Vol 41 # 3 September 2009 - Kma.org.kw

September 2009
KUWAIT MEDICAL JOURNAL 237
Table 1: Patient data, pre-reduction evaluation and post reduction findings
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Sex
F
M
F
F
F
F
F
F
F
F
F
F
F
F
M
F
F
M
F
F
M
F
F
M
F
F
Affected
hip
Rt
Rt
Lt
Lt
Lt
Lt
Lt
Lt
Lt
Lt
Lt
Rt
Rt
Lt
Rt
Rt
Rt
Rt
Lt
Lt
Rt
Lt
Rt
Lt
Lt
Lt
Rt
Lt
Rt
Age at
reduction
(months)
3
1
1
4
1
3
2
3
4.5
6
2
3
3
3
1
4
1.5
1
1
1
3.5
2
3
3
5
1
2
4
2
Prereduction
U/S
(Graf)
II D
III
III
IV
II D
II D
IV
IV
III
III
II D
III
III
III
IV
IV
IV
IV
IV
III
II D
II D
III
Prereduction
radiograph
Tonnis
AC o
Period of
immobilization
(weeks)
Follow-up
(months)
O.R = open reduction, SD = standard deviation, CFE = capital femoral epiphysis, D = decentered hip
2
2
2
2
4
2
45
42
38
40
44
34
9
11
11
8
9
6
11
6
6
6
X
9
8
X
4
X
6
6
6
X
9 x
X
10
10
X
6
8
6
12
24
24
24
24
75
37
30
93
24
24
24
24
24
60
28
28
68
58
44
48
24
26
Normalization
of AC o
2 nd SD
1 st SD
1 st SD
Abnormal
Normal
Normal
1 st SD
Normal
2 nd SD
Abnormal
O.R
border line
1 st SD
O.R
Abnormal
O.R
Normal
Abnormal
Abnormal
O.R
O.R
O.R
Normal
Normal
O.R
Normal
Abnormal
2 nd SD
Normal
Changes in CFE
No changes
No changes
Small
Mottling
Mottling
Small mottling
No changes
No changes
No changes
No changes
No changes
Small
Small
No changes
No changes
No changes
No changes
Mottling
No changes
No changes
Small
No changes
of life with Graf sonographic classification II D and
higher or Tonnis radiographic classification type
2 and higher and a minimum of two years follow
up. The exclusion criteria included all cases with
insufficient data or incomplete follow up, cases
with epiphyseal dysplasia, arthrogryposis or caudal
regression syndrome, all neuromuscular cases or
cases complicated by septic arthritis of the hip.
The final study group included 26 patients (29
hips). In cases where capital femoral epiphysis
(CFE) had not yet appeared Graf sonographic
classification was used (23 hips) [2] . The Tonnis
radiographic classification was used in six hips after
the appearance of CFE.
Normal acetabular angle refers to the angle within
the mean ± 2SD of normal. Any acetabular angle
outside mean ± 2SD is described as abnormal [3] .
Traction (longitudinal followed by overhead)
was used only in five cases because of
high dislocation three out of which had initial
irreducibility. Adductor tenotomy was used only
when the adductors were tight (6 cases).
Closed reduction in all hips was performed
under general anesthesia. Because of its accuracy, the
intra-operative arthrogram (Fig. 1) was used in all
cases to confirm concentric reduction [4] . Reduction
was defined as concentric if the hip was located
anatomically with minimal medial dye pooling.
Clinical stability was assessed according to the
safe zone of Ramsey [5] , The reinforcement of tactile
sensation of the hip stability by visualization during
arthrography is invaluable in the management of
DDH [6] . Hips requiring more than 60° of abduction
were considered unstable and booked later for
open reduction. Post reduction, all cases were kept
in spica cast in the human position [1] . After four to
six weeks all cases underwent removal of spica cast,
re-arthrography and examination under anesthesia.
The plaster (POP) was kept for an average period
of 8.3 weeks (range: 4 -12 weeks). After removal of
spica cast all cases were kept in abduction brace
for an average period of three to six months. The
average period of follow up was 42.4 months (range:
24 – 93 months).
Avascular necrosis of the femoral head was
defined according to the radiographic criteria of
Bucholz & Ogden [7] which includes criteria of AVN
described by Salter [1] supplemented by criteria of