CDH Congenital Dislocation of the Hip

1. بسم الله الرحمن الرحيم CDHCongenital Dislocation of the Hip Prof. Mamoun Kremli AlMaarefa College

2. Spectrum of diseases • Abnormality of proximal femur and acetabulum • Initial pathology is congenital, but • Progresses (becomes worse) if not treated • Does not always result in dislocation

3. Nomenclature • CDH: Congenital Dislocation of the Hip • DDH: Developmental Dysplasia of the Hip • CDH: Congenital Dysplasia of the Hip • CHD: Congenital Heart Disease!

4. CDH - Spectrum • Acetabular dysplasia: • Shallow acetabulum • Unstable hip: • Dislocatable - Reducible • Dislocated hip: • May or may not be reducible • Teratologic hip: • Fixed dislocation at birth, often with other major anomalies

5. Incidence • Hip instability at birth: 0.5 – 1 % • Classic CDH: 0.1% • Mild dysplasia: Substantial • Up to 50%of hip arthritis in ladies have underlying hip dysplasia

6. Incidence

7. Etiology Multi-factorial • Ligament laxity • Genetic • Mechanical factors

8. Etiology 1. Ligament laxity • Hormonal: • Estrogen, Relaxin: hormones secreted by mothers before birth • May affect baby girls more? – receptors • Familial ligament laxity: • Mild – Moderate – Sever • Ehler Danlos Syndrome

9. Etiology Ligament laxity: hypermobile joints

10. Etiology 2. Genetic factors • Twin studies • Monozygotic: 38% • Dizygotic: 3% (similar to other siblings) • Positive family history • Females: 4-6 X more than males • Could be hormonal – the effect of Relaxin hormone produced by mother on female fetus

11. Etiology 3. Mechanical factors • Prenatal: • Breach: • Normally: 2-4% • In CDH: 16% • The breach position in utero: extended knees, and flexed hips • cause dislocation of hip by ? stretch of Hamstring muscles

12. Etiology 3. Mechanical factors • Postnatal: • Swaddling / strapping hips adducted and extended, and knees extended المهاد – القماط – الزمام – الكوفلة

13. Etiology 3. Mechanical factors • Postnatal: • Swaddling / strapping hips adducted and extended, and knees extended • Proven experimentally • Proven statistically • Mechanics

14. Infants at risk • Positive family history: 10X • A baby girl: 4-6 X • Breach presentation: 5-10 X • Torticollis: CDH in 10-20% of cases • Foot deformities: • Calcaneo-valgus and metatarsus adductus • Knee deformities: • hyperextension and dislocation (Teratologic)

15. Clinical Examination • External rotation • Short one side

16. Clinical Examination • External rotation • Short one side • Lateralized contour • Wide perineum • In bilateral

17. Clinical Examination • External rotation • Short one side • Lateralized contour • Wide perineum • In bilateral • Asymmetrical folds • Anterior - posterior

18. Clinical Examination • External rotation • Short one side • Lateralized contour • Wide perineum • In bilateral • Asymmetrical folds • Anterior - posterior

19. Clinical Examination • Shortening • Might be difficult to detect early

20. Clinical Examination • Limitation of hip abduction in flexion

21. Clinical Examination • Limitation of hip abduction in flexion

22. Clinical Examination • Limitation of hip abduction in flexion

23. Clinical Examination • Special test – Hip Instability: • Ortolani / Barlow • Feel a Clunk, not hear a click!

24. Clinical Examination Ortolani / Barlow

25. Clinical Examination • Special test – Hamstring Stretch Sign: • Flex hip and knee 90o, and extend knee gradually • Normally: • feel resistance • CDH: • no resistance

26. Clinical Examination • After walking age: • Shortening – (if unilateral) • Limping: • Unilateral: limping • Bilateral: waddling (like a duck)

27. Investigation: Radiology • Early infancy: • X-ray is not reliable – all cartilage • Ultrasound is better

28. Radiology: X-ray • After 2-3 months: more reliable 39o 27o

29. Radiology: X-ray • After 2-3 months: more reliable out in

30. Radiology: X-ray • After 6 months: reliable • R hip out, and acetabulum open (dysplastic)

31. Treatment • Method depends on age • The earlier started, the easier it is • The earlier started, the better the results are • Should be detected EARLY

32. Treatment • Birth – 6m • Pavlik harness or hip spica cast • 6-12 m: • Closed reduction under GA and hip spica cast • 12 - 18 m: • Open reduction • 18 – 24 m: • Open reduction and Acetabuloplasty • 2-8 years: • Open reduction, Acetabuloplasty, and femoral shortening • Above 8 years: • Open reduction, Acetabuloplasty cutting all three pelvic bones, and femoral shortening No surgery One surgery Two surgeries Three surgeries Complex surgeries

33. Treatment: Neonatal • Pavlik Harness • Dynamic, effective, safe • Keeps hips abducted and flexed – for 6 weeks

34. Treatment: 6-12 m • Initially non-operative closed reduction UGA and immobilization in hip spica cast

35. Treatment: 6-12 m • Possibly closed reduction • Stable and concentric reduction • Possibly open reduction • Unstable or un-concentric reduction • Arthrography-guided

36. Treatment: 6-12 m • Arthrography-guided Closed Reduction Well in Dislocated Not well in

37. Treatment: 6-12 m Arthrography-guided Closed Reduction Acceptable Too lateralized

38. Treatment: 18-24 m • Open reduction – surgery • Acetabuloplasty - usually • Maybe: Femoral shortening – if high

39. Treatment: Above 2 years • Open reduction, and • Acetabuloplasty, and • Femoral shortening

40. Salter’s Acetabuloplasty Operated hip Dislocated hip

41. Pemberton’s Acetabuloplasty need a lot of improvement in acetabular cover

42. Triple Steel Acetabuloplasty • Osteotomy of: • Ilium, Pubic, • and Ischium • Rotation of • acetabulum • 12 years old, • Pain L hip • L hip not well • covered

43. Summary • Complex multi-factorial, endemic disease • Screening programs are needed to detect and treat cases early • Learning proper examination methods • Identify at risk groups • Efficient referral system • Proper management by specialized Drs

44. Summary - Infants at risk • Positive family history: 10X • A baby girl: 4-6 X • Breach presentation: 5-10 X • Torticollis • Foot deformities • Knee deformities