Guía de práctica clínica displasia luxante de caderas / Dislocating hip dysplasia clinical practice guide

Generar recomendaciones basadas en la mejor evidencia disponible acerca del diagnóstico, tratamiento y seguimiento de la displasia luxante de cadera en recién nacidos y lactantes. Recién nacidos y lactantes con displasia luxante de cadera o sospecha, que reciben atención en el nivel primario, secundario y terciario de atención en el sector público y privado de salud.

Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic review.

Developmental dysplasia of the hip (DDH) is a common condition predisposing to osteoarthritis (OA). Especially since DDH is best identified and treated in infancy before bones ossify, there is surprisingly a near-complete absence of literature examining mechanical behavior of infant dysplastic hips. We sought to identify current practice in finite element modeling (FEM) of DDH, to inform future modeling of infant dysplastic hips. We performed multi-database systematic review using PRISMA criteria. Abstracts (n = 126) fulfilling inclusion criteria were screened for methodological quality, and results were analyzed and summarized for eligible articles (n = 12). The majority of the studies modeled human adult dysplastic hips. Two studies focused on etiology of DDH through simulating mechanobiological growth of prenatal hips; we found no FEM-based studies in infants or children. Finite element models used either patient-specific geometry or idealized average geometry. Diversities in choice of material properties, boundary conditions, and loading scenarios were found in the finite-element models. FEM of adult dysplastic hips demonstrated generally smaller cartilage contact area in dysplastic hips than in normal joints. Contact pressure (CP) may be higher or lower in dysplastic hips depending on joint geometry and mechanical contribution of labrum (Lb). FEM of mechanobiological growth of prenatal hip joints revealed evidence for effects of the joint mechanical environment on formation of coxa valga, asymmetrically shallow acetabulum and malformed femoral head associated with DDH. Future modeling informed by the results of this review may yield valuable insights into optimal treatment of DDH, and into how and why OA develops early in DDH.

Effects of normal and abnormal loading conditions on morphogenesis of the prenatal hip joint: application to hip dysplasia.

Joint morphogenesis is an important phase of prenatal joint development during which the opposing cartilaginous rudiments acquire their reciprocal and interlocking shapes. At an early stage of development, the prenatal hip joint is formed of a deep acetabular cavity that almost totally encloses the head. By the time of birth, the acetabulum has become shallower and the femoral head has lost substantial sphericity, reducing joint coverage and stability. In this study, we use a dynamic mechanobiological simulation to explore the effects of normal (symmetric), reduced and abnormal (asymmetric) prenatal movements on hip joint shape, to understand their importance for postnatal skeletal malformations such as developmental dysplasia of the hip (DDH). We successfully predict the physiological trends of decreasing sphericity and acetabular coverage of the femoral head during fetal development. We show that a full range of symmetric movements helps to maintain some of the acetabular depth and femoral head sphericity, while reduced or absent movements can lead to decreased sphericity and acetabular coverage of the femoral head. When an abnormal movement pattern was applied, a deformed joint shape was predicted, with an opened asymmetric acetabulum and the onset of a malformed femoral head. This study provides evidence for the importance of fetal movements in the prevention and manifestation of congenital musculoskeletal disorders such as DDH.

Immobilized chicks as a model system for early-onset developmental dysplasia of the hip.

We have almost no understanding of how our joints take on their range of distinctive shapes, despite the clinical relevance of joint morphogenesis to postnatal skeletal malformations such as developmental dysplasia of the hip (DDH). In this study, we investigate the role of spontaneous prenatal movements in joint morphogenesis using pharmacological immobilization of developing chicks, and assess the system as a suitable model for early-onset hip dysplasia. We show that, prior to joint cavitation, the lack of dynamic muscle contractions has little impact on the shape of the hip joint. However, after the timepoint at which cavitation occurs, a dramatic effect on hip joint morphogenesis was observed. Effects in the immobilized chicks included flattening of the proximal femur, abnormal orientation of the pelvis relative to the femur and abnormal placement and coverage of the acetabulum. Although many clinical case studies have identified reduced or restricted movement as a risk factor for DDH, this study provides the first experimental evidence of the role of prenatal movements in early hip joint development. We propose that the immobilized chick embryo serves as a suitable model system for the type of early-onset DDH which arises due to neuromuscular conditions such as spinal muscular atrophy.

[Correlation between sex, intrauterine position and familial predisposition and neonatal hip ultrasound results]. / Populationsbasierte Studie zu Prädispositionsfaktoren und Häufigkeit der Hüftgelenksdysplasie.

AIM: To correlate findings of hip ultrasound on day 4-10 of life with sex, intrauterine position and a positive family history for congenital hip anomalies. METHODS: The SNiP-study ( Survey of Neonates In Pommerania) registered 2256 neonates (2030 term, 226 preterm) between May 2002 and March 2004. Hip ultrasound results of 1043 term and since October 2003 33 preterm neonates were analysed. Time of ultrasound was day 4-10 after birth. Preterm neonates were examined when reaching their corrected term gestational age. Ultrasound was applied with a 7.5 MHz linear scanner and results were classified according to Graf. Chi-square and Fishers exact test were used for statistical analysis. RESULTS: 4.9 % of the screened hips were classified as IIc or higher, 3.1 % were unilateral and 1.7 % bilateral. Incidence was significantly higher (p < 0.023) in females (6.6 %) than in males (3.2 %). There was no significant difference in intrauterine position or positive family history for hip anomalies with 3.7 % for mothers, 1.2 % of fathers and 2.4 % of siblings positive. There was a higher incidence for congenital hip dysplasia in preterms with 6.1 %, which is not significant due to the limited number. DISCUSSION: Current screening methods miss up to 18 % of newborns with severe hip dysplasia. We were able to demonstrate that screening for congenital hip dysplasia with ultrasound is a diagnostic tool even during the first days of life. There is a significantly higher incidence of congenital hip dysplasia in females, but in contrast to other studies we found no significant difference in intrauterine position or familial history. Earlier diagnosis and therapy on the base of relevant risk factors might correspond with an improved prognosis and outcome. Further studies are warranted to evaluate the significance in preterm neonates.

Growth and development of the child's hip.

The child's hip begins in intrauterine development as a condensation of mesoderm in the lower limb bud that rapidly differentiates to resemble the adult hip by eight weeks of life. The developmental instructions are transmitted through complicated cell signaling pathways. From eight weeks of development to adolescence, further growth of the hip is focused on differentiation and the establishment of the adult arterial supply. The postnatal growth of the child's hip is a product of concurrent acetabular and proximal femoral growth from their corresponding growth plates. Absence of appropriate contact between acetabulum and proximal femur yields an incongruent joint. Multiple disease processes may be understood in light of this growth process, including Legg-Calvé-Perthes disease and developmental dysplasia of the hip.

Detecting developmental dysplasia of the hip.

Recent guidelines from the American Academy of Pediatrics mandate the universal screening of all newborns for developmental hip dysplasia, in an effort to promote prompt recognition and treatment of this condition. The effectiveness of universal screening hinges on the appropriate education, training, and experience of health care providers. This article reviews the normal embryologic, natal, and postnatal development of the hip. Historical risk factors that may have an impact on this developmental sequence are outlined. A step-by-step guide to the examination of the hip is offered, along with a discussion of the sensitivity and specificity of the Ortolani and Barlow maneuvers. Clear guidelines for referral are presented. The indications for the use of ultrasound studies as a secondary screening tool are outlined. Treatment options and important aspects of counseling and teaching families are reviewed.

Perinatal development of the rat hip joint with restrained fetal movement.

We compared the structures of the femoral head (FH) of neonates between normal and operated legs with restrained fetal movement using an exo utero technique. At embryonic day (E) 16.5, one hind limb was sutured onto the embryonic membrane and the fetuses were allowed to develop exo utero until the term (E22.5). There was no significant difference in the largest diameter of the FH between the non-operated and operated side FH in the operated neonates and the FH of the non-operated neonates. By scanning electron microscopy, roughness and collagen fiber bundles, which were detected on the surface of the operated side FH at E18.5, disappeared at E22.5. However, the operated side FH was deformed and the surface cell arrangement was more irregular than that of the controls at E22.5 by light microscopy. These results suggest that the abnormality of cell arrangement caused by the restraint of fetal movement may induce the deformity and irregularity of the FH surface, although this operation may not disturb the basic cellular activities such as cell proliferation as well as the secretion of cartilage ma-trix and collagen fibers. To further investigate the recovery process in the operated newborns after releasing the restraint, we bred them artificially for a considerable period after birth. The operated side FH surface of the neonate bred for 45 hours was smoother than that at E22.5 and similar to that of the non-operated side FH. This result suggests that the proper movement of the extremities after birth may recover the deformity caused by restrained fetal joint movement.

[Effect of birth weight on hip maturation in the newborn infant]. / Der Einfluss des Geburtsgewichts auf die Hüftreifung des Neugeborenen.

In 2018 consecutive newborn ultrasound examination of the hip was performed according to the method of Graf within the first 14 days of life (average 4th day). Typ IIa was seen as normal in newborn child. Birth weight was classified according to standards of Lubchenco and Hohenauer. Newborn with high birth weight (LGA) revealed an incidence of CDH (Typ IIc according to Graf or worse) nearly twice as high as in normal weighted newborn (AGA) (6.11% vs 3.51% [Lubchenco] and 7.95 vs 3.09 [Hohenauer]). Even in children with birth weight between 75th and 90th percentile we found a CDH incidence of 5.54%. Ultrasound examination of the hip is suggested in newborn children with high birth weight because of a higher risk for development of a CDH. Other risk-factors like breech position or of CDH.

Factores de riesgo en la etapa intrauterina que predisponen a la luxación congénita de cadera / Risk factor in intrauterine stage, that predispose to congenital dislocation of the hip

La luxación congénita de cadera es uno de las patologías más frecuentes en la etapa neonatal en la que se interactúan una serie de factores para su presentación algunos de estos factores pueden ser identificados desde el periodo prenatal e incluyen la presentación pélvica, el sexo y la cantidad de líquido amniótico, además la luxación puede ser parte de un complejo sindromático que presenta también una serie de alteraciones agregadas, el seleccionar a la población con un mayor riesgo puede conducir a una evaluación mas detallada al nacimiento e iniciar las maniobras terapéuticas para una corrección temprana

Anatomic study of the pre- and neonatal hip. Physiopathologic considerations on dysplasia and congenital dislocation of the hip.

Therapeutic success in dysplasia and congenital dislocation of the hip depends on an early diagnosis. The physiopathology remains very debatable and several concepts are propounded. For a better physiopathologic understanding, the authors have carried out a study of the morphology and development of 22 pre- and neonatal hips. At first, the acetabulum is cartilaginous and distorted by the moving femoral head; this acetabulum is histologically affected by the femoral pressure. The pathologic hip is characterized by defective posterior bony coverage of the femoral head by the acetabulum. The acetabulum ossifies during the 3 months following birth, forming a cup-like cavity under the pressure of the femoral head. Therefore, neonatal screening tests such as sonography must take place in the first weeks of life.

Retardo do aparecimento do núcleo secundário de ossificaçäo da epífise femoral proximal: relato de caso / Delayed apperance of the secondary center of ossificarion of the proximal femoral epiphysis: case report

É muito difícil se determinar as condiçöes de normalidade, em relaçäo ao desenvolvimento do quadril desde, seu molde embrionário até a sua completa formaçäo. Existe muita controvérsia na literatura quanto ao aparecimento do núcleo de ossificaçäo secundário da epífise femoral nos quadris normais, visto que este pode aparecer desde os primeiros dias de vida (Jacobs, 1966), até um ano e meio após o nascimento (Paterson, 1976). Os autores apresentam o relato de um paciente de um ano e nove meses de idade, que näo apresentava a ossificaçäo da epífise femoral proximal, tratando-se provalvemente de um retardo do aparecimento do núcleo primário. O que foi comprovado após um seguimento clínico, ultra-sonográfico e por ressonância magnética, após um seguimento de um ano e nove meses

[Ultrasound anatomy of the fetal hip joint with special reference to the blood supply]. / Sonoanatomie des fetalen Hüftgelenks unter besonderer Berücksichtigung der Blutversorgung.

AIM: Study of the anatomy of the fetal hip joint in 115 pregnancies between 13. to 40.th weeks of gestation by ultrasound. METHOD: Sonoanatomy was studied by high resolution ultrasound (Acuson 128). For investigation of vascular supply of the fetal hip, colour-coded Doppler sonography was performed. In-vivo studies on vascular supply were correlated with histological sections of 34 fetal hip specimens, according to the conceptional age of 13-35 weeks. RESULTS: Vascular studies of the proximal end of the human femur showed a supply by the lateral and medial femoral circumflex arteries branched from the femoral artery or the deep femoral artery. After 22 weeks of gestation the acetabular artery supplied by the obturator artery was visible by means of Doppler sonography. At the end of pregnancy, large numbers of intraosseous blood vessels are demonstrable within the femoral head and neck. CONCLUSION: The basic arterial pattern of the hip joint is established at birth. Proximal end of the growing femur, acetabulum, os ilium and labrum acetabulare are clearly visible by ultrasound.

The acetabular notch in hip dysplasia.

In the first few months of life, a notch may be seen on radiographs of the superolateral margin of the infant hip. It may be associated with a steeply inclined acetabular roof and may be an indicator of persistent neonatal instability or displacement of the femoral head.

Anatomical basis for congenital deformities of the lower extremities. Part I. The hip and thigh.

Congenital deformities frequently produce problems not always discernible at birth. Often, a period of time is required for the development of signs and symptoms. The present discussion presents the intrauterine anatomy of a midterm fetus relative to conditions of the hip and thigh. Cryomicrotomy is used in this study to present the best anatomical evidence of the morphology involved.

[Embryology of the human hip with special reference to the development of the labra]. / Die Embryologie der menschlichen Hüfte unter besonderer Berücksichtigung der Entwicklung der Labra.

For the clinician the knowledge of the intrauterine development of the human hip is of great importance particularly for an understanding of the pathogenesis of congenital hip displacement. Observations based on serial sections of fetal hips from our collection showed that the acetabular roof is generally well developed. The posterior wall, on the other hand, consists mostly of the fibrous labrum and little coverage is provided by cartilage. Since the fetal hip is in a position of flexion, a pressure exerted on the knee will be transmitted to the posterior wall of the acetabulum and not to the acetabular roof. Any additional adduction, often found in utero, will further decrease the coverage. Both, the relative weak posterior structures and the position of adduction, may explain the posterior subluxation observed in one of our specimens.

Development of the hip joint in relation to congenital dislocation.

As an introduction to the pathology and treatment of C.D.H., a simplified outline of fundamental embryologic events and growth characteristics of the hip joint (selected from past and actual bibliography) is presented. Congenital dislocation of the hip appears to be the result of various genetic, developmental, environmental and mechanical factors that affect articular structures in the perinatal period. At this time, the hip joint is anatomically and functionally more vulnerable to alterations of its normal concentric disposition. If incongruency persists, subsequent morphological changes, characteristic of dysplasia will develop. The main conclusions derived from a review of the development of the hip joint in relation to C.D.H. are: 1) The hip joint is an anatomical and functional unit derived from a common primitive blastema. 2) Primitive condensed sclerotomic mesenchyme transforms into cartilage that shapes in a genetically determined pattern to form the femur and os innominatum in continuity. 3) The joint space develops by autolytic degeneration in the 7-8 week embryo. By the 11th week, the joint cavity, evolved in the capsule lined internally by synovium, has a well differentiated labrum and ligamentum teres with the basic morphology of a developed hip joint. Only after this stage is displacement possible. 4) Depth (and stability) of the acetabulum increase with development of the glenoid labrum and cartilaginous rim (incomplete only in its inferior portion). Here a fibrous band (transverse ligament) offers less resistance to displacement, but on occasions is an anatomic barrier to concentric reduction. 5) In the early fetal period, the acetabulum is a deep set cavity, becoming shallower at the time of birth. Femoral head coverage at birth is more deficient than at any other previous or subsequent stage of development. 6) The relationship between femoral and acetabular anteversion (instability index) is more important than absolute values which are variable during intrauterine life. The degree of femoral anteversion depends on teh rotational attitude and muscular action of the extremity.(ABSTRACT TRUNCATED AT 400 WORDS)