Mid- and long-term outcome of Salter’s,Pemberton’s and Dega’s osteotomy for treatment of developmental dysplasia of the hip: a systematic review and meta-analysis
Restricted accessReview articleFirst published online July, 2021
Mid- and long-term outcome of Salter’s,Pemberton’s and Dega’s osteotomy for treatment of developmental dysplasia of the hip: a systematic review and meta-analysis
Early diagnosis and early treatment have become the gold standard for management of developmental dysplasia of the hip. Surgery is required in case of failed initial treatment. Innominate pelvic osteotomy of Salter (SIO), Pemberton’s pericapsular osteotomy (PPO) and Dega’s acetabuloplasty (DA) are among the most used procedures.
We performed a systematic review and meta-analysis of the past 57 years in order to assess the mid- and long-term outcome of these techniques.
Methods:
Studies met inclusion criteria if they: (1) reported at least 5 cases treated by 1 of the abovementioned surgical techniques; (2) included children aged between 1 and 8 years; (3) surgical indication was late detected DDH or a failed initial treatment; (4) presented a minimal follow-up of 24 months; (5) reported the radiological score of Severin and/or the clinical score of McKay.
Clinical and radiological outcomes were dichotomised into favourable and unfavourable outcome and weighted summary rates were determined using meta-analysis models.
Results:
From a total of 7391 articles, 48 level of evidence grade IV articles were included in our review. A total of 2143 cases with a mean follow up of 112.4 months were included.
Pooled Severin score indicated a statistically better outcome for PPO and DA compared to SIO (p = 0.0003 and p = 0.002, respectively). By dichotomising the results in favourable and unfavourable outcome, PPO showed the best results (p = 0.0002 vs. SIO, p = 0.01 vs. DA).
Pooled McKay score showed a statistically better outcome for PPO and DA compared to SIO (p < 0.0001 and p = 0.03, respectively) as well as better outcomes for PPO compared to DA (p = 0.01). By dichotomising the results in favourable and unfavourable, PPO showed the best results.
Conclusions:
Even if our review demonstrates slightly better radiological and clinical results with the PPO, the currently available and limited data do not allow for clear recommendation towards one of these techniques.
HerringJA. Developmental dysplasia of the hip. In: HerringJA (ed.) Tachdijan’s pediatric orthopaedics. 4th ed.Philadelphia: Elsevier, 2008, pp.637–770.
2.
NelitzMReichelH.[Nonsurgical treatment of developmental dysplasia of the hip]. Orthopade2008; 37: 550, 552–555.
3.
WahlenRZambelliPY.Treatment of the developmental dysplasia of the hip with an abduction brace in children up to 6 months old. Adv Orthop2015; 2015: 103580.
4.
AlvesCTruongWHThompsonMV, et al. Diagnostic and treatment preferences for developmental dysplasia of the hip: a survey of EPOS and POSNA members. J Child Orthop2018; 12: 236–244.
5.
KuboHPilgeHWeimann-StahlschmidtK, et al. Use of the Tubingen splint for the initial management of severely dysplastic and unstable hips in newborns with DDH: an alternative to Fettweis plaster and Pavlik harness. Arch Orthop Trauma Surg2018; 138: 149–153.
6.
WalterSGBornemannRKoobS, et al. Closed reduction as therapeutic gold standard for treatment of congenital hip dislocation. Z Orthop Unfall2020; 158: 475–480.
7.
GrafR.Hip sonography: background; technique and common mistakes; results; debate and politics; challenges. Hip Int2017; 27: 215–219.
8.
GrafR.DDH: diagnosis and treatment strategies. In: BentleyG. (ed) European instructional lectures european federation of national associations of orthopaedics and traumatology. Berlin, Heidelberg: Springer-Verlag, 2009, pp.41–46.
9.
MalvitzTAWeinsteinSL.Closed reduction for congenital dysplasia of the hip. Functional and radiographic results after an average of thirty years. J Bone Joint Surg Am1994; 76: 1777–1792.
10.
JacobsenSSonne-HolmS.Hip dysplasia: a significant risk factor for the development of hip osteoarthritis. A cross-sectional survey. Rheumatology (Oxford)2005; 44: 211–218.
11.
TerjesenT.Residual hip dysplasia as a risk factor for osteoarthritis in 45 years follow-up of late-detected hip dislocation. J Child Orthop2011; 5: 425–431.
12.
BittersohlBHosalkarHSWengerDR.Surgical treatment of hip dysplasia in children and adolescents. Orthop Clin North Am2012; 43: 301–315.
13.
FeeleyIHGreenCJRowanFE, et al. International variance in the treatment of developmental dysplasia of the hip. J Child Orthop2014; 8: 381–386.
14.
GrafR.Hip sonography: 20 years experience and results. HIP Int2007; 17(Suppl. 5): S8–S14.
15.
LalondeFDFrickSLWengerDR.Surgical correction of residual hip dysplasia in two pediatric age-groups. J Bone Joint Surg Am2002; 84: 1148–1156.
16.
AkiyamaMNakashimaYOishiM, et al. Risk factors for acetabular retroversion in developmental dysplasia of the hip: does the Pemberton osteotomy contribute?J Orthop Sci2014; 19: 90–96.
17.
AydinAKalaliFYildizV, et al. The results of Pemberton’s pericapsular osteotomy in patients with developmental hip dysplasia. Acta Orthop Traumatol Turc2012; 46: 35–41.
18.
UmerMNawazHKasiPM, et al. Outcome of triple procedure in older children with developmental dysplasia of hip (DDH). J Pak Med Assoc2007; 57: 591–595.
19.
MoherDLiberatiATetzlaffJ, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg2010; 8: 336–341.
20.
LiberatiAAltmanDGTetzlaffJ, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med2009; 6: e1000100.
21.
AromatarisERiitanoD.Constructing a search strategy and searching for evidence. A guide to the literature search for a systematic review. Am J Nurs2014; 114: 49–56.
22.
SeverinE.Congenital dislocation of the hip; development of the joint after closed reduction. J Bone Joint Surg Am1950; 32: 507–518.
23.
McKayDW.A comparison of the innominate and the pericapsular osteotomy in the treatment of congenital dislocation of the hip. Clin Orthop Relat Res1974; 98: 124–132.
24.
TönnisD.Surgical treatment of congenital dislocation of the hip. Clin Orthop Relat Res1990; 258: 33–40.
25.
OkikeKKocherMS. Evidence-based orthopaedics: levels of evidence and guidelines in orthopaedic surgery. In: FlynnJM (ed.) Orthopaedic knowledge update 10. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2011, pp.157–165.
26.
DeWinterJFCDodouD. Five-point Likert items: t test versus Mann-Whitney-Wilcoxon. Pract Assess Res Evaluation2010; 15: 1–16.
27.
OlneyBLatzKAsherM.Treatment of hip dysplasia in older children with a combined one-stage procedure. Clin Orthop Relat Res1998; 347: 215–223.
28.
RyanMGJohnsonLOQuanbeckDS, et al. One-stage treatment of congenital dislocation of the hip in children three to ten years old. Functional and radiographic results. J Bone Joint Surg Am1998; 80: 336–344.
29.
ChangCHYangWEKaoHK, et al. Prognostic radiographic factors in developmental dysplasia of the hip following Salter osteotomy. J Pediatr Orthop B2015; 24: 31–34.
30.
ShihKSWangJHWangTM, et al. One-stage correction of neglected developmental dysplasia of the hip by open reduction and pemberton osteotomy. J Formos Med Assoc2001; 100: 397–402.
31.
VarnerKEIncavoSJHaynesRJ, et al. Surgical treatment of developmental hip dislocation in children aged 1 to 3 years: a mean 18-year, 9-month follow-up study. Orthopedics. Epub ahead of print 10March2010. DOI: 10.3928/01477447-20100129-0 .
32.
WuKWWangTMHuangSC, et al. Analysis of osteonecrosis following Pemberton acetabuloplasty in developmental dysplasia of the hip: long-term results. J Bone Joint Surg Am2010; 92: 2083–2094.
33.
GholvePAFlynnJMGarnerMR, et al. Predictors for secondary procedures in walking DDH. J Pediatr Orthop2012; 32: 282–289.
34.
BalioğluMBÖnerAAykutUS, et al. Mid term results of Pemberton pericapsular osteotomy. Indian J Orthop2015; 49: 418–424.
35.
BakiMEBakiCAydinH, et al. Single-stage medial open reduction and Pemberton acetabuloplasty in developmental dysplasia of the hip. J Pediatr Orthop B2016; 25: 504–508.
36.
SynderMZwierzchowskiH.One-stage hip reconstruction with Dega’s transiliacal osteotomy in the treatment of congenital hip dislocation in children. Beitr Orthop Traumatol1990; 37: 571–574.
37.
RuszkowskiKPucherA.Simultaneous open reduction and Dega transiliac osteotomy for developmental dislocation of the hip in children under 24 months of age. J Pediatr Orthop2005; 25: 695–701.
38.
El-SayedMAhmedTFathyS, et al. The effect of Dega acetabuloplasty and Salter innominate osteotomy on acetabular remodeling monitored by the acetabular index in walking DDH patients between 2 and 6 years of age: short- to middle-term follow-up. J Child Orthop2012; 6: 471–477.
39.
RampalVKleinCArellanoE, et al. Outcomes of modified Dega acetabuloplasty in acetabular dysplasia related to developmental dislocation of the hip. Orthop Traumatol Surg Res2014; 100: 203–207.
40.
El-SayedMMHegazyMAbdelatifNM, et al. Dega osteotomy for the management of developmental dysplasia of the hip in children aged 2-8 years: results of 58 consecutive osteotomies after 13-25 years of follow-up. J Child Orthop2015; 9: 191–198.
41.
Ming-HuaDRui-JiangXWen-ChaoL.The high osteotomy cut of Dega procedure for developmental dysplasia of the hip in children under 6 years of age. Orthopade2016; 45: 1050–1057.
42.
CrellinRQ.Innominate osteotomy for congenital dislocation and subluxation of the hip; a follow-up study. Clin Orthop Relat Res1974; 98: 171–177.
43.
BarrettWPStaheliLTChewDE.The effectiveness of the Salter innominate osteotomy in the treatment of congenital dislocation of the hip. J Bone Joint Surg Am1986; 68: 79–87.
44.
WatersPKuricaKHallJ, et al. Salter innominate osteotomies in congenital dislocation of the hip. J Pediatr Orthop1988; 8: 650–655.
GalpinRDRoachJWWengerDR, et al. One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening. J Bone Joint Surg Am1989; 71: 734–741.
47.
UyttendaeleDBurssensPMorteleH, et al. Open reduction and innominate osteotomy in the treatment of C.D.H. between 15 and 18 months of age. Acta Orthop Belg1990; 56: 251–255.
48.
SynderMForlinEXinS, et al. Results of the Kalamchi modification of Salter osteotomy in the treatment of developmental dysplasia of the hip. J Pediatr Orthop1992; 12: 449–453.
49.
GulmanBTuncayICDabakN, et al. Salter’s innominate osteotomy in the treatment of congenital hip dislocation: a long-term review. J Pediatr Orthop1994; 14: 662–666.
50.
KarakasESBaktirAArgunM, et al. One-stage treatment of congenital dislocation of the hip in older children. J Pediatr Orthop1995; 15: 330–336.
51.
HaidarRKJonesRSVergroesenDA, et al. Simultaneous open reduction and Salter innominate osteotomy for developmental dysplasia of the hip. J Bone Joint Surg Br1996; 78: 471–476.
52.
HuangSCWangJH.A comparative study of nonoperative versus operative treatment of developmental dysplasia of the hip in patients of walking age. J Pediatr Orthop1997; 17: 181–188.
LinCJLinYTLaiKA.Intraoperative instability for developmental dysplasia of the hip in children 12 to 18 months of age as a guide to Salter osteotomy. J Pediatr Orthop2000; 20: 575–578.
55.
ItoHOouraHKobayashiM, et al. Middle-term results of Salter innominate osteotomy. Clin Orthop Relat Res2001; 387: 156–164.
56.
BakiCSenerMAydinH, et al. Single-stage open reduction through a medial approach and innominate osteotomy in developmental dysplasia of the hip. J Bone Joint Surg Br2005; 87: 380–383.
57.
MacnicolMFBertolP.The Salter innominate osteotomy: should it be combined with concurrent open reduction?J Pediatr Orthop B2005; 14: 415–421.
58.
TezerenGTukenmezMBulutO, et al. The surgical treatment of developmental dislocation of the hip in older children: a comparative study. Acta Orthop Belg2005; 71: 678–685.
59.
ThomasSRWedgeJHSalterRB.Outcome at forty-five years after open reduction and innominate osteotomy for late-presenting developmental dislocation of the hip. J Bone Joint Surg Am2007; 89: 2341–2350.
60.
da RochaVLThoméALCda Silva CastroDL, et al. Clinical and radiological evaluation on developmental hip dysplasia after Salter and Ombredanne procedure. Rev Bras Ortop2011; 46: 650–655.
61.
ErtürkCAltayMAYarimpapuçR, et al. One-stage treatment of developmental dysplasia of the hip in untreated children from two to five years old. A comparative study. Acta Orthop Belg2011; 77: 464–471.
62.
MorinCBisognoJKulkarniS, et al. Treatment of late-presenting developmental dislocation of the hip by progressive orthopaedic reduction and innominate osteotomy. Our results with more than 30 years of follow up. J Child Orthop2011; 5: 251–260.
63.
BhuyanBK.Outcome of one-stage treatment of developmental dysplasia of hip in older children. Indian J Orthop2012; 46: 548–555.
64.
AhmedEMohamedAHWaelH.Surgical treatment of the late - presenting developmental dislocation of the hip after walking age. Acta Ortop Bras2013; 21: 276–280.
65.
YagmurluMFBayhanIATuhaniogluU, et al. Clinical and radiological outcomes are correlated with the age of the child in single-stage surgical treatment of developmental dysplasia of the hip. Acta Orthop Belg2013; 79: 159–165.
66.
KanekoHKitohHMishimaK, et al. Factors associated with an unfavourable outcome after Salter innominate osteotomy in patients with unilateral developmental dysplasia of the hip: does occult dysplasia of the contralateral hip affect the outcome?Bone Joint J2014; 96–B: 1419–1423.
67.
Kotzias NetoAFerrazABayer ForestiF, et al. Bilateral developmental dysplasia of the hip treated with open reduction and Salter osteotomy: analysis on the radiographic results. Rev Bras Ortop2014; 49: 350–358.
68.
ChenQDengYFangB.Outcome of one-stage surgical treatment of developmental dysplasia of the hip in children from 1.5 to 6 years old. A retrospective study. Acta Orthop Belg2015; 81: 375–383.
69.
BayhanIABengKYildirimT, et al. Comparison of Salter osteotomy and Tonnis lateral acetabuloplasty with simultaneous open reduction for the treatment of developmental dysplasia of the hip: midterm results. J Pediatr Orthop B2016; 25: 493–498.
70.
BaghdadiTBagheriNKhabiriSS, et al. The outcome of salter innominate osteotomy for developmental hip dysplasia before and after 3 years old. Arch Bone Jt Surg2018; 6: 318–323.
71.
BanskotaAKPaudelBPradhanI, et al. Results of simultaneous open reduction and Salter innominate osteotomy for developmental dysplasia of the hip. Kathmandu Univ Med J (KUMJ)2005; 3: 6–10.
72.
TezerenGTukenmezMBulutO, et al. One-stage combined surgery with or without preoperative traction for developmental dislocation of the hip in older children. J Orthop Surg (Hong Kong)2006; 14: 259–264.
73.
KotlarskyPHaberRBialikV, et al. Developmental dysplasia of the hip: what has changed in the last 20 years?World J Orthop2015; 6: 886–901.
74.
SalterRB. The classic. Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip by Robert B. Salter, J. Bone Joint Surg. (Brit) 43B:3:518, 1961. Clin Orthop Relat Res1978; 137: 2–14.
75.
FaciszewskiTKieferGNColemanSS.Pemberton osteotomy for residual acetabular dysplasia in children who have congenital dislocation of the hip. J Bone Joint Surg Am1993; 75: 643–649.
76.
PembertonPA.Pericapsular osteotomy of the ilium for the treatment of congenitally dislocated hips. Clin Orthop Relat Res1974; 98: 41–54.
77.
PembertonPA.Pericapsular osteotomy of the ilium for treatment of congenital subluxation and dislocation of the hip. J Bone Joint Surg Am1965; 47: 65–86.
78.
DegaW.[Selection of surgical methods in the treatment of congenital dislocation of the hip in children]. Chir Narzadow Ruchu Ortop Pol1969; 34: 357–366.
79.
SalesdeGauzyJ.Pelvic reorientation osteotomies and acetabuloplasties in children. Surgical technique. Orthop Traumatol Surg Res2010; 96: 793–799.
80.
DegaW.[Transiliac osteotomy in the treatment of congenital hip dysplasia]. Chir Narzadow Ruchu Ortop Pol1974; 39: 601–613.
81.
GrudziakJSLabaziewiczLKruczynskiJ, et al. Combined one-staged open reduction, femoral osteotomy, and Dega pelvic osteotomy for developmental dysplasia of the hip. J Pediatr Orthop1993; 13: 680.
82.
KarlenJWSkaggsDLRamachandranM, et al. The Dega osteotomy: a versatile osteotomy in the treatment of developmental and neuromuscular hip pathology. J Pediatr Orthop2009; 29: 676–682.
83.
SchulzeKJSchmidtHHilligM.[Follow-up results of Dega’s acetabuloplasty (author’s transl)]. Z Orthop Ihre Grenzgeb1980; 118: 905–914.
GrudziakJSWardWT.Dega osteotomy for the treatment of congenital dysplasia of the hip. J Bone Joint Surg Am2001; 83: 845–854.
86.
SalterRBHanssonGThompsonGH.Innominate osteotomy in the management of residual congenital subluxation of the hip in young adults. Clin Orthop Relat Res1984; 182: 53–68.
87.
AlbinanaJDolanLASprattKF, et al. Acetabular dysplasia after treatment for developmental dysplasia of the hip. Implications for secondary procedures. J Bone Joint Surg Br2004; 86: 876–886.
88.
UtterbackJDMacEwenGD.Comparison of pelvic osteotomies for the surgical correction of the congenital hip. Clin Orthop Relat Res1974; 98: 104–110.
89.
EzirmikNYildizK.Salter innominate osteotomy or Pemberton pericapsular osteotomy in treatment of developmental dysplasia of hip. Turk J Med Sci2012; 42: 1058–1062.
90.
ChapchalG.Indications for the various types of pelvic osteotomy. Clin Orthop Relat Res1974; 98: 111–115.
91.
ErturkCAltayMAIsikanUE.A radiological comparison of Salter and Pemberton osteotomies to improve acetabular deformations in developmental dysplasia of the hip. J Pediatr Orthop B2013; 22: 527–532.
92.
BohmPWeberG.Salter’s innominate osteotomy for hip dysplasia in adolescents and young adults: results in 58 patients (69 osteotomies) at 4-12 years. Acta Orthop Scand2003; 74: 277–286.
93.
CzubakJKowalikKKawalecA, et al. Dega pelvic osteotomy: indications, results and complications. J Child Orthop2018; 12: 342–348.
94.
ChenCWangTMKuoKN. Pelvic osteotomies for developmental dysplasia of the hip. In: SpasovskiD (ed.) Developmental diseases of the hip - diagnosis and managementRijeka: IntechOpen, 2017, Chapter 4.
95.
KriegAHHeftiF.[Acetabuloplasty - The Dega and Pemberton technique]. Orthopade2016; 45: 653–658.
96.
EzirmikNYildizK.A Biomech anical comparison between salter innominate osteotomy and pemberton pericapsular osteotomy. Eurasian J Med2012; 44: 40–42.
97.
HerngrenBStenmarkerMEnskarK.Barnhöft: a hip specific 6-item questionnaire for children. J Patient Rep Outcomes2017; 1: 16.
98.
OkIYKimSJOkJH.Operative treatment of developmental hip dysplasia in children aged over 8 years. J Pediatr Orthop B2007; 16: 256–261.
99.
ParvareshKCPennockATBomarJD, et al. Analysis of acetabular ossification from the triradiate cartilage and secondary centers. J Pediatr Orthop2018; 38: e145–e150.
100.
GrissomLEHartyMPGuoGW, et al. Maturation of pelvic ossification centers on computed tomography in normal children. Pediatr Radiol2018; 48: 1902–1914.
101.
WardWTVogtMGrudziakJS, et al. Severin classification system for evaluation of the results of operative treatment of congenital dislocation of the hip. A study of intraobserver and interobserver reliability. J Bone Joint Surg Am1997; 79: 656–663.
