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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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2
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Shaty W. Dega Osteotomy for the Treatment of Developmental Dysplasia of the Hip, a Clinical Evaluation and an Anatomic Study based on X-ray and CT Scan. Orthop Rev (Pavia) 2024; 16:120304. [PMID: 38957743 PMCID: PMC11218868 DOI: 10.52965/001c.120304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/01/2024] [Indexed: 07/04/2024] Open
Abstract
Background Dega osteotomy is becoming more widely used for the treatment of developmental dysplasia of the hip (DDH). Objective A thorough description of this procedure is needed as many of the technical aspects are not fully defined. Moreover, more follow-up series are also needed to evaluate its outcomes. Methods In this study, we gave a detailed anatomic description for this procedure and also presented our experience as a retrospective radiographic and case-note study. We examined the clinical and radiographic records of 44 patients (48 hips) with varying degrees of DDH. Results The average age of the patients was 2 months and 7 months while the average follow up period was 41 months. Clinical and radiographic assessment including CT with 3D reconstruction to examine the anatomic characteristics of the osteotomy were undertaken. We found that concentric reduction was achieved in 93.7% with excellent clinical and radiographic outcomes. Only 3 cases needed revision of the Dega osteotomy. The re-operation rate was 12.5%. CT scan revealed that the arcuate line was crossed by the osteotomy in the majority of cases. In 20.7% of cases, a bone cut that was intended to be a Dega osteotomy was found to have been inadvertently implemented as another osteotomy variant. However, this bore no significant effect on the outcome. Conclusion We found that a well-implemented Dega osteotomy is a reliable tool to cope with the acetabular changes in DDH.
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Affiliation(s)
- Wahby Shaty
- Department of Surgery, College of Medicine University of Thi Qar, Iraq
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Baljoun A, Bradley CS, Verma Y, Wedge JH, Gargan MF, Kelley SP. Intraoperative 3D Fluoroscopy During Open Reduction for DDH: An Effective Alternative to Postoperative CT/MRI. J Pediatr Orthop 2024:01241398-990000000-00568. [PMID: 38779959 DOI: 10.1097/bpo.0000000000002728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Computed tomography CT or magnetic resonance imaging (MRI) has been the most used imaging modality to assess hip reduction in developmental dysplasia of the hip (DDH) after open reduction (OR). In 2015, intraoperative 3D fluoroscopy (3D) was introduced at our center as an alternative to CT/MRI. 3D offers the advantage that if hip reduction is insufficient, it can be addressed at the time of surgery. The purpose of this study was to assess the efficacy of 3D in comparison to CT/MRI. METHODS This was a single-centre, retrospective comparative study of two consecutive cohorts: those with OR and 3D between 2015 and 2017 and those with OR and CT/MRI between 2012 and 2014. Time to imaging, re-imaging, length of stay (LOS), re-operation, and redislocation or subluxation after cast removal were evaluated. RESULTS Forty-two patients (46 hips) had 3D, and 30 patients (32 hips) had CT/MRI. Significant differences were found between groups in time to imaging, cast changes, and LOS. All 3D was intraoperative (46 hips), and only 69% (22 hips) of CT/MRI was on the day of surgery (P<0.01). In the 3D group, 1 hip (2%) had a cast change under the same anesthetic, and 4 hips (13%) from CT/MRI had cast changes in subsequent surgery (P=0.03). The mean LOS in days for 3D was 1.72 and 2.20 for CT/MRI (P=0.03). There were no statistically significant differences between groups in further imaging and subluxations or re-dislocations at cast removal. Two hips (4%) in the 3D group had MRI, but with no further intervention (P=0.51), and at cast removal, there were 3 subluxations in each group (P=0.69) and 1 redislocation in the 3D group (P=1.00). CONCLUSIONS Intraoperative 3D improved time to imaging, allowed for cast changes at surgery and had a shorter LOS. Moreover, there were no significant differences found in adverse outcomes between those who underwent 3D versus CT/MRI. 3D should thus be considered an effective alternative to CT/MRI for assessing hip reduction during OR for DDH. LEVEL OF EVIDENCE Diagnostic Study, level II.
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Affiliation(s)
- Amna Baljoun
- Division of Orthopaedic Surgery, The Hospital for Sick Children
- Department of Surgery, College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | | | - Yashvi Verma
- Division of Orthopaedic Surgery, The Hospital for Sick Children
| | - John H Wedge
- Division of Orthopaedic Surgery, The Hospital for Sick Children
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Martin F Gargan
- Division of Orthopaedic Surgery, The Hospital for Sick Children
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Simon P Kelley
- Division of Orthopaedic Surgery, The Hospital for Sick Children
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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Chen YP, Fan TY, Chu CC, Lin JJ, Ji CY, Kuo CF, Kao HK. Automatic and human level Graf's type identification for detecting developmental dysplasia of the hip. Biomed J 2024; 47:100614. [PMID: 37308078 PMCID: PMC10955653 DOI: 10.1016/j.bj.2023.100614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/11/2023] [Accepted: 06/07/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Developmental dysplasia of the hip (DDH) is a common congenital disorder that may lead to hip dislocation and requires surgical intervention if left untreated. Ultrasonography is the preferred method for DDH screening; however, the lack of experienced operators impedes its application in universal neonatal screening. METHODS We developed a deep neural network tool to automatically register the five keypoints that mark important anatomical structures of the hip and provide a reference for measuring alpha and beta angles following Graf's guidelines, which is an ultrasound classification system for DDH in infants. Two-dimensional (2D) ultrasonography images were obtained from 986 neonates aged 0-6 months. A total of 2406 images from 921 patients were labeled with ground truth keypoints by senior orthopedists. RESULTS Our model demonstrated precise keypoint localization. The mean absolute error was approximately 1 mm, and the derived alpha angle measurement had a correlation coefficient of R = 0.89 between the model and ground truth. The model achieved an area under the receiver operating characteristic curve of 0.937 and 0.974 for classifying alpha <60° (abnormal hip) and <50° (dysplastic hip), respectively. On average, the experts agreed with 96% of the inferenced images, and the model could generalize its prediction on newly collected images with a correlation coefficient higher than 0.85. CONCLUSIONS Precise localization and highly correlated performance metrics suggest that the model can be an efficient tool for assisting DDH diagnosis in clinical settings.
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Affiliation(s)
- Yueh-Peng Chen
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Master of Science Degree Program in Innovation for Smart Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzuo-Yau Fan
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Artificial Intelligence Research and Development, Chang Gung Medical Technology Co., Ltd., Linkou, Taiwan
| | - Cheng-Cj Chu
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Pediatric Critical Care Medicine and Pediatric Neurocritical Care Center, Chang Gung Children's Hospital and Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chin-Yi Ji
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Artificial Intelligence Research and Development, Chang Gung Medical Technology Co., Ltd., Linkou, Taiwan
| | - Chang-Fu Kuo
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
| | - Hsuan-Kai Kao
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Bone and Joint Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Suqaty R, Alomran AK, Alkhalifah MK, Aldughaythir SS, Albeshry AM, Aldilaijan Y, Alzahrani MT, Alhussainan T. How Ready are Pediatricians and Family Physicians in Saudi Arabia to Perform Clinical Screening of Developmental Dysplasia of the Hip? J Multidiscip Healthc 2023; 16:2567-2576. [PMID: 37667798 PMCID: PMC10475280 DOI: 10.2147/jmdh.s416459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/21/2023] [Indexed: 09/06/2023] Open
Abstract
Background Developmental dysplasia of the hip (DDH) is one of the most common hip pathologies in pediatric age group and late diagnosis remains a major concern in Saudi Arabia. Objective The aim of this study is to examine the ability of Saudi Arabian pediatricians and family physicians to conduct clinical screening for (DDH) by estimating their clinical knowledge and skills and analyzing the gaps therein to determine whether there is potential to launch a national screening protocol for DDH in Saudi Arabia. Methods This is a multicenter cross-sectional study from three major regions in Saudi Arabia (Central, Eastern and Western provinces). The assessed aspects are risk factors, age of screening, incidence in Saudi Arabia, physical signs and diagnostic markers, and treatment, along with their 'clinical knowledge and skills' score. Results Half of the participants were pediatricians, while the rest were family physicians. More than a third of the participants were considered to have adequate knowledge, ie, above the mean score. Dimensions with the most significant knowledge gaps included the incidence of DDH in Saudi Arabia, adverse effects of swaddling, and the management of a high-risk infants presenting with a negative physical examination. Additionally, there were relatively low rates of awareness regarding positive risk factors as well as a generally poor ability to identify physical signs. Clinical knowledge and skill levels were significantly lower among family physicians. Conclusion Pediatricians and family physicians in Saudi Arabia still need further training to improve their clinical skills for DDH screening. The proper administration of training programs could eventually enable the gradual implementation of a national systematic screening program.
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Affiliation(s)
- Rayyan Suqaty
- Department of Orthopedic Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Ammar K Alomran
- Department of Orthopedics, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed K Alkhalifah
- Department of Family Medicine & Polyclinics King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Saad S Aldughaythir
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulrahman M Albeshry
- Department of Family and Community Medicine, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Yousif Aldilaijan
- Primary Health Care Centers, Eastern Health Cluster, Khobar, Saudi Arabia
| | - Mohammed T Alzahrani
- Department of Orthopedic Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Thamer Alhussainan
- Department of Orthopedic Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Zein A, Khalifa AA, Elsherif ME, Elbarbary H, Badaway MY. Are the outcomes of single-stage open reduction and Dega osteotomy the same when treating DDH in patients younger than 8 years old? A prospective cohort study. J Orthop Traumatol 2023; 24:43. [PMID: 37592192 PMCID: PMC10435432 DOI: 10.1186/s10195-023-00725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/22/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The primary objective was to report our early results after a one-stage procedure [open reduction (OR), Dega pelvic osteotomy (DPO), and femoral osteotomy (FO) when needed] for surgical management of a cohort of patients with developmental dysplasia of the hip (DDH). The secondary objective was to compare the functional, radiological, and complications among patients younger and older than 30 months. MATERIALS AND METHODS This prospective cohort study included 71 hips with DDH in 61 patients with a mean age of 34.3 ± 19.5 months. All patients underwent one-stage surgical procedures, including OR + DPO and FO, if needed. Functional and radiographic assessment at the last follow-up was conducted using the modified Severin grading system and the Severin classification system, respectively, in addition to assessing the acetabular index (AI), osteotomies healing, and presence of complications. We divided patients into two groups, younger than 30 months (group I) and older than 30 months (group II). RESULTS We included 35 hips in group I and 36 in group II. All hips received OR + DPO, while 25 (69.4%) hips in group II had FO. The operative time was significantly longer in group II (103.19 ± 20.74 versus 72.43 ± 11.59 min, p < 0.001). After a mean follow up of 21.3 ± 2.3 months, the functional outcomes were satisfactory in 62 (87.3%) hips (94.3% in group I and 80.6% in group II, p = 0.35). There was a significant improvement in the AI in all patients compared with preoperative values (27.2° ± 2.9 versus 37° ± 4.2, p < 0.05). Furthermore, 63 (88.7%) hips had satisfactory radiographic outcomes (94.3% in group I and 83.3% in group II, p = 0.26), and all osteotomies showed radiographic healing. The overall complications incidence was significantly lower in group I compared with group II (5.7% versus 30.6%, p < 0.05), and avascular necrosis occurred in 4 (5.6%) hips, all in group II (p = 0.06). CONCLUSION One-stage procedure entailing open reduction, Dega pelvic osteotomy, and femoral osteotomy when needed for managing DDH in patients younger than eight years old revealed acceptable clinical and radiological outcomes. However, there was a higher need for a concomitant femoral osteotomy in patients older than 2.5 years, and complications were more frequent. LEVEL OF EVIDENCE III
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Affiliation(s)
- AboBakr Zein
- Orthopedics and Traumatology Department, Cairo University, Giza, Egypt
| | - Ahmed A Khalifa
- Orthopaedic Department, Qena Faculty of Medicine, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, 83523, Egypt.
| | | | - Hassan Elbarbary
- Orthopedics and Traumatology Department, Cairo University, Giza, Egypt
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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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Miao M, Jin S, Cai H, Cai H, Bian J, Wang Z. Modified Smith-Petersen approach with rectus-sparing reduces severe avascular necrosis for developmental dysplasia of the hip at walking age: minimum 5-year follow-up. J Orthop Surg Res 2022; 17:539. [PMID: 36514173 DOI: 10.1186/s13018-022-03441-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Developmental dysplasia of the hip (DDH) is one of the most common orthopedic malformations in children. Open reduction for DDH at walking age remains a major concern. The goal of this study is to evaluate the mid-term effect of a modified Smith-Petersen approach which preserves the rectus femoris on DDH at walking age, in particular avascular necrosis (AVN). METHODS A retrospective review of DDH patients aged between 12 and 24 months was carried out between January 2010 and June 2016. Open reduction through the Smith-Petersen approach (Group A) and modified Smith-Petersen approach, which preserves the rectus femoris (Group B), were both used. Measurement of hip geometry included acetabular index, the International Hip Dysplasia Institute classification, and AVN degree. Clinical records included operation time, bleeding volume, and abduction angle. RESULTS There were 101 children (119 hips) with DDH who met the inclusion criteria. There were 66 hips in Group A and 53 in Group B. The mean surgical age at open reduction was 17.0 ± 2.4 months, with a mean 104.9 ± 19.5 months at last follow-up. There was no statistical difference in surgical age between the two groups (17.2 vs. 16.4 months). There was no significant difference in the incidence of all types of clinically significant AVN between group A and group B (27.3 vs. 18.9%), but the incidence of severe AVN was lower in group B (19.7 vs. 5.7%, P = 0.026). In addition, the lower the age at the time of open reduction, the lower the severity of AVN (P = 0.002). CONCLUSIONS These mid-term data suggest that the modified Smith-Petersen approach with rectus-sparing could reduce severe AVN more than the classical Smith-Peterson approach in open reduction in DDH at walking age. In addition, early open reduction can reduce the postoperative degree of AVN.
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Affiliation(s)
- Mingyuan Miao
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Sheng Jin
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haiqing Cai
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haoqi Cai
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxia Bian
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhigang Wang
- Department of Orthopedic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Ogawa T, Shimizu T, Asano T, Iwasaki N, Takahashi D. Radiological predictors associated with success of treatment for developmental dysplasia of hip using the Pavlik harness: A retrospective study. J Orthop Sci 2022; 27:1067-1072. [PMID: 34364753 DOI: 10.1016/j.jos.2021.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND While various predictors of treatment outcome of Pavlik harness have been reported, appropriate indications for treatment and relationships between patient characteristics and outcome are unclear. The present study aimed to identify radiological predictors for successful Pavlik harness treatment of DDH at the initiation of treatment and investigate the progression of radiological characteristics after successful treatment. METHODS One-hundred-forty-two of 527 infants who visited our hospital for secondary screening of DDH were treated with the Pavlik harness. One-hundred-eight hips of 108 infants experienced successful treatment and could be followed up until 3 years of age (group S); treatment was unsuccessful within the first 2 weeks for 22 hips of 21 infants (group F). We investigated the Graf classification and radiological parameters. RESULTS We observed the ipsilateral-side measurements of distance A and B as defined by Yamamuro and Chene's method to be significantly smaller and greater, respectively, in group F compared with those of group S. Group F tended to exhibit the smaller distance A and larger distance B compared to the group S among the same Graf type. The cut-off values for successful treatment at were >7.4 mm at initiation of treatment for distance A and <11.2 mm for distance B. The acetabular index (AI) of the ipsilateral side at the initiation of treatment was significantly correlated with that at 1 and 3 years of age. Patients with an AI of >32° at the initiation of harness treatment were more likely to exhibit hip dysplasia at 3 years of age. CONCLUSIONS Radiographic parameters prior to the Pavlik harness could be predictors of treatment failure and DDH in the future. This study showed that AI at the initiation of treatment is associated with residual acetabular dysplasia, suggesting that radiographic assessment may be useful even considering the risks associated with radiation exposure.
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Affiliation(s)
- Takuya Ogawa
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tomohiro Shimizu
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tsuyoshi Asano
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Daisuke Takahashi
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
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Ma S, Zhou W, Li L, Wang E, Zhang L, Li Q. Retrospective Comparison of Outcomes Between Closed and Open Reduction for Developmental Dysplasia of the Hip in Children Aged 6-24 Months. Indian J Orthop 2022; 56:1640-1646. [PMID: 36052390 PMCID: PMC9385909 DOI: 10.1007/s43465-022-00690-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/13/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE We aimed to compare the outcomes between closed reduction (CR) and open reduction (OR) in children aged 6-24 months with developmental dysplasia of the hip (DDH) who could be reduced safely and stably by the closed reduction operation. METHODS We retrospectively reviewed the medical records of 77 patients who underwent CR or OR for DDH. Fifty-one patients (56 hips) underwent CR, 26 (29 hips) underwent OR. The demographic data, International Hip Dysplasia Institute classification and acetabular index (AI) before reduction and the centre-edge angle (CEA), AI, Alsberg angle (AA), Reimer's migration index (RMI), and height-to-width index (HWI) of the epiphysis were compared between two groups at the final follow-up. The percentage of coxa magna > 15% of the normal side and AA > 81° were calculated. RESULTS At the final follow-up, the mean AA in the CR and OR groups were 77.66° (60°-89°) and 81.97° (73°-91°) (p = 0.001), respectively, there were 32.14% and 58.62% of the hips with an AA > 81° (p = 0.019). The frequency of coxa magna > 15% of the normal side was higher in the OR group (60.9%) than in the CR group (6.5%) (p < 0.001). There was no difference in the improvement of AI, CEA, HWI, and RMI. CONCLUSION In children aged 6-24 months with DDH, if a stable and safe CR can be obtained but with medial joint space up to 6mm, CR should be attempted first.
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Affiliation(s)
- Shuyu Ma
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
| | - Weizheng Zhou
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
| | - Lianyong Li
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
| | - Enbo Wang
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
| | - Lijun Zhang
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
| | - Qiwei Li
- Department of Pediatric Orthopedics, Shengjing Hospital of China Medical University, Shenyang, 110004 China
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Motta GGB, Chiovatto ARS, Chiovatto ED, Duarte ML, de Lourenço AF, Takahashi MS, Rodrigues NVM, Iared W. Measurement of Pubofemoral Distance in the Diagnosis of Developmental Dysplasia of the Hip: Sensitivity and Specificity. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1205-1212. [PMID: 34405425 DOI: 10.1002/jum.15811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/26/2021] [Accepted: 07/11/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To evaluate the accuracy of measurement of the pubofemoral distance (PFD) for the diagnosis of developmental dysplasia of the hip (DDH), using the Graf method as the reference standard. METHODS This was a prospective diagnostic accuracy study evaluating 1980 hips in at-risk neonates. The PFD measurement and the Graf method were performed at the same opportunity, with the hips in the same position (slightly flexed, adducted, and medially rotated). RESULTS In our sample, the prevalence of DDH, defined as Graf type IIb or higher, was 15.6%. The mean PFD for dysplastic hips was 3.5 mm (median, 3.3 mm), whereas it was 3.0 mm (median, 2.9 mm) for nondysplastic hips. In both groups, there was a significant overlap between the PFD measurements and the Graf classifications. The PFD cutoff with the largest area under the receiver operating characteristic curve was 3.0 mm, which was found to have a sensitivity and specificity of 63.6 and 62.2%, respectively, with positive and negative predictive values of 31.2 and 71.4%, respectively, for the diagnosis of DDH. CONCLUSION Measurement of the PFD shows good overall accuracy for the diagnosis of DDH. However, given its low-positive predictive value, it should not be considered to be a replacement for the Graf method.
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Affiliation(s)
- Giovanna Galvão Braga Motta
- Department of Evidence-Based Health, Federal University of the State of São Paulo, São Paulo, Brazil
- Department of Ultrasonography, Ultrasonography Improvement and Research Center Prof. Dr. Giovanni Guido Cerri (DASA), São Paulo, Brazil
| | | | - Eduardo Davino Chiovatto
- Department of Ultrasonography, Ultrasonography Improvement and Research Center Prof. Dr. Giovanni Guido Cerri (DASA), São Paulo, Brazil
| | - Marcio Luís Duarte
- Department of Evidence-Based Health, Federal University of the State of São Paulo, São Paulo, Brazil
| | | | | | | | - Wagner Iared
- Department of Evidence-Based Health, Federal University of the State of São Paulo, São Paulo, Brazil
- Department of Ultrasonography, Ultrasonography Improvement and Research Center Prof. Dr. Giovanni Guido Cerri (DASA), São Paulo, Brazil
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Fludder CJ, Keil BG, Neave MJ. Case report: Morphological changes evident after manual therapy in two cases of late-diagnosed developmental dysplasia of the hip. Front Pediatr 2022; 10:1045812. [PMID: 36776679 PMCID: PMC9909744 DOI: 10.3389/fped.2022.1045812] [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: 09/16/2022] [Accepted: 12/28/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Late diagnosed Developmental Dysplasia of the Hip (DDH) is the detection of DDH after 3 months of age and is associated with significantly poorer outcomes than when diagnosed and managed early. Late diagnosed DDH has lower rates of success with bracing, higher rates of surgery and higher rates of complications, including avascular necrosis of the femoral head and early osteoarthritis of the hip. We describe two cases of late-diagnosed DDH which demonstrated changes in femoroacetabular joint morphology on radiographic interpretation after a 6-month trial period of manual therapy. CASE PRESENTATION Two cases (13 and 30 months of age) with late-diagnosed DDH presented to a private chiropractic clinic for conservative, non-bracing management. One case had unilateral DDH and the other bilateral DDH. A trial of manual therapy was utilized over a 6-month period. Both cases demonstrated changes to femoroacetabular morphology as well as improvements in gross motor activity and lower extremity muscle tone. CONCLUSION Manual therapy, as an adjunct or alternative to static bracing, may be of benefit in individuals with late-diagnosed DDH not responding to bracing, and prior to more invasive interventions. Additional cases of manual therapy-based management of this condition are required to inform the design of future trials to investigate this hypothesis.
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Liu KY, Wu KW, Lee CC, Lin SC, Kuo KN, Chang JF, Wang TM. A Long-Term Study of Alignment Correction Following Proximal Femoral Varus Osteotomy and Pemberton Osteotomy in Children With Legg-Calvé-Perthes Disease and Developmental Dysplasia of the Hip. Front Pediatr 2022; 10:835447. [PMID: 35463899 PMCID: PMC9020772 DOI: 10.3389/fped.2022.835447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/14/2022] [Indexed: 12/01/2022] Open
Abstract
Proximal femoral varus osteotomy (PFVO) is a common procedure performed in children with developmental dysplasia of the hip (DDH) and Legg-Calvé-Perthes disease (LCPD). However, the long-term effect on angular deformities of the knees and ankles following PFVO remains controversial. This study investigated the relationship between PFVO and alignment changes in the knee and ankle after the procedure. Twenty-five patients undergoing PFVO procedure with a minimum 4-year evaluation period were enrolled in the study, including 14 unilateral LCPD and 11 unilateral DDH. The standing scanogram examinations were collected before the operation, immediately following surgery, after a 1-year follow-up, after a 3-year follow-up, and at the final visit to the clinic. The radiographic parameters included leg length, femoral neck-shaft angle (FNSA), femorotibial angle (FTA), mechanical axis deviation (MAD), tibiotalar angle (TTA), and mechanical lateral distal femoral angle (mLDFA). At the final examination, FNSA demonstrated insignificant change between the operative and non-operative limbs in the DDH group. Compared with the postoperative result, FNSA significantly improved in the LCPD group (p = 0.039). Both groups did not develop statistical significance in TTA, mLDFA, MAD, and leg length discrepancy after more than a 5-year follow-up. From a biomechanical perspective that the foot passes more medial to the knee under the center of leg mass, varus knee was prone to develop. In order to correct the mechanical axis, the knee reverted to a valgus position gradually. Our study indicates that patients with LCPD or DDH receiving PFVO and Pemberton osteotomy narrow the gap of angular growth in knees and ankles between the operative and non-operative limbs after a long-term follow-up.
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Affiliation(s)
- Kuei-Yu Liu
- Department of Medical Education, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kuan-Wen Wu
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Che Lee
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Chieh Lin
- Department of Orthopaedic Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ken N Kuo
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Jia-Feng Chang
- Department of Internal Medicine, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Ting-Ming Wang
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei, Taiwan.,Department of Orthopaedic Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
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Lee SH, Ahn KS, Jung HW, Jang WY. The limbus in developmental dysplasia of the hip: An obstacle to reduction and its images changed by the femoral head position. Medicine (Baltimore) 2021; 100:e28198. [PMID: 34941078 PMCID: PMC8702278 DOI: 10.1097/md.0000000000028198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/12/2021] [Accepted: 11/19/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT This study aimed to describe the shape of the limbus arthroscopically and via arthrogram and magnetic resonance imaging (MRI), and to determine whether it prevents concentric reduction of the femoral head in developmental dysplasia of the hip (DDH).Twelve patients (mean age, 10.2 months; range, 3-31 months) who underwent arthroscopic-assisted reduction for DDH were retrospectively reviewed. Limbus shapes were captured on arthrogram before reduction, after closed reduction, and after arthroscopic-assisted reduction and categorized according to the Miyake classification.On arthrogram, the superior limbus was blocked in 2 hips, inverted in 2, intermediate in 5, and everted in 3 after attempted closed reduction. After arthroscopic-assisted reduction, the limbus was everted in 7 hips and normal in 5. On arthroscopy, in all cases, the limbus appeared as a whitish, cartilage-like ring with a variably blunted edge before reduction, without inversion or eversion. On postoperative MRI, 10 of 12 superior limbi showed hypertrophy or globular compression by the femoral head with intermediate or mixed MRI signal intensities and blunted edges. The remaining 2 hips had hypertrophied superior limbi with sharp edges. On transverse plane MRI, the posterior limbus of all hips showed sharp margins with low MRI signal intensity. Residual subluxation was observed in 7 of the 12 hips with interposition of the anteroinferior limbus.The appearance of the limbus varied according to the femoral head position, and it was neither inverted nor everted. Interposed anteroinferior limbi with residual subluxation suggest impeded concentric reduction in DDH.
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Affiliation(s)
- Soon Hyuck Lee
- Department of Orthopedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Sik Ahn
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hae Woon Jung
- Department of Pediatrics, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Woo Young Jang
- Department of Orthopedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Venkatadass K, Prasad VD, Jain D, Rajasekaran S. Short-term outcomes of treatment in children presenting with DDH in walking age - An analysis of 84 hips. J Clin Orthop Trauma 2021; 24:101712. [PMID: 34881171 PMCID: PMC8628216 DOI: 10.1016/j.jcot.2021.101712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/29/2021] [Accepted: 11/14/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Developmental Dysplasia of Hip (DDH) presenting at walking age is not uncommon, particularly in developing countries. The available treatment modalities in this age group are closed reduction (CR), open reduction (OR), OR with additional femoral and/or pelvic osteotomy. This study was done in patients who presented between 12 and 36 months of age to assess the following: 1) Percentage of hips amenable for successful CR, 2) failure rate after CR and OR in walking age DDH and 3) the need for secondary procedures to address subluxation and residual dysplasia within first 2 years. METHOD ology: After IRB approval, the institutional database was searched for patients admitted with a diagnosis of DDH from January 2009 to January 2019. We identified 142 patients, of which 65 patients with 84 hips formed the study cohort after applying inclusion and exclusion criteria. Demographic details, details of the interventions, brace wear, revision procedures and radiological data were collected from Hospital Information System. We divided the patients in three groups: Group I - CR, Group II -OR, and Group III - OR with an additional bony procedure in the form of femoral and/or pelvic osteotomy. RESULTS The mean age at presentation was 20.1 months. We had 10 (11.9%) hips in group I, 39 (46.4%) hips in group II and 35 (41.6%) hips in group III. The mean follow-up was 44.8 months (24-132 months). In Group I, 5 (50%) had re-dislocation and 2 (20%) needed revision intervention for residual dysplasia. In Group II, 4 (10%) had re-dislocation and 4 (10%) needed revision intervention. In Group III, 5 (14.2%) hips needed revision intervention for residual dysplasia. The mean final AI was 24.6°in Group I, 28.2° in Group II and 26.3°in Group III. There was no significant difference in the final AI between the groups (p > 0.05). CONCLUSIONS An attempted closed reduction has a 50% failure rate, and we recommend a low threshold for open reduction. There is a 10% rate of re-dislocation following open reduction with or without additional bony procedure. About 50% of the dysplastic hips treated without pelvic osteotomy at the time of index procedure fail to remodel and have residual acetabular dysplasia.
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Affiliation(s)
- K. Venkatadass
- Corresponding author. Ganga Hospital. 313, Mettupalayam Main Road, Coimbatore, Tamilnadu, India.
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Young JR, Anderson MJ, O'Connor CM, Kazley JM, Mantica AL, Dutt V. Team Approach: Developmental Dysplasia of the Hip. JBJS Rev 2021; 8:e20.00030. [PMID: 32890048 DOI: 10.2106/jbjs.rvw.20.00030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of hip disorders, including neonatal instability, acetabular dysplasia, hip subluxation, and frank dislocation of the hip. It is a common disorder, with a reported incidence of between 0.1% and >10% of live births.
Coordinated, interdisciplinary care is important to achieving successful outcomes. This starts with accurate assessment of risk factors in the prenatal period, thorough clinical examination by the primary care provider at all well-child visits, and early referral to a pediatric orthopaedic surgeon for prompt diagnosis and treatment. Early diagnosis and prompt treatment is critical for an excellent outcome. Ongoing, open communication between clinicians is essential for the effective coordination of care. Treatment options vary depending on the age of presentation. A Pavlik harness (dynamic hip abduction orthosis) is used for children up to 6 months of age. A more rigid abduction orthosis may be used if treatment with a Pavlik harness is unsuccessful, with a closed reduction and spica cast being the next step if needed for children up to 18 months of age. Finally, open reduction with possible concomitant femoral and/or pelvic osteotomies is the surgical option in an older child, when necessary. In general, the later the child is diagnosed with and treated for DDH, the greater the risk of a nonoptimal outcome. Depending on the severity of the condition, children with DDH may need to be followed closely until skeletal maturity so as not to miss the diagnosis of asymptomatic residual hip dysplasia, which can predispose patients to early hip arthritis.
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Affiliation(s)
- Joseph R Young
- Division of Orthopedic Surgery, Albany Medical Center, Albany, New York
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Lamback EB, Chiarini S, Roposch A, Dattani MT. Congenital growth hormone deficiency associated with hip dysplasia and Legg-Calve-Perthes disease. Clin Endocrinol (Oxf) 2021; 94:590-597. [PMID: 33147364 DOI: 10.1111/cen.14365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/11/2020] [Accepted: 11/01/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Growth hormone deficiency (GHD) is usually treated with recombinant human GH (rhGH), and this has been rarely associated with hip disorders. We analysed the clinical data of patients with congenital GHD receiving rhGH who had associated hip dysplasia or Legg-Calve-Perthes disease (LCPD), with a view to determining whether the hip dysplasia was associated with the underlying disease or with rhGH treatment. DESIGN We performed a retrospective analysis of paediatric and adolescent patients seen between 1992-2018 with congenital GHD and hip disorders. Data were collected through a review of the patients' medical records and included demographics, clinical and imaging data, and the time frame between the onset of the symptoms related to the hip disorders and the onset of GH treatment. RESULTS Of the 13 patients with hip disorders, hip dysplasia was present in ten patients and LCPD in three. Hip dysplasia was diagnosed before rhGH was initiated in 50% of cases. These patients had bilateral hip dysplasia and isolated GHD. LCPD was diagnosed in one patient before rhGH was commenced and did not progress. In two patients, LCPD was diagnosed after rhGH was started and did temporarily progress in one of them, but rhGH was not discontinued because LCPD did not seem to be related to rhGH treatment. CONCLUSIONS This study suggests that hip dysplasia could be a manifestation of an underlying GHD. Additionally, rhGH treatment may not necessarily be causative of LCPD.
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Affiliation(s)
| | | | | | - Mehul T Dattani
- Great Ormond Street Hospital for Children, London, UK
- UCL GOS Institute of Child Health, University College London, London, UK
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Zargarbashi R, Bozorgmanesh M, Panjavi B, Vosoughi F. The path to minimizing instability in developmental dysplasia of the hip: is Capsulorrhaphy a necessity or a futile habit? BMC Musculoskelet Disord 2021; 22:199. [PMID: 33596895 PMCID: PMC7890870 DOI: 10.1186/s12891-021-04065-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background To evaluate and quantify the intraoperative effect of capsulorrhaphy on the deep seating of femoral head within the acetabulum as measured by medial joint space, a surrogate measure of acetabular-head contact. Methods In order to determine the exact effect of capsulorrhaphy, we prospectively scrutinized a consecutive sample of 18 patients with unilateral dysplastic hips aging > 18 months and followed them for a period of at least 12 months. The procedure of open reduction is described in detail. Two pediatric orthopedists carried out the operations from August 2014 to January 2019 at a tertiary pediatric hospital. Intraoperatively, AP radiographs of the pelvis were obtained before and after capsulorrhaphy. The distance between the inferomedial edge of the proximal femoral metaphysis and the lateral edge of the obturator foramen was recorded. To determine if there were differences in medial joint space due to capsulorrhaphy, a generalized linear model was run on the study sample. All patients were followed for at least 12 months to determine the rate of re-dislocation. Results Mean age (±standard deviation) of the participants was 37.5 (±24.7) months. All cases underwent Salter osteotomy, 5 cases needed femoral shortening (27.8%) and none needed derotational osteotomy. Capsulorrhaphy lead to a statistically significant decrease in the mean medial joint space from 1.59 cm before (95% CI: 1.12–2.05) to 0.76 cm after (95% CI: 0.50–1.02) the capsulorrhaphy (P < 0.001). When we took the effect of age into account the corresponding figures were 1.47 (95% CI: 1.22–1.75) and 0.67 (95% CI: 0.39–0.94), respectively (P < 0.001). After follow up periods of 1 to 5.5 years, none of the patients experienced instability or re-dislocation. Conclusions Capsulorrhaphy, independently, of age was associated with a 1-cm decrease in the mean medial hip joint space and a more deeply seated femoral head. Furthermore, this study presents a successful experience with capsulorrhaphy to prevent hip instability.
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Affiliation(s)
- Ramin Zargarbashi
- Department of Pediatric Orthopedics, Children's Medical Center and school of medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Bozorgmanesh
- Department of Orthopedic Surgery, Vali-e-Asr Hospital, Arak University of Medical Science, Arak, Iran
| | - Behnam Panjavi
- Department of Pediatric Orthopedics, Children's Medical Center and school of medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fardis Vosoughi
- Department of Orthopaedic and Trauma Surgery, Jalal Street, Shariati Hospital and school of medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Pavone V, de Cristo C, Vescio A, Lucenti L, Sapienza M, Sessa G, Pavone P, Testa G. Dynamic and Static Splinting for Treatment of Developmental Dysplasia of the Hip: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2021; 8:104. [PMID: 33557053 PMCID: PMC7913860 DOI: 10.3390/children8020104] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Developmental dysplasia of the hip (DDH) is one of the most common pediatric conditions. The current gold-standard treatment for children under six months of age with a reducible hip is bracing, but the orthopedic literature features several splint options, and each one has many advantages and disadvantages. The aim of this review is to analyze the available literature to document the up-to-date evidence on DDH conservative treatment. METHODS A systematic review of PubMed and Science Direct databases was performed by two independent authors (C.d.C. and A.V.) using the keywords "developmental dysplasia hip", "brace", "harness", "splint", "abduction brace" to evaluate studies of any level of evidence that reported clinical or preclinical results and dealt with conservative DDH treatment. The result of every stage was reviewed and approved by the senior investigators (V.P. and G.T.). RESULTS A total of 1411 articles were found. After the exclusion of duplicates, 367 articles were selected. At the end of the first screening, following the previously described selection criteria, we selected 29 articles eligible for full text reading. The included articles mainly focus on the Pavlik harness, Frejka, and Tubingen among the dynamic splint applications as well as the rhino-style brace, Ilfeld and generic abduction brace among the static splint applications. The main findings of the included articles were summarized. CONCLUSIONS Dynamic splinting for DDH represents a valid therapeutic option in cases of instability and dislocation, especially if applied within 4-5 months of life. Dynamic splinting has a low contraindication. Static bracing is an effective option too, but only for stable hips or residual acetabular dysplasia.
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Affiliation(s)
- Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, 95123 Catania, Italy; (C.d.C.); (A.V.); (L.L.); (M.S.); (G.S.); (G.T.)
| | - Claudia de Cristo
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, 95123 Catania, Italy; (C.d.C.); (A.V.); (L.L.); (M.S.); (G.S.); (G.T.)
| | - Andrea Vescio
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, 95123 Catania, Italy; (C.d.C.); (A.V.); (L.L.); (M.S.); (G.S.); (G.T.)
| | - Ludovico Lucenti
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, 95123 Catania, Italy; (C.d.C.); (A.V.); (L.L.); (M.S.); (G.S.); (G.T.)
| | - Marco Sapienza
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, 95123 Catania, Italy; (C.d.C.); (A.V.); (L.L.); (M.S.); (G.S.); (G.T.)
| | - Giuseppe Sessa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, 95123 Catania, Italy; (C.d.C.); (A.V.); (L.L.); (M.S.); (G.S.); (G.T.)
| | - Piero Pavone
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, 95123 Catania, Italy;
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, 95123 Catania, Italy; (C.d.C.); (A.V.); (L.L.); (M.S.); (G.S.); (G.T.)
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Part-time Abduction Bracing in Infants With Residual Acetabular Dysplasia: Does Compliance Monitoring Support a Dose-dependent Relationship? J Pediatr Orthop 2021; 41:e125-e129. [PMID: 33165268 DOI: 10.1097/bpo.0000000000001704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Residual acetabular dysplasia is often seen after successful Pavlik treatment or during follow-up for infants with risk factors for developmental dysplasia of the hip. A previous study supported the effectiveness of part-time abduction bracing for treating this residual dysplasia. However, the relationship between time in the brace and acetabular improvement was not established given the lack of compliance data. The purpose of this prospective study was to validate the effect of part-time bracing on acetabular dysplasia and determine if a dose-dependent relationship exists. METHODS Eligibility criteria included infants ~6 months of age with an AP pelvic radiograph demonstrating acetabular dysplasia, defined as an acetabular index (AI) ≥30 degrees. After obtaining informed consent, a rigid abduction orthosis was prescribed with a thermal compliance sensor. Patients were instructed to wear the brace for nights/naps and follow-up at 1 year of age for repeat radiograph. AIs were measured by the senior author who was blinded to the compliance data. Hours of wear were compared with changes in AI over the study period using descriptive statistics and a generalized estimating equation model. RESULTS Our series consisted of 26 infants (36 hips) with a mean age at enrollment of 5.9 months (range, 4.9 to 7.9); 84.6% were female individuals. At a mean follow-up of 6 months (range, 5.1 to 8.2), average wear time/day was 11.5 hours (range, 1.3 to 21.7), and total time in brace averaged 1698 hours (range, 218 to 3244 hours). The mean improvement in AI over the study period was 4.8 degrees (95% confidence interval, 3.9-5.5 degrees). The authors found a significant correlation between average hours of brace wear per day and improvement in AI (r=0.36, P<0.05), a relationship that remained significant in our multivariate model after adjusting for confounders. CONCLUSIONS Part-time abduction bracing is effective for treating residual dysplasia, with the degree of improvement in AI correlating with hours of brace wear per day. Given this dose-dependent relationship, the optimal hours of wear may depend on the severity of residual dysplasia and the tolerance of the child and family to bracing.
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Should I Plan to Open? Predicting the Need for Open Reduction in the Treatment of Developmental Dysplasia of the Hip. J Pediatr Orthop 2020; 40:e329-e334. [PMID: 31385896 DOI: 10.1097/bpo.0000000000001429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Closed reduction is generally attempted on children under 18 months of age who present as older infants or who fail nonoperative management for developmental dysplasia of the hip (DDH). However, many of these patients will not achieve concentric reduction by closed means and will ultimately require open reduction (OR). Limited evidence exists to predict which patients can be adequately closed reduced versus those who will need open treatment. METHODS Prospectively collected data from 4 select centers of an international multicenter study group sharing a common treatment approach were reviewed for all DDH infants under 18 months old that required operative management. Patients were categorized into 2 groups: those whose hips were successfully closed reduced or those who ultimately required OR. Factors were compared between the closed reduction and OR groups for 2 separate cohorts-those presenting early in life with ultrasound (US) data, and those presenting later with radiographic data. RESULTS A total of 154 patients (166 hips) were included in the analysis. Overall, 87.3% were female. In the early-presenting cohort, purposeful entry multivariate regression revealed that patients with Graf IV hips on US had 3.8 times higher odds of requiring an OR. For the later cohort, hips that were clinically irreducible (ie, negative Ortolani sign) had 3.3 times higher odds of requiring OR. Patients with International Hip Dysplasia Institute (IHDI) grade IV hips had 2.5 times higher odds of needing an OR versus those with grade III hips and 15.4 times higher odds than those with grade II hips. Children with an IHDI grade IV hip and a negative Ortolani sign had 4.4 times higher odds of needing OR. CONCLUSION Children younger than 18 months with dislocated hips who require OR are more likely to have a high-grade radiographic dislocation (IHDI grade IV), negative preoperative Ortolani sign, and a Graf IV classification on initial US. This information may help surgeons budget the use of operating room time and better counsel parents about intraoperative expectations. LEVEL OF EVIDENCE Level III-Prognostic.
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Zhang Z, Li H, Li H, Zhang Z. Timing for closed reduction procedure for developmental dysplasia of the hip and its failure analysis. BMC Musculoskelet Disord 2020; 21:613. [PMID: 32928170 PMCID: PMC7488999 DOI: 10.1186/s12891-020-03635-1] [Citation(s) in RCA: 9] [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] [Received: 06/18/2020] [Accepted: 09/07/2020] [Indexed: 11/17/2022] Open
Abstract
Background It remains controversial whether the older age to perform closed reduction (CR) procedure for developmental dysplasia of the hip (DDH), the higher incidence of complications. The aim of this study is to evaluate the midterm outcome of CR for DDH among different age groups, and to analyze and identify risk factors for the failure of this procedure. Methods Clinical data of 107 DDH patients, who received CR, were retrospectively reviewed. Data were divided into three groups according to initial treatment age (Group I: younger than 12 months; Group II: 12 months to less or equal to18 months; Group III: older than 18 months). The presence of avascular necrosis (AVN), residual acetabular dysplasia (RAD), re-dislocation, and further surgeries (FS) were observed. The risk factors were identified for those outcomes aforementioned using univariable logistic regression models. For identified risk factor age, pre-op acetabular index (AI) and post-op AI, their prediction of CR failure were evaluated by receiver operating characteristics curve (ROC). Results A total of 107 patients (156 hips) undergoing CR procedure were evaluated with a median age at initial reduction of 13.0 ± 5.4 months (range, 4 to 28 mo). Mean follow-up time in this study was 6.7 ± 0.8 years (range, 3–8 years). The incidence of AVN, RAD and re-dislocation was 15.4% (24/156), 17.3% (27/156) and 14.7% (23/156) respectively. For AVN, RAD and re-dislocation, the significant risk factors are pre-op IHDI IV (p = 0.033), age ≥ 18 months (p = 0.012), and pre-op IHDI IV (p = 0.004) and walking (p = 0.011), respectively. The areas under the ROC curve of each type of failures were 0.841 (post-op AI), 0.688 (pre-op AI) and 0.650 (age). Conclusions Severe DDH patients older than 18 months with CR procedure may result in a high risk of RAD complication. Re-dislocation is significantly associated with pre-op IHDI IV and walking. Patients, who are older than 12.5 months or have a pre-op AI of 38.7° or a post-op AI of 26.4°, are also more likely to fail of CR procedure.
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Affiliation(s)
- Zhiqiang Zhang
- Department of Orthopedics, National Children's Medical Center & Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Hao Li
- Department of Orthopedics, Shanghai Sixth People's Hospital, School of Medicine, Shanghai Jiaotong University, 600 Yishan Road, Shanghai, 200233, China
| | - Hai Li
- Department of Pediatric Orthopedics, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Ziming Zhang
- Department of Pediatric Orthopedics, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China.
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Scott EJ, Dolan LA, Weinstein SL. Closed Vs. Open Reduction/Salter Innominate Osteotomy for Developmental Hip Dislocation After Age 18 Months: Comparative Survival at 45-Year Follow-up. J Bone Joint Surg Am 2020; 102:1351-1357. [PMID: 32769602 DOI: 10.2106/jbjs.19.01278] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite widespread use of single-stage open reduction and pelvic osteotomy for treatment of developmental dysplasia of the hip (DDH) after walking age, this aggressive strategy remains controversial. We directly compared dislocated hips treated with closed reduction (CR) to those treated with open reduction and Salter innominate osteotomy (OR/IO) to estimate the relative hazard of total hip arthroplasty (THA) and the THA-free survival time. METHODS In a series of patients 18 to 60 months of age, 45 patients (58 hips) underwent CR and 58 patients (78 hips) were treated with OR/IO and followed to a minimum 40 years post-reduction. Observations in the survival analysis were censored if no THA had occurred by 48 years. Multivariate Cox regression analysis was used to estimate the hazard of THA given treatment, age, and bilaterality. Complications and additional procedures were noted. RESULTS At 48 years of follow-up, 29 (50%) of the hips survived after CR compared with 54 (69%) after OR/IO. At 45 years, the survival probability after OR/IO was 0.63 (95% confidence interval [CI] = 0.50 to 0.78) compared with 0.55 (95% CI = 0.43 to 0.72) after CR. The hazard ratio (HR) of THA was modeled as a function of treatment, age at reduction, and bilaterality. The effect of age and treatment on the outcome of hips in patients with unilateral involvement was minimal. However, age did significantly alter the relationship between treatment and outcome in bilateral cases. In the bilateral group, the predicted HR of THA was lower after CR in hips that were reduced at the age of 18 months (HR = 0.16, 95% CI = 0.04 to 0.64) but higher in those that were reduced at 36 months (HR = 4.23, 95% CI = 2.00 to 8.95). Additional procedures were indicated for 17% and 22% of hips after CR and OR/IO, respectively. CONCLUSIONS Osteoarthritis and THA was more likely after CR than OR/IO, but the data do not indicate a difference in unadjusted hip-survival time. In patients with bilateral disease, an older age at reduction was associated with an increased hazard of THA after CR than after OR/IO. Both treatments provided substantial benefit relative to the natural history of DDH, but THA is the expected outcome in middle adulthood. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Elizabeth J Scott
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa, Iowa City, Iowa
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How to determine the type of femoral osteotomy in the management of developmental dysplasia of the hip: a prospective case series. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alhussainan TS, Alghamdi AM, Almogbel RA. Surgical outcomes of open hip reduction with synovectomy for developmental dysplasia of the hip patient with Juvenile idiopathic arthritis: A case report. Int J Surg Case Rep 2020; 72:482-485. [PMID: 32698270 PMCID: PMC7321781 DOI: 10.1016/j.ijscr.2020.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Developmental dysplasia of the hip (DDH) is a common hip disorder and its association with other musculoskeletal, genetic, and neurological diseases were well described in the literature. Juvenile idiopathic arthritis (JIA) is a rare rheumatological condition, and its presence in a Developmental dysplasia of the hip (DDH) child makes this a very challenging case. PRESENTATION OF THE CASE This case report is describing the presentation of 9 months old girl to orthopedic service referred from the pediatric rheumatology clinic after diagnosing her and starting the treatment for Juvenile idiopathic arthritis (JIA). Bilateral neglected Developmental dysplasia of the hip (DDH) - International Hip Dysplasia Institute (IHDI) type 4- was detected during her clinical and radiological assessment, necessitating surgical management after controlling her Juvenile idiopathic arthritis (JIA). The surgical procedure and its clinical and radiological outcomes more than four years after her surgical treatment are described in detail in this report as well. DISCUSSION The management of Developmental dysplasia of the hip (DDH) associated with Juvenile idiopathic arthritis (JIA) has no established guidelines in literature. Here, we share our experience in managing such rare cases. We believe that medical control of Juvenile idiopathic arthritis (JIA) before proceeding for open reduction of Developmental dysplasia of the hip (DDH) is the key to successful results. CONCLUSION The reported case is uniquely having both Developmental dysplasia of the hip (DDH) and Juvenile idiopathic arthritis (JIA) treated with open reduction, pelvic osteotomy, and femoral shortening resulting in outstanding clinical and radiological outcomes.
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Affiliation(s)
- Thamer S Alhussainan
- Department of Orthopedic Surgery, Pediatric Orthopedic Unit, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah M Alghamdi
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Rakan A Almogbel
- Department of Surgery, Division of Orthopedic Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.
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Swarup I, Ge Y, Scher D, Sink E, Widmann R, Dodwell E. Open and Closed Reduction for Developmental Dysplasia of the Hip in New York State: Incidence of Hip Reduction and Rates of Subsequent Surgery. JB JS Open Access 2020; 5:e0028. [PMID: 32309756 PMCID: PMC7147636 DOI: 10.2106/jbjs.oa.19.00028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: There are limited data on the incidence and outcomes of open and closed hip reduction in patients with developmental dysplasia of the hip (DDH). The aims of this study were to determine the incidence of open and closed reduction of the hip using population-level data and to assess the rates of subsequent surgery. Methods: Children aged 3 years and younger with DDH who underwent open or closed reduction of the hip between 1997 and 2013 were identified in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patient age, sex, race, and insurance status as well as concurrent procedures were extracted. Admissions through 2014 were searched for subsequent surgeries, providing a minimum 1-year post-reduction surveillance for all patients. Age-specific incidence rates were calculated using New York State annual population data. The rates of concurrent and subsequent surgeries were calculated. A sensitivity analysis was performed to provide a range for the rates of subsequent surgery. Univariate analyses consisted of chi-square or Fisher exact tests for categorical variables. Results: In total, 897 patients (637 who underwent closed reduction and 260 who underwent open reduction) were identified. The age-specific incidence per 100,000 population was 12.5 for closed reduction and 2.6 for open reduction for <1-year-olds, 2.2 for both closed and open reductions for 1-year-olds, 0.4 for closed reduction and 1.0 for open reduction for 2-year-olds, and <0.3 for closed reduction and 0.5 for open reduction for 3-year-olds. Overall, closed reductions were performed more frequently over the study period (p < 0.01). The estimated rate of subsequent ipsilateral surgery was 12.4% (range, 9.4% to 33.1%) after index closed reduction and was 14.2% (range, 8.5% to 40.1%) after index open reduction. Conclusions: We found that the incidence of closed or open hip reduction for DDH was small and that there was an increase in the number of closed reductions performed over time. The rates of subsequent surgery remained relatively high for patients after index closed or open hip reduction. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ishaan Swarup
- UCSF Benioff Children's Hospital, Oakland, California
| | - Yile Ge
- Hospital for Special Surgery, New York, NY
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Ucpunar H, Mert M, Camurcu Y, Sofu H, Yildirim T, Bayhan AI. Does Adductor Tenotomy Need During Closed Reduction Have a Prognostic Value in the Treatment of Developmental Dysplasia of the Hip Between 6 and 12 Months of Age? "Adductor Tenotomy in the Treatment of Developmental Dysplasia''. Indian J Orthop 2020; 54:486-494. [PMID: 32549964 PMCID: PMC7270239 DOI: 10.1007/s43465-020-00079-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/24/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Adductor tenotomy is needed for clinically complex hips with soft-tissue contractures. It may be proposed that the patients who need adductor tenotomy during closed reduction would have poorer prognosis than the ones without need for adductor tenotomy. The main purposes were to compare the normalization of acetabular index angle (AI), to determine the incidence of femoral head avascular necrosis (AVN), and to predict the need for any secondary surgical intervention between the patients who need adductor tenotomy and those who do not during closed reduction for developmental dysplasia of the hip. MATERIALS AND METHODS The study group consisted of 65 hips treated between 6 and 12 months of age. The mean age at the time of surgery was 8.1 ± 1.4 (6-12) months and the mean follow-up was 4.2 ± 1.5 years. Improvement of AI, rate and severity of AVN, and need for secondary surgery with its predictors were evaluated. RESULTS Adductor tenotomy was performed in 22 hips (Group 1), but not in 43 hips (Group 2). Normalization of the AI was - 14.8° ± 3.5° versus - 14.3° ± 3.2°. The overall incidence of AVN was 18.4%. The rate of secondary surgical intervention was higher in Group 1 (63.1% versus 36.9%) (p = 0.014). CONCLUSIONS No significant difference was detected regarding the improvement of AI as well as the incidence of AVN between the groups. The need for adductor tenotomy during closed reduction was one of the main predictors of the possible secondary surgery.
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Affiliation(s)
- Hanifi Ucpunar
- Department of Orthopedics and Traumatology, Erzincan Binali Yıldırım University Faculty of Medicine, Erzincan, Turkey
| | - Muhammed Mert
- University of Health Sciences, Baltalimani Bone Diseases Training and Research Center, Istanbul, Turkey
| | - Yalkin Camurcu
- Department of Orthopedics and Traumatology, Erzincan Binali Yıldırım University Faculty of Medicine, Erzincan, Turkey
| | | | - Timur Yildirim
- University of Health Sciences, Baltalimani Bone Diseases Training and Research Center, Istanbul, Turkey
| | - Avni Ilhan Bayhan
- University of Health Sciences, Baltalimani Bone Diseases Training and Research Center, Istanbul, Turkey
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Alsiddiky A, Alatassi R, Alfayez S, Alhuzaimi F, Alqarni M. Bone cement spacer: a novel technique for treating a complicated case of developmental dysplasia of the hip with an injured acetabulum: Case report with 7-year follow-up. Medicine (Baltimore) 2020; 99:e18655. [PMID: 31895830 PMCID: PMC6946272 DOI: 10.1097/md.0000000000018655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Developmental dysplasia of the hip (DDH) has an incidence of 5 per 1000 newborns and its management depends on various factors. We present a rare case of DDH with soft tissue obliteration and a bony prominence in the center of the acetabulum after failed open reduction and acetabuloplasty. PATIENT CONCERNS A 20-month-old girl presented to our clinic with right hip stiffness after undergoing open reduction and acetabuloplasty at another hospital. DIAGNOSES The diagnosis of DDH was made using a computed tomography scan that revealed a right hip dislocation with soft tissue obliteration and a bony prominence in the center of the acetabulum. INTERVENTIONS We used a novel technique for treating the rare presentation of complicated DDH with massive soft tissue obliteration and bony prominence in the center of the acetabulum after failed open reduction and acetabuloplasty. The right hip was surgically explored. The acetabulum was deepened and resurfaced. Bone cement was applied over the acetabulum to prevent future ankylosis. OUTCOMES At the follow-up 7 years after the last surgery, the patient had regained full range of motion and a properly reduced right hip with optimal acetabular coverage on radiographs. LESSONS Care must be taken in any patient with DDH who presents with hip redislocation after open reduction. If deepening and resurfacing of the acetabulum are required, bone cement could be used as a temporary spacer for 8 weeks; this was key in treating our patient.
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Affiliation(s)
- Abdulmonem Alsiddiky
- King Saud University, College of Medicine, Research Chair of Spinal Deformities, Department of Orthopedics
| | - Raheef Alatassi
- Security Forces Hospital, Department of Orthopedic Surgery, Riyadh, Saudi Arabia
| | - Saud Alfayez
- King Saud University, College of Medicine, Research Chair of Spinal Deformities, Department of Orthopedics
| | - Fahad Alhuzaimi
- King Saud University, College of Medicine, Research Chair of Spinal Deformities, Department of Orthopedics
| | - Mahdi Alqarni
- King Saud University, College of Medicine, Research Chair of Spinal Deformities, Department of Orthopedics
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Classifications in Brief: The Hartofilakidis Classification of Developmental Dysplasia of the Hip. Clin Orthop Relat Res 2020; 478:189-194. [PMID: 31135539 PMCID: PMC7000062 DOI: 10.1097/corr.0000000000000802] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Lussier EC, Sun YT, Chen HW, Chang TY, Chang CH. Ultrasound screening for developmental dysplasia of the hip after 4 weeks increases exam accuracy and decreases follow-up visits. Pediatr Neonatol 2019; 60:270-277. [PMID: 30143415 DOI: 10.1016/j.pedneo.2018.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/04/2018] [Accepted: 07/18/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Developmental dysplasia of the hip (DDH) is a preventable and treatable disorder in children. Hip ultrasound is recommended for early detection of affected hips. The timing of the initial hip ultrasound and the frequency of subsequent ultrasounds are controversial topics when considering costs and efficiency. METHODS Registry data from the Taiwanese Screening and Audit System for Developmental Dysplasia of the Hip were obtained for biometry of hip ultrasounds using the Graf classification and relevant demographic data from 2016. Initial screening results and final case management outcomes were compared to determine screening accuracy and the number of visits needed to determine final outcomes. RESULTS In total, we screened 1683 newborns in 2016. Of the initial cases screened within 28 days (n = 1168), 86.6% were negative, 10.1% positive, and 3.3% intermediate, while of the cases screened after 28 days (n = 515), 97.3% were negative, 0.8% positive, and 1.9% intermediate. Screening of the newborns' final hip outcomes revealed that 1641 (97.6%) were negative, treatment was administered in 8 cases (0.4%), and 34 (2.0%) cases were lost to follow-up. When comparing screening times, screening after 28 days improved specificity (89%-97%), and later screenings were associated with fewer visits needed to confirm hip outcomes (aOR = 0.19, CI95% = 0.10-0.38, p < 0.001) and improved accuracy (aOR = 13.84, CI95% = 4.23-45.26, p < 0.001). CONCLUSION This study provides evidence of the benefits of screening for DDH after 28 days, namely: reduced false positives, improved screening accuracy, and a reduced requirement for follow-up visits. Delaying screening can also potentially reduce unnecessary parental anxiety, eliminate unnecessary healthcare burdens, and reduce costs. We recommend performing hip ultrasound screening for newborns after 28 days.
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Affiliation(s)
| | | | - Hui-Wen Chen
- Taipei Tzu Chi Hospital, Xindian, Taiwan; Taiwan Adventist Hospital, Taipei, Taiwan
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Silva MS, Fernandes ARC, Cardoso FN, Longo CH, Aihara AY. Radiography, CT, and MRI of Hip and Lower Limb Disorders in Children and Adolescents. Radiographics 2019; 39:779-794. [DOI: 10.1148/rg.2019180101] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mariana S. Silva
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, DASA, São Paulo, Brazil (M.S.S., F.N.C., C.H.L., A.Y.A.); and Department of Diagnostic Imaging, Federal University of São Paulo (Departamento de Diagnóstico por Imagem, Universidade Federal de São Paulo), Napoleão de Barros 800, 04024-002 São Paulo, SP, Brazil (A.R.C.F., F.N.C., A.Y.A.)
| | - Artur R. C. Fernandes
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, DASA, São Paulo, Brazil (M.S.S., F.N.C., C.H.L., A.Y.A.); and Department of Diagnostic Imaging, Federal University of São Paulo (Departamento de Diagnóstico por Imagem, Universidade Federal de São Paulo), Napoleão de Barros 800, 04024-002 São Paulo, SP, Brazil (A.R.C.F., F.N.C., A.Y.A.)
| | - Fabiano N. Cardoso
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, DASA, São Paulo, Brazil (M.S.S., F.N.C., C.H.L., A.Y.A.); and Department of Diagnostic Imaging, Federal University of São Paulo (Departamento de Diagnóstico por Imagem, Universidade Federal de São Paulo), Napoleão de Barros 800, 04024-002 São Paulo, SP, Brazil (A.R.C.F., F.N.C., A.Y.A.)
| | - Carlos H. Longo
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, DASA, São Paulo, Brazil (M.S.S., F.N.C., C.H.L., A.Y.A.); and Department of Diagnostic Imaging, Federal University of São Paulo (Departamento de Diagnóstico por Imagem, Universidade Federal de São Paulo), Napoleão de Barros 800, 04024-002 São Paulo, SP, Brazil (A.R.C.F., F.N.C., A.Y.A.)
| | - André Y. Aihara
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, DASA, São Paulo, Brazil (M.S.S., F.N.C., C.H.L., A.Y.A.); and Department of Diagnostic Imaging, Federal University of São Paulo (Departamento de Diagnóstico por Imagem, Universidade Federal de São Paulo), Napoleão de Barros 800, 04024-002 São Paulo, SP, Brazil (A.R.C.F., F.N.C., A.Y.A.)
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Vafaeian B, Adeeb S, El-Rich M, Dulai SK, Jaremko JL. Prediction of mechanical behavior of cartilaginous infant hips in pavlik harness: A subject-specific simulation study on normal and dysplastic hips. J Orthop Res 2019; 37:655-664. [PMID: 30604892 DOI: 10.1002/jor.24213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/11/2018] [Indexed: 02/04/2023]
Abstract
In dysplastic infant hips undergoing abduction harness treatment, cartilage contact pressure is believed to have a role in therapeutic cartilage remodeling and also in the complication of femoral head avascular necrosis. To improve our understanding of the role of contact pressure in the remodeling and the complication, we modeled cartilage contact pressure in cartilaginous infant hips undergoing Pavlik harness treatment. In subject-specific finite element modeling, we simulated contact pressure of normal and dysplastic hips in Pavlik harness at 90° flexion and gravity-induced abduction angles of 40°, 60° and 80°. We demonstrated that morphologies of acetabulum and femoral head both affected contact pressure distributions. The simulations showed that in Pavlik harness, contact pressure was mainly distributed along anterior and posterior acetabulum, leaving the acetabular roof only lightly loaded (normal hip) or unloaded (dysplastic hip). From a mechanobiological perspective, these conditions may contribute to therapeutic remodeling of the joint in Pavlik harness. Furthermore, contact pressure increased with the angle of abduction, until at the extreme abduction angle (80°), the lateral femoral head also contacted the posterior acetabular edge. Contact pressure in this area could contribute to femoral head avascular necrosis by reducing flow in femoral head blood vessels. The contact pressure we simulated can plausibly account for both the therapeutic effects and main adverse effect of abduction harness treatment for developmental dysplasia of the hip. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Behzad Vafaeian
- Department of Civil and Environmental Engineering, University of Alberta, 7-203 Donadeo Innovation Centre for Engineering, 9211 - 116 Street, Edmonton, Alberta, T6G 1H9, Canada
| | - Samer Adeeb
- Department of Civil and Environmental Engineering, University of Alberta, 7-203 Donadeo Innovation Centre for Engineering, 9211 - 116 Street, Edmonton, Alberta, T6G 1H9, Canada
| | - Marwan El-Rich
- Department of Mechanical Engineering, Khalifa University, Abu Dhabi, UAE
| | - Sukhdeep K Dulai
- Department of Surgery and Stollery Children's Hospital, University of Alberta, 2C3.46 WMC, 8440 - 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, 2A2.41 WMC, 8440-112 Street, Edmonton, Alberta, T6G 2B7, Canada
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Abstract
The risk factors for increased perioperative morbidity following pediatric pelvic osteotomies are poorly understood. The purpose of this study was to characterize differences in adverse events, operative time, length of stay, and readmission following pelvic osteotomy for obese and nonobese patients. A retrospective cohort study was carried out using the National Surgical Quality Improvement Program Pediatric database to identify patients that underwent pelvic osteotomy with or without femoral osteotomy. Obesity was found to be an independent risk factor for blood transfusion (relative risk: 1.4, P=0.007) and readmission (relative risk: 2.3, P=0.032) within 30 days. These data can facilitate patient counseling and informed decision-making when planning for surgical correction of hip dysplasia.
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Coppa V, Marinelli M, Specchia N. Unilateral uniplanar modular external fixator for percutaneous proximal femoral osteotomy in children: surgical technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:205-211. [PMID: 30101361 DOI: 10.1007/s00590-018-2295-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
Varus derotation femoral osteotomy (VDFO) is a commonly used surgical procedure in association with pelvic osteotomy for dislocated hip in developmental hip dysplasia. Several types of internal fixation devices were described in the literature, but none of them showed a superiority or a lower rate of complication over the others. Different types of external fixator were also described for proximal osteotomy fixation with good results. We describe the surgical technique of the VDFO using a modular external fixator with an illustrative case.
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Affiliation(s)
- Valentino Coppa
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/A, 60126, Ancona, Italy.
| | - Mario Marinelli
- Clinic of Adult and Paediatric Orthopaedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Nicola Specchia
- Clinical Orthopedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, Via Tronto, 10/A, 60126, Ancona, Italy.,Clinic of Adult and Paediatric Orthopaedic, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, Ancona, Italy
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Park KB, Vaidya VN, Shin H, Kwak YH. Prereduction traction for the prevention of avascular necrosis before closed reduction for developmental dysplasia of the hip: a meta-analysis. Ther Clin Risk Manag 2018; 14:1253-1260. [PMID: 30087565 PMCID: PMC6063247 DOI: 10.2147/tcrm.s166531] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
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.
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Affiliation(s)
- Kun-Bo Park
- Division of Orthopaedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Hyejung Shin
- Biostatistics Collaboration Unit, Medical Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Hae Kwak
- Department of Orthopaedic Surgery, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea,
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Top ten journal articles for residents beginning a pediatric orthopaedic rotation. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Blood Transfusion Incidence, Risk Factors, and Associated Complications in Surgical Treatment of Hip Dysplasia. J Pediatr Orthop 2018; 38:208-216. [PMID: 27280901 PMCID: PMC5145781 DOI: 10.1097/bpo.0000000000000804] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perioperative bleeding requiring blood transfusion is a known complication of hip dysplasia (HD) surgery. Here we examine rates of, risk factors for, and postoperative complications associated with transfusion during HD surgery. METHODS The National Surgical Quality Improvement Program (NSQIP) Pediatric database was queried for patients treated by an orthopaedist from 2012 to 2013. HD cases were categorized by Current Procedural Terminology codes into femoral osteotomies, acetabular osteotomies, combined femoral/acetabular osteotomies, and open reductions. Patients were grouped by comorbidities: neuromuscular (NM) disease (eg, cerebral palsy) group, non-NM with other comorbidity (Other) group, and no known comorbidity (NL) group. Patients were stratified by weight-normalized transfusion volume. Multivariate regression analysis of transfusion association with procedures, demographics, comorbidities, preoperative laboratory values, and 30-day complications was performed. RESULTS A total of 1184 HD cases were included. Transfusion rates for the NL, Other, and NM groups, respectively, were 44/451 (9.8%), 61/216 (28.2%), and 161/517 (31.1%). Transfusion volumes (mean±SD) for the NL, Other, and NM groups, respectively, were 8.4±5.4, 13.9±8.8, and 15.5±10.0 mL/kg (P<0.001). Combined osteotomies had the highest transfusion rates in the NM and Other groups (35.7% and 45.8%, respectively), whereas acetabular osteotomies had the highest rate in the NL group (15.8%). Open reductions had the lowest transfusion rate (all groups). Longer operations were independently associated with transfusion (all groups, per hour increase, OR>1.5, P<0.001). Independent patient risk factors included preoperative hematocrit <31% (NM group, OR=18.42, P=0.013), female sex (NL group, OR=3.55, P=0.008), developmental delay (NM group, OR=2.37, P=0.004), pulmonary comorbidity (NM group, OR=1.73, P=0.032), and older age (NL group, per year increase: OR=1.29, P<0.001). In all groups, transfusion was associated with longer hospitalization (P<0.001). We observed a volume-dependent increase in overall complication rate within the Other group for transfusion volumes >15 mL/kg (25.0% vs. 5.4% for <15 mL/kg, P=0.048). CONCLUSIONS We identified several risk factors for transfusion in HD surgery. The incidence of transfusion in HD surgery and its association with adverse outcomes warrants development of appropriate patient management guidelines. LEVEL OF EVIDENCE Level III-prognostic.
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Wanner MR, Loder RT, Jennings SG, Ouyang F, Karmazyn B. Changes in femoral head size and growth rate in young children with severe developmental dysplasia of the hip. Pediatr Radiol 2017; 47:1787-1792. [PMID: 28765997 DOI: 10.1007/s00247-017-3938-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 05/25/2017] [Accepted: 06/30/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Developmental dysplasia of the hip (DDH) is known to result in smaller femoral head size in toddlers; however, alterations in femoral head size and growth have not been documented in infants. OBJECTIVE To determine with ultrasound (US) whether femoral head size and growth are altered in infants (younger than 1 year of age) with severe DDH. MATERIALS AND METHODS We identified all patients at our tertiary care children's hospital from 2002 to 2014 who underwent US for DDH. We included studies with at least one hip with severe DDH, defined as <25% coverage of the femoral head, and excluded teratological DDH. We constructed a control group of randomized patients with normal US studies. Two pediatric radiologists blinded to diagnosis measured bilateral femoral head diameter. Inter-reader variability and femoral head diameter difference between dislocated and contralateral normal femoral heads were evaluated. Mean femoral head diameters were compared across types of hip joint; femoral head growth rates per month were calculated. RESULTS Thirty-seven children with DDH (28 female) were identified (median age: 33 days). The control group contained 75 children (47 female) with a median age of 47 days. Fifty-three of the 74 hips in the study group had severe DDH. Twenty-four children with DDH had completely dislocated hips (nine bilateral, five with contralateral severe subluxations). Thirteen other children had severe subluxation, two bilaterally. There was good inter-reader agreement in the normal femoral head group and moderate agreement in the severe DDH group. In the study group, severe DDH femoral head diameter was significantly smaller than their contralateral normal hip. Severe DDH femoral head diameter was significantly smaller than normal femoral head diameter in the control group. The severe DDH femoral head growth rate was slightly less but not significantly slower than normal femoral head growth rate in the study group. CONCLUSION On US during infancy, femoral head size is significantly reduced in severe cases of DDH.
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Affiliation(s)
- Matthew R Wanner
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University School of Medicine, 702 Barnhill Drive, Room 1053, Indianapolis, IN, 46202, USA.
| | - Randall T Loder
- Department of Orthopaedic Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - S Gregory Jennings
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fangqian Ouyang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Boaz Karmazyn
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University School of Medicine, 702 Barnhill Drive, Room 1053, Indianapolis, IN, 46202, USA
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Closed reduction with or without adductor tenotomy for developmental dysplasia of the hip presenting at walking age. CURRENT ORTHOPAEDIC PRACTICE 2017; 28:195-199. [PMID: 28286603 PMCID: PMC5325246 DOI: 10.1097/bco.0000000000000478] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Many children with developmental dislocation of the hip especially in underdeveloped countries reach walking age and still remain undiagnosed, which can be detrimental to their growth and development. Because of the lack medical services often encountered in these regions, it would be attractive to find a cheap and effective treatment. Our work evaluated the results of treatment of these children by closed reduction with or without adductor tenotomy in a prospective study. METHODS We included 20 patients in this study with 29 affected hips (15 right and 14 left). Nine patients (45%) had bilateral DDH and 11 (55%) had unilateral DDH. There were 18 girls (90%) and two boys (10%) who were followed up for a mean of 21 mo (18-24 mo). Ages ranged from 9 to 36 mo (mean age 18.3 mo). Patients were divided according to age into two groups: between 9-18 mo and from 19-36 mo. The first group included nine patients (14 hips) while the second had 11 patients (15 hips). RESULTS In the first group, closed reduction failed in two patients (two hips) during the follow-up period (14.3%) and this necessitated shift to open reduction, while in the second group only one patient (bilateral DDH) had a similar failure (13.3%). We identified four hips with avascular necrosis. Three of them required no further treatment, the remaining hip was openly reduced. CONCLUSIONS Closed reduction in older children offers a valid and reproducible treatment modality in the hands of an experienced pediatric orthopaedic surgeon as long as there is close follow-up and thorough knowledge of possible complications and their management including the ability to shift timely to open reduction.
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Abstract
BACKGROUND Exstrophy of the bladder is a rare congenital defect seen in 2.15 children out of every 100,000 live births, with the most severe variant, cloacal exstrophy (CE), only occurring in 1 in 200,000. Developmental dysplasia of the hip (DDH) describes a spectrum of disease ranging from mild hip instability to frank dislocation. Underlying malformations, such as myelomeningocele and arthrogryposis, are often associated with the most severe variant of hip dysplasia, teratologic hip dislocation. The varying degrees of severity in DDH have been encountered in classic bladder exstrophy (CBE) patients, but the exact incidence is unknown. We sought to determine the incidence of DDH in CBE and CE patients. METHODS We performed a retrospective review of all children with CBE or CE presenting to a single pediatric center between 1994 and 2014. Each chart was reviewed for correct diagnosis of CBE or CE, patient age and demographics, associated medical conditions, pertinent surgeries performed, and the age at operation. Patient imaging was reviewed to determine whether bilateral hip imaging was available. RESULTS In a 20-year retrospective review, we identified 66 patients who were diagnosed with either CBE or CE and had available hip imaging (38 males and 28 females). Of these, 11 patients were found to have radiographic evidence of DDH, for an incidence of 16.7% (11/66). Five of these patients had CE, whereas 6 presented with CBE. The first radiographic evidence of DDH was noted at a mean age of 5.75 years (range, birth to 22 y). CONCLUSIONS We advocate the use of routine hip screening ultrasound in all infants born with either CBE or CE. Early identification of DDH in these patients may allow additional treatment options to coincide with frequently used osteotomy and orthopaedic interventions. LEVEL OF EVIDENCE Level III-retrospective study.
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Abstract
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.
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Bhaskar A, Desai H, Jain G. Risk factors for early redislocation after primary treatment of developmental dysplasia of the hip: Is there a protective influence of the ossific nucleus? Indian J Orthop 2016; 50:479-485. [PMID: 27746489 PMCID: PMC5017168 DOI: 10.4103/0019-5413.189610] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Re-dislocation after primary treatment of developmental dysplasia of the hip is a serious complication. We analyzed the various risk factors that contribute to re-dislocation, and whether the bony ossific nucleus (ON) confers increased stability against re-dislocation. MATERIALS AND METHODS Fifty-five children (60 hips) were classified into three treatment groups: Closed reduction (CR) in 15 children (17 hips), open reduction (OR) in 26 children (28 hips), and OR with bony surgery (ORB) in 14 children (15 hips). The mean age at initial treatment was 16 months (range 6-36 months). Fifty-one hips and 9 hips were Tonnis Grade 4 and 3, respectively. The mean preoperative acetabular index (AI) was 44.82° (range 32°-56°) for the study group. At initial treatment, bony ON was absent in 8 hips and present in 52 hips. RESULTS No hip developed stiffness and pain after primary treatment. Although the AI index, Tonnis grade, and absence of ossific nucleus were higher in the re-dislocated groups, this was not statistically significant. Excluding the re-dislocations, four children had a fair outcome, 11 had good outcome, and 36 had excellent outcome as per McKay's criteria. In the CR group (17 hips), two children (2 hips) with absent ON had re-dislocation. In the OR group (28 hips), three re-dislocations were seen (three children) at 3, 5, and 7 months, respectively. Two of these had an absent bony ON. In the ORB group (15 hips), one late sub-luxation occurred in a child with absent ON. The mean preoperative AI for the re-dislocated and located group was 44.66° (range 42°-48°) and 44.53° (range 39°-56°), respectively. The postoperative AI was 34.53. CONCLUSION The experience of the treating surgeon and technical factors play an overwhelming role in preventing early dislocation. The absence of ON should perhaps alert the surgeon for enhanced spica care, postoperative splinting, and meticulous intra-operative management.
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Affiliation(s)
- Atul Bhaskar
- Children Orthopaedic Clinic, MHADA, Oshiwara, Andheri West, Mumbai, Maharashtra, India,Department of Orthopaedics, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India,Department of Orthopaedics - Dr. R N Cooper Hospital, Mumbai, Maharashtra, India,Address for correspondence: Dr. Atul Bhaskar, Children Orthopaedic Clinic, Flat 3, Building No. 18, Mhada Complex, Oshiwara Link Road, Andheri West, Mumbai - 400 053, Maharashtra, India. E-mail:
| | - Hardik Desai
- Children Orthopaedic Clinic, MHADA, Oshiwara, Andheri West, Mumbai, Maharashtra, India,Department of Orthopaedics, MW Desai Municipal Hospital, Mumbai, Maharashtra, India
| | - Gaurav Jain
- Department of Orthopaedics, Bombay Port Trust Hospital, Mumbai, Maharashtra, India
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Quality of reduction and prognosis of developmental dysplasia of the hip: a retrospective study. Hip Int 2016; 26:355-9. [PMID: 27198970 DOI: 10.5301/hipint.5000348] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2015] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Using limited MRI we evaluated the quality of closed reduction and prognosis in a group of patients with developmental dysplasia of the hip (DDH). METHODS Limited MRI was performed on 28 DDH patients (41 hips) after closed reduction. All the hips were divided into deep and incomplete concentric reduction groups according to the femoral head-acetabular distance (FAD) and the shape of the labrum on limited MRI. The abduction angle of the hips, and the initial and final acetabular index (AI) were measured. Presence or absence of the ossification centre of the femoral head before treatment, the Tönnis classification and avascular necrosis of the femoral head and types (Bucholz and Ogden type) were recorded. The data of the 2 groups were analysed with SPSS software. RESULTS We found no significant differences in age, gender, side, preoperative ossification centre of the femoral head, preoperative AI, decreased postoperative AI and abduction angles of hips between the 2 groups. There were significant statistical differences in the preoperative Tönnis grade, FAD after reduction, AI at the final follow-up, severe residual deformity and severe avascular necrosis of the femoral head (p<0.05). The cure rate showed a significant trend (p = 0.052). CONCLUSIONS Limited MRI enables effective determination of the quality of reduction immediately after closed reduction. The prognosis of the deep concentric reduction group was better than the group with incomplete concentric reduction.
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Is Age or Surgical Approach Associated With Osteonecrosis in Patients With Developmental Dysplasia of the Hip? A Meta-analysis. Clin Orthop Relat Res 2016; 474:1166-77. [PMID: 26472583 PMCID: PMC4814411 DOI: 10.1007/s11999-015-4590-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Osteonecrosis of the femoral head is a major complication that negatively impacts the clinical and radiographic long-term outcome after treatment of developmental hip dysplasia (DDH). There are conflicting results in the literature whether age at the time of closed or open reduction and a specific surgical approach are associated with osteonecrosis. Better understanding of the impact of age at reduction and surgical approach is important to reduce the risk of osteonecrosis in patients with DDH. QUESTIONS/PURPOSES We aimed to evaluate the association between occurrence of osteonecrosis and (1) age at closed reduction; (2) age at open reduction; and (3) medial versus anterior operative approaches. METHODS A systematic review identified studies reporting osteonecrosis occurrence after treatment of DDH and at least 2 years of followup. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Methodologic quality was assessed using the methodologic index for nonrandomized studies. Generalized logistic models were used to estimate pooled odds ratios (ORs) in the meta-analysis. Sixty-six studies were included in the systematic review and 24 in the meta-analysis. Data on 481 hips treated by closed reduction and 584 hips treated by open reduction were available to evaluate the association between osteonecrosis and age. The association between osteonecrosis and operative approach was assessed using data on 364 hips treated by medial open reduction and 220 hips treated by anterior open reduction. RESULTS Age at reduction (> 12 months versus ≤ 12 months) was not associated with osteonecrosis after closed reduction (OR, 1.1; 95% confidence interval [CI], 0.4-3.2; p = 0.9) or open reduction (OR, 1.1; 95% CI, 0.7-1.9; p = 0.66). The overall, adjusted incidence of osteonecrosis (≥ Grade II) was 8.0% (95% CI, 2.8%-20.6%) among patients treated with closed reduction at or before 12 months of age and 8.4% (95% CI, 3.0%-21.5%) among those treated after 12 months. Similarly, the odds of osteonecrosis after open reduction did not differ between patients treated after the age of 12 months compared with those treated at or before 12 months (OR, 1.1; 95% CI, 0.7-1.9; p = 0.7). The incidence of osteonecrosis (≥ Grade II) was 18.3% (95% CI, 11.7%-27.4%) among patients who had index open reduction at or before 12 months of age and 20.0% (95% CI, 13.1%-29.4%) among those who had index open reduction after 12 months of age. Among hips treated with open reductions, there was no difference in osteonecrosis after medial versus anterior approaches (18.7% medial versus 19.6% anterior; OR, 1.1; 95% CI, 0.5-2.2; p = 0.9). Conclusions We did not find an association between closed or open reduction performed at or before 12 months of age and an increased risk of osteonecrosis of the femoral head. Delayed treatment past 1 year of age as a strategy to reduce the development of osteonecrosis was not supported by this meta-analysis. Open reduction through a medial or anterior approach may be recommended based on surgeon's preference, because we found no association between development of osteonecrosis and the type of surgical approach. However, many of the studies in the current literature are nonrandomized Level III or IV observational studies of inconsistent quality. Higher quality evidence is needed to better understand the effects of age at reduction and operative approach on the development of osteonecrosis after DDH treatment. LEVEL OF EVIDENCE Level III, therapeutic study.
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Rosenbaum DG, Servaes S, Bogner EA, Jaramillo D, Mintz DN. MR Imaging in Postreduction Assessment of Developmental Dysplasia of the Hip: Goals and Obstacles. Radiographics 2016; 36:840-54. [DOI: 10.1148/rg.2016150159] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Munhoz R, Moraes CADC, Tanaka H, Kunkel ME. A digital approach for design and fabrication by rapid prototyping of orthosis for developmental dysplasia of the hip. ACTA ACUST UNITED AC 2016. [DOI: 10.1590/2446-4740.00316] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
BACKGROUND Developmental dysplasia of the hip is an anomaly of the hip joint. In patients with early diagnosis, within 3 to 6 months of life, the treatment is essentially conservative and involves the use of dynamic harness. The indication for the use of the Tubingen hip flexion splint is a dysplastic hip. The aim of this study is to report the experience of the Orthopaedic Clinic of the "University of Catania" regarding conservative treatment with the Tubingen harness of dysplastic hips diagnosed in children within 3 months of life. METHODS From January 1997 to July 2012, 5137 infants (10,274 hips) aged within 3 months of life were submitted to ultrasonographic hip assessment. Start, duration of treatment, and outcome were investigated. RESULTS A total of 351 (6.83%) patients affected by developmental dysplasia of the hip for a total of 544 dysplastic hips (5.3%) were treated with the Tubingen hip flexion splint. Treatment was started on average 39 days of life. Harness were dressed for 24 hours a day and applied for a mean of 3.8 months. Mean follow-up was 6.4 years (range, 2.2 to 14 y). We obtained the following results: 482 (90.44%) dysplastic, unstable, or dislocated hips were successfully converted into type I hips with an α-angle of >64 degrees in the splint. Complications were reported in 3 (0.55%) hips.No statistically significant relationship was found between the duration of therapy and the time when treatment was started, early or late within the first week of life (P=0.152). CONCLUSIONS Dysplastic, unstable, and dislocated hips can be successfully treated with the Tubingen hip flexion splint, reporting good clinical and ultrasonographic outcomes.
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Abstract
The term “developmental dysplasia of the hip” (DDH) includes a wide spectrum of abnormalities that affect the hip during its growth, ranging from dysplasia to joint dislocation and going through different degrees of coxofemoral subluxation. The incidence of DDH is variable, and depends on a number of factors, including geographical location. Approximately one in 1,000 newborn infants may present hip dislocation and around 10 in 1,000 present hip instability. Brazil has an incidence of five per 1,000 in terms of findings of a positive Ortolani sign, which is the early clinical sign for detecting the disorder. The risk factors for DDH include: female sex, white skin color, primiparity, young mother, breech presentation at birth, family history, oligohydramnios, newborns with greater weight and height, and deformities of the feet or spine. Hip examinations should be routine for newborns, and should be emphasized in maternity units. Among newborns and infants, the diagnosis of DDH is preeminently clinical and is made using the Ortolani and Barlow maneuvers. Conventional radiography is of limited value for confirming the diagnosis of DDH among newborns, and ultrasound of the hip is the ideal examination. The treatment of DDH is challenging, both for pediatric orthopedists and for general practitioners. The objectives of the treatment include diagnosis as early as possible, joint reduction and stabilization of the hip in a secure position. Classically, treatment options are divided according to different age groups, at the time of diagnosis.
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Intraoperative assessment of closed reduction for developmental dislocation of the hip using 3-dimensional fluoroscopy. J Pediatr Orthop 2015; 35:246-52. [PMID: 24992347 DOI: 10.1097/bpo.0000000000000245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative imaging for operatively treated developmental dislocation of the hip typically uses computed tomography or a magnetic resonance imaging (MRI). Neither imaging modality offers the ability to intervene intraoperatively. The 3-dimensional (3D) C-arm provides an attractive alternative providing immediate intraoperative feedback on the quality of a hip reduction. Our primary research question was to determine whether 3D fluoroscopy could assess hip position after closed reduction and spica casting. Secondary questions included whether reduction was maintained postoperatively when compared with postoperative MRI, and to determine the radiation dose received by the infant. METHODS We retrospectively identified 16 patients from 2010 to 2013 who underwent closed reduction and spica casting for a developmentally dislocated hip who underwent both intraoperative 3D fluoroscopy and postoperative MRI imaging. Scans were retrieved and assessed by a blinded pediatric orthopaedic fellow. Assessment of hip reduction was graded based on the modified Shenton line of the pelvis in axial plane images. Effective radiation doses between imaging modalities were compared using an anthropomorphic phantom. RESULTS All hips were reduced on 3D fluoroscopic images. Comparing the intraoperative 3D scans with the postoperative MRI images all 16 hips were in the same position. At 12 weeks all hips were reduced and no signs of subluxation were identified on the plain anteroposterior radiograph. 3D fluoroscopy achieved the lowest effective dose of radiation per study measuring 0.3 mSv compared with 0.5 mSv for low-dose CT and 0.48 mSv for 60 seconds of live fluoroscopy. CONCLUSIONS Accurate assessment of the quality of hip reduction is possible in the axial plane using 3D fluoroscopy with no significant loss of reduction in the early postoperative period. When comparing the effective radiation exposure to limited-cut computed tomography protocols, 3D fluoroscopy offers a low-dose alternative that may facilitate cost savings and early discharge. LEVEL OF EVIDENCE Diagnostic studies-investigating a diagnostic test; study of nonconsecutive patients with consistently applied gold standard; level III.
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The safety and efficacy of a transarticular pin for maintaining reduction in patients with developmental dislocation of the hip undergoing an open reduction. J Pediatr Orthop 2015; 35:358-62. [PMID: 25075885 DOI: 10.1097/bpo.0000000000000284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Redislocation after an open reduction for develpmental dislocation of the hip is relatively common. The purpose of this study was to determine if the use of a transarticular pin (TAP) is safe and effective in maintaining reduction. METHODS A total of 578 patients (645 hips) were reviewed after an open reduction, mean age at the time of surgery was 2.1 years. In 621 cases a smooth Kirschner wire was placed across the joint. The rates of redislocation, avascular necrosis (AVN), and other complications were determined. AVN was classified according to Kalamchi et al. Outcome was determined at a minimum of 6 years using the Severin classification. RESULTS Redislocation occurred in 27 cases (4.1% rate), 24 had a TAP (3.8%) and 3 did not (12.5%). AVN was observed in 127 cases (19.7%), it was type I in 73 cases, type II in 38 cases, type III in 14 cases, and type IV in 2 cases; AVN was seen in 123 cases which had a TAP (19.8%) and 4 cases which did not (16.7%). Analyzing pin placement: when it was in the inferior third of the neck the rate of AVN was 15.2% (32/211), in the middle third it was 21.7% (71/326), and in the superior third it was 28.6% (24/84). According to the Severin classification for the hips with a TAP, 496 were type I or II (79.8%), 113 were type III (18.2%), 10 were type IV (1.6%), and 2 were type V (0.3%); in the group without a TAP 19 cases were type I or II (79.2%), 4 were type III (16.7%), and 1 was type IV. CONCLUSIONS The use of a TAP was effective in maintaining reduction and was not associated with significant morbidity. Placing the pin in the inferior third of the neck was associated with the lowest rate of AVN. LEVEL OF EVIDENCE Level IV--therapeutic.
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