ddh

• Dr. Sushil Paudel Management of Developmental Dysplasia of Hip

Developmental dysplasia of the hip (DDH) : spectrum of disorders of development of hip that present in different forms at different ages

Structures that make up hip are normal during embryogenesis and gradually become abnormal for a variety of reasons, chiefly fetal position and presentation at birth (malposition of the femoral head, abnormal forces acting on developing hip) and laxity of ligamentous structures about hip joint

Evolves over timeSyndrome in newborn:

instability of hip; subluxated or dislocated, dislocated position and be reducible on examination

Over time, femoral head becomes fully dislocated and cannot be reduced by changing position of the hip

Teratologic dislocation of the hip: distinct form of hip dislocation that usually occurs with other disorders

Dislocated before birth, have limited range of motion, and are not reducible on examination.

Associated with other neuromuscular syndromes, as myelodysplasia and arthro-gryposis

Affected hip slides in &outFlattenened posterior border

of acetabulumLoose capsule

Everted labrumbirth

uncorrectedcorrected

Secondary barriers

DOCKING OF THE FEMORAL HEAD

NEOLIMBUS(CLUNK)

PATHOGENESIS

SECONDARY BARRIERS

PULVINARLIGAMENTUM TERESTR.ACETABULAR LIGINVERTED LABRUM

CAPSULEILIOPSOAS

REDUCED-DOCKING

POINT OF REDUCIBILITY:?HARRIS et al: 4 yrs

HOURGLASS CONSTRICTION“CHINESE FINGER TRAP”

UNREDUCED

ACETABULAR ROOF FLATTENINGTHICKENED MEDIAL WALLDYSTROPHIC CARTILAGE

SUBCHONDRAL CYSTSLOSS OF CARTILAGE

OSTEOPHYTES

ACETABULARCHANGES

Management

Making the Diagnosis

High index of suspicionIdentifying risk factorsCareful physical

examinationProvactive dynamic

testsRisk baby evaluation by

USGRadiological evaluation

Clinical Features : Neonates

BARLOW’S TEST ( bahar lo)


ORTOLANI SIGN


Delicate “clunk” that is palpable but not audible

Repeat sequence 4-5 times to be certain of findings

If both signs negative but pt is high risk : follow up is essential

Clinical features : InfantsProgression from

instability to dislocation is gradual process

In some within a few weeks

others the hip dislocation remains reducible up to 5 or 6 months of age.

When the hip no longer reducible, specific physical findings appear

Limitation of Abduction

MOST RELIABLE SIGN

Galeazzi’s Sign

Asymmetric gluteal, thigh, labial folds

Telescopy

Klisic’s Test

Walking child:

LLD↓AbductionTip-toe-walkingTrendelenberg gaitWaddling [B/L]↑lumbar lordosis

Clinical Features : Walking Child

• Trendelenburg's sign

• Trendelenburg gait

Radiological evaluation Dysplasia Subluxation Dislocation

Each stage has a different radiological presentation

Ultrasonography

– lpha angle measures bony acetabuluBeta angle measures cartilagenous acetabulum

Ultrasonography

• Harcke & Kumar technique:– Dynamic examination with stress views that mirror

Barlow’s & Ortolani’s maneuver

Graf classification

RadiographsNewborns 27.5 degrees6 months 23.5 degrees2 years 20 degrees

Centre – Edge Angle Wiberg

6 – 13 years >19 degrees>14 years > 25 degrees

ANDREN-von ROSEN LINE

AP X-ray: hip in 45°abduction and IR Describes the longitudinal relationship between long axis of femur and acetabulum

Imaging

• Radiographs

Imaging

• Acetabular Index

Imaging

• Acetabular Index

< 30 wnl

Tear dropAP X-rayLateral:wall of acetabulumMedial:lesser pelvisInferior :acetabular notch

Appears between 6-23 mo[delayed in DDH]V-shaped in DDH

False Profile view

Arthrogram Severin [1941]Normal appearance:LABRUM:*Thorn over the

femoral head

*A recess of joint capsule overlies the thorn

Arthrogram in DDH

SUBLUXATED HIP DISLOCATED HIP

Imaging Tools

• CT scan:– Single section CT as check films– Neglected C.D.H.– Adolescent and adult

• MRI:– Equivalent to arthrography

Diagnosis

Reduction

maintain

Intervene adverse natural history

Ensure normal adult hip

Screening

• All neonates should have a clinical examination for hip instability

• Risk factors :– breech presentation– family history– torticollis– oligohydramnios– metatarsus adductus

USG SCREENING

http://www.ejbjs.org/cgi/content/full/85/9/1824/G07

CLINICAL USG

normal normal

&

normal ABnormal

REPEAT AT 6 WKS

normalABnormal

REPEAT AT 3 & 6 WKS

Clinical & USG normal

ABnormal

Closed / open reduction

F/U till maturityABnormal

Infant 1 – 6 months of Age

First choice is PAVLIK harness

Ensure hip > 90 degrees flexion

AP radiograph Does not have to be

reducible initially

Infant 1 – 6 months of age

weekly clinical examination & USGBy 3 weeks stable reduction mustContinue till radiographs show normal

acetabulum

Results : 95% of initially dysplastic hips normal 80% dislocated and not initially reducible were successfully reduced Higher dislocations had a higher failure rate The rate of AVN was 2.38%.

Grill F, Bensahel H, Canadell J, et al: J Pediatr Orthop 1988; 8:1.

Pavlik harness

Standard of treatment worldwideUpto 6 months Contraindicated when there is major muscle

imbalance (myelomeningocele, AMC or ligamentous laxity)

Complications of Pavlik Harness

• AVN• Failure to reduce• Femoral nerve

neuropathy• Inferior dislocation• Pavlik’s disease (flattening

posterolateral acetabulum)

Follow upThe child should be followed till

skeletal maturity

Increased risk of asymmetric physeal closureValgus deformity of the neck

Child 6 months to 2 years of age

• Closed or open reduction + adductor tenotomy

• If closed reduction fails then surgeon should be prepared for an open procedure

Closed reduction

Force should be avoidedCheck for safe zonePost reduction:

Spica change every six weeks plus stability check

Continue spica for 3-4 months

Safe Zone

20 to 30 degrees frommaximum abduction

extended to below 90 degreeswithout redislocation

Safe zone can be improvedwith adductor tenotomy

Open reduction

Unable to achieve closed reduction

Widening of the joint space

Unstable reductionsLoss of reduction on

follow upAdvanced age

Approach

MedialMinimal dissectionObstructions

encountered directly

BUT.. Limited viewMFCA violationNo capsulorrhaphySecondary procedures

AnteriorBetter exposureCapsulorrhaphyPelvic osteotomy

possible BUT..

Blood loss Iliac crest apophysis and

abductors damageStiffness of hip

Medial approach

Anterior approach

• Smith-Peterson anterior approach

• Stood the test of time• More commonly used • Bikini incision better

cosmetic results

Open Reduction with Femoral Shortening

• Pressure leads to risk of AVN• Better results than preoperative traction in older

children with less morbidityWhen to do??

• Anticipated increased pressure on reduced femur head• Recommended in child > 2yrs.• distract the joint few millimeter per operatively• Judge the tightness of soft tissues after reduction• irreducible dislocation

How much shortening?

• Pre op: bottom of the femoral head to the floor of the acetabulum (a to b)

• amount of overlap is noted after osteotomy• Tension of the soft tissue• Derotation usually combined

leaving 15 to 20 degrees of anteversion

Derotational femoral shortening osteotomy

2 Years of Age and Older

• For child 2 -3 years of age, during open reduction acetabular coverage if insufficient warrants reorientation osteotomy

• If coxa valga with excessive anteversion, VDRO may be done.

• Children > 3 years usually need an osteotomy

Bilateral untreated dislocation upto 5 years: Open reduction with femoral shortening with

salter / pemberton osteotomy with gap of 5-6 weeks.

Bilateral untreated subluxation upto 5-6 years: Open reduction + salter osteotomy.

Residual Dysplasia

Pelvic osteotomy

Re- orientation

Innominate

Periacetabular Triple

Augmentation

Shelf procedures Chiari

Acetabular Reorientation-Innominate Osteotomy

• Articular hyaline cartilage over femur head• Types:– Salter’s (innominate)– Sutherland’s (double innominate)

Salter’s Osteotomy

Redirects the entire acetabulumRoof “covers” the femoral head anteriorly and

superiorlyHinge at pubic symphysis

Pre-requisites Congrous Concentric reduction No Contractures

Salter’s osteotomy

Sutherland’s Osteotomy

1. Can be done for older child

2. Allows medial displacement

Peri-acetabular Ostetomies

• Provide greater correction of acetabular index• Reduce volume of hip joint• Possibility of growth disturbances

Types– Pemberton’s – Dial (Eppright) – Wagner – Dega’s– Ganz osteotomy (Bernese)

Pemberton’s Osteotomy

Pemberton’s Osteotomy

1. Incomplete2. Hinges at

triradiate cartilage

Dega’s Osteotomy

1. Incomplete2. Variable hinge3. Allows anterior,

lateral & posteriorcoverage

Ganz Osteotomy

Larger corrections all directions

Blood supply preserved

Shape of true pelvis unaltered

Technically demanding

Triple Osteotomies

Indication : Adolescent requiring more than 25° correctionPre-requisite:

Functional range of motiononly mild subluxation acceptable

Types:• Steel (Inferior)• Tonnis (Posterior)• Tachdjian - subinguinal adductor

Triple Osteotomies

STEEL TONNIS TACHDJIAN’S

Shelf Procedure

Chiari Osteotomy

Adolescent and young adult(older then 8-10 years

If femoral head cannot be repositioned distally to the level of acetabulum : Salvage procedures

Degenertive arthritis and enough pain and limitation of movements – reconstructive operation (total hip replacement)

Arthodesis – rarely done, contraindiacted for bilateral dislocation

Schanz osteotomy

Very late salvage

Joint replacementConsider for: Severe arthritis Failed “

conservative” Rx. Bilateral disease

ddh

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