Ddh 1

transcript

Developmental

Dysplasia of the Hip

Chair Person:

Dr.C.V.Mudgal

By: Dr.S.C.Hiremath

Adolph Lorenz, an early pioneer in the

treatment of developmental dislocation

of the hip

Overview

Introduction

Normal Development of the Hip

Etiology and Pathoanatomy

Epidemiology and Diagnosis

Treatment

Complications

Introduction:

• Developmental dysplasia of the hip is the condition in which the femoral head has an abnormal relationship to the acetabulum. Developmental dysplasia of the hip includes frank dislocation (luxation), partial dislocation (subluxation), instability wherein the femoral head comes in and out of the socket, and inadequate formation of the acetabulum.

Previously known as congenital dislocation of the hip implying a condition that existed at birth

developmental encompasses embryonic, fetal and infantile periods

includes congenital dislocation and developmental hip problems including subluxation, dislocation and dysplasia

Etiology and Epidemiology Multifactorial

Genetics and Syndromes○ Ehler’s Danlos○ Arthrogryposis○ Larsen’s syndrome

Intrauterine environmental factors○ Teratogens○ Oligohydramnios)○ breech

Neurologic Disorders: Spina Bifida ligamentous laxity

familial trait

Left : Right – 4 : 1

Breech : DDH ≥ x 10

Amniotic fluid↓ : moulded baby

- plagiocephaly

- scoliosis

- foot deformity

- skew pelvis

Postnatal positioning in extension, as in this child on

a Native American cradleboard, contributes to

developmental dysplasia of the hip

Normal Growth and

Development

Embryologically the acetabulum, femoral

head develop from the same primitive

mesenchymal cells

cleft develops in precartilaginous cells at 7th

week and this defines both structures

11wk hip joint fully formed

acetabular growth continues throughout intrauterine life with development of labrum

By birth femoral head is deeply seated in acetabulum by surface tension of synovial fluid and very difficult to dislocate

in DDH this shape and tension is abnormal in addition to capsular laxity

The cartilage complex is 3D with triradiate medially and cup-shaped laterally and interposed between ilium above and ischium below and pubis anteriorly

acetabular cartilage forms outer 2/3 cavity and the non-articular medial wall form by triradiate cartilage which is the common physis of these three bones

fibrocartilaginous labrum forms at margin of acetabular cartilage and joint capsule inserts just above its rim

articular cartilage covers portion articulating with femoral head

opposite side is a growth plate with degenerating cells facing towards the

pelvic bone

triradiate cartilage is triphalanged with each side of each limb having a

growth plate which allows interstitial growth within the cartilage causing

expansion of hip joint diameter during growth

In the infant the greater trochanter, proximal femur and intertrochanteric

portion is cartilage

By 4-7 months proximal ossification center appears which enlarges until

adult life when only thin layer of articular cartilage persists

Development cont..

Experimental studies in humans with unreduced hips suggest the main stimulus for concave shape of the acetabulum is presence of spherical head

for normal depth of acetabulum to increase several factors play a role

spherical femoral head

normal appositional growth within cartilage

periosteal new bone formation in adjacent pelvic bones

development of three secondary ossification centers

normal growth and development occur through balanced growth of proximal femur, acetabulum and triradiate cartilages and the adjacent bones

DDH Tight fit between head and acetabulum is absent and head can

glide in and out of acetabulum

hypertrophied ridge of acetabular cartilage in superior, posterior

and inferior aspects of acetabulum called “ neolimbus”

98% DDH that occur around or at birth have these changes and

are reversible in the newborn

2% newborns with teratologic or antenatal dislocations and no

syndrome have these changes

Development in treated DDH different from normal hip

goal is to reduce the femoral head to provide the stimulus

for acetabular development

Concentric reduction maintainance is essential for

recovery and resumption of normal growth

age at which DDH hip can still return to normal is

controversial and depends on

age at reduction

growth potential of acetabulum

damage to acetabulum from head or during reduction

Epidemiology

1 in 100 newborns examined have evidence of instability

( positive Barlow or Ortolani)

1 in 1000 live births true dislocation

Barlow stated that 60% stabilize in 1st week and 88%

stabilize in first 2 months without treatment remaining

12% true dislocations and persist without treatment

Incidence

-1 in 1000 live birth.

-male to female ratio 4:1

-family history 1:7

Normal Anatomy

Hip starts from common mesenchymal

block of tissue

7th week cleft forms to separate head

11th week hip fully formed

Acetabulum gets shallower close to birth

Normal Hip

Tight fit of head in

acetabulum

Transection of capsule

Still difficult to dislocate

Surface tension

Pathoanatomy

Ranges from mild dysplasia --> frank

dislocation

Bony changes

Shallow acetabulum

Typically on acetabular side

Femoral anteversion

Pathoanatomy

Soft tissue changes

Usually secondary to prolonged subluxation or

dislocation

Intra articular

Labrum

○ Inverted + adherent to capsule (closed reduction with inverted

labrum assoc with increased Avascular Necrosis)

Ligamentum teres

○ Hypertrophied + lengthened

Pulvinar

○ Fibrofatty tissue migrating into acetabulum

Pathoanatomy

Soft Tissue (Intra articular)

Transverse acetabular ligament

○ Contracted

Limbus

○ Fibrous tissue formed from capsular tissue interposed between everted labrum and acetabular rim

Extra articular

Tight adductors (adductor longus)

Iliopsoas

Teratological DDH

Irreducible

False acetabulum

Defective anterior acetabulum

“anteverted”

Increased femoral neck

anteversion

Arthrogryposis with dislocations

& delivery fracture

False acetabulum

Associated

conditions

-torticollis

-metatarsus adducts

-calcaneo valgus

-talipus varus

-plagiocephaly

CLINACAL

PRESENTATION

Neonatal Presentation

Exam one hip at a time

Baby must be quiet

Barlow’s sign: provocative maneuver

Ortolani’s sign: reduces hip

Other signs not helpful in newborn

Ortolani’s Maneuver

After 3 months of age

tests become negative

The Ortolani test for developmental dislocation of the hip in a

neonate.A, The examiner holds the infant's knees and

gently abducts the hip while lifting up on the greater trochanter with two

fingers.B, When the test is positive, the dislocated femoral head will fall

back into the acetabulum (arrow) with a palpable (but not audible) “clunk”

as the hip is abducted (Ortolani's sign). When the hip is adducted, the

examiner will feel the head redislocate posteriorly.

The Barlow test for developmental dislocation of the hip in a neonate.A, With the infant

supine, the examiner holds both of the child's knees and gently adducts one hip and

pushes posteriorly.B, When the examination is positive, the examiner will feel the femoral

head make a small jump (arrow) out of the acetabulum (Barlow's sign). When the

pressure is released, the head is felt to slip back into place.

Infant Presentation

Skin fold asymmetry

Limited hip abduction

Unequal femoral lengths (Galeazzi’s

(Flex both hips and one side shows

apparent femoral shortening)

Skin fold asymmetry

Asymmetrical thigh folds

Galeazzi’s sign

Developmental dysplasia of the right hip. One physical

finding is limited abduction of the affected hip.

After Walking Age

Trendelenberg gait

Leg length discrepancy

Increased lumbar lordosis in Bilateral

dislocation

Klisic test positive

The examiner places the middle finger over the greater trochanter, and the index

finger on the anterior superior iliac spine.A, With a normal hip, an imaginary line

drawn between the two fingers points to the umbilicus.B, When the hip is

dislocated, the trochanter is elevated and the line projects halfway between the

umbilicus and the pubis.

hyperlordosis –

bilateral involvement

Which hip dysplasia

pain? Complete dislocation with

no false acetabulum:

Complete dislocation with

false acetabulum:

Subluxation:

Imaging

X-rays

Femoral head ossification center

○ 4 -7 months

Ultrasound

Arthrograms

Open vs closed reduction

Radiography

Hilgenreiner's line is drawn through the triradiate cartilages. Perkin's line is drawn

perpendicular to Hilgenreiner's line at the margin of the bony acetabulum.

Shenton's line curves along the femoral metaphysis and connects smoothly to the

inner margin of the pubis

Imaging

Radiographs

Imaging

Radiographs

Imaging

Radiographs

Imaging

Radiographs

Imaging

Acetabular Index

The acetabular index is the angle between a line drawn along the margin

of the acetabulum and Hilgenreiner's line; it averages 27.5 degrees in

normal newborns and decreases with age.

Acetabular Index

Imaging

Acetabular Index < 30 wnl

Imaging

Wilberg's center-edge angle, the angle between Perkin's line and a line drawn

from the lateral lip of the acetabulum through the center of the femoral head.

considered normal if greater than 10 degrees in children 6 to 13 years of age, and

it increases with age.

Radiographs Summary

Femoral head appears 4 - 7 months

Shenton’s line

Perkin’s and Hilgenreiner’s lines Inferomedial quadrant

Center Edge Angle of WILBERG (< 20 abnormal)

Acetabular index Normal < 30 (Weintroub et al)

TEAR DROP SIGN

Acetabular TEAR DROP SIGN appears between 6 & 24 months in normal hip, but later in case of ddh.

Wall of acetabulum laterally, wall of lesser pelvis medially,acetabularnotch inferiorly.

U shaped teardrop

V shaped teardrop- Dysplastic hips and poor outcome

TEAR DROP

VON ROSEN VIEW

Both hips abducted, intrernally rotated

and extended.

NORMAL- Imaginary line from shaft of

femur extending upwards intersects the

acetabulum

DDH- Line crosses above acetabulum

Imaging

Ultrasound

Introduced in 1978 for eval of DDH

Operator dependent

Useful in confirming subluxation, identifying

dysplasia of cartilaginous acetabulum,

documenting reducibility

Prox Femoral Ossification Center interferes

Requires a window in spica cast.

Ultra sound BOTH morphologic assessment and dynamic

anatomical characteristics

○ alpha angle: slope of superior aspect bony

acetabulum

○ beta angle: cartilaginous component (problems with

inter and intraobserver error )

dynamic

○ Observing events occuring with Barlow and ortolani

tests.

•Alpha angle = between line of ilium & bony acetabulum

•Beta angle (less important) = between line of ilium & anterior labrum

http://emedicine.medscape.com/article/408225

Measures acetabular depth. Normal >60 degrees

Acetabular cartilaginous roof coverage.

Normal <55 degreesSmaller angle= better bony

coverage

Ultrasound

Femoral head

Abductors

Ultrasound

Femoral head

Abductors

Ultrasound

Femoral head

Abductors

Ultrasound

Femoral head

Abductors

Ultrasound

Graf’s alpha

Ultrasound

Graf’s alpha

>60 = normal

*line through

ilium bisects

head 50/50

• Type 1: mature hip joint with narrow, covering cartilaginous roof• Type 2 (a+, a-, b, c, d): range from immature to dysplastic• Type 3&4: both diplaced, range of severity• *This classification system has good reliability with Type 1 hips,

but recently has been scrutinized regarding inter and intra-observer reliability with all other Types.

Graf grading of DDH by

ultrasound

•Indications controversial due to high levels

of overdiagnosis and not currently

recommended as a routine screening tool

other than in high risk patients

•Best indication is to assess treatment

•Guided reduction of dislocated hip or check

reduction and stability during Pavlik harness

treatment

Arthrogram

Head shape

Congruity

Articularcartilage

Labrum

Arthrogram

•Limbus - 'Rose thorn sign' of inverted

labrum between femoral head & acetabulum

•Hour glass constriction of capsule - by

psoas tendon

•Capsular distension

Arthrogram in DDH

SUBLUXATED HIP DISLOCATED HIP

•Eliciting Medial pooling of dye

•(normal = < 7mm)

•Confirms reduction after surgery

Dye pooling <7mm & complete reduction

with arthrogram = no need for open

reduction.

Natural History

in Newborns Barlow

1 in 60 infants have instability ( positive Barlow)

60% stabilize in 1st week

88% stabilize in 2 months without treatment

12 % become true dislocations and persist

Coleman

23 hips < 3 months

26% became dislocated

13 % partial contact with acetabulum

39% located but dysplastic feature

22% normal

As it is not possible to predict the outcome, all infants with instability should be treated

Adults Variable

depends on 2 factors

well developed false acetabulum ( 24 % chance good result vs 52 % if

absent)

bilaterality

in absence of false acetabulum patients maintain good ROM with little

disability

femoral head covered with thick elongated capsule

false acetabulum increases chances degenerative joint disease

hyperlordosis of lumbar spine assoc with back pain

unilateral dislocation has problems

leg length inequality, knee deformity , scoliosis and gait

disturbance

Dysplasia and Subluxation

Dysplasia (anatomic and radiographic def’n)

inadequate development of acetabulum, femoral head or both

All subluxated hips are anatomically dysplastic

Radiologically difference between subluxated and dysplastic hip is disruption of Shenton’s line

subluxation: line disrupted, head is superiorly, superolaterally ar laterally displaced from the medial wall

dysplasia: line is intact

Important because natural history is different

A 36-year-old woman with bilateral anatomically abnormal

(dysplastic) hips. The left hip is radiographically subluxated, with

the Shenton line disrupted, and the right hip is radiographically

dysplastic, with the Shenton line intact.

Seven years later, note the marked loss of joint space

in the secondary acetabulum of the left hip and very

early disruption of the Shenton line on the right.

Natural History Con’t

Subluxation predictably leads to degenerative joint disease

and clinical disability

mean age symptom onset 36.6 in females and 54 in men

severe xray changes 46 in female and 69 in males

Cooperman

OUT OF 32 hips with CE angle < 20 without subluxation

BY 22 years all had x ray evidence of Degenerative Joint

Disease

no correlation between angle and rate of development

concluded that radiologically apparent dysplasia leads to

DJD but process takes decades

Treatment Options

Age of patient at presentation

Family factors

Reducibility of hip

Stability after reduction

Amount of acetabular dysplasia

Treatment 0 to 6 months

Goal is TO obtain reduction and maintain reduction to provide optimal environment for femoral head and acetabulardevelopment

Lovell and Winter

Treatment should be initiated immediately on diagnosis

AAOS (July,2000)

subluxation often corrects after 3 weeks and may be observed without treatment

if persists on clinical exam or ultrasound beyond 3 weeks treatment indicated

actual dislocation diagosed at birth treatment should be immediate

Treatment con’t

Pavlik Harness preferred

prevents hip extension and adduction but allows

flexion and abduction which lead to reduction and

stabilization

success 95% if maintained full time six weeks

In child > 6 months of age, success is < 50% as it is

difficult to maintain active child in harness

Pavlik Harness

Chest strap at nipple line

shoulder straps set to hold cross strap at this level

anterior strap flexes hip 100-110 degrees

posterior strap prevents adduction and allow comfortable abduction

safe zone arc of abduction and adduction that is between redislocation and comfortable unforced abduction

Pawlik harness

The transverse chest strap should be placed just below the

nipple line. The hips should be flexed to 120 degrees, and

the posterior straps should not produce forced abduction.

Pawlik contd..

Indications include presence of reducible hip femoral head directed toward triradiate cartilage on xray

follow weekly intervals by clinical exam and US for two weeks and if not reduced other methods are pursued

once successfully reduced, harness is continued for childs age at stability + 3 months

end of weaning process---- xray pelvis obtained--- and if normal

discontinue harness

Complications

Failure

poor compliance , inaccurate position and persistence of inadequate treatment

subgroup where failure may be predictable

○ absent Ortolani sign

○ bilateral dislocations

○ treatment commenced after age 7 week

NEXT Treatment is closed reduction and SpicaCasting

Femoral Nerve Compression 2 to hyperflexion

Inferior Dislocation

Skin breakdown

Avascular Necrosis

The Ilfeld or Craig splint

Von Rosen splint

6 months to 2 years age Closed reduction and spica cast immobilization

recommended

traction controversial with theoretical benefit of gradual stretching of soft tissues impeding reduction and neurovascular bundles to decrease AVN

skin traction preferred however vary with surgeon

usually 1-2 weeks

scientific evidence supporting this is lacking

Treatment contd.. closed reduction preformed in OR under general anesthetic

manipulation includes flexion, traction and abduction

percutaneous or open adductor tenotomy necessary in most cases to increase safe zone which lessen incidence of proximal femoral growth disturbance

reduction must be confirmed on arthrogram as large portion of head and acetabulum are cartilaginous

dynamic arthrography helps with assessing obstacles to reduction and adequacy of reduction

Treatment

reduction maintained in spica cast well molded to greater trochanter to prevent redislocation

human position of hyperflexion and limited abduction preferred

avoid forced abduction with internal rotation as increased incidence of proximal femoral growth disturbance

cast in place for 6 weeks then repeat Ct scan to confirm reduction

casting continued for 3 months at which point removed and xraydone then placed in abduction orthotic device full time for 2 months then weaned

Closed Reduction and Casting for Developmental

Dislocation of the Hip

Safe Zone

20 to 30 degrees frommaximum abduction

extended to below 90 degreeswithout redislocation

Safe zone can be improvedwith adductor tenotomy

Failure of Closed Methods

Open reduction indicated if failure of closed reduction,

persistent subluxation, reducible but unstable other

than extremes of abduction

variety of approaches

anterior smith peterson most common

○ allows reduction and capsular plication and

secondary procedures

○ Disadvantages - more blood loss, damage to iliac

apophysis and abductors, stiffness

Open Reduction

Medial approach ( between adductor brevis and magnus)

○ approach directly over site of obstacles with minimal soft tissue dissection

○ unable to do capsular plication so depend on cast for post op stability

anteromedial approach Ludloff ( between neurovascular bundle and pectineus)

○ direct exposure to obstacles, minimal muscle dissection

○ no plication or secondary procedures

○ increased incidence of damage to medial femoral circumflex artery and higher AVN risk

Open Reduction

Follow-up after open reduction

Abduction orthotic braces commonly used until acetabulardevelopment is caught up to normal side

in assessing development look for accessory ossification centers to see if cartilage in periphery has potential to ossify

secondary acetabular procedure rarely indicated < 2 years as potential for development after closed and open procedures is excellent and continues for 4-8 years

most rapid improvement measured by acetabular index , development of teardrop occurs in first 18 months after surgery

femoral anteversion and coxa valga also resolve during this time

Obstacles to Reduction

Extra- articular

Iliopsoas tendon

adductors

Intra-articular

inverted hypertrophic labrum

tranverse acetabular ligament

pulvinar, ligamentum teres

constricted anteromedial capsule in late cases

neolimbus is not an obstacle to reduction and represents epiphyseal cartilage that must not be removed as this impairs acetabular development

Age greater than 2 years

Open reduction usually necessary

54% AVN and 32% redislocation with use of skeletal

traction in ages > 3

For age > 3 open reduction and femoral

shortening and acetabular procedure is

recomended to avoid excess pressure on head

with reduction

Treatment con’t

2-3-years gray zone

potential for acetabular development is diminished

and therefore many surgeons recommend a

concomitant acetabular procedure with open

reduction or 6-8 weeks after

Incidence of AVN is greater with simultaneous open

reduction and acetabular procedure

Treatment contd..

Lovell and Winter advised to

judge stability at time of reduction and if stable observe for

period of time for development

if not developing properly with decreased acetabular

index, teardrop then consider secondary procedure

most common osteotomy is Salter or Pemberton

anatomic deficiency is anterior and Salter provides

this while Pemberton provides anterior and lateral

coverage

Natural Sequelae

Goal of treatment is to have radiographically normal hip

at maturity to prevent DJD

after reduction is achieved potential for development

continues until age 4.

In child < 4 years minimal dysplasia may be observed but

if it is severe than subluxations and presence of residual

dysplasia should be corrected

Residual Dysplasia

Determined by plain xray with measurement of CE

angle and acetabular index

In young children deficiency is usually anterior and in

adolescents it can be global

Deformities of femoral neck if significant it leads to

subluxation

lateral subluxation with extreme coxa valga or

anterior subluxation with excessive anteversion

usually DDH patients have a normal neck shaft

If there is Dysplasia for 2-3-years after reduction

proximal femoral derotation or varus osteotomy

should be considered

varus osteotomy is done to redirect head to center of

acetabulum which stimulates normal development

It must be done before age 4 as remodeling potential

goes down after this

Treatment in Adolescent or Adult Femoral osteotomy should only be used in

conjunction with pelvic procedure as there is no potential for acetabular growth or remodeling but changing orientation of femur shifts the weightbearing portion

Pelvic osteotomy considerations age

congruent reduction

range of motion

degenerative changes

Femoral Shortening

Schoenecker + Strecker 1984

Traction vs. Femoral shortening

56% AVN in traction group

0% AVN in femoral shortening

Femoral shortening for

Hey-Groves

(1928)

Valgus/ extension

osteotomy

In AVN with

trochanteric

overgrowth

Better in

adduction and flexion

Pelvic Procedures

Redirectional

Salter

Sutherland double innominate osteotomy

Steel ( Triple osteotomy)

Ganz ( rotational)

Acetabuloplasties ( decrease volume )

Pemberton

Salvage

depend on fibrous metaplasia of capsule

Shelf and Chiari

Pelvic Osteotomy

Done in Persistent instability + dysplasia

after open reduction and femoral

shortening

Requires concentric reduction of a

reasonably spherical femoral head

Usually based on surgeon preference

Pelvic Osteotomy

Volume changing

Pemberton

○ Hinges on triradiate

○ Requires remodeling of “new” incongruity

○ Provides more anterolateral coverage

Dega’s

Pelvic Osteotomy

Redirecting

Salter

○ Osteotomy through sciatic notch

○ Hinge through pubic symphysis

Triple innominate

Salter

Innominate

osteotomy

Salter’s osteotomy

Salter Single Innominate

•Age –18 months –6 years

•Requires concentrically reduced hip

–Open reduction at same time is possible

–Iliopsoas and adductor tenotomies often

required

•Covers antero-later alacetabular deficiency

–Up to 15 degree of acetabular index corrected

Salter

•Anterior approach to acetabulum

–Exposing inner and outer ilium

–Expose hip capsule if reduction needed

–Transverse osteotomy is done just above acetabulum

• Sciatic notch to Ant.Inf.iliac Spine

–Rotate on pubic symphysis in antero-lateral direction

–Hold correction with bone graft wedge & K-wires

Salter Osteotomy

K. E. 21 - 12 - 1999

Salter & femoral

osteotomy

Pemberton Acetabuloplasty

•Age –18 months –10 years

•Requires reduced hip

•Decreases acetabular volume

–Remodeling of acetabulum required

•Corrects >15 degree of Acetabular index

•Reduces antero-lateral acetabular defects

–Cuts altered to cover more anteriorly or laterally

Pemberton

•Anterior Approach -Exposure as for Salter

–Cut inner and outer table with small osteotome

– osteotomy 1cm above AIIS, staying 1 cm above

capsule

–Do not cut through to sciatic notch

–Lever through the cut until coverage is acceptable

•(Levers on tri-radiate cartilage)

–Hold correction with bone graft wedge

Dega Acetabuloplasty

•Similar to Pemberton

•Larger posterior hinge

–Hinges on horizontal tri-radiate limb

•Less inner table osteotomized for more lateral

coverage

(More inner table –more anterior coverage)

Steel Triple Innominate Osteotomy

•Age –Skeletally mature

•Requires congruent hip joint

•Divides ilium, ischium and superior ramus

–Acetabulum is rotationally free

–Indicated when other osteotomies not

possible

•Rotates to cover any acetabular defect

Steel•Multiple incision technique

–Posteriorly between gluteus and hamstrings

•Allows osteotomy of ischium

–Anteriorly freeing medial attachments

•Allows Salter and superior ramus osteotomy

–Rotate acetabulum as desired

•Avoid externally rotating

–Bone graft wedge is fixed as per Salter type

Salvage or Shelf

procedures Chiari and Staheli osteotomies

Requires capsular metaplasia

Pain is the main indication

Used in Treatment of chronic hip pain in

adolescents

Staheli Shelf Procedure

•Age –older child to skeletal maturity

•Salvage operation

•Indicated for non-concentric hips

•Augments supero-lateral deficency

–Slotted bone graft placed over capsule

deepening the acetablum

Staheli

•Anterior approach is used with outer wall exposure only

–Identify superior acetabular edge

–Create slot 1cm deep along edge in cephlad angle

–Remove 1 cm cortical strips from outer table

•Insert into slot, cutting at desired lateral overhang

•2nd layer inserted lengthwise

•Use remaining to fill in above slot edge

–Hold in place with reflected fascia and adductors

Staheli shelf

Chiari Medial Displacement

•Age –skeletally mature

•Salvage operation only

–Used when no other osteotomy possible

–Possible with subluxed hip

•Covers well laterally

–Anterior and posterior augmentation may be

necessary

•May be useful in other conditions

–Coxamagna, OA in dysplasichips

•Anterior approach –as per Salter

–Identify superior extent of capsule

–Cut from AIIS to notch following capsule

•Angle osteotome10-20ocephlad

–Displace distal fragment medially 50-100%

•Ensure complete head coverage

•Leg abduction, hinges on pubic symphysis

Chiari Osteotomy

Chiari osteotomy

Outcome of Chiari

osteotomy

236 of 388 osteotomiesreviewed at 25 years

51% good; 30% fair; 18% poorBest results: ≤ 7 years; no OA Femoral osteotomy: no better

(Windhager et al. JBJS 1991)

Schanz

osteotom

Very late

salvage

MANAGEMENT

Complications of Treatment

Worst complication is disturbance of growth

in proximal femur including the epiphysis and

physeal plate

commonly referred to as AVN however, no

pathology to confirm this

may be due to vascular insults to epiphysis

or physeal plate or pressure injury

occurrs only in patients that have been

treated and may be seen in opposite normal

Necrosis of Femoral Head Extremes of position in abduction ( greater 60

degrees ) and abduction with internal rotation

compression on medial circumflex artery as passes the iliopsoas tendon and compression of the terminal branch between lateral neck and acetabulum

“ frog leg position “ uniformly results in proximal growth disturbance

Avascular Necrosis

extreme position can also cause pressure necrosis onf epiphyseal cartilage and physeal plate

severin method can obtain reduction but very high incidence of necrosis

multiple classification systems with Salter most popular

Salter Classification 1 failure of appearance of ossific nucleus

within 1 year of reduction2

2 failure of growth of an existing nucleus within 1 year

3 broadening of femoral neck within 1 year

4 increased xray density then fragmentation of head

5 residual deformity of head when re-ossification complete including coxa magna,vara and short neck

Treatment

Femoral and/or acetabular osteotomy to maintain reduction and shift areas of pressure

trochanteric overgrowth causing an abductor lurch treated with greater trochanter physeal arrest if done before age 8 otherwise distal transfer

early detection is key with 95% success rate of treatment

identify growth disturbance lines

THANK YOU

Ddh 1

Health & Medicine