DDH

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DDH

  1. 1. • Dr. Sushil Paudel Management of Developmental Dysplasia of Hip
  2. 2. 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
  3. 3.  Evolves over time Syndrome 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
  4. 4.  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
  5. 5. PATHOGENESIS Affected hip slides in &out Flattenened posterior border NEOLIMBUS of acetabulum (CLUNK)birth Loose capsule Everted labrum corrected uncorrected DOCKING OF THE Secondary FEMORAL HEAD barriers
  6. 6. SECONDARY BARRIERS PULVINAR LIGAMENTUM TERES TR.ACETABULAR LIG INVERTED LABRUM CAPSULE ILIOPSOAS REDUCED-DOCKING HOURGLASS CONSTRICTIONPOINT OF REDUCIBILITY:? HARRIS et al: 4 yrs “CHINESE FINGER TRAP”
  7. 7. ACETABULAR UNREDUCED CHANGESACETABULAR ROOF FLATTENING THICKENED MEDIAL WALL DYSTROPHIC CARTILAGE SUBCHONDRAL CYSTS LOSS OF CARTILAGE OSTEOPHYTES
  8. 8. Management
  9. 9. Making the DiagnosisHigh index of suspicionIdentifying risk factorsCareful physical examinationProvactive dynamic testsRisk baby evaluation by USGRadiological evaluation
  10. 10. Clinical Features : NeonatesBARLOW’S TEST ( bahar lo)
  11. 11. Clinical Features : NeonatesBARLOW’S TEST ( bahar lo)
  12. 12. Clinical Features : NeonatesORTOLANI SIGN
  13. 13. Clinical Features : NeonatesORTOLANI SIGN
  14. 14. Clinical Features : Neonates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
  15. 15. Clinical features : Infants Progression 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
  16. 16. Limitation of Abduction MOST RELIABLE SIGN
  17. 17. Galeazzi’s Sign
  18. 18. Asymmetric gluteal, thigh, labial folds
  19. 19. Telescopy
  20. 20. Klisic’s Test
  21. 21. Walking child:LLD↓AbductionTip-toe-walkingTrendelenberg gaitWaddling [B/L]↑lumbar lordosis
  22. 22. Clinical Features : Walking Child• Trendelenburgs sign• Trendelenburg gait
  23. 23. Radiological evaluation Dysplasia Subluxation DislocationEach stage has a different radiological presentation
  24. 24. Ultrasonography– lpha angle measures bony acetabuluBeta angle measures cartilagenous acetabulum
  25. 25. Ultrasonography• Harcke & Kumar technique: – Dynamic examination with stress views that mirror Barlow’s & Ortolani’s maneuver Graf classification
  26. 26. Newborns 27.5 degreesRadiographs 6 months 2 years 23.5 degrees 20 degrees
  27. 27. Centre – Edge Angle Wiberg 6 – 13 years >19 degrees >14 years > 25 degrees
  28. 28. ANDREN-von ROSEN LINE AP X-ray: hip in 45 abduction and IR Describes the longitudinal relationship between long axis of femur and acetabulum
  29. 29. Imaging• Radiographs
  30. 30. Imaging• Radiographs
  31. 31. Imaging• Radiographs
  32. 32. Imaging• Radiographs
  33. 33. Imaging• Acetabular Index
  34. 34. Imaging• Acetabular Index
  35. 35. Imaging• Acetabular Index < 30 wnl
  36. 36. Tear drop AP X-ray Lateral:wall of acetabulum Medial:lesser pelvis Inferior :acetabular notch Appears between 6-23 mo [delayed in DDH] V-shaped in DDH
  37. 37. False Profile view
  38. 38. ArthrogramSeverin [1941]Normal appearance:LABRUM:*Thorn over the femoral head*A recess of joint capsule overlies the thorn
  39. 39. Arthrogram in DDHSUBLUXATED HIP DISLOCATED HIP
  40. 40. Imaging Tools• CT scan: – Single section CT as check films – Neglected C.D.H. – Adolescent and adult• MRI: – Equivalent to arthrography
  41. 41. Diagnosis Reduction maintainIntervene adverse natural history Ensure normal adult hip
  42. 42. Screening• All neonates should have a clinical examination for hip instability• Risk factors : – breech presentation USG SCREENING – family history – torticollis – oligohydramnios – metatarsus adductus
  43. 43. CLINICAL & USG normal normal normal ABnormalABnormal F/U till maturity REPEAT AT 6 WKS ABnormal normal Clinical & USG normal REPEAT AT 3 & 6 WKS ABnormal Closed / open reduction
  44. 44. 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
  45. 45. Infant 1 – 6 months of ageweekly clinical examination & USGBy 3 weeks stable reduction mustContinue 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.
  46. 46. Pavlik harnessStandard of treatment worldwideUpto 6 monthsContraindicated when there is major muscle imbalance (myelomeningocele, AMC or ligamentous laxity)
  47. 47. Complications of Pavlik Harness• AVN• Failure to reduce• Femoral nerve neuropathy• Inferior dislocation• Pavlik’s disease (flattening posterolateral acetabulum)
  48. 48. Follow upThe child should be followed till skeletal maturity Increased risk of asymmetric physeal closure Valgus deformity of the neck
  49. 49. 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
  50. 50. Closed reductionForce should be avoidedCheck for safe zonePost reduction:  Spica change every six weeks plus stability check  Continue spica for 3-4 months
  51. 51. Safe Zone 20 to 30 degrees from maximum abductionextended to below 90 degreeswithout redislocationSafe zone can be improvedwith adductor tenotomy
  52. 52. Open reductionUnable to achieve closed reductionWidening of the joint spaceUnstable reductionsLoss of reduction on follow upAdvanced age
  53. 53. Approach Medial Anterior Minimal dissection  Better exposure Obstructions encountered  Capsulorrhaphy directly  Pelvic osteotomy possible  BUT..  BUT..  Blood loss Limited view  Iliac crest apophysis and MFCA violation abductors damage No capsulorrhaphy  Stiffness of hip Secondary procedures
  54. 54. Medial approach
  55. 55. Anterior approach• Smith-Peterson anterior approach• Stood the test of time• More commonly used• Bikini incision better cosmetic results
  56. 56. Open Reduction with Femoral Shortening• Pressure leads to risk of AVN• Better results than preoperative traction in older children with less morbidity When 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
  57. 57. 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
  58. 58. Derotational femoral shortening osteotomy
  59. 59. 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
  60. 60. 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.
  61. 61. Residual Dysplasia Pelvic osteotomy Re- orientation AugmentationInnominate Periacetabular Triple Shelf Chiari procedures
  62. 62. Acetabular Reorientation-Innominate Osteotomy• Articular hyaline cartilage over femur head• Types: – Salter’s (innominate) – Sutherland’s (double innominate)
  63. 63. Salter’s OsteotomyRedirects the entire acetabulumRoof “covers” the femoral head anteriorly and superiorlyHinge at pubic symphysis Pre-requisites Congrous Concentric reduction No Contractures
  64. 64. Salter’s osteotomy
  65. 65. Salter’s osteotomy
  66. 66. Sutherland’s Osteotomy 1. Can be done for older child 2. Allows medial displacement
  67. 67. 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)
  68. 68. Pemberton’s Osteotomy
  69. 69. Pemberton’s Osteotomy 1. Incomplete 2. Hinges at triradiate cartilage
  70. 70. Dega’s Osteotomy 1. Incomplete 2. Variable hinge 3. Allows anterior, lateral & posterior coverage
  71. 71. Ganz Osteotomy Larger corrections all directions Blood supply preserved Shape of true pelvis unaltered Technically demanding
  72. 72. Triple OsteotomiesIndication : Adolescent requiring more than 25° correctionPre-requisite: Functional range of motion only mild subluxation acceptableTypes:• Steel (Inferior)• Tonnis (Posterior)• Tachdjian - subinguinal adductor
  73. 73. Triple OsteotomiesSTEEL TONNIS TACHDJIAN’S
  74. 74. Shelf Procedure
  75. 75. Chiari Osteotomy
  76. 76. 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
  77. 77. Very late salvageSchanzosteotomy
  78. 78. Joint replacementConsider for: Severe arthritis Failed “ conservative” Rx. Bilateral disease

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