DDH presntation for college synopsis.pptx

ddh classification

1. Dr Gautam Kumbhar JR 2 Dept . of Orthopedics DUPMC & H Dr Pramod Sarkelwad Ass. Prof & HOU Dept of Ortho DUPMC & H Dr Deepak Agrawal Prof & Head Dept of Ortho DUPMC & H

2. DEVELOPMENTAL DYSPLASIA OF THE HIP

3. Risk Factors Female sex- due to maternal hormone such as relaxin inducing greater joint laxity Breech presentation-Children delivered by cesarean section have lower chance of developing DDH than those delivered by vaginally. Intrauterine crowding phenomenon-Condition producing tighter intrauterine space such as oligohydramnios, larger birth weight, first born child. Family history. White children have a higher incidence than black children.

4. PROTECTIVE FACTORS Like the risk factors, certain protective factors have been identified that protect the child from developing DDH like: • Preterm baby less than 2 kg weight • Premature babies • Population where the ladies are in the habit of carrying child by the slide against their bodies in the shawl.

5. ASSOCIATIONS Lot of musculoskeletal abnormalities has been strongly associated with congenital dysplasia of the hip (most of these results from tight packaging say in primi gravida) that includes: • Congenital torticollis: The coexistence rate of congenital torticollis and congenital dysplasia is about 8%. • Metatarsus adductus • Talipes calcaneovalgus deformity • The association with clubfoot deformity is controversial with conflicting reports.

6. ETIOPATHOGENESIS Several theories exist regarding pathogenesis of congenital dysplasia. The actual cause appears to be a combination of more than one factor. • Mechanical: In-utero position—The most common intrauterine position of the fetus places left hip against maternal sacrum forcing it into a position of adduction resulting in dislocation. In fact, left hip dislocation and dysplasia are the most common, followed by both hip involvement and right hip involvement alone. Breech delivery is also an important mechanical factor predisposing dislocation of the hip.

7. Positional: An increased incidence is also seen in communities that swaddle infants (Americans and Swedish) with the hips lying in constant adduction and extension. In India, the incidence is low due to the habit of carrying the children by side. Hormonal: Maternal hormones like relaxin may produce ligamentous laxity thereby increasing chances of dislocation. This hormone can cross placental barrier. Genetic: Finally there may be familial occurrence of a shallow/dysplastic acetabulum which may predispose dislocation. Anatomical: lax joint capsule fails to correct the neonatal anteversion of femoral neck

8. Acetabulum appears as a mesodermal condensation at the end of 4th week of intrauterine life. The concavity develops due to pressure from the developing cartilaginous femoral head. The triradiate cartilage is the basic structure occupying a rotated “Y” position having lower vertical segment, anterosuperior limb and a horizontal posterior limb. Triradiate cartilage ossifies to for ilium, ischium and pubic bones during further development. At birth the both hips are in flexion contracture of 15–20˚ that is stretched by the infants activity in the first 6 weeks.

9. Bone Pathology Acetabulum: It is mainly amalgamation of malformation of the anatomical structures that have developed normally during the embryological period. The following changes are seen: Shallower than normal. Gap/groove in posterosuperior part [over which the head subluxates ] Triangular-depressed cavity with lack of rounded concavity . Outer surface of ilium and acetabular floor in a straight line . Overgrowth of the fibrocartilage in acetabulum (pulvinar) and remains of ligamentum teres. A ridge of thick articular cartilage forms over posterosuperior wall—termed “ Neolimbus ” by Ortolani; that remains inverted . It is over this that the femoral head slides in and out with a “clunk” or “ scatto ”, the latter term used by Ortolani.

10. Femoral head: It develops into a conical shape or buffer shape if resting on ilium. The ossification is delayed and flattening is seen on both posterior and medial aspects. Cartilage portion is larger than acetabular space’ Pelvis and lower spine: Pelvis tilts forwards. Deformation in pelvis seen in the form of approximated ilia and separated ischium (bilateral cases). For unilateral DDH the inlet is obliquely ovoid. Increased lumbar lordosis.

11. Soft Tissue Patholog Capsule Hourglass shape (iliopsoas induced constriction of the capsule between head and acetabulum) Adherent to acetabular floor Muscles Pelvifemoral muscles [adductors, hamstrings, gracilis , sartorius, tensor fasciae latae (TFL), pectineus and rectus femoris] shorten and most formidable obstacle to reduction.

12. Pelvitrochanteric group (obturator, quadratus, iliopsoas) become stretched and functionally incompetent. Gluteal muscles ( medius , minimus , maximus) reduces power due to shortened lever.

13. CLINICAL PRESENTATION The clinical presentation varies with the age. The classic signs for diagnosis of hip dysplasia include limited hip abduction with 90˚ knee flexion, positive Ortolani sign found up to 3 months and apparent shortening of thigh. The prominent findings are Upriding trochanter riding above Nelaton’s line, shortening of the limb. Adduction contracture. Absent femoral pulse (due to lack of support from underlying femoral head in a dislocation). Asymmetric thigh folds—increased in number on the side of dislocation.

14. Asymmetric thigh folds—increased in number on the side of dislocation. Higher buttock fold on side of dislocation. Widened perineum in bilateral dislocation. Galeazzi sign positive. ROM—restricted abduction, increased internal rotation. Ortolani (1937) test is performed by gently abducting the initially adducted and flexed hip through 90˚ arc while applying an anteromedial force to the greater trochanter (from fingers) to detect any reduction of the femoral head into acetabulum. If one of the hips is dislocated then a clunk “ scatto ” of entry is produced in 90˚ arc somewhere along.

15. False positive—fascia lata snapping over greater trochanter or iliopsoas tendon over femoral head. False negative—markedly lax capsule produces a smooth reduction without clunk Barlow’s test (modification of Ortolani test) is a provocative measure which detects the potential of hip joint instability. For the first part with the knees fully flexed and both hips adducted the normal hip kept in 90° of flexion, the affected hip is placed in 45–60° of flexion (in this position it is likely to be more unstable). The thighs are carried into mid abduction and pressure exerted by middle finger onto greater trochanter towards pubis to reduce the hip. For second part of the test (Barlow’s test for dislocatable hips) outward pressure is exerted

16. by the thumb onto inner aspect of thigh and pushing the shaft of femur along longitudinal axis posteriorly the clunk/jerk of exit is felt as the head slips out over the posterosuperior lip of acetabulum. This indicates a dislocatable hip and not a dislocated one.

17. The following are the findings in a walking child: Limitation of abduction and asymmetric thigh and gluteal folds are the most common clinical findings in such children. The Galeazzi sign may be positive when the femoral head is displaced laterally as well as proximally causing an apparent shortening of the femur. A child in walking age may walk with Trendelenburg gait (unilateral dislocation) described as waddling by parents with exaggerated lumbar lordosis. For bilateral cases the child has a duck-like or Sailors gait. Increased lumbar lordosis.

18. Ludloff’s sign—in a normal child with hips fully flexed and abducted, the knee cannot be fully extended due to hamstring tightness while in a dislocated hip due to proximal shortening knee can be fully extended. Klisic test—keep index finger on anterosuperior iliac spine (ASIS) and middle finger on greater trochanter. A line joining them meets at umbilicus while in bilateral dislocation the lines meet below it.

19. IMAGING STUDIES RADIOGRAPHY Proximal femoral epiphysis begin to ossify around 4–6 months of age, is delayed in DDH. In these cases the line drawn-up the femoral long axis with radiograph taken in 45° of abduction ( Andren -Von-Rosen line) should transect the triradiate cartilage and is true irrespective of the position of hip joint. Hilgenreiner’s line: It is the horizontal line drawn joining the uppermost aspect of triradiate cartilage of both sides.

20. Perkin’s line ( Ombredanne’s line): It is the line perpendicular to hilgenreiner’s line drawn at lateral margin of acetabulum. It divides the hip into four quadrants. 1. Normal hip—femoral epiphysis lies in the lower inner quadrant. 2. Subluxated hip—femoral epiphysis lies in the upper medial quadrant. 3. Dislocated hip—epiphysis in the lower outer quadrant. 4. High dislocation—epiphysis in the upper outer quadrant .

21. Quite often a grading system is used for DDH to evaluate hips in research papers and studies based on this “quadrant position of the femoral head”. The system gave rise to the classification of hip dysplasia by Tonnis as follows: Grade 1: Capital femoral epiphysis medial to Perkins line. Grade 2: Capital femoral epiphysis lateral to Perkins line but below the level of the superior acetabular rim. Grade 3: Capital femoral epiphysis at the level of superior acetabular rim. Grade 4: Capital femoral epiphysis above the level of superior acetabular rim

22. Ultrasound Ultrasound screenings is increasingly being used for the diagnosis and follow-up of treated cases of congenital dysplasia of the hip. It is noninvasive and easy to use, its interpretation is observer-dependent and may pick-up several false positive cases resulting in over diagnosis and tendency towards over-treatment. Ultrasonic examination is a useful adjunct to the physical examination. It has useful role in documenting the response of hip to closed reduction in Pavlik harness or spica.

23. Arthrography It is a wonderful tool to assess the reduction (closed reduction), depth of acetabulum and stability of reduction. The width of medial dye-pool indicates the likely stability of reduction. Fair reduction is indicated by 5–6 mm of medial dye pool. Medial space greater than 6 mm indicates poor reduction which is difficult to hold.

24. Radiological Screening Ultrasonography (USG) screening is currently indicated in female infants delivered by breech and/or positive family history of DDH. Other plausible indications for screening of hip include: Family history Breech presentation Torticollis Metatarsus adductus Oligohydramnios

25. DIFFERENTIAL DIAGNOSIS Coxa vara pathological dislocation paralytic dislocation cerebral palsy septic arthritis and its sequel.

26. TRERATMENT The treatment of DDH is age related, i.e. the age at presentation for treatment. Generally, the age-related treatment groups have been divided into five types: 1. Newborn (birth to 6 months) 2. Infant (6–18 months) 3. Toddler (18–26 months) 4. Child (3–8 years) 5. Adolescents (more than 8 years).

27. Treatment in Newborn (birth to 6 Months) The aim of treatment in this age group is to stabilize hip in reduced position and to allow flexion and abduction movements simultaneously. Pavlik Harness-Success rate is around 95%. he harness works on the mechanism of “dynamic flexion-abduction of hip Pavlik Harness is a “dynamic flexion-abduction orthosis” which has a chest strap, two shoulder straps and two stirrups. The harness is applied with the child in supine position (the most effective position for the harness to work).

28. Each stirrup has an anteromedial flexion strap and posterolateral abduction strap. The chest strap is applied first allowing enough space between skin and the strap. The shoulder straps are adjusted to keep the chest strap at the nipple line. The feet are placed in stirrup one by one. The hip is placed in 90–110° of flexion and anterior flexion strap is tightened. Lastly, the lateral abduction strap is tightened to limit adduction and not produce forced abduction. At full adduction, the knees should be 3–5 cm apart. An X-ray may be made on the harness which should show femoral neck directed towards the triradiate cartilage. An ultrasound evaluation is a good means to follow-up patients on a Pavlik Harness after closed reduction.

29. The harness treatment cannot be applied to an older child where soft tissue contracture has started to form or the child has started crawling. The Pavlik harness should be worn full-time until stability is achieved which takes about 6 weeks. Brace changes are required to take care of the growth every 3–4 weeks. Once a stable hip has been achieved the harness is weaned off allowing more harness free time in the day.

30. Potential Complications Avascular necrosis (less than 1%). Persistent dislocation: It is generally seen in superior, inferior, lateral and posterior. Femoral nerve palsy: Femoral nerve palsy may occur due to acute flexion (more than 90o ) required to apply the Pavlik harness. The physician should look for active knee extension after removal of the harness on each visit. If femoral nerve palsy develops, the harness treatment should be discontinued.

31. Failure of treatment on a Pavlik harness (reduction not achieved by 6 weeks max.) may occur in the following situations. Absent Ortolani sign at initial evaluation (irreducible dislocation) Bilateral hip dislocation. Development of femoral nerve palsy during treatment leading to discontinuation of treatment. Acetabular index of 36° or more on an X-ray. Initial coverage of less than 20% as determined on ultrasonographic examination. Inability to treat beyond 7 months of age.

32. Contraindications Contraindications for Pavlik harness: Older child in walking stage. If the hip cannot be centered toward triradiate cartilage in 90–110° of flexion. Dislocations developing several weeks after birth. Dislocations associated with muscle imbalance: – Meningomyelocele – Stiff extended knee – Down syndrome – Marfan syndrome – Osteogenesis imperfecta

33. There are other harness also available that can be variably used and have good success these include: Ilfeld splint Von Rosen splint Tubingen splint

34. Treatment in an Infant (6–18 months) A Pavlik harness usually fails once the soft tissue contractures have developed and the child begins to crawl. In this age group, the infant will require a closed or open reduction followed by a hip spica. A percutaneous or open adductor tenotomy may be performed for adductor contracture. Closed Reduction The closed reduction is generally preceded by arthrography because a plain radiograph or an ultrasound is unable to provide all the desired information.

35. An arthrogram may help in determining the acetabular dysplasia, degree of femoral head dislocation, extent of soft tissue obstruction to closed reduction, condition of the limbus and the quality of reduction. The criteria for accepting closed reduction include a medial dye pool of 5 mm or less and maintenance of reduction in a “safe-zone”. The safe zone concept is used to determine the zone of adduction and abduction is which the femoral head remains reduced in the acetabulum. While a wide safe zone (20–45°) is desirable, a narrow safe zone indicates an unstable/unacceptable reduction. A spica cast is applied in 90–100° of flexion and 40–45° of abduction. This position has been described as “human position” by Salter and reduces chances of avascular necrosis.

36. Open Reduction When gentle reduction without force is not possible, an open reduction may be indicated. Other indications for open reduction are: Femoral head lying persistently above the triradiate cartilage. • Arc of reduction or “safe zone” of less than 25°, i.e. redislocation occurs with hip adducted within 25° of the reduced position. • Previous failed reduction. • Femoral head remains laterally displaced at 6 weeks (most likely due to hourglass constriction of the capsule).

37. The aim of open reduction is to achieve concentric reduction of the femoral head in the acetabulum after correcting the soft tissue interposition. The open reduction may be performed through an anterior, anteromedial or medial approach. Additional Procedures Additional procedures may be needed for stable reduction of the hip in the still dysplastic shallow acetabular cup. As a rough guide if greater than 30% of head is visible after open reduction then additional procedures are needed to improve stability

38. Also acetabular side osteotomies are needed if there is progressive subluxation after either conservative or operative treatment. The third indication for ancillary procedure is uncommon cases where the acetabulum fails to remodel after open reduction. In addition to open reduction and capsulorrhaphy , concomitant bony procedures may increase the stability of reduction as follows: Innominate osteotomy- When the hip is stable only in flexion and abduction and dislocated posteriorly on adduction, an innominate osteotomy may be required to reposition the acetabulum for better coverage(Salters osteotomy).

39. Toddler (18–36 months) These patients characteristically have: A wide perineum Short extremity Hyperlordosis of the lower spine due to femoropelvic instability. Though manageable but extensive procedures in combination are often needed with less successful results . Often an “open reduction and capsulorrhaphy ” is accompanied by a “femoral or pelvic osteotomy or both”

40. Child (3–8 years) These are categorized as basically neglected DDH. Untreated or neglected congenital dislocations after 3 years are difficult to treat, due to adaptive changes in the soft tissue, pelvis and femoral head. The treatment is also hence directed to correct the identified adaptive pathology that is unique to individual cases.

41. Adolescents and Young Adults More than 8 years with unreduced hip dislocation may be treated with palliative salvaging surgeries. Even if this hip is reduced with pelvic and femoral osteotomies, it is rare to expect a normal hip in the rest of life time. Despite this a unilateral hip dislocation must be attempted to reduce. Bilateral dislocations in this age group should be left and total hip arthroplasty may be done during adulthood.

42. THANK YOU