Post on 29-Nov-2014
Clinical testsClinical tests:
• Done within 2 days of birth
• At discharge
• 6 weeks
• 6 – 9months
• 15 – 21 months
• Risk factors are recorded
• If positive or if risk factors are present:
• X ray evaluation is done• U/S screening is done – also at
follow up
Completely dislocated hip
• Progress to degenerative joint disease in well formed false acetabulum.
• In B/L cases low back pain develops as result of increased hyper-lordosis
In U/L cases secondary problems in back
can arise such as scoliosis, leg length
problems with gait disturbance, valgus
deformity of knee with OA of knee
• (1) newborn, birth to 6 months of age,
• (2) infant, 6 to 18 months of age,
• (3) toddler, 18 to 36 months of age,
• (4) child and juvenile, 3 to 8 years of age, and
• (5) adolescent and young adult, beyond 8 years of age.
Management of DDH – Guidelines
0 to 6 months
Pavliks Harness
6 to 18 months 18 to 36 months 3 to 8 years
Traction Closed reductionHip spica
Open reduction
Pri. open reduction
Pelvic osteotomy
Pri, open reduction withFemoral shortening6 weeks no
reductionArthrographyNo reduction >1/3rd head
visible
• Stabilizing the hip that has a positive Ortolani or Barlow test or
• reducing the dislocated hip with a mild to moderate adduction contracture.
• Pavlik harness is a dynamic flexion abduction orthosis.
• Evaluate carefully the direction of dislocation, the stability, and the reducibility of the hip before treatment
• Pavlik harness should not be used in teratological dislocation
• The Pavlik harness consists of a chest strap, two shoulder straps, and two stirrups.
• Each stirrup has an anteromedial flexion strap and a posterolateral abduction strap.
• It is applied with the child in supine position
• The chest strap is fastened first, allowing enough
room for 3 fingers to be placed between the chest
and the harness.
• This strap is placed just below the nipple line.
• The shoulder straps are buckled to maintain the chest strap at the nipple line.
• The feet are then placed in the stirrups one at a time.
• The hip is placed in flexion (90 to 110 degrees), and the anterior flexion strap is tightened to maintain this position.
• Hyper flexion of the hip may produce femoral nerve palsy
• Inferior dislocation of hip
• Less than 90° flexion will fail to reduce the hip
• Finally, the lateral strap is loosely fastened to limit adduction,
• Not to force abduction. It will occur by gravity itself
• Excessive abduction to ensure stability is not acceptable.
• The knees should be 3 to 5 cm apart at full adduction in the harness
• The Barlow test should be performed within the limits of the harness to ensure adequate stability.
• The child is then placed prone and the greater trochanters are palpated; if asymmetry is noted, a persistent dislocation is present.
• X ray to confirm reduction – femoral neck is directed towards tri-radiate cartilage
• After 3 weeks ultrasound can be used to confirm reduction
4 basic patterns of persistent 4 basic patterns of persistent dislocationdislocation
Superior
inferior
lateral and
posterior.
• Superior dislocation, additional flexion of the hip is indicated.
• Inferior, a decrease in flexion is indicated
• Lateral dislocation in the Pavlik harness should be observed initially.
• As long as the femoral neck is directed toward the triradiate cartilage, as confirmed by roentgenogram or ultrasound, the head may gradually reduce into the acetabulum.
• Persistent posterior dislocation is difficult to treat, and Pavlik harness treatment frequently is unsuccessful
• Posterior dislocation usually is accompanied by tight hip adductor muscles and may be diagnosed by palpation of the greater trochanter posteriorly.
• If any of these patterns of dislocation or subluxation persist for more than 3 to 6 weeks, treatment in the Pavlik harness should be discontinued and a new
• program initiated; in most patients, this consists of optional traction, closed or open reduction, and casting.
• The Pavlik harness should be worn full-time until stability is attained.
• Once or twice a week patient is examined and the harness straps are adjusted to accommodate growth.
• Duration of full-time harness wear approximately equal to the age at which stability is attained plus 2 months.
• Weaning is then started by removing the harness for 2 hours each day.
• This time is doubled every 2 to 4 weeks until the device is worn only at night.
• Night bracing can be continued until the hip is normal X ray wise
Radiological evaluation – follow-up
• 1 month after weaning begins,
• at 6 months of age, and
• at 1 year of age.
• Follow-up to skeletal maturity is recommended
In one series 20% patients treated successfully in harnessDeveloped acetabular dysplasia during 8 to 15 year follow-up
• In European series 95% successful results• 80% of these were dislocated and not initially
reducible• Rate of AVN in harness range from 0 to 15%• Higher the dislocation more is the risk of AVN
Problems and complications with harness
• AVN
• Failure to reduce
• Femoral nerve palsy
• Pavlik disease
Pavlik diseasePavlik disease
• Jones and associates noted that positioning of dislocated hip in flexion and abduction potentiated dysplasia.
• Flattening of postero-lateral acetabulum occurred
• Harness has to be discontinued and open reduction done
Other splints
• Von-rosen’s splint
• Ilfeld or Craig splint
• Use of Frejka pillow and triple diapers is to be discouraged
6 months to 18 months
Closed Reduction Open reduction
Pre operative traction
Objectives of tractionObjectives of traction
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.
Preoperative Traction
• According to Coleman no significant difference by using pre-op traction
• Home skin traction program in children with compliant and educated parents can be used
Adductor Tenotomy.
• A percutaneous adductor tenotomy under sterile conditions can be performed for a mild adduction contracture.
• For an adduction contracture of long duration, an open adductor tenotomy through a small transverse incision is preferable.
• Gentle closed reduction is accomplished with the child under general anesthesia.
Arthrography
• Criteria for accepting a reduction are a medial dye pool of 7 mm or less and
• maintenance of reduction in an acceptable "safe zone."
“Safe zone" concept of Ramsey, Lasser, and MacEwen
• 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
• narrow safe zone implies an unstable or unacceptable closed reduction.
A careful clinical evaluation of the reduction should be made before and after adductor tenotomy and before the arthrogram.
Application of Hip Spica
• Hip joint in 95 degrees of flexion and 40 to 45 degrees of abduction
• Salter Salter advocated this "human position" as best for maintaining hip stability and
• minimizing the risk of avascular necrosis.
After treatment
• Spica cast immobilization is continued for 4 months.
• The cast can be changed at 2 months with the patient under general anesthesia.
• Roentgenograms or arthrograms can be obtained to be sure that the femoral head is reduced anatomically into the acetabulum.
• Computed tomography (CT) scanning is useful
Indications:Indications:
• Failure of closed reduction
• Teratologic dysplasia
• Hour glass contracture, inverted labrum which prevent closed reduction
Pathology rather than age is the main indicator
Correct the offending soft tissue structures and to reduce the femoral head concentrically in the acetabulum.
Approaches for open reduction
• Anterior
• Anteromedial
• Medial approach
Anterior approach
• More anatomical dissection
• But provides greater versatility because the pathological condition in the anterior and lateral aspects is easily reached
• Pelvic osteotomy can be performed if necessary.
Somerville techniqueSomerville technique of anterior open reduction in congenital dislocation of hip. A, Bikini incision. B, Division of sartorius and rectus femoris tendons and iliac epiphysis. C, T-shaped incision of capsule. D, Capsulotomy of hip and use of ligamentum teres to find true acetabulum. E, Radial incisions in acetabular labrum and removal of all pulvinar from depth of true acetabulum. F, Reduction and capsulorrhaphy after excision of redundant capsule.
Anteromedial approach
• Described by Weinstein and Ponseti • Actually is an anterior approach to the hip
through an anteromedial incision.• Hip is approached in the interval between the
pectineus muscle and the femoral neurovascular bundle.
• Access to the lateral structures for dissection or osteotomy is not possible with this approach.
The medial (Ludloff) approach
• It is simpler and involves less dissection
• But places the medial circumflex vessels at a higher risk - higher incidence of avascular necrosis.
• Recommended in children aged 1year and younger
Incision for medial (Ludloff) approach and open reduction.
After treatment
• X rays or CT scans can be used to confirm reduction of the femoral head into the acetabulum.
• The spica cast is removed at 10 to 12 weeks. • Sequential X rays are used to assess development
of the femoral head and acetabulum• These are obtained on a regular basis until the
child reaches skeletal maturity.
Criteria Evaluation of Open Reduction.
• 1.Hip stable in neutral position—no osteotomy • 2.Hip stable in flexion and abduction—innominate
osteotomy • 3.Hip stable in internal rotation and abduction—
proximal femoral derotational varus osteotomy • 4."Double-diameter" acetabulum with
anterolateral deficiency—Pemberton-type osteotomy
Earliest x ray signindicating stability of reduction
• Appearance of the acetabular teardrop figure after reduction of the hip in DDH
• Tear appeared at an average of 6.5 months after reduction
Teratological Dislocations
• The acetabulum is small, with an oblique or flattened roof,
• the ligamentum teres is thickened, and
• the femoral head is of variable size and may be flattened on the medial side
• The hip joint is stiff and irreducible, and
• X rays show superolateral displacement
Treatment
• Age to initiate treatment – 3 to 6 months
• Anterior open reduction and femoral shortening produced the best results with the fewest complications.
• Older children may require pelvic osteotomy in addition
Avascular Necrosis.
• 2.5/1000 in infants referred for treatment before 6 months of age and
• 109/1000 in those referred after 6 months of age.• Children with avascular necrosis after treatment of
congenital dislocation of the hip should be followed to maturity with serial orthoroentgenograms
• Early innominate osteotomy induced spherical remodeling of the femoral head, with a resultant congruous hip joint.
• Symptomatic overgrowth of the greater trochanter can be treated in older patients with greater trochanteric advancement,
• which will increase the abductor muscle resting length and increase the abductor lever arm
• Open reduction
• with femoral shortening or
• pelvic osteotomy, or
• both, often 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.
• Older children, however, require both femoral and pelvic osteotomies if significant deformity is present on both sides of the joint.
Management after 3 years of age is difficult:
• Adaptive shortening of periarticular structures
• Structural alterations in both femoral head and acetabulum
“Open reduction combined with Open reduction combined with femoral shortening with or without femoral shortening with or without pelvic osteotomy”pelvic osteotomy”
Femoral shortening
• obtains predictable reduction, and
• results in a low rate of avascular necrosis.
Wenger recommends
• primary femoral shortening,
• anterior open reduction, and
• capsulorrhaphy,
• with or without pelvic osteotomy
Derotation or varus correction is not required as there is no excessive anteversion or valgus
• Pelvic osteotomy may be required at an age of 18 months and later .
• The degree of acetabular coverage of the femur when the head is placed in extension and neutral rotation and abduction.
• If more than 1/3rd is` seen in this position an innominate osteotomy will provide better coverage.
OPTIONS FOR OSTEOTOMY• Salters• PembertonsImportant points to be considered are:1. Place the oteotomy high enough to avoid
damage to cartilaginous acetabular margin2. If there is undue tension on reduction a
concomitant femoral shortening should be considered.
Complication of combining pelvic osteotomy with femoral shortening
• Posterior Dislocation of the hip
• Especially if hip is derotated
Age limit for reduction in U/L vs B/L cases
• U/L cases reduction should be attempted up to 9 to 10 years if there is possibility of restoring the acetabular coverage
• B/L – results are frequently unsatisfactory in children more than 8 years old.
• The natural outcome of untreated B/L dislocation is better than in treated cases
Salter Innominate Osteotomy
• Salter observed that the entire acetabulum faces more anterolaterally (ANTETORSION) than normal.
• Salter's osteotomy of the innominate bone redirects the entire acetabulum so that its roof "covers" the femoral head both anteriorly and superiorly.
• It doesnot increase or decrease volume.
• Salter recommended his osteotomy in the primary treatment of congenital dislocation of the hip in children between the ages of 18 months and 6 years and
• In the primary treatment of congenital subluxation as late as early adulthood.
• Secondary treatment of any residual or recurrent dislocation or subluxation after other methods of treatment
Prerequisites for Salters OsteotomyPrerequisites for Salters Osteotomy
• The femoral head must be positioned opposite the level of the acetabulum. (This may require a period of preop traction or primary femoral shortening.)
• Contractures of the iliopsoas and adductor muscles must be released.
• Open reduction is performed for hip dislocation but usually is unnecessary for hip subluxation.
• The femoral head must be reduced into the depth of the true acetabulum completely and concentrically.
• This generally requires careful open reduction and excision of any soft tissue, exclusive of the labrum, from the acetabulum.
• The joint must be reasonably congruous. • The range of motion of the hip must be good, especially in
abduction, internal rotation, and flexion.
AFTERTREATMENT.
• At 8 to 12 weeks the spica cast is removed, and with the patient under general or local anesthesia the Kirschner wires also are removed.
• The position of the osteotomy and of the hip is checked by roentgenograms.
Complications
• Sciatic nerve injuries
• Femoral nerve injuries
• Loss of position
• Pins placed into acetabulum, even into femoral head
• Post operative hip stiffness
Pemberton Acetabuloplasty
• Pericapsular osteotomy of the ilium in which an osteotomy is made through the full thickness of the ilium,
• Using the triradiate cartilage as the hinge about which the acetabular roof is rotated anteriorly and laterally.
Indications
• Marked defeceincy of anterior and superolateral wall of acetabulum
• Marked laxity of capsule and hypermobility of joint
• Age 2 to 6 years
Advantages over Salters
• Internal fixation is not required,and thus a second, but minor, operation is avoided.
• Furthermore, a greater degree of correction can be achieved with less rotation of the acetabulum in the
(because the fulcrum, the triradiate cartilage, is nearer the site of desired correction.)
Disadvantages
• Technically more difficult to perform.
• It alters the configuration and capacity of the acetabulum and can result in an incongruous relationship between it and the femoral head
Anterior iliofemoral approach.
Letournel and Judet iliofemoral approach. A, Skin incision. B, Anterior aspect of hip joint and anterior column are exposed by releasing sartorius and rectus femoris and reflecting iliacus medially.
After treatment
• At 8 to 12 weeks the cast is removed, and
• Osteotomy is checked by roentgenograms.
Steel Osteotomy
• provide more correction and
• improve femoral head coverage.
• Triple innominate osteotomy developed by Steel, the ischium, the superior pubic ramus, and the ilium superior to the acetabulum are all divided.
• The acetabulum is repositioned and stabilized by a bone graft and pins
• Joint must be congruous or become so once the acetabulum has been redirected
• Femoral shortening may be required
AFTERTREATMENT.
• A spica cast is applied with the hip in 20 degrees of abduction, 5 degrees of flexion, and neutral rotation.
• At 8 to 10 weeks the cast and pins are removed, and active and passive motion of the hip are started.
• All three osteotomies usually unite by 12 weeks after surgery, at which time progressive weight-bearing on crutches is started.
Dega Osteotomy
• Transiliac osteotomy for the treatment of residual acetabular dysplasia secondary to congenital hip dysplasia or dislocation.
• osteotomy of the anterior and middle portions of the inner cortex of the ilium
Shelf Operations
• performed to enlarge the volume of the acetabulum;
• However, pelvic redirectional and displacement osteotomies have largely replaced this type of operation.
Indication
• A deficient acetabulum that cannot be corrected by redirec-tional pelvic osteotomy is the primary indication for this operation.
Contraindication
• Dysplastic hips with spherical congruity suitable for redirectional osteotomy,
• Hips requiring concurrent open reduction that must have supplementary stability, and patients unsuited for spica cast immobilization.
• Before surgery the CE angle of Wiberg is determined from anteroposterior standing pelvic roentgenograms,
• and a normal CE angle (about 35 degrees) is drawn on the film.
• "bikini" skin incision 1 cm below and parallel to the iliac crest.
Chiari Osteotomy
• Capsular interposition arthroplasty and should be considered only in those instances when other reconstructions are impossible,
• femoral head cannot be centered adequately in the acetabulum
• painfully subluxated hips with early signs of osteoarthritis.
• This procedure deepens the deficient acetabulum by medial displacement of the distal pelvic fragment and improves superolateral femoral coverage.
Adolescent and Young Adult (Older Than 8 to 10 Years of Age)
• Palliative salvaging operations are possible
• Rarely a femoral shortening combined with a pelvic osteotomy could be considered, but the chances of creating a hip to last a lifetime are minimal.
Degenerative arthritis has set in:
Reconstructive operation such as a total hip arthroplasty may be indicated at the appropriate age
Arthrodesisis now rarely indicated for old unreduced dislocations and is contraindicated for bilateral dislocations.