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

Abstract

Background Osteonecrosis of the femoral head is a major complication that negatively impacts the clinical and radiographic long-term outcome after treatment of developmental hip dysplasia (DDH). There are conflicting results in the literature whether age at the time of closed or open reduction and a specific surgical approach are associated with osteonecrosis. Better understanding of the impact of age at reduction and surgical approach is important to reduce the risk of osteonecrosis in patients with DDH. Questions/purposes We aimed to evaluate the association between occurrence of osteonecrosis and (1) age at closed reduction; (2) age at open reduction; and (3) medial versus anterior operative approaches.Methods A systematic review identified studies reporting osteonecrosis occurrence after treatment of DDH and at least 2 years of followup. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Methodologic quality was assessed using the methodologic index for nonrandomized studies. Generalized logistic models were used to estimate pooled odds ratios (ORs) in the meta-analysis. Sixty-six studies were included in the systematic review and 24 in the meta-analysis. Data on 481 hips treated by closed reduction and 584 hips treated by open reduction were available to evaluate the association between osteonecrosis and age. The association between osteonecrosis and operative approach was assessed using data on 364 hips treated by medial open reduction and 220 hips treated by anterior open reduction. Results Age at reduction ([ 12 months versus B 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 (C 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.

Dysplasia of the hip in children-earlier referrals: a key for better outcomes

“…A meta-analysis by Novais et al, which comprised of 481 hips treated by closed reduction and 584 hips treated by open reduction, did not find any association between closed reduction undertaken before or after 12 months and avascular necrosis. 22 There was also no association between the type of surgical approach (anterior or medial approach) and avascular necrosis. In our study the incidence of avascular necrosis is 7.9% (7 out of 88 hips) and this is comparable to that reported in this meta-analysis (8%) (23) ( Table 2).…”

Timing for Closed Reduction Procedure for Developmental Dysplasia of the Hip and its Failure Analysis

“…Hence, early ultrasound screening using the Graf method in some countries is recommended to timely detect hip immaturity and pathologies and to provide the optimal approach [16]. Several studies reported older age at the time of CR showing a higher rate of complications or further corrective surgeries [5][6][7], while others not [8,9,17]. RAD in group III (older age) was found to be signi cantly high, compared with Group I and II.…”

“…Although this procedure generally achieves satisfactory outcomes, CR procedure may also lead to a number of adverse complications, including iatrogenic avascular necrosis (AVN), re-dislocation and residual acetabular dysplasia (RAD), which might need further surgeries (FS) to address the problem. Previous studies reported that increased age at the time of CR predicted a higher rate of complications or further corrective surgeries [5][6][7], while others not [8,9]. Moreover, it still remains controversial whether CR or open reduction (OR) should be adopted for children approaching or older than 18 months at the time of rst diagnosis, especially for the severe dislocated cases.…”

Developmental dysplasia of the hip: addressing evidence gaps with a multicentre prospective international study

“…Results of bracing studies may be obfuscated by including patients with reducible and irreducible dislocated hips, unstable or subluxable hips and dysplastic hips together, 11,13,14,25,62 and studies comparing operative management also often fail to clearly define the included patient population. 63 To attempt to identify best practice evidence in DDH management, the International Hip Dysplasia Institute (IHDI) initiated in 2010 an international, multicentre prospective study 64 of infants with the most severe form of DDHdislocated hips at rest. Infants diagnosed under 18 months of age with a dislocated hip at rest were enrolled at nine centres across North America, Europe and Australia.…”