title: Does Perfusion MRI After Closed Reduction of Developmental Dysplasia of the Hip Reduce the Incidence of Avascular Necrosis?
abstract: BACKGROUND
  Gadolinium-enhanced perfusion MRI (pMRI) after closed reduction/spica casting for developmental dysplasia of the hip (DDH) has been suggested as a potential means to identify and avoid avascular necrosis (AVN). To date, however, no study has evaluated the effectiveness of pMRI in clinical practice or compared it with other approaches (such as postreduction CT scan) to show a difference in the proportion of AVN.
  
  
  OBJECTIVE
  (1) Can a pMRI-based protocol be used immediately post closed reduction to minimize the risk that AVN would develop? (2) What are the overall hip-related outcomes after closed reduction/spica casting using this protocol? (3) Do any patient-specific factors at the time of closed reduction predict future AVN?
  
  
  METHODS
  This was a retrospective cohort study at a large tertiary care children's hospital. Between 2009 and 2013 we treated 43 patients with closed reduction/spica casting for DDH, of whom 33 (77%) received a postreduction pMRI. All patients were indicated for pMRI per treating surgeon preference. A convenience sample totaling 25 hips in 22 patients treated with pMRI was then established using the following exclusion criteria: DDH of neuromuscular/syndromic origin, failed initial closed reduction, less than 1 year of clinical and radiographic followup, and subsequent open reduction. Next, the 40 patients treated with closed reduction between 2004 and 2009 were screened until the chronologically most recent 25 hips (after applying the previously mentioned exclusion criteria) were identified in 21 of the first 34 patients (62%) screened. Although termed the CT group, specific postreduction imaging was not a defined inclusion criterion in this group with the majority (21 of 25 [84%]) receiving postreduction CT and the remainder (four of 25 [16%]) receiving only postreduction radiographs. All hips with globally decreased femoral head perfusion on postreduction pMRI were treated with immediate cast removal followed by repeat closed reduction or open reduction, as per surgeon preference, with two of 33 (6%) requiring such further interventions. Salter criteria were then used to determine the proportion of AVN on radiographs at 1-year and final followup. Secondary outcomes including residual dysplasia and the need for further corrective surgery were ascertained through radiographic and retrospective chart review.
  
  
  RESULTS
  At 1-year followup there was no difference in the proportion of AVN in the historical CT group as compared with the pMRI group (six of 25 [24%] versus one of 25 [4%]; odds ratio [OR], 7.6; 95% confidence interval [CI], 0.8-363; p = 0.098). However, by final followup there was a statistically higher proportion of AVN in the CT group (seven of 25 [28%] versus one of 25 [4%]; OR, 9.3; 95% CI, 1.0-438; p = 0.049). No patient with normal perfusion on postreduction pMRI went on to develop AVN. In those pMRI patients in whom a successful reduction was initially obtained, two of 25 (8%) went on to require further corrective surgery and one of 25 (4%) had a redislocation event. With the numbers available, no patient-specific factors at the time of closed reduction were predictive of future AVN, including the patient's age/weight, the presence of an ossific nucleus, history of previous bracing treatment, or the abduction angle in spica cast.
  
  
  CONCLUSIONS
  A pMRI-based protocol immediately after closed reduction/spica casting may decrease the risk of AVN by helping the surgeon to evaluate femoral head vascularity. Although preliminary in nature, this study could serve to guide further investigation into the potential role of pMRI for the treatment of patients who require closed reduction/spica casting for DDH.
  
  
  METHODS
  Level III, therapeutic study.
authors.affiliation: Division of Orthopaedics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
authors.forename: Alex L
authors.initials: AL
authors.lastname: Gornitzky
authors.affiliation: Division of Orthopaedics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Georgiadis
authors.affiliation: Division of Orthopaedics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Seeley
authors.affiliation: Division of Orthopaedics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
authors.forename: B David
authors.initials: BD
authors.lastname: Horn
authors.affiliation: Division of Orthopaedics, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA. sankarw@email.chop.edu.
authors.forename: Wudbhav N
authors.initials: WN
authors.lastname: Sankar
mesh_terms: D002370:Casts, Surgical; D005260:Female; D005270:Femur Head / Q000098:blood supply* / Q000000981:diagnostic imaging; D005271:Femur Head Necrosis / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D006618:Hip Dislocation, Congenital / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006621:Hip Joint / Q000002:abnormalities / Q000503:physiopathology / Q000601:surgery*; D006776:Hospitals, Pediatric; D006801:Humans; D015994:Incidence; D007223:Infant; D008279:Magnetic Resonance Imaging; D008297:Male; D016017:Odds Ratio; D019637:Orthopedic Procedures / Q000009:adverse effects*; D055420:Perfusion Imaging / Q000379:methods*; D015143:Philadelphia / Q000453:epidemiology; D011237:Predictive Value of Tests; D012039:Regional Blood Flow; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome