During the follow-up, few major complications were recorded in Group I. None of the hips developed stiffness or redislocation or ischemic necrosis of the femoral head attributed to index surgery. Only 1 child had to receive subsequent surgery of acetabular augmentation due to residual subluxation following Dega osteotomy. In Group II, 4 poor outcomes with several complications were recorded: residual hip subluxation in 3 hips and avascular necrosis (AVN) in 1 hip. Those hips were subsequently converted to subsequent operation of reefing of joint capsule and/or slotted acetabular augmentation procedure. Persistent pain was encountered in 2 hips, indicating progression of arthritis and possible requirement of total hip replacement. And another hip required a subsequent revision of distal transfer of the greater trochanter.
The efficiency of surgical treatments combined with repair of articular cartilage defects using periosteal autografts for DDH in older children and outcomes after surgery were assessed in this study. The most important novel findings may be that when surgical reduction were chosen to be performed for older DDH children after delayed diagnosis or late presentation of syndromes, repair of articular cartilage defects using periosteal autografts during surgical reduction could be indicated and performed to successfully prevent stiffness, reduce pain and improve ROM and outcomes in the early phase of rehabilitation and long-term follow-up observation.
Surgical intervention to reduce the displaced hip in children aged over 8 years is still controversial. With more complex pathomorphological changes in dysplastic hips, the management of neglected DDH in older children is perplexing and challenging. In general, it is accepted that the ease of treatment and the outcome are inversely related to the age at presentation. Many surgeons recommended that it would be better to forgo surgery for older children with dislocated hips before adulthood34 and have hip joint replacement after adulthood. However, if treated negatively, DDH would develop pain limp, hip stiffness, and finally progressive arthritis and disability. Some of the older DDH children would ultimately have to receive total hip arthroplasty even during young adulthood and often more than once during one's lifetime, depending on the severity of the osteoarthritic changes and pain or limitation of motion of the hip they suffer from. This would yield a tremendous social, economic, physical, and emotional impact on older children and their family.
In recent years, researches of the interaction of hip diseases and cartilage lesions are in a rapidly evolving and growing period. It has been demonstrated that cartilage defects are moderately common in dysplastic hips3–6 and proved to be highly correlated with hip pain, stiffness, and dysfunction in movement and function.6–11 Repair of cartilage defects in the hip has been reported to yield good clinical and radiologic outcomes through osteochondral7 or chondrocyte35 transplantation. To date, however, a systematic evaluation of the improvement in functionality, physical health, quality of life, and tolerability in association with the cartilage repair after transplantation of periosteal autografts has not yet been performed in dysplastic hip in older children. Given that free periosteal grafts transplantation has the capacity to differentiate into cartilage,36,37 this clinical study on the effects of periosteal transplantation in hip rehabilitation in older children with DDH was implemented.
The optimal management of DDH might be early diagnosis, less invasive, and more effective procedures to achieve a stable and concentrically located joint and satisfactory development of the hip in the majority of cases at an early age. However, neglected DDH in older children appears to be constantly at a modestly high prevalence because of late or missed diagnosis, or late presentation of syndromes. Dysplastic hips naturally progress to osteoarthritis in this age patients. When surgical therapy is required because of osteoarthritic progression, the degree of preoperative osteoarthritic involvement plays a decisive role on the consequences of pelvic osteotomy surgery.38 Thus, early management of any cartilage abnormalities is important when considering osteoarthritic development and surgical therapy.6 Generally, the choice of treatment for large cartilage defects depends on a number of factors, including patient's preference, physician's expertise, and the cost of the procedure.39 To adapt the periosteum transplantation for articular cartilage defects, several advantages have been acknowledged. This tissue meets the 3 primary requirements for tissue engineering: a source of cells, a scaffold for delivering and retaining them, and a source of local growth factors. When transplanted into osteochondral articular defects, it has the capacity of producing cartilage to restore the articular cartilage and being replaced by bone in the subchondral region. The succedent research priorities lie in investigating the mechanism of periosteal chondrogenesis at the cellular and molecular levels to optimize its application for cartilage repair and regeneration.40
In the hip, due to the restricted joint space, access to the joint is difficult. Exposure of cartilage defects on the femoral head and acetabulum is extremely hard in terms of overall view. This is critical because transplants need further fixation by suture or adhesives. Thus arthrotomies and incision of periosteum are required for approaching the defects, putting the patient at a high risk of postoperative complications and prolonged recovery time. When it comes to patients with dysplastic hips which would be reduced by surgical management, this surgery turns out to be an advantage for exposure and repair of articular cartilage defects during surgical reduction for older DDH children.
Among patients treated with combined acetabuloplasty and ATPT, pain was markedly reduced and hip ROM was improved in all hips including the 2 previously stiff hips during daily life activities. At latest follow-up, higher percentage of patients in Group I had a minimum of 80° of flexion with 20° of adduction–abduction and rotation and all except 2 patients were ambulating without assistive devices. No major concerns but one child developed residual subluxation and required subsequent acetabular augmentation. All children except one continued to function well. All hip showed good congruency between the femoral head and the shell during the visits to outpatient clinic, apart from radiographic sighs of slightly reduced articular space on one hip. The Shenton line kept continuity in most hips. All these results indicate that a very satisfactory functional and radiological outcome could be readily achieved in this older age group of DDH children. In terms of pain relief and improvement of hip function, the periosteal transplantation for articular cartilage defects in older children with DDH seems to be a reasonable adjunctive treatment option for surgical reduction.
Admittedly there are several limitations in our study. Little has been fully elucidated about the exact mechanisms by which periosteal autograft results in clinical improvement in hip rehabilitation. Besides, although there is no consensus statement on the influence of defect size on postoperative outcome, the distribution and size of the defects differ from case to case. A subsequent larger-scale randomized controlled clinical trial and experimental mechanism research at the cellular and molecular levels are needed to address these concerns.
In summary, data from this study would demonstrate that, application of periosteal autograft for the repair of cartilage defects within the hip joint as an adjunctive treatment during surgical reduction procedures in hip rehabilitation might be effective in preventing stiffness, reducing pain and improving ROM and outcomes in the long-term follow-up in older children with DDH. It could be considered as a salvage procedure to hip management in this older and difficult-to-treat group of DDH children.
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