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ORIGINAL ARTICLE

Use Of Synthetic Spica Casts For The Treatment Of Congenitally Dislocated Hips

Daniel M. Weigl,  Kalman Katz,  Tali Becker,  Elhanan Bar-On

Pediatric Orthopedic Unit, Schneider Children’s Medical Center of Israel, Petah Tiqwa, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Address for Correspondence:

Daniel M. Weigl
Pediatric Orthopedic Unit
Schneider Children’s Medical Center of Israel
Petah Tiqwa 49202, Israel.
Phone:+972-3-925 3759
Fax    :
+972-3-925 3287
E-mail:
dweigl@bezeqint.net
 

Abstract:

Background  The radiographic assessment of hip placement followed closed reduction is limited when plaster-of-Paris casts are used. The aim of this study was to systematically determine if closed hip reductions treated by fiberglass spica casts are more amenable to evaluation by plain x-ray. 

Methods The study group consisted of 21 children (age 1.5-5 months) treated for congenital dislocation of the hip (total, 23 hips) at a single tertiary pediatric medical center from 2006 to 2008. Hips were immobilized in a full spica cast made of semi-rigid and rigid fiberglass, applied by at least two experienced surgeons. Hip position was verified under fluoroscopy while the child was still under general anesthesia. Follow-up was performed with plain pelvic radiography and computed tomography. At 6 weeks, the cast was changed under general anesthesia and the reduction verified fluoroscopically. Radiograph quality, treatment outcome, and cast-related complications were compared with findings in 21 children treated several years earlier (before introduction of the fiberglass spica cast at our center) by the same team for the same indications with the identical protocol, but with a plaster-of-Paris spica cast.

Results  All bony landmarks of hip reduction in the study group were easily identified on the x-rays at all time points. Computed tomography was noncontributory. In one case, the reduced hip was found to be dislocated under fluoroscopy immediately at the end of the procedure, which allowed for instant re-reduction. Retrospective evaluation of the matched cohort revealed that 2 redislocations were initially missed because of the poor quality of the intraoperative fluoroscopy and x-ray films.

Conclusion  Using fiberglass spica casts after closed reduction in children with developmental dislocation of the hip, clinicians can properly evaluate hip placement on plain x-rays, both after application (for immediate re-reduction, if necessary) and  during follow-up. Furthermore, children are spared unnecessary ionizing radiation from computed tomography scanning.

J.Orthopaedics 2010;7(1)e6

Keywords:

Spica cast; Fiberglass; Hip reduction; CDH.

Introduction:
The plain radiographic assessment of concentric reduction in developmental dislocations of the hip is based on several well-established criteria.1,2 However, in children treated with a plaster-of-Paris spica cast after closed reduction of a dislocated hip, the plaster itself limits the quality of the radiographs, making it difficult for the clinician to identify the exact position of the femoral head.3-9 To overcome this problem, researchers have suggested cutting a window in the plaster above the reduced hip9 or the use of tomography,8 ultrasound,10 computed tomography (CT),3-7 or magnetic resonance imaging.11-13

Most authors today recommend a plaster cast for hip immobilization after closed reduction, and little attention has been addressed to the value of synthetic spica casts in this setting. Our preliminary experience suggested that when a synthetic spica cast is used, a clear view of all established landmarks can be achieved by plain radiography, and the correct position of the hip can be correctly ascertained.

The aim of this prospective study was to systematically determine if closed hip reductions treated by fiberglass spica cast are amenable to evaluation by plain x-ray compared to the commonly used plaster-of-Paris spica cast. 
Patients and Methods:

This prospective cohort study was conducted between January 2006 and April 2008 and included 21 consecutive children with congenital dislocation of the hip (2 bilaterally) who were scheduled for closed hip reduction at our Pediatric Orthopedic Unit after failed treatment with a Pavlik harness. The study protocol was approved by the local medical ethics committee, and the parents of all children provided written informed consent.

The procedure consisted of adductor longus tenotomy (open or percutaneous), hip arthrography, and reduction under fluoroscopy. A printout of the position of the reduced hip, as verified by arthrography, was made, and the  hip's bony relations were evaluated as follows: Shenton’s line; position of the femoral head in the medial lower quadrant produced by the juncture of Perkin's and Hilgenreiner's lines; and alignment of the femoral neck axis with the triradiate cartilage. The children were then immobilized in a full spica cast made of a mixture of semi-rigid and rigid fiberglass. The cast was applied by at least two surgeons: One held the child in position over a spica table, and the other placed the cast. Careful attention was addressed to mold the cast dorsal to the greater trochanters in order to prevent redislocation, and also to the padding at the cast edges.

At the end of the procedure, the child’s hip position was verified under fluoroscopy while he/she was still under general anesthesia. The radiographic criteria for hip reduction were position of the ossified nucleus, if present, at the inferomedial quadrant created by the intersection of the Perkin’s and Hilgenreiner’s lines or alignment of the femoral neck with the triradiate cartilage.

The children were followed in the first and second weeks after reduction by plain pelvic radiograms and CT scans. All images were assessed by a pediatric radiologist and 2 pediatric orthopedic surgeons, and their findings were recorded. At 6 weeks after reduction, the patients underwent a spica cast change under general anesthesia. During the procedure, the hips were examined for stability. The reduction was verified on clinical grounds and by fluoroscopy; arthrography was not performed. The second cast was removed 6 weeks later at the outpatient clinic; there was no need for general anesthesia.

End points for the study were quality of the radiographs after cast placement and cast change, outcome of treatment, and complications due directly to the spica casts.

The findings in the study  group were compared to a group of 21 patients treated at our center by the same team and for the same indications with the identical protocol, but with a plaster-of-Paris spica cast. The control patients all presented from January 2003 to January 2006, before the fiberglass cast was introduced for use in our department. Their data for the present study were collected from the medical files. 

Results :

The study group included 17 female and 4 male patients aged 1.5 to 5 months (average 3.6 months). In 7, the hip dislocation was on the right side, and in 12, on the left; the remaining 2 patients had bilateral dislocations (total, 23 hip dislocations).

The designated bony landmarks of hip alignment (Shenton’s line, position of the femoral head at the inferomedial quadrant created by the juncture of Perkin's and Hilgenreiner’s lines, and alignment of the femoral neck axis with the triradiate cartilage) were all clearly identified on the radiograph after cast placement and cast change, 6 weeks later (Fig.1).

Fig. 1: Pelvic x-ray film 6 weeks after closed reduction of the left hip in a fiberglass spica cast. Note the clear visualization of landmarks: neck axis and head position in the lower medial quadrant.

Twenty-two of the 23 hips were stable at all points of evaluation. In one case, dislocation was demonstrated with the help of fluoroscopy after completion of cast placement, which made it possible to perform immediate re-reduction and recasting while the patient was still under general anesthesia. (Fig.2)

Fig. 2: Pelvic x-ray after completion of cast placement. Right hip dislocation can be clearly seen at the end of the attempted closed reduction. Immediate re-reduction was performed, while the patient was still under general anesthesia. Note the clear visualization of the landmarks: neck axis pointing proximally to the triradiate cartilage.

There were no recurrent dislocations during the follow-up period.

Complications included an extensive skin rash along the encased left limb and buttock, noted at cast change in one child and at cast removal in another. The children were referred to a dermatologist who diagnosed contact dermatitis and prescribed a topical steroid cream. All casts remained aesthetically acceptable, with no breaks and no odor at removal.

The plaster-of-Paris comparison group included 19 female and 2 male patients with a unilateral hip dislocation, 4 on the right side and 17 on the left. The bony landmarks could not be clearly seen on the plain x-ray films. Only on CT scan, performed in all cases to confirm reduction stability, was a redislocation detected in 2 patients. In both these patients, a second attempt at conservative treatment failed, and they underwent open hip reduction.

Discussion :

Our study shows that when hips are immobilized in a synthetic spica cast after closed reduction, clear radiographs can be obtained immediately upon completion of the procedure, while the patient is still under general anesthesia, and during follow-up. In all of our patients treated with the fiberglass spica cast, all the radiological landmarks of hip reduction could be clearly observed. CT scans did not contribute any further information, and were found to be unnecessary in terms of identifying hip location. Thanks to the transparency of the fiberglass spica under fluoroscopy, the single case of closed reduction failure was detected immediately, while the patient was still under anesthesia. By contrast, in the comparison group treated by plaster-of-Paris casts, the plain radiographs were unclear and failed to show redislocation in 2 cases, which was detected only on CT scan. 

Most authors recommend the use of plaster-of-Paris spica casts for their ease of application and of molding after closed hip reduction.2 However, our results show that equally good results can be achieved with synthetic casts when applied by orthopedic surgeons well trained in their use. Furthermore, eliminating the need for CT spares children unnecessary exposure to radiation. Synthetic spica casts have additional advantages over  plaster-of-Paris casts: They are much lighter, making it easier for parents to lift and carry their immobilized children, and  more amenable to daily hygienic care. The main disadvantages of the synthetic spica casts are the need for clinician training in their application and their higher cost.

Skin rash developed during treatment in 2 of our patients and resolved upon removal of the cast. We do not know if the rash was a reaction specifically to the synthetic material. Our search of the literature yielded one report of a patient in whom skin maceration caused by the synthetic cast was complicated by skin infection and septicemia. However, as noted by the authors, the hygienic care of this child was neglected.14

In conclusion, with the use of a synthetic spica cast after closed reduction in the treatment of children with developmental dislocation of the hip, clinicians can properly evaluate hip placement by plain x-rays, both immediately after application of the spica cast and during follow-up. When applied by an experienced physician, the fiberglass cast yields an equally good outcome to the plaster-of-Paris cast, and children are spared the unnecessary ionizing radiation of CT. These findings have important clinical implications given the additional advantages of fiberglass spica casts in terms of lighter weight and hygiene, which ease the burden of care.

Reference :

  1. Herring JA, editor. Tachdjian’s pediatric orthopedics. 3rd ed. Philadelphia: WB Saunders; 2002. p. 530-2.

  2. Morrissy RT, Weinstein SL, editors. Lovell and Winter’s pediatric orthopaedics. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 1011.

  3. Toby EB, Koman LA, Bechtold RE, Nicastro JN.  Postoperative computed tomographic evaluation of congenital hip dislocation. Journal of Pediatric Orthopedics 1987; 7: 667-70.

  4. Smith BG, Kasser JR, Hey LA, Jaramillo D, Millis MB. Postreduction computed tomography in developmental dislocation of the hip. Part I: analysis of measurement reliability. Journal of Pediatric Orthopedics 1997; 17: 626-30.

  5. Browning WH, Rosenkrantz H, Tarquinio T. Computed tomography in congenital hip dislocation. The role of acetabular anteversion. The Journal of Bone and Joint Surgery. American volume 1982; 64: 27-31.

  6. Mandel DM, Loder RT, Hensinger RN (1998) The predictive value of computed tomography in the treatment of developmental dysplasia of the hip. Journal of Pediatric Orthopedics 1998; 18: 794-8.

  7. Stanton RP, Capecci R. Computed tomography for early evaluation of developmental dysplasia of the hip. Journal of Pediatric Orthopedics 1992; 12: 727-30.

  8. Samuelson KM, Nixon GW, Morrow RE. Tomography for evaluation of congenital dislocation of the hip while in a spica cast. The Journal of Bone and Joint Surgery. American volume 1974; 56: 844-5.

  9. Katz K, Yosipovitch Z (1994) Medial approach open reduction without preliminary traction for congenital dislocation of the hip. Journal of Pediatric Orthopedics. British volume 1994; 3: 82-5. 

  10. van Douveren FQ, Pruijs HE, Sakkers RJ, Nievelstein RA, Beek FJ. Ultrasound in the management of the position of the femoral head during treatment in a spica cast after reduction of hip dislocation in developmental dysplasia of the hip. The Journal of Bone and Joint Surgery. British volume 2003; 85: 117-20.

  11. Mitchell PD, Chew NS, Goutos I, Healy JC, Lee JC, Evans S, et al. The value of MRI undertaken immediately after reduction of the hip as a predictor of long-term acetabular dysplasia. The Journal of Bone and Joint Surgery. British volume 2007; 89: 948-52.

  12. Westhoff B, Wild A, Seller K, Krauspe R. Magnetic resonance imaging after reduction for congenital dislocation of the hip. Archives of Orthopaedic and Trauma Surgery 2003; 123: 289-92.

  13. Wirth T, Haake M, Hahn-Rinn R, Walthers E. Magnetic resonance tomography in diagnosis and therapy follow-up of patients with congenital hip dysplasia and hip dislocation. Zeitschrift für Orthopädie und ihre Grenzbegiete 1998; 136: 210-4.

  14. Kremli M. Septic shock with skin ulceration and infection after use of a synthetic hip spica cast for treatment of congenital dislocation of the hip. Annals of Saudi Medicine 2003; 23: 171-2.


 

This is a peer reviewed paper 

Please cite as: Daniel M. Weigl: Use Of Synthetic Spica Casts For The Treatment Of Congenitally Dislocated Hips

J.Orthopaedics 2010;7(1)e6

URL: http://www.jortho.org/2010/7/1/e6

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