Medial versus anterior open reduction for developmental hip dislocation in age-matched patients.
BACKGROUND
The difference between medial (MAOR) and anterior (AAOR) approaches for open reduction of developmental hip dysplasia in terms of risk for avascular necrosis (AVN) and need for further corrective surgery (FCS, femoral and/or acetabular osteotomy) is unclear. This study compared age-matched cohorts undergoing either MAOR or AAOR in terms of these 2 primary outcomes. Prognostic impact of presence of ossific nucleus at time of open reduction was also investigated.


METHODS
Institutional review board approval was obtained. Nineteen hips (14 patients) managed by MAOR were matched with 19 hips (18 patients) managed by AAOR based on age at operation (mean 6.0; range, 1.4 to 14.9 mo). Patients with neuromuscular conditions and known connective tissue disorders were excluded. Primary outcomes assessed at minimum 2 years' follow-up included radiographic evidence of AVN (Kalamchi and MacEwen) or requiring FCS.


RESULTS
MAOR and AAOR cohorts were similar regarding age at open reduction, sex, laterality, and follow-up duration. One hip in each group had AVN before open reduction thus were excluded from AVN analysis. At minimum 2 years postoperatively (mean 6.2; range, 1.8 to 11.7 y), 4/18 (22%) MAOR and 5/18 (28%) AAOR met the same criteria for AVN (P=1.0). No predictors of AVN could be identified by regression analysis. Presence of an ossific nucleus preoperatively was not a protective factor from AVN (P=0.27). FCS was required in 4/19 (21%) MAOR and 7/19 (37%) AAOR hips (P=0.48). However, 7/12 (54%) hips failing closed reduction required FCS compared with 4/26 (16%) hips without prior failed closed reduction (P=0.024). Cox regression analysis showed that patients who failed closed reduction had an annual risk of requiring FCS approximately 6 times that of patients without a history of failed closed reduction (hazard ratio=6.1; 95% CI, 1.5-24.4; P=0.009), independent of surgical approach (P=0.55) or length of follow-up (P=0.78).


CONCLUSIONS
In this study of age-matched patients undergoing either MAOR or AAOR, we found no association between surgical approach and risk of AVN or FCS. In addition, we identified no protective benefit of a preoperative ossific nucleus in terms of development of AVN. However, failing closed reduction was associated with a 6-fold increased annual risk of requiring FCS.


CONCLUSIONS
To the best of our knowledge, this is the first study comparing these 2 surgical techniques in an age-matched manner. It further corroborates previous studies stating that there may be no difference in risk of AVN based on surgical approach or presence of ossific nucleus preoperatively.


METHODS
Level III-retrospective comparative study.
*University of Southern California Medical Center, Los Angeles, CA †Boston Children's Hospital, Boston, MA.
Jason S
JS
Hoellwarth
Young-Jo
YJ
Kim
Michael B
MB
Millis
James R
JR
Kasser
David
D
Zurakowski
Travis H
TH
Matheney
D002657:Child Development / Q000502:physiology*; D005260:Female; D005269:Femur / Q000601:surgery; D005271:Femur Head Necrosis / Q000209:etiology / Q000517:prevention & control; D006617:Hip Dislocation / Q000209:etiology / Q000601:surgery; D006801:Humans; D007223:Infant; D008297:Male; D019637:Orthopedic Procedures / Q000009:adverse effects / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control*; D011379:Prognosis; D012107:Research Design; D012189:Retrospective Studies; D016896:Treatment Outcome