Developmental Dysplasia Of The Hip PDF

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…