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Treatment of DDH

- See:
       - DDH
       - Impediments to Reduction in DDH
       - Medial Approach to Hip
       - Open Reduction
       - Pelvic Osteotomy

- Treatment Goals:
    - goal is to achieve and manitain a concentric reduction of hip joint;
    - concave acetabulum cannot develop without concentric force exerted by the reduced femoral head;
    - up to age 1 yrs, concentric reduction generally results in normal hip;
    - up to age 4 yrs, reduction along w/ operative correction of acetabular dysplasia or correction of femoral anteversion can lead to
               normalization of the hip;

- Treatment Based on Age:
  - New born (birth to 6 months) and use of Pavlik harness:
  - Infants (6 to 20 months of age)
  - Age 18 mo to 36 months:
         - after 2 years of age, there is increased risk of AVN & closed reduction is more likely to fail;
         - open reduction thru anterolateral approach is generally preferred;
                - through anterolateral approach consider need for innominate osteotomy;
         - medial approach is advocated by some;
                - is of more value in the child younger than 18 months;
  - Age > 3 years:
         - as with all DDH patients, the goal is mainain a concentric reduction;
         - attempts at closed reduction risks AVN in these children, due to the adaptive shortening of soft tissues across the hip;
                (see impediments to reduction);
         - while the data is controversial for pts less than 3 years of age, in children older than age 3 yrs, femoral shortening yields
                significantly lower rates of AVN than does preoperative traction;
                - traction is associated w/ 50% incidence of AVN in pts older than 3 yrs;
         - open reduction, femoral shortening, & acetabular osteotmy may be required simultaneously to maintain concentric reduction;
                - often a VDRO is performed along with the femoral shortening;
                - post operatively these patients need to be placed ina hip spica cast with the hip in more than 90 deg of flexion and in less
                         than 90 deg of abduction;
         - references:
                - One-stage treatment of congenital dislocation of the hip in children three to ten years old. Functional and radiographic results.
  - Older Child:
         - upper age limit after which reduction of the hips is less favorable than natural history of untreated dislocation is controversial;
                - children older than 7 years at the time of treatment are more likely to have residual dysplasia;
                - general rule is 8 to 9 years for unilateral dislocation and 5 to 6 years for bilateral dislocation

- Complications:
    - avascular necrosis

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