- See:
DDH - Main Discussion
- Discussion:
- 95-98% of DDH cases are possibly reversible;
- 2% of DDH cases may have teratologic dislocation which is generally not reversible;
- less than 2% of infants will have a positive
Barlow's test (dislocatable hip);
- 60% will normalize w/ no treatment after 1 month;
- 88% will normalize w/ no treatment after 2 months;
- this comes to about 1-2 patients per 1000 which have a true DDH which
will go on to produce the pathological changes of DDH;
* Barlow TG. 1962.
- when radiographic findings are added to clinical findings the number of
good results (w/ no treatment) diminish significantly;
- 22% will normalize w/ no treatment;
- 39% will retain some dysplastic features;
- 13% will be subluxed;
- 26% will remain dislocated;
* Coleman, 1968.
- concave acetabulum cannot develop without concentric force exerted by the reduced femoral head;
- w/ time, there is progression of
pathologic features which include development of
intra-articular
impediments to reduction develop and muscule groups about
the hip become shortened and contracted;
- an untreated hip dislocation becomes more difficult to reduce causing
Ortolani's test to becomes negative;
- normal acetabular development ceases and the potential for the acetabulum
to resume normal growth onced reduced is diminished;
- this decrease in remodeling potential can occur after age one year;
-
CE angle may have limited predictive value for DJD, when patients w/ subluxation
are excluded from consideration (subluxation is probably the most important risk factor);
- Physical Exam:
- Natural History in Adults:
- development of false acetabulum;
- 76% will have poor result w/ well developed false acetabulum;
- 48% will have poor result w/ moderately developed or absent acetabulum;
- if femoral head does not articulate w/ the acetabulum, degenerative changes will
not occur and range of motion will generally be maintained;
- unilateral dislocation:
- flexion-adduction deformity of the affected hip;
- gait disturbance which is quite noticable;
- leg length inequality;
- valgus deformity of the knee which can lead to DJD of lateral compartment;
- scoliosis;
- contra-lateral "normal" hip is often found to have acetabular dysplasia;
- it may not be appropriate to apply standard hip functional studies (such as
Harris Hip Score) to DDH patients w/ complete dislocation;
- these studies are geared to the problems of elderly patients rather than
the functional considerations of younger patients;
- 48% will have poor result w/ moderately developed or absent acetabulum;
- if femoral head does not articulate w/ the acetabulum, degenerative changes will not
occur and range of motion will generally be maintained;
- even if degenerative changes do not develop, patients will often fatigue
when they attempt to walk distances more than several hundred meters;
- bilateral dislocation:
- when both hips are dislocated, perineal space is widened, & greater trochanters are more prominent than normal;
- buttocks are broad & flat, & lumbar spine is hyper-lorddotic;
- child with bilateral hip dislocation has a waddling gait;
- back pain may develop due to hyperlordosis;
- objective functional studies are lacking, but it is generally felt that complete bilateral dislocation
causes relatively mild functional limitations as compared to the complications associated w/ forced
reduction (AVN and DJD);
- subluxation:
- by definition implies not only subluxation but also acetabular dyplasia;
- Shenton's line is broken;
- clear progression of DJD based on age of patient and degree of subluxation;
- prognosis is worse in females;
- early radiographic changes include sclerosis along the wt bearing portion of the acetabulum;
- early clinical findings include groin pain;
- females begin to complain of pain in mid 30's (depending on
CE angle);
- degenerative changes usually develop around age 45 yrs;
- often DJD will not appear until 5 yrs or more after onset of symptoms;
- once degenerative changes begin, they can progress quickly;
- males begin to complain of pain in mid 40's-50's;
- radiographic changes may not develop until age 70 yrs;
- acetabular dysplasia:
- by definition subluxation is not present;
- Shenton's line is intact;
- has a better prognosis than subluxation and progression to DJD is less predictable than w/ subluxation;
- can be an incidential radiographic finding;
- prognosis is worse in females;
- often DJD will not appear for 10 yrs or more after onset of symptoms;
- in the report by Kiril Mladenov, M.D et al (Journal of Pediatric Orthopaedics 2002; 22(5):607-612), the authors that the management
of Management of clinically stable hips with an increased age-related acetabular index (AI) remains controversial;
- 4 patterns of evolution were observed:
- type 1 (25 hips) had rapid progression to normal range in the first 2 years;
- type 2 (19 hips) had slow improvement, with AI values reaching the normal range between 4 and 11 years;
- type 3 (20 hips) had improved hip morphology with persistence of minor deviations from the normal values;
- type 4 (4 hips) showed no improvement.
- references:
-
Acetabular Dyplasia in the Adult.
-
Case Example: of untreated DDH:
- 14 yr old female w/ untreated DDH who presented w/ progressive hip pain;
(patient's mother declined formal orthopaedic treatment, despite the advice of 3 different orthopaedists);
Congenital dysplasia of the hip in the Navajo infant.
Coleman SS.
Clinical Orthopaedics and Related Research. 1968. 58: 179.
Untreated congenital hip dysplasia in the Navajo.
Pratt WB, Freiberger RH, Arnold WD. Clinical Orthopaedics and Related Research. 1982; 162: 69.
Congenital Hip Dislocation.
Long Range Problems, Residual Signs, and Symptoms After Successful Treatment.
S.L. Weinstein MD
Clinical Orthopaedics and Related Research. No. 281: 69.
The Natural History of Congenital Dislocation of the Hip. A Critical Review.
JH Wedge MD FRCS and MJ Wasylenko MD
Clinical Orthopaedics and Related Research. No. 137: 155.
Early Diagnosis and Treatment of Congenital Dislocation of the Hip.
Barlow TG.
JBJS (Br). 1962. 44: 292.
Natural history of congenital hip dislocation (CDH) and hip dysplasia.
The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome.
The natural history of congenital disease of the hip.
