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