Does open reduction of the developmental dislocated hip increase the risk of osteonecrosis?

Dynamic versus static cast immobilization in children aged 6 to 24 months with developmental dysplasia of the hip treated by closed reduction

BACKGROUND

The aim of this study was to compare the effects of two types of cast immobilization (human position cast and dynamic cast) on hip development in children with Developmental dysplasia of the hip (DDH) after closed reduction (CR).

METHODS

A retrospective study of 60 children (64 hips) with DDH who underwent CR and cast immobilization between January 2015 and December 2016 at our Institution was performed. The average age at the time of CR was 14.6 months (range, 6.1-23.5). Fifty-seven females and 3 males were included. According to the technique of cast immobilization, two groups of patients could be identified: patients with DDH managed by human position cast immobilization (group A: 32 patients, 34 hips) and patients with DDH treated by dynamic cast immobilization (group B: 28 patients, 30 hips). Hip joint distance (HJD) after CR was measured on MRI. Acetabular Index (AI) and Acetabular Depth Radio (ADR) were measured of anterior-posterior (AP) radiographs before and 3 months after CR; AI and central edge angle (CEA) were measured last follow-up AP radiographs. The presence of subluxation or dislocation and avascular necrosis (AVN) at the last follow-up visit was also evaluated.

RESULTS

The patients were comparable regarding to sex, side, age, Tönnis degree, AI, and ADR before the reduction between two groups. There was no significant difference in HJD improvement between the two groups 6 weeks following closed reduction. The AI (27.5±5.1°) of group B was significantly lower than those of group A (31±4.9°) (P=0.03) when cast was removed 3 months after CR. At the last follow-up, the incidence of AVN was similar between the two groups of patients (group A: 11.8% versus group B: 13.3%), and the incidence of subluxation or dislocation (group A: 8.8% versus group B: 10%). At last follow-up visit, the AI (23.7±5.4°) in group B was significantly lower than in group A (26.9±4.1°) (P=0.02).

CONCLUSIONS

Dynamic cast immobilization promotes acetabular development following CR in patients aged 6 to 24 months with DDH. Dynamic cast immobilization does not increase the risk of dislocation or subluxation, nor of AVN.

Rates and risk factors for failure of reduction in closed reduction in developmental dysplasia of the hip: a systematic review and meta-analysis

Objective

In developmental dysplasia of the hip (DDH), concentric reduction of dislocated hips cannot be achieved by closed reduction in many cases, and open reduction is required ('failure of reduction'). The incidence of cases requiring open reduction and the significance of risk factors for unsuccessful reduction remain unclear. We investigated the overall rate and the risk factors for failed closed reduction in DDH.

Methods

We followed the Cochrane recommendations in our systematic review and meta-analysis. We performed a systematic search in three medical databases to identify all studies reporting on pediatric patients with hip dislocation in DDH on 2 July 2022. Eligible studies reported on the rate of failure in children younger than 36 months. We calculated odds ratios (ORs) with 95% CIs from two-by-two tables (event rate in risk group, event rate in non-risk group).

Results

We identified 13 316 studies and included 62 studies (5281 hips) for failure rate and 34 studies (3810 hips) for risk factor analysis. The overall rate of failure in closed reduction was 20%. The risk of failure of reduction increased with the grade of dislocation and was significantly higher for high dislocations (group 0-24: IHDI 4 vs IHDI 2 OR: 17.45, CI: 9.26-32.92; Tönnis 4 vs Tönnis 2 OR: 14.67, CI: 1.21-177.37; Graf IV vs Graf III OR: 3.4, CI: 2.27-5.09). Male gender was also a significant risk factor (OR: 2.27, CI: 1.13-4.56) in group 0-36.

Conclusion

Higher grade dislocations and male gender are significant risk factors for failure of reduction in closed reduction in hip dislocation in DDH.

Child Opportunity Index and Diagnosis of Developmental Dysplasia of the Hip: Insights From a Children's Hospital Serving Disadvantaged Communities

INTRODUCTION

Initiation of Pavlik harness treatment for developmental dysplasia of the hip (DDH) by 6 to 7 weeks of age predicts a higher rate of success. Child Opportunity Index (COI) 2.0 is a single metric designed to measure resources and conditions affecting children's healthy development. This study investigates COI in relation to the timing of DDH diagnosis.

METHODS

This is a retrospective cohort study on patients younger than 4 years diagnosed with DDH between 2016 and 2023, treated with a Pavlik harness, rigid hip abduction orthosis, and/or surgery. Demographic and clinical data were recorded, including date of first diagnostic imaging. Patients with syndromes, congenital anomalies, or neuromuscular disorders and those referred with an unknown date of first diagnostic imaging were excluded. A subgroup analysis of patients diagnosed at ≤6 weeks ("early") and >6 weeks ("late") was conducted. Statewide COI scores (total, three domains) and categorical quintile scores (very low, low, moderate, high, and very high) were recorded.

RESULTS

A total of 115 patients were included: 90 female infants (78%), with a median age of 32 days at diagnostic imaging. No notable difference was observed between median age at diagnosis for study patients in low or very low quintiles and those in moderate, high, or very high quintiles for COI total or domains. "Early" and "late" diagnosis subgroups did not differ markedly by COI total or domains, nor insurance type, race, or ethnicity. Subgroups differed markedly by race and insurance status.

DISCUSSION

In an urban children's hospital, COI did not differ markedly between patients diagnosed with DDH by ≤6 weeks and >6 weeks. This is the first study to pose this question on DDH in a population with predominantly low/very low COI scores and public insurance, which may lead to unexpected results. Replicating the study in a different setting could yield different results.

LEVEL OF EVIDENCE

III.

Risk factor analysis of femoral avascular necrosis after operation for Tönnis grade IV developmental dysplasia of the hip

PURPOSE

We explored the risk factors for avascular necrosis (AVN) after surgery using open reduction, pelvic osteotomy, and femoral osteotomy for Tönnis grade IV developmental dysplasia of the hip (DDH).

METHODS

In this retrospective study, we collected data of patients with Tönnis grade IV DDH treated with open reduction and pelvic osteotomy combined with femoral osteotomy from January 2012 to May 2020. The patients were divided into the AVN group and non-AVN group using the Kalamchi-MacEwen classification system. The clinical and imaging data of the two groups were collected, and the possible risk factors were included in the analysis. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors and odds ratios of AVN.

RESULTS

In all, 254 patients (mean age; 2.6±0.9 years, 278 hips) were included. The mean follow-up time was 3.8±1.5 years. A total of 89 hips (32%) were finally classified as AVN (Kalamchi-MacEwen II-IV). Univariate analysis showed significant associations with AVN for age (p=0.006), preoperative femoral neck anteversion (FAV) (p<0.001), femoral osteotomy length to dislocation height ratio (FDR) <1 (p<0.001), and the epiphyseal ossific nucleus diameter to the neck diameter ratio (ENR) <50% (p=0.009). Multivariate logistic regression analysis showed that only excessive preoperative FAV (OR: 1.04; 95% CI: 1.02-1.05; p<0.001) and FDR<1 (OR: 3.58; 95% CI: 2.03-6.31; p<0.001) were independent risk factors for femoral head necrosis.

CONCLUSION

Excessive preoperative FAV and FDR<1 are important risk factors for femoral AVN after open reduction, pelvic osteotomy, and femoral osteotomy for Tönnis grade IV DDH. For children with DDH with high dislocation and excessive FAV, clinicians should fully evaluate their condition and design more personalized treatment programs to prevent AVN.

Open reduction after failed closed reduction following failed Pavlik harness treatment in developmental dysplasia of the hip: One- or two-stage?

INTRODUCTION

The current published evidence for the treatment of developmental dysplasia of the hip (DDH) with failed closed reduction (CR) following failed Pavlik harness (PH) treatment is still limited. This study aimed to determine whether an one-stage open reduction (OR) would lead to a similar outcome to a two-stage OR in these patients. Meanwhile, the occurrence of femoral head avascular necrosis (AVN) and further surgery (pelvic osteotomy, PO) within the follow-up period was investigated.

MATERIALS AND METHODS

A consecutive series of DDH patients who failed CR following failed PH treatment and received OR finally between January 2008 and December 2020 were studied. The patients were divided into two groups. One group of which received OR immediately after failed CR (one-stage OR group, Group A), and the other received a delayed OR (two-stage OR group, Group B). The McKay's criteria, acetabular index (AI) and the degree of dislocation of the hips were evaluated for the final outcomes.

RESULTS

At the last follow-up, 54 (84.4%) of the 64 hips in Group A and 26 (83.9%) of 31 hips in Group B were in excellent or good condition. Comparison between the two groups revealed that there were no differences in terms of McKay grading (P = 0.950), AI (P = 0.783), incidence of AVN (P = 0.745), and also incidence of PO (P = 1.000). However, a significant lower mean AI was found in Group A, when the OR was performed in Group B (31.06 ± 4.45° vs. 33.87 ± 4.12°, P = 0.004).

CONCLUSION

Both of the one- and two-stage OR may acheive favorable outcomes. Moreover, one-stage OR is of without the general anesthesia risk associated with two-stage OR. We therefore advocate that an OR should be performed in appropriate DDH patients during the same session once a failed CR is detected.

Abduction Bracing Following Anterior Open Reduction for Developmental Dysplasia of the Hip Does Not Improve Residual Dysplasia or Reduce Secondary Surgery

BACKGROUND

Abduction bracing is commonly used following open reduction and spica casting of developmental dysplasia of the hip. However, there is little evidence to support or refute this practice that carries associated cost and burden for families. The purpose of this study was to determine the efficacy of abduction bracing after open reduction in improving the acetabular dysplasia and reducing the rate of secondary surgery for residual dysplasia.

METHODS

This is a retrospective study of patients treated with open reduction at a single tertiary referral center. Demographic data, severity of dislocation [International Hip Dysplasia Institute (IHDI) class], age at reduction, and casting duration were obtained. Patients were prescribed no bracing, part-time (≤18 h/d), or full-time (≥20 h/d) brace wear based on surgeon preference. Acetabular index (AI) measurements were obtained at cast removal and at 2- and 4-year follow-up.

RESULTS

A total of 146 hips underwent open reduction with 61% (89/146) of hips treated with abduction bracing. There was no difference between braced and nonbraced cohorts with regards to sex, age at time of reduction, dislocation severity, cast duration, immediate postcasting AI, or incidence of medial open reduction. There was no difference in hips treated with or without brace following open reduction with regards to AI at 2 years postreduction (31.8±6.7 vs. 30.4±6.1 degrees, P =0.27) or at 4 years postreduction (24.9±6.5 vs. 24.7±6.5 degrees, P =0.97). However, further analysis showed lower mean AI at 2-year follow-up for braced versus nonbraced patients following medial open reduction (30.0±5.7 vs. 34.5±7.0 degrees, P =0.02). This difference was no longer present at 4-year follow-up (26.6±6.8 vs. 24.2±6.6 degrees, P =0.44). However, 4/19 (21%) nonbraced hips underwent secondary surgery for residual dysplasia and were consequently excluded from the AI measurement at 4 years postreduction (compared with 4/39 [10%] braced hips within the same time period). There was no difference in the rate of secondary surgery between braced and nonbraced hips (30% vs. 33%, respectively, P =0.70). Multivariate analysis demonstrated that neither IHDI classification, bracing, nor age at reduction predicted residual dysplasia.

CONCLUSIONS

Abduction bracing following anterior open reduction for developmental dysplasia of the hip is not associated with decreased residual dysplasia at 2/4 years postreduction or with decreased secondary surgery. These results suggest that abduction bracing following anterior open reduction may not provide clinical benefit. However, abduction bracing may be beneficial following medial open reduction. A prospective study is necessary to provide more definitive recommendations.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Closed versus medial open reduction in the treatment of developmental dysplasia of the hip under age 1: A retrospective comparative study

OBJECTIVE

This study aimed to compare the mid-term results of closed reduction (CR) versus medial open reduction (MOR) in the treatment of children with developmental dysplasia of the hip (DDH) under age 1.

METHODS

Thirty-four patients with DDH (41 hips) were included in this retrospective study with a mean follow-up of 4.2 years (range: 2-6.9 years). All hips were then divided into 2 groups based on the treatment type: the CR group (20 hips) and the MOR group (21 hips). All hips from both groups were assessed with post-spica magnetic resonance imaging (MRI) in the first 24 hours, and reinterventions were recorded. Medial dye pool width was also measured.

RESULTS

Age at the time of reduction was similar between the CR and MOR groups (6.6 ± 1.3 months vs. 6.7 ± 1.6 months). There was no significant difference between groups regarding avascular necrosis rate and further corrective surgery (FCS) requirement (P=.454, .697). The appropriate reduction was seen at 38/41 hips. Three hips in the CR group had revealed dislocation in post-spica MRIs and required re-intervention, and none of the hips in the MOR group required re-intervention (P=.107). Medial dye pool width in 3 planes showed no significant difference between MOR and CR.

CONCLUSION

There is no difference in the avascular necrosis rate and FCS requirements between CR and MOR under age 1. Post-spica MRI is a favorable tool for evaluating reduction after CR, but its efficacy after MOR is questionable.

Is seizure disorder a risk factor for complications following surgical treatment of hip dysplasia in the pediatric population?

The impact of seizure disorders on pediatric patients who undergo hip dysplasia surgery has yet to be elucidated. This study focused on identifying the effect of seizure disorders on the incidence of complications following surgical management of hip dysplasia. Pediatric patients undergoing surgical treatment for hip dysplasia from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were divided into two cohorts: patients with and patients without a seizure disorder. Patient demographics, comorbidities and postoperative outcomes were compared between the two groups. Bivariate and multivariate analyses were performed. Of 10 853 pediatric patients who underwent hip dysplasia surgery, 8117 patients (74.8%) did not have a seizure disorder whereas 2736 (25.2%) had a seizure disorder. Bivariate analyses revealed that compared to patients without a seizure disorder, patients with a seizure disorder were at increased risk of developing surgical site infections, pneumonia, unplanned reintubation, urinary tract infection, postoperative transfusion, sepsis, extended operation time and length of stay and readmission ( P  < 0.05 for all). Following adjustment for patient demographics and comorbidities on multivariate analysis, there were no differences in any postoperative complications between pediatric patients with and without a seizure disorder. There were no differences in 30-day postoperative complications in patients with and without a seizure disorder. Due to potential decreased bone mineral density as an effect of antiepileptic drugs and the risk of femur fracture during surgery for hip dysplasia, pediatric patients with a seizure disorder should be closely monitored as they may be more susceptible to injury. Level of Evidence: III.

A Prospective, Multicenter Study of Developmental Dysplasia of the Hip: What Can Patients Expect After Open Reduction?

BACKGROUND

Although there are several predominantly single-center case series in the literature, relatively little prospectively collected data exist regarding the outcomes of open hip reduction (OR) for infantile developmental dysplasia of the hip (DDH). The purpose of this prospective, multi-center study was to determine the outcomes after OR in a diverse patient population.

METHODS

The prospectively collected database of an international multicenter study group was queried for all patients treated with OR for DDH. Minimum follow-up was 1 year. Proximal femoral growth disturbance (PFGD) was defined by consensus review using Salter's criteria. Persistent acetabular dysplasia was defined as an acetabular index >90th percentile for age. Statistical analyses were performed to compare preoperative and operative characteristics that predicted re-dislocation, PFGD, and residual acetabular dysplasia.

RESULTS

A cohort of 232 hips (195 patients) was identified; median age at OR was 19 months (interquartile range 13 to 28) and median follow-up length was 21 months (interquartile range 16 to 32). Re-dislocation occurred in 7% of hips (n=16/228). The majority (81%; n=13/16) occurred in the first year after initial OR. Excluding patients with repeat dislocation, 94.5% of hips were IHDI 1 at most recent follow-up. On the basis of strict radiographic review, some degree of PFGD was present in 44% of hips (n=101/230) at most recent follow-up. Seventy-eight hips (55%) demonstrated residual dysplasia compared with established normative data. Hips that had a pelvic osteotomy at index surgery had about half the rate of residual dysplasia (39%; n=32/82) versus those without a pelvic osteotomy with at least 2 years follow-up (78%; n=46/59).

CONCLUSIONS

In the largest prospective, multicenter study to date, OR for infantile DDH was associated with a 7% risk of re-dislocation, 44% risk of PFGD, and 55% risk of residual acetabular dysplasia at short term follow-up. The incidence of these adverse outcomes is higher than previous reports. Patients treated with concomitant pelvic osteotomy had lower rates of residual dysplasia. These prospectively collected, multicenter data provide better generalizable information to improve family education and appropriately set expectations.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Risk factors for postoperative avascular necrosis of the femoral head in children with developmental dysplasia of the hip

Aim

To investigate factors associated with postoperative avascular necrosis of the femoral head (ANFH) in developmental dysplasia of the hip (DDH) patients, and if or how the associations varied among different subpopulations of age, sex and surgical method.

Methods

Patients with DDH were enrolled between October 31, 2016 and July 15, 2020 in this retrospective cohort study. The average follow-up time was 21.42 ± 10.02 months. The outcome was postoperative ANFH. The main study variables were the DDH classification, Tonnis grade, International Hip Dysplasia Institute (IHDI) classification, and preoperative traction. Multivariate logistic regression was employed to assess the associations between main study variables and postoperative ANFH. Subgroup analysis was carried out based on age at reduction, sex and surgical method. Odds ratio (ORs) and 95% confidence intervals (CIs) were calculated.

Results

A total of 427 children with DDH were included, with 92 (21.55%) in the ANFH group, and 335 (78.45%) in the non-ANFH group. DDH classification was positively correlated with the risk of postoperative ANFH (OR = 4.14, 95% CI, 1.08-15.77, P = 0.038). Children with preoperative traction had a significantly decreased risk of postoperative ANFH in contrast to those without preoperative traction (OR = 0.37, 95% CI, 0.22-0.61, P < 0.001). Children aged 1-3 years who received preoperative traction has a significantly reduced risk of postoperative ANFH than those who did not receive preoperative traction (OR = 0.28, 95% CI, 0.15-0.51, P < 0.001). For children aged >3 years, positive association was found between DDH classification and the risk of postoperative ANFH (OR = 3.75, 95% CI, 1.51-9.31, P = 0.004). Girls with a more severe DDH type had a significantly higher risk of postoperative ANFH (OR = 3.80, 95% CI, 1.80-8.02, P < 0.001). Receiving preoperative traction was associated with a significantly decreased risk of postoperative ANFH in girls (OR = 0.37, 95% CI, 0.22-0.61, P < 0.001). For children undergoing open reduction, DDH classification was positively associated with the risk of postoperative ANFH (OR = 3.01, 95% CI, 1.65-5.50, P < 0.001), and those with preoperative traction had a lower risk of postoperative ANFH compared with those without preoperative traction (OR = 0.35, 95% CI, 0.20-0.61, P < 0.001).

Conclusion

DDH classification and preoperative traction were associated with the risk of postoperative ANFH, and these associations varied across DDH patients with different ages, sexes and surgical methods.

The Effect of Traction before Closed Reduction in Patients with Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) with a dislocated hip can be treated with traction before closed reduction (CR). Currently, there is insufficient evidence supporting the use of preoperative traction treatment for a successful CR. The objective of this study was to determine the effect of preoperative traction on the success rate of primary CR in DDH patients with dislocated hips. A retrospective pair-matched study was performed in DDH patients with dislocated hips. Patients with preoperative traction treatment prior to primary CR were matched (based on age and the severity of DDH on the radiograph) to patients without preoperative traction treatment. The primary outcome was the presence or absence of maintained reduction after three weeks. A match was found for 37 hips, which resulted in the inclusion of 74 hips. No significant difference was found in the number of successful reductions after three weeks between the traction group and the control group (31 vs. 33 hips, p = 0.496). Traction treatment did not significantly improve the short-term or mid-term outcomes for closed reduction. Based on these results, we suggest that traction treatment should not be used as standard care for dislocated hips in DDH.

Retrospective Comparison of Outcomes Between Closed and Open Reduction for Developmental Dysplasia of the Hip in Children Aged 6-24 Months

PURPOSE

We aimed to compare the outcomes between closed reduction (CR) and open reduction (OR) in children aged 6-24 months with developmental dysplasia of the hip (DDH) who could be reduced safely and stably by the closed reduction operation.

METHODS

We retrospectively reviewed the medical records of 77 patients who underwent CR or OR for DDH. Fifty-one patients (56 hips) underwent CR, 26 (29 hips) underwent OR. The demographic data, International Hip Dysplasia Institute classification and acetabular index (AI) before reduction and the centre-edge angle (CEA), AI, Alsberg angle (AA), Reimer's migration index (RMI), and height-to-width index (HWI) of the epiphysis were compared between two groups at the final follow-up. The percentage of coxa magna > 15% of the normal side and AA > 81° were calculated.

RESULTS

At the final follow-up, the mean AA in the CR and OR groups were 77.66° (60°-89°) and 81.97° (73°-91°) (p = 0.001), respectively, there were 32.14% and 58.62% of the hips with an AA > 81° (p = 0.019). The frequency of coxa magna > 15% of the normal side was higher in the OR group (60.9%) than in the CR group (6.5%) (p < 0.001). There was no difference in the improvement of AI, CEA, HWI, and RMI.

CONCLUSION

In children aged 6-24 months with DDH, if a stable and safe CR can be obtained but with medial joint space up to 6mm, CR should be attempted first.

Avascular necrosis under different treatment in children with developmental dysplasia of the hip: a network meta-analysis

The objective of this study was to evaluate the incidence of avascular necrosis (AVN) of the femoral head in children less than 3 years of age with developmental dysplasia of the hip (DDH) treated with closed reduction, open reduction alone and open reduction combined with osteotomy. We reviewed clinical trials from the PubMed, EMBASE and Cochrane Library databases (up to November 2020) that were related to closed reduction, open reduction alone and open reduction combined with osteotomy for the treatment of children under 3 years of age with DDH. The screening and quality evaluation of the literature were performed independently by two researchers. In case of disagreement, a third researcher resolved the discourse. Finally, the data were extracted, and the R software and GeMTC program package were used to conduct a network meta-analysis (NMA). The evaluation index was the incidence of AVN. Fourteen articles were included. The NMA showed that in terms of the incidence of AVN, cases treated with open reduction alone were higher than those with closed reduction, and the difference was statistically significant. Open reduction alone had the highest probability (94.4%) of having the highest incidence of AVN, followed by open reduction combined with osteotomy (5.5%) and closed reduction (0.1%). In the treatment of children with DDH who are younger than 3 years old, open reduction alone is most likely to be the treatment with the highest incidence of AVN, followed by open reduction combined with osteotomy. The closed reduction had the smallest probability of AVN.

Guided growth versus varus osteotomy for type II avascular necrosis following surgery for developmental dysplasia of the hip

AIMS

The aim of this study was to compare outcomes of guided growth and varus osteotomy in treating Kalamchi type II avascular necrosis (AVN) after open reduction and Pemberton acetabuloplasty for developmental dysplasia of the hip (DDH).

METHODS

This retrospective study reviewed patients undergoing guided growth or varus osteotomy for Kalamchi type II AVN between September 2009 and January 2019. All children who had undergone open reduction and Pemberton acetabuloplasty for DDH with a minimum two-year follow-up were enrolled in the study. Demographic and radiological data, which included the head-shaft angle (HSA), neck-shaft angle (NSA), articulotrochanteric distance (ATD), Sharp angle (SA), and lateral centre-edge angle (LCEA) at baseline, two years, and at the extended follow-up, were compared. Revision rates were evaluated. Clinical outcomes using the Harris Hip Score were assessed two years postoperatively.

RESULTS

A total of 24 patients underwent guided growth and 19 underwent varus osteotomy, over a mean period of 3.3 years (95% confidence interval (CI) 2.8 to 3.8) and 5.2 years (95% CI 4.5 to 6.0), respectively. There were no differences in demographic and preoperative radiological data, except for a younger age at time of acetabuloplasty and larger ATD for the osteotomy group. The HSA did not differ at two years and the extended follow-up because of postoperative rebound in the osteotomy group. The NSA of the osteotomy group remained smaller postoperatively. There were no significant differences in the follow-up ATD, SA, and LCEA, except for a smaller two-year ATD of the osteotomy group. Seven patients (29.2%) in the guided growth group underwent revision surgery and none in the osteotomy group. The Harris Hip Score was similar between groups.

CONCLUSION

Guided growth and varus osteotomy had comparable results in improving caput valgum deformity, given the rebound of lateral tilting of the physis after osteotomy correction. There were no differences in clinical outcomes at two years postoperatively. Cite this article: Bone Joint J 2022;104-B(7):902-908.

Impact of Failed Pavlik Harness Treatment on the Outcomes Following Closed or Open Reduction in Developmental Dysplasia of the Hip

PURPOSE

To investigate the impact of failed Pavlik harness (PH) treatment on the outcomes following closed reduction (CR) or open reduction (OR) in developmental dysplasia of the hip (DDH).

METHODS

Ninety-three DDH patients treated with CR or OR were enrolled. One group of which received previous PH treatment (F group) and the other (L group) not. The clinical outcomes were evaluated according to McKay's criteria. Radiographs were evaluated for acetabular index (AI) and the degree of dislocation of the hips.

RESULTS

A higher rate of CR was found in F group (P = 0.034). Before CR/OR, the mean AI in F group was significantly lower than that in L group (P = 0.000), while at the last follow-up, the AIs in both groups were all improved. In F group, there were 7 (16.67%), 18 (42.86%) and 17 (40.48%) hips were classified as Graf type II, III and IV pathologic changes, respectively, when PH treatment started, while the corresponding data were 17 (40.48%), 17 (40.48%) and 8 (19.05%) after PH treatment (P = 0.024). At the last follow-up, no significant difference was found concerning the complications between the two groups (P > 0.05).

CONCLUSIONS

PH treatment, even if failed, may have the ability of accelerating the development of the acetabulum and increasing the rate of successful CR. Thus we advocate a trial of PH treatment for all DDH patients less than 6 months of age. Meanwhile, a close monitoring by dynamic ultrasonography is required due to the risk of AVN.

Minimally Invasive Surgery to Remove a Broken and Retained Epidural Catheter Fragment

Epidural anaesthesia (EA) has consistently been used for treatments affecting the pelvis, lower limbs, lower abdomen, and perineum; however, it is progressively employed as a single anaesthetic or supplement to general and spinal anaesthesia for a broader range of procedures. The retention of a broken epidural catheter piece is an uncommon but well-known complication. In this report, we present a 30-year-old male with avascular necrosis (AVN) of the hip who was referred for total hip replacement (THR). An epidural catheter had been placed at the presumed L2-3 interspace to administer EA. The catheter had been set too deep and it broke on extraction with the Tuohy needle, leaving a fragment inside. The patient was then given general anaesthesia and the planned procedure of THR was done in the lateral position. The patient was then shifted to the prone position to remove the retained fragment of the epidural catheter by a minimally invasive spinal surgery (MISS). Right-sided L2 laminotomy was done, as the epidural catheter was inserted from the right side, to retrieve the broken fragment without any added postoperative neurological complications. MISS may be attempted by experienced surgeons for the removal of a retained fragment of the epidural catheter from the spinal canal before adhesion as a safe option.

Interobserver and Intraobserver Reliability in the Salter Classification of Avascular Necrosis of the Femoral Head in Developmental Dysplasia of the Hip

BACKGROUND

Avascular necrosis (AVN) of the femoral head is a concerning complication that can result from treatments for developmental dysplasia of the hip (DDH). AVN can lead to degenerative osteoarthritis, persistent acetabular dysplasia, reduced function, and continuing hip pain. The incidence of AVN reported in the DDH literature is widely varied (0% to 73%). This variability may arise from lack of consensus on what constitutes true AVN in this patient population, and lack of clear criteria provided in studies reporting incidence rates.

METHODS

A multicentre, prospective database of infants diagnosed with DDH between 2010 and 2014 from 0 to 18 months of age was analyzed for patients treated by closed reduction (CR). Twelve pediatric orthopaedic surgeons completed 2 rounds of AVN assessments. Deidentified anteroposterior radiographs at most recent follow-up were provided to surgeons along with patient age at radiographic assessment, length of follow-up, ands affected hip. Ten of 12 surgeons completed a third round of assessments where they were provided with 1 to 2 additional radiographs within the follow-up period. Radiographic criteria for total AVN described by Salter and colleagues were used. Surgeons rated the presence of AVN as "yes" or "no" and kappa values were calculated within and between rounds.

RESULTS

A total of 69 hips in 60 patients were assessed for AVN a median of 22 months (range: 12 to 36) post-CR. Interobserver kappa values for rounds 1, 2, and 3 were 0.52 (range: 0.11 to 0.90), 0.61 (range: 0.21 to 0.90), and 0.53 (range: 0.10 to 0.79), respectively. Intraobserver agreement for AVN diagnosis was an average of 0.72 (range: 0.31 to 0.96).

CONCLUSIONS

Despite using the most commonly referenced diagnostic criteria, radiographic diagnosis of AVN following CR in DDH patients demonstrated only moderate agreement across surgeons. The addition of sequential radiographs did not improve cross-observer reliability, and while substantial agreement was seen within observers, the range of intraobserver kappa values was large.

LEVEL OF EVIDENCE

Level I-diagnostic study.

Narrative Review of Complications Following DDH Treatment

BACKGROUND

The purpose of this narrative review was to survey the literature for common complications following treatment of DDH in children less than 4 years old.

METHODS

The Pubmed database was queried. Search result titles were reviewed to identify papers that were pertinent to the topic. Abstracts for these papers were obtained and read, and a subset of these were selected for review of the complete manuscript.

RESULTS

92 manuscripts were reviewed. Residual dysplasia, redislocation, and osteonecrosis are the primary complications of treatment in this age group. In the long term, hips without complications related to DDH treatment tend to do well, although a significant percentage of them will inevitably require joint replacement surgery.

CONCLUSION

Although there is excellent potential for a good outcome when DDH is diagnosed and treated under age 4 years, osteonecrosis continues to be a concern with all treatment methods. A subset of patients from this young cohort will continue to have residual dysplasia or recurrent dislocation requiring return to the operating room.

Timing for closed reduction procedure for developmental dysplasia of the hip and its failure analysis

Background

It remains controversial whether the older age to perform closed reduction (CR) procedure for developmental dysplasia of the hip (DDH), the higher incidence of complications. The aim of this study is to evaluate the midterm outcome of CR for DDH among different age groups, and to analyze and identify risk factors for the failure of this procedure.

Methods

Clinical data of 107 DDH patients, who received CR, were retrospectively reviewed. Data were divided into three groups according to initial treatment age (Group I: younger than 12 months; Group II: 12 months to less or equal to18 months; Group III: older than 18 months). The presence of avascular necrosis (AVN), residual acetabular dysplasia (RAD), re-dislocation, and further surgeries (FS) were observed. The risk factors were identified for those outcomes aforementioned using univariable logistic regression models. For identified risk factor age, pre-op acetabular index (AI) and post-op AI, their prediction of CR failure were evaluated by receiver operating characteristics curve (ROC).

Results

A total of 107 patients (156 hips) undergoing CR procedure were evaluated with a median age at initial reduction of 13.0 ± 5.4 months (range, 4 to 28 mo). Mean follow-up time in this study was 6.7 ± 0.8 years (range, 3–8 years). The incidence of AVN, RAD and re-dislocation was 15.4% (24/156), 17.3% (27/156) and 14.7% (23/156) respectively. For AVN, RAD and re-dislocation, the significant risk factors are pre-op IHDI IV (p = 0.033), age ≥ 18 months (p = 0.012), and pre-op IHDI IV (p = 0.004) and walking (p = 0.011), respectively. The areas under the ROC curve of each type of failures were 0.841 (post-op AI), 0.688 (pre-op AI) and 0.650 (age).

Conclusions

Severe DDH patients older than 18 months with CR procedure may result in a high risk of RAD complication. Re-dislocation is significantly associated with pre-op IHDI IV and walking. Patients, who are older than 12.5 months or have a pre-op AI of 38.7° or a post-op AI of 26.4°, are also more likely to fail of CR procedure.

Salter osteotomy without open reduction in the Tönnis type II developmental hip dysplasia: A retrospective clinical study

PURPOSE

We aimed to evaluate the clinical and radiological outcomes of children older than 18 months who were treated with Salter osteotomy without open reduction for Tönnis type II hip dysplasia.

METHODS

Thirty-two type II hips of 24 patients were included in the study. The mean age was 43.22 (18-108) months. The mean follow-up period was 50 (24-142) months. Seven patients had left sided, nine had right sided, and eight had bilateral developmental dysplasia of the hip. All patients underwent closed reduction and Salter osteotomy. Preoperative and postoperative radiographs were assessed by measuring the center-edge (CE) angle of Wiberg, Smith's c/b and h/b ratio, and acetabular index (AI). Patients were evaluated clinically according to McKay's criteria and radiologically according to Severin criteria. The Kalamchi and MacEwen criteria were used in the evaluation of avascular necrosis.

RESULTS

The mean preoperative AI, CE angle, c/b, and h/b ratio were 36.7° (±4.1), 7.2° (±5.9), 0.9 (±0.08), and 0.05 (±0.04), respectively. The mean latest follow-up AI, CE angle, c/b, and h/b ratio were 18.2° (±1.7), 38.8° (±5.4), 0.6 (±0.03), and 0.19 (±0.04), respectively. The comparison of preoperative and postoperative radiological values revealed statistically significant improvement ( p < 0.01). On the latest physical examinations of the patients, 25 (78.1%) hips were rated excellent, and 7 (21.9%) were rated good according to the McKay criteria. The Severin classification determined 25 (78.1%) hips were grade I and 7 (21.9%) hips were grade II. Type I avascular necrosis (AVN) was seen in four (12.5%) hips. Three of these four hips were more superolateral in preoperative radiographs (c/b > 1 and h/b < 0.05).

CONCLUSIONS

Salter osteotomy without open reduction is a good surgery option for Tönnis type II hip dysplasia, in which closed reduction can be performed. However, the risk of AVN should be kept in mind in more superolateral type 2 hips.

Closed vs open reduction in developmental dysplasia of the hip: The short-term effect on acetabular remodeling

BACKGROUND

This study aims to assess acetabular remodeling following closed vs, open hip reduction in children younger than 2 years of age.

METHODS

Records of children with DDH, who underwent closed or open reduction, were reviewed. Acetabular index (AI) was measured on radiographs taken prior to reduction and on outcome radiographs taken at age 4 years. Radiographic outcomes were analyzed and residual dysplasia (outcome AI ≥ 30) degrees recorded.

RESULTS

42 hips had closed reduction; and 26 hips had open reduction. A higher percentage of hips treated with successful closed reduction, had outcome AI ≥ 30° (29% vs. 19% p = 0.387). Residual dysplasia was more common in IHDI-IV hips than IHDI-III hips for both groups. A higher incidence of AVN was seen in the open reduction group (13% vs. 7%; p = 0.43).

CONCLUSION

In children with DDH under the age of two, open reduction with capsulorrhaphy may benefit acetabular remodeling more so than closed reduction despite maintenance of reduction. Although AVN remains a risk, higher remodeling might be expected with open reduction.

Avascular necrosis of the femoral head: Assessment following developmental dysplasia of the hip management

OBJECTIVES

Avascular necrosis (AVN) of the femoral head is a major complication following treatment for developmental dysplasia of the hip (DDH). It is caused by excessive pressure over the femoral head, which compromises its blood supply. The rate of AVN following DDH treatment ranges from 6% to 48%. This study aimed to analyze the rate of AVN in DDH patients following different standard surgical treatments.

METHODS

A retrospective cohort study was performed on patients diagnosed with DDH between January 2007 and December 2013. All idiopathic DDH patients who underwent standard surgical treatments were included in the study. Neuromuscular and teratologic patients and patients with previous surgical treatment outside the institute were excluded from the study.

RESULTS

Overall, 204 hips in 143 pediatric patients were included in the study. The majority (84.8%) of the patients were female. Most patients (82.2%) received single treatment. The most commonly used surgical treatment was open reduction with pelvic osteotomy (82.8%). Type 4 Tonnis classification of DDH was found in 62.3% of patients. AVN was found in 14.3% of our study population. The majority (57.1%) of diagnosed AVN patients showed Grade 1 (Kalamchi) AVN classification. Patients who underwent closed reduction and hip spica showed a significantly higher rate of AVN compared to other treatments (14.3%, P = 0.044).

CONCLUSION

Close follow-up of patients treated with closed reduction is mandatory as these patients have the highest risk of AVN. We recommend the introduction of national screening programs targeting all newborn children and including systematic follow-up at well-baby clinics during the early years of life.

Traction does not decrease failure of reduction and femoral head avascular necrosis in patients aged 6-24 months with developmental dysplasia of the hip treated by closed reduction: a review of 385 patients and meta-analysis

This study aimed to investigate the effects of preliminary traction on the rate of failure of reduction and the incidence of femoral head avascular necrosis (AVN) in patients with late-detected developmental dysplasia of the hip treated by closed reduction. A total of 385 patients (440 hips) treated by closed reduction satisfied the inclusion criteria. Patients were divided in two groups according to treatment modality: a traction group (276 patients) and a no-traction group (109 patients). Tönnis grade, rate of failure reduction, AVN rate, acetabular index, center-edge angle of Wiberg, and Severin's radiographic grade were assessed on plain radiographs, and the results were compared between the two groups of patients. In addition, a meta-analysis was performed based on the existing comparative studies to further evaluate the effect of traction on the incidence of AVN. Tönnis grade in the traction group was significantly higher than in the no-traction group (P = 0.021). The overall rate of failure reduction was 8.2%; no significant difference was found between the traction (9.2%) and no-traction groups (5.6%) (P = 0.203). The rates of failure reduction were similar in all Tönnis grades, regardless of treatment modality (P > 0.05). The rate of AVN in the traction group (14%) was similar to that of the no-traction group (14.5%; P = 0.881). Moreover, the rates of AVN were similar in all Tönnis grades, regardless of treatment modality (P > 0.05). The meta-analysis did not identify any significant difference in the AVN rate whether preliminary traction was used or not (odds ratio = 0.76, P = 0.32). At the last follow-up visit, the two groups of patients had comparable acetabular indices, center-edge angles, and Severin's radiographic grades (P > 0.05). In conclusion, preliminary traction does not decrease the failure of reduction and the incidence of AVN in developmental dysplasia of the hip treated by closed reduction between 6 and 24 months of age.

Comparison of arthroscopic and open reduction of conservatively irreducible dislocated hips of children

PURPOSE

Children with sonographic grade IV hip dysplasia according to Graf and with failed conservative treatment usually need surgical reduction afterwards. Surgical reduction of the hip can lead to severe complications, the occurrence of residual acetabular dysplasia, osteonecrosis, redislocation and other postoperative complications. This paper investigates whether arthroscopic reduction is a promising alternative to open reduction.

METHODS

We retrospectively examined 66 patients (78 hips) who were not older than two years at the first time of surgery. Arthroscopic reduction was performed on 17 children (19 hips) and open reduction on 49 children (59 hips). Patient records were used to determine redislocation, postoperative complication and residual dysplasia. Radiographs were used to determine Tönnis classification for osteonecrosis and pathological acetabular (AC) angle for residual dysplasia. We considered data up to a two-year follow-up. Statistical evaluation was performed with binary logistic regression.

RESULTS

After arthroscopic reduction, 6% showed osteonecrosis, compared with 20% with open reduction (p = 0.334). Redislocation was not observed after arthroscopic reduction but for 29% after open reduction (p = 0.005). An improvement of femoral head coverage was achieved with residual dysplasia of 23.5% after arthroscopic reduction, compared with 62% after open reduction (p = 0.002).

CONCLUSION

The arthroscopic procedure represents a meaningful alternative to the open procedure due to a lower complication rate, a safe setting, a lower rate of residual dysplasia, no observed redislocation and occurrence of osteonecrosis only once in the arthroscopic group of developmental dysplasia of the hip. The arthroscopic procedure should be tested in further studies and in other clinics in order to broaden the empirical base.

LEVEL OF EVIDENCE

Level III (retrospective cohort study).

Arthroscopic versus open, medial approach, surgical reduction for developmental dysplasia of the hip in patients under 18 months of age

Background and purpose - The value of arthroscopic surgical reduction in developmental hip dysplasia is poorly known. We compared the clinical and radiographic efficacy of arthroscopic and medial open surgical reduction in patients less than 18 months of age with developmental hip dysplasia. Patients and methods - 54 patients with a mean age of 11 months who were treated by Ludloff's medial open reduction technique (28 hips, Group L) or arthroscopic surgical reduction technique (26 hips, Group A) were evaluated in this case series. Data on age, sex, preoperative Tönnis grade, operative time, estimated blood loss, residual leg length discrepancy, range of motion (ROM), acetabular index (AI) angle, coverage ratio of the femoral head, continuity of Menard-Shenton line, re-dislocation rate, McKay classification, and Kalamchi-MacEwen avascular necrosis (AVN) classification were collected. Results - Preoperatively, the mean AI angle was 39° in Group L and 37° in Group A. At the latest follow-up, the mean AI was 26° in both groups. The mean femoral head coverage ratio was 79% in Group L and 80% in Group A. The Menard-Shenton line was intact in all patients. Residual leg length discrepancy or limited ROM was not detected in any patients. 4 patients in Group L and 2 in Group A were diagnosed with type 2 AVN. Interpretation - Arthroscopic surgical reduction in patients aged 6-18 months revealed promising clinical and radiographic outcomes similar to medial open reduction using Ludloff's technique.

[Hip dysplasia-new and proven methods]

BACKGROUND

Hip dysplasia is one of the most common disorders in paediatric orthopedics. With the development of ultrasound techniques treatment has changed, and earlier diagnosis and treatment is possible. So, for more than 20 years diagnosis and treatment has been focused on ultrasound. Many papers reporting new diagnostic techniques like MRI have been published. Arthroscopic reduction is a new surgical procedure. However, established surgical procedures continue to play an important role in the treatment.

CURRENT TREATMENT

This paper presents new and established diagnostic techniques, conservative and surgical treatment options. Unfortunately, due to the great number of publications, not all aspects could be taken into account. In particular, we describe the diagnostic and treatment standards in German-speaking countries based on ultrasound hip screening. However, also international aspects of diagnostic and treatment options have been included.

Radiographic outcome of children older than twenty-four months with developmental dysplasia of the hip treated by closed reduction and spica cast immobilization in human position: a review of fifty-one hips

PURPOSE

This study aimed to investigate the radiographic outcomes, rate of redislocation, and avascular necrosis of proximal femoral epiphysis (AVN) in patients aged 24 to 36 months with developmental dysplasia of the hip (DDH) treated by closed reduction (CR) and spica cast immobilization in human position.

MATERIAL AND METHODS

We reviewed the medical records of 39 patients (51 hips) aged 24 to 36 months with DDH treated by CR and spica cast immobilization in human position. The Tönnis grade, rate of redislocation and AVN, acetabular index (AI), centre-edge angle (CEA), and Severin radiographic grade were evaluated on plain radiographs.

RESULTS

Among the included 39 patients (51 hips), 15 hips (29.4%) were Tönnis grade II, 24 hips (47.1%) were grade III, and 12 hips (23.5%) were grade IV. In 47 hips (92.2%), the ossific nucleus was present at the time of CR. Stable reduction was achieved by CR in 39/51 hips (76.5%) and redislocation occurred in 12/51 hips (23.5%). Among the 12 hips that redislocated, 11 underwent open reduction and one repeated CR. Two out of 40 hips (5%) treated by CR developed AVN. Overall, 54.6% of the hips had satisfactory outcomes (39.2% Severin type I and 17.6% type II), while 45.4% had unsatisfactory outcomes (39.2% Severin type III and 3.9% type IV). Of the 40 hips treated by CR, 57.5% and 42.5% of cases had satisfactory outcomes and residual acetabular dysplasia, respectively. Six out of 11 hips (54.6%) treated by open reduction and pelvic osteotomy had satisfactory outcomes.

CONCLUSIONS

Our study showed that stable CR could be achieved in 76.5% of patients aged 24 to 36 months with DDH at the time of index procedure. Satisfactory outcomes can be expected in 56.4% of the cases (5.0% AVN rate), although late acetabular dysplasia may develop in 43.6% of the hips.

Closed Reduction for Developmental Dysplasia of the Hip: Early-term Results From a Prospective, Multicenter Cohort

BACKGROUND

Closed reduction (CR) is a common treatment for infantile developmental dysplasia of the hip. The purpose of this observational, prospective, multicenter study was to determine the early outcomes following CR.

METHODS

Prospectively collected data from an international multicenter study group was analyzed for patients treated from 2010 to 2014. Baseline demographics, clinical exam, radiographic/ultrasonographic data, and history of previous orthotic treatment were assessed. At minimum 1-year follow-up, failure was defined as an IHDI grade 3 or 4 hip and/or need for open reduction. The incidence of avascular necrosis (AVN), residual dysplasia, and need for further surgery was assessed.

RESULTS

A total of 78 patients undergoing CR for 87 hips were evaluated with a median age at initial reduction of 8 months (range, 1 to 20 mo). Of these, 8 hips (9%) were unable to be closed reduced initially. At most recent follow-up (median 22 mo; range, 12 to 36 mo), 72/79 initially successful CRs (91%) remained stable. The likelihood of failure was unaffected by initial clinical reducibility of the hip (P=0.434), age at initial CR (P=0.897), or previous treatment in brace (P=0.222). Excluding those hips that failed initial CR, 18/72 hips (25%) developed AVN, and the risk of osteonecrosis was unaffected by prereduction reducibility of the hip (P=0.586), age at CR (P=0.745), presence of an ossific nucleus (P=0.496), or previous treatment in brace (P=0.662). Mean acetabular index on most recent radiographs was 25 degrees (±6 degrees), and was also unaffected by any of the above variables. During the follow-up period, 8/72 successfully closed reduced hips (11%) underwent acetabular and/or femoral osteotomy for residual dysplasia.

CONCLUSIONS

Following an initially successful CR, 9% of hips failed reduction and 25% developed radiographic AVN at early-term follow-up. History of femoral head reducibility, previous orthotic bracing, and age at CR did not correlate with success or chances of developing AVN. Further follow-up of this prospective, multicenter cohort will be necessary to establish definitive success and complication rates following CR for infantile developmental dysplasia of the hip.

LEVEL OF EVIDENCE

Level II-prospective observational cohort.

Reduction by Pelvic External Fixator Followed by Innominate and Derotational Femoral Osteotomies for Late Presenting Bilateral Developmental Dysplasia of the Hip

Introduction

Bilateral developmental dysplasia of the hip is a challenging situation, closed and open reduction with or without pelvic and femoral osteotomies are all proposed.

Methods

We investigated the feasibility of closed ilizarov reduction combined with Salter and femoral osteotomy to provide stable concentric hips.

Results

We retrospectively reviewed 19 patients (38 hips). Tonnis Criteria, acetabular index and Center-edge angle were measured preoperatively and postoperatively. Acetabular index changed significantly (P<0,001), 80% were excellent or good according to Mckay, 25% were Ia and 69% were IIa Severin's criteria with at least three years follow-up.

Conclusion

The midterm overall results are favorable for application of this technique.

Outcomes of Isolated Varus Derotational Osteotomy in Children With Cerebral Palsy Hip Dysplasia and Predictors of Resubluxation

BACKGROUND

The appropriate intervention for hip subluxation or dislocation in children affected by cerebral palsy (CP) remains controversial. The purpose of this retrospective study was to report radiographic and clinical outcomes following isolated femoral varus derotational osteotomy (VDRO) in children with CP hip dysplasia. Risk factors for resubluxation and avascular necrosis (AVN) were also examined.

METHODS

A cohort of 100 patients (199 hips) with CP treated with isolated VDRO between 2003 and 2009 was reviewed. All but 1 patient received bilateral surgery. Patients were followed for an average of 5.4 years (range, 1.03 to 10.20 y). Anteroposterior pelvic radiographs were used to assess migration percentage (MP), Shenton's line, and presence of AVN. Resubluxation was defined as a postoperative break in Shenton's line. Radiographic outcomes and risk analysis was performed in the 91 subjects (179 hips) with radiographic follow-up >1 year.

RESULTS

Significant improvement was observed in MP, and all hips had a reconstituted Shenton's line following surgery. Over the course of follow-up, 16% of hips were noted to have a repeat break in Shenton's line. Univariate risk analysis showed preoperative MP, Gross Motor Function Classification System (GMFCS) level, and age at surgery were risk factors for a recurrent line break. Preoperative MP and GMFCS level were found to be predictors of resubluxation in multivariate analysis. AVN was detected in 10 hips (5.7%). GMFCS level V patients were more at risk for resubluxation, but less at risk for AVN when compared with ambulatory (GMFCS I/II/II) patients and GMFCS level IV patients.

CONCLUSIONS

Performing a VDRO without additional procedures provided a stable and concentrically reduced hip joint in this population of children with CP. Attention should be paid to initial ambulatory status during the postoperative period. Concomitant procedures such as pelvic osteotomy should be considered for patients of GMFCS level IV and V, as these patients were more at risk for recurrent subluxation.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Closed reduction and dynamic cast immobilization in patients with developmental dysplasia of the hip between 6 and 24 months of age

BACKGROUND

Closed reduction and spica cast is still the preferred treatment option for children presenting with developmental dysplasia of the hip (DDH) after the age of 6 months. This study aims to investigate the outcomes of patients with DDH treated by closed reduction and dynamic cast immobilization.

METHODS

In total, 159 patients (mean age 15.6 ± 4.2 months; 172 hips) were treated with a dynamic cast immobilization for 3 months, followed by an abduction brace until a stable concentric reduction was achieved. Radiological examination was performed at each follow-up visit to assess reduction, redislocation rate and presence of avascular necrosis (AVN) of the femoral epiphysis. Final radiographic results were evaluated with the Severin classification.

RESULTS

The redislocation rate was 4.1% (7/172); the overall AVN rate was 14.5% (grade II: 16 hips; grade III: 5 hips; grade IV: 3 hips). At last follow-up visit, the mean age of patients was 61.6 ± 21.3 months (range 30.8-141), and the mean acetabular index was 22.6° ± 5.6°; 67.3% of the hips had Severin type I radiographic criteria, 8.5% had type II, 23.6% had type III, and 0.6% had type IV.

CONCLUSIONS

Dynamic cast is an alternative to spica cast immobilization in DDH patients undergoing closed reduction. It has similar redislocation and AVN rates compared to standard spica cast immobilization, as reported by previous studies.

Long-term outcome after anterolateral open reduction and Salter osteotomy for late presenting developmental dysplasia of the hip

INTRODUCTION

Only a handful of studies report outcomes after open reduction for developmental hip dislocation beyond skeletal maturity. For successfully reduced hips it is the outcome into late adulthood on which the results of this intervention should be judged. These studies indicate clearly the importance of preservation of the acetabular growth centres during surgery. The acetabulum must also be addressed when insufficient growth remains reliably to remodel residual dysplasia even after stable, concentric reduction.

SUMMARY

Comparing the longest-term outcome studies for open reduction to less invasive, but mainly historical, techniques of gradual traction reduction it is unsettling to note that the latter protocols are associated with the best results. Whereas open reduction and innominate osteotomy are practised as originally described by Salter, gradual traction reduction has largely been abandoned.

CONCLUSIONS

There are probably aspects of the more time-consuming methods of gradual reduction that do not violate the hip joint capsule that expose the femoral head to a lower risk of femoral head osteonecrosis leading to better long-term outcomes.

[Treatment recommendations for protracted hip immaturity in infants : Conservative approach versus open reduction]

The healthy upright posture is a result of a continuous maturation process of the locomotor system throughout skeletal growth rendering muscle strength and stability: The hip joint in its central position plays a key role for unimpaired and pain-free gait. Nonetheless, it is also regularly affected by delayed maturation, thus being of special interest for the disease screening procedures of every newborn child. Structured screening examinations in the first 3 postnatal months will ideally detect any dysplasia, therefore simple conservative interventions will usually accelerate the maturation process. Effective hip screening programs in Austria and Germany have reduced the necessity for open surgical hip reductions to a worldwide all-time low. Perinatal risk factor awareness in doctors and parents triggers an increased sensitivity to possible immature hip structures. Nevertheless, severe hip dysplasia in toddlers is regularly presented in pediatric orthopedic centers with or without hip dislocation, mostly due to the delay of or inefficiency of treatment options. This review deals with highly effective strategies for quick treatment and provides a balanced view on conservative and surgical methods.

Evaluating the role of prereduction hip traction in the management of infants and children with developmental dysplasia of the hip (DDH): protocol for a systematic review and planned meta-analysis

INTRODUCTION

Developmental dysplasia of the hip (DDH) affects 4-6 per 1000 live births in developed countries. Effective treatment to realign the hip is necessary to avoid long-term morbidities and maximise functional outcome. Treatment options depend on patient age but typically involve hip bracing and/or reduction under general anaesthetic. Some centres also employ prereduction hip traction. Historical papers suggest traction reduces risk of avascular necrosis (AVN) femoral head and reduces requirement for open reduction. However, several studies including a large retrospective cohort study, dispute this. We propose to perform the first systematic review and meta-analysis to clarify the value of prereduction hip traction in the management of DDH in children under the age of 3 years by identifying whether it impacts on the rate of successful closed reduction (CR) and risk of AVN.

METHODS AND ANALYSIS

We will search MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to identify potentially relevant studies. Studies reporting on incidence of successful CR, AVN femoral head and complications associated with prereduction hip traction in children of less than 3 years with DDH will be eligible for inclusion. Only randomised controlled trials, prospective and retrospective case-control and comparative cohort studies will be included in quantitative review. There will be no study design restrictions for inclusion in qualitative review. Following study selection, full-text paper retrieval, data extraction and synthesis, studies will be assessed for risk of bias and heterogeneity. If the included studies are sufficiently homogeneous, then we will perform meta-analysis. A narrative synthesis of the systematic review's results will also be presented.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as primary patient data will not be collected. The systematic review's results will be disseminated through a peer-reviewed publication.

TRIAL REGISTRATION NUMBER

CRD42017064254; Pre-results.

Medium-term results following arthroscopic reduction in walking-age children with developmental hip dysplasia after failed closed reduction

Background

Arthroscopic reduction has become increasingly popular as an alternative to open reduction for the treatment of developmental dysplasia of the hip (DDH). However, patient outcomes beyond one and a half years after surgery remain unclear. The purpose of this study is to report the medium-term outcomes of walking-age patients who received arthroscopic reduction after an unsuccessful closed reduction. This research was conducted as part of a retrospectively registered study.

Methods

We performed arthroscopic reduction in eight children with DDH after failed closed reduction between January 2010 and January 2012 and followed all cases for a minimum of 5 years. Arthroscopic reduction was performed using a two-portal approach without traction. Capsular release and resection of the transverse acetabular ligament were also performed if needed. Patient demographics, clinical variables, anatomical assessment measures, and post-operative complications were extracted from medical records.

Results

We treated five male and three female patients with an average age at operation of 15.6 months (range, 12 to 22 months). All obstacles to reduction were corrected arthroscopically. Concentric reduction of the hip joint was observed in post-operative X-rays in all cases. The average safe zone was increased from 17.5° (8° to 30°) to 42.1° (36° to 50°) after the operation. The average acetabular (AC) index was reduced from 40.3° (33° to 65°) to 21.9° (19° to 26°) at the end of follow-up. No complications occurred and no patients developed necrosis of the femoral head, recurrent dislocation, or residual hip dysplasia.

Conclusions

Arthroscopic reduction is a suitable surgical procedure for the treatment of DDH among walking-age children with failed closed reduction and severe dislocation. This method is quick and safe, and it can be performed without post-operative complications over the medium term.

An improved method for measuring hip abduction in spica after surgical reduction for developmental dysplasia of the hip

PURPOSE

Excessive in-spica abduction is a risk factor for oste-onecrosis after surgical reduction for developmental dysplasia of the hip (DDH). The traditional method for radiographically measuring hip abduction using axial imaging does not reflect the true angle, which usually lies in an oblique plane. The purpose of this study was to describe a novel method for measuring true hip position using advanced imaging.

METHODS

A trigonometric model was derived to define hip position based upon the femoral axis angular deviation from midline as measured on axial and coronal sequences of MRI studies. In-spica MRIs of 28 hips having undergone surgery for DDH were reviewed. On two separate occasions, the same three raters measured the femoral axis deviation from mid-line on axial and coronal imaging. Abduction was estimated using the traditional method of measurement and our novel method. Intra- and inter-rater reliability were assessed.

RESULTS

The methods yielded different estimates (p < 0.001). Inter- and intra-rater reliability were excellent for both methods (inter-rater ICC > 0.922, intra-rater ICC > 0.919). The traditional method is accurate at 90° of flexion, but it increasingly overestimates abduction as hip flexion decreases. All cases where hip flexion was ≤ 40° exhibited ≥ 10° of error.

CONCLUSIONS

Decreasing hip flexion in spica modifies the perceived angle of abduction as measured using axial imaging. This inaccuracy can be overcome through assessment of orthogonal views using our new approach, which is accurate and reliable. It should be considered for future research investigating the effects of in-spica hip position on outcomes of DDH treatment.

Presence of the Ossific Nucleus and Risk of Osteonecrosis in the Treatment of Developmental Dysplasia of the Hip: A Meta-Analysis of Cohort and Case-Control Studies

BACKGROUND

Concern for increased risk of osteonecrosis in hips with an absent ossific nucleus has led some surgeons to delay reduction in the treatment of developmental dysplasia of the hip (DDH) until the ossific nucleus is present. A previous meta-analysis reported a potential protective effect against high-grade osteonecrosis (II to IV) when the ossific nucleus was present. With a greater number of publications on this topic, revisiting this analysis is warranted. The aim of this meta-analysis was to systematically review and analyze the best clinical evidence regarding the association between the status of the ossific nucleus and development of osteonecrosis following the treatment of DDH.

METHODS

MEDLINE, Embase, and Cochrane databases were systematically searched for studies including the status of the ossific nucleus and rate of osteonecrosis after open and closed reductions for the treatment of DDH. Study characteristics and risk estimates were extracted. Study quality was assessed using the Newcastle-Ottawa Scale. Pooled effect estimates were calculated using a random-effect model. Meta-regression assessed the relationships of reduction method, study quality, mean age at reduction, surgical approach, method of ossific nucleus assessment, and duration of follow-up to the odds of osteonecrosis.

RESULTS

In the 21 observational studies (18 retrospective, 3 prospective) that were included, osteonecrosis developed in 20.4% of the hips in which the ossific nucleus was present at reduction compared with 21.2% of the hips in which the ossific nucleus was absent. Presence of the ossific nucleus was not associated with decreased odds of any grade of osteonecrosis (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.43 to 1.12) or of more severe osteonecrosis of Grades II to IV (OR = 0.70, 95% CI = 0.30 to 1.17). Meta-regression did not show any effect of the mean age at reduction, reduction method, surgical approach, study quality, minimum or mean duration of follow-up, method of ossific nucleus imaging, or osteonecrosis classification system on the relationship between presence of the ossific nucleus and the risk of osteonecrosis.

CONCLUSIONS

The current literature does not support the hypothesis that presence of the ossific nucleus at reduction is associated with lower risk of osteonecrosis. Prospective studies with long-term follow-up and blinded assessors are warranted to optimally evaluate the relationship between potential risk factors and the development of osteonecrosis.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association between the ossific nucleus and osteonecrosis in treating developmental dysplasia of the Hip: updated meta-analysis

Background

A meta-analysis concluded that there was no effect of the femoral head ossification and the incidence of osteonecrosis in the treatment of developmental dysplasia of the hip (DDH), unless only osteonecrosis grades II-IV were considered. The meta-analysis, limited due to the small number of studies available at that time, identified a need for an update as further research emerges. We observed a trend in recent years towards delaying treatment of DDH in the absence of an ossified nucleus. Numerous new publications on this topic encouraged us to update the 2009 meta-analysis.

Methods

We performed a systematic review of the literature from 1967 to 2016 and included studies that reported on the treatment of DDH, the ossific nucleus and osteonecrosis. Two independent reviewers evaluated all articles. We performed a meta-analysis with the main outcome defined as the development of osteonecrosis of the femoral head at least two years after closed or open reduction.

Results

Of four prospective and ten retrospective studies included in the systematic review, 11 studies (1,021 hips) met the inclusion criteria for the meta-analysis. There was no significant effect of the ossific nucleus on the development of all grades of osteonecrosis (relative risk, 0.88; 95% confidence interval, 0.56–1.41) or osteonecrosis grades II–IV (0.67; 0.41–1.08). In closed reductions, the ossific nucleus halved the risk for developing osteonecrosis grades II–IV (0.50; 0.26–0.94).

Conclusions

Based on current evidence there does not appear to be a protective effect of the ossific nucleus on the development of osteonecrosis. In contrast to the previous meta-analysis, this update demonstrates that this remains the case irrespective of the grade of osteonecrosis considered relevant. This updated meta-analysis is based on twice as many studies with a higher quality of evidence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1468-6) contains supplementary material, which is available to authorized users.

Overhead Bryant's Traction Does Not Improve the Success of Closed Reduction or Limit AVN in Developmental Dysplasia of the Hip

BACKGROUND

Preoperative Bryant's overhead traction before closed reduction (CR) in developmental dysplasia of the hip (DDH) remains controversial and its success in increasing CR rates and reducing avascular necrosis (AVN) rates has not been specifically reported in a large cohort.

METHODS

IRB-approved retrospective study of patients (below 3 y)who were treated with attempted CR for idiopathic DDH from 1980 to 2009. Successful CR was defined as a hip that remained reduced and did not require repeat CR or open reduction. Patients were grouped by age, hip instability [Ortolani positive (reducible) vs. fixed dislocation], and Tonnis classification and rates of successful CR were compared between groups with P<0.05.

RESULTS

A total of 342 hips were included with a mean age of 0.9 years (0.2 to 2.8 y) and a mean follow-up of 10.4 years (2.0 to 27.7 y). There were 269 hips with fixed dislocations and 73 Ortolani-positive hips. Traction was used in 276 hips. There was no difference in traction utilization in the 3 age groups (below 1, below 1.5, and below 2 y) for either Ortolani-positive hips (P=0.947) or fixed dislocations (P=0.943). There was no difference in achieving a successful CR comparing traction (60.9%) and no-traction groups (60.6%) (P=1.00). For Ortolani-positive hips, traction did not improve the incidence of a successful CR for any age group: below 1 year: P=0.19; below 1.5 years: P=0.23; and below 2 years: P=0.25. Similarly, fixed dislocation patients had no benefit from traction: below 1 year: P=0.76; below 1.5 years: P=0.82; and below 2 years: P=0.85. Tonnis classification did predict success of CR but had no influence on traction success. There was no difference in the rate of AVN between the traction (18%) and no-traction (8%) groups for all patients (P=0.15).

CONCLUSIONS

In this retrospective series, preoperative Bryant's traction does not improve the rate of a successful CR for patients with DDH and has no protective effect on the development of AVN of the femoral head. These results suggest that Bryant's overhead traction may not be warranted for patients below 3 years of age with DDH.

LEVEL OF EVIDENCE

Level III.

Avascular necrosis following closed reduction for treatment of developmental dysplasia of the hip: a systematic review

BACKGROUND

Avascular necrosis (AVN) is a significant and potentially devastating complication following the treatment of developmental dysplasia of the hip (DDH). The reported rate of AVN following closed reduction for DDH ranges from 4 to 60%, and the resultant influence on hip development remains unclear.

PURPOSE

A systematic review of the literature was undertaken to evaluate the frequency of AVN after more than 5 years of follow-up in children that underwent closed reduction at younger than 2-years of age for DDH.

METHODS

The search strategy was formulated with key-concepts and keywords identified using the patient problem, intervention, comparison and outcome process. Searches were undertaken using Pubmed, Scopus and Web of Science up to and including May, 2016 to identify potential studies.

RESULTS

A total of seven papers met the a priori inclusion and exclusion criteria of this review. The overall rate of significant AVN in 441 patients (538 hips) was 10% at a mean length of follow-up of 7.6 years (5-18.8) following closed reduction. This finding can be used to inform the feasibility of future intervention studies, and act as a baseline for which surgeons to compare their results to a 'standard'.

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.

Effects of arthroscopic-assisted surgery on irreducible developmental dislocation of hip by mid-term follow-up: An observational study

The purpose of this study was to investigate the indications, surgical technique, and the clinical effects of arthroscopic-assisted treatment of irreducible developmental dislocation of the hip by mid-term follow-up. Arthroscopic-assisted surgeries were performed on 40 children (52 hips) between January 2005 and December 2009. Anterior and antero-superior greater trochanter portals were used in these treatments. Spica cast and abduction splint were applied for 3 months postoperatively. The follow-up was conducted on every 3 months postoperatively. During 12-month follow-up, a secondary treatment such as acetabuloplasty and/or femoral osteotomy (shortening, varus, and derotation) was applied if the acetabular angle was greater than 25°. The pelvic acetabular angle, Mckay and Severin score were evaluated every 6 months in all children. With 36 to 96 months (average 71 months) follow-up, 35 children (44 hips) were successfully followed up with complete case data while 5 children unsuccessfully. According to Tönnis classification, there were 5 grade 1 hips, 14 grade 2 hips, 14 grade 3 hips, 11 grade 4 hips, in which 3 children (4 hips) were failed in arthroscopic reduction and femoral head avascular necrosis occurred in 2 children (4 hips). According to Mckay standard, the good rate is 100%. According to Severin standard, the good rate is 84.1%. Arthroscopic assisted treatment is an effective way of reduction of the irreducible hip. Compared with the open reduction, arthroscopic treatment combined with acetabuloplasty and/or femoral osteotomy has advantages of less trauma and better function preservation.

Association between open or closed reduction and avascular necrosis in developmental dysplasia of the hip: A PRISMA-compliant meta-analysis of observational studies

BACKGROUND

The risk of avascular necrosis of the femoral head (AVN) after treatment of developmental dysplasia of the hip is associated with the method of reduction. Some authors have suggested that open reduction is a risk factor for AVN; however, this is controversial. To our knowledge, a quantitative comparison of the incidence of AVN between closed and open reduction has not been conducted.

METHODS

Published studies were identified by searching PubMed, EMBASE, and the Cochrane Library up to May, 2015, focusing on the incidence of AVN after closed or open reduction for developmental dysplasia of the hip in children aged <3 years. Patients were age-matched who were treated by either closed or open reduction, but without pelvic or femoral osteotomy. Two authors independently assessed eligibility and abstracted data. Discrepancies were discussed and resolved by consensus. We pooled the odds ratios (ORs) and 95% confidence intervals (95%CIs) from individual studies using a random-effects model and evaluated heterogeneity and publication bias.

RESULTS

Nine retrospective studies were included in this analysis. The pooled OR for comparing open reduction with closed reduction for all grades of AVN was 2.26 (95%CI = 1.21-4.22), with moderate heterogeneity (I = 44.7%, P = 0.107). The pooled OR for grades II to IV AVN was 2.46 (95%CI = 0.93-6.51), with high heterogeneity (I = 69.6%, P = 0.003). A significant association was also found for the further surgery between open and closed reduction, with a pooled OR of 0.30 (95%CI = 0.15-0.60) and moderate heterogeneity (I = 46.4%, P = 0.133). No evidence of publication bias or significant heterogeneity between subgroups was detected by meta-regression analyses.

CONCLUSION

Findings from this meta-analysis suggest that open reduction is a risk factor for the development of AVN compared with closed treatment. Future studies are warranted to investigate how open reduction combined with pelvis and/or femoral osteotomy affects the incidence of AVN.

Risk factors for avascular necrosis after closed reduction for developmental dysplasia of the hip

PURPOSE

The purpose of this study was to identify and evaluate risk factors of avascular necrosis (AVN) after closed treatment for developmental dysplasia of the hip (DDH).

METHODS

A retrospective review of children diagnosed with DDH at a tertiary-care children's hospital between 1986 and 2009 was performed. The presence of AVN was assessed according to Salter's classification system.

RESULTS

Eighty-two affected hips in 70 children with an average age of 10 months at closed reduction (range 1-31 months) and 5 years (range 2-19 years) of follow-up met the inclusion criteria. Twenty-nine (of 82, 35 %) affected hips developed AVN. The use of pre-reduction traction (p = 0.019) increased the risk of AVN, while preoperative Pavlik harness or brace trial (p = 0.28), presence of ossific nucleus at the time of closed reduction (p = 0.16), and adductor tenotomy (p = 0.37) were not significant factors. Laterality (right vs. left) was also not a significant risk factor (p = 0.75), but patients who underwent closed reduction for bilateral DDH were less likely to develop AVN (p = 0.027). Overall, the degree of abduction did not affect the rate of AVN (p = 0.87). However, in patients treated with closed reduction younger than 6 months of age, the rate of AVN was increased with abduction ≥50° (9/15, 60 %) compared to abduction <50° (0/8, 0 %) (p = 0.007). Patients who developed AVN were more likely to require subsequent surgery (p = 0.034) and more likely to report a fair/poor clinical outcome (p = 0.049).

CONCLUSIONS

The risk of AVN (35 %) following closed reduction and spica casting for DDH is high. The degree of abduction in spica casts appears to be a risk factor in patients ≤6 months old. The authors recommend that abduction in spica casts should be limited to <50° in children younger than 6 months of age.

LEVEL OF EVIDENCE

IV.

How Does Bony Surgery Affect Results of Anterior Open Reduction in Walking-age Children With Developmental Hip Dysplasia?

BACKGROUND

Anterior open reduction is commonly used to treat hip subluxation or dislocation in developmental dysplasia of the hip (DDH) in walking-age children. Pelvic and/or femoral osteotomy may be used in addition, but it is unclear how this affects avascular necrosis (AVN) risk and radiological and clinical results.

QUESTIONS/PURPOSES

The purpose of this study was to review studies of walking-age patients treated either with an open reduction alone or combined with pelvic and/or femoral osteotomies and determine whether there is a difference between groups in the proportion of patients: (1) developing clinically relevant femoral head AVN (Kalamchi & MacEwen Types II to IV or equivalent); (2) achieving a satisfactory radiological result (Severin Grade I/II or equivalent); (3) achieving a satisfactory clinical result (McKay excellent or good rating or equivalent); and (4) requiring further nonsalvage surgery.

METHODS

MEDLINE, Embase, the Cochrane Centre Register of Controlled Trials, and ClinicalTrials.gov were searched for studies of anterior open reduction for DDH in children aged 12 months to 6 years old. We assessed AVN, clinical and radiological results, and requirement for further procedures. The effect of failed conservative management, traction, age at operation, and followup duration was also assessed. Eighteen studies met the review eligibility criteria.

RESULTS

Open reduction alone had a lower risk of AVN than open reduction combined with pelvic and femoral osteotomy (4% versus 24%), but there was no significant difference compared with open reduction with either pelvic (17%) or femoral osteotomy (18%). More hips treated with open reduction alone had satisfactory radiological results than open reduction combined with pelvic and femoral osteotomy (97% versus 83%) and satisfactory clinical results than all other interventions. More hips treated with open reduction alone required further surgical management (56%) compared with open reduction and pelvic osteotomy (11%) and combined pelvic and femoral osteotomies (8%).

CONCLUSIONS

Open reduction with concomitant pelvic osteotomy is the most appropriate option to provide durable results with the lowest risk of AVN and best radiological and clinical results. There is no evidence that addition of a femoral osteotomy provides any additional benefit to the patient, although it may be necessary to achieve reduction.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Acetabuloplasties at Open Reduction Prevent Acetabular Dysplasia in Intentionally Delayed Developmental Dysplasia of the Hip: A Case-control Study

BACKGROUND

Avascular necrosis (AVN) and residual acetabular dysplasia are the two main complications of developmental dysplasia of the hip (DDH) treatment. Although early reduction of the hip may decrease the incidence of residual dysplasia, it may increase the incidence of AVN and vice versa. However, we do not know if changes in surgical technique may lead to a modification in these outcomes.

QUESTIONS/PURPOSES

Does an incomplete periacetabular acetabuloplasty, as an added step to delayed open reduction, (1) diminish the risk of developing acetabular dysplasia; or (2) increase the rate of AVN compared with patients treated with open reduction alone?

METHODS

We conducted a retrospective matched case-control study comparing 22 patients (27 hips) with early isolated DDH who underwent intentionally delayed open reduction and acetabuloplasty from 2004 to 2010 and followed up > 4 years (88% of the cohort) with early historic controls treated with delayed open reduction alone. Of 53 patients available for matching, 45 (85%) had enough followup (> 10 years) to be considered. They were matched one to one for age at presentation and bilaterality (fuzz 45, 0). This generated a control group of 25 patients (27 hips). The mean followup was different between the groups (p < 0.001). Residual dysplasia considered when center-edge angle < 15° (6-13 years old) or < 20° (≥ 14 years old) or as a nonevolving acetabular index > 30° and pelvic osteotomies were used as our primary outcomes. The proportion of patients with AVN was also compared.

RESULTS

Patients treated with open reduction and an incomplete periacetabular acetabuloplasty were less likely to develop acetabular dysplasia and undergo pelvic osteotomies than were patients in the control group (0% [zero of 27] versus 37% [10 of 27]; odds ratio [OR], 11; 95% confidence interval [CI], 2-80; p = 0.02 and 0% [zero of 27] versus 26% [seven of 27]; OR, 8; 95% CI, 1-60; p = 0.025, respectively). With the available numbers, there was no difference in terms of the proportion of patients who developed AVN (11 of 27 [41%] both groups; OR, 1; 95% CI, 1-2; p = 1).

CONCLUSIONS

The addition of an incomplete periacetabular acetabuloplasty to all hips undergoing open reduction eliminated residual acetabular dysplasia, whereas it did not appear to have deleterious effects as evidenced by the similar AVN proportion.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Developmental Dislocation of the Hip Successfully Treated by Preoperative Traction and Medial Open Reduction: A 22-year Mean Followup

BACKGROUND

During the last 35 years, the medial approach has been reported more frequently than the anterior approach for open reduction of developmental dislocation of the hip (DDH), however, few studies have followed children treated by medial open reduction to adulthood.

QUESTIONS/PURPOSES

The purposes of our study were: (1) to assess the development of 71 completely dislocated hips after medial open reduction, the incidence of additional surgery and avascular necrosis during the followup period, and the long-term radiographic and functional results; and (2) to compare our results with those obtained by others who performed open reduction either by the medial or anterior approach.

PATIENTS AND METHODS

We retrospectively evaluated, after the end of growth, 71 hips in 52 patients who underwent open reduction by the medial approach. The mean age of the patients was 16 months (range, 3-36 months). After surgery, the hips were immobilized in 100° flexion, 60° abduction, and neutral rotation for an average of 6 months. All patients had staged clinical and radiographic followups until skeletal maturity. The length of followup averaged 22 years (range, 13-32 years).

RESULTS

In all the surgically treated hips, the acetabular index normalized by the end of growth, the incidence of avascular necrosis was 18%, and additional surgery was required in 15% of our cases. At the last followup, 93% of the hips were classified as Severin Classes I or II and 7% as Class III; 76% of the hips had an excellent result, 17% had a good result, and 7% had a fair result according to the McKay scale as modified by Barrett and colleagues.

CONCLUSIONS

Open reduction of DDH through a medial approach provided good long-term radiographic and functional results in patients 3 to 36 months old and it was the only surgery performed in 85% of our cases. Future comparative studies are needed to confirm our results, especially in older children.

LEVEL OF EVIDENCE

Level IV, therapeutic study.