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Closed Reduction for DDH

- 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.

    - 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.