- 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 & 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;
    - failed closed reduction:
          - 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;
- 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;
- Impediments to Reduction in DDH:
- 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);
    - avascular necrosis:
          - may follow hip reduction;
          - forced abduction is a likely risk factor;
                - medial circumflex femoral artery may be stretched & compressed w/ thigh in full abduction;
                       - MCFA may also be compressed between labrum & femoral neck;

- 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