Complication DDH treatment of theHip


Destruction (avascular necrosis) of the ball shaped head of the thigh bone is the most frequent complication due to of DDH treatment which causes a blood vessel disturbance in the hip joint(full abduction causes malfunction of blood supplies in the hips of the each newborn baby) The crying (that cannot be stopped) is due to the painful dying cartilage cells in the thigh head .The crying stops after a few hours, when all cells with lack of blood have destroyed (avn).


It occurs most often when there is too big pressure or elongation of the nutritious vessel of the femoral head toward cup shaped socket during not gentle traumatic treatment or manipulations, for example during placing the head in or out of the socket. It cause elongation and shortening of all hip joint structure at the same time.

.

 

Not gentle and too long clinical examination may also lead to worsening of defect through mechanical damages and blood supply disturbances in femoral head. Clinical examination also lasts much more longer (even up to almost an hour)than ultrasound, which lasts only several seconds and it totally safe for patient.

 

That is why , in case of severe contractures caused by head dislocation, these contractures first need to be delicately eliminated (ex by Vojta technique) and then femoral head should be positioned properly in the acetabulum, or the contracture should be treated by an over- head extension, even with possibility delaying of treatment.

Medical statistics show a close correlation between an early diagnosis and complications due to traumatic treatment.Avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are treated for DDH.

Thanks to an early diagnosis and adequate treatment we are able to avoid a lot of serious problems( hospitalization, anesthesia, traction, manipulation, trauma, plaster immobilization, passive abduction frames and other serious secondary changes of all hip joint structures:a worsening hip dislocation, contractures, adhesions, growth malformations of bone and cartilage, aseptic necrosis of bone and cartilage, traumatic osteochondroses and traumatic osteoarthritis, chronic pain in the hip joint due to its destruction (osteoarthritis) and its replacement (30% of all cases) at a younger age and more frequently than normally,expensive and risky surgery in nearly 100% of cases,rash, pressure sores, and femoral nerve palsy, intraoperative complications and postoperative wound infections ).

 

Curently references Pavlik harness

Pavlik harness treatment is not always successful, it should be adapted to the child's age and type of defects in the hip. Improperly selected and implemented causes necrosis of the femoral head - from 7 to 14% of infants. Pavlik harness is also very ineffective in the treatment of congenital dislocated hips (even diagnosed just after birth) of at least 15.2% for displaced hips to 40% (5) in the case of its instability and 3.3% dysplastic hips. Some used the  tractio the "over head" in order to reduce the number of complications. Moreover, in infants up to 3 months of age can result in deterioration of the hip defects, as at this age the bones are softer than the strength of ligaments and muscles.

 

1)   1: Acta Orthop Belg. 1990;56(1 Pt A):195-206. Links
Ischemic necrosis as a complication of treatment of C.D.H
.
Tönnis D.
University Hospital, Orthopedic Department, Dortmund, Germany.
Ischemic necrosis is seen after both closed and open reduction. Its causes have been clarified during the last two decades. The position of the immobilized hip after reduction is an important factor; the method of reduction is another. There are other factors such as development of the epiphyseal nucleus and the degree of dislocation. In a collective series of 20 hospitals our study group on hip dysplasiainvestigated 3316 hip joints reduced by different techniques. It was shown that methods working with the Lorenz position of immobilization have an average rate of 27% ischemic necrosis. Lange's position of abduction with internal rotation, without flexion of the hip joint, has a 17% necrosis rate. Pavlik's harness, as a more functional method, had a 7% rate. Methods reducing bij increased flexion and less abduction, such as that of Fettweis, Hanausek and Krämer, had 2% on the average. The percentage of necrosis was increased with the degree of dislocation. The length of time of immobilization had no influence. These findings correspond with the investigations on the femoral blood circulation in different positions of the femoral head and under pressure that have been published by Schoenecker et al. and Law et al. The cartilaginous epiphysis may be squeezed so much that the circulation is interrupted. Another cause is direct pressure to epiphyseal vessels in extreme Lorenz and Lange positions (Ogden and others). There has been a question as to what degree the reduction itself is the cause of ischemic necrosis. The method of reduction was determined by arthrography. If it seemed possible, a cast in squatting position according to the method of Fettweis was applied immediately. In the beginning we even allowed the joints to reduce themselves slowly against a narrow introitus of the joint. In other joints traction was applied first, and in a few older patients open reduction was performed immediately. A total of 388 joints was evaluated. There was an increasing rate of ischemic necrosis from open acetabular inlets (3.6% necrosis) to constricted joints (8.5%) and those with an inverted upperlabrum (31%). The width of the acetabular introitus, as measured between the upper and lower labrum (ligamentum transversum), also showed a correlation with ischemic necrosis. When the degree of reduction is classified as "deeply seated", there is a definite correlation with ischemic necrosis. Also when the distance of the femoral head from the acetabular floor is measured, the same increase in incidence of necrosis is noted.(ABSTRACT TRUNCATED AT 400 WORDS)

 

2) The natural history of developmentaldysplasia of the hip after early supervisedtreatment in the Pavlik harness
A PROSPECTIVE, LONGITUDINAL FOLLOW-UPJ. P. Cashman, J. Round, G. Taylor, N. M. P. Clarke
From Southampton General Hospital, England
Between June 1988 and December 1997, we treated332 babies with 546 dysplastic hips in a Pavlik
harness for primary developmental dysplasia of thehip as detected by the selective screening programmein Southampton. Each was managed by a strictprotocol including ultrasonic monitoring of treatmentin the harness. The group was prospectively studiedduring a mean period of 6.5 ± 2.7 years with follow-upof 89.9%. The acetabular index (AI) and centre-edgeangle of Wiberg (CEA) were measured on annualradiographs to determine the development of the hipafter treatment and were compared with publishednormal values.
The harness failed to reduce 18 hips in 16 patients(15.2% of dislocations, 3.3% of DDH). These requiredsurgical treatment. The development of those hipswhich were successfully treated in the harness showedno significant difference from the normal values of theAI for the left hips of girls after 18 months of age. O fthose dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA <20°) and 0.2% persistent severe late
dysplasia (CEA <15°). All could be identified by anabnormal CEA (<20°) at five years of age, and manyfrom the progression of the AI by 18 months.Dysplasia was considered to be sufficient to require innominate osteotomy in five (0.9%). Avascularnecrosis was noted in 1% of hips treated in the harness.(ale tylko duże deformacje wg.Saltera od administratora)

 

3.)Preliminary traction and the use of under-thigh pillows to prevent avascular necrosis of the femoral head in Pavlik harness treatment of evelopmental dysplasia of the hip
Shigeo Suzuki, Yoichi Seto, Tohru Futami, and Naoya Kashiwagi Department of Orthopaedic Surgery, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, Shiga 524-0022, Japan
At the Shiga Medical Center for Children, the Pavlik harness had been used in the outpatient clinic between 1980 and 1987. In 1988, according to Iwasaki’s s uggestion,6 we introduced two measures in order to reduce avascular necrosis; preliminary skin traction and the use of pillows placed under the thighs during application of the harness to prevent extreme abduction. We compared the results of the treatment used during the period between 1980 and 1987 and that in the period 1988 to 1992.Patients and methods between 1980 and 1992, 161 hips in 145 patients (13
boys and 132 girls) were treated with the Pavlik harness at Shiga Medical Center for Children, and these patients were followed-up for at least 1 year after application of the harness. Patients who had had p revious treatment elsewhere or who were treated initially with a different method were excluded from the study.A dislocation was diagnosed when the hip was felt to have relocated with abduction, as described by Ortolani. If the hip could not be reduced but there was limited abduction, asymmetry of the thigh folds, or shortening of the affected extremity, a dislocation was
suspected. The diagnosis was made radiographically.The radiograph was taken with the infant in the supine position, with both lower extremities maintained in a n eutral position. The focus of the tube was adjusted to the center of the triangle that is formed bilaterally by the iliac crests and the symphysis, and the focal distance  as 1m. The diagnosis was established when there was lateral and cephalad displacement of the proximal
end of the femur accompanied by interruption of the Shenton line.The amount of dislocation was measured on anteroposterior radiographs according to the method of Abstract One hundred and sixty-one hips of 145 patients were treated with the Pavlik harness for developmental dysplasia of the hip. The patients were divided into two groups. Group A consisted of 65 patients (70 hips) who were treated between 1980 and 1987. The harness was applied immediately after the diagnosis. Group B consisted of 80 patients (91 hips) who were treated between 1988 and 1992. These patients received preliminary traction, and small pillows supported the lower extremities from just above the knee to the foot to prevent extreme abduction when the
harness was applied. When the distance from the middle point of the proximal metaphyseal border of the femur to the Y-line  distance “a”) was 8 mm or more on the initial X-ray picture,the rate of avascular necrosis in group A was 11% and that in group B was 0%; the difference was significant. However,
when distance “a” was less than 8 mm, the rate of avascular necrosis in group A was 13% and that in group B was 12%, and there was no significant difference. Thus, we suggest that the Pavlik harness is indicated for developmental dysplasia of t he hip in which distance “a” is 8 mm or more. Traction should precede application of the harness, and pillows placed under the thigh must be used during application.

4.)Copyright 983 by The Journal of Bone and Joint Surgery. Incorporated 760 THE JOURNAL OF BONE AND JOINT SURGERY
Treatment of Congenital Dislocation of the Hip by the Pavlik Harness
MECHANISM OF REDUCTION AND USAGE  bY KATSURO IWASAKI, M.D.*, NAGASAKI CITY, JAPAN
From the Department of Orthopaedic Surgery, Nagasaki University School of Medicine, Nagasaki City


ABSTRACT: The Pavlik harness was used in the treatment of complete congenital dislocation of one or both hips in a series of infants, on either an outpatient or an inpatient basis. The results in the two groups  were compared. For the children treated as outpatients the incidence of avascular necrosis of the femoral head was 7.2 per cent and for the group treated as inpatients the rate was 28 per cent. Application of the Pavlik harness allowed reduction of the hip by shifting the femoral head first to the posterior part of the acetabulum through fiexion of the hip, followed by
movement of the femoral head anteriorly into the acetabulum through abduction of the hip, which is possible because of stretching of the adductor muscles by the weight of the lower extremity. When the reduction i s obtained by forced abduction there is a greater danger of avascular necrosis of the femoral head

.5.Failure of the Pavlik Harness

The Pavlik Harness fails in approximately 40% of "Ortolani Positive" hip dislocations. These are hips that are dislocated at birth but can be put back into the socket during examination. The Pavlik Harness is used instead of a cast or more rigid immobilization in an attempt to hold the hip in the joint until the hip becomes stable. A recent scientific publication by KK White, et.al. have identified a possible ultrasound finding that may predict failure of the Pavlik Harness. Such a finding would allow earlier change to a different, and hopefully more successful, form of treatment.[9]

 

How are CDH checked?

 

More recent specialist literature considers ultrasound screening and clinical examination of neonates as early as possible to be ideal.

There are two methods of CDH diagnostics In newborns: clinical examination and ultrasonsound introduced by prof.Graf in 1978.
Each of these methods has some advantages and drawbacks. The ability of applying both of them enabless to discover every abnormality in the hip joint structure. Despite better and better clinical examination techniques to find clinical hip Instability by the Ortolani and Barlow tests( provoked stabilisation and dislocation) ) pict1,2 ; only 10% of CDH is discovered but 30% is false positive, and 5% of them need operative treatment, so effects of such screening are not satisfying.

Their prognosis may be worse for the babies with CDH than that before screening began,because the diagnosis is not suspected by their parents, doctors and health workers who believe that neonatal screening is fully effective.

Not gentle and too long clinical examination may laso lead to worsening of defect through mechanical damages and blood supply disturances in femoral head. Clinical examination also lasts much more longer (even up to almost an hour)than ultrasound, which lasts only several seconds and it totally safe for patient.


Contraction of hip muscles pict3(until recently the only indication in the diagnosis of DDH currently of little importance in the diagnosis according to the latest American research) occurs to a various degree in 10 per cent of all infants,however,only a small percentage (18%)is caused by an abnormal hip joint

Only an ultrasound examination of the hips enables a detailed noninvasive diagnosis of the smallest anomaly in the infant’s hip joint.

Only sufficiently qualified orthopedists can both establish the usg diagnosis of malformations in hip structure and can distinguish which disturbances require treatment, and which require onlyobservation and prophylaxis. So only qualifield orthopedists should perform examinations. Examinations done by poorly qualified doctors lead either to a great number of hip joint disease diagnose (which is more frequent because it is easier) or to omitting it. Especially these examinations should not be performed by medical technicians, because hip ultrasonography is a dynamic examination and hip assessment takes place during treatment a minimal movement of an infant or usg warhead creates changes in the image, and the disorder of hip joint can be found even if there is no hip defect at all.

Part of improper and not-diagnosed hips are symptomless. Part of hips with shallow acetabulum reveal no symptoms over many years, until joint destruction followed by pain,when it is too late for prevention .

The ultrasound hip screening by a qualified doctor is a standard procedure in highly developed countries such as Germany,Switzerland Austria,which achive four time better results of treatment ( at present the best ever results in the world) than countries which do not apply obligatory ultrasound examinations

Due to limited expenses of public health service and Lack of appropriately qualified doctor, decision about hip ultrasonography in neonatal ward should belong to parents, who in majority of cases, decide to perform hip usg, even if they have to pay for it additionally. They increase the chances of their child for health hip. Cost of single examination is lower than complaints and costs caused by hip insufficiency due to DDH.

Pict.1 Barlow test

Rehabilitation of contracure muscles in DDH.Practical guide.

Rehabilitation of contracuture muscles with DDH
Prevention of contractions of hip joints in persons with DDH
Rehabilitation practice, Dr M. Matyja, Sosnowiec, Poland
Racławicka 23, phone no. +48 501 540 201
e-mail address: sebastian.sroczynski@poczta.fm
M. Sc. Sebastian Sroczyński, certified NDT-Bobath therapist

Practical  guide.


Contractions of thigh adductor muscles constitute a particularly tough issue in case of need to use orthopaedic equipment. When we are dealing with contractions of the hip joint, the baby is distressed, it cries, because it experiences visible discomfort.
Prevention of contractions of hip joints is taken care of in Sosnowiec, Poland, at the rehabilitation practice of Dr M. Matyja.
Neurodevelopment therapy techniques according to the NDT-Bobath concept are applied for this purpose, aiming to reduce the tension of the contracted muscles, as well as fascial techniques to relax the muscles.
The elimination of contractions of the hip joint is an indispensable condition of effective and quick treatment of hip joint dysplasia.
Short description of the therapy:

 


Here we see photographs showing one of the techniques of the neurodevelopmental therapy according to the NDT-Bobath method, called dissociation. In this case the part undergoing therapy is the left hip.
1. We grab the hip so that the patient's knee rests on our palm, and the fingers should hold the thigh and be positioned parallel to the direction of the femur.
2. We execute the dissociation, or a slight movement in axial direction towards the hip joint (a push), and release (not drag it back!). This motion should be rhythmical and done at a constant pace (three pushes per second), while at the same time we should abduct the contracted hip to the point of resistance from the hip, after which we return to the intermediate position, and repeat the same cycle. The entire cycle should be executed until the hip reaches a threshold which one cannot cross (the hip will not allow for more).

.

 

Here we also have shown fascial techniques. The difference is another technique to keep.

   

Here a fascial technique is applied to the adductor muscles.
1. Grab the patient's thigh with the hand gently, so as to feel the taut muscle.
2. Execute slight supination, but not of the thigh! We are working here with the muscle fasciae, thus the rotation takes place only on the level of the muscle fasciae.
3. Gently stretch the fascia of the adductor muscle specifically through rotation, and hold for several seconds. After that, release the rotation, and repeat the same, but adding thigh supination this time.
4. Repeat entire exercise until we see that the supination is not progressing further, or when we reach full supination.

 

The final technique. It entails stretching the adductor muscles.
1. Supinate the patient's thigh so that we distinctly feel the adductor muscle taut.
2. Gently press with the thumb (pushing the code) this muscle on the side in the direction of supination.
3. Hold for several seconds; if the child protests, for a shorter period.
4. Release and repeat after a few seconds.
5. Execute approximately 10 repetitions.
The entire therapy takes approx. 20 minutes. Observations show that the minimum number of treatments before the application of orthopaedic equipment is three sessions, 20 minutes each, over the course of a week.
In addition, the parents receive advice on caring for the child, to support the therapy. This is even more important, because even if one applies the best possible therapy, the lack of proper care at home will render the work of the therapist useless, and will hinder reaching the ultimate goal of eliminating the contractions as much as possible before using orthopaedic equipment.

Some scientific facts about CDH

The value of any screening programme must be judged by its failures

The inadequate prevention of the infant hip recomended by Health Service is caused that the prognosis may be worse for the babies, which are borned with diclocation of the hip, than that before screening began,
because the diagnosis is not suspected by,parents, doctors and health workers who believe that neonatal screening is fully effective.

About us