JBJS | Congenital Dislocation of the Hip in the Older Child. The Effectiveness of Overhead Traction*

The Journal of Bone & Joint Surgery, Volume 78, Issue 1

Articles | January 01, 1996

Congenital Dislocation of the Hip in the Older Child. The Effectiveness of Overhead Traction*

ABDELHAMID DAOUD, M.D.†; ABDELTIF SAIGHI-BOUOUINA, M.D.‡, DOUERA, ALGERIA

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Investigation performed at the Orthopaedic Pediatric Department, Centre Hospitalier et Universitaire, Douera

The Journal of Bone & Joint Surgery. 1996; 78:30-40

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Abstract

We studied the use of overhead traction in the treatment of congenital dislocation of the hip in thirty-five children (fifty hips) whose mean age at the time of the diagnosis was thirty-three months (range, eighteen to seventy-two months). None of the children had had any previous treatment. The mean time in traction was twenty-three days (range, eight to thirty-six days). Closed reduction was successful for relocation of the femoral head in thirty-eight of the fifty hips; twenty of these hips needed no additional treatment, sixteen were treated with an innominate osteotomy because of severe acetabular dysplasia, and two needed femoral derotation and an innominate osteotomy to correct persistent subluxation. In the remaining twelve hips, closed reduction failed at the outset and an open reduction was necessary. Femoral shortening also was performed in seven of the twelve hips to maintain concentric reduction.After a mean duration of follow-up of forty-eight months (range, thirty-two to sixty-five months), thirty-three hips were rated as class 1; seven, as class 2; four, as class 3; and five, as class 4, according to the criteria of Severin. The remaining hip could not be so classified. Avascular necrosis developed in two hips that had been treated with closed reduction followed by Salter osteotomy and in three hips that had been treated with primary open reduction. We found that preliminary overhead traction facilitated closed reduction of untreated congenitally dislocated hips in children who were eighteen to seventy-two months old.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Open and closed reduction of a dislocated hip in a child who has begun to walk each has advantages and disadvantages. Closed reduction usually is attempted after a period of traction, which is believed to facilitate reduction of the femoral head and to decrease the risk of avascular necrosis. Traction is applied to the lower extremities, with the degree of hip flexion based on the preference of the orthopaedic surgeon^{5,9,11,19,26,29,32,33,42}. Although some authors have suggested that traction before closed reduction is of little value^3,15,25, most surgeons still use some form of traction before attempting closed reduction of an untreated congenitally dislocated hip in an older child^{3,4,7-11,19-31,33,40,42}. The advantages of closed reduction are the relative safety and non-invasive nature of the procedure and a decreased tendency for stiffness of the hip. The disadvantages of longitudinal traction are the possibility of persistent unreduced subluxation, redislocation, or avascular necrosis; lengthy hospitalization; the need for repeated roentgenograms to ascertain progress^19,42; and the difficulty of nursing the children.

Open reduction is believed to eliminate some of the problems of prolonged hospitalization and the need for numerous roentgenograms. Another advantage is the ability to treat associated problems, such as acetabular dysplasia or excessive femoral anteversion, at the same time. However, open reduction is difficult to perform and frequently has been associated with stiffness of the hip and an increased risk of avascular necrosis^34,42. The choice between open and closed reduction of the hip in an older child remains controversial, but most authors have agreed that open reduction should be reserved for hips that cannot be reduced with the closed method^19,34,42. In developing countries, both methods of treatment have been used, and problems have been encountered with each^8,26.

Before performing the present study, we managed thirty patients (forty-four hips), in whom the dislocation of the hip was first detected after the child had begun to walk, with longitudinal traction before attempting to reduce the hip. The traction was used for a mean of eight weeks (range, two to nine weeks). Closed reduction after traction was successful in twenty-five patients (thirty-seven hips). During the same period, we managed twenty-nine children (thirty-nine hips) with open reduction, capsulorrhaphy, and a pelvic or femoral osteotomy. Avascular necrosis developed in six hips. These results stimulated us to perform the present study to evaluate the efficacy of overhead traction in the treatment of dislocation of the hip in older children.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Hôpital Lenval pour Enfants, 57 Avenue de la Californie, 06200 Nice, France.

‡Centre Hospitalier et Universitaire, Douera 42455, Algeria.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Hôpital Lenval pour Enfants, 57 Avenue de la Californie, 06200 Nice, France.

‡Centre Hospitalier et Universitaire, Douera 42455, Algeria.

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TABLE I DATA ON THE PATIENTS

*In patients with bilateral involvement, the first value is for the right hip and the second value is for the left hip.†A1 = arthrography performed before the adductor tenotomy and application of the first cast, A2 = arthrography performed at the time of the first change of the cast, and A3 = arthrography performed at the time of the second change of the cast.

Case	Sex, Age at Diagnosis (Mos.)	Hip	Initial Roentgenographic Findings		Traction		Arthrography†	Treatment	Durat. That Cast Was Worn (Mos.)	Epiphyseal Involvement‡	Complications	Durat. of Follow-up (Mos.)	Result
Tönnis³⁶ Grade*	Acetab. Index* (Degrees)	Durat. (Days)	Per Cent of Body Weight	Acetab. Index* (Degrees)	Center-Edge Angle* (Degrees)	Severin³⁰ Class*
1	F, 21	Bilat.	2/2	46/36	24	27	A2	Closed red.; no pelvic osteot.	5 mos. & 8 days			39	22/18	17/15	1/4
2	F, 24	L	2	45	22	25	A2	Closed red.; no pelvic osteot.	6			43	26	10	3
3	M, 24	Bilat.	3/3	40/50	21	27	A1, A2	Closed red.; no pelvic osteot.	6			65	14/19	28/20	1/1
4	F, 21	R	2	48	21	31	A1	Closed red.; no pelvic osteot.	6		Redisloc.	48	28	11	3
5	F, 24	Bilat.	4/4	40/45	26	29	—	Open red. & pelvic osteot.	2	R: avasc. necrosis; L: TIO	R: redisloc.	57	16/16	34/34	None/1
6	F, 20	Bilat.	2/2	48/52	25	23	A1, A2	Primary Closed red.; no pelvic osteot. Secondary: bilat. varus derot. & innom. osteot.	7			53	20/20	25/22	1/1
7	F, 19	Bilat.	4/4	41/41	19	23	A1, A2	Closed red.; no pelvic osteot.	6	R: TIO		60	20/22	16/15	1/1
8	M, 24	R	3	52	24	19	A1, A2	Closed red.; no pelvic osteot.	6	TIO		54	21	26	1
9	F, 20	L	2	38	15	22	A1, A2, A3	Closed red.; no pelvic oteot.	5			64	14	25	1
10	F, 23	Bilat.	2/3	50/50	26	33	R: A1	R: closed red. & pelvic osteot.; L: open red. & pelvic osteot.	6			36	13/10	30/32	1/1
11	F, 19	Bilat.	2/2	38/48	22	33	A1, A2	Closed red.; no pelvic osteot.	6			55	34/31	9/10	4/4
12	F, 22	L	2	46	20	30	A1, A2, A3	Closed red.; no pelvic osteot.	6	TIO		57	25	10	3
13	F, 18	L	2	47	25	30	A1, A2	Closed red.; no pelvic osteot.	4			42	16	26	1
14	F, 36	L	2	53	8	25	A3	Closed red.; no pelvic osteot.	6			40	22	27	1
15	F, 30	R	3	52	20	35	A2	Closed red. & pelvic osteot.	6			44	13	34	1
16	F, 36	L	3	44	15	25	A2	Closed red. & pelvic osteot.	4.5			45	14	26	1
17	F, 32	R	3	40	22	27	A1, A2	Closed red. & pelvic osteot.	5 mos. 20 days			42	14	27	1
18	M, 26	L	2	38	15	27	A1, A2, A3	Closed red.; no pelvic osteot.	6			43	17	25	1
19	F, 29	R	3	40	28	28	—	Closed red.; no pelvic osteot.	6		Redisloc.; open red., capsulorraphy, & innom. osteot.	35	16	18	1
20	F, 29	Bilat.	3/3	44/46	29	19	A1, A2	Closed red.; no pelvic osteot.	6			60	19/24	23/18	1/1
21	M, 36	Bilat.	4/4	35/42	23	25	—	Open red., pelvic osteot., & fem. short.	4	L: avasc. necrosis		60	0/8	35/32	1/2
22	F, 36	Bilat.	4/4	32/45	24	26	—	Open red., pelvic osteot. & fem. short.	4			36	15/16	26/29	2/2
23	F, 28	R	4	40	20	32	A1, A2, A3	Closed red.; no pelvic osteot.	6	TIO		36	28	8	4
24	F, 26	L	4	35	23	25	—	Open red. & pelvic osteot.	3			32	18	18	2
25	F, 36	L	3	33	26	32	A1, A2	Closed red.; no pelvic osteot.	5.5			64	12	23	1
26	F, 38	Bilat.	4/2	44/50	17	35	A2, A3	Closed red. & pelvic osteot.	7			45	16/13	14/17	3/1
27	M, 49	R	4	64	68	28	A2	Closed red. & pelvic osteot.	7		Lasting stiffness	60	14	28	1
28	F, 42	L	3	50	24	27	A1, A2	Closed red. & pelvic osteot.	5			38	22	34	1
29	F, 41	Bilat.	4/4	28/30	23	25	—	Open red., pelvic osteot., & fem. short.	3			36	14/8	37/37	1/1
30	M, 41	Bilat.	4/4	50/54	28	29	A1, A2	Closed red. & pelvic osteot.	5			57	16/16	27/27	1/1
31	F, 55	R	4	48	25	30	A1	Closed red. & pelvic osteot.	6	Avasc. necrosis	Redisloc.	53	10	30	2
32	M, 46	Bilat.	1/3	38/40	29	21	A1, A2	Closed red. & pelvic osteot.	6.5			40	18/28	20/32	1/2
33	F, 39	L	4	36	30	29	A1, A2	Closed red. & pelvic osteot.	6			36	10	20	1
34	F, 60	Bilat.	3/3	50/52	36	25	L: A1, A2	R: open red., pelvic osteot., & fem. short.; L: closed red. & pelvic osteot.	6	Avasc. necrosis (bilat.)		36	18/14	20/35	4/2
35	F, 72	L	4	45	21	24	A1, A2	Closed red. & pelvic osteot.	6			58	20	22	1

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TABLE I DATA ON THE PATIENTS

Case	Sex, Age at Diagnosis (Mos.)	Hip	Initial Roentgenographic Findings		Traction		Arthrography†	Treatment	Durat. That Cast Was Worn (Mos.)	Epiphyseal Involvement‡	Complications	Durat. of Follow-up (Mos.)	Result
Tönnis³⁶ Grade*	Acetab. Index* (Degrees)	Durat. (Days)	Per Cent of Body Weight	Acetab. Index* (Degrees)	Center-Edge Angle* (Degrees)	Severin³⁰ Class*
1	F, 21	Bilat.	2/2	46/36	24	27	A2	Closed red.; no pelvic osteot.	5 mos. & 8 days			39	22/18	17/15	1/4
2	F, 24	L	2	45	22	25	A2	Closed red.; no pelvic osteot.	6			43	26	10	3
3	M, 24	Bilat.	3/3	40/50	21	27	A1, A2	Closed red.; no pelvic osteot.	6			65	14/19	28/20	1/1
4	F, 21	R	2	48	21	31	A1	Closed red.; no pelvic osteot.	6		Redisloc.	48	28	11	3
5	F, 24	Bilat.	4/4	40/45	26	29	—	Open red. & pelvic osteot.	2	R: avasc. necrosis; L: TIO	R: redisloc.	57	16/16	34/34	None/1
6	F, 20	Bilat.	2/2	48/52	25	23	A1, A2	Primary Closed red.; no pelvic osteot. Secondary: bilat. varus derot. & innom. osteot.	7			53	20/20	25/22	1/1
7	F, 19	Bilat.	4/4	41/41	19	23	A1, A2	Closed red.; no pelvic osteot.	6	R: TIO		60	20/22	16/15	1/1
8	M, 24	R	3	52	24	19	A1, A2	Closed red.; no pelvic osteot.	6	TIO		54	21	26	1
9	F, 20	L	2	38	15	22	A1, A2, A3	Closed red.; no pelvic oteot.	5			64	14	25	1
10	F, 23	Bilat.	2/3	50/50	26	33	R: A1	R: closed red. & pelvic osteot.; L: open red. & pelvic osteot.	6			36	13/10	30/32	1/1
11	F, 19	Bilat.	2/2	38/48	22	33	A1, A2	Closed red.; no pelvic osteot.	6			55	34/31	9/10	4/4
12	F, 22	L	2	46	20	30	A1, A2, A3	Closed red.; no pelvic osteot.	6	TIO		57	25	10	3
13	F, 18	L	2	47	25	30	A1, A2	Closed red.; no pelvic osteot.	4			42	16	26	1
14	F, 36	L	2	53	8	25	A3	Closed red.; no pelvic osteot.	6			40	22	27	1
15	F, 30	R	3	52	20	35	A2	Closed red. & pelvic osteot.	6			44	13	34	1
16	F, 36	L	3	44	15	25	A2	Closed red. & pelvic osteot.	4.5			45	14	26	1
17	F, 32	R	3	40	22	27	A1, A2	Closed red. & pelvic osteot.	5 mos. 20 days			42	14	27	1
18	M, 26	L	2	38	15	27	A1, A2, A3	Closed red.; no pelvic osteot.	6			43	17	25	1
19	F, 29	R	3	40	28	28	—	Closed red.; no pelvic osteot.	6		Redisloc.; open red., capsulorraphy, & innom. osteot.	35	16	18	1
20	F, 29	Bilat.	3/3	44/46	29	19	A1, A2	Closed red.; no pelvic osteot.	6			60	19/24	23/18	1/1
21	M, 36	Bilat.	4/4	35/42	23	25	—	Open red., pelvic osteot., & fem. short.	4	L: avasc. necrosis		60	0/8	35/32	1/2
22	F, 36	Bilat.	4/4	32/45	24	26	—	Open red., pelvic osteot. & fem. short.	4			36	15/16	26/29	2/2
23	F, 28	R	4	40	20	32	A1, A2, A3	Closed red.; no pelvic osteot.	6	TIO		36	28	8	4
24	F, 26	L	4	35	23	25	—	Open red. & pelvic osteot.	3			32	18	18	2
25	F, 36	L	3	33	26	32	A1, A2	Closed red.; no pelvic osteot.	5.5			64	12	23	1
26	F, 38	Bilat.	4/2	44/50	17	35	A2, A3	Closed red. & pelvic osteot.	7			45	16/13	14/17	3/1
27	M, 49	R	4	64	68	28	A2	Closed red. & pelvic osteot.	7		Lasting stiffness	60	14	28	1
28	F, 42	L	3	50	24	27	A1, A2	Closed red. & pelvic osteot.	5			38	22	34	1
29	F, 41	Bilat.	4/4	28/30	23	25	—	Open red., pelvic osteot., & fem. short.	3			36	14/8	37/37	1/1
30	M, 41	Bilat.	4/4	50/54	28	29	A1, A2	Closed red. & pelvic osteot.	5			57	16/16	27/27	1/1
31	F, 55	R	4	48	25	30	A1	Closed red. & pelvic osteot.	6	Avasc. necrosis	Redisloc.	53	10	30	2
32	M, 46	Bilat.	1/3	38/40	29	21	A1, A2	Closed red. & pelvic osteot.	6.5			40	18/28	20/32	1/2
33	F, 39	L	4	36	30	29	A1, A2	Closed red. & pelvic osteot.	6			36	10	20	1
34	F, 60	Bilat.	3/3	50/52	36	25	L: A1, A2	R: open red., pelvic osteot., & fem. short.; L: closed red. & pelvic osteot.	6	Avasc. necrosis (bilat.)		36	18/14	20/35	4/2
35	F, 72	L	4	45	21	24	A1, A2	Closed red. & pelvic osteot.	6			58	20	22	1

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Figs. 1-A through 1-D: Case 18. Roentgenograms and arthrograms of the pelvis and hips of a twenty-six-month-old boy who was managed with closed reduction because of congenital dislocation of the left hip. Fig. 1-A: Anteroposterior roentgenogram showing a grade-2 dislocation³⁶ of the left hip. The acetabular index was 38 degrees.

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Arthrogram, made after fifteen days of overhead traction, showing the hip to be reduced. A square-shaped limbus (arrow) at the superior pole of the epiphysis and marked capsular distension are evident.

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Arthrogram, made after two months of immobolization in a plaster cast, showing a reduction of the height of the limbus (arrow).

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At the time of the latest follow-up, when the patient was five years and nine months old, the roentgenographic result was Severin³⁰ class 1, the acetabular index was 17 degrees, and the center-edge angle was 25 degrees.

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Figs. 2-A through 2-D: Case 10. Roentgenograms and arthrograms of a twenty-three-month-old girl who had bilateral congenital dislocation of the hip. The patient was managed with closed reduction on the right side and open reduction and innominate osteotomy on the left side. Subsequently, she had an innominate osteotomy on the right side as well. Fig. 2-A: Anteroposterior roentgenogram demonstrating bilateral dislocation of the hip, which was grade 2 on the right and grade 3 on the left³⁶. The acetabular index was 50 degrees on both sides.

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After twenty-six days of overhead traction, the closed reduction was successful on the right side only.

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Arthrogram showing the interposition of the limbus in the left hip. An open reduction and innominate osteotomy was performed on the left hip, and a closed reduction was performed on the right. The hips were immobilized in a plaster cast. An innominate osteotomy was performed two months later on the right side.

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At the three-year follow-up examination, when the child was almost five years old, both hips were graded as Severin³⁰ class 1. The acetabular index was 13 degrees on the right and 10 degrees on the left; the center-edge angle was 30 degrees on the right and 32 degrees on the left.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From January 1985 through May 1986, forty-four patients (sixty-two hips) who were eighteen to seventy-two months old were managed for congenital dislocation of the hip at the Orthopaedic Pediatric Department of the Centre Hospitalier et Universitaire in Douera, Algeria. Patients in whom the dislocation was secondary to a neuromuscular disorder or an infection were excluded from the study. None of the patients had been treated before being admitted to our unit. Nine patients were lost to follow-up; the remaining thirty-five patients (fifty hips) form the basis of the present study.

There were twenty-eight girls and seven boys. Twenty patients had unilateral involvement, and fifteen had bilateral involvement. The mean age at the time of the diagnosis was thirty-three months (range, eighteen to seventy-two months). Thirteen children (group I) were eighteen to twenty-four months old, twelve (group II) were more than two years to three years old, and ten (group III) were more than three years old.

The preoperative roentgenographic evaluation included measurement of the acetabular index and classification of the hip according to the system described by Tönnis³⁶. In that system, grade 1 indicates dysplasia of the hip and mild subluxation; grade 2, that the center of ossification of the femoral head is displaced laterally and is inferior to the superolateral corner of the true acetabulum; grade 3, that the center of ossification is at the level of the superolateral corner of the true acetabulum; and grade 4, that the center of ossification is proximal to the superolateral corner of the acetabulum. The center-edge angle was not measured preoperatively because it was always negative as a result of the dislocated position of the femoral head.

Skeletal traction was not used in any patient. Before closed reduction was attempted, both lower extremities were placed in overhead skin traction according to the technique described by Morel¹⁹. Longitudinal bands (adhesive straps) were applied to the medial and lateral aspects of each lower extremity, from the level of the greater trochanter to the ankle, and were held in place with two or three semicircular transverse straps on the thigh and leg. The semicircular bands were applied at different levels to avoid the problems associated with the use of circumferential bandages. Finally, elastic crepe bandages were applied over the adhesive straps, from the ankle to the proximal part of the thigh, to prevent the straps from slipping on the skin. The bandages were changed every two days to check the viability of the skin and to maintain tension on the adhesive straps. The extremities were monitored every hour for the first twenty-four hours, and then twice a day thereafter, for voluntary movements of the toes, the temperature of the skin, and any signs of discoloration of the skin or swelling.

The traction was applied with the hips in 90 degrees of flexion, neutral rotation, and 20 degrees of abduction. The child was prevented from getting up by a jacket that secured the child to the bed. The weight that was used to provide traction was equal to the amount necessary to lift the buttocks of the child just slightly off the mattress. In all three age-groups, the mean traction weight was 27 per cent (range, 19 to 35 per cent) of the body weight of the patient (Table I). The hips were clinically examined daily, and reduction was confirmed by the presence of a palpable clunk. Roentgenograms were not made while the child was in traction.

The mean duration of traction was twenty-three days (range, eight to thirty-six days) over-all, twenty-two days (range, fifteen to twenty-six days) in group I, twenty-one days (range, eight to twenty-nine days) in group II, and twenty-five days (range, seventeen to thirty-six days) in group III. Traction often was continued for an additional five, six, or seven days after the femoral head had been reduced because the operating room was unavailable for the application of the cast or for an open reduction.

At the end of the period of traction, closed reduction was attempted. With the patient under general anesthesia, gentle longitudinal traction was applied to the thigh with the hip in 90 degrees of flexion, and the hip then was gradually abducted. An open adductor tenotomy was performed in all of the hips. The reduction was considered satisfactory if the femoral head remained reduced when the hip was flexed 90 degrees and abducted 45 degrees. The reduction was confirmed with a roentgenogram. For twenty-nine hips, arthrography was performed, through a medial approach, to assess the size and position of the limbus, the degree of capsular distension, and the extent of pooling of contrast medium in the medial part of the joint. A bilateral hip-spica cast was then applied with the hips in 90 degrees of flexion and 60 degrees of abduction.

The cast was removed two months later, with the patient under general anesthesia. Stability of the hip was assessed with use of a roentgenogram and, for thirty-five hips, with use of an arthrogram. A second bilateral hip-spica cast then was applied, with the hips in 30 to 40 degrees of flexion and 30 to 40 degrees of abduction. We believe that this position corresponds to the actual length of the contracted iliopsoas muscle. Currently, we determine the optimum position with use of an arthrogram and check the stability of the reduction under fluoroscopy.

The cast was removed once again, two months later, with the patient under general anesthesia. The stability of seven of the hips was assessed with use of arthrography. A third bilateral hip-spica cast then was applied and was worn for two months. After this third cast had been removed, an abduction orthosis was used full-time for one month; the patient then was permitted to walk, and the orthosis was used only at night. Four patients (Cases 1, 9, 13, and 25) wore a cast for a total of less than six months after the reduction because the hip was clinically and roentgenographically stable.

An innominate osteotomy was performed, at the time of the first change of the cast, if the patient was more than three years old, if there was evidence of severe acetabular dysplasia, or if the child had had a previous open reduction and a Salter innominate osteotomy of the contralateral hip. In patients who had bilateral involvement, the pelvic osteotomies were done one week apart. Two months later, the cast was changed and the Kirschner wires were removed with the patient under general anesthesia. Roentgenograms were made to assess the reduction.

In eight patients (twelve hips), closed reduction was considered to be a failure because the femoral head could not be centered within the acetabulum or because the patient had had an open reduction. If the femoral head could be centered within the acetabulum but the reduction was not stable, the patient had an open reduction and a pelvic osteotomy without femoral shortening. If the femoral head could not be pulled down to the level of the acetabulum, the patient had an open reduction, femoral shortening, and a pelvic osteotomy. These eight patients wore a bilateral hip-spica cast for four weeks and were followed for a mean of forty-one months (range, thirty-two to sixty months).

Postoperatively, the acetabular index and the center-edge angle of Wiberg²⁹ were measured. The final results were evaluated with use of the criteria described by Severin³⁰.

Results

Introduction | Materials and Methods | Results | Discussion | References

We used two criteria to assess the efficiency of overhead traction in the treatment of dislocation of the hip: (1) the prevalence of avascular necrosis and (2) the success of a closed reduction with regard to maintenance of the reduction.

Closed Reduction

Closed reduction was successful for relocation of the femoral head in thirty-eight hips (twenty-nine children) (Figs. 1-A, 1-B, 1-C through 1-D). Preoperatively, one of these hips had been rated as grade 1; fifteen, as grade 2; twelve, as grade 3; and ten, as grade 4, according to the system described by Tönnis³⁶. In nine patients who had bilateral dislocation, closed treatment was successful on both sides; in two other such patients (Cases 10 and 34), one hip was reduced with the closed method and the other needed an open reduction.

Twenty-two of the thirty-eight hips (sixteen of the twenty-nine patients) in which closed reduction was initially successful did not need a pelvic osteotomy. Preoperatively, thirteen of the hips had been classified as grade 2; six, as grade 3; and three, as grade 4, according the system of Tönnis³⁶. The mean preoperative acetabular index was 44 degrees (range, 33 to 53 degrees). One patient (Case 6) had bilateral femoral derotation and innominate osteotomy one year after completion of the initial treatment because of persistent subluxation. After a mean duration of follow-up of fifty-one months (range, thirty-six to sixty-five months), fifteen hips were graded as class 1; three, as class 3; and four, as class 4, according to the criteria described by Severin³⁰. The mean center-edge angle was 19 degrees (range, 8 to 28 degrees), and the mean acetabular index was 21 degrees (range, 12 to 34 degrees).

Sixteen of the thirty-eight hips (thirteen of the twenty-nine patients) that had been treated initially with closed reduction only had a pelvic osteotomy at the time of the first change of the cast because the patient was more than three years old, the acetabulum was dysplastic, or the contralateral hip had been treated operatively (Figs. 2-A, 2-B, 2-C through 2-D). The closed reduction was considered successful in this group since the purpose of the osteotomy was to treat the acetabular dysplasia. The mean age of these patients at the time of the diagnosis was forty-three months (range, twenty-three to seventy-two months). Preoperatively, one hip had been classified as grade 1; two, as grade 2; six, as grade 3; and seven, as grade 4, according to the criteria of Tönnis³⁶. The mean preoperative acetabular index was 47 degrees (range, 36 to 64 degrees). After a mean duration of follow-up of forty-five months (range, thirty-six to sixty months), twelve hips were rated as class 1; three, as class 2; and one, as class 3, according to the system of Severin³⁰. The mean center-edge angle was 26 degrees (range, 14 to 35 degrees), and the mean postoperative acetabular index was 16 degrees (range, 10 to 28 degrees).

An arthrogram was made before the adductor tenotomy and the application of the first cast for twenty-nine hips (Table I). Technical errors during injection of the contrast medium prevented correct interpretation of the findings in three hips, and the data on those hips were not included in the tabulation of the results. The limbus was found to be obstructing a perfect reduction in twenty-six hips. In nineteen hips, the limbus was square-shaped on the arthrogram and prevented full reduction of the femoral head (Fig. 1-B); in five hips, the limbus had lost its height and was flattened against the lateral edge of the acetabulum; and in two hips, the limbus was not flattened. Two months later, at the time of the first change of the cast, with the patient under general anesthesia, an arthrogram showed complete reduction of the femoral head (Figs. 1-A, 1-B, 1-C, 1-D, 2-A, 2-B, 2-C through 2-D) in thirty-five hips. Roentgenograms made at the time of the second change of the cast showed the hips to be reduced; this finding suggests that the femoral head, if properly positioned, will become more deeply seated.

Open Reduction

In twelve hips (eight patients), closed reduction failed at the outset and an open reduction was performed. The mean age of these patients at the time of the diagnosis was thirty-four months (range, twenty-three to sixty months), and the mean duration of traction was twenty-six days (range, twenty-three to thirty-six days). Preoperatively, three of these hips had been classified as grade 3 and nine, as grade 4, according to the system of Tönnis³⁶. At the time of the open reduction, an innominate osteotomy was performed in five hips, and femoral shortening and derotation as well as a pelvic osteotomy was performed in seven hips. The mean preoperative acetabular index was 39 degrees (range, 28 to 50 degrees). After a mean duration of follow-up of forty-one months (range, thirty-two to sixty months), six hips were rated as class 1, four were rated as class 2, and one was rated as class 4; the remaining hip could not be classified, according to the criteria described by Severin³⁰. The mean center-edge angle was 29 degrees (range, 18 to 37 degrees), and the mean postoperative acetabular index was 13 degrees (range, 0 to 18 degrees).

Complications

Avascular necrosis developed in five hips (four patients), after primary open reduction in three and after closed reduction in two. The mean age of these patients at the time of the diagnosis of the dislocation was forty-four months (range, twenty-four to sixty months). Preoperatively, two of these hips had been rated as grade 3 and three, as grade 4, according to the system of Tönnis³⁶. After a mean duration of follow-up of fifty-two months (range, thirty-six to sixty months), three hips were rated as class 2 and one hip was rated as class 4; the fifth hip (Case 5) could not be classified with use of the criteria described by Severin³⁰. The latter hip was found to have redislocated at the time of open reduction of the contralateral hip and was treated with closed reduction; both hips were immobilized for six weeks. The roentgenograms showed complete disappearance of the entire epiphysis at fifty-seven months.

In five patients (five hips), the contour of the femoral epiphysis had an irregular appearance (transitory irregular ossification) on the roentgenograms. The mean age of these patients was twenty-three months (range, nineteen to twenty-eight months). Preoperatively, the dislocation had been classified as grade 2 in one hip, grade 3 in one hip, and grade 4 in three hips, according to the system of Tönnis³⁶. At the time of the most recent follow-up examination, three hips were rated as class 1; one, as class 3; and one, as class 4, according to the system of Severin³⁰.

Four hips redislocated during treatment: three (Cases 4, 19, and 31), after a closed reduction and one (Case 5), after an open reduction. A second closed reduction was successful in three hips; at the time of the most recent examination, one (Case 31) was rated as class 2, one (Case 4) was rated as class 3, and one (Case 5) could not be classified, according to the criteria of Severin³⁰. The fourth hip (Case 19) in this group redislocated after four months in a bilateral hip-spica cast. This patient then had open reduction, capsulorrhaphy, and innominate osteotomy. At the time of the latest examination, the hip was rated as Severin³⁰ class 1.

One hip (Case 27) remained stiff in abduction for more than one year after the completion of treatment. The child could not be managed with physiotherapy and walked with the limb in abduction for a long time (nine months). After sixty months of follow-up, the hip was rated as Severin³⁰ class 1.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Several methods have been proposed for the treatment of congenital dislocation of the hip in a child who has begun to walk^{2,3,8,9,12,15,16,19,25,27,29,31,37,40,42}. The modality of treatment that is chosen usually reflects the training, experience, and temperament of the treating orthopaedic surgeon. This choice also is often influenced by the resources and facilities that are available.

Algeria has a large population of children who are walking and have untreated congenital dislocation of the hip. There are several reasons for this situation. The socioeconomic conditions and demographics of Algeria make it difficult to establish and maintain an efficient newborn-screening program. A dearth of pediatricians and orthopaedic surgeons, insufficient resources such as operating rooms, and the exigencies and demands of emergency problems all contribute to the delay in the detection and treatment of congenital dislocation of the hip. The lack of adequate nursing staff, skin ulcerations of the groin and buttocks, the need for repeated roentgenograms, and the high number of failures of reduction with use of longitudinal traction led us to consider the use of overhead traction. Furthermore, we found it difficult to center the femoral head within the acetabulum with use of longitudinal traction^19,31. Despite these problems, we believe that reduction should be obtained with a closed method whenever possible.

Overhead traction has been used to facilitate the reduction of dislocated hips in younger children^7,28,33. In the series described by Coleman⁷ and by Salter et al.²⁸, the children were less than eighteen months old. Tachdjian³³ reported on children who were walking, but he did not mention their exact ages. Wilkinson⁴⁰ used overhead traction in the treatment of dislocated hips in 230 children who were ten months to three years old.

Several studies have demonstrated the efficacy of preliminary traction in rendering closed reduction of the hip safe and in reducing the prevalence of avascular necrosis^{7,9,11,19,31,40}. The reported prevalence of avascular neurosis after closed reduction for congenital dislocation of the hip has ranged from 5 to 7 per cent^15,27,32,42. We agree with King and Coleman¹⁶ as well as with Thomas et al.³⁴ that open reduction increases the risk of the development of avascular necrosis. This may be because hips that are treated with open reduction usually are more resistant to treatment or are more severely displaced (grades 3 and 4³⁶) and extensive operative dissection is often needed to obtain reduction. The data from those reports reinforced our decision to perform operative reduction only in hips in which closed reduction, performed after preliminary traction, was unsuccessful.

There is no consensus concerning the direction of pull applied to the lower limbs during longitudinal traction. Morel¹⁹ and Somerville³¹ recommended that traction be applied with the hips fully extended, Zionts and MacEwen⁴² recommended a position of 30 degrees of flexion, and Tachdjian³³ recommended 60 degrees of flexion. Several other authors have noted that children appeared to tolerate the overhead traction position with the hips in 90 degrees of flexion^{7,11,15,28,33,42}.

Avascular necrosis has been reported during the course of longitudinal traction when extreme positions of flexion, extension, or abduction have been used and when the traction has been performed too rapidly^10,38. Full extension of the hip can compress the medial femoral circumflex artery at the level of the lesser trochanter as it passes between the iliopsoas and the adductor-pectineus muscle group^22-24. Theoretically, flexion of the hip relaxes the iliopsoas and opens the area between the iliopsoas and the adductor-pectineus muscle group, thereby decreasing the risk of compression of the medial femoral circumflex artery. It is mandatory that longitudinal traction be gradual and progressive to permit sufficient stretching of the contracted soft tissues. The traction weight should be increased gradually to avoid sudden lengthening of the muscles. The effectiveness of longitudinal traction is assessed in terms of its ability to pull the capital femoral epiphysis to the level of the Hilgenreiner line^19,33,42 (+1 station of Gage and Winter¹¹) or down to the position of the normal, contralateral epiphysis⁵ (+2 station of Gage and Winter).

Several investigators have recommended that open reduction, femoral shortening, and pelvic osteotomy, all performed at the same time, is the safest means of reducing a dislocated hip in an older child^12,16,29. The choice of treatment in those studies was primarily influenced by the age of the patient. The results of the present study suggest that femoral shortening may not always be necessary in a child who is more than three years old. We observed that hips can respond differently in patients of different ages, and even from one side to the other in the same patient (Figs. 2-A, 2-B, 2-C through 2-D). We believe that when the hip is flexed, the relative discrepancy between the length of the muscles and that of the femur gradually disappears and the hip reduces easily; hence, some patients may not need femoral shortening.

The rate of failure of closed reduction has ranged from 5 to 100 per cent^{2,3,9,15,19,25,32,37,41,42}. This wide range probably is related to the fact that the series differed with regard to many variables, including the ages of the patients, the type of traction, the criteria used to define a successful closed reduction, and the position in which the hip was immobilized. A review of all of those studies showed that, although preliminary traction was not necessary to obtain closed reduction, it could decrease the risk of avascular necrosis^2,15,35. Ponseti and Frigerio²⁵ reported a successful closed reduction after premanipulative traction in twenty-eight of thirty-one hips, while Blockey³ reported a successful closed reduction without the use of traction in ninety (77 per cent) of 117 hips in children who were one to four years old. Kahle et al.¹⁵ suggested that preliminary traction does not decrease the prevalence of avascular necrosis or facilitate closed reduction in patients who are less than two years old, but the rate of success of closed reduction without preliminary traction in their study was only 57 per cent (twenty-seven of forty-seven hips). In contrast, the results of the present study of older patients who had more severe dislocations suggest that preliminary overhead traction does facilitate closed reduction (a 76 per cent rate of success; thirty-eight of fifty hips) and decrease the prevalence of avascular necrosis (5 per cent; two of thirty-eight hips).

A number of authors have reported on the use of longitudinal traction before closed reduction. This method was successful in eighty-two (73 per cent) of 112 hips in the study by Esteve⁹, in fifty-six (78 per cent) of seventy-two hips in the study by Morel¹⁹, in thirty-nine (76 per cent) of fifty-one hips in the study by Zionts and MacEwen⁴², and in none of fifty-one hips in the study by Berkeley et al.². The criteria used to determine a successful closed reduction were different in each of those studies.

The use of overhead traction before reduction has been studied. Vickers and Catterall³⁷ reported a successful closed reduction in thirty-three (66 per cent) of fifty hips in children who were between one and three years old. Wilkinson⁴⁰ reported that 196 (85 per cent) of 230 hips in children who were ten months to three years old needed an open reduction.

Several authors have reported high rates of failure of closed reduction after preliminary traction^2,31,40,41. However, these high rates possibly were due to the rigid criteria used to define an acceptable reduction. For example, mild instability at the time of the first change of the cast could be construed as a failure. We believe that it is better to assess the status of the hip at the time of the second change of the cast and that adherence to this policy decreases the number of open reductions. Arthrograms that were made after two months of treatment in a hip-spica cast showed concentric reduction of the hip.

Although overhead traction commonly is employed for children who are less than eighteen months old^7,28,37, its use in older children has been condemned because of the risk of vascular compromise of the lower limbs^14,33. Volkmann contracture has been reported in children who have been managed with overhead traction because of femoral fracture^18,20,21,35. We believe that overhead traction was not the culprit¹³, since Volkmann contracture also has been reported in children who have been managed with longitudinal traction because of femoral fracture³⁵. Volkmann contracture did not occur in the present series. We have used overhead traction in children more than three or four years old, and we think that awareness of this problem and close monitoring of the child should prevent these complications.

We believe that primary open reduction of a congenital dislocation of the hip is associated with a high prevalence of complications even when performed by an experienced surgeon. We found that a mean of three weeks of overhead traction with a mean weight of 27 per cent of the body weight of the patient facilitated a gentle closed reduction in thirty-eight (76 per cent) of the fifty hips in the present study. We observed a decrease in the rate of acetabular dysplasia when the dislocation was reduced in patients less than three years old^{4,6,16,17,25,39,42}. We now believe that an innominate osteotomy is necessary only for children who are more than three years old or who have severe acetabular dysplasia^1,17,39. Femoral shortening with a derotational osteotomy should be used only when traction fails to center the femoral head within the acetabulum. Preliminary overhead traction followed by gentle closed reduction is still an excellent method of reducing a dislocated hip.

NOTE: The authors thank Dr. David D. Aronson for critically reading and rewriting the manuscript.

References

Introduction | Materials and Methods | Results | Discussion | References

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Berkeley, M. E.; Dickson, J. H.; Cain, T. E.; and |and |Donovan, M. M.: Surgical therapy for congenital dislocation of the hip in patients who are twelve to thirty-six months old. J. Bone and Joint Surg.,66-A: 412-420, March 1984.66-A412 1984

Blockey, N. J.: Derotation osteotomy in the management of congenital dislocation of the hip. J. Bone and Joint Surg.,66-B(4): 485-490, 1984.66-B(4)485 1984

Brougham, D. I.; Broughton, N. S.; Cole, W. G.; and |and |Menelaus, M. B.: The predictability of acetabular development after closed reduction for congenital dislocation of the hip. J. Bone and Joint Surg.,70-B(5): 733-736, 1988.70-B(5)733 1988

Buchanan, J. R.; Greer, R. B., III; and |and | Cotler, J. M.: Management strategy for prevention of avascular necrosis during treatment of congenital dislocation of the hip. J. Bone and Joint Surg.,63-A: 140-146, Jan. 1981.63-A140 1981

Cherney, D. L., and |and |Westin, G. W.: Acetabular development in congenitally dislocated hips as a function of age at the time of reduction. Orthop. Trans.,6: 77-378, 1982.677 1982

Coleman, S. S.: Management of congenital dysplasia and dislocation of the hip from birth to eighteen months of age. In Congenital Dislocation of the Hip, pp. 181-203. Edited by M. O. Tachdjian. New York, Churchill Livingstone, 1982.

Daoud, A., and |and |Saighi-Bouaouina, S.: Ferguson's operation in the treatment of congenital dislocation of the hip. Results in 42 hips. French J. Orthop. Surg.,3: 73-381, 1989.373 1989

Esteve, R.: Congenital dislocation of the hip. A review and assessment of results of treatment with special reference to frame reduction as compared with manipulative reduction. J. Bone and Joint Surg.,42-B(2): 253-263, 1960.42-B(2)253 1960

Fogarty, E. E., and |and |Accardo, N. J., Jr.: Incidence of avascular necrosis of the femoral head in congenital hip dislocation related to the degree of abduction during preliminary traction. J. Pediat. Orthop.,1: 307-311, 1981.1307 1981 [CrossRef]

Gage, J. R., and |and |Winter, R. B.: Avascular necrosis of the capital femoral epiphysis as a complication of closed reduction of congenital dislocation of the hip. A critical review of twenty years' experience at Gillette Children's Hospital. J. Bone and Joint Surg.,54-A: 373-388, March 1972.54-A373 1972

Galpin, R. D.; Roach, J. W.; Wenger, D. R.; Herring, J. A.; and |and |Birch, J. G.: One-stage treatment of congenital dislocation of the hip in older children, including femoral shortening. J. Bone and Joint Surg.,71-A: 734-741, June 1989.71-A734 1989

Holmes, S. J. K.; Sedgwick, D. M.; and |and |Scobie, W. G.: Domiciliary gallows traction for femoral shaft fractures in young children. Feasibility, safety and advantages. J. Bone and Joint Surg.,65-B(3): 288-290, 1983.65-B(3)288 1983

Irani, R. N.; Nicholson, J. T.; and |and |Chung, S. M. K.: Long-term results in the treatment of femoral shaft fractures in young children by immediate spica immobilization. J. Bone and Joint Surg.,58-A: 945-951, Oct. 1976.58-A945 1976

Kahle, W. K.; Anderson, M. B.; Alpert, J.; Stevens, P. M.; and |and |Coleman, S. S.: The value of preliminary traction in the treatment of congenital dislocation of the hip. J. Bone and Joint Surg.,72-A: 1043-1047, Aug. 1990.72-A1043 1990

King, H. A., and |and |Coleman, S. S.: Open reduction and femoral shortening in congenital dislocation of the hip. Orthop. Trans.,4: 302-303, 1980.4302 1980

Lindstrom, J. R.; Ponseti, I. V.; and |and |Wenger, D. R.: Acetabular development after reduction in congenital dislocation of the hip. J. Bone and Joint Surg.,61-A: 112-118, Jan. 1979.61-A112 1979

Miller, D. S.; Markin, L.; and |and |Grossman, E.: Ischemic fibrosis of the lower extremity in children. Am. J. Surg.,84: 317-322, 1952.84317 1952 [PubMed][CrossRef]

Morel, G.: The treatment of congenital dislocation and subluxation of the hip in the older child. Acta Orthop. Scandinavica,46: 364-399, 1975.46364 1975

Mubarak, S. J., and |and |Carroll, N. C.: Volkmann's contracture in children: aetiology and prevention. J. Bone and Joint Surg.,61-B(3): 285-293, 1979.61-B(3)285 1979

Nicholson, J. T.; Forster, R. M.; and |and |Heath, R. D.: Bryant's traction: a provocative cause of circulatory complications. J. Am. Med. Assn.,157: 415-418, 1955.157415 1955

Ogden, J. A.: Changing patterns of proximal femoral vascularity. J. Bone and Joint Surg.,56-A: 941-950, July 1974.56-A941 1974

Ogden, J. A. Normal and abnormal circulation. In Congenital Dislocation of the Hip, pp. 59-92. Edited by M. O. Tachdjian. New York, Churchill Livingstone, 1982.

Ogden, J. A., and |and |Moss, H. L.: Pathologic anatomy of congenital hip disease. Prog. Orthop. Surg.,2: 3-45, 1978.23 1978

Ponseti, I. V., and |and |Frigerio, E. R.: Results of treatment of congenital dislocation of the hip. J. Bone and Joint Surg.,41-A: 823-846, July 1959.41-A823 1959

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Salter, R. B., and |and |Dubos, J.-P.: The first fifteen years' personal experience with innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip. Clin. Orthop.,98: 72-103, 1974.9872 1974 [PubMed][CrossRef]

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Schoenecker, P. L., and |and |Strecker, W. B.: Congenital dislocation of the hip in children. Comparison of the effects of femoral shortening and of skeletal traction in treatment. J. Bone and Joint Surg.,66-A: 21-27, Jan. 1984.66-A21 1984

Severin, E.: Contribution to the knowledge of congenital dislocation of the hip joint. Late results of closed reduction and arthrographic studies of recent cases. Acta Chir. Scandinavica, Supplementum,63, 1941.63 1941

Somerville, E. W.: Results of treatment of 100 congenitally dislocated hips. J. Bone and Joint Surg.,49-B(2): 258-267, 1967.49-B(2)258 1967

Somerville, E. W.: Displacement of the Hip in Childhood: Aetiology, Management, and Sequelae. New York, Springer, 1982.

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Arthrogram, made after two months of immobolization in a plaster cast, showing a reduction of the height of the limbus (arrow).

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After twenty-six days of overhead traction, the closed reduction was successful on the right side only.

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TABLE I DATA ON THE PATIENTS

Case	Sex, Age at Diagnosis (Mos.)	Hip	Initial Roentgenographic Findings		Traction		Arthrography†	Treatment	Durat. That Cast Was Worn (Mos.)	Epiphyseal Involvement‡	Complications	Durat. of Follow-up (Mos.)	Result
Tönnis³⁶ Grade*	Acetab. Index* (Degrees)	Durat. (Days)	Per Cent of Body Weight	Acetab. Index* (Degrees)	Center-Edge Angle* (Degrees)	Severin³⁰ Class*
1	F, 21	Bilat.	2/2	46/36	24	27	A2	Closed red.; no pelvic osteot.	5 mos. & 8 days			39	22/18	17/15	1/4
2	F, 24	L	2	45	22	25	A2	Closed red.; no pelvic osteot.	6			43	26	10	3
3	M, 24	Bilat.	3/3	40/50	21	27	A1, A2	Closed red.; no pelvic osteot.	6			65	14/19	28/20	1/1
4	F, 21	R	2	48	21	31	A1	Closed red.; no pelvic osteot.	6		Redisloc.	48	28	11	3
5	F, 24	Bilat.	4/4	40/45	26	29	—	Open red. & pelvic osteot.	2	R: avasc. necrosis; L: TIO	R: redisloc.	57	16/16	34/34	None/1
6	F, 20	Bilat.	2/2	48/52	25	23	A1, A2	Primary Closed red.; no pelvic osteot. Secondary: bilat. varus derot. & innom. osteot.	7			53	20/20	25/22	1/1
7	F, 19	Bilat.	4/4	41/41	19	23	A1, A2	Closed red.; no pelvic osteot.	6	R: TIO		60	20/22	16/15	1/1
8	M, 24	R	3	52	24	19	A1, A2	Closed red.; no pelvic osteot.	6	TIO		54	21	26	1
9	F, 20	L	2	38	15	22	A1, A2, A3	Closed red.; no pelvic oteot.	5			64	14	25	1
10	F, 23	Bilat.	2/3	50/50	26	33	R: A1	R: closed red. & pelvic osteot.; L: open red. & pelvic osteot.	6			36	13/10	30/32	1/1
11	F, 19	Bilat.	2/2	38/48	22	33	A1, A2	Closed red.; no pelvic osteot.	6			55	34/31	9/10	4/4
12	F, 22	L	2	46	20	30	A1, A2, A3	Closed red.; no pelvic osteot.	6	TIO		57	25	10	3
13	F, 18	L	2	47	25	30	A1, A2	Closed red.; no pelvic osteot.	4			42	16	26	1
14	F, 36	L	2	53	8	25	A3	Closed red.; no pelvic osteot.	6			40	22	27	1
15	F, 30	R	3	52	20	35	A2	Closed red. & pelvic osteot.	6			44	13	34	1
16	F, 36	L	3	44	15	25	A2	Closed red. & pelvic osteot.	4.5			45	14	26	1
17	F, 32	R	3	40	22	27	A1, A2	Closed red. & pelvic osteot.	5 mos. 20 days			42	14	27	1
18	M, 26	L	2	38	15	27	A1, A2, A3	Closed red.; no pelvic osteot.	6			43	17	25	1
19	F, 29	R	3	40	28	28	—	Closed red.; no pelvic osteot.	6		Redisloc.; open red., capsulorraphy, & innom. osteot.	35	16	18	1
20	F, 29	Bilat.	3/3	44/46	29	19	A1, A2	Closed red.; no pelvic osteot.	6			60	19/24	23/18	1/1
21	M, 36	Bilat.	4/4	35/42	23	25	—	Open red., pelvic osteot., & fem. short.	4	L: avasc. necrosis		60	0/8	35/32	1/2
22	F, 36	Bilat.	4/4	32/45	24	26	—	Open red., pelvic osteot. & fem. short.	4			36	15/16	26/29	2/2
23	F, 28	R	4	40	20	32	A1, A2, A3	Closed red.; no pelvic osteot.	6	TIO		36	28	8	4
24	F, 26	L	4	35	23	25	—	Open red. & pelvic osteot.	3			32	18	18	2
25	F, 36	L	3	33	26	32	A1, A2	Closed red.; no pelvic osteot.	5.5			64	12	23	1
26	F, 38	Bilat.	4/2	44/50	17	35	A2, A3	Closed red. & pelvic osteot.	7			45	16/13	14/17	3/1
27	M, 49	R	4	64	68	28	A2	Closed red. & pelvic osteot.	7		Lasting stiffness	60	14	28	1
28	F, 42	L	3	50	24	27	A1, A2	Closed red. & pelvic osteot.	5			38	22	34	1
29	F, 41	Bilat.	4/4	28/30	23	25	—	Open red., pelvic osteot., & fem. short.	3			36	14/8	37/37	1/1
30	M, 41	Bilat.	4/4	50/54	28	29	A1, A2	Closed red. & pelvic osteot.	5			57	16/16	27/27	1/1
31	F, 55	R	4	48	25	30	A1	Closed red. & pelvic osteot.	6	Avasc. necrosis	Redisloc.	53	10	30	2
32	M, 46	Bilat.	1/3	38/40	29	21	A1, A2	Closed red. & pelvic osteot.	6.5			40	18/28	20/32	1/2
33	F, 39	L	4	36	30	29	A1, A2	Closed red. & pelvic osteot.	6			36	10	20	1
34	F, 60	Bilat.	3/3	50/52	36	25	L: A1, A2	R: open red., pelvic osteot., & fem. short.; L: closed red. & pelvic osteot.	6	Avasc. necrosis (bilat.)		36	18/14	20/35	4/2
35	F, 72	L	4	45	21	24	A1, A2	Closed red. & pelvic osteot.	6			58	20	22	1

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TABLE I DATA ON THE PATIENTS

Case	Sex, Age at Diagnosis (Mos.)	Hip	Initial Roentgenographic Findings		Traction		Arthrography†	Treatment	Durat. That Cast Was Worn (Mos.)	Epiphyseal Involvement‡	Complications	Durat. of Follow-up (Mos.)	Result
Tönnis³⁶ Grade*	Acetab. Index* (Degrees)	Durat. (Days)	Per Cent of Body Weight	Acetab. Index* (Degrees)	Center-Edge Angle* (Degrees)	Severin³⁰ Class*
1	F, 21	Bilat.	2/2	46/36	24	27	A2	Closed red.; no pelvic osteot.	5 mos. & 8 days			39	22/18	17/15	1/4
2	F, 24	L	2	45	22	25	A2	Closed red.; no pelvic osteot.	6			43	26	10	3
3	M, 24	Bilat.	3/3	40/50	21	27	A1, A2	Closed red.; no pelvic osteot.	6			65	14/19	28/20	1/1
4	F, 21	R	2	48	21	31	A1	Closed red.; no pelvic osteot.	6		Redisloc.	48	28	11	3
5	F, 24	Bilat.	4/4	40/45	26	29	—	Open red. & pelvic osteot.	2	R: avasc. necrosis; L: TIO	R: redisloc.	57	16/16	34/34	None/1
6	F, 20	Bilat.	2/2	48/52	25	23	A1, A2	Primary Closed red.; no pelvic osteot. Secondary: bilat. varus derot. & innom. osteot.	7			53	20/20	25/22	1/1
7	F, 19	Bilat.	4/4	41/41	19	23	A1, A2	Closed red.; no pelvic osteot.	6	R: TIO		60	20/22	16/15	1/1
8	M, 24	R	3	52	24	19	A1, A2	Closed red.; no pelvic osteot.	6	TIO		54	21	26	1
9	F, 20	L	2	38	15	22	A1, A2, A3	Closed red.; no pelvic oteot.	5			64	14	25	1
10	F, 23	Bilat.	2/3	50/50	26	33	R: A1	R: closed red. & pelvic osteot.; L: open red. & pelvic osteot.	6			36	13/10	30/32	1/1
11	F, 19	Bilat.	2/2	38/48	22	33	A1, A2	Closed red.; no pelvic osteot.	6			55	34/31	9/10	4/4
12	F, 22	L	2	46	20	30	A1, A2, A3	Closed red.; no pelvic osteot.	6	TIO		57	25	10	3
13	F, 18	L	2	47	25	30	A1, A2	Closed red.; no pelvic osteot.	4			42	16	26	1
14	F, 36	L	2	53	8	25	A3	Closed red.; no pelvic osteot.	6			40	22	27	1
15	F, 30	R	3	52	20	35	A2	Closed red. & pelvic osteot.	6			44	13	34	1
16	F, 36	L	3	44	15	25	A2	Closed red. & pelvic osteot.	4.5			45	14	26	1
17	F, 32	R	3	40	22	27	A1, A2	Closed red. & pelvic osteot.	5 mos. 20 days			42	14	27	1
18	M, 26	L	2	38	15	27	A1, A2, A3	Closed red.; no pelvic osteot.	6			43	17	25	1
19	F, 29	R	3	40	28	28	—	Closed red.; no pelvic osteot.	6		Redisloc.; open red., capsulorraphy, & innom. osteot.	35	16	18	1
20	F, 29	Bilat.	3/3	44/46	29	19	A1, A2	Closed red.; no pelvic osteot.	6			60	19/24	23/18	1/1
21	M, 36	Bilat.	4/4	35/42	23	25	—	Open red., pelvic osteot., & fem. short.	4	L: avasc. necrosis		60	0/8	35/32	1/2
22	F, 36	Bilat.	4/4	32/45	24	26	—	Open red., pelvic osteot. & fem. short.	4			36	15/16	26/29	2/2
23	F, 28	R	4	40	20	32	A1, A2, A3	Closed red.; no pelvic osteot.	6	TIO		36	28	8	4
24	F, 26	L	4	35	23	25	—	Open red. & pelvic osteot.	3			32	18	18	2
25	F, 36	L	3	33	26	32	A1, A2	Closed red.; no pelvic osteot.	5.5			64	12	23	1
26	F, 38	Bilat.	4/2	44/50	17	35	A2, A3	Closed red. & pelvic osteot.	7			45	16/13	14/17	3/1
27	M, 49	R	4	64	68	28	A2	Closed red. & pelvic osteot.	7		Lasting stiffness	60	14	28	1
28	F, 42	L	3	50	24	27	A1, A2	Closed red. & pelvic osteot.	5			38	22	34	1
29	F, 41	Bilat.	4/4	28/30	23	25	—	Open red., pelvic osteot., & fem. short.	3			36	14/8	37/37	1/1
30	M, 41	Bilat.	4/4	50/54	28	29	A1, A2	Closed red. & pelvic osteot.	5			57	16/16	27/27	1/1
31	F, 55	R	4	48	25	30	A1	Closed red. & pelvic osteot.	6	Avasc. necrosis	Redisloc.	53	10	30	2
32	M, 46	Bilat.	1/3	38/40	29	21	A1, A2	Closed red. & pelvic osteot.	6.5			40	18/28	20/32	1/2
33	F, 39	L	4	36	30	29	A1, A2	Closed red. & pelvic osteot.	6			36	10	20	1
34	F, 60	Bilat.	3/3	50/52	36	25	L: A1, A2	R: open red., pelvic osteot., & fem. short.; L: closed red. & pelvic osteot.	6	Avasc. necrosis (bilat.)		36	18/14	20/35	4/2
35	F, 72	L	4	45	21	24	A1, A2	Closed red. & pelvic osteot.	6			58	20	22	1