DDH: Pathology, Diagnosis & Treatment before Walking Age 고려대학안암병원

Transcription

1 DDH: Pathology, Diagnosis & Treatment before Walking Age 이 순혁 고려대학안암병원

2 Developmental Hip Dysplasia (DDH) Klisic 1988 AAOS 1991 Congenital Hip Dislocation Not always congenital or dislocated

3 Causes, Risk factors Mechanical factors 1. Intrauterine Breech Crowding phenomenon 1 st born children Oligohydroamnios Left hip torticollis, metatarsus adductus

4 Causes, Risk factors Mechanical factors 2. Postnatal environment Swaddling in cradleboard in American Navajo Indian Successful national campaign in Japan (Traditional Swathing Diaper)

5 Causes, Risk factors Genetic & Ethnic factors Girl 80% of cases Family history 10 times high from affected parents Variations among races Caucasian, Blacks

6 Growth of hip joint Acetabulum Triradiate cartilage Diametric growth Acetabular cartilage Deepening interstitial, apposition growth, periosteal new bone

7 Growth of hip joint Acetabulum Labrum fibrocarilage deepening, stability Capsule continuous with periosteum above labrum

8 Growth of hip joint Proximal femur 3 main growth area 1. proximal femur 2. greater trochanter 3. femoral neck Normal growth Muscle pull, normal loading Nutrition Balance of 3 physeal growth

9 Growth of hip joint Normal growth for acetabulum, proximal femur Concentric reduced femoral head

10 Pathoanatomy of DDH Neolimbus Hypertrophied ridge of acetabular cartilage By Ortolani Ortolani + : in & out over ridge

11 Pathoanatomy of DDH Limbus Hypertrophied labrum Rarely inverted Confusion with Neolimbus in the literatures

12 Pathoanatomy of DDH Hypertrophied lig.teres

13 Pathoanatomy of DDH Hypertrophied Pulvinar Contracted transverse ligament Narrowing of introitus

14 Pathoanatomy of DDH Extraarticular obstacles Contracted adductors, Iliopsoas Anteromedial joint capsule constriction

15 Natural history Barlow positive 1/60 infant 88% stabilized in 2 months 12% true dislocation : Barlow DDH under 3months clinical or X-ray 26% dislocated 13% subluxated 39% dysplastic 22% normal : Coleman

16 Dislocated Subluxated Unstable Normal ( undetected instability, acetabular dysplasia) Dislocated Subluxated Acetabular dysplasia Normal Unpredictablity of unstable hip : must be treated

17 Natural history Dislocated Hip 60% Significant symptom 40% No symptom Unilateral : Leg length inequality, scoliosis knee valgus deformity & pain, abnormal gait Bilateral : Lumbar hyperlordosis & pain

18 Dislocated Hip False acetabulum : 75% Absent or moderate false acetabulum : 48% Minimal Symptom reported in Many cases F 17 y

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

20 Dysplastic Hip Eventually to osteoarthritis but later

21 Etiology of end-stage osteoarthritis Hip dysplasia 43% : Aronson 1986 Female 79% : Stulburg & Harris 1974

22 Park hyun o Neonate 38 Ms

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

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

25 33 yrs results of surgical tx of late diagnosis 40% moderate to severe osteoarthritis 14% THR or arthrodesis at 36.5 years old : Angliss et al, JBJS, 2005

26 Prognosis : Timing of Tx - Critical Even after reliable Tx After 6 weeks old, : higher rate of residual dysplasia Later Diagnosis : Less potential for remodelling Higher Cx rate

27 Prognosis of DDH Missed case can be a disaster. Lancet 2003

28 Clinical presentation in infancy Not definite Limited abduction - Asymmetric skin folds vs physiologic Galleazzi sign

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

30 Early Diagnosis Ortolani test

31 All abnormal hips are not clinically abnormal on testing! Sonographically pathologic 52.25% No clinical sign 40.7 % No risk factor : Tonnis et al, Germany, 1990

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

33 Simple radiography Diagnostic validity : after 3-4 Months old Cartilagenous structure Position during examination

34 Simple radiography Petit triad 1. acetabular index 2. delayed ossific nucleus 3. upper lateral displacement Perkin s line Acetabular index Hilgenreiner s line

35 Simple radiography Follow-up Acetabular index Center-Edge angle Shenton s line

36 Ultrasonography of hip Graf 1980 Nonivasive, simple, real-time Sensitive indicator for position, instability, acetabular development

37 Ultrasonography of hip Graf Harcke Morphology, static Dynamic Dual components of DDH acetabular development Instability

38 Graf Techniques Single view : Static coronal image

39 Graf Gluteus Medius Ilium Perichondrium & Capsule Bony Acetabulum Labrum Ischium Chondrosseous border

40 Graf : Acetabular measurement Angle α : Bony acetabulum Angle β : Cartilage Acetabulum

41 Graf Classification Class Alpha Beta Description Treatment I > 60 < 55 Normal IIa Immature (< 3 m) IIb > 3 m + IIc > 77 Aetabular deficiency + IId > 77 Everted labrum + III < 43 > 77 Everted labrum + IV unmeasurable Dislocated +

42 Type I : Mature stable alpha : 60º beta : 55º

43 Type II : Immature alpha: beta: 55 Ila : less than 3 months IIb : more than 3 months

44 above IIc : Treatment needed Type IIc : Deficient acetabulum alpha: beta: less than 77 centered Type IId ( Decentering ) Beta : more than 77

45 Type III: Dislocation Everted labrum

46 Type IV : Dislocation Inverted labrum

47 Dynamic method Harcke Techniques Multi view Orthogonal Planes Static & Dynamic Classification by Stability & Morphology ( Not Measurement )

48 Two View MINIMUM Exam Combine the Harcke and Graf technique 1993 Accepted as Standard by ACR (1998)

49 Components Coronal Neutral or Flexion Stress optional Measurement optional Transverse flexion Stress required

50 Coronal Flexion Stress Rest Stress

51 Coronal Flexion Stress Coronal Unstable

52 Transverse Flexion

53 Transverse Flexion

54 Transverse Flexion

55 Transverse Flexion Stress Stable Unstable

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

57 Clinical presentations after 3 months old

58 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

59 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)

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

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

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

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

64 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

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

66 Goal of Treatment Obtain & Maintain Reduction : optimal environment for growth Prevent Complications of treatment, AVN

67 Neonate to 6 Ms old Von Rosen Splint Neonate Pavlik harness

68 Pavlik method Not Harness But Method 1. Movement for healing 2. Suitable Flexion of hip & Knee Tired muscle Abduction without force

69 Pavlik method Centering femoral head to acetabulum spontaneously Harness prevent extension only Abduction, adduction and rotation free

70 Contraindications Muscle imbalance : myelodysplasia, CP Joint stiffness : arthrogryposis Excessive ligament laxity : Ehler-Danlo s syndrome

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

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

73 Pavlik harness disease Prolonged dislocation in harness Femoral & acetabular cartilage Damage Difficulty in treatment Pavlik Hip Spica Cast Not reduced in 2-3 weeks

74 Hip position in Pavlik harness Sono : 100% accuracy X-ray : 49% in dislocated hip Ultrasonography to confrim reduction

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

76 From 6 Months to Walking age Closed or open reduction older than 6 months Failed Pavlik harness

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

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

79 Traction Bryant Split Russel on Bradford frame

80 Traction Bryant Caution! Neurovascular status

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

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

83 Safe Zone Never excessive abduction Point of Dislocation Marginal Safe Zone Marginal Adductor tenotomy to inc. abduction

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

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

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

87 Adequacy of reduction? Metaphysis below the Hilgenreiner s line 2/3 of head medial to into the Perkin s line Deep seated with limited obstacles

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

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

90 Redislocation in Poor Cast Poor moulding good moulding at the greater trochanter

91 Cast change 6 weeks arthrography Another cast change 6 weeks

92 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

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

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

95 Anterolateral Approach Hypertrophied lig.teres Pulvinar Capsule Limbus

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

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

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

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

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

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

102 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

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

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

105 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

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

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

108 Thank You for Your Attention!