8/8/2019 DDH ortho. 01-01-2011

1/62

Aleppo is the Capital of Islamic Culture 2006 www.aleppo-cic.sy

Aleppo Castle

8/8/2019 DDH ortho. 01-01-2011

2/62

IMAGINGand

DEVELOPMENTAL DYSPLASIA OF THE HIP

(DDH)01 Jan 2011

Dr. Abdulmonhem OBAIDEENSenior Consultant Radiologist

NWAFH

KSA

TABUK

8/8/2019 DDH ortho. 01-01-2011

3/62

DDHTerminology

DDH Developmental Dysplasia ofthe Hip

-The dislocation is notalways congenital (CDH)it can be acquired.

-Acetabular deformity due to disruptedrelationship between femoral headandacetabulum

8/8/2019 DDH ortho. 01-01-2011

4/62

DDHDefinition:

DDH: a spectrum of disorders affecting the acetabulumand proximal femur (so hips are):

Subluxatable:femoral head beingable to move within the acetabulum

Dislocatable:femoral head beingable to move outside the acetabulum

Dislocated:femoral headbeing outside the acetabulum

8/8/2019 DDH ortho. 01-01-2011

5/62

DDHEtiology

A-Late Intrauterine event(98%

)a-Mechanical:

-Oligohydramnios (restricted space)

-Firstborn 60% (tight maternal musculature)

-Breech 30-50%while only 2-4% deliveries are breech(hip hyperflexion)

b-Physiologic:-maternal estrogen-pregnancy hormone relaxin

B-Teratology (2%) due neuromuscular disorders

C-Postnatal onset (

8/8/2019 DDH ortho. 01-01-2011

6/62

DDHPresentation:

Early: usually withan instable ordislocatable hipat birth or inthe neonatalperiod

or

Late: usually withadislocatedhip after sixmonths ofage

8/8/2019 DDH ortho. 01-01-2011

7/62

DDHIncidence

Significant DDH = 1-2 per 1000 live births

Unstable hips at birth = 5-20 per 1000

F:M = 7:1

Lefthip > righthip

8/8/2019 DDH ortho. 01-01-2011

8/62

1:100 instability

1:1000 Dislocation

1:5000 at 18-months of age

8/8/2019 DDH ortho. 01-01-2011

9/62

DDHIncidence cont.

More common if:Female Breech --------------

First born ----------- (decr. intrauterine space) Oligohydramnios --

Family History (firstdegree)

8/8/2019 DDH ortho. 01-01-2011

10/62

DDHPathogenesis

Excessive capsular laxity & a shallow acetabulum at birthare the primary initiating factors.

Femoral head: - femoral headandneck remainantevertedand inthe valgus position

Hip joint fills with fibro-fatty debris knownas pulvinar Acetabular labrum - becomes enlarged;- may infold into

joint (inverted limbus); - limbus blocks reduction of

femoral head; Acetabulum - becomes flattened (dysplastic) because it is

not stimulated to develop aroundthe absent ordisplacedfemoral head

8/8/2019 DDH ortho. 01-01-2011

11/62

DDH

Pathogenesis cont.

Ligamentum teresbecomes lengthened, hypertrophic &redundant

Capsule ofhip joint becomes expanded

Muscles - crossingthe hip joint (hamstring,hip adductors,& psoas) become shortened and contracted

8/8/2019 DDH ortho. 01-01-2011

12/62

DDH

8/8/2019 DDH ortho. 01-01-2011

13/62

DDHNatural History

90% ofunstable hips stabilize by 9 weeks of age.

The maximum remodeling ofthe acetabulum occurs belowthe age of18 months.

Inadislocatedhip the affectedleg will become shortenedandthis will put pressure onthe back, increasingthe risk of

osteoarthrosis to the back. The false acetabulum is smaller thanatrue acetabulum will

develop osteoarthritisbetween 20-60 years ofage ifnottreated.

8/8/2019 DDH ortho. 01-01-2011

14/62

Noria (Hama)

8/8/2019 DDH ortho. 01-01-2011

15/62

DDHDIAGNOSIS Clinical

Early:

Barlows(dislocataBle)

Ortolani's (Out) Accurate withinthe first 48 hours andthen may become

increasingly inaccurate.

90% Specificity & 60% Sensitivity

8/8/2019 DDH ortho. 01-01-2011

16/62

DDHClinical

Late:

usually presents withlimited abduction anda legdiscrepancy.

At walkingage,they may have a limp.

Asymmetrical skin folds are notanaccurate clinical

sign Galeazzi sign - shorteraffected side

seen when knees & hips flexed

8/8/2019 DDH ortho. 01-01-2011

17/62

DDHDIAGNOSIS

IMAGING

Ultrasound

Radiography

Arthrogram (evaluation of reducibility)CT (evaluation of reduction)MRI (non-locatable & complications)

8/8/2019 DDH ortho. 01-01-2011

18/62

DDHUltrasound

Advantages:

Gives accurate diagnosis of dislocation, dislocatabilityand dysplasia.

The cartilage can be visualized, the morphology of the

acetabulum determined, and the stability of the hipassessed

More accurate than radiographs under the age of sixmonths.

Non-invasive

Reduces the need for arthrograms.

8/8/2019 DDH ortho. 01-01-2011

19/62

8/8/2019 DDH ortho. 01-01-2011

20/62

Umayyad Masjed Damascus

8/8/2019 DDH ortho. 01-01-2011

21/62

DDHUltrasound

A. Static - Graf (1984) mid-coronal scan of hip joint.

The straight line of the iliummust be viewed to ensure thatthe scan plane is through thecentre of the acetabulum.

Alpha angle = between line ofilium & bony acetabulum

Beta angle (less important) =between line of ilium &anterior labrum

8/8/2019 DDH ortho. 01-01-2011

22/62

DDH

Alpha angle

Iliac wing

ischium

Femoral head

8/8/2019 DDH ortho. 01-01-2011

23/62

DDH

Beta angle

Iliac wing

ischium

Femoral head

8/8/2019 DDH ortho. 01-01-2011

24/62

DDHDescriptionAlpha

angle

Type

normal>60 1

Delayed ossification in a child > 3

months, Physiological if< 3 months

43-592

dislocated

8/8/2019 DDH ortho. 01-01-2011

25/62

Type 1 is a mature hip with >60.It is divided into two subgroups:Type 1a, with angle >55;and

Type 1b with angle

8/8/2019 DDH ortho. 01-01-2011

26/62

Inthe Type D hip,the angle is inthe same range as inthe Type 2c hip;however,the Type D is decentered,andhas a angle >77.

*Type 3 andType 4 hips are bothdecenteredhips, with 77 in each.Determination ofthe position ofthe cartilaginous roof is crucial fordifferentiation ofType 3 and 4, which is

pushed cranially inType 3 hips,andpushed caudally inType 4 hips.

*Type 3 hip is furtherdivided into two subgroups accordingto the echogenicity ofthecartilaginous roof.InType 3ahips,the roof is hypoechoic, whereas intheType 3b hip,the hyaline cartilage is deformed,andappears hyperechoic.

Grafs classification cont.

8/8/2019 DDH ortho. 01-01-2011

27/62

DDH

Iliac wing

ischium

Femoral head

8/8/2019 DDH ortho. 01-01-2011

28/62

DDH

Iliac wing

ischium

Femoral head

8/8/2019 DDH ortho. 01-01-2011

29/62

DDH

Iliac wing

ischium

Femoral head

8/8/2019 DDH ortho. 01-01-2011

30/62

DDHUltrasound

B. Dynamic - Harcke etal. (1984)

Baby lying on his side - perform a visual

Barlow and Ortolani tests whilescanning in the coronal plane on the

femoral neck.

8/8/2019 DDH ortho. 01-01-2011

31/62

DDH

8/8/2019 DDH ortho. 01-01-2011

32/62

Located (normal) hip >>> ? Dislocatable or not

8/8/2019 DDH ortho. 01-01-2011

33/62

8/8/2019 DDH ortho. 01-01-2011

34/62

Dislocated hip>>> ? Locatable (reducible) or not

8/8/2019 DDH ortho. 01-01-2011

35/62

8/8/2019 DDH ortho. 01-01-2011

36/62

8/8/2019 DDH ortho. 01-01-2011

37/62

8/8/2019 DDH ortho. 01-01-2011

38/62

8/8/2019 DDH ortho. 01-01-2011

39/62

8/8/2019 DDH ortho. 01-01-2011

40/62

8/8/2019 DDH ortho. 01-01-2011

41/62

8/8/2019 DDH ortho. 01-01-2011

42/62

neutral add

abd

8/8/2019 DDH ortho. 01-01-2011

43/62

neutral

add

abd

8/8/2019 DDH ortho. 01-01-2011

44/62

DDHFrankdislocation (luxation)

Partial dislocation (subluxation)

Instability (the femoral head comes inandout ofthe socket)

Acetabularabnormalities (inadequate

formation ofthe acetabulum)

8/8/2019 DDH ortho. 01-01-2011

45/62

1. We should perform adynamic study with stress maneuvers on every hip that ismorphologically normal.

2. Hips thatare morphologically normal and stable indynamic study are consideredto besonographically normalanddo not require follow-up US.Follow-up clinical examinations untilone year ofage are recommended inthese cases (5, 9).

3. Detection of instability inType 1 orType 2ahips (whichhas an incidence of 8.42% inthepresent study) does not indicate anabnormality that requires immediate treatment.Suchhipsshouldhave follow-up US examinations until they become stable accordingto the dynamic study.

4.In orderto minimize the number oflate DDH cases, persistent instability ofthe hip evenwithnormal morphology should be followed by US.

Comparison of morphologic anddynamic US methods in examination ofthe newbornhip

Pnar Koar, ElifErgun, Dilek nlbay,Uur KoarDiagnInterv Radiol 2009; 15:284289

8/8/2019 DDH ortho. 01-01-2011

46/62

DDHRadiographs

8/8/2019 DDH ortho. 01-01-2011

47/62

DDH Shentons line (broken)

Hilgenreiners & Perkins (the femoralhead should be inthe inner & lowerquadrant ifnormal)

The Acetabular Index (below 30 degreesatthe age ofone year)

Radiographs

8/8/2019 DDH ortho. 01-01-2011

48/62

DDHRadiographs

Shentons line

Perkins

Acetabular Index

8/8/2019 DDH ortho. 01-01-2011

49/62

8/8/2019 DDH ortho. 01-01-2011

50/62

C T Scan

Palmyra

8/8/2019 DDH ortho. 01-01-2011

51/62

8/8/2019 DDH ortho. 01-01-2011

52/62

3 M. old US: dislocated non-locatable Lt. hip

Lost of F up and came after 6 M.

abd

neutral

abd

neutral

8/8/2019 DDH ortho. 01-01-2011

53/62

US: Lt. dislocated partially locatable

US: Rt. dislocated non-locatable

neutral

abd

neutral

abd

With good management ,excellent result

8/8/2019 DDH ortho. 01-01-2011

54/62

Intra-articular contrast outlines thecartilaginous acetabular roofs, whichare

medial to the femoral heads (white arrows),andthe left iliopsoas tendon(black arrows).Asterisk, labrum.

Althoughthe ossifiedacetabular roof is steep,intra-articular contrast outlines the normalcontour ofthe cartilaginous femoral head,which is contained by the cartilaginous labrum(asterisk) duringabduction

8/8/2019 DDH ortho. 01-01-2011

55/62

Coronal T2-weightedMRI of rightdevelopmental dysplasia ofthe hip (DDH) withdislocation

8/8/2019 DDH ortho. 01-01-2011

56/62

DDH

Conclusion

Ultrasonography of all newborns is notrecommended

Its advised if:

-below age of 6 months

-baby with a risk factor (Girl, firstborn,positive F/H of DDH and Breech )

-follow up treatment

8/8/2019 DDH ortho. 01-01-2011

57/62

DDH(AMERICAN ACADEMY OF PEDIATRICS) advise

For early detection of DDH includes the following:

-Screenall newborn hips by physical examination.

-Examine all infants hips accordingto a periodicityschedule and follow-up until the child is an establishedwalker.

-Record anddocument physical findings.-If physical findings raise suspicion of DDH, or if parental

concerns suggesthip disease, confirmation is required byexpert physical examination, referral to anorthopaedist,or by anage-appropriate imaging study.

8/8/2019 DDH ortho. 01-01-2011

58/62

AMERICAN ACADEMY OF PEDIATRICS

Committee on Quality Improvement,Subcommittee on Developmental Dysplasia ofthe Hip

8/8/2019 DDH ortho. 01-01-2011

59/62

8/8/2019 DDH ortho. 01-01-2011

60/62

DDH

Althoughultrasonography is widelyavailable, obtainingaccurate results in

imagingthe hip requires trainingandexperience (butall US procedures are !!!)

The Ultrasound is operator dependent

8/8/2019 DDH ortho. 01-01-2011

61/62

The Ultrasound is operator dependent

sunrise

sunset

8/8/2019 DDH ortho. 01-01-2011

62/62

Bon Apetit, Nice GALA,