Long-term outcome of medial open reduction in developmental dysplasia of hip

Evaluation of the labrum on postoperative magnetic resonance images: a predictor of acetabular development in developmental dysplasia of the hip

INTRODUCTION

Residual acetabular dysplasia of the hip after open reduction can complicate the treatment of developmental dysplasia of the hip (DDH) due to the potential need for corrective surgery. This retrospective study aimed to determine the predictive factors for acetabular development using postoperative radiographs and magnetic resonance imaging (MRI).

METHODS

We retrospectively investigated 74 hips of patients with DDH who underwent open reduction after reaching walking age and were followed up radiologically until skeletal maturity. We evaluated the cartilaginous acetabulum and labrum using a new method that measures the cartilaginous and labral landmarks on coronal and axial MR T2*-weighted images in patients aged 5 years. The mean age at the time of surgery was 22 months and that at the final survey was 20 years. Severin classification was determined at the final follow-up. Groups with good (53 hips) and poor (21 hips) outcomes were compared using the postoperative radiographic and MRI parameters recorded at 5 years of age. Factors predicting acetabular development were identified using univariate and multiple logistic analyses.

RESULTS

There were no significant differences in the bony-acetabular index (AI) and centre-edge (CE) angle between the good and poor outcome groups. However, the poor outcome group had significantly larger cartilaginous- and labral-AIs but significantly smaller cartilaginous- and labral-CE angles than the good outcome group (both p < 0.05). Multiple logistic regression analysis showed that labral-AI and labral-CE angle were predictors of acetabular development after open reduction for DDH, and their optimal cut-offs were 4° (77% sensitivity, 76% specificity) and 37° (68% sensitivity, 85% specificity), respectively.

DISCUSSION

Normal cartilaginous acetabulum development occurs in childhood, and evaluation using only radiographs is difficult. However, labral-AI ⩾4° and labral-CE angle <37° on MRI at 5 years of age offer useful indications for corrective surgery in patients with DDH.

A Comparative Study of Clinical and Radiological Outcomes of Open Reduction Using the Anterior and Medial Approaches for the Management of Developmental Dysplasia of the Hip

BACKGROUND

The literature is scanty on reports directly comparing the outcomes of anterior open reduction (AOR) and medial open reduction (MOR) in the management of developmental dysplasia of the hip (DDH).

PURPOSE OF THE STUDY

To compare clinical and radiographic outcomes of surgical treatment using either AOR or MOR in children with DDH aged < 24 months and to evaluate the procedure-inherent risks of avascular necrosis of the femoral head (AVN) and need for further corrective surgery (FCS).

METHODS

61 children who underwent surgical treatment for DDH were categorized into two groups: AOR (31 hips of 28 patients) and MOR (39 hips of 33 patients). The mean age was 17 ± 5.85 (range 7-24) months in group AOR and 13 ± 5.31 (range 6-24) months in group MOR. The mean follow-up was 118 ± 41.2 (range 24-192) months and 132 ± 36.7 (range 24-209) months in group AOR and MOR. At the final follow-up, mid- to long-term clinical and radiographic outcomes were assessed. FCS was recorded.

RESULTS

Regarding McKay's clinical criteria, both groups exhibited similar results (p = 0.761). No significant differences were observed between the groups in both the center-edge-angle (p = 0.112) and the Severin score (p = 0.275). The AVN rate was 32% in the AOR group and 20% in the MOR group (p = 0.264). The FCS rate was 22% in the AOR group and 12% in the MOR group (p = 0.464).

CONCLUSIONS

This study showed similar clinical and radiological outcomes with AOR and MOR with no significant relation to AVN and FCS.

LEVEL OF EVIDENCE

Level III.

Predicting acetabular growth in developmental dysplasia of the hip following open reduction after walking age

BACKGROUND

Acetabular dysplasia of the hip following open reduction can complicate the treatment of developmental dysplasia of the hip (DDH). The purposes of this retrospective study were to investigate the long-term results of open reduction performed via an extensive anterolateral approach for DDH after walking age and to predict acetabular development using postoperative radiographs and arthrograms.

METHODS

From 1973 to 2001, we performed open reduction for 131 hips in 119 pediatric patients with DDH after failed closed reduction. Of these, 85 hips of 73 patients who underwent arthrography at 5 years old were followed-up radiologically until skeletal maturity. Mean age at the time of surgery was 17 ± 4.6 months (range, 10-33 months), and mean age at final survey was 19 ± 5.7 years (range, 14-33 years). Mean follow-up time was 17.7 ± 5.8 years (range, 13-32 years). Groups with satisfactory outcomes (66 hips) and unsatisfactory outcomes (19 hips) according to the Severin classification were compared. Factors predicting acetabular development were identified using univariate and multiple logistic analyses.

RESULTS

Univariate analysis showed a significant between-group difference in acetabular index (AI) at 2 months postoperatively, and in center-edge (CE) angle, cartilaginous AI (CAI), and cartilaginous CE angle at 5 years old (p < 0.05 each). In multiple logistic regression analysis, CAI at 5 years old represented a predictor of acetabular development after open reduction for DDH (odds ratio, 1.81; 95% confidence interval (CI), 1.04-3.13; p < 0.05). Area under the receiver operating characteristic curve for CAI at 5 years old was 0.93 (95%CI, 0.85-1.0), and the optimal cut-off was 10° (81.8% sensitivity, 92% specificity).

CONCLUSIONS

A CAI ≥10° on hip arthrograms at 5 years old may offer a useful indicator of the need for corrective surgery following open reduction after walking age.

Acetabular development after open reduction to treat dislocation of the hip after walking age

BACKGROUND

Treatment of hip dislocation diagnosed after walking age is often difficult. We report the surgical treatment of these patients by open reduction with a soft tissue surgical procedure without osteotomy.

METHODS

Thirty-eight children (43 hips) diagnosed with complete dislocation of the hip after walking age were included in this study. We radiographically analysed postoperative hip joint development up to 6 years of age. To assess the predictors of acetabular development, we evaluated the radiographs, using an acetabular index of ≤35° and a centre-edge angle of >5° at 6 years of age as satisfactory outcomes, and evaluated the advance of acetabular development over time.

RESULTS

AI on the affected side was improved with time after open reduction. The diameter of the capital femoral ossific nucleus on the affected side was almost equivalent to that on the unaffected side at 6-12 months after surgery, after which the centre-edge angle improved gradually from one year after surgery. We compared hips classified as satisfactory to unsatisfactory at 6 years of age, and found that the centre-edge angle at one year after open reduction was significantly associated with acetabular development (P = 0.044). The cut-off value was -2° with sensitivity of 0.909 and specificity of 0.677.

CONCLUSIONS

The results of the current study suggest that initial development of the capital femoral ossific nucleus after open reduction would be followed by improved joint congruity, and that this would facilitate acetabular development. The centre-edge angle at one year after surgery could be regarded as a potential predictor of acetabular development in open reduction surgery for late-diagnosed developmental dysplasia of the hip cases.

Single-stage medial open reduction and Pemberton acetabuloplasty in developmental dysplasia of the hip

In this study, we aimed to evaluate the long-term clinical and radiological results of single-stage open reduction through a medial approach and Pemberton acetabuloplasty in developmental dysplasia of the hip. We treated 32 hips (22 patients) with developmental dysplasia by a single-stage open reduction through Ferguson's medial approach and Pemberton acetabuloplasty. The procedure was performed bilaterally in 10 patients. The mean age of the patients at the time of the operation was 19.8 months (16-24 months). The mean follow-up period was 10.9 years (7-19 years). Group I avascular necrosis according to the Kalamchi and MacEwen classification was observed in two hips and group II in one hip. Radiologically, 90.6% of the hips were classified as Severin class I and 9.4% of the hips were classified as Severin class II. At the latest follow-up, 30 hips were assessed clinically as excellent and two hips as good. No patient required subsequent surgery. We conclude that single-stage medial open reduction and Pemberton acetabuloplasty represent an effective method for developmental dysplasia of the hip in children older than 15 months of age.

The medial approach open reduction for developmental dysplasia of the hip: do the long-term outcomes validate this approach? A systematic review of the literature

INTRODUCTION

Developmental dysplasia of the hip (DDH) is one of the most commonly diagnosed and treated paediatric orthopaedic conditions.

OBJECTIVE

To systematically identify, appraise and synthesise the best evidence for the long-term outcomes of the medial approach open reduction (MAOR) for DDH.

METHODS

MEDLINE, EMBASE and the Cochrane databases were searched up to July 2013. All study designs that reported on the long-term outcomes of the MAOR as the primary treatment modality for DDH were included. The risk of bias in each study was evaluated using the Cochrane risk of bias assessment tool with some modification to accommodate different study designs.

RESULTS

From the 162 citations screened, five retrospective observational studies that fulfilled the eligibility criteria were included. The mean age at surgery varied from 10 to 17 months with an average follow-up period of 16-25 years. Acetabular development, as defined by the Severin Classification, was reported as satisfactory (Severin I/II) in between 38 and 79 % of study cohorts. However these good and excellent outcomes were less promising when patients who had additional operations were considered as unsatisfactory results. Avascular necrosis, as predominantly defined by the Kalamchi criteria, varied from 5 to 43 %. Negative prognostic factors implicated were mean age at surgery >17 months, the absence of the ossific nucleus and eccentric posturing of the femoral head postoperatively. The rate of secondary operations reported varied from 11 to 50 %. There were no reported total hip replacements.

CONCLUSION

There is a paucity of robust evidence pertaining to the long-term outcomes of the MAOR for developmental dysplasia of the hip. The trends from observational studies suggest that the long-term outcomes are not as positive as short- to intermediate-term studies suggest. Further prospective, controlled and rigorously designed studies are required to validate this approach.