Treatment of Congenital Dislocation of the Hip in Older Children

The aims of treatment of a child with congenital dislocation of the hip (CDH) untreated until walking age should be to reestablish the mechanics of the hip joint and avoid complications, especially avascular necrosis, thus delaying the development of ostcoarthritis. The pathology in the older child shows that both soft tissues and bony parts are distorted to some degree. The acetabular index and center-edge (CE) angle evaluations are helpful in the initial evaluation and in the follow-up examinations. A computed tomography (CT) scan may be helpful in determining a reduction and distinguishing between dysplasia and subluxation. A controversy still exists as to the relative value of closed and open reduction in the treatment of a child who has reached walking age. For most surgeons, in a child up to three years of age, a careful closed reduction following a period of traction is the most useful form of treatment. The home traction program has been successful in* this age group. For gentle closed reduction all maneuvers must be done as gently as possible and carried out as “positioning” the leg rather than forcing a reduction. The indications for open reduction are (1) if the femoral head persistently lies above the triradiate cartilage on roentgenographic examination, (2) if the arc of reduction and redis-location is less than 25° after an adductor tenotomy, (3) if the femoral head will not enter the acetabulum, (4) if the femoral head is still laterally placed in the acetabulum after four weeks of partial reduction, and (5) if a previous reduction has failed. In the hands of most surgeons, it is probably best to consider open reduction as the only primary procedure, reserving femoral or pelvic osteotomy as a secondary measure. The older child with bilateral hip dislocation is a difficult problem. One should strongly consider withholding treatment in a child older than four years of age because the risk of stiffness in both hips is significant. If it is not possible or desirable to lower the femoral head to the level of the acetabulum with traction because of tightness in the surrounding tissues, a femoral shortening can be used. Standing roentgenograms should always be used after a child reaches walking age. If a child requires a secondary procedure, it is important to consider that both the femoral and acetabular components are abnormal to some degree. The innominate osteotomy of Salter is used to redirect the acetabulum in order to produce femoral head coverage laterally and anteriorly. It is ideal for acetabular dysplasia and mild subluxation in children three years of age until early puberty. In the Pemberton procedure, both the direction and the shape of the acetabular roof are changed through the triradiate cartilage. This procedure is particularly indicated when there is a major, true deficiency in the angle of the cartilaginous acetabular roof. If there has been any upward migration of the femoral head, the procedure should be performed only following a period of femoral traction to bring the femoral head down to the appropriate level. A femoral deformity is associated with anteversion or true valgus angulation of the femoral neck. The latter is rare unless previous surgery has disrupted the growth of the greater trochanteric epiphysis or there has been a previous avascular necrosis of the epiphysis, with damage to the lateral portion of the epiphyseal line of the femoral head and secondary growth into valgus. The results of the varus derotation osteotomy have been quite reliable in children younger than four