Developmental Dysplasia of the Hip Developmental Dysplasia of the Hip Anastacio Kotzias-Neto, MD Anastacio Kotzias-Neto, Bowen, MD J. Richard J. Richard Bowen, MD Anastacio Kotzias-Neto, MD Published by www.datatrace.com Data Trace Publishing Company DEVELOPMENTAL DYSPLASIA OF THE HIP By J. Richard Bowen, MD Anastacio Kotzias-Neto, MD Frontmatter.pmd 1 3/3/2006, 7:21 PM Copyright © 2006 Data Trace Publishing Company All rights reserved, First Edition Printed in the United States of America Published by Data Trace Publishing Company P.O. Box 1239 Brooklandville, Maryland 21022-9978 410-494-4994 Fax: 410-494-0515 ISBN 1-57400-108-6 Library of Congress Cataloging-in-Publication Data Developmental dysplasia of the hip / by J. Richard Bowen, Anastacio Kotzias-Neto.— 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 1-57400-108-6 1. Hip joint—Dislocation—Treatment. 2. Hip joint—Dislocation—Surgery. 3. Pediatric orthopedics. [DNLM: 1. Hip Dislocation, Congenital—surgery. 2. Hip Dislocation, Congenital—therapy. 3. Orthopedic Procedures. WE 860 B786d 2006] I. Kotzias-Neto, Anastacio. II. Title. RD772.B69 2006 617.5'81—dc22 2005034950 Frontmatter.pmd 2 3/3/2006, 7:21 PM CONTENTS CHAPTER 1: INTRODUCTION . 1 DISEASE HISTORY OF DDH . 1 EMBRYOLOGY . 13 ETIOLOGY . 18 INCIDENCE . 22 ANATOMY OF THE HIP . 24 RADIOGRAPHIC MEASUREMENTS . 31 BLOOD AND NERVE SUPPLY TO THE HIP . 41 CHAPTER 2: THE NATURAL HISTORY OF DDH . 47 NATURAL HISTORY OF DYSPLASIA WITHOUT SUBLUXATION . 47 NATURAL HISTORY OF SUBLUXATION . 49 NATURAL HISTORY OF COMPLETE DISLOCATION . 50 CHAPTER 3: DIAGNOSIS OF DDH . 53 EARLY DIAGNOSIS (BIRTH TO 3 MONTHS OF AGE) . 53 DIAGNOSIS FROM 4 MONTHS TO WALKING AGE (ABOUT 1 YEAR) . 64 DIAGNOSIS AFTER WALKING AGE (1 YEAR OF AGE AND OLDER) . 82 CHAPTER 4: TREATMENT OF DDH, BIRTH THROUGH 3 MONTHS OF AGE . 85 FROM BIRTH THROUGH 3 MONTHS OF AGE . 85 INDICATIONS FOR THE USE OF THE PAVLIK HARNESS . 86 ADVANTAGES OF USING THE PAVLIK HARNESS . 86 CONTRAINDICATIONS FOR THE USE OF THE PAVLIK HARNESS . 87 APPLICATION OF THE PAVLIK HARNESS . 87 FUNCTION OF THE PAVLIK HARNESS . 88 TREATMENT WITH THE PAVLIK HARNESS . 88 CHAPTER 5: TREATMENT FROM 4 MONTHS TO WALKING AGE . 95 STEP 1: BRINGING THE FEMORAL HEAD DOWN TO THE JOINT LEVEL . 95 STEP 2: ACHIEVING REDUCTION OF A DISLOCATED HIP . 98 STEP 3: MAINTAINING STABILITY OF THE REDUCTION . 102 Frontmatter.pmd 3 3/3/2006, 7:21 PM iv Developmental and Dysplasia of the Hip CHAPTER 6: TREATMENT AFTER WALKING AGE . 111 CLOSED REDUCTION . 112 OPEN REDUCTION . 112 OPERATIVE REDUCTION TECHNIQUE FOR A DISLOCATED HIP . 113 CHAPTER 7: RESIDUAL DYSPLASIA FOLLOWING TREATMENT . 127 FEMORO-ACETABULAR IMPINGEMENT . 127 PATHOGENESIS OF RESIDUAL DYSPLASIA . 129 ASSESSMENT OF RESIDUAL DYSPLASIA . 134 COMPUTED TOMOGRAPHY . 135 THREE-DIMENSIONAL COMPUTED TOMOGRAPHY ANALYSIS . 142 MAGNETIC RESONANCE IMAGING (MRI) . 134 TREATMENT OF RESIDUAL DYSPLASIA . 147 CHAPTER 8: OSTEOTOMIES FOR THE TREATMENT OF A MATROTATED ACETABULUM . 155 SINGLE INNOMINATE OSTEOTOMIES . 155 DOUBLE INNOMINATE OSTEOTOMIES . 165 TRIPLE INNOMINATE OSTEOTOMIES . 170 CHAPTER 9: OSTEOTOMIES FOR THE TREATMENT OF A CAPACIOUS ACETABULUM . 201 OSTEOTOMY OF PEMBERTON . 203 CHAPTER 10: FEMORAL OSTEOTOMIES . 211 VARUS OSTEOTOMY OF THE PROXIMAL FEMUR . 213 PROCEDURES . 215 CHAPTER 11: AVASCULAR NECROSIS OF THE PROXIMAL FEMUR . 225 CLASSIFICATIONS OF AVN OF THE FEMORAL HEAD . 228 TROCHANTERIC PROCEDURES . 235 CHAPTER 12: OSTEOTOMIES, ARTHRODESIS, AND TOTAL HIP ARTHROPLASTY FOR SALVAGE . 249 SHELF OPERATION . 249 PELVIC OSTEOTOMY OF CHIARI . 258 DOME PELVIC OSTEOTOMY OF KAWAMURA . 265 OPERATIVE HIP DISLOCATION BY GANZ ET AL. 268 ARTHROSCOPY OF THE HIP BY BOWEN . 270 PELVIC SUPPORT OSTEOTOMY AND FEMORAL LENGTHENING . 271 TOTAL HIP ARTHROPLASTY . 283 HIP ARTHRODESIS . 285 REFERENCES . 293 INDEX . 319 Frontmatter.pmd 4 3/3/2006, 7:21 PM Chapter One IIIntroductionntroductionntroduction Many thousands of children have been prevented from being crippled since orthopae- dists learned to treat developmental dysplasia of the hip (DDH) effectively. DDH is a condition caused by abnormal development of the hip joint that presents clinically in infancy as a wide spectrum of abnormalities. These abnormalities can range from instabil- ity to complete dislocation of the joint. In utero, the hip with DDH is thought to form normally during the fetal period of development and to undergo abnormal growth of the chondro-osseous components during the embryonic period. The precise etiology of DDH is unknown; however, both genetic and environmental factors have statistical associa- tions. In some infants, mild dysplasia will resolve spontaneously; however, in others the untreated hip abnormality will become progressively worse, resulting in pain, limited motion, an abnormal gait, and eventually degenerative arthritis in adulthood. Untreated severe dysplasia or dislocation of the hip results in an abnormal gait and degenerative arthritis in young adulthood. When the abnormalities of DDH are diagnosed and treat- ment is started soon after birth, the outcome is generally good; however, when treatment is delayed, the outcome is often poor. DDH has also been called congenital dislocation (and dysplasia) of the hip (CDH). The authors believe both names correctly describe some components of the condition, and they often use the names interchangeably. “Congenital dysplasia of the hip” implies that the hip is abnormal at birth, distinguishing this condition from other diseases that cause dysplasia and dislocation in childhood, such as cerebral palsy, polio, muscular dystrophy, and other neuromuscular diseases. “Developmental dysplasia of the hip” emphasizes that the etiology is a developmental abnormality that results in a hip disorder with a wide spectrum of prob- lems, ranging from instability to complete (frank) dislocation. DDH is currently the most popular name for this condition and is therefore the one that will be used in this text. This text will cover many concepts of developmental dysplasia of the hip and will include a brief history of some important articles, normal and dysplastic hip development, screening and diagnosis, and treatment, with outcomes and complications. DISEASE HISTORY OF DDH Prior to Its Recognition as a Disease The disability of a dislocated hip has been mentioned for centuries, but understanding of the condition was poor. Hippocrates (460–357 BC)257 clearly described the disabling chapter1.pmd 1 3/4/2006, 5:37 PM 2 Developmental Dysplasia of the Hip effects of a dislocation of the hip. The British Museum has a specimen of a dysplastic hip from Neolithic times and a bronze figurine with congenital dislocation from Hellenistic times. Although the disability of infantile dislocated hip was very well known in the Medi- terranean world by the end of the first millennium BC, its etiology was poorly understood. In France, Andry mentioned the condition in 1741.9 Hip dislocation was considered either accidental or spontaneous (symptomatic) until Guillaune Dupuytren (1777–1835) de- scribed a failure of fetal hip development and classified it as a third variety called “original or congenital dislocation.”137,138 He considered the condition incurable. Recognition of DDH as a Disease The first classical monograph about congenital hip dislocation was written by Charles Gabriel Pravaz of Lyon in 1837.468 For treatment he recommended manipulation of the hip in extension and abduction, with pressure on the greater trochanter to bring the femoral head into the acetabulum. The reduction was maintained by prolonged traction. Paci (1887)442 and Adolf Lorenz355,356 described a forcible reduction by manipulation and cast- ing (frog-leg position), which was later modified by Denuce (1898);125,126 however, compli- cations of these treatments were common and severe. At the turn of the twentieth century, the diagnosis of a congenital dislocated hip was usually made in older children of walking age: the reduction was by forceful manipulation, maintenance of reduction was by splinting the hip in abduction, and the results were frequently poor. Medical attention was then directed toward more effective techniques of reducing dislocated hips in older children of walking age. Lange developed a method of traction on the extended thigh and application of hip flexion and abduction to obtain the reduction.335 The reduction was then maintained by casting. Putti470,471 recognized the problems of forceful reductions in older children and emphasized the importance of early diagnosis and treat- ment. He even suggested the necessity of beginning treatment at the moment the deformity was observed, even on the day of birth. Most of the classic historical articles address treat- ment of the persistently dislocated hip, but few had satisfactory outcomes. Craig100,101 in- troduced an overhead traction technique to reduce the hip into the acetabulum; the re- duction was held by a cast or splint. In 1964, Hoffmann-Daimler261 developed a flexible bandage in which the hip was flexed and abducted at a slow pace and the reduction was accomplished in 8 to 14 days. Hanausek developed an apparatus with a metallic base plate and movable thigh supports, which were adjusted to achieve the reduction.29 Kramer used traction and developed pathways of hip reduction by gradual flexion and abduction of the hip.324 Fettweis157 developed a technique of hip reduction using a squatting-position cast. These techniques often required prolonged hospitalization and had a significant rate of complication. Gradually the knowledge developed that diagnosis at an early age and gen- tle reduction were necessary for success. Diagnosis of DDH at an Early Age Ortolani,438,440 an Italian paediatrician, believed that congenital hip dysplasia was the result of endogenous factors involving heredity and mechanical exogenous factors influ- encing the fetal hip in utero. He examined the hips of three generations and found heredi- chapter1.pmd 2 3/4/2006, 5:37 PM Introduction 3 B C A Figure 1-1 Ortolani test. A, B. With the pelvis stabilized, the leg is abducted and with pressure over the greater trochanter the femoral head is felt to reduce into the acetabulum. C.