DDH

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DDH 

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01 مه« e Dysplasia of the hip that develop during fetal life or in infancy. e It ranges from dysplasia of the acetabulum (shallow acetabulum) to subluxation of the joint to complete dislocation. e The old name was “congenital dysplasia of the hip (CDH).” The name has changed to indicate that not all cases are present at birth and that some cases can develop later on during infancy and childhood 

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Developmental Dysplasia of the Hip 1. Complete hip dislocation. 2. Partial hip subluxation. 3. Hip dysplasia (incomplete development). 4.Dislocatable hip 

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Acetabulum | (socket) Hip / Head of femur (ball) Normal Subluxation Dislocation 

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Etiology A positive family history for DDH is found in 12-33% of affected patients. DDH is more common among female patients (80%). This is thought to be due to the greater susceptibility of female fetuses to maternal hormones such as relaxin, which increases ligamentous laxity Primigravida. Breech presentation(2-3%). Oligohydramnios ,primi gravida and large baby ( crowding phenomenon ). Adduction and Extension postnatally. 

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Associated conditions torticollis metatarsus adducts calcaneo valgus talipus varus -plagiocephaly Jipes varus 8 oat arsus varus loom ysis deformities ‏ان يع ا فاه لاقيو‎ wares, 6 

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CLINACAL PRESENTATION 

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CLINICAL FINDINGS e IN NEWBORNS e Usually asymptomatic and must be screened by special maneuvers e 1) Barlow test. It is a provocative test that attempts to dislocate an unstable hip. - Flexion ,adduction, posteriorly. - “Clunk” 

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‘The Barlow test for developmental dislocation of the hip in a neonate.A, With the infant supine, the examiner holds both of the child's knees and gently adducts one hip and pushes posteriorly.B, When the examination is positive, the examiner will feel the femoral head make a small jump (arrow) out of the acetabulum (Barlow's sign). When the pressure is released, the head is felt to slip back into place. 

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2) Ortolani test It is a maneuver to reduce a recently dislocated hip. Flexion, abduction, anteriorly. We cant use X-rays because the acetabulum and proximal femur are cartilaginous and wont be shown on X-ray. US is the best method to Dx. 

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The Ortolani test for developmental! dislocation of the hip in a neonate.A, The examiner holds the infant's knees and gently abducts the hip while lifting up on the greater trochanter with two fingers.B, When the test is positive, the dislocated femoral head will fall back into the acetabulum (arrow) with a palpable (but not audible) “clunk” as the hip is abducted (Ortolani's sign). When the hip is adducted, the examiner will feel the head redislocate posteriorly. 

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Clinical Manifestations e In infants: e As the baby enters the 2nd and 3rd months of life, the soft tissues begin to tighten and the Ortolani and Barlow tests are no longer reliable. e Shortening of the thigh, the Galeazzi sign , is best appreciated by placing both hips in 90 degrees of flexion and comparing the height of the knees, looking for asymmetry 

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The most diagnostic sign ۶ 5 limitation of abduction. Abduction less than 60 degrees is almost diagnostic. X-rays after the age of 3 months can be helpful esp. after the appearance of the ossific nucleus of the femoral head US is 100% diagnostic. 

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INFANT..!! 

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Skin fold asymmetry 

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Asymmetrical thigh folds < 

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After Walking Age m™ Trendelenberg gait mLeg length discrepancy @ Increased lumbar lordosis in Bilateral dislocation —Klisic test positive 

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The examiner places the middle finger over the greater trochanter, and the index finger on the anterior superior iliac spine.A, With a normal hip, an imaginary line drawn between the two fingers points to the umbilicus.B, When the hip is dislocated, the trochanter is elevated and the line projects halfway between the umbilicus and the pubis. 

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Physical examination...! ‏لمكم‎ aaa aay Remains dislocated Klisic sign Decreased Abduction Galleazi sign Limp(Painless) Shortening Hyperlordosis Dislocatable( occasionally) Reducible(ocassionally) Klisic sign Decreased Abduction Galleazi sign Dislocatable Reducible Klisic sign 

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Which hip dysplasia pain? ~ Complete dislocation with > false acetabulum: NO ~ Complete dislocation with ‏دده‎ acetabulum: YES ~ Subluxation: YES 

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SCREENING..!! e All neonates should have a clinical examination for hip instability e Risk factors : — breech presentation USG SCREENING — family history — torticollis — oligohydramnios — metatarsus adductus 

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Imaging X-rays — Femoral head ossification center ۰ 4 -7 months Ultrasound Cr MRI Arthrograms — Open vs closed reduction 

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Radiograph e Itis not reliable in early stages of DDH but new born screening may reveal severe acetabular dysplasia or teratological dislocation. e as child grows soft tissue become contracted and radiographs become more helpful in diagnosis. ٠ Most common used lines of reference are vertical line of Perkins and horizontal line of Hilgenreiner, both used to assess the position of femoral head. 

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X-ray e Horizontal line of Hilgenreiner: drawn between upper ends of tri-radiate cartilage of the acetabulum. © Vertical line of perkins: drawn from the lateral edge of the acetabulum vertical to horizontal line. e 4 quadrants: Normal hip: the ossification center of the femoral hip lower medial quadrant. Dislocated hip: upper lateral quadrant. 

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Perkin line is through lateral margin of acetabulum e While hilgenreiner line is through triradiate cartilage. e Shenton line is curved line that begins at lesser trochanter, goes upto femoral neck, and connect with line along inner margin of pubis. e In normal hip, medial beak of femoral metaphysis lies in lower inner quadrant produced by junction of Perkin and hilgenreiner lines. 

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RADIOGRAPHY...!! Acetabular index ) index (normal) . 5 J (abnormal Medial gap Acetabular index and the medial gap Dimensions H and D are measured to quantify proximal ‏سس لیس‎ rpg ‏التسص سوسم سه ويه حك‎ when the head is not ossified. 

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X-ray e Acetabular index: angle between horizontal line of hilgenreiner and the line between the two edges of the acetabulum. normal hip 20°30 dilocated or dysplastic hip = 30° e Shenton’s line: semicircle between femoral neck and upper arm of obturator foramen, in dislocated hip this line is broken. 

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The acetabular index is the angle between a line drawn along the margin of the acetabulum and Hilgenreiner’s line; it averages 27.5 degrees in normal newborns and decreases with age. e Acetabular Index 

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Acetabular tear drop It is seen in AP radiograph of pelvis. Formed by several lines , Derived from — wall of acetabulum laterally, Wall of lesser pelvis medially, Curved line inferiorly and Acetabular notch. In normal hip it appears between 6-24 months of age. 6۵ ۵ 0 0 6 6 

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TEAR DROP و حور سپ ۳ - ~ 

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Tear drop ‎AP X-ray‏ وی ‎Lateral:wall of‏ ++ ‎acetabulum‏ ‎Medial:lesser pelvis‏ + ‎INferior :acetabular‏ 93¢ . مه هس ‎notch‏ ۱ ‎Cotytota. ‎fosse ‎++ Appears between 6-23 mo ++ [delayed in DDH] ‎ ‎ 

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DIAGNOSIS 1. ULTRA SOUND In the Graf technique, the transducer is placed over the greater trochanter, which allows visualization of the ilium, the bony acetabulum, the labrum, and the femoral epiphysis The angle formed by the line of the ilium and a line tangential to the boney roof of the acetabulum is termed the a angle and represents the depth of the acetabulum. Values > 60 degrees are considered normal, and those < 60 degrees imply acetabular dysplasia. 

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۰ ۲۳6 B angle is formed by a line drawn tangential to the labrum and the line of the ilium; this represents the cartilaginous roof of the acetabulum. e A normal B angle is < 55 degrees, as the femoral head subluxates, the B angle increases. 

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ULTRASONOGRAPHY..!! 

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۴۷۷۶ ۱2 4 ‏اج هت‎ of alpha G) and beta (B> angles scans to establish Graf class. The alpha angie angle between the baseline and the root of the bony acetabulum. The beta angle is the angle between the baseline and the cartilaginous acetabular roof- 

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Ultrasound ACETABULAR ROOF LINE INCLINATION LINE BASELINE و ین ALPHA ANGLE wes 

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e In DDH , alpha angle decreases and beta angle increases, depending upon femoral head subluxation. ¢ Depending upon alpha angle measurment he proposed a classification system 

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GRAF CLASSIFICATION..!! Class AlphaAnale Beta Anale Descriotion | > 60° <5" Normal 43-0 55-77۳ ۰ Delayed ossification ‏فله *43> |ا‎ Lateralization ۷ Unmeasurable Dislocated B decreased:better cartilagenous acetabulum @ decreased:shallow acetabulum 

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Treatment Is divided in 5 age — related groups 1) newborn ( birth to 6 months old ) 2) infant ( 6 to 18 months old ) 3) toddler ( 18 to 36 months old ) 4) child ( 3 to 8 yrs. Old ) 5) adolescent and young adult ( > 8 yrs. Old ) 

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Birth to Six Months yess, e Triple-diaper technique — Prevents hip adduction — “Success” no different in some untreated hips e Pavilk harness (1944) r — Experienced staff* — Very successful — Allows free movement within confines of restraints *posterior straps for preventing add. NOT producing abd. 

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Pavlik harness:1* choice Continued till achieving stability 4 weeks ‏ال تحص و‎ Reduced Continue for 6 more weeks Appearance of the notch predicts سس ‎no reduction‏ ‎discontinued‏ better development of acetabulum 

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AIM: obtain & maintain concentric reduction without damaging femoral head 1 Closed/open reduction Pre op traction ???? Femoral shortening &Innominate osteotomy may be needed 

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Open Reduction...!! e Unable to achieve closed reduction e Widening of the joint space e Unstable reductions e Loss of reduction on follow up Advanced age 

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2 Years of Age and Older ¢ For child 2 -3 years of age, during open reduction acetabular coverage if insufficient warrants reorientation osteotomy e If coxa valga with excessive anteversion, VDRO may be done. ¢ Children > 3 years usually need an acetabular procedure Femoral shortening is essential part of it’s management. In past , child is put on skeletal traction but result of shortening are better and 

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‎Pea ee‏ ی ‎18 to 36 months ‎1 ‎3 to 8 years ‎ ‎ ‎ ‎Pri, open reduction with ‎Femoral ‎shortening ‎>1/34 head visible ‎ ‎Pelvic osteotomy ‎Management of DDH — Guidelines ‎ ‎ ‎ ‎1 ‎ ‎6 to 18 months ‎ ‎ ‎Traction ‎Closed reduction Hip spica ‎| ‎Open reduction ‎ ‎Arthrography ‎No reduction ‎ ‎ ‎0 to 6 months | ‎ ‎avliks Harness ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ ‎ 

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Pelvic Procedures «۰ Redirectional — Salter — Sutherland double innominate osteotomy — Steel ( Triple osteotomy) — Ganz ( rotational) « Acetabuloplasties ( decrease volume ) — Pemberton — Dega ٠ Salvage — depend on fibrous metaplasia of capsule — Shelf and Chiari 

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