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DDH over 18 months

DDH over 18 months. Academic Half-Day November 2012. Marie-France Rancourt PGY-4, University of Ottawa. Developmental Dysplasia of the Hip. Most common disorder of the hip in children 80% female Multifactorial: genetic, hormonal, mechanical Risk factors: breech, firstborn, family history.

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DDH over 18 months

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  1. DDH over 18 months • Academic Half-Day • November 2012 Marie-France Rancourt PGY-4, University of Ottawa

  2. Developmental Dysplasia of the Hip • Most common disorder of the hip in children • 80% female • Multifactorial: genetic, hormonal, mechanical • Risk factors: breech, firstborn, family history

  3. Anatomy • Femur • Head: small, deformed, uncovered, delayed ossification (N=6 months) • Neck: narrow, short, anteverted • Greater Trochanter: small and posterior • Canal: straight, narrow • Acetabulum • Roof is vertical • Socket shallow • Deficient anterior, superior, lateral • Increased anteversion • Associated with labral tears

  4. SAFE ZONE • Range between • 1. maximum passive abduction • 2. abduction angle at which femoral head is unstable

  5. Presentation • Pelvic obliquity • Positive Galeazzi (if unilateral) • Limited ABduction • Lumbar lordosis (secondary to hip contractures) • Trendelenburg gait (secondary to abductor insufficiency) • LLD • Toe walking (secondary to LLD) • In adolescents: fatigue and pain in hip, thigh, knee

  6. Radiographic Features • shallow acetabulum • small capital femoral epiphysis • delayed ossification of the femoral head • acetabular sclerosis • loss of Shenton's curve • femoral head lateral to Perkin's line • femoral head superior to Hilgenreiner's line

  7. Radiographic FeaturesOlder than 5 yrs old ↑ = abnormal

  8. Radiographic FeaturesOlder than 5 yrs old ↓ = abnormal

  9. 2 yo

  10. Treatments GOAL: Maintain a stable, reduced, and concentric hip joint at the earliest safe age • Skin Traction • Gentle Closed Reduction • Adductor Tenotomy • Spica Cast • Open Reduction • Femoral shortening • Pelvic Osteotomies

  11. Treatment by Age • 18 to 24 months • Closed Reduction and Spica Cast • Open Reduction and Spica Cast • over 2 yrs old • Open Reduction and Femoral Osteotomy (4-8 yo) • Open Reduction and Pelvic Osteotomy

  12. A SKILLFUL OPEN REDUCTION ISFAR LESS DANGEROUS THAN AFORCEFUL CLOSED REDUCTION

  13. Closed reduction - Traction • Closed Reduction • Under GA • Longitudinal traction, flexion, abduction • Asses reduction: intra-operative arthrogram • medial dye pool > 7mm - dislocated • Closed reduction at 18 mo: 50% will need another procedure (osteotomy) because of failure to remodel • Traction: • pre vs post op • Traction with hip in mild flexion

  14. Spica Cast post Closed Reduction • Position: • 100 deg hip flexion • 45 deg ABduction • Neural rotation • Mold dorsal to GT • Change q6 weeks • Total time: 3 months • Post cast: abduction orthosis x 4wks then at night x 4wks

  15. Open Reduction • Indications: • Preferred treatment older than 18 months • If concentric closed reduction cannot be achieved • More than 60 degrees ABduction needed to maintain reduction • Approachs: • Anterior (Smith-Peterson) • Medial (Ludloff)

  16. Anterior (Smith-Peterson) • Advantage: • decrease risk to medial femoral circumflex artery (femoral head AVN) • may perform capsulorrhaphy • may perform pelvic osteotomy • shorter casting period • Disadvantages: • LFCN at risk • Post op stiffness

  17. ANTERIOR APPROACH TO HIP (SMITH-PETERSON) Position: Supine Incision: ASIS down 8cm to the lateral side of the patella Planes: Sartorius (femoral n) and TFL (superior gluteal n) Rectus femoris (femoral) and gluteus medius (superior gluteal n) 18

  18. Medial (Ludloff) • Advantages: • minimal blood loss • access to medial blocks • cosmetically pleasing scar

  19. Medial (Ludloff) • Position: Supine with hip flexed + abducted + ER • Incision: 3 cm below pubic tubercle • Plane: • Adductor longus (obturator n) and Gracilis (obturator n) • Adductor brevis (obturator n) and adductor magnus (obturator and sciatic n)

  20. Medial (Ludloff)

  21. Open Reduction • Potential blocks • Extra-articular • Adductor tenetomy (if unable to achieve appropriate ABd) • Iliopsoas release • Intra-articular • hypertrophied ligament teres • capsule • pulvinar (fibrofatty debris) • inverted labrum • contracted transverse ligament

  22. Confirmation of reduction • Limited CT Scan • Line drawn parallel to pubic rami should intersect the proximal femoral metaphysis

  23. Spica cast post open reduction • Casting period • Anterior approach: 6 weeks • Medial approach: 12 weeks • Position • 30 deg: IR • 30 deg: flexion • 30 deg: Abduction • After cast removal: physio for ROM

  24. Femoral Osteotomy • Goals • Derotation • Alignment • Shortening • Reduce head but keep good ROM

  25. Femoral Osteotomy • Derotation • Femoral anteversion • Alignment • Correct excessive valgus (often in CP hips) • Effects on acetabulum seen 1-2 yrs post op • Shortening • difficult reduction • Usually 1-2 cm • high riding dislocation • Decrease tension and pressure (of soft tissues) on femoral head thus minimize risk of osteonecrosis • AVN Rate • Reduction alone: 20-54% • Reduction + Femoral osteotomy: 0-10%

  26. Femoral shortening +/- Valgus correction

  27. femoral osteotomy

  28. Pelvic Osteotomy • Corrects an increased acetabular index

  29. Late diagnosis • Over 4yrs old: poor remodeling potential • Bilateral • If over 6 yrs old: do not reduce • Unilateral • If over 8 yrs old: do not reduce • Triradiate cartilage matures until 8 yo

  30. Follow up • Follow clinically and radiographically until maturity • Monitor contralateral side if unilateral • At risk for early onset osteoarthritis

  31. Literature

  32. Surgical treatment of developmental dysplasia of the hip presenting in children above 10 years • METHOD: • 75 hips mean age of11.5 years • Salter osteotomy, Pemberton acetabuloplasty, Dega osteotomy, or Westin osteotomy. • Subtrochanter transverse femoral shortening and derotation osteotomy in all patients. • A long leg cast then progressive ROM 2 weeks after the surgery. • RESULT: • FU 7.6 years • 4 cases of semiluxation (6.3%); 4 of femoral head ischemia necrosis (6.3%), 9 of hip joint stiffness (14.3%).

  33. Effect of innominate and femoral varus derotation osteotomy on acetabular development in developmental dysplasia of the hip • Spence G. et al, J Bone Joint Surg Am. 2009 • METHODS: • 15 months to 4 yrs old • Treated at 2 different centers (1 surgeon per centre) • 38 patients: open reduction combined with a femoral varus derotation osteotomy • 38 patients: open reduction combined with an innominate osteotomy • mean follow-up period of 6.2 years • RESULTS: • acetabular index improved in both groups • Patients with varus derotation osteotomy never improved as much as that in patients who underwent an innominate osteotomy • Innominate osteotomy group demonstrated better acetabular architecture and hip stability over time as quantified by the change in the acetabular floor thickness (p = 0.03)

  34. One-stage treatment of developmental dysplasia of the hip in untreated children from two to five years old. A comparative study. • Erturk et al. Acta Orthop Belg. 2011 Aug;77(4):464-71. • 49 hipsuntreated children 2 to 5 years of age. • open reduction, Salter innominate osteotomy, femoral shortening and derotation osteotomy. • Group I included 24 hips in patients aged < 3 years • Group II included 25 hips aged > or = 3 years • Mean follow-up was 5.08 years • Clinical and radiological assessment at final followup showed that the outcome was not significantly different between the two groups • the rates of avascular necrosis were similar.

  35. Predictors for secondary procedures in walking DDH. • Gholve et al. J Pediatr Orthop. 2012 Apr-May;32(3):282-9. • 49 children with idiopathic DDH treated with open reduction of the hip • mean age of 31.3 months • mean follow-up of 9.7 years • Operations: 12 open reduction only, 15 concurrent pelvic osteotomy, 4 femoral osteotomy, 18 had both femoral and pelvic osteotomy. • Re operations • 4 patients required repeat open reduction at a mean of 5.1 months • 24 patients had at least 1 secondary surgery for dysplasia at a mean of 3.2 years • 2 patients had 3 additional operations • Of the 27 patients who did not have concurrent femoral osteotomy at index surgery, 19/27 (73%) required a secondary procedure • CONCLUSIONS: • 49% of the patients in this cohort required secondary procedures to treat hip dysplasia. • Open reduction without concurrent femoral osteotomy strongly predicted the need for a secondary procedure.

  36. OITE

  37. OITE • In patients older than 12-months of age with developmental dysplasia of the hip, all of the following physical exam findings are likely present EXCEPT? • 1. Limited hip abduction • 2. Positive Ortolani maneuver • 3. Galeazzi test • 4. Trendelenburg gait • 5. Pelvic obliquity

  38. OITE • In patients older than 12-months of age with developmental dysplasia of the hip, all of the following physical exam findings are likely present EXCEPT? • 1. Limited hip abduction • 2. Positive Ortolani maneuver • 3. Galeazzi test • 4. Trendelenburg gait • 5. Pelvic obliquity

  39. OITE • A five-year-old boy with cerebral palsy presents to the clinic with a dislocated right hip, what quadrant of the acetabulum is most likely deficient? • 1. Anterior-inferior • 2. Anterior-superior • 3. Posterior-superior • 4. Posterior-inferior • 5. Anterior-inferior and anterior-superior

  40. OITE • A five-year-old boy with cerebral palsy presents to the clinic with a dislocated right hip, what quadrant of the acetabulum is most likely deficient? • 1. Anterior-inferior • 2. Anterior-superior • 3. Posterior-superior • 4. Posterior-inferior • 5. Anterior-inferior and anterior-superior

  41. Thank you

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