Judd J, Gibson C, Clarke NMP, Ed FRCS

Language: Spanish
References: 14
Page: 26-31
PDF size: 245.76 Kb.

ABSTRACT

It has always been considered, prior to the appearance of the proximal femoral epiphysis, that the structure and blood supply of the femoral head is very susceptible to compression. Initially the cartilage canals are endarteriolar. With the appearance if the ossific nucleus the blood supply becomes anastomotic. Continuing controversy therefore surrounds the question of whether or not the presence of a bony ossific nucleus protects the femoral head from avascular necrosis. Advocates of early reduction argue that the joint congruency is achieved earlier with a reduced incidence of acetabular dysplasia; but by delaying reduction until the appearance of the ossific nucleus, there is an increased incidence of open reduction and reoperation. Previously, in a series of 50 hips treated by either closed reduction or open reduction following intentional delay in surgery, until the appearance of the ossific nucleus or 12 months of age: further surgery was required in 57% of the closed reduction group and 41% of the open reduction group. The avascular necrosis rate was 7% in the closed reduction group and 14% in the open reduction group. Failed splintage hips were excluded and the overall incidence of avascular necrosis was 4%. Previously it was concluded that intentional delay does not condemn the hip to open reduction and that the presence of the ossific nucleus was important but multifactorial factors would be present. The previous analysis could not demonstrate a significant effect of the ossific nucleus, on the development of avascular necrosis. However, the presence of the ossific nucleus might have a protective effect against the development of avascular necrosis grades II, III and IV. The quality of evidence however is moderate and further research is likely to have an important impact on the confidence and effect estimate. It is probable that the only way of defining whether or not the ossific nucleus is protective, would be by a randomized control trial. A subsequent series has shown that waiting for the development of the ossific nucleus does not affect the incidence of open reduction and probably does protect against higher grade avascular necrosis.

REFERENCES

1. Clarke NMP, Taylor CC. Diagnosis and management of developmental hip dysplasia. Paediatrics and Child Health. 2012; 22(6): 235-238.

2. Wilkinson JA. Congenital displacement of the hip joint. Berlin Springer Verlag. 1995; 39-42.

3. Morcuende JA, Weinstein SL. Developmental dysplasia of the hip: natural history, results of treatment, and controversies. 2002. Accessed online 5th February 2012.

4. Roposch A, Stöhr KK, Dobson M. Effect of femoral head ossific nucleus in the treatment of hip dislocation: systematic review with meta-analysis. J Bone Joint Surg (Am). 2009; 91(4): 911-918.

5. Roposch A, Odeh O, Doria AS, Wedge JH. The presence of an ossific nucleus does not protect against osteonecrosis after treatment of developmental dysplasia of the hip. Clin Orthop Relat Res. 2011; 469(10): 2838-2845.

6. Bolland BJ, Wahed A, Al-Hallao S, Culliford DJ, Clarke NMP. Late reduction in congenital dislocation of the hip and the need for secondary surgery: radiologic predictors and confounding variables. J Pediatr Orthop. 2010; 30(7): 676-682.

7. Segal LS, Boal DK, Borthwick L, Clark MW, Localio AR, Schwentker EP. Avascular necrosis after treatment of DDH. The protective influence of the ossific nucleus. J Paediatr Orthop. 1999; 19(2): 177-184.

8. NHS Newborn and infant physical examination (NIPE) 2010 Online 5th February: www. newbornphysical.screening.nhs.uk

9. Davis A. Developmental dysplasia of the hip. Screening for developmental dysplasia of the hip. 2009 BMJ. Online: 23rd July 2012: www.bmj.com/rapid-response/2011/11/02/screening-developmental-dysplasia-hip

10. Uçar DH, Işiklar ZU, Kandemir U, Tümer Y. Treatment of developmental dysplasia of the hip with Pavlik harness: prospective study in Graf type IIc or more severe hips. J Pediatr Orthop B. 2004; 13(2): 70-74.

11. International Hip Dysplasia Institute. Revisado el 05/02/2013 www.hipdysplasia.org

12. Luhmann SJ, Schoenecker PL, Anderson AM, Bassett GS. The prognostic importance of the ossific nucleus in the treatment of congenital dysplasia of the hip. J Bone Joint Surg (Am). 1998; 80(12): 1719-1727.

13. Clarke NMP, Jowett AJ, Parker L. The surgical treatment of established congenital dislocation of the hip: results of surgery after planned delayed intervention following appearance of the capital femoral ossific nucleus. J Paed Orthop. 2005; 25(4): 434-439.

14. Kalamachi A, MacEwen GD. Avascular necrosis following treatment of congenital dislocation of the hip. J Bone Joint Surg (Am). 1980; 62: 876-888.