Does open reduction of the developmental dislocated hip increase the risk of osteonecrosis?

Abstract

Background: Osteonecrosis (ON) of the femoral head is one of the main complications associated with treatment of developmental dysplasia of the hips (DDH). The reported rates of ON vary widely between 6% and 48%, suggesting varying factors in these studies influence the rate. Several studies suggest open reduction combined with femoral shortening provides protection against ON. However, it is unclear whether confounders such as failed Pavlik harness treatment, preliminary traction, closed versus open reduction, and redislocation influence the rate of ON.

Questions/purpose: We therefore asked whether open reduction with concomitant osteotomies without femoral shortening, redislocation, and secondary surgical procedures for residual acetabular dysplasia influenced the rate of ON.

Methods: We retrospectively reviewed 64 children (78 hips) hospitalized with developmental dislocation of the hip between January 1998 and February 2007. Patients younger than 12 months were treated with closed or open reduction. Open reduction combined with concomitant pelvic and femoral osteotomies was performed in patients past walking age. ON was diagnosed from radiographs obtained at last followup. We used logistic regression analysis to identify predictors for the development of ON. The minimum followup was 3.2 years (mean, 6.8 years; range, 3.2-11.5 years).

Results: The overall rate of ON was 40%. Patients who underwent open reduction combined with concomitant osteotomies, experienced redislocation, or required secondary reconstructive procedures after initial reduction were at higher risk for having ON develop.

Conclusions: We advocate early reduction of the dislocated hip in the first year of life to avoid the need for concomitant osteotomies combined with open reduction.

Figures

Fig. 1

The flowchart shows the sample selection of patients with developmental dislocated hips.

Fig. 2

An arthrogram of the left hip of a 3-month-old patient shows the hip in a flexion-abduction position. The reduction was maintained. The labrum lies flat over the femoral head and has a sharp border.

Fig. 3

An arthrogram is shown of the right hip of a 4-month-old patient before open reduction of a developmental dislocated hip. When the head was docked, the labrum was interposed between the femoral head and the acetabular wall. Because of capsular constriction of the iliopsoas, stable reduction was not possible.

Fig. 4A–B

AP view radiographs of the pelvis of a 3-year-old patient show developmental dislocation of the right hip. The radiographs were obtained (A) at the time of presentation and (B) 6 months after open reduction with capsulorrhaphy and Pemberton osteotomy. Successful reduction is shown.

Fig. 5A–B

Preoperative and postoperative AP view radiographs of a patient managed with open reduction, capsulorrhaphy, and femoral varus derotation osteotomy for the treatment of a dislocated right hip are shown. (A) This radiograph was obtained at first presentation when the patient was 17 months old. (B) Six months after surgery, the radiograph shows successful reduction.