Hip dysplasia in children - advanced methods of diagnosis and treatment

At the National Medical Research Center for Pediatric Traumatology and Orthopedics named after. G.I. Turner develop and apply modern methods for treating pathologies of the hip joints in children. Specialists deal with the most unusual and serious cases, treating children not only from all regions of the country, but also from foreign countries.

Surgical treatment is carried out according to federal quotas as part of the provision of specialized and high-tech medical care, which is free for patients under 18 years of age from any region of Russia.

Employees of the only specialized department of hip joint pathology of the National Medical Research Center for Children's and Pediatric Traumatology named after. G.I. Turner successfully use modern methods of conservative and surgical treatment of children with hip dysplasia of varying severity.

According to international studies and statistics from our Center, 5-10 children per 1000 newborns suffer from this congenital pathology.
The disease affects girls approximately 7 times more often than boys. Unilateral lesions occur 1.5-2 times more often than bilateral ones.
This pathology is the cause of every third case of coxarthrosis in adults.

What is hip dysplasia?

Hip dysplasia is a severe pathology characterized by underdevelopment of all elements of the hip joint (bones, ligaments, joint capsule, muscles, blood vessels, nerves).

The modern name of this pathology is Developmental dysplasia of the hip, i.e. developmental dysplasia of the hip joint, which occurs during pre- and postnatal ontogenesis and may include neonatal instability, isolated underdevelopment of the acetabulum, subluxation and dislocation of the hip - the most severe degree of hip dysplasia, which is characterized by complete separation of the contact of the articular surfaces of the femoral head and acetabulum.

Causes, symptoms and therapeutic measures

The main source of dystrophic-degenerative destruction in the joint is the changes in the body that occur upon reaching 65-70 years of age. With age, the necessary elements are synthesized in the joint fluid in a smaller volume, as a result, the joint tissue becomes less elastic and durable.

Drying particles of cartilage settle on the joint capsule, which is why the acetabulum cannot function fully. The inflammatory process and necrosis of rubbing areas lead to the appearance of unpleasant painful manifestations.

In some cases, a significant acceleration of the onset of degenerative processes is possible. This can happen in the background:

congenital dislocation of the hip joint (dysplasia);
shock-mechanical damage or fracture of the femoral neck;
hereditary disorders of the musculoskeletal system in the pelvic region;
psoriatic infectious or rheumatic inflammation;
sedentary lifestyle or increased physical activity on the pelvic elements;
hormonal changes in the body.

The manifestation of clinical signs of pathology is due to the severity of the inflammatory process:

Arthrosis of the first stage is accompanied by painful discomfort that occurs against the background of physical overload or prolonged movement. A little rest helps relieve pain. Laboratory diagnostics can determine the presence of a slight narrowing of the gap between the joints and fleecy growths along the contour of the acetabulum.
After arthrosis develops to stage 2, pain symptoms increase, and they are disturbing even when stationary. Motor activity decreases, changes in gait occur, and lameness appears. The main symptom of this form of the disease is the inability to completely abduct the hip to the side, and the patient experiences acute piercing pain at the time of movement. During the X-ray examination, it is possible to examine bone growths on the outer and inner sides of the acetabular notch.
The most difficult and difficult to correct disease is stage 3 coxarthrosis. With this form of arthrosis of the hip joint, the patient is bothered by constant pain. There is complete limitation of motor activity in combination with a decrease in leg length. On an x-ray, you can see that the surface of the cartilage is completely destroyed, and large osteophytes (bone growths) are formed in its place. Due to this condition, a person may find himself completely immobilized.

According to clinicians, the development of such problems with the hip joint in men is much less common compared to women. The reason for this is the physiological characteristics of the female body.

The goal of therapy for coxarthrosis of the hip joint stages 1 and 2:

relieve painful manifestations with the help of drugs that have anti-inflammatory, analgesic and analgesic effects - Ibuprofen, Voltaren in gel form, Diclofenac, Ketanol, etc.;
activate the supply of nutrients to cartilage tissue and start blood circulation with the help of Teraflex, Hondrex, Mucosat, etc.

In some cases, injections into the joint are indicated. For this purpose, they use Osteonil, Fermatron, etc. Also, for arthrosis of the hip joint of stages 1 and 2, physiotherapeutic procedures are prescribed, namely magnetic therapy, paraffin, high-frequency electrophoresis, physical therapy and massage.

If the patient is diagnosed with stage 3 coxarthrosis of the hip joint, surgical intervention – endoprosthetics – is indicated.

Classification and assessment of the condition of the hip joint

The condition of the hip joints is assessed based on ultrasound and x-ray data. Ultrasound screening is carried out according to the method of R. Graf (1984)

The main advantages of ultrasound screening:

The earliest possible diagnosis of hip joint pathology (“the gold standard” is in the maternity hospital)
Reducing the duration of conservative treatment!!!
Significant reduction in the likelihood of surgical interventions!
No radiation exposure

There are several types of hip joint structure, according to R.Graf assessment criteria:

Type 1a – mature hip joint

Type 1b – transitronic – is usually typical for premature babies and does not require orthopedic treatment

Type 2a – immature hip joint. In children under 3 months of age, this type is regarded as functional immaturity and does not require orthopedic treatment; in children older than 3 months, such changes are considered pathological immaturity and require treatment, and the type itself is 2b

2c – hip subluxation

3 – hip subluxation

4 – hip dislocation

In children older than 3 months, in addition to an ultrasound examination, an X-ray examination is performed. Before this age, radiation research methods are not informative, since there is no proper ossification of the bone structures of the hip joint and their adequate assessment is extremely difficult.

Today, in world practice, the degree of hip dysplasia is determined based on X-ray data according to the classification developed by the International Hip Dysplasia Institute, which is based on the relationship between the head of the femur and the acetabulum.

First degree – hip joint without pathology
Second degree (hip subluxation) - the head of the femur is displaced cranially, but is located below the superolateral edge of the true acetabulum
Third degree (marginal hip dislocation) - the head of the femur is displaced cranially and is located at the level of the superolateral edge of the true acetabulum
Fourth degree (supraacetabular hip dislocation) - the head of the femur is located above the superolateral edge of the true acetabulum

Experience in introducing ultrasound of the hip joints in children's clinic No. 31 in Volgograd.

Details Published 10/24/2003 07:34 Umetsky I.N., Grigorov V.M., Shlykova O.E., Pervushina O.V.

Preface

In September 2003, a conference of Russian pediatric orthopedists and traumatologists was held in Volgograd.

The report of the country's chief pediatric orthopedist, Professor Malakhov, contained terrifying figures: early diagnosis of congenital hip dislocation is carried out in only 18% of cases! The same report endorsed the ultrasound method as the most reliable and inexpensive. All authors touching on this topic in their reports stated that impaired formation of the hip joints (dysplasia) is the main problem in pediatric orthopedics. Our report was also presented - “Ultrasound diagnosis of disorders of the formation of hip joints in children of the 1st year of life in an outpatient setting”, in which we tried to tell our colleagues about our experience in implementing this technique.

Before this conference, I was sure that the reason for such a slow and difficult introduction of ultrasound of the hip joints into widespread practice lies in the conservatism of orthopedists, but now it seems to me that the problem is not only this. Ultrasound practitioners are ready to master the new method, but today there is only one Russian-language publication with which (in my opinion) you can start working - “Ultrasound diagnosis of disorders of the formation of the hip joints in newborns and children in the first year of life.” (A. Yu. Kinzersky, E. M. Ermak., educational and methodological manual for medical students, Chelyabinsk, 2000). Unfortunately, it cannot be called accessible. The remaining publications either provide a general overview of the methodology or lack a clear presentation of it. And this despite the fact that congenital hip dislocation ranks first among the causes of disability in the structure of orthopedic pathology! There are regions where this technique is not used at all.

I am far from thinking that this material will change the situation, but something needs to be done...

Experience in implementing ultrasound technology of the hip joints

Violation of the formation of the hip joints remains one of the pressing problems of modern pediatric orthopedics, especially in outpatient practice. A surgeon at one of the clinics, a doctor with extensive experience, admitted to me that these patients are the most difficult for her in terms of diagnostics. Clinical diagnosis of dysplasia at an early age is difficult. Often, a reduction in the range of motion in a joint is caused by neurological disorders. According to Professor Kinzersky A.Yu. overdiagnosis of dysplasia in a clinical study up to 3 months of age is 60%, and underdiagnosis is 10%.

To this day, the most common instrumental method for diagnosing this pathology remains radiological. However, early diagnosis is not possible with this method. In addition, its use is associated with radiation exposure and requires proper placement. The ultrasound technique for studying the hip joints was first proposed by the Austrian professor Reinhard Graf in the late 70s. Today this technique is generally accepted. It is actively used in many developed countries, and in some of them as a screening test. What are the prerequisites for ultrasound examination of the hip joints, and what is its advantage over the X-ray method?

Possibility of early diagnosis of dysplasia, from the first days of life. By the time of birth, the structures that form the joint are represented mainly by cartilage, which transmits ultrasound well. Ultrasound performed in the first days and weeks of life makes it possible to identify children in need of orthopedic correction and begin treatment immediately.
High reliability. The ability to clearly distinguish between dislocation, subluxation and dysplasia. The impossibility of “incorrectly positioning” the child, because the study is carried out in real time for as long as necessary to obtain the required section.
The non-invasiveness of the method and the absence of radiation exposure allows it to be used for screening and dynamic monitoring.

Ultrasound of the hip joints has been performed in our clinic since August 2000. Research and evaluation are carried out according to the standard R. Graf method using Aloka 1100 ultrasonic devices with a 5 MHz linear scanning sensor. Ultrasound results—protocols and echograms—are stored in the disk memory of the computer on which the “LookInside” automated workstation for ultrasound diagnostics is installed. During this time, more than 1,300 children were examined for clinical indications, of which 991 were examined for the first time. The indications for the study were:

“clinical” joint instability;
limitation of range of motion in the joint;
asymmetry of the gluteal folds, shortening of the limb;
complicated medical history (breech presentation, oligohydramnios, multiple pregnancy, female gender of the child)

Based on the results of a clinical study, children are referred by a surgeon after the first medical examination at 1 month, and if unfavorable anamnestic factors are identified, by a local pediatrician during the first visit to the newborn.

The studies were carried out at ages from 2 weeks to 1 year, mainly at 1–3 months, and 527 girls (53%) and 464 boys (47%) were examined.

Structure by age Structure by gender

In our work, we use the generally accepted classification of types of hip joints according to R. Graf.
Types of hip joints (R.Graf)

Form		Age	angle α in degrees	angle β in degrees
Normal (type I)		any	more than 60	less than 55
Transient (II A type)		up to 3 months	50–59	56–77
Dysplasia	Mild degree (II B)	3 months or more	50–59	56–77
	Severe stable (II C)	any	43–49	less than 77
	Severe unstable (II D)	any	43–49	more than 77
Subluxation	With preservation of the structure of hyaline cartilage (III A type)
Subluxation	With preservation of the structure of hyaline cartilage (III A type)
Dislocation (type IV)

The structure of the identified types of hip joints is as follows:

It should be said that the given figures do not reflect the true frequency of occurrence of the pathology, because no screening was performed.

Absolutely normal joints were found in 61% of cases of mild dysplasia in children under 3 months (type 2A), this type is also called a transient form of the joint structure - 29%

2B - the same joints in children older than 3 months - mild dysplasia - 9%
2C - severe stable dysplasia - 1%
2D, 3 and 4 – severe unstable dysplasia, subluxation and dislocation, respectively - less than 1%

In addition, a connection with the sex of the child was revealed - all cases of severe dysplasia, subluxation and dislocation were identified only in girls, all cases of decentered joints were identified in girls who were in the breech position in utero.

What results were achieved:

Complete refusal of X-ray examination in children under 3–4 months of age.
Timely detection of decentered joints made it possible to completely exclude cases of late diagnosis.
Early diagnosis of mild dysplasia and timely prescription of massage and exercise therapy made it possible to obtain correctly formed joints in 100% of cases by 3–4 months, which was confirmed sonographically.
The number of children receiving treatment with orthopedic structures has been significantly reduced.

Before demonstrating a clinical example, I will allow myself to dwell on what structures of the hip joint can be assessed by ultrasound, as well as on research and assessment methods. The joint is assessed in the frontal plane passing through its center.

Normal hip joint colors showing joint structures

femoral head

bony roof of the acetabulum and wing of the ilium

labrum (limbus)

joint capsule

gluteus minimus

lower edge of the bony roof;

bony bay - the place of transition of the bony roof into the wing of the ilium.

To evaluate a joint, there is a standard plane, after which lines are drawn and angles are assessed:

Constructing lines and angles

baseline (drawn strictly parallel to the plane of examination through the wing of the ilium);
bony roof line (through the lower edge of the ilium and the bony bay window); when intersecting the baseline, it forms an alpha angle, which characterizes the degree of development of the bony roof.
line of the cartilaginous roof (through the middle of the labrum and the bony bay window), forming the beta angle, which characterizes the development of the cartilaginous roof.

Over 3 years, I observed only one congenital bilateral hip dislocation in a girl born in the breech position. The sonographic picture of the right hip joint is presented below.

Sonographic picture of congenital dislocation

The joint is decentered, the bony roof is significantly flattened, and the bony bay window is not reliably visualized. The head of the CD is located outside the acetabulum. The cartilaginous covering is insufficient, the limbus is visualized on the medial surface of the head (in interposition), this is a differential diagnostic sign of dislocation; in all other types it is located on the lateral surface.

The preliminary diagnosis was made in the maternity hospital. At the age of 2 weeks, an ultrasound scan was performed and the child was sent for treatment to the pediatric orthopedic department. As a result of early diagnosis, surgical intervention was avoided. The child underwent manual reduction and an orthopedic device was applied. With ultrasound control at the stages of treatment, persistent positive dynamics were noted and at the age of 3 months we received the following picture:

Dynamics after 3 months are highlighted in colors

The joint is centered, the head of the joint is in the acetabulum, the bony roof is formed, with a differentiated bony bay window. The cartilaginous covering of the head is sufficient, the limbus is on its lateral surface, and the ossification nucleus is visualized. This is an echographic picture of a normal joint.

It seems to us that it is necessary to actively implement this technique precisely at the stage of the children's clinic. This approach does not require significant material investments, because The study is performed on any gray scale ultrasound device with a 5–7.5 MHz linear sensor. With coordinated work of all participants in the process, this will completely eliminate cases of late diagnosis of this pathology.

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Signs and symptoms of hip dysplasia

Symptoms of severe degrees of dysplasia (subluxation and dislocation) are pronounced in children. To exclude the diagnosis, the child should be examined by a pediatric orthopedist for preventive purposes. The “golden” standard for making a diagnosis is the maternity hospital! In the first year of life, an orthopedic examination is carried out at 1, 3, 6 and 12 months.

Main specific clinical signs in a child 1-2 months old

Barlow test and Ortolani test

Additional (less specific) clinical signs

Asymmetrical arrangement of skin folds on the thighs
Asymmetrical location of the gluteal folds
Excessive hip rotation
External rotation of feet
Oblique location of the genital fissure in girls.
Shortening of the lower limb
Palpation of the femoral head behind the posterior edge of the socket
Limitation of abduction of legs bent at right angles at the hip and knee joints

Indications for the procedure

In the first months of life, the formation of the hip joints is monitored very carefully; at the slightest suspicion of abnormalities, it is better to undergo an ultrasound of the hip joint

It is recommended that all newborns undergo an ultrasound scan of the hip joints at least once, regardless of the presence of a predisposition to diseases of the hip joints or negative factors during pregnancy and childbirth.

A pediatrician or pediatric orthopedist may refer a child for an ultrasound of the hip joint for the following indications:

different lengths of the legs, noticeable visually;
clicking when hips move apart;
hypertonicity of the lower extremities;
limited mobility of the limb in the hip area;
asymmetry of skin folds in the buttocks area;
diagnosed arthritis.

Children who were born prematurely deserve special attention. If the pregnancy (especially multiple pregnancy) was difficult, there was a breech presentation, the newborns are at risk and need this type of diagnosis. Children whose parents suffered from similar diseases in childhood are also susceptible to developing pathologies of the hip joints.

Joints also vary in functionality and degree of mobility:

Freely movable joints (diarthrosis) - elbows, knees, shoulders, wrists. They are more likely than others to be susceptible to arthrosis and arthritis.
Amphiarthroses - allow slight movements of the bones. This category includes joints that are less known to us - intervertebral discs, the pubic symphysis, and the sphenodvicular joint on the foot.
Synarthrosis is a fixed connection between bones, cartilage and bone tissue, for example the connection of teeth with the skull, the sutures of the skull.

The structure of joints is fibrous, cartilaginous and synovial. Fibrous consist of tough collagen fibers, such as the sutures of the skull. Cartilaginous are groups of cartilages that connect bones to each other, for example diarthrosis between the ribs and costal cartilage, intervertebral discs.

Synovial - filled with synovial fluid, which absorbs the load. With its deficiency, the preconditions for arthrosis of the hip, knee or other joint with high mobility are formed.

What are joints made of and what function do they perform? Briefly - in the video:

Treatment

Complex conservative therapy is used, which may include:

Drug treatment of hip bursitis - depending on the symptoms, painkillers, anti-inflammatory drugs, glucocorticosteroids and antibiotics are prescribed (for purulent and infectious inflammation). Medicines can be in different forms of release, administered by injection, and their effect will be enhanced by physiotherapeutic procedures.
Physiotherapy using various methods: laser, magnetic and ultrasound therapy, electrophoresis, galvanization, darsonvalization, procedures with interference currents and other physiotherapeutic methods at the discretion of the doctor. They improve blood circulation and lymphatic drainage in the area of inflammation, provide pain relief, reduce inflammation, relax muscles and enhance the penetration and effect of drugs.
Taping, wearing an orthosis and other methods to reduce the load and support the joint, ensure its immobility - this is especially effective for new-onset acute bursitis.
Acupuncture (acupuncture, acupuncture) – effects on biological active points on the body.
Therapeutic massage and manual therapy are procedures that effectively reduce pain, swelling and serve for the treatment and prevention of a wide variety of joint diseases.
Physical therapy is a set of exercises that will speed up the healing process. They activate blood circulation and lymph flow, reduce pain and inflammation. Treatment with movement is especially important for the chronic form of the disease and prevention of relapses. Measurement is important - not every exercise will help. With bursitis that appears due to heavy physical activity, on the contrary, you need to provide rest to the joint and reduce stress. What exercises will the exercise therapy doctor recommend, and the training itself in the exercise therapy room with an instructor will be more effective and safe than independent exercise at home.
Surgical intervention - drainage of pus from the bursa and washing of the capsule with antiseptic drugs, antibiotics, removal of the bursa in case of acute inflammation with the risk of rupture of the bursa membrane and spillage of pus into adjacent periarticular tissues. Thus, surgical treatment of trochanteric bursitis of the hip joint allows a person to return to physical activity without restrictions several months after treatment.

In general, the prognosis for the treatment of bursitis is positive - inflammation can be relieved by various methods and complications such as tissue sepsis, the formation of fistulas, the development of arthritis and osteomyelitis and other pathologies can be avoided. But much depends on the patient himself - how quickly he sought help, how he adheres to the doctor’s recommendations.

Therapy is aimed not only at relieving inflammation and improving mobility in the joint, but also at treating the cause of inflammation so that there are no relapses. It determines which doctor treats hip bursitis - only an orthopedic traumatologist or will require the participation of an immunologist and other doctors.

Types of articular surfaces

Articular surfaces are also different:

cylindrical - have the shape of a cylinder;
block-shaped - look like a transversely lying cylinder;
helical - an angled groove and a comb on the articulated surfaces form a helical line;
ellipsoid - one end of the bone is convex, the other concave;
condylar - one bone of the articulation has a rounded process, the second resembles a depression;
saddle-shaped - the surfaces are located one on top of the other (the bones move along and across);
spherical - convex and concave surfaces (circular movements);
cup-shaped - a deep depression on one bone covers most of the area of the head of the second;
flat – due to almost identical dimensions, movements are limited;
tight - joints of bones of different shapes and sizes are closely connected and have low mobility.

Why are the joints so different?

During the process of evolution, the joints of the human body have changed and adapted to the load. Elbow - has become as convenient as possible for work. Only he is able to rotate the forearm around its axis and perform characteristic movements of unwinding and twisting.

The head of the humerus is not limited in the wide circular movements of the arms, unlike the head of the femur, since these joints have different functions. The knee joint has a special structure, because it bears the maximum load when walking upright.

Human joints have evolved over the years

Causes

The main causes of hip bursitis:

Injuries and damage to the joint and femur due to falls and impacts. The most dangerous cases of purulent and infectious bursitis are injuries with violations of the integrity of the skin.
Heavy physical activity - standing work, running on uneven terrain, cycling and some other sports.
Diseases of the spine and joints - arthritis, scoliosis, arthrosis and others.
Allergies or autoimmune diseases (rheumatoid arthritis, scleroderma and others), when inflammation occurs due to the reaction of one's own immune cells.
Deposits of calcium or uric acid salts in the joints, for example, with gout.
Diseases and conditions in which metabolism is disrupted: diabetes mellitus, kidney disease, long-term treatment with steroid hormones.
Performed operations on the hip joint.

Risk factors for bursitis include:

Overweight.
Postural disorders and body asymmetry.
Flat feet.
Congenital joint dysplasia.