Dennis R. Wenger, M.D.

Volume VI, No. 6 of the MVP Video Journal of Orthopaedics featured "Developmental Dysplasia of the Hip: A Contemporary Review." As an extension of that programming, this presentation by pediatric orthopaedic specialist Dr. Dennis Wenger examines the contemporary role of operative intervention for the child of walking age (2 years and older).

Perhaps the most important question relating to the treatment of DDH in children two years of age and older is "What is the current role of traction?" A primary form of first-line management, traction has been primarily used to avoid the problem of vasomicrosis. Unfortunately, traction does not correct the often present deformation in both proximal femur and acetabulum, nor is it predictable.

Two procedures commonly used for advanced forms of DDH include the Salter and Pemberton osteotomy procedures. The Salter procedure simply reorients or redirects the acetabulum for a child with a completely dislocated hip. The Pemberton procedure is employed to change the shape of the acetabulum, primarily to make it smaller and/or deeper for children with hip dysplasia. Of primary concern with both of these procedures is the often resultant postoperative limp caused from leg length discrepancy.

Dr. Wenger's surgical technique of choice for anterior, open reduction of DDH for children of walking age (2 years and older with completely dislocated hip) involves the simultaneous correction of the acetabulum, femur and capsule, and includes:

• Salter incision
• Wide capsular exposure (freeing posterior and lateral muscles adherent to capsule)
• Capsule is opened with a T-incision
• Excise superolateral triangle (forces better capsulorrhaphy)
• Ligamentum of teres is followed to the base of the true acetabulum (occasionally avulsed from head)
• Femoral ("overlap method") shortening and derotational osteotomy is completed (if indicated) through separate incision. It is important to not add varus (DDH femur not in valgus, just anteverted). Secured with either mandibular plate (2-4 years) or AO infant plate (4-plus years).
• Sutures are placed for secure capsular repair (#1 Merselene or Tevdek)
• Salter innominate osteotomy is completed (if indicated, femoral derotational osteotomy decreases need for innominate osteotomy in children 2-3 years).
• Capsular repair is completed

Wound is closed with the hip flexed, abducted, and internally rotated 30 degrees in each plane (less if femoral derotation performed)

If the details of this procedure are followed, Dr. Wenger believes this method is the safest and most predictable way to treat DDH, if one is unfortunate enough to be presented with a child who displays this condition at the age of walking.

References
1. Szepesi K, Biro B, Fazekas K, Szucs G The effect of early anterior approach open reduction with functional postoperative treatment on the early development of the acetabulum in CDH Orthopedics 1991;14(1):81-85
2. MacEven GD Treatment of congenital dislocation of the hip in older children Clin Orthop 1997;225:86-92
3. Zionts LE, MacEven GD, Delaware W Treatment of congenital dislocation of the hip in children between the ages of one and three years J Bone Joint Surg 1986;68A:829-846
4. Povell EN, Gerratana FJ, Gage FR Open reduction for congenital hip dislocation: the risk of avascular necrosis with three different approaches J Pediatr Orthop 1986;6:127-132

• Total Run Time: 14:45 minutes
• Catalog Number: 4021
• Publication Date: October 1992

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