1. Published in J Ped. Orthop B 2005
THE ROLE OF ARTHOGRAPHY GUIDED CLOSED REDUCTION IN REDUCING THE INCIDENCE OF AVN IN CDH
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Published in J Ped. Orthop B 2005

2. INTRODUCTION CDH is common in S.A.
AVN is a know major complication of CDH treatment that should be avoided.
Aim of the study:
Compare incidence of AVN in C.R:
Without arthrography,
With Arthrography guidance.
Relation of type of limbus with incidence of AVN.

3. INTRODUCTION
AVN
. AVN has no treatment so far, the acceptance of the risk of AVN in the treatment of DDH is not justifiable, especially that the outcome of no treatment is most of the times better than the outcome of treatment with severe form of AVN.

4. Hip Arthrogram

5. Medial adductor approach
INTRODUCTION .
Medial adductor approach

6. INTRODUCTION Arthrogram
Severin followed by Leveuf provided the earliest description of pathological findings seen in DDH hip orthography.
Arthrogram

7. INTRODUCTION .

8. INTRODUCTION * “L-distance” .
Tanaka et al  normal acetabular cartilage thickness = 0 – 3.5 mm.
Called it the “T distance”.
“L-distance”

9. INTRODUCTION Type of limbus (Leveuf):.
Type of limbus (Leveuf):
Normal  type I, sharp “Rose Thorn” sign.
Everted (subluxation pattern)  type II
Inverted (dislocation pattern)  type III

10. INTRODUCTION * * * .

11. INTRODUCTION .
Unconcentric
Concentric

12. MATERIALS & METHODS A prospective study.
Riyadh College of Medicine & KKUH.
Jan 1992 – 1996.
N = 85 patients.
No prior treatment received.
All  closed reduction & hip spica.
Under G.A, & image intensifier. .

13. MATERIALS & METHODS Two groups (closed reduction):
Group 1  arthrography guided.
Group 2  no arthrogram.
Percutaneous adductor tenotomy done when needed.
Follow up ≥ 5y.
s.c adductor tenotomy done when needed to /i zone of Ramsey.
Way only 6 pt in gp 2 ??.

14. MATERIALS & METHODS F/U: AVN  Kalamchi & MacEwen. 6 wks post C.R:
If stable in extension  broom-stick cast.
Otherwise another spica.
Every 6 wks till hips fully stable:
Good acetabular cover,
Or till covered operatively.
AVN  Kalamchi & MacEwen. .

15. MATERIALS & METHODS Chi square test Fisher’s exact test
(compare the incidence of AVN in both groups).
Fisher’s exact test
(compare between different types of limbus at time of reduction in relation to development of AVN). .

16. MATERIALS & METHODS Accepted criteria for reduction Group 1
Concentric reduction (of the cartilaginous head).
< 6 mm lateralization (irrespective of the limbus position). .

17. MATERIALS & METHODS Accepted criteria for reduction Group 2
Clinical  femoral head felt stable with C.R.
XR  ossific nucleus:
Present  opposite triradiate c. & medial to Perkin’s line.
Not present  normal Von Rosen line & intact Shenton’s line.

18. RESULTS 85 patients. 124 hips. Female 59 (69%). Male 26 (31%).
Age  3 -14m (average 7.3) .

19. RESULTS Percutaneous adductor tenotomy done in: 69 hips of 124 .
Group 1 = 40/48 (50.6%).
Group 2 = 29/37 (64.4%). .
In the normal hips  no AVN.

20. RESULTS Comparison of patients in both groups
(CR with orthography)
Group 2
(CR without orthography)
Total patients 48 37
Total hips 79 45
Mean age (m)
7.1
7.6
Female / Male
33 / 15
26 / 11

21. RESULTS Occurrence of AVN in both groups
(CR without orthography)
Group 1
(CR with orthography)
13 ( 28.9% )
6 ( 7.6% )
AVN total 5 1
type I 2
type II 3
type III 4
type IV
8.9 8
Mean age with AVN
Can I put / total # of pts & hips (as 48/85).

22. RESULTS Relationship between classification of limbus & AVN in group I
AVN IV
AVN III
AVN II
AVN I
Lateralization
F/M
No. of hips
Type of limbus
2.6% 1
2 ± 0.5
31/8 39
Normal
5.7% 2
2.7 ± 1.3
29/6 35
Everted
60%
4.5 ± 0.5
5/0 5
inverted .

23. DISCUSSION Severin’s “Docking Theory”:
“Soft tissue obstructing concentric reduction would yield in time with continuous pressure from the head if the hip is maintained in an appropriate position”.
Might be true for the soft pulvinar, but not so with the more rigid obstacles that will increase pressure on the head also producing AVN.

24. DISCUSSION
Leveuf’s:
Docking without damage to the femoral head can occur if the obstacles to concentric reduction were minimal.
(e.g. everted limbus, minimal lateralization, & mild hour glass constriction).
Can it overcome / iliopsoas conc.???
Leveuf J. Primary congenital subluxation of the hip. J Bone Joint Surg [Am] 1947; 29-A :
Leveuf J. Results of open reduction of true congenital luxation of the hip. J Bone Joint Surg [Am] 1948; 30-A :

25. DISCUSSION
Chuinard:
Femoral head cannot be relied upon to compress all soft tissue obstacles and seat itself normally without adverse effects on the femoral head especially in infants with a mostly cartilaginous femoral heads. .
Chuinard EG. Femoral osteotomy in the treatment of congenital dysplasia of the hip. Orthop Clin North America 1972; 3 :

26. DISCUSSION Attempting C.R without arthrogram depends on:
Feeling good reduction,
Impression on position of the ossific nucleus:
Not present !
If present it may be eccentric.
Impression on amount of lateralization:
Other hip normal, can compare.
Other hip DDH !

27. DISCUSSION
Eccentric nucleus

28. DISCUSSION Still NO treatment for AVN.
Its not justifiable to subject DDH patients to AVN.
Most of the time the outcome of no treatment is better than the outcome of treatment with severe form of AVN.

29. CONCLUSION C.R. without arthrography guidance is unsafe
due to high incidence of AVN. .

30. Arthrography guided C.R.
CONCLUSION
Arthrography guided C.R.
less incidence of AVN.
( 7.6% c.f % ) .

31. CONCLUSION
Inverted type of limbus higher incidence of AVN c.f. normal or everted limbus.
( 60% c.f. 4.1% ) .

32. arthrography-guided closed reduction
RECOMMENDATION
Criteria of accepting
arthrography-guided closed reduction
Stable,
Concentric,
Lateralization ≤ 4 mm,
Non-inverted limbus. .

33. .