Comparison of Pediatric and General Orthopedic Surgeons’ Approaches in Management of Developmental Dysplasia of the Hip and Flexible Flatfoot: the Road to Clinical Consensus

Document Type : SHORT COMMUNICATION

Authors

1 Orthopedics and Trauma Surgery Department, Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran

2 School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

3 Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran

4 Orthopedics and Trauma Surgery Department, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran

Abstract

 
Developmental dysplasia of the hip (DDH) and flatfoot are common pediatric orthopedic disorders, being referred to and managed by both general and pediatric orthopedic surgeons, through various modalities. Our study aimed to evaluate their consensus and perspective disagreements in terms of diagnostic and therapeutic approaches of the mentioned deformities. Forty participants in two groups of general orthopedic surgeons (GOS) (n=20) and pediatric orthopedic surgeons (POS) (n=20), were asked to answer an 8-item questionnaire on DDH and flexible flatfoot. The questions were provided with two- or multiple choices and a single choice was accepted for each one. Chi-square and Fisher’s exact tests was performed to compare the responses. For a neonate with limited hip abduction, hip ultrasonography was the agreed-upon approach in both groups (100% POS vs 71% GOS), and for its interpretation 79% of POS relied on their own whereas 73% of GOS relied on radiologist’s report (P=0.002). In failure of a 3-week application of the Pavlik harness, ending it and closed reduction (57% POS vs. 41% GOS) followed by surgery quality assessment with CT scan (64% POS vs. 47% GOS) and without the necessity for avascular necrosis evaluation (79% POS vs. 73% GOS) were the choice measures. In case of closed reduction failure, open reduction via medial approach was the favorite next step in both groups (62% POS and 80% GOS). For the patient with flexible flat foot, reassurance was the choice plan of 79% of pediatric orthopedists. Our findings demonstrated significant disagreements among the orthopedic surgeons. This proposes insufficiency of high-level evidence.

Keywords

Main Subjects

References

1. Leck I. Congenital dislocation of the hip. Oxford: Antenatal
and Neonatal Screening Ed; 2000. P. 398-424.
2. Schwend RM, Schoenecker P, Richards BS, Flynn JM,
Vitale M. Screening the newborn for developmental
dysplasia of the hip: now what do we do? J Pediatr
Orthop. 2007; 27(6):607-10.
3. Jackson JC, Runge MM, Nye NS. Common questions
about developmental dysplasia of the hip. Am Fam
Physician. 2014; 90(12):843-50.
4. Dezateux C, Rosendahl K. Developmental dysplasia of
the hip. Lancet. 2007; 369(9572):1541-52.
5. Roposch A, Wright JG. Increased diagnostic
information and understanding disease: uncertainty
in the diagnosis of developmental hip dysplasia 1.
Radiology. 2007; 242(2):355-9.
6. Williams D, Protopapa E, Stohr K, Hunter JB, Roposch A.
The most relevant diagnostic criteria for developmental
dysplasia of the hip: a study of British specialists. BMC
Musculoskelet Disord. 2016; 17(1):38.
7. Dare DM, Dodwell ER. Pediatric flatfoot: cause,
epidemiology, assessment, and treatment. Curr Opin
Pediatr. 2014; 26(1):93-100.
8. Hosalkar HS, Spiegel DA, Davidson RS. The foot
and toes. Nelson Textbook of Pediatrics. 19th ed.
Philadelphia, Pa: Saunders Elsevier; 2011.
9. Jane MacKenzie A, Rome K, Evans AM. The efficacy
of nonsurgical interventions for pediatric flexible
flat foot: a critical review. J Pediatr Orthop. 2012;
32(8):830-4.
10. Driano AN, Staheli L, Staheli LT. Psychosocial
development and corrective shoewear use in
childhood. J Pediatr Orthop. 1998; 18(3):346-9.
11. Ponce de León Samper MC, Herrera Ortiz G,
Castellanos Mendoza C. Relationship between flexible
flat foot and developmental hip dysplasia. Rev Esp Cir
Ortop Traumatol. 2015; 59(5):295-8.
12. Mulpuri K, Song KM, Gross RH, Tebor GB, Otsuka
NY, Lubicky JP, et al. The American academy of
orthopaedic surgeons evidence-based guideline on
detection and nonoperative management of pediatric
developmental dysplasia of the hip in infants up
to six months of age. J Bone Joint Surg Am. 2015;
97(20):1717-8.
13. Guille JT, Pizzutillo PD, MacEwen GD. Development
dysplasia of the hip from birth to six months. J Am
Acad Orthop Surg. 2000; 8(4):232-42.
14. Vedantam R, Bell MJ. Dynamic ultrasound assessment
for monitoring of treatment of congenital dislocation
of the hip. J Pediatr Orthop. 1995; 15(6):725-8.
15. Castelein RM, Sauter AJ. Ultrasound screening for
congenital dysplasia of the hip in newborns: its value.
J Pediatr Orthop. 1988; 8(6):666-70.
16. Paton RW, Hinduja K, Thomas CD. The significance
of at-risk factors in ultrasound surveillance of
developmental dysplasia of the hip. A ten-year
prospective study. J Bone Joint Surg Br. 2005;
87(9):1264-6.
17. Malvitz TA, Weinstein SL. Closed reduction for
congenital dysplasia of the hip. Functional and
radiographic results after an average of thirty years. J
Bone Joint Surg Am. 1994; 76(12):1777-92.
18. Mubarak SJ, Bialik V. Pavlik: the man and his method.
J Pediatr Orthop. 2003; 23(3):342-6.
19. Tiruveedhula M, Reading IC, Clarke NM. Failed Pavlik
harness treatment for DDH as a risk factor for avascular
necrosis. J Pediatr Orthop. 2015; 35(2):140-3.
20. Thomas SR. A review of long-term outcomes for late
presenting developmental hip dysplasia. Bone Joint J.
2015; 97-B(6):729-33.
21. 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):1719-27.
22. Sllamniku S, Bytyqi C, Murtezani A, Haxhija EQ.
Correlation between avascular necrosis and the
presence of the ossific nucleus when treating
developmental dysplasia of the hip. J Child Orthop.
2013; 7(6):501-5.
23. Roposch A, Stohr KK, Dobson M. The effect of the
femoral head ossific nucleus in the treatment of
developmental dysplasia of the hip. A meta-analysis.
J Bone Joint Surg Am. 2009; 91(4):911-8.
24. Kotlarsky P, Haber R, Bialik V, Eidelman M.
Developmental dysplasia of the hip: What has
changed in the last 20 years? World J Orthop. 2015;
6(11):886-901.
25. Yamada K, Mihara H, Fujii H, Hachiya M. A long-term
follow-up study of open reduction using Ludloff’s
approach for congenital or developmental dislocation
of the hip. Bone Joint Res. 2014; 3(1):1-6.
26. Hoellwarth JS, Kim YJ, Millis MB, Kasser JR, Zurakowski
D, Matheney TH. Medial versus anterior open
reduction for developmental hip dislocation in agematched
patients. J Pediatr Orthop. 2015; 35(1):50-6.
27. Koizumi W, Moriya H, Tsuchiya K, Takeuchi T,
Kamegaya M, Akita T. Ludloff’s medial approach
for open reduction of congenital dislocation of the
hip. A 20-year follow-up. J Bone Joint Surg Br. 1996;
78(6):924-9.
28. Weinstein SL. Closed versus open reduction of
congenital hip dislocation in patients under 2 years of
age. Orthopedics. 1990; 13(2):221-7.
29. Kalamchi A, Schmidt TL, MacEwen GD. Congenital
dislocation of the hip. Open reduction by the medial
approach. Clin Orthop Relat Res. 1982; 169(1):127-32.
30. Mau H, Dorr WM, Henkel L, Lutsche J. Open reduction
of congenital dislocation of the hip by Ludloff’s
method. J Bone Joint Surg Am. 1971; 53(7):1281-8.
The Archives of Bone and Joint Surgery
Volume 5, Issue 1 - Serial Number 1
January 2017
Pages 46-51

Files

History

  • Receive Date: 14 June 2016
  • Revise Date: 03 January 2017
  • Accept Date: 15 October 2016

Share

How to cite

Statistics