Results:
At the final follow up for each hip, final clinical and radiological results were evaluated.The final radiological results were satisfactory in 29 hips (97 %) and unsatisfactory in one (3%). Twenty hips (67%) were Class ? (excellent), 9 hips (30%) Class II (good) and one hip (3%) Class II? (fair). The final clinical results were satisfactory in all hips; 10 hips (33%) were excellent and 20 (67%) good) .
The preoperative acetabular index was above 30 degrees in all hips which was considered abnormal .The average AI preoperatively was 45o ± 2o (ranging from 35o to 47o) . The preoperative CEA was negative in all hips. At the final follow up the mean AI was 24o and there was statistical significant improvement (p=0.001), the mean CEA was 35o with significant improvement (p=0.002). The final results were not significantly affected by the age, sex and side affected (p=0.32. p=0.43, p=0.20) respectively. One hip was classified radiologically fair due to under corrected AI (35o) and CEA (18o) but clinically had a good scoring.
Discussion.
The rate of redislocation after successful initial reduction has been reported to be 0% to 8% for the more popular, anterolateral approach to the hip. These failures are very serious problem as revision surgery has been associated with high rates of stiffness, residual dysplasia, and avascular necrosis (AVN).
The causes for failure of primary surgery for (DDH) are multiple and can be classified into three types: Immediate failures (immediate postoperative), delayed failures (4-6 weeks) and late failures (after a period of re-location of the head). (2-4) The causes for immediate failures may be related to approach and technical errors.
Inadequate capsuloraphy was considered the most common cause for a delayed failure beside inadequate immobilization and inadequate stabilization of the pelvic or femoral osteotomies.
Chidambaram et al attributed most failures to inadequate release of the transverse acetabular ligament and incomplete capsulotomy.
There are several factors maintain stable open reduction of the hip in DDH, among these the adequate strength of the hip joint capsule. A careful capsuloplasty following open reduction is considered one of the most important surgical steps for maintenance of the concentric hip reduction.
In the previous capsulotomies techniques either T-shap or V-shap , there were more than one line capsular incisions, these may led to persistent gaps between suture knots ,plication of the capsular flaps in overlapping manner may led to thickening and adhesions especially on the anterolateral part of the head which may cause stiffness and limitation of movement later on. Also, after the femoral head reduction there is difficulty to reach the inferomedial part of the capsule to pass the suture needle through it that may led to a gap at the iferomedial corner of the acetabulum through it the head can go out the acetabulum. The presented technique in this work allowed easy adequate capsuloplasty where there was only one capsular incision, excision of the redundant part of the capsule and easy closure of the inferomedial gap by the the stay suture with its kept needle.
In this work, no re-dislocations were reported and there were good range of motions in all hips. Lejman et al (18) compared capsulorrhaphy and capsulectomy in open reduction of the hip for 39 hips with DDH, 16 capsulorrhaphy and 23 capsulectomy. They reported avascular necrosis in one capsulorrhaphy hip, radiolocation in 3 capsulorrhaphy and non in capsulectomy hips. Three capsulorrhaphy and three capsulectomy hips had acetabular dysplasia. The same hip motion in both.
All operations in this work were performed by the same surgeon; also all hips receive on form of operation with the same steps. I think these factors add some strength to this work but there were some limitations as; lack of a comparison groups done by other capsuloplasty techniques as well as a relatively short follow up duration.
Conclusion: The presenting technique was found to be effective in maintaining concentric hip reduction, it was easy to do, and proper tight capsuloraphy could be achieved easily. No limitation of hip motions were reported with technique.
