Solving a Controversy in Pediatric Developmental Hip Dislocation?

For little pediatric patients—at least 18 months old—the initial treatment for developmental hip dislocation is not without controversy. Noting that single-stage open reduction and pelvic osteotomy is aggressive, a group of surgeons from the University of Iowa in Iowa City set out to compare dislocated hips treated with closed reduction to those treated with open reduction and Salter innominate osteotomy. Results were presented at the Pediatric Orthopaedic Society of North America Annual Meeting.

Co-author Stuart L. Weinstein, M.D., a past president of the Pediatric Orthopedic Society of North America, told OTW, “At Iowa we have a long standing tradition of following children with various musculoskeletal conditions long term to either determine the natural history of the condition or to determine the outcomes of standard treatments of a condition to see if natural history has been favorably altered. For a number of years we have been following a large number of children with developmental hip dysplasia treated only by closed reduction. We began to see the development of hip osteoarthritis developing in these patients in young and mid adult life.”

“In children diagnosed after 18 months of age there was a cohort treated at the Hospital for Sick Children in Toronto, Canada, in the same era but by a more aggressive approach; open reduction accompanied by innominate osteotomy and followed long term. We hence decided to take the unique opportunity to estimate the relative hazard of total hip arthroplasty and the total hip free survival time in children treated by these two methods between 18 and 36 months of age.”

The team looked at 45 patients (58 hips) ages 18-60 months who underwent CR [closed reduction] and 58 patients (78 hips) of similar ages who were treated with open reduction and Salter innominate osteotomy.

Dr. Weinstein: “Those of us who treat DDH have learned from personal experience and the literature that the only way to guarantee good long term outcomes in developmental hip dysplasia is to detect it in the nursery. Late diagnosed developmental hip [DDH] dysplasia puts the hip at risk for developing osteoarthritis at an early age. What was surprising was the similarity in survival analysis in both treatment groups.”

He told OTW, “At 48 years of follow-up, 29 (50%) of the hips survived after closed reduction compared with 54 (69%) after open reduction and Salter innominate osteotomy. At 45 years, the survival probability after open reduction and Salter innominate osteotomy was 0.63 (95% confidence interval [CI] = 0.50 to 0.78) compared with 0.55 (95% CI = 0.43 to 0.72) after closed reduction. Both treatments provided substantial benefit relative to the natural history of DDH, but THA [total hip arthroplasty] is the expected outcome in middle adulthood.”

Co-author Lori Dolan, Ph.D. added,“I would emphasize that this was a unique opportunity to perform a comparative effectiveness study, which only came about because Simon, et al. published the raw data in the Appendix to their article. It is also extremely rare that two centers would have reliable serial data to characterize both the treatment and the long-term outcomes of a cohort of pediatric patients.”