Other Hip Disorders: Congenital (Developmental) & Idiopathic 이대목동병원 윤여헌

Other Hip Disorders: Congenital (Developmental) & Idiopathic 이대목동병원 윤여헌

Children s hip disorders Congenital & developmental disorders Developmental hip dysplasia (dislocation) of the hip Developmental coxa vara Proximal femoral focal deficiency Idiopathic Legg-Calve-Perthes disease Slipped capital femoral epiphysis Transient synovitis of the hip Idiopathic chondrolysis of the hip Infectious & inflammatory disorders Neoplasm Trauma

Developmental Coxa Vara Developmental coxa vara Not at birth, but in early childhood Progressive Primary ossification defect in the inferior femoral neck: shearing fatigue failure Congenital coxa vara At birth Not progressive Assoc. PFFD, cong. short femur Aquired coxa vara Fracture, tumor, fibrous dysplasia, rickets

Coxa Vara Physical findings Abductor weakness Trendelenburg (+) LLD or waddling gait LOM Abduction (decreased NSA) IR (decreased F. anteversion) Radiography Vertical physis Hilgenreiner angle: 40~70 (N<25) Triangular metaphyseal fragment Inverted radiolucent Y pattern Decreased F. anteversion

Coxa Vara (Treatment) Recovery if H-angle < 45 Op indications NSA < 90 or progressing H angle > 45 Trendelenburg (+) Valgus derotational osteotomy Goals NSA > 160 H angle < 30-40

Proximal Femoral Focal Deficiency (PFFD) Spectrum of femoral defects Minor hypoplasia to complete agenesis Variable hip instability Shortening Other anomalies Fibular hemimelia Cruciate ligament deficiency Clubfoot, tarsal coalition Spinal, heart, facial anomalies

PFFD (Classification) Aitken (1969) Pappas (1983) Kalamchi (1985) I : short femur, intact hip II : short femur, coxa vara III : short femur, well developed acetabulum, dysplastic femur IV : dysplastic femur, absent hip V : total absence of femur

PFFD (Treatment) Bilateral PFFD: nonoperative Stability of the hip Aitken A & B surgery for pseudarthrosis Pappas VII, VIII, IX prox. Femoral osteotomy Severe cases - no surgery vs iliofemoral fusion Limb lengthening 10~25% of initial segment length Staged lengthening for higher discrepancy Severe cases knee arthrodesis with foot amputation Rotationplasty

M/16 Coxa vara with short femur

Slipped Capital Femoral Epiphysis (SCFE) Most common hip disorder in adolescence Pathology in proximal femoral physis Neck displaced - anterolateral Head (epiphysis) displaced - posteromedial Apparent varus (Pistol grip deformity) Valgus SCFE (rare)

SCFE (epidemiology) During growth spurt Male 10-16Y, Female 9-15Y Bilateral in 25 (18~63)% Younger children (< 10Y) 5~10% Mostly bilateral Endocrine/systemic disorder Hypothyroidism Panhypopituitarism Hypogonadism Hyperparathyroidism Renal osteodystrophy Tumor, radiation Obesity (adioposo-genital syndrome)

SCFE (pathoanatomy) In preslip stage Physeal widening Hypertrophic zone Slip cleft Synovial congestion Joint fluid collection Metaphysis decalcification Posteromedial (anterolateral) displacement of femoral head (neck) Apparent varus

SCFE (classification) By clinical presentation Preslip Acute (< 3 wks) Chronic Acute on chronic By stability Stable Unstable Unable to ambulate, remodelling (-), effusion AVN 50% cold bone scan AVN in 80~100%

SCFE (classification) By displacement Mild: slip<1/3, HSA<30 Moderate: 1/3~1/2, 30~60 Severe: >1/2, >60

SCFE (clinical finding) Overweight teenager Pain hip, groin, thigh, knee Limited IR of hip Most consistent physical finding passive flexion steers abductionexternal rotaton (obligate ER of hip) ER gait Leg length discrepancy

SCFE (radiography) Early X-ray findings (AP) Physis: widening, irregularity Epiphysis: decreased ht. Blanch sign of Steel (crescent sign) Kline s line Chronic or AOC SCFE Remodelling on femoral metaphysis (superior and anterior) New bone on epi-metaphyseal junction (inferior and posterior)

SCFE (radiography) Lateral Better defines posterior displacement Head-shaft angle

Goals SCFE (treatment) Prevention of further slip Avoid osteonecrosis / chondrolysis Treatment modalities In situ fixation with a single central screw Reduction & fixation with 1~2 screws Prophylactic fixation of the contralat. hip Corrective osteotomy subcapital (physeal), basilar neck, intertrochanteric Obsolete Bone peg epiphyseodesis, Cast, IF with multiple pins

Stable SCFE (in situ fixation) Currently gold standard for stable SCFE Metaphyseal remodelling Surgical technique Percutaneous single screw 6.5~7.3mm, cannulated, stainless steel Center of epiphysis, perpendicular to physis Avoid posterosuperior quadrant of femoral head Avoid violation of posterior retinacular art. Anterior intertroch line 5 threads in epiphysis Check the screw tip 5mm from subchondral bone

Stable SCFE (treatment) Osteotomy Severe chronic slip Proximal realignment Subcapital (physeal) AVN 21~35% Base of neck Intertrochanteric Valgus-flexion closing wedge osteotomy

Unstable SCFE Controversies Urgency (8 hours) > emergency > elective Gentle closed (complete) reduction < incidental reduction Joint decompression < not One > two screws POSNA study (JPO, 2005)

Prophylactic fixation of the contralateral hip Indications Younger patient (<10Y) with metabolic-endocrine disease Reliable follow-up is not feasible

SCFE (complications) 1. Progression of slip 2. Osteonecrosis 3. Chondrolysis

SCFE (complications) Osteonecrosis acute, unstable slip iatrogenic ill-advised reduction violation of posterior cortex of neck posterosuperior quadrant of epiphysis osteotomy

SCFE (complications) Chondrolysis Persistent pin penetration Manipulative reduction Prolonged immobilization Corrective osteotomy

Transient Synovitis of the Hip (TSH) Acute nonspecific inflammatory disease of hip 3~8 year old Healthy child Etiology unknown URI etc. 70% Acute monarticular hip pain Limping, antalgic gait LOM (abduction, IR)

TSH Normal x-ray Joint effusion in 71% (ultrasound)

TSH Gradual but complete recovery Association with LCP (1.5%?) Treatment Bed rest full relief from weight bearing for 2 weeks Oral NSAID: sometimes Useless Traction Antibiotics Steroid Aspiration

Idiopathic Chondrolysis of the Hip Idiopathic progressive destruction of articular cartilage from acetabulum & femoral head Joint space narrowing Stiffness Adolescent age Insidious onset Autoimmune disease? X-ray findings Joint space <3mm Osteopenia Blurring subchondral Enlarged fovea capitis femori Mild coxa magna

Idiopathic Chondrolysis Premature closure of proximal physis & trochanteric apophysis (bone scan) Dry joint (aspiration) Two clinical stage Acute (6-16M) Chronic (Years) Nl basal layer & subchon. bone Subsequent regeneration Partial-complete recovery in 50-60%