Michael Albert, MD Bio: Chief of Orthopaedics, Dayton Children’s Hospital Attended Wright State University School of Medicine Expertise in spinal deformity “I went to medical school thinking I wanted to become a pediatrician, but once I did surgery and orthopedics, I decided to combine my dedication and love of children's health with orthopedic surgery.”

hip disorders from birth to maturity 22nd annual pediatric orthopaedic symposium hip disorders from birth to maturity developmental dysplasia of the hip Michael C. Albert, M.D. Chief of Orthopaedics Dayton Children’s Hospital September 27, 2019

disclosure I have no disclosures related to the following topic.

case presentation 13 month old female presents with Limb Length Inequality Mother’s first baby Full term, vaginal delivery No breech presentation AP 3/21/2017

treatment Open reduction Anterior approach Adductor and iliopsoas tenotomy Spica cast 4/18/17

3/19/2019

DDH Spectrum of abnormalities of the growing hip “Immature hip” Dysplasia (malformed anatomy) Subluxable hip Dislocatable hip Reducible hip dislocation Chronically subluxed or dislocated hip Disruption of normal tight fit between the femoral head and acetabulum Growth and development of acetabulum depend on femoral head within 10/1000 positive physical exam, 1/1000 dislocated hip

DDH Etiology multifactorial Risk factors Mechanical (breech) Genetic (family history) Hormonal (female) Risk factors Left hip 80% of patients (40% on right) Female 80% of pts Family history 1.5X risk Breech 7X risk Others: firstborn, prematurity, oligohydramnios, torticollis, metarsus adductus

detection and screening Physical exam All newborns Ortolani, Barlow, Galeazzi Positive exam (clunk, asymmetry) should be referred to orthopaedic surgeon with or without ultrasound Equivocal exam (click, mild asymmetry) re-examine at 2 weeks Hip clicks do not correlate with hip dysplasia If exam at 2 weeks negative or equivocal, consider risk factors Older child (>3 months) Asymmetric/decreased abduction Galeazzi sign, asymmetric skin folds, Abductor lurch

detection and screening Physical Exam - Bilateral Dislocation Limited Abduction Wide Perineal Space Prominemt Gr. Trochs. Lumbar Lordosis Waddling Gait Broad Flat Buttocks 12

imaging Plain Radiography Ultrasonography Arthrography CT SCAN/MRI Michael C. Albert, MD 14

ultrasound All aspects of use in hip dysplasia controversial High inter and intra-observer variability Excessive sensitivity Uncertain natural history Static and dynamic exam Static coronal exam for coverage and angle Dynamic transverse exam for subluxation

ultrasound Screening of all newborns not recommended Most sensitive test As many as 21 percent of newborns with normal physical exam have abnormal ultrasound Cannot differentiate between immaturity and early DDH

ultrasound recommendations Ultrasound recommended for equivocal exam or patients risk factors Females with family history (44/1000) Males and females with breech presentation (26/1000 and 120/1000) Screening at 6 weeks of age Monitor treatment

natural history Newborn natural history is variable DDH Many patients improve spontaneously DDH Not painful during childhood May have little or no functional disability Does not delay development Not worsened by parent behavior or positioning Swaddling in extension

natural history Hip pain and early degenerative hip disease in adulthood 20-50% of hip DJD

treatment Goal: obtain and maintain reduction of femoral head to promote normal development of the hip and reverse pathologic changes Acetabulum and femoral head remodel for many years after reduction Early treatment  more potential for remodeling  better anatomic result  lower risk of DJD No treatment option is entirely benign Avascular necrosis of the hip Poor natural history

pathological findings Birth: Minimal Continued Dislocation: Soft Tissue Contracture Deformation of Head/Acetabulum Inverted Labrum Constriction Inferior Capsule 15

treatment guidelines Acetabular dysplasia: Treatment controversial May improve or resolve Newborn: mild dysplasia or “immaturity” resolve in greater than 95% of patients Remodeling possible in young child Uncertain risk of DJD Should at least be observed: some will go on to subluxation or dislocation

treatment guidelines Subluxation and Dislocation 0-6 months: Pavlik harness/abduction brace 6 months – 2 years, failed bracing: closed reduction, possible open reduction > 2 years: open reduction >3 years: open reduction with femoral and pelvic osteotomy Persistent subluxation or dysplasia after reduction Pelvic/acetabular osteotomy

Pavlik Harness Prevents Hip Extension, Adduction Dynamic Splint Flexion Straps 100-110 Degrees Abduction Straps 45-60 Degrees Confirm Reduction by U.S. Do Not Use Over 3 wks if Irreducible

Pitfalls in the Use of the Pavlik Harness for Treatment of CDH Mubarak, et al JBJS 1981 21

Pavlik Harness Contraindications Teratologic Arthrogryposis Spina Bifida Ehlers-Danlos Poor Family Dynamics Age Over 9 mos. 22

success with Pavlik >95% in Newborn 85% in 1 - 5 mos. 50% in 6 - 9 mos. 23

summary Developmental dysplasia of the hip is a spectrum of abnormalities of the growing hip Dysplasia  Subluxation  Dislocation Natural history: hip pain and DJD in early adulthood All newborns screened with physical exam Early detection  early reduction  hip remodeling  better results Early recognition also allows simpler treatment

Thank you!