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Presentation and Management of Neglected Developmental Dysplasia of Hip (DDH): 8-years' experience with single stage triple procedure.

Byline: Farid Ullah Khan Zimri, Syed Shujaat Ali Shah, Muhammad Saaiq, Faisal Qayyum and Muhammad Ayaz


Objective: To document the clinical presentation of neglected DDH and evaluate the outcome of triple procedure.

Methods: It was a descriptive case series study, conducted at the Department of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad over a period of 8-years. It included children aged >1 and 1 and <9 years who presented with neglected or late diagnosed DDH were included in the study. Exclusion criteria were children 40Adeg. Postoperatively the hips were immobilized with a double hip spica cast. The hip joints were placed in 90Adeg-100Adeg of flexion and 40Adeg-55Adeg of abduction with neutral internal rotation. The spica was continued for three months. Home physiotherapy was initiated after removal of the spica. The first spica cast was changed after four weeks postoperatively with removal of the hip joint K-wire. The osteotomy site K-wire was removed after X-ray confirmation of the consolidation at the osteotomy site usually three months postoperatively.

The patients were then regularly followed up in the outpatient department on monthly basis for the first 3 months and then every three monthly till the end of one year. The development of the operated hip joint was monitored through serial X-rays. The pelvis anteroposterior views were evaluated for the Tonnis grading of the femoral head displacement, measuring the acetabular index and CEA, the continuity of the Shenton's line and any evidence of AVN. The outcome measure of triple procedure was treatment success which was evaluated clinically using McKay's criteria and radiologically using Severin's criteria. The final results of these were documented at one year follow up. The data were analysed through SPSS-17 to measure the outcomes. Fig.1 is the radiographic illustration of the triple procedure.

Table-I: McKay's clinical criteria.


I###Excellent###Stable painless hip;

###Negative Trendelenberg sign;

###Full range of motion (ROM)

II###Good###Slight limp;

###Slight reduction in ROM

III###Fair###Positive Trendelenberg sign;

###Moderate limp;

###Limited ROM

IV###Poor###Positive Trendelenberg sign.

###Unstable and/or Painful hip;

Table-II: Severin's radiographic classification for postoperative outcome.

Class/ Grade###Description###Centre-Edge Angle(Degrees)

I###Normal appearance###15(5-13 Years)

###20(>14 Years)

II###Mild deformity of femoral head, neck or acetabulum###15(5-13 Years)


III###Dysplasia/ moderate deformity###<15(5-13 Years)

###14 Years)

IV###Subluxation of femoral head###-

V###Articulation of femoral head with false acetabulum###-



We had a total of 193 children in our study with 213 DDH affected hips. There were 152 females (78.75%) while 41 males (21.24%). Children with left sided DDH were 127(59.62%), right sided 46 (21.59%) and bilateral DDH were 20(9.38%).

The age ranged from 1-8 years with a mean of 3.31+-1.6 years. The hospital stay was 7-15 days with a mean stay of-8.03+-1.98 days.

Results of clinical evaluation as assessed according to the McKay's criteria are as follows: Preoperatively, Grade-III in 115(53.99%) while Grade-IV in 98(46%) hips. Postoperatively, Grade-I in 89(41.78%), Grade-II in 104(48.82%), Grade-III in 13(6.10%) and Grade-IV in 7(3.28%) hips.

The preoperative severity of the femoral head dislocation per Tonnis classification was as follows: Grade I in 7.98%(n=17), Grade-II in 48.35%(n=103) and Grade-III in 43.66%(n=93) hips.

All hips had an acetabular index(AI) of over 30 degrees preoperatively. The preoperative AI ranged from 39O to 51O with a mean of 43.91+-3.69O. The postoperative AI was 15O -25O with a mean of 18.42+-2.99O. Preoperatively CEA was negative among all cases whereas the postoperative CEA ranged from 21O to 26O with a mean of 23.18+-1.35O.

The radiographic outcome as per Severin's classification is as follows: Preoperatively, Grade-IV in 110(51.64%) and grade V in 103(48.35%) hips. Postoperatively, Grade-I in 113(53%), Grade-II in 48(22.53%), Grade-III in 43(20.18%), and Grade-IV in 9(4.22%) hips.

Among our share of complications included AVN and re-dislocation three cases each (1.40%). Moderate stiffness following removal of hip spica was observed among 13 cases (6.10%).


We found high frequency of neglected DDH in our patients. Our centre is located in the capital city of Pakistan and severs as a referral centre for the rehabilitation of disabled children from all over the country. The Orthopedic unit has one hundred beds with a 15 bedded bay dedicated for DDH children We receive patients particularly from areas such as Gilgit-Baltistan, Khyber-Pakhtunkhwa, Azad Jammu Kashmir, Federally administered tribal areas, Afghanistan, upper Punjab in addition to the main catchment areas of the twin cities of Islamabad and Rawalpindi. In our country, we neither have a screening programme for timely detection of DDH, nor have any structured referral system for these children. Hence majority of our children present with neglected DDH or late diagnosed DDH and need more aggressive surgical remedies such as the triple procedure.

We observed relatively more frequent affliction of females than males. Left side was also more frequently affected than the right sided hip. Our current findings conform to most of the reported literature.1-3 In our study we employed the single-stage triple surgical procedure. This extensive procedure consists of open reduction, femoral shortening, and Salter's pelvic osteotomy. It is technically more demanding procedure than a staged procedure. Our results favourably compare with most of the published literature. Vallamshetla et al.11 in their series reported 100% good or excellent clinical results using McKay's criteria while 100% Severin's classification class I and II. Similarly Umer et al.12 have reported 86.2% good to excellent clinical results and 51.7% Severin's class I in their series.

Open surgical reduction is the mainstay of the triple procedure Indeed it is the most effective modality for reducing DDH in grown up children. Certainly reduction in an older child often poses more challenge owing to a host of reasons. For instance, there is associated adaptive shortening of the soft tissues, capsular constriction, increased femoral anteversion, acetabular dysplasia, presence of obstructing structures such as the fibrofatty tissue in the acetabulum, hypertrophied ligamentum teres, the transverse acetabular ligament and fixed inversion of limbus.1-4,13,14 Femoral diaphyseal shortening is superior to traction as an aid in operative reduction of DDH in older children. It greatly decreases the rate of AVN and also decreases the risk of redislocation.3,15-17 The femoral shortening is particularly helpful in high dislocations to prevent undue pressure on the femoral head, which is the main cause of postoperative AVN, joint stiffness and reduction failures.

We employed Salter osteotomy in our patients and found it to be easy and useful for stabilizing hips after open reduction. It improves the cover of the femoral head and provides stability in the weight-bearing position. It can be done safely and reliably without any increase in the risk of AVN. Several other types of pelvic osteotomies have also been described to stabilize the reduced hip in older children.17-19 In our study we set the upper age limit of eight years in unilateral while six years in bilateral cases of DDH to be managed with the standard triple procedure.

Although most of the authorities agree to eight years as the upper age limit for this treatment, Ok IY et al.20 have recommended that, if there is a high likelihood of achieving a functionally good hip joint with biological remodeling, an open reduction is a reasonable strategy for an untreated dislocation in patients even older than eight years of age. They found that joint remodeling continued even after this age after a concentric reduction of the DDH.


The single stage triple procedure entailing open reduction, femoral shortening and Salter's osteotomy offers the surgical remedy of choice with favourable and lasting results for managing neglected DDH among children aged 1-8 years. Attention to fine details regarding correction of the complex morbid anatomy holds the key to successful outcome.

Conflicts of Interest: None declared.

Financial Disclosure: None declared.


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Publication:Pakistan Journal of Medical Sciences
Geographic Code:9PAKI
Date:Jun 30, 2018
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