Long-term outcome of gradual reduction using overhead traction for developmental dysplasia of the hip over 6 months of age

Clinical outcomes of gradual reduction of late-detected developmental dysplasia of the hip using ultrasound-guided flexion abduction continuous traction: a midterm follow up study

Reducing the avascular necrosis (AVN) rate in infants treated for developmental dysplasia of the hip (DDH) is important. We previously reported the clinical outcomes of gradual reduction via ultrasound-guided flexion abduction continuous traction (FACT-R), which achieved a 99% reduction with an AVN rate of 1.0% in infants <12 months. Here, we investigated the clinical outcomes of late-detected DDH after FACT-R. Infants ≥12 months who were treated with FACT-R for DDH from January 1995 to 2007 and followed up for 6 years were enrolled. Treatment comprised continuous traction, a hip-spica cast, and an abduction brace. The rates of reduction, redislocation, AVN, and secondary osteotomy surgery were evaluated. In the study patients (n = 26, hips 30), the mean age at the time of traction therapy was 23 months (range: 13-44) and the mean follow-up was 12.5 years (range: 6-16.4). Female gender and the left side were predominant. The rates of reduction, redislocation, and AVN were 100%, 0%, and 0%, respectively. However, 25 hips (83%) required secondary osteotomy surgery, including Salter innominate osteotomy in 21 hips, Salter innominate osteotomy combined with femoral osteotomy in 3 hips, and triple pelvic osteotomy in 1 hip. They had a larger acetabular index after FACT-R (P = 0.04) and a longer duration of FACT-R (P = 0.05). All hips were successfully reduced, with no redislocation or AVN. However, most hips required a secondary osteotomy surgery because of residual dysplasia. Careful follow-up and informed consent for secondary osteotomy surgery is thus essential.

Gradual Reduction Using Overhead Traction for Late-Detected Developmental Dysplasia of the Hip: A Report of Three Cases Diagnosed Among Children Over Four Years Old

Optimal reduction methods for late-detected developmental dysplasia of the hip (DDH) remain debatable. Gradual reduction (GR) using traction is a safer and more reliable option for late-detected DDH than closed reduction or open reduction with or without preliminary traction. GR using overhead traction, one of the current GR methods, has been indicated for children of walking age up to four years of age, whereas the upper age limit of this method has not yet been determined. We present three cases of late-detected DDH whose hips were treated between four and six years of age with this method. Stable reduction without subsequent redislocation was technically accomplished for all patients, albeit the duration of horizontal traction became longer than usual. Clinically significant avascular necrosis (AVN) has developed in children aged ≥5 years, indicating the need for some modifications to the conventional protocol to prevent AVN.

The efficacy of gradual reduction using two-stage traction for developmental dysplasia of the hip in southern China

Purpose

This study aimed to report the preliminary outcome of gradual reduction (GR) utilizing two-stage traction (TST) compared with traditional traction (TT) in the treatment of developmental dysplasia of the hip (DDH) and to evaluate whether the prognosis of the TST is better than that of TT.

Methods

The following information on children diagnosed with DDH who underwent treatment with GR using two-stage traction or traditional traction between June 2016 and August 2017 was collected: sex, age, weight, acetabular index (AI), International Hip Dysplasia Institute (IHDI) classification, femoral head ossification, traction time, reduction quality, and labrum shape in arthrography. The AI, IHDI classification, second operation rate, and incidence of femoral head avascular necrosis (AVN) were analyzed after the final comprehensive 1-year follow-up.

Results

In this study, 27 cases (31 hips: 18 left and 13 right) were enrolled, with 18 hips (16 cases) assigned to the TT group and 13 hips (11 cases) assigned to the TST group, with the corresponding average age at diagnosis of 5.56 ± 1.66 and 4.06 ± 1 months (p < 0.001). For both TT and TST groups, the average age at operation was 6.01 ± 1.67 and 65 ± 0.86 months (p = 0.435), the distribution of affected left and right sides was 10/8 and 8/5 hips (p = 1), and the average initial AI was 37.11 ± 3.26 and 36.77 ± 4.34 (p = 0.804), respectively. IHDI classification III/IV was observed in 15/3 and 11/2 hips, respectively (p = 1). Femoral head ossification was present in 6/18 hips in the TT group and 2/13 hips in the TT group (p = 0.412). The total traction time was 13.22 ± 2.6 days for the TT group and 49.23 ± 25.77 days for the TST group (p < 0.001). After GR, IHDI classification III/IV was observed in 9/9 and 12/1 hips, respectively (p = 0.02). AVN was present in 5/18 hips in the TT group and 0/13 hips in the TST group (p = 0.048), while the need for a second operation was approved in 5/18 hips in the TT group and 1/13 hips in the TST group (p = 0.359) at the final follow-up.

Conclusions

Two-stage traction can significantly decrease the ratios of IHDI classifications III and IV and the incidence of AVN compared to traditional traction; also, it significantly reduces the total traction time.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Appropriate Surgical Timing of Salter Innominate Osteotomy for Residual Acetabular Dysplasia in Children

BACKGROUND

Salter innominate osteotomy (SIO) provides favorable results for treating residual acetabular dysplasia in young children. In this study, we examined the midterm results of SIO according to the age at surgery to determine the optimal timing of this procedure.

METHODS

We retrospectively examined 50 hips of 42 patients (8 boys and 34 girls) with acetabular dysplasia who underwent SIO and were followed up until skeletal maturity. The center-edge angle (CEA) was measured based on the anteroposterior radiographs of the hip obtained before surgery, 5 weeks after surgery, and at the latest follow-up. Severin classification was evaluated at the latest follow-up. Patients were categorized into 3 groups according to age at surgery: younger than 7 years of age (group A), 7 to 8 years of age (group B), and 9 years of age or older (group C).

RESULTS

The mean preoperative CEA level of 0.9 degrees improved to 17.1 degrees postoperatively, which was increased to 28.1 degrees at the latest examination. Overall, 45 hips (90%) were classified as Severin I or II, with 96% in group A, 94% in group B, and 57% in group C. In group C, postoperative acetabular coverage was similar to that in the other groups (16.6 degrees in group A, 14.8 degrees in group B, and 18.1 degrees in group C), although the final outcome was unsatisfactory. The average improvement in CEA from postoperative to skeletal maturity was significantly smaller in group C than in the other groups (12.7 degrees in group A, 11.3 degrees in group B, and 3.0 degrees in group C).

CONCLUSIONS

SIO showed favorable outcomes with satisfactory acetabular coverage at skeletal maturity. However, satisfactory acetabular coverage could not be obtained in some older patients because of limited postoperative remodeling capacity and smaller secondary improvement of CEA. We recommend that SIO should be performed in patients aged 8 years or younger.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Outpatient Bryant's Overhead Traction Does Not Affect the Rate of Open Reduction or Avascular Necrosis in Developmental Dislocation of the Hip

BACKGROUND

The efficacy of preliminary traction to increase the likelihood of closed reduction and/or decrease the incidence of avascular necrosis in the management of developmental dysplasia of the hip (DDH) is controversial. We sought to document compliance with and effectiveness of Bryant's outpatient traction in patients with idiopathic DDH.

METHODS

Patients presenting between 6 and 24 months of age with idiopathic irreducible DDH were prospectively enrolled in the study. Prereduction outpatient traction was prescribed at participating surgeons' preference and parents' expressed willingness to comply with a traction protocol of at least 14 hours/day for 4 weeks. Traction hours were documented using a validated monitor; parents also reported average daily usage. Rate of successful closed reduction and evidence of capital epiphyseal growth disturbance 1 year' and 2 years' postreduction were documented.

RESULTS

Ninety-six patients with 115 affected hips were enrolled. Reliable recorded traction hours were obtained in 31 patients with 36 affected hips. Defining compliance as 14 hours/day average use, 14 of 31 patients (45.2%) were compliant, 2 (6.5%) admitted noncompliance, while 15 (48.2%) claimed to be compliant, but were not. Overall, 68/115 hips (59.0%) were closed reduced. Age at treatment was the only demographic characteristic associated with an increased incidence of closed reduction (11.7 vs. 14.6 mo, P<0.01). Successful closed reduction was achieved in 10/16 hips (62.5%) of compliant patients, 12/20 (60.0%) of noncompliant patients, and 43/72 (59.7%) of no-traction patients. Irregular ossific nucleus development was noted 1-year postindex reduction in 5/16 (31.3%) of complaint-patient hips and 25/92 (27.2%) of noncomplaint and no-traction hips. Distorted proximal femoral epiphysis was noted at 2 years postreduction in 2/15 hips (13.3%) of compliant patients and 15/52 hips (28.8%) in noncompliant and no-traction patients. None of these differences was statistically significant.

CONCLUSIONS

Parent-reported use of outpatient traction is unreliable. Four weeks of outpatient overhead Bryant's traction did not affect the rate of closed reduction or avascular necrosis in late-presenting DDH in this cohort.

LEVEL OF EVIDENCE

Level II-prospective cohort.

Petit-Morel method for hip development dysplasia in toddlers: A retrospective observational study in 34 patients

BACKGROUND

The Petit-Morel method allows the treatment of developmental hip dysplasia in toddlers by combining gradual traction to achieve reduction followed by immobilisation during which pelvic osteotomy is performed. The objective of this study was to assess the radiographic and clinical outcomes in a retrospective cohort of patients.

HYPOTHESIS

The Petit-Morel method is associated with low rates of avascular necrosis and residual acetabular dysplasia at skeletal maturity, as well as with satisfactory medium-term clinical outcomes.

MATERIAL AND METHODS

We conducted a single-centre retrospective study of 34 patients (35 hips) treated between 1997 and 2014. The radiological assessment criteria included an evaluation for avascular necrosis classified according to Kalamchi and MacEwan, the vertical centre edge (VCE) angle, femoral head sphericity according to Mose, and acetabular dysplasia at skeletal maturity according to Severin. Hip function was assessed by determining the Postel-Merle d'Aubigné (PMA) score.

RESULTS

Mean age at treatment was 19±4 months (range, 14-29). Mean follow-up was 11 years (range, 5-20). There were two failures including one case of recurrent dislocation requiring surgical reduction. Group II avascular necrosis occurred in 1 (3%) patient. Tönnis Grade IV dysplasia was significantly associated with resolving irregularity of the ossification centre, seen in 19 (54%) cases (p=0.002). In the 18 patients followed-up to skeletal maturity, with a mean follow-up of 15 years (range, 12-20 years), 17 hips were Severin Class I. The mean VCE angle was 29° (range, 15°-38°), and the head was spherical for 34 (98%) hips. The PMA score at last follow-up was excellent (17-18). The mean VCE angle was greater in all 5 patients who experienced pain during long walks (35° [range, 32°-37°]) than in the asymptomatic patients (28° [range, 15°-38°]) (p=0.009).

DISCUSSION

The Petit-Morel method is a reliable treatment that provides good clinical and radiological outcomes. Overcorrection of the VCE angle was noted in the patients who experienced walking-related pain in adulthood.

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

Docking phenomenon and subsequent acetabular development after gradual reduction using overhead traction for developmental dysplasia of the hip over six months of age

PURPOSE

This study aimed to explore the docking of the femoral head into the acetabulum after gradual reduction (GR) using traction for developmental dysplasia of the hip (DDH) and the impact on subsequent acetabular development.

METHODS

A total of 40 patients with DDH (42 hips) undergoing GR using overhead traction and spica casting were retrospectively reviewed. The presence of inverted labrum and the coronal and axial femoral-acetabular distances (FADs) were compared between MRI immediately and five weeks after spica casting. The change in the acetabular index on anteroposterior pelvic radiographs were compared between hips with inverted labrum (residual group) and with normally-shaped labrum (normalized group) on follow-up MRI.

RESULTS

The mean age at reduction was 13.1 months (7 to 33) and the mean follow-up duration was 7.7 years (4 to 11). The rate of inverted labrum and the FADs significantly decreased between the MRI scans (all p-values < 0.001), and previous Pavlik harness failure had no negative effect on these decreases. The acetabular indices at the ages of three and five years in the residual group were significantly larger than those in the normalized group (both p-values < 0.001). Residual acetabular dysplasia was seen in 84.2% of the residual group compared with 34.8% of the normalized group (p = 0.002).

CONCLUSION

The docking phenomenon can occur during spica casting following GR using traction in children with DDH between the ages of six months and three years. The remaining inverted labrum at the cast removal may negatively affect subsequent acetabular development.

LEVEL OF EVIDENCE

III - retrospective comparative study.

DDH in the Walking Age: Review of Patients with Long-Term Follow-Up

INTRODUCTION

The best treatment option in children with late detected DDH is still a subject of much controversy and only few studies have investigated the long-term outcome of treatment in such patients. We performed a systematic review to assess long-term outcome of late detected DDH hips treated after walking age.

METHODS

Studies met inclusion criteria if they: (1) reported at least 30 hips treated; (2) included children aged between 9 months and 12 years; (3) treatment indication was late detected DDH after walking age; (4) presented a minimum follow-up of 10 years; (5) reported a clinical or radiological outcome. The Kaplan-Meier method was used to evaluate long-term survival according to clinical and radiological outcomes. The rate of total hip replacement (THR) was retrieved.

RESULTS

From a total of 6561 articles, 13 articles with grade IV level of evidence were included in our review. A total of 988 hips in 800 patients with a mean follow-up of 27.9 years (range 10-67) were included. The mean age at surgery was 3.3 years (range, 9 months-12 years). The rate of THR increased according to the length of final follow-up. In particular, all studies reported no case of THR at 23.5 years of follow-up, a rate of 10.2% of THR between 30 and 40 years of follow-up and a rate of 35.6% of THR in patients with follow-up more than 40 years.

CONCLUSIONS

In patients with late detected DDH, most THR became necessary more than 30 years after the index procedure and their number increased further after 40 years and more of follow-up. Late detected DDH diagnosed after walking age is a life-long disease.

Does the vascular development of the femoral head correlate with the incidence of avascular necrosis of the proximal femoral epiphysis in children with developmental dysplasia of the hip treated by closed reduction?

PURPOSE

The purpose of this study was to identify the correlation between the vascular development of the femoral head and avascular necrosis (AVN) in patients with developmental dysplasia of the hip (DDH) treated by closed reduction (CR).

METHODS

We retrospectively reviewed 78 patients with DDH treated by CR (83 hips). The vascular maturity, number of vessels and perfusion changes of the femoral head were assessed on perfusion MRI (pMRI) before and after CR.

RESULTS

The number of vessels (mean 4.2 sd 1.4) of the femoral head and the ratio (36.1%) of mature vessels (type III) on the dislocated side were significantly less than those at contralateral side (mean 6.0 sd 1.2; 82.2%) (p < 0.001). Of the included 83 hips, 39 hips (61.5%) showed decreased perfusion of the femoral head, including partial decreased (Class B, 47.0%) and global decreased (Class C, 14.5%), at the dislocated side, which was significantly more than those at contralateral side (0.0%) (p < 0.001). In total, 32 out of 83 hips (38.5%) developed AVN. The rate of AVN with Class A (18.8%) which perfusion of the femoral head was normal (unchanged or enhanced) was significantly less than those with Class C (66.7%) (p = 0.006).

CONCLUSION

The vascular development and perfusion changes of the femoral head on the dislocated side are significantly worse than those at contralateral side. Immature vascularity of the femoral head before CR and poor perfusion of the femoral head after CR may be risk factors for AVN in patients with DDH.

LEVEL OF EVIDENCE

III.

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.

Management of late-detected DDH in children under three years of age: 49 children with follow-up to skeletal maturity

AIMS

When the present study was initiated, we changed the treatment for late-detected developmental dislocation of the hip (DDH) from several weeks of skin traction to markedly shorter traction time. The aim of this prospective study was to evaluate this change, with special emphasis on the rate of stable closed reduction according to patient age, the development of the acetabulum, and the outcome at skeletal maturity.

METHODS

From 1996 to 2005, 49 children (52 hips) were treated for late-detected DDH. Their mean age was 13.3 months (3 to 33) at reduction. Prereduction skin traction was used for a mean of 11 days (0 to 27). Gentle closed reduction under general anaesthesia was attempted in all the hips. Concurrent pelvic osteotomy was not performed. The hips were evaluated at one, three and five years after reduction, at age eight to ten years, and at skeletal maturity. Mean age at the last follow-up was 15.7 years (13 to 21).

RESULTS

Stable closed reduction was obtained in 36 hips (69%). Open reduction was more often necessary in patients ≥ 18 months of age at reduction (50%) compared with those under 18 months (24%). Residual hip dysplasia/subluxation occurred in 12 hips and was significantly associated with avascular necrosis (AVN) and with high acetabular index and low femoral head coverage the first years after reduction. Further surgery, mostly pelvic and femoral osteotomies to correct subluxation, was performed in eight hips (15%). The radiological outcome at skeletal maturity was satisfactory (Severin grades 1 or 2) in 43 hips (83%).

CONCLUSIONS

Gentle closed reduction can be attempted in children up to three years of age, but is likely to be less successful in children aged over 18 months. There is a marked trend to spontaneous improvement of the acetabulum after reduction, even in patients aged over 18 months and therefore simultaneous pelvic osteotomy is not always necessary.

Variables influencing the pelvic radiological evaluation in children with developmental dysplasia of the hip managed by closed reduction: a multicentre investigation

PURPOSE

This study aims to evaluate (1) the probability to achieve normal pelvic radiographs in children with developmental dysplasia of the hip (DDH) treated by closed reduction and (2) the amount of time needed to achieve normal pelvic radiographs and to assess what factors influence both probability and time to achieve normal radiographic parameters following CR and spica cast immobilization for DDH.

METHODS

We retrospectively reviewed 436 patients (393 girls, 43 boys; 507 hips) with DDH treated by closed reduction (CR). Tönnis grade, AVN, acetabular index (AI), centre-edge angle (CEA), and Severin radiographic grade were evaluated on plain radiographs. Criteria to rate pelvis radiographs as normal were established. Cox regression was used to evaluate the factors influencing the probability and the time to achieve normal radiographs.

RESULTS

According to our criteria, 167 hips (32.9%) achieved normal radiographic parameters during follow-up. The overall amount of time to achieve normal pelvis radiographs was 36.1 ± 15.5 months. Patients older than 24 months of age at the time of CR needed longer time to achieve normal radiographic parameters (55.2 ± 28 months) compared with other age groups. Cox regression analysis suggested the overall cumulative probability of recovery increased by 46% at five years following CR, then it tended to plateau with an annual increase less than 5%. Age older than 24 months, bilateral dislocation, pre-operative AI greater than 40°, and AVN were risk factors for reduced probability of achieving normal radiographic parameters.

CONCLUSIONS

The cumulative probability of achieving normal pelvis radiographs increases linearly during the first five years following CR, then it tends to plateau. Age older than 24 months and Tönnis grade III and IV are associated with longer time to achieve normal radiographic parameters. Age older than 24 months, bilateral dislocation, pre-operative AI greater than 40°, and AVN are risk factors for reduced probability of achieving normal radiographic parameters in children with DDH treated by closed means.

Evaluation of errors in measurements of infantile hip radiograph using digitally reconstructed radiograph from three-dimensional MRI

Purpose

Plain hip radiograph is commonly used for the diagnosis of infantile acetabular dysplasia. Many infants are unable to maintain adequate position during radiography. Besides, the infantile hip is much smaller and has a higher cartilage component in the acetabulum and proximal femur compared with the adult hip. In this study, we developed a digitally reconstructed radiograph synthesized from magnetic resonance imaging (MRI) and investigated errors of hip radiographic measurements in different pelvic positions.

Patients and methods

MRI of both hips was performed in 10 patients (mean age 3.9 years). Three-dimensional (3D) bone models were created from MRI data. We tilted 3D pelvic bone models between 10° anteversion and retroversion and through 10° rotation on the affected and contralateral sides using 3D axes. Following this, we created digitally reconstructed radiographs in each pelvic position and calculated the acetabular index (AI), center-edge angle (CEA), migration percentage (MP), and teardrop distance (TDD).

Results

AI tended to increase with pelvic retroversion and did not change with pelvic rotation. CEA tended to decrease with pelvic retroversion and rotation on the contralateral side. MP increased with pelvic retroversion and rotation on the contralateral side. TDD did not change significantly with pelvic tilt and rotation.

Conclusions

Radiographic measurements of hip in infants were highly influenced by pelvic movement. AI was influenced by pelvic tilt; CEA and MP were influenced by both pelvic tilt and rotation. We need to keep in mind that infantile hip radiographs could have about ±5° errors in AI and CEA.

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.

Closed reduction in late-detected developmental dysplasia of the hip: indications, results and complications

PURPOSE

The aim of the study was a review of the literature in order to evaluate the results and complications of closed reduction in late-detected developmental dysplasia of the hip (DDH).

METHODS

This study consisted of an analysis of the literature relative to late-detected DDH treatment options considering hip congruency, rates of re-dislocation and of avascular necrosis.

RESULTS

Gradual closed reduction (Petit-Morel method) appears to be an effective method concerning joint congruency restitution. Dislocation relapse and avascular necrosis are more efficiently prevented with closed versus open reduction. The tendency for spontaneous correction of acetabular dysplasia decreases if closed reduction is performed after 18 months of age. Patient age at the beginning of traction should be considered for the prognosis, with a lower rate of satisfactory results showing after the age of 3 years.

CONCLUSION

In our opinion, the Petit-Morel method is a suitable treatment option for children aged between six months and three years with idiopathic DDH.

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.

Prereduction traction for the prevention of avascular necrosis before closed reduction for developmental dysplasia of the hip: a meta-analysis

BACKGROUND AND PURPOSE

Avascular necrosis (AVN) is one of the common complications after closed reduction and hip spica cast for developmental dysplasia of the hip (DDH). Prereduction traction has been used to reduce a dislocated hip or decrease the risk of AVN, but there are conflicting results in prevention effects on AVN. The purpose of this study was to systematically review the current literature and evaluate the effect of prereduction traction in preventing AVN in children with DDH treated by closed reduction through a meta-analysis.

MATERIALS AND METHODS

A systematic review of the literature was performed using PubMed and EMBASE with variations of three major terms: 1) hip dislocation; 2) closed reduction; and 3) avascular necrosis. Seven studies that could compare the incidence of AVN between the traction and no-traction group were included. Methodological quality was assessed, a heterogeneity test was done (p=0.008), and the pooled risk ratios were estimated.

RESULTS

The association between traction and AVN was assessed, using data on 683 hips treated by closed reduction. The incidence of AVN in the traction and no-traction groups ranged from 5% to 47.7% and from 0% to 72.7%, respectively. A meta-analysis with a random effects model indicated no significant difference in the incidence of AVN between traction and no-traction groups (p=0.536).

CONCLUSION

There was insufficient evidence to decide the efficacy of prereduction traction before closed reduction in reducing the risk of AVN in patients with DDH in this meta-analysis. To recommend prereduction traction for the prevention of AVN, long-term follow-up studies considering age, severity of dislocation, and appropriate traction method are needed.

Diagnosis and treatment of developmental dysplasia of the hip: A current practice of paediatric orthopaedic surgeons

BACKGROUND

Developmental dysplasia of the hip (DDH) is one of the prevalent musculoskeletal conditions in young adults and is a leading cause of hip osteoarthrosis in this age group. The optimum age for surgical intervention when needed is not well established in the literature and the lack of management guidelines and standard practice of DDH leads to different practices worldwide. This study aims to investigate the current practice of paediatric orthopaedic surgeons in diagnosing and treating DDH worldwide and identify points of agreement and disagreement.

METHODS

A cross-sectional study utilizing an online questionnaire was designed to examine the different points of view and current practice of paediatric orthopaedic surgeons worldwide regarding DDH diagnosis and treatment.

RESULTS

Ninety-one surgeons responded, with an overall response of 45.5%. The vast majority of respondents use ultrasonography in children less than 3 months of age and pelvic radiography in over 3 months to diagnose DDH. Pavlik harness is the most popular DDH treatment for children younger than 6 months. For older children, closed reduction with hip spica cast is the most preferable treatment. The maximum duration of first-line treatment has a broad range. The treatment of bilateral DDH varies widely among surgeons.

CONCLUSION

This study shows clearly that paediatric orthopaedic surgeons do not agree on the diagnosis and treatment protocol of DDH, hence different approaches to this common disease are practised. The lack of an international guideline should motivate paediatric orthopaedic surgeons to discuss and formulate a uniform and evidence-based protocol for the diagnosis and treatment of DDH.

The correlation between Salter's criteria for avascular necrosis of the femoral head and Kalamchi's prognostic classification following the treatment of developmental dysplasia of the hip

AIMS

The aim of this study was to evaluate the correlation between Salter's criteria and Kalamchi's classification of avascular necrosis in patients treated for developmental dysphasia of the hip (DDH).

PATIENTS AND METHODS

The study involved a retrospective analysis of 123 patients (123 hips) with DDH treated by operative and non-operative reduction before the age of two years, with a minimum follow-up of ten years. Salter's criteria (S1 to S4) were determined from radiographs obtained at one to two years post-reduction, whilst the Kalamchi grade was determined from radiographs obtained at ten or more years of age. Early post-reduction radiographs were also used to evaluate the centre-head distance discrepancy (CHDD) and the occurrence of a dome-shaped deformity of the proximal femoral metaphysis (D-shaped metaphysis). The prognosis was described as good (Kalamchi grade K0 or KI), fair (Kalamchi grade KII) or poor (Kalamchi grade KIII or KIV) for analysis and correlation with the early Salter criteria, CHDD and D-shaped metaphysis.

RESULTS

S1 and S2 criteria were predictive of a poor prognosis. The outcome following S3, S4 and S3 + S4 varied; 18 (40%) had a good prognosis, 17 (38%) a fair prognosis and ten (22%) a poor prognosis. A CHDD ≥ 10% and a D-shaped metaphysis were also predictive of a poor prognosis.

CONCLUSION

The Salter criteria were predictive of the Kalamchi grade of avascular necrosis in patients with DDH aged ten or more years after reduction of the hip. Cite this article: Bone Joint J 2017;99-B:1115-20.

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.

Dynamic long leg casting fixation for treating 12- to 18-month-old infants with developmental dysplasia of the hip

Objective To evaluate the effect of dynamic long leg casting in paediatric patients with developmental dysplasia of hip (DDH) diagnosed at 12-18 months. Methods The adductor tenotomy, closed reduction, and dynamic long leg casting method was adopted to treat paediatric patients with DDH. The hips were divided into four groups according to the Tonnis radiographic dislocation classification. Groups were also classified according to the baseline acetabular index (AI): 30°-35°, 36°-40°, and > 40°. The outcomes of the reductions were evaluated according to McKay's hip function criteria and Severin's radiological criteria. Results A total of 246 patients (339 hips) had complete follow-up data. After 3 months of orthosis fixation, the results were satisfactory in 264 hips (77.88%). Hip function was rated as 'excellent' or 'good' in 43 of 51 (84.31%) Tonnis type 1 hips, 125 of 155 (80.65%) type 2 hips, 70 of 90 (77.78%) type 3 hips, and 34 of 43 (79.07%) type 4 hips. The higher the baseline AI, the lower the rates of 'excellent' and 'good' hip function. Favourable radiological results (Severin types I and II) were found in 266 of 339 (78.47) hips. Conclusions Dynamic long leg casting is an effective method for treating patients with DDH aged 12-18 months at diagnosis.

Surgical Management of Pediatric Developmental Dysplasia of the Hip

In pediatric patients with developmental dysplasia of the hip with late presentation or failure of nonsurgical treatment, surgical management is indicated. The goal of surgery is to obtain a stable reduction to promote development of the femoral head and acetabulum while avoiding osteonecrosis of the femoral head and the need for further surgery. Treatment is related to the age of the patient and the degree of soft-tissue contracture or bony deformity present. As a general rule, in children aged <12 months, closed reduction and spica casting is preferred. Children aged 12 to 18 months may require open reduction, which can be performed safely through a medial or anterior approach. In children aged 18 months to 3 years, residual bony deformity can be corrected with a femoral or pelvic osteotomy in addition to open reduction. In children with complex deformity or in children aged >3 years, both pelvic and femoral osteotomies are commonly required to stabilize an open reduction.

Have Changes in Treatment of Late-detected Developmental Dysplasia of the Hip During the Last Decades Led to Better Radiographic Outcome?

BACKGROUND

Despite considerable changes in the treatment of of late-detected congenital or developmental hip dislocation (DDH) during the last 50 years, it is unclear whether and to what degree these changes have led to better long-term outcome for the patients.

QUESTIONS/PURPOSES

The aims of this study were to see whether decreasing use of skin traction and instead a more aggressive approach to open reduction resulted in (1) reduced use of secondary procedures; (2) improved radiographic appearance of the hips at long-term followup; and (3) changes in the proportion of patients developing avascular necrosis.

METHODS

Two groups of patients were compared retrospectively. Inclusion criteria were patient age older than 3 months and younger than 5 years at the initiation of treatment, no associated anomaly, no previous treatment in other hospitals, and available radiographs from the time of diagnosis to skeletal maturity. Group A consisted of 56 patients (51 girls [91%]; 74 hips) primarily treated during the period 1958 to 1962. Group B comprised 38 patients (36 girls [95%]; 40 hips) treated during the period 1996 to 2002. The mean age at the time of hip reduction was 20 months (SD 9.6) in Group A and 17 months (SD 11.9) in Group B. The mean time in skin traction had decreased from 35 days (SD 12.5) to 11 days (SD 5.7) over the years (p < 0.001). Open reduction was performed in six of 74 hips (8%) in Group A and 15 of 40 hips (37%) in Group B (p < 0.001). The immobilization time in the hip spica had decreased from 9 to 6 months (p < 0.001). The indication for secondary procedures to correct residual dysplasia was center-edge angle < 20° and was similar in both groups. A modified version of the radiographic classification of Severin was used to compare the results.

RESULTS

Secondary procedures to correct residual dysplasia were performed in 28 of 74 hips (38%) in Group A and seven of 40 hips (18%) in Group B (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.14-0.89; p = 0.025) At skeletal maturity, the proportion of patients with satisfactory radiographic results (Severin Grades I/II) was larger in Group B (33 of 40 hips [82%]) than in Group A (46 of 74 hips [62%]; OR, 0.35; CI, 0.14-0.89; p = 0.025). Femoral head coverage, assessed as the center-edge angle, was greater in Group B than in Group A (mean 26° versus 22°; CI, 0.8-7.9; p = 0.016). There was no difference in the proportion of avascular necrosis of the femoral head (seven of 74 hips [9%] in Group A and five of 40 [13%] in Group B; OR, 1.4; CI, 0.4-4.6; p = 0.614).

CONCLUSIONS

The move away from prolonged use of skin traction and toward more frequent open reduction for children with a late diagnosis of DDH appears to result in fewer secondary procedures and a better radiographic appearance of the hip at skeletal maturity. Based on the present results, we cannot conclude whether preliminary traction is needed; this question should be evaluated in future long-term studies with a prospective, randomized design.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.

Developmental dysplasia of the hip: What has changed in the last 20 years?

Developmental dysplasia of the hip (DDH) describes the spectrum of structural abnormalities that involve the growing hip. Early diagnosis and treatment is critical to provide the best possible functional outcome. Persistence of hip dysplasia into adolescence and adulthood may result in abnormal gait, decreased strength and increased rate of degenerative hip and knee joint disease. Despite efforts to recognize and treat all cases of DDH soon after birth, diagnosis is delayed in some children, and outcomes deteriorate with increasing delay of presentation. Different screening programs for DDH were implicated. The suspicion is raised based on a physical examination soon after birth. Radiography and ultrasonography are used to confirm the diagnosis. The role of other imaging modalities, such as magnetic resonance imaging, is still undetermined; however, extensive research is underway on this subject. Treatment depends on the age of the patient and the reducibility of the hip joint. At an early age and up to 6 mo, the main treatment is an abduction brace like the Pavlik harness. If this fails, closed reduction and spica casting is usually done. After the age of 18 mo, treatment usually consists of open reduction and hip reconstruction surgery. Various treatment protocols have been proposed. We summarize the current practice for detection and treatment of DDH, emphasizing updates in screening and treatment during the last two decades.

A review of long-term outcomes for late presenting developmental hip dysplasia

Successful management of late presenting hip dislocation in childhood is judged by the outcome not just at skeletal maturity but well beyond into adulthood and late middle age. This review considers different methods of treatment and looks critically at the handful of studies reporting long-term follow-up after successful reduction.

Ultrasound-guided gradual reduction using flexion and abduction continuous traction for developmental dysplasia of the hip: a new method of treatment

We describe our experience in the reduction of dislocation of the hip secondary to developmental dysplasia using ultrasound-guided gradual reduction using flexion and abduction continuous traction (FACT-R). During a period of 13 years we treated 208 Suzuki type B or C complete dislocations of the hip in 202 children with a mean age of four months (0 to 11). The mean follow-up was 9.1 years (five to 16). The rate of reduction was 99.0%. There were no recurrent dislocations, and the rate of avascular necrosis of the femoral head was 1.0%. The rate of secondary surgery for residual acetabular dysplasia was 19.2%, and this was significantly higher in those children in whom the initial treatment was delayed or if other previous treatments had failed (p = 0.00045). The duration of FACT-R was significantly longer in severe dislocations (p = 0.001) or if previous treatments had failed (p = 0.018). This new method of treatment is effective and safe in these difficult cases and offers outcomes comparable to or better than those of standard methods.

Factors associated with an unfavourable outcome after Salter innominate osteotomy in patients with unilateral developmental dysplasia of the hip: does occult dysplasia of the contralateral hip affect the outcome?

Salter innominate osteotomy is an effective reconstructive procedure for the treatment of developmental dysplasia of the hip (DDH), but some children have a poor outcome at skeletal maturity. In order to investigate factors associated with an unfavourable outcome, we assessed the development of the contralateral hip. We retrospectively reviewed 46 patients who underwent a unilateral Salter osteotomy at between five and seven years of age, with a mean follow-up of 10.3 years (7 to 20). The patients were divided into three groups according to the centre-edge angle (CEA) of the contralateral hip at skeletal maturity: normal (> 25°, 22 patients), borderline (20° to 25°, 17 patients) and dysplastic (< 20°, 7 patients). The CEA of the affected hip was measured pre-operatively, at eight to nine years of age, at 11 to 12 years of age and at skeletal maturity. The CEA of the affected hip was significantly smaller in the borderline and dysplastic groups at 11 and 12 years of age (p = 0.012) and at skeletal maturity (p = 0.017) than in the normal group. Severin group III was seen in two (11.8%) and four hips (57.1%) of the borderline and dysplastic groups, respectively (p < 0.001). Limited individual development of the acetabulum was associated with an unfavourable outcome following Salter osteotomy.