What is Hip Dysplasia?
Developmental dysplasia of the hip (DDH) is often referred to as congenital hip dysplasia or simply hip dysplasia. It is one of the most commonly treated lower limb conditions in Paediatric Orthopaedic care.
The hip joint comprises a ball at the top of the thigh bone (femoral head), which sits within a socket in the pelvic bone (acetabulum). Hip dysplasia means that the socket of the hip joint is shallow. It is a spectrum condition with complete hip dislocation at birth, existing as the most severe manifestation. The mildest form is where the ball is in the socket, but the socket remains shallow in adult life, giving rise to painful arthritis.
Early diagnosis plays a crucial role in determining successful outcomes, often preventing the need for surgical treatment of developmental dysplasia of the hip. Hip dysplasia treatment can be highly effective if detected early. Ultrasound screening in infants at the walking stage increases the likelihood of avoiding surgery.
For more information on early diagnosis, visit the link: Developmental Hip Dysplasia – Early Diagnosis.
Explore non-operative treatment for hip dysplasia—book a consultation today!
How common is Hip Dysplasia?
Hip dysplasia is prevalent. One in a hundred babies receive treatment for hip dysplasia. One in 500 babies is born with completely dislocated hips. The identified risk factors include
- Family history of affected family members – usually the patient’s mother, aunty or sibling has had treatment as a child or hip replacement in early adulthood.
- Breech lie towards the end of pregnancy – baby is in an upside down position with head up and bottom down. This position can cause the hip to dislocate.
- Packaging disorders – these are features which indicate the baby is very tightly packed in the womb. They include plagiocephaly (head flattening), torticollis (stiff neck) and foot abnormalities (calcaneovalgus feet and metatarsus adductus).
However, up to 50% of children diagnosed with hip dysplasia may not have any of the above risk factors. Hip dysplasia is more common in girls than boys and more common in the first-born child compared with later children. However, these are considered soft risk factors as most firstborn female babies have normal hips.
If you are a paediatric orthopaedic surgeon in Dubai, contact Dr. Assad Qureshi for dhd surgical treatment.
How do we detect Hip Dysplasia?
Ultrasound of a baby’s hips is our best clinical tool for detecting hip dysplasia early. The recommendation is that a baby’s hips are scanned at 4-6 weeks of age.
Ultrasound assessment undertaken in the first few days of life (especially in premature births) frequently over-diagnoses hip dysplasia. The reason is that the hips develop quite a lot in the first few weeks following birth (this is the basis for the recommendation of scanning hips between 4-6 weeks).
Although a few countries practice universal ultrasound screening of all newborn babies’ hips, most countries adopt selective screening based on the presence of risk factors for hip dysplasia.
The main risk factors that are screened for are a family history of hip dysplasia amongst first-degree relatives and breech lying towards the end of pregnancy.
Hip sonographers are usually the best operators for undertaking hip ultrasound assessment in newborns. The sonographer will usually scan the baby on their side, scanning each hip in turn.
They will save an image of each hip in a defined plane, assess stability and measure the Alpha angle (used to define a threshold for treatment with <60 degrees viewed as abnormal). Alpha angle and stability are the key assessments on which a decision to treat is based. The baby can often be safely discharged from further follow-up if these parameters are normal.
The best ultrasound assessment for hip dysplasia is when the Pediatric Orthopedic Surgeon reviews the scan in real-time with the sonographer. Whether to treat is based on real-time interpretation of the ultrasound images to ensure that dysplasia is appropriately diagnosed and treated.
Dr Qureshi undertakes a combined clinic with the sonographer for these cases, where the sonographer undertakes the scan while Dr Qureshi interprets the findings and decides on treatment.
In many centres, the sonographer does the scan in isolation, and the static images are reviewed later by a radiologist, who may have difficulty interpreting them. The report is often sent to the orthopaedic surgeon to decide on treatment.
This can alter the threshold for treatment as the orthopaedic surgeon may have to decide based on the measured angles alone rather than the real-time images showing the extent of hip coverage and stability on dynamic testing.
How do we treat hip dysplasia in early life?
If the scan findings are abnormal, the doctor may treat your child in a Pavlik harness. Pavlik harnesses are “dynamic flexion abduction orthoses.” They work best in hip dysplasia diagnosed under six months of age. The harness encourages the baby’s hips to be positioned outward at rest, which is the best position for hip stability whilst permitting some movement.
They are low profile, and babies will sleep comfortably in them. The Pavlik harnesses are usually applied and fitted by Dr Qureshi, who oversees all aspects of treatment. The straps are marked so that parents know the settings when re-applying. Dr Qureshi recommends 23 hours daily (off for 1 hour for bath and stretch) until the next visit.
Appropriate sizing of the harness, adjustment of straps and looking for any complications are undertaken at each visit. The frequency of visits is based on the ultrasound findings at each visit to judge the response to treatment.
Schedule your child’s orthopedic consultation in Dubai today!
What if my child is too old for a harness or it doesn’t work?
For older children or cases where the Pavlik harness fails, ddh surgical treatment may be necessary. In such cases, harness treatment may be discontinued as there is a risk of damaging the femoral head through prolonged use if the hip remains dislocated.
In cases where the Pavlik harness is ineffective, Dr. Qureshi would recommend an arthrography (dye injection) assessment of the hip under general anaesthetic when the child is a little older. This is usually done around the age of 6 months. The dye injection study (arthrogram) involves the injection of contrast into the hip to visualise the femoral head (usually, the cartilaginous femoral head is invisible on x-ray).
Once the head is visualised, we can determine where it is in relation to the socket and how easily and satisfactorily it can be placed in the socket. The arthrogram (dye study) assesses hip dysplasia and whether it can be treated without open surgery. Sometimes, the hip can be manually placed into its normal position by moving the leg (closed reduction).
If possible, the Consultant will apply a plaster cast to the child’s hips (hip spica) to keep them in this position, allowing them to develop further. The hip spica is usually removed at six weeks, and an arthrogram is performed to assess if the hips are stable. A further spica cast may be applied for six weeks if the hips are still unstable.
If the hip is unstable (easily slipping in or out) or can not be placed back into the joint in a good position, it is usually best not to attempt treatment with a hip spica. It is better to leave the hip free and undertake surgery when the child is older to place the hip back in.
The hip’s instability problem is that it will come out of the joint even with the cast on. It is also very important to avoid forcing the head into the joint and applying a cast. This can cause a severe complication – avascular necrosis of the femoral head.
In this complication, the femoral head is injured from the pressure of being squashed into the joint. The damage leads to the development of an abnormally shaped femoral head as the child ages. Avascular necrosis is a serious problem for the hip and can not be reversed with surgery.
A core principle of hip dysplasia treatment is to avoid causing avascular necrosis. Therefore, correcting the hip dislocation through surgery is done using a plaster cast.
If non-operative methods are ineffective, surgery for developmental hip dysplasia may be recommended. The primary goal is to avoid complications such as avascular necrosis—damage to the femoral head caused by excessive pressure.
If your child is affected by hip dysplasia, consult Dr Assad Qureshi for best-in-class care. Book an appointment now!
