Axial STIR MRI: A faster method for confirming femoral head reduction in DDH

Abstract

Non-concentric reduction of the femoral head within the acetabulum is detrimental to its delicate cartilaginous structure and may result in a growth disturbance. Successful relocation of the dislocated femoral head depends on subtle clinical findings and radiography. The combination of a dislocated femoral head and a severely dysplastic acetabulum can result in a clinical examination that is unhelpful in confirming reduction under anaesthesia. In cases where uncertainty existed regarding head reduction in a spica cast, we performed axial short inversion time inversion recovery (STIR) and axial proton density magnetic resonance imaging (MRI) scans. We retrospectively reviewed the efficiency and accuracy of MRI in confirming femoral head location after closed reduction and spica application in eight children. One hundred and fifty-three cases of developmental dysplasia were treated with examination under anaesthesia and spica application in our unit over a 3-year period. Eight cases where MRI scanning was performed were identified. Before application of the spica cast, we used radiographic screening to assess the stability of the reduction. Absence of the ossific nucleus within the femoral head made confirmation of the location with the image intensifier unreliable. To confirm concentric femoral head location after closed reduction and spica application, we performed an MRI scan in the immediate post-anaesthesia period. All scans were performed within 30 min of application of the spica, and the average time for each scan was 5 min. All eight children who had MRI post-application of the spica had concentric reduction of the femoral head. MRI allowed three-dimensional appreciation of the acetabulum and femoral head. Use of the axial STIR images allows accurate assessment of the cartilaginous ossific nucleus. All patients were discharged the same afternoon and followed up as outpatients. No patient in our group required contrast arthrography. While not indicated in all cases of femoral head dislocation, MRI is useful to confirm concentric reduction of the femoral head in a dysplastic acetabulum when examination under anaesthesia and radiographic screening have been uncertain. In our series, 1 in 20 cases needed MRI. This is a reliable, non-invasive method confirming definite reduction of the femoral head prior to discharge in all of our patients. In this initial series, all patients had axial and coronal STIR and proton density MRI. We now only use axial STIR images because they provide adequate information regarding the position of the femoral head relative to the acetabulum.