%) AVN changes.
Further evaluation of AVN showed no correlation
between the operative age and the rate of AVN
(P > 0.05). In addition, 11 Kalamchi changes (13.3%) in
group 1 and nine (10.8%) in group 2 were noted (Fig. 2ad).
Although statistically not significant, with regard to the
weight-for-age percentile, 14 of 20 Kalamchi changes were
noted in patients at 50 percentile or more. There were no
short-term complications other than reduction loss in eight
patients, six of whom had a high weight-for-age percentile.
All eight were treated by closed reduction and cast
reapplication.

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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Results of open reduction of hip after walking age Altay et al. 39

Sener et al. [24], Okano et al. [6,25], and Mardam-Bey

et al. [26] reported high failure and complication rates of
the medial open reduction when done after walking age.

Apart from these studies, however, Chmielewski

et al. [27] stated that a medial approach, which is simple
and effective, goes directly to the area where main
obstacles of an anatomic reduction exists.

Table 4 Comparison of two groups in the clinical outcome scores

and radiological outcome measurements at the last visit

The current standard of practice for managing DDH is to

perform and maintain an anatomic reduction for acetabular development. Most orthopedic surgeons prefer the
anterolateral approach for the treatment of DDH after
walking age. The anterolateral approach allows capsulorrhaphy, simultaneous pelvic osteotomy, and eversion of
the limbus. A review of failed open reductions showed
the anteromedial area to be the area of failure [21,22].
Mankey et al. [28] has stated the importance of effective
capsulorrhaphy in the first postoperative week and
OHara et al. [29] has reported the adverse effects of
limbectomy on acetabular development. Keeping these
considerations in mind, a medial approach was chosen for
the treatment of DDH at walking age as having
advantages compared with an anterolateral approach with

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

n, number of patients calculated; NS, not significant (P > 0.05).

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

Journal of Pediatric Orthopaedics B 2013, Vol 22 No 1

respect to minor bleeding risk, shorter operation time,

and smaller exposure, with reduced damage to tissues.
According to the modified McKay criteria, our results
(65.6% with excellent or good results) were similar to
previous studies [3,16,17,19,20]. The mean correction of
the AI (22.61) and CEA (17.41) and Severin classification
(65% at acceptable range) also corresponded to those in
the literature [4,1618,30,31]. The most favorable result
of this study was that although the radiological grade and
femoral head involvement of the patients remained in the
moderate-to-good zone, 55 of 67 parents provided
positive feedback for the procedure at a mean follow-up
of 6.6 years.
We also observed a relatively high risk for AVN and
moderate subluxation in patients with a high weight-forage percentile. This may be due to several factors that
may increase the likelihood of cast complications or
complexity of the disease. First and most importantly,
many of these patients may have been followed up
inexpertly in the early stages. Second, many of these
patients with a high weight-for-age percentile may have
had advanced or delayed bone age, both of which may
have contributed to a higher risk of postoperative
radiographic moderate results.
Our surgical indications for a medial approach for DDH
have expanded over time. Careful preoperative assessment is necessary to determine whether a high-grade
dislocated hip can be reduced with a less invasive surgical
approach, such as the Ferguson technique. Surgical
treatment is then tailored to reduce the hip. In a highgrade dislocation in a walking child or a child with
proximal femur or acetabular deformities, a combination
of techniques may be used, including anterior approach,
proximal femoral varus, and derotation osteotomy or
innominate osteotomy. Currently, when acetabular dysplasia is present in a child with a low acetabular growth
potential, the accepted management should be focused
on acetabular correction [7,32]. However, it must be
emphasized that normalizing the acetabular inclination
by acetabular reorientation needs large surgical exposures
with relatively high complication rates. This is of specific
concern because of the potential growth potential of the
acetabulum. For this reason, we remain reluctant to
perform a medial approach unless the child does not have
a high-grade dislocation. Thus, independent of whether
the child is walking or not, anatomical acetabular
reduction and maintenance of this anatomic reduction
without any associated complications may result in
continuous acetabular development. Eight of our patients
on whom the medial approach was used early in our
experience suffered loss of reduction in the initial
postoperative period, and they required reapplication of
the cast. These two instances heightened our awareness
of this problem and prompted us to be more aggressive in
releasing the medial capsule and to make a more effective

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

We emphasize that surgical treatment of a dislocated hip in

a walking-age child can be performed with a medial
approach, which is safe and reliable. Our results suggest
that appropriately applied medial open reduction is
associated with good clinical results at short-term to midterm follow-up regardless of the ambulation pattern of the
patient. Continued clinical and radiographic evaluation is
essential to assess the efficacy of this surgical strategy.

Acknowledgements
Conflicts of interest

There are no conflicts of interest.

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