Preliminary results of an anteverting triple periacetabular osteotomy for the treatment of hip instability in down syndrome

Abstract

PurposeTo investigate the outcomes of an anteverting triple periacetabular osteotomy for the treatment of hip instability in skeletally immature patients with Down syndrome.MethodsWe evaluated 16 patients (21 hips) with Down syndrome and hip instability who underwent an anteverting triple periacetabular osteotomy between 2007 and 2016. There were nine females and seven males with an average age of 7.4 years SD 2.0. We assessed the level of hip pain, gait ability and clinical stability at a minimum of one year after surgery. Radiographic evaluation included pre- and postoperative lateral centre-edge angle (LCEA), Tönnis acetabular angle and extrusion index.ResultAfter an average follow-up of 4.1 years SD 2.6, 20 of 21 hips (95%) remained clinically stable. In all, 12 of 16 (75%) patients had a full gait without a major limp, but three patients (19%) had a persistent limp. Of the 21 procedures, one hip (5%) was considered a failure due to persistent instability. There was a mean increase of 18.3º SD 15.3º of the LCEA (p < 0.001); a mean decrease of 15.2º SD 11.6º (p < 0.001) for the Tönnis angle and the extrusion index had a mean decrease of 0.27 SD 0.20 (p < 0.001). The most common complications were minor and included nonunion of the pubis or ischium (24%) and stress fractures of the pubis and ischium (14%). Only one patient required unplanned surgery for the treatment of an infection; which was considered a major complication.ConclusionThe anteverting triple periacetabular osteotomy provided global deformity correction and achieved hip stability in 95% of the hips after a mean follow-up of 4.1 years.Level of EvidenceTherapeutic level IV.

Treatment of Hip Instability in Children With Down Syndrome: Keys to Managing a Challenging Problem

“…This current study as well as prior literature demonstrate that maintaining a reduced hip can be difficult to achieve without complications. [5][6][7][8][9][10] Surgeons must balance the patient's hypotonia, ligamentous laxity, and variable degrees of coxa valga, femoral anteversion, relative acetabular retroversion and acetabular undercoverage. Prior literature has suggested that focusing on just the soft tissue, or just the femoral malrotation, leads to an unacceptable failure rate.…”

“…4 Management of these patients is not for the inexperienced or ill-equipped surgeon given its high complication rate, even in the most experienced hands. [5][6][7][8][9][10] Unfortunately, there is a paucity of literature to guide management.…”

“…1,2,7,11 With advances in imaging and our appreciation for the impact of acetabular orientation and morphology, surgeons focused on the relative acetabular retroversion and posterior deficiency in these patients with improved clinical results. 6,8,9,12,13 The aim of this study was to evaluate the clinical and radiographic outcomes of children with Down syndrome and hip instability who underwent surgical reconstruction with either femoral, acetabular, or combined procedures. We hypothesized that surgical reconstruction with both femoral and acetabular procedures would result in improved clinical and radiographic outcomes.…”

“…Authors reported variable success in maintaining a well reduced hip, and this success was highly dependent on the length of follow up and concomitant acetabular pathology 1,2,7,11. With advances in imaging and our appreciation for the impact of acetabular orientation and morphology, surgeons focused on the relative acetabular retroversion and posterior deficiency in these patients with improved clinical results 6,8,9,12,13…”

Effect of the Sharrard procedure on hip instability in children with down syndrome: A retrospective study

“…12 Multiple interventions for hip instability in children with DS, including closed reduction and several surgical techniques, have been described over the years, often showing suboptimal outcomes and considerable complication rates. [13][14][15][16][17][18][19][20][21][22] In 1959 and 1964, Sharrard 23,24 described a posterior iliopsoas transfer of the tendon insertion for the treatment of paralytic dislocation of the hip in patients with meningomyelocele and cerebral palsy, showing positive results in 17/22 patients. The Sharrard procedure transfers the iliopsoas muscle tendon insertion from the trochanter minor to the trochanter major through a foramen in the ala iliaca (Fig.…”