Avascular Necrosis After Treatment of DDH: The Protective Influence of the Ossific Nucleus

Segal, Lee S.; Boal, Danielle K.; Borthwick, Laura; Clark, Mary Williams; Localio, A. Russell; Schwentker, Edwards P.

doi:10.1097/01241398-199903000-00008

Cited by 99 publications

(85 citation statements)

References 30 publications

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“…The controversy about the association between age at open reduction and osteonecrosis remains. Previous studies proposing delaying the treatment of DDH hypothesized that the development of the microcirculation in the femoral head, concomitant with the radiographic appearance of the ossific nucleus, would protect against osteonecrosis [16,75]. However, other studies [21,53,70] did not find older age and the presence of ossific nucleus as protective factors for osteonecrosis.…”

Section: Discussionmentioning

confidence: 96%

“…In contrast, a more severe pattern of osteonecrosis when reduction is performed before 6 months of age has been reported [42,50]. Segal et al [75] studied 49 patients (57 hips) who were younger than 12 months of age at reduction (closed and open) with 18 hips complicated by osteonecrosis. They recommended delaying treatment until the ossification of the femoral head is present on radiographs.…”

Section: Discussionmentioning

confidence: 99%

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Is Age or Surgical Approach Associated With Osteonecrosis in Patients With Developmental Dysplasia of the Hip? A Meta-analysis

Novais

Hill

Carry

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Osteonecrosis of the femoral head is a major complication that negatively impacts the clinical and radiographic long-term outcome after treatment of developmental hip dysplasia (DDH). There are conflicting results in the literature whether age at the time of closed or open reduction and a specific surgical approach are associated with osteonecrosis. Better understanding of the impact of age at reduction and surgical approach is important to reduce the risk of osteonecrosis in patients with DDH. Questions/purposes We aimed to evaluate the association between occurrence of osteonecrosis and (1) age at closed reduction; (2) age at open reduction; and (3) medial versus anterior operative approaches.Methods A systematic review identified studies reporting osteonecrosis occurrence after treatment of DDH and at least 2 years of followup. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Methodologic quality was assessed using the methodologic index for nonrandomized studies. Generalized logistic models were used to estimate pooled odds ratios (ORs) in the meta-analysis. Sixty-six studies were included in the systematic review and 24 in the meta-analysis. Data on 481 hips treated by closed reduction and 584 hips treated by open reduction were available to evaluate the association between osteonecrosis and age. The association between osteonecrosis and operative approach was assessed using data on 364 hips treated by medial open reduction and 220 hips treated by anterior open reduction. Results Age at reduction ([ 12 months versus B 12 months) was not associated with osteonecrosis after closed reduction (OR, 1.1; 95% confidence interval [CI], 0.4-3.2; p = 0.9) or open reduction (OR, 1.1; 95% CI, 0.7-1.9; p = 0.66). The overall, adjusted incidence of osteonecrosis (C Grade II) was 8.0% (95% CI, 2.8%-20.6%) among patients treated with closed reduction at or before 12 months of age and 8.4% (95% CI, 3.0%-21.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Is Age or Surgical Approach Associated With Osteonecrosis in Patients With Developmental Dysplasia of the Hip? A Meta-analysis

Novais

Hill

Carry

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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“…Clinical studies have remained mixed on the importance of the ossific nucleus. Although many studies looking at both open and closed reduction have shown a protective response with respect to its presence [4,6,27], studies looking more specifically at closed reduction have shown no effect [7,18,30,35]. Some studies have linked older age at treatment to an increased risk of AVN [30,35] and an increased rate of residual dysplasia [16], whereas others have concluded younger age has either no influence [3,16,18,27] or a negative effect on AVN rates [15,25].…”

Section: Discussionmentioning

confidence: 99%

“…Although many studies looking at both open and closed reduction have shown a protective response with respect to its presence [4,6,27], studies looking more specifically at closed reduction have shown no effect [7,18,30,35]. Some studies have linked older age at treatment to an increased risk of AVN [30,35] and an increased rate of residual dysplasia [16], whereas others have concluded younger age has either no influence [3,16,18,27] or a negative effect on AVN rates [15,25]. Furthermore, early reduction takes advantage of the acetabulum's increased remodeling potential at young ages [18,23,27] and may improve clinical outcomes [20] and reduce the need for future corrective surgeries [17].…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, the radiographic signs used to diagnose AVN are only appreciable months to years after the presumed vascular insult. Reports have also investigated the potential influence of factors such as the ossific nucleus at the time of reduction or the hip abduction angle in the postoperative spica cast on AVN rate [27,32], but these results are inconclusive.…”

Section: Introductionmentioning

confidence: 99%

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Does Perfusion MRI After Closed Reduction of Developmental Dysplasia of the Hip Reduce the Incidence of Avascular Necrosis?

Gornitzky

Georgiadis

Seeley

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Gadolinium-enhanced perfusion MRI (pMRI) after closed reduction/spica casting for developmental dysplasia of the hip (DDH) has been suggested as a potential means to identify and avoid avascular necrosis (AVN). To date, however, no study has evaluated the effectiveness of pMRI in clinical practice or compared it with other approaches (such as postreduction CT scan) to show a difference in the proportion of AVN. Questions/purposes (1) Can a pMRI-based protocol be used immediately post closed reduction to minimize the risk that AVN would develop? (2) What are the overall hiprelated outcomes after closed reduction/spica casting using this protocol? (3) Do any patient-specific factors at the time of closed reduction predict future AVN? Methods This was a retrospective cohort study at a large tertiary care children's hospital. Between 2009 and we treated 43 patients with closed reduction/spica casting for DDH, of whom 33 (77%) received a postreduction pMRI. All patients were indicated for pMRI per treating surgeon preference. A convenience sample totaling 25 hips in 22 patients treated with pMRI was then established using the following exclusion criteria: DDH of neuromuscular/ syndromic origin, failed initial closed reduction, less than 1 year of clinical and radiographic followup, and subsequent open reduction. Next, the 40 patients treated with closed reduction between 2004 and 2009 were screened until the chronologically most recent 25 hips (after applying the previously mentioned exclusion criteria) were identified in 21 of the first 34 patients (62%) screened. Although termed the CT group, specific postreduction imaging was not a defined inclusion criterion in this group with the majority (21 of 25 [84%]) receiving postreduction CT and the remainder (four of 25 [16%]) receiving only postreduction radiographs. All hips with globally decreased femoral head perfusion on postreduction pMRI were treated with immediate cast removal followed by repeat closed reduction or open reduction, as per surgeon preference, with two of 33 (6%) requiring such further interventions. Salter criteria were then used to determine the proportion of AVN on radiographs at 1-year and final followup. Secondary outcomes including residual dysplasia and the need for further corrective surgery were ascertained through radiographic and retrospective chart review. 049). No patient with normal perfusionEach author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conform...

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Developmental Dysplasia of the Hip

Shapiro¹

2019

Pediatric Orthopedic Deformities, Volume 2

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Avascular Necrosis After Treatment of DDH: The Protective Influence of the Ossific Nucleus

Cited by 99 publications

References 30 publications

Is Age or Surgical Approach Associated With Osteonecrosis in Patients With Developmental Dysplasia of the Hip? A Meta-analysis

Is Age or Surgical Approach Associated With Osteonecrosis in Patients With Developmental Dysplasia of the Hip? A Meta-analysis

Does Perfusion MRI After Closed Reduction of Developmental Dysplasia of the Hip Reduce the Incidence of Avascular Necrosis?

Developmental Dysplasia of the Hip

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