7th N Balachandran Professorship Instructional Lectures in Paediatric Orthopaedics: DDH: Management in childhood Adj Asst Prof Arjandas Mahadev < single image > Head and Senior Consultant Department of Orthopaedic Surgery 4.3cm x 5.5cm 7th October 2014 Developmental Dysplasia of Hips Syndrome in the newborn consisting of instability of the hip – Subluxable/Dislocatable hip – Subluxated/Dislocated hip – Clinically Unapparent Acetabular Dysplasia Diagnosed by Imaging modalities Developmental Dysplasia of Hips • Incidence 1:1000 live births • Risk factors – – – – 1st female child Family history Breech Condition predisposing to crowding of uterus • • • • • Multiple pregnancies Primipararity Fibroids or other uterine growths Low AFI Big baby e.g. in GDM Incidence Study, Year Walker, 1973 Geographic Area: Population Island Lake Region (Manitoba, Canada): Canadian Indians 188.5 Klisic, 1975 Belgrade, Yugoslavia 75.1 Coleman, 1956 Incidence per Thousand Utah Adademiska Sjulchuset, Hiertonn and James, 1968 Uppsala, Sweden 20.0 Stanisavljevic,1961 Detroit, Michigan 10.0 Paterson, 1976 Adelaide, Australia 6.2 Von Rosen, 1962 Malmö, Sweden 1.7 Barlow, 1962 Salford, England 1.5 Hoaglund et al., 1981 Hong Kong: Chinese 0.1 Edlestein, 1966 Africa: Bantus 0.0 20.0 DDH statistics 2005-2010 Arjandas M et al - unpublished YEAR NEW CASES REPORTED TOTAL LIVE BIRTHS /YEAR INCIDENCE: NO:OF NEW CASES/1000LIVE BIRTHS 2005 15 12743 1.2 2006 20 12207 1.64 2007 25 12304 2.0 2008 15 12535 1.2 2009 20 12154 1.63 2010 15 11309 1.32 DDH Embryology and Pathophysiology Henceforth the head and acetabulum have to remain in close contact to ensure •Spherical •Concentric •Well covered Hip to avoid abnormal stresses that can bring about OA PATHOPHYSIOLOGY Assessment – Clinical – Ultrasound – Xrays Assessment – Clinical – Ultrasound – Xrays Barlow maneuver –Test of “dislocatability” Assessment – Clinical – Ultrasound – Xrays Ortolani maneuver –Test of “reducibility” Assessment Beyond 3 months – Clinical – Ultrasound – Xrays – Reduced Abduction – Asymmetrical crease – LLD ( Galeazzi positive) – Gait Treledenburg Reduced Abduction LLD ( Galeazzi positive) SCREENING Diagnosis – Clinical – Ultrasound – Xrays Graf R: Fundamentals of sonographic diagnosis of infant hip dysplasia. J Pediatr Orthop 1984; 4:735 Abductors Bony acetabulum Labrum Head a b Standard Classification Class Alpha Angle Beta Angle Description Treatment I > 60° < 55° Normal None IIa 50°–60° 55°–77° Observation IIb >50°–60° 55°–77° Immature (<3 mo) >3 mo IIc 43°–49° >77° IId 43°–49° >77° Acetabular Pavlik harness deficiency Everted labrum Pavlik harness III <43° >77° Everted labrum Pavlik harness IV Unmeasurable Dislocated Graf R: Classification of hip joint dysplasia by means of sonography. Arch Orthop Trauma Surg 1984; 102:248 Pavlik harness Pavlik harness/closed vs. open reduction Simplified Classification Class Alpha Angle Beta Angle Description Treatment I > 60° < 55° Normal None II 43°–60° 55°–77° ? III <43° >77° Delayed ossification Lateralization IV Unmeasurable Dislocated Pavlik harness/closed vs. open reduction Graf R: Classification of hip joint dysplasia by means of sonography. Arch Orthop Trauma Surg 1984; 102:248 Pavlik harness Assessment – Clinical – Ultrasound – Xrays When to do – For high risk cases/hip laxity/hip clicks • At 4 to 6 weeks – To ensure concentric stable reduction after treatment • weekly after with splint to ensure reduction and correct application of splints. • 6 weeks after once hip reduced – Most effective < 3 months old Assessment – Clinical – Ultrasound – Xrays When to do – 3 months onwards – Each Xray must show concentric reduction with good acetabular cover Assessment – Clinical – Ultrasound – Xrays Assessment – Clinical – Ultrasound – Xrays Acetabular Index (AI) Medial Gap Severin Classification System of Developmental Dysplasia of the Hip Class Radiographic Appearance Center–Edge Angle (Age) Ia Normal >19° (6–13 yr) >25° (≥14 yr) Ib Normal 15°–19° (6-13 yr) 20°–25° (≥14 yr) IIA III Moderate deformity of femoral head, femoral neck, or acetabulum Dysplasia without subluxation Same as class I <15° (6-13 yr) < 20° (≥14 yr) IVa Moderate subluxation ≥ 20° IVb Severe subluxation < 0° V Femoral head articulates with pseudoacetabulum in superior part of original acetabulum Redislocation VI DDH Management GOAL: CONCENTRICALLY REDUCED AND STABLE HIPS WITH GOOD ACETABULAR COVER To Avoid Early Degenerative Disease of the Hips SCREENING • There is a lack of consensus as to screening criteria • Screening with ultrasonography remains controversial – cost – disadvantage of general ultrasonographic screening is the identification of a large number of children with a sonographic abnormality for which there are no firm treatment guidelines. – low yield of significant abnormalities in the absence of clinical findings, even in hips at risk SCREENING • Possibly ultrasonograph for those with risk factors – – – – – family history of DDH breech birth position Torticollis metatarsus adductus Oligohydramnios • Ortolani’s and Barlow’s in the newborn highly specific and sensitive in the practiced hands Our screening programme is a combination of the above Case 1 Newborn Ortolani positive at birth DDH Pavlik Harness Anterior straps – to keep hips flexed at 100° Posterior straps – to limit adduction of the hips ( 4 finger breadths) Check U/S at 1 week after Pavlik harness Right Left Weekly U/S for 2 weeks Right Left Pavlik harness worn full time for 3 months then wean DDH Newborn to 6 Months 1st Xray at 4 months Follow up at 8 months DDH Newborn to 6 Months Clinically reducible hips • Pavlik Harness • Check U/S weekly until hip reduced – Usually trial of 2 to 3 weeks • Then 6 weekly • Xrays at 3,6,12 and 18 months • Discharged with – Spherical – Concentrically reduced – Well covered hips DDH Newborn to 6 Months • Hip Irreducible at presentation • Failed Pavlik Management: – Adductor Tenotomy – Closed Reduction Hip Spica Case 2 3 month old girl 3 month old girl Adductor tenotomy Human position ARTHROGRAM Labrum outlined Medial pooling of dye UNREDUCED No more medial pooling of dye REDUCED SINGLE CUT CT 3 months post reduction with 1 change of cast Abduction Orthosis until ambulating At 3 months At 5 years old DDH Newborn to 6 Months • Hip Irreducible at presentation • Failed Pavlik Consider a Teratologic Hip Newborn with multiple congenital deformities with abdominal Xrays. Right hip clinically irreducible at birth Referred back at 4 months when all Medical issues sorted Adductor AND Iliospoas release by Medial Approach Followed by hip spica for 3 months and Abduction Braces till ambulating At 3 years old DDH 6 Months to 18 months • Failed Pavlik • Failed Adductor Tenotomy and Closed Reduction Hip Spica • Hip Irreducible at presentation DDH 6 Months to 18 months Blocks to Reduction Extra Articular – Adductors – Iliopsoas Intra Articular – Tight hour glass capsule – Transverse ligament – Pulvinar Extra Articular obstacles Intra Articular Obstacles DDH 6 Months to 18 months Blocks to Reduction and their Remedy Extra Articular Intra Articular – Adductors – Iliopsoas Remedy – Adductor and Iliopsoas release – Tight hour glass capsule – Transverse ligament – Pulvinar Remedy – Release of Hour glass tightness – Release of Transverse ligament – Removal of Pulvinar – Open Reduction – Capsuloraphy Open Reduction Medial Approach Open Reduction Antero Lateral Approach Open Reduction Antero Lateral Approach CEPHALAD CAUDAL Hourglass constriction of Medial capsule Femur Head Open Reduction Case 3 2 year old girl DDH Beyond 18 months • Remodelling potential of acetabulum thought to decrease after this age. • Not enough to just reduce the hip • Need to also provide acetabular cover – Salter Osteotomy added after hip reduced DDH Salter Osteotomy Intra operative 4 month post op 3 years old (1 year post op) 4 years old (2 years post op) For Discussion • • • • Use of traction Use of Medial Approach for the very young Need for Femoral Shortening Use of Pemberton as an alternative to Salter • Upper limit for attempted reductions 20 year female SUMMARY Age Newborn to 6 months Treatment Reducible hips Ultra sound diagnosed Pavlik harness Irreducible hips Adductor release and Closed Reduction 6 months to 18 months Adductor and Iliospoas release. Open reduction. Capsuloraphy. > 18 months Add Salter Possibly Femoral shortening after 2 years Age Newborn to 6 months Treatment Reducible hips Ultra sound diagnosed Pavlik harness Irreducible hips Adductor release and Closed Reduction Adductor AND Iliospoas release by Medial Approach Teratologic hips 6 months to 18 months Adductor and Iliospoas release. Open reduction. Capsuloraphy. > 18 months Add Salter Possibly Femoral shortening after 2 years QUESTIONS Thank you [email protected]
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