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Imerci A, Thacker MM, Bowen JR. Failure of Pavlik Harness Treatment in Infants Under 6 Months Old with Dislocated Hips: Short- and Intermediate-Term Results of Subsequent Treatment Modalities. Indian J Orthop 2024; 58:1288-1296. [PMID: 39170665 PMCID: PMC11333783 DOI: 10.1007/s43465-024-01162-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/16/2024] [Indexed: 08/23/2024]
Abstract
Objective This study aimed to determine the short- and medium-term outcomes of hip dislocation in infants who failed Pavlik harness therapy and were subsequently treated with brace, closed reduction (CR) or open reduction (OR) before 6 months of age. Methods Fifty infants (66 hip dislocations) who failed Pavlik harness therapy between 2000 and 2018 and were treated with a rigid abduction brace or undergoing a CR or OR/cast were evaluated. All demographic data obtained from the medical system, developments and complications during the follow-up and treatment process were recorded and evaluated. Results Fifty infants (66 hips) with dislocated hips failed Pavlik harness therapy. Of these, 9 infants (12 hips) underwent rigid abduction splint therapy: 9 hips were successful, 2 hips had CR and 1 had OR. Thirty-eight infants (51 hips) had index CR, of which 3 (3 hips) failed and had OR. Radiographs of 49 hips (44 patients) were normal at the final evaluation. Pavlik harness therapy starting after 3 weeks (P = 0.028) and unilateral dislocations (P = 0.028) increased the risk of needing operating room. There was an association between OR and avascular necrosis (P = 0.025), but not between OR and other complications-dysplasia and re-dislocation/subluxation (P = 0.257 and P = 0.508, respectively). Conclusion Closed treatment of hip dislocation is possible in most babies who fail Pavlik treatment. Babies who are started on Pavlik therapy after 3 weeks of age may be at increased risk of needing an operating room. Level of Evidence IV.
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Affiliation(s)
- Ahmet Imerci
- Department of Orthopaedic Surgery, Nemours Children’s Health, Delaware, 1600 Rockland Rd., Wilmington, DE 19803 USA
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Mihir M. Thacker
- Department of Orthopaedic Surgery, Nemours Children’s Health, Delaware, 1600 Rockland Rd., Wilmington, DE 19803 USA
| | - James Richard Bowen
- Department of Orthopaedic Surgery, Nemours Children’s Health, Delaware, 1600 Rockland Rd., Wilmington, DE 19803 USA
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Cummings JL, Oladeji AK, Rosenfeld S, Johnson M, Goldstein R, Georgopoulos G, Stephenson L, White NW, Hosseinzadeh P. Severity of hip dysplasia as the major factor affecting outcome of closed reduction in children with hip dysplasia. J Pediatr Orthop B 2024; 33:322-327. [PMID: 37669157 DOI: 10.1097/bpb.0000000000001122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
The objective of this study was to analyze a multicenter cohort of children with developmental dysplasia of the hip (DDH) who underwent treatment with closed reduction. We sought to report the effects that severity of hip dysplasia and age have on the development of femoral head avascular necrosis (AVN) and the need for additional procedures. All patients with DDH and minimum 2 years of follow-up who underwent closed reduction were identified. The following variables were recorded: sex, laterality of hip involvement, age, acetabular index (AI), and International Hip Dysplasia Institute (IHDI) grade. The effects of patient age and pre-procedure IHDI grade on the rate of AVN and need for additional procedures after the closed reduction were analyzed using an alpha of 0.05. Seventy-eight total hips were included in the final analysis. The average patient age was 12 months. AVN of the femoral head was reported in 24 hips (30.8%) and 32 hips (41.0%) required additional surgery. Higher pre-op IHDI grade was associated with higher risk of developing Bucholz-Ogden grades II-IV AVN of the femoral head ( P = 0.025) and requiring additional surgery ( P = 0.033) regardless of patient age. There were no statistically significant differences for the effect of age on the measured outcomes ( P > 0.05). These findings suggest that severity of dislocation (IHDI grade) is a significant risk factor for the development of AVN and need for additional procedure.
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Affiliation(s)
- Jason L Cummings
- Department of Orthopedic Surgery, Washington University in St. Louis, Saint Louis, Missouri
| | - Afolayan K Oladeji
- Department of Orthopedic Surgery, Washington University in St. Louis, Saint Louis, Missouri
| | | | - Megan Johnson
- Vanderbilt Children's Hospital, Nashville, Tennessee
| | | | | | | | - Nathan W White
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Pooya Hosseinzadeh
- Department of Orthopedic Surgery, Washington University in St. Louis, Saint Louis, Missouri
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Zhang Y, Weng L, Zhang G, Zhou H, Liu X, Cao Y. Arthroscopic debridement and reduction is an effective procedure for failed closed reduction in young children with developmental dislocation of the hip. INTERNATIONAL ORTHOPAEDICS 2024; 48:1401-1409. [PMID: 38478021 DOI: 10.1007/s00264-024-06140-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 03/02/2024] [Indexed: 05/08/2024]
Abstract
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.
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Affiliation(s)
- Yuan Zhang
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics; Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Liuqi Weng
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics; Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Ge Zhang
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics; Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Hai Zhou
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics; Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Xing Liu
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics; Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China
| | - Yujiang Cao
- Department of Orthopaedics, National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics; Children's Hospital of Chongqing Medical University, 136 Zhongshan Er Road, Yuzhong District, Chongqing, 400014, People's Republic of China.
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Cummings JL, Oladeji AK, Rosenfeld S, Johnson M, Goldstein R, Georgopoulos G, Stephenson L, White NW, Hosseinzadeh P. Outcomes of Open Reduction in Children With Developmental Hip Dislocation: A Multicenter Experience Over a Decade. J Pediatr Orthop 2023; 43:e405-e410. [PMID: 37037660 DOI: 10.1097/bpo.0000000000002413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
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.
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Affiliation(s)
- Jason L Cummings
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO
| | - Afolayan K Oladeji
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO
| | | | | | | | | | | | - Nathan W White
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX
| | - Pooya Hosseinzadeh
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO
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Arneill M, Cosgrove A, Robinson E. Should closed reduction of the dislocated hip be attempted after failed Pavlik harness treatment in developmental dysplasia of the hip? Bone Jt Open 2021; 2:584-588. [PMID: 34351213 PMCID: PMC8384449 DOI: 10.1302/2633-1462.28.bjo-2021-0088.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures. Methods Data was obtained from the Northern Ireland DDH database. All children who underwent an attempted closed reduction between 2011 and 2016 were identified. Children with a dislocated hip that failed Pavlik harness treatment were included in the study. Successful closed reduction was defined as a hip that reduced in theatre and remained reduced. Most recent imaging was assessed for the presence of AVN using the Kalamchi and MacEwen classification. Results There were 644 dislocated hips in 543 patients initially treated in Pavlik harness. In all, 67 hips failed Pavlik harness treatment and proceeded to arthrogram (CR) under general anaesthetic at an average age of 180 days. The number of hips that were deemed reduced in theatre was 46 of the 67 (69%). A total of 11 hips re-dislocated and underwent open reduction, giving a true successful CR rate of 52%. For the total cohort of 67 hips that went to theatre for arthrogram and attempted CR, five (7%) developed clinically significant AVN at an average follow-up of four years and one month, while none of the 35 hips whose reduction was truly successful developed clinically significant AVN. Conclusion The likelihood of a successful closed reduction of a dislocated hip in the Northern Ireland population, which has failed Pavlik harness treatment, is 52% with a clinically significant AVN rate of 7%. As such, we continue to advocate closed reduction under general anaesthetic for the hip that has failed Pavlik harness. Cite this article: Bone Jt Open 2021;2(8):594–598.
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Andras LM, Abousamra O. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2021; 103:287-294. [PMID: 33369978 DOI: 10.2106/jbjs.20.01953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
PURPOSE The aims of this study were to evaluate the reliability of three classifications of severity of dislocation in late-detected developmental dysplasia of the hip (DDH), especially to assess whether they are predictive of long-term outcomes. METHODS Two groups of patients were analyzed. Group 1 (57 patients, 69 hips) underwent closed reduction between 1958 and 1962. Mean age at reduction was 20.3 months (4 to 65). Group 2 (50 patients, 54 hips) treated between 1996 and 2005, was used for analysis of the association between severity of dislocation and treatment (open or closed reduction). The primary radiographs were graded according to the Tönnis classification, the classification of the International Hip Dysplasia Institute and a new method based on the position of the most lateral point of the proximal femoral metaphysis (lateral metaphysis height classification, LMH). The outcome at a mean age of 51.2 years (55 to 60) was graded according to the occurrence of osteoarthritis (OA) and total hip arthroplasty (THA). RESULTS There were significant associations between the classifications, and the intra- and interobserver agreements were high. More severe grades of DDH were significantly associated with age ≥ 18 months and with open reduction. None of the classifications were significantly associated with long-term OA. The LMH method was significantly associated with the need for THA, whereas the other classifications were not. CONCLUSION All the classifications were reliable in grading severity of DDH. The LMH method seems preferable in clinical practice because the main landmarks were easy to define and because it had long-term prognostic value. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Terje Terjesen
- Division of Orthopaedic Surgery, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway,Correspondence should be sent to Terje Terjesen, Division of Orthopaedic Surgery, Oslo University Hospital, Rikshospitalet, and University of Oslo, Postbox 4950 Nydalen, 0424 Oslo, Norway. E-mail:
| | - Joachim Horn
- Division of Orthopaedic Surgery, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
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Jia G, Wang E, Lian P, Liu T, Zhao S, Zhao Q. Anterior approach with mini-bikini incision in open reduction in infants with developmental dysplasia of the hip. J Orthop Surg Res 2020; 15:180. [PMID: 32434526 PMCID: PMC7238660 DOI: 10.1186/s13018-020-01700-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 05/06/2020] [Indexed: 11/10/2022] Open
Abstract
Purpose The anterior and medial approaches in open reduction for developmental dysplasia of the hip (DDH) had been widely used. The former could not directly approach the intra-articular interposition, while the latter had been associated with injury to blood vessel and avascular necrosis (AVN) of the femoral head. Meanwhile, the bikini incision had also been mentioned in some studies. The purpose of this study was to introduce a modified anterior approach through a mini-bikini incision and report its short-term outcomes. Methods Data of DDH patients younger than 2 years at the time of surgery who had received this mini-bikini incision between June 2013 and December 2018 were collected. The surgical technique, operation duration, intraoperative blood loss, and length of incision were recorded in detail. In the latest follow up, the objective measurement of the scar and the subjective feeling towards the scar were collected. X-ray and magnetic resonance imaging (MRI) were performed at the last follow-up, and the incidence of residual dysplasia, redislocation, and femoral head AVN was analyzed. Results Forty-three cases (49 hips) were included with an averaged follow-up of 43 months. The operation duration was 22 min, and the blood loss was 9.8 ml on average. The length of the scar averaged 2.6 cm. The mean University of North Carolina “4P” scar scale (UNC4P) for the scar was 0.92, and no patients complained numbness. Overall, all the parents were satisfied with the cosmetic appearance. The mean acetabular index (AI) was 27.42° ± 6.41° in dislocated hip in the last follow-up. One hip redislocated soon after the operation and was reduced in a closed manner right away. MRI showed improved coverage but still some residual dysplasia that was in accordance with the post-operative recovery nature. Four hips (8%) had signs of AVN in X-ray. Conclusion Open reduction through the anterior approach with the mini-bikini incision was a safe procedure with comparable outcomes to classical approaches. It would be a complementary approach for DDH patients younger than 2 years old who need an open reduction.
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Affiliation(s)
- Guoqiang Jia
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, China.,Department of Orthopedics, Anhui Provincial Children's Hospital, Hefei, China
| | - Enbo Wang
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, China.
| | - Peng Lian
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, China
| | - Tianjing Liu
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, China
| | - Shuyi Zhao
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, China
| | - Qun Zhao
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, China.
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