- 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 thru 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 (JBJS Dec 1994), it is essential to only accept a perfect reduction (as judged by arthrography), and
otherwise the surgeon should consider
open reduction;
- 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
T Hattori et al (JBJS Vol 81-B, May 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;
- the 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;
- the 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.
-
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;
-
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.
Closed reduction for congenital dysplasia of the hip. Functional and radiographic results after an average of thirty years.
Congenital dislocation of the hip in the older child. The effectiveness of overhead traction.
Congenital hip dislocation: Review of 152 closed reductions with 31 year follow up.
TA Malvitz and SE Weinstein.
Orthop Trans. Vol 12. 1988. p 573.
