THE ROLE OF ARTHOGRAPHY GUIDED
CLOSED REDUCTION
IN REDUCING THE INCIDENCE OF
AVN IN CDH
Published in J Ped. Orthop B 2005
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.
INTRODUCTION
AVN
Hip Arthrogram
INTRODUCTION
Medial adductor approach
INTRODUCTION
Arthrogram
INTRODUCTION
INTRODUCTION
*
“L-distance”
INTRODUCTION
• Type of limbus (Leveuf):
– Normal  type I, sharp “Rose Thorn” sign.
– Everted (subluxation pattern)  type II
– Inverted (dislocation pattern)  type III
INTRODUCTION
*
*
*
INTRODUCTION
Unconcentric
Concentric
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.
MATERIALS & METHODS
• Two groups (closed reduction):
– Group 1  arthrography guided.
– Group 2  no arthrogram.
• Percutaneous adductor tenotomy done
when needed.
• Follow up ≥ 5y.
MATERIALS & METHODS
• F/U:
– 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.
MATERIALS & METHODS
• Chi square 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).
MATERIALS & METHODS
Accepted criteria for reduction
Group 1
• Concentric reduction (of the cartilaginous head).
• < 6 mm lateralization (irrespective of the limbus position).
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.
RESULTS
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•
•
•
•
85 patients.
124 hips.
Female 59 (69%).
Male 26 (31%).
Age  3 -14m (average 7.3)
RESULTS
• Percutaneous adductor tenotomy done in:
– 69 hips of 124 .
– Group 1 = 40/48 (50.6%).
– Group 2 = 29/37 (64.4%).
RESULTS
Comparison of patients in both groups
Group 1
Group 2
(CR with orthography)
(CR without orthography)
Total patients
48
37
Total hips
79
45
7.1
7.6
33 / 15
26 / 11
Mean age
(m)
Female / Male
RESULTS
Occurrence of AVN in both groups
Group 1
Group 2
(CR with orthography)
(CR without orthography)
AVN total
6 ( 7.6% )
13 ( 28.9% )
type I
1
5
type II
2
1
type III
3
3
type IV
0
4
8
8.9
Mean age with AVN
RESULTS
Relationship between classification of limbus & AVN in group I
Type of
limbus
No.
of
hips
F/M
Lateralization
AVN
I
AVN
II
AVN
III
AVN
IV
AVN %
Normal
39
31/8
2 ± 0.5
1
0
0
0
2.6%
Everted
35
29/6
2.7 ± 1.3
0
2
0
0
5.7%
inverted
5
5/0
4.5 ± 0.5
1
0
2
0
60%
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”.
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).
Leveuf J. Primary congenital subluxation of the hip. J Bone Joint Surg [Am] 1947; 29-A : 149-162
Leveuf J. Results of open reduction of true congenital luxation of the hip. J Bone Joint Surg [Am] 1948; 30-A : 875-882
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 : 157-174
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 !
DISCUSSION
Eccentric nucleus
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.
CONCLUSION
C.R. without arthrography guidance is
unsafe
due to high incidence of AVN.
CONCLUSION
Arthrography guided C.R.
less incidence of AVN.
( 7.6% c.f. 28.9% )
CONCLUSION
Inverted type of limbus higher incidence of
AVN c.f. normal or everted limbus.
( 60% c.f. 4.1% )
RECOMMENDATION
Criteria of accepting
arthrography-guided closed reduction
1.
2.
3.
4.
Stable,
Concentric,
Lateralization ≤ 4 mm,
Non-inverted limbus.