Carlos Cuevas De Alba, M.D., Pediatric Orthopaedic Research Fellow
S. Jay Kumar, M.D., Attending Pediatric Orthopaedic Surgeon.
August 30, 1995
CLINICAL CASE PRESENTATION
THE ALFRED I. DUPONT INSTITUTE
This is an 11 months old white male patient who had congenital dislocation of right hip. This was first detected 6 weeks of age. The patient was a breech child delivered by C-section. He is the first child for this 38 year old mother. At 6 weeks of age, he was placed in a Pavlik harness but this treatment was unsuccessful. Closed reduction was performed, but the hip redislocated. He was kept in an Ilfield brace for a short time and then had open reduction followed by 3 months in a spica cast. Following removal of the cast he redislocated again, and at that time the patient was referred to this Institute.
Physical exam showed the right hip to be dislocated. X-rays demonstrated a dislocation of the right hip without the presence of an ossific nucleus on the right side suggesting ischemic necrosis. Following traction, open reduction was repeated, with satisfactory results; however subsequent radiographs show an irregular pattern of growth with a tendency for subluxation even though it was treated part time in an abduction brace. X-rays and arthrogram at two years of age show irregular ossification of the femoral head and dysplastic acetabulum, but the hip coverage was acceptable even in adduction. At 5 + 8 years of age , a clinical diagnosis of Charcot-Marie-Tooth disease was made, and Shelf arthroplasty was performed to increase the femoral head coverage. On the last evaluation (10 years old), the patient was pain free, and showed acceptable range of motion, however, his right limb is 3 cms. short and the patient is wearing a 2 cm. shoe lift.
Ischemic necrosis of the proximal femur is an occlusion of a select group of vessels that supply blood to the proximal femur. It is a serious complication not observed in untreated hips; and it may occur in contralateral normal hips after closed treatment. A non-ossified femoral head is more susceptible to experience damage to the blood supply and subsequent necrosis (14% versus 6% in ossified femoral head). Ischemic necrosis may affect the ossific nucleus, with or without involvement of the epiphyseal growth plate (partially or totally). This pathology may produce unsatisfactory long term results, and the changes at maturity cannot be fully predicted from the early changes seen in the femoral head.
Several factors have been attributed to either increase or decrease the risk of ischemic necrosis of the proximal femur:
Recently, a detailed description of DDH in boys reported an increased incidence of the redislocation, and ischemic necrosis of the proximal femur in males more than in female patients:
TYPE OF TREATMENT BOYS GIRLS*
Success of Pavlik harness 0% 0%
Failure of Pavlik harness 7% I.N. 0-28% I.N
Close reduction 45% I.N. 6% I.N
Open reduction 73% I.N. 0-60% I.N.
*Series including boys and girls.
TREATMENT ALGORITHM FOR AVASCULAR NECROSIS:
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