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Review Article Gait Parameters Associated with Untreated Developmental Dysplasia of the Hip: a Systematic Review

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Review Article Gait Parameters Associated with Untreated Developmental Dysplasia of the Hip: a Systematic Review Int J Clin Exp Med 2017;10(9):13037-13047 www.ijcem.com /ISSN:1940-5901/IJCEM0059469 Review Article Gait parameters associated with untreated developmental dysplasia of the hip: a systematic review Chao Xu1*, Xinxin Wen2*, Wei Wei1*, Luyu Huang1, Jian Wang1, Yabo Yan1, Wei Lei1 1Department of Orthopaedics, Xijing Hospital, The Fourth Military Medical University, Xi’an, China; 2Department of Orthopaedics, No. 463 Hospital of Chinese PLA, Shenyang, China. *Equal contributors. Received June 14, 2017; Accepted August 25, 2017; Epub September 15, 2017; Published September 30, 2017 Abstract: Developmental dysplasia of the hip (DDH) has been linked to functional disability and altered gait patterns in adults. However, specific gait alterations in patients with DDH are unclear. The objective of this study is to inves- tigate gait parameters associated with untreated DDH in otherwise healthy adults. Electronic databases (PubMed and Embase) were searched systematically for articles reporting the gait patterns in patients with untreated DDH. Outcome measures assessed included spatiotemporal parameters, lower limb kinematics and kinetics, plantar pres- sure and electromyogram (EMG). Four studies were included consisting of 76 patients and 99 healthy controls. The quality of the studies varied, with Quality Index scores ranging from 9 to 15 out of a possible 17. Three-dimensional gait analysis and a repeated measures design were used in all included studies. Results revealed that patients with untreated DDH walked more slowly with shorter steps compared with controls. The untreated DDH patients also demonstrated a lower value of the maximum hip flexion angle, hip extension angle and external hip flexion moment in the diseased limb. Meanwhile, lots of gait parameters have been shown to correlate with the Harris Hip score. No included study attempt to investigate the dynamic EMG and plantar pressure parameters in patients with untreated DDH. Current evidence suggests the existence of specific gait deviations in patients with untreated DDH. Definitive conclusions are hampered by the heterogeneous nature of the participants and small sample sizes of the included studies. Future well-designed studies with a large sample size on this topic are warranted. Keywords: Developmental dysplasia of the hip (DDH), gait, systematic review, biomechanics, motion Introduction had received different operative treatments for DDH [11-18]. Most of them reported that the Developmental dysplasia of the hip (DDH) is a patients had an improvement in gait parame- common orthopedic disorder, referring to a ters after the therapy, but did not return to the wide spectrum of conditions ranging from mild normal level. To our knowledge, only a limited dysplasia to irreducible hip dislocation [1]. number of studies have investigated gait pat- terns in untreated DDH patients [19-23]. Early detection and intervention for patients with DDH are essential to achieve good results A systematic review and methodological ap- [2, 3]. However, there are still lots of adult DDH praisal is required, to make clear to physicians patients who did not receive any treatment at the current state of the evidence for gait devia- their early age. Untreated DDH is closely relat- tions in patients with untreated DDH. Firstly, ed to long-term morbidities such as gait devia- the information of the gait parameters will help tions, avascular necrosis of the femoral head, clinicians to improve their understanding of mo- degenerative hip osteoarthritis (OA), muscular tion performance related to untreated DDH [21] fatigue and chronic pain [4-6]. and the consequences of the pathological and mechanical changes in the hip. Secondly, Gait analysis is commonly utilized for assessing awareness of the gait compensations these the walking patterns in different patients [7-10]. patients adopt is related to the treatment These evaluations have been regarded as a choice [19, 20, 22]. Thirdly, if the clinicians want useful supplement to clinical and radiologic to objectively monitor the progress after a cer- assessment [7-10]. Analyses of gait patterns tain treatment by gait analysis, the baseline have been reported previously for patients who data before the therapy will be necessary [17- Gait parameters in untreated DDH Table 1. Methodological quality assessment of the included studies Q1 Q2 Q3 Q5a Q6 Q7 Q10 Q11 Q12 Q16 Q18 Q20 Q21 Q22 Q25 Q27b Total Romano et al. [19] (1996) Y Y Y Y Y Y N U U Y Y Y U U Y Y 12 Lai et al. [21] (1997) Y Y Y P Y Y N U U Y Y Y U U N N 9 Pederson et al. [22] (2004) Y Y Y P Y Y Y U U Y Y Y Y Y N Y 13 Jacobsen et al. [20] (2013) Y Y Y Y Y Y Y U U Y Y Y Y Y Y Y 15 This methodological quality assessment was performed by CX and YBY utilizing a modified version of Downs and Black Qual- ity Index. Y (Yes) = 1, N (No) = 0, U (Unable to determine) = 0. The total score was out of 18. Q1: clear aim/hypothesis, Q2: outcome measures clearly described, Q3: clear patient characteristics, Q5: distributions of principal confounders in each group of subjects clearly described, Q6: clear main findings, Q7: estimates of the random variability provided, Q10: actual probability values provided, Q11: representative of population (asked), Q12: representative of population (prepared to participate), Q16: no data dredging, Q18: use of appropriate statistical tests, Q20: valid and reliable outcome measures, Q21: participants recruited from the same population, Q22: participants recruited over the same period of time, Q25: adjustment for confounding, Q27: suf- ficient statistical power. aThis question was scored on the basis of P (partial) = l, Y (Yes) = 2 and N (No) = 0. bThis question was converted to a yes or no answer to make the comparison simpler. available up to April 2017. The following search strategy was used in the PubMed data- base: (Gait[Mesh] OR gait* [All Fields] OR Walking [Mesh] OR walk* [All Fields] OR step [All Fields] OR stride [All Fields] OR cadence [All Fields] OR spatio- temporal [All Fields] OR Pedo- barograph* [All Fields] OR el- ectromyograph* [All Fields] OR EMG [All Fields] OR biome- chanic* [All Fields] OR kine- matic [All Fields] OR kinetic [All Fields] OR “plantar pressure” [All Fields] OR locomotion [All Fields] OR power [All Fields] OR motion [All Fields] OR “gr- ound reaction force” [All Fiel- ds] OR moment [All Fields] OR Figure 1. Flowchart of study compensation [All Fields] OR inclusion. DDH = develop- mental dysplasia of the hip. adaptation [All Fields]) AND (“Hip Dislocation, Congenital” [Mesh] OR “developmental dy- 20, 22]. The comparisons of these gait param- splasia of the hip” [All Fields] OR “congenital eters are valuable for doctors to plan, imple- dislocation of the hip” [All Fields] OR DDH [All ment and evaluate the clinical managements. Fields] OR CDH [All Fields] OR “hip dislocation” The aim of this systematic review was to study [All Fields] OR “hip joint instability” [All Fields] the gait parameters in otherwise healthy indi- OR “congenital hip dislocation” [All Fields] OR viduals with untreated DDH compared to he- “hip dysplasia” [All Fields]). Search strategy althy controls (HC). applied in Embase was derived from the PubMed search. We also screened the refer- Methods ences from key papers to ensure that all key studies were included. Literature search strategy Selection of studies In order to identify the key papers on this topic, comprehensive searches of electronic databas- Evaluation of study eligibility was performed by es (PubMed and Embase) were performed by three authors (CX, XXW and WW). The titles and three authors (CX, XXW and WW) for all years abstracts retrieved from all identified records 13038 Int J Clin Exp Med 2017;10(9):13037-13047 Gait parameters in untreated DDH were screened for eligibility utilizing the ques- pants, study designs and gait parameters of tion: ‘Did the research discuss gait parameters interest. in patients with untreated DDH?’ Eligible full text articles were then obtained for detailed Results assessment for the final decision on inclusion according to the following criteria: 1) studies Search results reporting gait parameters in clearly identified With our search we originally identified 4130 untreated DDH group in comparison to HC; 2) unique records. After screening the titles and outcome measures including spatiotemporal abstracts, 49 articles were assessed for full parameters, kinematics, kinetics, plantar pres- text review. Of these, 4 were deemed suitable sure parameters, dynamic instability or electro- for inclusion [19-22] (Figure 1). myogram (EMG) results; 3) study population without any systemic disease; 4) studies in the Quality assessment English language. The quality of the four studies varied, and they Assessment of methodological quality scored 9, 12, 13 and 15 respectively out of a possible 17 according to the modified quality A quality assessment index of 16 items (maxi- assessment instrument (Table 1). One study mum score of 17) was used to assess the qual- was of fair quality [21] and three studies were ity of the studies. The assessment was based of good quality [19, 20, 22]. All studies clearly on the Quality Index (27 items) developed by described participant characteristics (e.g., age, Downs and Black [24] and items which were body mass, sex). However, only one study not applicable to the included studies were reported sample size calculation [20]. All stud- omitted from the analysis [8, 25]. Two review- ies were deemed to correctly perform statisti- ers (CX and YBY) independently assessed the cal tests to assess the main findings, but only quality of each article. After the initial scoring, two of them reported actual probability values the assessors met and discussed any differ- (i.e. P = 0.003) rather than approximate values ences and obtained a final score (Table 1). The (i.e. P < 0.05) [20, 22].
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