The rate of total hip arthroplasty after closed reduction of late-detected hip dislocation: 147 hips followed to patient age 70 years

Terje Terjesen; Anders Wensaas

doi:10.1302/2633-1462.710.BJO-2026-0171.R1

. 2026 Oct 5;7(10):1261–1268. doi: 10.1302/2633-1462.710.BJO-2026-0171.R1

The rate of total hip arthroplasty after closed reduction of late-detected hip dislocation

147 hips followed to patient age 70 years

Terje Terjesen ^1,^✉, Anders Wensaas ¹

PMCID: PMC13634661 PMID: 42852547

Abstract

Aims

The outcome of late-detected developmental dysplasia and dislocation of the hip (DDH) deteriorates with the length of follow-up. The aims of this study were to explore the rate of total hip arthroplasty (THA) with follow-up to patient age 60 to 76 years, and to define risk factors for THA.

Methods

Inclusion criteria were patient age at diagnosis < three years, closed reduction, and no acetabular procedures. A total of 114 patients (147 hips) met these criteria: 98 females and 16 males with a mean age of 1.4 years (0.4 to 2.7). Residual acetabular dysplasia was defined as centre-edge (CE) angle < 20° at skeletal maturity. Information on THA was obtained from the Norwegian Arthroplasty Register.

Results

Overall, 39% of the hips (n = 54) had residual dysplasia at skeletal maturity, with a mean CE angle of 14.9° (7° to 19°). In total, 52 hips (35%) had undergone THA at a mean patient age of 53.2 years (33 to 71). Risk factors for THA were residual acetabular dysplasia and severe degree of avascular necrosis. Kaplan-Meier survival analysis, with THA as the endpoint, showed survival rates of 95% in hips without residual acetabular dysplasia at patient age 50 years and 76% at 70 years. In hips with residual dysplasia, the survival rate was 83% at age 50 years and 41% at 70 years. The estimated mean survival time was significantly lower in hips with residual dysplasia than in hips without dysplasia (62.6 years vs 71.4 years; p < 0.001).

Conclusion

The long-term outcome was very good in hips with no residual dysplasia at skeletal maturity. Only 24% of such hips had undergone THA at patient age 70 years. Dysplastic hips showed markedly worse outcomes, with a THA rate of 59% at 70 years. Routine concurrent pelvic osteotomy at the time of reduction in children < three years at diagnosis is hardly indicated.

Cite this article: Bone Jt Open 2026;7(10):1261–1268.

Keywords: Developmental hip dislocation, Closed reduction, Long-term follow-up, Total hip arthroplasty, total hip arthroplasty (THA), closed reduction, dislocation of the hip, hips, developmental dislocation of the hip, residual dysplasia, residual acetabular dysplasia, Pelvic osteotomies, avascular necrosis, Kaplan-Meier survival analysis

Introduction

The outcome of late-detected (diagnosis at age ≥ three months) developmental dysplasia and dislocation of the hip (DDH) deteriorates with the length of follow-up. DDH is a lifelong disease and the final outcome might be poor and result in insertion of total hip arthroplasty (THA) in patients with pain and reduced function. Thus, follow-up should continue into late adulthood. According to a systematic review,¹ the number of studies on the long-term outcome of DDH with THA as the endpoint is scarce and heterogenous. Only a few studies have a follow-up of more than 40 years.^2-4 These studies included relatively few patients, and the survival rates with THA as the endpoint showed considerable differences.

Although THA relieves pain and improves function in most patients, it is a relevant measure of ‘failure’ after treatment for DDH, since the aim is that the hip should last a lifetime. In long-term studies, certain matters should be taken into consideration. The number of patients should be sufficient for reliable statistical analysis, the initial radiographs and those at or after skeletal maturity should be available for analysis of risk factors for THA, and the rate of THA should be based on a national or regional registry to reduce the number of hips lost to follow-up.

There is no consensus on the treatment of late-detected DDH. The initial treatment is usually closed or open reduction, with or without preliminary traction to facilitate the reduction. Pelvic osteotomies have been advocated to improve femoral head coverage, but the indications and timing of such procedures vary.^5-7 Some decades ago, preliminary skin traction to obtain gradual closed reduction was the main treatment concept in our hospital. The 50-year outcome of this treatment showed that nearly one-quarter of the hips had undergone THA.⁸ There is a need for studies with longer follow-up and studies that focus on the development of hips that have not undergone additional pelvic procedures, to help establish correct indications for such surgery.

The main purpose of this study was to explore the rate of THA in children aged under three years with late-detected DDH, treated with closed reduction and no concurrent or later pelvic osteotomy, and with follow-up to the age of 60 to 76 years. Another purpose was to define risk factors for THA.

Methods

Patients treated for late-detected DDH were identified through a search of the radiological files at our hospital for the 15-year period from 1949 to 1964. In total, 218 individuals were identified. Inclusion criteria for the study were hip dislocation, age at diagnosis < three years, initial treatment with skin traction and closed reduction, no concurrent or later pelvic procedures, and age at final follow-up ≥ 60 years. A total of 104 patients were excluded for various reasons (Figure 1): insufficient patient identification (six patients), modified Spitzy shelf operation in late childhood or early adulthood (65 patients), open reduction either initially or because closed reduction was not achieved (25 patients), incomplete follow-up during childhood (five patients), and three patients who refused participation. Thus, 114 patients (147 hips) were included. Passive consent from the patients was obtained, which means that the patients received a letter with information about the study, and they were informed that they could refuse to participate by contacting the first author by telephone or email. The study was approved by the Regional Committee of Medical Research Ethics (ref. 960508) and our institutional review board.

Flow diagram of patient selection. From 218 patients with late-detected DDH (1949 to 1964), 104 were excluded for various reasons, leaving 114 patients (147 hips) treated with closed reduction and no pelvic procedure. Flow chart showing participant selection for a study of 218 patients with late-detected developmental dysplasia of the hip (DDH) diagnosed between 1949 and 1964. A series of exclusion categories branch from the main cohort: six patients with uncertain identification data, 25 patients who underwent open reduction, 65 patients who underwent a Spitzy shelf operation, three patients who refused participation, and five patients with short follow-up. These exclusions total 104 patients. The final study group consists of 114 patients, representing 147 hips, who were treated with closed reduction and did not undergo a pelvic procedure. — Flowchart of included and excluded patients with late-detected developmental dysplasia and dislocation of the hip (DDH) during the period 1949 to 1964.

Patient characteristics

The study included 114 patients, 98 females and 16 males, with a mean age of 1.4 years (0.4 to 2.7) at diagnosis.

Treatment

The patients were initially treated with bilateral, longitudinal skin traction to obtain gradual closed reduction, as previously described.⁸ An anteroposterior radiograph was obtained once a week or every second week. When the reduction was considered satisfactory, a bilateral hip spica cast was applied. The mean time in traction was 31 days (6 to 65) and the mean time in spica cast was 6.2 months (2 to 15). The cast was changed every three months. Later operations in childhood and adolescence included proximal femoral osteotomy to correct residual dysplasia and/or increased femoral anteversion in 17 hips. No pelvic procedures had been performed.

Radiological evaluation

The initial radiographs were used for classification of severity of dislocation according to Tönnis,⁹ using the position of the ossific nucleus of the femoral head in relation to the acetabular roof (Table I). In grade I hips, the ossific nucleus is medial to Perkins’ line and in grade II it is lateral to Perkins’ line and below the superolateral margin of the acetabulum (Figure 2). In Tönnis grade III, the ossific nucleus is lateral to Perkins’ line and level with the superolateral margin of the acetabulum, and in grade IV (the most severe) it is located above the superolateral margin (Figure 3). Since the classification is based on the position of the ossific nucleus, 16 hips without ossific nucleus were not classified (Table I).

Table I.

Possible risk factors for total hip arthroplasty in patients with late-detected developmental dysplasia of the hip, who were aged under three years at the time of diagnosis.

Variable	Hips, n	Univariable analysis (chi-squared test)
Variable	Hips, n	No THA, n	THA, n	p-value	OR	95% CI
Sex				0.439	1.5	0.6 to 3.7
Female	126	83	43
Male	21	12	9
Age at diagnosis, yrs				0.776	0.9	0.5 to 1.8
< 1.5	74	47	27
≥ 1.5	73	48	25
Uni/bilateral DDH				0.205	1.6	0.8 to 3.1
Unilateral	81	56	25
Bilateral	66	39	27
Severity of DDH				0.543	N/A^*
Grade II	92	61	31
Grade III	33	20	13
Grade IV	6	5	1
Residual dysplasia				< 0.001	4.3	2.0 to 9.1
Severin grade I/II	85	67	18
Severin grade III/IV	54	25	29
AVN^†				0.039	4.9	0.9 to 26.5
No AVN	140	93	47
AVN	7	2	5

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Odds ratio (OR) could not be calculated because there were > two categories.

^†

Group III or IV (Kalamchi and MacEwen 1980); Severity of DDH (Tönnis 1987).

AVN, avascular necrosis of the femoral head; DDH, developmental dysplasia and dislocation of the hip; N/A, not applicable; THA, total hip arthroplasty.

Series of five pelvic radiographs showing the course of developmental hip dysplasia from childhood to adulthood, including early hip displacement, follow-up imaging after treatment, later degenerative changes, and total hip replacement. Composite figure of five labelled pelvic and hip radiographs (a-e) illustrating the long-term progression of developmental dysplasia of the hip. Panel a shows a childhood pelvic radiograph with displacement of the hip joint. Panel b shows a follow-up childhood radiograph after treatment, with the central pelvic region obscured for privacy. Panel c presents an adult pelvic radiograph demonstrating residual hip deformity and joint changes. Panel d is a magnified view of the affected hip, showing advanced degenerative changes with joint narrowing and deformity. Panel e shows the same hip after surgical treatment with a total hip arthroplasty, including an acetabular cup and femoral stem prosthesis. The sequence documents the condition from childhood through adult follow-up and eventual joint replacement. — a) Initial anteroposterior (AP) pelvic radiograph of a female aged 1.4 years, showing a dislocated left hip (Tönnis dislocation grade II). b) AP radiograph at age 6.7 years, showing slight dysplasia of the left hip, with centre-edge (CE) angle 13° (CE angle of the right hip 20°). c) AP radiograph at the age of 45 years, showing acetabular dysplasia of both hips, with CE angles 12° in the left hip and 10° in the right hip. There is no osteoarthritis of the left hip, but slight lateral osteoarthritis of the right hip that underwent total hip arthroplasty (THA) three years later. d) AP radiograph at age 51 years, showing osteoarthritis of the left hip. e) Radiograph at age 51 years, two months after THA of the left hip had been inserted.

Three pelvic radiographs showing the progression of developmental dysplasia of the hip from childhood to adulthood, including initial hip displacement, post-treatment follow-up, and residual adult hip deformity. Composite figure of three labelled pelvic radiographs (a-c) illustrating the long-term course of developmental dysplasia of the hip. Panel a shows a childhood radiograph with marked displacement of the hip joint. Panel b shows a later childhood follow-up radiograph after treatment, with the central pelvic region obscured for privacy. Panel c shows an adult pelvic radiograph demonstrating residual structural abnormalities of the hip and pelvis, with the affected hip appearing irregular compared with the opposite side. The sequence depicts the condition from initial childhood presentation through follow-up and into adulthood. — a) Initial anteroposterior (AP) pelvic radiograph of a female aged 1.8 years, showing bilateral dislocated hips. Although it is difficult to define the superolateral acetabular rim of both hips, the dislocation grades were classified as Tönnis grade III of the right hip and grade II of the left. b) AP radiograph at age 16.6 years, showing mild residual dysplasia in both hips, with centre-edge angles of 17° bilaterally. c) Radiograph at the age of 51 years, showing sclerosis of the acetabular roof on both sides, but no narrowing of the joint spaces. She had no complaints from the hips at the last clinical examination at age 57 years, and no total hip arthroplasty had been performed by the age of 64 years.

Radiographs at or after skeletal maturity were used for classification of the radiological outcome (Table I). The centre-edge (CE) angle was measured as described by Wiberg.¹⁰ The outcome was evaluated using the classification of Severin.¹¹ Grade I and II means a normal or nearly normal hip with CE angle ≥ 20°. Severin grade III is residual acetabular dysplasia with CE angle < 20°, and grade IV is subluxation. The classification was simplified into two grades: satisfactory outcome when the Severin grade was I or II and unsatisfactory outcome when the grade was III or IV. The CE angle was not measured in eight hips because of lack of radiographs at skeletal maturity (one patient) or because severe avascular necrosis made it difficult to define the centre of the femoral head (seven hips, six patients).

Avascular necrosis of the femoral head (AVN) was assessed according to Kalamchi and MacEwen.¹² Group I is the mildest form and includes only temporary changes of the ossific nucleus. Group II is damage to the lateral part of the physis, leading to a lateral tilt of the femoral head into valgus. In group III, the damage to the growth plate is more pronounced and results in overgrowth of the greater trochanter. Group IV is total damage to the femoral head and physis. In the present study, only the most severe groups, III and IV, were registered and included in the statistical analysis (Table I). The radiological analysis was performed by the first author (TT), who has a long experience in evaluation of radiographs of hip joints in children and adults.

THA

Information regarding THA was obtained from the Norwegian Arthroplasty Registry (NAR), which was established in 1987. The data were received in September 2025 and included whether the patient had undergone THA, the date of THA, and which side had been operated. The survival time of the hip was defined as patient age at THA in hips that had undergone THA and patient age in September 2025 in hips that had not undergone THA. In patients who died during follow-up without having undergone THA, survival time was age of death; at that timepoint, they were censored. The survival rate of the hips is the percentage of hips that had not undergone THA according to increasing patient age.

Possible risk factors for THA included age at diagnosis, sex, unilateral or bilateral dislocation, severity of DDH, AVN groups III/IV, and residual hip dysplasia at skeletal maturity.

Statistical analysis

SPSS (v. 30, IBM, USA) was used for statistical analysis. Categorical data were analyzed with the Pearson chi-squared test. Continuous variables were analyzed using the independent-samples t-test. For correlation between parameters, Pearson’s correlation coefficient (r) was used. All tests were two-sided and differences were considered significant when the p-value was < 0.05. Kaplan-Meier survival analysis with the log-rank test was used to assess the survival rate of the hips and the estimated survival time.

Results

In total, 81 patients had unilateral DDH and 33 had bilateral DDH. The degree of dislocation according to the Tönnis classification was significantly associated with patient age at diagnosis (r = 0.32; p < 0.001). In patients aged under < 1.5 years, 53 of 62 hips (85%) had a relatively mild dislocation (Tönnis grade II) and no hips had the most severe grade IV. In older children, grade II occurred in 39 of 69 hips (56%), grade III in 24 hips (35%), and grade IV in six hips (9%).

The mean CE angle in adulthood was 21.9° (7° to 40°). A total of 54 hips (39%) had residual acetabular dysplasia (Severin grade III/IV) with a mean CE angle of 14.9° (7° to 19°). The remaining hips were Severin grade I/II and had a mean CE angle of 26.4° (20° to 40°). There was a weak correlation between residual dysplasia and patient age at diagnosis (r = 0.19; p = 0.023).

Total hip arthroplasty

In total, 52 hips (35%) had undergone THA at a mean patient age of 53.2 years (33 to 71). The mean age at THA was lower in hips with residual dysplasia compared with age of hips without dysplasia (51.8 vs 56.6 years), but the difference was not statistically significant (p = 0.058, independent-samples t-test). Risk factors for THA are shown in Table I. Risk factors were residual acetabular dysplasia (Severin grade III/IV) and AVN groups III/IV. In the AVN group of seven hips, THA had been inserted in five hips (71%). Sex, age at diagnosis (< or ≥ 1.5 years), uni- or bilateral DDH, and severity of DDH according to the Tönnis classification were not significant risk factors.

The mean age of the patients when the data from NAR were received, was 65.7 years (60 to 76). Kaplan-Meier survival analysis of all 147 hips, with THA as the endpoint, showed survival rates of almost 100% up to patient age 40 years (Table II). Thereafter, survival rates differed markedly according to the presence or not of residual acetabular dysplasia. In hips with Severin grade I/II, survival rates remained high, with survivals of 95% at age 50 years and 76% at 70 years (Table II, Figure 4). In hips with Severin grade III/IV, the survival rates fell from 94% at age 40 years to 83% at 50 years and 41% at 70 years. The reduction was largest in the five-year periods 50 to 55 years (15%) and 55 to 60 years (15%). In the other five-year periods the reduction was smaller (2% to 9%). Kaplan-Meier analysis with the log-rank test showed that the estimated mean survival time was significantly lower in hips with Severin grades III/IV (62.6 years; 95% CI 58.8 to 66.3) than in Severin I/II hips (71.4 years; 95% CI 69.1 to 73.7; p < 0.001).

Table II.

Kaplan-Meier survival analysis with total hip arthroplasty (THA) as the endpoint in all 147 hips, and separate analyses in 139 hips according to residual acetabular dysplasia (or lack thereof) (Severin groups I/II vs groups III/IV).

Age, yrs	All hips (n = 147)	Severin I/II (n = 85)			Severin III/IV (n = 54)
Age, yrs	Survival (95% CI)	Events	Survival (95% CI)	Remaining	Events	Survival (95% CI)	Remaining
30	100	0	100	85	0	100	54
35	99 (97 to 100)	0	100	85	1	98 (94 to 100)	53
40	97 (94 to 100)	0	100	85	3	94 (88 to 100)	51
45	93 (89 to 97)	1	99 (97 to 100)	84	8	85 (75 to 95)	46
50	90 (85 to 95)	4	95 (90 to 100)	81	9	83 (73 to 93)	45
55	83 (77 to 89)	6	93 (87 to 99)	78	17	68 (55 to 81)	35
60	73 (66 to 80)	10	88 (81 to 95)	74	25	53 (39 to 67)	27
65	66 (58 to 74)	16	80 (71 to 89)	39	28	46 (32 to 60)	10
70	62 (53 to 71)	17	76 (65 to 87)	8	29	41 (25 to 57)	3

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Events = number of hips with THA; Remaining = number of hips without THA.

Line graph of survival versus patient age (30 to 70 years) comparing Severin grade I/II and grade III/IV. Survival declines with age in both groups, with a steeper decline for grade III/IV, especially after about 50 years. A line graph plots percentage survival against patient age in years, from 30 to 70. Two groups are compared: Severin grade I/II (solid line) and Severin grade III/IV (dashed line). Survival is approximately 100% at age 30 for both groups and decreases with increasing age. The Severin grade I/II group shows a gradual decline, remaining above 90% through the mid-50s and ending at about 76% by age 70. The Severin grade III/IV group declines more rapidly, falling to about 85% by age 45, about 68% by age 55, and about 41% by age 70. Shaded bands around each line indicate uncertainty or variability and widen with age, particularly for the Severin grade III/IV group. Overall, survival is consistently higher for Severin grade I/II than for Severin grade III/IV, and the difference between the groups increases with age. — Kaplan-Meier survival analysis with 95% CIs from patient age 30 years to age 70 years with total hip arthroplasty as the endpoint. The unbroken line shows the hips without residual dysplasia (Severin grades I/II), and the broken line shows the hips with residual acetabular dysplasia (Severin grades III/IV). Numbers at risk are included in Table II.

During the follow-up time, six patients died at a mean age of 60.0 years (54 to 67). All of them had bilateral hip dislocation. THA had been performed on one of the 12 hips.

Discussion

The most important findings in this study were that the survival rate of hips with THA as the endpoint was high (> 90%) up to patient age 45 years, and that survival remained high in hips without residual dysplasia (76% at 70 years), whereas the survival rate in hips with residual (persistent) acetabular dysplasia decreased gradually to 41% at 70 years.

To our knowledge, this study has the longest reported follow-up of late-detected DDH. Few previous studies have follow-up longer than 40 years.^2,3 These studies had a survival rate of 100% at 30 years of follow-up, which is similar to the results of our study. At 40 years of follow-up we had a survival rate of 97%, which was markedly higher than those reported by Thomas et al² after open reduction and Salter type pelvic osteotomy (81%), and Scott et al³ after closed reduction (77%). After 40 years, both these studies reported a marked fall in survival, ending with survival rates of 63% and 55%, respectively, at the last follow-up at 45 years. Our analysis did not show such a marked reduction during the same five-year period, and the survival was still high (> 90%) at age 45 years. Thereafter, the survival rates differed significantly with the presence or absence of residual dysplasia. The survival was satisfactory up to age 70 years in hips without residual dysplasia. At this age, 24% of the hips (n = 17) had undergone THA, which is only a moderately higher rate than the lifetime risk of THA (16%) for osteoarthritis among Norwegian females in 2013.¹³

In dysplastic hips (Severin grades III/IV), the survival rate after age 40 years decreased more rapidly, to 41% at age 70 years. The largest reduction occurred during the age span of 50 to 60 years, when the survival fell 30%. Thus, the greatest need of THA seems to be after age 50 years, rather than during the previously indicated age span of 40 to 45 years.^2,3

One probable reason for the better long-term outcome in our study, compared with previous studies, was that many severe cases of DDH were not included. We wished to investigate the outcome in patients treated with traction, closed reduction, and no pelvic procedures. Thus, patients with open reduction and patients with Spitzy acetabular shelf operation were not included. Since such hips represent the most severe cases, the present study is representative mainly of less severe cases. We had only 4.5% of the most severe dislocation grade (Tönnis IV), which is in accordance with 5% grade IV hips in a study on closed reduction in children at similar age.¹⁴ Other studies of closed and open reduction had a considerably higher frequency of grade IV hips.^15-17

The risk factors for THA were residual hip dysplasia (Severin grades III/IV) and AVN groups III/IV. Evaluation of residual dysplasia may be unreliable if radiographs before skeletal maturity are used, since the hips might deteriorate with further growth. Thomas et al² found that 96% of the hips were in Severin grades I/II at a mean of 5.5 years after open reduction and Salter osteotomy; nevertheless, 31% of these hips had undergone THA at 45 years of follow-up. In our study, 61% of the hips were Severin grades I/II, and only 5% of them had undergone THA at age 50 years. However, these rates can hardly be directly compared since the Severin classification was performed before skeletal maturity by Thomas et al;² Severin classification of adult hips was performed by Scott et al,³ but no analysis of the association with THA was presented. Severe degrees of AVN was a risk factor in our study, which supported the experience of others.³

Higher age at diagnosis (≥ 1.5 years) was weakly correlated with residual acetabular dysplasia, but was not a risk factor for THA. Other studies have shown divergent findings. Whereas older age at reduction was a risk factor for a poor result at skeletal maturity by Albinana et al,¹⁶ Thomas et al² reported no significant association between age at open reduction/pelvic osteotomy and poor long-term outcome. Scott et al³ found minimal effect of age on the outcome in unilateral DDH, however older age was associated with higher frequency of THA in bilateral cases.

It was somewhat unexpected that the degree of dislocation was not associated with the rate of THA. However, this was probably caused by a statistical type 2 error, because of the few hips with the most severe dislocation grade. Grade of dislocation seems not to have been analyzed in previous studies on the long-term need of THA. There are certain challenges with the Tönnis classification, of which the most obvious is the correct identification of the most important landmark, the superolateral acetabular rim. This landmark is often resorbed in hips with severe dislocation. Another issue is that hips can hardly be reliably graded when the ossific nucleus has not yet appeared, since the classification is based on the position of the nucleus.

There are some limitations to our study. First, the lack of a control group with another treatment method makes the results relevant mainly for patients with closed reduction. Second, the long-term outcome was not known in patients who had not undergone THA, since no clinical examination was performed. However, in a previous study on 49 patients with 58 years of follow-up,⁴ a poor Harris Hip Score was found in 16% of the hips that had not undergone THA. Since these patients were included in the present study, a similar rate might be reasonable to assume. This would give a total rate of poor outcome of about 50% (35% THA plus those with poor Harris Hip Score). Third, the number of patients aged > 65 years was limited, which might affect the reliability of the statistics in the oldest patients. Finally, since NAR started registration of THA in 1987, some patients could have undergone THA before 1987. However, this seems unlikely, since the patients would be aged < 40 years and the indications for THA in younger individuals were stricter than today.

The strengths of the study are that follow-up of all the patients was achieved, thanks to the national arthroplasty registry, along with the exceptionally long follow-up time with survival analysis up to age 70 years. These data are well suited for comparison with future studies on alternative methods such as open reduction, with or without pelvic osteotomy.

In spite of relatively good long-term outcomes, our treatment has changed over the years to no traction and more often open reduction, especially in older children and those with severe degrees of dislocation. The main reason for the change was the inconvenience for the child and parents with a long traction period. Although not proven by the present study, we believe that an attempt at closed reduction under general anaesthesia without preliminary traction is a recommendable treatment concept for late-detected hip dislocation in children aged < three years. The reduction manoeuvre is more reliably achieved when guided by direct visualization using dynamic ultrasonography, when the effects of positioning of the lower limb on the stability of the reduction can also be assessed.¹⁸ If closed reduction fails, open reduction should be performed under the same anaesthesia. Based on the present results with similar rates of THA in patients aged under and over 1.5 years, routine concurrent pelvic osteotomy in children aged 1.5 to 3.0 years, as has been recommended by some authors,^19-21 is hardly necessary. However, corrective pelvic osteotomy should be considered in hips with residual acetabular dysplasia that does not normalize during the first years after the initial treatment, especially if the patient experiences hip pain. Whether this policy would improve the long-term outcome compared with that of the present study, remains to be seen.

Take home message

- After skin traction to obtain gradual closed reduction in late-detected developmental dislocation of the hip in patients under three years, the survival of the hips up to patient age 70 years, with total hip arthroplasty (THA) as the endpoint, was markedly better in hips without residual hip dysplasia at skeletal maturity compared with hips with residual dysplasia (76% vs 41%).

- Risk factors for THA were residual hip dysplasia at maturity and severe grades of avascular necrosis of the femoral head.

- Routine concurrent pelvic osteotomy at the time of hip reduction in children aged < three years is hardly indicated.

Author contributions

T. Terjesen: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

A. Wensaas: Conceptualization, Methodology, Validation, Writing – review & editing

Funding statement

The authors received no financial or material support for the research, authorship, and/or publication of this article, other than the open access funding outlined below.

ICMJE COI statement

The authors have no disclosures to report.

Data sharing

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

Acknowledgements

The authors would like to thank the photographer Ine Eriksen for help with the illustrations. We also thank the Norwegian Arthroplasty Registry for access to the total hip arthroplasty data.

Ethical review statement

Consent from the patients was required before inclusion, and the study was approved by the Regional Committee of Medical Research Ethics (ref. 960508) and our institutional review board.

Open access funding

The open access fee for this article was funded by Oslo University Hospital.

© 2026 Terjesen and Wensaas. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

Data Availability

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

References

1. Lucchesi G, Sacco R, Zhou W, Li Y, Li L, Canavese F. DDH in the walking age: review of patients with long-term follow-up. Indian J Orthop. 2021;55(6):1503–1514. doi: 10.1007/s43465-021-00531-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
2. Thomas SR, Wedge JH, Salter RB. Outcome at forty-five years after open reduction and innominate osteotomy for late-presenting developmental dislocation of the hip. J Bone Joint Surg Am. 2007;89-A(11):2341–2350. doi: 10.2106/JBJS.F.00857. [DOI] [PubMed] [Google Scholar]
3. Scott EJ, Dolan LA, Weinstein SL. Closed vs. open reduction/Salter innominate osteotomy for developmental hip dislocation after age 18 months: comparative survival at 45-year follow-up. J Bone Joint Surg Am. 2020;102-A(15):1351–1357. doi: 10.2106/JBJS.19.01278. [DOI] [PubMed] [Google Scholar]
4. Terjesen T. Long-term outcome of closed reduction in late-detected hip dislocation: 60 patients aged six to 36 months at diagnosis followed to a mean age of 58 years. J Child Orthop. 2018;12(4):369–374. doi: 10.1302/1863-2548.12.180024. [DOI] [PMC free article] [PubMed] [Google Scholar]
5. Berkeley ME, Dickson JH, Cain TE, Donovan MM. Surgical therapy for congenital dislocation of the hip in patients who are twelve to thirty-six months old. J Bone Joint Surg Am. 1984;66-A(3):412–420. [PubMed] [Google Scholar]
6. Rampal V, Sabourin M, Erdeneshoo E, Koureas G, Seringe R, Wicart P. Closed reduction with traction for developmental dysplasia of the hip in children aged between one and five years. J Bone Joint Surg Br. 2008;90-B(7):858–863. doi: 10.1302/0301-620X.90B7.20041. [DOI] [PubMed] [Google Scholar]
7. Kiani SN, Gornitzky AL, Matheney TH, et al. A prospective, multicenter study of developmental dysplasia of the hip: what can patients expect after open reduction? J Pediatr Orthop. 2023;43(5):279–285. doi: 10.1097/BPO.0000000000002383. [DOI] [PubMed] [Google Scholar]
8. Terjesen T, Horn J, Gunderson RB. Fifty-year follow-up of late-detected hip dislocation. J Bone Joint Surg Am. 2014;96-A(4):e28. doi: 10.2106/JBJS.M.00397. [DOI] [PubMed] [Google Scholar]
9.Tönnis D. Congenital dysplasia and dislocation of the hip in children and adults. Springer Verlag; 1987. pp. 82–83. [Google Scholar]
10. Wiberg G. Studies on dysplastic acetabula and congenital subluxation of the hip joint. Acta Chir Scand. 1939;83(Suppl 58):7–135. [Google Scholar]
11. Severin E. Contribution to the knowledge of congenital dislocation of the hip joint. Acta Chir Scand. 1941;84(Suppl 63):1–142. [Google Scholar]
12. Kalamchi A, MacEwen GD. Avascular necrosis following treatment of congenital dislocation of the hip. J Bone Joint Surg Am. 1980;62-A(6):876–888. [PubMed] [Google Scholar]
13. Ackerman IN, Bohensky MA, de Steiger R, et al. Lifetime risk of primary total hip replacement surgery for osteoarthritis from 2003 to 2013: a multinational analysis using National Registry Data. Arthritis Care Res (Hoboken) 2017;69(11):1659–1667. doi: 10.1002/acr.23197. [DOI] [PubMed] [Google Scholar]
14. Ramo BA, De La Rocha A, Sucato DJ, Jo C-H. A new radiographic classification system for developmental hip dysplasia is reliable and predictive of successful closed reduction and late pelvic osteotomy. J Pediatr Orthop. 2018;38(1):16–21. doi: 10.1097/BPO.0000000000000733. [DOI] [PubMed] [Google Scholar]
15. Schoenecker PL, Dollard PA, Sheridan JJ, Strecker WB. Closed reduction of developmental dislocation of the hip in children older than 18 months. J Pediatr Orthop. 1995;15(6):763–767. doi: 10.1097/01241398-199511000-00008. [DOI] [PubMed] [Google Scholar]
16. Albinana J. Dolan LA, Spratt KF, Morcuende J, Meyer MD, Weinstein SL. Acetabular dysplasia after treatment for developmental dysplasia of the hip: implications for secondary procedures. J Bone Joint Surg Br. 2004;86-B:876–886. doi: 10.1302/0301-620X.86B6.14441. [DOI] [PubMed] [Google Scholar]
17. Bolland BJ, Wahed A, Al-Hallao S, Culliford DJ, Clarke NMP. Late reduction in congenital dislocation of the hip and the need for secondary surgery: radiologic predictors and confounding variables. J Pediatr Orthop. 2010;30(7):676–682. doi: 10.1097/BPO.0b013e3181efb8c7. [DOI] [PubMed] [Google Scholar]
18. Terjesen T. Closed reduction guided by dynamic ultrasound in late-diagnosed hip dislocation. J Pediatr Orthop. 1992;12(1):54–60. [PubMed] [Google Scholar]
19. Salter RB. Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip. J Bone Joint Surg Br. 1961;43-B(3):518–539. doi: 10.1302/0301-620X.43B3.518. [DOI] [Google Scholar]
20. Morin CM, Bisogno J, Kulkarni S, Morel G. Treatment of late-presenting developmental dislocation of the hip by progressive orthopaedic reduction and innominate osteotomy. Our results with more than 30 years of follow up. J Child Orthop. 2011;5(4):251–260. doi: 10.1007/s11832-011-0346-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
21. Chang CH, Yang WE, Kao HK, Lee WC, Shih CH, Kuo KN. Prognostic radiographic factors in developmental dysplasia of the hip following Salter osteotomy. J Pediatr Orthop B. 2015;24(1):31–34. doi: 10.1097/BPB.0000000000000109. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.

[b1] 1. Lucchesi G, Sacco R, Zhou W, Li Y, Li L, Canavese F. DDH in the walking age: review of patients with long-term follow-up. Indian J Orthop. 2021;55(6):1503–1514. doi: 10.1007/s43465-021-00531-1. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b2] 2. Thomas SR, Wedge JH, Salter RB. Outcome at forty-five years after open reduction and innominate osteotomy for late-presenting developmental dislocation of the hip. J Bone Joint Surg Am. 2007;89-A(11):2341–2350. doi: 10.2106/JBJS.F.00857. [DOI] [PubMed] [Google Scholar]

[b3] 3. Scott EJ, Dolan LA, Weinstein SL. Closed vs. open reduction/Salter innominate osteotomy for developmental hip dislocation after age 18 months: comparative survival at 45-year follow-up. J Bone Joint Surg Am. 2020;102-A(15):1351–1357. doi: 10.2106/JBJS.19.01278. [DOI] [PubMed] [Google Scholar]

[b4] 4. Terjesen T. Long-term outcome of closed reduction in late-detected hip dislocation: 60 patients aged six to 36 months at diagnosis followed to a mean age of 58 years. J Child Orthop. 2018;12(4):369–374. doi: 10.1302/1863-2548.12.180024. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b5] 5. Berkeley ME, Dickson JH, Cain TE, Donovan MM. Surgical therapy for congenital dislocation of the hip in patients who are twelve to thirty-six months old. J Bone Joint Surg Am. 1984;66-A(3):412–420. [PubMed] [Google Scholar]

[b6] 6. Rampal V, Sabourin M, Erdeneshoo E, Koureas G, Seringe R, Wicart P. Closed reduction with traction for developmental dysplasia of the hip in children aged between one and five years. J Bone Joint Surg Br. 2008;90-B(7):858–863. doi: 10.1302/0301-620X.90B7.20041. [DOI] [PubMed] [Google Scholar]

[b7] 7. Kiani SN, Gornitzky AL, Matheney TH, et al. A prospective, multicenter study of developmental dysplasia of the hip: what can patients expect after open reduction? J Pediatr Orthop. 2023;43(5):279–285. doi: 10.1097/BPO.0000000000002383. [DOI] [PubMed] [Google Scholar]

[b8] 8. Terjesen T, Horn J, Gunderson RB. Fifty-year follow-up of late-detected hip dislocation. J Bone Joint Surg Am. 2014;96-A(4):e28. doi: 10.2106/JBJS.M.00397. [DOI] [PubMed] [Google Scholar]

[b9] 9.Tönnis D. Congenital dysplasia and dislocation of the hip in children and adults. Springer Verlag; 1987. pp. 82–83. [Google Scholar]

[b10] 10. Wiberg G. Studies on dysplastic acetabula and congenital subluxation of the hip joint. Acta Chir Scand. 1939;83(Suppl 58):7–135. [Google Scholar]

[b11] 11. Severin E. Contribution to the knowledge of congenital dislocation of the hip joint. Acta Chir Scand. 1941;84(Suppl 63):1–142. [Google Scholar]

[b12] 12. Kalamchi A, MacEwen GD. Avascular necrosis following treatment of congenital dislocation of the hip. J Bone Joint Surg Am. 1980;62-A(6):876–888. [PubMed] [Google Scholar]

[b13] 13. Ackerman IN, Bohensky MA, de Steiger R, et al. Lifetime risk of primary total hip replacement surgery for osteoarthritis from 2003 to 2013: a multinational analysis using National Registry Data. Arthritis Care Res (Hoboken) 2017;69(11):1659–1667. doi: 10.1002/acr.23197. [DOI] [PubMed] [Google Scholar]

[b14] 14. Ramo BA, De La Rocha A, Sucato DJ, Jo C-H. A new radiographic classification system for developmental hip dysplasia is reliable and predictive of successful closed reduction and late pelvic osteotomy. J Pediatr Orthop. 2018;38(1):16–21. doi: 10.1097/BPO.0000000000000733. [DOI] [PubMed] [Google Scholar]

[b15] 15. Schoenecker PL, Dollard PA, Sheridan JJ, Strecker WB. Closed reduction of developmental dislocation of the hip in children older than 18 months. J Pediatr Orthop. 1995;15(6):763–767. doi: 10.1097/01241398-199511000-00008. [DOI] [PubMed] [Google Scholar]

[b16] 16. Albinana J. Dolan LA, Spratt KF, Morcuende J, Meyer MD, Weinstein SL. Acetabular dysplasia after treatment for developmental dysplasia of the hip: implications for secondary procedures. J Bone Joint Surg Br. 2004;86-B:876–886. doi: 10.1302/0301-620X.86B6.14441. [DOI] [PubMed] [Google Scholar]

[b17] 17. Bolland BJ, Wahed A, Al-Hallao S, Culliford DJ, Clarke NMP. Late reduction in congenital dislocation of the hip and the need for secondary surgery: radiologic predictors and confounding variables. J Pediatr Orthop. 2010;30(7):676–682. doi: 10.1097/BPO.0b013e3181efb8c7. [DOI] [PubMed] [Google Scholar]

[b18] 18. Terjesen T. Closed reduction guided by dynamic ultrasound in late-diagnosed hip dislocation. J Pediatr Orthop. 1992;12(1):54–60. [PubMed] [Google Scholar]

[b19] 19. Salter RB. Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip. J Bone Joint Surg Br. 1961;43-B(3):518–539. doi: 10.1302/0301-620X.43B3.518. [DOI] [Google Scholar]

[b20] 20. Morin CM, Bisogno J, Kulkarni S, Morel G. Treatment of late-presenting developmental dislocation of the hip by progressive orthopaedic reduction and innominate osteotomy. Our results with more than 30 years of follow up. J Child Orthop. 2011;5(4):251–260. doi: 10.1007/s11832-011-0346-2. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b21] 21. Chang CH, Yang WE, Kao HK, Lee WC, Shih CH, Kuo KN. Prognostic radiographic factors in developmental dysplasia of the hip following Salter osteotomy. J Pediatr Orthop B. 2015;24(1):31–34. doi: 10.1097/BPB.0000000000000109. [DOI] [PubMed] [Google Scholar]

PERMALINK

The rate of total hip arthroplasty after closed reduction of late-detected hip dislocation

Terje Terjesen, MD, PhD

Anders Wensaas, MD, PhD

Roles

Abstract