Association between the ossific nucleus and osteonecrosis in treating developmental dysplasia of the Hip: updated meta-analysis.

BACKGROUND: A meta-analysis concluded that there was no effect of the femoral head ossification and the incidence of osteonecrosis in the treatment of developmental dysplasia of the hip (DDH), unless only osteonecrosis grades II-IV were considered. The meta-analysis, limited due to the small number of studies available at that time, identified a need for an update as further research emerges. We observed a trend in recent years towards delaying treatment of DDH in the absence of an ossified nucleus. Numerous new publications on this topic encouraged us to update the 2009 meta-analysis. METHODS: We performed a systematic review of the literature from 1967 to 2016 and included studies that reported on the treatment of DDH, the ossific nucleus and osteonecrosis. Two independent reviewers evaluated all articles. We performed a meta-analysis with the main outcome defined as the development of osteonecrosis of the femoral head at least two years after closed or open reduction. RESULTS: Of four prospective and ten retrospective studies included in the systematic review, 11 studies (1,021 hips) met the inclusion criteria for the meta-analysis. There was no significant effect of the ossific nucleus on the development of all grades of osteonecrosis (relative risk, 0.88; 95% confidence interval, 0.56-1.41) or osteonecrosis grades II-IV (0.67; 0.41-1.08). In closed reductions, the ossific nucleus halved the risk for developing osteonecrosis grades II-IV (0.50; 0.26-0.94). CONCLUSIONS: Based on current evidence there does not appear to be a protective effect of the ossific nucleus on the development of osteonecrosis. In contrast to the previous meta-analysis, this update demonstrates that this remains the case irrespective of the grade of osteonecrosis considered relevant. This updated meta-analysis is based on twice as many studies with a higher quality of evidence

The most relevant diagnostic criteria for developmental dysplasia of the hip: a study of British specialists.

BACKGROUND: Developmental dysplasia of the hip (DDH) is the most common orthopaedic disorder in newborns. Despite this considerable variation in practice exists. The aim of this study was to determine the clinical relevance and a ranking order for the diagnostic criteria in DDH amongst paediatric orthopaedic surgeons practicing in the UK. METHOD: One hundred members of the British Society of Children's Orthopaedic Surgery (BSCOS) were asked to rate the importance of 37 criteria useful in the diagnosis of DDH in newborns, using a 10 cm visual analogue scale. We determined the consistency among specialists in rating the criteria with the intraclass correlation coefficient (ICC) and compared the results to a group of international peers. RESULTS: Ortolani/Barlow tests, asymmetry in abduction ≥20° and a first-degree relative treated for DDH ranked among the top ten. Participants demonstrated poor consistency in rating the 37 criteria (ICC 0.39; 95% CI 0.29, 0.52), but for clinical examination criteria alone their consistency improved (ICC 0.52; 0.35, 0.75). The importance ratings of members of BSCOS and members of the European Paediatric Orthopaedic Society differed for 15/37 (41%) criteria (p <0.05). CONCLUSIONS: Members of BSCOS had a preference for criteria relating to clinical examination and ultrasound

Preoperative botulinum neurotoxin A for children with bilateral cerebral palsy undergoing major hip surgery: a randomized double-blind placebo-controlled trial.

AIM: To assess whether preoperative botulinum neurotoxin A (BoNT-A) affects pain after major hip surgery for children with bilateral cerebral palsy (CP). METHOD: This was a randomized, parallel arms, placebo-contolled trial. Children with hypertonic CP aged 2 to 15 years awaiting bony hip surgery at a tertiary hospital were randomized to receive either BoNT-A or placebo injections into the muscles of the hip on a single occasion immediately before surgery. The primary outcome was the paediatric pain profile (PPP), which was assessed at baseline and weekly for 6 weeks. Treatment allocation was by minimization. Participants, clinicians, and outcome assessors were masked to group assignment. RESULTS: Twenty-seven participants (17 males, 10 females; mean 8y 8mo [SD 3y 9mo], range 3y 4mo-15y 10mo) were allocated to BoNT-A and 27 participants (14 males, 13 females; mean 8y 11mo [SD 3y 5mo], range 4y 1mo-15y 2mo) to placebo. Mean (SD) PPP at 6 weeks for the BoNT-A group (n=24 followed up) was 10.96 (7.22) and for the placebo group (n=26) was 10.04 (8.54) (p=0.69; 95% confidence interval [CI] -4.82, 3.18). There were 16 serious adverse events in total during 6 months of follow-up (n=6 in BoNT-A group). INTERPRETATION: Use of BoNT-A immediately before bony hip surgery for reducing postoperative pain for children with CP was not supported. WHAT THIS PAPER ADDS: Botulinum neurotoxin A (BoNT-A) does not reduce postoperative pain following bony hip surgery. BoNT-A also does not affect postoperative quality of life

Variations in the use of diagnostic criteria for developmental dysplasia of the hip

Background: Wide variation exists in reported prevalence estimates and management standards of developmental dysplasia of the hip (DDH). Discrepancies in diagnosticians' opinions may explain some of this variation. Questions/Purposes: We sought to determine (1) the consistency with which pediatric orthopaedic surgeons rate the importance of diagnostic criteria for DDH, and (2) whether there were geographic differences in how the diagnostic criteria were rated by surgeons. Methods: One hundred ninety-seven of 220 members of the European Paediatric Orthopaedic Society and 100 of 148 members of the British Society of Children's Orthopaedic Surgery treating children with DDH participated in this cross-sectional study across 35 countries (15 regions). Each rated 37 items in four domains that specialists previously had identified as the most important features associated with DDH in early infancy. We determined consistency using the intraclass correlation coefficient (ICC; two-way random-effects model) interpreted as poor (0-0.40), acceptable (0.41-0.74), or good (≥ 0.75). Results: Poor consistency among surgeons was found in rating the 37 diagnostic criteria (ICC, 0.33; 95% CI, 0.24-0.45). Consistency was poor for three domains (patient characteristics/history: ICC, 0.29; 95% CI, 0.16-0.58; ultrasound: ICC, 0.26; 95% CI, 0.14-0.52; radiography: ICC, 0.34; 95% CI, 0.12-0.95) and acceptable for one (clinical examination: ICC, 0.50; 95% CI, 0.33-0.73). Surgeons in particular regions appeared to have a concept of DDH diagnosis that distinguished them from specialists of other regions; consistency in eight regions was greater (ICC ≥ 0.40) than consistency among all 15 regions. Conclusions: The consistency of specialists in rating diagnostic criteria for DDH was lower than expected, and there was considerable geographic variation in terms of how specialists assigned importance ratings of the diagnostic criteria; these findings are somewhat counterintuitive, given the frequency with which this condition is diagnosed. These inconsistencies could explain, partly, the widely differing prevalence estimates and management standards of DDH

Weighted diagnostic criteria for developmental dysplasia of the hip.

OBJECTIVE: To establish clinical diagnostic criteria for developmental dysplasia of the hip (DDH) that model the practices of expert clinicians. STUDY DESIGN: Of 23 clinical criteria for the diagnosis of DDH, ranked in order of diagnostic importance by international consensus, the 7 most highly ranked were placed in all possible combinations to create unique case vignettes. Twenty-six experts rated 52 vignettes for the presence of DDH. We modeled the data to determine which of the 7 criteria were associated with a clinician's opinion that the vignette represented DDH. From the resulting regression coefficients, for each vignette we calculated a probability of DDH. An independent panel rated the same vignettes using a visual analog scale response. We correlated the visual analog scale ratings with probabilities derived from the model. RESULTS: Our model identified 4 of 7 criteria as predictive of DDH (P < .001): Ortolani/Barlow test (β = 3.26), limited abduction (β = 1.48), leg length discrepancy (β = 0.74), and first-degree family history of DDH (β = 1.39). There was substantial correlation between the probability of DDH predicted by the model and that derived from an independent expert panel (r = 0.73; P < .001). CONCLUSION: Weighted clinical criteria for inferring the likelihood of DDH produced consistent results in the judgment of 2 separate groups of experts. Using these weights, nonexperts could establish the probability of DDH in a manner approaching the practice of clinical experts

Osteonecrosis complicating developmental dysplasia of the hip compromises subsequent acetabular remodeling.

BACKGROUND: Osteonecrosis of the femoral head secondary to treatment of developmental dysplasia of the hip (DDH) affects acetabular remodeling but the magnitude of this effect is unclear. QUESTIONS/PURPOSES: Using four measures of acetabular development, we (1) determined whether acetabular remodeling differed in hips with and without osteonecrosis; and (2) determined the impact of severity of osteonecrosis contributing to acetabular remodeling. METHODS: We retrospectively reviewed 95 patients (118 hips) treated for DDH by closed or open reduction with or without femoral osteotomy between 1992 and 2006. We evaluated serial radiographs from the time when a stable reduction had been achieved. In 902 radiographs taken over 19 years, we measured the acetabular index and three other indices of hip development. Patients were followed for a mean of 8 years (range, 1-19 years). At last followup, 86 of the 118 hips (73%) had osteonecrosis according to the criteria by Bucholz and Ogden. RESULTS: The acetabular index improved with time in all hips but the magnitude of improvement was larger in hips without osteonecrosis. The adjusted mean acetabular index at 14 years was 17° for hips with osteonecrosis (95% CI, 15°-18°) and 10° for hips without osteonecrosis (95% CI, 7°-13°). The lateral centering ratio improved after reduction to a normal value less than 0.85 in both groups but the rate of change with 0.06 versus 0.05 was higher in hips with osteonecrosis. The superior centering ratio was worse at all times in hips with osteonecrosis with a mean difference of 0.04. If only radiographic changes of Grades II and greater were considered osteonecrosis, the mean adjusted acetabular index at 14 years was 17.7° (15.6°-19.7°) for hips with osteonecrosis and 12.4° (10.3°-14.4°) for hips without osteonecrosis. CONCLUSIONS: Although radiographic indices improved consistently with time in hips without osteonecrosis, hips with osteonecrosis had abnormal indices of acetabular remodeling throughout followup. Osteonecrosis of the femoral head inhibited acetabular remodeling. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence