Efficacy of a Graftless Salter Osteotomy in Developmental Dysplasia of the Hip

Abstract

Background: Salter's innominate osteotomy is one of the most popular pediatric hip procedures for developmental dysplasia of the hip (DDH). Traditionally, Salter osteotomies require harvesting of autograft from the iliac crest, which can result in iliac wing deformities, pelvic asymmetry, and abductor dysfunction. A graftless variation of this procedure has been described in which the iliac osteotomy is fixed with threaded pins without an intervening graft, but literature surrounding this technique is sparse. The purpose of this study was to evaluate the efficacy of a graftless Salter osteotomy and compare the degree of correction to the traditional method.

Methods: A retrospective review was performed of all Salter osteotomies performed at a single tertiary care children's hospital from 2009 to 2024. Demographic and clinical variables were extracted from electronic medical records. Acetabular indices (AIs) on preoperative and 3-month postoperative AP pelvic radiographs were compared to assess the degree of acetabular correction. Traditional and graftless procedures were propensity score matched 1:2 based on age, gender, and preoperative AI. Acetabular correction was compared between the two cohorts using the Wilcoxon Mann-Whitney test.

Results: Forty-seven hips were identified (14 traditional, 33 graftless). Seventy-two percent of patients were female; the mean age at surgery was 29.9 months (range: 15-70). Thirty-eight hips (81%) underwent concomitant open reduction. Propensity score matched analysis demonstrated no significant difference in the degree of acetabular correction between the cohorts (traditional vs graftless: 11.9° ± 5.4 vs 12.7° ± 5.7, P = .69). All osteotomies healed by 3 months, and there were no cases of lost fixation with either technique.

Conclusions: The graftless variation of Salter's osteotomy yields a comparable degree of acetabular correction to the traditional technique. There were no complications in either cohort from the osteotomy. The graftless Salter osteotomy is a safe and effective alternative to the traditional Salter osteotomy without the risk of iliac wing deformities and potential abductor dysfunction.

Key concepts: (1)Graftless Salter osteotomy provides similar degrees of correction to the traditional technique.(2)No complications related to the osteotomy were observed in both the graftless and traditional cohort.(3)All Salter osteotomies demonstrated healing at the 3-month postoperative timepoint.

Level of evidence: IV.

Keywords: DDH; Pelvic osteotomy; Salter osteotomy.

Figure 1

Acetabular index on (a) preoperative and (b) 3-month postoperative anteroposterior radiographs was measured by determining the angle between Hilgenreiner's line and a tangential line from the superolateral margin of the triradiate cartilage to the superolateral margin of the acetabular sourcil.

Figure 2

Intraoperative photo of the right ilium of a two-year old patient demonstrating fixation of the Salter osteotomy with three threaded K-wires without an intervening bone.

Figure 3

Intraoperative photo of the right ilium displaying typical options for autogenous bone graft. The traditional bone graft for the Salter osteotomy is harvested from the brim of the pelvis including the ASIS (blue arrow). An alternative technique harvests a triangle of bone graft from the proximal ilium which better preserves the contour of the pelvis (yellow arrows). ASIS, anterior superior iliac spine.