| Congenital Dislocations of the Hip | | Counselor, Known also as developmental dysplasia of the hip (DDH), congenital dislocation of the hip (CDH) occurs ubiquitously and is due to abnormal growth of the hip. Abnormal development involves bony and soft tissue structures. Dislocation may occur at any time from conception to skeletal maturity. Dislocation is defined as the complete loss of contact between the articular surface of the femoral head and acetabular cup. CDH is significant because of long term adverse health consequences. We value all your comments, so, if you have a suggestion for a newsletter subject but haven't submitted it yet, or if you have already submitted one but think of another, please take a minute to let us know by clicking on your "Reply" button and dropping us a note. To learn more about AMFS, Inc., the organization run by Physicians and Attorneys that provides medical experts and case review services nationwide, and has produced the following informational newsletter to aid you in understanding complex medical issues, please click here - www.medicalexperts.com. |
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| Etiology and Pathophysiology: The etiology is not clear, but hip dysplasia does appear to be related to a number of different factors. An underlying genetic disposition appears to exist in that a 10-fold increase in the frequency of hip dysplasia occurs in children whose parents had CDH compared with those whose parents did not, and there is an increased incidence of CDH in different populations. Also, female sex, being the first-born child, and breech positioning are all associated with an increased prevalence of CDH. CDH involves abnormal growth of the hip. Ligamentous laxity is also believed to be associated with hip dysplasia, although this association is less clear. |
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| Frequency: The overall frequency is usually reported as approximately 1 case per 1000 individuals, although some studies have demonstrated that the instance of hip instability during newborn examinations was as high as 1 case per 60 newborns. The peak ages for actual dislocation are under one year old and between 11 and 15 years of age. |
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| | History and Physical: Early clinical manifestations of CDH are identified during examination of the newborn. The classic examination finding is revealed with the Ortolani maneuver; a palpable "clunk" is present when the hip is reduced in and out of the acetabulum. Late clinical examination, when the child is aged 3-6 months, is quite different. At this point, the hip, if dislocated, is often dislocated in a fixed position. Physical examination findings for late dislocation include asymmetry of the gluteal thigh or labral skin folds, decreased abduction on the affected side, standing or walking with external rotation, and leg length inequality. |
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| | Imaging Studies: Ultrasonograms have been of significant benefit in the assessment and treatment of children with hip dysplasia. Likewise, plain x-rays can be quite useful in confirming the diagnosis. An abducted internal rotation view of the pelvis can help determine if the hip reduces and better determines the true neck-shaft angle of the proximal femur. Also, a CT scan can also be helpful in determining femoral anteversion and in determining the extent of posterior acetabular coverage. |
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| | Treatment: Indications for treatment depend on the patient's age and the success of the previous techniques. Children younger than 6 months with instability upon examination are treated with a form of bracing, usually a Pavlik harness. If this is not effective or if the hip instability or dislocation is noted when the child is older than 6 months, closed reduction is typically recommended, often with traction prior to the reduction. When the child is older than 2 years or with failure of the previous treatment, open reduction is considered. If the patient is older than 3 years, femoral shortening is performed instead of traction, with additional varus applied to the femur if necessary. A patient with residual acetabular dysplasia who is older than 4 years should be treated with an acetabular procedure. Relative contraindications to surgery include older age, that is >8 y for a unilateral hip dislocation or >4-6 y for bilateral hip dislocation, especially if a false acetabulum is not present. When dislocations occur, closed reduction is typically performed with the aid of arthrography, which is used to determine the adequacy of the reduction. A spica cast is then placed, with care taken in molding over the posterior aspect of the greater trochanter of the ipsilateral limb. After this is performed, a CT scan is then obtained to ensure that no evidence of posterior subluxation is present. The cast is typically worn for 6-12 weeks, at which time the hip is reexamined, and, if found to be stable, the patient is placed in an abduction brace. If it remains unstable, the patient is again placed in a spica cast. Open reduction is the treatment of choice for children older than 2 years at the time of initial diagnosis or for children in whom attempts at closed reduction have failed. Most often, especially in older children, the standard anterolateral or Smith-Petersen approach is used. This can be combined with a capsule placation, if needed, and/or an acetabular procedure. In a child older than 3 years, femoral shortening is typically performed instead of traction. When open reduction is performed, a spica cast is worn for 6 weeks. The patient is then placed in an abduction orthosis. Pelvic osteotomy may be needed for residual hip dysplasia. If open reduction is performed in a child older than 4 years with significant hip dysplasia, an acetabular procedure should be probably be performed at the time of open reduction. If closed reduction is performed earlier, at least 12-18 months of acetabular remodeling should be allowed before an acetabular procedure is undertaken. At that time, if no evidence of acetabular modeling is noted, a pelvic osteotomy should be considered. |
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| | Complications: Numerous possible complications can occur, including redislocation, stiffness of the hip, infection, blood loss, and, possibly the most devastating, necrosis of the femoral head. Overall, the prognosis for children treated for hip dysplasia is very good, especially if the dysplasia is managed with closed treatment. If closed treatment is unsuccessful and open reduction is needed, the outcome is less favorable, although short-term outcome appears to be satisfactory. If secondary procedures are needed to obtain reduction, then the overall outcome is significantly worse, and the rate of avascular necrosis can be as high as 75% in some studies. |
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| | Medical/Legal Concerns: Early diagnosis is the most crucial aspect of the treatment of children with DDH. The use of ultrasonography and other diagnostic imaging modalities and the implementation of improved educational programs will most likely decrease the number of children with CDH diagnosed late. Newer, less invasive surgical techniques (eg, endoscopic techniques, image-guided surgery) are currently being developed in an effort to decrease the morbidity of surgery and to ease recovery. Delay in diagnosis and treatment of a dislocated hip will result in the complications mentioned above, and this inevitably could lead to litigation. |
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