TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
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developemental dysplasia of hip
1. DevelopmentalDevelopmental
Dysplasia of the HipDysplasia of the Hip
Dr.HARDIK S PAWARDr.HARDIK S PAWAR
DEPARTMENT OF ORTHOPAEDICSDEPARTMENT OF ORTHOPAEDICS
CARE HOSPITALSCARE HOSPITALS
2. OverviewOverview
ī§ IntroductionIntroduction
ī§ Normal Development of the HipNormal Development of the Hip
ī§ Etiology and PathoanatomyEtiology and Pathoanatomy
ī§ Epidemiology and DiagnosisEpidemiology and Diagnosis
ī§ TreatmentTreatment
ī§ ComplicationsComplications
3. IntroductionIntroduction
ī§ Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip
ī§ Intracapsular displacementIntracapsular displacement
ī§ SubluxationSubluxation
ī§ Dislocation-usually posterosuperior (reducibleDislocation-usually posterosuperior (reducible
vs irreducible)vs irreducible)
ī§ DysplasiaDysplasia
ī§ Before, during or just after birthBefore, during or just after birth
4. HISTORYHISTORY
ī§ Chapple and davidson â 1941Chapple and davidson â 1941
ī§ Muller and seddon â 1953Muller and seddon â 1953
ī§ AR hodgson - 1959AR hodgson - 1959
ī§ Wilkinson - 1963Wilkinson - 1963
5. EPIDEMIOLOGYEPIDEMIOLOGY
ī§ 1/1,000 born with dislocated hip1/1,000 born with dislocated hip
ī§ 10/10,000 born with subluxation or dysplasia10/10,000 born with subluxation or dysplasia
ī§ 5:1 Female:Male child5:1 Female:Male child
ī§ Left 60% (left occiput ant), Right 20%, both 20%Left 60% (left occiput ant), Right 20%, both 20%
ī§ Risk FactorsRisk Factors
ī§ Family history (6% one affected child, 12% oneFamily history (6% one affected child, 12% one
affected parent, 36% one child + one parent)affected parent, 36% one child + one parent)
ī§ OligohydramniosOligohydramnios
ī§ Breech (sustained hamstring forces)Breech (sustained hamstring forces)
ī§ Native Americans (swaddling cultures)Native Americans (swaddling cultures)
ī§ Torticollis or LE deformityTorticollis or LE deformity
6. Normal DevelopmentNormal Development
ī§ EmbryonicEmbryonic
ī§ 7-87-8thth
th week - acetabulum and head formedth week - acetabulum and head formed
from same primitive mesenchymal cellsfrom same primitive mesenchymal cells
ī§ 11th week - complete devlopement of hip11th week - complete devlopement of hip
ī§ Prox fem ossific nucleus - 4-7 monthsProx fem ossific nucleus - 4-7 months
ī§ Hip at risk of dislocation at 4 period :Hip at risk of dislocation at 4 period :
at 12at 12thth
weekweek
at 18at 18thth
weekweek
final 4 weeksfinal 4 weeks
post natal periodpost natal period
14. DiagnosisDiagnosis
ī§ Newborn screeningNewborn screening
ī§ Ortolaniâs and Barlowâs maneuvers with aOrtolaniâs and Barlowâs maneuvers with a
thorough history and physicalthorough history and physical
ī§ Warm, quiet environment with removal ofWarm, quiet environment with removal of
diaperdiaper
ī§ Head to toe exam to detect any associatedHead to toe exam to detect any associated
conditons (Torticollis, Ligamentous Laxityconditons (Torticollis, Ligamentous Laxity
etc.)etc.)
ī§ Baseline Neuro and Spine ExamBaseline Neuro and Spine Exam
16. Clinical Features : NeonatesClinical Features : Neonates
īļDelicate âclunkâ thatDelicate âclunkâ that
is palpable but notis palpable but not
audibleaudible
īļRepeat sequence 4-5Repeat sequence 4-5
times to be certain oftimes to be certain of
findingsfindings
īļIf both signs negativeIf both signs negative
but pt is high risk :but pt is high risk :
follow up is essentialfollow up is essential
17. Clinical features : InfantsClinical features : Infants
īļProgression fromProgression from
instability to dislocationinstability to dislocation
is gradual processis gradual process
īļIn some within a fewIn some within a few
weeksweeks
īļothers the hipothers the hip
dislocation remainsdislocation remains
reducible up to 5 or 6reducible up to 5 or 6
months of age.months of age.
īļWhen the hip no longerWhen the hip no longer
reducible, specificreducible, specific
physical findingsphysical findings
appearappear
31. DiagnosisDiagnosis
ī§ Some cases still missedSome cases still missed
ī§ At risk groups should be further screenedAt risk groups should be further screened
ī§ AAPAAP
ī§ Recs further imaging (e.g. US) if exam isRecs further imaging (e.g. US) if exam is
âinconclusiveâ ANDâinconclusiveâ AND
ī§ First degree relative + femaleFirst degree relative + female
ī§ BreechBreech
ī§ Positive provocative maneuver (Ortolani or Barlow)Positive provocative maneuver (Ortolani or Barlow)
ī§ Referral to OrthopaedistReferral to Orthopaedist
32. ImagingImaging
ī§ X-raysX-rays
ī§ Femoral head ossification centerFemoral head ossification center
ī§ 4 -7 months4 -7 months
ī§ UltrasoundUltrasound
ī§ Operator dependentOperator dependent
ī§ CTCT
ī§ MRIMRI
ī§ ArthrogramsArthrograms
ī§ Open vs closed reductionOpen vs closed reduction
45. Centre â Edge Angle WibergCentre â Edge Angle Wiberg
6 â 13 years >19
degrees
>14 years > 25
degrees
46. ANDREN-von ROSENANDREN-von ROSEN
LINELINE
īļAP X-ray: hip in 45AP X-ray: hip in 45°abduction and IR°abduction and IR
īļDescribes the longitudinal relationship betweenDescribes the longitudinal relationship between
īļlong axis of femur and acetabulumlong axis of femur and acetabulum
47. Tear dropTear drop
īļAP X-rayAP X-ray
īļLateral:wall ofLateral:wall of
acetabulumacetabulum
īļMedial:lesser pelvisMedial:lesser pelvis
īļInferior :acetabularInferior :acetabular
notchnotch
īļAppears between 6-23Appears between 6-23
momo
īļ[delayed in DDH][delayed in DDH]
48. Radiographs SummaryRadiographs Summary
ī§ Femoral head appears 4 - 7 monthsFemoral head appears 4 - 7 months
ī§ Shentonâs lineShentonâs line
ī§ Perkinâs and Hilgenreinerâs linesPerkinâs and Hilgenreinerâs lines
ī§ Inferomedial quadrantInferomedial quadrant
ī§ Center Edge Angle (< 20 abnormal)Center Edge Angle (< 20 abnormal)
ī§ Acetabular indexAcetabular index
ī§ Normal < 30 (Weintroub et al)Normal < 30 (Weintroub et al)
ī§ Tear drop*Tear drop*
ī§ Abnormal widening in DDHAbnormal widening in DDH
*may be only sign in mild subluxation*may be only sign in mild subluxation
49. ImagingImaging
ī§ UltrasoundUltrasound
ī§ Introduced in 1978 for eval of DDHIntroduced in 1978 for eval of DDH
ī§ Operator dependentOperator dependent
ī§ Useful in confirming subluxation, identifyingUseful in confirming subluxation, identifying
dysplasia of cartilaginous acetabulum,dysplasia of cartilaginous acetabulum,
documenting reducibilitydocumenting reducibility
ī§ Prox Femoral Ossification Center interferesProx Femoral Ossification Center interferes
ī§ Requires a window in spica cast (avoid)Requires a window in spica cast (avoid)
58. ArthrogramArthrogram
īļSeverin [1941]Severin [1941]
īļNormal appearance:Normal appearance:
īļLABRUM:LABRUM:
īļ*Thorn over the*Thorn over the
femoral headfemoral head
īļ*A recess of joint*A recess of joint
capsule overlies thecapsule overlies the
thornthorn
60. Imaging ToolsImaging Tools
ī§ CT scan:CT scan:
ī§ Single section CT as check filmsSingle section CT as check films
ī§ Neglected C.D.H.Neglected C.D.H.
ī§ Adolescent and adultAdolescent and adult
ī§ MRI:MRI:
ī§ Equivalent to arthrographyEquivalent to arthrography
61. Natural HistoryNatural History
ī§ NewbornNewbornī ī VariableVariable
ī§ > 6 months> 6 monthsī ī more aggressive tx requiredmore aggressive tx required
due to more extensive pathology anddue to more extensive pathology and
decreased potential for acetabulardecreased potential for acetabular
remodelingremodeling
ī§ Abnormal Gait, Decreased Abduction andAbnormal Gait, Decreased Abduction and
Strength, Increased DJDStrength, Increased DJD
ī§ Unilateral worse than BilateralUnilateral worse than Bilateral
ī§ Subluxation worse than DysplasiaSubluxation worse than Dysplasia
62. Treatment OptionsTreatment Options
ī§ Age of patient at presentationAge of patient at presentation
ī§ Family factorsFamily factors
ī§ Reducibility of hipReducibility of hip
ī§ Stability after reductionStability after reduction
ī§ Amount of acetabular dysplasiaAmount of acetabular dysplasia
63.
64. Birth to Six MonthsBirth to Six Months
ī§ Triple-diaper techniqueTriple-diaper technique
ī§ Prevents hip adductionPrevents hip adduction
ī§ ââSuccessâ no different in someSuccessâ no different in some
untreated hipsuntreated hips
ī§ Pavilk harness (1944)Pavilk harness (1944)
ī§ Experienced staff*Experienced staff*
ī§ Very successfulVery successful
ī§ Allows free movement withinAllows free movement within
confines of restraintsconfines of restraints
*posterior straps for preventing add. NOT producing abd.
65. Birth to Six MonthsBirth to Six Months
ī§ Pavlik harnessPavlik harness
ī§ IndicationsIndications
ī§ Fully reducible hip*Fully reducible hip*
ī§ Child not attempting to standChild not attempting to stand
ī§ FamilyFamily
âĸ Close regular follow-up (every 1-2 weeks)Close regular follow-up (every 1-2 weeks)
âĸ For imaging and adjustmentsFor imaging and adjustments
âĸ DurationDuration
âĸ Childs age at hip stability + 3 monthsChilds age at hip stability + 3 months
66. Pavlik HarnessPavlik Harness
ī§ FailuresFailures
ī§ Poor parent compliancePoor parent compliance
ī§ Improper use by the physicianImproper use by the physician
ī§ Inadequate initial reductionInadequate initial reduction
ī§ Failure to recognize persistent dislocationFailure to recognize persistent dislocation
ī§ Viere et al 1990Viere et al 1990
ī§ Bilateral dislocationBilateral dislocation
ī§ Absent Ortolaniâs signAbsent Ortolaniâs sign
ī§ > 7weeks of age> 7weeks of age
67. Pavlik HarnessPavlik Harness
ī§ ComplicationsComplications
ī§ Avascular necrosisAvascular necrosis
ī§ Forced hip abductionForced hip abduction
ī§ Safe zone (abd/adduction and flexion/extension)Safe zone (abd/adduction and flexion/extension)
ī§ Femoral nerve palsyFemoral nerve palsy
ī§ HyperflexionHyperflexion
*Be aware of Pavlik Harness Disease*Be aware of Pavlik Harness Disease
*Follow until skeletal maturity*Follow until skeletal maturity
68. Birth - Six monthsBirth - Six months
ī§ Closed reduction + SpicaClosed reduction + Spica
ī§ Failure after 3 weeks of Pavlik trialFailure after 3 weeks of Pavlik trial
69. Birth - Six monthsBirth - Six months
ī§ Closed reductionClosed reduction
ī§ General anesthesiaGeneral anesthesia
ī§ ArthrogramArthrogram
ī§ Safe zone - avoid AVNSafe zone - avoid AVN
ī§ +/- adductor tenotomy+/- adductor tenotomy
ī§ Open reduction if concentric reduction notOpen reduction if concentric reduction not
possiblepossible
ī§ Usually teratogenic hips in this age groupUsually teratogenic hips in this age group
70. Open reductionOpen reduction
īļUnable to achieveUnable to achieve
closed reductionclosed reduction
īļWidening of the jointWidening of the joint
spacespace
īļUnstable reductionsUnstable reductions
īļLoss of reduction onLoss of reduction on
follow upfollow up
īļAdvanced ageAdvanced age
71. Open ReductionOpen Reduction
ī§ Medial approachMedial approach
ī§ Pectineus / adductor longus + brevisPectineus / adductor longus + brevis
ī§ Cannot address simeoultaneous bony workCannot address simeoultaneous bony work
ī§ Antero -lateralAntero -lateral
ī§ Smith-petersonSmith-peterson
ī§ Sartorius / Tensor Fascia lataSartorius / Tensor Fascia lata
74. Open Reduction with FemoralOpen Reduction with Femoral
derotation osteotomyderotation osteotomy
ī§ Pressure leads to risk of AVNPressure leads to risk of AVN
ī§ Better results than preoperative traction in olderBetter results than preoperative traction in older
children with less morbiditychildren with less morbidity
When to do??When to do??
ī§ Anticipated increased pressure on reduced femurAnticipated increased pressure on reduced femur
headhead
ī§ Recommended in child > 2yrs.Recommended in child > 2yrs.
ī§ distract the joint few millimeter per operativelydistract the joint few millimeter per operatively
ī§ Judge the tightness of soft tissues after reductionJudge the tightness of soft tissues after reduction
ī§ irreducible dislocationirreducible dislocation
77. 2 Years of Age and Older2 Years of Age and Older
ī§ For child 2 -3 years of age, during openFor child 2 -3 years of age, during open
reduction acetabular coverage ifreduction acetabular coverage if
insufficient warrants reorientationinsufficient warrants reorientation
osteotomyosteotomy
ī§ If coxa valga with excessive anteversion,If coxa valga with excessive anteversion,
VDRO may be done.VDRO may be done.
ī§ Children > 3 years usually need anChildren > 3 years usually need an
osteotomyosteotomy
78. īļBilateral untreated dislocation upto 5Bilateral untreated dislocation upto 5
years:years:
Open reduction with femoral shorteningOpen reduction with femoral shortening
with salter / pemberton osteotomy withwith salter / pemberton osteotomy with
gap of 5-6 weeks.gap of 5-6 weeks.
īļBilateral untreated subluxation upto 5-6Bilateral untreated subluxation upto 5-6
years:years:
Open reduction + salter osteotomy.Open reduction + salter osteotomy.
79. 6 months - 4 years6 months - 4 years
ī§ Present a more difficult problemPresent a more difficult problem
ī§ Prolonged dislocationProlonged dislocation
ī§ Contracted soft tissuesContracted soft tissues
ī§ 6 - 18 months6 - 18 months
ī§ Closed reduction +/- adductor tenotomyClosed reduction +/- adductor tenotomy
ī§ Spica in human position of 100 degrees of flexion andSpica in human position of 100 degrees of flexion and
about 55 degrees abduction (3 months)about 55 degrees abduction (3 months)
ī§ Abduction Orthosis 4 wks full time/4 wks nighttimeAbduction Orthosis 4 wks full time/4 wks nighttime
ī§ Open reduction (if closed fails)Open reduction (if closed fails)
ī§ CapsulorraphyCapsulorraphy
ī§ CT scanCT scan
ī§ Spica for 6 wks followed by PTSpica for 6 wks followed by PT
80. 6 months - 4 years6 months - 4 years
ī§ 18 months - 4 years18 months - 4 years
ī§ Closed reductionClosed reduction
ī§ Reducibile - check arthrogram andReducibile - check arthrogram and medial dye poolmedial dye pool
ī§ Irreducible - Open reductionIrreducible - Open reduction
ī§ Open redcutionOpen redcution
ī§ Tight - femoral shorteningTight - femoral shortening
ī§ Stable - +/- pelvic osteotomyStable - +/- pelvic osteotomy
81.
82.
83. Femoral osteotomyFemoral osteotomy
ī§ Schoenecker + Strecker 1984Schoenecker + Strecker 1984
ī§ Traction vs. Femoral shorteningTraction vs. Femoral shortening
ī§ 56% AVN in traction group56% AVN in traction group
ī§ 0% AVN in femoral shortening0% AVN in femoral shortening
87. Acetabular Reorientation-Acetabular Reorientation-
Innominate OsteotomyInnominate Osteotomy
ī§ Articular hyaline cartilage over femur headArticular hyaline cartilage over femur head
ī§ Types:Types:
ī§ SSalterâsalterâs (innominate)(innominate)
ī§ SSutherlandâs (double innominate)utherlandâs (double innominate)
88. Salterâs OsteotomySalterâs Osteotomy
īļRedirects the entire acetabulumRedirects the entire acetabulum
īļRoof âcoversâ the femoral head anteriorlyRoof âcoversâ the femoral head anteriorly
and superiorlyand superiorly
īļHinge at pubic symphysisHinge at pubic symphysis
Pre-requisitesPre-requisites
īļCongrous Concentric reductionCongrous Concentric reduction
īļNo ContracturesNo Contractures
103. Salvage or Shelf proceduresSalvage or Shelf procedures
ī§ ChiariChiari
ī§ Requires capsular metaplasiaRequires capsular metaplasia
ī§ Pain - main indicationPain - main indication
ī§ Treatment of chronic hip pain in adolescentsTreatment of chronic hip pain in adolescents
112. Adolescent and young adult(olderAdolescent and young adult(older
then 8-10 yearsthen 8-10 years
īļIf femoral head cannot be repositionedIf femoral head cannot be repositioned
distally to the level of acetabulum :distally to the level of acetabulum :
Salvage proceduresSalvage procedures
īļDegenertive arthritis and enough pain andDegenertive arthritis and enough pain and
limitation of movements â reconstructivelimitation of movements â reconstructive
operation (total hip replacement)operation (total hip replacement)
īļArthodesis â rarely done, contraindiactedArthodesis â rarely done, contraindiacted
for bilateral dislocationfor bilateral dislocation
119. THR outcomes in DDHTHR outcomes in DDH
ī§Charnley cemented hips:Charnley cemented hips:
5 of 38 loose at 11 years5 of 38 loose at 11 years
Bobak, Wroblewski et al 2000Bobak, Wroblewski et al 2000
ī§Harris uncemented hips:Harris uncemented hips:
20% loose at 7 years20% loose at 7 years
46% loose at 12 years46% loose at 12 years
Jasty, Anderson, Harris, 1999Jasty, Anderson, Harris, 1999
121. Avascular NecrosisAvascular Necrosis
ī§ Most commonMost common
ī§ Not part of the natural history of DDHNot part of the natural history of DDH
ī§ IatrogenicIatrogenic
ī§ Etiology unknownEtiology unknown
ī§ Femoral head compressionFemoral head compression
ī§ Injury to blood supplyInjury to blood supply
ī§ Excessive abductionExcessive abduction
ī§ Sullivan et al 1997Sullivan et al 1997
ī§ SigSig ââ blood flow w/ increasing abd angleblood flow w/ increasing abd angle
122. TX SummaryTX Summary
ī§ Best if treated before 6 weeks of ageBest if treated before 6 weeks of age
ī§ 0 - 6 months of age0 - 6 months of age
ī§ PavlikPavlik
ī§ 6 - 18 months6 - 18 months
ī§ Closed vs open reduction and spicaClosed vs open reduction and spica
ī§ 18 - 48 months18 - 48 months
ī§ ClosedClosed
ī§ Open +/- osteotomiesOpen +/- osteotomies
123. SummarySummary
ī§ Femoral shortening better than tractionFemoral shortening better than traction
ī§ Pelvic osteotomiesPelvic osteotomies
ī§ Dega, PembertonDega, Pemberton
ī§ Salter, triple innominate, GanzSalter, triple innominate, Ganz
ī§ ChiariChiari