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THE ROLE OF ARTHOGRAPHY GUIDED CLOSED REDUCTION IN REDUCING THE INCIDENCE OF AVN IN CDH

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:

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THE ROLE OF ARTHOGRAPHY GUIDED CLOSED REDUCTION IN REDUCING THE INCIDENCE OF AVN IN CDH

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  1. THE ROLE OF ARTHOGRAPHY GUIDED CLOSED REDUCTIONIN REDUCING THE INCIDENCE OF AVN IN CDH 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

  4. Hip Arthrogram

  5. INTRODUCTION Medial adductor approach

  6. INTRODUCTION Arthrogram

  7. INTRODUCTION

  8. INTRODUCTION * “L-distance”

  9. INTRODUCTION • 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.

  13. MATERIALS & METHODS • Two groups (closed reduction): • Group 1  arthrography guided. • Group 2  no arthrogram. • Percutaneous adductor tenotomy done when needed. • Follow up ≥ 5y.

  14. 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.

  15. 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).

  16. MATERIALS & METHODSAccepted criteria for reductionGroup 1 • Concentric reduction(of the cartilaginous head). • < 6 mm lateralization(irrespective of the limbus position).

  17. MATERIALS & METHODSAccepted criteria for reductionGroup 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%).

  20. RESULTSComparison of patients in both groups

  21. RESULTSOccurrence of AVN in both groups

  22. RESULTSRelationship between classification of limbus & AVN in group I

  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”.

  24. DISCUSSION • Leveuf’s: Docking without damage to the femoral head can occur if the obstacles to concentric reduction wereminimal. (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

  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 : 157-174

  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. CONCLUSION Arthrography guidedC.R. less incidence of AVN. ( 7.6% c.f. 28.9% )

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

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

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