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DEVELOPMENTAL DYSPLASIA of the HIP

DEVELOPMENTAL DYSPLASIA of the HIP

Muhammad Rizal, dr., SpOTMuhammad Rizal, dr., SpOT

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CDH DDH Klisic (1989)CDH DDH Klisic (1989)

Definition :DDH : generic term describing a spectrum of

anatomic abnormalities of the hip, that may be congenital or develop during infancy or childhood

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DDH : Unstable Hip :DDH : Unstable Hip :

1. Dislocated Ortolani test

2. Subluxated

3. DislocatableBarlow test

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Obstetricians

Pediatricians

Family practitioners

Orthopaedists

Nurses

Midwifes

be familiar with Ortolani & Barlow test

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IncidenceIncidence

• USA : (1-2) per 1000 lives birth• ♀:♂ : (6-7) : 1• Left hip > right hip = 80%• 1 in 5 cases : bilateral = 20%• Prevalent in certain area

In New York : Caucasian = 15.5 per 1000

Black = 4.9 per 1000

Lapps & North American Indians : (25-50) per 1000

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IncidenceIncidence

Screening Unstable hips at birth• Barlow :

• 1 out 60 newborn infants• 60% : spontaneous recover in 1st week• 88% : recover in 1st two months

• Health Dept.in UK :• Hip instability at birth :

• 20 per 1000 births• 80% resolve without Tx• 10% persist as subluxated or dysplastic hip• 10% dislocated

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EtiologyEtiology

Multifactorial :

1. Mechanical factor

2. Physiologic factor

3. Postnatal environmental factor

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Mechanical factora. Fetal movement restriction

– prevent limb folding• In 1st borns (60%)• Oligohydramnion• Fetal pelvis is trapped in maternal pelvis

b. Breech presentation (30-50)%– Knees are extended

• genu recurvatum• genu dislocation

Breech born : – DDH 10x Vertex (Dunn)– associate deformity (Mercer)

• mandibular = 22%• torticollis = 20%• postural scoliosis = 42%• DDH = 50%• genu recurvatum =100%• talipes = 22%

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Physiologic factorPhysiologic factor

• Maternal estrogen temporary laxity of capsule

• Estrogen metabolism error • DDH familial• inherited 20%• ethnic

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Environmental factorEnvironmental factor

1st month infant after delivery• hip in flexion & mild abduction (physiologic)

extended :– swaddled DDH 10x greater– upside down in extended limbs

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PathomechanicsPathomechanics

• Estrogen capsule (hip joint)

• Fall out easily : reduced by Ortolani test

• Head in the acetabulum is : maintained normal hip

• If dislocation persist :– soft tissue, bone will change– difficult to reduce

• Muscles, acetabulum, head will change

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Recognition and DiagnosisRecognition and Diagnosis

1. in Newborn & infant2. in Older childCondition raising suspicion of DDH :

– breech– female– first born– family history– talipes– torticollis– other congenital anomalies (heart, kidney), any

syndrome.

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Newborn and InfantNewborn and Infant

The exam of the hip should conclude

• Normal

• Subluxatable

• Dislocatable – Barlow positive

• Dislocated :a. reducable : Ortolani test position

b. not reducable : teratologic dislocation

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Why is newborn DDH so often missed?Why is newborn DDH so often missed?

• crying baby

• tense baby

• hungry baby

• hurried doctor

• inexperienced doctor (tests)

• too firm in grip

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Older childOlder child

The signs of DDH change with the infant’s age Inspection :• Skin fold• Galeazzi’s sign• Telescoping• Trendelenburg’s test• Trendelenburg gait• Bilateral DDH :

– perineum widen– hiperlordotic– waddling gait

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Diagnostic ImagingDiagnostic ImagingRadiology• In newborn : seldom reliable (cartilaginous)• Reliable at the age 6 weeksArthography• By indication :

– unsatisfactory reduction– hip redislocation

Ultrasonography (USG)• Valuable under age 4 months (ossification of

nucleus)• Dynamic study of DDH (similar to Ortolani/Barlow)

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TreatmentTreatmentGoal• Reduce the head to normal position• Maintained until stable• Avoid avascular necrosis of the head• Correction of residual dysplasiaDelay in diagnostic and problems in management• Residual anatomic defect• Subsequent degenerative arthritis

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TreatmentHip instability in neonatal period TreatmentHip instability in neonatal period Barlow• 60% : spontaneous recovery in the first week• 88% : spontaneous recovery in the first 2

monthsSoon after Dx was made : Tx by :• triple diapers• Frejka pillow• Pavlic harness (the best)“Pekeh” yes“Bodong” no

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Reduction Reduction Method of reduction depends on :• Age of the infant• Severety of DDHA. Infant age (0-6) MO

– Hip instability or established dislocations– Actively Tx until the hip clinically & radiologically normal– initial Tx: brace (Pavlic harness the best)

B. Infant age (6-18) MO– starts nonooperatively– skin traction – manipulation (anaesthesia) + adductor tenotomy– spica cast in safezone position

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Reduction Reduction C. Children age (18-36) MO

– Start by traction– Open reduction :

• soft tissue release• pelvic osteotomy (acetabular dysplasia)• cast

D. Children age >36 MO– open reduction– + femoral shortening, – + derotation osteotomy – + pelvic osteotomy

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Treatment scheme for DDH

Developmental Dysplasia of the Hip

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15 monthsOver

15 months

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Thank you for your attention

Thank you for your attention