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The Effect of the Femoral Head Ossific Nucleus in the Treatment of Developmental Dysplasia of the HipA Meta-Analysis
Andreas Roposch, MD, MSc, FRCS1; Kuldeep K. Stöhr, MBBS, FRCS1; Michael Dobson, MBBS, MSc, FRCS1
1 Department of Orthopaedic Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, United Kingdom. E-mail address for A. Roposch: a.roposch@ich.ucl.ac.uk
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Arthritis Research Campaign, UK. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Great Ormond Street Hospital for Children, and the Institute of Child Health, University College London, London, England

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Apr 01;91(4):911-918. doi: 10.2106/JBJS.H.00096
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Abstract

Background: The role of the presence of the femoral head ossific nucleus as a risk factor for the development of osteonecrosis of the femoral head in infants with developmental dysplasia of the hip has been investigated in several small studies, but the results have been inconsistent. The purpose of the present study was to determine the effect of the presence of the ossific nucleus on the development of osteonecrosis.

Methods: A systematic review of the medical literature from 1966 to 2007 was performed. Two independent reviewers evaluated all articles. Interrater agreement was determined, and the quality of evidence was evaluated. A meta-analysis was then performed with the main outcome defined as the development of osteonecrosis of the femoral head two years after reduction.

Results: Six observational studies (five retrospective and one prospective) met the inclusion criteria. Inconsistency was found in that half of the studies demonstrated a protective effect of the ossific nucleus on the development of osteonecrosis whereas half of the studies did not. A meta-analysis (including 358 patients) showed no significant effect of the presence of the ossific nucleus on the development of grades-I through IV osteonecrosis, with forty-one cases of osteonecrosis (19%) found in infants in whom the ossific nucleus had been present at the time of hip reduction compared with thirty cases (22%) in the group without an ossific nucleus (relative risk = 0.75, 95% confidence interval = 0.46 to 1.21). When only radiographic changes of grade II or worse were considered to represent osteonecrosis, a significant difference in the prevalence of osteonecrosis was found, with fourteen cases of osteonecrosis (7%) in infants with an ossific nucleus compared with eighteen cases (16%) in those without an ossific nucleus (relative risk = 0.43, 95% confidence interval = 0.20 to 0.90). A subgroup analysis showed that the presence of the ossific nucleus reduced the probability of osteonecrosis by 60% (relative risk = 0.41, 95% confidence interval = 0.18 to 0.91) after closed reduction, but no significant effect was found in patients treated with open reduction (relative risk = 1.14, 95% confidence interval = 0.62 to 2.07). All studies demonstrated methodological weaknesses compromising the quality of evidence.

Conclusions: We did not find that the presence of the ossific nucleus had a significant effect on the development of osteonecrosis of any grade after hip reduction in infants with developmental dysplasia of the hip. The meta-analysis suggested that the presence of the ossific nucleus has a protective effect against the development of the more severe forms of femoral head osteonecrosis. However, the quality of evidence is moderate, and additional research is likely to have an important impact on the confidence in the estimate of the effect and may change this estimate.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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