ddh-PRESENTATION in orthopaedics and anatomy.pptx

ddh

1. Developmental Dysplasia of Hip Presented by-Dr. Eshaan

2. Introduction Developmental dysplasia of the hip (DDH) is a spectrum of disorders of development of the hip that present in different forms at different ages Generally includes Subluxation (partial dislocation) of the femoral head Acetabular dysplasia Complete dislocation of the femoral head from true acetabulum American Academy of Pediatrics defines DDH as a condition in which the femoral head has an abnormal relationship to the acetabulum

3. Etiology Ligamentous laxity (often inherited) Breech position (especially footling) Postnatal positioning (hips swaddled in extension) Primary acetabular dysplasia (unlikely) Iliopsoas and glutei paralysis – former cause lateral torsion/latter cause increased femoral anteversion (Bone) Acetabulum – shallow, gap/groove @ posteriosuperior part, lack of rounded cavity, outer surface of ilium and acetabular floor in straight line, over growth of fibro-cartilage in acetabulum ( pulvinar ) and remains of ligamentum teres

4. Ligamentous Laxity Newborn’s response to maternal relaxin hormones may explain the higher incidence of DDH among girls Cross the placenta and induce laxity in the infant. This effect is much stronger in female than in male children

5. Prenatal Positioning 16% of infants with DDH are born in breech presentation A double breech position is associated with a low incidence of DDH. A single footling breech is associated with a 2% risk of DDH. A frank breech, especially with the knee(s) extended, is associated with 20% risk of DDH.

6. Incidence of DDH is also higher among first-born children and in those pregnancies that are complicated by oligohydramnios These findings suggest that there is an intrauterine crowding effect on the developing hip Left hip is more often involved than the right Because the most common intrauterine position has the left hip adducted against the maternal sacrum

7. Postnatal Positioning People who wrap their newborn babies in a hip extended position (e.g., Native Americans who use cradle boards have a much higher incidence of DDH as compared with other populations People who usually carry their infants astride the hip or in a wrap that flexes and abducts the hips have a lower incidence of DDH as compared with other groups

8. Conditions Associated With Developmental Dysplasia of the Hip Torticollis Metatarsus adductus Oligohydramnios

9. Natural History Neonatal Hip The fate of the unstable hip remains an enigma. Subluxation of the hip at birth often corrects spontaneously and may be observed for 3 weeks without treatment Neonates with mild dysplasia and mild instability may have a benign course, with up to 88% resolving by 8 weeks of age. Spontaneous resolution without intervention is unlikely in children over the age of 6 months. Barlow found 1 hip in 60 to exhibit instability sign. 60% normalized within 1 week, and 88% were corrected within 2 months without treatment

10. After the Neonatal Period Dysplastic hips without subluxation Usually become painful and develop degenerative changes over time. Often become subluxated as the degenerative disease progresses. Cooperman and associates reported that all dysplastic hips without subluxation with a center–edge angle of less than 20 degrees sustained osteoarthritic changes over 22 years of follow-up

11. Subluxated Hip Always leads to symptomatic degenerative hip disease Often presents with gradually increasing pain in one or both hips Severe subluxation leads to symptoms during 2 nd decade of life moderate subluxation- 3 rd and 4 th decades least subluxation- 5 th and 6 th decades

12. Dislocated Hip Symptoms much later than a subluxated hip In some individuals, these hips never become painful Well developed false acetabulum may be seen

13. Pathophysiology

14. Clinical Features Neonate Usually asymptomatic Diagnosed by eliciting Ortolani or Barlow sign or from significant changes seen in the sonographic morphology of the hip Examination Barlow test Ortolani test Klisic sign

15. Barlow Test With the infant supine, the examiner holds both of the child’s knees, gently adducts one hip, and pushes posteriorly. When the examination is positive, examiner will feel femoral head make a small jump out of the acetabulum (Barlow sign). When the pressure is released, head is felt to slip back into place.

16. Ortolani Test Examiner holds the infant’s knees and gently abducts the hip while lifting up on the greater trochanter with two fingers. When the test is positive,dislocated femoral head will fall back into the acetabulum with a palpable “clunk” as the hip is abducted ( Ortolani sign). When the hip is adducted, examiner will feel the head redislocate posteriorly.

17. The Ortolani and Barlow maneuvers are the mainstay of clinical diagnosis in the first months of life Even in the best hands physical examination can fail to detect DDH After 3 months of age the Ortolani and Barlow tests become negative due to progressive soft tissue contractures.

18. Klisic Test Test to recognize a bilateral dislocation Examiner places the third finger over the greater trochanter and the index finger on the anterior superior iliac spine. An imaginary line drawn between the fingers should point to the umbilicus In dislocated hip, trochanter is elevated, and the line projects halfway between the umbilicus and the pubis.

19. Infant Progression from instability to dislocation is a gradual process Irreducible dislocation develops within a few weeks or upto 6 months When the hip is no longer reducible, specific physical findings appear : Limited abduction Shortening of the thigh Proximal location of the greater trochanter Asymmetry of the thigh folds, and Pistoning of the hip

20. Limitation of Abduction Most reliable sign of a dislocated hip Best appreciated by abducting both hips simultaneously with the child on a firm surface A unilateral dislocation produces a visible reduction in abduction on the affected side

21. Galeazzi Sign Best appreciated by placing both hips in 90 degrees of flexion and comparing the height of the knees, again looking for asymmetry

22. Asymmetry of the thigh folds Asymmetry of the popliteal and gluteal creases Apparent shortening of the extremity on the right

23. Telescopy Test Child in placed supine position Flex the hip and knee to 90 deg. & the thigh is push down and lift up Positive : if excessive movement or pistoning

24. Walking Child Affected side appears to be shorter than the normal extremity Child toe-walks on the affected side Trendelenburg gait With each step, the pelvis drops as the dislocated hip adducts, and the child leans over the dislocated hip

25. Trendelenburg gait As the child shifts weight to the side of the dislocated hip, the pelvis on the opposite and normal side drops as a result of the weakness of the hip abductor muscles on the affected side. The sideways lean of the body toward the affected side is known as the Trendelenburg sign .

26. Exaggerated lumbar lordosis Bilateral hip dislocation more difficult to recognize Excessive lordosis is often the presenting complaint that occurs as a result of hip flexion contracture.

27. Imaging studies Ultrasonography Xray Arthrography MRI

28. Ultrasonography Ultrasonography shows the soft anatomy of the hip and the relationship of the femoral head and the acetabulum very well Graf, who pioneered the use of ultrasonography for evaluation of the infant hip Recommended a lateral imaging technique with transducer placed over the greater trochanter

29. Alpha angle is the angle between the baseline and the roof of the bony acetabulum. Beta angle is the angle between the baseline and the cartilaginous acetabular roof. Smaller alpha angle indicates a shallower bony acetabulum. Smaller beta angle indicates a better cartilaginous acetabulum. As the femoral head subluxates , the alpha angle decreases, and the beta angle increases

30. Graf Classification System on the Basis of the Sonographic Angles of the Hip

31. Imre studied 300 babies who were born breech; of those with normal examinations and ultrasound studies, 29% later had abnormal radiographs of the hips at 5 months of follow-up. Thus it also must conclude that a “normal” ultrasound at 6 weeks of age does not guarantee a normal hip later in life .

32. Radiography Plain radiography of the pelvis usually demonstrates a frankly dislocated hip In newborns with typical DDH, however, the unstable hip may appear radiographically normal As the child reaches 3 to 6 months of age, the dislocation will be evident radiographically Several classic lines are helpful when evaluating the immature hip

33. Hilgenreiner line, Perkin line and shenton line Hilgenreiner's line is a line through the tri-radiate cartilages Perkin's line, drawn at the lateral margin of the acetabulum, is perpendicular to Hilgenreiner's line Shenton line is a curved line that begins at lesser trochanter, goes up the femoral neck, and connects with a line along the inner margin of the pubis .

34. Acetabular Index Acetabular index, is an angle formed by the juncture of the Hilgenreiner line and a line drawn along the acetabular surface. Radiographic measurement of femoral head bony coverage by the acetabulum In normal newborns, the acetabular index averages 27.5 degrees & decreases with age. Thirty degrees is considered the upper limit of normal

35. Wilberg center-edge angle Angle formed between the Perkin line and a line drawn from lateral lip of the acetabulum through the center of the femoral head Considered normal if it is more than 10 degrees in children between the ages of 6 and 13 years It increases with age.

36. Von Rosen View Both hips are abducted internally rotated, and extended In the normal hip, an imaginary line extended up the femoral shaft intersects the acetabulum. When the hip is dislocated, the line crosses above the acetabulum

37. Acetabular Teardrop Seen on an anteroposterior (AP) radiograph of the pelvis It is derived from wall of the acetabulum laterally, wall of the lesser pelvis medially curved line formed by the acetabular notch inferiorly Appears between 6 and 24 months of age in a normal hip and later in a dislocated hip

38. In dislocated or subluxated hip, the teardrop loses its convexity & appears wider from the superior to the inferior direction Hips in which the teardrop appears within 6 months of reduction have a better outcome than hips in which the teardrop appears later In a study by Smith and associates, the teardrop did not appear until hips were reduced which is an indication of inadequate acetabular deepening

39. Tonnis classification for DDH Grade I: ossification center of the capital epiphysis is medial to the perpendicular line from the superolateral margin of acetabulum Grade II: ossification center of capital epiphysis is lateral to the Perkin line, but below the superolateral margin of acetabulum (SMA-line). Grade III: ossification center is at the level of superolateral margin of acetabulum. Grade IV: ossification center is above the superolateral margin of acetabulum.

40. Arthrography Important role in deciding between closed and open reduction in older infants and toddlers Helpful for evaluating the depth and stability of reduction Width of medial dye pool to assess lateralization Sub adductor approach with image intensification Needle is inserted just beneath the adductor longus , approximately 2 cm distal to its origin

41. In normal hip, the free border of labrum is easily seen as a sharp “thorn” with a recess of joint capsule overlying it In DDH, when the hip is in the dislocated position, the capsule is enlarged as it extends over the femoral head. Capsule is constricted at its middle portion into an hourglass shape by the iliopsoas tendon .

42. Magnetic Resonance Imaging Provides excellent anatomic visualization of the infant hip Not commonly used because of the expense involved and the need for sedation Kashiwagi proposed an MRI-based classification : Group I : Sharp acetabular rim All reducible with a Pavlik harness. Group 2 : Rounded acetabular rim Almost all could be reduced with harness. Group 3 : Inverted acetabular rim None was reducible with the harness .

43. Screening Criteria All neonates should undergo a clinical examination for hip instability Infants with risk factors should receive careful screening that includes an examination by an experienced examiner and possibly ultrasonography Risk factors include family history of DDH, breech birth position, torticollis, metatarsus adductus , and oligohydramnios American Academy of Pediatrics recommends radiographic screening (ultrasonography) for female infants who were either carried in breech position or have a positive family history of DDH

44. Treatment When evidence of subluxation of the hip persists beyond 3 weeks on physical examination or ultrasonographic evaluation, treatment is indicated. When actual hip dislocation is noted at birth, treatment is indicated without need for an observation period

45. Outcome Measures When assessing results of any surgical intervention, surgeon must have a working understanding of the outcome measures Three domains considered in evaluation of results of surgical management: Patient’s clinical function Development and severity of osteonecrosis Radiographic assessment of hip joint .

46. Functional Assessment McKay criteria include Pain Range of motion Muscular strength Limp

47. Radiographic Hip Congruency Severin grade I and II results are considered acceptable, whereas grades III to VI are not Four radiographic markers for successful reduction Improvement in acetabular index Sharp (not rounded) lateral border of acetabulum Narrow teardrop Intact Shenton line

48. Birth to 6 months Treatment is based on: Stabilizing the hip that has positive ortalani or barlows test or Reducing the dislocated hip with mild to moderate adduction contracture. Triple diaper technique Pavlik harness

49. Pavlik Harness Introduced in eastern Europe in 1944 Dynamic positioning device Allows the child to move freely within the confines of its restraints. It consists of Circumferential chest strap Shoulder straps Lower-extremity straps Anterior lower extremity straps is to flex the hips Posterior lower-extremity straps prevent adduction of the hips

50. How long pavlik harness should be continued After closed reduction and application of pavlik harness. Follow up in every 1-2 weeks. Hip stability is checked. Discontinued according to weaning protocol after clinically hip stability is obtained.

51. Weaning of Pavlik Harness If the findings from clinical examination and radiographs are consistent with hip stability, weaning from the harness is initiated 4 hours a day for the first third of the remaining treatment period Reevaluation is at 2-week intervals If stability is maintained, the child is progressively weaned out of the harness 8 hours a day for the next third of the weaning period 12 hours a day for the final third of the weaning period .

52. If residual acetabular dysplasia exists, harness is worn for 12 hours a day until dysplasia resolves on radiographic evaluation When the child begins to pull to stand, an Ilfeld brace is substituted for Pavlik harness and is used until the hip is radiographically normal.  If the hip is not reduced in 2 weeks by this technique, other methods of treatment should be pursued

53. Closed Reduction and Spica Casting If stable concentric reduction of the hip joint is not attained after a trial period of 3 weeks in the Pavlik harness, this method should be abandoned Closed reduction and hip spica casting may also be the treatment of choice

54. Cause of Failure Poor parent compliance Improper use by the physician Inadequate initial reduction Failure to recognize persistent dislocation • Bilateral dislocation • more than 7 weeks of age

55. Complications Avascular necrosis Femoral nerve palsy Pavlik disease (flattening posterolateral acetabulum)

56. 6 to 18 months Preoperative traction Adductor tenotomy Arthrography and closed reduction Open reduction in children with a failed closed reduction Preoperative traction Objective : To bring the laterally and proximally displaced femoral head down to and below the level of the true acetabulum to allow a more gentle reduction with less risk of osteonecrosis

57. Adductor tenotomy If soft-tissue contracture limits the amount of abduction available to achieve a stable reduction Helps release soft-tissue contracture and increases the safe zone of abduction. Mild contracture: percutaneous tenotomy Severe contracture: open adductor tenotomy through a small transverse incision

58. Arthrography and closed reduction Arthrography is helpful in determining Whether mild dysplasia is present, Whether the femoral head is subluxated or dislocated, Whether manipulative reduction has been or can be successful, To what extent any soft-tissue structures within the acetabulum may interfere with complete reduction of the dislocation, Condition and position of the acetabular labrum (the limbus ), Whether the acetabulum and femoral head are developing normally during treatment

59. Criteria for accepting a reduction Medial dye pool of 5 mm or less Maintenance of reduction in an acceptable “safe zone. Sensation of a “clunk” as the femoral head reduces in the true acetabulum. Increase in the knee flexion angle (popliteal angle)

60. Safe zone acceptability of closed reduction Safe zone” concept can be used in determining the zone of abduction and adduction in which the femoral head remains reduced in the acetabulum. A wide safe zone (minimum of 20 degrees, preferably 45 degrees) is desirable A narrow safe zone implies an unstable or unacceptable closed reduction

61. Application of Hip Spica After confirmation of a stable reduction, hip spica cast is applied with the hip joint in 95 degrees of flexion and 40 to 45 degrees of abduction. Hip spica changed every 6 weekly and stability checked Continue spica for 3 to 4 months Salter advocated this “human position” as best for maintaining hip stability and minimizing the risk of osteonecrosis

62. Open reduction Patients who are age >12 months or in whom closed treatment has been unsuccessful Purposes of open reduction are To remove any anatomic impediments to femoroacetabular congruence To release any soft-tissue contractures To obtain a stable concentric reduction Limiting the risk of osteonecrosis or the need for secondary procedures

63. Toddler (18 to 36 months) Open reduction with femoral or pelvic osteotomy, or both is required Persistent dysplasia can be corrected by a redirectional proximal femoral osteotomy in very young children If the primary dysplasia is acetabular , pelvic redirectional osteotomy alone is more appropriate

64. Femoral Osteotomy Used to shorten the femur so that femoral head does not experience excessive contact pressure after reduction Thus reducing the risk of osteonecrosis Used to reorient the femoral head into a better position within the acetabulum, usually by derotation of excessive anteversion Femoral osteotomies are performed together with open reduction, usually because of age of patient and associated soft-tissue contracture or deformity

65. Child (3 to 8 years) Primary femoral shortening Aids in reduction and decreases potential for complication in older children Technically demanding in older age group.

66. Pelvic Osteotomies Used in the surgical treatment of pediatric hip dysplasia to alter the acetabulum The purpose of pelvic osteotomy is to enhance the stability of an open reduction and improve coverage of the femoral head, not to obtain the reduction primarily Choice of pelvic osteotomy largely depends on the surgeon’s preference.

67. Three types of pelvic osteotomies Redirectional orientation osteotomies ( eg , Salter, triple ), Volume reducing osteotomies ( eg , Dega , Pemberton ) Salvage osteotomies ( eg , shelf, Chiari )

68. Salter Innominate Osteotomy First pelvic osteotomy described for use in the management of DDH Reorientation of the acetabulum to improve deficient anterior and lateral coverage of femoral head Indications Acetabular dysplasia that persists after primary treatment Acetabular dysplasia discovered in an untreated child Persistent dysplasia after the age of 5 years Prerequisite Hip should be concentrically reduced Contractures of the iliopsoas and adductor muscles must be released

69. Pemberton Pericapsular Osteotomy Alters the volume of acetabulum by using triradiate cartilage as a hinge Used to improve anterior coverage Especially appropriate for cases in which the acetabulum is capacious Contraindicated if the acetabulum is small relative to the size of the femoral head Potential complication Premature closure of the triradiate cartilage Can result in an incongruous relationship between acetabulum and the femoral head More difficult to perform One advantage of pericapsular over innominate osteotomies is that internal fixation is not always required

70. Dega Osteotomy Primarily improves anterior and lateral coverage Used for the treatment of residual acetabular dysplasia secondary to congenital hip dysplasia or dislocation

71. Chiari Osteotomy Capsular interposition arthroplasty Considered only in situations in which other reconstructions are impossible, such as When femoral head cannot be centered adequately in the acetabulum Painful ubluxated hips with early signs of osteoarthritis Deepens the deficient acetabulum by medial displacement of the distal pelvic fragment Improves superolateral femoral coverage

72. Thank You