INDICATIONS AND TECHNIQUE OF CLOSED REDUCTION TREATMENT NORMAN RAMÍREZ MD HOSPITAL DE LA CONCEPCIÓN SAN GERMÁN PUERTO RICO

INDICATIONS FAILURE OF SPLINT TREATMENT DISLOCATED HIP PATIENT BETWEEN 6 MONTHS OF AGE TO 2 YEARS OF AGE Closed Reduction for Developmental Dysplasia of the Hip: Early-term Results From a Prospective, Multicenter Cohort. Sankar WN, Herrera Soto , et al JPO 2016

GOALS OBTAIN GOOD HIP CONTAINMENT MAINTAIN GOOD HIP CONTAINMENT Closed reduction in the treatment of developmental dysplasia of the hip Cemalettin 2007 Acta Orthopaedica et Traumatologica Turcica

TRACTION GOALS: 1: DECREASE AVN INCIDENCE 2: DECREASE OPEN REDUCTION RATE NO INDICATION….. Preliminary traction as a single determinant of avascular necrosis in developmental dislocation of the hip Kutlu JPO 2000 Overhead Bryant's Traction Does Not Improve the Success of Closed Reduction or Limit AVN in Developmental Dysplasia of the Hip. Sucato D JPO 2017

CLOSE REDUCTION

TECHNIQUE GENERAL ANESTHESIA HIP FLEXION 90 DEGREES HIP ABDUCTION UNTIL REDUCTION ( ORTOLANI )

TECHNIQUE RANGE OF MOTION FROM REDUCTION TO DISLOCATION WATCH SAFE ZONE- RAMSEY IF THE HIP CAN BE ABDUCTED LESS THAN 50 DEGREES OF ABDUCTION AND FLEXION LESS THAN 90 DEGREES WITHOUT REDISLOCATION STABLE REDUCTION

IF MORE THAN 15 OF INTERNAL REDUCTION OR WIDE ABDUCTION- UNSTABLE REDUCTION CONSIDER ADDUCTOR TENOTOMY

AVOID …. FULL ABDUCTION MORE 15 DEGREES OF INT. ROT. FORCEFUL REDUCTION Risk factors for avascular necrosis after closed reduction for developmental dysplasia of the hip. Schur MD, Arkade A , et al J Child Orthop. 2016 Jun

ARTHROGRAM Intraoperative Arthrogram Predicts Residual Dysplasia after Successful Closed Reduction of DDH. Zhang ZL et al Orthop Surg. 2016 Aug

TECHNIQUE…. WIDTH OF THE MEDIAL DYE POOL. 7 mm or LESS Congenital dislocation of the hip : an evaluation of close reduction. Race et al JPO 1983 MEDILIZATION RATIO Prognostic Factors in congenital dislocation of the hip treated with close reduction Forlin E et al JBJS 1992 LIMBUS SHAPE

ROSE THORN SING

AFTER CASTING POST REDUCTION X-RAY

SINGLE SHOT COMPUTED TOMOGRAPHY Useful to confirm an adequate reduction. Postoperative computed tomographic evaluation of congenital hip dislocation Toby et al 1987 Computed Tomography for early evaluation for developmental dysplasia of the hip Stanton et al JPO 1992 The predictive value of computed tomography in the treatment of developmental dysplasia of the hip . Mandel D JPO 1998

UlTRASOUND Decrease amount of radiation Wide open perineal window Extended learning curve Ultrasound in the management of the reduction of the femoral head during treatment in a spica cast after reduction of hip dislocation in developmental dysplasia of the hip Florens et al JBJS BR 2003

MAGNETIC RESONANCE ACCURATE ASSESMENT OF REDUCTION EXCELLENT DELINEATION OF SOFT TISSUE FEMORAL HEAD PERFUSSION - GALODINIUM COST $$$$$ Post closed reduction perfusion magnetic resonance imaging as a predictor of avascular necrosis in developmental hip dysplasia Tiderius et al JPO 2009 MRI in Postreduction Evaluation of Developmental Dysplasia of the Hip: Our Experience.Dibello D J Pediatr Orthop. 2017

POST OP MANAGEMENT 6 WEEKS OF CASTING EVALUATION UNDER ANESTHESIA 6 MORE WEEKS ABDUCTION SPLINT

COMPLICATIONS

LACK OF REDUCTION Inverted limbus Ligament Teres Transverse Acetabular ligament Hourglass constriction of the capsule Fibrofatty pulvinar tissue Soft tissue interposition after closed reduction in developmental dysplasia of the hip Hattori JBJS BR 1999

OSTEONECROSIS RATE : 6 % TO 48 % RISK FACTORS: 1. TRACTION 2. CLOSE REDUCTION TECHNIQUE 3. HIP SPICA POSISTION 4. ADDUCTOR TENOTOMY 5. OSSIFIC NUCLEUS Avascular necrosis following closed reduction for treatment of developmental dysplasia of the hip: a systematic review. Bradley CS et al J Child Orthop. 2016

THE PRESENCE THE FEMORAL HEAD OSSIFIC NUCLEUS.... DECREASE THE RISK OF OSTEONECROSIS Avascular necrosis after the treatment of DDH :the protective influence of the ossific nucleus Segal L JPO 1999. The contribution of the ossific nucleus to the structural stiffness of the capital femoral epiphisis : a porcine model for DDH Segal L JPO 1999 The surgical treatment of established congenital dislocation of the hip. Clarke et al JPO 2005

THE PRESENCE OF THE FEMORAL HEAD OSSIFIC NUCLEUS... WAIT UNTIL THE OSSIFIC NUCLEUS INCREASE THE NEED OF FUTURE SURGERY…… The prognostic importance of the ossific nucleus in the treatment of Congenital Dysplasia of the hip. Luhman s, Shoenecker PL et al JBJS 1998 Reduction of a dislocation of the hip due to DDH: implications for the need for future surgery. Luhman S, Schoenecker et al JBJS 2003 Avascular necrosis rate in early reduction after failed Pavlik harness treatment of developmental dysplasia of the hip. Senaran et al JPO 2007

2009 ... The presence of the ossific nucleus did not alter the development of AVN, but has a protective effect against the development of severe AVN The effect of the femoral head ossific nucleus in the treatment of developmental dysplasia of the hip A meta analysis Roposh et al JBJS 2009

2017….. The current literature does not support the hypothesis that presence of the ossific nucleus at reduction is associated with lower risk of osteonecrosis. Presence of the Ossific Nucleus and Risk of Osteonecrosis in the Treatment of Developmental Dysplasia of the Hip: A Meta-Analysis of Cohort and Case-Control Studies. Chen C et al J Bone Joint Surg Am. 2017 May

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