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

2. 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

3. 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

4. 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

5. CLOSE REDUCTION

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

7. 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

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

10. 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 Jun

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

13. 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

14. ROSE THORN SING

17. AFTER CASTING
POST REDUCTION X-RAY

18. 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

22. 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

23. 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

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

25. COMPLICATIONS

26. 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

27. 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

31. 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

32. 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

33.
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

34. 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 May

35. THANKS