Outcomes following medial open reduction in infants aged ≤6 months with developmental dysplasia of the hip

Abstract

Aim: To evaluate mid-long term radiological outcomes following early medial approach open reduction (MAOR) performed for developmental dysplasia of the hip (DDH) in infants aged ≤6 months old at time of surgery, specifically incidence of clinically significant avascular necrosis (AVN), Severin outcomes and rates of further surgery.

Methods: This is a single centre retrospective study of patients treated from 1999 to 2017. Only infants aged ≤6 months old at time of MAOR, and aged at least 6 years old at latest follow-up were included (minimum 5.5 years follow-up). Data was collected from electronic healthcare records and serial radiographs reviewed to assess outcomes. AVN was classified according to Kalamchi and MacEwen, with types 2-4 considered clinically significant. Severin classes I (excellent) and II (good) were considered satisfactory outcomes, and classes III + considered unsatisfactory.

Results: MAOR was performed on 48 hips in 44 patients. Mean age at time of surgery was 4 months (SD 1.4, range 2-6), with mean follow-up of 9.8 years (SD 2.7, range 6.2-16.2). Clinically significant AVN developed in 9/48 hips (19 %), all of which were type 2. Only 1/48 hips (2 %) required a subsequent pelvic osteotomy due to residual dysplasia with subluxation at 2 years post MAOR. At final follow-up, 81 % of patients had excellent or good radiological outcomes (Severin I/II). No statistically significant predictors for developing AVN, including age and presence of ossific nucleus, were identified.

Conclusion: Early MAOR in infants aged ≤6 months was associated with a very low rate of significant residual dysplasia requiring further surgery, yet was not associated with unacceptable rates or severe forms of AVN. We therefore recommend MAOR is performed early to optimise acetabular remodelling potential and minimise the need for concurrent or subsequent bony procedures.

Keywords: Avascular necrosis; Congenital dislocation; DDH; Developmental dysplasia; Hip; Medial approach; Open reduction.

Fig. 1

Flowchart of patient inclusion in the study.

Fig. 2A–G

Typical examples of cases considered to represent type 2 AVN in 5 different patients, with radiological features including horizontal orientation of the physis, coxa valga, and increased leg length resulting in pelvic tilt. X-rays are taken with the patient standing and patellae facing forwards. (A) Example in right hip at 7 years old. (B) Left hip at 7 years old. (C) Right hip at 8 years old. (D) Left hip at 8 years old. (E) Bilateral AVN following bilateral MAOR at 8 years old.

Fig. 3A–B

X-rays of the single patient who underwent subsequent pelvic osteotomy. (A) At 2 years post-op bilateral MAOR, demonstrating subluxation of the right hip. (B) At 6 years old, almost 4 years post-op right sided Salter osteotomy.