A comprehensive review of the common developmental disorders of hip – Developmental dysplasia of the hip, slipped capital femoral epiphysis, and Perthes disease

Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a 'trochanteric flip' osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage.

1. Blaise A. Nemeth, MD, MS* 2. Vinay Narotam, MD† 1. *Associate Professor, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI. 2. †Assistant Professor, Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC. * Abbreviations: AVN: : avascular necrosis DDH: : developmental dysplasia of the hip Early detection of developmental dysplasia of the hip is essential because restoration of the normal relationship of the femoral head and acetabulum increases the likelihood of normal development. Pediatricians must be aware of the American Academy of Pediatrics guidelines for early detection. After completing this article, readers should be able to: 1. Acknowledge the spectrum of hip pathology included in developmental dysplasia of the hip (DDH). 2. Identify newborns at risk for DDH. 3. Diagnose hip dislocations by using appropriate physical examination maneuvers. 4. Appropriately use imaging modalities to screen for DDH in infants who have normal or equivocal physical findings. 5. Recognize the presentation of hip dislocation in the older child. Developmental dysplasia of the hip (DDH) encompasses the spectrum of hip abnormalities involving the relationship between the femoral head and the acetabulum during early growth and development. A hip may be dislocated at rest, dislocatable (but in a normal position at rest), subluxed (incomplete contact between the femoral head and acetabulum), subluxable (incomplete contact induced with provocative maneuvers), or appear normal on physical examination yet have an abnormally shaped acetabulum or femoral head radiographically. The previously used term, “congenital hip dislocation,” has been abandoned in recognition of this spectrum, acknowledging as well the fact that a child may have normal examination findings at birth but progress to dislocation later in life. Strictly speaking, the term DDH does not apply to abnormal development of the hip due to other diseases, such as cerebral palsy, Legg-Calve-Perthes disease, or slipped capital femoral epiphysis, in which “hip dysplasia” is a sufficient term, nor does the term include traumatic dislocation. In addition, the term “teratologic dislocation” is reserved …

ABJS Carl T. Brighton Workshop on Hip Preservation Surgery: Editorial Comment

Etiology and clinical trends in hip osteoarthritis in Japan: Insights from a multicenter cross-sectional study.

ACR Appropriateness Criteria® on Developmental Dysplasia of the Hip—Child

Introduction: Joint pain is a prevalent concern among pediatricians, orthopedists, and general practitioners, affecting up to 50% of children during childhood. The hip joint is particularly vulnerable, with degenerative diseases of the hip joints (DDHJ) being the leading cause of pediatric orthopedic visits. Various conditions, such as developmental dysplasia of the hip (DDH), Legg-Calve-Perthes Disease (LCPD), and slipped capital femoral epiphysis (SCFE), contribute to the spectrum of hip joint disorders in children. Material and methods: We have gathered the available materials and scientific reports, analyzing and summarizing them in a single study. Aim of study: This study aims to explore the etiology, diagnosis, and management of hip joint pain in children, focusing on DDH, LCPD, SCFE, and other related conditions. By examining the risk factors, clinical presentations, and current treatment strategies, the study seeks to enhance the understanding and early detection of these disorders, ultimately improving patient outcomes. Conclusion: Hip joint pain in children encompasses a broad differential diagnosis, ranging from self-limiting conditions like transient synovitis to serious disorders such as septic arthritis and JIA. Early identification and appropriate management of conditions like DDH, LCPD, and SCFE are crucial in preventing long-term complications. While physical activity is generally safe, intense exercise may increase the risk of musculoskeletal pain. A multidisciplinary approach, supported by further research, is essential for effective pain management and treatment optimization in pediatric patients.

BackgroundPelvic and femoral osteotomies have been effective methods to treat developmental dysplasia of the hip (DDH), neurogenic dislocation of the hip (NDH), and Legg–Calvé–Perthes disease (LCPD). The aim of this study was to evaluate the mid-term results after hip reconstruction in children with DDH, NDH, and LCPD.MethodsIn a retrospective study, X-rays of 73 children (2–19 years) with DDH, NDH, and LCPD were measured before, 3 months, and at final follow-up (FU) after hip reconstructive surgery (open reduction, and femoral and/or pelvic osteotomy ± soft-tissue procedures between 2008 and 2018). Measurement of hip geometry included acetabular index (AI), center-edge angle (CE), and Reimers migration index (RMI). Mean follow-up time at final FU was 4.9 years. P value was set P < 0.05.ResultsAfter surgery (femoral osteotomy: 84 hips, Salter innominate osteotomy: 21 hips, Pemberton osteotomy: 30 hips, open reduction: 28 hips, Chiari osteotomy: 4 hips, and soft-tissue release: 24 hips), hip geometry parameters improved significantly. Nevertheless, at final FU, there was deterioration in hip geometry with femoral head lateralization (RMI) compared to the data at 3 months after surgery (RMI: preop/3 months/final FU: 40.6 ± 16.1%/6.1 ± 9.0/15.4 ± 16.0%; CE: 11.3° ± 20.0°/30.2° ± 9.5°/27.9 ± 15.4°; AI: 28.8° ± 9.6°/19.1° ± 7.6°/18.3 ± 7.6°). Sub-group analysis did not show differences concerning the progression of RMI in DDH, NDH, and LCPD at final FU. Regardless of basic disease, the lateralization was observed in all three groups (DDH, NDH, and LCPD) and statistically significant comparing X-rays 3 months postoperatively to maximum follow-up (DDH; NDH; LCPD: 2.7 ± 6.8%/7.6 ± 10.1%; 13.7 ± 15.3%/22.8 ± 19.8%; 1.7 ± 4.1%/14.9 ± 11.3%). Additional soft-tissue release techniques in patients with DDH or NDH did not show postoperative differences with statistical significance. Concerning surgical techniques, a connection between the lower RMI and the procedure of osteotomy of the ilium was found. In 25 patients, (34%) complications were observed: superficial skin lesions in 8, deep skin lesions in 3, contraction of adductors in 3, subluxation in 2, dislocations of the cast in 2, osteonecrosis of the femoral head in 2 cases, reluxation in 1, infection of the implanted plate in 1, compliance problem in 1, delayed bone healing in 1, and contraction of knee flexors in 1 case.DiscussionThe basic results of this study show a significant improvement of hip geometry at a follow-up of 4.9 years and prove findings of previously published literature. Moreover, the study was able to show a progression of RMI in all patient groups, which have undergone reconstructive surgery, despite basic hip geometry data (AI, CE angle) did not change. Those findings were independent from underlying pathology. Complications were counted in 34% of the patients and involved all known adverse events after hip reconstructive surgery. This makes clear why annual follow-up checks are needed not to miss the right indication for revision surgery.Clinical relevanceEvidence level: Level IV, case series.Trial registration: This manuscript is part of a prospective randomized clinical trial, registered in the German Clinical Trials Register DRKS-ID: DRKS00016861.

A new method to quantify proximal femoral head-neck deformity in slipped capital femoral epiphysis (SCFE) is presented. In SCFE the femoral head slips posteriorly and inferiorly relative to the femoral neck. The distance of the femoral head center from the femoral neck axis (center-axis distance, CAD) represents the severity of the post-slip deformity. CAD is calculated on the anteroposterior and the frog-lateral pelvis views. It is shown that CAD is only a function of the femoral head-neck offset difference on both sides of the femoral neck. The percentage of CAD relative to the diameter of femoral neck is the femoral head-neck translation ratio (FHNTR) on the respective x-ray projection. Measurements on radiographs of 37 patients with history of unilateral SCFE were performed. The asymptomatic contralateral hips were used as controls. On the anteroposterior pelvis view, mean FHNTR was -12.2% and -4.3% for the affected and asymptomatic contralateral hips, respectively (paired t-test, p < .01), indicating inferior translation of the femoral head relative to the femoral neck. On the frog-lateral view, mean FHNTR was -21.1% and -6.5% for the affected and the contralateral hips, respectively (paired t-test, p < .01), indicating posterior translation of the femoral head relative to the femoral neck. There is a moderate inverse correlation between FHNTR on the frog-lateral pelvis view and Southwick's slip angle (Pearson correlation coefficient r = -0.679, p < .001). FHNTR on two radiological planes (anteroposterior and frog-lateral) is a simple measurement of the posteroinferior translation of the femoral head relative to the femoral neck in SCFE. It is a measurement of the true deformity of the proximal femur in SCFE. Calculation of FHNTR may be applicable to classify SCFE, to monitor femoral head-neck remodeling after slip stabilization, to describe the femoral head-neck relation in healthy individuals, and to monitor femoral head-neck changes secondary to other hip pathology, such as Perthes disease or developmental dysplasia of the hip.

IntroductionIt has been well documented that labral tear is frequently associated with femoroacetabular impingement and dysplasia of the hip; however, there have been few reported cases of labral tear associated with idiopathic osteonecrosis of the hip. Here we report the case of a patient with labral tear associated with idiopathic osteonecrosis of the femoral head who was treated by hip arthroscopy, with a favorable short-term outcome.Case presentationUnder the diagnosis of systemic lupus erythematosus, a 28-year-old Japanese woman was treated with the oral administration of steroid in 2007. A year after the treatment, she developed right hip joint pain and was diagnosed with idiopathic osteonecrosis of the femoral head at our institution. In November of 2011, she revisited our hospital when her right hip joint pain exacerbated and she became unable to walk. On the visit, the anterior impingement sign and Patrick test were positive. Radiography and magnetic resonance imaging in 2011 demonstrated neither spreading of the osteonecrosis area nor collapse of the femoral head in the right joint; however, magnetic resonance imaging showed a high-intensity area in the articular labrum in a T2-weighted image, leading to a diagnosis of labral tear. She underwent labral repair with hip arthroscopy in August of 2012. Now, 1 year after surgery, she does not feel any pain during walking and her modified Harris hip score has improved from 20 prior to surgery to 85.ConclusionThe case indicated that it is important to be aware of the possibility of labral tear in patients with idiopathic osteonecrosis of the femoral head, when spreading of the osteonecrosis area or collapse of the femoral head has not been seen on magnetic resonance imaging.

Developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) are common hip pathologies and important risk factors for osteoarthritis, yet the disease mechanisms differ. DDH involves deficient femoral head coverage and a shortened abductor moment arm, so this study hypothesized that the cross-sectional area (CSA) of the gluteus medius/minimus muscle complex and the stabilizing iliocapsularis muscle would be larger in DDH versus FAI, without increased fatty infiltration. A longitudinal cohort identified prearthritic patients with DDH or FAI who underwent imaging before surgery. Patients with DDH and FAI (Cam, Pincer, or Mixed) were 1:1 matched based on age, sex, and body mass index. Magnetic resonance imaging was used to measure the gluteus medius/minimus complex and iliocapsularis in two transverse planes. Amira software was used to quantify muscle and noncontractile tissue. Paired samples t-tests were performed to compare muscle size and composition (p < 0.05). There were no differences in the iliocapsularis muscle. Patients with DDH had significantly larger CSA of the gluteus medius/minimus complex at both transverse planes, and the noncontractile tissue proportion did not differ. The mean difference in overall muscle CSA at the anterior inferior iliac spine was 4.07 ± 7.4 cm2 (p = 0.005), with an average difference of 12.1%, and at the femoral head this was 2.40 ± 4.37 cm2 (p = 0.004), with an average difference of 20.2%. This study reports a larger CSA of the gluteus medius/minimus muscle complex in DDH compared to FAI, without a difference in noncontractile tissue, indicating increased healthy muscle in DDH.

Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders. The vascularity of the lateral epiphyseal vessels supplying the femoral head in patients with healed SCFE has not been well defined. The purpose of this study was to characterize the location and number of lateral epiphyseal vessels in young adults with healed SCFE. This was a retrospective study of 17 patients (18 hips) with a diagnosis of SCFE and a matched control group of 17 patients (17 hips) with developmental dysplasia of the hip. All patients underwent high-resolution contrast-enhanced magnetic resonance imaging to visualize the path of the medial femoral circumflex artery and the lateral epiphyseal arterial branches supplying the femoral head. There were 5 unstable SCFEs and 13 stable SCFEs with an average slip angle of 31 degrees. (All patients had been treated with in situ pinning and screw removal). Average age at time of magnetic resonance imaging was 24.5 years (range, 15 to 34 y). The lateral epiphyseal vessels reliably inserted on the posterior-superior aspect of the femoral neck from the superior-anterior to the superior-posterior position in both the SCFE and control groups. An average of 2 (±0.8) retinacular vessels were identified in the SCFE group compared with 5.2 (±0.7) retinacular vessels in the control group (P<0.001). In healed SCFE, the lateral epiphyseal vessels reliably insert in the same anatomic region as patients with hip dysplasia; however, the overall number of vessels is significantly lower.

Objective To evaluate the biological characteristics of hip joint in infants with developmental dislocation of the hip (DDH). Methods From January 2013 to June 2016, 30 patients (age from 1 to 8 months, 25 females and 5 males) who were diagnosed as DDH, underwent ultrasound examination in Shenzhen Children′s Hospital, in these patients 20 cases were treated surgically, and 10 cases were treated with non-surgical treatment. There were 34 hips (26 unilateral dislocation and 4 bilateral dislocation) dislocation in 60 hips. All the patients were confirmed by X-ray, magnetic resonance imaging (MRI) examination or operation. All the patients were examined by ultrasound through the coronal and transverse plane of the hip joint. The α angle, femoral head coverage ratio by acetabulum (FHC), femoral head length and width, distance from pubis to femoral head (P-H) and distance from ischium to femoral head (I-H) were measured. The dislocation joints were compared with contralateral joints. Results The α angle in the hip dislocation group was smaller than the contralateral group [(50.5±3.75)° vs (64.8±3.38) °], and there was significant difference between the two groups (t=-15.181, P<0.001). The FHC, femoral head length and width in the hip dislocation group were all smaller than the contralateral group [(23.4±17.63)% vs (64.3±6.45)%, (0.98 ±0.15) cm vs (1.19 ±0.11) cm, (1.38±0.21) cm vs (1.61±0.16) cm ], and there were significant differences between the two groups (t= -12.469, -6.034, -4.568, all P<0.001). The P-H and I-H in the hip dislocation group were larger than the contralateral group [(0.97±0.45) cm vs (0.27±0.05) cm, (0.75±0.30) cm vs (0.17±0.05) cm], and there were significant differences between the two groups (t= 8.805, 10.696, both P<0.001). The α angle, femoral head length and width in bilateral dislocation of hip group were slightly smaller than the unilateral dislocation of hip group [(50.3±2.75)° vs (51.3±4.77)°, (0.90 ±0.15) cm vs (0.97 ±0.12) cm, (1.25±0.20) cm vs (1.37 ±0.17) cm], but there were no significant differences between the two groups. The P-H and I-H in bilateral dislocation of hip group were slightly larger than the unilateral dislocation of hip group [(0.97±0.49) cm vs (0.80±0.31) cm, (0.92±0.26) cm vs (0.68±0.18) cm], but there were no significant differences between the two groups. The value of acetabular index in the ultrasound group was slightly larger than the X-ray group [(33.13±7.82)° vs (31.20±8.31)°], and there were no significant differences between the two groups. Conclusions The characteristics of DDH includes acetabulum and femoral head dysplasia, and femoral head and acetabulum position relationship abnormalities. Quantitative ultrasonography of the hip can be used to quantitatively evaluate the structural features of DDH, and it is helpful to the early diagnosis and follow-up of DDH. Key words: Ultrasonography; Developmental dysplasia of the hip; Dislocation; Infant

Intra-articular abnormalities of the hip, such as labral tears, loose bodies, chondral lesions, ligamentum teres tears and femoral acetabular impingement are increasingly being recognized in the pediatric age group. Evaluation for these abnormalities starts with a good history and physical exam. Radiographic imaging with plain films and magnetic resonance imaging help confirm the clinical impression. Arthroscopy of the hip can be utilized to diagnose and treat these abnormalities. Arthroscopy of the hip is a challenging procedure with a learning curve that requires a thorough knowledge of the anatomy of the hip. The hip is a deeply recessed joint that has a large muscular envelope, thick joint capsule and convex and concave surfaces of the femoral head and acetabulum, respectively. The normal anatomy may be distorted due to childhood developmental disorders such as hip dysplasia, Legg-Calve-Perthes Disease and Slipped Capital Femoral Epiphysis that adds additional challenges to the arthroscopist. Isolated intra-articular abnormalities occur rarely and an underlying morphologic abnormality should be identified which also requires management. Complications can be minimized with attention to detail.

THE TREATMENT OF ADOLESCENT SLIPPING OF THE UPPER FEMORAL EPIPHYSIS

Developmental dysplasia of the hip (DDH) is known to result in smaller femoral head size in toddlers; however, alterations in femoral head size and growth have not been documented in infants. To determine with ultrasound (US) whether femoral head size and growth are altered in infants (younger than 1year of age) with severe DDH. We identified all patients at our tertiary care children's hospital from 2002 to 2014 who underwent US for DDH. We included studies with at least one hip with severe DDH, defined as <25% coverage of the femoral head, and excluded teratological DDH. We constructed a control group of randomized patients with normal US studies. Two pediatric radiologists blinded to diagnosis measured bilateral femoral head diameter. Inter-reader variability and femoral head diameter difference between dislocated and contralateral normal femoral heads were evaluated. Mean femoral head diameters were compared across types of hip joint; femoral head growth rates per month were calculated. Thirty-seven children with DDH (28 female) were identified (median age: 33days). The control group contained 75 children (47 female) with a median age of 47days. Fifty-three of the 74 hips in the study group had severe DDH. Twenty-four children with DDH had completely dislocated hips (nine bilateral, five with contralateral severe subluxations). Thirteen other children had severe subluxation, two bilaterally. There was good inter-reader agreement in the normal femoral head group and moderate agreement in the severe DDH group. In the study group, severe DDH femoral head diameter was significantly smaller than their contralateral normal hip. Severe DDH femoral head diameter was significantly smaller than normal femoral head diameter in the control group. The severe DDH femoral head growth rate was slightly less but not significantly slower than normal femoral head growth rate in the study group. On US during infancy, femoral head size is significantly reduced in severe cases of DDH.