The effectiveness of preliminary traction in the treatment of congenital dislocation of the hip

The Optimal Age for Surgical Management of DDH Differs by Treatment Method

BACKGROUND

There is a lack of consensus on the optimal age for specific surgical interventions for developmental dysplasia of the hip. We compared radiographic and clinical outcomes among patients who were treated with closed reduction (CR), open reduction (OR), and open reduction with concomitant pelvic osteotomy (ORP) for the treatment of a dislocated hip. We sought to identify the optimal age at treatment within each of these groups.

METHODS

We retrospectively reviewed 256 hips (n=195 patients) who underwent CR (n=96), OR (n=116), or an ORP (n=44) as their index procedure at a single institution between January 1, 2004 and September 23, 2020. Radiographic outcomes included acetabular index, The International Hip Dysplasia Institute classification, and acetabular depth ratio. The incidence of further corrective surgery (FCS), defined as the need for an additional femoral and/or pelvic osteotomy before skeletal maturity, and the optimal age cutoffs for index surgery within each surgical group were determined.

RESULTS

After adjusting for age and sex, the incidence of FCS was 13.8% in the CR group, 29.2% in the OR group, and 9.2% in the ORP group. Earlier surgery was protective against FCS in the CR and OR groups. In contrast, patients in the ORP group who were older at index procedure were less likely to undergo FCS. Optimal age at surgery was 9.9 months (CR), 11.5 months (OR), and 21.4 months (ORP). Compared with older patients, younger patients were associated with a larger average decrease in the acetabular index and a larger average increase in acetabular width during the first 5 years post surgery.

CONCLUSIONS

Age at index surgical procedure was correlated with both clinical and radiographic outcomes. Age at index procedure did impact the risk of subsequent FCS, particularly in the CR and ORP groups. Based on our analysis, CR should be considered before 9.9 months of age and OR considered before 11.5 months of age to minimize the risk of FCS during childhood. This work highlights the importance of considering age-related heterogeneity in developmental dysplasia of the hip treatment outcomes.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

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

Aim

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

Methods

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

Results

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

Conclusion

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

Treatment of congenital hip dislocation before the walking age

The worst type of hip developmental dysplasia, known as congenital hip dislocation (CHD), is characterized by acetabular cavity, proximal femoral segment, and ligamentus capsule apparatus dysmorphisms that result in partial or total loss of the hip joint's relationship. We provide the following example: Hip dislocation has been diagnosed in a male infant 2 months old. The patient underwent progressive abduction followed by longitudinal skin traction using the Morel technique. After performing an artrography on the hip while under general anesthesia, which revealed a reducible and stable hip, we continued with spica cast immobilization in a human position. To promote proper joint development, improve standing posture, enhance gait, and correct pelvic and spinal imbalances, the treatment aims to reduce joint dislocation and rebuild joint relationships. To gradually clean the structures and lower the risk of distant avascular necrosis (AVN) of the femoral head development, slow and gradual traction is applied to Morel's bed.

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

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