Pre-operative Gallows traction as an adjunct to hip open reduction surgery: Is it safe and is it effective?

Dear Professor Hefti,

Thank you for this letter which provides a lovely detail of some of the surgical outcomes of developmental dysplasia of the hip (DDH) at our unit over several decades. It is a pleasure to see this reference and we are humbled by the level of knowledge of the authors of the letter. We can clarify the evolution of practice in our unit, which explains all the findings highlighted in the letter, and justifies the conclusion of the manuscript that pre-operative traction is safe and effective.

Traction has been used at our institution for around 4 or 5 decades. This was from my predecessor Professor Nick Clarke, and the traction regime remains in place today as it has been under Professor Clarke’s practice, who joined Southampton Children’s Hospital in the 1980s. Where the authors of the letter may be confused is in the evolution of the pelvic procedure at our unit. Previously, Professor Clarke did an isolated open reduction of the hip without doing anything to the pelvis. He did use pre-operative traction then, as we do now. However, due to the considerable residual acetabular dysplasia rate, and high volume of later pelvic osteotomies, Professor Clarke instigated the growth stimulating minimal acetabular osteotomy, based upon that described in Beijing in the 1980s. ¹ This has been termed ‘open reduction, capsulorrhaphy, acetabuloplasty (ORCA)’ as a neat acronym. The open reduction and capsulorrhaphy are the same as they always have been. The pre-operative traction is the same as it has always been. Both remain our current practice and the patients in this study all had pre-operative traction and ORCA. The attention to the pelvis is what has evolved. Early results of this mini pelvic procedure were published by Ms Belen Carsi and Professor Clarke, and longer-term results have been presented by myself at BSCOS, POSNA and The New York University DDH Symposium, as the authors of this letter have correctly identified. That manuscript is in the final stages of data cleaning and we look forward to that being in press. All the while, the same regime of pre-operative traction has been used.

There are undoubtedly confounding influences in the longer-term outcomes of any DDH surgery, which we have been clear to highlight in the manuscript. This is exactly the reason that the primary outcome of this paper was the resting position of the hip pre- and post-traction, which can be measured objectively. Qualitatively, we observed that, in most of the hips that did not show a change in IHDI grade, there was a lowering of the height of the hip dislocation. However, we are not aware of a validated measurement tool for this, so decided not to add this potential confounding factor into our outcomes. This is also mentioned in the manuscript.

The initial hypothesis of the study was that traction would make no difference to the resting position of the hips, which would enable us to discontinue its use. To our surprise, pre-operative traction has a clear effect on resting hip position. The longer-term Severin outcomes from this operative regime are commendable, alongside only very rarely finding the need to de-tension with a femoral shortening osteotomy. This is compared to age-matched cohorts in the literature whereby pre-operative traction is not used. We do not have a non-traction cohort at our institution that can be used for comparison.

This study has informed our continued use of pre-operative traction, in finding it safe and effective. This is despite our initial expectation and hypothesis that actually it would make no difference, and that we could discontinue the practice.

Yours sincerely,

Supplemental Material

sj-pdf-1-cho-10.1177_18632521241283249 – Supplemental material for Pre-operative Gallows traction as an adjunct to hip open reduction surgery: Is it safe and is it effective?

Supplemental material, sj-pdf-1-cho-10.1177_18632521241283249 for Pre-operative Gallows traction as an adjunct to hip open reduction surgery: Is it safe and is it effective? by Nicholas C Uren, Julia Judd, Edward A Lindisfarne, Kirsten G Elliott and Alexander Aarvold in Journal of Children's Orthopaedics

Professor Alexander Aarvold and co-authorsConsultant paediatric orthopaedic surgeon, Southampton Children’s Hospital, UKHonorary Professor of orthopaedic surgery, University of Southampton, UK