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Comparison of transverse and modified subtrochanteric femoral shortening osteotomy in total hip arthroplasty for developmental dysplasia of hip: a meta-analysis.
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PMID:  25277218     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
BACKGROUND: Subtrochanteric femoral shortening osteotomy is a crucial procedure to prevent nerve injury in total hip arthroplasty for severe developmental dysplasia of the hip. Transverse osteotomy was first applied, and other modified methods have also been reported. Each has its own advantages and limitations, but no definitive conclusions regarding differences in outcomes have been reached to date.
METHODS: We therefore performed a comprehensive meta-analysis to compare the outcomes of different approaches. 37 studies (795 hips) were included in the final analysis. Meta-analysis, subgroup analysis and meta-regression were performed.
RESULTS: Meta-analysis and subgroup analysis showed no significant difference between transverse and modified method. This is further confirmed by meta-regression. Method of osteotomy was found to be not associated with nonunion rate (P = 0.472), as well as other post-operative outcomes including nerve palsy (P = 0.240), dislocation (P = 0.735), revision (P = 0.653) and Harris hip score improvement (P = 0.562). In addition, western countries (P = 0.010) and duration of follow-up more than 5 years (P = 0.0.014) were associated with higher revision rate.
CONCLUSIONS: Transverse osteotomy and modified osteotomy appear to be equivalent in terms of nonunion, safety and efficacy. Transverse osteotomy may be recommended, due to its simplicity and convenience in adjusting the anteversion angle. Well-designed and large-sample-size randomized controlled trials are expected to confirm and update the findings of this analysis.
Authors:
Changchuan Li; Chi Zhang; Maolin Zhang; Yue Ding
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2014-10-3
Journal Detail:
Title:  BMC musculoskeletal disorders     Volume:  15     ISSN:  1471-2474     ISO Abbreviation:  BMC Musculoskelet Disord     Publication Date:  2014 Oct 
Date Detail:
Created Date:  2014-10-3     Completed Date:  -     Revised Date:  2014-10-4    
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Nlm Unique ID:  100968565     Medline TA:  BMC Musculoskelet Disord     Country:  -    
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Languages:  ENG     Pagination:  331     Citation Subset:  -    
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Journal ID (nlm-ta): BMC Musculoskelet Disord
Journal ID (iso-abbrev): BMC Musculoskelet Disord
ISSN: 1471-2474
Publisher: BioMed Central, London
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© Li et al.; licensee BioMed Central Ltd. 2014
open-access:
Received Day: 11 Month: 6 Year: 2014
Accepted Day: 29 Month: 9 Year: 2014
Electronic publication date: Day: 3 Month: 10 Year: 2014
pmc-release publication date: Day: 3 Month: 10 Year: 2014
collection publication date: Year: 2014
Volume: 15 Issue: 1
E-location ID: 331
PubMed Id: 25277218
ID: 4201680
Publisher Id: 2280
DOI: 10.1186/1471-2474-15-331

Comparison of transverse and modified subtrochanteric femoral shortening osteotomy in total hip arthroplasty for developmental dysplasia of hip: a meta-analysis
Changchuan LiAff4 Address: 635710258@qq.com
Chi ZhangAff4 Address: 50039979@qq.com
Maolin ZhangAff4 Address: 84208406@qq.com
Yue DingAff4 Address: profdingyue@163.com
Department of Orthopaedic Surgery, Sun Yat-sen Memorial Hospital, No.107 on Yanjiangxi Road, Yuexiu District, 510120 Guangzhou, Guangdong China

Background

Developmental dysplasia of the hip (DDH), formerly defined as congenital dislocation of the hip, is one of the most common neonatal deformities that may have significant influence on the life quality of patient [1]. Its incidence is estimated to be 3 to 5 per 1000 hips, which is clouded by the absence of definitive diagnostic criteria and the wide range of mild to severe anatomical variations that fall within the spectrum of DDH [2]. Although several options exist including proximal femoral and periacetabular osteotomies, total hip arthroplasty (THA) remains the standard treatment in end stage DDH, predominantly Crowe type IV in Crowe classification [3] or high dislocation DDH in Hartofilakidis classification [4], which leads to significant pain and loss of function [5].

Severely dysplastic hips present challenging surgical problems. The formation of a false acetabulum superior to the true acetabulum may lead to the need of leg lengthening, during the operation to get the center of rotation more anatomically [3, 6]. However, leg lengthening over 3–4 cm is associated with an increased risk of sciatic nerve injury [7]. Femoral shortening osteotomy has become a standard approach to avoid nerve injury [8]. Compared with great trochanter osteotomy, subtrochanteric femoral shortening has been more commonly used, because it has lower nonunion rate of osteotomy [9], and preserves the proximal femoral metaphysis, and thus allows for correction of rotation and the use of an uncemented femoral component [10]. On the other hand, it also provides correction of the excessive anteversion and lateral location of the abductor lever [1012].

There are various techniques for subtrochanteric femoral shortening osteotomy, in attempt to decrease nonunion of osteotomy, which is one of the most commonly reported complications [6]. Transverse subtrochanteric femoral shortening osteotomy was first performed in THA for DDH patients. Subtrochanteric femur was transversely dissected to remove the excessive length, and the both ends of osteotomy were connected (Figure 1a). Due to the centrosymmetry of intersecting surface, adjustment of the two fragments of transverse osteotomy during the surgery is possible, when the initial alignment is not ideal [13]. This is important for the correction of femoral anteversion, the most common and one of the most important anatomic abnormalities caused by DDH [6, 10, 14], which is correlated with postoperative hip function [14].

However, the centrosymmetry of intersecting surface in turn increases the rotational instability, which in combination with a smaller surface contact might lead to nonunion of the osteotomy [9]. Step-cut [15], oblique [14], and chevron type [16] subtrochanteric femoral shortening osteotomies, which we categorize as “modified osteotomy”, were introduced in attempt to enhance the rotational stability of the osteotomy, and to reduce the risk of rotational instability and non-union [17]. Compared with transverse osteotomy, the osteotomy lines are step-cut, oblique and double-V-shaped, respectively (Figure 1b-1d). So they were expected to have lower nonunion rate of osteotomy. Many researchers have published their results and opinions on this issue, but few of them conducted a head-to-head comparison. Moreover, single clinical trials are often underpowered and lack generalizability [18]. Up to date, no definitive conclusions regarding differences in outcomes have been reached. We therefore systemically searched the literatures currently available, and performed a comprehensive meta-analysis to compare the outcomes of the two methods.


Methods
Data source

We searched PubMed, Embase and Cochrane Library up to August, 2014 for literatures which focused on subtrochanteric femoral shortening osteotomy for DDH and specified the method of osteotomy and the outcomes, using the following terms: ((((((congenital) OR developmental)) AND hip) AND (((dysplasia) OR dislocation) OR dislocations))) AND ((subtrochanteric) AND ((osteotomy) OR osteotomies)) (see Additional file 1). There was no restriction to regions or languages. The computer search was supplemented with manual searches of the reference lists of all retrieved literatures. When there were two or more reports describing the same population, the most recent or complete version was involved.

Study eligibility and selection

The studies have to meet the following pre-determined inclusion criteria:

  1. It investigated the subtrochanteric femoral shortening osteotomy in the surgical treatment of DDH, and short- and long-term outcomes of the surgery.
  2. It provided data that allowed for quantitative analysis.
  3. It had been published or accepted for publication.

Literatures that failed to meet the inclusion criteria were excluded. Besides, our exclusion criteria included:

  1. Case report or review;
  2. Not clinical studies (e.g. biomechanical);
  3. Data of interest are not clear, and couldn’t be obtained by contacting the authors;
  4. Duplicated data.

Two reviewers (C. Li and M. Zhang) independently evaluated the eligibility of involved studies. Discrepancies between evaluators were resolved by discussion or consultation with the corresponding author (Y. Ding).

Data abstraction

Study characteristics were retrieved including author, year of publication, country, demographics of the population, method of subtrochanteric femoral shortening osteotomy, duration of follow-up, and union of the osteotomy sites. Data were extracted independently and in duplicate by both reviewers (C. Li and C. Zhang). Discrepancies between evaluators were resolved by discussion or consultation with the corresponding author (Y. Ding).

Outcomes of interest

The following outcomes were used to compare transverse and modified subtrochanteric osteotomy:

Primary outcomes

  1. Nonunion (permanent failure of bone healing without treatment, usually identified at 8 months postoperatively). In consideration that delayed union might also require a revision surgery sometimes, like the case of nonunion, we also included delayed union that required a revision surgery into the category of nonunion.
  2. Nerve palsy (transient or permanent, predominantly caused by stretching, could happen to sciatic nerve, femoral nerve, and occasionally to peroneal nerve).

Secondary outcomes

Dislocation (early or recurrent), revision (due to all causes), leg-length discrepancy (average leg-length discrepancy, and discrepancy within ideal range, which was defined as 0-2 cm), Harris hip score (HHS) improvement (proportion of the difference between post- and pre-operative HHS in the post-operative HHS) and deep infection.

Statistical analysis

This meta-analysis was performed according to the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses [19]. Raw rates of outcome events were calculated in each study. As the inverse variance weight in fixed-effect meta-analysis is suboptimum when dealing with binary data with low probability, the variances of the raw rates were stabilized using Freeman-Tukey double-arcsine transformation [20]. In the meantime, the double-arcsine transformation could avoid the situation where the rate and standard error of a certain outcome is zero, which is not allowed for meta-analysis. All outcomes were reported with 95% CIs. Wilson’s method was used to calculate the 95% CI of the estimated rate to construct the forest plot, because the asymptotic method may produce confidence intervals that extend below zero, especially when the rates are estimated to be low.

We estimated heterogeneity between studies with Cochrane’s Q (reported as χ2 and P values), which is calculated as the weighted sum of squared differences between individual study effects and the pooled effect across studies, and the I2 statistic, which describes the percentage of variation between studies that is due to heterogeneity rather than chance [21]. I2 values of 25%, 50% and 75% are taken to indicate low, moderate and high degrees of heterogeneity, respectively. When the I2 statistic didn’t exceed 50%, we selected the fixed effects model, which could achieve higher statistical power than random effects model. Otherwise, random effects model is adopted. Sensitivity analysis was carried out to judge the weight of each study. After the meta-analysis of transformed data, we inversed the pooled estimate and its 95% CI back to proportions [22]. Up to date, there is no widely accepted scoring system for assessing the methodological quality of observational studies with no control.

Potential sources of heterogeneity were explored further by meta-regression analysis. The factors investigated in meta-regression included method of osteotomy (by comparing transverse and modified osteotomy), country (by comparing western and eastern countries), mean age (as a continuous variable, and then by dichotomizing the studies by the median of 49 years), proportion of female patients (as a continuous variable, and then by dichotomizing the studies by the median of 93%), duration of follow-up (as a continuous variable, and then by dichotomizing the studies by the median of 5 years), and year of publication (by dichotomizing the studies by the median of the year 2010). Categorical variables were taken into meta-regression using dummy variables [23].

All analyses were performed using STATA statistical software package (Version 13.0, StataCorp, 2013) using the commands cii (to calculate Wilson CIs), metan (for meta-analysis), metareg (for meta-regression) and metabias (to assess the publication bias). Generally, a P value <0.05 was considered to indicate statistical significance (α = 0.05).


Results
Characteristics of eligible studies

37 studies (791 hips) were included in the final analysis (Figure 2). None of them was randomized controlled trial, case–control study or cohort study. The characteristics of the included studies are listed in Table 1. Agreement between the two reviewers was achieved.

Of the 37 studies enrolled in the meta-analysis, 10 were conducted in Europe [11, 12, 14, 15, 2429], 6 in the North America [7, 16, 3033], 1 in Australia [34], and the other 20 in Asia [9, 13, 17, 3551]. Female took the majority of the patients, and 9 studies were based on female patients exclusively.

Most researchers have used only one method of subtrochanteric osteotomy in their own studies, however, with two exceptions. Erdemli et al. [35] applied step-cut osteotomy in 3 hips, and transverse osteotomy in 22 hips. The other researcher, Dallari [14], performed step-cut osteotomy in 14 hips, and oblique osteotomy in 19 hips. These two studies were split in meta-analysis and meta-regression. The transverse group included 24 studies (550 hips), and the modified group included 15 studies (241 hips).

Primary outcomes
Nonunion

Pooled estimate of nonunion rate was 3.79% (95% CI 2.60%-5.20%). Heterogeneity among the studies was low (I2 = 14.5%). Data of nonunion were further analyzed in two subgroups (modified osteotomy and transverse osteotomy). Figure 3 showed the forest plot of subgroup analysis. There was no significant difference in nonunion rate between modified group and transverse group (Table 2).

Nerve palsy

Pooled estimate of nerve palsy rate was 2.63% (95% CI 1.60%-3.87%). Forest plot of meta-analysis was shown in Figure 4. According to Table 2, there was so little heterogeneity among the studies (I2<0.1%), that subgroup analysis was not necessary.

Secondary outcomes
Dislocation

Pooled estimate of dislocation rate was 5.88% (95% CI 4.22%-7.80%) Heterogeneity among the studies was moderate (I2 = 36.2%). Data of dislocation were further analyzed in subgroup analysis, and forest plot was constructed (Figure 5). No significant difference in dislocation rate was revealed between modified group and transverse group, and subgroup heterogeneity were not significantly less (I2 = 38.4% for modified subgroup and I2 = 38.5% for transverse subgroup) (Table 2).

Revision

Pooled estimate of revision rate due to all causes was 8.90% (95% CI 6.56%-11.50%). Heterogeneity among the studies was moderate (I2 = 43.3%). Data of revision were further analyzed in subgroups, and forest plot was constructed (Figure 6). As Table 2 indicated, no significant difference in revision rate was shown between modified group and transverse group.

Leg-length discrepancy

Only five studies provided related data on the number of patients who achieved ideal rage of leg-length discrepancy. Occurrence of discrepancy out of the ideal range was analyzed. Pooled estimate of occurrence was 6.31% (95% CI 2.90%-11.00%). Obvious heterogeneity existed among the studies (I2 = 67.2%). Subgroup analysis was carried out, revealing no significant difference between modified group and transverse group (Table 2).

HHS improvement

Average HHS in each of the eligible studies have elevated after the surgery. Heterogeneity among the studies was high (I2 = 96.5%). However, subgroup analysis revealed no significant difference between modified group and transverse group (Table 2).

Deep infection

Pooled estimate of deep infection rate was 1.34% (95% CI 0.46%-2.67%). There was so little heterogeneity among the studies (I2<0.1%), that subgroup analysis was not necessary (Table 2).

Sensitivity analysis

Sensitivity analysis was carried out by excluding each study in turn to ensure that no single study would be solely responsible for the heterogeneity of any result. The results were almost the same as those when all studies were involved.

Meta-regression

Univariate meta-regression analysis was carried out for outcomes of interest to explore potential influencing factors. Method of osteotomy was found to be not associated with nonunion rate (P = 0.472), as well as other post-operative outcomes including nerve palsy (P = 0.240), dislocation (P = 0.735), revision (P = 0.653) and Harris hip score improvement (P = 0.562) (Table 3).

Results of the meta-regression on revision rate indicated that western countries and longer follow-up (>5y) are associated with higher revision rate (Table 3).

Meta-regression analysis was not performed for leg-length discrepancy, due to limited quantity of eligible studies. Similarly, there was only one case of deep infection among all the involved studies, and thus meta-regression was not performed for deep infection.

Publication bias assessment

Begg’s funnel plots and Egger’s regression asymmetry tests were performed to investigate whether publication bias existed (Figure 7). All outcomes were distributed symmetrically in funnel plots, indicating no obvious publication bias. Egger’s regression asymmetry tests for nonunion, nerve palsy, revision, dislocation, leg-length discrepancy and HHS improvement showed no evidence of publication bias (P value was 0.380, 0.186, 0.714, 0.165, 0.524 and 0.393, respectively). P value of Egger’s test for deep infection was 0.044, indicating a potential publication bias.


Discussion

This meta-analysis included 15 studies concerning modified osteotomy and 24 studies concerning transverse osteotomy. The results showed that method of osteotomy was not associated with nonunion rate, as well as other post-operative outcomes including nerve palsy, dislocation, revision, leg-length discrepancy, HHS improvement and deep infection. In addition, western countries and longer follow-up (>5.1y) were associated with higher revision rate.

According to our analysis, transverse osteotomy and modified osteotomy didn’t show significant difference in nonunion rate (Figure 3). The analysis also showed that transverse and modified osteotomy didn’t show significant difference in terms of occurrence of nerve palsy, indicating that they have equal efficacy in preventing post-operative complication concerning nerve stretching (Figure 4). This could be attributed to the fact that the occurrence of nerve palsy is predominantly associated with the extent of leg lengthening.

In addition, occurrence of other post-operative complication including dislocation and deep infection is similar between transverse osteotomy and modified osteotomy. Recognized risk factors of dislocation after total hip arthroplasty include age, sex, head diameter of femoral prosthesis, surgical approach and experience of surgeon [52]. It wasn’t unexpected that method of osteotomy had no influence on post-operative dislocation. As for the relationship between method of osteotomy and infection rate, there had been different opinions. Modified osteotomies seem to take more time than transverse osteotomies due to their complexity [45, 46, 49], and there were several studies showing that prolonged operation time would increase the risk of deep infection after total hip arthroplasty [5355]. The deduction may seem reasonable that modified osteotomy would have higher infection rate than transverse osteotomy. However, our meta-analysis revealed that modified osteotomy and transverse osteotomy shared similar infection rate. This is probably because that the difference of operation time for modified and transverse osteotomy was not so significant to bring a difference in infection rate. On the other hand, some studies suggested that operation time might have no significant impact on deep infection rate at all [56, 57]. As for revision rate, there’s also no significant difference. In term of clinical improvement, modified osteotomy didn’t seem to show better performance than transverse osteotomy in post-operative leg-length discrepancy and HHS.

There was continuous suspicion that transverse osteotomy may not yield so good bone union as modified osteotomy, because of its lesser contact area for bone union, and potential rotational instability [9, 58]. However, our analysis showed that transverse osteotomy could yield similar bone union as modified osteotomy. In the meantime, transverse osteotomy equally improved hip function, and is equally safe in avoiding complications as modified osteotomy. And modified osteotomy is reported to be under the risk of arm fracture of osteotomy as a postoperative complication [14], which is impossible after transverse osteotomy. We concluded that transverse osteotomy share similar nonunion rate with modified osteotomy, and is equally safe and effective as modified osteotomy.

As a matter of fact, derotation for femoral anteversion is usually necessary, which in turn requires prompt preoperative preparation and extreme accuracy of osteotomy to correct the femoral anteversion [13, 17]. For modified osteotomy, once dissection is performed, there would be no chance for further adjustment of the anteversion angle of the femoral neck. Modified osteotomy also takes longer time than transverse osteotomy, due to the complexity of the surgical procedure, and the technically difficult procedure needs a lot of time and exercise for surgeons to master. Transverse osteotomy may be recommended, due to its simplicity and convenience in adjusting the anteversion angle.

Researchers have been trying to enhance the rotational stability of osteotomy, in order to improve bone union. Meanwhile, additional remarks should be made that rotational stability is influenced by not only the method of osteotomy, but also the design of implant used. Usually, DDH patient who receives THA is not so old to be free of risk of revision, and bone cement impedes later revision. On the other hand, possible leakage of bone cement would disturb the bone union. Taking these into consideration, researchers tended to perform cementless THA for DDH patients who needed subtrochanteric femoral shortening osteotomy at the same time. However, cross section and coating of femoral prostheses vary due to different designs. More importantly, press-fit femoral stem used in cementless THA mainly rely on proximal fixation, which might be insufficient to provide favorable stability for subtrochanteric osteotomy, for subtrochanteric osteotomy itself requires stable fixation of both proximal and distal femur, on metaphysis and diaphysis, respectively [43]. In recent years, some researchers applied modular femoral stem (e.g. S-ROM, DePuy) to these patients [33, 34, 43, 44, 46, 48], and there were few reports on nonunion among them. Due to its distinctive design, modular stem guarantees both proximal and distal fixation, and thus has potential advantages in providing rotational stability for subtrochanteric osteotomy. Nevertheless, more studies are expected before consensus is achieved whether modular stem facilitates better union of subtrochanteric osteotomy.

Further analysis indicated that western countries and longer follow-up (>5y) are associated with higher revision rate. Longer follow-up was to be expected on the basis of common sense and reasonable deduction. Western countries turned out to be associated with higher revision rate, probably due to its correlation with longer follow-up. Mean follow-up was 8.6 years in the studies of western countries, while 6.0 years in those of eastern countries.

This meta-analysis has the following limitations that must be taken into account. First, all the studies included were not randomized controlled trials, and thus of lower level of evidence. The studies were conducted with varying protocols and different levels of surgical expertise. Second, we compare transverse osteotomy and modified osteotomy, which is a category including step-cut, oblique and double-chevron osteotomy. There were much less studies on each of the modified osteotomy than on transverse osteotomy, which would result in significant loss of statistical efficacy if we compare each to transverse osteotomy separately. On the basis that the step-cut, oblique and double-chevron osteotomy shared some certain common ground, we categorized them into modified osteotomy in statistical analysis, as a strategy against potential loss of statistical efficacy. Third, the computer-based literature was systematic, and supplemented with manual searches. However, we may not be able to identify all the relevant studies despite our precise selection. In addition, the quantity of eligible studies was limited, and meta-regression analysis was not carried out for limb-length discrepancy due to lack of data.

To the best of our knowledge, this is the first meta-analysis comparing transverse and modified subtrochanteric femoral shortening osteotomy in THA for DDH patients. Second, it was conducted at an appropriate time, when enough data have accumulated for inspection by meta-analytical method. Third, this study was based on systematic up-to-date searching and filtering of literature, strictly according to the predetermined inclusion and exclusion criteria. Moreover, non-English language studies were included to minimize publication bias [36, 44, 46, 48, 49]. In addition, the variances of the raw rates were stabilized using Freeman-Tukey double-arcsine transformation, for the data were binary with low probability. Last but not least, it brings out a universal conclusion by including studies of various continents and countries. This meta-analysis therefore provides the most up-to-date information in this area.


Conclusions

This meta-analysis indicated that transverse osteotomy shared similar nonunion rate with modified osteotomy, and was equally safe and effective as modified osteotomy. Transverse osteotomy may be recommended, due to its simplicity and convenience in adjusting the anteversion angle. Despite our rigorous methodology, the inherent limitations of the included studies are barriers for us to reach definitive conclusions. Well-designed and large-sample-size randomized controlled trials are expected to confirm and update the findings of this analysis.



Notes

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

CL and YD participated in the design of this study, and they both performed the statistical analysis. CL and CZ collected important background information, and drafted the manuscript. MZ participated in the design of the study and data extraction and helped in the statistical analysis. All authors have read and approved the final manuscript.

Acknowledgements

This study was not supported by any company or grants.


References
Pre-publication history
1.. Dezateux C,Rosendahl K. Developmental dysplasia of the hipLancetYear: 20073691541155210.1016/S0140-6736(07)60710-717482986
2.. Peled E,Eidelman M,Katzman A,Bialik V. Neonatal incidence of hip dysplasia: ten years of experienceClin Orthop Relat ResYear: 200846677177510.1007/s11999-008-0132-818288551
3.. Crowe JF,Mani VJ,Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hipJ Bone Joint Surg AmYear: 1979611523365863
4.. Hartofilakidis G,Stamos K,Karachalios T,Ioannidis TT,Zacharakis N. Congenital hip disease in adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplastyJ Bone Joint Surg AmYear: 1996786836928642024
5.. Sanchez-Sotelo J,Berry DJ,Trousdale RT,Cabanela ME. Surgical treatment of developmental dysplasia of the hip in adults: II. Arthroplasty optionsJ Am Acad Orthop SurgYear: 20021033434412374484
6.. Rosenstein AD,Diaz RJ. Challenges and solutions for total hip arthroplasty in treatment of patients with symptomatic sequelae of developmental dysplasia of the hipAm J Orthop (Belle Mead NJ)Year: 201140879121720596
7.. Krych AJ,Howard JL,Trousdale RT,Cabanela ME,Berry DJ. Total hip arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV developmental dysplasiaJ Bone Joint Surg AmYear: 2009912213222110.2106/JBJS.H.0102419723999
8.. Dunn HK,Hess WE. Total hip reconstruction in chronically dislocated hipsJ Bone Joint Surg AmYear: 197658838845956229
9.. Kilicoglu OI,Turker M,Akgul T,Yazicioglu O. Cementless total hip arthroplasty with modified oblique femoral shortening osteotomy in Crowe type IV congenital hip dislocationJ ArthroplastyYear: 20132811712510.1016/j.arth.2012.06.01422868069
10.. Yang S,Cui Q. Total hip arthroplasty in developmental dysplasia of the hip: review of anatomy, techniques and outcomesWorld J OrthopYear: 20123424810.5312/wjo.v3.i5.4222655221
11.. Zadeh HG,Hua J,Walker PS,Muirhead-Allwood SK. Uncemented total hip arthroplasty with subtrochanteric derotational osteotomy for severe femoral anteversionJ ArthroplastyYear: 19991468268810.1016/S0883-5403(99)90223-110512440
12.. Reikeras O,Haaland JE,Lereim P. Femoral shortening in total hip arthroplasty for high developmental dysplasia of the hipClin Orthop Relat ResYear: 20104681949195510.1007/s11999-009-1218-720077043
13.. Baz AB,Senol V,Akalin S,Kose O,Guler F,Turan A. Treatment of high hip dislocation with a cementless stem combined with a shortening osteotomyArch Orthop Trauma SurgYear: 20121321481148610.1007/s00402-012-1560-122684740
14.. Dallari D,Pignatti G,Stagni C,Giavaresi G,Del Piccolo N,Rani N,Veronesi F,Fini M. Total hip arthroplasty with shortening osteotomy in congenital major hip dislocation sequelaeOrthopedicsYear: 201134e328e33321815571
15.. Decking J,Decking R,Schoellner C,Fuerderer S,Rompe JD,Eckardt A. Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hipArch Orthop Trauma SurgYear: 200312335736210.1007/s00402-003-0554-412844229
16.. Becker DA,Gustilo RB. Double-chevron subtrochanteric shortening derotational femoral osteotomy combined with total hip arthroplasty for the treatment of complete congenital dislocation of the hip in the adult. Preliminary report and description of a new surgical techniqueJ ArthroplastyYear: 19951031331810.1016/S0883-5403(05)80180-97673910
17.. Makita H,Inaba Y,Hirakawa K,Saito T. Results on total hip arthroplasties with femoral shortening for Crowe’s group IV dislocated hipsJ ArthroplastyYear: 200722323810.1016/j.arth.2006.02.15717197306
18.. Strom L. Textbook of PharmacoepidemiologyYear: 2007West SussexJohn Wiley & Sons
19.. Moher D, Liberati A, Tetzlaff J, Altman DG, Group PPreferred reporting items for systematic reviews and meta-analyses: the PRISMA statementBMJYear: 2009339b253510.1136/bmj.b253519622551
20.. Freeman M,Tukey J. Transformations related to the angular and the square rootAnn Math StatsYear: 19502160761110.1214/aoms/1177729756
21.. Higgins JP,Thompson SG. Quantifying heterogeneity in a meta-analysisStat MedYear: 2002211539155810.1002/sim.118612111919
22.. Miller J. The inverse of the freeman-Tukey double arcsine transformationAm StatYear: 197832138138
23.. Higghins J,Green S. Cochrane Handbook for Systematic Reviews of InterventionsYear: 2008
24.. Reikeraas O,Lereim P,Gabor I,Gunderson R,Bjerkreim I. Femoral shortening in total arthroplasty for completely dislocated hips: 3–7 year results in 25 casesActa Orthop ScandYear: 199667333610.3109/174536796089956058615099
25.. Gotze C,Winkelmann W,Gosheger G,Rodl R. Is there a need of an additional extramedullary fixation in transverse subtrochanteric shortening in primary total hip arthroplasty for patients with severe hip dysplasia? Short-term experience in seven patients with congenital dislocationZ Orthop UnfallYear: 200714556857317939065
26.. Howie CR,Ohly NE,Miller B. Cemented total hip arthroplasty with subtrochanteric osteotomy in dysplastic hipsClin Orthop Relat ResYear: 20104683240324710.1007/s11999-010-1367-820461484
27.. Charity JA,Tsiridis E,Sheeraz A,Howell JR,Hubble MJ,Timperley AJ,Gie GA. Treatment of Crowe IV high hip dysplasia with total hip replacement using the Exeter stem and shortening derotational subtrochanteric osteotomyJ Bone Joint Surg BrYear: 201193343810.1302/0301-620X.93B1.2468921196540
28.. Starker M,Bischof F,Lindenfeld T. Total hip arthroplasty with shortening subtrochanteric osteotomy and custom-made prosthesis in Crowe type IV developmental dysplasiaZ Orthop UnfallYear: 201114951852521984422
29.. Semenowicz J,Szymanski S,Walo R,Czuma P,Pijet B. Total hip arthroplasty with shortening subtrochanteric Z osteotomy in the treatment of developmental dysplasia with high hip dislocationOrtop Traumatol RehabilYear: 20121434134910.5604/15093492.100509423043057
30.. Yasgur DJ,Stuchin SA,Adler EM,DiCesare PE. Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hipJ ArthroplastyYear: 19971288088810.1016/S0883-5403(97)90157-19458253
31.. Chareancholvanich K,Becker DA,Gustilo RB. Treatment of congenital dislocated hip by arthroplasty with femoral shorteningClin Orthop Relat ResYear: 199936012713510.1097/00003086-199903000-0001610101318
32.. Masonis JL,Patel JV,Miu A,Bourne RB,McCalden R,Macdonald SJ,Rorabeck CH. Subtrochanteric shortening and derotational osteotomy in primary total hip arthroplasty for patients with severe hip dysplasia: 5-year follow-upJ ArthroplastyYear: 200318687310.1054/arth.2003.5010412730932
33.. Bernasek TL,Haidukewych GJ,Gustke KA,Hill O,Levering M. Total hip arthroplasty requiring subtrochanteric osteotomy for developmental hip dysplasia: 5- to 14-year resultsJ ArthroplastyYear: 20072214515010.1016/j.arth.2007.05.01417823034
34.. Bruce WJ,Rizkallah SM,Kwon YM,Goldberg JA,Walsh WR. A new technique of subtrochanteric shortening in total hip arthroplasty: surgical technique and results of 9 casesJ ArthroplastyYear: 20001561762610.1054/arth.2000.433510960001
35.. Erdemli B,Yilmaz C,Atalar H,Guzel B,Cetin I. Total hip arthroplasty in developmental high dislocation of the hipJ ArthroplastyYear: 2005201021102810.1016/j.arth.2005.02.00316376258
36.. Ozturkmen Y,Karli M,Dogrul C. Cemented total hip arthroplasty for severe dysplasia or congenital dislocation of the hipActa Orthop Traumatol TurcYear: 20023619520212510076
37.. Sener N,Tozun IR,Asik M. Femoral shortening and cementless arthroplasty in high congenital dislocation of the hipJ ArthroplastyYear: 200217414811805923
38.. Park MS,Kim KH,Jeong WC. Transverse subtrochanteric shortening osteotomy in primary total hip arthroplasty for patients with severe hip developmental dysplasiaJ ArthroplastyYear: 2007221031103610.1016/j.arth.2007.05.01117920477
39.. Nagoya S,Kaya M,Sasaki M,Tateda K,Kosukegawa I,Yamashita T. Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hipJ Bone Joint Surg BrYear: 2009911142114710.1302/0301-620X.91B9.2173619721037
40.. Togrul E,Ozkan C,Kalaci A,Gulsen M. A new technique of subtrochanteric shortening in total hip replacement for Crowe type 3 to 4 dysplasia of the hipJ ArthroplastyYear: 20102546547010.1016/j.arth.2009.02.02319577893
41.. Akiyama H,Kawanabe K,Yamamoto K,Kuroda Y,So K,Goto K,Nakamura T. Cemented total hip arthroplasty with subtrochanteric femoral shortening transverse osteotomy for severely dislocated hips: outcome with a 3- to 10-year follow-up periodJ Orthop SciYear: 20111627027710.1007/s00776-011-0049-z21442186
42.. Kilicarslan K,Yalcin N,Karatas F,Catma F,Yildirim H. Cementless total hip arthroplasty for dysplastic and dislocated hipsEklem Hastalik CerrahisiYear: 20112281521417980
43.. Takao M,Ohzono K,Nishii T,Miki H,Nakamura N,Sugano N. Cementless modular total hip arthroplasty with subtrochanteric shortening osteotomy for hips with developmental dysplasiaJ Bone Joint Surg AmYear: 20119354855510.2106/JBJS.I.0161921411705
44.. Zhong C,Cai XZ,Yan SG,He RX. S-ROM modular arthroplasty combined with transverse subtrochanteric shortening for Crowe type IV congenital dislocation of hipChin Med J (Engl)Year: 20111243891389522340315
45.. Hasegawa Y,Iwase T,Kanoh T,Seki T,Matsuoka A. Total hip arthroplasty for Crowe type developmental dysplasiaJ ArthroplastyYear: 2012271629163510.1016/j.arth.2012.02.02622552220
46.. Sun QC,Wang XH,Song BS,Zhu FB,Yan SG. Total hip arthroplasty for crowe type IV developmental dysplasia of the hip with S-ROM prosthesisZhongguo Gu ShangYear: 20132615315723678766
47.. Kawai T,Tanaka C,Ikenaga M,Kanoe H. Cemented total hip arthroplasty with transverse subtrochanteric shortening osteotomy for Crowe group IV dislocated hipJ ArthroplastyYear: 20112622923510.1016/j.arth.2010.03.02920570099
48.. Li W,Zhang W,Bai G,Huang Z,Shen R. Total hip arthroplasty for treatment of Crowe type IV congenital dysplasia of hip with dislocation in adultsZhongguo Xiu Fu Chong Jian Wai Ke Za ZhiYear: 2013271153115624397121
49.. Li Y,Ma W,Sun J,Song X,An M,Zhang Q. Becker V-shaped lateral rotation osteotomy in total hip arthroplasty for Crowe type IV development dislocation of hipZhongguo Xiu Fu Chong Jian Wai Ke Za ZhiYear: 2013271032103624279008
50.. Oe K,Iida H,Nakamura T,Okamoto N,Wada T. Subtrochanteric shortening osteotomy combined with cemented total hip arthroplasty for Crowe group IV hipsArch Orthop Trauma SurgYear: 20131331763177010.1007/s00402-013-1869-424121623
51.. Oinuma K,Tamaki T,Miura Y,Kaneyama R,Shiratsuchi H. Total hip arthroplasty with subtrochanteric shortening osteotomy for Crowe grade 4 dysplasia using the direct anterior approachJ ArthroplastyYear: 20142962662910.1016/j.arth.2013.07.03823998992
52.. Brooks PJ. Dislocation following total hip replacement: causes and curesBone Joint JYear: 201395-B676910.1302/0301-620X.95B11.3264524187356
53.. Jamsen E,Varonen M,Huhtala H,Lehto MU,Lumio J,Konttinen YT,Moilanen T. Incidence of prosthetic joint infections after primary knee arthroplastyJ ArthroplastyYear: 201025879210.1016/j.arth.2008.10.01319056210
54.. Dale H,Hallan G,Hallan G,Espehaug B,Havelin LI,Engesaeter LB. Increasing risk of revision due to deep infection after hip arthroplastyActa OrthopYear: 20098063964510.3109/1745367090350665819995313
55.. Pulido L,Ghanem E,Joshi A,Purtill JJ,Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factorsClin Orthop Relat ResYear: 20084661710171510.1007/s11999-008-0209-418421542
56.. Harrison T,Robinson P,Cook A,Parker MJ. Factors affecting the incidence of deep wound infection after hip fracture surgeryJ Bone Joint Surg BrYear: 20129423724010.1302/0301-620X.94B1.2768322323693
57.. Edwards C,Counsell A,Boulton C,Moran CG. Early infection after hip fracture surgery: risk factors, costs and outcomeJ Bone Joint Surg BrYear: 20089077077710.1302/0301-620X.90B6.2019418539671
58.. Bracken J,Tran T,Ditchfield M. Developmental dysplasia of the hip: controversies and current conceptsJ Paediatr Child HealthYear: 20124896397210.1111/j.1440-1754.2012.02601.x23126391
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/15/331/prepub

Figures

[Figure ID: Fig1]
Figure 1 

Schematic illustration of different methods of subtrochanteric femoral shortening osteotomy. (a) transverse (b) oblique (c) double-chevron (d) step-cut.



[Figure ID: Fig2]
Figure 2 

Flowchart of the study selection process.



[Figure ID: Fig3]
Figure 3 

Forest plot of all eligible studies for nonunion rate.



[Figure ID: Fig4]
Figure 4 

Forest plot of all eligible studies for nerve palsy rate.



[Figure ID: Fig5]
Figure 5 

Forest plot of all eligible studies for dislocation rate.



[Figure ID: Fig6]
Figure 6 

Forest plot of all eligible studies for revision rate.



[Figure ID: Fig7]
Figure 7 

Begg’s funnel plot of all eligible studies for (a) nonunion rate (b) nerve palsy (c) dislocation rate (d) revision rate.



Tables
[TableWrap ID: Tab1] Table 1 

Characteristics of included studies


Study Country Mean age (range), year Sex, Female % Crowe classification Total, hips/patients Method of osteotomy Mean follow-up (range), years Nonunion, hips Nerve injury, hips Revision Dislocation Deep infection Harris hip score Limb-length discrepancy Acceptable discrepancy, patients
Pre-operative Post-operative Pre-operative Post-operative
Becker, 1995 USA 61 (48–72) N/A IV 7/4 Double-chevron 2.7 (0.3-6) 0 0 1 0 N/A N/A N/A N/A N/A N/A
Reikeraas, 1996 Norway 54 (17–67) 93.8 IV 25/19 Transverse (3–7) 0 1 N/A N/A N/A 43 93 N/A N/A N/A
Yasgur, 1997 USA 42 (22–77) 77.8 IV 9/8 Transverse 3.6 (2–7) 1 0 1 1 N/A N/A N/A N/A 1.5 N/A
Chareancholvanich, 1999 USA 51 (21–74) N/A N/A 15/11 Double-chevron 5.5 (2–8.5) 0 0 N/A 0 N/A N/A N/A 3.9 1.4 N/A
Zadeh, 1999 UK 49 (34–61) 71.4 I, II & IV 7/7 Transverse 2.6 (1.3-5.0) 1* N/A N/A N/A N/A 44 91 N/A N/A N/A
Bruce, 2000 Australia 53 (26–77) N/A III & IV 6/5 Transverse 4.7 (0.5-7.2) 0 0 N/A N/A 0 31 81 N/A N/A N/A
Ozturkmen, 2002 Turkey N/A N/A IV 7/7 Step-cut N/A 1 N/A N/A N/A N/A N/A N/A N/A N/A N/A
Sener, 2002 Turkey 43 (26–64) 95.7 III & IV 28/23 Step-cut 4.0 (0.6-7.7) 2 2 0 0 0 36.9 95.3 N/A N/A 19
Decking, 2003 Germany 47 (19–58) 70.0 II.III & IV 12/10 Step-cut 5.1 (1.6-10) 0 1 1 0 0 36 82 5.4 1.3 N/A
Masonis, 2003 Canada 48.2 (21–70) 84.2 III & IV 21/19 Transverse 5.8 (2.0-11.2) 2 0 3 3 0 32.5 73.6 N/A N/A N/A
Erdemli, 2005 Turkey 44 (28–61) 100.0 IV 25/22 Step-cut in 3 hips 5 (2–10) 0 0 N/A N/A 0 N/A N/A N/A N/A N/A
Transverse in 22 hips 1 0 N/A N/A 0 N/A N/A N/A N/A N/A
Bernasek, 2007 USA 43 (17–67) 91.3 I.II.III & IV 23/20 Transverse 8 (5–14) 0 0 1 4 0 42 82 N/A N/A N/A
Gotze, 2007 Germany 41.7 (29–64) N/A III & IV 7/7 Transverse 1.5 0 N/A N/A N/A N/A 43 77 N/A N/A N/A
Makita, 2007 Japan 59.6 (42–76) 100.0 IV 11/11 Step-cut 5.4 (2.5-14.1) 0 2 1 1 0 N/A N/A 4.7 1.2 7
Park, 2007 Korea 44.8 (20–66) N/A III & IV 24/23 Transverse 4.7 (2.0-7.6) 3 0 1 1 N/A 35.6 81.7 N/A N/A 21
Krych, 2009 USA N/A N/A IV 28/24 Transverse 4.8 2 0 N/A 4 N/A 43 89 N/A N/A N/A
Nagoya, 2009 Japan 55 (44–69) 94.4 IV 20/18 Transverse 8.1 (4–11.5) 0 0 2 0 0 N/A N/A N/A 1.2 N/A
Howie, 2010 UK 47.3 (26–75) N/A III & IV 35/28 Transverse 5.6 (2–14) 1 2 7 3 1 N/A N/A N/A N/A N/A
Reikeraas, 2010 Norway 48 (16–79) 70.8 III & IV 65/46 Transverse 13 (8–18) 2 2 11 1 N/A N/A 87 N/A 1.0 N/A
Togrul, 2010 Turkey 42.3 (33–52) 85.7 III & IV 21/14 Transverse 3.4 (2.0-5.3) 0 0 N/A 2 0 N/A N/A N/A 0.3 N/A
Akiyama, 2011 Japan 58.9 (42–77) 90.9 III & IV 15/11 Transverse 6.3 (2.8-10.4) 3 0 3 2 N/A N/A N/A 2.9 0.3 11
Charity, 2011 UK 51 (33–75) 100.0 IV 18/15 Transverse 9.5 (4.3-14) 1 1 4 0 N/A N/A N/A N/A N/A N/A
Dallari, 2011 Italy 52 (34–66) 76.9 IV 33/26 Step-cut in 14 hips 7.3 (2.2-15.3) 0 N/A N/A N/A N/A N/A N/A 7.0 3.0 N/A
Oblique in 19 hips 1 N/A N/A N/A N/A N/A N/A N/A
Kawai, 2011 Japan 64.8 (57–73) 100 IV 19/12 Transverse 3.2 (0.5-8) 0 0 N/A 0 0 N/A N/A N/A N/A N/A
Kilicarslan, 2011 Turkey 46 (20–72) N/A III & IV 45/31 Transverse 7.2 (2.0-10.1) 5 0 N/A 2 N/A N/A N/A 2.9 1.4 N/A
Starker, 2011 Germany 44.6 83.3 IV 25/20 Step-cut N/A 0 N/A N/A N/A N/A N/A 90 N/A 0.8 20
Takao, 2011 Japan 60 92.0 IV 33/25 Step-cut 8 (5–11) 0 0 1 2 N/A N/A N/A 5.1 2.8 N/A
Zhong, 2011 China 45.2 (36–56) 100.0 IV 36/28 Transverse 4.4 (2.3-7.8) 0 0 N/A 0 0 39 87 5.7 0.6 N/A
Baz, 2012 Turkey 41.6 (24–56) 86.7 IV 21/15 Transverse 4.9 (3–8) 0 1 2 2 0 36.2 90.8 N/A N/A N/A
Hasegawa, 2012 Japan 58.5 (48–72) 100.0 IV 15/N/A Step-cut 10.2 (5–20) 0 1 4 3 0 56 85 3.8 1.4 N/A
Semenowicz, 2012 Poland 53.4 100.0 IV 10/10 Step-cut 2.3 0 0 N/A N/A N/A 43.7 86 N/A N/A N/A
Kilicoglu, 2013 Turkey 43 (27–60) 95.0 IV 20/16 Oblique 6.8 (3.7-10.3) 1* 0 2 3 N/A 50 83 N/A 1.0 N/A
Li WB, 2013 China N/A 100 IV 5/5 Transverse N/A 0 0 0 0 N/A N/A N/A N/A N/A N/A
Li YW, 2013 China 54 (41–75) 83.3 IV 22/18 Double-chevron 8 (3–12) 0 0 0 0 0 30 91.9 2.5 1 18
Oe, 2013 Japa 64.9 (35–80) 96.2 IV 34/26 Transverse 5.2 (3–10) 0 0 0 3 0 N/A N/A 4.7 1.2 26
Sun, 2013 China 47 (38–65) 63.3 IV 32/27 Transverse 4 (0.6-7) 0 1 0 0 0 41.7 89.1 N/A N/A N/A
Oinuma, 2014 Japan 61.5 (46–73) 100 IV 12/9 Transverse 3.7 (1.5-6.3) 0 0 0 1 0 N/A N/A N/A N/A N/A
Total / 50.0 88.1 / 791/N/A / / 27 14 45 38 1 / / / / /

N/A: not available.

*Delayed union that needs a second procedure.


[TableWrap ID: Tab2] Table 2 

Outcomes of meta-analysis and subgroup analysis


Outcome of interest No. of studies No. of hips No. of events Pooled estimate 95% CI Study heterogeneity
χ 2 I 2 Pvalue
Nonunion 39 791 27 3.79% (2.60%, 5.20%) 39.25 3.2% 0.414
Modified subgroup 15 241 5 3.03% (1.29%, 5.51%) 8.29 0.0% 0.874
Transverse subgroup 24 550 22 4.14% (2.67%, 5.20%) 30.34 24.2% 0.140
Nerve palsy 33 712 14 2.63% (1.60%, 3.87%) 21.9 0.0% 0.910
Dislocation 27 641 38 5.88% (4.22%, 7.80%) 42.35 36.2% 0.030
Modified subgroup 9 163 9 5.47% (2.57%, 9.36%) 12.99 38.4% 0.112
Transverse subgroup 18 478 29 6.03% (4.14%, 8.29%) 29.28 38.5% 0.045
Revision 22 482 45 8.90% (6.56%, 11.50%) 45.57 53.9% 0.001
Modified subgroup 8 148 10 6.66% (3.31%, 11.12%) 14.04 50.1% 0.050
Transverse subgroup 14 334 35 9.96% (7.06%, 13.35%) 29.99 56.7% 0.005
Limb-length discrepancy 7 132* 10* 6.31% (2.90%, 11.00%) 18.37 67.3% 0.005
Modified subgroup 4 72 8 9.02% (3.64%, 16.40%) 13.86 78.4% 0.003
Transverse subgroup 3 60 2 3.72% (0.50%, 9.72%) 2.83 29.3% 0.243
HHS improvement 17 337 / 26.79% (26.35%, 27.32%) 654.87 97.6% <0.001
Modified subgroup 6 107 / 27.41% (26.52%, 28.31%) 569.55 99.1% <0.001
Transverse subgroup 11 230 / 26.61% (25.99%, 27.14%) 82.56 87.9% <0.001
Deep infection 19 393 1 1.34% (0.46%, 2.67%) 2.24 0.0% 1.000

*Number of patients; CI: confidential interval.


[TableWrap ID: Tab3] Table 3 

Outcomes of meta-regression analysis


Nonunion Nerve palsy Revision Dislocation HHS improvement
P Co. P Co. P Co. P Co. P Co.
Method of osteotomy (modified vs. transverse) 0.472 −0.030 0.240 0.051 0.653 −0.033 0.735 −0.020 0.562 −0.025
Country (western vs. eastern) 0.731 0.013 0.272 0.042 0.010 0.169 0.592 0.029 0.819 −0.010
Mean Age 0.141 −0.004 0.734 0.000 0.760 −0.001 0.919 0.000 0.736 −0.001
Mean Age (<49y vs. ≥ 49y) 0.302 0.042 0.958 −0.002 0.980 0.002 0.948 −0.004 0.940 0.004
Proportion of female 0.845 0.000 0.587 0.000 0.721 0.001 0.367 0.003 0.290 −0.002
Proportion of female (<93% vs. ≥ 93%) 0.645 0.019 0.833 −0.009 0.793 0.021 0.723 0.026 0.143 0.073
Follow up 0.906 0.000 0.700 0.003 0.074 0.021 0.937 0.000 0.408 −0.008
Follow up (≤5y vs.>5y) 0.937 0.003 0.871 −0.006 0.014 −0.163 0.391 −0.046 0.354 0.042
Year of publication (2010 or before vs. after 2010) 0.187 0.051 0.244 0.044 0.300 0.071 0.716 0.019 0.504 0.028

HHS: Harris hip score; Co.: meta-regression coefficient.



Article Categories:
  • Research Article

Keywords: Keywords Subtrochanteric femoral shortening osteotomy, Total hip arthroplasty, Developmental dysplasia of the hip, Post-operative outcome, Meta-analysis.

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