DDH.pptx
Transcript
NEAR EAST UNIVERSITY HOSPITAL ORTOPAEDICS AND TRAUMATOLOGY DEPT. DEVELOPMENTAL DYSPLASIA OF THE HIP Developmental Dysplasia 2 of the Hip DDH - preferred term Teratogenic hips Subluxation Dislocation-usually posterosuperior (reducible vs...
NEAR EAST UNIVERSITY HOSPITAL ORTOPAEDICS AND TRAUMATOLOGY DEPT. DEVELOPMENTAL DYSPLASIA OF THE HIP Developmental Dysplasia 2 of the Hip DDH - preferred term Teratogenic hips Subluxation Dislocation-usually posterosuperior (reducible vs irreducible) Dysplasia Pathoanatomy 3 Ranges from mild dysplasia --> frank dislocation Bony changes Shallow acetabulum Typically on acetabular side Femoral anteversion Pathoanatomy 4 Soft tissue changes Usually secondary to prolonged subluxation or dislocation Intraarticular Labrum Inverted + adherent to capsule (closed reduction with inverted labrum assoc with increased Avascular Necrosis) Ligamentum teres Hypertrophied + lengthened Pulvinar Fibrofatty tissue migrating into acetabulum Pathoanatomy 5 Soft Tissue (Intraarticular) Transverse acetabular ligament Contracted Limbus Fibrous tissue formed from capsular tissue interposed between everted labrum and acetabular rim Extraarticular Tight adductors (adductor longus) Iliopsoas Obstacles to reduction 6 Extraarticular Tight iliopsoas and adductors Intraarticular Labrum Ligamentum teres Transverse acetabular ligament Pulvinar Redundant capsule (hourglass) +/- limbus Etiology and 7 Epidemiology Multifactorial Genetics and Syndromes Ehler’s Danlos Arthrogryposis Larsen’s syndrome Intrauterine environmental factors Teratogens Positioning (oligohydramnios) Neurologic Disorders Spina Bifida Risk Factors 8 1/1,000 born with dislocated hip = with subluxation or dysplasia 80% Female First born children Family history Intermarriage Oligohydramnios Torticollis or vertebral deformities Diagnosis 9 Newborn screening Ortolani’s and Barlow’s maneuvers with a thorough history and physical Warm, quiet environment with removal of diaper Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity etc.) Baseline Neuro and Spine Exam Diagnosis 10 Key physical findings Asymmetry Limb length- Galeazzi Abduction ROM Skin folds Limp Waddilng gait / hyperlordosis - bilateral involvement Ortolani’s Maneuver 11 * After 3 months of age tests become negative Barlow’s Maneuver 12 Diagnosis 13 Some cases still missed At risk groups should be further screened AAP Recs further imaging (e.g. US) if exam is “inconclusive” AND First degree relative + female Breech Positive provocative maneuver (Ortolani or Barlow) Referral to Orthopaedist Imaging 14 Ultrasound Operator dependent X-rays Femoral head ossification center 4 -7 months CT MRI Arthrograms Open vs closed reduction Ultrasound 15 Introduced in 1978 for early evaluation Graf2s technique = Operator independent Useful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum, documenting reducibility Prox. Femoral Ossification Center may interfere Ultrasound 16 Femoral head Abductors Ilium Ultrasound 17 Graf’s alpha angle >60 = normal *line w/ ilium bisects head 50/50 18 Radiographs Summary 19 Femoral head appears 4 - 7 months Shenton’s line Perkin’s and Hilgenreiner’s lines Inferomedial quadrant Acetabular index Normal < 30 (Weintroub et al) Treatment Options 20 Age of patient at presentation Family factors Reducibility of hip Stability after reduction Amount of acetabular dysplasia 21 Birth to Six Months 22 Pavlik harness (1944) Experienced staff* Very successful (20-80%) Allows free movement within confines of restraints *posterior straps for preventing add. NOT producing abd. Birth to Six Months 23 Pavlik harness Indications Fully reducible hip* Child not attempting to stand Family Close regular follow-up (every 1-2 weeks) For imaging and adjustments Duration Childs age at hip stability + 3 months Pavlik Harness 24 Complications Avascular necrosis Forced hip abduction Safe zone (abd/adduction and flexion/extension) Femoral nerve palsy Hyperflexion > 6 months 25 Closed reduction + Spica Failure after 3 weeks of Pavlik trial > 6 months 26 Closed reduction General anesthesia Arthrogram Safe zone - avoid AVN +/- adductor tenotomy Open reduction if concentric reduction not possible Usually teratogenic hips in this age group > 6 months 27 Closed reduction +/- adductor tenotomy Spica in human position of 100 degrees of flexion and about 55 degrees abduction (3 months) Abduction Orthosis 4 wks full time/4 wks nighttime Open reduction (if closed fails) Femoral Shortening 28 Pelvic Osteotomy 29 Summary 30 Best if treated before 6 weeks of age 0 - 6 months of age Pavlik 6 - 18 months Closed vs open reduction and spica 18 - 48 months Closed Open +/- osteotomies Thanks…
