DDH: Pathology Diagnosis, and Treatment before Walking Age

Transcription

1 DDH: Pathology Diagnosis, and Treatment before Walking Age 영남의대 김세동

2 Ⅰ. Terminology of hip dysplasia a. Congenital dysplasia or dislocation of the hip(cdh): Hippocrates Congenital -Existing at Birth but not Hereditary b. Developmental dysplasia of the hip(ddh) : more representative Developmental -The Act of Developing or State of Being Developed

3 Terminology Dysplasia -Abnormal Development of Tissuse, Organs or Cells Dislocation -To Displace from the Usual Relationship with Adjoining Parts Subluxation -Incomplete Dislocation of a Bone in a Joint Instability -Lack of Resistance to Sudden Change, Dislodgment, or Overthrow

4 Developmental Dysplasia Subluxation Dislocatable Reducible Dislocation - Weinstein Developmental Dislocation Complete Unreducible Dislocation DDH Not all DDH is either present or Identifiable at Birth Litigation Driven Diagnosis

5 Ⅱ. Classification a. teratologic D/L - 2% of DDH cases Irreversible Pathologic Findings b. typical DDH Ⅲ. Types of DDH - standard A.P pelvis x-ray a. dysplasia b. subluxation c. dislocation

6 Ⅳ. Incidence Hip instablility at birth : 0.5-1% Classic DDH : 0.1% Mild dysplasia : substantial Ⅴ. Etiology Genetic and ethnic-key role Etiologic Features Risk Factors

7 DDH Risk Factors Caucasian First-Born - Limited Fetal Mobility(Crowding Phenomenon) - Associated With Torticollis & Metatarsus Adductus - Oligohydramnios - Left Hip Most Common (Most Common Lie)

8 Postnatal Extrauterine Environment - Swaddling Clothes - Cradle Boards In Face of Newborn Hip Flexion & Hamstring Contractures

9 HIGH-RISK FACTORS Breech position Female gender Positive family history or ethnic background(e.g., Native American, Laplander) Lower limb deformity Torticollis Metatarsus adductus Oligohydramnios Significant persistent hip asymmetry(e.g., abducted hip on one side, adducted hip on the other side) Other significant musculoskeletal abnormalities

10 Ⅵ. Normal Growth and Development of the Hip Joint Acetabular Growth and Development Growth of the Proximal Femur : Balance, Interdependent

11 Determinants of Acetabulum Shape and Depth Main stimulus for the concave shape of Acetabulum : presence of spherical femoral head - normal interstitial and appositional growth (acetabulum) - peiosteal new bone formation (pelvis) - 3 secondary centers of ossification

12 Ⅶ. Pathology Spectrum of pathologic anatomy - type, grade, age of D/L Grades of D/L (Howorth and Dunn) Grade 1. Unstable, subluxatable hip Grade 2. Subluxated hip Grade 3. Complete dislocation

13 Barriers to reduction 1. Intraarticular Structures capsule : contracted anteromedial joint capsule - the most significant obstacle lig. teres pulvinar labrum-inverted, hypertrophied transverse acetabular ligament

14 2. Extraarticular Structures Iliopsoas-hourglass constriction Adductors-shortened Gluteus medius, minimus Pyriformis

15 Neolimbus : The most common pathologic change in newborn DDH Hypertrophied Ridge of Acetabular Cartilage Ortolani Reversible Changes in 95% Typical of 98% of DDH Cases

16 Bony Changes 1. Proximal femur 1) increased femoral anteversion up to and causes instability (resubluxation or redislocation after surgery) 2) posteromedially flattened femoral head making the hip joint incongruous 2. Acetabulum 1) excessive acetabular antetorsion 2) thick, shallow, and oblique acetabulum 3) deficiency of anterior wall, eversion and widening of superolateral wall

17 Chondroosseous hip in growing infant and child 1. biologically dynamic structure, not a static unit. 2. primary stimulus for normal growth & development comes from the femoral head within acetabulum(concentric reduction) 3. acetabular growth can improve within 1-2 years after concentric reduction and growth persists for several years thereafter. Blood vessels 1 medial femoral circumflex a. - displaced superiorly 2 posteroinferior branch - between iliopsoas and inferior femoral neck

18 Ⅷ. Diagnosis Examination & Physical Findings in the Newborn Nursery Newborn Hip Flexion Contracture Newborn Knee Flexion Contracture These Contractures are lost in DDH

19 1) Clinical diagnostic test LeDamany(1912) Ortolani(1936) - clunk of entry Barlow(1962) - clunk of exit Ortolani test Reduction test for reducible hip Barlow's test Provocative test for subluxable or dislocatable hip

20

21 Hip Click Do Not confuse with "Clunk of Entry or Exit" Dry Sound, Crunching or Crepitation "Click" is not a sign of DDH Ligamentous or Myofascial

22 2) Birth to 2 months of age(newborn) Clinical - gold standard Barlow, Ortolani test Radiograph : not much diagnostic value Ultrasonography : screening tool, early diagnosis

23 3) Between 3 and 12 months of age ⅰ) Clinical limitation of abduction-most reliable : short adductor longus asymmetry of the gluteal, thigh or labial folds relative femoral shortening uneven knees(galeazzi sign) ⅱ) Radiographic proximal and lateral migration of the femoral head, delayed ossification shallow acetabular index teardrop-delayed ossification

24 Klisic test for DDH Greater Trochanter - ASIS

25 4) After walking age ⅰ) Clinical limp : Trendelenburg + waddling gait and hyperlordosis of L-spine(bilateral D/L) ⅱ) Radiographic more definite acetabular index - Shenton's line - disruption

26

27 5) Ultrasonography

28 2 basic ways Morphologic assessment (Graf) - non-stress, static image Alpha Angle ( 60 ) - Angle Formed by Ossified Lateral Wall of the Ilium Line & Bony Roof Line Beta Angle ( 55 ) - Angle Formed by Ossified Lateral Wall of the Ilium Line & Cartilaginous Roof Line Dynamic assessment(harcke) - stress image

29 Static image - interobserver and intraobserver variations Dynamic stress method axial & coronal planes stress - similar to the Ortolani & Barlow test - operator dependent subjective assessment

30 6) Arthrography visualization of the cartilage surface assessment of the hip joint invasiveness

31 7) Computed Tomography(CT) exact imaging of the cross sectional anatomy The best technique for 3-dimensional imaging Radiation exposure & cost

32 8) MRI Excellent visualization of the soft tissue structures in any plane Perfect information about the anatomy of the acetabulum and the femoral head need for immobilization; costs

33 Treatment of Hip Dislocation Goals concentric reduction maintain reduction prevent AVN

34 Treatment of Hip Dislocation Neonate and 1 6 Months Infants Pavlik Harness

35 Treatment of Hip Dislocation Children 6 18 Months Traction Closed Reduction Open Reduction

36 Treatment before 6 Months High Risk Neonate Clinically Suspicious Patient U S Normal FU X-ray later

37 Treatment before 6 Months High Risk Neonate Clinically Suspicious Patient U S Dysplasia / Subluxation Pavlik Harness l FU U S l Weaning l FU

38 Treatment before 6 Months High Risk Neonate Clinically Suspicions Patient U S l Dislocation l Pavlik Harness l U S FU (3wks) Reduction Unreduced Reapply after Traction C/R O/R

39 Treatment of 6 18 Months Closed Reduction Preliminary traction or not C/R under G/A Adductor Tenotomy Zone of safety Arthrogram Cast immobilization : Human position ( Salter) CT, MRI (pelvis)

40 Treatment of 6 18 Months Open Reduction Medial approach Remove Barrier Capsulorrhaphy(-) Anterior approach Capsulorrhaphy (+) Arthroscopic or Arthroscopic assisted