DR. MOSI

DDH Coxa vara Genu valgum Genu varus Genu recarvatum

Spectrum of disorders including : Acetabular dysplasia Instability (dislocation and subluxation) Teratological malarticulation – dislocation in utero ,

irreducible at birth , pseudoacetabulum and associted with neuro muscular conditions eg arthrogyposis

Left > right Females > males at 7:1 20 % bilateral At birth dislocation is 1:1000 and dysplasia

1:100

Genetics Generalized joint laxity – dominant Shallow acetabular – polygenic

Hormonal factors High levels of progesterone and relaxin in last days of

pregnancy hence ligament laxity

Intrauterine malposition complete breech, oligohydraminos,packaging

deformities ( congenital muscular torticollis, metatarsus adductus, congenital knee dislocation

Postnatal factors

Initial instability leads to dysplasia Normal acetabulum but lax capsule Changes in the acetabulum and femoral

head occur from the instabilty but some from primary acetabular and femoral head dysplasia

Dislocation is posterolateral then superolateral

Cartilagenous head of normal size but nucleus appears late

Shallow anteverted socket Stretched capsule

Elongated and hypertrophied ligamentum teres

Superior limbus and capsule pushed into socket

On weightbearing above changes worsen False socket is created

Idelly diagonised at birth Barlows test Ortolanis test Galeazzis test limited abduction clicking hip asymetry in skin folds – thigh gluteal labial trendelenburg gait , waddling gait Ludolfs sign

Radiographs useful at 4-6 months after head begins to ossify

Helgenreiners line Shentons line Perkins line Acetabular index Center edge angle of wiberg

Ce 20 -25. ai- 30 20 <20

Ultrasound Dynamic ( Hacke) and static (graf) Useful before head ossification Alpha angle : lines along bony acetabulum and ilium ( >60) Beta angle : line along labrum and ilium (<55) Use in high risk group or in positive physical findings Monitoring of treatment

Confirmation after closed reduction Identification of possiblle blocks:

◦ Inverted labrum◦ Inverted limbus◦ Hour glass appearance

CT Scan : study of choice MRI : significant role

6 – 2yrs Failure of pavlicks harness Traction may be applied prior Under anaesthesia or gradually over about

three weeks 60 flexion, 40 abduction, 20 internal

rotation At 6 weeks convert to splint that prevents

adduction

> 2YEARS or in failed closed reduction between 6 mnths and 2 years

Anatomic changes such as anteversion and coxa valga

Traction preop may help Hip spica for three months the splinting

Older children Severe dysplasia with marked acetabular

changes Reduced potential of acetabular remodeling

Dega, ganz, permbenton

Avascular necrosisSeen in all treatment formsEscessive forceful abductionLate surgerydx. By late appearance of ossification centerBroadening of femoral neck or fragmentation

Failed reduction and recurence

Reduction in neck shaft angle <120 160 at birth 125 by adulthood

Developemental Congenital Dysplastic Acquired

Physis Metaphysis Subtrochanteric

Associated with congenital short femur and proximal femoral deficiency

Unilateral Subtrochanteric Ass with retroversion of femur and out

toeing High propensity of progression

Onset of ambulation, trendelenburg gait usually noted

Defective endochondral ossification posteromedialy (physeal defect)

Pathognomonic sign is a inferoposterior metaphyseal fragment

Underlying bone anomaly eg rickets, fibrous dysplaia

Usually bilateral

Commonly due to Trauma Infection iatrogenic

Halting deformity progression – investigate and treat renal osteodystrophy , rickets etc

Correct proximal femoral anatomy : Poximal valgus osteotomy

Trochanteric Subtrochanteric

Greater trochanter epiphysodesis Greater trochanter transfer

Pauwels Y-SHAPED OSTEOTOMY, Langenskiöld intertrochanteric osteotomy, BORDEN SUBTROCHANTERIC OSTEOTOMY

Averages 40 at birth but decreases to about 10 -15 in adults.

about 5 more in females Idiopathic or associated with other hip

disorders eg sufe ddh cp dcv In toeing gait but this usually resolves

Cosmesis Anterior knee pain due to patellar

malalignment

• Observation• Rotational osteotomy

Rarely indicated ( most children have no functional deficits)

Child over 10 – 12 years with internal rotation of > 80 and external rotation of <10

Intertrochanteric vs mid-diaphysis

Physiologic – usually <2 years and bilateral) Pathologic – trauma , infection, rickets,

dysplaisia of bone ,blounts disease, >2years Unilateral Severe Associated shortening Obesity

10m-15

Cosmesis Patellofemoral instability/ maltracking Altered gait - lateral thrust, circumduction Early walkers – genu varum

Full length standing Line should bisect knees

Md 11, 11 - 16

tibia vara or osteochondrosis deformans of the proximal tibia

Impaired ossification medial proximal tibia Hueter volkamn effect Infantile Juvenile Adolescents

Observation Bracing – children less than 2 yrs with early

blounts ( stage 1 and 2) Guided growth

Hemiepiphysiodesis on convex side using screws, staples, tension band paltes

In the past relied on growth charts Corrective osteotomy ( acute vs gradual

correction using an ilizarov ) Blounts – before 4 yrs and at stage 1 or 2( surgery differs

for 3&4,5&6) Children near maturity Permanent physeal issue

Mechanism Laxity of posterior capsule Abnormal inclination of tibia articular

surface Usually 14+/- 3.6 posterioly. Forward tilt if the anterior

physis is damaged

Observation – hypermobile, (10 -15 ) Bracing

Prevents hyper extension Can result in stiff knee Ankle orthosis holding at 5-10 shown to prevent recarvatum

in cerebral palsy Anterior wedge osteotomy Poserior closed wedge osteotomy Flexion supracondylar osteotomy of femur Gradual correction using an external fixator Epiphysiodesis :

When secondary to physeal damage

Reefing of the posterior capsule of the knee joint

Anterior patellar block Quadriceps lengthening

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