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Children's Orthopaedics: M. M. Zamzam, K. I. Khosshal, A. A. Abak, K. A. Bakarman, A. M. M. AlSiddiky, K. O. AlZain, and M. K. Kremli One-stage bilateral open reduction through a medial approach in developmental dysplasia of the hip J Bone Joint Surg Br 2009; 91-B: 113-118 [Abstract] [Full text] [PDF]

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Mohammed M Zamzam   (22 January 2009)

Our experience with open reduction in the treatment of DDH in not at all encouraging!

Zoran S. Vukasinovic, Goran Cobeljic, Zorica Zivkovic, and Igor Seslija.   (14 January 2009)

Author's reply: 22 January 2009
Mohammed M Zamzam, Associate Professor & Consultant Pediatric Orthopedic Surgeon College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia Send letter to journal: Re: Author's reply: mmzamzam{at}yahoo.com Mohammed M Zamzam	Sir, We thank Professor Vukasinovic and his colleagues for their comments. We have no definite explanation for the high incidence of AVN in their patients, but we do not think that the procedure is the only possible cause. Many other factors can contribute, such as the previous treatment, the age of the patient, the grade of the treating physician, trauma to the femoral head during surgery, excessive dissection, and the position of the hips in the post-operative cast. We think that all these factors and others should be studied before abandoning this procedure. In fact, the main problem we faced after open reduction using a medial approach was loss of reduction. We found this to be due to the persistent acetabular dysplasia in older patients, so we limited the procedure to children younger than 12 months of ege. M. Zamzam, Associate Professor and Consultant Pediatric Orthopedic Surgeon, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
Our experience with open reduction in the treatment of DDH in not at all encouraging! 14 January 2009
Zoran S. Vukasinovic, Professor of Orthopaedics Institute of Orthopaedic Surgery, Goran Cobeljic, Zorica Zivkovic, and Igor Seslija. Send letter to journal: Re: Our experience with open reduction in the treatment of DDH in not at all encouraging! zvukasin{at}beotel.net Zoran S. Vukasinovic, et al.	Sir, We read this paper with great interest. We congratulate the authors on their very good results! However, we would like to make some comments representing our experience. We have been dealing with developmental dysplasia of the hip (DDH), in different age groups, for about forty years. In the first 18 months of age we most frequently used non-surgical methods of treatment (closed reduction, different abduction devices - mostly Pavlik harnesses), but occasionally without success. In these rare cases we used to perform combined surgical and non-surgical methods of treatment. The surgical component of treatment was a soft tissue procedure (similar to that described in this paper) and consisted of one-stage open reduction, usually through a Ludloff approach, and rarely (in less than 10% of cases) through a Smith-Petersen approach. We treated 28 hips in this way. Reduction of the dislocated hip was achieved in all cases, with maintenance of reduction in most cases (27 hips, 96.43%). Unfortunately, we had a very high rate of post-reduction avascular necrosis of the hip (24 hips, 85.71%). Therefore we abandoned this form of treatment in 1999. We then decided to leave all the unreducible hips (by non-surgical means) until the age of two years, and to treat them at that age by open reduction combined with Salter pelvic and corrective femoral osteotomies. The rate of post-reduction avascular hip necrosis was acceptable in both treatment groups (non-surgically treated hips in children younger than 18 months of age, 3.4%; surgically treated hips in children older than two years of age, 1.1%).1 Our results differ enormously from the results in this study, as well as from the results of other authors. 2-8 Perhaps the reason is in extensive surgery required which resulted in a high rate of reduction and retention but with a high rate of post-reduction avascular hip necrosis in our series. Z.S. Vukasinovic, Professor of Orthopaedics, G. Cobeljic, Z. Zivkovic, I. Seslija, Institute of Orthopaedic Surgery, Belgrade, Serbia. 1. Cobeljic G, Vukadin O, Vukasinovic Z, Aleksic V. Results of the soft-tissue operative procedures in treating the developmental disorder of the hip in children up to two years of age. Acta Orthop Iugosl 1999;30:137-9. 2. Trolic Z, Ljubic B, Gavrankapetanovic I, et al. Open reduction of congenital hip dislocation by medial approach: case series. Croat Med J 2002;43:312-8. 3. Albinana J, Dolan LA, Spratt KF, et al. Acetabular dysplasia after treatment for developmental dysplasia of the hip: implications for secondary procedures. J Bone Joint Surg [Br] 2004;86-B:876-86. 4. Doudoulakis J, Cavadias A. Open reduction of CDH before one year of age: 69 hips followed for 13 (10-19) years. Acta Orthop Scand 1993;64:188-92. 5. Koizumi W, Moriya H, Tsuchiya K, et al. Ludloff's medial approach for open reduction of congenital dislocation of the hip: a 20-year follow-up. J Bone Joint Surg [Br] 1996;78-B:924-9. 6. Mankey MG, Arntz GT, Staheli LT. Open reduction through a medial approach for congenital dislocation of the hip: a critical review of the Ludloff approach in sixty-six hips. J Bone Joint Surg [Am] 1993;75-A:1334-45. 7. Morcuende JA, Meyer MD, Dolan LA, Weinstein SL. Long-term outcome after open reduction through an anteromedial approach for congenital dislocation of the hip. J Bone Joint Surg [Am] 1997;79-A:810-7. 8. Szepesi K, Biró B, Fazekas K, Szücs G. Preliminary results of early open reduction by an anterior approach for congenital dislocation of the hip. J Pediatr Ortho 1995;4:171-8.