- Discussion:
- Pavlik harness is seldom effective after 6 months of age;
- in children between 6 months and 1 year of age, treatment consists of closed reduction w/ GEA following a period of skin traction
& (w/ or w/o) adductor tenotomy (to reduce AVN);
- this will be successful in 60-80% of pts;
- concentricity of reduction is confirmed by arthrography or CT;
- radiographs will not penetrate hip spica;
- children > age 2 years:
- should not be treated closed since there is increased risk of AVN & failure to maintain reduction by closed means;
- open reduction through anterolateral approach is generally preferred;
- Radiographs:
- concentricity of reduction is confirmed by arthrography or CT since x-rays taken through a spica cast may be misleading;
- as reported by Malvitz and Weinstein (1994), it is essential to only accept a perfect reduction (as judged by arthrography), and
otherwise the surgeon should consider open reduction;
- Congenital hip dislocation: Review of 152 closed reductions with 31 year follow up. Malvitz TA and Weinstein SE. Orthop
Trans. 1988;12:573.
- Close Reduction w/ Traction & Spica Casting;
- note: impediments to reduction in DDH;
- most indicated in children between 6 mo & 2 1/2 years of age;
- as noted by Daoud, et al (1996), closed reduction was successful in 76% of children (avg age 33 months) when it was preceded by
skin traction (avg 23 days);
- these children did not require any other additional form of treatment;
- skin traction followed by closed reduction w/ gea (w/ or w/o adductor tenotomy) will reduce AVN:
- expect success in 60 - 80% of patients;
- technique of reduction:
- hip is flexed & thigh is lifted & abducted to bring femoral head into acetabulum;
- reduced hip must be maintained in physiologic position of flexion-abduction;
- ideal hip position:
- flexion to about 90 deg
- moderate abduction (human position), and always avoid abduction more than 60 deg;
- assessment of reduction:
- typically an intraoperative arthrogram is performed to confirm adequacey of the reduction;
- in the study by Hattori T, et al (1999) the authors investigated whether or not soft tissue interposition influenced acetabular
development and AVN;
- they found that even when marked soft tissue interposition was present on the initial arthrogram, spontaneous
disappearance was noted in 71% of patients at 5 years;
- requirements for secondary surgery at the age of five years was significantly higher in those with more than 3.5 mm
of soft tissue interposition;
- authors concluded that the appearance of radiographic soft tissue interposition by itself is not necessarily an indication
for open reduction;
- references:
- Ultrasound in the management of the position of the femoral head during treatment in a spica cast after reduction of hip dislocation in developmental dysplasia of the hip.
- Congenital dislocation of the hip in the older child. The effectiveness of overhead traction.
- Soft-tissue interposition after closed reduction in developmental dysplasia of the hip. The long-term effect on acetabular development and avascular necrosis.
- difficult closed reduction:
- attempt closed reduction w/ pt under GEA w/ possible percutaneous release of adductor longus muscle;
- if this is not successful, then consider open reduction;
- this allows immediate hip reduction w/ minimal risk of AVN;
- alternative is to consider skin traction & repeat reduction;
- ref: A protocol for the use of closed reduction in children with developmental dysplasia of the hip incorporating open psoas and adductor releases and a short-leg cast: Mid-term outcomes in 113 hips.
- Complications:
- persistent subluxation;
- avascular necrosis:
- may follow hip reduction;
- forced abduction is a likely risk factor;
- prolonged hospitalization and multiple radiographic studies;
- failed closed reduction:
- impediments to reduction in ddh:
- if reduction cannot be achieved easily or if hip is not stable in 90 deg of flexion and 45 to 55 deg of abduction then reduction is
considered a failure & open reduction is necessary
Acetabular development after closed reduction of congenital dislocation of the hip.
- Pavlik harness is seldom effective after 6 months of age;
- in children between 6 months and 1 year of age, treatment consists of closed reduction w/ GEA following a period of skin traction
& (w/ or w/o) adductor tenotomy (to reduce AVN);
- this will be successful in 60-80% of pts;
- concentricity of reduction is confirmed by arthrography or CT;
- radiographs will not penetrate hip spica;
- children > age 2 years:
- should not be treated closed since there is increased risk of AVN & failure to maintain reduction by closed means;
- open reduction through anterolateral approach is generally preferred;
- Radiographs:
- concentricity of reduction is confirmed by arthrography or CT since x-rays taken through a spica cast may be misleading;
- as reported by Malvitz and Weinstein (1994), it is essential to only accept a perfect reduction (as judged by arthrography), and
otherwise the surgeon should consider open reduction;
- Congenital hip dislocation: Review of 152 closed reductions with 31 year follow up. Malvitz TA and Weinstein SE. Orthop
Trans. 1988;12:573.
- Close Reduction w/ Traction & Spica Casting;
- note: impediments to reduction in DDH;
- most indicated in children between 6 mo & 2 1/2 years of age;
- as noted by Daoud, et al (1996), closed reduction was successful in 76% of children (avg age 33 months) when it was preceded by
skin traction (avg 23 days);
- these children did not require any other additional form of treatment;
- skin traction followed by closed reduction w/ gea (w/ or w/o adductor tenotomy) will reduce AVN:
- expect success in 60 - 80% of patients;
- technique of reduction:
- hip is flexed & thigh is lifted & abducted to bring femoral head into acetabulum;
- reduced hip must be maintained in physiologic position of flexion-abduction;
- ideal hip position:
- flexion to about 90 deg
- moderate abduction (human position), and always avoid abduction more than 60 deg;
- assessment of reduction:
- typically an intraoperative arthrogram is performed to confirm adequacey of the reduction;
- in the study by Hattori T, et al (1999) the authors investigated whether or not soft tissue interposition influenced acetabular
development and AVN;
- they found that even when marked soft tissue interposition was present on the initial arthrogram, spontaneous
disappearance was noted in 71% of patients at 5 years;
- requirements for secondary surgery at the age of five years was significantly higher in those with more than 3.5 mm
of soft tissue interposition;
- authors concluded that the appearance of radiographic soft tissue interposition by itself is not necessarily an indication
for open reduction;
- references:
- Ultrasound in the management of the position of the femoral head during treatment in a spica cast after reduction of hip dislocation in developmental dysplasia of the hip.
- Congenital dislocation of the hip in the older child. The effectiveness of overhead traction.
- Soft-tissue interposition after closed reduction in developmental dysplasia of the hip. The long-term effect on acetabular development and avascular necrosis.
- difficult closed reduction:
- attempt closed reduction w/ pt under GEA w/ possible percutaneous release of adductor longus muscle;
- if this is not successful, then consider open reduction;
- this allows immediate hip reduction w/ minimal risk of AVN;
- alternative is to consider skin traction & repeat reduction;
- ref: A protocol for the use of closed reduction in children with developmental dysplasia of the hip incorporating open psoas and adductor releases and a short-leg cast: Mid-term outcomes in 113 hips.
- spica cast:
- bilateral hip spica cast is applied in the appropriate position;
- casts are removed at 8 weeks under anesthesia;
- stability is again re-assessed;
- if reduction is not adequate, procede to open reduction;
- a second spica cast is applied, but usually less flexion and less abduction is required;
- at 4 months, the hip is again assessed under anesthesia, and a third spica cast will usually be required;
- after the third spica has been worn for 2 months, an abduction splint is worn for one month;
- Complications:
- persistent subluxation;
- avascular necrosis:
- may follow hip reduction;
- forced abduction is a likely risk factor;
- prolonged hospitalization and multiple radiographic studies;
- failed closed reduction:
- impediments to reduction in ddh:
- if reduction cannot be achieved easily or if hip is not stable in 90 deg of flexion and 45 to 55 deg of abduction then reduction is
considered a failure & open reduction is necessary
Acetabular development after closed reduction of congenital dislocation of the hip.
Congenital dislocation of the hip in the older child. The effectiveness of overhead traction.