orthopedics cdh,perthes

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Disorders of the Hip in Childhood Types of hip diseases – disorders 1. Congenital 2. Acquired Posttraumatic(extremely rare in children) Non – traumatic abnormality of the hip joint due to changes in anatomy, ie. deformities (eg. coxa vara) Inflammatory disorders (eg. rheumatoid arthritis, tuberculosis,gout) leading to destruction of articular cartilage Avascular necrosis of femoral head (Gaucher’s disease, posttraumatic ) CDH – Congenital Dislocation of the Hip All degrees of displacement are included from subluxation to complete dislocation of hip joint Other term: congenital dysplasia of hip joint Incidence Incidence: 0,5% - frequent congenital anomaly (1/1000 neonates) Geographical incidence: highest in Middle- Europe and Japan , lowest in China and Black Africa Gender: male – female ratio: 1 - 6 Causal factors Genetic: joint laxity – dominant inheritrance, predisposes for CDH diagnosed within the 1st week of life Acetabular dysplasia – polygenetic inheritance, most cases are diagnosed in later life

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Orthopedics CDH,Perthes

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Page 1: Orthopedics CDH,Perthes

Disorders of the Hip in ChildhoodTypes of hip diseases – disorders

1. Congenital2. Acquired• Posttraumatic(extremely rare in children)• Non – traumatic abnormality of the hip joint due to changes in anatomy, ie. deformities

(eg. coxa vara)• Inflammatory disorders (eg. rheumatoid arthritis, tuberculosis,gout) leading to destruction

of articular cartilage• Avascular necrosis of femoral head (Gaucher’s disease, posttraumatic )

CDH – Congenital Dislocation of the HipAll degrees of displacement are included from subluxation to complete dislocation of hip jointOther term: congenital dysplasia of hip joint

Incidence• Incidence: 0,5% - frequent congenital anomaly (1/1000 neonates)• Geographical incidence: highest in Middle- Europe and Japan , lowest in China and Black Africa• Gender: male – female ratio: 1 - 6

Causal factorsGenetic: • joint laxity – dominant inheritrance, predisposes for CDH diagnosed within the 1st week of life• Acetabular dysplasia – polygenetic inheritance, most cases are diagnosed in later life

Environment:• Intrauterine malpositiion (breech position, with extended legs)• Postnatal: babies swaddled tightly with hips fully extended - rare, if babies are carried on

mother’s back with hips abducted

Page 2: Orthopedics CDH,Perthes

Forms of CDH according to etiology• Hip Dysplasy : acetabular hypoplasy• Generalised laxity: hip dislocates either in utero, or at delivery• Symptomatic dislocation of hip: part of other congenital anomaly - eg. Ehler- Danlos syndrome-

generalized joint laxity or arthrogryposis multiplex congenita – generalized stiffness of joints)• Secondary hip dislocation: due to neuro-muscular disorder of the infant

Types , degrees of CDH: dysplasia, subluxation, dislocation

Pathology of hip joint in CDHBony elements:• Acetabular hypoplasy (primary pathological factor)• Antetorsion of proximal femur - due to deficient anterior wall of acetabulum • Coxa valga – counterpressure of acetabular floor is missing , abnormal collo- diaphyseal angle is

resultedCollo –diaphyseal angle (α normally 135°) and torsion of femoral neck (β – normally ~ 40° at birth, 10 ° at adult age)

Page 3: Orthopedics CDH,Perthes

Blood supply of femoral head from below (from femoral artery) –abundant blood supply through ascending cervical arteries

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Blood supply of femoral head through lig.teres

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Pathology of hip joint in CDH: capsule hourgall shaped, thick labrum is interposed between head and acetabulum

Anatomical – pathological changes in CDH: hour glass shaped capsule, iliopsoas muscle in lateral position, compressing on joint capsule

Pathology of hip joint in CDHSoft tissue elements:• Capsule is hourglass in shape• Cartilaginous labrum (limbus) is too large and is folded into acetabulum• Ligamentum teres is too thick• Muscles arising from pelvis (m. iliopsoas, m. adductors) become shortened• Gluteus medius- minimus becomes insufficient

Page 6: Orthopedics CDH,Perthes

Symptomatology of CDH in neonate1. Suspicion: family history of CDH, problems with pregnancy2. Clinical signs: • assymetrical skin creases (thigh, gluteus), leg shorter, in slight external rotation • limitation of abduction (normal position of neonate: hip in 70 - 90º abduction („Lorenz-

position”), passive abduction is significantly limited (on one side)• Ortolani’s jerk of entry: pressure on femoral head in abduction - clunk as the dislocation

reduces• Barlow’s sign – femoral head reduced with thumb

Clinical signs: • assymetrical skin creases (thigh, gluteus), leg shorter, in slight external rotation

limitation of abduction (normal position of neonate: hip in 70 - 90º abduction („Lorenz-

position”), passive abduction is significantly limited (on one side)• Ortolani’s jerk of entry: pressure on femoral head in abduction - clunk as the dislocation

reduces. hip is reduced in abduction with a clickBarlow’s sign: femoral head is reduced with thumb

Page 7: Orthopedics CDH,Perthes

See the early physical sign: limitation of abduction, assymetry of skin creases

Advanced stage in CDH: leg shorter, externally rotated, assymetrical skin creases, later hyperlordosis (at walking age), Trendelenburg gait („waddling gait”)

Special importance of these signs: CDH can be detected at the earliest age (in few weeks) when the hip is reducible (in most cases) and after conservative treatment it will be normal. Imaging procedures of CDH:• In neonate (<4 months) SONOGRAPHY. Reliable diagnostic tool, can be repeated, correct

interpretation needs experience. Can be used for screening .• X-ray: after 4 months:

Special difficulty: bony nucleus of femoral head is not visible until later age.

Dislocation may be displayed only by drawing special lines through existing bony landmarks

Page 8: Orthopedics CDH,Perthes

Perkin’s lines at a 4 month old infant – left acetabulum is steep (dysplastic)

Bony nucleus of femoral head is visible – obvious sign of left hip dislocation

Page 9: Orthopedics CDH,Perthes

same case as previous pic.CDH – late signs• Abnormal gate: Trendelenburg gait (waddling gate)• Trendelenburg sign: standing on one leg pelvis is sagged, if hip is dislocated (gluteus medius

muscle is insufficient)• Closed reduction of hip will not be succesful

Trendelenburg sign positive on left side- Pelvic sag

CDH: treatment – before weight bearing age (before walking)Principle: • Keep hip in abducted position, if restriction of abduction (stiff hip) is the only problem, other

signs of CDH are not noted• Slightest suspicion of CDH: sonography• reduce femoral head and hold it in acetabulum – pressure of head will deepen the socket

(acetabulum) until x-ray imaging of hip shows good position (6 mo.)

Page 10: Orthopedics CDH,Perthes

Rationale of keeping hip in abduction – femoral head deepens the acetabulum

Pavlik (czech) - harness: hips in 90° flexion + abduction

Conservative treatment:• Splint holding hips in abducted position• Pavlik- harness: movements of hip in extension – abduction are allowed, extension is not

Page 11: Orthopedics CDH,Perthes

Abduction diaper - keeps hips abducted, good for „healthy” children too)

CDH: operative treatment – before weight bearing age1. Before 1 year: If hip is not reducible,traction for few weeks, then open reduction, transfer of

iliopsoas muscle (relax), partial resection of labrum if it obstructs reduction2. 1-2 years: same, but tight suture of capsule is important3. Above 2 years: shortening + derotation of femur, reduction of femoral head, capsule suture

CDH: treatment – at weight bearing ageProblems: • femoral neck anteversion• Acetabular roof is shallow

These are not always in combination, but if present, both abnormalities must be treated - ie. femur osteotomy (derotation + varus, if necessary) and/or pelvic osteotomy (pericapsular osteotomy) in order to deepen the acetabulum

Possibilities of operative treatment of CDH in weight bearing age: a: strucural anomalies in CDHb: osteotomy of femur to correct increased anteversion – derotational osteotomyC,D: deepening the shallow acetabulum – making a roof, or pushing the femoral head into pelvis, providing cover

Page 12: Orthopedics CDH,Perthes

Femur Osteotomy – to correct valgus and antetorsion.

Watson-Jones ANTEROLATERAL APPROACH TO HIP

Labrum in hip joint, preventing reduction - excised

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Postop: plaster spica for 4-6 weeks

Varus osteotomy of femur + correction of soft tissue abnormalities

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2 year old child: CDH, femur varus- rotational osteotomy.Femoral head in normal acetabulum at age 4, 6, 8 and 31

Osteotomy around the hip to correct for shallow acetabulum : „pericapsular” osteotomies1. Salter, 2. Pemberton, 3. Chiari , 4. triple osteotomy

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Late neglected case of CDH

Late case: shallow acetabulum, femoral neck shortened, greater trochanter overgrowth – typical phenomenon in CDH

„Shelf plasty” - acetabulum deepened with bone graft in late cases (skeletal maturity)

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Take home Message: early recognition of congenital hip dysplasy or dislocation :suspicion to be raised at birth, should be confirmed by sonography and treated immediately, but by all means within 6 weeks!

Perthes diseaseSymptoms, signs:• painful hip,• limping. • Pain at weight bearing• Age: 4-8years• Boy/girl= 4/1• Age:4-8 yrs• Pathology: circuatory disturbance of femoral head - result: femoral head becomes soft (like

clay)- will be deformed• Cause: unknown• Symptoms, signs: painful hip• Stages• Treatment

Blood supply comes from metaphyseal arteries – if they are damaged - due to trauma or inflammation – blood supply of femoral head may be damaged

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Catteral’s classification according to area of involvement of the femoral head (4 stages)Stages: 1:<25%

2:<50% 3.<75% 4. Total involvement

Symptoms, signs:• Painful hip,• Limping. • Pain at weight bearing• Age: 4-8 YEARS

Perthes – classification acc. to Catterall:

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Stage I

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Stage 4 Perthes disease (predisposition to oseteoarthritis of the hip)

Late case of Perthes: femoral epiphysis is flat

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Late Perthes: femoral epiphysis flat, fragmented, widened

Treatment of Perthes disease of hip:Conservative as long as possibleBED REST, UNTIL THE HIP IS PAINFUL (3 weeks)Further treatment is decided according to prognosisGood prognostic signs:• Child under 6 yrs• Partial involvement of femoral head• Normal shape of femoral head

NO ACTIVE TREATMENT - careful follow up for years!! Unfavourable prognostic signs:• Child over 6 years at onset of disease• Full involvement of femoral head• Lateral displacement of femoral head• Aim of treatment in these cases: CONTAINMENT of femoral head (to keep head in socket)

One concept of containment:Keep hip abducted, relieve weight bearing - 6-12 monthsOther concept: „self- curing” condition, leave alone

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Operative treatment for Perthes: provide full cover for femoral head (keep it in acetabulum in order to maintain spherical shape)- „containement of femoral head• Preop.• Postop.• Late x-ray

Slipped capital femoral epiphysis (epiphyseolysis capitis femoris)Age: 11- 17 yearsAcute or chronic onsetCause: unknown, trauma is not primary cause (growth hormons and sexual hormones play essential role)Symptoms, signs:typically intermittent pain in knee and hip, limping gait, leg axternally rotated and slightly shortened (like in femoral neck fracture)Acute slip: following fall, similar to acute femoral neck fracturex-ray: lateral view shows typical signs of slipped epiphysis

Epiphyseolysis of femoral head (slipped femoral head) on the left side:

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Acute slip- gross displacement of femoral epiphysis

Operation (epiphyseodesis) in slipped capital femoral epiphysis

Blood supply of proximal femoral epiphysis: vulnerable, if slip occurs, it may be damaged

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Forces acting of proximal femoral growth plate – shearing forces (they promote slipping)

Visible hormonal disturbance on a 14 yr boy With slipped capital femoral epiphysisSee position of right lower extremity

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Left hip - slipped, see other side

Typical xr on lateral position: obvious signs of slip left side

Slipped capital femoral epiphysisTreatment:„in situ” fixation with K-wires, or with screws (this means epiphyseodesis – ie. Growth will not occur at proximal epiphysis)Reduction carries risk of damage to blood supply of proximal femoral epiphysis – it should be avoided if possible, otherwise blood supply may be damagedIn a high percentage of cases slip may occur on the other side too – close observation (or preventive fixation on the other side too)