DDH Developmental Dysplasia of the Hip.ppt

Developmental Dysplasia of the Hip - assessment and management

5. “Condition in which there is subluxation or
dislocation of the femoral head or acetabular
hypoplasia that is seen at birth”

6. CDHCDH
•Unsatisfactory term
•Not always associated with
dislocation
•Not always congenital
Hence the term DDHDDH
Coined by Klisic in 1989

8. •Hippocrates (460-357 B C) was familiar
with crippling effects of untreated CDH
•Only in 2
nd
half of 20
th
century substantial
progress was made in early treatment.
Earlier to 1960 diagnosis was made only after the age of 2years
When child started to walk

9. Barlow and Von Rosen’s publications – 1962
Change in the conceptChange in the concept
“ Why not treat the condition immediately
after birth before secondary changes set in?”

10. Problems faced even after early treatment:
•In 2.5% hips diagnosed early and treatment initiated, failed to
prevent dislocation
•Epiphyseal damage secondary to neonatal splinting in
abduction was reported.
•Cases have still continued to slip through the diagnostic net,
only to present themselves when the child begins to walk.
However imaging modalities , Ultrasonography in particular
have improved the results of early detection

11. •188.5 per 1000 in Canadian Indians to Zero
among Bantus in Africa -Tachdjian
•0.7 / 1000 – Birmingham series
•2 /1000 live births Hospital based study
from Manipal (Karnataka, India)

12. •5 to 8 times more common in females
•60% occur in first born child
•20% of DDH patients are born breech
•Left hip more than Right hip (60% left, 20% right
and 20% bilateral)
•Siblings of affected children  10 times increased
risk of DDH

13. Classification
Type 1 Developmental - Occur in the
perinatal period and respond well
Type 2 Acquired - Neuromuscular origin
infection
Type 3 Teratologic disorders

14. Classification by degree:
Type 1: Hip stable
Type 2: Hip subluxable
Type 3: Hip dislocatable
Type 4: Hip dislocated

16. Several theories have been proposedSeveral theories have been proposed

17. 3 periods during intra-uterine life, 3 periods during intra-uterine life,
when risk of DDH is highwhen risk of DDH is high
•1212
thth
week week
•1818
thth
week week
•Final 4 weeks of gestationFinal 4 weeks of gestation

18. 12
th
week of gestation:
•1
st
major positional change – medial
rotation takes place.
•If neuro-muscular mechanism do not
develop in synchronised manner then
chance of dislocation is high.
•Acetabulum becomes shallow due to lack of
growth stimulus

19. •1818
thth
week of gestation week of gestation
•Active motion of the hip joint develops.
•Under developed limbus
•Shallow acetabulum
•Capsular weakness
•Asynchronous muscle innervation

20. Final 4 weeks of gestationFinal 4 weeks of gestation
•Mechanical factors concerning position of fetus
play crucial role:
•Breech position with extended legs
•Oligohydamnios
•Hormonal action
•Common denominator- genetically induced
abnormal collagen distribution in capsule and
ligaments of hip joint.

21. •Wynne-Davies described a familial
occurrence of a "shallow" acetabulum,
defined as a "dysplasia trait," as one of
the risk factors for congenital dysplasia
of the hip.
•Inherited as multiple gene system
•Usually detected late as they are
clinically stable after birth

22. Risk Factors
•FFemale
•FFirst born
•FFamilial
•FFaulty position

23. •Torticollis
•metatarsus adductus
•calcaneovalgus feet
•congenital recurvatum or disloc. knee
Associated conditiondAssociated conditiond

25. Bony changes Soft tissue changes
Pathological changes

26. Acetabular changesAcetabular changes:
•Shallow dysplastic acetabulum.
•Later the cavity becomes filled with
fibro cartilage and remains of
ligamentum teres

27. Changes in the femoral headChanges in the femoral head
•Delayed ossification of the head
•Becomes flat – postero-medially
•Disproportionate compared to the
acetabulum

28. Changes in the neck of femurChanges in the neck of femur
•Neck becomes short
•anteverted

29. Capsular changesCapsular changes
•Soft tissue changes are maximum in
capsule
•Capsule is hpertrophied
•Hour glass constriction of the capsule –
central constriction caused by Ilio-psoas
tendon

30. •Hypertrophy of acetabular labrum – major
obstruction to reduction
•Hypertrophy of ligamentum teres, Iliopsoas

31. MusclesMuscles:
•Pelvi-femoral group of muscles- adductors,
hamstrings and quadriceps are shortened
•Pelvi-trochanteric muscles: Iliopsoas becomes
elongated and is functionally incompetent
•Gluteal group of muscles – no organic change
but power is reduced due to lack of fulcrum

34. •Assymetry of thigh folds
•Assymetry of gluteal fold
•Widened perineum
•Abduction reduced , internal rotation
increased

35. Performed by gently abducting and
adducting the flexed hip to detect any
reduction into or dislocation of the
femoral head from the true acetabulum.
Should not be repeated more than few times – damages
articular cartilage

36. Detects any potential subluxation or
posterior dislocation of the femoral head
by direct pressure on the longitudinal axis
of the femur while the hip is in adduction
Can be performed twice at the most – potentially unstable hip can
become unstable

37. Hip and knee flexed to 90 degrees

38. •Present with c/o limp
•Gait – Trendlenbergs / Waddling gait
•Limb shortening present
•Vascular sign of Narath - +ve
•Abduction and external rotation reduced
•Telescopy +, Transmitted movements present
•Trendlenbergs Sign +ve
•Supratrochanteric shortening present

39. •All the before mentioned signs
•And also signs of osteoarthritis of hip –
painful and generalised restriction of
movements.

42. •At birth femoral head is catilagenous
Which is not visualised
•Hazards of radiation
•Assymetrical position of the pelvis
Limitations

43. X rays measurements
Hilgenreiner’s line
Perkin’s line
Acetabular index
Shentons line

45. •Type 1: Femoral capital epiphysis medial to
Perkins line and below Hilgenreiners line
Type 2: Epiphysis below Hilgenreiners line
but lateral to Perkins
Type 3: Epiphysis lateral to Perkins line at
the level of the acetabular margin
Type 4: Epiphysis lateral to Perkins line and
above the acetabular rim

46. It is normally about 30 degree and should not
be more than 40 degree

47. Von Rosen’s lineVon Rosen’s line

49. CE Angle of Wiberg:
CE angle provides useful information after the age of 5
years
- Angle between line drawn from the center of the
femoral head to the outer edge of acetabular roof, and
a vertical line drawn thru the center of the femoral head;

 
-> 25 deg are considered normal;
 

-< 20 deg indicates severe dysplasia;

50. Medial gap and superior gap

51. H line
D lineShortened H line and lengthened D line

52. •An arthrogram of the hip is beneficial in all
children, regardless of age, who are given a
general anesthetic for closed reduction
•Again radiation hazards do exist
•Has to be done only under anaesthesia
•Risk of anaphylaxis to dye exists
Permits analysis of the cartilaginous anlage of the femoral head
and acetabulum

53. Locate the hip joint immediately inferior to the middle of the inguinal
ligament and one fingerbreadth lateral to the pulsating femoral artery

54. normal saline solution is injected first then dye
22-gauge needle, to which is attached a 5-ml syringe
5 ml of a 25% strength Hypaque solution is used and 1 to 3 ml
injected with image intensification

55. •High resolution multiplanar real time U/S
used
•Cartilaginous structures visualized
•Multiplanar imaging possible
•Dynamic studies possible
•Non-invasive, non-ionizing, No sedation
Becomes unreliable as the secodary ossification centre
increases in size

56. Dynamic Standard Minimum Dynamic Standard Minimum
ExaminationExamination
•The Graf technique of ultrasonography
being a static method is based on the
morphological characteristics of hip joint.
•The Harcke technique being a dynamic
method is based on the position & stability
of the femoral head.
•In 1993, Graf & Harcke agreed on merger
of their techniques

57. Includes two mandatory components –
• a coronal view at rest in the Mid
Acetabular plane for assessment of
acetabular development.
•a transverse view during a stress maneuver
of the adducted hip held in 90
0
of flexion
for assessment of hip stability.

58. Coronal-flexion view

59. The standard mid acetabular image with Alpha and Beta angles

60. Transverse flexion view

61. “U” configuration in the transverse flexion stress view

62. •Deliniation of soft tissues is excellent
•Non invasive, no risk of radiation
•Disadvantages
•Dynamic testing is not possible
•Costly

63. •Also a good imaging modality, details of
concentric reduction are well made out
•Risk of radiation
•Cost
•More useful after 6 months of age

65. Coxa VaraCoxa Vara
•Limp is less severe
•Head not palpable in abnormal position
•Telescopy Negative
•On X ray can ruled out

66. OthersOthers
•Pathological dislocation
•Paralytic dislocation
•CP
•Septic arthritis

67. •Progress to degenerative arthritis of hip
•Spinal deformities: In B/L cases
hyperlordosis – Lumbago
•U/L cases can develop scoliosis, genu
valgus with OA of knee

68. Clinical testsClinical tests:
•Done within 2 days of birth
•At discharge
•6 weeks
•6 – 9months
•15 – 21 months
•Risk factors are recorded

69. •If positive or if risk factors are
present:
•X ray evaluation is done
•U/S screening is done – also at
follow up

70. Birth to 6 months of age:
“Hold if need pull”
Pavlick Harness, Von Rosen splint
W/F 6-8 weeks – no improvement – Closed reduction and
casting

71. •

  
                                                                               
 
                                                                                           

72. 6 months to 18 months
“Pull and hold”
•Pre-op traction
•Closed reduction and hip spica casting
If not stable – open reduction

73. 18 months to 3 years
“Break and hold”
Open reduction and cast application
Femoral osteotomies

74. 3 to 8 years – Juvenile
“Open and break”
Open reduction
Femoral shortening
Pelvic osteotomies

75. 8 to 10 years and beyond
“Open and replace”
Palliative salvaging surgeries
Replacement surgeries at appropriate age