Treatment of DDH before Walking Age 고려대학안암병원

Transcription

1 Treatment of DDH before Walking Age 이 순혁 고려대학안암병원

2 Subluxated Hip Always to deg. hip The more, the earlier Even in 2nd Decade

3 Dysplastic Hip Eventually to osteoarthritis but later

4 Etiology of end-stage osteoarthritis Hip dysplasia 43% : Aronson 1986 Incidence of Acetabular Dysplasia with primary osteoarthritis of Hip Female 79% : Stulburg & Harris 1974

5 Shelf op. at the age of 3 yrs 33 Yrs 37 Yrs 38 Yrs Coxa valga, articular incongruency Acetabular dysplasia

6 No history of treatment Coxa valga, acetabular dysplasia 15Yrs 20 Yrs hip pain limbus impingement test + OA : subchondral cyst Jt. space narrowing

7 Goal of Tx Anatomically normal as possible at maturity Function Follows Form

8 Goal of Tx Obtain & maintain reduction : optimal environment for growth Prevent complications of treatment, AVN

9 Park hyun o 38m

10 F 14m F 17m F 41m F 7yr Coxa valga Acet. Dysplasia

11 Prognosis : timing of Tx - Critical Even after reliable Tx E v e n a f t e r r e k i a b After 6 weeks old, : higher rate of residual dysplasia Later Diagnosis : Less potential for remodelling Higher Cx rate

12 Early Diagnosis Not definite presentations in infancy Asymmetric skin folds ± vs physiologic Limited abduction - Galleazzi sign ±

13 Early Diagnosis Gold standard: Ortolani test 1, 2 Barlow test 2, 1 Spectrum of instability 1 2

14 Early Diagnosis Ortolani test

15 Early Diagnosis Imaging : Ultrasonography X-ray : not reliable until 3 Ms

16 Ultrasonography Clinical Screening only Excellent in some specialized centre Failure in the country as a whole Sonographically pathologic 52% No clinical sign

17 Two View MINIMUM Exam Combine Harcke and Graf technique Coronal Stress Optional Measurement Optional Transverse Flexion Stress Required as Standard by ACR (1998)

18 Coronal ( Graf Classification ) Measurement Optional : Alpha & beta angle Type IIc Type III Type IV

19 Coronal Stress Optional Normal Dysplasia Stress: unstable

20 Transverse Flexion Stress Required Stable Unstable

21 Clinical presentations after 3 months old

22 Clinical presentations after 3 months old Limited abduction of hip the most reliable & earlier sign

23 Limited abduction of hip Within the first 3 months of age 1. Teratologic hip dislocation (2%) 2. Reducible hip become irreducible 3. Congenital pelvic obliquity

24 Asymmetric skin folds Leg length descrepancy Limited abduction of hip Asymmetric acetabulum

25 3. Congenital pelvic obliquity Pelvic rotation mimic dysplasia Ultrasono mature, stable hip

26 Congenital abduction contracture of hip with pelvic obliquity Moulded baby syndrome Persistent fetal lie Infantile Skeletal Skew TAC syndrome (Turned head-adducted hip-truncal curvature)

27 Congenital abduction contracture of hip with pelvic obliquity Truncal curvature Plagiocephaly Hip abduction contracture

28 3. Congenital pelvic obliquity Usually benign course Possibility of developing dysplasia May co-existent with DDH : need Ultrasonongraphy

29 How treat? Neonate to 6 Ms old Until 3 Ms : Pavlik harness 3 6 Ms Pavlik harness C/R & Hip spica cast From 6 Ms old to walking age

30 How treat? Not depend upon the Age But upon the Pathoanatomy including 2ndary change

31 How treat? Neonate to 6 Ms old Von Rosen Splint Neonate Pavlik harness

32 Pavlik method Principles 1. Movement for healing 2. Flexion of hip & Knee Tired muscle Abduction without force Centering femoral head to acetabulum Harness prevent extension only Abduction,adduction and rotation free

33 Pavlik method 1. Chest halter strap 2. Shoulder strap 3. Ant. strap :flexion Post. Strap : prevent adduction to neutral 5. Calf strap

34 Physician inappropriate indication Contraindications Muscle imbalance : myelodysplasia, CP Joint stiffness : arthrogryposis Excessive ligament laxity : Ehler-Danlo s syndrome

35 Pavlik harness disease Prolonged dislocation in harness Damage the femoral & acetabular cartilage Anterior + posterolateral acetabular deficiency No More Pavlik Not reduced in 2 weeks After 3 weeks : Hardinge et al

36 Pavlik method Ortolani positive, dysplastic hips confirm reduction by Ultrasono adjust strap every week 1-2 week s interval Ultrasono Not achieve stable reduction in 4-6 weeks : convert to spica cast

37 Weaning of Pavlik method Full Time 8-12 weeks Then gradual weaning Two key factors 1. Clinical stability 2. Normal ultrasonic morphology Initial 2 weeks 4 weeks 8 weeks

38 Pavlik method Success rate 94% 100% in dysplasia & subluxation 82% in dislocation : Pavlik Ortolani + : 65-95% Ortolani - : 45-80%

39 Pavlik method Success rate Graf IV 50% Irreducible hip 43% High Dislocation 50%

40 Pavlik harness (methods) Ortolani - hips guided reduction enough hyperflexion or abduction Trial can be done. Irreducible in 2 weeks by Ultrasonography : convert to C/R & spica cast

41 Hip position in Pavlik harness Sono : 100% accuracy X-ray : 49% in dislocated hip Ultrasono / every week confrim reduction

42 Pavlik methods Complications Inferior dislocation Femoral nerve palsy Knee subluxation Skin breakdown AVN %

43 Children from 6 Months to Walking age Closed or open reduction older than 6 months Failed Pavlik harness

44 Traction Facilitate reduction by gradual stretching of contracted soft tissue - iliopsoas, adductors Stretching of neurovascular bundle to avoid AVN

45 Traction Controversy Reduction of AVN rate? Increase successful C/R? main obstacles: intraarticular

46 Traction Controversy Hip position Horizontal vs Vertical Initial or progressive abduction Knee position Radiography to check position

47 Traction Bryant Split Russel on Bradford frame

48 Traction Bryant Caution! Neurovascular status

49 Traction 2 4 weeks Plus one station minus one plus one zero Plus two

50 Closed Reduction General anesthesia Arthrography Positioning rather than reduction Just like Ortolani test

51 Safe Zone Never excessive abduction Point of Dislocation Marginal Safe Zone Marginal Reduced Dislocated Adductor tenotomy to inc. abduction

52 Dynamic Arthrography Assess Obstacles Adequacy of reduction Stability of reduction Acceptable only anatomic reduction?

53 Adequacy of reduction? Metaphysis below the Hilgenreiner s line 2/3 of head medial to into the Perkin s line

54 Adequacy of reduction? Femoral head below the limbus Shape & position of Limbus

55 Adequacy of reduction? Width of Medial Dye pool?

56 Width of Medial Dye pool Less Reliable Thickness of the Pulvinar Amount of the dye

57 Hip spica Cast Human position ( flexion 100, abduction ) molded dorsal to the greater trochanter

58 Confirm reduction by imaging Radiography, Ultrasono, CT, MRI CT MRI

59 Redislocation in Poor Cast Poor and good moulding at the greater trochanter

60 Cast change 6 weeks arthrography Another cast change 6 weeks C/R & hip spica cast 6 weeks later

61 Open Reduction 1. Teratologic dislocation 2. Failure of closed treatment Can t reduce closed Can t maintain reduction Inadequate safe zone Redislocation in good cast

62 Open Reduction Medial Approach younger than 1 yr 1 1. Ludloff 2. Ferguson 2 3. Weinstein 3

63 Medial Approach Advantage Minimal blood loss Direct assess over obstacle : medial joint capsule & iliopsoas No damage to iliac apophysis & abductors No joint stiffness

64 Medial Approach Disadvantage Narrow exposure Less familiar Impossible capsular plication : Stability of reduction by prolonged cast Higher rate of AVN? : Injury of nearby MFC

65 Open Reduction Anterolateral Approach Standard approach Bikini incision : minimal scar

66 Hypertrophied lig.teres Pulvinar Capsule Limbus

67 Anterolateral Approach Advantage Familiar Possible capsular plication & pelvic osteotomy Cast in functional position : minimal hip flexion & some abduction Less period of cast

68 Anterolateral Approach Disadvantage Greater blood loss Damage to iliac apophysis & abductors Postop joint stiffness

69 Combined procedures Rarely indicated Femoral shortening : Undue tension in reduction Salter or pemberton osteotomy : Coverage in doubt

70 After cast removal Abduction brace full time for several months, thereafter part time Acetabular development

71 Acetabular development most in first 18 months after reduction until 4-8 yrs old : Pelvic osteotomy

72 Pelvic Osteotomy Timing Considered at 18 Ms of age Salter 1961 Delayed until at least 3 or 4 yrs Harris 1976

73 Pelvic Osteotomy Timing Popular movement toward earlier surgery By age 2 or 3 yrs Large enough pelvis for Surgery

74 Femoral antetorsion & valgus Excessive antetorsion and valgus with persistent acetabular dysplasia for 2-3 years after reduction :Intertrochanteric femoral osteotomy

75 Avascular Necrosis Most disastrous complication Only in treated hip No Pathologic Evidence of Avascular Necrosis Disturbance of Growth of the Proximal femur

76 Avascular Necrosis Incidence 0-73%, severe AVN : less than 5% Marked variance Definition? Late appearance?

77 Risk Factors 1. Age of reduction younger age : lower rate, but higher rate of severe form mostly cartilage - risk of total involvement

78 Risk Factors 2. Extreme position Severe abduction Abduction with marked internal rotation : MFC under Iliopsoas Vascular branches betw lateral neck & acetabulum

79 Risk Factors 3. Pressure necrosis pressured closed reduction to overcome obstacles Only Anatomic Perfect Reduction Accepted

80 Diagnosis Fail to ossify or growth of femoral head within 1 year Widening of femoral neck within 1 year Changes of bone densities of femoral head Residual deformity : coxa magna, plana, vara : Salter

81 Diagnosis Disagreed Coxa magna : common after O/R Flattend medial femoral head : prereduction deformity Temporary irregular ossification : Multiple ossification center?

82 Bucholz & Ogden Classification Type I: only head II: lateral physis III: entire physis IV : medial physis

83 Kalamchi & MacEwen Classification Grade 1 : Bucholz & Ogden type I Grade 2 : Bucholz & Ogden type II Grade 3 : Large central metaphyseal defect central injury: short neck Grade 4 : Bucholz & Ogden type III

84 Kalamchi & MacEwen Classification II? Type I Type III Type IV

85 Summary Early Neonatal Diagnosis is critical. Ultrasonography is very useful in Dx & Tx. Tx should be aimed for perfect anatomical hip without AVN.

86 Thank You for Your Attention!