Vergleich von arthroskopischer und offener Repositionsmethode bei konservativ irreponibler Hüftluxation im Kindesalter

The focus of this retrospective observational study was to answer the question to what extent arthroscopic reduction is a possible alternative to the established open procedure. This study confirmed the assumption that promising treatment results can be achieved with the arthroscopic procedure. In addition to a stable and centered reduction of the femoral head, the primary goal of the treatment of patients with dislocation of the hip should be to avoid complications such as femoral head necrosis. Further consequences such as the persistence of residual dysplasia and dislocation have a negative effect on the further development of the child through additional interventions and significantly prolong the course of treatment. A detailed discussion of the risk factors for the development of femoral head necrosis, residual dysplasia and dislocation has been included in the present study. In the present study 78 patients were observed. Each of these patients has at least one hip joint with grade IV hip dysplasia according to Graf at the first outpatient examination in the Olga Hospital in Stuttgart and a conservative treatment concept was unsuccessful. Only patients not older than 2 years at the first surgical reduction were included. After evaluation of the patient documentation, radiological measurements were taken preoperatively, one year and two years after the operation. Binary logistic regression was used for the statistical analysis of the data. There were no comparable studies in the literature of patients with grade IV hip dysplasia according to Graf. A femoral head necrosis (grade III and grade IV according to Tönnis) developed 24 % of all hip joints. Redislocation was documented in 25 % of the hip joints within the two-year observation period. A residual dysplasia was found in 54 % of the hip joints due to a lack of femoral head cover. By comparing the 19 arthroscopically and 78 openly reduced hip joints using binary logistic regression, it was discovered that in two of the three target variables (dislocation, residual dysplasia, femoral head necrosis) an overall better treatment outcome was achieved in the arthroscopic group. After arthroscopic reduction, no redislocation were observed and residual dysplasia occurred significantly less frequently compared to the open surgical method. Thus, both an improvement in the dislocation tendency and better femoral head coverage was achieved by concentric and, in particular, more stable centering of the hip joint. In contrast, femoral head necrosis was detected more frequently with the arthroscopic procedure. After arthroscopic reduction, no matter being the dislocation a primary teratologic or secondary congenital, hip dislocation was of particular importance. The probability of developing femoral head necrosis was significantly increased in patients with a teratological dislocation of the hip. The poorer result observed in the arthroscopic group could be attributed exclusively to the treatment of teratologic hip joints. A missing psoastenotomy in the course of arthroscopic reduction could be the primary cause for this. As a consequence of this work, children with non-teratologic dislocation of the hip should continue to be operated on arthroscopically, due to the better centering of the femoral head and the associated lower dislocation and reduced residual dysplasia and necrosis of the femoral head. On the other hand, in the case of teratological dislocations of the hip, the arthroscopic surgical method should be abandoned until a soft tissue management comparable to the open procedure can be guaranteed. This should be a procedure that can be used to sever the psoas tendon. However, the results of the present work should be evaluated with caution, as this work has some limitations. A variety of preoperative, intraoperative and postoperative risk factors (disturbances) can influence the results. They are partly controversially discussed in the literature and have also been considered in this paper. Further limitations are due to existing bias and false correlations (e.g. with regard to femoral head necrosis caused by the inclusion of teratologic dislocation). The heterogeneous and small patient collective, a short observation period of 2 years and a patchy data situation due to missing radiographs and patient documentation also reduce the significance of this work. The results presented here provide a first contribution to the comparison of the new arthroscopic and older open reduction method in patients with severe dislocation of the hip. The results can be regarded as a starting point for further scientific investigation.