Post-closed reduction perfusion magnetic resonance imaging as a predictor of avascular necrosis in developmental hip dysplasia: a preliminary report.

INTRODUCTION: Avascular necrosis (AVN) of the femoral head remains a major complication in the treatment of developmental dysplasia of the hip (DDH) in infants. We performed a retrospective analysis to look at the predictive ability of postclosed reduction contrast-enhanced magnetic resonance imaging (MRI) for AVN after closed reduction in DDH. METHODS: Twenty-eight hips in 27 infants (aged 1-11 months) with idiopathic hip dislocations who had failed brace treatment underwent closed reduction +/- adductor tenotomy and spica cast application under general anesthesia. Magnetic resonance imaging of the hips after intravenous gadolinium contrast injection for evaluation of epiphyseal perfusion was obtained immediately after cast application. Patients were followed with serial radiographs for a minimum of 1 year after closed reduction. Presence of AVN was determined by the presence of any one of the 5 Salter criteria by 2 readers. Magnetic resonance imaging was graded as normal, asymmetric enhancement, focal decreased enhancement, or global decreased enhancement by 2 radiologists. RESULTS: Six (21%) of 28 hips showed evidence of clinically significant AVN on follow-up radiographs. Fifty percent of the hips with AVN, but only 2 of 22 hips without AVN, showed a global decreased MRI enhancement (P < 0.05, Fisher exact test). Multivariate logistic regression indicated that a global decreased enhancement was associated with a significantly higher risk of developing AVN (P < 0.01), independently of age at reduction (P = 0.02) and abduction angle. CONCLUSIONS: In addition to accurate anatomical assessment of a closed reduction in DDH, gadolinium-enhanced MRI provides information about femoral head perfusion that may be predictive for future AVN. At present, it is premature to use the perfusion information for routine clinical use. However, it opens the door to studies looking at repositioning or alternative reduction methods that may reduce the risk of AVN in this higher risk group.

Chronic recurrent anterior sternoclavicular joint instability: results of surgical management.

Chronic anterior sternoclavicular joint (SCJ) instability may cause pain and persistent functional limitation in active patients. Although SCJ reconstruction and medial clavicular resection have been advocated in these situations, the results of surgical treatment are not well characterized. The purpose of this investigation was to determine the functional outcome of surgical treatment in adolescent and young adult patients with chronic recurrent anterior SCJ instability. Fifteen patients with chronic recurrent anterior SCJ instability refractory to nonoperative therapy who underwent joint reconstruction or medial clavicular resection were evaluated for pain and function using the American Shoulder and Elbow Surgeons (ASES) Standard Shoulder Assessment Form and the Simple Shoulder Test (SST). At average follow-up of 55 months, the mean ASES score was 85 and the mean SST score was 10.9. Sixty percent of patients reported stable, pain-free joints, although 87% (n = 13) reported some limitations of athletic or recreational activity. There were no surgical complications, and no patient underwent subsequent revision procedures. Although subsequent activity modification is often required, surgical treatment of chronic anterior SCJ instability in adolescents and young adults can provide near-complete pain relief and return of shoulder and upper extremity function.