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Developmental Dysplasia of Hip

Developmental Dysplasia of Hip/ DDH is common among newborns, so it is important to screen all newborns for DDH

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Developmental Dysplasia of Hip

  1. 1. By: Dr. Daniel Joseph Augustine MOSC Medical College, Kolenchery
  2. 2. ANATOMY OF HIP JOINT  It is a multiaxial ball and socket joint designed for stability and weight bearing.  Movements at the joint include flexion, extension, abduction, adduction, medial and lateral rotation, and circumduction. ARTICULAR SURFACES:  Head of femur articulates with acetabulum of hip bone to form hip joint  Head of femur- more than ½ a sphere, covered with hyaline cartilage  Acetabulum- lunate shape –notch & fossa
  3. 3.  Except for the fovea, the head of the femur is also covered by hyaline cartilage
  4. 4. LIGAMENTS OF HIP JOINT 1. Fibrous Capsule 2. Acetabular labrum 3. Ligaments:  Iliofemoral  Pubofemoral  Ischiofemoral  Ligament of the head of the femur  Transverse ligament of the acetabulum
  5. 5. BLOOD SUPPLY  Obturator .A, two circumflex femoral .A, two gluteal.A  Retinacular br. NERVE SUPPLY  Femoral .N  A/D of obturator .N, Accessory obturator .N  Nerve to Quadratus femoris  Superior gluteal .N
  6. 6. STABILITY OF HIP JOINT  Depth of acetabulum  Tension and strength of ligaments & surrounding muscles  Length & obliquity of the neck of femur High degree of stability & mobility
  7. 7. DDH  DDH is defined as partial or complete displacement of the femoral head from the acetabular cavity since birth  It comprises a spectrum of disorders including acetabular dysplasia without displacement, subluxation and dislocation  Incidence: Females affected 7 times more  The left hip is more often affected than the right, B/L involvement in 1 in 5 cases
  8. 8. Theories of Etiology  GENETIC- hereditary predisposition- generalized joint laxity and shallow acetabula  HORMONAL – common in females, maternal relaxin, high E & P levels – aggravate laxity  INTRAUTERINE MALPOSITION: extended breech - favour D/L- “packaging d/o”  POST NATAL FACTORS: uncommon in Asia and India
  9. 9. PATHOLOGY  Dislocated at birth (classic DDH) or dislocatable after birth (underlying laxity) Following changes seen:  Femoral head is d/l upwards & laterally, epiphysis is small & ossifies late  Femoral neck- excessively anteverted  Acetabulum shallow, ligamentum teres HP  Labrum may be folded into the cavity  Capsule is stretched, Hip muscles undergo adaptive shortening
  10. 10. CLINICAL FEATURES  Detected at birth or soon after when child starts walking  Birth –Routine screening for suggestive signs in every newborns especially those at high risk  Early childhood- Asymmetry of groin fold, click, limitation of movement  Older child- peculiar gait, no pain
  11. 11. CLINICAL TESTS For infants :  Look for asymmerty of groin crease, limitation of movt or audible click  Special tests include Barlow’s and Ortolani’s
  12. 12. Barlow’s Test  To assess DDH in neonate.  The Barlow maneuver identifes the unstable hip that is in a reduced position that the clinician can passively dislocate  Here the hip is started reduced and the test will dislocate the hip
  13. 13. Ortolani Test  Ortolani maneuver is performed following Barlow's test to determine if the hip is actually dislocated  Here the hip is started dislocated and the test will reduce the hip
  14. 14.  For Older Child:  Limitation of hip abduction, limb short & ext rotated  Higher buttock fold, asymmetrical thigh fold, lordosis of the lumbar spine  Galeazzi’s sign: Hips flexed to 70o ,knees flexed-compare level –lowering on affected side  Ortolani’s may be +ve  Trendelenberg’s Test is +ve  U/L D/L –trendelenberg gait  B/L D/L- waddling gait
  15. 15. INVESTIGATIONS Radiological Imaging  Ultrasonography has replaced radiography for imaging hips in the newborn. Sequential assessment allows monitoring of the hip during a period of splintage.  Plain X-rays: X-ray examination is more useful after the first 6 months, and assessment is helped by drawing lines on the x-ray.
  16. 16. X-ray findings:  Delayed appearance of ossification center of head of femur  Retarded development of ossification center  Sloping acetabulum  Lateral and upward displacement of ossification centre of femoral head  A break in Shenton’s line.
  17. 17. Hilginreiner’s line Perkins line Shenton’s line
  18. 18.  Aim is to achieve reduction of the head into the acetabulum and maintain it until the hip becomes clinically stable and a “round” acetabulum covers the head  Most cases closed reduction possible, else open reduction done MANAGEMENT OF DDH
  19. 19. Birth to 6m: Where facilities for ultrasound scanning are available, all newborn infants at risk are examined by USG. 1. If hip is reduced and has a normal cartilaginous outline, no treatment is required, observe for 3-6m 2. If acetabular dysplasia or hip instability, the hip is splinted in a position of flexion and abduction and USG done at intervals
  20. 20. Splintage  Splintage The object of splintage is to hold the hips somewhat flexed and abducted maintainence of reduction)  Von Rosen’s splint is an H-shaped splint  The Pavlik harness is more difficult to apply but gives the child more freedom while still maintaining position 3 golden rules of splintage are:  the hip must be properly reduced before it is splinted;  extreme positions must be avoided;  the hips should be able to move.
  21. 21.  If ultrasound is not available: nurse them in double napkins or an abduction pillow for the first 6 weeks and observe for first 6m for devpt of acetabular roof
  22. 22. Persistent Dislocation : 6-18m  The hip must be reduced – preferably by closed methods but if necessary by operation – and held reduced until acetabular development is satisfactory.  Closed reduction : suitable after 3m and is performed under G/A with an arthrogram to confirm a concentric reduction.  Failure to achieve concentric reduction should lead to abandoning this method in favour of an operative approach at approximately 1 year of age
  23. 23. Splintage  Held in a plaster spica at 60 degrees of flexion, 40 degrees of abduction and 20 degrees of internal rotation.  After 6 weeks the spica is changed & stability assessed  If satisfactory, spica retained for 6w, then abduction splint for 6m  If concentric reduction is not achieved, open operation is done
  24. 24.  The psoas tendon is divided; obstructing tissues are removed and the hip is reduced.  It is usually stable in 60 degrees of flexion, 40 degrees of abduction and 20 degrees of internal rotation. A spica is applied and the hip is splinted
  25. 25. Persistent Dislocation 18m to 4y:  In older children, arthrography and OR preffered over CR  Traction: help to loosen the tissues and bring the femoral head down opposite the acetabulum.  Arthrography: anatomy of hip, degree of acetabular dysplasia  Acetabular reconstruction procedures- If there is marked acetabular dysplasia, either a  Pericapsular reconstruction of the acetabular roof (Pemberton’s operation)  An innominate (Salter) osteotomy
  26. 26.  Salter’s osteotomy Osteotomy of iliac bone, so that acetabulum becomes more horizontal and covers the head  Chiari’s Osteotomy: Iliac bone transversly divided avobe acetabulum & medially displaced for additional depth  Pemberton’s osteotomy: The roof is deflected over the femoral head.
  27. 27. Splintage  After operation, the hip is held in a plaster spica for 3 months and then left unsupported
  28. 28. D/L in children >4yr:  U/L D/L in the child over 8 years often leaves the child with a mobile hip and little pain. This justifies non- intervention, though the child must accept the fact that gait is distinctly abnormal.  B/L D/L the deformity –waddling gait – is symmetrical and therefore not so noticeable;  Operation avoided unless the hip is painful or deformity unusually severe.
  29. 29. COMPLICATIONS  Failed reduction: The acetabulum remains undeveloped, the femoral head may be deformed, the neck is usually anteverted and the capsule is thickened and adherent.  AVN: ischaemia of the immature femoral head. It may occur at any age and any stage of treatment and is probably due to vascular injury or obstruction d/t forceful reduction and hip splintage in abduction.
  30. 30. To avoid AVN  Traction should be gentle and in the neutral position;  Soft-tissue release (adductor tenotomy) should precede closed reduction;  If difficulty is anticipated open reduction is preferable
  31. 31. Persistent D/L in Adults:  If disability is severe enough - total joint replacement.