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Carol Berg
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Developmental
dysplasia of Hip
Dr Waqar HassanTMO Orthopedic Unit
HMC
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Objectives
Understand what is DDH
How to diagnose
Treatment
Research and cases in our unit
Conclusion & suggestion
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Definition
DDH is a spectrum of disorders. Hipcan be
Dislocated
Dislocatable
Subluxated
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Age
1. Teratological Dislocation (congenital dislocation of hip)
Typical DDH Child is otherwise normal
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Epidemiology
& risk factors Incidence 1 in 1000 live birth
Left hip 67%
Family history 20% In breech 30-50%
Bilateral 35%
Sex Ratio (Relaxin) F(4 - 6) : M(1)
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Risk factor
Environmental & Mechanical
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Risk factor
Geneticunknown genetic factor
Runs in familiesRisk to next child increases
Families with Generalised Ligament
Laxity Families with Acetabular Dysplasia
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Nursingrace
Rare in China, Asia, Africa (carrychildren with hips flexed andabducted)
High in native American (Used tonurse with legs extended)
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Aetiology-Ligamentous
LaxityMaternal Relaxin hormones
Induce hip capsule laxity in infant
Effect is much stronger in females
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PathologyBone
Soft tissues
Muscles
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Screening for DDH
Methods
Clinical
U.S. Scan
Aim of screeningEarly detection
Reduces late presentation
Reduces surgical intervention
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Clinical screening
Standard programme
Barlows/Ortolanis tests done on
every child at birth and then at 6-8weeks
Barlows/Ortolanis Tests
Specificity- 100%
Sensitivity- 60%
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Barlow Provocative Test
in neonate
Dislocates hip(exit)
Clunk
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Ortolani Maneuver
in neonate
Reducesdislocated hip(entry)
Abduction
Clunk
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Infant >3 Months
57 43
Limited abduction is key26
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Infant >3 Months
Asymmetricthigh folds
Limb-length
discrepancy
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Galeazzi test
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Toddler
Limping
waddling gaitLordosis
Deformity
Limited abduction and lateral rotationTelescoping
Leg length discrepancies
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Ultrasound Screening
High Specificity and Sensitivity: >90%
Helps in diagnosis of not onlySubluxated/ Dislocated hips but alsoDysplastic hips
Helps in Monitoring the treatment
Reduces the need for Arthrograms /Xrays.
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Radiology
Standard films AP of the pelvis withboth hip joint
frog-leg views
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Central edge
angle
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Von Rosens line
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Treatment
Aim
Proper reduction of femoral head
is important for development ofacetabulum and lowers incidenceof acetabular dysplasia
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According to Campbells
operative orthopedicsbirth to 6 months (New born)
6 to 18 months (Infant)18 to 36 months (toddler)
3 to 8 years (child)
Juvenile & Young adults-
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TREATMENT :
In newborn
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Denis Brown Abduction
Splint
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Von Rosen Splint
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Pavlik harness should not becontinued for more than 4 weeks if
failedComplicationAVN
Femoral nerve palsyPersistant dislocated hip can wear
away acetabulum (pavlik harnessdisease)
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Failure of Pavlik harness
6-8 weeks notstabilised
TractionClosed reduction&radiographicassesment
Open reduction ifnecessary
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Treatment: Infant 6 to 18
monthsClosed reduction & Spica
Must be gentle flex hip > 90
degree and in safe zone of 30 -60degree abduction
Arthrography is often useful
Adductor tenotomy
Open reduction if necessary
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Hip spica
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Aftercare
After close reduction
Spica for 4 months with cast
changes every 6 weeksCheck X-rays or CT scans
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Open reduction in 12 to 18
monthsAs child get older chance ofsuccessful close reduction
decreaseOpen reduction may be neededdue to soft tissues contracture
Seldom need bony procedure
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Open reduction
Structural obstacles to closereduction are
Hour glass capsular contractureLigamentum teres
Iliopsoas
PulvinarTransverse acetabular ligament
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Toddler 18-36months
Open reduction combined withfemoral osteotomy
Pelvic and femoral combinedosteotomies
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Oteotomy
Femoral osteotomyFemoral shortening
DerotationVarus
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Pelvic Osteotomies
Reconstructive
Salter 18m 6yPemberton18m 10y
Steel skeletal maturity
PAO (Ganz) skeletal maturity
SalvageChiari skeletal maturity
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Overview of Pelvic
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Overview of PelvicOsteotomies
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d i f
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How to determine forosteotomy
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Juvenile & Young adults> 8 years
Palliative salvage procedures
Rarely femoral shortening &pelvic osteotomy
Bilateral: leave it alone
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Researh work in our unit
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Study in orthopedic unit
HMCPeriod : Sep2003 to July 2007
Ref no. : JPMI 2008 VOL22
NO.01:27-32Title : One stage surgery of
CDH/DDH in children of
2-5 years of age
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Results
Total no. of patients: 25Total hips operated: 30
Gender :
Female: 17Male: 8
Bilateral : 5 Cases
Left side : 18 casesMean age at surgery: 38.56months
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Radiological assessmentmodified Severin classification
Excellent I A CE angle>19 degree 9
Good I B
II
CE angle15-19 degree
Moderate deformity of femoral head
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10
Fair III Dysplastic hip, no subluxation CE
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Case -2
Irtiza
2 yr old
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Case-3
Alia
2 yr old
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Case- 4
Faiza
2 yr old
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Suggestion
Radiologist
Pediatrician
Gynecologist
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THANK YOU
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Ul d
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Ultrasound
Alpha > 60Slope of osseus
acetabulum
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