Follow-up regarding the DDH case I sent a while ago. Didn’t receive many responses. Here is what I received.
1)
In this case for example, could you expect the reduction to improve with time as the pulvinar atrophied?
no-
muscle strengthening may help to keep head somewhat in
early cart deg is the rule till pao or replacement is done- I have seen surgeons doing hip replacement at the age of 13 as these hips are supposed to last their lifetime with new polymers
Do you think a case like this one would go back for open reduction at your institution?
hope is to keep it in till pao- persistent symptoms or d/l dictate that- not so much yr findings
Do you agree the laburm is inverted (from what I’m showing you) and does anyone know if surgeons can do anything with this?
These are hypertrophied labrum with tear. I dont report inversion
Or is it usually chronically inverted and scarred in place so to speak? Also, we don’t do post-contrast imaging, but I see there is support for this in the literature. Do the post-contrast images ever swing the pendulum in management?
not needed
2)
Reductions are often not perfect on imaging. Surgeons here value their physical exam more and often leave it alone if the exam is to their satisfaction. I’m typically descriptive if it’s not perfectly aligned with the triradiate cartilage but not obviously out. I think in your case it’s a judgement call on part of the surgeon. Our surgeons might have watched it and re-evaluated at next cast change in a few weeks. After open reduction, the femoral head perfusion in a small percentage of patients is jeopardised. If surgeon thinks the patient is at risk for this, they sometimes ask for MRI with contrast. Or intra-op ultrasound with lumason contrast which is a research application so far.
Take home point for me is to be descriptive and surgeon’s decision based on combination of imaging and clinical factors.
Drew
Hello OCAD-
I’m looking for advice on post-reduction spica MRI interpretation. My MSK fellowship was focused on adolescent and adult imaging. However, I do a decent amount of young pediatric imaging in my job, and it’s definitely an area of discomfort and stress.
I had this case recently, which I’m hoping to learn from and better help these kiddos moving forward. DDH with dislocation. Post-reduction spica MRI showed reduction, but it is non-concentric. There is still a good amount of lateral femoral head subluxation. I think this is largely due to fatty hypertrophy of the pulvinar. I also think the superior labrum is inverted (see red arrow), as I could make this hypointense structure contiguous with anterior labrum when scrolling.
After some discussion with the pediatric orthopedic surgeon on this case, he did decide to take the patient back to the OR for open reduction. I could sense he had some uncertainty on whether to take the patient back to surgery or not, and I’m not sure I helped with that. He ended up resecting the pulvinar hypertrophy and debriding the thickened ligamentum teres. He told me it was hard to tell what was going on with the labrum and didn’t do anything with it. He was happy after taking patient back to surgery and the reduction was definitely improved (images not shown).
My question is, how good of a reduction is good enough? I admittedly haven’t seen a lot of these, but I feel they often don’t look perfectly concentric especially when significant underlying dysplasia. In this case for example, could you expect the reduction to improve with time as the pulvinar atrophied? Do you think a case like this one would go back for open reduction at your institution? Do you agree the laburm is inverted (from what I’m showing you) and does anyone know if surgeons can do anything with this? Or is it usually chronically inverted and scarred in place so to speak? Also, we don’t do post-contrast imaging, but I see there is support for this in the literature. Do the post-contrast images ever swing the pendulum in management? There is a lot I don’t know about this topic.
Thanks for any help.
Drew
