Closed Reduction as Therapeutic Gold Standard for Treatment of Congenital Hip Dislocation

Abstract

Background Congenital hip dislocation (luxation) has an incidence of 0.4 – 0.7% and is regarded as a prearthrotic deformity. Thus, if not being diagnosed and treated at a very early age, extensive surgical measures are inevitable in childhood and early adulthood.

Methods In the time between 01/2013 and 02/2019 we performed 28 600 hips sonographies in babies as part of general screening measures at U2 or U3. There were 71 instable, dysplastic or dislocated hips diagnosed that were treated by arthrographic, closed reduction. After a hip spica cast was applied, reposition was controlled by MRI, estimating the acetabular head index (ACI), the head coverage index (HCI) as well as the femoral headʼs sphericity or by sonography using the Graf method.

Results Overall success rate was 91.6% for primary closed reduction. Patients with primarily irreducible hips were significantly older (p < 0.003) than patients with primarily successful reducible hips. Congenital dislocated hips had significantly higher ACIs (p < 0.001) and HCIs (p = 0.03) as well as significantly less well rounded femoral heads (sphericity; p < 0.001) compared to stable hips.

Conclusion Early diagnosis and treatment of congenital dislocated hips by closed reduction is essential for a sufficient and regular maturation of the hips without further surgical interventions.

Key messages

1. General hip screening (clinical and sonographic) for neonates is a reliable instrument for diagnosing hip dysplasia and dislocation.

2. Early diagnosis and treatment are essential for successful treatment of congenital hip dysplasia or dislocation.

3. Closed reduction has better success rates than other procedures for treatment of infant hip dislocation.

4. A combination of AHI, HCI and sphericity allow assessment of the reduction result on MRI.

5. Successful reduction regularly results in cartilage and bone maturation of the hips.

Kernaussagen

1. Ein generelles Hüftscreening (klinisch und sonografisch) für Neugeborene ist ein verlässliches Instrument zur Diagnose von Hüftdysplasien und -luxationen.

2. Die frühe Diagnose und Behandlung sind essenziell für eine erfolgreiche Therapie der kongenitalen Hüftdysplasie bzw. -luxation.

3. Die geschlossene Reposition hat bessere Erfolgsraten als andere Verfahren zur Therapie der Säuglingshüftluxation.

4. AKI, KÜX und Sphärizität erlauben in Zusammenschau eine Bewertung des Repositionsergebnisses im MRT.

5. Erfolgreiche Repositionen resultieren regelhaft in knorpeliger und knöcherner Ausreifung der Hüften.

Key words

DDH - closed reduction - ACI - HCI - hip luxation

Publication History

Article published online:
18 September 2019

• References/Literatur

• 1 Graf R. Hip sonography: background; technique and common mistakes; results; debate and politics; challenges. Hip Int 2017; 27: 215-219
• 2 Engesaeter IO, Lehmann T, Laborie LB. et al. Total hip replacement in young adults with hip dysplasia: age at diagnosis, previous treatment, quality of life, and validation of diagnoses reported to the Norwegian Arthroplasty Register between 1987 and 2007. Acta Orthop 2011; 82: 149-154
• 3 Thallinger C, Pospischill R, Ganger R. et al. Long-term results of a nationwide general ultrasound screening system for developmental disorders of the hip: the Austrian hip screening program. J Child Orthop 2014; 8: 3-10
• 4 von Kries R, Ihme N, Oberle D. et al. Effect of ultrasound screening on the rate of first operative procedures for developmental hip dysplasia in Germany. Lancet 2003; 362: 1883-1887
• 5 Zídka M, Džupa V. Pavlik harness and Frejka pillow: compliance affects results of outpatient treatment. Arch Orthop Trauma Surg 2019; DOI: 10.1007/s00402-019-03179-7.
• 6 Tschauner C, Klapsch W, Baumgartner A. et al. [Maturation curve of the ultrasonographic alpha angle according to Grafʼs untreated hip joint in the first year of life]. Z Orthop Ihre Grenzgeb 1994; 132: 502-504
• 7 Sewell MD, Eastwood DM. Screening and treatment in developmental dysplasia of the hip-where do we go from here?. Int Orthop 2011; 35: 1359-1367
• 8 Druschel C, Placzek R, Selka L. et al. MRI evaluation of hip containment and congruency after closed reduction in congenital hip dislocation. Hip Int 2013; 23: 552-559
• 9 Placzek R, Funk JF, Druschel C. [Congenital hip dysplasia in newborns: clinical and ultrasound examination, arthrography and closed reduction]. Oper Orthop Traumatol 2013; 25: 417-429
• 10 Stover B, Bragelmann R, Walther A. et al. Development of late congenital hip dysplasia: significance of ultrasound screening. Pediatr Radiol 1993; 23: 19-22
• 11 Bolland BJ, Wahed A, Al-Hallao S. et al. Late reduction in congenital dislocation of the hip and the need for secondary surgery: radiologic predictors and confounding variables. J Pediatr Orthop 2010; 30: 676-682
• 12 Loder RT, Skopelja EN. The epidemiology and demographics of hip dysplasia. ISRN Orthop 2011; 2011: 238607
• 13 Li Y, Guo Y, Li M. et al. Acetabular index is the best predictor of late residual acetabular dysplasia after closed reduction in developmental dysplasia of the hip. Int Orthop 2018; 42: 631-640
• 14 Douira-Khomsi W, Smida M, Louati H. et al. Magnetic resonance evaluation of acetabular residual dysplasia in developmental dysplasia of the hip: a preliminary study of 27 patients. J Pediatr Orthop 2010; 30: 37-43
• 15 Sankar WN, Gornitzky AL, Clarke NMP. et al. Closed reduction for developmental dysplasia of the hip: early-term results from a prospective, multicenter cohort. J Pediatr Orthop 2019; 39: 111-118
• 16 Duffy CM, Taylor FN, Coleman L. et al. Magnetic resonance imaging evaluation of surgical management in developmental dysplasia of the hip in childhood. J Pediatr Orthop 2002; 22: 92-100
• 17 Wirth T, Stratmann L, Hinrichs F. Evolution of late presenting developmental dysplasia of the hip and associated surgical procedures after 14 years of neonatal ultrasound screening. J Bone Joint Surg Br 2004; 86: 585-589
• 18 Graf R. Hip sonography: 20 years experience and results. Hip Int 2007; 17 (Suppl. 05) S8-S14
• 19 Studer K, Williams N, Antoniou G. et al. Increase in late diagnosed developmental dysplasia of the hip in South Australia: risk factors, proposed solutions. Med J Aust 2016; 204: 240
• 20 Biedermann R, Riccabona J, Giesinger JM. et al. Results of universal ultrasound screening for developmental dysplasia of the hip: a prospective follow-up of 28 092 consecutive infants. Bone Joint J 2018; 100-B: 1399-1404
• 21 Broadhurst C, Rhodes AML, Harper P. et al. What is the incidence of late detection of developmental dysplasia of the hip in England?. Bone Joint J 2019; 101-B: 281-287
• 22 Anuar R, Mohd-Hisyamudin HP, Ahmad MH. et al. The economic impact of managing late presentation of developmental dysplasia of hip (DDH). Malays Orthop J 2015; 9: 40-43