Developmental Dislocation of the Hip

- Discussion:
    - DDH involves displacement of the femoral head from the acetabulum (during the perinatal period)
            which disrupts the normal development of the hip joint;
    - DDH is estimated to occur in 1 - 1.5 cases per 1000 live births;
            - when an agressive screening system is in place (including routine use of ultrasound), it is not uncommon to
                    have a prevalence of 5 / 1000 cases;
            - in certain sub-populations, such as North American Indians, incidence can be as high as 35/1000.
    - normal hip development: (limb development); 
            - references:
                   - Perinatal observations on the etiology of congenital dislocation of the hip
                   - The fetal acetabulum. A histomorphometric study of acetabular anteversion and femoral head coverage.
                   - Growth and development of the acetabulum in the normal child. Anatomical, histological, and roentgenographic studies.
                   - Morphometric study of the fetal development of the human hip joint: significance for congenital hip disease.
                   - Histological study of the fetal development of the human acetabulum and labrum: significance in congenital hip disease.
                   - Growth characteristics of the fetal ligament of the head of femur: significance in congenital hip disease.
                   - The pathogenesis of femoral head deformity in congenital dislocation of the hip. Experimental study of the effects of articular interpositions in pigs.

    - risk factors for DDH:
            - left hip is more often involved (? due to fetal positioning);
            - females: 80% of cases;
            - breech birth (may account for 25-45% of DDH cases):
            - first born:
            - fixed positions of extension and adduction;
            - Down's syndrome
            - congenital muscular torticollis
    - pathogenic factors (impediments to reduction)
    - natural history of untreated DDH
            - references:
                   - The conservative management of congenital dislocation of the hip after walking age.
                   - Conservative treatment of congenital dislocation of the hip in the newborn and infant.
            - teratologic dislocation:
                   - distinct category which represents a true congenital hip dislocation;
                   - occurs in 1-2% of perinatal hip dislocations;
                   - associated w/ arthrogryposis, chromosomal abnormalities, Larsen's syndrome, and others;
                   - typically the hip is not reducible at birth (equivalent to the untreated hip in a 3-4 year old;
                   - operative treatment is controversial and is associated w/ multiple procedures to keep the hip reduced;
                   - references:
                           - Teratologic congenital dislocation of the hip. Report of two cases.
                           - Teratologic dislocation of the hip.   
                           - The hip in arthrogryposis multiplex congenita.   
                           - Pathology of limbus in untreated teratologic congenital dislocation of hip. A case report of a ten-month-old- infant.
- Physical Exam:
    - Barlow's Test
    - Ortolani's test

- Radiographic Features:
    - x-ray features:
           - references:
                  - Radiological outcome of innocent infant hip clicks.
                  - Improvement in acetabular index after reduction of hips with developmental dysplasia.
    - ultrasound of the hip

- Management of DDH:
    - primary goal is to obtain a concentric reduction of the femoral head in the acetabulum;
          - w/o this reduction, normal development and growth does not occur;
    - diff dx: consider septic hip in the differential diagnosis of DDH;
    - treatment based on age:
          - references:
                 - Treatment of congenital dislocation of the hip in older children.
                 - Treatment of congenital dislocation of the hip. Management before walking age.
                 - Treatment of dislocation of the hip, detected in early childhood, based on magnetic resonance imaging.
                 - Acetabular dysplasia in the adult.
                 - Acetabular dysplasia in the adolescent and young adult.
                 - Acetabular development after reduction in congenital dislocation of the hip.
  - treatment options:
           - neonates with a hip "click" or an equivocal examination should be evaluated with ultrasound at 4 to 6 weeks of age
                   if the physical examination does not improve; 
                   - ref:  A clicking hip in a newborn baby should never be ignored
           - pavlik harness
           - traction
                   - ref: Ultrasound-guided gradual reduction using flexion and abduction continuous traction for developmental dysplasia of the hip: a new method of treatment.
           - closed reduction
           - open reduction
           - femoral osteotomy
           - pelvic osteotomy
           - total hip replacement

- Long Term Complications:
    - avascular necrosis:
          - ref:
                - The surgical treatment of established congenital dislocation of the hip: results of surgery after planned delayed intervention following the appearance of the capital femoral ossific nucleus.
                - Presence of the Ossific Nucleus and Risk of Osteonecrosis in the Treatment of Developmental Dysplasia of the Hip
    - subluxation
    - dysplasia
    - references:
             - Growth disturbance of the proximal part of the femur after treatment for congenital dislocation of the hip.
             - Cause and prevention of osteochondritis in congenital dislocation of the hip.
             - Congenital hip dislocation. Long-range problems, residual signs, and symptoms after successful treatment.

 Current Concepts Review. Reduction of Congenital Dislocation of the Hip.
 Subluxation of the femoral head in coxa plana.
 Osteoarthrosis and congenital dysplasia of the hip in family members of children who have congenital dysplasia of the hip.
 Congenital dislocation of the hip in Ehlers-Danlos syndrome.
 Hip dysplasia associated with abduction contracture of the contralateral hip.
 Paralytic pelvic obliquity. Its prognosis and management and the development of a technique for full correction of the deformity.
 Paralytic dislocation of the hip in myelodysplasia. The role of the adductor transfer.
 Etiologic factors in congenital displacement of the hip and myelodysplasia
 Hip dislocation in spastic cerebral palsy: long-term consequences.
 Hip dysplasia associated with abduction contracture of the contralateral hip.
 Congenital dislocation of the hip in boys.
 Management of hip dislocations in children with arthrogryposis.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, October 3, 2018 1:21 am