Congenital dislocation of the hip (CDH) refers to an abnormal configuration of, or relationship between, the femoral head and the acetabulum. It is a continuum of disorders that ranges from shallowness of the acetabulum, to instability and subluxation of the femoral head, to frank dislocation, the term congenital implies that a condition existed at birth. In the paediatric orthopaedic literature, the long standing terminology of congenital dislocation of the hip has been progressively replaced by the use of dysplasia or developmental dysplasia of hip (DDH) [1].

Developmental dysplasia of the hip (DDH) refers to abnormality in size, shape, orientation and organization of femoral head, acetabulum or both anatomical structures.

In 2% of cases the hip dislocation is not evident at birth but manifest in first few months of the life [2].

The true incidence of DDH cannot be estimated because there is no ‘‘gold standard’’ for diagnosis. Most developed countries report an incidence of 1.5 to 20 cases of DDH per 1000 births, depending in part on the methods of screening used [3].

The etiology of DDH is multifactorial involving genetic, hormonal and intra-uterine factors. Several recent studies have focused on the genetic etiology of DDH. Certain genetic markers have been identified for DDH but these are not yet diagnostic [4].

In order to obtain normal function and development of the hip, an anatomical reduction is necessary. It should be stated that a certain proportion of patients with a good reduction still do not achieve normal function, with possibility of osteoarthrosis development in later life [5].

The aim of this study is to evaluate the result of the management of DDH either closed or open in Alnoor specialist hospital over a period of time of 10 years. The indication of open reduction is late presentation and failure of closed reduction.

From 2004 to 2014, 188 patients (296 hips) had managed at the Orthopaedic department, Alnoor specialist hospital, Saudi Arabia, representing the senior author’s first ten years’ experience of this procedure. Patients admitted 10 days prior to the procedure for Galos traction most of the time all over 24 hours, all patients received general anaethesia, all patient underwent adductor tenotomy and trial of closed reduction, if reduced easily and safety zone within the accepted range then bilateral hip spica applied for 3 months, indications for open reduction was failed closed reduction, or the patient age more than 3 years. Open reduction was proceeded under general anaethesia, after prep and drap, through pikini incision, tenotomy of the sartorius and straight head of rectus femoris, exposing the capsule with tenotomy of the tendinous part of the iliopsoas muscle, splitting of the iliac apophysis, subperiosteal dissection of the outer iliac bone to mobilize the capsule from the pseudo acetabulum and reflect it down, the opening the capsule T-shaped, follow the ligamentum teres to the true acetabulum then excised with the transverse acetabular ligament, cleaning of the acetabulum from the pulvinar, test the ease of reduction of the hip joint, if difficult then consider femoral shortening osteotomy to be fixed with 4 holes plate and screws, the point is to reduce the hip easily to minimize the pressure on the femoral head so keep viability of the head, the femoral osteotomy was needed in 53 patients including 71 hips, if the acetabulum is shallow, salter innominate osteotomy done which was indicated in 6 patients including 6 hips, the capsule is reflected down subperioteally to create shelf like to aid to the coverage of the femoral head, capsulorraphy done and sutured by two stitches, reattachment of the rectus femoris and sartorus, repositioning of the iliac apophysis and lastly the skin sutured subcuticular, application of bilateral hip spica for total period of 3 months. In case of bilateralty two weeks gap between the two procedures.

We noticed changes of the articular cartilage of the femoral head at the time of open reduction areas of erosions and denuded cartilage which might explain the occurrence of AVN in certain cases (Figures 1-5).

Figure 1: Postoperative X-rays both hips for all patients managed by open reduction but for all patients managed by closed reduction CT both hips is done for evaluation of the accuracy of concentric reduction.

Figure 2: 4 years old female patient presented at the age of 1.5 years with unilateral DDH, patient operated after 3 months (two years follow up).

Figure 3: 9 years old female patient presented at the age of 6 years with unilateral DDH, patient operated after 4 months (3years follow up).

Figure 4: 8 years old male patient presented at the age of 5 years with unilateral DDH operated after 5 months (3years follow up).

Figure 5: 8 years old male patient presented at the age of one year and eight months age with unilateral DDH operated after 3 months (six years follow up).

182 hips in were treated by closed reduction (61.5%) and 114 hips were treated with open reduction (38.5%).

There were no post-operative infections and concentric reduction was obtained at the time of operation in all hips. Number of patients required subsequent surgery for recurrence after closed reduction 9 hips in 9 patients (3%), no recurrence of dislocation after open reduction, one patient only need change of spica because of dirty and broken spica, one patient developed pressure sore which resolve completely after removal of spica. At the final follow-up, the clinical results were rated as excellent in 182 hips, good in 32 hips and fair in 82 hips (Table 1).

Table 1: Clinical results according to modified McKay criteria

Avascular necrosis of the femoral head was observed 23 hips (7.8%) of closed reduction and 18 hips (6.1) of open reductions. Acetabular irregularity was noted in one hip of open reduction and a mild coxa valga deformity in two although Shenton’s line was normal. Leg lengthening of less than 1 cm was present in 9 hips (3%) of closed reduction and 13 hips (4.4%) of open reduction hips at the final followup, but gait was normal and the Trendelenburg test negative. Femoral shortening derotation osteotomy was needed in 71 hips due to difficult reduction, salter innominate osteotomy was required in 6 hips.

The aim of treatment in developmental dysplasia of the hip is to achieve stable concentric reduction as early as possible. This study showed according to clinical and radiographic results in the final follow-up, were rated as excellent in 182 hips, good in 32 hips and fair in 82 hips, at an average of 5.1 years of follow-up. The results were compared to what was published in literature.

Berkeley et al reported a series of 51 dislocated hips in patients between 12 and 36 months. They performed a derotational femoral osteotomy in 85% of the hips and a femoral shortening osteotomy in only two hips. They found excellent radiographic results in 57% and good results in 35% [6]. Galpin et al. reported a series of 33 dislocated hips in patients older than two years of age who were treated with a one-stage open reduction, femoral shortening, and pelvic osteotomy. They found satisfactory results clinically in 85% of hips and radiographically in 75% [7]. Nakamura et al. reported long term results after one-stage treatment in children with an average age of 2 years and 1 month. They found satisfactory results clinically in 73% and radiographically in 45% [8]. El-Sayed reported on 55 children (71 hips) with neglected DDH who had a one-stage combined operation between the ages of 2 and 4. They found satisfactory results clinically in 87% and radiographically in 83% [9].

Avascular necrosis of the femoral head is still a serious complication in treatment of DDH. Femoral head AVN does not occur in untreated hips. Therefore, there is no doubt that it is an iatrogenic complication [10].

• Late presentation of DDH is still common in Saudi Arabia, which necessitates more complex management and more frequent occurrences of unfavorable results.

• The overall results of either closed or open reduction was good.

• Early discovery of DDH is essential for successful treatment

• Developmental hip dysplasia is a major Dilemma if neglected

• The early the management the best will be the result regarding hip function and growth of the joint

• Skin traction we consider its effectiveness and aid for successful reduction

• Reduction of the hip should be with ease in order to reduce the risk of avascular necrosis otherwise femoral shortening is indicated

• The need for salter osteotomy is less frequent