Treatment of decentered developmental dysplasia of the hip under the age of 1 year: an evidence-based clinical practice guideline - Part 2.

Background and purpose: Diagnostics and treatment of developmental dysplasia of the hip (DDH) are highly variable in clinical practice. To obtain more uniform and evidence-based treatment pathways, we developed the 'Dutch guideline for DDH in children < 1 year'. This study describes recommendations for unstable and decentered hips. Materials and methods: The Appraisal of Guidelines for Research and Evaluation criteria (AGREE II) were applied. A systematic literature review was performed for six predefined guideline questions. Recommendations were developed, based on literature findings, as well as harms/benefits, patient/parent preferences, and costs (GRADE). Results: The systematic literature search resulted in 843 articles and 11 were included. Final guideline recommendations are (i) Pavlik harness is the preferred first step in the treatment of (sub) luxated hips; (ii) follow-up with ultrasound at 3-4 and 6-8 weeks; (iii) if no centered and stable hip after 6-8 weeks is present, closed reduction is indicated; (iv) if reduction is restricted by limited hip abduction, adductor tenotomy is indicated; (v) in case of open reduction, the anterior, anterolateral, or medial approach is advised, with the choice based on surgical preference and experience; (vi) after reduction (closed/open), a spica cast is advised for 12 weeks, followed by an abduction device in case of residual dysplasia. Interpretation: This study presents recommendations on the treatment of decentered DDH, based on the available literature and expert consensus, as Part 2 of the first official and national evidence-based 'Guideline for DDH in children < 1 year'. Part 1 describes the guideline sections on centered DDH in a separate article.

Treatment of centered developmental dysplasia of the hip under the age of 1 year: an evidence-based clinical practice guideline - Part 1.

Despite the high incidence of developmental dysplasia of the hip (DDH), treatment is very diverse. Therefore, the Dutch Orthopedic Society developed a clinical practice guideline with recommendations for optimal and uniform treatment of DDH. This article summarizes the guideline on centered DDH (i.e. Graf types 2A-C). The guideline development followed the criteria of Appraisal of Guidelines for Research and Evaluation II. A systematic literature review was performed to identify randomized controlled trials and comparative cohort studies including children <1 year with centered DDH. Articles were included that compared (1) treatment with observation, (2) different abduction devices, (3) follow-up frequencies, and (4) discontinuation methods. Recommendations were based on Grading Recommendations Assessment, Development, and Evaluation, which included the literature, clinical experience and consensus, patient and parent comfort, and costs. Out of 430 potentially relevant articles, 5 comparative studies were included. Final guideline recommendations were (1) initially observe 3-month-old patients with centered DDH, start abduction treatment if the hip does not normalize after 6-12 weeks; (2) prescribe a Pavlik harness to children <6 months with persisting DDH on repeated ultrasonography, consider alternative abduction devices for children >6 months; (3) assess patients every 6 weeks; and (4) discontinue the abduction device when the hip has normalized or when the child is 12 months. This paper presents a summary of part 1 of the first evidence-based guideline for treatment of centered DDH in children <1 year. Part 2 presents the guideline on decentered DDH in a separate article.

Productivity costs and medical costs among working patients with knee osteoarthritis.

OBJECTIVE: Although the knee joint is one of the joints most affected by osteoarthritis (OA), research on the economic implications of joint disease has generally focused only on OA. The goal of this study was to identify and quantify knee-related productivity and medical costs in knee OA patients with paid employment. Furthermore, we evaluated associations between productivity loss and relevant patient, health, and work characteristics. METHODS: Consecutive knee OA patients with mild to moderate knee OA who were 18-65 years of age, had conservative treatment for ≥6 months, and had paid employment were included. Productivity loss and health care consumption were measured by questionnaires. The associations between productivity loss and patient, health, and work characteristics were explored with regression analyses. RESULTS: In total, 117 knee OA patients with a mean age of 53.2 years and a mean body mass index of 28.8 kg/m(2) were included. Total knee-related productivity costs and medical costs were €871 (median €411, interquartile range [IQR] €107-1,200) per patient per month, with total productivity costs of €722 (median €217, IQR €0-1,041) and total medical costs of €149 (median €137, IQR €72-198). More pain during activity and performing physically intensive work were significantly associated with productivity loss. CONCLUSION: The total knee-related productivity costs and medical costs of conservatively treated symptomatic knee OA patients with paid employment in The Netherlands are €871 per patient per month, with productivity costs accounting for 83% and medical costs for 17%. Productivity loss is associated with having more pain during activity and performing physically intensive work. Developing adequate treatment strategies for knee OA may be cost beneficial.