In the treatment of DDH, open reduction is used in cases where treatment with closed methods fails or when treatment with closed methods is impossible. The most important principle of treatment is gentle and stable reduction. If gentle reduction cannot be achieved with closed methods, the adage "there is no beauty by force" is also valid for DDH treatment. In DDH treatment, no one patient is the same. It requires weighing each patient individually with a precision jeweler's scale. There are two main methods in open reduction. Medial and anterior. The experience of the surgeon plays a decisive role here. In open reduction, the anterior approach is generally the preferred method in cases requiring capsuloplasty. Capsuloplasty may be required in cases of significantly high hip dislocation and joint laxity, usually in children older than 12 months. Some hips may present with high dislocation and other anomalies at a very early stage. In these patients, medial or anterior open reduction can be performed without trying closed methods and by delaying the intervention depending on the case. With the anterior approach, it is possible to make infrommedial capsule incision and psoas tendon incision in less than 12 months. However, in cases where capsuloplasty is not required, folding and maceration may develop in the incision area if the hip is cast in 90° flexion and 30-45° abduction.
What Should We Pay Attention to Before Open Reduction
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Type of dislocation
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Previous treatments
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Another anomaly
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Teratogenic hip
Hip The type of dislocation should be evaluated before open dislocation surgery. The patient may have had a previous unsuccessful cast or long-term Pavlik device application. After this application, AVN at the femoral head may develop to varying degrees. In this case, you have to ensure that the family perceives the incident without criticizing your colleague. For this reason, open surgery can be postponed for a certain period of time to detect changes in the femoral head, without using the words "immediate surgery is required". It may be necessary to delay DDH treatment due to clubfoot, cone knee dislocation, and temporomandibular joint movement limitation, among other anomalies. Teratogenic hip dislocation arthrogrypotic patient I would like to point out that I have encountered this type of hip dislocation twice in 30 years, where open reduction is impossible due to deformity of the femoral head, adhesion of the capsule to the head, and head-acetabular incompatibility. The AVN-like appearance of the femoral head in these hips should be a warning in patients who have never received treatment and have no history of infection.
ANTERIOR OPEN REDUCTION:
Anterior open reduction Smith-Peterson or It is performed through a bikini incision (transverse-oblique). I prefer oblique incision. It is entered with a 3-4 cm incision starting from SIAS. Cutaneus femoris lateralis is entered medially between M.Sartorius and tensor fascia lata. M.Rectus femoris is separated from SIAI. The capsule is released from the supero-lateral and inferomedial. Meanwhile, it moves medially. The right ileus muscle is peeled off the capsule. The psoas tendon is exposed. With the hip in 90° flexion and adduction, the tendon is held over the capsule with the index finger and tension is felt. The tendon is held with a 90° angle clamp and only the tendinous part is cut without cutting the muscle. It is important not to make an insufficient incision here. The most important part of the surgery. It is one of the important steps.
Capsuloplasty:
It is the second important part of the surgery. A 5-7 mm capsule piece is left parallel to the acetabulum from the acetabular attachment point, which will allow re-stitching, and an incision is made extending from superolateral to inferomedial. It is important that the inferomedial capsule incision is not made inadequately. During this process, care should be taken not to cut the medial circumflex vessels. The capsular inverted U flap (20?7-10mm), which widens and thickens due to superolateral dislocation, is removed. Structures that prevent intra-articular reduction: Lig. Teres, Pulvinar, Inf transfer ligaments are cut if necessary. Femoral head reduction and stability are tested. The superior capsule flap is pulled anteriorly and superolateral repair is performed with Vicryl number 2. Closure is performed with the capsule flap turned anteriorly in hip adduction and flexion. The excess capsule is cut. The rectus muscle is stitched back into place. The skin is closed with intracutaneous absorbable sutures. The hip is placed in a pelvipedal synthetic cast in 10-15° Flexion and 25-30° Abduction. There is no need to use drains and blood even in bilateral interventions if good hemostasis is achieved. 2-month plaster fixation after application ti is sufficient. FTR is not required after the cast. A hip abduction device can be used day and night for 3 months, and only at night for 3 months.
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