ddh treatment - pf
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Developmental Dysplasia of the Hip
(DDH) : Treatment
GROUP I: IH / RR / DW / NR / PF
Introduction
The Term DDH is more likely than CDH (congenital Dysplasia of the Hip)
Girls are affected 5 times more than boys.The left hip is affected in 45%, right one 20% and
35% of the cases are bilateral.Two facts about DDH:
1) not all hip dislocation are present at birth. But they all occur before the age of 3 months2) newborns have hypotonic muscles in the 1st 6 wks till 3 months so not all cases of DDH can be diagnosed at that time.
Etiology
Generalized relaxation of the hip joint.
- Genetics- Hormonal Factors- Intrauterine Malformation- Postnatal factors
X-ray
Acetabular index: angle between horizontal line of
hilgenreiner and the line between the two edges of the acetabulum.
normal hip 20º30 dislocated or dysplastic hip ≥ 30ºShenton’s line: semicircle between femoral neck and
upper arm of obturator foramen, in dislocated hip this line is broken.
TREATMENT
The earlier the better.Best time for treatment is in newborn period.It depends on the device and age of the
patient.Goal is to:1.Flex and abduct hips.2.Reduce femoral head and maintaining it.
TREATMENT
From (1-6 months) use Pavlik Harness.From 6 months – 18 months use hip spika.From 18 months - 4 years : traction , adductor tenotomy , surgical
closed reduction, salter innominate osteotomy.
Treatment Options
Age of patient at presentationFamily factorsReducibility of hipStability after reductionAmount of acetabular dysplasia
Birth to Six Months
Triple-diaper techniquePrevents hip adduction“Success” no different in
some untreated hipsPavilk harness (1944)
Experienced staff*Very successfulAllows free movement
within confines of restraints
*posterior straps for preventing add. NOT producing abd.
Birth to Six Months
Pavlik harness
IndicationsFully reducible hip*
Child not attempting to standFamily
•Close regular follow-up (every 1-2 weeks)•For imaging and adjustments
•Duration•Childs age at hip stability + 3 months
Pavlik Harness
Complications
Avascular necrosisForced hip abductionSafe zone (abd/adduction and flexion/extension)Femoral nerve palsyHyperflexion
*Be aware of Pavlik Harness Disease*Follow until skeletal maturity
Birth - Six months
Closed reduction + SpicaFailure after 3 weeks of Pavlik trial
Birth - Six months
Closed reductionGeneral anesthesiaArthrogramSafe zone - avoid AVN -/+adductor tenotomyOpen reduction if concentric reduction not possible
Usually teratogenic hips in this age group
6 months – 18 months
Present a more difficult problemProlonged dislocationContracted soft tissues
6 - 18 monthsClosed reduction +/- adductor tenotomySpica in human position of 100 degrees of flexion
and about 55 degrees abduction (3 months)Abduction Orthosis 4 wks full time/4 wks
nighttimeOpen reduction (if closed fails)
CapsulorraphyCT scanSpica for 6 wks followed by PT
18 months - 4 years
Closed reductionReducibile - check arthrogram and medial dye poolIrreducible - Open reduction
Open reductionTight - femoral shorteningStable - +/- pelvic osteotomy
Femoral Shortening
Schoenecker + Strecker 1984Traction vs. Femoral shortening56% AVN in traction group0% AVN in femoral shortening
Pelvic Osteotomy
1 )Persistent instability + dysplasia after open reduction + femoral shortening
2 )Requires concentric reduction of a reasonably spherical femoral head
3 )Usually based on surgeon preferenceSalter and Pemberton
Pelvic Osteotomy
Volume changing
Pemberton Hinges on triradiateRequires remodeling of “new” incongruityProvides more anterolateral coverage
Pemberton
Pelvic Osteotomy
RedirectingSalter
Osteotomy thru sciatic notchHinge thru pubic symphysis
Triple innominateGanzDial
Salter Osteotomy
Salter Osteotomy
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