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 laxity Acetabular 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

False acetabulum Arthrogryposis with dislocations & delivery fracture

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

Ultra Sound !

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 role practitioner & orthopaedic team working

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 with trochanteric overgrowth Better in adduction and flexion

Neck-shaft angle after femoral osteotomy

Pelvic operation Re-alignment Re-shaping : Augmentation : simple e.g. Salter complex e.g. Bernese e.g. Pemberton : e.g. shelf Chiari

Salter Innominate osteotomy

Salter & femoral osteotomy K. E. 21 - 12 - 1999

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)

Very late salvage Schanz osteotomy

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