Synonymous in a broader sense
Luxation of the hip, hip arthrosis, rearrangement operation, Sater - operation, Chiari, operation, Containment, tripple osteotomy, 3- times osteotomy, disrotating femurosteotomy
Definition
A dysplasia of the hip is a childlike maturation disturbance with disturbance of the socket roof ossification. In the further development the femoral head can be put out of the joint (put out of the socket) = luxate and a luxation of the hip can develop.
A dysplasia of the hip is a high risk factor for the development of an arthrosis of the hip (coxarthrosis). By the missing socket roof (bay) the weight assignment of the thigh (femur) to the pelvis by a missing congruence of the joint partners gets unfavorable.
Sex distribution
The sex relationship female man is 4:1.
Frequency
Between 2 -5 % of all newborn children that are given birth to are born with dysplasia of the hip in Central Europe. By the x-ray- dysplasia- screenings, which are practiced throughout Germany with all newborn children (U2 (3. to 10th day of living) or the U3 between the 4th - 6th weeks of living) the roof of the socket can still be repositioned at an early diagnosis and resultant problems like a hip arthrosis can be avoided.
The left hip joint is predominantly concerned. One finds a double-sided dysplasia or luxation of the hip in 20% of the cases.
Cause / etiology
In principle, one can distinguish between three different causes of dysplasia of the hip:
- mechanical causes
- genetic causes
- hormonal causes
- Risk factors
There are different risk factors which promote the development of a dysplasia of the hip.
Factors are covered for certain during the pregnancy:
- by a so-called pelvic presentation the hips become strongly bended in the uterus through which the roof of the socket cannot develop correctly.
- Too little amniotic fluid, therefore the child has not sufficient freedom of movement
- Primiparous women have an increased risk since by the tight abdominal musculature and uterus the freedom of movement of the fetus is also limited.
- Premature births
Another risk factor is a weakness of the connective tissue:
- Combined all risk factors are with an amplified Laxizität of the ligaments, which means that there is a too big elasticity of capsule and ligaments. Through this the femoral head can more easily glide from the socket.
- The Laxizität of the ribbons will be strengthened by the female sex hormones estrogen and progesterone.
Genetic factors play an important role:
Children of parents with dysplasia or luxation of the hip have a 5 - 10 times increased risk.
Chromosome changes, which can be combined with a dysplasia of the hip, are the trisomy 18 = Edwards syndrome, Ulrich- Turner- syndrome = X0- syndrome, Arthrogryposis multiplex congenita. As a rule, these illnesses are combined with further innate wrong formations, like clump feet.
Clinic / symptoms
A dysplasia or also luxation of the hip does not have to cause any troubles with the newborn child. Only by starting to walk a hip disease can be noticed. However, the childlike hip joint only has a ability of further maturation up to the end of the 2nd year of life. The early diagnosis therefore is of outstanding importance.
Demonstrative symptoms can be delayed walking, strain dependent pains in the inguinal region or lateral hip area.
At a dislocation of the hip joint the mechanical levers of the hip change. The pelvis cannot be kept horizontal by the musculature when running any more. Therefore, it comes to a kind of "waddling walk", which is described as Duchenne - limp. When standing on only one leg the pelvis falls through muscle weakness of the spreaders of the hip (abductors) to the opposite side. This phenomenon becomes judged as positive Trendelenburg- test.
Diagnosis
Collection of the medical history (case history):
The medical history should purposefully be carried out on the risk factors mentioned above.
Further important questions are when first run attempts were made. Whether a limping has been noticed. Whether there exist asymmetries in the area of the buttocks. Whether an amplified hollow back formation can be noticed in standing.
Inspection (consideration)
The femoral head stands higher by the luxation of the hip joint. Because of a one-sided luxation it comes to an asymmetry of the buttocks folds. The conclusion, however, is not permitted that every fold asymmetry must be a luxation of the hip inevitably. No asymmetry is available at a mutual luxation since both hips are luxated. It comes, however, to an amplified hollow back formation (hyper-lordosis) compensatory within these children.
Examination
At the examination of the hip joint particularly the stability is checked. You pay particularly on stability and ability to luxate of the joint.
Particularly the examination method to Ortolani has to be mentioned here. In this examination it is tried to luxate the hip joint by pressure of the outside on the femoral head or at least on the socket edge of the pelvis specifically. By a situation change of the femoral head the examining doctor tries to let the femoral head jump back into the socket now, which is clearly noticeable by spring up or click you can hear. This phenomenon is called positive Ortolani -sign. At a healthy hip joint the Ortolani- sign can not be aroused.
The examination at a luxation of the hip (hip head is not in the pan) which does not jump back into the socket again appears to be problematic. The Ortolani- sign also cannot arouse.
Critics of this examination method find fault, that by springing up the femoral head could be damaged.
Ultrasound (sonography)
The ultrasound of the baby hip represents the most important diagnostic of a dysplasia of the hip of a baby.
Since large portions of the hip joint are still not of bone but laid out only cartilaginously, the radiograph only has restricted meaningfulness with regard to the early diagnose.
The ultrasound (sonography) of the hip joint however can make soft partial structures of the joint visible. So the cartilaginous part of the roof of the socket and femoral head can be judged well with regard to a dysplasia by the sonography. It should routinely be carried out at the U2 and U3.
The method of the ultrasound scan of the baby hip was developed by the Austrian professor Dr. Graf (Stolzalpe) at the beginning of the eighties. The advantage of this method that it is free of any radiation exposure (no X rays). It can therefore arbitrarily be frequently repeated. Furthermore a dynamic examination is possible. One understands by it that the hip joint can be examined under movement and the behavior judged by femoral head to the socket at movement.
With an increasing ossification of the femoral head and socket of the hip the statement ability of the ultrasound decreases. Since the ultrasonic waves cannot penetrate the bone, an ultrasound scan can be carried out to judge the dysplasia of the hip until the completion of the first year of life, after that the radiograph examination is superior.
Professor Graf developed two measuring angles for the judgement of the roof of the socket as a help.
By the means of the socket roof angle alpha and the cartilage roof angles beta and under consideration of the age of the child the degrees of the dysplasia and derive therapy forms from it.
Hip type Alpha Beta possible therapy
1 are > 60° < 55° none necessary
1 B > 60° > 55° none necessary, control
2 ares 50 -59 ° > 55° none or wrap broadly
2 B 50 -59 ° < 70° spreading treatment
2 C 43-49 ° 70 -77 ° spreading treatment by hip bending splint
2 d 43-49 ° > 77° spreading treatment with secure fixation
3 ares < 43° > 77° Hip luxated, reposition (put the femoral head back in position) and plaster fixation
3 B < 43° > 77° Hip luxated, reposition and plaster fixation in addition cartilage structure disturbances in the roof of the socket provable
4 < 43° > 77° Hip luxated, reposition and plaster specification
Radiograph
X-rays are rarely made before the first year of life. She is mandatorily necessary for an operative planning.
A so-called pelvis overview photo in general is done. The pelvis with the hip joints becomes x- rayed from the front to the behind (a.p. = anterior, posterior)
On this x-ray the position of the femoral head and hip socket is judged. Different measurements are also important.
Particularly important are:
Ménard- Shenton- line
the socket roof angle = AC- angle to Hilgenreiner
the CE- angle (center – corners- angles) to Wiberg
the CCD- angle (centre- collum- diaphysis – angle= femoral neck- shaft- angle)
The Ménard- Shenton- line the prolongation of the inner part of the femoral neck and the lower pubic bone branch (symphysis). This should yield a harmonious almost semicircular structure. Cf. the blue bend in the childlike radiograph on the right a healthy hip joint
There is the suspicion that the femoral head is not in the socket centrally, if this line seems interrupted, stepped or not round. Cause can be a dysplasia or luxation of the hip.
conservative therapy
An early therapy of a dysplasia of the hip can cause maturing of the socket roof and prevent a hip arthrosis in the adulthood.
Belonging to the conservative therapy measures:
- maturation treatment
- closed reposition (relocation of the hip joint)
- Fixation
- maturation treatment
By a maturation treatment is tried to positively influence the growth of the "dysplastic" socket roof by a specific position of the hip head in the hip socket favorably.
For this different aids are possible. The spreading trousers or the hip bending splint (e.g. Tuebinger- splint) is frequently used. Through this the hip joint becomes spreaded and strongly bended through which the femoral head deeply adapts in the hip socket.
Only within the first 12 life months this therapy makes sense. These methods are used at the types of dysplasia 2 a-c.
The reposition
The femoral head must be brought back at first once again at a more severe dysplasia of the hip (type 2 d -4) into the hip socket (reposition). For example the bandage to Pavlik is suitable for it. Fixed by a very strong diffraction in the hip joint and in this position.
All methods have in common, however, that by the fixated position of the hip head a circulation disturbance can follow. Parts of the femoral head can die and influence the function of the hip joint durably through this.
The specification
If the results of the reposition cannot be kept, fixations through tracks and plaster are possible.
The so-called Fettweiß- plaster, is frequently used. The hip joint is being bend about 100 -110 ° and approx. 45° spreaded. As a rule, this plaster type is well tolerated by the children.
operative therapy
As a rule, operative therapy measures add to application only after failure of the conservative therapies mentioned above. Interventions are frequently combined at the femoral neck in the area of the socket roof with position corrections of the femoral head.
Derotating varisierende femoral neck corrections come with corrections of the socket roof at the pelvis
Hip correction treatments frequently used at the pelvis are:
- the Salter - osteotomy
- the Chiarie - osteotomy
- the trippple, osteotomy
In the childhood the Salter- osteotomies are frequently carried out (limit 8th year of life) due to anatomical events, whereas beyond the 8th year of life until adulthood the triple- osteotomy is carried out.
It is the aim of all operative measures to improve the roof the femoral head so that the burden spreads out over a greater part of the femoral head.
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