Late-diagnosed DDH: a prospective 11-year follow-up of 71 consecutive patients (75 hips)

Neglected Developmental Hip Dysplasia Treated With External Iliofemoral Distraction, Open Reduction, and Pelvic Osteotomy: Eleven-Year Follow-Up

Neglected untreated developmental hip dysplasia can result in severe deformities and functional disabilities. This report describes the treatment and 11-year follow-up of a patient who underwent the procedure in two stages. At the time of treatment, the patient was 7 years of age and was diagnosed with acetabular dysplasia and neglected right hip dysplasia. A stepwise treatment approach, including gradual distraction of the iliofemoral joint, open reduction, and pelvic osteotomy, was performed. Subsequent postoperative rehabilitation and regular follow-up assessments were performed over 11 years. The long-term results indicated notable improvements in hip joint congruency, functional range of motion, and overall quality of life. Early diagnosis and appropriate intervention are crucial for patients with developmental hip dysplasia, and the treatment methods described here are effective.

Narrative Review of Complications Following DDH Treatment

BACKGROUND

The purpose of this narrative review was to survey the literature for common complications following treatment of DDH in children less than 4 years old.

METHODS

The Pubmed database was queried. Search result titles were reviewed to identify papers that were pertinent to the topic. Abstracts for these papers were obtained and read, and a subset of these were selected for review of the complete manuscript.

RESULTS

92 manuscripts were reviewed. Residual dysplasia, redislocation, and osteonecrosis are the primary complications of treatment in this age group. In the long term, hips without complications related to DDH treatment tend to do well, although a significant percentage of them will inevitably require joint replacement surgery.

CONCLUSION

Although there is excellent potential for a good outcome when DDH is diagnosed and treated under age 4 years, osteonecrosis continues to be a concern with all treatment methods. A subset of patients from this young cohort will continue to have residual dysplasia or recurrent dislocation requiring return to the operating room.

Increased Loading Rates During Gait Correlate With Morphology of Unaffected Hip in Juveniles With Treated Developmental Hip Dysplasia

Long-term follow-up studies on children with surgically treated developmental dysplasia of the hip (DDH) have shown that not only the affected side progresses to premature osteoarthritis, but the unaffected side may also suffer from insidious hip dysplasia or osteonecrosis. The current gait analysis study identified the loading and unloading rates of the ground reaction forces (GRF) and lower limb joint axial forces during gait, and their correlations with the hip morphology in twenty juvenile patients with surgically treated unilateral DDH during toddlerhood. In a gait laboratory, each subject walked at preferred speed on a 10-m walkway while the kinematics and the GRF were measured. Loading and unloading rates of the vertical GRF and the joint axial forces were obtained as the maximum instantaneous slope of these force curves. Radiographic measurements of the hips were taken, and the correlations between the morphological parameters and the loading and unloading rates were obtained. The patients showed greater-than-normal peak loading rates of the joint axial forces, and the loading rates on both the affected and unaffected sides were strongly correlated to the acetabular index on the unaffected side, which was also significantly correlated with the peak unloading rates on the affected side. These results suggest that apart from regular follow-up of the affected hip, routine assessment of the morphological changes and/or increased loading rates on the unaffected hip is also important for early identification of any signs of insidious hip dysplasia and risk of premature degeneration of the cartilage.

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

Aims

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

Methods

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

Results

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

Conclusions

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

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.

Reduction by Pelvic External Fixator Followed by Innominate and Derotational Femoral Osteotomies for Late Presenting Bilateral Developmental Dysplasia of the Hip

Introduction

Bilateral developmental dysplasia of the hip is a challenging situation, closed and open reduction with or without pelvic and femoral osteotomies are all proposed.

Methods

We investigated the feasibility of closed ilizarov reduction combined with Salter and femoral osteotomy to provide stable concentric hips.

Results

We retrospectively reviewed 19 patients (38 hips). Tonnis Criteria, acetabular index and Center-edge angle were measured preoperatively and postoperatively. Acetabular index changed significantly (P<0,001), 80% were excellent or good according to Mckay, 25% were Ia and 69% were IIa Severin's criteria with at least three years follow-up.

Conclusion

The midterm overall results are favorable for application of this technique.

Outcomes following open reduction for late-presenting developmental dysplasia of the hip

PURPOSE

Patients with late-presenting developmental dysplasia of the hip (DDH) are more likely to require an open reduction. Since many developing countries do not have mandated screening, there continues to be a relatively high incidence of late-presenting DDH. We report the clinical and radiographic outcomes of open reduction in a series of patients who presented late.

PATIENTS AND METHODS

This was a retrospective review of 712 hips in 645 patients that underwent open reduction, alone or in combination with a pelvic osteotomy. In all, 91 hips had open reduction alone and 621 had open reduction and pelvic osteotomy. Femoral shortening was performed in 221 hips. The mean age at the time of surgery was 2.1 years (1 to 6.5) and the mean follow-up time was 9.3 years (6 to 14). We used the Children's Hospital Oakland Hip Evaluation Score (CHOHES) to determine functional outcomes and the Severin classification was used to evaluate radiographic outcomes. The rate of avascular necrosis (AVN) and the need for a reoperation were also recorded and analyzed.

RESULTS

In all 80% (570 hips) had good radiographic outcomes (Severin type I or II) and 87% had a CHOHES score of > 90 at final follow up. There was a 14% rate of AVN and only a 2% rate of redislocation. Better radiographic outcomes and lower reoperation rates were seen with patients who underwent both an open reduction and pelvic osteotomy. A trend was observed towards worse outcomes in older patients.

CONCLUSIONS

There was a high rate of good clinical and radiographic outcomes at a minimum six-year follow-up in patients with late-presenting DDH who underwent open reduction. Those who underwent open reduction in combination with a pelvic osteotomy had a higher rate of good radiographic outcomes and a lower rate of complications, particularly reoperation.

Prevalence of Developmental Dysplasia of the Hip in Chinese Adults: A Cross-sectional Survey

Background:

The prevalence of developmental dysplasia of the hip (DDH) is unknown in China. We aimed to determine the prevalence of DDH in Chinese adults.

Methods:

In this study, we performed a cross-sectional survey of a nationally representative sample of Chinese adults. All participants underwent questionnaire investigation, physical examination, and X-ray examination. Factors associated with DDH were analyzed with logistic regression.

Results:

We invited 29,180 individuals aged 18 years and over to participate, randomly selected from 18 primary sampling units (street districts in urban areas and townships in rural areas). The survey and examination were completed in 25,767 people (10,296 men and 15,471 women). DDH was diagnosed in 391 people, yielding an overall DDH prevalence of 1.52%. Based on this information, we estimate the number of individuals with DDH in China to be approximately 16.05 million. DDH prevalence increased with age (odds ratio = 1.53 [1.03–2.27], P = 0.036), was significantly higher among women than men (2.07% vs. 0.75%, P < 0.001), and was higher among rural residents than urban residents (1.75% vs. 1.29%, P < 0.001). Economic development was independently associated with the presence of DDH. There was no evidence of an association between body mass index alone, education, or current smoking or drinking and risk of DDH (P > 0.05).

Conclusions:

DDH has become an important public health problem. Special attention should be paid to residents with DDH. Screening for DDH should be performed in China.

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.

Avascular necrosis following closed reduction for treatment of developmental dysplasia of the hip: a systematic review

BACKGROUND

Avascular necrosis (AVN) is a significant and potentially devastating complication following the treatment of developmental dysplasia of the hip (DDH). The reported rate of AVN following closed reduction for DDH ranges from 4 to 60%, and the resultant influence on hip development remains unclear.

PURPOSE

A systematic review of the literature was undertaken to evaluate the frequency of AVN after more than 5 years of follow-up in children that underwent closed reduction at younger than 2-years of age for DDH.

METHODS

The search strategy was formulated with key-concepts and keywords identified using the patient problem, intervention, comparison and outcome process. Searches were undertaken using Pubmed, Scopus and Web of Science up to and including May, 2016 to identify potential studies.

RESULTS

A total of seven papers met the a priori inclusion and exclusion criteria of this review. The overall rate of significant AVN in 441 patients (538 hips) was 10% at a mean length of follow-up of 7.6 years (5-18.8) following closed reduction. This finding can be used to inform the feasibility of future intervention studies, and act as a baseline for which surgeons to compare their results to a 'standard'.

Is Age or Surgical Approach Associated With Osteonecrosis in Patients With Developmental Dysplasia of the Hip? A Meta-analysis

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.

Medial percutaneous hemi-epiphysiodesis improves the valgus tilt of the femoral head in developmental dysplasia of the hip (DDH) type-II avascular necrosis

BACKGROUND AND PURPOSE

Avascular necrosis (AVN) is a major cause of disability after treatment of developmental dysplasia of the hip (DDH), leading to femoral head deformity, acetabular dysplasia, and osteoarthritis in adult life. Type-II AVN is characterized by retarded growth in the lateral aspect of the physis or by premature lateral fusion, which produces a valgus deformity of the head on the neck of the femur. We investigated the effect of medial percutaneous hemi-epiphysiodesis as a novel technique in the treatment of late-diagnosed type-II AVN.

PATIENTS AND METHODS

9 patients (11 hips) with a diagnosis of type-II AVN who underwent medial percutaneous hemi-epiphysiodesis after the surgical treatment for DDH were included in the study. 10 patients (12 hips) with the same diagnosis but who did not undergo hemi-epiphysodesis were chosen as a control group. Preoperative and postoperative articulotrochanteric distances, head-shaft angles, CE (center-edge) angles, and physeal inclination angles were measured. The treatment group underwent medial hemi-epiphysodesis at a mean age of 8 years. The mean ages of the treatment group and the control group at final follow-up were 14 and 12 years respectively. The mean duration of follow-up was 5.7 years in the treatment group and 8.3 years in the control group.

RESULTS

Preoperative articulotrochanteric distance, head-shaft angle, and functional outcome at the final follow-up assessment were similar in the 2 groups. However, preoperative and postoperative CE angles and physeal inclination angles differed significantly in the treatment group (p < 0.05). The final epiphyseal valgus angles were better in the treatment group than in the control group (p = 0.05). The treatment group improved after the operation.

INTERPRETATION

Medial percutaneous epiphysiodesis performed through a mini-incision under fluoroscopic control is a worthwhile modality in terms of changing the valgus tilt of the femoral head.

The safety and efficacy of a transarticular pin for maintaining reduction in patients with developmental dislocation of the hip undergoing an open reduction

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.

Analyses of outcomes of one-stage operation for treatment of late-diagnosed developmental dislocation of the hip: 864 hips followed for 3.2 to 8.9 years

Background

The one-stage procedure for treatment of older developmental dislocation of the hip (DDH) is used widely. However, the best age group for this operation is still unknown. The aims of our study were to evaluate middle-term outcomes of one-stage surgical treatment of a large number of patients with late-diagnosed DDH, and to explore the best age group for treatment.

Methods

We retrospectively reviewed 652 patients with a total of 864 hip joints with DDH, all aged >18 months. All the hip joints were treated with one-stage procedures including open reduction, pelvic osteotomy, and femoral shortening. The patients were divided into three groups according to age at surgery: Group I: 1.5–2.5 years; Group II: 2.5–8 years; and Group III: >8 years. The latest clinical and radiographic outcomes, complications and avascular necrosis (AVN) of the femoral head were evaluated and compared among the three groups.

Results

The mean age at surgery was 5.8 years (range: 1.5–13.2 years). The average time of follow-up was 6.2 years (range: 3.2–8.9 years). A total of 79.4% of good or excellent outcomes were obtained for clinical functional evaluation according to the McKay classification. For radiographic outcomes, 732 hips (84.7%) were classified as good or excellent according to the Severin classification. A total of 27.4% of all hips had a poor outcome according to the Kalamchi and MacEwen classification for AVN. The poorest outcomes were observed for clinical, radiographic and AVN results in Group III (p < 0.001). Compared with Group I, the better results for clinical and AVN outcomes were found in Group II (p < 0.001). However, similar clinical outcomes were observed between Groups I and II (p > 0.05). A significantly higher incidence of redislocation and residual acetabular dysplasia was observed in Tonnis grade II and III hip dislocation (p < 0.001).

Conclusions

One-stage treatment of late-diagnosed DDH had a good outcome in young and middle group. Younger patients achieved better results than older patients. However, the best age group was 2.5–8 years. Tonnis grade II and III DDH is a risk factor for redislocation and residual acetabular dysplasia after the one-stage operation.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-401) contains supplementary material, which is available to authorized users.

An Unusual Complication Seen in a Six-Year-Old Girl Treated with Open Reduction and Pemberton Osteotomy for Neglected Developmental Dysplasia of the Hip: A Femoral Neck Fracture Sustained during Passive Motion under General Anesthesia

Despite the screening programs for newborn children with hip ultrasonography, neglected developmental dysplasia of the hip (DDH) is still continuing to be a problem in the east and southeast parts of our country. The main complications are redislocation, avascular necrosis, and joint stiffness. We present an unusual complication, femoral neck fracture during passive motion under general anesthesia, of a six-year-old girl with neglected DDH treated by open reduction and Pemberton osteotomy without femoral shortening. The fracture was treated by open reduction and internal fixation combined with proximal femoral shortening. After 5 years the patient had excellent clinical results, no avascular necrosis was seen, and the radiologic appearance was type IA according to modified Severin classification. In conclusion older children with neglected DDH are more likely to have joint stiffness after open reduction. If there is even a little doubt about joint stiffness after open reduction, one should not refrain from femoral shortening. Also passive motion under general anesthesia should be applied very carefully with fluoroscopic control.

Congenital dislocation of the hip, with late diagnosis after 1 year of age: update and management

When congenital dislocation of the hip (CDH) is diagnosed only after walking age, management is greatly complicated. In view of the increasing number of such cases treated by members of the French Society of Paediatric Orthopaedics (SOFOP) in recent years, a 3-part study was conducted within the Society to shed light on the reasons for late diagnosis, to give an update on treatment strategies currently implemented in France, and to report long-term outcomes.

Predictors for secondary procedures in walking DDH

BACKGROUND

Persistent or recurrent hip dysplasia and/or loss of reduction can complicate the treatment of developmental dysplasia of the hip (DDH) in walking children. In this study, we identify predictors for secondary procedures after open reduction of the hip in walking children with DDH.

METHODS

We performed a retrospective study of walking children with idiopathic DDH treated with open reduction of the hip and followed up for >5 years. Perioperative factors were analyzed to investigate predictors of reoperation. Factors associated with the need for secondary procedures were identified. Acetabular remodeling was analyzed with a graphical plot of serial (0, 6 and 12 mo, and yearly) mean acetabular index and SD.

RESULTS

There were 49 open reductions of the hip in 42 patients (34 female, 8 male) at a mean age of 31.3 months (range, 15.3 to 92.6 mo), with a mean follow-up of 9.7 years (5 to 16.9 y). Twelve (24%) patients had open reduction only, 15 (31%) had concurrent pelvic osteotomy, 4 (8%) had femoral osteotomy, and 18 (37%) had both femoral and pelvic osteotomy. Four (8%) patients required repeat open reduction at a mean of 5.1 months (range, 4 to 7.5 mo) after index surgery. Twenty-four (49%) patients had at least 1 secondary surgery for dysplasia at a mean of 3.2 years after index surgery. Six of the 24 (25%) had 2 and 2/24 (8.3%) had 3 additional operations. Of the 27 patients who did not have concurrent femoral osteotomy at index surgery, 19/27 (73%) required a secondary procedure; this significantly predicted the need for reoperation (P<0.001). Only 5/22 patients with femoral osteotomy at index surgery required a secondary procedure. Maximum acetabular remodeling was observed in the first 4 years after primary reduction, and the mean acetabular index remodeled from 43.9 to 20.3 degrees during this period.

CONCLUSIONS

Forty-nine percent of the patients in this cohort required secondary procedures to treat hip dysplasia. Open reduction without concurrent femoral osteotomy strongly predicted the need for a secondary procedure. Maximum acetabular remodeling was observed in the first 4 years after open reduction.

LEVEL OF EVIDENCE

Retrospective case series, level IV.

Late diagnosis of developmental dysplasia of the hip: an analysis of risk factors

A neonatal clinical screening program for developmental dysplasia of the hip (DDH) operates in South Australia to diagnose DDH as early as possible. However, some cases of DDH are diagnosed late (>3 months of age). The aims of this study were to identify the specific risk factors for late diagnosis by comparing early diagnosed DDH, late diagnosed DDH, and normal controls in the South Australian population. There were 1945 children with DDH born between 1988 and 2003, of which 67 cases were late diagnosis (3.4%). Maternal characteristics, pregnancy, and delivery details were analyzed, and compared with controls (early diagnosed DDH and the general population). There was a trimodal pattern of age at presentation with a gradual increase in the incidence of late diagnosed DDH over the time period in this study. Birthweight (<2500 g), birth in a rural setting, and early hospital discharge following delivery (<4 days) were significant risk factors for late diagnosed DDH. Breech presentation and delivery by caesarean section were protective for late diagnosed DDH. Risk factors for late diagnosed DDH relate to factors that influence the screening program. A rigorous population-based hip surveillance program is important for early diagnosis of DDH.

New treatment method for developmental dysplasia of the hips after walking age: arthroscopic reduction with limboplasty based on the findings of preoperative imaging

BACKGROUND

What makes treatment choice for developmental dysplasia of the hips diagnosed after walking age difficult is the poor understanding of prereduction conditions that obstruct the reduction in spatial terms. To evaluate these problems, we employed subtraction three-dimensional imaging to search for the factors involved in intraarticular obstruction. On the basis of the findings of preoperative subtraction threedimensional imaging from computed tomography, we developed a new method, a minimum invasive arthroscopic reduction with limboplasty, for reduction of developmental dysplasia of the hips after walking age. The purposes of this report were to: (1) describe the technique of the arthroscopic procedure, and (2) evaluate our new method using radiographic parameters.

METHODS

Ten patients with ten hips with developmental dysplasia after walking age treated by arthroscopic reduction with limboplasty were included in this study. The mean age of the patients at reduction was 22.6 months (range, 18.6-29.7 months); mean age at follow up was 7.2 years (range, 3.9-10.9 years); and mean follow up was 5.4 years (range, 1.7-9.0 years). These ten hips were evaluated using radiographic measurements.

RESULTS

Moderate or severe avascular necrosis of the femoral head was not observed. Two hips that had a spherical-shaped head with minimal residual height loss or coxa magna were classified as Kalamchi and MacEwen grade 1. Additional surgery had been performed for two hips classified as Severin group 4 during the course of follow up. These two hips were classified as Severin group 1 at final examination. One more hip was classified as Severin group 4 at final examination, and additional surgery was recommended. The remaining seven hips (70%) therefore obtained good evaluations by arthroscopic reduction with limboplasty alone.

CONCLUSIONS

We developed a new reduction method by using an arthroscopic procedure for the reduction of developmental dysplasia of the hips after walking age when this dysplasia failed to be reduced with nonoperative methods. The result of our new method is acceptable because good evaluations were obtained in 70% of hips 5.4 years after reduction by our new method alone.

Single-stage open reduction, Salter innominate osteotomy, and proximal femoral osteotomy for the management of developmental dysplasia of the hip in children between the ages of 2 and 4 years

The management of neglected developmental dysplasia of the hip in walking children has always been a challenge to orthopedic surgeons. The aim of this study was to access the early clinical and radiographic results of surgical treatment of such cases using one-stage open reduction, Salter innominate osteotomy, and proximal femoral osteotomy. Seventy-one surgeries were performed in 55 patients. Favorable clinical and radiographic outcomes were comparable to other studies. We concluded that this single-stage surgery is a technically demanding, but satisfactory procedure in the management of neglected developmental dysplasia of the hip patients, and when performed adequately in indicated patients in specialized centers, it is expected to give good short-term results.

Operative treatment of developmental hip dysplasia in children aged over 8 years

Nine patients aged over 8 years with developmental dislocation of the hip were treated by an open reduction, femoral shortening and varus derotation osteotomy with or without a Chiari osteotomy. The mean age of the patients was 11.1 years (range 8-17 years), and the mean follow-up period was 7.1 years (range 1-13 years). The left hip was involved in four cases: the right in three and two cases were bilateral. One hip redislocated. The remaining patients recovered nearly full movement of the affected hip. Five out of eight patients had a normal gait without limping or pain. Two others limped secondary to a leg-length discrepancy, which was corrected with leg equalization. The remaining patient had an improvement of her preoperative limp and was pain-free. These results indicate that it is possible to obtain good hip function after open reduction of a developmentally dislocated hip, even after the age of 8 years.

Differences in risk factors between early and late diagnosed developmental dysplasia of the hip

BACKGROUND

Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in South Australia. Clinical screening programmes exist to identify the condition early to gain the maximum benefit from early treatment. Although these screening programmes are effective, there are still cases that are missed. Previous research has highlighted key risk factors in the development of DDH.

OBJECTIVE

To compare the risk factors of cases of DDH identified late with those that were diagnosed early.

METHODS

A total of 1281 children with DDH born in 1988-1996 were identified from the South Australian Birth Defects Register. Hospital records of those who had surgery for DDH within 5 years of life were examined for diagnosis details. Twenty seven (2.1%) had been diagnosed at or after 3 months of age and were considered the late DDH cases (a prevalence of 0.15 per 1000 live births). Various factors were compared with early diagnosed DDH cases.

RESULTS

Female sex, vertex presentation, normal delivery, rural birth, and discharge from hospital less than 4 days after birth all significantly increased the risk of late diagnosis of DDH.

CONCLUSIONS

The results show differences in the risk factors for early and late diagnosed DDH. Some known risk factors for DDH are in fact protective for late diagnosis. These results highlight the need for broad newborn population screening and continued vigilance and training in screening programmes.

Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force

BACKGROUND

Developmental dysplasia of the hip (DDH) represents a spectrum of anatomic abnormalities that can result in permanent disability.

OBJECTIVE

We sought to gather and synthesize the published evidence regarding screening for DDH by primary care providers.

METHODS

We performed a systematic review of the literature by using a best-evidence approach as used by the US Preventive Services Task Force. The review focused on screening relevant to primary care in infants from birth to 6 months of age and on interventions used in infants before 1 year of age.

RESULTS

The literature on screening and interventions for DDH suffers from significant methodologic shortcomings. No published trials directly link screening to improved functional outcomes. Clinical examination and ultrasound identify somewhat different groups of newborns who are at risk for DDH. A significant proportion of hip abnormalities identified through clinical examination or ultrasound in the newborn period will spontaneously resolve. Very few studies examine the functional outcomes of patients who have undergone therapy for DDH. Because of the high rate and unpredictable nature of spontaneous resolution of DDH and the absence of rigorous comparative studies, the effectiveness of interventions is not known. All surgical and nonsurgical interventions have been associated with avascular necrosis of the femoral head, the most common and most severe harm associated with all treatments of DDH.

CONCLUSIONS

Screening with clinical examination or ultrasound can identify newborns at increased risk for DDH, but because of the high rate of spontaneous resolution of neonatal hip instability and dysplasia and the lack of evidence of the effectiveness of intervention on functional outcomes, the net benefits of screening are not clear.

Successful treatment of high congenital dislocated hips in older children by open reduction, pelvic and femoral osteotomy with external fixator stabilization (average 8.2 years of age)

A new technique using a hinged external fixator to stabilize an open reduction with pelvic and femoral osteotomies has been developed for treating high-dislocated hips in older children with developmental dislocated hip (DDH). This technique was performed in 11 patients (12 hips) at a mean age of 8.2 years. At follow up, radiographic results showed no redislocation/subluxation and clinical results demonstrated 11 hips as excellent/good and only one hip as poor from persistent stiffness. In conclusion, this new technique produces acceptable results in the treatment of older children with high dislocation of the hip from DDH.

Single-stage open reduction through a medial approach and innominate osteotomy in developmental dysplasia of the hip

We treated 15 hips (15 patients) with developmental dysplasia by a single-stage combination of open reduction through a medial approach and innominate osteotomy. The mean age of the patients at the time of operation was 20 months (13 to 30). The mean follow-up period was 9.6 years (4 to 14).

At the final follow-up, 14 hips were assessed clinically as excellent and one hip as good. Radiologically, ten hips were rated as class I, four as class II and one as class III according to the criteria of Severin. No avascular necrosis was seen. No patient required subsequent surgery. Our results indicate that satisfactory results can be obtained with the single-stage combination of open reduction by the medial approach and innominate osteotomy for developmental dysplasia of the hip in a selected group of children older than 12 months. To our knowledge, no similar combined technique has been previously reported.