Congenital hip dysplasia

A malformation of the hip joint that is present at birth. Genetic factors likely play a role in this disorder. Features include hip dislocation, asymmetry of leg positions, asymmetric fat folds, and diminished movement on the affected side. Some children will exhibit little or no features and must be diagnosed by physical examination of the hip joints.

Description
Congenital hip dysplasia is an abnormal formation of the hip joint in which the ball at the top of the thighbone (femoral head) is not stable in the socket (acetabulum). Also, the ligaments of the hip joint may be loose and stretched. The degree of instability or looseness varies. A baby born with DDH may have the ball of his or her hip loosely in the socket, the looseness may worsen as the child grows and becomes more active, or the ball may be completely dislocated at birth.

Left untreated, DDH or Congenital hip dysplasia leads to pain and osteoarthritis by early adulthood. It may cause legs of different lengths or a "duck-like" walk and decreased agility. DDH has a familial tendency. It usually affects the left hip and is predominant in:

Girls. First born children. Babies born in the breech position (especially with feet up by the shoulders). The American Academy of Pediatrics now recommends ultrasound screening of all female, breech babies.

Although congenital hip dysplasia is usually noted in the newborn exam, treatment is easier and safer the earlier the diagnosis is made. Hips found normal at birth can be found abnormal later, but this is rare. Pediatricians screen for DDH at a newborns first exam and at every well-baby checkup thereafter. Otherwise, the condition may not be noticed until a child begins to walk by which time treatment is more complicated and uncertain.

In a normal hip, the head of the femur is firmly inside the hip socket.

In some cases of DDH, the thighbone is completely out of the hip socket.

Symptoms
Although some dislocated hips show no signs, contact a doctor if your baby has:

Legs of different lengths. Uneven thigh skin folds. Less mobility or flexibility on one side.

In children who have begun to walk, limping, toe walking and a waddling "duck-like" gait are also signs. In addition to visual clues, doctors use careful physical examination tests to check for subtle signs of hip instability or dislocation in babies, such as listening and feeling for clunks." Hip Xrays also may be helpful in older infants and children. Treatment methods depend upon the childs age. Causes Hip dysplasia is considered to be a multifactorial condition. That means that several factors are involved in causing the condition to manifest.[16] Cause is unknown but common in breech position or large fetal size.
[edit] Congenital

Some studies suggest a hormonal link.[15] Specifically the hormone relaxin has been indicated.[17] A genetic factor is indicated by the trait running in families and increased occurrence in some ethnic populations (e.g. native Americans,[18] Lapps[19] / Sami people[20]). A locus has been

described on chromosome 13.[21] Beukes familial dysplasia, on the other hand, was found to map to an 11-cM region on chromosome 4q35. With nonpenetrant carriers not affected.[22]
[edit] Acquired

As an acquired condition it has often been linked to traditions of swaddling infants[23] or use of a cradle board which locks the hip joint in an "adducted" position (pulling the knees together tends to pull the heads of the femur bone out of the sockets or acetabulae) for extended periods. Modern swaddling techniques allow some room for leg movement.[24] Further risk factors include breech birth and firstborns.[25] In breech position the femoral head tends to get pushed out of the socket. A narrow uterus also facilitates hip joint dislocation during fetal development and birth.

Diagnosis
Because the abnormalities of this hip problem often vary, a thorough physical examination is necessary for an accurate diagnosis of congenital Congenital hip dysplasia. The hip disorder can be diagnosed by moving the hip to determine if the head of the femur is moving in and out of the hip joint. One specific method, called the Ortolani test, begins with each of the examiners hands around the infant's knees, with the second and third fingers pointing down the child's thigh. With the legs abducted (moved apart), the examiner may be able to discern a distinct clicking sound with motion. If symptoms are present with a noted increase in abduction, the test is considered positive for hip joint instability. It is important to note this test is only valid a few weeks after birth. The Barlow method is another test performed with the infant's hip brought together with knees in full bent position. The examiner's middle finger is placed over the outside of the hipbone while the thumb is placed on the inner side of the knee. The hip is abducted to where it can be felt if the hip is sliding out and then back in the joint. In older babies, if there is a lack of range of motion in one hip or even both hips, it is possible that the movement is blocked because the hip has dislocated and the muscles have contracted in that position. Also in older infants, hip dislocation is evident if one leg looks shorter than the other. X-ray films can be helpful in detecting abnormal findings of the hip joint. X rays may also be helpful in finding the proper positioning of the hip joint for treatments of casting. Ultrasound has been noted as a safe and effective tool for the diagnosis of congenital Congenital hip dysplasia. Ultrasound has advantages over x rays, as several positions are noted during the ultrasound procedure. This is in contrast to only one position observed during the x ray.

Treatment
The objective of treatment is to replace the head of the femur into the acetabulum and, by applying constant pressure, to enlarge and deepen the socket. In the past, stabilization was achieved by placing rolled cotton diapers or a pillow between the thighs, thereby keeping the knees in a frog like position. More recently the Pavlik

harness and von Rosen splint are commonly used in infants up to the age of six months. A stiff shell cast may be used, which achieves the same purpose, spreading the legs apart and forcing the head of the femur into the acetabulum. In some cases, in older children between six to 18 months, surgery may be necessary to reposition the joint. Also at this age, the use of closed manipulation may be applied successfully, by moving the leg around manually to replace joint. Operations are not only performed to reduce the dislocation of the hip, but also to repair a defect in the acetabulum. A cast is applied after the operation to hold the head of the femur in the correct position. The use of a home traction program is now more common. However, after the age of eight years, surgical procedures are primarily done for pain reduction measures only. Total hip surgeries may be inevitable later in adulthood.

Alternative treatment
Nonsurgical treatments include exercise programs, orthosis (a force system, often involving braces), and medications. A physical therapist may develop a program that includes strengthening, range-of-motion exercises, pain control, and functional activities. Chiropractic medicine may be helpful, especially the procedures of closed manipulations, to reduce the dislocated hip joint.

Prevention
Prevention includes proper prenatal care to determine the position of the baby in the womb. This may be helpful in preparing for possible breech births associated with hip problems. Avoiding excessive and prolonged infant hip adduction may help prevent strain on the hip joints. Early diagnosis remains an important part of prevention of congenital Congenital hip dysplasia.

Diagram of Pavlik harness Surgery

In older children the hip abductor and iliopsoas muscles have to be treated surgically because they adapt to the dislocated joint position (contracture). Braces and splints are often used following either of these methods to continue treatment. Although some children "outgrow" untreated mild hip dysplasia and some forms of untreated dysplasia cause little or no impairment of quality of life, studies have as yet been unable to find a method of predicting outcomes. On the other hand, it has often been documented that starting treatment late leads to complications and ends in poor results.

Stem cells

One avenue of research is using stem cells. They are applied in grafting (bone grafting) or by seeding porous arthroplasty prosthesis with autologous fibroblasts or chondrocyte progenitor cells to assist in firmly anchoring the artificial material in the bone bed.
Hip replacement and osteotomy

Hip dysplasia is often cited as causing osteoarthritis of the hip at a comparatively young age. Dislocated load bearing surfaces lead to increased and unusual wear. Subsequent treatment with total hip arthroplasty (hip replacement) is complicated by a need for revision surgery (replacing the artificial joint) owing to skeletal changes as the body matures, loosening/wear or bone resorption. Osteotomies are either used in conjunction with arthroplasty or by themselves to correct misalignment.