Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Have Changes in Treatment of Late-detected Developmental Dysplasia of the Hip During the Last Decades Led to Better Radiographic Outcome?

Terje Terjesen MD, PhD, Joachim Horn MD, PhD

Abstract

Background

Despite considerable changes in the treatment of of late-detected congenital or developmental hip dislocation (DDH) during the last 50 years, it is unclear whether and to what degree these changes have led to better long-term outcome for the patients.

Questions/purposes

The aims of this study were to see whether decreasing use of skin traction and instead a more aggressive approach to open reduction resulted in (1) reduced use of secondary procedures; (2) improved radiographic appearance of the hips at long-term followup; and (3) changes in the proportion of patients developing avascular necrosis.

Methods

Two groups of patients were compared retrospectively. Inclusion criteria were patient age older than 3 months and younger than 5 years at the initiation of treatment, no associated anomaly, no previous treatment in other hospitals, and available radiographs from the time of diagnosis to skeletal maturity. Group A consisted of 56 patients (51 girls [91%]; 74 hips) primarily treated during the period 1958 to 1962. Group B comprised 38 patients (36 girls [95%]; 40 hips) treated during the period 1996 to 2002. The mean age at the time of hip reduction was 20 months (SD 9.6) in Group A and 17 months (SD 11.9) in Group B. The mean time in skin traction had decreased from 35 days (SD 12.5) to 11 days (SD 5.7) over the years (p < 0.001). Open reduction was performed in six of 74 hips (8%) in Group A and 15 of 40 hips (37%) in Group B (p < 0.001). The immobilization time in the hip spica had decreased from 9 to 6 months (p < 0.001). The indication for secondary procedures to correct residual dysplasia was center-edge angle < 20° and was similar in both groups. A modified version of the radiographic classification of Severin was used to compare the results.

Results

Secondary procedures to correct residual dysplasia were performed in 28 of 74 hips (38%) in Group A and seven of 40 hips (18%) in Group B (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.14–0.89; p = 0.025) At skeletal maturity, the proportion of patients with satisfactory radiographic results (Severin Grades I/II) was larger in Group B (33 of 40 hips [82%]) than in Group A (46 of 74 hips [62%]; OR, 0.35; CI, 0.14–0.89; p = 0.025). Femoral head coverage, assessed as the center-edge angle, was greater in Group B than in Group A (mean 26° versus 22°; CI, 0.8–7.9; p = 0.016). There was no difference in the proportion of avascular necrosis of the femoral head (seven of 74 hips [9%] in Group A and five of 40 [13%] in Group B; OR, 1.4; CI, 0.4–4.6; p = 0.614).

Conclusions

The move away from prolonged use of skin traction and toward more frequent open reduction for children with a late diagnosis of DDH appears to result in fewer secondary procedures and a better radiographic appearance of the hip at skeletal maturity. Based on the present results, we cannot conclude whether preliminary traction is needed; this question should be evaluated in future long-term studies with a prospective, randomized design.

Level of Evidence

Level III, therapeutic study.

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