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Developmental Dysplasia Hip
- 1. DDH Dr. LOKESH CHUGH PG RESIDENT GMC. AMRITSAR
- 2. RISK FACTORS • Girls.>boys(5x) • Breech deliveries • White.>black • Positive F/H
- 3. ASSOCIATIONS • Congenital torticollis • Metatarsus adductus • Talipes calcaneovalgus
- 4. THEORIES • Mechancal factors • hormonal factors- relaxin, joint laxity • Primary acetabular dysplasia- shallow
- 5. DIAGNOSIS AND CLINICAL FEATURES • NEWBORN(<6 months) ; clinical examination • One hip at one time • Positive test- audible clunk • BARLOW; adduction, post. disloc, longitu. axis. • ORTOLANI; gentle abduction, A/M directed
- 7. 6 -18 months • Decrease in ability to abduct • Adductor contracture • Asymmetric skin fold • GALEAZZI SIGN/ ALLIS SIGN- lateral proximal shift of femoral head, apparent shortening • KLISIC’S SIGN-B/L dislocation • Undetected- WADDLING GAIT
- 9. ULTRASOUND SCREENING • Moderate evidence:-universal screening of newborn • Imaging in risk factors, breech, F/H, clinical instability history • Limited evid.:- guidence for brace t/t initiation • To support x ray finding in 4 months age • Reexamine normal hip in 6 months • Serial physical, periodic imaging, unstable hip
- 10. IMAGING • USG- overdiagnose dysplasia before 6 weeks • X-ray- screening of severe dysplasia • PERKIN • HILGENREINER LINE • SHENTON LINE • Metaphyseal beak – inner lower quadrant (N) • ACETABULAR INDEX ≤30 (N), Increase- dysplasia
- 11. • Subluxation- outer lower quadrant • Acetabular dysplasia- shallow • Complete dislocation – outer upper quadrant
- 12. ACETABULAR INDEX (N <25º)
- 13. CEA –WIBERG(N 25-40º) • <25º = dysplasia
- 14. TREATMENT
- 15. BIRTH-6 MONTHS • Positive O/B test • Evaluate direction, stability, reducibility • PAVLIK HARNESS • Dynamic flexion abduction orthosis • First few months , prior to contracture development • Not given - crawling
- 16. PAVLIK HARNESS (PH) • Teratologic dislocation- c/I • Chest strap-3 finger gap • 2 shoulder strap- adjust, C/S-nipple level • 2 stirrups: 2(A/M flexion strap, P/L abd strap) • Feet-stirrup, one at a time • Hip flex- 90-110 deg(ant flx strap) • Lat strap- loose, limits add, no forced abd
- 17. • Knee:- 3-5 cm apart at full abduction • X-ray taken: confirms Fem. neck directed to Trirad cartilage( gradually , head docks into acetab) • Clinical stable- USG evaluation, to confirm reduction • Superior dislocation- add flexion • Inferior dislocation- reduce flexion
- 18. • Lateral dislocation:- observed initially • Posterior:- persistant, difficult to treat, PH unsuccessful, discontinued • Tight adductors • GT posterior • > 3-6 weeks- PH discontinued • Otherwise, worn fulltime, until stability attained
- 19. • Reassess at 1-2 weeks, readjusted • Quad function assessed, femoral nerve palsy ruled out • Discontinue PH till recovery
- 20. Risk factors- failure of PH • Absent ortolani(irreducible) • B/L • Femoral nerve palsy • Acetabular ang> 36 degree • Coverage <20 degree(USG) • Delay to start PH >7 weeks
- 22. 6-18 months • Closed/open reduction • Preop traction • Adductor tenotomy • CR-arthrogram • OR- failed CR • Femoral shortening-high prox disloct
- 23. • Acceptable safe zone- 20-45 degree • Adduction, abd possible without dislocation (safe zone) • Goal-reduce risk of ON
- 24. 18-36 months • Redirectional prox femoral osteotomy- persistant dysplasia • Pelvic redirectional osteotomy- primary acetabular dysplasia • Combined • Concentric reduction achievement is must
- 25. VARUS DEROTATION OSTEOTOMY • Femur • In hip dysplasia • Pediatric hip screw fixation • Femur rotation-anteversion correction (15- 30degree) • Deformity - rotational>angular • Varus angulation- medial bone wedge (NSA-120 to 135 degree)
- 27. 3-8 yrs • OR –ant, • Capsulorrhaphy • soft tissue reconstruction -deformed capsule, sublx,dislocation,± false acetabulum • FEMORAL SHORTENING- prox end to Trirad car • ± pelvic osteotomy • Lowers rate of ON
- 28. • Teratologic dislocation- procedure in younger • Prior traction/femoral shortening failed- • Soft tissue release (iliopsoas/gracilis/pyriformis) • Capsule release from overlying ms • Contracted TAL release
- 29. CONCOMITANT OSTEOTOMY • HIP STABLE IN • Neutral- no • Flx and abd- innominate • IR and ABD- prox femoral derotation varus osteotomy • DOUBLE DIAMETER acetabulum with A/L def- PEMBERTON OSTEOTOMY
- 30. Pelvic osteotomy
- 31. SALTER INNOMINATE OSTEOTOMY • Performed when congruous OR possible ( soft tissue release may be reqd.), ROM good • When <10-15 degree AI correction reqd. • 18 months to 6 yrs(primarily), adults( sec) • Rotate acetabulum together with pubis and ischium • Symphysis pubis as hindge • Roof of acetabular- shifted A/L
- 33. PEMBERTON ACETABULOPLASTY • 18 months – 10 yr age • Small head • Large acetabulum • Full thickness, Pericapsular osteotomy of ilium • Superior to AIIS(ant), TC(post) • TC- hinge • Decreases volume of acetabulum, requires remodelling
- 34. • Acetabular roof rotated A/L • TC- flexible hinge (1-12yr girls, 14yrs boys) • No additional implant reqd. • Alters capacity configration of acetabulum- incongruous –requires remodelling
- 35. TRIPLE INNOMINATE • STEEL- Ischium, sup pubic ramus and ilium, divided, repositioned, stabilised with BG, pins. • GANZ-creates free acetabular segment, osteotomies in ischium,ilium, sup pubic ramus, preserving posterior column of pelvis • Late adolescence to skeletal maturity • Indicated- acetabular dysplasia • Congruous joint
- 36. Steel triple innominate osteotomy • Acetabulum repositioning • BG + pinning • Objective- stabilize hip • Disadv- excessive ext rotation • Decreased posterior coverage • Lateralisation of joint centre
- 37. Steel triple innominate osteotomy
- 38. GANZ(BERNESE) PERIACETABULAR • Triplanar, requires correction of congruency and containment • Blood supply acetabulum-preserved • post column hemipelvis kept intact • Pelvis shape unaltered • Can be combined with trochanteric osteotomy
- 40. DEGA OSTEOTOMY • Treats residual dysplasia • Secondary to dislocation • Incomplete transiliac osteotomy • Ant , middle inner ilium portion osteotomy • Leaving intact posterior hinge • Done before TC closure • Accompanies reduction of hip
- 42. SHELF • Enlarges volume of acetabulum • Pelvic redirectional osteotomy • Not done- femor head, acetabulum misshapen • Hip res
- 43. CHIARI OSTEOTOMY • Capsular interpositional arthroplasty • Indications- incongruous reduction -painful subluxated hip • Osteotomy- sup margin acetabulum • Distal pelvis along with femur displaced medially • Superior fragment –shelf • Capsule interpositioned
- 44. Indications-CHIARI OSTEOTOMY • Congenital subluxation/dislocation unresponsive to innominate in 4-6 yrs or older • Persistant subluxation in adults after conservative t/t • Dysplastic hip- osteoarthritis • Paralytic dislocation-spastic/weakness • Coxa magna after perthes • ON after congenital dysplasia
- 46. >8 yrs • Reduction –U/L • Arthrodesis c/i- B/L • B/L- Total hip arthroplasties in adulthood,left unreduced • B/l asymptomatic DDH- waddlening gait- left as such • Symptomatic /painful acetabular dysplasia- appropriate pelvic osteotomy
- 47. THANK YOU