congenital hip dislocation treatment - Developmental Dysplasia of the Hip (DDH)

Treatment for newborns up to six months of age.
Treatment for babies younger than 6 months old is usually with an orthosis braces.
Today, the orthosis most commonly used is Pavlik's harness.
This orthosis provides simultaneous flexion and abduction of the hip joint through straps that join together relatively easily.
anterior straps flex the hips to 90-100° flexion and prevent extension
posterior straps prevent adduction of the hips.
the treatment is based on the concept that if the reduced hip is kept positioned in flexion and slight abduction, the stimulus needed for normal development of the joint will be provided.
the treatment with Pavlik requires normal muscle function for successful outcomes.
so that its contraindicated in teratologic hip dislocations and patients with spina bifida or spasticity.
At first you should keep your baby in the harness all the time.
After about 6 weeks, you will be able to take your baby out of the harness during the day.
The baby will need to continue wearing the harness at night for about 6 more weeks.
The harness is adjustable, so it can change as your baby grows.
the child has to be examined frequently in order to evaluate whether the device has been applied correctly,
usually once a week.
It is very important to have your baby's legs positioned correctly.
Do not try to adjust the harness yourself.
the baby will also need regular ultrasounds every 4-6 weeks to follow development of the hip joint.
90% of the dislocated hips among children aged under six months
could be successfully reduced and thereafter presented normal development through using this orthosis.
if concentric reduction is not achieved over the first two to three weeks of use of the harness,
this approach is abandoned to prevent Pavlik disease.
then the choice is to perform closed reduction and immobilization in a plaster cast brace.
complications specific to this treatment.
avascular necrosis (AVN).
The safe zone or safe arc of motion is the range of abduction in which the hip maintains stability.
Hips with a narrow zone of safety less than 30° are less likely to be stable.
A popular method of increasing the safe zone is to perform an abduction tenotomy. The abductor tenotomy theoretically would increase the maximum and unforced abduction and increase the safe zone.
transient femoral nerve palsy.
seen with hip hyperflexion.
Pavlik disease.
it is an erosion of the pelvis superior to the acetabulum and prevention of the development of the posterior wall of it, due to prolonged positioning of dislocated hip in flexion and abduction.
it is important to discontinue the harness if the hip is not reduced by 3-4 weeks.
Treatment between three months of age and walking age.
Within this age range, most patients with DDH can be treated by means of closed reduction
and immobilization in a plaster cast brace from the pelvis to the foot called spica cast under general anesthesia.
apply spica cast to immobilize in 100° of hip flexion and 45° of abduction with neutral rotation for 3 months.
you have to change cast at 6 weeks.
avoid wide abduction because extreme abduction more than 60° is associated with avascular necrosis of the humoral head ,
so we can prevent the AVN via placement of abduction within safe zone.
percutaneous tenotomy of the hip adductor muscles may be necessary if the patient has an unstable safe zone.
confirm reduction with CT scan in spica cast with selective cuts to minimize radiation to the child.
After the period of immobilization in the plaster cast brace,
which will range from two to three months,
the patient will progress to using an abduction orthosis for a further two to three months.
When reduction through closed maneuvers cannot be achieved, open reduction is indicated.
Treatment after reaching walking age.
surgery is necessary with a procedure called “open reduction” for children older than one and a half or If a closed reduction doesn’t work.
during surgery the possible anatomic blocks to reduction will be removed such as: iliopsoas contracture.
capsular constriction.
inverted labrum.
pulvinar.
or hypertrophied ligamentum teres.
perform adductor tenotomy if the patient has an unstable safe zone
For this age group, along with the need to operations to perform complementary osteotomy in the acetabular region to improve the femoral head coverage such as Steel osteotomy.
Dega osteotomy.
Salter osteotomy.
Pemberton osteotomy,
after the age of 3 years, the femoral bone shortening to enable the joint reduction has to be taken into consideration.
it facilitates reduction and decreases the risk of AVN by relieving the tension produced by the reduction of a previously dislocated hip.
the child will be put into a hip spica cast in functional position of 30° of flexion, 30° of abduction and 30° of internal rotation after surgery for three months.
Often a child will then need a hip abduction brace to finish the healing process.

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[@sunnymaghnani2985]

Less than 30° safe zone then abduction tenotomy or adduction tenotomy needed ?

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