Transcript ANATOMIC HIP AND KNEE CONDITIONS

DR. MOSI
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DDH
Coxa vara
Genu valgum
Genu varus
Genu recarvatum
Spectrum of disorders including :
 Acetabular dysplasia
 Instability (dislocation and subluxation)
 Teratological malarticulation – dislocation in utero ,
irreducible at birth , pseudoacetabulum and associted
with neuro muscular conditions eg arthrogyposis
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Left > right
Females > males at 7:1
20 % bilateral
At birth dislocation is 1:1000 and dysplasia
1:100
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Genetics
 Generalized joint laxity – dominant
 Shallow acetabular – polygenic
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Hormonal factors
 High levels of progesterone and relaxin in last days of
pregnancy hence ligament laxity
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Intrauterine malposition
 complete breech, oligohydraminos,packaging deformities
( congenital muscular torticollis, metatarsus adductus,
congenital knee dislocation
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Postnatal factors
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Initial instability leads to dysplasia
Normal acetabulum but lax capsule
Changes in the acetabulum and femoral head
occur from the instabilty but some from
primary acetabular and femoral head
dysplasia
Dislocation is posterolateral then
superolateral
Cartilagenous head of normal size but
nucleus appears late
Shallow anteverted socket
Stretched capsule
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Elongated and hypertrophied ligamentum
teres
Superior limbus and capsule pushed into
socket
On weightbearing above changes worsen
False socket is created
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Idelly diagonised at birth
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Barlows test
Ortolanis test
Galeazzis test
limited abduction
clicking hip
asymetry in skin folds – thigh gluteal labial
trendelenburg gait , waddling gait
Ludolfs sign
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Radiographs useful at 4-6 months after head
begins to ossify
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Helgenreiners line
Shentons line
Perkins line
Acetabular index
Center edge angle of wiberg
Ce 20 -25. ai- 30 20 <20
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Ultrasound
 Dynamic ( Hacke) and static (graf)
 Useful before head ossification
 Alpha angle : lines along bony acetabulum and ilium
( >60)
 Beta angle : line along labrum and ilium (<55)
 Use in high risk group or in positive physical findings
 Monitoring of treatment
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Confirmation after closed reduction
Identification of possiblle blocks:
◦ Inverted labrum
◦ Inverted limbus
◦ Hour glass appearance
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CT Scan : study of choice
MRI : significant role
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Abduction splinting
Pavliks harness , Von rosens
< 6months
Contraindicated in teratological hip
Requires normal muscle function for successful
outcome
◦ Complications
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 Avn
 Skin breakdown
 Brachial plexus injury
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6 – 2yrs
Failure of pavlicks harness
Traction may be applied prior
Under anaesthesia or gradually over about
three weeks
60 flexion, 40 abduction, 20 internal rotation
At 6 weeks convert to splint that prevents
adduction
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obstacles to reduction
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ligamentum teres,
the transverse acetabular ligament,
the constricted anteromedial joint capsule
, an inverted and hypertrophied labrum
degree of anteromedial hip capsular constriction
Shortened iliopsoas and adductors
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> 2YEARS or in failed closed reduction
between 6 mnths and 2 years
Anatomic changes such as anteversion and
coxa valga
Traction preop may help
Hip spica for three months the splinting
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Older children
Severe dysplasia with marked acetabular
changes
Reduced potential of acetabular remodeling
Dega, ganz, permbenton
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Avascular necrosis
Seen in all treatment forms
Escessive forceful abduction
Late surgery
dx. By late appearance of ossification center
Broadening of femoral neck or fragmentation
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Failed reduction and recurence
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Reduction in neck shaft angle <120
160 at birth
125 by adulthood
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Developemental
Congenital
Dysplastic
Acquired
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Physis
Metaphysis
Subtrochanteric
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Associated with congenital short femur and
proximal femoral deficiency
Unilateral
Subtrochanteric
Ass with retroversion of femur and out toeing
High propensity of progression
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Onset of ambulation, trendelenburg gait
usually noted
Defective endochondral ossification
posteromedialy (physeal defect)
Pathognomonic sign is a inferoposterior
metaphyseal fragment
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Underlying bone anomaly eg rickets, fibrous
dysplaia
Usually bilateral
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Commonly due to
 Trauma
 Infection
 iatrogenic
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Results in increasing limb length discrepancy
and abductor weaknes
Clinical features
 Painless limp – waddling or trendelenburgs gait
 Limb length desripancy
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Developemental :Hilgenreiner epiphyseal
angle > 60 - all progress. 45 – 60 may or
may not progress. < 45 often correct
spontaneously
Dysplastic and acquired unpredictable
Traumatic may resolve due to remodelling
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Halting deformity progression – investigate
and treat renal osteodystrophy , rickets etc
Correct proximal femoral anatomy :
 Poximal valgus osteotomy
 Trochanteric
 Subtrochanteric
 Greater trochanter epiphysodesis
 Greater trochanter transfer
Pauwels Y-SHAPED OSTEOTOMY, Langenskiöld intertrochanteric
osteotomy, BORDEN SUBTROCHANTERIC OSTEOTOMY
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Averages 40 at birth but decreases to about
10 -15 in adults.
about 5 more in females
Idiopathic or associated with other hip
disorders eg sufe ddh cp dcv
In toeing gait but this usually resolves
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Cosmesis
Anterior knee pain due to patellar
malalignment
• Observation
• Rotational osteotomy
 Rarely indicated ( most children have no functional
deficits)
 Child over 10 – 12 years with internal rotation of > 80 and
external rotation of <10
 Intertrochanteric vs mid-diaphysis
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Physiologic – usually <2 years and bilateral)
Pathologic – trauma , infection, rickets,
dysplaisia of bone ,blounts disease,
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>2years
Unilateral
Severe
Associated shortening
Obesity
10m-15
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Cosmesis
Patellofemoral instability/ maltracking
Altered gait - lateral thrust, circumduction
Early walkers – genu varum
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Determine severity
Site :
 Intermalleoar distance and intercondylar distance
 Metadiaphyseal angle
 Langenskiold classification of tibia vara
 distal femur vs proximal tibia
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Likelihood of progress
 is the cause permanent eg epiphyseal bar, achondroplasia,
osteochondroma
 BMI >22
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Full length standing
Line should bisect knees
Md 11, 11 - 16
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tibia vara or osteochondrosis deformans of
the proximal tibia
Impaired ossification medial proximal tibia
Hueter volkamn effect
Infantile
Juvenile
Adolescents
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Observation
Bracing – children less than 2 yrs with early
blounts ( stage 1 and 2)
Guided growth
 Hemiepiphysiodesis on convex side using screws, staples,
tension band paltes
 In the past relied on growth charts
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Corrective osteotomy ( acute vs gradual
correction using an ilizarov )
 Blounts – before 4 yrs and at stage 1 or 2( surgery differs for
3&4,5&6)
 Children near maturity
 Permanent physeal issue
Mechanism
 Laxity of posterior capsule
 Abnormal inclination of tibia articular surface
 Usually 14+/- 3.6 posterioly. Forward tilt if the anterior
physis is damaged
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Observation – hypermobile, (10 -15 )
Bracing
 Prevents hyper extension
 Can result in stiff knee
 Ankle orthosis holding at 5-10 shown to prevent recarvatum in
cerebral palsy
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Anterior wedge osteotomy
Poserior closed wedge osteotomy
Flexion supracondylar osteotomy of femur
Gradual correction using an external fixator
Epiphysiodesis :
 When secondary to physeal damage
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Reefing of the posterior capsule of the knee
joint
Anterior patellar block
Quadriceps lengthening
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