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


OBJECTIVE
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.


RESULTS
Open reduction alone had a lower risk of AVN than open reduction combined with pelvic and femoral osteotomy (4% versus 24%), but there was no significant difference compared with open reduction with either pelvic (17%) or femoral osteotomy (18%). More hips treated with open reduction alone had satisfactory radiological results than open reduction combined with pelvic and femoral osteotomy (97% versus 83%) and satisfactory clinical results than all other interventions. More hips treated with open reduction alone required further surgical management (56%) compared with open reduction and pelvic osteotomy (11%) and combined pelvic and femoral osteotomies (8%).


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.


METHODS
Level III, therapeutic study.
Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK. Alpesh.kothari@ndorms.ox.ac.uk.
Alpesh
A
Kothari
Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK.
George
G
Grammatopoulos
Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK.
Sally
S
Hopewell
Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK.
Tim
T
Theologis
D000367:Age Factors; D001696:Biomechanical Phenomena; D002648:Child; D002657:Child Development; D002675:Child, Preschool; D005260:Female; D005269:Femur / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005271:Femur Head Necrosis / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D006618:Hip Dislocation, Congenital / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006621:Hip Joint / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D016017:Odds Ratio; D019637:Orthopedic Procedures / Q000009:adverse effects; D010027:Osteotomy / Q000009:adverse effects; D011859:Radiography; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D016138:Walking