In this paper, Dr Rejholec has made a considerable contribution towards our understanding of the problems of developmental dysplasia of the hip (DDH) and their solutions in the older child with a subluxated or dislocated hip. Along with the anteversion of both acetabulum and femoral neck, he highlights the clear boundary between the true and false acetabulum. Once this has become established, it is debatable or unlikely that innominate osteotomy alone is enough to keep a reduced femoral head in the true acetabulum. In my own practice I address the problem by combining open reduction with a femoral osteotomy and acetabuloplasty, restricting the latter to a ‘turn-down’ of the false acetabulum and plugging the gap with the wedge of femoral bone. Dr Rejolec introduces the majority of us to the much more specific Lance acetabuloplasty, whereby the subchondral ‘turn-down’ allows space above for an innominate osteotomy or formal acetabuloplasty. He also reassures us that his technique of blunt dissection through the subchondral plane does not result in avascular necrosis of the acetabulum.
He presents clearly the indications for the choice of acetabuloplasty or innominate osteotomy to complement the Lance procedure. Finally, his technique of innominate osteotomy should be considered, as it prevents the problem of leg lengthening associated with the traditional Salter technique.
I know Dr. Rejholec to be a very experienced hip surgeon who has published widely on DDH and this paper from Kuwait, where the disease is endemic and late cases common, presents a reasoned approach which is worthy of consideration in a wider arena
Mr David Jones
Consultant Orthopaedic Surgeon at Great Ormond Street Hospital (Retired)