Indien een gesloten heuprepositie niet resulteert in een goed gecentreerde en stabiele heup dient er over gegaan te worden tot een chirurgisch geassisteerde of open heuprepositie. Voor deze heuprepositie worden in de huidige praktijk verschillende chirurgische benaderingen gebruikt, waaronder de mediale en de anterieure benadering. Ook de arthroscopisch geassisteerde repositie is in opkomst in de behandeling van DDH, wat deels verklaard kan worden door de recente sterke groei in arthroscopische ingrepen aan het heupgewricht in de orthopedie voor volwassenen.

De mediale benadering is het eerste beschreven (Ludloff, 1913, interval: m. adductor brevis en m. pectineus) en historisch het meeste gebruikt in de klinische praktijk. Tevens zijn diverse varianten bekend (Ferguson, 1973, interval: m. adductor brevis en m. gracillis; Ponseti, 1979, interval: m. pectineus en neurovasculaire bundel). In de meer recente literatuur wordt daarnaast de anterieure benadering beschreven. Over het algemeen wordt in dit protocol naar de direct anterieure benadering volgens Smith-Peterson gerefereerd (interval: m. sartorius en m. tensor fascia latae), of naar de (anterolaterale) benadering volgens Watson-Jones (interval: m. tensor fascia latae en gluteus medius). Bij deze anterieure benaderingen zou kapsel-reving beter mogelijk zijn dan via mediale benaderingen en kunnen de mediale circumflex vaten gespaard worden. Dit zou in theorie tot minder reluxaties en avasculaire necrose leiden. Daarnaast is de anterieure benadering bij oudere kinderen te combineren met een peri-acetabulaire procedure (indien geïndiceerd).

Daarom bestaat de vraag wat de beste benadering voor het heupgewricht is bij een open heuprepositie, en of er verschil is in behandeluitkomsten (succesvolle repositie (geen reluxaties), bloedverlies, operatieduur) en complicatierisico (avasculaire necrose (AVN), neurapraxie van onder andere de n. femoralis) bij kinderen met Graf D/III/IV DDH jonger dan één jaar?

Description of studies

Duman (2019) performed a retrospective comparative cohort study in patients less than 18 months of age with developmental dysplasia of the hip. The aim of the study was to compare the clinical and radiological efficacy of arthroscopic assisted versus medial approach open reduction. Patients were included if they had primary DDH treated surgically using a medial open or an arthroscopic approach, after failed closed reduction, in patients aged 6 to 18 months with a minimum postoperative follow-up of 24 months. Patients with a pelvic osteotomy during surgical reduction, past medical history of hip surgery, teratologic or neuromuscular hip dislocation, hip dysplasia as part of a syndrome, incomplete clinical follow-up records and patients who were lost to follow-up were excluded.

The intervention consisted of an arthroscopic assisted reduction performed under general anesthesia. In the control group the medial approach open reduction was performed, based on the Ludloff technique (surgical interval: adductor brevis and pectineus).

A total of 26 patients (26 hips) were included in the intervention group and 28 (28 hips) included in the control group. The median age of the intervention and control group was 12 months (range, 7 to 17) and 11 months (range, 6 to 17), respectively. The percentage of males in the intervention and control group was 15% and 11%, respectively. No variables were taken into consideration to adjust for possible confounding.

Yorgancigil (2016) performed a retrospective comparative cohort study in children undergoing open reduction via a medial or anterior approach for DDH, after failed closed reduction. The aim of the study was to investigate the effects of surgical approach on the clinical and radiological outcomes, the incidence of AVN and the need for revision surgery. Patients were included if they attended the follow-up appointments for at least four years and were at least five years old at time of the last visit. Subjects were excluded in case of known neuro-muscular disease, cases in which closed reduction could be achieved with only iliopsoas tenotomy using a medial approach, and cases requiring further surgical interventions in the same procedure, such as pelvic osteotomies.

The intervention consisted of an anterior approach open reduction (surgical interval: m. tensor fascia latae and m. sartorius) and the control consisted of a medial approach open reduction, according to Ferguson (surgical interval: m. adductor brevis and m. gracilis).

A total of 17 patients (22 hips) underwent open reduction with an anterior approach and 19 patients (21 hips) underwent open reduction with a medial approach. The mean age of the intervention and control group was 14.6 months (SD=2.60) and 13.0 months (SD=2.87), respectively. The percentage of males in the intervention and control group was 18.2% and 28.6%, respectively. No variables were taken into consideration to adjust for possible confounding.

Hoellwarth (2015) performed a retrospective comparative study in children with developmental dysplasia of the hip. The aim of the study was to compare aged-matched cohorts undergoing either medial based approach open reduction (MAOR) or direct anterior approach open reduction (AAOR), in terms of the risk of AVN and need for further corrective surgery (FCS).

Patients were included if they underwent a hip arthrogram between the years 1995 and 2009 and were diagnosed with DDH. Patients who had arthrograms not performed by orthopaedic surgeons, those who were above five years old at the start of treatment, had incomplete charts, had < 2 years of follow-up, or who had neuromuscular comorbidities such as cerebral palsy or arthrogryposis, or did not have DDH were excluded.

The intervention consisted of an anterior approach (AAOR), or a medial approach (MAOR) in the controls. The anterior approach was according to the Smit-Peterson technique (surgical interval: m. tensor fascia latae and m. sartorius). The medial approach in this study was described as medial or anteromedial, according to the surgeons’ preference. Surgical intervals were not described.

A total of 18 patients (19 hips) underwent AAOR and 14 patients (19 hips) underwent MAOR. There were 10 patients (53%) in the intervention group and 3 patients (16%) in the control group with previously failed closed reduction with or without adductor tenotomy. All other subjects had undergone treatment with a Pavlik harness before the decision of open reduction was made.

Mean age of the intervention and control group was 6.1 months (SD=3.2) and 5.9 months (SD=2.7), respectively. In addition, the percentage of males in the intervention and control group was 26% and 0%, respectively. A multivariable Cox regression analysis was performed to compare outcomes in both groups, and account for possible confounding factors.

Holman (2012) performed a retrospective cohort study in children with DDH. The aim of the study was to examine the long-term results of open reduction surgery in developmental dysplasia of the hip, and to evaluate whether there is an age at time of surgery above which the outcome is too poor to recommend the operation.

Included children with DDH had to be otherwise healthy and have achieved a satisfactory open reduction, defined as a complete, concentric open reduction, to be included in the study. Patients whose hips were judged to have an incomplete initial open reduction were excluded from the study because it was hypothesized that these hips could never be expected to develop normally. Patients with neurological or syndromic conditions were also excluded, as were those with teratologic dislocations.

The intervention consisted of an anterior approach open reduction (surgical interval not reported) and the control group had a medial approach (Ludloff) open reduction.

A total of 148 patients (179 hips) were assessed for eligibility. Eventually, 53 patients (66 hips) were located and participated in the study (intervention = 48 hips; control = 18 hips). There were 14 patients (29.2%) in the intervention group and 4 patients (22.2%) in the control group that had a previous unsuccessful closed reduction. The mean age of the intervention and control group was 2.9 years (range= 0.25 to 8.08) and 1.4 years (range= 0.41 to 3.5), respectively. No variables were taken into consideration to adjust for possible confounding.

The following two studies did not fully meet the inclusion criteria due to that a substantial part of the study population was older than one year (i.e. youngest age in intervention and/or control group over one year old). The guideline development group has nevertheless decided to include these studies, because of their clinical relevance and lack of alternative available literature.

Tarasolli (2014) performed a prospective cohort study in children with persistent developmental dysplasia of the hip (DDH) in whom closed reduction had failed. The aim of the study was to compare the medial approach with the anterior approach, primarily for the risk of osteonecrosis. Patients were included with an age of between three months and two years at the time of surgery (after failed closed reduction; failure to achieve concentric closed reduction within a safe zone of stability after percutaneous adductor tenotomy at arthrography in the operating theatre). Exclusion criteria were neuromuscular conditions, teratological dislocations and previously failed open reductions.

All children in both groups had an attempted closed reduction after percutaneous adductor tenotomy. The control group had a medial approach open reduction based on the Ludloff technique (surgical interval: m. adductor brevis and m. pectineus). The intervention group had an open reduction through an anterior approach (surgical interval: m. tensor fascia latae and m. sartorius), which was delayed until the appearance of the ossific nucleus, or until the age of 12 to 14 months (whichever was sooner).

A total of 21 children (22 hips) were included in the intervention group and 22 children (26 hips) were included in the control group. The mean age of the intervention and control group was 17.8 months (range, 12 to 24) and 11.0 months (range, 3 to 24), respectively. In addition, the ratio male to female in the intervention and control group was 1:19 and 3:19, respectively. No variables were taken into consideration to adjust for possible confounding.

Matsushita (1999) performed a retrospective cohort study in children with congenital hip dislocation. The aim of the study was to compare the wide exposure method (circumferential capsulotomy), with the medial approach according to Ludloff.

Patients were included when they were treated with an open reduction at either Ehime Disabled Children’s Hospital or Kouchi Disabled Children’s Hospital between January 1973 and December 1980. In this study, patients were excluded when they had previous avascular necrosis, residual subluxation, or dislocation associated with neurologic disorders.

The intervention consisted of the wide exposure method (circumferential capsulotomy via a lateral approach, including release of the gluteus medius and minimus, and short external rotators) and the control consisted of the medial approach according to Ludloff (surgical interval: m. adductor brevis and m. pectineus).

A total of 24 patients (31 hips) were assigned to the intervention group and 27 patients (32 hips) were assigned to the control group. The mean age at surgery in the intervention and control group was 18 months (range= 12 to 31) and 12 months (range= 5 to 30), respectively. No variables were taken into consideration to adjust for possible confounding.

Results

1. Successful reduction (no re-dislocation)

There were three studies that reported on re-dislocations (Tarasolli, 2014; Holman, 2012; Duman, 2019).

Tarasolli (2014) reported 1 re-dislocation in their medial approach group, versus none in the anterior approach group.

Holman (2012) reported 9 (19%) re-dislocations in the anterior approach group, and 2 (11%) in the medial approach group (p=0.46).

Duman (2019) reported 1 re-dislocation in the medial open reduction group, and none in the arthroscopic group. No statistics were performed.

Level of evidence of the literature

The level of evidence regarding the outcome measure “successful reduction” comes from observational studies and therefore starts low. The level of evidence was downgraded by one level because of study limitations (bias by indication, no adjustment for confounding), applicability (bias due to indirectness for age and no closed reduction before the open reduction) and low numbers of included patients (imprecision). Resulting in a level of evidence of very low.

2. Functional outcome

There were three studies (Yorgancıgil, 2016; Matsushita, 1999; Duman, 2019) that reported on functional outcome.

Yorgancıgil reported that in the anterior approach and medial approach group 18 hips (81.8%) and 17 hips (80.9%) had a successful functional outcome, respectively, as defined by the criteria of Mac-Kay (which takes into account hip stability, pain, stiffness and walking pattern). There was no statistically significant difference (p= 0.23).

Matsushita reported that 24 hips (77.4%) and 24 hips (75%) were rated as excellent functional outcome as defined by the criteria of the modified Mac-Kay criteria in the intervention and control group, respectively. No statistic tests were performed.

Duman reported 18 patients (64%) with an excellent Mac-Kay score in the medial approach group, and 16 (62%) in the arthroscopic group. No statistic tests were performed.

Level of evidence of the literature

The level of evidence regarding the outcome measure “functional outcome” comes from observational studies and therefore starts low. The level of evidence was downgraded by one level because of study limitations (bias by indication, no adjustment for confounding), applicability (bias due to indirectness for age and no closed reduction before the open reduction) and low numbers of included patients (imprecision). Resulting in a level of evidence of very low.

3. Residual dysplasia

There were 5 studies (Duman, 2019; Yorgancıgil, 2016; Hoellwarth, 2015; Tarasolli, 2014; Matsushita, 1999) that reported on the outcome residual dysplasia. In 4 studies, this was quantified with the Acetabular Index (AI), and in 1 study with the Severin Classification.

Duman (2019) reported a median AI of 27° (range=19° to 36°) in the arthroscopic approach group and 26° (range= 11° to 39°) in the medial approach group, after a minimal follow-up of 24 months. There was no statistically significant difference.

Yorgancıgil (2016) reported a mean AI of 21.23° (SD=3.70°) in the anterior approach group and 21.86° (SD=3.93°) in the medial approach group, after an average follow-up of 14.6 and 13.0 months, respectively. There was no statistically significant difference (p= 0.23)

Hoellwarth (2015) reported a mean AI of 17° (range=6° to 25°) in the anterior approach group and 19° (range=11° to 33°) in the medial approach group at an average of 6 years of follow-up. There was no statistically significant difference (p= 0.23).

Tarasolli (2014) reported an absolute mean value of 24° (range= 15° to 34°) in the anterior approach group and 25° (range= 16° to 35°) in the medial approach group. Mean decrease in AI two years postoperatively was 7.9° (range= 6° to 10°) in the anterior approach group and 8.8° (range= 4° to 12°) in de medial approach group. There was no statistically significant difference (p= 0.18).

Matsushita (1999) reported on 5 patients (20.8%) with residual dysplasia (defined by Severin classification III or IV) in the intervention group, and 14 patients (51.9%) in the control group (p<0.05) after a follow-up until the age of 17 years on average.

Level of evidence of the literature

The level of evidence regarding the outcome measure “residual dysplasia” comes from observational studies and therefore starts low. The level of evidence was downgraded by one level because of study limitations (bias by indication, no adjustment for confounding), applicability (bias due to indirectness for age and no closed reduction before the open reduction) and low numbers of included patients (imprecision). Resulting in a level of evidence of very low.

4. Residual dysplasia as defined by re-interventions in follow-up (without interventions for re-dislocations)

There were two studies (Holman, 2012; Matsushita, 1999) that reported residual dysplasia defined by re-interventions in follow-up.

Holman (2012) reported that nine hips (50%) in the medial approach group required further surgery for dysplasia. These subsequent operations included 2 varus/derotational femoral osteotomies, 6 Pemberton osteotomies, and 1 periacetabular osteotomy. In the anterior group 20 hips (41.7%) had a pelvic osteotomy, either Salter or Pemberton, and/or a femoral osteotomy. No statistic tests were performed.

In the study of Matsushita (1999), 10 of 32 hips (31%) in the medial approach group underwent re-interventions for instability, lateralisation and/or residual dysplasia, compared to 0 of 31 in the “wide exposure” group. No statistic tests were performed.

Level of evidence of the literature

The level of evidence regarding the outcome measure “residual dysplasia as defined by re-interventions” comes from observational studies and therefore starts low. The level of evidence was downgraded by one level because of study limitations (bias by indication, no adjustment for confounding), applicability (bias due to indirectness for age and no closed reduction before the open reduction) and low numbers of included patients (imprecision). Resulting in a level of evidence of very low.

5. Secondary procedures (unspecified)

There were two studies (Yorgancıgil, 2016; Hoellwarth, 2015) that reported on the outcome measure “secondary procedures” or “revision procedures” in follow-up. The specific indications for secondary procedures were not mentioned in these studies.

Yorgancıgil (2016) reported that four hips (18.1%) in the anterior approach group and three hips (14.3) in the medial approach group underwent revision surgery. There was no statistically significant difference (p= 0.17).

Hoellwarth (2015) reported that seven hips (37%) in the anterior approach group and four hips (21%) in the medial approach group underwent revision surgery. There was no statistically significant difference (p= 0.48).

Level of evidence of the literature

The level of evidence regarding the outcome measure “secondary procedures” comes from observational studies and therefore starts low. The level of evidence was downgraded by one level because of study limitations (bias by indication, no adjustment for confounding), applicability (bias due to indirectness for age and no closed reduction before the open reduction) and low numbers of included patients (imprecision). Resulting in a level of evidence of very low.

6. Complications (including AVN and (femoral) neuropathy)

Duman (2019) reported that no vascular or nerve injury occurred in any of the patients with either medial or arthroscopic approach.

There were five studies (Yorgancıgil, 2016; Hoellwarth, 2015; Tarasolli, 2014; Holman, 2012; Matsushita, 1999) that reported on the complication AVN, or osteonecrosis.

Yorgancıgil (2016) reported five hips (22.7%) with AVN in the anterior approach group, and five hips (23.8%) in the medial approach group. There was no statistically significant difference (p= 0.93).

Hoellwarth (2015) reported ten hips (53%) with AVN in the anterior approach group and six hips (32%) in the medial approach group. There was no statistically significant difference (p= 0.32).

Matsushita (1999) reported 1 hip (3.2%) with AVN in the wide exposure group and 7 hips (21.9%) in the medial approach group. No statistic tests were performed.

Tarasolli (2014) reported four hips (18%) with osteonecrosis in the anterior approach group and three hips (12%) in the medial approach group. There was no statistically significant difference (p= 0.52).

Holman (2012) reported nine hips (18.8%) with osteonecrosis in the anterior approach group and one hip (6%) in the medial approach group. There was no statistically significant difference (p=0.18).

Level of evidence of the literature

The level of evidence regarding the outcome measure “complications (incl. AVN and femoral neuropathy)” comes from observational studies and therefore starts low. The level of evidence was downgraded by one level because of study limitations (bias by indication, no adjustment for confounding), applicability (bias due to indirectness for age and no closed reduction before the open reduction) and low numbers of included patients (imprecision). Resulting in a level of evidence of very low.

7. Blood loss

There was one study (Duman, 2019) that reported on the outcome measure “blood loss”.

Duman (2019) reported that blood loss was higher in patients with a medial approach, compared to arthroscopic assisted reduction: a median of 35 (range, 15 to 55) versus 9 (range, 5 to15) ml. No statistics investigations were performed.

Level of evidence of the literature

The level of evidence regarding the outcome measure “blood loss” comes from an observational study and therefore starts low. The level of evidence was downgraded by one level because of study limitations (bias by indication, no adjustment for confounding), applicability (bias due to indirectness for age and no closed reduction before the open reduction) and low numbers of included patients (imprecision). Resulting in a level of evidence of very low.

8. Operative time

There was one study (Duman, 2019) that reported on the outcome measure “operative time”. Duman reported no differences between operative time in medial compared to arthroscopic assisted reduction: a median of 34 (range 30 to 40) versus 32 (range 30 to 40) minutes.

Level of evidence of the literature

The level of evidence regarding the outcome measure “operative time” comes from an observational study and therefore starts low. The level of evidence was downgraded by one level because of study limitations (bias by indication, no adjustment for confounding), applicability (bias due to indirectness for age and no closed reduction before the open reduction) and low numbers of included patients (imprecision). Resulting in a level of evidence of very low.

A systematic review of the literature was performed to answer the following two questions: 1) What are the (un)favorable effects of a surgical reduction through a medial approach of the hip joint in patients younger than one year, with DDH Graf D/III/IV, compared to other surgical approaches of the hip ?

2) What are the (un)favorable effects of a surgical reduction through an anterior approach of the hip joint in patients younger than one year, with DDH Graf D/III/IV, compared to other surgical approaches of the hip?

PICO 1

P: (patients) patients with DDH Graf D/III/IV, below one year old, without centralization and reduction of the femoral head after treatment with an abduction device and attempted closed reduction;

I: (intervention) surgical/Open reduction with medial approach;

C: (control) other surgical approaches;

O: (outcome measures) successful reduction/reposition (no re-dislocation), operative time, blood loss, residual dysplasia, acetabular index (AI), complications (incl. avascular necrosis (AVN), (femoral) neuropathy), secondary procedures.

PICO 2

P: (patients) patients with DDH Graf D/III/IV, below one year old, without centralization and reduction of the femoral head after treatment with an abduction device and attempted closed reduction;

I: (intervention) surgical/Open reduction with anterior approach;

C: (control) other surgical approaches;

O: (outcome measures) successful reduction/reposition (no re-dislocation), operative time, blood loss, residual dysplasia, acetabular index (AI), complications (incl. avascular necrosis (AVN), (femoral) neuropathy), secondary procedures.

Relevant outcome measures

The guideline development group considered successful reduction as a critical outcome measure for decision making; and blood loss, operative time, residual dysplasia, complications (incl. AVN, femoral neuropathy, and secondary procedures) as important outcome measures for decision making.

A priori, the guideline development group did not define the outcome measures listed above but used the definitions used in the selected studies.

Search and select (Methods)

The databases Medline (via OVID) and Embase (via Elsevier) were searched with relevant search terms until 22^nd of July 2019. The detailed search strategy is depicted under the tab Methods. The systematic literature search resulted in 230 hits. Studies were selected based on the following criteria: randomized controlled trials (when these are not available then comparative cohort studies), studies including children under one year, and comparing surgical approaches for surgical or open reductions.

Nineteen studies were initially selected based on title and abstract screening. After reading the full texts, 13 studies were excluded (see the table with reasons for exclusion under the tab Methods), and 6 studies were included.

Results

Six studies (Duman, 2019; Yorgancigil, 2016; Hoellwarth, 2015; Tarasolli, 2014; Holman, 2012; Matsushita, 1999) were included in the analysis of the literature. Important study characteristics and results are summarized in the evidence tables. The assessment of the risk of bias is summarized in the risk of bias tables.