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Arthroscopic-assisted reduction for developmental dysplasia of the hip in children: A systematic review
, Riccardo Giai Viab,, Alessandra Cipollab, Andrea Audisioc, Stephan Erdmengerd, Matteo Giachinob, Alessandro Massèb, Alessandro Apratoc
⁎Corresponding author: Riccardo Giai Via. riccardo.giaivia@unito.it
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Developmental dysplasia of the hip (DDH) is a pediatric orthopedic condition characterized by abnormal hip joint formation, leading to subluxation or dislocation of the femoral head from the acetabulum. Early diagnosis and treatment are essential to prevent long-term disability. Conservative treatments are effective if diagnosed early, but late diagnosis often requires more invasive interventions, such as closed or open reduction. Open reduction, although practical, carries significant risks, including avascular necrosis (AVN). Arthroscopic reduction has emerged as a less invasive alternative with potential benefits.
This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including a thorough search of five main databases: PubMed, Scopus, Embase, Medline, and Cochrane. Eligible articles were evaluated according to predefined criteria for levels of evidence (LoE), with retrospective studies assessed using the Coleman Methodology Score (mCMS). This systematic review was registered in the International Prospective Registry of Systematic Reviews (PROSPERO).
The review included 11 studies involving 169 patients with 195 hips treated arthroscopically for DDH. The majority of the patients were female (136, 80.5%). The ages of the patients ranged from 3 months to 3.4 years. The follow-up period ranged from 9 months to 9 years after treatment. Success rates of arthroscopic reduction ranged from 70% to 100%, with a median AVN rate of 10.2%. Complications included AVN (11.3%), redislocation (8.2%) and the need for secondary procedures (29.7%). Most of the studies used sub-adductor and anterolateral portals.
Arthroscopic-assisted reduction for DDH is a viable and less invasive treatment method that offers good clinical and radiological results. This technique can be particularly beneficial for pediatric patients when performed by experienced surgeons. This study's findings contribute to the growing body of evidence supporting the use of arthroscopic reduction as a possible alternative to open reduction in treating DDH. However, further high-quality research is needed to confirm these results and improve the validity of the data.
1 Introduction
Developmental dysplasia of the hip (DDH) is an orthopedic condition prevalent in children. It is characterized by an abnormal hip joint formation in which the femoral head is subluxated or dislocated from the acetabulum.1 This condition ranges from mild acetabular dysplasia to complete dislocation of the hip. Early diagnosis and treatment prevent long-term disability and ensure optimal hip development.2
If diagnosed within the first weeks of life, conservative treatments such as bracing or spica cast are effective and show high success rates.3 However, late diagnosis and treatment are common in many developing countries and may require more invasive interventions. Closed reduction and stabilization in spica cast is indicated for cases of DDH that are diagnosed late or do not respond to initial conservative treatment.4 Arthrography can be helpful to assess depth and stability of reduction.5
If closed reduction is unsuccessful, open reduction becomes necessary. This is often combined with procedures such as superior capsulorrhaphy, pulvinar and ligamentum teres exeresis. In older children, acetabuloplasty and femoral osteotomy may be associated, to achieve hip stability.6 Despite its effectiveness, open reduction carries significant risks if not performed properly, including avascular necrosis (AVN) of the femoral head, which was reported in up to 69 % of cases with a medial approach and up to 30 % with an anterior approach.7,8
These complications have prompted the search for less invasive but effective therapeutic alternatives. Arthroscopic procedures offer several advantages, including less invasiveness, better visualization of anatomical structures, and the possibility of directly addressing intra-articular obstacles to reduction.9 Initial studies have demonstrated the feasibility and potential benefits of arthroscopic reduction in infants and children, providing a hopeful outlook for the future of DDH treatment.10
The primary outcomes of this systematic review are to evaluate the clinical outcomes and the radiological outcomes of pediatric patients who underwent arthroscopic treatment for DDH after unsuccessful closed reduction. As secondary outcomes, we assessed the number of post-operative complications and the need for subsequent osteotomy surgeries.
2 Material and methods
This study adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).11 To ensure accuracy, two investigators performed the literature review and study evaluation independently. In case of uncertainty, a third author was consulted for clarification.
2.1 Inclusion and exclusion criteria
Studies on patients treated arthroscopically to reduce Developmental Dysplasia of the Hip (DDH). These studies were published in English, involved human subjects, randomized controlled trials (RCTs), prospective or retrospective studies with levels of evidence (LoE) 1 to 4 which included patients treated with arthroscopic-assisted reduction of hip dislocation with follow-up more than 6 months and including at least 5 patients were included.12 Biochemical and in vitro studies, case reports, editorials, book chapters, technical reports, preclinical studies, review articles, and studies with LoE 5 were excluded.
2.2 Search strategy and study screening
A systematic literature search was conducted in five databases (PubMed, Scopus, Embase, Medline, and Cochrane) using the following MeSH terms: ((arthroscop∗) OR (endoscop∗)) AND ((DDH) OR (Developmental Dysplasia Hip) OR (Hip dysplasia) OR (congenital hip dislocation)) AND (child∗). The search included studies published between 2004 and May 2024. After removing duplicates, 275 studies were included. After a review of titles and abstracts, 264 studies were excluded, leaving 11 eligible studies. After full-text evaluation, 11 clinical studies met the eligibility criteria of the qualitative analysis. These studies reported pre and post-operative radiological outcomes, arthroscopic portals used and intraoperative findings, adductor and iliopsoas tenotomy, mean operation time, post-surgical rehabilitation programs, success, recurrences and complication rates. The PRISMA diagram is presented in Fig. 1.
2.3 Methodological quality assessment
Each selected article was evaluated according to the 2011 Oxford Centre for Evidence-Based Medicine levels of evidence (LoE), ranging from 1 to 512. Retrospective studies were analyzed using the Coleman Methodology Score (mCMS), modified by Ramponi et al.13,14 (Fig. 2). Two authors used this tool, while a third author was consulted to resolve any uncertainties. All authors contributed significantly to the conception and design of the study, data collection, manuscript preparation, and the text's final edits. All authors approved the final version of the article. This systematic review was registered in the International Registry of Systematic Reviews (PROSPERO; CRD42024561824) in July 2024.15
2.4 Data extraction
Data extracted from the included studies were systematically recorded in Excel spreadsheets by two authors, who worked independently and then merged their results. This process included various details about the data, such as author and year of publication, study design, patient sample size, mean follow-up time, pre-and post-operative radiological outcomes, patient positioning, number and which arthroscopic portals used, intra-operative findings, iliopsoas or adduction tenotomy, secondary surgical procedures, the post-operative rehabilitation program, success rates, recurrence rates, and complication rates.
2.5 Statistical analysis
Statistical analysis was conducted using R software (version 4.1.3, released in 2022) developed by the R Core Team in Vienna, Austria. Descriptive statistical techniques were applied to the collected data. Continuous variables were summarized using mean values, while measures of variability such as standard deviation (SD) or range (minimum-maximum) were also used. Categorical variables were analyzed by determining absolute numbers and frequency distributions.
3 Results
Most of the studies included in this review8–10,16–23 are retrospective, except the prospective studies by Eberhardt et al. and Zhao et al. 169 patients, with 195 also suffering from DDH, were included in this review.10,22 The majority of the patients were female (136, 80.5 %). The ages of the patients ranged from 3 months to 3.4 years. The follow-up period ranged from 9 months to 9 years after treatment.
Of the 169 patients, 29 (17 %) had bilateral DDH. In the ten studies that mentioned the diseased side, the left was affected in 78 patients and the right in 58 patients.8–10,16–19,21–23Table 1shows all the characteristics of the included studies and patients, while Table 2 shows the intraoperative joint characteristics of the included patients.
| Authors (year) | Study design (LoE) | No of patients (hips) | Age months (range) | Male/Female | Right/Left | Unilateral/Bilateral | Tonnis grading | FU mns (range) |
| Duman et al. (2019)9 | Retrospective (IV) | 26 (26) | 12 (7–17) | 4/22 | 10/16 | 26/0 | 10 Grade II | (24–30) |
| 13 Grade III | ||||||||
| 3 Grade IV | ||||||||
| Eberhardt et al. (2012)21 | Retrospective (IV) | 5 (8) | 5.8 (4–7) | 1/4 | 3/5 | 2/3 | 7 Grade IV | 13.2 (9–24) |
| 1 Grade III | ||||||||
| Eberhardt et al. (2015)22 | Prospective (IV) | 21 (25) | 12.5 (3–41) | 5/16 | 12/13 | 17/4 | 13 Grade IV | 19.3 (6–48) |
| Infancy 6.4 (3–10) | 6 Grade III | |||||||
| Walking 21.8(14–41) | 6 Grade II | |||||||
| Eberhardt et al. (2014)23 | Retrospective (IV) | 9 (9) | 21.4 (14–41) | 1/8 | 3/6 | 9/0 | 1 Grade IV | 15.4 (6–29) |
| 4 Grade III | ||||||||
| 4 Grade II | ||||||||
| Feng et al. (2019)16 | Retrospective (IV) | 12 (12) | 14 (10–20 | 2/10 | 4/8 | 12/0 | 3 Grade II | 26 (18–36) |
| 6 Grade III | ||||||||
| 3 Grade IV | ||||||||
| Kitano et al. (2010)17 | Retrospective (IV) | 10 (11) | 22.6 (18.6–29.7) | 1/9 | 3/7 | 9/1 | / | 64.8 (20.4–108) |
| Öztürk et al. (2013)18 | Retrospective (IV) | 9 (9) | 9–16 | 0/9 | 2/7 | 9/0 | / | 47.7 (22–79) |
| Presch et al. (2019)8 | Retrospective (IV) | 17 (19) | 9.89 (3–21) | 3/14 | 9/10 | 15/2 | 3 Grade II | 24 |
| 10 Grade III | ||||||||
| 6 Grade IV | ||||||||
| Xu et al. (2016)19 | Retrospective (IV) | 35 (44) | 17.7 (4–40) | 9/26 | 20/24 | 26/9 | 5 Grade 1 | 71 (36–96) |
| 14 Grade 2 | ||||||||
| 14 Grade 3 | ||||||||
| 11 Grade 4 | ||||||||
| Zhang et al. (2024)20 | Retrospective (IV) | 48 (58) | 16.98 ± 5.07 (6–28) | 7/41 | / | 38/10 | 17 Grade III | 40.21 ± 10.27 (25–74) |
| 41 Grade IV | ||||||||
| Zhao et al. (2017)10 | Prospective (IV) | 8 (8) | 15.6 (12–22) | 5/3 | 5/3 | 8/0 | 2 Grade III | 60 |
| 6 Grade IV |
| Authors (year) | Hypertrophic ligamentum teres | Thickened pulvinar soft tissues | Tightened TAL | Inverted labrum | Capsule adhesion | Capsule contracture |
| Duman et al. (2019)9 | 26 (100 %) | 26 (100 %) | 26 (100 %) | / | / | 5 (19 %) |
| Eberhardt et al. (2012)21 | 7 (87.5 %) | 8 (100 %) | 8 (100 %) | 0 (0 %) | 0 (0 %) | 8 (100 %) |
| Eberhardt et al. (2015)22 | 23 (92 %) | 25 (100 %) | 14 (56 %) | 0 (0 %) | 0 (0 %) | 22 (88 %) |
| Eberhardt et al. (2014)23 | 9 (100 %) | 9 (100 %) | 5 (55.6 %) | 0 (0 %) | 0 (0 %) | 8 (88.9 %) |
| Feng et al. (2019)16 | 10 (83.3 %) | 12 (100 %) | 0 (0 %) | 0 (0 %) | 0 (0 %) | 6 (50 %) |
| Kitano et al. (2010)17 | / | / | / | / | / | / |
| Öztürk et al. (2013)18 | / | / | / | / | / | / |
| Presch et al. (2019)8 | 18 (95 %) | 19 (100 %) | 8 (42 %) | 1 (5 %) | 0 (0 %) | 17 (89 %) |
| Xu et al. (2016)19 | / | / | / | / | / | / |
| Zhang et al. (2024)20 | 58 (100 %) | 58 (100 %) | 0 (0 %) | 0 (0 %) | 26 (44.8 %) | 15 (25.9 %) |
| Zhao et al. (2017)10 | 8 (100 %) | 8 (100 %) | 8 (100 %) | 2 (25 %) | 0 (0 %) | 8 (100 %) |
3.1 Diagnosis
In the included studies, the diagnosis of DDH was based on history, physical examination, pre-operative plain radiographs, computed tomography (CT) with 3D imaging, arthrography and/or magnetic resonance imaging (MRI) showing intra-articular soft tissue obstructions that prevented concentric reduction. Pre-operative imaging revealed the presence of a thick and taut posterior and/or postero-superior limbus preventing concentric reduction of the femoral head in the acetabulum, a hypertrophied ligamentum teres and pulvinar, and a hypertrophic acetabular labrum. Eight studies indicated the number of patients with these intra-articular obstacles.8–10,16,20–23 Lesions of the acetabular head and cartilage were classified according to the Tönnis classification in nine studies, as shown in Tables 1.8–10,16,19–23
3.2 Indication of arthroscopy
The indications for arthroscopic reduction in DDH were cases in which closed reduction failed to achieve an acceptable hip reduction, defined as a concentric and stable reduction of the hip maintained without undue position or force.
3.3 Surgical technique
In all studies, the surgical procedure was performed with the patient supine under general anesthesia. Hip arthrography was conducted to assess the relationship between the head and the acetabulum using fluoroscopy.8–10,16–23
In six studies, percutaneous tenotomies of the adductors were performed on subjects with hip abduction restrictions of less than 60°.8,10,16,18–20
The arthroscopic technique involves the removal of the acetabular pulvinar tissue and the hypertrophied acetabular labrum with resection of the ligamentum teres. After these steps, the horseshoe-shaped articular surface and the acetabular fossa become visible. If capsular constriction was present, a capsular release was performed using an electrocautery probe. If necessary, transverse acetabular ligament resection is also performed. Tenotomy of the iliopsoas has only been described in three studies.8,16,23 See Table 3.
| Authors (year) | Operation time min (range) | Portals | Surgical technique | Iliopsoas tenotomy | Adductor tenotomy | Post operative protocol |
| Duman et al. (2019)9 | 32 (30–40) | Subadductor and anterolateral portals | Ablation and excision of the ligamentum teres and the pulvinar tissue, cutting TAL and capsular release with radiofrequency | 0 (0 %) | / | Pelvipedal cast applied in 100° flexion, 50° abduction, and 10° IR for 3 months then Denis Browne orthosis for 8 weeks with the hip in 30–45° of abduction |
| Eberhardt et al. (2012)21 | / | Subadductor and anterolateral portals | Hypertrophic ligamentum teres and acetabular pulvinar were resected, and a limited release of the capsule | / | / | Spica cast is applied in moderate flexion, ER and abduction. |
| Eberhardt et al. (2015)22 | / | Subadductor and high anterolateral portals | Ligamentum teres and pulvinar removal then resection of the hypertrophic TAL, capsular release if needed | / | / | Spica cast was applied for 10.8 (8–12) weeks |
| Eberhardt et al. (2014)23 | / | Subadductor and high anterolateral portals | Resection of the ligamentum teres and the pulvinar then TAL excision and capsular release was performed | 1 (11.1 %) | / | A plaster cast is used to retain the pelvis in reduction position for 8 weeks |
| Feng et al. (2019)16 | / | / | Adductor muscle, iliopsoas muscle, hypertrophic round ligaments and pulvinar excision. Two-thirds of inverted labrum was cut | 12(100 %) | 12 (100 %) | Plaster cast with fixed flexion and abduction of the hips (frog-leg position) was used for 2–3 months. |
| Kitano et al. (2010)17 | 192 (108–342) | Medial and anterior portals | Thick and/or tight limbus was incised in a radial pattern using basket forceps (8), vaporizing of limbs (2), suture pullout (4) | / | / | Hip spica cast or brace was used to retain the reduction position with the hip flexed by 90° and abducted by 70°. |
| Öztürk et al. (2013)18 | 40 (35–65) | Anterolateral and anteromedial portals | Hypertrophic ligamentum teres, pulvinar and TAL excision | / | 7 (77.8 %) | A spica casting and an abduction splint for 13.6 (12–17) weeks |
| Presch et al. (2019)8 | 137 | Subadductor and anterolateral portals | Resection of hypertrophic ligamentum teres and pulvinar, resection of hypertrophic TAL, capsular release and Inverted labrum incision | 1 (5 %) | 2 (10 %) | / |
| Xu et al. (2016)19 | 28 (22–36) | Anterior and anterosuperior GT portals | Ligamentum teres and pulvinar were excised and posterior labrum was vaporized and fixed to relieve the obstacles and TAL was cut off | 0 (0 %) | 44 (100 %) | Improved hip frog cast was applied for 3 months then spica cast for 3 months and then abduction brace was used for 3–6 months. |
| Zhang et al. (2024)20 | Unilateral 60.7 (20–120) | Inferior adductor and superior adductor medial portals | Hypertrophic ligamentum teres and pulvinar resection, inner TAL trimming with a shaver, hypertrophic labrum released radially, capsule adhesion detached by a straight arthroscopic hook, capsular release by an articular shaver | 0 (0 %) | if hip abduction <60°. | Hip spica plaster at 90°–110° of flexion and 40°–60° of abduction for 12 weeks, changed at 6 weeks then abduction orthosis for 3 until the concentric reduction was stable. |
| Bilateral 115.5 | ||||||
| (80–165) | ||||||
| Zhao et al. (2017)10 | 50 ± 10 | Anterolateral and posterolateral portals | resection of the pulvinar tissue and ligamentum teres, transverse ligament incision, and capsule release | 0 (0 %) | 8 (100 %) | Spica cast was applied in a flexed and abducted position for 12 weeks then a Pavlik harness for 3–6 months. |
The average operative time for the operation was reported in seven studies,8–10,17–20 ranging from 28 min (22–36 min) in the shortest study to 3.2 h (1.8–5.7 h) in the longest study. The estimated amount of blood loss with arthroscopic reduction was only mentioned by Duman et al., and it was 9 ml (range 5–15) when they compared it with open reduction blood loss, which was 35 ml (range 15–55) ml8.
3.4 Post-operative protocol
Ten studies specified post-operative protocols,9,10,16–23 mainly involving a spica cast in a flexed and abducted position for three months, as shown in Table 3.
3.5 Reported outcomes and complications
The patient-reported outcome scores used in the studies included in this systematic review were acetabular index, central rim angle, safe zone of dislocation, medialization rate of the femoral head, percentage of head coverage and Severin or McKay classification.
Five studies showed residual acetabular dysplasia in 14 patients among those studies at the last follow-up.8,17,18,20,22 Of the 195 hips included in this review, 22 (11.3 %) hips showed avascular necrosis of the head. Most of them were grade II. Recurrence of either subluxation or dislocation occurred in 16 (8.2 %) patients only in three studies.17,19,20 Secondary procedures such as acetabular or femoral osteotomies were needed in 58 (29.7 %) patients reported in 7 studies.8,17–20,22,23
The success rates of the arthroscopic reduction of DDH in the included studies ranged from 70 % to 100 %. The surgery results and complications during follow-up for each study are presented in (Table 4).
| Authors (year) | Pre operative outcomes | Final outcomes | RAD (%) | Head AVN (%) | Success (%) | Recurrence rate | Complication (pts) | Secondary procedures |
| Duman et al. (2019)9 | AI 38° (28°–44°) | AI 27° (19°–36°)McKay 6 Grade I, 6 Grade II head coverage 80 % (50–100) | 0 | 2 grade II (7 %) | 93 % | 0 | 0 | 0 |
| Eberhardt et al. (2012)21 | AI 35.5° (30°–40°) | AI 23.3° (17°–28°) | 0 | 3 (37.5 %) | 70 % | 0 | 0 | 0 |
| Eberhardt et al. (2015)22 | AI infancy 36.5° (30°–46°), walking 40°(34°–47°) | AI Infancy 23.3° (17°–28°)AI Walking 20.2° (11°–27°) | 2 (8 %) | 1 (10 %) | 90 % | 0 | 0 | Pemberton acetabuloplasty (9) |
| Eberhardt et al. (2014)23 | AI 40° (34°–47°) | AI 18.7° (11°–27°) | 0 | 2 grade II (22 %) | 80 % | 0 | 0 | Salter acetabuloplasty (9) |
| Feng et al. (2019)16 | Safe zone 18.5° (10–30°)AI 37.5° (30–52°)Medialization 72 % (34–128) | Safe zone 53.5° (45–60°) | 0 | 0 | 100 % | 0 | 0 | 0 |
| AI 25° (19–40°) | ||||||||
| Medialization 141 % (85–176) | ||||||||
| Kitano et al. (2010)17 | / | Severin I 7, II 2, IV 1 | 2 (18 %) | 2 grade I (18 %) | 70 % | 1 (9 %) | Ossification (1) | Salter's innominate osteotomy (2) |
| Öztürk et al. (2013)18 | AI 39.9°(34°–52°) | AI 26.0° (22°–34°) | 2 (22 %) | 1 grade I (11 %) | 89 % | 0 | 0 | Salter innominate osteotomy (1) |
| Presch et al. (2019)8 | AI 37.4° (30°–55°) | AI 23° (range 11°–34°) | 4 (23.5 %) | 1 (6 %) | 94 % | 0 | Anemia (1) | Reduction with concomitant osteotomies (6) |
| Xu et al. (2016)19 | AI 43.8° (31°–55°) | AI 29.5° (22°–41°)Severin I 27, II 10, III 4, IV 3 (good rate 84.1 %).McKay Excellent 35, Good 9 | 0 | 4 Grade II (9 %) | 91 % | 4(9 %) | 0 | Pemberton acetabuloplasty 19 (26 hips)Varus osteotomy 1 hip |
| Zhang et al. (2024)20 | Safe zone 17.7° ± 5.7° (10°–30°)AI 38° ± 3.6° (32–45) | Safe zone 40.9 ± 6° (30–50°)AI 23.7 ± 4° (15–34)CEA 21 ± 3.4° (17–34)McKay Excellent 30 (63.8 %) good 15 (32 %), fair 2 (4.3 %) | 4 (8.5 %) | 2 grade I (4.3 %)3 grade II (6.4 %)1 grade III (2.1 %) | 81 % | Redislocation 4 (6.9 %)Subluxation 7(12 %) | 0 | Capsulorrhaphy, pelvic osteotomy and femoral shortening (7)Pelvic osteotomy and femoral shortening (4) |
| Zhao et al. (2017)10 | safe zone 17.5° (8- 30)AI 40.3° (33–65) | safe zone 42.1° (36°–50°)AI 21.9° (19°–26°) | 0 | 0 | 100 % | 0 | 0 | 0 |
4 Discussion
The most important finding of this systematic review is that, in selected cases, arthroscopic-assisted reduction in DDH shows good clinical and radiological outcomes without increasing the risk of AVN or other complications.
The indications for hip arthroscopy as primary treatment in pediatric settings continue to grow. In patients with DDH, capsular constriction, hypertrophied pulvinar tissue, hypertrophied ligamentum teres and strained transverse ligament are the most common reasons for the failure of a closed reduction.24 To identify which structure obstructs the reduction, the release must be performed in the following order: start with the ligamentum teres, then proceed with excision of the pulvinar and finally resect the transverse ligament. The capsular release is only performed if the reduction is still impossible.22 All intra-articular structures that block the reduction can be removed with the arthroscopic technique.
Generally, the arthroscopic technique is well known for its minimally invasive nature, a quality that becomes even more important in pediatric patients.18 The advantages of this procedure include the absence of surgical dissection of the joint capsule, minimal blood loss and reduced incisions with acceptable residual scars.25 In this systematic review, 29 patients (17 %) had irreducible bilateral DDH. Another valuable aspect of arthroscopic surgery is that bilateral disease can be safely operated on in a single surgical session.
The main disadvantages are the limited exposure and accessibility of the joint space, limited possibility to address the postero-superior capsular insufficiency and the high technical difficulty, which requires experience in both pediatric surgery and hip arthroscopy. In addition, surgical devices are often a limitation of this technique. Still, studies show that a 2.7-mm cannulated system allowed safe portal placement even in children younger than eight months.21
Damage to nerves and blood vessels is a possible complication. The obturator nerve and the medial femoral circumflex artery may be damaged through the medial portal, resulting in avascular necrosis of the acetabulum and femoral head.19 Eberhardt et al. published a detailed analysis of the obstacles to arthroscopic reduction and the order in which they must be overcome.22 According to their experience, intra- or extra-articular release of the joint capsule to perform a tenotomy of the iliopsoas muscle should be avoided because of the proximity to anatomical structures and to reduce the risk of blood vessel injury.
In our systematic review, this procedure was not performed in any cases. Some authors propose routine iliopsoas tenotomy to reduce the risk of AVN.16,18 However, there is insufficient evidence on the effects of ileo-psoas tenotomy. All authors agree that the release of the inferior capsule must be performed with care because of the proximity of the circumflex artery. In all cases, if necessary, the capsule release was performed more antero-superiorly.8
In our systematic review, the success rates of arthroscopic DDH reduction in the included studies ranged from 70 % to 100 %. However, the true success of any technique for DDH reduction depends on the incidence of complications, and open reduction reports a higher risk of AVN, reaching 69 %, especially with the medial approach, as the medial circumflex artery is particularly dangerous.26–28 Our systematic review detected a median AVN rate was 10.2 % ± 10.4, ranging from 0 % to 37.5 %.
Other possible complications are redislocation, persistent dysplasia with subsequent pain, limitation of range of motion (ROM), anatomical bone deformity and subsequent need for pelvic osteotomy.24 In our systematic review, recurrence of subluxation or dislocation occurred in 16 (8.2 %) patients. Secondary procedures, such as acetabular or femoral osteotomies, were necessary in 58 (29.7 %) patients.
To reduce this risk, achieving reduction as early as possible is essential. A deep, concentric reduction that allows proper dynamic force distribution is the most important prognostic factor for the anatomical and complete development of the hip joint. There is no consensus on the best age for surgery; however, it is generally accepted that it is preferable before 18 months.8 Children operated on before one year of age seem to have a better chance of achieving normal acetabular development.22 In our systematic review, the median age was 12.7 ± 5.6 months, ranging from 3 months to 3.4 years. Eberhardt et al.22 and Presch et al.8 treated younger cases (around three months), describing technical difficulties in using the surgical devices.
Regarding arthroscopic portals, most authors used sub-adductor and anterolateral portals, except for Kitano et al. and Öztürk et al., who used an anteromedial portal.17,18 In only one study, nine patients (mean age 21 months) were treated with arthroscopic hip reduction combined with an open acetabuloplasty.23
We recognize several limitations of this study that need to be highlighted: Few articles were analyzed, most of them retrospective and with small sample sizes. Several biases could influence the results, such as heterogeneity of patient characteristics, differences in the surgical team's experience, and different follow-up periods with different post-operative protocols. The absence of a control group with an open technique prevents an accurate comparison of success and complication rates. A more homogeneous study, including a comparison group and a standardized procedure, could improve the validity of the data.
Therefore, it is essential to interpret the results cautiously and consider further high-quality research to confirm the results obtained in this systematic review.
5 Conclusions
Arthroscopic-assisted reduction of DDH can be considered an effective method to improve the treatment of hip dysplasia in children in selected cases. If performed by a surgeon with a high level of experience in both pediatric surgery and hip arthroscopy, it shows good clinical and radiological results without increasing the risk of avascular necrosis or other complications.
Informed consent
Not applicable.
Availability of data and materials (data transparency)
Dataset analyzed in this study is available from the corresponding author on reasonable request.
Code availability (software application or custom code)
Not applicable.
Authors’ contributions
RGV, AE, and AA have contributed substantially to conception and design, data acquisition, analysis, and interpretation. They have been involved in drafting the manuscript and revising it critically for important intellectual content, given final approval of the version to be published. They agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved, AC, MG and SE have contributed substantially to the data analysis, interpretation, and manuscript drafting. AA and AM have made substantial contributions to the concept and design of the manuscript and revising it critically for important intellectual content.
Funding
There is no funding source.
Ethical statement
Not applicable.
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