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