CDH

CDH - CTEV

Prof. Mamoun Kremli Dr. Tarif Alakhras

Nomenclature

• CDH: Congenital Dislocation of the Hip
• DDH: Developmental Dysplasia of the Hip
• X - other ab CHD: (Congenital Heart Disease)*

Spectrum of Disease

• Different etiologies, pathologies, and natural history
• Affects proximal femur and acetabulum
• Initial pathology is congenital, but progresses if untreated
• Does not always result in dislocation

Classification of CDH

• Teratologic hip: Fixed dislocation at birth, often with other major anomalies
• Dislocated hip: May or may not be reducible
• Unstable hip: Dislocatable and reducible
• Acetabular dysplasia: Shallow acetabulum

Incidence

• Hip instability at birth: 0.5 – 1%
• Classic CDH: 0.1%
• Mild dysplasia: Substantial (up to 50% of hip arthritis in women have underlying hip dysplasia)

Etiology

Multi-factorial condition with several contributing factors:

Ligamentous and Hormonal Factors

• Ligament laxity
• Hormonal influences:
  • Estrogen and Relaxin from mothers
  • May affect baby girls more due to receptor differences
• Familial (congenital):
  • Mild to severe forms including Ehler-Danlos syndrome

Genetic Factors

• Gender predisposition: Females 4-6 times more affected than males
• Twin studies:
  • If one twin has DDH, incidence in second twin:
    • Monozygotic: 38%
    • Dizygotic: 3% (similar to other siblings)

Mechanical Factors

• Prenatal factors:
  • Breech position: Normally 2-4%, in CDH: 16%
  • Oligohydramnios, primigravida
  • Associated with torticollis and metatarsus adductus
• Postnatal factors:
  • Swaddling/strapping hips in adducted and extended position with knees extended

Risk Factors

High-Risk Infants

• Positive family history: 10× increased risk
• Female gender: 4-6× increased risk
• Breech presentation: 5-10× increased risk
• Torticollis: CDH present in 10-20% of cases
• Foot deformities:
  • Calcaneo-valgus
  • Metatarsus adductus
• Knee deformities:
  • Hyperextension and dislocation (Teratologic)

Management of High-Risk Infants

When risk factors are present:

• The infant should be examined repeatedly
• The hips should be imaged (Ultrasound or X-ray)

Clinical Examination

Inspection (Look)

• General appearance:
  • Externally rotated hip
  • Lateralized contour
  • Wide perineum (in bilateral cases)
  • Asymmetrical skin folds (anterior and posterior)

Physical Measurements

• Shortening assessment:
  • Supine position
  • Galeazzi test (Allis sign)

Range of Motion (Move)

• Abduction limitation in flexion:
  • Careful assessment in bilateral cases
  • Symmetrical limitation may indicate bilateral involvement
  • If abduction < 60° bilaterally: considered abnormal

Special Tests

• Galeazzi test and limited abduction in flexion
• Note: Use of a lollipop can help during examination

Neonatal Special Tests

Ortolani Test

• Purpose: Reduces a dislocated hip
• Technique:
  • Feel a clunk (positive sign)
  • Do not rely on hearing a click (can be misleading)

Barlow Test

• Purpose: Dislocates a reduced hip
• Technique:
  • Feel a clunk (positive sign)
  • Do not rely on hearing a click (can be misleading)

Trendelenburg Test

• Unilateral cases: Trendelenburg gait
• Bilateral cases: Waddling gait

Age-Specific Examination Findings

• Neonatal: Limited abduction, positive Ortolani/Barlow tests
• Toddler: Shortening, limited abduction
• Walking age: Shortening, limited abduction, positive Trendelenburg sign

Imaging

Ultrasound

• Early infancy: More reliable than X-ray
• Expert interpretation required for accurate results
• Timing considerations:
  • Incidence of hip stability declines rapidly to 50% within first week of neonatal life
  • Better to delay ultrasound until after 2 weeks of age

Radiology (X-ray)

Early Infancy

• Not reliable in early infancy - ultrasound is preferred

After 3 Months

• More reliable for assessment
• AP abduction view:
  • Long axis of femur normally passes through acetabulum

After 6 Months

• Clearly shows dislocation
• Femoral head ossific center size and position assessment

Radiological Assessment Methods

1. Horizontal Line Through Tri-radiate Cartilage

• Normal: Femoral head ossific center below the horizontal line
• Dislocated: Femoral head ossific center above the horizontal line

2. Perpendicular Line from Acetabular Edge

• Normal: Femoral head ossific center medial to perpendicular line
• Dislocated: Femoral head ossific center lateral to perpendicular line

3. Acetabular Index (Acetabular Angle)

• Measurement: Angle from acetabular edge to base at horizontal line
• Normal: ≤ 25°
• Dislocated: > 35°

4. Shenton’s Line

• Important assessment tool for hip joint integrity

Treatment

Treatment Goals

• Obtain concentric reduction of the hip
• Non-traumatic approach to preserve blood supply to femoral head
• Early detection and intervention for optimal outcomes

Key Principles

• Method depends on age at presentation
• Earlier treatment = easier management and better results
• Early detection is critical for successful outcomes

Age-Specific Treatment Protocols

Neonatal Hip Instancy (Birth to 6 months)

• Initial observation (most resolve spontaneously):
  • Avoid adduction swaddling
  • Apply double diapers
  • Re-evaluate at 2 weeks of age

• If unstable at 2 weeks: Pavlik Harness
  • Dynamic, effective, and safe treatment option

6-12 Months of Age

• Closed reduction with hip spica cast
• Open reduction (surgery) with hip spica cast
• Arthrography-guided procedures

18-24 Months of Age

• Surgical intervention: Open reduction with possible acetabuloplasty

Above 2 Years of Age

• Comprehensive surgical approach:
  • Open reduction
  • Acetabuloplasty
  • Femoral shortening

Complete Treatment Algorithm

Age Range	Primary Treatment
Birth - 6 months	Pavlik harness or hip spica
6-12 months	Closed reduction under GA and hip spica (Note: some approaches avoid this)
12-18 months	Open reduction
18-24 months	Open reduction and acetabuloplasty
2-8 years	Open reduction, acetabuloplasty, and femoral shortening
Above 8 years	Open reduction, acetabuloplasty (all three pelvic bones), and femoral shortening

CDH Summary

• Complex multi-factorial, endemic disease
• Identify at-risk groups for early screening
• Learn proper examination methods for accurate diagnosis
• Early treatment is easier and yields better results