DDH

Congenital Dislocation of Hip: 

Congenital Dislocation of Hip By Dr. Ganesh R. Yeotiwad JR-2 ↓ Dr. S.A.JAGTAP

PowerPoint Presentation: 

Definition Displacement of femoral head from its normal position within the acetabulum at birth.

Previously known definition!!! Developmental Dysplasia of Hip Development – embryonic fetal and infantile periods. Dysplasia: Dislocation: Subluxation: : 

Previously known definition!!! Developmental Dysplasia of Hip Development – embryonic fetal and infantile periods. Dysplasia: Dislocation: Subluxation:

Normal Growth and Development : 

Normal Growth and Development Primitive mesenchymal cells – Acetabulum, femoral head. 7th week - cleft develops in mesenchymenof primitive limb bud 11wk - hip joint fully formed acetabular growth continues throughout intrauterine life birth femoral head - deeply seated in acetabulum by surface tension of synovial fluid

Development con’t: 

Development con’t Main stimulus for concave shape of the acetabulum – presence of spherical head For normal depth of acetabulum to increase – several factors play a role : Spherical femoral head Normal appositional growth within cartilage Periosteal new bone formation in adjacent pelvic bones

DDH: 

DDH “ NEOLIMBUS” 98% DDH that occur around or at birth have these changes and are reversible in the newborn

Epidemiology: 

Epidemiology 1 in 100 newborns - instability 1 in 1000 live births true dislocation Most detectable at birth in nursery Barlow stated that 60% stabilize in 1st week and 88% stabilize in first 2 months without treatment remaining 12% true dislocations and persist without treatment

Etiology: 

Etiology Genetic and ethnic Positive family history 12-33% Intrauterine factors Breech position ( normal pop’n 2-4% , DDH 17-23% ) Oligohydroamnios Neuromuscular conditions like myelomeningocele High association with intrauterine molding abnormalities-- metatarsus adductus and torticollis first born female baby ( 80% cases) left hip more common

pathphysiology: 

pathphysiology Neolimbus Pulvinar Ligamentus teres Transverse acetabular ligament Hour glass shape of inferior capsule of hip

Clinical presentations: 

Clinical presentations NEONATE: Ortolani’s test Barlow’s test

Diagnosis: 

Diagnosis Physical exam Ortolani Test hip flexion and abduction , trochanter elevated and femoral head glides into acetabulum

PowerPoint Presentation: 

Ortolani

PowerPoint Presentation: 

Barlow Test provocative test where hip flexed and adducted and head palpated to exit the acetabulum partially or completely over a rim

PowerPoint Presentation: 

Barlow

Clinical presentations: 

Clinical presentations INFANTS: Limited abduction Galazzi sign Asymmetry of thigh folds Proximal location of GT KLISIC TEST for bilateral DDH

Clinical presentations: 

Clinical presentations Walking child: Shortening Toe walking on affected side Abductor lurch or trendenlenberg’s lurch Limited abduction Gallezi sign

Clinical presentations: 

Clinical presentations Bilateral DDH: Excessive lordosis Back pain Knees are at same levels Abduction limited but symmetric Widened perineum,prominent gt Waddling gait

PowerPoint Presentation: 

Galleazi sign flex both hips and one side shows apparent femoral shortening

Diagnosis: 

Diagnosis Clinical Radiological: Ultrasonography X-ray Arthography CT/MRI

Radiography: 

Radiography ULTRASONOGRAPHY: Features Empty acetabulum Inverted limbus Hourglass constiction of capsule Graph classification Alpha angle ( normal: > 60 degree) Beta angle ( normal: <55 degree)

Graph Classification: 

Graph Classification

Graph Classification: 

Graph Classification

Graph Classification: 

Graph Classification

X-ray: 

X-ray 6 weeks Von Rosen view- 45 0 abduction 25 0 internal rotation Normal femur shaft points towards triradiate cartilage In CDH femoral shaft points towards ileum

Radiological Diagnosis: 

Radiological Diagnosis Classic features increased acetabular index ( n=27, >30-35 dysplasia) disruption shenton line ( after age 3-4 should be intact on all views) absent tear drop sign center-edge angle useful after age 5 . Normal 20 0 -46 0 Proximal migration of femoral head Irregular maturation of ossification centre Delayed appearance of capital epiphysis

ARTHROGRPHY: 

ARTHROGRPHY To see intrarticular changes hourglass configuration of capsule inverted limbus Anteversion of femoral neck To confirm reduction Detection of mild dysplasia

Adults: 

Adults Variable Depends on 2 factors well developed false acetabulum ( 24 % chance good result vs 52 % if absent) bilaterality In absence of false acetabulum patients maintain good ROM with little disability Femoral head covered with thick elongated capsule False acetabulum increases chances degenerative joint disease Hyperlordosis of lumbar spine assoc with back pain Unilateral dislocation has problems leg length inequality, knee deformity , scoliosis and gait disturbance

Treatment 0 to 6 months: 

Treatment 0 to 6 months Goal is obtain reduction and maintain reduction subluxation often corrects after 3 weeks and may be observed without treatment if persists on clinical exam or US beyond 3 weeks treatment indicated actual dislocation diagosed at birth treatment should be immediate

Treatment: 

Treatment 0 to 6 months: Pavlik Harness preferred prevents hip extension and adduction but allows flexion and abduction which lead to reduction and stabilization success 95% if maintained full time six weeks > 6 months success < 50% as difficult to maintain active child in harness

Pavlik Harness: 

Pavlik Harness Consists of: Chest strap 2 Shoulder straps 2 Stirrups : Each stirrup has anteromedial flexion strap & posterolateral abduction strap

Pavlik Harness: 

Pavlik Harness Chest strap at nipple line 2 shoulder straps set to hold cross strap at this level Anterior strap flexes hip 100-110 degrees Posterior strap prevents adduction and allow comfortable abduction safe zone arc of abduction and adduction that is between redislocation and comfortable unforced abduction

Pavlik con’t: 

Pavlik con’t Monitoring done by USG every 3 weeks. After 6 weeks Hip examine out of harness and USG performed

PowerPoint Presentation: 

Normal Discontinue harness F/up at 3-4 months X ray if normal Follow up after 1 year Standing x-ray if normal Follow up upto skeletal maturity

Complications : 

Complications Failure poor compliance , inaccurate position and persistence of inadequate treatment ( > 2-3- weeks) 4 types of persistent dislocations: Superior, inferior, lateral, posterior Treatment closed reduction and Spica Casting Femoral Nerve Compression due to hyperflexion Skin breakdown Avascular Necrosis

6 months to 2 years age: 

6 months to 2 years age Presentation – Short extremity - Positive Gallezi’s sign - Limited Passive Abduction - X-Ray s/o -delayed ossification of femoral head -lateral & proximal displacement of femoral head - Shallow &Dysplastic acetabulum

6 months to 2 years age: 

Preoperative traction – Controversial. Adductor tenotomy Closed Reduction & Arthrogram Open Reduction 6 months to 2 years age

Traction: 

Traction Human position –hip 90 -100 degree and abduction 30-60 degree Bryants position : hip flexion 90 degree and knees extended Frog position- more risk of avn Lorenz –flexion 90 /abd 70

Closed Reduction: 

Closed Reduction closed reduction preformed in OR under general anesthetic manipulation includes flexion, traction and abduction reduction must be confirmed on arthrogram as large portion of head and acetabulum are cartilaginous dynamic arthrography helps with assessing obstacles to reduction and adequacy of reduction reduction maintained in spica cast well molded to greater trochanter to prevent redislocation

Closed Reduction: 

human position of hyperflexion and limited abduction preferred avoid forced abduction with internal rotation as increased incidence of proximal femoral growth disturbance cast in place for 6 weeks then repeat Ct scan to confirm reduction casting continued for 3 months at which point removed and xray done then placed in abduction orthotic device full time for 2 months then weaned Closed Reduction

Open Reduction: 

Open Reduction Open reduction indicated if : failure of closed reduction, persistent subluxation. Approaches – Anterior - Anteromedial - Medial

Open Reduction: 

Open Reduction Anterior approach by Somerville technique Transverse incision: Wider exposure Dissection difficulty Capsulorrhapy allows reduction and capsular plication and secondary procedures like pelvic osteotomy disadv- > blood loss, damage iliac apophysis and abductors, stiffness After surgery: Spica cast

Open Reduction con’t: 

Open Reduction con’t Medial approach Ludloff’s( between pectineus and iliopsoas) approach directly over site of obstacles with minimal soft tissue dissection unable to do capsular plication so depend on cast for post op stability increased incidence of damage to medial femoral circumflex artery and higher AVN risk After surgery : below knee spica is applied in human position.

Open Reduction con’t: 

Open Reduction con’t Anteromedial approach Weinstein & Ponsetti ( between neurovascular bundle and pectineus) direct exposure to obstacles, minimal muscle dissection no plication or secondary procedures

Follow-up : 

Follow-up Abduction orthotic braces commonly used until acetabular development caught up to normal side in assessing development look for accessory ossification centers to see if cartilage in periphery has potential to ossify secondary acetabular procedure rarely indicated < 2 years as potential for development after closed and open procedures is excellent and continues for 4-8 years most rapid improvement measured by acetabular index , development of teardrop occurs in first 18 months after surgery

Obstacles to Reduction: 

Obstacles to Reduction Extra- articular Iliopsoas tendon adductors Intra-articular inverted hypertrophic labrum tranverse acetabular ligament pulvinar, ligamentum teres constricted anteromedial capsule espec in late cases *Neolimbus is not an obstacle to reduction and represents epiphyseal cartilage that must not be removed as this impairs acetabular development

2 YEARS TO OLDER: 

2 YEARS TO OLDER Open reduction usually necessary Femoral osteotomy Varus derotation osteotomy

PowerPoint Presentation: 

age > 3 femoral shortening recommended to avoid excess pressure on head with reduction age > 3 recommend open reduction and femoral shortening and acetabular procedure most common osteotomy is Salter or Pemberton anatomic deficiency is anterior and Salter provides this while Pemberton provides anterior and lateral coverage

PowerPoint Presentation: 

Pelvic osteotomy Osteotomy of Innominate bone (Salter) Acetabular Plasty (Pemberton) Triple Innominate osteotomy (Steel) Shelf Operation Chiari’s osteotomy

Osteotomy of Innominate bone (Salter) : 

Osteotomy of Innominate bone (Salter) Only indicated when any subluxation has been or can be reduced by open surgery at the time of osteotomy. Principle :- In CDH acetabulum faces more anteriorly & laterally In hip extension anterior coverage & in adduction superior coverage is poor Salter redirects acetabulum to covere femoral headd anteriorly & superiorly

Pemberton’s acetabuloplasty: 

Pemberton’s acetabuloplasty Pericapsular osteotomy of ileum It redirects acetabulum anteriorly & laterally Greater degree of correction can be achieved Difficult

Steel osteotomy: 

Steel osteotomy Its tripple innominate osteotomy Ischium, superior pubic rami & ileum superior to acetabulum are devided Acetabulum repositioned by bone grafts & pins Objective is to establish stable hip in anatomical position

Shelf osteotomy: 

Shelf osteotomy Performed to enlarge volume of acetabulum Pelvic redirectional & displacement osteotomies replaced this procedure Primary indication- deficient acetabulum that cannot be corrected by redirectional pelvic osteotomy Contraindication- dysplastic hips

Chairi osteotomy: 

Chairi osteotomy Its capsular interposition arthroplasty Indications - congenital subluxation upto 4-6 yrs - untreated CDH >4 yrs - dysplastic hip with osteoarthritis It places femoral head beneath cancellous bone with the capacity for regeneration & corrects lateral pathological displacement

Ganz procedure: 

Ganz procedure Periacetabular osteotomy Used in adolescents & adults with dysplastic hips Advantages - only one approach is used - large amount of corerction obtained in all directions - blood supply to acetabulum is preserved - shape of the true pelvis is unaltered

PowerPoint Presentation: 

Osteotomy Age Indications Salter innominate osteotomy 18 months-6 years Congruous hip reduction; <10-15 degrees correction of acetabular index required Pemberton acetabuloplasty 18 months-10 years > 10-15 degrees correction of acetabular index required; small femoral head, large acetabulum Steel or Ganz osteotomy Late adolescence to skeletal maturity Residual acetabular dysplasia; symptoms; congruous joint Shelf procedure or Chiari osteotomy Adolescence to skeletal maturity Incongruous joint; symptoms; other osteotomy not possible Recommended Osteotomies

Complications of Treatment: 

Complications of Treatment disturbance of growth in proximal femur including the epiphysis and physeal plate commonly referred to as AVN however, no pathology to confirm this may be due to vascular insults to epiphysis or physeal plate or pressure injury occurs only in patients that have been treated and may be seen in opposite normal hip

Necrosis of Femoral Head: 

Necrosis of Femoral Head Extremes of position in abduction ( greater 60 degrees ) and abduction with internal rotation compression on medial circumflex artery as passes the iliopsoas tendon and compression of the terminal branch between lateral neck and acetabulum “ frog leg position “ uniformly results in proximal growth disturbance

PowerPoint Presentation: 

extreme position can also cause pressure necrosis onf epiphyseal cartilage and physeal plate severin method can obtain reduction but very high incidence of necrosis multiple classification systems with Salter most popular

Treatment: 

Treatment Femoral and/or acetabular osteotomy to maintain reduction and shift areas of pressure trochanteric overgrowth causing an abductor lurch treated with greater trochanter physeal arrest if done before age 8 otherwise distal transfer early detection is key with 95% success rate of treatment identify growth disturbance lines

Thank You!!!: 

Thank You!!!