The medial approach for the treatment of children with developmental dysplasia of the hip

Abstract

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged < 24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre-edge angle (CEA) were also measured. The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups. Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols.

Developmental Dislocation of the Hip Successfully Treated by Preoperative Traction and Medial Open Reduction: A 22-year Mean Followup

“…We agree with those authors because in patients younger than 24 months, AVN and additional surgery have been reported in patients treated by anterior open reduction at a similar or higher rate than patients treated by medial open reduction [12]. In a recent prospective study of two cohorts of patients with an upper age limit of 24 months [72], one cohort had the medial approach and the other had the anterior approach, and the AVN rate was significantly lower in the medial approach cohort at an average followup of 7 years (12% versus 18%). In our series, the prevalence of AVN in patients younger than 24 months was 9.4%, although in a recent meta-analysis of open reduction by the medial approach, the average prevalence of AVN was 20% [26].…”

Association between the ossific nucleus and osteonecrosis in treating developmental dysplasia of the Hip: updated meta-analysis

“…We included studies which defined osteonecrosis by radiographic criteria (Bucholz and Ogden [10] or Kalamchi and MacEwen [11]). We excluded studies with a follow-up of less than two years and studies reporting on neuromuscular hip disorders, teratological hip dislocation and septic arthritis [2, 4, 5, 7, 13, 14, 16]. We excluded paper written in languages other than English, Polish and German.…”

Developmental dysplasia of the hip: What has changed in the last 20 years?

“…The modified Smith-Petersen anterolateral approach is very useful because it allows for a concomitant pelvic osteotomy, capsulorrhaphy and usually a shorter period in a spica. Therefore, it is usually the procedure of choice in children older than 18 mo [4,23,127] . Redislocation following open reduction is an important problem with a variable incidence.…”