Costs of open, arthroscopic and combined surgery for developmental dysplasia of the hip

The incidence of subsequent hip arthroscopy after rectus-sparing periacetabular osteotomy

Aims

Periacetabular osteotomy (PAO) is the preferred treatment for symptomatic acetabular dysplasia in adolescents and young adults. There remains a lack of consensus regarding whether intra-articular procedures such as labral repair or improvement of femoral offset should be performed at the time of PAO or addressed subsequent to PAO if symptoms warrant. The purpose was to determine the rate of subsequent hip arthroscopy (HA) in a contemporary cohort of patients, who underwent PAO in isolation without any intra-articular procedures.

Methods

From June 2012 to March 2022, 349 rectus-sparing PAOs were performed and followed for a minimum of one year (mean 6.2 years (1 to 11)). The mean age was 24 years (14 to 46) and 88.8% were female (n = 310). Patients were evaluated at final follow-up for patient-reported outcome measures (PROMs). Clinical records were reviewed for complications or subsequent surgery. Radiographs were reviewed for the following acetabular parameters: lateral centre-edge angle, anterior centre-edge angle, acetabular index, and the alpha-angle (AA). Patients were cross-referenced from the two largest hospital systems in our area to determine if subsequent HA was performed. Descriptive statistics were used to analyze risk factors for HA.

Results

A total of 16 hips (15 patients; 4.6%) underwent subsequent HA with labral repair and femoral osteochondroplasty, the most common interventions. For those with a minimum of two years of follow-up, 5.3% (n = 14) underwent subsequent HA. No hips underwent total hip arthroplasty and one revision PAO was performed. Overall, 17 hips (4.9%) experienced a complication and 99 (26.9%) underwent hardware removal. All PROMs improved significantly postoperatively. Radiologically, 80% of hips (n = 279) reached the goal for acetabular correction (77% for acetbular index and 93% for LCEA), with no significant differences between those who underwent subsequent HA and those who did not.

Conclusion

Rectus-sparing PAO is associated with a low rate of subsequent HA for intra-articular pathology at a mean of 6.2 years' follow-up (1 to 11). Acetabular correction alone may be sufficient as the primary intervention for the majority of patients with symptomatic acetabular dysplasia.

Supplementary orthopaedic screening for children and adolescents to prevent permanent skeletal deformities - protocol for the "OrthoKids" study

BACKGROUND

Skeletal deformities (SD) in children and adolescents can lead to arthritic conditions, impairment of quality of life, and high treatment costs in the long term. However, comprehensive data on the prevalence of SDs in children and adolescents are limited and it remains therefore unclear whether there is a healthcare gap. "OrthoKids" is a project that addresses this evidence gap by implementing an orthopaedic screening for children and adolescents that supplements existing detection examinations within statutory standard care in Germany.

OBJECTIVE

To detect SDs so that they can be treated as needed at an early stage.

METHODS

The implementation of the supplementary orthopaedic screening will be evaluated through an exploratory cohort study that is set up in the German state Baden-Wuerttemberg. 20,000 children and adolescents aged 10 to 14 years will be recruited as a prospective cohort. A retrospective control cohort will be formed based on claims data provided by two cooperating statutory health insurances (SHIs). Participating children and adolescents receive a one-time orthopaedic screening. If at least one SD is diagnosed, treatment will be provided as part of the statutory standard care. Within the scope of the project, a follow-up examination will be performed after one year. An IT-platform will complement the study. The primary outcome measure is the point prevalence of scoliosis, genu varum/valgum, hip dysplasia, and flat feet. Secondary outcome measures are (i) the point prevalence of further less common SDs, (ii) health-related quality of life (HRQoL), (iii) sports ability based on activity (physical/athletic), physical constraints, and (sports) injuries, as well as (iv) monetary consequences of the orthopaedic screenings' implementation. Implementation determinants will be evaluated, too.

DISCUSSION

If the supplementary orthopaedic screening proves to be viable, it could be considered as a supplementary examination for children and adolescents within the frame of SHI in Germany. This could relieve the burden of disease among children and adolescents with SDs. In addition, it could disburden SHIs in the medium to long term.

TRIAL REGISTRATION

The OrthoKids study was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) on 26th July 2022 under the number 00029057.

Racial disparities in readmission rates following surgical treatment of pediatric developmental dysplasia of the hip

PURPOSE

Across orthopedic subspecialties, significant racial disparities have been identified with regard to postoperative outcomes. Despite these findings among adult patients, the literature assessing these disparities within pediatric orthopedics is limited. The purpose of this study was to determine the independent predictors for unplanned readmission following surgical treatment of developmental dysplasia of the hip.

METHODS

Pediatric patients undergoing hip dysplasia surgery from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Two patient groups were defined: patients who had unplanned hospital readmission within 30 days of surgery and patients who were not readmitted. Clinical characteristics assessed included gender, race, and American Society of Anesthesiologists (ASA) class. Risk factors for complications were assessed using bivariate and multivariate analysis.

RESULTS

Of 6561 pediatric patients undergoing surgical treatment for hip dysplasia, 540 (8.2%) had unplanned readmission. On bivariate analysis, non-white race (Black, Asian, Hispanic, American Indian, and Native Hawaiian), an ASA class of III, IV, or V, pulmonary, renal, neurological, and gastrointestinal comorbidities, as well as immune disease, steroid use, and nutritional support were significantly associated with unplanned readmission (p < 0.05 for all). After controlling for confounding variables on multivariate analysis, non-white race (OR 1.46; p = 0.042) and ASA class of III-V (OR 2.21; p = 0.002) were found to be independent predictors for readmission.

CONCLUSION

Clinicians should be advised of the increased readmission rates observed in non-white patients and those of higher ASA scores. Further work is needed to combat existing disparities within pediatric orthopedics.

Lateral Center-edge Angle of 18° (Bone-Edge): Threshold for Hip Arthroscopy Treatment in Patients with Borderline Developmental Dysplasia of the Hip?

OBJECTIVE

Hip arthroscopy for the treatment of symptomatic borderline developmental dysplasia of the hip (BDDH) has been controversial. The purpose of this study was to retrospectively analyze minimum 2-year outcomes of BDDH after arthroscopic surgery and explore the criteria and thresholds of the lateral center-edge angle (LCEA) in arthroscopic surgery for BDDH.

METHODS

Data were retrospectively collected from patients aged 18-50 who underwent arthroscopic surgery for BDDH and had an LCEA 18-25° between September 2016 and June 2020. The consistency of interobserver and intraobserver measurements of bone-edge LCEA was analyzed. Patients were divided into two groups based on LCEA (18-20°and 20-25°) and the results of arthroscopy compared between groups. Patient-reported outcome (PRO) scores, consisting of the modified Harris hip score (mHHS), the visual analogue scale (VAS) and the international hip outcome tool-12 (IHOT-12), the minimal clinically important difference (MCID) and patient acceptable symptom status (PASS) were calculated.

RESULTS

In 52 patients with ≥2-year follow-up, female patients accounted for 71.2% and the mean age was 30.8 ± 8.4 years (range: 18 to 49 years). There was a high level of agreement when measuring the bone-edge LCEA definition of BDDH (Kappa = 0.921). Interobserver repeatability (ICC = 0.909, 95%CI: 0.847-0.947) and intraobserver repeatability (ICC = 0.944, 95%CI: 0.905-0.968) were excellent for bone-edge LCEA measurements. In addition to LCEA and Tönnis angle, there were no significant differences in α angle, neck stem angle, femoral anteversion angle, medial joint space, Tönnis grade of osteoarthritis, acetabular retroversion (8 sign), Cam deformity and anterior inferior iliac spine (AIIS) morphology between the two groups (p > 0.05). Intraoperative findings and procedures showed no statistical difference between groups (p > 0.05). The mean follow-up time was 44.4 ± 11.0 months (range: 25 to 64 months). Postoperative VAS, mHHS and IHOT-12 scores in the LCEA 18-20° group and the LCEA 20-25° group were significantly improved compared with those before surgery, and there was no statistically significant difference in the percentage of MCID and PASS (mHHS and iHOT-12) between the groups (p > 0.05).

CONCLUSION

Patients in the LCEA 18-20° group and the LCEA 20-25° group achieved favorable outcomes after arthroscopic surgery. LCEA 18° (bone-edge) should be the threshold for hip arthroscopic surgery in BDDH patients without obvious hip instability.

Outcomes and complications of patients undergoing Salter's innominate osteotomies for hip dysplasia: a systematic review of comparative studies

The purpose of this systematic review is to assess outcomes and complications of patients undergoing Salter's innominate osteotomies (SIOs) for the correction of hip dysplasia along with patient and technical factors that can be optimized to improve outcomes after SIO. MEDLINE and EMBASE were searched from data inception to 9 October 2018. Data were presented descriptively. Twenty-seven studies were identified including 1818 hips (87.1%) treated with SIO (mean age of 2.1 ± 2.5 years and mean follow-up of 3.5 ± 5.0 years). Patients undergoing SIO had a post-operative center-edge angle (CEA) of 31.3° ± 5.3° and an acetabular index (AI) angle of 16.1° ± 5.2°. Patients undergoing SIO with pre-operative traction had significantly lower (P = 0.049) post-operative McKay criteria scores compared to patients without pre-operative traction. Patients undergoing SIO between the ages of 1.5-2 years had significantly better (P < 0.05) post-operative McKay criteria scores compared to patients aged 4-6 years. The complication rate was 9.4% with avascular necrosis (2.5%) being most common. This review found that SIO for developmental dysplasia of the hip produces generally good post-operative clinical outcomes. The CEA and AI can be corrected to normal range after SIO. Patients may have superior outcomes if they have SIO at a younger age, were not treated with pre-operative traction and did not have untreated contralateral hip dysplasia. Outcomes appear to be similar between one-stage bilateral SIO and a two-stage procedure in the setting of bilateral hip dysplasia; however, more multicentered studies are needed to confirm these results.