- [Home](https://ortopediaevolutiva.com/en) - [Pediatric Orthopaedics Blog — Dr. Priano](https://ortopediaevolutiva.com/en/blog) - DDH and osteonecrosis after surgery: risk factors in a 2026 meta-analysis # DDH and osteonecrosis after surgery: risk factors in a 2026 meta-analysis May 11, 2026 3 min read Edited and medically reviewed by [Dr. Daniele Priano](https://ortopediaevolutiva.com/en/about) ![DDH and osteonecrosis after surgery: risk factors in a 2026 meta-analysis](https://ortopediaevolutiva.com/blog-images/ddh-osteonecrosi-avn-rischio-meta-analisi-2026-cover-20260908-v2.webp) This English version is based on the original Italian article. For wording nuances, you can refer to the Italian version. ## In short, for parents - • In the meta-analysis, an absent femoral-head ossification centre and more severe dislocations were associated with a higher risk of osteonecrosis. - • Additional procedures may indicate a more complex course: the association does not establish that they caused the damage. - • These findings help discuss risk and plan follow-up; they do not, by themselves, justify delaying treatment. Osteonecrosis of the femoral head remains one of the most feared complications after surgical treatment for [developmental dysplasia](https://ortopediaevolutiva.com/en/conditions/hip-dysplasia) of the hip. A meta-analysis published in 2026 in *Frontiers in Pediatrics* gathered 16 retrospective studies, totaling 1,631 children and 1,941 hips. AVN was diagnosed in 468 hips. [1] The value of the work lies primarily in the multivariable analysis, which reduces the number of factors independently associated with risk. ## Absence of the Ossification Centre The absence of the ossification centre was associated with a higher risk of AVN, with an OR of 2.60 and a 95% confidence interval of 1.73–3.91. [1] However, this data does not prove that it is beneficial to delay reduction until the nucleus appears. The studies are retrospective, and the nucleus can also represent a marker of biological age or different patient characteristics. Therefore, a timing decision cannot be directly derived from this association. ## Severity of Dislocation IHDI III–IV dislocations showed a higher risk of AVN compared to lower grades, with an OR of 2.43. [1] This is plausible: more severely dislocated hips often require more complex maneuvers and may have greater vascular vulnerability from the outset. Initial severity should therefore also be considered in counseling with the family. ## Secondary Procedures The need for secondary procedures was associated with a higher risk, with an OR of 2.56. [1] Here too, the causal relationship is not simple. An additional procedure can be a sign of a more difficult hip, a less stable reduction, or a more complex therapeutic pathway. It is not possible to conclude that the procedure itself causes osteonecrosis. ## Less Robust Factors Age, surgical approach, and abduction angle did not emerge with the same consistency in the multivariable analysis. [1] This does not mean they are irrelevant in individual cases. It only means that, in the available aggregated literature, they do not behave as equally robust independent predictors. ## How to Use This Data In children with more severe dislocations or without an ossification centre, the risk of AVN should be discussed with particular attention. A treatment pathway requiring secondary procedures also identifies a more complex group. The meta-analysis does not indicate a surgical technique capable of eliminating the risk. Rather, it helps to distinguish what appears to be linked to biology and initial severity from what, with the available data, remains more difficult to isolate. ## Limitations All included studies are retrospective. The diagnostic criteria for osteonecrosis are not uniform, and confounding by severity remains significant: more complex cases also receive more complex treatments. The confidence interval for secondary procedures is also wide. [1] For now, these results are primarily useful for risk stratification and follow-up, rather than for transforming a single factor into a new therapeutic rule. Disclaimer This content is for informational purposes only and does not replace an individual clinical evaluation. References [1] Guo Z, Chen X, Dai G, Xue M. **Risk factors for avascular necrosis of the femoral head after surgical treatment of developmental dysplasia of the hip in children: a systematic review and meta-analysis.** *Frontiers in Pediatrics.* 2026;14:1811138. doi:10.3389/fped.2026.1811138. PubMed: [https://pubmed.ncbi.nlm.nih.gov/42051953/](https://pubmed.ncbi.nlm.nih.gov/42051953/) Full text: [https://pmc.ncbi.nlm.nih.gov/articles/PMC13111955/](https://pmc.ncbi.nlm.nih.gov/articles/PMC13111955/) ## Complete pathway on the child’s hip This page is part of the pathway on the child’s hip. - [2 Treating dysplasia: from bracing to surgery Pavlik harness, reduction, osteotomies: when and why.](https://ortopediaevolutiva.com/en/surgery/hip-dysplasia) [Movement guidance after the harness](https://ortopediaevolutiva.com/en/parents-kids/exercises/hip/post-pavlik) - [1 Developmental dysplasia of the hip (DDH)](https://ortopediaevolutiva.com/en/conditions/hip-dysplasia) - [7 Hip movement and functional recovery](https://ortopediaevolutiva.com/en/parents-kids/exercises/hip) Adjacent clinical pictures: [Sudden limp](https://ortopediaevolutiva.com/en/emergencies/sudden-limp) · [Limb torsion](https://ortopediaevolutiva.com/en/conditions/limb-torsion) · [In-toeing gait](https://ortopediaevolutiva.com/en/conditions/in-toeing) ![Dott. Daniele Priano](https://ortopediaevolutiva.com/assets/doctor-avatar-3d-CTvqnoPa.webp) ### Concerned about your child? If you recognize any of these signs in your child, a specialist assessment can give you clarity. I see children at Gaetano Pini and CTO institutes in Milan. 5.0 · Google & MioDottore [Book a private visit](https://ortopediaevolutiva.com/en/locations#prenota) ### Related Conditions [Hip dysplasia](https://ortopediaevolutiva.com/en/conditions/hip-dysplasia) ### Related Surgery Pages [Hip dysplasia surgery](https://ortopediaevolutiva.com/en/surgery/hip-dysplasia) ### Related Exercises [Exercises for Hip dysplasia](https://ortopediaevolutiva.com/en/parents-kids/exercises/hip/hip-dysplasia) ### Related Articles [Pediatric Septic Arthritis: Diagnosis and Clinical Pathway Beyond Kocher's Criteria Read](https://ortopediaevolutiva.com/en/blog/pediatric-septic-arthritis-diagnostic-pathway)[Perthes Disease: prognosis, containment, and treatment in light of recent studies Read](https://ortopediaevolutiva.com/en/blog/perthes-disease-containment-and-treatment)[SCFE (Slipped Capital Femoral Epiphysis): Where Diagnostic Delays Originate Read](https://ortopediaevolutiva.com/en/blog/scfe-why-diagnosis-is-still-delayed) ![Dott. Daniele Priano](https://ortopediaevolutiva.com/assets/doctor-avatar-3d-BiLSxBxW.webp) Author and medical reviewer ## Dr. Daniele Priano [Pediatric orthopaedic care in Milan](https://ortopediaevolutiva.com/en) — Gaetano Pini & CTO [Read full bio](https://ortopediaevolutiva.com/en/about) --- Canonical: https://ortopediaevolutiva.com/en/blog/ddh-osteonecrosis-risk-after-surgery Le informazioni cliniche sono divulgative e non sostituiscono una valutazione medica diretta.