A protocol for the use of closed reduction in children with developmental dysplasia of the hip incorporating open psoas and adductor releases and a short-leg cast: Mid-term outcomes in 113 hips.
OBJECTIVE
Our aim was to assess the effectiveness of a protocol involving a standardised closed reduction for the treatment of children with developmental dysplasia of the hip (DDH) in maintaining reduction and to report the mid-term results.


METHODS
A total of 133 hips in 120 children aged less than two years who underwent closed reduction, with a minimum follow-up of five years or until subsequent surgery, were included in the study. The protocol defines the criteria for an acceptable reduction and the indications for a concomitant soft-tissue release. All children were immobilised in a short- leg cast for three months. Arthrograms were undertaken at the time of closed reduction and six weeks later. Follow-up radiographs were taken at six months and one, two and five years later and at the latest follow-up. The Tönnis grade, acetabular index, Severin grade and signs of osteonecrosis were recorded.


RESULTS
A total of 67 hips (51%) were Tönnis grade 3/4 hips. By 12 months, 20 reductions (15%) had not been maintained, and these required open reduction. In all, 55% of these were Severin 1; the others were Severin 2, due to minor acetabular dysplasia. Of the 113 successful closed reductions, 98 hips (87%) were Severin 1. Surgery for residual DDH was offered for ten hips. Osteonecrosis was seen in 32 hips (29%) but was transient in 28. In total, two children (1.5%) had severe osteonecrosis. Bilateral dislocations were significantly more likely to fail and most Tönnis 4 hips failed.


CONCLUSIONS
Closed reduction, with concomitant adductor and psoas release when required and the use of a short leg plaster of Paris cast for three months, can produce good mid-term results in children with DDH aged less than two years. This protocol is not recommended for Tönnis 4 hips. Cite this article: Bone Joint J 2016;98-B:1548-53.
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
S J
SJ
Tennant
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
D M
DM
Eastwood
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
P
P
Calder
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
A
A
Hashemi-Nejad
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK.
A
A
Catterall
D000367:Age Factors; D001175:Arthrography; D002370:Casts, Surgical; D002985:Clinical Protocols; D005260:Female; D005271:Femur Head Necrosis / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D005500:Follow-Up Studies; D006618:Hip Dislocation, Congenital / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D018482:Muscle, Skeletal / Q000601:surgery*; D010027:Osteotomy / Q000379:methods; D016658:Psoas Muscles / Q000601:surgery; D012307:Risk Factors; D017211:Treatment Failure; D016896:Treatment Outcome
Above knee abduction cast; Closed reduction; Developmental dysplasia of the hip; Psoas tenotomy