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Open Reduction for DDH

Open Reduction for DDH

- Inidications:
    - older age:
         - attempts at closed reduction should be limited to children who are less than three years old;
         - once children begin to walk, there is decreased chance for successful closed reduction & increased risk of AVN;
    - failure of closed treatment to maintain a concentric reduction at any age;
         - in infants, soft tissue interposition in hip joint should resolve w/ in four weeks (impediments to reduction)
         - usually surgeon will attempt reduction w/ either traction or GEA;
    - failure of previous open reduction;

- Traction or Shortening Before Open Reduction
     - traction:
           - in children < 3 years of age, traction may decrease avascular necrosis;
           - children greater than 3 years probably do not benefit from preop traction;
     - in children > 3 years of age femoral shortening will prevent excessive compression of femoral epiphysis & will prevent AVN;

- Surgical Approach:
     - open reduction thru anterolateral approach is generally preferred;
     - w/ anterolateral approach consider need for innominate osteotomy;
     - medial approach is advocated by some;
     - anterior approach:
            - indicated for children older than 18 months or in children of walking age;
            - this approach allows capsulorraphy in older children and is less likley to cause AVN;
     - consideration for osteotomy:
            - following open reduction, a pelvic or femoral osteotomy may be required to maintain a stable reduction;
            - as outlined by Zadeh HG, et al, the authors followed 82 children (95 hips) treated by open reduction using an anterior
                    approach, followed by an assessment of requirements for osteotomy based on intra-operative hip stability;
                    - mean age at the time of surgery was 28 months (9 to 79) and at the latest follow-up, 17 years (12 to 25).
                    - hips which required flexion with abduction for stability were considered to need an innominate osteotomy.
                    - hips which required only internal rotation and abduction, underwent an upper femoral derotational and varus osteotomy;
                    - 86% of the patients have had a satisfactory radiological outcome (Severin groups I and II);
                    - results were better (p = 0.04) in children under the age of two years;
                    - incidence of postoperative avascular necrosis was 7%.
                    - in 18% of hips, premature physeal arrest was noted during the adolescent growth spurt;
            - femoral osteotomy:
                    - indicated during open reduction, if the extremity needs to be significantly abducted and internally rotated to achieve
            - pelvic osteotomy:
                    - may be indicated during open reduction, if the acetabular index is more than 35 deg;
                    - may be indicated for hips which require flexion with abduction for stability;
            - references:
                    - Test of stability as an aid to decide need for osteotomy in association with open reduction in developmental dysplasia of the hip

The Safety and Efficacy of a Transarticular Pin for Maintaining Reduction in Patients With Developmental Dislocation of the Hip Undergoing an Open Reduction

Revision of failed open reduction of congenital dislocation of the hip.

A new open reduction treatment for congenital hip dislocation: long-term follow-up of the extensive anterolateral approach.

Reduction of a Dislocation of the Hip Due to Developmental Dysplasia. Implications for the Need for Future Surgery

The Surgical Treatment of Established Congenital Dislocation of the Hip: Results of Surgery After Planned Delayed Intervention Following the Appearance of the Capital Femoral Ossific Nucleus.

The Early Detection and Management of Unstable Concentric Closed Reduction of DDH With Percutaneous K-wire Fixation in Infants 6 to 12 Months of Age

Long-term Follow-up of Open Reduction Surgery for Developmental Dislocation of the Hip