Treatment of developmental hip dysplasia under 24 months by modified anterior open reduction: A short-term follow-up study

doi:10.21203/rs.3.rs-1827946/v1

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Treatment of developmental hip dysplasia under 24 months by modified anterior open reduction: A short-term follow-up study

https://doi.org/10.21203/rs.3.rs-1827946/v1

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Background: Open reduction(OR) through an anterior approach for the treatment of developmental dysplasia of the hip (DDH) in children younger than 24 months of age is a popular method with proven high success rates . The aim of this study is to present the results of open reduction through a modified anterior approach.

Methods: We retrospectively reviewed 60 hips of 45 patients with DDH under 24 months who underwent this modified anterior approach from June 2017 to February 2020. The surgical technique, operative time, intraoperative bloodloss and preoperative Tonnis grade and acetabular index (AI) were recorded in detail. In the latest follow up, the length of the scar, range of motion (ROM), the postoperative AI, centre-edge angle (CEA), Severin radiographic grade and avascular necrosis (AVN) of the femoral head were all assessed.

Results: The average operation time was 25 ± 2.8 minutes in unilateral side and 45 ± 4.5 minutes in bilateral sides, the average intraoperative bloodloss was 10.0 ± 4.2 ml in unilateral side and 25.0 ± 1.3ml in bilateral sides. The mean AI was 35.03 ± 2.18°(range 29-45°) in the preoperative period and 20.68 ± 2.01°(range16-33°) at the final follow-up visit. The mean CEA at the final follow-up visit was 23.15 ± 2.05° (range18-32°). On the basis of the modified McKay classification for functional evaluation of hips, the postoperative excellent and good rate reached 96.6%. According to Severin radiological classification evaluation criteria, the postoperative excellent and good rate also reached 93.3%. Three of the hips that had been operated on showed type I signs of avascular necrosis(AVN) in X-ray. Four hips in three patients underwent secondary revision surgery.

Conclusions: Open reduction through the modified anterior small incision approach was an encouraging and safe option for treating DDH patients younger than 24 months old who need an open reduction-only treatment, especially for patients with bilateral DDH. Bone procedures may be required for those patients with preoperative AI greater than 40° and(or) Tonnis grade IV.

Level of evidence: IV, retrospective non-randomized study.

Developmental dysplasia of the hip

Modified anterior small incision approach

Open reduction

Developmental dysplasia of the hip is one of the most common congenital defects of the skeletal and muscular system, including hip dislocation, subluxation and acetabular dysplasia. The main goal of treatment is to achieve a concentric stable reduction to facilitate proper femoral head and acetabulum development and to prevent AVN of the femoral head and further corrective surgery, including acetabular and/or femoral osteotomy as well as re-surgery for subluxation or dislocation ^{[1, 2]}. Early reduction is known to accelerate development of both the femoral head and the acetabulum. Open reduction is indicated when closed concentric reduction cannot be achieved or achieved with the hip kept in extreme flexion, abduction or internal rotation. Two basic approaches have been used for open reduction, i.e. medial and anterior approach^{[3, 4]}. The two approaches provide excellent access to the transverse acetabular ligament, iliopsoas, ligamentum teres, pulvinar, neolimbus, and acetabulum. Anterior approach is a popular method with proven high success rates which ensures a comprehensive approach to the hip joint^[5]. This approach can be performed in all age groups with its advantage of performing both capsular plication and pelvic osteotomy in the same session. For patients with DDH who need an open reduction-only treatment at the age of less than 24 months, the conventional anterior approach has greater trauma, longer operation time and more intraoperative bleeding, So we describe a modified anterior small incision approach. The surgical technique will be described in details and its follow-up outcomes will be reported and analyzed.

After obtaining approval from our institutional review board, a total of 60 hips of 45 patients of DDH who underwent surgical treatment with a modified anterior small incision approach between June 2017 and February 2020 were retrospectively reviewed. Open reduction of hips was performed using this modified anterior approach by two pediatric orthopedic surgeons. Open reduction is indicated based on the following reasons: 1)Failure of closed reduction; 2)Unstable hip following closed reduction; 3)Non-concentric reduction after closed reduction; 4)Stability achieved by closed reduction can be only maintained by placing the hip in an extreme degree of internal rotation or abduction. The inclusion criteria and exclusion criteria were shown in Table 1. Patients’ demographic data was shown in Table 2. Parents were informed that medical records could be used for scientifc purposes only; Thus, written informed consent was obtained at the final visit. Six hips of 5 children experienced previous treatment failure with closed reduction under general anesthesia and a hip spica cast. 15 children with bilateral involvement were operated at the same session. None of the patients underwent preoperative hip traction.

Surgical technique and postoperative management

After general anesthesia, the patient lay in the supine position on a standard operating table. Perioperative arthrography was performed routinely before open reduction. Patients who met the indication of open reduction were performed modified anterior approach surgery. The incision started approximately 1.5cm distal to the anterosuperior iliac spine along the groin crease, and the length was 2 to 3 cm(Fig.1a,b). The subcutaneous tissue was dissected transversely till the deep fascia and then went on across the lateral edge of the sartorius muscle longitudinally through the interval between the tensor fascia lata and sartorius. The proximal lateral edge of the rectus femoris was separated and pulled medially to expose the anterior part of the capsule, and then an small oblique incision was made in the anteromedial joint capsule, the schematic diagram of operation approach was shown in Fig.2. After releasing the iliopsoas tendon and the transverse ligament of the acetabulum, as well as excising the ligamentum teres and fibrofatty pulvinar, an Irrigation of articular capsule was performed and no capsulorrhaphy was performed. After reducing the hip joint, the safe zone angle was checked and generally improved to above 40°. Then the subcutaneous tissue incision would be closed cautiously and the skin incision would be glued up by histoacryl without sutures. The adductor longus would be released percutaneously if necessary. Patients with bilateral DDH underwent contralateral surgery with the same procedure. After achieving a concentric hip reduction, all patients were placed in a hip spica cast postoperatively, with hip abduction of <50° and flexion of not > 100° (Fig.1d) for 3 months based on the surgeon’s preference. The results were confirmed with an immediate postoperative MRI. The postoperative imaging showed concentric reduction and congruity of the femoral head into the true acetabulum. The cast was routinely changed at least once under general anesthesia at the midpoint of this period. Then, patients were put in an abduction orthosis with both hips flexed at 90° and abducted at 30° for nearly 12 weeks (full time for the first 6 weeks and only during sleep for the next 6 weeks).

Clinical outcomes

The operative time, intraoperative bloodloss and range of motion (ROM) at the latest follow-up were recorded in detail. The length of the scar and the patients’ feeling towards the cosmetic appearance were collected. Signs and symptoms of the patients at the final follow-up were evaluated according to modified McKay functional criteria, as shown in Table 3.

Radiological evaluation

All patients were followed up for at least 24 months. Anteroposterior (AP) pelvic radiographs of the hip were obtained at each follow-up visit. The AI was measured on preoperative and postoperative AP pelvic radiographs. The dislocation of the hip was assessed on AP pelvic radiographs according to the Tonnis grading system^[6]. The CEA was measured at each follow-up visit. The measurement of AI and CEA was performed with the Picture Archiving and Communication System (PACS) by two observers who were blinded to the final Severin classification. AVN of the femoral head was identified according to the criteria described by Salter et al^[7], and was graded according to Bucholz and Ogden’s method^[8]. We grouped type I AVN with the normal hip category because type I AVN is a transient ischemia of the femoral head which can resolve completely^{[9, 10]}. Two independent raters evaluated AVN. If they could not come to an agreement on the type of AVN, a discussion with at least three other senior paediatric orthopaedic surgeons was performed. Final radiographic outcomes of the hips were graded according to the criteria described by Severin. Severin types I and II were considered to represent a good result and types III, IV, V, and VI were considered to represent a poor result.

Statistical analysis

All statistical analyses were performed using the statistics package SPSS 22.0 (SPSS, Chicago, IL, USA). Data were expressed as numerical variable, frequencies, and percentages, with the means and standard deviations. Owing to the descriptive nature of the analysis used in this case series, descriptive statistics were presented using the means and standard deviations with ranges (minimum–maximum).

We had a total of 60 hips of 45 patients (5 male, 40 females), bilateral involvement was seen in 15 cases. 35 right hips and 25 left hips were operated. During the initial operation, the mean age of the patients was 19 ± 2.8 (range 7–24) months. The average follow-up was 32 ± 4.2 (range 24-48) months. The average operation time was 25 ± 2.8 minutes in unilateral side and 45 ± 4.5 minutes in bilateral sides, the average intraoperative bloodloss was 10.0 ± 4.2 ml in unilateral side and 25.0 ± 1.3ml in bilateral sides. The length of the scar averaged 2.5 ± 0.5 cm.

Clinical outcomes

The mean abduction angle of the affected hip was 50°± 3.2°(range 45–60°) after OR in spica cast. Residual leg length discrepancy or limited ROM of the operated hip joint was not detected in any patient during follow-up. All the parents were very satisfied with the postoperative appearance (Fig.1c). According to the modified McKay hip function assessment classification, the hip postoperative status was assessed as excellent (n=44; 73.3%), good (n=14; 23.3%) and average (n=2; 3.3%), as shown in Table 4. Reduction of all hip dislocations was achieved.

Radiologic outcomes

According to the radiological Tonnis classification, 38 hips were grade II, 17 hips were grade III and 5 hips were grade IV, as shown in Table 7. The preoperative and final follow-up radiological outcomes of the 60 hips (45 children) are shown in Table 5. Based on Severin radiological classification, as shown in Table 6, 31 (51.7%) hips were type I (excellent), 25 (41.7%) were type II (good), thus excellent and good results(satisfactory) were obtained in 93.3 % of the hips at the final follow-up; A total of 4 hips (6.7%) were Severin type III or higher(fair), three (5%) were type III, one (1.7%) were type IV, and thus fair results (unsatisfactory) were obtained in 6.7 %.

Complications and secondary revision surgery

Three of the hips that had been operated on showed signs of avascular necrosis(AVN) in X-ray. Among them, all were type I. The preoperative Tonnis grade of all patients with avascular necrosis of the femoral head is grade IV, as shown in Table 7, which indicates that the occurrence of avascular necrosis of the femoral head may be related to the preoperative Tonnis grade. no one of these patients required a secondary osseous intervention. Four hips in three patients with preoperative AI greater than 40° underwent secondary revision surgery for residual acetabular dysplasia or subluxation, including three acetabular dysplasia and one subluxation, as shown in Table 8, which may indicate an increased risk of residual acetabular dysplasia or subluxation in patients with a preoperative AI greater than 40 °. The rate of secondary osseous intervention was 6.7 %. None of the other complications, such as infection, residual leg length discrepancy, postoperative hip stiffness, were seen in the operated patients.

As we all know, the primary objective of the treatment of patients with DDH should be a stable and centred reduction as well as the avoidance of complications with negative effects on the further development of the child. The treatment of patients with DDH is largely related to the age of the patient and the degree of soft-tissue contracture or bony deformity present. As a general rule^[11], in children aged ༜12 months, closed reduction and spica casting is typically the preferred treatment, with or without the use of preoperative traction or intraoperative adductor tenotomy. Children aged 12 to 18 months may require open reduction of the hip through either a medial or anterior approach. As children grow older, the ability of the hip to remodel in response to soft-tissue procedures diminishes, and more aggressive treatments are indicated. In children aged 18 months to 3 years, residual bony deformity can be corrected with either a femoral or pelvic osteotomy in addition to open reduction. Furthermore, another common consensus is that the upper age limit for open reduction-only treatment without osseous intervention is 18 months. However, we often encounter some DDH children aged 18 months to 2 years old in clinic. Some authors prematurely choose pelvic osteotomy for treatment according to the above-mentioned general principles, which will increase the possibility of complications such as postoperative pelvic deformity, femoral head necrosis and postoperative hip stiffness. In fact, how long the spontaneous remission potential of osseous acetabular dysplasia in a replaced hip lasts is controversial. During the 1960s, under the leadership of R.B. Salter, the suggestion was made that osseous dysplasia of the acetabulum could not be improved after 18 months. But subsequent studies found that the improvement of the osseous dysplasia of the acetabulum could continue until 5 and even 8 years of age ^[12]. It has since been shown that anterior open reductions can be performed securely until 24 months ^{[13, 14, 15]}. In agreement with these latter studies, we chose a modified small incision anterior approach for treatment. We believe that open reduction of DDH by the modified small incision anterior approach is one of the most effective surgical treatment methods during early childhood ^[16], and We also believe that it is a feasible and safe approach. We diminished the injury to surrounding tissue, reduced blood loss, shortened the operation time, and maintained the integrity of the femoris rectus by this modified small incision anterior approach. At the same time, we can complete all crucial steps of open reduction through this single smaller incision approach, including the clearance of intra- and extra-articular obstacles, the release of the iliopsoas tendon, the contracted capsule, and the transverse ligament, as well as the clearance of the ligamentum teres and the hypertrophic tissue in the acetabulum. And we obtained satisfactory results from the majority of patients in our study. Most of the hips developed well with time (Fig. 3,4). More than half of our patients were༞18 months, and the incidence of a secondary osteotomy was very low. Residual leg length discrepancy or limited ROM of the operated hip joint was not detected in any patient during follow-up. All the parents were very satisfied with the post-operative appearance. On the basis of the modified McKay classification for functional evaluation of hips, the postoperative excellent and good rate reached 96.6%. In terms of radiological evaluation, according to Severin radiological classification evaluation criteria, the postoperative excellent and good rate also reached 93.3%.

The most important problem in DDH in all age groups is residual dysplasia and subluxation ^[17]. Four hips (6.67%) required a secondary acetabular intervention in our cases, the need for a secondary intervention were lower compared to the literature ^{[18, 19, 20]}. This is probably due to the shorter follow-up period in our cases. Among the patients who needed secondary acetabular intervention, the preoperative AI was greater than 40 °. So we prefer to choose pelvic osteotomy to reduce the incidence of postoperative residual dysplasia and subluxation for patients with a preoperative AI greater than 40 °.

There are different rates of avascular necrosis in open reduction using both anterior and medial approach reported in the literature ^{[21, 22, 23]}. Avascular necrosis, which all were type I, developed in 3 (5%) of 60 hips in our cases. Although this rate is low, we believe that it would not be accurate to compare it to the variable and complicated data in the literature, especially taking into account the short follow-up period. In our cases, almost all postoperative avascular necrosis of the femoral head occurred in patients with preoperative Tonnis grade IV. Therefore, we tend to choose femoral shortening or derotation osteotomy according to the femoral anteversion angle to reduce the pressure between the femoral head and the acetabulum for patients with preoperative Tonnis grade IV.

The treatment options for patients with bilateral DDH requiring bilateral open reduction may be particularly difficult. Some authors prefer open reduction using the medial approach for bilateral cases due to the short and simple duration of the operation, less bleeding, and less cosmetic scars^[24]. There are some relevant studies with good results in the literature ^{[25, 26, 27]}. However, some authors disapprove, and claim that open reduction using the medial approach is not simple and should be performed only by experienced pediatric orthopedists ^{[28, 29]}. The duration of open reduction using the medial approach was reported between 90 and 137 minutes in bilateral cases^{[28, 29]}. According to kiely et al, open reduction using the medial approach is reliable and appropriate only for low dislocations^[30]. Furthermore, one-stage bilateral open reduction using the conventional anterior approach is probably less performed, and there is no relevant data in the literature. The conventional anterior approach is usually performed in two stages in bilateral cases because it lasts longer and leads to more bleeding^[31]. Although the two-stage procedure is safe, patients need to be hospitalized twice, the treatment costs increase, and more importantly, hip treatment is delayed^{[32, 33, 34, 35]}. So we believe that the modified small incision anterior approach is especially suitable for children with bilateral DDH under 24 months who need an open reduction-only treatment. The average operation time was 25 ± 2.8 minutes in unilateral side and 45 ± 4.5 minutes in bilateral sides, the average intraoperative bloodloss was 10.0 ± 4.2 ml in unilateral side and 25.0 ± 1.3ml in bilateral sides in our cases. The bilateral operation was completed in one operation at the same time, which restored the anatomical relationship of bilateral hip dislocation in time, shortened the treatment time for the overall treatment of children, and both hip joints were treated timely and effectively. So the one-stage bilateral open reduction using the modified small incision anterior approach leads to shorter hospitalization time, and the treatment of the second hip is not delayed.

The surgical techniques that should be paid attention to in this surgical approach are as follows: Firstly, additional vascular injuries, which occur by capsulotomy during open reduction, can be avoided by the small oblique incision on the anteromedial part of the articular capsule. Akazawa et al^[36] points out that in open reduction the incision of the capsule should be performed under vision and close to the acetabular margin to avoid injury and to ensure sufficient blood supply to the femoral head. So the capsule incision should be cut along the acetabular margin, and only cut the anteromedial part of the articular capsule enough to gain an overview of the acetabular component in order to clear it out, which is conducive to protecting the blood supply of the femoral head and neck, reducing the possibility of avascular necrosis of the femoral head, and avoiding the anterolateral capsule incision can also reduce the probability of anterolateral subluxation of the femoral head. Secondly, Increased joint pressure in the hip joint can also cause damage and necrosis of the femoral head^[37]. So it is unnecessary to suture the anteromedial part of the articular capsule during operation, which can reduce the hip joint pressure caused by intra-articular hemorrhage after operation and avoid affecting the blood supply of the femoral head and increasing the possibility of avascular necrosis of the femoral head. In addition, We believe that the tenotomy of the tendon of the iliopsoas muscle can also reduce the postoperative hip joint pressure, we will routinely choose iliopsoas tendon amputation. The incidence of osteonecrosis may be lower after iliopsoas tendon amputation. Thirdly, this modified anterior approach is suitable for Tonnis grade I, II and III patients, but Tonnis grade IV patients should be more cautious.

There are some limitations to this study. First, this was a retrospective study with a relatively small number of patients and all cases were not followed up to skeletal maturity. A long-term outcome of the procedure has not been performed. Therefore, further studies with a long follow-up and a larger sample size are required to confirm our results. Second, Our study only represents the experience of a single institution without a comparative study.

Open reduction through the modified anterior small incision approach was an encouraging and safe option for treating DDH patients younger than 24 months old who need an open reduction-only treatment, especially for patients with bilateral DDH. Bone procedures may be required for those patients with pre-operative AI greater than 40° and(or) Tonnis grade IV.

OR : Open reduction; DDH: Developmental dysplasia of the hip; AI: acetabular index; ROM: range of motion; CEA: centre-edge angle; AVN: avascular necrosis

Ethics approval and consent to participate: The Ethical review board of Hunan Children’s Hospital approved this study and the form of consent. Written informed consent was received from all study participants.

Consent for publication: We have obtained consent from the guardian of the patients to publish the pictures and clinical data.

Competing interests: The authors declare that no conﬂicts of interest.

Availability of data and materials: The data supporting the conclusions of this article is stored at the orthopedics department, Hunan Children’s Hospital.

Acknowledgements: The authors would like to thank all participating patients, as well as all the co-investigators, and colleagues who made this study possible.

Funding: The study is not supported by any funding.

Authors’ contributions: Xiping Liu is accountable for the integrity and analysis of the data, and drafted the manuscript, performed data collection, and cases follow-up; Kun Liu is accountable for the analysis and interpretation of data. The manuscript has been read and approved by all authors; each author believes that the manuscript represents honest work. All authors read and approved the final manuscript.

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Treatment of developmental hip dysplasia under 24 months by modified anterior open reduction: A short-term follow-up study

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