Prereduction traction for the prevention of avascular necrosis before closed reduction for developmental dysplasia of the hip: a meta-analysis

Figures & data

Figure 1 Systematic search strategy results.

Table 1 Population characteristics

Author	Year	Outcome of the study	Clinical setting	Age at reduction (months)	Follow-up (years)	Classification of AVN	Other variables
Kutlu et al^Citation21	2000	The effect of traction	Traction No-traction	8.1 (1.5–20) 7.2 (1.5–12)	5 (1–12.3) 2.5 (1–3)	Salter^Citation5	Adductor tenotomy
Langenskiold and Paavilainen^Citation3	2000	The effect of traction	Traction No-traction	6–36	14 11	Their own	No other factors
Brougham et al^Citation8	1990	The extent of avascular necrosis	Traction No-traction	14 (1–55)	12 (6–17)	Salter^Citation5 Gage and Winter^Citation6	Adductor tenotomy Abduction device
Ishii and Ponseti^Citation22	1978	The displacement of the femoral head	CR under 1 year	7 (2–12)	15.1 (8–29)	Salter^Citation5 Gage and Winter^Citation6	Adductor tenotomy
Sibinski et al^Citation23	2006	The effect of traction	Traction No-traction	14.2 (6–32) 16.2 (6–32)	20.7 (14–40)	Bucholz and Ogden^Citation25	Abduction brace
Segal et al^Citation24	1999	The protective influence of the ossific nucleus	AVN Absence of AVN	6 (3–9) 6 (2–11)	4.4 (0.7–15.2) 3.0 (0.5–10.2)	Salter^Citation5 Gage and Winter^Citation6	Adductor tenotomy Pavlik harness
Sucato et al^Citation16	2017	The effect of traction	Traction	10.8 (2.4–33.6)	10.4 (2.0–27.7)	Bucholz and Ogden^Citation25	No other factors

Note: Values in parentheses are minimum and maximum.

Abbreviations: AVN, avascular necrosis; CR, closed reduction.

Table 2 Onset and risk ratio of AVN at the time of follow-up

Author	Number of hips		Number of AVN		Risk ratio
	Traction	No-traction	Traction	No-traction
Kutlu et al^Citation21	89	65	4	0	6.6
Langenskiold and Paavilainen^Citation3	65	33	20	24	0.423
Brougham et al^Citation8	168	42	80	19	1.053
Ishii and Ponseti^Citation22	7	33	1	11	0.429
Sibinski et al^Citation23	107	48	31	20	0.695
Segal et al^Citation24	33	4	12	1	1.455
Sucato et al^Citation16	168	40	30	3	2.381

Abbreviation: AVN, avascular necrosis.

Figure 2 Meta-analysis of the effect of prereduction traction on the prevention of AVN.

Abbreviation: AVN, avascular necrosis.

Table 3 Variables associated with the use of traction

Author	Direction	Weight	Position in traction	Duration (days)	Cast position	Cast duration
Kutlu et al^Citation21	Longitudinal bilateral	0.5–1.5 kg for each leg	Hip flexion 45° Hip abduction neutral Knee mild flexion	9 (7–21)	Human position	3 months
Langenskiold and Paavilainen^Citation3	Trunk direction	2–4 kg	Hip and knee extension	14–28	Lorenz frog position	4–6 months
Brougham et al^Citation8	N/A	N/A	Hip abduction 60° or 90°	12 (1–28)	N/A	N/A
Ishii and Ponseti^Citation22	Overhead	N/A	Bryant’s traction	8	Hip flexion 100° Hip abduction 60°–70°	3 months (6 weeks–6 months)
Sibinski et al^Citation23	Longitudinal bilateral	Until both buttocks were off the bed	Hip flexion 90°–100° Hip abduction 20° Knee extension	17 (10–40)	Modified Lorenz position Hip flexion more than 100° Hip abduction less than 70°	3 months and Lange cast for next 2 months
Segal et al^Citation24	N/A	N/A	N/A	14–56	Human position: 32 children Frog-leg: 1 child N/A: 24 children	N/A
Sucato et al^Citation16	Overhead	Until flat hand under buttock	Bryant’s traction	20.3 (6.3–51.8)	N/A	N/A

Abbreviation: N/A, not applicable.

Figure S1 Criteria for total AVN.

Abbreviation: AVN, avascular necrosis.

Figure S2 Criteria for partial AVN.

Abbreviation: AVN, avascular necrosis.

Figure S3 Bucholz and Ogden¹ classification.

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