Post-reduction avascular necrosis in congenital dislocation of the hip.

Background Anterior open reduction is commonly used to treat hip subluxation or dislocation in developmental dysplasia of the hip (DDH) in walking-age children. Pelvic and/ or femoral osteotomy may be used in addition, but it is unclear how this affects avascular necrosis (AVN) risk and radiological and clinical results. Questions/purposes The purpose of this study was to review studies of walking-age patients treated either with an open reduction alone or combined with pelvic and/or femoral osteotomies and determine whether there is a difference between groups in the proportion of patients: (1) developing clinically relevant femoral head AVN (Kalamchi & MacEwen Types II to IV or equivalent); (2) achieving a satisfactory radiological result (Severin Grade I/II or equivalent); (3) achieving a satisfactory clinical result (McKay excellent or good rating or equivalent); and (4) requiring further nonsalvage surgery. Methods MEDLINE, Embase, the Cochrane Centre Register of Controlled Trials, and ClinicalTrials.gov were searched for studies of anterior open reduction for DDH in children aged 12 months to 6 years old. We assessed AVN, clinical and radiological results, and requirement for further procedures. The effect of failed conservative management, traction, age at operation, and followup duration was also assessed. Eighteen studies met the review eligibility criteria. Conclusions Open reduction with concomitant pelvic osteotomy is the most appropriate option to provide durable results with the lowest risk of AVN and best radiological and clinical results. There is no evidence that addition of a femoral osteotomy provides any additional benefit to the patient, although it may be necessary to achieve reduction. Level of Evidence Level III, therapeutic study.

Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

How Does Bony Surgery Affect Results of Anterior Open Reduction in Walking-age Children With Developmental Hip Dysplasia?

Kothari

Grammatopoulos

Hopewell

et al. 2016

“…Avascular necrosis of the femoral head is a devastating complication after closed reduction [3,15] potentially resulting in early degenerative joint disease and impaired function [3,9,15,20]. To date, no factors have been shown as reliable predictors of future AVN.…”

Section: Discussionmentioning

confidence: 99%

Does Perfusion MRI After Closed Reduction of Developmental Dysplasia of the Hip Reduce the Incidence of Avascular Necrosis?

Gornitzky

Georgiadis

Seeley

et al. 2016

Background Gadolinium-enhanced perfusion MRI (pMRI) after closed reduction/spica casting for developmental dysplasia of the hip (DDH) has been suggested as a potential means to identify and avoid avascular necrosis (AVN). To date, however, no study has evaluated the effectiveness of pMRI in clinical practice or compared it with other approaches (such as postreduction CT scan) to show a difference in the proportion of AVN. Questions/purposes (1) Can a pMRI-based protocol be used immediately post closed reduction to minimize the risk that AVN would develop? (2) What are the overall hiprelated outcomes after closed reduction/spica casting using this protocol? (3) Do any patient-specific factors at the time of closed reduction predict future AVN? Methods This was a retrospective cohort study at a large tertiary care children's hospital. Between 2009 and we treated 43 patients with closed reduction/spica casting for DDH, of whom 33 (77%) received a postreduction pMRI. All patients were indicated for pMRI per treating surgeon preference. A convenience sample totaling 25 hips in 22 patients treated with pMRI was then established using the following exclusion criteria: DDH of neuromuscular/ syndromic origin, failed initial closed reduction, less than 1 year of clinical and radiographic followup, and subsequent open reduction. Next, the 40 patients treated with closed reduction between 2004 and 2009 were screened until the chronologically most recent 25 hips (after applying the previously mentioned exclusion criteria) were identified in 21 of the first 34 patients (62%) screened. Although termed the CT group, specific postreduction imaging was not a defined inclusion criterion in this group with the majority (21 of 25 [84%]) receiving postreduction CT and the remainder (four of 25 [16%]) receiving only postreduction radiographs. All hips with globally decreased femoral head perfusion on postreduction pMRI were treated with immediate cast removal followed by repeat closed reduction or open reduction, as per surgeon preference, with two of 33 (6%) requiring such further interventions. Salter criteria were then used to determine the proportion of AVN on radiographs at 1-year and final followup. Secondary outcomes including residual dysplasia and the need for further corrective surgery were ascertained through radiographic and retrospective chart review. 049). No patient with normal perfusionEach author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conform...

“…It has been suggested that osteonecrosis of the femoral epiphysis secondary to treatment of DDH can affect acetabular remodeling [5,6,8,9], but there are no robust data from longitudinal studies describing the magnitude of this effect. Understanding this effect would allow for more accurate anticipation of residual dysplasia and thus be helpful in planning additional treatment.…”

Section: Discussionmentioning

confidence: 99%

“…The degree of osteonecrosis may range from mild epiphyseal hypoplasia to severe deformity [7]. Consequences of osteonecrosis such as loss of femoral head sphericity or subluxation have been associated with premature osteoarthritis [8,12]. Although osteonecrosis primarily affects the proximal femur, it has been suggested that it can produce a compromise in acetabular remodeling [5,6,8,9], the degree to which this occurs is unclear.…”

Section: Introductionmentioning

confidence: 99%

Osteonecrosis Complicating Developmental Dysplasia of the Hip Compromises Subsequent Acetabular Remodeling

Roposch

Ridout

Protopapa

et al. 2013

Background Osteonecrosis of the femoral head secondary to treatment of developmental dysplasia of the hip (DDH) affects acetabular remodeling but the magnitude of this effect is unclear. Questions/purposes Using four measures of acetabular development, we (1) determined whether acetabular remodeling differed in hips with and without osteonecrosis; and (2) determined the impact of severity of osteonecrosis contributing to acetabular remodeling. Methods We retrospectively reviewed 95 patients (118 hips) treated for DDH by closed or open reduction with or without femoral osteotomy between 1992 and 2006. We evaluated serial radiographs from the time when a stable reduction had been achieved. In 902 radiographs taken over 19 years, we measured the acetabular index and three other indices of hip development. Patients were followed for a mean of 8 years (range,