1
INTRODUCTION
Treatment for congenital dislocation of the hip (CDH) is quite complex,
comprising many stages. If detected early before 6 month old baby wearing
a splint corrected Parlik, children 6-18 months of age can be treated with
closed reduction or open reduction combined cast. The patient is detected,
treatment late has serious risks and complications such as dislocated joints,
avascular femoral necrosis, dysplasia and femoral head dislocation causing
lower limb discrepancy.
Globally, acetabuloplasty using bone allografts of the same type with
different techniques has produced superior results in shortening operation
time, minimizing encroachment to surrounding tissue, and achieving
aesthetic value. The treatment has been applied by authors such as Trevor
(1975), Kessler (2001), Grudziak 2001, Wade (2010), and Nguyen Ngoc
Hung in Vietnam (2013).
Salter innominate surgical is often surgeons used treatment of congenital
dislocation of the hip, the results are quite good. Nguyen Ngoc Hung (2004)
treatment of congenital dislocation of the hip, according to the Salter
technique for 79 hip joint results are as follows: good is 17.5%, quite is
73%, poor is 9.5%. However, the surgery must take autologous iliac, so
long incision, causing iliac wing bone defects, also need surgery to remove
foreign body. For the purpose of limiting the disadvantages we have
improved the Ziggaz bone cutting method, combined with the use of Bone
Allograft to create grafts instead of self-pelvic bone. In order to evaluate the
effectiveness of the above techniques, we conducted the research:
“Diagnosis and application of acetabuloplasty using bone allografts
treating congenital dislocation of the hip in young children at Vietnam
National Hospital of Pediatrics”. The objectives of our study are:
1. Clinical and diagnostic subclinical of congenital dislocation of the hip in
young children undergoing Salter's improved technique at the National
Hospital of Paediatrics, 2011-2015.
2
2. Assessing the results of Salter's improved technique of acetabuloplasty
using bone allografts of the same type in the treatment of congenital
dislocation of the hip in young children.
CHAPTER 1 - OVERVIEW
1.1. Anatomy and development of the hip, acetabulum, femur
1.2. Causes and diagnosis of CDH
1.3. Treatment status of CDH
1.3.1. In the world
1.3.1.1. Methods of osteotomy for dysplasia
In reality, an acetabula angle greater than 30 0 is considered abnormal and
suffers a risk of dislocation. Kleinberg and Lieberman conducted research
and came to a similar conclusion.
The treatment options for acetabular dysplasia are divided into the
following categories:
- The first group consists of osteotomies of the pelvis that redirect the entire
acetabulum, increasing the coverage of the femoral head.
Salter innominate osteotomy, done in the mid-1950s.
Advantages: does not affect the volume of the acetabulum, the technique is
simple.
Disadvantages: Relatively unstable, the bone is immobilized with Kirshner
wires inside, so a second surgery is needed to remove these wires.
- The second group: acetabuloplasties that involve incomplete cuts on
different aspects of the "Y" cartilage, including the acetabular procedures
described by Pemberton and Dega.
- The third group: acetabuloplasty involving placing bone over the hip joint
capsule on the uncovered portion of the femoral head. This includes the
various shelf procedures and the medial displacement osteotomy described
by Chiari
1.3.1.2. Methods of bone grafting
Autograft bone: autograft bone is effective in providing not only the threedimensional bone structure, but also a network of bone-forming cells,
which help to regenerate the bones better.
3
The drawback of self-grafting is that it causes pain, risk of complications
such as high blood loss, hematoma or fracture and limited supply.
* Characteristics and mechanics of bone allograft freeze
Bone morphogenetic protein (BMP), collagen-containing organic substrates
and bone-forming proteins retain the most important components.
* Risks of bone allografts
- Infectious disease.
- The graft is rejected.
1.3.1.3. Surgery methods to form joints
* Colonna’ capsular arthroplasty
* Salter’ capsular arthroplasty
1.3.1.4. Classification and treatment of CDH according to age
* Infants and children under 6 months
In 1945, Pavlik successfully treated CDH for children under 6 months with
Pavlik harness.
* Children from 6 months to 18 months
- Closed reduction: fixed and fixed castings are indicated for children
diagnosed with CDH over 6 months and those who have failed treatment
with Pavlik harness.
- Open reduction: indicated for patients aged 6 to 18 months, when seizure
control treatment has failed, subluxation of the hip, soft tissue insertion in
the middle and instable hip structure.
* Children over 18 months to 36 months
In this age group, the placenta is often deficient in the frontal area. The
operation usually applied is Salter’s or Pemberton’s osteotomy
* Children older than 3 years of age, open reduction with femoral
shortening is required. Surgery can be executed immediately or delayed for
about 6 weeks, depending on hip joint stability at the time of surgery.
1.3.2. In Vietnam
In 2001, Phan Van Tiep reported the second dissertation on the
epidemiological factor of congenital hip replacement.
In 2004, Nguyen Ngoc Hung reported treating for 76 patients CDH.
4
In 2012, Hoang Hai Duc, Nguyen Ngoc Hung reported treating 292
children with CDH using Salter’s method.
In 2013, Nguyen Ngoc Hung described the Zigzag pelvic osteotomy
combined with Fibular Allograft treating for 73 patients with CDH. Report
published in the Open Journal of Orthopedics.
1.4. SEQUELAE AND COMPLICATIONS
* Redislocation
* Deformation of proximal femoral
* Avascular necrosis of the capital femoral.
Avascular necrosis of the capital femoral may be due to causes such as
damage to blood vessel, cartilage growth, or pressure stress that affects the
cartilage.
Kalamchi and MacEwen developed a classification of avascular necrosis
combined with growth disorders at four different levels.
1.5. The role of postoperative rehabilitation
Chapter 2
SUBJECTS AND STUDY METHODS
2.1. Object, location, time of study
2.1.1. Research subjects
61 patients with 73 dislocated hips treated at Orthopedic Department of
National Hospital of Paediatrics.
2.1.1.1. Patient selection criteria
* Patients selected in this study meet the following criteria: Patients
diagnosed with congenital hip dislocation and indicatied for surgery.
Patients are aged ≥ 18 months - <36 months.
* Indication surgery: Grade III, IV dislocation according to Tonnis.
Acetabular angle > 350. Pelvic osteotomy is indicated when Zadeh test
result is positive.
2.1.1.2. Exclusion criteria
5
- Cases in which surgery is denied include bodily diseases, patients with
congenital malformation, patients treated at other facilities, patients outside
of the target age group, patients who did not consent to participate in the
study.
* Contraindications surgery: dislocated hip with cerebral palsy causing
cramps in the lower limbs, children with dysplasia, patients with multiple
stiffness.
2.1.2. Research location
The study was conducted at Orthopedic Department - National Hospital of
Paediatrics.
2.1.3. Research period
The study was conducted from July 2011 to July 2015, consisting of
patients diagnosed with CDH and indicatied for surgery.
2.2. Research methods
2.2.1. Research design
This research is designed by two methods:
- Analytical and descriptive research.
- Clinical intervention combined with longitudinal monitoring study.
2.2.2. Sample size and sampling methods
2.2.2.1. Study sample size
As the study proceeded by prospective descriptive method, all patients who
met the criteria for selection, were diagnosed and prescribed for CDH at the
Orthopedic Department of National Hospital of Pediatrics during the
research period.
2.2.2.2. Sampling method
2.2.3. Research content, data collection and evaluation
2.2.3.1. Exploring medical history
2.2.3.2. Collection of clinical indicators, clinical examination before and
after surgery
2.2.3.3. Information about surgery
2.2.3.4. Collection of laboratory parameters before and after surgery
* X-ray
6
- Patients were assessed for the Tonnis degree of CDH.
- Measure the acetabular angle.
- Assess femoral cap necrosis, classified according to Kalamchi and Mac
Ewen, with four levels.
- Measure the angle of the femur
- Measure the Wiberg angle
* CT scan of the hip and knee joint to determine the angle of the front of the
femur neck.
Resonance from the hip to determine the angle of the acetabulum.
* Blood test: evaluation of HBsAg infection, HIV.
2.2.4. Treatment procedure, surgery CDH
2.2.4.1. Preparing patients before surgery
2.2.4.2. Prepare instruments for pelvic osteotomy.
2.2.4.3. Preparation of bone graft: freeze-dried fibula of the same type,
originated from laboratory preservation tissue, Department of Molecular
Medicine, Hanoi Medical University.
2.2.4.4. Hip-shaping surgery technique
* Step 1: Incision
- Patients lie on their back, the hip joint being operated on is padded up.
- Adductor tenotomy
- The skin incision begins at 1- 2cm below anterior superior iliac spine, 4 6cm long along the inguinal crease.
- Tenotomy Psoat tendon.
- Cut the rectus femoris muscle origin.
- Expose the front of the hip.
* Step 2: Surgery on the acetabulum
+ T-shape capsulotomy according to Salter.
+ Cut the teres ligaments.
+ Cut the transverse ligament.
+ Remove the fat at the bottom of the acetabulum
+ Cut the Limpus hypertrophy cartilage
* Step 3: Cut the pelvis
7
Osteotomy site: on the graft of the straight muscle of the thigh (between the
superior frontal spine and the inferior frontal spine). Use a drill to mark the
osteotomy site. After sketching the cut lines, use small saw and chisel to
connect the cut lines (Figure 2.12).
+ Line 1: transversal line at just above anterior iliac spine, about 5 - 8mm.
+ Line 2: Followed by road 1, go down and internal oblique to create angle
900 or 1350, about 5 - 7mm long.
Between lines 1 and 2, a bone bridge will be created.
+ Line 3: to go internal obliquely to create angle 90 - 135 0 with line 2, about
8 - 10mm long. The graft site.
+ Line 4: connective line 3 and go down, about 10mm long.
+ Line 5: perpendicular to the line 4, to go internal transversal line, 6 - 8mm
long.
Between lines 4 and 5, a bone bridge will be created.
Figure 2.12. line osteotomy of Pelvic
- Perform bone grafts: Prepare bone grafts:
Length about 11 - 15mm, height 12 - 14mm, width 8 - 10mm
The bone is grafted to the middle of Line 3.
* Step 4: Closing the incision
2.2.4.5. Postoperative care
2.2.4.6. Casting and rehabilitative physiotherapy
- The spica cast was applied immediately post-surgery with the hip in 30 0 of
flexion, 40-450 of abduction, and 100 - 200 of internal rotation.
- Combine with rehabilitative physiotherapy.
8
2.2.4.7. Revise and evaluate the results after surgery
Periodic examination at 6 months, 12 months, 24 months.
Evaluation of the results was based on Trevor et al. (Classification adapted
from McKay and Severin). Evaluation of femoral necrosis based on grading
according to Kalamchi and Mac Ewen.
9
* Standardization of Trevor et al
Pain
Movement
Limping
Function-as
described
and by the
patient assessed
in the follow up
clinic
Radiological
features the C/E
angle of Wiberg
The appearance
of the femoral
head
Shenton’s line
Evidence of
degenerative
changes
- None
- Occasional
- Persistent
- Full
- Slight limitation but no fixed deformity
- More than half the normal range
- Less than half the normal
or some fixed deformity range
- Little or none
- Absent
- Present
- Full
- Slightly limited
- Severely limited
- 25 degrees or more
- 0-24 degrees
- Less than 20 degrees
- Normal
- Partial coxa plana or coxa magna
- Complete coxa plana or other severe
deformity
- Intact
- Present
- Absent
- Present
Point
s
3
2
1
5
4
3
2
1
1
0
3
2
1
3
2
1
3
2
1
1
0
1
0
10
Excellent
18 - 20 points
Good
15 - 17 points
Fair
12 - 14 points
Poor
< 12 points
2.3. Method of data processing research
The data is digitised, entered and processed by medical statistical method
with software SPSS 20.0.
2.4. The ethics of research
The study was approved by Hanoi Medical University and approved by the
National Hospital of Paediatrics under Decision No. 220B/BVNTWVNCSKTE dated April 11, 2013.
CHAPTER 3
RESULTS OF STUDY
3.1. Clinical and subclinical characteristics of CDH
3.1.1. Characteristics of research subjects
- Age of research object (month)
Table 3.1. Detection age and surgery age (n = 61 patients)
Detection and
CDH status
Age
n
Rate (%)
surgery age
< 12 months
16
26,2
12 - < 24 months
42
68,9
Detection age
≥ 24 - < 36 months
3
4,9
(CDH)
Total
61
100
(Ẍ±SD)
14,69 ± 4.05
18 - < 24 months
42
68,9
≥ 24 months - < 36
19
31,1
Surgery age
months
Total
61
100
(Ẍ±SD)
23,06 ± 4,9
Remarks:
Detection age in group 12 - < 24 months accounted for the highest rate at
68,9% (42/61).
11
Patients receiving surgery interventions at the age of 18 - 24 months
accounted for the highest rate of at 68,9%.
3.1.3. Clinical features
- Status of CDH by sex (n = 61 patients)
11%
Tỷ lệ mắc ở nam
Tỷ lệ mắc ở nữ
54; 89%
Figure 3.2. Hip dislocation by sex
Remarks:
Of the 61 patients, the group of female patients was highest at 88,5%; the
rate of male patients was 11,5%. Female/male ratio = 7,7/1.
- The extent of the difference in the length of the limb (only for the children
with the difference in the length of the lower limb)
Table 3.6. Degree of difference in limb length (n = 49)
Difference in limb length
n
Rate (%)
before surgery
1 - ≤ 1,5cm
6
12,2
> 1,5 - ≤ 2cm
31
63,4
> 2cm
12
24,4
Total
49
100,0
p
< 0,01
Remarks:
Patients with length difference of > 1,5 - ≤ 2cm account for the highest rate
at 63,4%.
3.1.4. Subclinical characteristics
- Left hip dislocation, right, bilateral on X-ray (n = 61 patients)
12
60%
52.400%
50%
40%
27.870%
30%
19.670%
20%
10%
0%
Bên trái
Bên phải
Hai bên
Figure 3.4. Dislocate the groin on the left, right, and both sides
(p <0,05)
Remarks: Left hip dislocation composes the highest rate at 52,4%. There
were a 52,4% difference in left hip dislocation rate compared with right hip
dislocation rate 27,9% and 19,7% in both sides; difference was statistically
significant with p <0,05).
- Assessment of CDH according to Tonnis levels (n = 73 joints)
Patients with CDH level IV in accordance with Tonnis account for 71,2%;
Level III is 28,8%
3.2. Surgical results
3.2.1. Results related to surgery
- Dimensions of shin bone (n = 73 pieces of bone):
+ Average length (Ẍ ± SD) = 12,3 ± 0,7mm, the longest is 15mm, the
shortest is 11mm.
+ Average height (Ẍ ± SD) = 13,5 ± 0,9mm, highest 15mm, lowest 13mm.
+ Average width (Ẍ ± SD) = 9,2 ± 0,5mm, width is 10mm, narrowest is
8mm.
- Complications caused by surgery
Table 3.12. A combination of complications and complications caused by
surgery
Complications during surgery
n
Rate (%)
Damage to femoral artery
0/73
0
13
Damage to femoral nerves
0/73
0
Damage to lateral cutaneous nerve of the
4/73
5,5
thigh
Comment:
- Surgery related injury: In surgery, there is no case of artery and nerve
damage. Only 4 in 73 cases damage lateral cutaneous nerve of the thigh.
3.2.2. Short-term results
3.2.3. Long-term results
All patients were followed up until 12 months after surgery. Then, from 24
months onwards, we examined and evaluated 48 patients with 59 joints who
underwent surgery, all patients were over 5 years old.
3.2.3.1. Redislocation (n = 73 joints)
5,48%(4/73)
Tái trật khớp
Không tái trật khớp
Figure 3.7. Rate of dislocation
Remarks:
There were 4 out of 73 (5,48%) cases of redislocation during 6 months
post-surgery.
3.2.3.2. Results related to bone grafts (n = 73 pieces of bone):
There are no cases of slipping fragments.
All of fibular allografts were completely in corporated post-surgery (from
12 to 18 weeks)
3.2.3.3. Effectiveness of pain relief intervention after surgery
3.2.3.4. Effectiveness of intervention that improves movement
Table 3.15. Trevor’s Effectiveness of Intervention in Movement
Improvement
14
Movement
After
After
After
Before
surgery surgery surgery
surgery
6
12
≥ 24
months months months
(1)
(2)
(3)
(4)
Rate
Rate
Rate
Rate
n
n
n
n
(%)
(%)
(%)
(%)
p
31 42,5 40 54,8 37 62,7
a (1: 2; 3; 4)
< 0,01
Slight limitation but
no fixed deformity 66 90,4 20 27,4 22 30,1 14 23,7
(b)
b (1: 2; 3; 4)
< 0,01
Full (a)
More than half the
normal range (c)
0
7
0
9,6
15 20,5
9
12,3
8
13,6
Less than half the
normal
0
0
7 9,6 2 2,8 0
0
or some fixed
deformity range (d)
Little or none
0
0
0
0
0
0
0
0
(e)
Total
73 100 73 100 73 100 59 100
p
< 0,01
< 0,01
< 0,01
< 0,01
c (1: 3; 4) > 0,05
c (2: 1; 3; 4)
< 0,05
d (2: 1; 3; 4)
< 0,05
e (1: 2; 3; 4)
> 0,05
Remarks:
Post-surgery hip joints that have a "full movement" range has increased
from 0% in to 42,5% after 6 months; 54,8% after 12 months and 62,7%
after surgery ≥ 24 months; Significant change in motor range with p <0,01.
There were no significant cases before surgery and after 6 months, 12
months and ≥ 24 months.
3.2.3.5. Effectiveness in reducing limping after surgery
3.2.3.6. Effectiveness in reducing function restriction
3.2.3.7. Evaluating the effectiveness of post-surgery intervention of the
Wiberg angle
This standard applies to patients under 14 years of age.
Table 3.18. Wiberg angle before and after surgery by Trevor
Wiberg angle value After surgery ≥ 24
p
months
15
n
>25°
20°- 24°
< 20°
< 00
Total
20
18
17
4
59
Percentag
e (%)
33,9
30,5
28,8
6,8
100
< 0,01
< 0,01
< 0,01
< 0,01
Remarks:
After the surgery, cases of good coverage of the acetabulum with Wiberg
angle >200 account for 64,4%. The incidence of Wiberg angle <20°
accounted for 28.8% after ≥ 24 months of surgery.
There are 4 cases of Wiber's angle <0 0 due to the femoral head located
outside the acetabular. These are cases of redislocation.
3.2.3.8. Assessing avascular necrosis of the capital femoral
Table 3.19. Avascular necrosis of the capital femoral before and after
surgery according to Trevor
Avascular
necrosis of
the capital
femoral
Before
surgery
(1)
6
9
4
Rat
e
(%)
94,
5
5,5
0
0
0
0
0
0
7
3
100
n
No necrosis (a)
Level 1
necrosis (b)
Level 2
necrosis (c)
Level 3
necrosis (d)
Level 4
necrosis (e)
Total
After
surgery
6
months
(2)
Rat
n
e
(%)
6
94,5
9
4
5,5
0
0
0
0
0
0
7
3
100
After
surgery
12
months
(3)
Rat
n
e
(%)
6 91,8
7
6
8,2
After
surgery ≥
24
months(4
)
n
Rate
(%)
54
91,5
1
1,7
0
0
1
1,7
0
0
2
3,4
0
0
1
1,7
7
3
100
59
100
p
a (1: 2; 3;
4)>0,05
b (3: 4) < 0,05
c (1: 2; 3;
4)>0,05
d (1: 2; 3;
4)>0,05
e (1: 2; 3;
4)>0,05
b4: c4, d4, e4
>0,05
Remarks:
The rate of Level 1 necrosis before surgery is 5,5%, that after 6 months is
5,5% and that after 12 months is 8,2%; remains unchanged at p > 0,05. This
16
change was statistically significant at p < 0,05 for 12 months versus ≥ 24
months (from 8,2% to 1,7%).
After > 24 months of surgery, the necrosis rates of Levels 2, 3, 4 increase
because of Level 1 necrosis has transitioned but the change is not
statistically significant at p > 0,05.
3.2.3.9. Evaluating femoral neck before and after surgery
Table 3.20. Change in the femoral neck before and after surgery according
to Trevor
After
After
After
Before
surgery surgery ≥
surgery 6
The appearance
surgery
12
24 months
p
months
of the femoral
(1)
months
(4)
(2)
head
(3)
Rat
Rat
Rat
Rate
n
e
n
e
n
e
n
(%)
(%)
(%)
(%)
Normal (a)
68 93,2 68 91,2 66 90,4 51 86,4 > 0,05
Partial deformity (b)
5
6,8
Severe deformity
(c)
0
0
73
100
Total
5
6,8
0
0
73
100
7
9,6
8
13,6
> 0,05
0
0
0
0
> 0,05
73
100
59
100
Remarks: Cases of "partial deformity" of the femoral neck before and after
surgery did not significantly change, the change was not statistically
significant; 6,8% before surgery versus 6,8% after surgery 6 months; 9,6%
after 12 months and 13,6% after surgery ≥ 24 months, with p> 0,05. There
are no cases of severe deformity of femoral head before and after surgery.
3.2.3.10. Evaluating the effectiveness of Shenton line intervention
3.2.3.11. Assessing the acetabular angle, before and after surgery
Table 3.22. Acetabula before and after surgery
Evaluation time
Acetabular angle
17
Before surgery (1)
Immediately after surgery (2)
6 months after surgery (3)
12 months after surgery (4)
≥ 24 months after surgery
(5)
p
n
73
73
73
73
59
Average
40,70
24,30
22,40
20,90
18,60
SD
3,65
1,75
1,53
1,54
1,69
(1: 2; 3; 4; 5) < 0,05;
0,05
Range
350-500
190-280
190-260
170-250
150-24,50
(2: 3; 4; 5) >
Remarks:
The acetabular angle before surgery was significantly reduced compared to
6 months, 12 months and ≥ 24 months with values of 40,7 0 versus 24,30;
22,40; 20,90 and 18,60; The change is statistically significant with p <0,05.
3.2.3.12. Trendelenburg's sign (n = 73 joints)
3.2.3.13. Evaluation of HBsAg and HIV test results before and after
surgery
3.2.3.14. Summary of the evaluation results of the effectiveness of
intervention
- Evaluate the results of the last check, classified by Trevor
Table 3.25. Synthesized results after surgery classified by Trevor
Evaluation
after
surgery
≥ 24
months
Excellent
(18 - 20
points)
n
%
39
66,1
Good
(15 - 17
points )
n
%
10
16,9
Average (12 14 points )
n
6
%
10,2
Poor
(< 11
points )
n
%
4
6,8
Total
59
Remarks: Evaluation of follow-up results when patients over 5 years old;
“Excellent” accounted for the highest percentage at 66,1% (39/59 hip
joints); “Good” at 16,9% (10/59 hip joints); “Average” at 10,2% (6/59 of
the hip). “Poor” results only account for 6,8% (4/59 of the hip) involve hip
replacement, gait, avascular necrosis of the capital femoral.
3.3. Analysis of related factors in hip dislocation
18
Chapter 4
DISCUSSION
4.1. Clinical features and imaging diagnostics in pediatric patients at
the National Hospital of Paediatrics
4.1.1 Characteristics of research subjects
4.1.1.1. Detection age
The results showed that the detection age group of 12 - <24 months
accounted for the highest share at 68,9%. At this age, children begin to
learn to walk. Thus, difficulty in movement is easily detected by the parents
by observing the length of the foot, the gait of the child with signs of
limping and deflection.
This finding is consistent with studies by Kocer et al. (2016), with 96% of
cases detected early in the 24 month period. Samarah OQ et al. (2016)
found that the prevalence of CKD below 12 months was 41,9%.
4.1.1.2. Age of surgery
The results showed that the mean age of intervention was 23,06 ± 4,9
months (Table 3.1). This finding is consistent with some reports from other
authors such as Ahmed E et al. (2013) for CDH in 20 patients with an
average age of 14,7 months. Bhatti A et al. (2014) performed one CDH
treatment for 38 children under 3 years of age with 50 patients with an
average age of 24,26 ± 7,6 months.
The results of the authors' study showed that the higher the age limit, the
more open reduction in combination with pelvic osteotomy, and the higher
the risk of femoral cap necrosis.
4.1.2. Factors related to CDH
4.1.3. Clinical characteristics CDH
4.1.3.1. Hip dislocation classified by sex
RESULTS: Of the 61 patients with CDH, the proportion of female patients
was 88,5% (54/61), the proportion of male patients was only 11,5% (7/61),
female/male ratio = 7,7/1 (Figure 3.2).
The results of our study are similar to those of local and international
studies: Ulici A et al. (2016). Male/female ratio is 7/1. Woodacre T (2016)
shows that the prevalence of female CDH cases is higher in men than in
men, with 7,2/1 in female. In the study conducted by Nguyen Ngoc Hung
19
(2013), the percentage of female is 86,3% (63/73); 13,7% (10/73) are male;
the female/male ratio is 6,3.
4.1.3.2. Dislocation of the hip on the left, right, and both sides
Results showed that the rate of left hip replacement was highest at 52,4%
(Figure 3.4).
This result is similar to many other authors’ studies: In a study by Bhatti A
et al. (2014), 31.57% of cases was on both sides; 28,94% right hip; 39,47%
was on left hip. Phan Van Tiep (2001) showed that the rate of left hip
dislocation was 50,0%, right hip dislocation 16,7%; and both 33,3%.
4.1.3.3. Hip pain
4.1.3.4. Difference of lower limb
According to our result, the difference in length of the legs from more than
1,5cm - ≤ 2cm is 63,4% and the difference in length of over 2cm is 24,4%
(Table 3.6).
This result is perfectly consistent with the clinical manifestations of CDH.
4.1.3.5. Galeazzi sign
The authors claimed that when Galeazzi test returns a positive, it is certain
that the hip is dislocated.
4.2. Zigzag's modified pelvic bone transplantation technique improves
combined with fibular allograft in treating CDH in young children.
4.2.1. Effectiveness in improving movement after surgery
Research results show that the proportion of patients with full movement
before surgery is 0% (0/0); after surgery this increased to 62,7% (37/59)
(table 3.15). Thus, movement is significantly increased by surgery.
This finding is in high accordance with the clinical situation of patients and
studies of authors at home as well as abroad: Aksoy C et al (2013) studied
35 patients with an average age of 35 months (18 to 65 months), with 43
hips dislocated. Statistics show that before surgery, 100% of patients
experienced pain with varying degrees and their movement was restricted.
After surgery, at the last follow-up, 100% of the patients were no longer
restricted in movement.
4.2.2. Changes in the Wiberg angle and the acetabular angle
Results showed that the rate of post-surgery patients with Wiberg angle >
25° is 33,9% (Table 3.18).
20
The results showed that the change in the acetabular angle prior to surgery
decreased from 40,70 to 24,30 immediately after surgery (Table 3.22). After
24 months, the average acetabular angle was 18,60.
The results of our study are congruent to that of other authors such as
Aksoy C et al (2013), on treatment of dysplasia. The results show that the
average acetabular angle before surgery is 35°, and that after surgery is 20°.
At the end of the follow-up, the average angle was 13°. In Vietnam,
Nguyen Ngoc Hung (2013) concluded in his research that the acetabular
angle was significantly improved: before surgery was 42,95°, last
examination, after surgery was 19,15°.
4.2.3 Complications after intervention
4.2.3.1. Avascular necrosis of the capital femoral (AVN)
Our results show that the rate of Level 1 necrosis prior to surgery is 5,5%
and after 6 months, 5,5% and after 12 months, 8,2% with p> 0,05. After 24
months, Levels 2, 3, and 4 necrosis rate increased, having transitioned from
Level 1 necrosis. However, the change was not statistically significant with
p> 0,05 (Table 3.19).
Prior to 1960, according to Esteve Rafael, the incidence of femoral necrosis
was 70% after open reduction, with the lowest rate being 5% after open
reduction and 0% after closed reduction.
Aydin A et al. (2012) performed Pemberton pelvic osteotomy technique for
86 patients with dysplasia from 12 to 36 months of age. As a result, Level 1
necrosis was 9,9%; Level II is 7,7% and Level III is 1,1%.
Postoperative surgery results showed that the femoral head necrosis
complication rate in our group was lower than those of the authors. This
result is due to the fact that we do not cut the femur combined
acetabuloplasty using bone allografts, thus minimizing the damage to the
arteries, and the soft tissues around the hip.
4.2.3.2. Femoral neck deformity
The results show that partial femoral neck deformity rate before surgery is
6,8% compared to 6,8% after 6 months post-surgery; 9,6% after 12 months
and 13,6% after surgery ≥ 24 months, the change was not statistically
significant with p> 0,05 (Table 3.20). No cases of severe deformity of the
capital femoral, and neck before and after surgery were detected.
Trevor D, Johns DL, Fixsen JA (1975) showed that in 15 excellent joints, 7
experienced coxa magna; in 44 good joints, 20 joints experienced coxa
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