cdh congenital dislocation of the hip prof. mamoun kremli almaarefa college

CDHCongenital Dislocation of the

HipProf. Mamoun Kremli

AlMaarefa College

Spectrum of diseases

• Abnormality of proximal femur and acetabulum

• Initial pathology is congenital, but• Progresses (becomes worse) if not

treated• Does not always result in dislocation

Nomenclature

• CDH: Congenital Dislocation of the Hip• DDH: Developmental Dysplasia of the

Hip• CDH: Congenital Dysplasia of the Hip• CHD: Congenital Heart Disease!

CDH - Spectrum

• Acetabular dysplasia:– Shallow acetabulum

• Unstable hip: – Dislocatable - Reducible

• Dislocated hip:– May or may not be reducible

• Teratologic hip:– Fixed dislocation at birth,

often with other major anomalies

Incidence

• Hip instability at birth: 0.5 – 1 %

• Classic CDH: 0.1%

• Mild dysplasia: Substantial– Up to 50%of hip arthritis in ladies have

underlying hip dysplasia

Incidence

Area Incidence per 1000

Canadian Indians188.5

Hungary28.7

Uppsala, Sweden20

USA Caucaseans Blacks

15.54.9

Malmo, Sweden2.18

Chinese, Hong Kong0.1

Bantus, Africa0.0 among (16678)

Etiology

Multi-factorial– Ligament laxity– Genetic– Mechanical factors

Etiology

1. Ligament laxity• Hormonal:

– Estrogen, Relaxin: hormones secreted by mothers before birth

– May affect baby girls more? – receptors

• Familial ligament laxity:– Mild – Moderate – Sever– Ehler Danlos Syndrome

Etiology

Ligament laxity: hypermobile joints

Etiology

2. Genetic factors• Twin studies

– Monozygotic: 38%– Dizygotic: 3% (similar to other siblings)– Positive family history

• Females: 4-6 X more than males– Could be hormonal – the effect of

Relaxin hormone produced by mother on female fetus

Etiology

3. Mechanical factors

• Prenatal:– Breach:

•Normally: 2-4%•In CDH: 16%

– The breach position in utero: extended knees, and flexed hips• cause dislocation of hip by ? stretch of

Hamstring muscles

Etiology

3. Mechanical factors• Postnatal:

– Swaddling / strapping hips adducted and extended, and knees extended

الكوفلة – – – الزمام القماط المهاد

Etiology

3. Mechanical factors• Postnatal:

– Swaddling / strapping hips adducted and extended, and knees extended

– Proven experimentally– Proven statistically– Mechanics

Infants at risk

• Positive family history: 10X• A baby girl: 4-6 X• Breach presentation: 5-10 X• Torticollis: CDH in 10-20% of cases

• Foot deformities:– Calcaneo-valgus and

metatarsus adductus

• Knee deformities:– hyperextension and dislocation (Teratologic)

Clinical Examination

• External rotation• Short one side

Clinical Examination

• External rotation• Short one side• Lateralized contour• Wide perineum

– In bilateral

Clinical Examination

• External rotation• Short one side• Lateralized contour• Wide perineum

– In bilateral

• Asymmetrical folds– Anterior - posterior

Clinical Examination

• External rotation• Short one side• Lateralized contour• Wide perineum

– In bilateral

• Asymmetrical folds– Anterior - posterior

Clinical Examination

• Shortening– Might be difficult to

detect early

Clinical Examination

• Limitation of hip abduction in flexion

Clinical Examination

• Limitation of hip abduction in flexion

Clinical Examination

• Limitation of hip abduction in flexion

Clinical Examination

• Special test – Hip Instability:• Ortolani / Barlow

• Feel a Clunk, not hear a click!

Clinical Examination

Ortolani / Barlow

Clinical Examination

• Special test – Hamstring Stretch Sign:– Flex hip and knee 90o, and extend knee

gradually

• Normally:– feel resistance

• CDH:– no resistance

Clinical Examination

• After walking age:– Shortening – (if unilateral)– Limping:

• Unilateral: limping• Bilateral: waddling (like a duck)

Investigation: Radiology

• Early infancy:– X-ray is not reliable – all cartilage– Ultrasound is better

Radiology: X-ray

• After 2-3 months: more reliable

27o 39o

Radiology: X-ray

• After 2-3 months: more reliable

in out

Radiology: X-ray

• After 6 months: reliable– R hip out, and acetabulum open

(dysplastic)

Treatment

• Method depends on age• The earlier started, the easier it is• The earlier started, the better the

results are

• Should be detected EARLY

Treatment

• Birth – 6m– Pavlik harness or hip spica cast

• 6-12 m:– Closed reduction under GA and hip spica cast

• 12 - 18 m:– Open reduction

• 18 – 24 m:– Open reduction and Acetabuloplasty

• 2-8 years:– Open reduction, Acetabuloplasty, and femoral

shortening

• Above 8 years:– Open reduction, Acetabuloplasty cutting all three pelvic

bones, and femoral shortening

Treatment: Neonatal

• Pavlik Harness– Dynamic, effective,

safe– Keeps hips abducted

and flexed – for 6 weeks

Treatment: 6-12 m

• Initially non-operative closed reduction UGA and immobilization in hip spica cast

Treatment: 6-12 m

• Possibly closed reduction– Stable and concentric reduction

• Possibly open reduction– Unstable or un-concentric reduction

• Arthrography-guided

Treatment: 6-12 m

• Arthrography-guided Closed Reduction

Well in Dislocated Not well in

Treatment: 6-12 m

Arthrography-guided Closed Reduction

Too lateralized Acceptable

Treatment: 18-24 m

• Open reduction – surgery• Acetabuloplasty - usually• Maybe: Femoral shortening – if high

Treatment: Above 2 years

• Open reduction, and• Acetabuloplasty, and• Femoral shortening

Salter’s Acetabuloplasty

Operated hip Dislocated hip

Pemberton’s Acetabuloplasty

need a lot of improvement in acetabular cover

Triple Steel Acetabuloplasty

• 12 years old,• Pain L hip

• L hip not wellcovered

• Osteotomy of:• Ilium, Pubic,

and Ischium• Rotation of

acetabulum

Summary

• Complex multi-factorial, endemic disease

• Screening programs are needed to detect and treat cases early

• Learning proper examination methods• Identify at risk groups• Efficient referral system• Proper management by specialized Drs

Summary - Infants at risk

• Positive family history: 10X• A baby girl: 4-6 X• Breach presentation: 5-10 X• Torticollis• Foot deformities• Knee deformities