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

Fate of acetabular dysplasia after closed and open reduction of hips in children with developmental hip dislocation

Acetabular underdevelopment (acetabular dysplasia) is a common finding in children with hip dislocation, and residual acetabular dysplasia can remain after hip reduction. Residual dysplasia leads to unsatisfactory long-term outcomes and osteoarthritis. Dynamics of acetabular dysplasia [measured as Acetabular Index (AI)] in a pediatric cohort that underwent open (OR) or closed reduction are reported. Retrospective data from six tertiary pediatric orthopedic centers were gathered. Hips were classified as having 'Critical', 'Monitoring', or 'Normal' acetabular dysplasia based on age-adjusted normative AI measurements. From 193 hips, 108 (56%) underwent open reduction. Children younger than 24 months had a strong AI decline but children > 24 months did not. Among 78 hips with critical dysplasia at time of OR, 36 (46.2%) remained critical and 19 (24.4%) underwent an acetabular osteotomy (AO) during follow-up. CR hips had a similar AI decline in patients younger and older than 12 months. Among 51 hips with critical dysplasia at the time of CR, 13 (25.5%) remained critical and 21 (41.2%) underwent AO during follow-up. Acetabular dysplasia improves with AI decreasing in children who undergo OR and CR under the age of 2 years with slower acetabular remodeling afterwards. Around 2/3 of patients with AI in the critical range at CR or OR either underwent AO or had significant acetabular dysplasia at final follow-up. Our data supports considering simultaneous AO at the time of OR for hips with AI in the critical range or children who undergo hip open reduction after 24 months of age. Level of Evidence: Level III.

Arthroscopic debridement and reduction is an effective procedure for failed closed reduction in young children with developmental dislocation of the hip

PURPOSE

To assess the efficacy of arthroscopic debridement and reduction through two medial portals for the treatment of developmental dislocation of the hip (DDH) with failure of initial closed reduction and to explore key pathological structures obstructing reduction.

METHODS

Forty-eight children with 58 irreducible dislocated hips treated by arthroscopic reduction between January 2017 and December 2020 were retrospectively evaluated. Arthroscopic reduction was performed via two medial portals located in the superior and inferior adductor longus. All intra-articular obstacles were eliminated via arthroscopy, followed by manual reduction and spica cast immobilization. The surgical duration, extent of improvement in the safe zone, and extent of secondary surgical treatment were noted. All the children were followed up for > 24 months. Hip function and radiographic outcomes were evaluated.

RESULTS

All 58 hips showed safe zone improvement and concentric reduction after arthroscopic debridement. Hypertrophic ligamentum teres and thickened pulvinars were detected and resected in all hips. Constrictive capsules preventing reduction were observed in 15 hips, which needed to be further released. No inverted labrum was observed. Secondary surgery was performed in four hips with redislocation and seven hips with subluxation during follow-up. The remaining 47 hips (81.03%) maintained their reduction at the last follow-up. Excellent and good clinical outcomes were achieved in 95.74% of patients according to McKay's criteria. Two hips, three hips, and one hip were diagnosed with grade I, II, and III osteonecrosis of the femoral head, respectively.

CONCLUSION

This study demonstrated that arthroscopic debridement and reduction is a safe and feasible choice for treating irreducible DDH.

Intraoperative medial wall disruption in Dega pelvic osteotomy: Does it effect the radiographic outcome at medium-term?

OBJECTIVES

To compare the radiographic outcomes of our patients who encountered medial wall disruption, with those who did not while undergoing Dega osteotomy.

METHODS

We retrospectively reviewed the records of 95 hips with developmental dysplasia of the hip who were treated with Dega pelvic osteotomy. Hips were divided into 2 groups according to medial wall disruption: group A included the hips with medial wall disruption, while group B included the hips without disruption. Preoperative, immediate postoperative, 12 weeks and last follow-up anteroposterior radiographs of the pelvis were reviewed for changes in the acetabular index (AI) between groups.

RESULTS

There were 22 hips in group A and 73 hips in the group B. Preoperative (34.6 versus [vs] 37.2, p=0.231), postoperative (17.9 vs 18.4, p=0.682), 12th week (18 vs 18, p=0.504) and last follow-up (13.3 vs 15.1, p=0.097). The acetabular index measurements were comparable between the groups. Corrections achieved during surgery, and during the follow-up period were also comparable between the two groups, indicating no loss of radiographic correction caused by medial wall disruption. Ninety one percent of the patients in group A and 90% of group B achieved good or excellent results according to the Severin classification (p=0.944).

CONCLUSION

Our study shows that disruption of the medial wall did not have a significant detrimental effect on radiographic correction when performing Dega osteotomy.

Outcomes of Open Reduction in Children With Developmental Hip Dislocation: A Multicenter Experience Over a Decade

BACKGROUND

Open reduction of the hip is commonly performed in children with severe developmental dysplasia of the hip, or in cases that are refractory to nonoperative forms of treatment. The open reduction has been associated with numerous complications including avascular necrosis (AVN) of the femoral head, the need for reoperation, and residual radiographic dysplasia. This study seeks to determine the effects of preoperative severity of dysplasia, associated procedures (femoral and acetabular osteotomies), age on AVN, and the need for reoperation.

METHODS

Children with developmental dysplasia of the hip and a minimum of 2 years of follow-up who underwent open reduction were identified. The following data points were recorded: sex, laterality of hip involvement, simultaneous procedures, surgical approach used, age, acetabular index, and International Hip Dysplasia Institute grade. We analyzed the effects of preoperative International Hip Dysplasia Institute, age, surgical approach (anterior/medial), bilateral reduction, and simultaneous femoral shortening or pelvic osteotomy on the outcomes of AVN and reoperation.

RESULTS

One hundred eighty-five hips in 149 patients were included in this study with an average follow-up of 4 years (range: 2 to 5 y). The average age at index surgery was 23 months (range: 1 to 121 mo). Overall, 60 hips (32.4%) required secondary surgical procedures at an average age of 58.5 months. High-grade AVN was noted in 24 hips (13.0%) and was found to be associated with the severity of the hip dislocation ( P = 0.02). A higher rate of reoperation was found in children over 18 months at the time of open reduction who did not receive an acetabular osteotomy ( P = 0.012).

CONCLUSION

Approximately 1/3 of patients require another operative intervention within the first 4 years after open reduction of the hip. We found the severity of hip dislocation to be associated with a higher risk of AVN development. These findings support performing an acetabular osteotomy in children over 18 months of age at the time of open reduction to decrease the likelihood of requiring future reoperation during the first 4 years after the index procedure.

LEVEL OF EVIDENCE

Level III.

Femoral Head Coverage Assessment in Healthy Children Younger than 6 Years

Introduction

Developmental dysplasia of the hip (DDH) is one of the commonest hip joint pathologies in children; to treat it properly, hip surgeons should know the normal femoral head (FH) coverage by the acetabulum. This paper aims to assess the femoral head coverage in healthy children younger than 6 years.

Methods

270 hip joint CT scans were selected, and digital pelvic models were created according to these scans. FH coverage by the five acetabular regions was assessed according to patient's age and sex.

Results

Normal reference values of FH coverage by different acetabular regions were obtained. It was found that the growth process of different acetabular regions occurs nonlinearly with the periods of acceleration. Anterior and superior-anterior acetabular regions grow more intensively in boys up to 3 years old and between 4 and 5 years old both in boys and girls; superior-posterior, posterior-superior, and posterior-inferior acetabular regions grow more intensively in boys and girls up to 3 years old and between 4 and 5 years old (p ≤ 0.005). The following sex differences in FH coverage by the acetabulum were found: more superior-anterior FH coverage was found in boys and posterior FH coverage in girls (p ≤ 0.005).

Acetabular remodeling after graft extrusion, rotation or impaction in Dega and Pemberton acetabuloplasties for developmental dysplasia of the hip

Traditionally graft displacement following Pemberton and Dega acetabuloplasties involves internal fixation for treatment of developmental dysplasia of hip (DDH). This study was performed to assess the acetabular remodeling by conservative management of graft displacement among patients with DDH. This was a retrospective study of 20 patients 17 (85%) women and 3 (15%) men; mean age 22.90 ± 6.96 months with DDH who underwent Pemberton and Dega acetabuloplasties at King Khalid University Hospital, Riyadh between January 2013 and January 2018. All patients after losing acetabular correction during immediate postoperative period were treated by conservative management. The management involved application of Spica cast for 6 weeks that was trimmed to broomstick cast for an extended period of time and finally replaced by nocturnal abduction brace until normal acetabular index (AI) was achieved. The patients were followed up for a mean period of 44.60 ± 12.36 months. Out of the total, 18 (90%) patients with DDH were successfully treated by conservative management. The mean preoperative AI of 43.70° ± 5.91° improved to 21.35o ± 6.32o at the final follow-up (P < 0.001) which was no different when compared to the mean of unaffected hips (19.70o ± 2.96o; P < 0.44). The mean preoperative CEA of all the patients was negative that improved during the conservative treatment to 29.20° ± 10.0° which was no different when compared with the mean of unaffected (31.70° ± 4.64o; P = 0.32) hips at the final follow-up. doption of less aggressive approach for management of displaced, rotated or impacted autograft following acetabuloplasties among children with DDH was not only a useful conservative approach for remodeling of hips but also obviated the need for additional surgical intervention.

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.

Residual acetabular dysplasia in congenital hip dysplasia

Residual hip dysplasia may exist despite appropriate treatment of congenital hip dysplasia (CHD). The abnormalities chiefly affect the acetabulum and can lead to premature osteoarthritis. Although the main cause is delayed treatment of CHD, primary lesions are also possible and may be worsened by the initial treatment itself. Residual hip dysplasia must be detected during the follow-up of patients with CHD. The antero-posterior radiograph of the pelvis is the main diagnostic tool. However, the importance of non-ossified anatomical structures requires additional investigations such as arthrography and magnetic resonance imaging. The risk of premature osteoarthritis is difficult to predict based only on the imaging-study findings. Hip dysplasia is best treated before 5 years of age. The work-up at this age should allow determination of the best treatment. Surgery is required but should not be performed unnecessarily. The decision rests on the absence of improvement in the radiographic criteria and on the findings from additional imaging studies. The usual treatment is Salter's osteotomy, during which excessive anterior displacement should be avoided. At adolescence, the information provided by radiography in the coronal plane should be completed by a three-dimensional evaluation of the acetabulum and an assessment of the quality of the labrum. The shelf procedure has been proven to relieve pain and to significantly postpone the need for hip arthroplasty, when performed early, before the development of visible osteoarthritis, and on a congruent hip. Chiari's osteotomy has a role to play in complex dysplasia affecting both the acetabulum and the femur. Periacetabular osteotomy is getting more used thanks to cooperation between paediatric and adult orthopaedic surgeons. This osteotomy provides optimal correction in all three dimensions.

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.

Is It Possible to Treat Developmental Dysplasia of the Hip with Anterior Open Reduction and Pemberton Osteotomy Under 18 Months of Age?

PURPOSE OF THE STUDY

The purpose of the present study is to determine the outcome success of anterior open reduction with Pemberton osteotomy in patients under 18 months of age with developmental dysplasia of the hip.

METHODS

We retrospectively reviewed the clinical and radiological results of 27 developmental hip dysplasia patients under 18 months of age (26 girls, 1 boy) who underwent anterior open reduction with Pemberton osteotomy. Bilateral surgery was performed in 18 patients and unilateral in nine patients. At the final follow-up, the clinical results were evaluated according to the McKay's clinical evaluation criteria, the radiological results according to the Severin's radiological evaluation criteria, and the presence of avascular necrosis according to the Kalamchi-MacEwen's classification criteria.

RESULTS

We treated 36 hips of 27 patients who were younger than 18 months of age (range 10-18 months) at the time of surgery and followed up a minimum of 5 years (mean 6.5 years). At the final follow-up, 34 (94.4%) were assessed clinically as excellent, one hip (2.7%) as good and one hip (2.7%) as fair according to the McKay's clinical classification. Radiological classification revealed that, 97.2% of the hips were Severin Type-1 and 2.8% Severin Type-3. Avascular necrosis was observed in 5 of 36 hips (13.8%). Two hips were assessed as Type-2, two hips Type-3 and one hip Type-4 according to the Kalamchi-MacEwen's classification.

CONCLUSION

We conclude that Pemberton osteotomy with anterior open reduction is useful technique for developmental hip dysplasia treatment of patients under the age of 18 months with good clinical and radiological results as well as with low complication rates.

Relapsed hip stiffness after recovery of range of motion in a hip treated for developmental dysplasia of the hip? Think again: A case report

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How to evaluate complications following DDH treatment.

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Muscular spasm can mislead physicians following treatment of DDH.

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Hip stiffness vs muscular spasm in DDH patients.

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Examination under anesthesia could be the answer for relapsed hip stiffness.

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The value of examination under anesthesia in DDH complications.

Introduction

Several complications have been reported following treatment of developmental dysplasia of the hip (DDH). Local muscular spasm is an extremely rare complication. This case serves to enlighten orthopedists about various and unique presentations of idiopathic local muscular spasm, natural history of such condition, and appropriate treatment.

Presentation of case

A two-year-old child presented with bilateral acetabular dysplasia for orthopedic evaluation and treated with bilateral simultaneous Dega osteotomy and postoperative cast for 12 weeks. Full range of motion (ROM) of both hips was regained three months after removal of the postoperative cast. Five months later, the child presented with apparent leg length discrepancy, and severe and painless global limitation of the right hip ROM, which initially was thought to be relapsed hip stiffness. Laboratory and radiological investigations were normal apart from pelvic obliquity on radiographs. Symptoms persisted for one month. Examination under anesthesia (EUA) was then performed and revealed full ROM of the involved hip. Physical therapy was started, and hip ROM fully recovered within 3 months without further intervention.

Discussion

Stiffness, which is one of the most reported complications following surgical treatment of DDH, is usually related to lengthy periods of immobilization and/or surgical treatment. Clinically, local muscular spasm of the hip can mimic stiffness. EUA is invaluable to differentiate the common postoperative stiffness from the rare local muscular spasm.

Conclusion

Idiopathic local muscular spasm of hip might present clinically as stiffness that pose a diagnostic dilemma to the treating physician. Close observation coupled with physical therapy is sufficient.

Which Acetabular Landmarks are the Most Useful for Measuring the Acetabular Index and Center-edge Angle in Developmental Dysplasia of the Hip? A Comparison of Two Methods

BACKGROUND

The acetabular index and center-edge angle are widely used radiographic parameters. However, the exact landmarks for measuring these parameters are not clearly defined. Although their measurement is straightforward when the lateral osseous margin of the acetabular roof coincides with the lateral end of the acetabular sourcil, where these two landmarks disagree, recommendations have differed about which landmark should be used. Using a radiographic parameter with high reliability for predicting residual hip dysplasia helps avoid unnecessary treatment.

QUESTIONS/PURPOSES

We aimed to (1) compare two landmarks (the lateral osseous margin of the acetabular roof and the lateral end of the acetabular sourcil) for measuring the acetabular index and center-edge angle with respect to intraobserver and interobserver reliability and the predictability of residual hip dysplasia in patients with developmental dysplasia of the hip (DDH) and (2) evaluate longitudinal change in the acetabular edge's shape after closed reduction with the patient under general anesthesia.

METHODS

Between February 1985 and July 2006, we performed closed reduction with the patient under general anesthesia as well as cast immobilization in 116 patients with DDH. To be included in this study, a patient had to have dislocated-type DDH. We excluded patients with a hip dislocation associated with neuromuscular disease, arthrogryposis, or congenital anomalies of other organs or systems (n = 9); hips that underwent osteotomy within 1 year since closed reduction (n = 8); hips that underwent open reduction because of re-dislocation after closed reduction (n = 4); and hips with Type III or IV osteonecrosis according to Bucholz-Ogden's classification (n = 4). Ninety-one patients were eligible. We excluded 19% (17 of 91) of the patients, who were lost to follow-up before they were 8 years old, leaving 81% (74 of 91 patients) with full preoperative and most-recent data. Ninety-seven percent (72 patients) were girls and 3% (two patients) were boys. The mean ± standard deviation age was 14.0 months ± 6.4 months (range 3-40 months) at the time of closed reduction and 12.1 years ± 2.3 years (range 8.0-16.0 years) at the time of the latest follow-up examination, the duration of which averaged 11 years ± 2.2 years (range 6.5-15.4 years). To investigate whether longitudinal change in the acetabular edge's shape differed among hips with DDH, contralateral hips, and control hips, we identified control participants after searching our hospital's database for patients with a diagnosis of congenital idiopathic hemihypertrophy from October 2000 to November 2006 who had AP hip radiographs taken at 3 years old and then at older than 8 years. From 29 patients who met these criteria, we randomly excluded two male patients to match for sex because girls were predominant in the DDH group. We excluded another female patient from the control group because of a hip radiograph that revealed unacceptable rotation. Eventually, 26 patients were assigned to the control group. Control patients consisted of 24 girls (92%) and two boys (8%). The demographic characteristics of control patients was not different from those of 67 patients with unilateral DDH, except for laterality (left-side involvement: 64% [43 of 67] in the DDH group versus 38% [10 of 26] in the control group; odds ratio 1.7 [95% confidence interval, 1.0-2.8]; p = 0.035). The acetabular index and center-edge angle at 3 years old were measured using the lateral osseous margin of the acetabular roof (AIB and CEAB) and the lateral end of the acetabular sourcil (AIS and CEAS). The treatment outcome was classified as satisfactory (Severin Grade I or II) or unsatisfactory (Grade III or IV). The intraclass correlation coefficient (ICC) was used to compare the intraobserver and interobserver reliability of each method. We compared the predictability of residual hip dysplasia of each method at 3 years old as a proxy using the area under the receiver operating characteristic (AUC) curve. To evaluate longitudinal change in the acetabular edge's shape, we compared the proportion of hips showing coincidence of the two landmarks between 3 years old and the latest follow-up examination. To investigate whether the longitudinal change in the acetabular edge's shape differs among hips with DDH, contralateral hips, and control hips, we compared the proportion of coincidence among the three groups at both timepoints.

RESULTS

Intraobserver and interobserver reliabilities were higher for the CEAB (ICC 0.96; 95% CI, 0.94-0.98 and ICC 0.88; 95% CI, 0.81-0.92, respectively) than for the CEAS (ICC 0.81; 95% CI, 0.70-0.88 and ICC 0.69; 95% CI, 0.55-0.79, respectively). The AIB (AUC 0.88; 95% CI, 0.80-0.96) and CEAB (AUC 0.841; 95% CI, 0.748-0.933) predicted residual hip dysplasia better than the AIS (AUC 0.776; 95% CI, 0.67-0.88) and CEAS (AUC 0.72; 95% CI, 0.59-0.84) (p = 0.03 and p = 0.01, respectively). The proportion of hips showing coincidence of the two landmarks increased from 3 years old to the latest follow-up examination in hips with DDH (37% [25 of 67] to 81% [54 of 67]; OR = 8.8 [95% CI, 3.1-33.9]; p < 0.001), contralateral hips (42% [28 of 67] to 85% [57 of 67]; OR = 16.5 [95% CI, 4.2-141.9]; p < 0.001), and control hips (38% [10 of 26] to 88% [23 of 26]; OR = 14 [95% CI, 2.1-592.0]; p = 0.001). The proportion of coincidence in hips with DDH was not different from that in the contralateral hips and control hips at both timepoints.

CONCLUSIONS

Measuring the acetabular index and center-edge angle at 3 years old using the lateral osseous margin of the acetabular roof has higher reliability for predicting residual hip dysplasia than that using the lateral end of the acetabular sourcil in patients with DDH treated with closed reduction. Measuring the acetabular index and center-edge angle at an early age using the lateral end of the sourcil may lead to overdiagnosis of residual hip dysplasia and unnecessary treatment.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Does Late Hip Dysplasia Occur After Normal Ultrasound Screening in Breech Babies?

BACKGROUND

Recent literature has raised concern regarding the occurrence of late dysplasia after normal screening in breech babies. One paper states a late dysplasia incidence of 29%. This finding is in contrast with other published work, which suggests breech presentation is predictive of spontaneous stabilization of the unstable neonatal hip. We decided to identify the rate of late dysplasia after normal screening in our patient cohort and also to investigate the use of a prophylactic abduction diaper.

METHODS

During the study period of December 2012 to June 2014, breech babies referred to the screening program at our institution were identified. Ninety babies were prospectively enrolled into the study and randomized to either the observational arm or prophylactic treatment with the Healthy Hip Diaper (HALO, Minnetonka, MN). All babies had a normal initial clinical examination and ultrasound. Regular follow-up including clinical and ultrasound examination was undertaken culminating in pelvic x-rays performed at 13±1 months. A total of 63% of patients elected against their randomization to prophylactic treatment, 28% opted for prophylactic treatment against their randomization to observation only, meaning a total of 40% of babies proceeded against their initial randomization. In total, 75% of recruited babies completed follow-up. Dysplasia was defined as an acetabular index >2 SD from the mean sex, age, and side-specific values.

RESULTS

The overall rate of radiographic dysplasia at 13 months was 7.4%. The rate was 5% in those using a Healthy Hip Diaper and 8.3% in those under observation only. This was not a statistically significant difference. Two patients required operative intervention, one requiring capsulorraphy with acetabuloplasty, the other requiring an arthrogram. Overall compliance with the abduction diaper was low.

CONCLUSIONS

We conclude that late radiographic dysplasia does occur after normal clinical and ultrasound screening in breech babies, although not to the same extent as recently published data. We cannot recommend prophylactic abduction devices for breech babies who have a normal hip ultrasound at 6 weeks of age. Consideration must be given to further clinical and radiographic follow-up for hip dysplasia when the risk factor of breech presentation is present.

LEVEL OF EVIDENCE

Level II-prospective comparative trial.