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Cause and prevention of osteochondritis in congenital dislocation of the hip
J G Pous1, J Y Camous, S el Blidi
1Pediatric Orthopaedic Department, Montpellier Medical School, France.
Insights
Treatments for congenital displacement of the hip (CDH) can cause ischemic necrosis. Reducing intraarticular pressure through careful traction and moderate positioning can lessen this risk.
Area of Science:
- Orthopedics
- Pediatric Surgery
- Biomedical Engineering
Background:
- Congenital displacement of the hip (CDH) treatments carry a risk of proximal femoral epiphyseal ischemic necrosis.
- Increased intraarticular pressure, leading to osteochondritis, is a primary mechanism.
- Factors contributing to increased pressure include muscle spasm, vascular compromise, and newborn microcirculation issues.
Purpose of the Study:
- To investigate the causes of ischemic necrosis in congenital displacement of the hip (CDH).
- To identify risk factors associated with treatment modalities for CDH.
- To outline preventive strategies to reduce the incidence and severity of ischemic necrosis.
Main Methods:
- Comprehensive literature review spanning 30 years.
- Analysis of personal clinical experience with CDH patients.
- Identification of causative factors and risk assessment of various treatment interventions.
Main Results:
- Forced reduction under anesthesia, extreme hip positioning in casts (Lorenz or Lange), inadequate pre-reduction traction, and rigid bracing are significant risk factors.
- Intertrochanteric varus osteotomy during reduction can also precipitate ischemic necrosis.
- Increased intraarticular pressure is a key factor, influenced by muscle spasm and vascular compromise.
Conclusions:
- Preventive measures like adequate traction, moderate casting positions, and dynamic bracing can mitigate risks.
- While no method guarantees prevention, these strategies can reduce the incidence and severity of ischemic necrosis.
- Careful management of intraarticular pressure is crucial in CDH treatment to avoid complications.
Abstract:
All treatment modalities of congenital displacement of the hip (CDH) bear the risk of ischemic necrosis at the proximal femoral epiphysis. The causes of ischemic necrosis were investigated in a review of the literature and personal experience with CDH patients during the past 30 years. Compression of articular cartilage, caused by an increase in intraarticular pressure, has been implicated as the mechanism of osteochondritis. Muscle spasm, pressure on posterior circumflex vessels, and compromised pericephalic microcirculation in the newborn have been demonstrated to increase intraarticular pressure. The most dangerous causative factors include forced reduction under general anesthesia, spica cast immobilization of the hips in the Lorenz or Lange position, insufficient continuous prereduction traction, and splints or braces that are either too rigid or that force the hip into an extreme position. An intertrochanteric varus osteotomy can also lead to ischemic necrosis when performed at the time of reduction. Preventive measures include sufficient continuous traction, casting in a moderate position, and bracing that allows active movement. None of these measures constitute a guarantee against necrosis, but they will lessen the incidence and severity of involvement.