Treatment of DDH before Walking Age 이 순혁 고려대학안암병원
Subluxated Hip Always to deg. hip The more, the earlier Even in 2nd Decade
Dysplastic Hip Eventually to osteoarthritis but later
Etiology of end-stage osteoarthritis Hip dysplasia 43% : Aronson 1986 Incidence of Acetabular Dysplasia with primary osteoarthritis of Hip Female 79% : Stulburg & Harris 1974
Shelf op. at the age of 3 yrs 33 Yrs 37 Yrs 38 Yrs Coxa valga, articular incongruency Acetabular dysplasia
No history of treatment Coxa valga, acetabular dysplasia 15Yrs 20 Yrs hip pain limbus impingement test + OA : subchondral cyst Jt. space narrowing
Goal of Tx Anatomically normal as possible at maturity Function Follows Form
Goal of Tx Obtain & maintain reduction : optimal environment for growth Prevent complications of treatment, AVN
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F 14m F 17m F 41m F 7yr Coxa valga Acet. Dysplasia
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
Early Diagnosis Not definite presentations in infancy Asymmetric skin folds ± vs physiologic Limited abduction - Galleazzi sign ±
Early Diagnosis Gold standard: Ortolani test 1, 2 Barlow test 2, 1 Spectrum of instability 1 2
Early Diagnosis Ortolani test
Early Diagnosis Imaging : Ultrasonography X-ray : not reliable until 3 Ms
Ultrasonography Clinical Screening only Excellent in some specialized centre Failure in the country as a whole Sonographically pathologic 52% No clinical sign
Two View MINIMUM Exam Combine Harcke and Graf technique Coronal Stress Optional Measurement Optional Transverse Flexion Stress Required as Standard by ACR (1998)
Coronal ( Graf Classification ) Measurement Optional : Alpha & beta angle Type IIc Type III Type IV
Coronal Stress Optional Normal Dysplasia Stress: unstable
Transverse Flexion Stress Required Stable Unstable
Clinical presentations after 3 months old
Clinical presentations after 3 months old Limited abduction of hip the most reliable & earlier sign
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
Asymmetric skin folds Leg length descrepancy Limited abduction of hip Asymmetric acetabulum
3. Congenital pelvic obliquity Pelvic rotation mimic dysplasia Ultrasono mature, stable hip
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)
Congenital abduction contracture of hip with pelvic obliquity Truncal curvature Plagiocephaly Hip abduction contracture
3. Congenital pelvic obliquity Usually benign course Possibility of developing dysplasia May co-existent with DDH : need Ultrasonongraphy
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
How treat? Not depend upon the Age But upon the Pathoanatomy including 2ndary change
How treat? Neonate to 6 Ms old Von Rosen Splint Neonate Pavlik harness
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
Pavlik method 1. Chest halter strap 2. Shoulder strap 3. Ant. strap :flexion 100-110 4. Post. Strap : prevent adduction to neutral 5. Calf strap
Physician inappropriate indication Contraindications Muscle imbalance : myelodysplasia, CP Joint stiffness : arthrogryposis Excessive ligament laxity : Ehler-Danlo s syndrome
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
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
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
Pavlik method Success rate 94% 100% in dysplasia & subluxation 82% in dislocation : Pavlik Ortolani + : 65-95% Ortolani - : 45-80%
Pavlik method Success rate Graf IV 50% Irreducible hip 43% High Dislocation 50%
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
Hip position in Pavlik harness Sono : 100% accuracy X-ray : 49% in dislocated hip Ultrasono / every week confrim reduction
Pavlik methods Complications Inferior dislocation Femoral nerve palsy Knee subluxation Skin breakdown AVN 7.2-28%
Children from 6 Months to Walking age Closed or open reduction older than 6 months Failed Pavlik harness
Traction Facilitate reduction by gradual stretching of contracted soft tissue - iliopsoas, adductors Stretching of neurovascular bundle to avoid AVN
Traction Controversy Reduction of AVN rate? Increase successful C/R? main obstacles: intraarticular
Traction Controversy Hip position Horizontal vs Vertical Initial or progressive abduction Knee position Radiography to check position
Traction Bryant Split Russel on Bradford frame
Traction Bryant Caution! Neurovascular status
Traction 2 4 weeks Plus one station minus one plus one zero Plus two
Closed Reduction General anesthesia Arthrography Positioning rather than reduction Just like Ortolani test
Safe Zone Never excessive abduction Point of Dislocation Marginal Safe Zone Marginal Reduced Dislocated Adductor tenotomy to inc. abduction
Dynamic Arthrography Assess Obstacles Adequacy of reduction Stability of reduction Acceptable only anatomic reduction?
Adequacy of reduction? Metaphysis below the Hilgenreiner s line 2/3 of head medial to into the Perkin s line
Adequacy of reduction? Femoral head below the limbus Shape & position of Limbus
Adequacy of reduction? Width of Medial Dye pool?
Width of Medial Dye pool Less Reliable Thickness of the Pulvinar Amount of the dye
Hip spica Cast Human position ( flexion 100, abduction 30-40 ) molded dorsal to the greater trochanter
Confirm reduction by imaging Radiography, Ultrasono, CT, MRI CT MRI
Redislocation in Poor Cast Poor and good moulding at the greater trochanter
Cast change 6 weeks arthrography Another cast change 6 weeks C/R & hip spica cast 6 weeks later
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
Open Reduction Medial Approach younger than 1 yr 1 1. Ludloff 2. Ferguson 2 3. Weinstein 3
Medial Approach Advantage Minimal blood loss Direct assess over obstacle : medial joint capsule & iliopsoas No damage to iliac apophysis & abductors No joint stiffness
Medial Approach Disadvantage Narrow exposure Less familiar Impossible capsular plication : Stability of reduction by prolonged cast Higher rate of AVN? : Injury of nearby MFC
Open Reduction Anterolateral Approach Standard approach Bikini incision : minimal scar
Hypertrophied lig.teres Pulvinar Capsule Limbus
Anterolateral Approach Advantage Familiar Possible capsular plication & pelvic osteotomy Cast in functional position : minimal hip flexion & some abduction Less period of cast
Anterolateral Approach Disadvantage Greater blood loss Damage to iliac apophysis & abductors Postop joint stiffness
Combined procedures Rarely indicated Femoral shortening : Undue tension in reduction Salter or pemberton osteotomy : Coverage in doubt
After cast removal Abduction brace full time for several months, thereafter part time Acetabular development
Acetabular development most in first 18 months after reduction until 4-8 yrs old : Pelvic osteotomy
Pelvic Osteotomy Timing Considered at 18 Ms of age Salter 1961 Delayed until at least 3 or 4 yrs Harris 1976
Pelvic Osteotomy Timing Popular movement toward earlier surgery By age 2 or 3 yrs Large enough pelvis for Surgery
Femoral antetorsion & valgus Excessive antetorsion and valgus with persistent acetabular dysplasia for 2-3 years after reduction :Intertrochanteric femoral osteotomy
Avascular Necrosis Most disastrous complication Only in treated hip No Pathologic Evidence of Avascular Necrosis Disturbance of Growth of the Proximal femur
Avascular Necrosis Incidence 0-73%, severe AVN : less than 5% Marked variance Definition? Late appearance?
Risk Factors 1. Age of reduction younger age : lower rate, but higher rate of severe form mostly cartilage - risk of total involvement
Risk Factors 2. Extreme position Severe abduction Abduction with marked internal rotation : MFC under Iliopsoas Vascular branches betw lateral neck & acetabulum
Risk Factors 3. Pressure necrosis pressured closed reduction to overcome obstacles Only Anatomic Perfect Reduction Accepted
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
Diagnosis Disagreed Coxa magna : common after O/R Flattend medial femoral head : prereduction deformity Temporary irregular ossification : Multiple ossification center?
Bucholz & Ogden Classification Type I: only head II: lateral physis III: entire physis IV : medial physis
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
Kalamchi & MacEwen Classification II? Type I Type III Type IV
Summary Early Neonatal Diagnosis is critical. Ultrasonography is very useful in Dx & Tx. Tx should be aimed for perfect anatomical hip without AVN.
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