Outpatient Bryant's Overhead Traction Does Not Affect the Rate of Open Reduction or Avascular Necrosis in Developmental Dislocation of the Hip

BACKGROUND

The efficacy of preliminary traction to increase the likelihood of closed reduction and/or decrease the incidence of avascular necrosis in the management of developmental dysplasia of the hip (DDH) is controversial. We sought to document compliance with and effectiveness of Bryant's outpatient traction in patients with idiopathic DDH.

METHODS

Patients presenting between 6 and 24 months of age with idiopathic irreducible DDH were prospectively enrolled in the study. Prereduction outpatient traction was prescribed at participating surgeons' preference and parents' expressed willingness to comply with a traction protocol of at least 14 hours/day for 4 weeks. Traction hours were documented using a validated monitor; parents also reported average daily usage. Rate of successful closed reduction and evidence of capital epiphyseal growth disturbance 1 year' and 2 years' postreduction were documented.

RESULTS

Ninety-six patients with 115 affected hips were enrolled. Reliable recorded traction hours were obtained in 31 patients with 36 affected hips. Defining compliance as 14 hours/day average use, 14 of 31 patients (45.2%) were compliant, 2 (6.5%) admitted noncompliance, while 15 (48.2%) claimed to be compliant, but were not. Overall, 68/115 hips (59.0%) were closed reduced. Age at treatment was the only demographic characteristic associated with an increased incidence of closed reduction (11.7 vs. 14.6 mo, P<0.01). Successful closed reduction was achieved in 10/16 hips (62.5%) of compliant patients, 12/20 (60.0%) of noncompliant patients, and 43/72 (59.7%) of no-traction patients. Irregular ossific nucleus development was noted 1-year postindex reduction in 5/16 (31.3%) of complaint-patient hips and 25/92 (27.2%) of noncomplaint and no-traction hips. Distorted proximal femoral epiphysis was noted at 2 years postreduction in 2/15 hips (13.3%) of compliant patients and 15/52 hips (28.8%) in noncompliant and no-traction patients. None of these differences was statistically significant.

CONCLUSIONS

Parent-reported use of outpatient traction is unreliable. Four weeks of outpatient overhead Bryant's traction did not affect the rate of closed reduction or avascular necrosis in late-presenting DDH in this cohort.

LEVEL OF EVIDENCE

Level II-prospective cohort.

Decreased orthotic effectiveness in overweight patients with adolescent idiopathic scoliosis

BACKGROUND

Many studies have demonstrated that orthotic treatment is effective for the prevention of curve progression in patients with adolescent idiopathic scoliosis. However, the effect of being overweight on the outcome of orthotic treatment has not been reported. The purpose of the present study was to determine whether orthotic treatment of adolescent idiopathic scoliosis is less successful for patients who are overweight than it is for those who are not overweight.

METHODS

A ten-year multicenter retrospective review of patients in whom adolescent idiopathic scoliosis had been treated with a Boston or a custom-molded thoracolumbosacral orthosis was performed. The inclusion criteria were no previous treatment, skeletal immaturity (a Risser sign of 0, 1, or 2), a curve of 25 degrees to 40 degrees at the time of orthotic initiation, and follow-up to skeletal maturity. Patients were divided into two groups according to body habitus, with overweight patients defined as those with a body mass index in the eighty-fifth percentile or greater. Curve progression was compared between the two groups. Successful orthotic treatment was defined as no more than a 5 degrees increase in the primary curve from the start of orthotic wear to skeletal maturity. Absolute curve progression to 45 degrees or greater also was considered to be an adverse outcome.

RESULTS

Two hundred and seventy-six consecutive patients from two institutions were analyzed, and thirty-one patients were considered to be overweight. The mean curve progression was 9.6 degrees +/- 7.3 degrees for the patients who were overweight, compared with 3.6 degrees +/- 9.4 degrees for those who were not overweight (p < 0.01). Overweight patients were 3.1 times more likely to have an unsuccessful result than those who were not overweight. Curve progression to 45 degrees or greater occurred in fourteen (45%) of the thirty-one patients who were overweight, compared with sixty-nine (28%) of the 245 patients who were not overweight.

CONCLUSIONS

The results of the present study suggest that overweight patients with adolescent idiopathic scoliosis will have greater curve progression and less successful results following orthotic treatment than those who are not overweight. The ability of an orthosis to transmit corrective forces to the spine through the ribs and soft tissue may be compromised in overweight patients. This factor should be taken into consideration when making treatment decisions. Additional study is warranted to determine a threshold effect.