Triple prevention of congenital dislocation of the hip

Pathogeny and natural history of congenital dislocation of the hip

Based on a review of the literature, the authors have made a critical study of several etiological factors. Endogenous factors such as acetabular dysplasia, increased anteversion of the femoral neck, and capsular laxity support the genetic theory but are neither constant nor necessary and are only facilitating factors. The major factor seems to be a mechanical one linked to the position in the uterus: hyperflexion with adduction and external rotation constituting the dislocating foetal posture combined with abnormal pressure on the greater trochanter and leading to expulsion of the head upward and backward. This theory can explain the natural history of C D H which is first, at birth a hip instability followed by two possible evolutions: either persistent luxation becoming irreducible or spontaneous stabilisation leading sometimes to complete healing or to residual abnormalities (subluxation or dysplasia). This concept suggests practical conclusions: the importance of an early diagnosis, the selection of the signs of the hip at risk, the pattern of prevention, the role for non-clinical investigations, the principles of the treatment based on postures, the indications for the different types of treatment.

Prevention of hip dysplasia in children and adults

Klisic and Pajic summarized the history of early diagnosis and treatment of hip dysplasia when they wrote, Devising the preventive approach to developmental dysplasia of the hip (DDH) required much time.... Despite the 2400-year-old suggestion made by Hippocrates that children's hip dislocations are curable if treatment is started very early, the preventive approach was proposed by Roser only in 1879 [who] described early diagnosis in newborns and performed reduction by abduction... He also advocated early treatment by fixing babies' hips in abduction. However, surgeons did not readily accept these proposals, despite the good results shown by Froelich in 1906 and Le Damany in 1911. In 1927, Putti succeeded in interesting some orthopedic surgeons in the procedure by showing the results of early treatment. But the practical problem remained: ie, how to detect the DDH in patients at an early age. The turning point came in 1935 when pediatrician Ortolani introduced early detection of DDH by “early clinical search” shortly after a child's birth, instructing obstetricians, pediatricians, and midwives to perform the search. Rediscovering the diagnostic “segno della scatto,” ie, reducible displacement, he popularized the prophylactic approach to DDH by early detection and treatment. Fifteen years later, another pediatrician, Palmen, organized systematic screening in nurseries by pediatricians. Since Klisic and Pajic wrote this in 1993, the use of ultrasound, albeit still controversial in some ways, has influenced the treatment and prevention of DDH. Klisic's attempts to universally prevent the disease may still be able to be incorporated into further efforts at disease prevention through education and the systematic trials of hip abduction pillows or braces similar to his wide-diaper diapering technique. The goal of prevention is to eradicate a disease so that it does not present to the physician. For DDH, this goal may be tenable.

Plastazote abduction orthosis in the management of neonatal hip instability

Since 1987, 113 consecutive newborns with either Ortolani-positive or provocative-positive hip examinations in the newborn nursery have been treated with a Plastazote hip abduction orthosis when diagnosed and followed to determine if the method was safe, effective, and easy to use. Ortolani-positive hips often had bilateral abnormalities in the hip examination, were frequently associated with breech position, and were anatomically more dysplastic than those hips that were unstable by provocative testing. No patient developed ischemic necrosis during follow-up. Only two had additional treatment of their unstable hips. The rest had excellent results. Parents and caregivers found the device easy to use. The orthosis is recommended as the primary method for managing newborns with clinical instability to either the provocative or Ortolani test as being safe, effective, and easy to use across all skill levels.

Splinting for CDH--initial impressions of a 'user-friendly' alternative

A lightweight, washable, and easily adjusted splint for the congenitally dislocated hip, designed to improve maternal compliance, is described. Observations are currently scientifically uncontrolled, though initial impressions are favourable.

Screening for congenital dislocation of the hip, scoliosis, and other abnormalities affecting the musculoskeletal system

The three main conditions affecting the musculoskeletal system currently being screened for are spina bifida cystica, congenital dislocation of the hip, and scoliosis. The techniques of screening are different for each: amniotic fluid analysis for spina bifida cystica, a manual physical examination for congenital dislocation of the hip, and a visual examination for scoliosis. Properly time amniotic fluid analysis for alpha-fetoprotein is both a sensitive and specific test for neural tube defects. However, because of the low incidence of spina bifida cystica, this examination is justified only in high-risk pregnancies. Maternal serum screening has not achieved widespread acceptance because of its lack of sensitivity and the low and apparently falling incidence of the deformity. The neonatal manual examination for congenital dislocation of the hip is now well established and widely practiced. Almost all agree that the incidence of persistent congenital dislocation of the hip has been lowered as a result. However, the examination lacks both sensitivity and specificity because of intrinsic difficulties with the examination and the occurrence of late onset subluxation and dislocation. It is becoming apparent that congenital dislocation of the hip is a dynamic problem in the peri- and early neonatal period. Repeated careful evaluation of the hips during infancy is necessary to make the diagnosis as early as possible. To further enhance early detection, it may be necessary to consider obtaining an anteroposterior pelvis radiograph at age 4 to 6 months in babies at high risk. The visual evaluation for scoliosis is a very sensitive test but lacks specificity. Efforts are now being made to quantify visual screening techniques and thus decrease the numbers of false-positive examinations.