How are outcomes affected by performing a one-stage combined procedure simultaneously in bilateral developmental hip dysplasia?

Impact of avascular necrosis on outcomes in the management of developmental dysplasia of hip: a systematic review

Avascular necrosis (AVN) is a known complication during the management of developmental dysplasia of the hip (DDH). It has the potential to alter the growth of the head or acetabulum and prevent the best outcomes. While past literature has evaluated the risks of AVN and strategies to avoid it, studies on the impact of AVN on the outcomes are scarce. In this systematic review, we aim to study the extent of the effects of AVN on the outcomes, in the management of DDH. In this systematic review series for 1990 to 2021 were pooled. The clinical and radiological outcomes of the AVN and non-AVN groups were compared. The effects of other modifying factors were also evaluated. A total of 170 AVN and 585 non-AVN hips from 21 papers were compared. The analysis did not show any statistically significant difference between the AVN and non-AVN groups in terms of clinical or radiological parameters. Interestingly patients who had the index surgery at a younger age had a higher risk of further surgery, with acetabular osteotomy being the most common secondary procedure. The negative impact of AVN may not be as severe as previously thought. Thus, the fear of AVN should not take precedence over the primary goal of DDH management i.e. obtaining a stable concentric mobile hip.

Comparison of clinical and radiological outcomes for the anterior and medial approaches to open reduction in the treatment of bilateral developmental dysplasia of the hip: a systematic review protocol

BACKGROUND

Developmental dysplasia of the hip (DDH) affects 1-3% of newborns and 20% of cases are bilateral. The optimal surgical management strategy for patients with bilateral DDH who fail bracing, closed reduction or present too late for these methods to be used is unclear. There are proponents of both medial approach open reduction (MAOR) and anterior approach open reduction (AOR); however, there is little evidence to inform this debate.

METHODS

We will perform a systematic review designed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol. We will search the medical and scientific databases including the grey and difficult to locate literature. The Medical Subject Headings "developmental dysplasia of the hip", "congenital dysplasia of the hip", "congenital hip dislocation", "developmental hip dislocation", and their abbreviations, "DDH" and "CDH" will be used, along with the qualifier "bilateral". Reviewers will independently screen records for inclusion and then independently extract data on study design, population characteristics, details of operative intervention and outcomes from the selected records. Data will be synthesised and a meta-analysis performed if possible. If not possible we will analyse data according to Systematic Review without Meta-Analysis guidance. All studies will be assessed for risk of bias. For each outcome measure a summary of findings will be presented in a table with the overall quality of the recommendation assessed using the Grading of Recommendations Assessment Development and Evaluation approach.

DISCUSSION

The decision to perform MAOR or AOR in patients with bilateral DDH who have failed conservative management is not well informed by the current literature. High-quality, comparative studies are exceptionally challenging to perform for this patient population and likely to be extremely uncommon. A systematic review provides the best opportunity to deliver the highest possible quality of evidence for bilateral DDH surgical management.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42022362325).

Salter pelvic osteotomy for the treatment of Developmental Dysplasia of the Hip: assessment of postoperative results and risk factors

BACKGROUND

If non-surgical treatment of Developmental Dysplasia of the Hip (DDH) fails or if DDH is late-detected, surgery is necessary. Salter pelvic osteotomy (SPO) is an effective surgical option for such cases.

OBJECTIVES

To study the results after SPO; to evaluate risk factors; to reveal radiological parameters that may correlate with results.

METHODS

Results analysis in 17 patients (22 hips). Risk factors included those that do not depend on the surgeon (patient's age, value of the acetabular index (AI) preoperatively, DDH Tonnis grade) and those that depend on the surgeon (amount of AI correction). To radiological parameters which may correlate with the amount of AI correction we referred distance "d" and the lateral rotation angle.

RESULTS

SPO allows performing AI correction in ranges 24.1 ± 6.5°. Excellent and good clinical results were obtained in 95.5% of patients; excellent and good radiological results in 86.4% of patients. Risk factors that do not depend on the surgeon were older patient's age and higher preoperative AI values (p <0.05). The risk factor that depends on the surgeon was the amount of AI correction (p <0.05). The distance "d" was recognized as a radiological parameter that may indicate sufficient AI correction (p <0.05).

CONCLUSION

In older patients with a higher preoperative AI value the results will be predictably worse. The surgeon may influence the result with a greater amount of AI correction (which may also be indicated radiologically by the distance "d" values).

LEVEL OF EVIDENCE

IV, therapeutic, case series.

Simultaneous versus staged surgeries for the treatment of bilateral developmental hip dysplasia in walking age: A comparison of complications and outcomes

OBJECTIVES

This study aims to compare the radiological outcomes and rate of complication between single-stage and staged operation for the treatment of bilateral developmental dysplasia of the hip (DDH).

PATIENTS AND METHODS

A total of 100 patients (13 males, 87 females; mean age: 18.1±2.1 months; range, 12 to 36 months) with bilateral DDH who were older than 15 months of age and treated with open reduction (OR) or Pemberton pericapsular osteotomy (PPO) were retrospectively analyzed. Of the patients, 48 were operated with OR and 52 were operated with PPO. Improvements in acetabular indices, presence of avascular necrosis, radiological results, and other complications were noted.

RESULTS

There was no statistically significant difference in the preoperative acetabular indices, range of International Hip Dysplasia Institute (IHDI) classification, follow-up period, and age at the time of operation between the groups (p>0.05). There was no statistically significant difference in the acetabular indices, rate of avascular necrosis, and radiological results at the end of 24 months of follow-up between the groups (p>0.05).

CONCLUSION

Our study results show no significant difference in the radiological outcomes and complications between simultaneous and staged surgeries for the treatment of bilateral DDH in children in the walking age.

Open reduction and Salter innominate osteotomy combined with femoral osteotomy in the treatment of developmental dysplasia of the hip: Comparison of results before and after the age of 4 years

OBJECTIVE

This study aimed to compare the clinical and radiological findings of radical reduction (open reduction and Salter innominate osteotomy combined with femoral osteotomy) for children of walking age, younger and older than 4 years in the treatment of with developmental dysplasia of the hip (DDH).

METHODS

In this retrospective study, children of walking age with DDH who underwent radical reduction between 2008 and 2014 were identified. They were then divided into 2 groups according to the age at which the surgery was performed: before and after the age of 4 years. Improvement in the acetabular index was examined on follow-up radiographs. The presence of avascular necrosis (AVN) was determined and classified on the basis of the Kalamchi-MacEwen classification on final follow-up radiographs. Clinical assessment was performed with the modified McKay criteria at the final follow-up appointment.

RESULTS

A total of 19 children (14 girls, 5 boys; mean age=37.5±21 months) (25 hips) were included. Their mean age was 27.9±4.9 and 63.3±19.7 months in children operated before and after the age of 4 years, respectively. The mean follow-up time was 29.9±19 and 19.6±5 months in children operated before and after the age of 4 years, respectively. No significant difference was observed in improvements in the acetabular index between children younger than 4 years (24±6.9°) and those older than 4 years (20.7±6.7°) (p=0.25). According to the modified McKay criteria, all the children younger than 4 years exhibited excellent or good clinical results compared with those operated after the age of 4 years (67%) (p=0.013). At the final follow-up, 64% of all patients demonstrated no radiographical sign of AVN. The rates of AVN were significantly higher in children operated after the age of 4 years (33%) than in those operated before the age of 4 years (19%) (p=0.049).

CONCLUSION

Better clinical and radiographical results can be expected from radical reduction in children undergoing surgery before the age of 4 years.

LEVEL OF EVIDENCE

level III, Therapeutic Study.

Outcomes and complications of patients undergoing Salter's innominate osteotomies for hip dysplasia: a systematic review of comparative studies

The purpose of this systematic review is to assess outcomes and complications of patients undergoing Salter's innominate osteotomies (SIOs) for the correction of hip dysplasia along with patient and technical factors that can be optimized to improve outcomes after SIO. MEDLINE and EMBASE were searched from data inception to 9 October 2018. Data were presented descriptively. Twenty-seven studies were identified including 1818 hips (87.1%) treated with SIO (mean age of 2.1 ± 2.5 years and mean follow-up of 3.5 ± 5.0 years). Patients undergoing SIO had a post-operative center-edge angle (CEA) of 31.3° ± 5.3° and an acetabular index (AI) angle of 16.1° ± 5.2°. Patients undergoing SIO with pre-operative traction had significantly lower (P = 0.049) post-operative McKay criteria scores compared to patients without pre-operative traction. Patients undergoing SIO between the ages of 1.5-2 years had significantly better (P < 0.05) post-operative McKay criteria scores compared to patients aged 4-6 years. The complication rate was 9.4% with avascular necrosis (2.5%) being most common. This review found that SIO for developmental dysplasia of the hip produces generally good post-operative clinical outcomes. The CEA and AI can be corrected to normal range after SIO. Patients may have superior outcomes if they have SIO at a younger age, were not treated with pre-operative traction and did not have untreated contralateral hip dysplasia. Outcomes appear to be similar between one-stage bilateral SIO and a two-stage procedure in the setting of bilateral hip dysplasia; however, more multicentered studies are needed to confirm these results.

Biomechanical investigation of pelvic stability in developmental dysplasia of the hip: unilateral salter osteotomy versus one-stage bilateral salter osteotomy

Background

Developmental dysplasia of the hip (DDH) is a common disease in infants and children, and the treatment of bilateral DDH remains controversial. This study aimed to evaluate the stability of one-stage bilateral Salter pelvic osteotomy for bilateral DDH in patients of walking age.

Methods

In total, nine child cadavers aged 2–6 years were included. A universal mechanical testing machine was used for stability test. We performed two different surgical procedures on the specimens: nine child cadavers underwent unilateral Salter pelvic osteotomy, and six child cadavers were randomly selected to undergo Salter pelvic osteotomy again to simulate one-stage bilateral Salter pelvic osteotomy. The stability of the bilateral sacroiliac joints, local stability of the operation area, ultimate load test, and axial stiffness were evaluated.

Results

Both unilateral and bilateral Salter osteotomy could destroy the integrity of the pelvic ring and increase the risk of pelvic instability. In this study, compared with unilateral Salter osteotomy, bilateral Salter osteotomy had similar pelvic stability, and there was no significant difference between unilateral and bilateral Salter osteotomy in sacroiliac joint stability (p > 0.05), local stability (p = 0.763), ultimate load (p = 0.328), and axial stiffness (p = 0.480).

Conclusions

One-stage bilateral Salter pelvic osteotomy as a potential surgical method is viable and stable for children with bilateral DDH.

Comparison of total cost and outcomes between single-stage open reduction and Pemberton periacetabular osteotomy operation and two separate consecutive operations in treatment of bilateral developmental hip dysplasia in children at walking age

Open reduction and Pemberton periacetabular osteotomy (PPO) is one of the most preferred techniques for the treatment of developmental hip dyslaplasia (DDH) after the walking age. Performing the surgery as a one-stage operation or two separate consecutive operations is a controversial issue. In this study, we aimed to compare the outcomes, length of hospitalization and total cost between the patients whom had single-stage open reduction and PPO or two consecutive operations due to bilateral DDH in the walking age children. One hundred thirty patients with bilateral DDH had undergone open reduction and PPO for both hips. Seventy-five patients had one-stage open reduction and PPO for both of the hips, whereas 55 patients have two separate consecutive operations. Total time of exposure to anesthetics, blood loss and duration of operation were noted. Hospitalization period and total treatment costs were also noted for each patient. There was no statistically significant difference between the groups regarding the preoperative and postoperative AIs (P > 0.05). Comparing the total cost, length of hospitalization, exposure to anesthetics, perioperative blood loss, there was statistically significant difference between the groups (P < 0.005). Single-stage surgery had favorable outcomes. Major benefits of single-stage surgery for treatment of bilateral DDH are the reduced costs, anesthesia duration, intraoperative blood loss and hospitalization period. Also it can be presumed that prolonged immobilization can lead to loss of bone strength and resulting in fragility fractures. So single-stage open reduction and PPO for bilateral DDH can be preferred in experienced clinics.

Simultaneous bilateral single-stage combined open reduction and pelvic osteotomy for the treatment of developmental dysplasia of the hip

Children older than 18 months with developmental dysplasia of the hip (DDH) for the first time or who do not respond to closed treatment require open reduction with/without acetabuloplasty. We determined whether open reduction and pelvic acetabuloplasty using the Pemberton or Dega technique for both hips simultaneously was well tolerated and offered better outcomes. A total of 140 hips of 70 patients with bilateral DDH were identified. All patients were diagnosed after they started walking. Patients were treated with bilateral single-stage open reduction with acetabuloplasty using the Pemberton or Dega procedure. All patients were prospectively followed up between 2007 and 2018. Results were considered satisfactory if the acetabular index was <24°. Hemoglobin levels were evaluated in all patients. At the final follow-up, the results were evaluated radiologically and clinically based on the modified Severin's classification and modified McKay criteria, respectively. The mean age at surgery was 20.3 months (range, 16-24). The mean operative time was 228 minutes. The mean postoperative hemoglobin level was 90.5 g/L (range, 61-122; SD, ±13.4). The mean differences between the preoperative and postoperative acetabular index values for both hips were 22.36° (SD, ±6.69°) and 22.64° (SD, ±6.69°) for the right and left hips, respectively. Open reduction with pelvic acetabuloplasty using the Pemberton or Dega technique simultaneously in both hips was well tolerated, cost-effective, had excellent outcomes, and posed no additional risk to patients with DDH younger than 24 months.

Salter osteotomy without open reduction in the Tönnis type II developmental hip dysplasia: A retrospective clinical study

PURPOSE

We aimed to evaluate the clinical and radiological outcomes of children older than 18 months who were treated with Salter osteotomy without open reduction for Tönnis type II hip dysplasia.

METHODS

Thirty-two type II hips of 24 patients were included in the study. The mean age was 43.22 (18-108) months. The mean follow-up period was 50 (24-142) months. Seven patients had left sided, nine had right sided, and eight had bilateral developmental dysplasia of the hip. All patients underwent closed reduction and Salter osteotomy. Preoperative and postoperative radiographs were assessed by measuring the center-edge (CE) angle of Wiberg, Smith's c/b and h/b ratio, and acetabular index (AI). Patients were evaluated clinically according to McKay's criteria and radiologically according to Severin criteria. The Kalamchi and MacEwen criteria were used in the evaluation of avascular necrosis.

RESULTS

The mean preoperative AI, CE angle, c/b, and h/b ratio were 36.7° (±4.1), 7.2° (±5.9), 0.9 (±0.08), and 0.05 (±0.04), respectively. The mean latest follow-up AI, CE angle, c/b, and h/b ratio were 18.2° (±1.7), 38.8° (±5.4), 0.6 (±0.03), and 0.19 (±0.04), respectively. The comparison of preoperative and postoperative radiological values revealed statistically significant improvement ( p < 0.01). On the latest physical examinations of the patients, 25 (78.1%) hips were rated excellent, and 7 (21.9%) were rated good according to the McKay criteria. The Severin classification determined 25 (78.1%) hips were grade I and 7 (21.9%) hips were grade II. Type I avascular necrosis (AVN) was seen in four (12.5%) hips. Three of these four hips were more superolateral in preoperative radiographs (c/b > 1 and h/b < 0.05).

CONCLUSIONS

Salter osteotomy without open reduction is a good surgery option for Tönnis type II hip dysplasia, in which closed reduction can be performed. However, the risk of AVN should be kept in mind in more superolateral type 2 hips.

Sequential one-stage combined procedure for treating bilateral developmental hip dysplasia after walking age

Objective

This study aimed to evaluate outcomes of the sequential one-stage combined procedure for treating bilateral developmental dysplasia of the hip (DDH) that was diagnosed after walking age.

Methods

Thirty-five patients (70 hips) with late-presenting bilateral DDH were treated with the sequential one-stage combined procedure. Hips were reclassified according to the operative time and divided into the first and the second operated hips. The outcomes were compared clinically and radiographically between the two sides preoperatively and postoperatively.

Results

The mean interval time between the two procedures was 5.9 months (range: 2–9 months). The first operated hip achieved better results than did the second operated hip. A total of 68.6% (24/35) of the patients in our series had an asymmetric outcome.

Conclusions

The sequential one-stage combined procedure is a challenge, but a reasonable alternative surgery for bilateral DDH in children after walking age. An asymmetric outcome is a special complication of this procedure.

Bilateral Developmental Dysplasia of the Hip: Does Closed Reduction Have a Role in Management? Outcome of Closed and Open Reduction in 92 Hips

BACKGROUND

Bilateral developmental dysplasia of the hip (DDH) is believed to have a worse outcome than unilateral DDH with the optimal treatment unclear. To define indications for treatment we report a retrospective series of 92 hips (46 patients) who underwent closed reduction (CR) and/or open reduction (OR).

METHODS

A total of 58 hips in 29 patients underwent attempted CR using our standardized protocol. In the same 12 year time period, 54 hips in 27 patients underwent an OR. Outcome measures included resolution of acetabular dysplasia, need for further surgery, development of osteonecrosis (ON), and modified Severin Grade.

RESULTS

CR was successful in 57% of hips; in this group secondary surgery was required in 15% and ON was seen in 12%. In the OR group, 11% failed to stabilize and required further early surgery: ON rate was 15% overall, and secondary surgery was required in 5%. In Tonnis 2/3 hips younger than 2 years, Severin grading was comparable following CR and OR, with 92% and 90% graded as Severin 1, respectively. The rate of significant ON was higher after CR in Tonnis 2/3 hips (12%) than after OR (0%). Overall, Tonnis 4 hips did badly: 94% failed CR and following OR, further surgery for redislocation/residual dysplasia was required in 21%.

CONCLUSIONS

CR can be successful in Tonnis 2/3 bilateral hips, with acceptable rates of secondary surgery, ON, and Severin grading, the latter equivalent to open reduction. Importantly, persisting with casting of a unilateral dislocation, to allow the contra-lateral hip to stabilize, does not have an adverse effect. CR is not advised in Tonnis 4 bilateral hips. Parents should be counseled that the outcome of surgery for bilateral hips is not as good as for unilateral DDH, particularly for Tonnis 4 hips which are more difficult to stabilize and more likely to require supplementary surgery even after open reduction.

LEVEL OF EVIDENCE

Level IV-Therapeutic Study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of surgical outcome in advanced age patients with developmental hip dysplasia

BACKGROUND

This study aimed at determining the efficacy of the surgical treatment conducted on children with delayed presentation developmental dysplasia of the hip (DDH). The objective was to provide a good comparison of functional and radiographic outcomes and to determine various surgical treatment options.

METHOD

In this study, we evaluated the results of 38 hips of 27 patients aged 4 years onset which had been operated due to DDH. Radiographic outcomes were evaluated by using acetabular index, CE angle, Tonnis and the Severin classification system. Clinical evaluation was made by using IOWA hip scores. Degenerative changes were evaluated according to Boyer and avascular necrosis according to Kalamchi-MacEwen criteria.

RESULTS

The mean age of the patients at the operation time was 10 years 3 months (range: 4 years 3 months-30 years). While the mean acetabular index was 37.97 preoperatively, in the last follow-up it was 19.92. Thirty-six hips (94%) had an excellent and good outcomes, and two hips (%6) had a fair outcome with respect to the Severin criteria. The mean hip score with respect to IOWA was 93.736 (range: 75-98) and the rate of excellent and good outcomes was 98%.

CONCLUSION

For the treatment of patients with DDH of late onset, a one-staged operative procedure is recommended. This method is applied successfully and enables us to achieve good clinical and radiographic results.