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Why are babies hips checked at birth in a newborn unit ?




After birth all newborn babies are in the  unit and you will not miss any
baby In case of a decentred hip joint you can start with treatment
immediately and you don?t waste time(1)
Up to10% of newborns avoid the obligatory control of hips examinations 
for different reasons(2)
Infants with CDH are born with a shalow acetabulum
(type D), but the  head is kept in the acetabulum. In exceptional cases the situation is different as is commonly agreed.

Ligamentum teres ,which keeps the head in the acetabulum, starts to elongate and grow with each movement of the leg. It is an irreversible
Process- we are not able to shorten the elongated ligament nor the nerves or vessels inside  (going to epiphysis), that is why examination in neonatal ward is so crucial.

There occurs also the mechanical damage of nervous fibres of nociceptive and prioproceptive  in the limbus and ligamentum teres of the Hip Joint(responsible for steering and positioning of the head in the acetabulum , (7)- they are more numerous  than in  The AC ligaments of the Knee (9)).

Which may result in the unsuccessful treatment of the CDH due to lack of
Co-ordination between the proper muscle tension and  child’s movement. This  makes  maintaining the correct position of the head in  the acetabulum impossble and speeds up destruction of joint cartilage. (8)

Incorrect head movement changes also the position of the iliopsoas muscle, which presses medial circumflex artery (the main nutritional vessel) to the
Edge of acetabulum  and  makes insertion of the head in the acetabulum impossible ,reduced  blood inflow hinders correct head growth, or destroys it if the process happens suddenly.(13)

The above mentioned changes are instrumental to the treatment
and if we allow them to occur, the treatment’s result never is
never sutisfactory. 
Up till now, it is estimated, that  the same number of newborns  babies with CDH requires the hip joint replacement as about 60 years ago ,when  the clinical examin.  (4,6)



More recent specialist literature considers screening of neonates as
early as possible to be ideal [1,3,7, 11, 12].
In order to guarantee successful treatment, the CDH must be detected in
the Newborn Unit right after the birth and rebuilding of hip instability
must be completed by 5th week of age when the  regeneration process is
the fastest(5)
One week of treatment after the birth equals one month of treatment later
and there are no complications (1)

Medical statistics show a close correlation between an early diagnosis and complications due to treatment.(8) 
What is most crucial ,an early diagnosis and appropriate treatment helps
to prevent a risk of femur head destruction (avascular necrosis) which may
occur as a result of incorrectly chosen treatment and delayed
diagnosis(9).

In extreme cases of CDH  with  late diagnosis(  even a few weeks after
the newborn unit ) with highest (most severe)dislocation of a femur head,
necrosis occurs in every child regardless of kind of treatment(including
operative procedure).(11)

Failure to detect CDH in time or inappropriate treatment will result in
complication many year later,when it is too late for prevention.

The ultrasound hip screening by an orthopaedic doctor is a standard in
Germany,Switzerland Austria,which achieve four time better results of
operative treatment and in head destruction at least 10 time better ( at
present  the best ever results in the world) then countries which do not
apply obligatory ultrasound examinations

Due to limited expenses of public health service and Lack of
appropriately qualified doctor, decision about hip ultrasound in neonatal
unit should belong to parents, who in majority of cases, decide to
perform  an ultrasound hip examination, even if they have to pay for it
additionally. They increase the chances of their child for health hip.The
cost of a single examination is lower than complaints and costs caused
by hip insufficiency due to congenital dislocation of the hip.

 

 

somatic sense - the faculty of bodily perception; sensory systems associated with the body; includes skin senses and proprioception and the internal organs

somaesthesissomataesthesissomatic sensory systemsomatosensory systemsomesthesissomaesthesiasomesthesia,somatesthesiainteroception - sensitivity to stimuli originating inside of the bodycutaneous sensessense of touchskin senses,touch modalitytouch - the faculty by which external objects or forces are perceived through contact with the body (especially the hands); "only sight and touch enable us to locate objects in the space around us"proprioception - the ability to sense the position and location and orientation and movement of the body and its partsskin perceptivenesstactilitytouch perception,tactual sensation - the faculty of perceiving (via the skin) pressure or heat or painfeeling of movementkinaesthesiakinesthesia- the perception of body position and movement and muscular tensions etc

Publikacje

 

 

1).Screening the newborn for developmental dysplasia of the hip: now what do we do?

Schwend RM, Schoenecker P, Richards BS, Flynn JM, Vitale M; Pediatric Orthopaedic Society of North America.

Section of Orthopaedics, Children's Mercy Hospital, Kansas City, MO, USA. Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.

Comment in:

•    J Pediatr Orthop. 2007 Sep;27(6):605-6.

The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. Although evaluation of children with risk factors for DDH is important, most DDH occurs in infants who have no risk factors. For all infants, a competent newborn physical examination using the Ortolani maneuver is the most useful procedure to detect hip instability. Early treatment of an unstable hip with a Pavlik harness or similarly effective orthosis is effective, safe, and strongly advised. Despite having had normal newborn and infant hip examinations, there remains the possibility of a late-onset hip dislocation needing treatment in approximately 1 in 5000 infants.

 

No direct evidence that  screening for DDH, results in less surgery or better functional outcomes,althoug there was evidence that screening leads to earlier identification was found.

 

 

2)Developmental dysplasia of the hip Carol Dezateux, Karen Rosendahl

In its severest form, developmental dysplasia of the hip is one of the most common congenital malformations. The

pathophysiology and natural history of the range of morphological and clinical disorders that constitute developmental

dysplasia of the hip are poorly understood. Neonatal screening programmes, based on clinical screening examinations,

have been established for more than 40 years but their eff ectiveness remains controversial. Whereas systematic

sonographic imaging of newborn and young infants has aff orded insights into normal and abnormal hip development

in early life, we do not clearly understand the longer-term outcomes of developmental hip dysplasia, its contribution

to premature degenerative hip disorders in adult life, and the benefi ts and harms of newborn screening. High quality

studies of the adult outcomes of developmental hip dysplasia and the childhood origins of early degenerative hip

disease are needed, as are randomised trials to assess the eff ectiveness and safety of neonatal screening and earlytreatment.

 

Lancet 2007; 369: 1541–52Centre of Epidemiology forChild Health, Institute of ChildHealth, London, UK(Prof C Dezateux FMedSci);

Section for Radiology,University of Bergen, Bergen,Norway; and Department ofImaging, Great Ormond StreetHospital for Children, London,

UK (Prof K Rosendahl PhD)Correspondence to:Prof Carol DezateuxMedical Research Council Centreof Epidemiology for Child Health,

Institute of Child Health,University College London,30 Guilford Street, LondonWC1N 1EH, Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.

Developmental dysplasia of the hip is an important cause of childhood disability. This disorder underlies up to 9%

of all primary hip replacements and up to 29% of thosein people aged 60 years and younger.In the past, without detection by screening,developmental dysplasia of the hip usually presented

clinically after walking age, and at least 50% of patientsstarted treatment by 5 years of age.121 The recognised

longer-term complications of untreated developmentaldysplasia of the hip include pain in the hip, knee, and

lower back; disturbances of gait; and degenerativechanges in the hip joint. However, the risk of such

complications is not well defi ned. Some reports suggestthat, without treatment, functional impairment due to

developmental dysplasia of the hip is common, and thatit increases with age but is not inevitable.42,121,122 When

followed up for an average of 50 years, 11–41% of thosewith untreated dislocation remained free of pain.42,121,122

 

3) Lancet. 1998 Apr 18;351 (9110):1149-52 9643684 (P,S,G,E,B) Cited:3

Surgery for congenital dislocation of the hip in the UK as a measure of outcome of screening. MRC Working Party on Congenital Dislocation of the Hip. Medical Research Council.

S Godward, C Dezateux

BACKGROUND: Universal clinical screening for congenital dislocation of the hip to detect hip instability in neonates was introduced in the UK as a national policy in 1969, but its effectiveness is not known. We aimed to assess the extent to which surgery for congenital dislocation of the hip is the result of a failure of detection through screening or follows non-surgical treatment after detection by screening. METHODS: We established a national orthopaedic surveillance scheme and used routine hospital data for inpatients for 20% of births in the UK (Scotland and the Northern and Wessex regions) to ascertain the number of children aged under 5 years per 1000 livebirths who had received at least one operative procedure for congenital dislocation of the hip from April, 1993, to April, 1994. Estimates of the incidence of operative procedures were adjusted for under-ascertainment by capture-recapture techniques. FINDINGS: The ascertainment-adjusted incidence of a first operative procedure for congenital dislocation of the hip in the UK was 0.78 per 1000 livebirths (95% CI 0.72-0-84). Congenital dislocation of the hip had not been detected by routine screening in 222 (70%) of 318 children reported to the national orthopaedic surveillance scheme. In 112 (35%) children the diagnosis was made primarily as a result of parental concern. 67 (21%) children had previously received non-surgical treatment. In Scotland and the Northern and Wessex regions, 81 cases were notified to the national orthopaedic surveillance scheme, 62 cases were identified only through routine hospital data on inpatients, and an estimated 20 cases were not identified by either source, making a total of 163 cases. Thus, 81 (50%) of these 163 cases were identified by surveillance, 125 (77%) by routine data, and 143 (88%) by both sources. INTERPRETATION: The incidence of a first operative procedure for congenital dislocation of the hip in the UK was similar to that reported before screening was introduced. In most children who received surgery, congenital dislocation of the hip was not detected by screening. Formal evaluation of current and alternative screening policies, including universal primary ultrasound imaging, is needed

 

4)  FAILURES OF SCREENING AND MANAGEMENT OF ONGENITAL DISLOCATION OF THE HIP

I. A. C. LENNOX, J. McLAUCHLAN, R. MURALI

From the Royal Aberdeen Children’s Hospital, Scotland

We report the screening of 67 093 infants for congenitaldislocation of the hip from 1980 to 1989 and comparethe results with those during the preceding two decades.More dislocations have been missed at neonatal examination during the last decade (0.13% of livebirths). Operative treatment was needed in 54 children(0.08% of live births) some of whom had been diagnosedat birth. We discuss the reasons for the failure ofneonatal screening.Boneloint Surg[Br] 1993;75-B:72-5.Received 11 May 1992; Accepted l2June 1992

Congenita ldislocation ofthe hip(CDH) is still potentiall ycrippling although Roser (1879), Le Damany (1912) andPutti (1927) showed that neonatal diagnosis and simplesplinting were successful as treatment. Ortolani described his test in 1937 and Barlow (1962) modified it for the dislocatable hip by applying posterolateral pressure. I twas thought that by screening every child at birth, usinga combination of these two tests, and splinting everyaffected child, the late results of congenital dislocationwould be eliminated.A regional service was started in Aberdeen in 1960,whereby every child born in the Grampian region ofScotland was screened at birth. Those thought to have evidence of CDH were referred to a special clinic for reexaminationand splinting if necessary. The result of this programme has, however, fallen short of the original expectations. Thirty years later, some children stillpresent for treatment long after the neonatal period,despite having been screened in a specialist clinic. Their prognosis may be worse than that before screening began,because the diagnosis is not suspected by doctors and health workers who believe that neonatal screening is fully effective

 

The value of any screening programme must be judged by its failures

 

 

 

5): J Orthop Res. 1992 Nov;10(6):800-6. Links

Acute effect of traction, compression, and hip joint tamponade on blood flow of the femoral head: an experimental model.

Naito M, Schoenecker PL, Owen JH, Sugioka Y.

Department of Orthopedic Surgery, Kyushu University, Fukuoka, Japan.

Blood flow rates of the canine femoral head were experimentally determined during traction, compression, and hip joint tamponade using the hydrogen washout technique. In puppies, blood flow rate of the femoral head was significantly decreased with either traction or compression applied at one half body weight. Either maneuver, when combined with hip joint tamponade, reduced blood flow rate of the femoral head an average of more than 70% as compared with the initial control rate. In adult dogs, combinations of either traction or compression, at one-half body weight, with hip joint tamponade did not significantly decrease blood flow rate of the femoral head as compared with control values. Perfusion defect of blue silicone could be observed only in puppies around the hip during combinations of traction or compression with hip joint tamponade and involved the posterior superior capital branches of the medial circumflex artery and the arteries in the ligamentum teres. These experimental data may have important implications for the pathogenesis of iatrogenic avascular necrosis in the treatment of congenitally dislocated hip, Legg-Perthes dis1: Orthop Nurs. 1995 Jan-Feb;14(1):33-40. Links

 

 

 

 

 

6) : Clin Orthop Relat Res. 2008 Apr;466(4):791-801. Epub 2008 Feb 21.   Links

Imaging in the surgical management of developmental dislocation of the hip.

Grissom L, Harcke HT, Thacker M.

Alfred I. duPont Hospital for Children, 1600 Rockland Road, PO Box 269, Wilmington, DE, 19899, USA. Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.

Although the use of ultrasound in the diagnosis and early treatment of developmental dysplasia of the hip (DDH) has reduced the number of patients diagnosed late and decreased the number of operative procedures, surgical treatment is still needed in some patients. Late cases continue to occur as a result of missing the screening examination, being normal at initial screening and missing followup. Dysplasia may persist despite appropriate nonoperative or operative treatment. Many of these patients subsequently undergo closed or open reduction and femoral or acetabular reconstruction. Ultrasound of the hips is generally used up to 6 or 8 months of age, during which time the hips are largely cartilaginous, and radiographs after that time when bony development is more complete. Options to supplement ultrasound and radiography include arthrography, computed tomography, and magnetic resonance imaging. Several advances have been made in the imaging of DDH and its complications including acetabular labral pathology and of femoroacetabular impingement (FAI). We review imaging techniques other than ultrasound used in the management of DDH. LEVEL OF EVIDENCE: Level V, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

 

7)

 

: J Pediatr Orthop. 1994 Jan-Feb;14(1):16-23. Links

Changes in soft tissue interposition after reduction of developmental dislocation of the hip.

Tanaka T, Yoshihashi Y, Miura T.

Department of Orthopedic Surgery, Nagoya University School of Medicine, Japan.

Changes occurring in soft tissue interposition in 111 cases of developmental dislocation of the hip (DDH) reduced by overhead traction (OHT) were assessed by arthrogram. Soft tissue interposition was classified into five types based on the shape of the limbus, and changes in tissue thickness in the acetabular floor were examined. Thickness of soft tissue interposition was in the normal range in 92 hips of 111 hips (82.9%), but in hips in which a thick pad of the soft tissue was apparent at the acetabular floor both in the dislocated and reduced positions, soft tissue did not recede in 61.5% of hips.

8). Free nerve endings in the ligamentum capitis femoris

Michael Leunig1, Martin Beck1, Edouard Stauffer2, Ralph Hertel1 and Reinhold Ganz1

Departments of 1Orthopedic Surgery and 2Pathology, University of Bern, Inselspital, CH-3010 Bern, Switzerland

Tel +41 31 632 2222. Email: Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.

Submitted 99-12-09. Accepted 00-04-16

 

ABSTRACT – We report the presence of free nerve endings (FNE) in the ligamentum capitis femoris

(LCF). Qualitative and quantitative measurements onthe incidence of FNE, as assessed by immuno-histochemistry

for the S-100 protein, were obtained from18 patients undergoing hip surgery. We found FNE in

all LCF, with no association to age. The presence ofFNE in the LCF suggests a role in noci-/proprioception

of the hip.

 

 

9).The development of the ligament of the head of the femur

S. F. Brewster *

Department of Anatomy, Charing Cross and Westminster Medical School, London W6 8RF, England

*Correspondence to S. F. Brewster, Department of Surgery, Bristol Royal Infirmary, Marlborough St., Bristol, Avon, BS2 8HW, England

The hip joints of 30 human male and female fetuses and stillborns between 20 mm and 350 mm crown-rump length were studied by light microscopy.

The ligament of the head of the femur developed in situ as a condensation of mesenchyme at the end of the second month of intra-uterine life (IUL), and was vascularized by branches of acetabular vessels early in the fourth month. In the majority of fetuses older than 5.5 months IUL, vessels in the ligament passed a short way into the femoral head within cartilage canals, to supply a small region around the fovea capitis. The remainder of the head was supplied by vessels in canals from around the upper part of the neck.

The ligament changed from predominantly cellular to fibrous during the last 4 months of IUL. This increase in strength suggested significant mechanical functions in utero: limitation of adduction-flexion and opposition to postero-superior dislocation were the most likely.

 

 

10).Free nerve endings and morphological features of the ligamentum capitis femoris in developmental dysplasia of the hip.

J Pediatr Orthop B.  2007; 16(5):351-6 (ISSN: 1060-152X)

Sarban S; Baba F; Kocabey Y; Cengiz M; Isikan UE

Department of Orthopaedic Surgery, Harran University Faculty of Medicine, Turkey. Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.

A conflict exists on whether the ligamentum capitis femoris has the neuro-morphological structures required for nociception or proprioception of the hip joint. Therefore, we investigated the morphological features and the presence of mechanoreceptors in 24 ligamentum capitis femoris biopsies obtained at open reduction in patients with developmental dysplasia of the hip. Of these 24 hips, 16 were completely dislocated and eight were subluxated. The mean age was 33.8 months (range 13-52 months) at the time of surgery. En bloc ligamentum capitis femoris and pulvinar were taken for biopsy specimen. Ligamentum capitis femoris was dissected and the weight of each ligament was determined using a highly sensitive balance. Specimens were stained with hematoxylin and eosin and Masson trichrome for routine histolopathological evaluation and examined immunohistochemically using monoclonal antibody against S-100 protein. All specimens were graded on a four-grade system according to the amount of coarse-thick collagen bundles and hyalinization. The mean number and type of mechanoreceptors of each specimen were recorded. When the mean age, the patient's weight and the ligamentum capitis femoris weight of each group (completely dislocated vs. subluxated) were compared, there were no significant differences. In the ligamentum capitis femoris of the dislocated hips, the cells were irregularly distributed, had different shapes, and appeared to be in different stages of functional activity. The collagen fiber bundles were thicker than in the subluxated hips, distributed and of varied thickness. The elastic fibers of the dislocated hips were thicker and more numerous than those in the subluxated hips. We found a significant difference between the two groups with regard to the grade of collagen and hyalinization of ligamentum capitis femoris (P<0.004). We found type IVa, free nerve endings in 16 of 24 samples of ligamentum capitis femoris. The 66.6% presence of free nerve endings in the ligamentum capitis femoris suggests a role in nociception/proprioception of the hip in developmental dysplasia of the hip. Interestingly, the percentage and the mean numbers of free nerve endings containing ligamentum capitis femoris were similar in completely dislocated hip group and the subluxated group (62.5 vs. 75%, 12.13+/-9.07 vs. 9.37+/-9.24, respectively). We conclude that the morphological features of ligamentum capitis femoris are influenced by the severity of developmental dysplasia of the hip, whereas the distribution of free nerve endings are not influenced.

 

11).

From Institute of Experimental Research in Surgery, University of Copenhagen,

 

(Head: H. H. Wandall) andThe Orthopedic Hospital, Department I., Copenhagen, (Head : A. Bertelsen)

with support from Fondet ti1 Videnskabens Fremme.

 

THE VASCULAR SUPPLY TO

THE FElMORAL HEAD FOLLOWING DISLOCATION

 

OF THE HIP JOINT

 

An Experimental Study in New-Born Rabbits

 

B€l

 

H. BOHRK, . BAADSGAAaRndD P H.S AGER

 

It was shown by Langenskjold, Sarpio & Michelsson (1962) that

the characteristic deformities in the acetabulum and the femoral head

 

following congenital dislocation in man can be produced by traumatic

 

dislocations of the hip joint in new born rabbits. In the present investigation

 

similar dysplastic changes have been demonstrated

 

12) Hip disease and the prognosis of total hip replacements

A REVIEW OF 53 698 PRIMARY TOTAL HIP REPLACEMENTS

REPORTED TO THE NORWEGIAN ARTHROPLASTY REGISTER 1987-99

O. Furnes, S. A. Lie, B. Espehaug, S. E. Vollset,L. B. Engesaeter, L. I. Havelin

From Haukeland University Hospital, Bergen and the University of Bergen, NorwayWe studied the rates of revision for 53 698 primary total hip replacements (THRs) in nine

different groups of disease. Factors which have previously been shown to be associated with increased risk of revision, such as male gender, young age, or

certain types of uncemented prosthesis, showed important differences between the diagnostic groups.Without adjustment for these factors we observed an

increased risk of revision in patients with paediatric hip diseases and in a small heterogeneous ‘other’group, compared with patients with primary

osteoarthritis. Most differences were reduced or

disappeared when an adjustment for the prognostic

factors was made. After adjustment, an increased

relative risk (RR) of revision compared with primary

osteoarthritis was seen in hips with complications

after fracture of the femoral neck (RR = 1.3,

p = 0.0005), in hips with congenital dislocation

(RR = 1.3, p = 0.03), and in the heterogenous ‘other’

group. The analyses were also undertaken in a more

homogenous subgroup of 16 217 patients which had a

Charnley prosthesis implanted with high-viscosity

cement. The only difference in this group was an

increased risk for revision in patients who had

undergone THR for complications after fracture of the

femoral neck (RR = 1.5, p = 0.0005).

THR for diagnoses seen mainly among young

patients had a good prognosis, but they had more

often received inferior uncemented implants. If a

cemented Charnley prosthesis is used, the type of

disease leading to THR seems in most cases to have

only a minor


 
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