23-05-2025
Hip surgery at the heart of audit explained
The release of an independent audit of bone surgeries carried out on children with hip dysplasia between January 2021 to December 2023 was much anticipated, not least by the parents of children who had had these surgeries in that time.
The audit was looking at the basis on which decisions were made to perform a pelvic osteotomy or bone surgery on a child. Or, to put it more bluntly, whether it was necessary for the surgery to be carried out.
To understand the concern around all of this, it is first important to look at what these surgeries are used to treat, and just what the surgery in question involves.
The condition is called developmental dysplasia of the hips, or DDH, and it occurs when the "ball and socket" joint in the hip does not form properly in babies and young children.
"It's a very common condition that we see, and in its simplest form it is a mismatch between the shapes that make up the component of the hip joint," Dr Pablo Castañeda, Medical Director of the International Hip Dysplasia Institute explained.
There are a number of treatments, including non-operative and surgical interventions.
An osteotomy or bone surgery is arguably the most extreme. This is a bone surgery undertaken to "correct" or "reshape" the hip joint.
"When we talk about doing a pelvic osteotomy it is a cut of the bone, that's what the word osteotomy means, a cut of the bone, so we cut the pelvic bone to essentially make that socket deeper and match the ball in a better way," Dr Castañeda said.
According to information published by Children's Health Ireland (CHI), there are two possible options: to reshape or reposition the thigh bone or femur, called a femoral osteotomy, or to deepen the hip socket, and this is a pelvic osteotomy.
It was decisions to perform the later, pelvic osteotomies, that were examined in this audit.
As previously mentioned this procedure involves cutting the bone, and it usually involves the use of bone grafts and pins.
After a pelvic osteotomy "most children are treated in a hip abduction brace or a cast after pelvic osteotomy," according to CHI literature.
A foam hip abduction brace immobilises both legs, a hinged hip abduction brace immobilises the operated side only, and a hip spica cast.
Hip spica casts can be on for 12 to 16 weeks, with plaster changes under anaesthetic every six to eight weeks.
If pins are used, they may be dissolvable or the child may need a second surgery to remove them eight weeks later.
Children will need also need a special car seat which is compatible with the brace or the cast.
Parents are also warned that a child "may be limp for weeks after their osteotomy".
Archie 'had to learn how to walk again'
Áine Gladney-Knox's son Archie had the surgery on both hip joints in 2022 when he was aged three.
An already difficult procedure was made even more so when Archie suffered complications and needed to be re-admitted to CHI Crumlin where he spent almost two weeks recovering.
When he got home, Ms Gladney Knox described how Archie had lost a lot of muscle density in his legs.
"He had to learn how to walk again," she said, adding: "They don't recommend physiotherapy, but children are resilient."
She described how Archie's hip spica cast needed to be cut off due to the swelling when he experienced complications, and afterwards he wore a "brace".
"There's a lot to it, its very very intense and it has a big impact on a family," she said.
"This is a tough tough surgery for any child to go through, and surgery is always going to be the last option," Ms Gladney-Knox said.
Dr Castañeda said that a pelvic osteotomy "is not a procedure which is done all too commonly because fortunately we have very good non-operative means to improve the congruency of the joint, as long as hip dysplasia in infants is detected in a timely way, which typically is done by screening of neonates (a baby who is four weeks old or younger), then hip dysplasia, in the vast majority of cases can be treated non-operatively".
As for some of the alternatives, babies diagnosed early with DDH are usually treated with a fabric splint called a pavlik harness.
Children can also wear hip abduction brace, which is a bit sturdier.
And then there are reduction procedures, where the "ball" is manipulated back into a "socket", and these can be closed (under anaesthetic but without surgery) or open (surgical).
Both of these procedures also require a child to wear a hip spica cast.
Ms Gladney-Knox, who is a member of Sinn Féin and was a general election candidate last year, was among the parents contacted by CHI Crumlin in March about the audit.
We now know that it found a number of the surgeries carried out in CHI Temple Street and the National Orthopeadic Hospital Cappagh were unnecessary, but that similar issues were not identified in CHI Crumlin where Archie's surgery were carried out.
Ms Gladney-Knox said that while she was "relieved" she still had questions.
"Definitely I will be ringing the helpline and I will be looking to see was (Archie) reviewed in that audit," she said.
She also expressed concern for the parents whose children were did undergo the procedure in CHI Temple Street and NOHC, who she believed were now "under a cloud of anxiety and worry and stress and... anger".
