CDH - Congenital Dislocation of the Hip: Mamoun Kremli, Professor/Consultant Pediatric Orthopedics

1. بسم الله الرحمن الرحيم

2. CDHCongenital Dislocation of the Hip Mamoun Kremli Professor / Consultant Pediatric Orthopedics College of Medicine & King Khalid University Hospital

3. CDH • The most common disorder affecting the hip in children • Spectrum of diseases/abnormalities of the hip with different etiologies, pathologies, and natural histories affecting the proximal femur and acetabulum • Initial pathology is congenital, progresses if untreated. • Does not always result in dislocation.

4. CDHDefinition • A progressive deformation of previously normally formed structures during the embryonic period NOT A malformation arising during the period of organogenesis

5. CDHNomenclature • CDH Congenital Dislocation of the Hip • DDH Developmental Dysplasia of the Hip • CDH Congenital Dysplasia of the Hip • CHD Congenital Heart Disease !

6. CDH Spectrum • Teratologic Hip : Fixed dislocation Occurrs prenatally Often with other anomalies • Dislocated Hip : Completely out May or may not be reducible • Subluxated Hip : Only partially in • Unstable Hip : Femoral head can be dislocated • Acetabular Dysplasia : Shallow Acetabulu Head Subluxated or in place

7. CDHIncidence • Hip Instability at Birth : 0.5 – 1 % of infants • Classic CDH : 0.1 % of infants • Mild Dysplasia : Substantial Contributing to adult Osteoarthritis Up to 50 % of Hip Arthritis in Ladies Have underlying hip dysplasia

8. CDH Incidence

9. CDHEtiology Multi-factorial

10. CDHEtiology Physiologic Factors Ligament Laxity : Hormonal : ( Estrogen, Relaxin) Females Familial hyper laxity : mild - moderate - Ehler Danlos ADD Picture of knee hyperextension

11. CDHEtiology Genetic Factors • Gender :Female Most studies: Females > 4-6 X than males • Twin studies: Monozygotic 38 % Dizygotic 3 % (similar to siblings)

12. CDHEtiology Family Incidence and Genetic Counselling

13. CDHEtiology Mechanical Factors Prenatal : - Breech position - Oligohydramnious - Primigravida - Cong. Knee recurvatum/dislocation - Metatarsus adductus - Torticollis Postnatal : - Swaddling / Strapping – Knees extended

14. CDHEtiologyMechanical Factors • Breech Presentation : Normally 2 –4 % CDH 16 % The Breech positionIn Utero Extended knees and flexed hips

15. CDHEtiologyEnvironmental & Mechanical Factors • Swaddling / strapping ( Mihad ): Knees extended & Hips adducted • Proven experimentally • Proven statistically • American Indians. • Eskimos, and • Saudi Arabia • Mechanics • Hip adduction and extension

16. CDHPatients At Risk • Positive Family History : increases risk 10X • A baby girl : increases risk 4-6 times • Breech Presentation : increases risk 5-10 X • Torticollis : CDH in 10-20 % cases • Foot Deformities : ( calcaneovalgus & metatarsus adductus) signs of intrauterine crowding • Knee Deformities : ( hyperextension & dislocation ) associated with Teratologic type

17. CDH Risk FactorsWhen Risk Factors Are Present • The infant should be examined repeatedly • The hip should be imaged ( by U/S or X-ray )

18. CDHNeonatal Examination The infant should be quiet and comfortable

19. CDHNeonatal Examination LOOK : • External rotation attitude • Lateralized contour • Wide perineum • ( in bilateral )

20. CDHNeonatal Examination LOOK : • Asymmetric thigh folds anterior posterior

21. CDHClinical Examination • Look : Shortening ( not in neonates ) -in supine - Galeazzy sign

22. CDHNeonatal Examination FEEL : • Empty groin • Weak Femoral pulse

23. CDHNeonatal Examination MOVE : • Hip instability in early infancy • Limited hip abduction in flexion - later (careful in bilateral) if <600 on both sides: request imaging

24. Cerebral palsyClinical AssessmentHip Flexion Deformity SPECIAL : • Loss of fixed flexion deformity of hips ( early infancy ) • Normally FFD newborn 28o at 6 weeks 19o at 6 months 7o Thomas Test FFD Normal No FFD ?CDH

25. CDHNeonatal ExaminationOrtolani Feel a Clunk Not hear a click !

26. CDHNeonatal ExaminationBarlow

27. CDHNeonatal ExaminationOrtolani / Barlow clunk Ortolani Barlow

28. CDHNeonatal ExaminationOrtolani / Barlow Ortolani Barlow

29. CDHNeonatal ExaminationHamstring Stretch Sign • Flex hip and knee 900 each. • Keep hip flexed and gradually extend the knee • Normally a resistance is felt towards the end of knee extension (caused by the hamstrings which are pulled from both ends) • In cases of CDH, no resistance is felt (when the hip is dislocated, the origin of the hamstrings are not pulled by hip flexion)

30. CDHNeonatal ExaminationHamstring Stretch Sign

31. CDHClinical Examination • Neonate (up to 2-3 months) : - Instability/ Ortolani-Barlow - Thomas test • Infant ( > 2-3 months) : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign • Toddler : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign • Walking : - Trendelenburgh - Hamstring stretch sign

32. CDHClinical Examination

33. CDHClinical Examination

34. CDHClinical ExaminationThe Walking Child • Trendelenburgh: unilateral / bilateral (waddling)

35. CDHScreening Program • Clinical screening proven to be effective • Performed by Trained personnel • Must be DYNAMIC with periodic examination till walking • Adjunctive use of U/S controversial

36. CDHUltrasound Screening • Incidence of hip instability declines rapidly to 50 % within the first week of neonatal life • Better to delay U/S screening

37. CDHUltrasound Screening • Early U/S screening not recommended • Delayed U/S screening : -Older than 6 weeks -Those at risk only - by History Clinical exam

38. CDHUltrasound Referral • If hip normal : no need • If hip clearly unstable : no need • If suspicious : U/S appropriate • If at risk factors : U/S appropriate

39. CDHUltrasound • Too sensitive detects a lot of hip anomalies most of which would develop normally • Operator dependant Static Vs Dynamic

40. CDHRadiography • Early infancy : not reliable • By 2-3 months of age : reliable AP view - neutral position - draw reference lines - acetabular index - in early infancy < 30o : normal 30o – 40o : questionable > 40o : abnormal Von Rosen view : 45o abduction

41. CDHRadiography

42. CDHRadiography

43. CDHRadiography

44. CDHRadiography in out out in Von Rosen view

45. CDHRadiography 39o 27o

46. CDHRadiography out in

47. CDHTreatmentAims • Obtain and Maintain concentric reduction • In an Atruamatic fashion • Without disrupting the blood supply

48. CDHTreatment • Method depends onAge • The earlier started, the easier the treatment • The earlier started, the better the results • Should be detected EARLY

49. CDHTreatment • Birth to 6 months : Pavlik harness or hip spica cast • 6 months – 12 months : closed reduction UGA and hip spica casts • 12 months – 18 months : possible closed / possible open reduction • Above 18 months : open reduction and ? Acetabuloplasty • Above 2 years : open reduction,acetabulplasty, and femoral osteotomy • Above 8 years : open reduction,acetabulplasty cutting three bones, and femoral osteotomy

50. CDHTreatmentHip instability in the neonatal period Most resolve spontaneously • Observation • Pavlik harness • Double /triple diapers ??