CDH Congenital Dislocation of the Hip بسم الله الرحمن الرحيم CDH Congenital Dislocation of the Hip Prof. Mamoun Kremli AlMaarefa College

Spectrum of diseases Abnormality of proximal femur and acetabulum Initial pathology is congenital, but Progresses (becomes worse) if not treated Does not always result in dislocation

Nomenclature CDH: Congenital Dislocation of the Hip DDH: Developmental Dysplasia of the Hip CDH: Congenital Dysplasia of the Hip CHD: Congenital Heart Disease!

CDH - Spectrum Acetabular dysplasia: Unstable hip: Dislocated hip: Shallow acetabulum Unstable hip: Dislocatable - Reducible Dislocated hip: May or may not be reducible Teratologic hip: Fixed dislocation at birth, often with other major anomalies

Incidence Hip instability at birth: 0.5 – 1 % Classic CDH: 0.1% Mild dysplasia: Substantial Up to 50%of hip arthritis in ladies have underlying hip dysplasia

Incidence Area Incidence per 1000 Canadian Indians 188.5 Hungary 28.7 Uppsala, Sweden 20 USA Caucaseans Blacks 15.5 4.9 Malmo, Sweden 2.18 Chinese, Hong Kong 0.1 Bantus, Africa 0.0 among (16678)

Etiology Multi-factorial Ligament laxity Genetic Mechanical factors

Etiology 1. Ligament laxity Hormonal: Familial ligament laxity: Estrogen, Relaxin: hormones secreted by mothers before birth May affect baby girls more? – receptors Familial ligament laxity: Mild – Moderate – Sever Ehler Danlos Syndrome

Ligament laxity: hypermobile joints Etiology Ligament laxity: hypermobile joints

Etiology 2. Genetic factors Twin studies Monozygotic: 38% Dizygotic: 3% (similar to other siblings) Positive family history Females: 4-6 X more than males Could be hormonal – the effect of Relaxin hormone produced by mother on female fetus

Etiology 3. Mechanical factors Prenatal: Breach: Normally: 2-4% In CDH: 16% The breach position in utero: extended knees, and flexed hips cause dislocation of hip by ? stretch of Hamstring muscles

Etiology 3. Mechanical factors Postnatal: Swaddling / strapping hips adducted and extended, and knees extended المهاد – القماط – الزمام – الكوفلة

Etiology 3. Mechanical factors Postnatal: Swaddling / strapping hips adducted and extended, and knees extended Proven experimentally Proven statistically Mechanics

Infants at risk Positive family history: 10X A baby girl: 4-6 X Breach presentation: 5-10 X Torticollis: CDH in 10-20% of cases Foot deformities: Calcaneo-valgus and metatarsus adductus Knee deformities: hyperextension and dislocation (Teratologic)

Clinical Examination External rotation Short one side

Clinical Examination External rotation Short one side Lateralized contour Wide perineum In bilateral

Clinical Examination External rotation Short one side Lateralized contour Wide perineum In bilateral Asymmetrical folds Anterior - posterior

Clinical Examination External rotation Short one side Lateralized contour Wide perineum In bilateral Asymmetrical folds Anterior - posterior

Clinical Examination Shortening Might be difficult to detect early

Clinical Examination Limitation of hip abduction in flexion

Clinical Examination Limitation of hip abduction in flexion

Clinical Examination Limitation of hip abduction in flexion

Clinical Examination Special test – Hip Instability: Ortolani / Barlow Feel a Clunk, not hear a click!

Clinical Examination Ortolani / Barlow

Clinical Examination Special test – Hamstring Stretch Sign: Normally: Flex hip and knee 90o, and extend knee gradually Normally: feel resistance CDH: no resistance

Clinical Examination After walking age: Shortening – (if unilateral) Limping: Unilateral: limping Bilateral: waddling (like a duck)

Investigation: Radiology Early infancy: X-ray is not reliable – all cartilage Ultrasound is better

Radiology: X-ray After 2-3 months: more reliable 39o 27o

Radiology: X-ray After 2-3 months: more reliable out in

Radiology: X-ray After 6 months: reliable R hip out, and acetabulum open (dysplastic)

Treatment Method depends on age The earlier started, the easier it is The earlier started, the better the results are Should be detected EARLY

Treatment Birth – 6m 6-12 m: 12 - 18 m: 18 – 24 m: 2-8 years: Pavlik harness or hip spica cast 6-12 m: Closed reduction under GA and hip spica cast 12 - 18 m: Open reduction 18 – 24 m: Open reduction and Acetabuloplasty 2-8 years: Open reduction, Acetabuloplasty, and femoral shortening Above 8 years: Open reduction, Acetabuloplasty cutting all three pelvic bones, and femoral shortening No surgery One surgery Two surgeries Three surgeries Complex surgeries

Treatment: Neonatal Pavlik Harness Dynamic, effective, safe Keeps hips abducted and flexed – for 6 weeks

Treatment: 6-12 m Initially non-operative closed reduction UGA and immobilization in hip spica cast Position: Human Avoid sever abduction Avoid frog position Must obtain stable concentric reduction, otherwise needs surgery

Treatment: 6-12 m Initially non-operative closed reduction UGA and immobilization in hip spica cast

Treatment: 6-12 m Possibly closed reduction Possibly open reduction Stable and concentric reduction Possibly open reduction Unstable or un-concentric reduction Arthrography-guided

Treatment: 6-12 m Possibly closed reduction Possibly open reduction Stable and concentric reduction Possibly open reduction Unstable or un-concentric reduction Arthrography-guided

Treatment: 6-12 m Arthrography-guided Closed Reduction Well in Dislocated Not well in

Arthrography-guided Closed Reduction Treatment: 6-12 m Arthrography-guided Closed Reduction Too lateralized Acceptable

Treatment: 18-24 m Open reduction – surgery Acetabuloplasty - usually Maybe: Femoral shortening – if high

Treatment: Above 2 years Open reduction, and Acetabuloplasty, and Femoral shortening

Acetabuloplasties Many types

Salter’s Acetabuloplasty Operated hip Dislocated hip

Pemberton’s Acetabuloplasty need a lot of improvement in acetabular cover

Triple Steel Acetabuloplasty Osteotomy of: Ilium, Pubic, and Ischium Rotation of acetabulum 12 years old, Pain L hip L hip not well covered

Summary Complex multi-factorial, endemic disease Screening programs are needed to detect and treat cases early Learning proper examination methods Identify at risk groups Efficient referral system Proper management by specialized Drs

Summary - Infants at risk Positive family history: 10X A baby girl: 4-6 X Breach presentation: 5-10 X Torticollis Foot deformities Knee deformities