developmental dysplasia of the hip (ddh)
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Developmental dysplasia of the Hip (DDH)
Natural history,management and outcomes
West Bank, Autumn 2009
Aetiology
Genetic: polygenic syndromic sex-linked Hormonal: oestrogen ; relaxin Mechanical: breech liquor deficiency
Mechanical
Left : Right – 4 : 1 Breech : DDH ≥ x 10 (N.B. frank) Liquor ↓ : moulded baby - plagiocephaly - scoliosis - foot deformity - skew pelvis
Genetic / mechanical
Joint laxityAcetabular and femoral version
Birth pathology in DDH
Simple: Acetabulum normal Femoral head normal Labrum normal Capsule stretched
Neonatal DDH
Ligamentum teres
True socket
Teratological DDH
Irreducible False acetabulum Defective anterior acetabulum
“anteverted” Increased femoral neck anteversion
Arthrogryposis with dislocations & delivery fracture
False acetabulum
Untreated dysplasia without dislocation in the Navajo
18 children
15 became normal 3 stayed dysplastic Pratt, Freiberger, Arnold. CORR; 1982
Which hip dysplasia pain?
• Complete dislocation with no false acetabulum: NO
• Complete dislocation with false acetabulum: YES
• Subluxation: YES Wedge, Wasylenko. CORR, 1978
45-year old
• Subluxation• False
acetabulum• Severe OA
... and adult unrecognised dysplasia?
Early treatment
• Diagnose!• Splint• Review
Ortolani test
UltraSound
!
UK Screening Committee: the problems
• Poor science• Poor testers • No national training programme• No national audit• Litigation
U.K. National Screening Committee (2006)
• Universal U.S. not recommended• Clinical exam. by properly trained ( at birth & 6 weeks)• Refer “at risk” babies
The extended rolepractitioner
&orthopaedic team working
The questionnaire
Ultrasonographer at work
Annie: extended role physio.
Oxford experience
• 1500 new screenings / year• 700 follow-up screenings / year• 95% successful splints
Challenges in hip dysplasia
• Subluxation• Incongruity• Early arthritis
The older child
Closed reduction
• E.U.A.• Adductor tenotomy• Safe position in POP
Open reduction
• Bikini incision• Psoas tenotomy• Ligamentum teres?• Transverse ligament• Limbus?• Capsulorraphy
Arthrogram
•Head shape•Cover•Congruity•Articular cartilage• Labrum
DDH: what influences arthritis risk?
• Age at treatment• Quality of reduction• Stability• AVN
Oxford DDH follow-up
Results - Arthritis
Opposite hips
4%: moderate/
severe OA
Affected hips
40%: moderate/
severe OA
Femoral operation • Shortening• Varus/valgus +/- rotation• Trochanteric transfer• Neck lengthening
Femoral shortening for DDH
Hey-Groves(1928)
Valgus/ extension osteotomy?
AVN withtrochantericovergrowth
Better in adduction and
flexion
Neck-shaft angle after femoral osteotomy
Pelvic operation
Re-alignment:
simple e.g. Salter complex e.g. Bernese Re-shaping:
e.g. PembertonAugmentation:
e.g. shelf Chiari
SalterInnominate osteotomy
K. E. 21 - 12 - 1999
Salter & femoral osteotomy
Staheli shelf
Chiari osteotomy
Outcome of Chiari osteotomy
• 236 of 388 osteotomies reviewed at 25 years• 51% good; 30% fair; 18% poor• Best results: ≤ 7 years; no OA • Femoral osteotomy: no better (Windhager et al. JBJS 1991)
Schanz osteotomy
Very late salvage
Radical salvage
• Fusion• Replacement• Excision
Hip arthrodesis
Consider for: i. Young male ii. Unilateral iii. Infection
Joint replacement
Consider for: i. Severe arthritis ii. Failed “ conservative” Rx. iii. Bilateral disease
Joint replacement
• May be complex• +/- femoral shortening• +/- acetabular grafting
Severe arthritis DDH
AVN
OA
End-stage O.A.
High,painful
DDH
DDH: THR does not solve all ills!
Right: painless
Left: severe pain
THR outcomes in DDH
•Charnley cemented hips: 5 of 38 loose at 11 years Bobak, Wroblewski et al 2000
•Harris uncemented hips: 20% loose at 7 years 46% loose at 12 years Jasty, Anderson, Harris, 1999
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