1. Steven L. Frick, MD Carolinas Medical Center Charlotte, NC
Pediatric Hip
Steven L. Frick, MD
Carolinas Medical Center
Charlotte, NC

2. Pediatric Hip Problems
Common, age related differences in presentation
Traction rarely used now as treatment
If used, often in-line skin traction (Buck’s) for comfort temporarily
Remember to limit weight, watch skin
DDH, LCP, SCFE, trauma

3. Normal DDH

4. Developmental Hip Dysplasia DDH- definition
Developmental instead of congenital- more reflective of etiology
Any hip which can be provoked to subluxate (partial contact between femoral head and acetabulum) or dislocate (no contact between femoral head and acetabulum), or any subluxated or dislocated hip that can be reduced

5. DDH Incidence Depends on criteria 2-9/1000 births 70% female
Left > Right, 20% bilateral
some populations at higher risk

6. Risk Factors 1st born Female Breech + family history
Torticollis, MTA – some debate
Some populations- swaddling

8. Barlow positive

9. Ortolani positive

10. Treatment Goals
Obtain and maintain reduction to provide optimal environment for hip development
Potential for remodeling/development present for many years
Intervene to alter otherwise unfavorable natural history
AVOID ischemic necrosis

11. Treatment: Newborn - 6 mo.
CR => Pavlik harness
Arnold Pavlik, MD 1945
“functional” treatment
531/632 dislocated hips reduced with no AVN

12. Mubarak et al. – JBJS 1981- Pitfalls
Pavlik Harness
Mubarak et al. – JBJS Pitfalls

13. Success-Pavlik Harness
Dislocated- 85%
Dislocatable %
Residual Dysplasia- may have acetabular dysplasia in up to 15% after successful reduction/stabilization

14. “Failed Pavlik” Hip Arthrogram closed vs. open reduction
spica cast 6-12 weeks
Can try rigid abduction bracing- about 50% of Pavlik failures will dock and stabilize

15. Plastizote abduction brace for failed Pavlik harness reduction
>50% success at reduction
Boston Children’s series 13/15 success

16. Ultrasound Static angles (Graf)‏
% fem head coverage (Morin – 58% normal)‏
Dynamic stability (Harcke)‏

17. Ultrasound - Dynamic Harcke
Evaluate stability, real time, no radiation, document success/failure of reduction, easy to perform in harness

18. Ultrasound Disadvantages Only < 9mos (ossific nucleus)‏ Expense
Technique/expertise dependent
not good at quantifying dysplasia
May lead to overtreatment (stable hips dysplastic by US become normal)

19. Pavlik Success

20. Newborn male B dislocated hips
Pavlik for 4 weeks
Ultrasound to document reduction

24. Closed Reduction – age 6 to 18 mos

28. Keep Hip in Socket
while...
Avoiding AVN
is goal

29. Ogden’s anatomic dissections

30. Ogden’s anatomic dissections

31. To assess closed reduction after spica cast :
Check CT scan or MRI scan

32. Repeat arthrogram 6 weeks after closed reduction- normal

33. Open Reduction
For failure to achieve acceptable closed reduction, late presentation (>18 mos)
Anterior (capsulorrhaphy) or anteromedial (remove obstacles, no capsulorrhaphy)‏
Higher % ON (mild) with anteromedial approach

34. Radiographs in DDH

35. X-Rays

36. Follow until skeletal maturity
Make sure acetabulum develops properly
Goal = normal motion and normal radiograph at maturity
radiographic assessment 6-12 mo intervals, then 2-3 year intervals
acetabular index, lateralization ratio, teardrop, subluxation, femoral head ossification

37. 42 months
21 months
38 years
24 years
Courtesy of S. Weinstein, MD Univ. of Iowa

38. Persistent Acetabular Dysplasia
Scoles – normal values for AI- 20 deg by 2 yrs
Lindseth/Ponseti/Wenger – acetabular development may proceed up to age 8 after CR
Lalonde/Frick/Wenger – residual hip dysplasia treated < age 8 more normal radiographic anatomy
AI>35 2 yrs post CR- 80% Severin III or IV

39. Subluxation Those with subluxation more symptomatic
Usually symptomatic by mid 30’s for women

40. Salter Pelvic Osteo-tomy
Redirects acetabulum to give more coverage to femoral head

41. Peri-acetabular osteotommies Dega, Pemberton, Tonnis, Albee

44. Exam - Older Infant > 3 Months
Limited abduction
Asymmetric thigh folds
Galeazzi or Allis sign- short femoral segment with hip and knee flexed

45. Limited Abduction
Galeazzi sign

46. 4 yr old
missed bilat DDH
Waddling gait
Lumbar lordosis
Trendelenberg

48. DDH Older child Treatment principles the same
reduce hip without excessive pressure
operative treatment
shorten femur – traction out of favor
femoral and pelvic osteotomies
older, bilateral - ? No treatment
Unilateral – up to age 10, bilateral age 6

49. 4 yo late dx DDH

50. No femoral shortening - AVN

51. Remember to examine intoer’s hips

53. Natural History - Dislocated Hip
High riding, no pseudo- acetabulum do better
Back pain, valgus knee

54. Untreated Hip Dislocation
90 years old
4 years old

55. What is this? Stage?

56. Same patient later – what happened
Same patient later – what happened? List the head-at-risk factors you see. What stage now?

57. At Risk Signs Catterall
Calcification lateral to physis
Lateral subluxation
Gage’s sign
Diffuse metaphyseal reaction
Horizontal physis
Gage’s sign- V notch lateral physis

58. What is this patient’s story?

59. What is this?

60. What is this?

61. Which is better for LCP?

62. Legg-Calve-Perthes Disease
Idiopathic osteonecrosis of the proximal femoral epiphysis

63. Etiology Mechanical obstruction of extraosseous vessels
Intraosseous venous obstruction
Capsular swelling
Generalized disorder of epiphyseal cartilage
Thrombophilia- factor V Leiden mutation, anticardiolipin antibodies

64. Early XR Findings Smaller femoral head Widened cartilage space
Subchondral fx line (Caffey’s sx)‏
Increased density
Fragmentation

65. Who gets Perthes? Smaller, very active boys ADHD - Loder, 1993
Delayed skeletal age

66. Females with Perthes
? Less favorable outcome – now no if control for age of onset
Female – age onset 9 yrs

67. Classification Salter - Thomson
Gp A - Subchondral fracture involves < 1/2 femoral head
Gp B - Subchondral fracture involves > 1/2 femoral head

69. Stulberg ClassificationII
III
I – Normal head
II – Round head but big/short
III – Ovoid head and acetabulum
IV – Flattened head and acetabulum
V – Head collapsed without acetabular remodeling IV V

70. Prognostic Factors Age at onset Extent of femoral head involvement
subluxation
Loss of motion

71. Treatment
Needs to be in initial or fragmentation phase to alter shape of head
Goal = congruity, containment

72. Containment Treatments
Non-operative
Petrie casts, Orthoses, ROM exercises
Operative
Femoral Osteotomy
Innominate Osteotomy
Combined Osteotomy
Shelf Osteotomy

73. Orthoses Birmingham Tachdjian Brace Toronto Brace Brace Note Chain And
Padlocks
Newington Brace
Atlanta-Scottish Brace

74. Abduction Bracing
Meehan JBJS No advantage to other methods or no treatment
Martinez JBJS Not recommended
May make a comeback (don’t just stand there, do something!)‏

75. Femoral Osteotomy Few stiff hips Abductor lurch Unsightly scar
Hardware removal
Future surgery - valgus

78. Pelvic Osteotomies Recalcitrant stiffness
? Increase pressure on femoral head with Salter innominate osteotomy

79. Femoral vs. Innominate Osteotomy Sponseller 1988
49 pelvic
9 yr f/u
No significant difference

80. Hinge Abduction
Failure of movement of lateral corner of epiphysis under edge of acetabulum on radiograph taken with hip abducted and internally rotated
- Reinker, JPO 1996

81. Hinge Abduction Arthrogram Abduction traction Petrie cast
Surgical containment
- Reinker, JPO 1996

82. Chiari Chiari pelvic osteotomy Deformed head
Displace acetab superomedially
Cover femoral head, enlarge acetabular capacity, relieve pain
Head covered laterally by ilium, capsulefibrous metaplasia

83. Shelf Shelf Acetabuloplasty (Gill, then Staheli)
Lateral subluxation & uncoverage, hinged abduction
Increases acetabular volume
Pry down ilium and create notch to augment with bone graft above capsule
Fibrous metaplasia
Some advocate in pts > 5 y.o as a primary option (Jacobs, 2004)‏

84. Perthes Horizon Bisphosphonates Return of bracing Earlier surgery?
Hinged distraction of severe, late cases

85. 13 yo male c/o knee pain Knee pain for one month overweight
worse with activity
no night pain

88. Slipped Capital Femoral Epiphysis
Heavy adolescents, groin or hip pain
16% present with “knee pain”
PE : limited IR of hip
XR : frog lateral most sensitive
Tx = screw fixation
Goal = prevent further deformity, AVN

89. Classification
Stable – can weight bear. At risk for deformity progression (convert to unstable) and arthrosis secondary to anatomic abnormality
Unstable- cannot weight bear. At risk for ON- 3 to 47%

90. In situ screw fixation Use C-arm- mark lines on skin

91. Perc placement of guidewire
Start more anterior on neck for
more severe slips- screw head may impinge

92. Pin center - center
Rotate C-arm around –
Get this perpendicular view

93. Screw fixation AP / Lat
Try to get 5 screw threads into epiphysis

94. Perpendicular view- true length
Use approach-withdrawal technique to check length

95. Skin incision

96. Don’t start too low

97. Where did I put this screw? Rare “valgus slip”

98. Postop CT can help – rarely needed

99. When to pin?

100. Knee Pain

101. 12 days later- admit?? or
Crutches and operate later??

102. Ten days later
In ED - Unstable

104. If deformity is really bad – should we do something different?
Impingement – by neck or our screw?
Natural history reasonable- most say pin first and follow

105. Unstable SCFE – urgent traction “reduction”, screw fixation, arthrotomy decompression

106. 1 month postop

107. 11 months postop

108. Unstable slips Timing controversial – early may be better
Arthrotomy recommended- some studies show lower ON rate
Reduction ok-incidental or gentle
to “stable” position – not forceful closed reduction

109. 13 yo male, slip and fall. No antecedent pain. Can’t move.

110. Urgent ORIF with neck osteotomy via surgical dislocation

111. 1 or 2 screws for unstable slip?- controversial

112. Displaced femoral neck fracture

114. MECHANISM MVC, car vs. ped, high falls
Minor trauma can still be a cause

115. CLASSIFICATION
Delbet 1928

116. 10 yo female- Injury – type I fracture dislocation of hip

117. ORIF and pins attempted

118. CT prior to return to OR

119. Repeat ORIF

120. 11 mos- osteonecrosis

121. Type II

122. TYPE III

123. S.E.--OR

124. TYPE IV

125. R.K.R.--14 yo male

126. R.K.R.--ORIF, tape

127. R.K.R.--15 months

128. TYPE IV--13 yo

129. TYPE IV--DHS, wire

130. TYPE IV--2 mo post-op