DDH New Developments and Timeless Classics. DDH Define Treatment Group. (by age) DDH Imaging Choice in 6wk old Infant?

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1 The 59 th Annual Edward T. Smith Orthopaedic Lectureship Emerging Concepts in the Surgical Management of the Hip: Deformity, Impingement and Fracture DDH New Developments and Timeless Classics Perry L. Schoenecker, MD St. Louis Shriners & St. Louis Children s Hospitals; Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, Missouri, USA DDH Define Treatment Group (by age) Birth to 6 months? Seven to 18/24 months? successful tx likely w/splinting (Pavlik harness) closed reduction possible >18/24 months? open reduction preferred DDH Imaging Choice in 6wk old Infant? Ultrasound assess anatomy & stability up to 4-5 mos old & monitor tx in Pavlik harness 1

2 Located Ultrasound more sensitive than x-ray Dislocated Located 2

3 . maintaining the infant s hip and knee in flexion, abduction reduction of the hip Pavlik Harness Tx Fit & check frequently Tx duration until resolved on US Hip Ultrasound 3

4 Dislocated Pre- Pavlik Located Post Pavlik Tx (6wks) 4

5 mos of age Reduces in Pavlik, Planned Open Reduction Post Pavlik Tx 12mos of age 5

6 R hip L hip L hip 4wks of age L hip 12wks of age, post Pavlik Tx 13 mos of age, No prev Tx 6

7 Presents at 20y/o Postnatal (developmental): hip dysplasia noted much later perhaps US screening would detect? DDH Closed reduction 7 mos of age failed Pavlik Limited abduction Galeazzi sign 7

8 The safe zone assesses maximum ABD/ADD Limited abduction Adductor tenotomy to widen the safe zone IN AT REST BUT DISLOCATABLE 8

9 Positioning Avoid Tight Reductions The Worst Outcome Is AVN Birth J. Schoenecker, MD 9

10 Metaphyseal Vessels Birth Metaphyseal Vessels Birth Avascular Epiphysis Metaphyseal Vessels Birth Avascular Epiphysis Barrier to Vascular Anastomosis 10

11 Child Secondary Ossification Center Lateral Epiphyseal Metaphyseal Vessels Child Secondary Ossification Center Peri-physeal Vessel Medial Epiphyseal Reduction is confirmed by? Plain x-rays 11

12 Spica cast/then Confirm w/images 90º flex & <50º ABD What other image check is helpful? Spica cast/then Confirm w/images CAT scan Reduced Dislocated posteriorly (remove spica!) MRI now image of choice 12

13 7 mos of age b c 13

14 J. Schoenecker, MD Abduction >60 J. Schoenecker, MD 14

15 c Abduction >60 Abduction <60 7 mos of age failed Pavlik 18mos of age subluxation post CR Your Tx? 15

16 18mos of age subluxation post CR Capsule Labrum A gram to assess if head anatomically reduced Proximal Femoral Ost. 18mos of age subluxation post CR 3 y/o, dysplasia resolved 2+11 false acetabulum Deformed head Moseley, et al 16

17 Anterior Iliofemoral approach Tight psoas Psoas Tenotomy expose the capsule laterally, anteriorly & medially critical! Excise Transverse acetab. lig Open capsule medially & cut transverse ligament 17

18 AC 3 y/o walks w/ limp AC 3 y/o walks w/ limp Doppler probe 18

19 19

20 Take care w/lateral capsulotomy & later w/ suture technique Capsular closure sutures are placed very close to lateral retinaculum (& vessel) possible AVN 20

21 20y/o intermittent L hip pain Purpose of Osteotomy Osteotomy improves the stability achieved w/ open reduction Not a substitute for a poorly performed open reduction What are the Upper Age Limits for Open Reduction? Bilateral 6 y/o Unilateral 8 y/o 6 y/o B.T. 8 y/o 21

22 Post Tx Follow-Up... How Long? - til normal hip noted... if not than indefinitely Covered: Lat & Ant CE 25 <20% head uncovered Stable: Tonnis <10 & Shenton s line intact Most Importantly Optimally Congruent FAILED PAVLIK 2mos FAILED CLOSED POST OPEN RED 15 mo 6mo post OR AI=33 2½y/o 2 yrs post OR Pelvic ost.? AI=20 22

23 Relative Criteria for Observation AI=30 3 y/o AI=15 Progressive decrease in A-I & development of near normal teardrop Shenton s line intact Full ROM (abduction) No limp Post reduction, acetabular remodeling varies Good acetabular response Tonnis D, 1987 Congenital dysplasia & dislocation of the hip in children & adults AI=30 3 y/o observation only 7y/o 13y/o 16+7 Normal Hips 23

24 4mos 2½yrs post CR 6y/o 5yrs post CR Your Tx? Relative Osteotomy Indicators (growing child) Min change in acetab index Shenton s line persistently broken Signs of instability: limp, Trendelenberg test or pain 31º 6y/o 5yrs post CR Post reduction, acetabular remodeling varies Poor acetabular response Tonnis D, 1987 Congenital dysplasia & dislocation of the hip in children & adults 24

25 31º 6y/o 5yrs post CR 30º 8y/o Further observation was a bad idea Any in acetabular depth is minimal after age 8 with hip dysplasia\subluxation 30º 8y/o 13y/o 16y/o painful Post CR R & Open (Medial) L 7+4 Post Pemberton Post PFO & Pemberton Prognosis? 25

26 y/o Recurrent valgus & acetab dys subluxation 14y/o Given Residual Acetabular Dysplasia... 8 y/o 4 yrs old What is the Correct Ost.?... Must: Select an age appropriate pelvic osteotomy Assure congruent reduction in a functional post 26

27 Assess Congruency in ABD/IR 8y/o ABD/IR If the hip(s) do congruently reduce, then we can redirect hyaline cartilage over hyaline cartilage Congruent Reduction into Functional Acetabulum? 8y/o ABD/IR YES PFO Salter Pemberton Dega Triple Ganz NO Shelf Chiari +/- s of Pelvic Osteotomies Salter Limited correction Pemberton Age restriction Dega < yrs Triple Innom. More correction but cuts thru post. column Ganz Preserves post. column, lots of correction, tech. more difficult 27

28 Complete vs. Incomplete: Complete (Salter) Incomplete (Pemberton/ Dega) Complete (Salter) less likely to over correct 3y/o 2 yrs post CR After Salter Ost. Incomplete (Pemberton, Dega) Relatively easy to over correct restricts flexion, IR & abduction 28

29 Dega Pemberton Dega Pemberton Grudziak JS, Ward WT. JBJS 83A: , Pemberton P. JBJS A: C P D S D S P C 4 yrs old > 2 yrs.... most of deformity is acetabular dysplasia st correct acetabular deficiency, then +/- prox fem ost 29

30 4 yrs old Pemberton cut Opening ost. 4 yrs old Bone graft placed >3 yrs & dysplastic/subluxated Where is the Deformity? 8y/o subluxated Reduces congruently acetab dysplasia & coxa valga pelvic & fem ost. 7mos post Pemb s, PFO s 2 yrs post Pemb s, PFO s 30

31 5+4, post tx w/pavlik 11y/o bilat hip pain 11y/o bilat hip pain Acetabulae are deficient Subluxated dysplastic hip 11y/o AP False Profile Don t overcorrect... an incomplete osteotomy 31

32 Placing bone graft Stabilizing bone graft Now assess hip motion Hip extension Hip flexion Must assure >90º of hip flexion.. If not correction 32

33 11y/o bilat hip pain 8 mos post-op pain resolved 3+6 bilat. Dislocation Bilat OR, PFO, Pemb Enough coverage? 6y/o 2 yrs post tx Bilat AT, OR, Pemb, PFO Enough coverage? 10y/o lots of coverage 33

34 CS 17+9 pain 10 5 Surgical Tx Must Address: Deficient lateral/anterior coverage Acetabular (sourcil) slope Version Lateralization of joint center Triple Innom. More correction but cuts thru post. column Ganz Preserves post. column, lots of correction, tech. more difficult lateral tilt & adduction 2- medialization 3- anterior tilt Millis & Murphy. Periacetabular Osteototmy. In: The Adult Hip 2 nd Ed., vol I. 2007:

35 Ganz-PAO preferred mos post-op Hip Joint Center, typically lateralized in acetabular dysplasia Assessed as distance between medial fem head & ilio-ischial line lateralized Normal 6-8mm Clohisy, Schoenecker et. al. Iowa Orthop J Hip Joint Center, as affected by PAO Lateralized No Change Medialized Ganz R, et. al. A new periacetabular osteotomy for the tx of hip dysplasia. Tech & preliminary results. CORR 232, 1988:

36 Pre-op R hip Corrected w/ medialization Should try to Medialize Ganz R, et al CORR 232,

37 Unchanging Essentials in Treating DDH Assure physiologic reduction of fem head w/in the true acetabulum w/either Pavlik; closed reduction &/or open reduction Abduction >60 Unchanging Essentials in Treating DDH Avoid circulatory embarrassment w/ closed reduction 2 to pressure w/open reduction direct injury Unchanging Essentials in Treating DDH Correct residual dysplasia w/ re-directional pelvic (& femoral) osteotomies and assure satisfactory residual hip motion 8y/o subluxated 7mos post Pemb s, PFO s acetab dysplasia & coxa valga pelvic & fem ost. 37

38 Unchanging Essentials in Treating DDH Balance of coverage & congruency minimize 2 FAI Hip extension Hip flexion Must assure >90º of hip flexion.. If not correction Residual Dysplasia - Tx Goals: Head Covered: Lat & Ant CE 25...<20%head uncov Stable: Tonnis <10 & Shenton s line intact & Most Importantly Congruent w/satis ROM 38

39 13+10 Released for all sports 20y/o pain as Fed Ex driver Pre Now Can address noted problems of: Impingement & Instability 39

40 Pre Post SHD Post PAO Pre-op 5 mos Post-op Pre Post Major Correction of Problematic Pathoanatomy Obtained 40

41 15+9y/o ambulatory diplegic w/ hip pain/ function Max ABD Post-op: AT, PFO, PAO, capsulorrhaphy, ABD casting Pre-op False Profile Post Given Problematic Residual Developmental Hip Dysplasia in the Skeletally Mature Patient DDH 2 to acute disease (LCP) 2 to NM disease (CP) Similar Outcome Goals of Surgical Tx Congruency & stability w/ functional ROM Optimal clinical outcome 41

42 New Shriners Hospital St. Louis Shriners Hospital St. Louis Children s Hospital Barnes-Jewish Hospital Patient Population Study Group 16 consecutive hips (16 pts.) Study period (30 other hips tx w/sdh w/o PAO during this time) Av Age 21yrs (14-36) Mean Follow-up 32.6 mos (24-52) 42

43 16 Hips Greater than 2 year follow up post SHD / PAO Pre Post Change LCEA ACEA Tonnis angle % Coverage 63% 93% 30% Center (head) Trochanteric Distance (CTD) Clinical Outcome Pre Post Change HHS (hip pain & function in daily living, best =100) UCLA no change (activity level, best =10) 2 failures: 2 to deep infection (1) & persistent pain (1) 43

44 6y/o 2 yrs post tx Bilat AT, OR, Pemb, PFO Enough coverage? 10y/o lots of coverage 13mos Your Tx? Technique (by protocol) Transect adductor longus & dissect between pectineus & brevis With hip reduced, iliopsoas tenotomy, cruciate capsulotomy Dislocated +/- Excise ligamentum teres, transect transverse acetabular ligament Reduced Spica cast in 90 flexion, ABD (12-18 wks) 44

45 13mos 2y/o Pre-op Post bilat OR & PFO 2yrs post Open Red Your Tx?... I strongly recommend a pelvic ost.! 45