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The Canadian Orthopaedic Association
Current Concepts in the Treatment of DDH l
Timothy P. Carey, M.D., FRCSC
Children's Hospital of Western Ontario
London, ON
Introduction
Developmental Dysplasia of the Hip (DDH) is a term that has been adopted to represent the spectrum of abnormalities that can involve the growing hip. It is well recognized that early diagnosis of DDH allows intervention that results in a favourable alteration of the natural history of the condition1. Unfortunately orthopaedic surgeons are still occasionally faced with late diagnosed cases that represent a greater challenge to achieving good long-term function of the hip joint. It is useful, therefore, to separate review of the clinical management of DDH into early presentation cases (birth to 6 months) and late presentation cases (>6 months to 4 years).
Diagnosis and Screening
The clinical signs of neonatal hip instability (NHI) are well recognized by orthopaedic surgeons. However, in most clinical situations the orthopaedic surgeon is not the first point of contact, and children with NHI are only referred for assessment if the screening exam is positive. Thus, it is incumbent upon the health care practitioners evaluating newborn infants to be well trained in the clinical assessment of hip stability. Although the efficacy of clinical screening programmes has been reported in the literature2, 3, the Ortolani and Barlow tests for NHI can be unreliable in less experienced hands, resulting in both false positive and false negative results4, 5. Sensitivity is improved with well-trained examiners and orthopaedic surgeons are in a position to contribute to the education of these individuals6.
Due to concerns regarding the adequacy of clinical detection, ultrasound has become widely used in the diagnosis of hip disorders in infants over the past decade7,8,9. Some have advocated universal ultrasonographic screening of all neonatal hips, while others feel it should be reserved for selective screening of high-risk patients10. Numerous papers looking at the role of ultrasonographic screening have been published, and the use of universal screening programmes has not been clearly supported11, 12, 13, 14, 15. A recent prospective randomized trial from Norway suggested that in the presence of a high quality clinical screening programme, the addition of ultrasonography did not significantly reduce the incidence of late presenting dysplasia16. The clinical practise guidelines of the American Academy of Pediatrics echo this position, recommending clinical screening of all infants at birth, at two weeks, and periodically afterwards at regular visits17. Obviously unstable hips are referred for early assessment by an orthopaedic surgeon. Imaging is reserved for equivocal cases with suspicious physical findings, although ultrasonography prior to 4-6 weeks of life is not recommended. Imaging (defined as ultrasonography at six weeks or pelvic radiography at four months) is also recommended for high-risk cases, defined as female breech presentations and possibly male breech presentations and females with a positive family history. The Canadian Task Force on Preventive Health Care came to similar conclusions, although they did not feel the evidence for screening with imaging was very strong in the high-risk groups mentioned above18.
Further work on the effectiveness of screening programmes will hopefully lead to a standardization of the level of care and a reduction in the incidence of late presenting DDH, although regardless of screening an incidence of DDH of 1 per 5,000 infants at 18 months age is reported.
Treatment from Birth to Six Months
Frank hip dislocations require treatment as soon as diagnosed. Treatment is also indicated in lesser degrees of hip instability if they persist past 2-3 weeks of life. The Pavlik harness has become the mainstay of treatment in this age group, with a reported success rate of greater than 90% and an acceptably low rate of complications19. Most physicians use a similar protocol of three months treatment after hip stability has been obtained, with weaning commencing at about the 6-8 week mark if there is clinical and ultrasonographic evidence of stability. Most reported problems with the harness occur in infants with dislocated hips, and every effort must be made to obtain a reduction within 2-3 weeks of the institution of treatment, and to confirm this ultrasonographically and clinically. If reduction has not occurred by this time, the use of the harness must be abandoned. Closed reduction and casting under general anaesthesia is usually required in this situation, although rarely, open reduction can be necessary. The risk of complications, particularly avascular necrosis, is significantly increased with these treatment methods20.
Treatment Greater than Six Months of Age
The pathoanatomy of the dysplastic hip becomes progressively more difficult to correct as the child matures. After approximately six months of age, a more aggressive approach to DDH will usually be required to obtain a good functional result. An algorithmic approach is employed, starting with a closed reduction under general anaesthesia, usually associated with an adductor tenotomy and an arthrogram to confirm a concentric reduction21. Preoperative traction remains a controversial topic, as available evidence in the literature of its effectiveness is lacking. Hip spica cast application after closed reduction is a technically demanding procedure, and requires appropriate equipment and assistance. CT scans are mandatory after both closed and open reductions, to both confirm reduction and to assess leg position. Post reduction positioning in the hip spica cast is critical to successful treatment, both in terms of achieving and maintaining a reduction, and in preventing the significant complication of avascular necrosis. The concept of the "safe zone" representing the arc of hip abduction between the position at which the femoral head becomes unstable and the position of maximum passive hip abduction is well established. With respect to the position of hip immobilization in the spica cast after closed reduction, post reduction CT scan studies have shown that a hip abduction angle of greater than 55° is associated with increased risk of avascular necrosis22.
In patients who fail closed reduction, treatment progresses to open reduction and capsulorrhaphy. Older children (>2 years) often require femoral shortening osteotomies as part of the treatment, and pelvic osteotomies are also frequently done to aid stability and improve the residual acetabular dysplasia which has less potential for remodelling.
Conclusion
DDH represents a spectrum of hip abnormalities in the growing child. Early diagnosis and intervention affords the highest chance of normal long-term hip function, and the complexity of treatment correlates directly with age of diagnosis. Every effort should be made to ensure adequate programmes are in place for screening and identifying infants with DDH at an early age.
References
1. Haynes R.J. Developmental dysplasia of the hip: etiology, pathogenesis, and examination and physical findings in the newborn. Instr Course Lect. 2001;50:535-40.
2. Macnicol M.F. Results of a 25 year screening programme for neonatal instability. J Bone Joint Surg 1990; 72-B: 1057–60.
3. Tredwell S.J. Neonatal screening for hip joint instability. Its clinical and economic relevance. Clin Orthop. 1992 Aug;(281):63-8.
4. Ortolani M. Un segno poco noto e sua importanza per la diagnosi precoce di prelussazione conenita dell'anca. Pediatria 1937;45:129-36.
The Canadian Orthopaedic Association
Current Concepts in the Treatment of DDH l
Timothy P. Carey, M.D., FRCSC
Children's Hospital of Western Ontario
London, ON
Introduction
Developmental Dysplasia of the Hip (DDH) is a term that has been adopted to represent the spectrum of abnormalities that can involve the growing hip. It is well recognized that early diagnosis of DDH allows intervention that results in a favourable alteration of the natural history of the condition1. Unfortunately orthopaedic surgeons are still occasionally faced with late diagnosed cases that represent a greater challenge to achieving good long-term function of the hip joint. It is useful, therefore, to separate review of the clinical management of DDH into early presentation cases (birth to 6 months) and late presentation cases (>6 months to 4 years).
Diagnosis and Screening
The clinical signs of neonatal hip instability (NHI) are well recognized by orthopaedic surgeons. However, in most clinical situations the orthopaedic surgeon is not the first point of contact, and children with NHI are only referred for assessment if the screening exam is positive. Thus, it is incumbent upon the health care practitioners evaluating newborn infants to be well trained in the clinical assessment of hip stability. Although the efficacy of clinical screening programmes has been reported in the literature2, 3, the Ortolani and Barlow tests for NHI can be unreliable in less experienced hands, resulting in both false positive and false negative results4, 5. Sensitivity is improved with well-trained examiners and orthopaedic surgeons are in a position to contribute to the education of these individuals6.
Due to concerns regarding the adequacy of clinical detection, ultrasound has become widely used in the diagnosis of hip disorders in infants over the past decade7,8,9. Some have advocated universal ultrasonographic screening of all neonatal hips, while others feel it should be reserved for selective screening of high-risk patients10. Numerous papers looking at the role of ultrasonographic screening have been published, and the use of universal screening programmes has not been clearly supported11, 12, 13, 14, 15. A recent prospective randomized trial from Norway suggested that in the presence of a high quality clinical screening programme, the addition of ultrasonography did not significantly reduce the incidence of late presenting dysplasia16. The clinical practise guidelines of the American Academy of Pediatrics echo this position, recommending clinical screening of all infants at birth, at two weeks, and periodically afterwards at regular visits17. Obviously unstable hips are referred for early assessment by an orthopaedic surgeon. Imaging is reserved for equivocal cases with suspicious physical findings, although ultrasonography prior to 4-6 weeks of life is not recommended. Imaging (defined as ultrasonography at six weeks or pelvic radiography at four months) is also recommended for high-risk cases, defined as female breech presentations and possibly male breech presentations and females with a positive family history. The Canadian Task Force on Preventive Health Care came to similar conclusions, although they did not feel the evidence for screening with imaging was very strong in the high-risk groups mentioned above18.
Further work on the effectiveness of screening programmes will hopefully lead to a standardization of the level of care and a reduction in the incidence of late presenting DDH, although regardless of screening an incidence of DDH of 1 per 5,000 infants at 18 months age is reported.
Treatment from Birth to Six Months
Frank hip dislocations require treatment as soon as diagnosed. Treatment is also indicated in lesser degrees of hip instability if they persist past 2-3 weeks of life. The Pavlik harness has become the mainstay of treatment in this age group, with a reported success rate of greater than 90% and an acceptably low rate of complications19. Most physicians use a similar protocol of three months treatment after hip stability has been obtained, with weaning commencing at about the 6-8 week mark if there is clinical and ultrasonographic evidence of stability. Most reported problems with the harness occur in infants with dislocated hips, and every effort must be made to obtain a reduction within 2-3 weeks of the institution of treatment, and to confirm this ultrasonographically and clinically. If reduction has not occurred by this time, the use of the harness must be abandoned. Closed reduction and casting under general anaesthesia is usually required in this situation, although rarely, open reduction can be necessary. The risk of complications, particularly avascular necrosis, is significantly increased with these treatment methods20.
Treatment Greater than Six Months of Age
The pathoanatomy of the dysplastic hip becomes progressively more difficult to correct as the child matures. After approximately six months of age, a more aggressive approach to DDH will usually be required to obtain a good functional result. An algorithmic approach is employed, starting with a closed reduction under general anaesthesia, usually associated with an adductor tenotomy and an arthrogram to confirm a concentric reduction21. Preoperative traction remains a controversial topic, as available evidence in the literature of its effectiveness is lacking. Hip spica cast application after closed reduction is a technically demanding procedure, and requires appropriate equipment and assistance. CT scans are mandatory after both closed and open reductions, to both confirm reduction and to assess leg position. Post reduction positioning in the hip spica cast is critical to successful treatment, both in terms of achieving and maintaining a reduction, and in preventing the significant complication of avascular necrosis. The concept of the "safe zone" representing the arc of hip abduction between the position at which the femoral head becomes unstable and the position of maximum passive hip abduction is well established. With respect to the position of hip immobilization in the spica cast after closed reduction, post reduction CT scan studies have shown that a hip abduction angle of greater than 55° is associated with increased risk of avascular necrosis22.
In patients who fail closed reduction, treatment progresses to open reduction and capsulorrhaphy. Older children (>2 years) often require femoral shortening osteotomies as part of the treatment, and pelvic osteotomies are also frequently done to aid stability and improve the residual acetabular dysplasia which has less potential for remodelling.
Conclusion
DDH represents a spectrum of hip abnormalities in the growing child. Early diagnosis and intervention affords the highest chance of normal long-term hip function, and the complexity of treatment correlates directly with age of diagnosis. Every effort should be made to ensure adequate programmes are in place for screening and identifying infants with DDH at an early age.
References
1. Haynes R.J. Developmental dysplasia of the hip: etiology, pathogenesis, and examination and physical findings in the newborn. Instr Course Lect. 2001;50:535-40.
2. Macnicol M.F. Results of a 25 year screening programme for neonatal instability. J Bone Joint Surg 1990; 72-B: 1057–60.
3. Tredwell S.J. Neonatal screening for hip joint instability. Its clinical and economic relevance. Clin Orthop. 1992 Aug;(281):63-8.
4. Ortolani M. Un segno poco noto e sua importanza per la diagnosi precoce di prelussazione conenita dell'anca. Pediatria 1937;45:129-36.
Observações:
ResponderExcluir- Na suspeita clínica, em menores de 4 a 6 semanas a USG não é recomendada.
- Casos de alto risco, apresentação pélvica e em meninas com história familiar, indica-se USG na 6a. semana ou radiografia pélvica aos 4 meses de idade.
- A AAP recomenda triagem clínica de todas as crianças ao nascimento, com 2 semanas de vida e periodicamente nas consultas pediátricas.
- Considera-se diagnóstico precoce quando do nascimento até 6 meses e tardio quando maior de 6 meses até os 4 anos.
- Tratamento do nascimento aos 6 meses de idade geralmente o suspensório de Pavlik (sucesso de 90% ou mais) e em maiores de 6 meses de idade geralmente tratamento cirúrgico. Após a redução fechada ou aberta sempre deve ser realizado CT scan.