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Developmental dysplasia of the hip involves a spectrum of disorders resulting from abnormal hip development. Abnormal hip development results in acetabular dysplasia, subluxation of the femoral head, and hip dislocation. Evaluation of the pediatric hip with arthrography demonstrates the cartilaginous anatomy of the acetabulum and femoral head. Arthrography aids in evaluating the congruency of the hip joint, joint stability, femoral head sphericity, and reducibility of the femoral head. Pediatric hip arthrograms are performed in developmental dysplasia of the hip to identify any possible blocks to reduction and confirm adequate closed reduction under anesthesia. Soft tissue barriers to successful closed reduction include an inverted labrum, inverted limbus, ligamentum teres hypertrophy, pulvinar, transverse acetabular ligament hypertrophy, and iliopsoas tendon constriction on the hip joint capsule. This activity describes the examination and highlights the role of the interprofessional team in evaluating pediatric patients who undergo hip arthrography. Objectives: Describe the anatomy of the pediatric hip joint. Summarize the technique for performing a pediatric hip arthrogram. Review indications and contraindications for a pediatric hip arthrogram. Identify normal and abnormal findings on a pediatric hip arthrogram. Access free multiple choice questions on this topic.

Arthrography is a useful resource, especially for pediatric orthopedic surgery. Periarticular structures in pediatric patients can be difficult to identify and assess secondary to the cartilaginous nature. Improved visualization of a given structure is integral to patient care, as this may impact surgical management for a given condition. Arthrography is useful for the evaluation of the pediatric hip joint, specifically as it pertains to developmental dysplasia of the hip. Originally, arthrography was primarily used as an adjunct to radiography for diagnostic joint evaluation. More recently, CT and MRI have replaced arthrography for diagnostic purposes. Arthrography remains a helpful resource in the operating room. While the patient is under general anesthesia, arthrography provides diagnostic information that directly impacts decision-making. The hip radiograph in a pediatric patient cannot yield all the information desired to diagnose or treat developmental dysplasia of the hip. Pediatric hip structures that are cartilaginous are not easily identified on plain radiographs. Hip arthrography can be used to visualize these cartilaginous structures. Hip arthrography aids the pediatric orthopedic surgeon in establishing a diagnosis and treatment for developmental hip dysplasia.[1] Hip arthrography is safe, minimally invasive, quick, and inexpensive when performed correctly.[2] Arthrography is paramount for evaluating and managing pathology in the pediatric hip because it allows for visualization of the femoral head, acetabulum, and any soft tissue blocks to adequate hip reduction.[3] Evaluation of the pediatric hip with arthrography demonstrates the cartilaginous anatomy of the acetabulum and femoral head. Arthrography is a dynamic test to assess the stability and quality of hip reduction. Hip arthrography plays an integral role in the decision between closed and open reduction in patients with developmental dysplasia of the hip.[4]

Complications with hip arthrography rarely occur, but with any procedure, there are risks. Hip arthrogram risks include septic arthritis, allergic reactions, bleeding, contrast reactions, and damage to surrounding structures. Reports have described complications related to the use of air with a double-contrast technique. One case report noted that a near-fatal air embolus occurred after air was injected into a hip joint during arthrography. The authors discouraged the use of air arthrography to confirm intra-articular needle placement.[21] A review study found a single death related to a double-contrast technique with an air embolus injected during a hip arthrogram.[22] Due to these reports, using air with a double-contrast technique is not recommended. It is imperative to properly expulse any air from the intravenous tubing and syringe before contrast injection into the hip joint.

The pediatric orthopedic surgeon’s experience level, the technique of making a hip arthrogram, and the ability to interpret a hip arthrogram are all factors to consider for patients with developmental dysplasia of the hip. Diagnosis and treatment aside, a pediatric hip arthrogram involves an entire interprofessional healthcare team in the operating room. The team includes the pediatric orthopedic surgeon, anesthesiologist, nurse anesthetist, surgical technologist, circulating nurse, and radiology technologist. It is the primary goal of the healthcare team to prioritize the safety of the patient. Patients with developmental dysplasia of the hip commonly undergo frequent radiographic examinations of bilateral hips. During these X-ray examinations, the gonads are exposed to radiation unless a lead shield is used. Although gonad lead shields exist, they often provide inadequate protection secondary to size and improper placement. Gonad lead shields are frequently not used for female patients. A previous study performed a retrospective analysis using a database in which 766 pediatric female pelvic radiographs were reviewed. A gonad lead shield design was then developed using radiographic measurements based on the distance between the anterior superior iliac spine markers. The researchers made custom lead shields based on these measurements. Standard general-purpose lead shields were then compared to the custom design lead shields regarding shielding rates and shielding accuracy. The gonad shielding rate increased from 14.5 to 72.7% after implementing the custom lead shields. The gonad shield accuracy increased from 8.4 to 32.2% after implementing the custom lead shields.[25] A gonad lead shield that is available in multiple different sizes and is placed in the anatomically correct position may decrease the likelihood of gonad radiation exposure during radiographic examinations in patients with developmental dysplasia of the hip.