Reduction For Developmental Dysplasia Of The Hip Research Articles

Rates and risk factors for failure of reduction in closed reduction in developmental dysplasia of the hip: a systematic review and meta-analysis.

In developmental dysplasia of the hip (DDH), concentric reduction of dislocated hips cannot be achieved by closed reduction in many cases, and open reduction is required ('failure of reduction'). The incidence of cases requiring open reduction and the significance of risk factors for unsuccessful reduction remain unclear. We investigated the overall rate and the risk factors for failed closed reduction in DDH. We followed the Cochrane recommendations in our systematic review and meta-analysis. We performed a systematic search in three medical databases to identify all studies reporting on pediatric patients with hip dislocation in DDH on 2 July 2022. Eligible studies reported on the rate of failure in children younger than 36 months. We calculated odds ratios (ORs) with 95% CIs from two-by-two tables (event rate in risk group, event rate in non-risk group). We identified 13 316 studies and included 62 studies (5281 hips) for failure rate and 34 studies (3810 hips) for risk factor analysis. The overall rate of failure in closed reduction was 20%. The risk of failure of reduction increased with the grade of dislocation and was significantly higher for high dislocations (group 0-24: IHDI 4 vs IHDI 2 OR: 17.45, CI: 9.26-32.92; Tönnis 4 vs Tönnis 2 OR: 14.67, CI: 1.21-177.37; Graf IV vs Graf III OR: 3.4, CI: 2.27-5.09). Male gender was also a significant risk factor (OR: 2.27, CI: 1.13-4.56) in group 0-36. Higher grade dislocations and male gender are significant risk factors for failure of reduction in closed reduction in hip dislocation in DDH.

External Fixator Stabilization Following Open Reduction and Combined Pelvic and Proximal Femur Osteotomy in Developmental Dysplasia Hip: A Surgical Note

Introduction: Maintenance of hip joint reduction after combined pelvic and femoral osteotomy in developmental dysplasia of the hip (DDH) in children using a hip-spica cast has the potential to cause numerous cast-related complications. We proposed a modification of the surgical technique where the hip reduction is maintained with an external fixator to avoid cast-related complications. Methodology: The surgical technique involved the placement of Scahnz pins along the iliac crest or lateral aspects of the ilium, in the supra-acetabular region below the pelvic osteotomy site, and the proximal femur. The pins were connected and stabilized with tubular/solid rods. Six children with 10 dysplastic hips [4 bilateral and 2 unilateral, International Hip Dysplasia Institute (IDHI) grade IV] were operated on with pelvic and femoral osteotomies and external fixator construct. The fixators were removed after 8 weeks and the children were followed up at 3, 6, 12, and 18 months. Results: The average age of the children was 6.5 years (range: 4 to 11 y). After an average follow-up of 10 months, the hips were reduced with IDHI grade of I in 7 hips and IDHI grade of II in 3 hips. There were no wound complications. Superficial pin tract infections were seen in all patients but responded to topical antibiotic application. There was no unplanned visit by the parents and no one complained of perineal hygiene issues. Conclusion: The external fixator construct maintains the hip reduction in DDH and allows the osteotomy sites to heal without any wound-related complications.

Bilateral Involvement in Developmental Dislocation of the Hip: Analysis of 561 Patients Operated on Using the Limited Posteromedial Approach.

Our objective was to scrutinize the risk factors related to bilateral involvement in the developmental dysplasia of the hip (DDH) and to inspect the impact of bilaterality on the enduring results of the DDH. All patients, aged between 6 and 18 months, who underwent surgery using the limited posteromedial approach (734 hips from 561 patients), were included in this study. The number of births, birth type, history of consanguineous marriage, family history, and swaddling were analyzed. Physical examination and complaints of the patients were evaluated, and direct radiographs were examined in terms of the redislocation, avascular necrosis, and residual acetabular dysplasia. Among the 561 patients, bilateral DDH was observed in 173 patients (30.8%). The use of swaddling was found to be statistically significant between groups (p = 0.012). The use of swaddling for more than one month was associated with a higher odds ratio for bilaterality (p = 0.001, OR = 1.56, 95% CI: 1.2-2.0). Furthermore, bilaterality was associated with a higher risk for redislocation in DDH (p = 0.001, OR = 4.25, 95% CI: 1.6-11.2). The study concludes that swaddling for over a month is strongly linked with the bilateral involvement in DDH. It is important to note that bilaterality plays a crucial role in the development of redislocation after open reduction in DDH.

Failure to achieve reduction on developmental dysplasia of hip: an ultrasound evaluation.

Ultrasound examination of the medial side of the hip joint has been rarely used to evaluate the status of developmental dysplasia of the hip (DDH) in Pavlik harness treatment according to the literature. To analyze the effects of cartilaginous acetabulum, hip joint labrum, and acetabular tissue on the reduction of DDH. A total of 50 cases (100 hips) were detected by the Graf method with a high-frequency linear transducer (L 5-12), and there were 59 dislocated hips and 41 non-dislocated hips. Patients were treated with a Pavlik harness. Ultrasound examination of the medial side of the hip joint was performed for follow-up. The hip joints were divided into three groups: the non-dislocated group; the reducible group; and the non-reducible group. The success rate of reduction was significantly higher when the acetabulum cartilage was located on the cephalic side (chi-square = 28.12, P < 0.001). The success rate was also significantly higher when the hip joint labrum was located on the cephalic side (chi-square = 17.21, P < 0.001). Type III and D had a higher success rate of reduction than type IV (P < 0.001). The pairwise comparison of the measurements of acetabular tissue between the non-dislocated group, the reducible group, and the non-reducible group showed statistical differences (P < 0.001). The present study confirmed that the location of acetabulum cartilage and hip joint labrum affected the outcome of treatment. The degree of dislocation and the amount of acetabular tissue were correlated with the success rate of treatment.

Redislocation After Posteromedial Open Reduction in Developmental Dysplasia of the Hip: Analyzing the Risk Factors and Determining the Optimal Treatment Method.

Redislocation, which is one of the most serious problems in developmental dysplasia of the hip (DDH), might occur because of several reasons. Regardless of the treatment, redislocations are reported to be associated with high complication rates in the literature. Our objective was to identify the risk factors for redislocation in the patients treated for DDH and to determine the optimal treatment method for redislocations. Patients with DDH who were treated with the limited posteromedial approach in our clinic between 1993 and 2021 and followed up prospectively were examined in this single-centered study. The participants were assigned into 2 groups: a study group consisting of 25 hips of 17 patients with redislocation and a control group consisting of 502 hips of 390 patients without redislocation. To determine the risk factors for redislocation, demographic data, known risk factors for DDH, preoperative Tönnis stage, and whether the capsule was opened or not were evaluated. To determine the optimal treatment method, a subgroup analysis based on applied treatment (closed reduction and cast replacement vs. repeating open reduction) was conducted, and recurrent redislocation, complication, and secondary surgery rates were evaluated. Bilaterality and high-grade hip dislocations were found to be associated with higher odds ratio (OR) for redislocation [ P =0.007, OR=3.64, 95% confidence interval (CI), 1.3 to 8.8; and P =0.006, OR=4.52, 95% CI, 1.37 to 14.91, respectively]. Recurrent redislocation and complication rates were found to be significantly higher in redislocations treated with closed reduction and cast replacement ( P =0.007 and P =0.015, respectively). Bilaterality and higher preoperative Tönnis stage are critical risk factors for redislocation after open reduction in DDH. It should be kept in mind that closed reduction and cast replacement is associated with higher rates of recurrent redislocation and complications, and redislocation cases should be treated by repeating open reduction. Level II-therapeutic study.

The limbus in developmental dysplasia of the hip: An obstacle to reduction and its images changed by the femoral head position.

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.

Day-case open reduction for developmental dysplasia of the hip.

AimsOpen reduction in developmental dysplasia of the hip (DDH) is regularly performed despite screening programmes, due to failure of treatment or late presentation. A protocol for open reduction of DDH has been refined through collaboration between surgical, anaesthetic, and nursing teams to allow same day discharge. The objective of this study was to determine the safety and feasibility of performing open reduction of DDH as a day case.MethodsA prospectively collected departmental database was visited. All consecutive surgical cases of DDH between June 2015 and March 2020 were collected. Closed reductions, bilateral cases, cases requiring corrective osteotomy, and children with comorbidities were excluded. Data collected included demographics, safety outcome measures (blood loss, complications, readmission, reduction confirmation), and feasibility for discharge according to the Face Legs Activity Cry Consolidability (FLACC) pain scale. A satisfaction questionnaire was filled by the carers. Descriptive statistics were used for analysis.ResultsOut of 168 consecutive DDH cases, 16 patients fit the inclusion criteria (age range 10 to 26 months, 13 female). Intraoperative blood loss ranged from "minimal" to 120 ml, and there were no complications or readmissions. The FLACC score was 0 for all patients. The carers satisfaction questionnaire expressed high satisfaction from the experience with adequate information and support provided.ConclusionOpen reduction in DDH, without corrective osteotomy, is safe and feasible to be managed as a day case procedure. It requires a clear treatment pathway, analgesia, sufficient counselling, and communication with carers. It is even more important during the COVID-19 pandemic when reduced length of hospital stay is likely to be safer for both patient and their parents.Cite this article: Bone Joint Open 2021;2(4):271–277.

Spica MRI predictors for epiphyseal osteonecrosis after closed reduction treatment of dysplasia of the hip.

Spica MRI with intravenous gadolinium contrast after closed reduction for developmental dysplasia of the hip (DDH) helps to determine successful reduction and attempts to identify patients at risk for epiphyseal osteonecrosis. The objective of our study was to evaluate spica MRI predictors for epiphyseal osteonecrosis after closed reduction. This was a retrospective study of all patients undergoing closed reduction for DDH followed by gadolinium-enhanced spica MRI between July 2011 and November 2014. Patient demographics and clinical follow-up through 2017, including the development of epiphyseal osteonecrosis and need for reintervention after the initial reduction, were recorded. MRI data included hip abduction angles and quantifying the percentage of femoral head enhancement. Twenty-five hips in 21 patients (16 girls, five boys, mean age: 0.99 years, range: 0.4-3.1 years) were included in our study. The mean follow-up period was 3 ± 1.5 years (range: 0.65-6.1 years). Eight (32%) of 25 hips went on to develop osteonecrosis. Epiphyseal osteonecrosis was more likely with less than 80% enhancement (sensitivity 87.5%, specificity 88.25%, positive predictive value 78%, negative predictive value 94%). The mean contrast enhancement for patients developing osteonecrosis compared with those who did not was 37.5 and 86.5%, respectively; P = 0.001. Immediate postspica MRI with gadolinium is a useful prognostic tool for determining future risk for epiphyseal osteonecrosis in children treated for DDH. Our data complement existing literature and suggest that even in cases with partial epiphyseal enhancement, osteonecrosis may still develop. When the epiphyseal enhancement is less than 80%, it is recommended that spica cast revision is considered.

Predictors of femoral shortening for pediatric developmental hip dysplasia surgery: an observational study in 435 patients

BackgroundOpen reduction of the congenitally dislocated hip may not be possible without femoral shortening. The goal of this study is to develop a prognostic prediction model for the need of femoral shortening in children undergoing anterior open reduction for the treatment of developmental dysplasia of the hip (DDH). The secondary objective was to determine if femoral shortening influences the risk of adverse events.MethodsA cohort from February 1, 2008 thru July 31, 2017 was studied retrospectively at a single centre. Patients between the age of 1 and 8 years, having international hip dysplasia institute (IHDI) grade 3 and 4, undergoing primary anterior open reduction for DDH were included in the study. The outcome of interest was femoral shortening, and the potential predictors were age, sex, side, body mass index and IHDI grade. Logistic regression was employed to identify the independent predictors and was followed by internal validation using bootstrapping. In addition, complications encountered were recorded and analysed.ResultsA total of 548 hips in 435 patients were included. Median follow-up (interquartile range) was 27 (13–48.25) months. Femoral shortening was needed on 119 hips. Factors that increased the probability of femoral shortening in the reduced model were age, male gender, and IHDI grade 4. Adjusting for IHDI and the addition of pelvic osteotomy, the probability of recurrence was lower when femoral shortening is included and higher with increased patient age. There were more deep infections when femoral shortening is added. Femoral shortening did not affect the occurrence of avascular necrosis.ConclusionIn addition to age and superior displacement of the femoral head, male gender is considered to be an independent predictor for needing femoral shortening. Studying the probability of femoral shortening in DDH surgery may optimize family education, operating room preparation, and operative time utilization. Moreover, there appears to be less risk of recurrence when femoral shortening is performed at the cost of higher probability of deep surgical site infection.

Obstacles to reduction in infantile developmental dysplasia of the hip.

PurposeIdentification of anatomical structures that block ­reduction in developmental dysplasia of the hip (DDH) is ­important for the management of this challenging condition. Obstacles to reduction seen on arthrogram are well-known. However, despite the increasing use of MRI in the assessment of adequacy of reduction in DDH, the interpretation of MRI patho-anatomy is ill-defined with a lack of relevant literature to guide clinicians.MethodThis is a retrospective analysis of the MRI of patients with DDH treated by closed reduction over a five-year period (between 2009 and 2014). Neuromuscular and genetic disorders were excluded. Each MRI was analysed by two orthopaedic surgeons and a paediatric musculoskeletal radiologist to identify the ligamentum teres, pulvinar, transverse acetabular ligament (TAL), capsule, labrum and acetabular roof cartilage hypertrophy. Inter- and intraobserver reliability was calculated. The minimum follow-up was 12 months.ResultsA total of 29 patients (38 hips) underwent closed reduction for treatment of DDH. Eight hips showed persistent subluxation on post-operative MRI. Only three of these eight hips showed an abnormality on arthrogram. The pulvinar was frequently interpreted as ‘abnormal’ on MRI. The main obstacles identified on MRI were the ligamentum teres (15.8%), labrum (13.1%) and acetabular roof cartilage hypertrophy (13.2%). The inter-rater reliability was good for TAL, capsule and pulvinar; moderate for ligamentum teres and labrum; and poor for hypertrophied cartilage.ConclusionThe labrum, ligamentum teres and acetabular roof cartilage hypertrophy are the most important structures seen on MRI preventing complete reduction of DDH. Focused interpretation of these structures may assist in the management of DDH.

Verification of hip reduction using anterior ultrasound scanning during Pavlik harness treatment of developmental dysplasia of the hip

AimUltrasound scanning (USS) is used for diagnosis and surveillance in developmental dysplasia of the hip (DDH). Lateral coronal scanning is performed with the hip flexed, in neutral adduction. In this position an unstable hip may dislocate, failing to demonstrate a reducible hip, leading to abandonment of harness treatment. Anterior ultrasound permits imaging of the flexed abducted hip in harness. This study evaluates the role of anterior & lateral USS in determining duration of treatment and reduction in DDH. MethodBetween 1997 & 2010, 233 patients requiring harness treatment received lateral USS, with dislocated & dysplastic hips re-imaged fortnightly. From 2005, anterior USS was used additionally to assess reduction in harness. ResultsOne-hundred and eighteen patients (167 hips) received lateral USS, 115 (160 hips) received both. In the lateral cohort, 103 (140 hips) were treated successfully, mean duration 66.2 days (95% CI 60.2–72.1), with 15 (26 hips) failures (15.5%), mean 30 (CI 95% 19.3–40.6). In the anterior cohort, 107 (150 hips) were treated successfully, mean 53.3 (95% CI 49.8–56.7), with 8 (10 hips) failures (6.25%), mean 35.3 (CI 95% 25.5–44.9). Children receiving an anterior USS had a shorter duration of treatment (p = 0.011) and no difference in failures (p = 0.21). ConclusionsA reduced duration of treatment for Graf 3 hips was observed. Anterior ultrasound allows earlier recognition of hips that fail to stabilize, via two observed modes of failure; failure of hip reduction and failure to stabilize after reduction.

Post-closed Reduction Perfusion Magnetic Resonance Imaging as a Predictor of Avascular Necrosis in Developmental Hip Dysplasia

Avascular necrosis (AVN) of the femoral head remains a major complication in the treatment of developmental dysplasia of the hip (DDH) in infants. We performed a retrospective analysis to look at the predictive ability of postclosed reduction contrast-enhanced magnetic resonance imaging (MRI) for AVN after closed reduction in DDH. Twenty-eight hips in 27 infants (aged 1-11 months) with idiopathic hip dislocations who had failed brace treatment underwent closed reduction +/- adductor tenotomy and spica cast application under general anesthesia. Magnetic resonance imaging of the hips after intravenous gadolinium contrast injection for evaluation of epiphyseal perfusion was obtained immediately after cast application. Patients were followed with serial radiographs for a minimum of 1 year after closed reduction. Presence of AVN was determined by the presence of any one of the 5 Salter criteria by 2 readers. Magnetic resonance imaging was graded as normal, asymmetric enhancement, focal decreased enhancement, or global decreased enhancement by 2 radiologists. Six (21%) of 28 hips showed evidence of clinically significant AVN on follow-up radiographs. Fifty percent of the hips with AVN, but only 2 of 22 hips without AVN, showed a global decreased MRI enhancement (P < 0.05, Fisher exact test). Multivariate logistic regression indicated that a global decreased enhancement was associated with a significantly higher risk of developing AVN (P < 0.01), independently of age at reduction (P = 0.02) and abduction angle. In addition to accurate anatomical assessment of a closed reduction in DDH, gadolinium-enhanced MRI provides information about femoral head perfusion that may be predictive for future AVN. At present, it is premature to use the perfusion information for routine clinical use. However, it opens the door to studies looking at repositioning or alternative reduction methods that may reduce the risk of AVN in this higher risk group.

Preliminary Results after Reduction of DDH via Medial Approach

Purpose: We report the outcomes of medial open reduction for developmental dysplasia of the hip (DDH). Materials and Methods: This study reviewed the medical records and radiographs of 33 DDH cases treated by a medial open reduction and followed for at least two years. The mean age at surgery and follow-up duration was 11.4 months (range, 4 to 22) and 88 months (range, 24 to 168), respectively. The perioperative parameters, maintenance of reduction, and postoperative changes in the acetabular index and center-edge angle were recorded. Results: The acetabular index decreased from a preoperative average of 35 o to 16 o at the latest follow-up. o at postoperative 1 year to 22 o at the latest follow-up. A secondary bony procedure was performed in 15 cases at average age of 4.4 years. Avascular necrosis was noted in 8 cases, all of whom belonged to Kalamchi group I. Among the 21 patients over 6 years-old at the latest follow-up, 18 belonged to Severin groups I or II and the remaining 3 to group III. Redislocation occurred in one case. Conclusion: A medial open reduction is a minimal surgical procedure that can effectively release the structures obstructing a femoral head reduction. It should be a useful treatment modality for selected cases with DDH.

Avascular necrosis after treatment of DDH: the protective influence of the ossific nucleus.

We retrospectively reviewed the results of open or closed reduction for developmental dysplasia of the hip (DDH) in 49 children younger than 12 months old, who had 57 hip dislocations. Group A (18 hips) developed partial or complete avascular necrosis (AVN), and group B (39 hips) did not develop AVN. Thirty-eight hips were treated by closed reduction, and 17 had open reduction. One patient with bilateral hip dislocation initially had closed reductions followed by bilateral open reduction 3 months later. With the numbers available for study, there was no significant difference in the occurrence of AVN with respect to variables such as preliminary traction, closed versus open reduction, Pavlik harness use, and age at the time of operative intervention. However, the presence of the ossific nucleus before reduction, detected either by radiographs (p < 0.001) or ultrasonography (p = 0.033) was statistically significant in predicting AVN. Only one (4%) of 25 hips with an ossific nucleus developed AVN, whereas 17 (53%) of 32 hips without an ossific nucleus before reduction developed AVN. Our results suggest that the presence of the ossific nucleus before closed or open reduction for DDH may decrease the risk of AVN.

MRI AFTER OPERATIVE REDUCTION FOR DEVELOPMENTAL DYSPLASIA OF THE HIP

We performed MRI on 13 infants after operative reduction for developmental dysplasia of the hip (DDH). Using an axial gradient-echo sequence, MRI accurately depicted the acetabular anatomy and confirmed adequate reduction in 12 patients. The one patient with redislocation after surgery was correctly identified. MRI can be carried out quickly, inexpensively and without risk of radiation and is the investigation of choice to confirm adequate reduction in DDH.

MRI after operative reduction for developmental dysplasia of the hip.

We performed MRI on 13 infants after operative reduction for developmental dysplasia of the hip (DDH). Using an axial gradient-echo sequence, MRI accurately depicted the acetabular anatomy and confirmed adequate reduction in 12 patients. The one patient with redislocation after surgery was correctly identified. MRI can be carried out quickly, inexpensively and without risk of radiation and is the investigation of choice to confirm adequate reduction in DDH.