Hip Dysplasia

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Original Editors - Daan Vandebriel

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Definition/Description

Hip dysplasia is a general term used to describe certain abnormalities of the femur or the acetabulum, or both that result in inadequate containment of the femoral head within the acetabulum. A shallow acetabulum, a femoral or acetabular anteversion, and a decreased head offset or perpendicular distance from the center of the femoral head to the axis of the femoral shaft are a few of those bony abnormalities.

Clinically Relevant Anatomy

The hip exist of the acetabulum and the caput femoris. The acetabulum has the shape of a cup and the caput femoris has the shape of a ball. These caput femoris placed in the acetabulum creates the hip joint witch is an articulatio speroidea.

Epidemiology /Etiology

Hip dysplasia exists in two forms. You have the "developmental dysplasia of the hip" or DDH and "congenital dislocation of the hip" or CDH. DDH is the sort of hip dysplasia witch is acquired condition. This is often created due to swaddling infant and the use of cradle board which locks the hip joint in an "abducted" position for extended periods. Other risk factors are firstborn and breech born. In breech position the caput femoris tends to be pushed out of the acetabulum. A narrow uterus also facilitates hip joint dislocation during fetal development and birth. CDH is the sort of hip dysplasia witch is created by a genetic factor witch runs in the family ore who is increased in certain ethnic populations(Native Americans and Sami people). Same studies suggest it has something to do with the hormone relaxine and others suggest it has something to do with chromosone 13.
Conditions can also be bilateral or unilateral. With bilateral dysplasia botch hips are affected. With unilateral dysplasia only one hip is affected.
Hip Dysplacia can be caused by a lot of structural abnormalities like a shallow acetabulum, a femoral or acetabular anteversion, and a decreased head offset or perpendicular distance from the center of the femoral head to the axis of the femoral shaft, a flat ore irregular caput femoris are a few of those bony abnormalities.

Characteristics/Clinical Presentation

Hip dysplasia an be recognized by legs of different length, uneven skin folds on the thigh or asymmetric gluteus folds, Less mobility or flexibility on one side limping, toe walking, or a waddling, duck-like gait.

In 1979 Dr. John F. Crowe et al created a classification to define the degree of malformation and dislocation. This clasification has 4 degrees from less severe(1) to severe(4).

Class Description Dislocation
Crowe I Femur and acetabulum show minimal abnormal development. Less than 50% dislocation
Crowe II The acetabulum shows abnormal development. 50% to 75% dislocation
Crowe III The acetabula is developed without a roof. A false acetabulum develops opposite the dislocated femur head position. The joint is fully dislocated. 75% to 100% dislocation
Crowe IV The acetabulum is insufficiently developed. Since the femur is positioned high up on the pelvis this class is also known as "high hip dislocation". 100% dislocation

Differential Diagnosis

Pain in the hip region can also be caused by hip joint contusion, strain, athlethis pubalgia, osteitis pubis, inflammatory arthritis, osteoarthritis, septic arthritis, piriformis syndrome, snapping hip syndrome, bursitis, femoral head avascular necrosis, fracture, dislocation, tumor, hernia, slipped femoral capital epiphysis, Legg-Calve-Perthes disease, or referred pain from the lumbosacral and sacroiliac areas.

Diagnostic Procedures

Two maneuvers commonly employed for diagnosis in neonatal exams are the Ortolani test and the Barlow test. If the patient feels a ‘click’ ore ‘cluck’ during one of those test it is possible that a hip dysplasia is present. Also X-rays and ultrasound can be used to confirm a hip dysplasia. A ultrasound has proven to be more useful defining the anatomy until the cartilage is ossified. Sometimes an MRI is also used. CT scans or 3D CT scans rarely are used. Sonografic examination is a new diagnostic procedure. Its main disadvantage is that it might lead to over diagnosis, which might cause over treatment.
Other signs of hip dysplasia are asymmetric gluteus folds and an apparent limb-length inequality.

Outcome Measures

Examination


Medical Management

There are a lot of possibilities when you chose for a surgery to treat hip dysplasie. Children have two options. Soft tissue surgery and bony surgery also called osteotomies. The first option is closed reduction. Witch this treatment they try to manipulate the bone structures to correct the joint without surgical exposure of the fragments. The other option of soft tissue surgery is open reduction. This is used when a closed reduction failed to correct the joint. In an open reduction, the surgeon cuts into the hip capsule and re-positions the femoral head. Once the hip is sutured, a spica cast is applied for 4 months or longer to stabilize the hip. Once children are older soft tissue surgery isn’t possible anymore. Then there are the bony surgeries. Here are two options including reshaping and redirecting. With the reshaping treatment the hip socket is reshaped to increase the hip congruention. This is only possible witch children who have pliable bones. Redirecting is performed on older patients who no longer have pliable bone. The surgeon repositions the socket but does not change its shape.
When you are not a child you have the option between two surgeries. The first reshapes, redirects or salvages bone in order to preserve the natural joint for as long as possible. The second option is a hip replacement. Shelf and Chiari osteotomy are some of those salvage procedures. In these cases non-articular cartilage is used to help hold the hip in place. The cartilage added in these procedures is fibrocartilage rather than true articular cartilage. Arthroscopy is a surgical procedure often performed on the soft tissue surrounding the joint. It's a minimally invasive procedure that can postpone more invasive surgery. In some cases where the dysplasia is relatively non-advanced, arthroscopy can rule out the need for further surgery altogether. Also the use of stam cells is possible. These stam cells are used in grafting or by seeding porous arthroplasty prosthesis with autologous fibroblasts or chondrocyte progenitor cells to assist in firmly anchoring the artificial material in the bone bed.
Another option for the treatment are diets. Diatry suplements are often used. Oral glucosamine comes from shellfish (although vegetarian options exist) and may help rebuild cartilage. Another alternative treatment is an anti-inflammatory diet, which may reduce inflammation. Ginger, garlic, green tea and Omega-3 fatty acids may have anti-inflammatory effects and can be found in fish and fish oil supplements, as well as in flaxseed, squash, collard greens, nuts, broccoli, cauliflower and spinach. Certain foods in the nightshade family can increase inflammation. The most common edible nightshades are tomato, potato, eggplant and red pepper.
Also anti-inflammatory medications or NSAIDs can be used.
Doctor can also give steroid shots to reduce inflammation an pain. However some studies have shown that repeated use of cortisone can weaken tendons and soften cartilage.

Physical Therapy Management

The treatment of hip dysplasia depends on the age of the child. The goal of the treatment is to position the hip in the proper position. Once the proper position is obtained the doctor will hold the hip in that position and that will allow the body to adapt to the new position. The younger the child, the better capacity to adapt the hip, and the better chance of full recovery. When the child is younger then 6 month the use of a special brace called a Pavlik harness is used. The brace holds the hips of the baby in the correct position. Over time the joint begins normal formation. About 90% of the newborns treated by de Pevlik harness will recover fully. Also a Frejka Pillow is used but is not indicated in all forms of hip dysplasia. Complications mainly arise because the sheet of the iliopsoas muscle pushes circumflex artery against the neck of the femur and decreases blood flow to the femoral head. When the child is older then 6 months the Pevlik harness may not be successful. In that case a surgeon will place the hip in the proper position under anesthasia. Once in this position the child will be placed in a spica cast. The spica cast is similar to the Pevlik harness but allows less movement. When the child is older surgery is used to position the hip in the proper position. Surgery is needed because the body made scar tissue that prevents the hip from assuming its proper position. After surgery a spica cast is also used. A treatment that in’t often used is traction. Traction exists of the application of a force to stretch certain farts of the body in a certain direction. This will soften the tissue around the caput femoris and will allow the caput femoris to move back in the acetabulum. Traction consists of pulleys, strings, weights, and a metal frame attached over or on the bed. Traction is most often used for approximately 10 to 14 days. The application of ice on the painful regions helps to numb pain and reduces the inflammation.
Regular, low- or non-impact exercise such as swimming, aquatic therapy or cycling train strength and range of motion. Strong muscles will act like shock absorbers and provide greater support for the hip.
Weight loss for those with overweight can significantly reduce the stress on the hip and reduce pain.
Physical therapy can be used to increase strength and flexibility around the joint witch will decrease pain. Physical therapy can also be used to teach the body to better align itself what will lead to a decrease of tress on the joint.

Key Research


James J McCarthy, MD, FAAOS, FAAP. Developmental Dysplasia of the Hip. Sep 23, 2009(C)
van der Linden MH, Kruyt MC, Sakkers RJ, de Koning TJ, Oner FC, Castelein RM. Orthopaedic management of Hurler's disease after hematopoietic stem cell transplantation: a systematic review. Department of Orthopaedics, University Medical Center Utrecht. 2011 Mar 17(B) 


Gharedaghi M, Mohammadzadeh A, Zandi B. Comparison of clinical and sonographic prevalence of developmental dysplasia of the hip. Department of Orthopedic Surgery, Neonatal Research Center, School of Medicine, Mashhad, University of Medical Science, Mashhad, Iran. 2011 Jan.(B)


Engesæter IO, Lehmann T, Laborie LB, Lie SA, Rosendahl K, Engesæter LB. Total hip replacement in young adults with hip dysplasia. The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital. 2011 Mar 24.(C)


Chang CH, Yang WE, Kao HK, Shih CH, Kuo KN. Predictive value for femoral head sphericity from early radiographic signs in surgery for developmental dysplasia of the hip. Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan †Department of Orthopedic Surgery, Chung Shan Hospital ‡Department of Orthopedic Surgery, National Taiwan University Hosptial §College of Medicine, Taipei Medical University, Taipei, Taiwan. 2011 Apr-May. (C)



Sankar WN, Young CR, Lin AG, Crow SA, Baldwin KD, Moseley CF. Risk Factors for Failure After Open Reduction for DDH: A Matched Cohort Analysis. Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA †Shriners Hospitals for Children, Los Angeles, CA. 2011 Apr-May. (C)


Delaney LR, Karmazyn B. Developmental dysplasia of the hip: background and the utility of ultrasound. Department of Radiology, Riley Hospital for Children, Indianapolis, IN. 2011 Apr. (C)


Takao M, Ohzono K, Nishii T, Miki H, Nakamura N, Sugano N. Cementless modular total hip arthroplasty with subtrochanteric shortening osteotomy for hips with developmental dysplasia. Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan. 2011 Mar. (C)


Murnaghan ML, Browne RH, Sucato DJ, Birch J. Femoral nerve palsy in pavlik harness treatment for developmental dysplasia of the hip. The Hospital for Sick Children, Room S-107 Elm Wing, 555 University Avenue, Toronto. 2011 Mar. (C)


Lee YK, Chung CY, Koo KH, Lee KM, Kwon DG, Park MS. Measuring acetabular dysplasia in plain radiographs. Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-Gu, Sungnam-si, Gyeonggi-do, 463-707, Korea. 2011 Mar. (C)


Brurås KR, Aukland SM, Markestad T, Sera F, Dezateux C, Rosendahl K. Newborns With Sonographically Dysplastic and Potentially Unstable Hips: 6-Year Follow-up of an RCT. PhD Department of Paediatric Radiology, Haukeland University Hospital, 5021 Bergen, Norway. 2011 Feb 14. (B)


Akiyama K, Sakai T, Koyanagi J, Yoshikawa H, Sugamoto K. Evaluation of translation in the normal and dysplastic hip using three-dimensional magnetic resonance imaging and voxel-based registration. Dept. of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, Suita, Japan. 2011 Feb 23. (C)

References

Enseki K, Martin R, Draovitch P, Kelly B, Philippon M, Schenker M. The hip joint: Arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther. 2006;36(7):516-525.


Schmerl M, Pollard H, Hoskins W. Labral Injuries of the hip: a review of diagnosis and management. J Manipulative Physiol Ther. 2005;28(8):632.


Sherman S.Coleman.Congenital dysplacia and dislocations of the hip.Mosby.1978.


Reinhard Graf.Hip Somography.Diagnosis and managemant of infant hip dysplacia.Springer-Verslag.2006.Berlin.