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Year : 2003  |  Volume : 37  |  Issue : 4  |  Page : 244-246
The role of hip arthrography in developmental dysplasia of the hip


Department of Orthopaedics, BJ Wadia Hospital for Children, Parel, Mumbai, India

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   Abstract 

This study was undertaken to evaluate the role of arthrography in facilitating concentric reduction of the hip in children with developmental dysplasia of the hip.
Arthrograms were performed in a total of thirty­two hips with developmental dysplasia. In twenty-two hips it was performed to evaluate the adequacy of closed reduction. In eight hips it was carried out prior to open reduction in order to identify the obstacles to reduction and in two hips the procedure was undertaken to in an attempt to explain why open reduction had failed. Arthrography was found to be most useful in evaluating the adequacy of closed reduction. It did not significantly facilitate pre­operative planning prior to open reduction. Besides not providing additional information, it was also difficult to perform in cases where open reduction had failed.

Keywords: Arthrography - Developmental dysplasia of the hip

How to cite this article:
Singh B, Johari A N. The role of hip arthrography in developmental dysplasia of the hip. Indian J Orthop 2003;37:244-6

How to cite this URL:
Singh B, Johari A N. The role of hip arthrography in developmental dysplasia of the hip. Indian J Orthop [serial online] 2003 [cited 2019 Oct 19];37:244-6. Available from: http://www.ijoonline.com/text.asp?2003/37/4/244/48487

   Introduction Top


The primary goal of treatment in developmental dysplasia of the hip is to obtain and maintain concentric reduction in order to create an optimum environment for development of the femoral head and the acetabulum. [1],[2] . The second goal is to avoid any disturbance of growth in the proximal femur. [3],[4]

The assessment of the adequacy of reduction is often difficult. Plain radiography does not delineate the cartilaginous component of the paediatric hip. On account of this, accurate estimation of the relationship of the femoral head and the acetabulum cannot be made with any degree of confidence. [1],[3],[5] Furthermore, all major impediments to concentric reduction are soft tissue structures, which cannot be visualized on plain radiographs.

Though magnetic resonance imaging (MRI) can delineate all the soft tissue obstacles for reduction, its routine use is not a feasible proposition. [1]

There are many studies in the western literature that have acknowledged the role of arthrography in determining the adequacy of closed reduction. [3],[4],[5],[6],[7],[9]

However, the Indian experience with arthrography has not been sufficiently documented.

This study was undertaken to evaluate the efficiency of arthrography in:

  1. Assessing adequacy of closed reduction of the hip.
  2. Identifying impediments to reduction prior to open reduction and
  3. Facilitating pre-operative planning in cases that required re-operation.



   Materials and Methods Top


In a prospective study, thirty-two arthrograms of the hip were performed in twenty-four children with a median age of eleven months. Arthrograms were performed on twenty-two hips of children undergoing conservative treatment to evaluate the adequacy of reduction. It was performed on eight hips prior to open reduction in order to identify the obstacles to reduction and in two hips the procedure was undertaken to in an attempt to explain why open reduction had failed.

All arthrograms were performed in the operating room under sedation or short general anaesthesia. Intravenous cephalosporin was administered before the procedure. After observing all aseptic precautions and draping the patient, the hip to be studied was flexed and abducted.

Through the perineal approach, a 20 gauge spinal needle was passed in the adductor interval and advanced in the direction of the ipsilateral shoulder. [7],[9] In most cases, the position of the tip of the needle was not confirmed radiologically. We relied on the clinical sign of movement of the limb as the capsule was distended. Two to four ml of ionic contrast medium diluted 1:1 with normal saline was injected into the joint and radiographs were taken in three standard projections viz. neutral, von Rosen's view and in the position of best reduction (flexion + abduction + appropriate rotation).

The hip was considered concentrically reduced if medial pooling of dye in the neutral projection was less than 2 mm and over 75% coverage of the femoral head was present. [3]


   Results Top


a) Assessment of adequacy of reduction

Of the twenty-two hips assessed for adequacy of reduction, eight hips were found to have non-concentric reduction on the basis of the arthrographic findings [Figure 1]. In all eight hips, the femoral head coverage was less than 75% and in seven of the eight hips medial pooling of dye was greater than 2 mm in the neutral projection radiograph. In five of the subluxed hips, an appreciable reduction in the medial pooling of dye was observed in the von Rosen's view [Figure 2a],[Figure 2b]. The remaining fourteen hips, which showed concentric reduction on arthrography, were treated conservatively. Follow up clinical and radiographic examinations over a maximum period of fourteen months displayed stable, reduced hips.

b) Pre-operative assessment

Eight hips were assessed pre-operatively for obstacles that may be encountered during surgery. Narrowing of the introitus, hypertrophy of the labrum and hypertrophy of the pulvinar were identified in all cases. A 'napkin ring constriction' of the capsule was demonstrated in five arthrograms but was found in all eight hips during surgery [Figure 3a],[Figure 3b].

c) Pre-op assessment of cases which required re-operation

Two children in whom previous open reduction had failed were subjected to arthrography in the hope that it would facilitate pre-operative planning. Unfortunately in both cases injection of dye was difficult and it displayed a tendency to extravasate into the surrounding tissue.

In addition to the above, extravasation of the dye hindered visualization in three hips, necessitating repetition of the procedure. There were no cases of contrast reaction or infection.


   Discussion Top


The primary aim of treatment in developmental dysplasia of the hip is to obtain and maintain concentric reduction without jeopardizing the growth of the proximal femur. Evaluation of the adequacy of reduction is often difficult because plain radiography does not delineate the cartilaginous part of the child's hip. Arthrography provides a more accurate assessment of the femoral head-acetabular relationship. In our study we found it extremely useful in assessing the concentricity of closed reduction. This in turn helped us decide whether we should continue with conservative treatment or perform an open reduction. In hips that went on to demonstrate a more concentric reduction in abduction and internal rotation we performed a varus derotation osteotomy in addition to an open reduction. This clearly demonstrates the utility of arthrography in aiding decision making in this situation.

To be adjudged a useful pre-operative tool, arthrography would have to delineate impediments to reduction that would be difficult to visualize while performing an open reduction. However, structures like a hypertrophied labrum, pulvinar and capsular constrictions that were well defined by arthrography were also easily visible during surgery. In fact, structures like the transverse acetabular ligament, which in many instances was not seen on arthrography, were still found to be obstacles to reduction during surgery. Hence, the usefulness of arthrography as a pre-operative tool can be questionable.

We hoped that arthrography would elucidate the cause of failed open reduction and also facilitate planning for revision surgery. Unfortunately, we found injection of dye into the joint to be difficult in these situations and there was a tendency to extravasate when forcefully injected.

In conclusion, we found arthrography to be most useful in evaluating the adequacy of closed reduction and aiding decision making on the further course of treatment from that point. It did not greatly facilitate pre-operative planning prior to open reduction. Besides not providing additional information, it was also difficult to perform in cases where open reduction had failed.

 
   References Top

1.Weinstein S. Developmental dysplasia of the hip. In: Lovell and Winter's Pediatric Orthopedics 5th edn. Phila­delphia; Lippincott, Williams and Wilkins. 2000: 905-956.  Back to cited text no. 1    
2.Renshaw TS. Inadequate reduction of congenital dislo­cation of the hip. J Bone Joint Surg [Am] 1981; 63-A: 1114-1121.  Back to cited text no. 2    
3.Drummond DS, O' Donnell J, Breed A, Albert MJ et al. Arthrography in the evaluation of congenital disloca­tion of the hip. Clin Orthop. 1989; 243: 148-156.  Back to cited text no. 3    
4.Ishii Y, Weinstein SL, Ponsetti IV. Correlation between arthrograms and operative findings in congenital dislo­cation of the hip. Clin Orthop 1980; 153: 138-145.  Back to cited text no. 4    
5.Forlin E, Choi IH, Guille JT, Bowen JR et al. Prognostic factors in congenital dislocation of the hip treated with closed reduction. The importance of arthrographic evalu­ation. J Bone Joint Surg [Am] 1992; 74-A: 1140-1152.  Back to cited text no. 5    
6.Ando M, Gotoh E, Matsuura J. Tangential view arthro­gram at closed reduction in congenital dislocation of the hip. J Pediatr Orthop 1992; 12: 390-395.  Back to cited text no. 6  [PUBMED]  
7.Cortillo JA, Molano C, Albinana J. Correlative study between arthrograms and surgical findings in congeni­tal dislocation of the hip. J Pediatr Orthop B 1998; 7: 62­-65.  Back to cited text no. 7    
8.Ponsetti IV. Morphology of the acetabulum in congeni­tal dislocation of the hip. Gross, histological, and roent­genographic studies. J Bone Joint Surg [Am] 1978; 60­-A: 586-599.  Back to cited text no. 8    
9.Lonnerholm T. Arthrography of the hip in children. Tech­nique, normal anatomy and findings in unstable hip joints. Acta Radiol Diagn (Stockh) 1980; 21: 279-292.  Back to cited text no. 9    

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Correspondence Address:
B Singh
Department of Orthopaedics, BJ Wadia Hospital for Children, Parel,
India
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Source of Support: None, Conflict of Interest: None


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    Figures

  [Figure 1], [Figure 2a], [Figure 2b], [Figure 3a], [Figure 3b]



 

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    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    References
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