developemental dysplasia of hip

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DDH by dr. hardik pawar

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developemental dysplasia of hip

  1. 1. DevelopmentalDevelopmental Dysplasia of the HipDysplasia of the Hip Dr.HARDIK S PAWARDr.HARDIK S PAWAR DEPARTMENT OF ORTHOPAEDICSDEPARTMENT OF ORTHOPAEDICS CARE HOSPITALSCARE HOSPITALS
  2. 2. OverviewOverview  IntroductionIntroduction  Normal Development of the HipNormal Development of the Hip  Etiology and PathoanatomyEtiology and Pathoanatomy  Epidemiology and DiagnosisEpidemiology and Diagnosis  TreatmentTreatment  ComplicationsComplications
  3. 3. IntroductionIntroduction  Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip  Intracapsular displacementIntracapsular displacement  SubluxationSubluxation  Dislocation-usually posterosuperior (reducibleDislocation-usually posterosuperior (reducible vs irreducible)vs irreducible)  DysplasiaDysplasia  Before, during or just after birthBefore, during or just after birth
  4. 4. HISTORYHISTORY  Chapple and davidson – 1941Chapple and davidson – 1941  Muller and seddon – 1953Muller and seddon – 1953  AR hodgson - 1959AR hodgson - 1959  Wilkinson - 1963Wilkinson - 1963
  5. 5. EPIDEMIOLOGYEPIDEMIOLOGY  1/1,000 born with dislocated hip1/1,000 born with dislocated hip  10/10,000 born with subluxation or dysplasia10/10,000 born with subluxation or dysplasia  5:1 Female:Male child5:1 Female:Male child  Left 60% (left occiput ant), Right 20%, both 20%Left 60% (left occiput ant), Right 20%, both 20%  Risk FactorsRisk Factors  Family history (6% one affected child, 12% oneFamily history (6% one affected child, 12% one affected parent, 36% one child + one parent)affected parent, 36% one child + one parent)  OligohydramniosOligohydramnios  Breech (sustained hamstring forces)Breech (sustained hamstring forces)  Native Americans (swaddling cultures)Native Americans (swaddling cultures)  Torticollis or LE deformityTorticollis or LE deformity
  6. 6. Normal DevelopmentNormal Development  EmbryonicEmbryonic  7-87-8thth th week - acetabulum and head formedth week - acetabulum and head formed from same primitive mesenchymal cellsfrom same primitive mesenchymal cells  11th week - complete devlopement of hip11th week - complete devlopement of hip  Prox fem ossific nucleus - 4-7 monthsProx fem ossific nucleus - 4-7 months  Hip at risk of dislocation at 4 period :Hip at risk of dislocation at 4 period : at 12at 12thth weekweek at 18at 18thth weekweek final 4 weeksfinal 4 weeks post natal periodpost natal period
  7. 7. Normal HipNormal Hip
  8. 8. GARDES OF DDHGARDES OF DDH Grade 1 : subluxtable hip Grade 2 : dislocatable Grade 3 : severe
  9. 9. PathologyPathology  Ranges from mild dysplasia --> frankRanges from mild dysplasia --> frank dislocationdislocation  Bony changes soft tissue chagesBony changes soft tissue chages  Acetabulum capsuleAcetabulum capsule  Head musclesHead muscles  Femoral NeckFemoral Neck  PelvisPelvis
  10. 10. PathoanatomyPathoanatomy  Soft tissue changesSoft tissue changes  Usually secondary to prolonged subluxation orUsually secondary to prolonged subluxation or dislocationdislocation  IntraarticularIntraarticular  LabrumLabrum  Inverted + adherent to capsule (closed reduction withInverted + adherent to capsule (closed reduction with inverted labruminverted labrum assoc with increased Avascular Necrosis)assoc with increased Avascular Necrosis)  Ligamentum teresLigamentum teres  Hypertrophied + lengthenedHypertrophied + lengthened  PulvinarPulvinar  Fibrofatty tissue migrating into acetabulumFibrofatty tissue migrating into acetabulum
  11. 11. PathoanatomyPathoanatomy  Soft Tissue (Intraarticular)Soft Tissue (Intraarticular)  Transverse acetabular ligamentTransverse acetabular ligament  ContractedContracted  LimbusLimbus  Fibrous tissue formed from capsular tissueFibrous tissue formed from capsular tissue interposed between everted labrum and acetabularinterposed between everted labrum and acetabular rimrim  ExtraarticularExtraarticular  Tight adductors (adductor longus)Tight adductors (adductor longus)  IliopsoasIliopsoas
  12. 12. Tough Reductions…Tough Reductions…  Obstacles to reductionObstacles to reduction  ExtraarticularExtraarticular  Tight iliopsoas andTight iliopsoas and adductorsadductors  IntraarticularIntraarticular  LabrumLabrum  Ligamentum teresLigamentum teres  Transverse acetabularTransverse acetabular ligamentligament  PulvinarPulvinar  Redundant capsuleRedundant capsule (hourglass)(hourglass)  +/- limbus+/- limbus
  13. 13. Etiology and EpidemiologyEtiology and Epidemiology  MultifactorialMultifactorial  Genetics and SyndromesGenetics and Syndromes  Ehler’s DanlosEhler’s Danlos  ArthrogryposisArthrogryposis  Larsen’s syndromeLarsen’s syndrome  Intrauterine environmental factorsIntrauterine environmental factors  TeratogensTeratogens  Positioning (oligohydramnios)Positioning (oligohydramnios)  Neurologic DisordersNeurologic Disorders  Spina Bifida ,CP , polio , myelomonigoceleSpina Bifida ,CP , polio , myelomonigocele
  14. 14. DiagnosisDiagnosis  Newborn screeningNewborn screening  Ortolani’s and Barlow’s maneuvers with aOrtolani’s and Barlow’s maneuvers with a thorough history and physicalthorough history and physical  Warm, quiet environment with removal ofWarm, quiet environment with removal of diaperdiaper  Head to toe exam to detect any associatedHead to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxityconditons (Torticollis, Ligamentous Laxity etc.)etc.)  Baseline Neuro and Spine ExamBaseline Neuro and Spine Exam
  15. 15. DiagnosisDiagnosis  Key physical findingsKey physical findings  AsymmetryAsymmetry  Limb length- GaleazziLimb length- Galeazzi  Telsescopic testTelsescopic test  Limited AbductionLimited Abduction  Skin foldsSkin folds  LimpLimp  TrendelenbergTrendelenberg  Waddilng gait /Waddilng gait / hyperlordosis - bilateralhyperlordosis - bilateral involvementinvolvement  Vascular sign of narathVascular sign of narath
  16. 16. Clinical Features : NeonatesClinical Features : Neonates Delicate “clunk” thatDelicate “clunk” that is palpable but notis palpable but not audibleaudible Repeat sequence 4-5Repeat sequence 4-5 times to be certain oftimes to be certain of findingsfindings If both signs negativeIf both signs negative but pt is high risk :but pt is high risk : follow up is essentialfollow up is essential
  17. 17. Clinical features : InfantsClinical features : Infants Progression fromProgression from instability to dislocationinstability to dislocation is gradual processis gradual process In some within a fewIn some within a few weeksweeks others the hipothers the hip dislocation remainsdislocation remains reducible up to 5 or 6reducible up to 5 or 6 months of age.months of age. When the hip no longerWhen the hip no longer reducible, specificreducible, specific physical findingsphysical findings appearappear
  18. 18. Limitation of AbductionLimitation of Abduction MOST RELIABLE SIGNMOST RELIABLE SIGN
  19. 19. Galeazzi’s SignGaleazzi’s Sign
  20. 20. Asymmetric gluteal, thigh, labialAsymmetric gluteal, thigh, labial foldsfolds
  21. 21. TelescopyTelescopy
  22. 22. Klisic’s TestKlisic’s Test
  23. 23. Walking child:Walking child: LLDLLD ↓↓AbductionAbduction Tip-toe-walkingTip-toe-walking Trendelenberg gaitTrendelenberg gait Waddling [B/L]Waddling [B/L] ↑↑lumbar lordosislumbar lordosis
  24. 24. Clinical Features : WalkingClinical Features : Walking ChildChild  Trendelenburg's signTrendelenburg's sign  Trendelenburg gaitTrendelenburg gait
  25. 25. Clinical Features : NeonatesClinical Features : Neonates BARLOW’S TEST (BARLOW’S TEST ( bahar lobahar lo))
  26. 26. Clinical Features : NeonatesClinical Features : Neonates BARLOW’S TEST (BARLOW’S TEST ( bahar lobahar lo))
  27. 27. Clinical Features : NeonatesClinical Features : Neonates ORTOLANI SIGNORTOLANI SIGN
  28. 28. Clinical Features : NeonatesClinical Features : Neonates ORTOLANI SIGNORTOLANI SIGN
  29. 29. Ortolani’s ManeuverOrtolani’s Maneuver
  30. 30. Barlow’s ManeuverBarlow’s Maneuver
  31. 31. DiagnosisDiagnosis  Some cases still missedSome cases still missed  At risk groups should be further screenedAt risk groups should be further screened  AAPAAP  Recs further imaging (e.g. US) if exam isRecs further imaging (e.g. US) if exam is “inconclusive” AND“inconclusive” AND  First degree relative + femaleFirst degree relative + female  BreechBreech  Positive provocative maneuver (Ortolani or Barlow)Positive provocative maneuver (Ortolani or Barlow)  Referral to OrthopaedistReferral to Orthopaedist
  32. 32. ImagingImaging  X-raysX-rays  Femoral head ossification centerFemoral head ossification center  4 -7 months4 -7 months  UltrasoundUltrasound  Operator dependentOperator dependent  CTCT  MRIMRI  ArthrogramsArthrograms  Open vs closed reductionOpen vs closed reduction
  33. 33. ImagingImaging  RadiographsRadiographs
  34. 34. ImagingImaging  RadiographsRadiographs
  35. 35. ImagingImaging  RadiographsRadiographs
  36. 36. ImagingImaging  RadiographsRadiographs
  37. 37. ImagingImaging  Acetabular IndexAcetabular Index
  38. 38. ImagingImaging  Acetabular IndexAcetabular Index
  39. 39. ImagingImaging  Acetabular IndexAcetabular Index < 30° wnl
  40. 40. ImagingImaging
  41. 41. ImagingImaging
  42. 42. ImagingImaging
  43. 43. ImagingImaging
  44. 44. RadiographsRadiographs Newborns 27.5 degrees 6 months 23.5 degrees 2 years 20 degrees
  45. 45. Centre – Edge Angle WibergCentre – Edge Angle Wiberg 6 – 13 years >19 degrees >14 years > 25 degrees
  46. 46. ANDREN-von ROSENANDREN-von ROSEN LINELINE AP X-ray: hip in 45AP X-ray: hip in 45°abduction and IR°abduction and IR Describes the longitudinal relationship betweenDescribes the longitudinal relationship between long axis of femur and acetabulumlong axis of femur and acetabulum
  47. 47. Tear dropTear drop AP X-rayAP X-ray Lateral:wall ofLateral:wall of acetabulumacetabulum Medial:lesser pelvisMedial:lesser pelvis Inferior :acetabularInferior :acetabular notchnotch Appears between 6-23Appears between 6-23 momo [delayed in DDH][delayed in DDH]
  48. 48. Radiographs SummaryRadiographs Summary  Femoral head appears 4 - 7 monthsFemoral head appears 4 - 7 months  Shenton’s lineShenton’s line  Perkin’s and Hilgenreiner’s linesPerkin’s and Hilgenreiner’s lines  Inferomedial quadrantInferomedial quadrant  Center Edge Angle (< 20 abnormal)Center Edge Angle (< 20 abnormal)  Acetabular indexAcetabular index  Normal < 30 (Weintroub et al)Normal < 30 (Weintroub et al)  Tear drop*Tear drop*  Abnormal widening in DDHAbnormal widening in DDH *may be only sign in mild subluxation*may be only sign in mild subluxation
  49. 49. ImagingImaging  UltrasoundUltrasound  Introduced in 1978 for eval of DDHIntroduced in 1978 for eval of DDH  Operator dependentOperator dependent  Useful in confirming subluxation, identifyingUseful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum,dysplasia of cartilaginous acetabulum, documenting reducibilitydocumenting reducibility  Prox Femoral Ossification Center interferesProx Femoral Ossification Center interferes  Requires a window in spica cast (avoid)Requires a window in spica cast (avoid)
  50. 50. UltrasoundUltrasound Femoral head Abductors Ilium
  51. 51. UltrasoundUltrasound Femoral head Abductors Ilium
  52. 52. UltrasoundUltrasound Femoral head Abductors Ilium
  53. 53. UltrasoundUltrasound Femoral head Abductors Ilium
  54. 54. UltrasoundUltrasound Graf’s alpha angle
  55. 55. UltrasoundUltrasound Graf’s alpha angle >60° = normal *line w/ ilium bisects head 50/50
  56. 56. UltrasonographyUltrasonography  lpha angle measures bony acetabuluBetalpha angle measures bony acetabuluBeta angle measures cartilagenous acetabulumangle measures cartilagenous acetabulum
  57. 57. UltrasonographyUltrasonography  Harcke & Kumar technique:Harcke & Kumar technique:  Dynamic examination with stress views thatDynamic examination with stress views that mirror Barlow’s & Ortolani’s maneuvermirror Barlow’s & Ortolani’s maneuver Graf classification
  58. 58. ArthrogramArthrogram Severin [1941]Severin [1941] Normal appearance:Normal appearance: LABRUM:LABRUM: *Thorn over the*Thorn over the femoral headfemoral head *A recess of joint*A recess of joint capsule overlies thecapsule overlies the thornthorn
  59. 59. Arthrogram in DDHArthrogram in DDH SUBLUXATED HIP DISLOCATED HIP
  60. 60. Imaging ToolsImaging Tools  CT scan:CT scan:  Single section CT as check filmsSingle section CT as check films  Neglected C.D.H.Neglected C.D.H.  Adolescent and adultAdolescent and adult  MRI:MRI:  Equivalent to arthrographyEquivalent to arthrography
  61. 61. Natural HistoryNatural History  NewbornNewborn VariableVariable  > 6 months> 6 months more aggressive tx requiredmore aggressive tx required due to more extensive pathology anddue to more extensive pathology and decreased potential for acetabulardecreased potential for acetabular remodelingremodeling  Abnormal Gait, Decreased Abduction andAbnormal Gait, Decreased Abduction and Strength, Increased DJDStrength, Increased DJD  Unilateral worse than BilateralUnilateral worse than Bilateral  Subluxation worse than DysplasiaSubluxation worse than Dysplasia
  62. 62. Treatment OptionsTreatment Options  Age of patient at presentationAge of patient at presentation  Family factorsFamily factors  Reducibility of hipReducibility of hip  Stability after reductionStability after reduction  Amount of acetabular dysplasiaAmount of acetabular dysplasia
  63. 63. Birth to Six MonthsBirth to Six Months  Triple-diaper techniqueTriple-diaper technique  Prevents hip adductionPrevents hip adduction  ““Success” no different in someSuccess” no different in some untreated hipsuntreated hips  Pavilk harness (1944)Pavilk harness (1944)  Experienced staff*Experienced staff*  Very successfulVery successful  Allows free movement withinAllows free movement within confines of restraintsconfines of restraints *posterior straps for preventing add. NOT producing abd.
  64. 64. Birth to Six MonthsBirth to Six Months  Pavlik harnessPavlik harness  IndicationsIndications  Fully reducible hip*Fully reducible hip*  Child not attempting to standChild not attempting to stand  FamilyFamily • Close regular follow-up (every 1-2 weeks)Close regular follow-up (every 1-2 weeks) • For imaging and adjustmentsFor imaging and adjustments • DurationDuration • Childs age at hip stability + 3 monthsChilds age at hip stability + 3 months
  65. 65. Pavlik HarnessPavlik Harness  FailuresFailures  Poor parent compliancePoor parent compliance  Improper use by the physicianImproper use by the physician  Inadequate initial reductionInadequate initial reduction  Failure to recognize persistent dislocationFailure to recognize persistent dislocation  Viere et al 1990Viere et al 1990  Bilateral dislocationBilateral dislocation  Absent Ortolani’s signAbsent Ortolani’s sign  > 7weeks of age> 7weeks of age
  66. 66. Pavlik HarnessPavlik Harness  ComplicationsComplications  Avascular necrosisAvascular necrosis  Forced hip abductionForced hip abduction  Safe zone (abd/adduction and flexion/extension)Safe zone (abd/adduction and flexion/extension)  Femoral nerve palsyFemoral nerve palsy  HyperflexionHyperflexion *Be aware of Pavlik Harness Disease*Be aware of Pavlik Harness Disease *Follow until skeletal maturity*Follow until skeletal maturity
  67. 67. Birth - Six monthsBirth - Six months  Closed reduction + SpicaClosed reduction + Spica  Failure after 3 weeks of Pavlik trialFailure after 3 weeks of Pavlik trial
  68. 68. Birth - Six monthsBirth - Six months  Closed reductionClosed reduction  General anesthesiaGeneral anesthesia  ArthrogramArthrogram  Safe zone - avoid AVNSafe zone - avoid AVN  +/- adductor tenotomy+/- adductor tenotomy  Open reduction if concentric reduction notOpen reduction if concentric reduction not possiblepossible  Usually teratogenic hips in this age groupUsually teratogenic hips in this age group
  69. 69. Open reductionOpen reduction Unable to achieveUnable to achieve closed reductionclosed reduction Widening of the jointWidening of the joint spacespace Unstable reductionsUnstable reductions Loss of reduction onLoss of reduction on follow upfollow up Advanced ageAdvanced age
  70. 70. Open ReductionOpen Reduction  Medial approachMedial approach  Pectineus / adductor longus + brevisPectineus / adductor longus + brevis  Cannot address simeoultaneous bony workCannot address simeoultaneous bony work  Antero -lateralAntero -lateral  Smith-petersonSmith-peterson  Sartorius / Tensor Fascia lataSartorius / Tensor Fascia lata
  71. 71. ApproachApproach MedialMedial Minimal dissectionMinimal dissection ObstructionsObstructions encountered directlyencountered directly BUT..BUT.. Limited viewLimited view MFCA violationMFCA violation No capsulorrhaphyNo capsulorrhaphy Secondary proceduresSecondary procedures AnterolateralAnterolateral Better exposureBetter exposure CapsulorrhaphyCapsulorrhaphy Pelvic osteotomyPelvic osteotomy possiblepossible BUT..BUT.. Blood lossBlood loss Iliac crest apophysisIliac crest apophysis and abductors damageand abductors damage Stiffness of hipStiffness of hip
  72. 72. Open ReductionOpen Reduction
  73. 73. Open Reduction with FemoralOpen Reduction with Femoral derotation osteotomyderotation osteotomy  Pressure leads to risk of AVNPressure leads to risk of AVN  Better results than preoperative traction in olderBetter results than preoperative traction in older children with less morbiditychildren with less morbidity When to do??When to do??  Anticipated increased pressure on reduced femurAnticipated increased pressure on reduced femur headhead  Recommended in child > 2yrs.Recommended in child > 2yrs.  distract the joint few millimeter per operativelydistract the joint few millimeter per operatively  Judge the tightness of soft tissues after reductionJudge the tightness of soft tissues after reduction  irreducible dislocationirreducible dislocation
  74. 74. Derotational femoral shorteningDerotational femoral shortening osteotomyosteotomy
  75. 75. 2 Years of Age and Older2 Years of Age and Older  For child 2 -3 years of age, during openFor child 2 -3 years of age, during open reduction acetabular coverage ifreduction acetabular coverage if insufficient warrants reorientationinsufficient warrants reorientation osteotomyosteotomy  If coxa valga with excessive anteversion,If coxa valga with excessive anteversion, VDRO may be done.VDRO may be done.  Children > 3 years usually need anChildren > 3 years usually need an osteotomyosteotomy
  76. 76. Bilateral untreated dislocation upto 5Bilateral untreated dislocation upto 5 years:years: Open reduction with femoral shorteningOpen reduction with femoral shortening with salter / pemberton osteotomy withwith salter / pemberton osteotomy with gap of 5-6 weeks.gap of 5-6 weeks. Bilateral untreated subluxation upto 5-6Bilateral untreated subluxation upto 5-6 years:years: Open reduction + salter osteotomy.Open reduction + salter osteotomy.
  77. 77. 6 months - 4 years6 months - 4 years  Present a more difficult problemPresent a more difficult problem  Prolonged dislocationProlonged dislocation  Contracted soft tissuesContracted soft tissues  6 - 18 months6 - 18 months  Closed reduction +/- adductor tenotomyClosed reduction +/- adductor tenotomy  Spica in human position of 100 degrees of flexion andSpica in human position of 100 degrees of flexion and about 55 degrees abduction (3 months)about 55 degrees abduction (3 months)  Abduction Orthosis 4 wks full time/4 wks nighttimeAbduction Orthosis 4 wks full time/4 wks nighttime  Open reduction (if closed fails)Open reduction (if closed fails)  CapsulorraphyCapsulorraphy  CT scanCT scan  Spica for 6 wks followed by PTSpica for 6 wks followed by PT
  78. 78. 6 months - 4 years6 months - 4 years  18 months - 4 years18 months - 4 years  Closed reductionClosed reduction  Reducibile - check arthrogram andReducibile - check arthrogram and medial dye poolmedial dye pool  Irreducible - Open reductionIrreducible - Open reduction  Open redcutionOpen redcution  Tight - femoral shorteningTight - femoral shortening  Stable - +/- pelvic osteotomyStable - +/- pelvic osteotomy
  79. 79. Femoral osteotomyFemoral osteotomy  Schoenecker + Strecker 1984Schoenecker + Strecker 1984  Traction vs. Femoral shorteningTraction vs. Femoral shortening  56% AVN in traction group56% AVN in traction group  0% AVN in femoral shortening0% AVN in femoral shortening
  80. 80. Residual DysplasiaResidual Dysplasia
  81. 81. Pelvic OsteotomyPelvic Osteotomy  Persistent instability + dysplasia afterPersistent instability + dysplasia after open reduction + femoral shorteningopen reduction + femoral shortening  Requires concentric reduction of aRequires concentric reduction of a reasonably spherical femoral headreasonably spherical femoral head
  82. 82. Salter OsteotomySalter Osteotomy
  83. 83. Acetabular Reorientation-Acetabular Reorientation- Innominate OsteotomyInnominate Osteotomy  Articular hyaline cartilage over femur headArticular hyaline cartilage over femur head  Types:Types:  SSalter’salter’s (innominate)(innominate)  SSutherland’s (double innominate)utherland’s (double innominate)
  84. 84. Salter’s OsteotomySalter’s Osteotomy Redirects the entire acetabulumRedirects the entire acetabulum Roof “covers” the femoral head anteriorlyRoof “covers” the femoral head anteriorly and superiorlyand superiorly Hinge at pubic symphysisHinge at pubic symphysis Pre-requisitesPre-requisites Congrous Concentric reductionCongrous Concentric reduction No ContracturesNo Contractures
  85. 85. Salter’s osteotomy
  86. 86. Salter’s osteotomy
  87. 87. K. E. 21 - 12 - 1999 Salter & femoral osteotomySalter & femoral osteotomy
  88. 88. Salter OsteotomySalter Osteotomy
  89. 89. Sutherland’s OsteotomySutherland’s Osteotomy 1. Can be done for older child 2. Allows medial displacement
  90. 90. Peri-acetabular OstetomiesPeri-acetabular Ostetomies  Provide greater correction of acetabular indexProvide greater correction of acetabular index  Reduce volume of hip jointReduce volume of hip joint  Possibility of growth disturbancesPossibility of growth disturbances TypesTypes  PPemberton’semberton’s  DDial (Eppright)ial (Eppright)  WWagneragner  DDega’sega’s  GGanz osteotomy (Bernese)anz osteotomy (Bernese)
  91. 91.  Dega’sDega’s
  92. 92. Pemberton’s OsteotomyPemberton’s Osteotomy
  93. 93. Pemberton’s OsteotomyPemberton’s Osteotomy •Volume changing •Hinges on triradiate •Requires remodeling of “new” incongruity •Provides more anterolatera coverage
  94. 94. Dial osteotomyDial osteotomy
  95. 95. Dega’s OsteotomyDega’s Osteotomy 1. Incomplete 2. Variable hinge 3. Allows anterio lateral & poste coverage
  96. 96. Ganz OsteotomyGanz Osteotomy Larger corrections all dire Blood supply preserved Shape of true pelvis unalt Technically demanding
  97. 97. Triple OsteotomiesTriple Osteotomies Indication :Indication : Adolescent requiring more than 25°Adolescent requiring more than 25° correctioncorrection Pre-requisite:Pre-requisite: Functional range of motionFunctional range of motion only mild subluxation acceptableonly mild subluxation acceptable Types:Types:  Steel (Inferior)Steel (Inferior)  Tonnis (Posterior)Tonnis (Posterior)  Tachdjian - subinguinal adductorTachdjian - subinguinal adductor
  98. 98. Triple OsteotomiesTriple Osteotomies STEEL TONNIS TACHDJIAN’S
  99. 99. Salvage or Shelf proceduresSalvage or Shelf procedures  ChiariChiari  Requires capsular metaplasiaRequires capsular metaplasia  Pain - main indicationPain - main indication  Treatment of chronic hip pain in adolescentsTreatment of chronic hip pain in adolescents
  100. 100. Chiari OsteotomyChiari Osteotomy
  101. 101. Chiari OsteotomyChiari Osteotomy
  102. 102. Chiari OsteotomyChiari Osteotomy
  103. 103. Chiari OsteotomyChiari Osteotomy
  104. 104. Chiari OsteotomyChiari Osteotomy
  105. 105. Chiari osteotomyChiari osteotomy
  106. 106. Shelf ProcedureShelf Procedure
  107. 107. Adolescent and young adult(olderAdolescent and young adult(older then 8-10 yearsthen 8-10 years If femoral head cannot be repositionedIf femoral head cannot be repositioned distally to the level of acetabulum :distally to the level of acetabulum : Salvage proceduresSalvage procedures Degenertive arthritis and enough pain andDegenertive arthritis and enough pain and limitation of movements – reconstructivelimitation of movements – reconstructive operation (total hip replacement)operation (total hip replacement) Arthodesis – rarely done, contraindiactedArthodesis – rarely done, contraindiacted for bilateral dislocationfor bilateral dislocation
  108. 108. Schanz osteotomy Very late salvage
  109. 109. Radical salvageRadical salvage  FusionFusion  ReplacementReplacement  ExcisionExcision
  110. 110. Hip arthrodesisHip arthrodesis Consider forConsider for:: i. Young malei. Young male ii. Unilateralii. Unilateral iii. Infectioniii. Infection
  111. 111. Joint replacementJoint replacement Consider for:Consider for:  Severe arthritisSevere arthritis  Failed “Failed “ conservative”conservative” Rx.Rx.  BilateralBilateral diseasedisease
  112. 112. Severe arthritisSevere arthritis DDHDDH AVNAVN OAOA
  113. 113. End-stage O.A.End-stage O.A.
  114. 114. THR outcomes in DDHTHR outcomes in DDH Charnley cemented hips:Charnley cemented hips: 5 of 38 loose at 11 years5 of 38 loose at 11 years Bobak, Wroblewski et al 2000Bobak, Wroblewski et al 2000 Harris uncemented hips:Harris uncemented hips: 20% loose at 7 years20% loose at 7 years 46% loose at 12 years46% loose at 12 years Jasty, Anderson, Harris, 1999Jasty, Anderson, Harris, 1999
  115. 115. complicationcomplication
  116. 116. Avascular NecrosisAvascular Necrosis  Most commonMost common  Not part of the natural history of DDHNot part of the natural history of DDH  IatrogenicIatrogenic  Etiology unknownEtiology unknown  Femoral head compressionFemoral head compression  Injury to blood supplyInjury to blood supply  Excessive abductionExcessive abduction  Sullivan et al 1997Sullivan et al 1997  SigSig ↓↓ blood flow w/ increasing abd angleblood flow w/ increasing abd angle
  117. 117. TX SummaryTX Summary  Best if treated before 6 weeks of ageBest if treated before 6 weeks of age  0 - 6 months of age0 - 6 months of age  PavlikPavlik  6 - 18 months6 - 18 months  Closed vs open reduction and spicaClosed vs open reduction and spica  18 - 48 months18 - 48 months  ClosedClosed  Open +/- osteotomiesOpen +/- osteotomies
  118. 118. SummarySummary  Femoral shortening better than tractionFemoral shortening better than traction  Pelvic osteotomiesPelvic osteotomies  Dega, PembertonDega, Pemberton  Salter, triple innominate, GanzSalter, triple innominate, Ganz  ChiariChiari
  119. 119. QuestionsQuestions
  120. 120. Thank YouThank You

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