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With a 2007 research grant from the Orthopaedic Research and Education Foundation (OREF), James W. Roach, MD, is investigating whether patient selection factors that optimize long-term results may help target the elusive ideal age for surgical correction of developmental dysplasia of the hip (DDH) (Fig. 1).

AAOS Now

Published 8/1/2011
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Sally T. Halderman

What would Hippocrates do about DDH?

By Sally T. Halderman

OREF grant recipient wants to know when surgical reduction results begin to deteriorate

The concept of “first do no harm” is central to the Hippocratic Oath embraced by every physician. But in a world of increasingly complex treatments and subtle risk-to-benefit calculations, it may be difficult to know where that Hippocratic bar is set.

James W. Roach, MD

Dr. Roach aims to discover the maximum age for a child’s hip joint to remodel itself into a perfect sphere. Beyond this age, the matured joint will not remodel properly. A hip joint that’s less than perfectly round predisposes patients to future joint degeneration and osteoarthritis, sometimes as early as in their 20s. Uncorrected hip dysplasia leaves patients with a limp, may cause pain, and also increases future risk of osteoarthritis. Arthritis develops in about half of patients with untreated DDH by their 40s.

Dr. Roach’s OREF-supported investigation seeking to clarify these issues, “Long-term Follow-up of Open Reduction Surgery in Developmental Dysplasia of the Hip,” is one of the largest studies to date with a long follow-up horizon.

“During my 30 years as a pediatric orthopaedic surgeon, I’ve developed a special interest in exploring whether there’s solid evidence that our traditional interventions actually help patients in the way we intend,” said Dr. Roach. “Today, we have limited evidence for deciding how old is too old for open DDH surgery. Is it age 4? Age 7? We just don’t know.”

The study also aims to document whether DDH that is severe enough to require open surgery inevitably results in a joint that won’t last as long as a normal hip.

“Even under the best of circumstances, these joints may just have a shorter life expectancy,” Dr. Roach said.

A common condition, a range of solutions
DDH is a spectrum of common abnormalities of the immature hip joint in which the head of the femur doesn’t sit firmly within the acetabulum. In mild cases, ligaments holding the femur in place may be stretched or loose. More severe cases involve hip subluxation or full dislocation.

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With a 2007 research grant from the Orthopaedic Research and Education Foundation (OREF), James W. Roach, MD, is investigating whether patient selection factors that optimize long-term results may help target the elusive ideal age for surgical correction of developmental dysplasia of the hip (DDH) (Fig. 1).
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Fig. 1 Radiograph of a child with developmental dysplasia of the hip. Note that the hip is fully dislocated.
Courtesy of James Roach, MD

DDH may be present at birth or become worse as a child matures and grows more active. When diagnosed in a newborn, DDH can usually be treated with a Pavlik harness, a soft leg-positioning device that the baby wears for a few months to promote normal hip joint formation. The harness may also work in older infants, but sometimes the femur must be manipulated into proper position by a surgeon while the baby is under anesthesia. After babies with DDH reach 12 months of age, the likelihood increases that surgeons will need to reposition the hip during open surgery.

Tracking outcomes to guide treatment
To shed light on factors affecting the long-term impact of corrective DDH surgery, Dr. Roach and his research team are reaching out to 148 patients who had open procedures between 1955 and 1995 at Shriners Hospital for Children–Salt Lake City.

Shriners Hospitals provide treatment at no charge for pediatric patients with orthopaedic conditions, burns, spinal cord injuries, and cleft palate. The good will created by providing free care has helped drive interest in Dr. Roach’s study—most patients contacted have agreed to participate.

When patients return for follow-up, radiographs are taken to assess the current status of their hips. Patients also complete the hip and knee outcomes questionnaire developed by the AAOS and several other orthopaedic specialty societies, as well as other questionnaires to evaluate their levels of mobility, pain, disability, and stiffness. These evaluations will provide the most robust evidence to date about long-term outcomes and may suggest a cutoff age for attempting surgical DDH correction.

Dr. Roach’s OREF-funded work has spurred additional grant applications to the Shriners Research Foundation to support further exploration of the impact of family history on the incidence of DDH, subclinical hip abnormalities and arthritis, and genetic factors that may be implicated.

Problem-solving, teaching, and philanthropy
Dr. Roach’s greatest professional satisfactions include his commitment to clinical problem-solving; teaching residents, fellows, and colleagues from U.S. organizations and other countries, including Iraq and Iran; and supporting organizations like OREF that nurture research to move the field forward.

“Over a lifetime of learning and teaching, I’ve seen time and again how important OREF funding can be for young physicians who are considering a clinician-scientist career path,” Dr. Roach noted. “In many academic settings, getting that first grant is a critical first step to obtaining future funding. Now, I have firsthand experience of the importance of OREF’s support in pursuing a new line of investigation and establishing its credibility with other funding bodies.

“I’ve been a member of the OREF Shands Circle for many years,” he continued. “I believe all physicians have a stake in clinical research because it’s such a big factor in improving quality of life for both us and our patients.”

Dr. Roach is a pediatric orthopaedic surgeon at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, where he leads a new partnership between Children’s Hospital and Shriners Hospital for Children–Erie. He formerly served as chief of staff at Shriners Hospital for Children–Salt Lake City. Dr. Roach was the 2010–2011 president of the Pediatric Orthopaedic Society of North America.

Disclosure information: Dr. Roach—Kuwait Medical Journal

Sally T. Halderman is a contributing writer for OREF and can be reached at communications@oref.org