Evaluation of Surgical Treatment of Developmental Dysplasia of Hip for Avascular Necrosis of Femoral Head in Children
Developmental Dysplasia of the Hip (DDH) is a common congenital
malformation. Avascular necrosis of femoral head is the major complication of
both close and open reduction of the dislocated joint. Aim of this study was
to determine the incidence and influencing factors in different types of a vascular
necrosis of femoral head, following surgical treatment of developmental dysplasia
of hip in 1-7 years patients. In this study, 120 patients aged from 1 to 7 years
old with DDH who had been undergone open surgery, entered to the study. All
of these patients followed up for at least 1 year. Surgery procedures divided
to 4 groups: open reduction, open reduction+salter osteotomy, open reduction+femur
shortening and open reduction+salter osteotomy+femur shortening. The presence
of Avascular Necrosis (AVN) had been appraised. 27.5% of surgeries performed
on male and 72.5 on female patients. 35.0% of DDH cases were unilateral and
remaining was bilateral. 36 patients (30%) shows radiologic findings of AVN,
although all of them placed at group I of Bucholz-Ogden classification. 40%
of group A patients, 25% of group B, 14.3% of group C and 36.4% of group D patients
developed this findings. Open reduction of DDH in older children is effective
in the management of DDH and if all of the contrivance considered in the surgery,
the rate of AVN would be low and mild (at least in short term follow ups).
Received: January 23, 2012;
Accepted: July 19, 2012;
Published: September 03, 2012
Developmental Dysplasia of Hip joint (DDH) includes a range of hip disorders
differently manifest at different ages (Libri and Marchesini,
2010). In this disease, there is no natural relation between femoral head
with acetabulum and natural position of hip joint and it can be seen as a complete
or incomplete dislocation with or without dysplasia (Kitano
et al., 2010). In children, this syndrome is defined as instability
of hip joint so that it can be completely or incompletely removed from commissural
(Joo et al., 2009). It is also possible that
the joint be seen as displaced in resting position (Sibinski
et al., 2009). Lasting this disorder to puberty results in ineffectively
cover of femur head by acetabulum. This is called dysplasia of hip joint (Funk
et al., 2008). DDH is more prevalent in females than males (Pach
et al., 2008). On the other hand, race differences are significantly
effective in prevalence of this disorder. Comparing with African- Americans
and yellows, DDH incidence is more prevalent in white newborns (Kotnis
et al., 2008). It is likely results from baby-caring methods in
different races (Tukenmez and Tezeren, 2007). Although,
no single factor has been known for DDH incidence, some factors have been introduced
to be involved in etiology of this disorder (Dezateux and
Rosendahl, 2007). The most important of these factors are flabby ligaments
(often congenital), bridge location while pregnant, status after delivery and
initial dysplasia of acetabulum (Sibinski and Synder, 2006).
This status, like other birth-time diseases such as phenylketonuria and hypothyroid
should be recognized and treated before developing of complications (Sibinski
et al., 2006). Early treatment of the disease plays an important
role in preventing subsequent disabilities (Kesa et al.,
2005). Avascular necrosis of femur head is one of the main factors of long-term
disability following DDH treatment (Wirth, 2005). It
can be almost always prevented as a complication relevant to treatment method.
Several protocols have been offered in order to prevent this complication (LeBel
and Gallien, 2005) To this end, the present study was conducted to clarify,
if considering all methods in preventing AVN of femur head, whether prevalence
of this complication subsequent to DDH treatment reduce.
MATERIALS AND METHODS
In this cross sectional study, 120 children (1-7 years old) who have undergone
surgery for DDH correction in Shohada hospital, Tabriz University of Medical
Sciences from March 2008 to March 2011 entered the study. They were followed
up for about at least one year. In order to collect and document data, a checklist
was designed according to the required variables. It was completed through referring
to the patients file and later examinations as per the follow-up cares. Bucholz-Ogden
classification was used for classifying AVN incidence. Patients were in four
different surgical groups:
||Open reduction, capsulorrhaphy, adductor tenotomy and psoas
||Open reduction, capsulorrhaphy, adductor tenotomy and psoas+salter osteotomy
||Open reduction, capsulorrhaphy, adductor tenotomy and psoas+initial shortening
||Open reduction, capsulorrhaphy, adductor tenotomy and psoas+salter osteotomy+initial
shortening of femur
The cast was opened and pines were removed 6 weeks after surgery. The first
control-graphy after surgery was done at this time and AVN incidence was examined.
Then, the cast was repeated for another 6 weeks. Subsequent control-graphies
were done during the patients follow up. AVN incidence was verified through
study of the obtained graphs and their comparison with those obtained before
surgery. The results were registered so that before surgery dysplastic deficiencies
are not considered as AVN incidence after surgery. One of radiologist colleagues
evaluated the graphs. This radiologist was not aware of the study aims resulted
in preventing from bias in this study. The collected data were analyzed through
use of SPSS statistical software (version 16). Chi-square and ANOVA tests were
used for verify existence of any meaningful relationship between variables.
p value less than 0.05 was regarded as meaningful in this study.
According to the collected data and considering all patients, 33 surgeries
(27.5%) were done on male patients and 87 (72.5%) on female ones. Among them,
42 cases (35%) were suffering unilateral DDH and 68 cases (65%) from bilateral
DDH. Considering 120 surgeries, 54 cases (45%) operated at right side and 66
cases (55%) at left side (Table 1). In 24 cases (20%) of all
surgeries, unusual bleeding was observed but it did not occurred at the remaining
96 cases (80%).
|| Demographic characteristics of the study population
Only 12 patients (10%) out of 120 were treated through use of before surgery
Among 30 patients of the group A, 12 and 18 surgeries were done on male and
female patients, respectively. There were 6 cases suffering from unilateral
DDH and 24 cases with bilateral DDH. Considering 30 surgeries done in this group,
12 cases were on right side and 18 on left side. Unusual bleeding was observed
in 6 cases of this group. It was not occurred in the remaining 24 cases. Only
6 patients out of 30 were treated through use of before surgery nonsurgical
methods (Table 1).
Among 36 patients of the group B, 9 surgeries were done on male patients and
27 on females. There were 9 cases suffering from unilateral DDH and 27 cases
with bilateral DDH. Considering 36 surgeries done in this group, 12 cases were
on right side and 24 on left. No unusual bleeding was observed in this group.
Only 3 patients out of 36 were treated through use of before surgery nonsurgical
methods (Table 1).
Among 21 patients of the group C, 6 and 15 surgeries were done on male and
female patients, respectively. There were 12 cases suffering from unilateral
DDH and 9 cases with bilateral DDH. Considering 21 surgeries done in this group,
9 cases were on right side and 12 on left. Unusual bleeding was observed in
12 cases of this group. It was not occurred in the remaining 9 cases. None of
the patients of this group was treated through use of before surgery nonsurgical
methods (Table 1).
Among 33 patients of the group D, 6 surgeries were done on male patients and
27 on females. There were 12 cases suffering from unilateral DDH and 21 cases
with bilateral DDH. Considering 33 surgeries done in this group, 21 cases were
on right side and 12 on left side. Unusual bleeding was observed in 6 cases
of this group. It was not occurred in the remaining 27 cases. Only 3 patients
out of 30 were treated through use of before surgery nonsurgical methods (Table
Referring follow-up considerations it was observed that 36 patients (30%) out
of the 120 ones undergone surgery afflicted by AVN but it was not observed at
the remaining 84 cases (70%).
||Distribution of AVN manifestation cases considering involved
side and type of surgery
Amount of AVN incidence in different surgical groups with p-value of 0.647
was not statistically meaningful (Table 2).
Mean age of the patients was 4.42±2.13; the youngest one was 1 and the
oldest 7 years old. Mean age in 36 cases resulted in AVN equal to 2.33 with
minimum 1 and maximum 4 years old but at the other 84 cases not suffering from
AVN, mean age was 4.52±2.18 with minimum 1 and maximum 5 years old. Difference
between two groups with the P value of 0.730 was not statistically meaningful.
Follow-up duration was averagely 16.60 months in all patients with minimum of
6 and maximum of 36 months. Average of operation time in all patients was 3.93±2.24
h. with at least 3 and maximum 5.5 h.
DDH is a congenital dislocation or subluxation of the hip joint found in children.
It occurs in 1 out of 1000 births (Burian et al.,
2010). The hip joint is a ball and socket joint, constant of femoral head
(the ball) and the acetabulum (the socket). This joint may be fully dislocate
or be little shallow in birth, it has many risk factors but the real reason
is unknown till now (Walton et al., 2010). Tukenmez
and Tezeren (2007) studied results of Salter in 79 operations in a research
conducted in Turkey during 1994- 2002, This study which its results was published
in 2007 divided the patients into two groups: younger than 3 years old (46 surgeries)
and older than 3 years old (33 surgeries). DDH was observed in left side of
34% of cases, right side of 37% cases and both sides in 30% of cases. Follow-up
duration was 58 months for patients of the group one and 62 months for the second
group. According to this study, 11% of younger than 3 years patients and 15%
of older than 3 years ones afflicted by AVN. From among 10 hip joints suffered
from AVN, 5, 3, 1 and 1 was in groups I, II, III and IV of Severin classification,
respectively. Roth et al. (1974) study, 147 hip
joints undergone femur lumpectomy+osteotomy and the results were averagely evaluated
for 22 years. In this study, AVN prevalence reported as 5% in these patients
(Roth et al., 1974). In another study 34 hip
joints undergone femur lumpectomy+osteotomy and resulted outcomes were averagely
evaluated for 17 years. In this study, AVN prevalence reported as 12% in these
patients (Wilkinson and Weissman, 1988). In Gulman
et al. (1994) study; open reduction operation with anterolateral+anonymous
osteotomy approach was done on 52 hip joints and the results were evaluated
for about 13 years. In this study, AVN prevalence reported as 63% in these patients.
In Barrett et al. (1986) study, open reduction
operation with anterolateral+anonymous osteotomy approach was done on 15 hip
joints and the results were evaluated for about 11 years. In this study, AVN
prevalence reported as 13% in these patients. In (Morcuende
et al., 1997) study, open reduction operation with medial approach
was done on 93 hip joints and the results were evaluated for about 10 years.
In this study, AVN prevalence reported as 43% in these patients. In Koizumi
et al. (1996) study, open reduction operation with medial approach
was done on 35 hip joints and the results were evaluated for about 19 years.
In this study, AVN prevalence reported as 43% in these patients. In most of
these studies, it has been stated that follow-up duration after surgery should
be at least 10 years or until growth plates become stable because AVN of type
II in Bucholz classification often occurs after 10 years old (in some studies,
follow up measures continues for 36 years). These studies revealed that short
follow-up period can falsely demonstrate lower levels of AVN prevalence (Wu
et al., 2010). As mentioned in the results section, amount of AVN
prevalence was calculated as 30% in our study. Comparing with other studies,
this seems a little higher but it should be noted that this study put all AVN
cases in Type I of Bucholz classification. This is while AVN had usually higher
degrees in other studies. On the other hand, the conducted studies demonstrate
that more mistakes are observed considering diagnosis and radiologic evaluation
of DDH even in developed countries (Perry and Bruce, 2010).
Comparing most of other studies, AVN incidence in open reduction of femur was
higher in this study. All AVN cases were put in type I of Bucholz classification
our study. No meaningful difference was observed between different surgical
groups considering amount of AVN incidence. There was no meaningful difference
in age of patients afflicted by AVN at the time of surgery with those did not
suffer this complication.
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