um I have no disclosures relevant to this topic. This is an outline of the subdivisions that will be addressing today. Um definition the path of physiology, epidemiology, etiology, diagnosis and treatment of developmental hip dysplasia. What is D. D. H. So there is a variation of severity these we have here. The illustration of the normal hip was around from all had and full assad tabular coverage. A display plastic but can grew it hip has around us to have their head an insufficient coverage of the entirety of that subluxation hit demonstrates abnormal motion between the asset and the federal check and subsequently a dislocated hip as a federal had outside of the bony ass attack. The reason that this is important is because the natural history of hip dysplasia and particularly untreated hip dysplasia is degenerative arthritis. One in 10 patients who have a total hip replacement are suspected of having DTH as their primary etiology. We have a seven classification which characterizes the adult hip for patients who have a 1-2 separate hits, meaning that the anatomy is either normal or very slightly abnormal. Such as a display plastic hip with minimal coverage that those patients do fairly well. Whereas when the anatomy becomes more abnormal, those patients do poorly with 80 to 81% of seven and three and four hips, resulting in significant arthritis and morbidity apologize. But I think these slides are advancing a little too quickly on the app. Gretchen. Do you have any recommendations? All right. Well hopefully we can slow that down a little bit. Um no gradual pop in and tell me did anything I need to do differently. So one of the reasons that um we also have dysfunction is that the muscles around the hip have to work harder if the hip is unstable that can contribute to pain as well. Gretchen or D. C. E. Can you help me with the fact that the slides are skipping? All right. I think we might get back to where we were. All right. So when we look at the path of physiology of a dislocated hip or subluxation, hip or just plastic hip there are certain things are happening that are not happening in normal hips. This slide on the X ray shows you that a normal hip distribute that compressive force across the bony asses pabulum. Whereas a dis plastic hip with an acid tablet that is very steeply inclined shear forces occur between the federal head and the assad pabulum resulting in cartilage damage. Moving to the epidemiology and etiology. So when does developmental hip dysplasia develops the cartilage on log of the hip joint Develops at 6 7 weeks of gestation And then the cleft occurs for complete joint formation at 11. How do we determine who's at risk? There are several things that may be at play. In terms of genetics, we know that the risk of having D. D. H. Is seven times higher if a sibling is affect And the risk goes up to 12 times higher. If a parent is affected In 10- 29 pairs of identical twins with d. d. h. 10 of those patients had both tips involved with the twins. The risk is one in 3 if a parent and sibling have deviated. So these risk factors help us determine who we need to screen more specific. I guess Gretchen hasn't come on to let me know how I can fix this. Um In terms of hormonal influences that may also be a play. Maternal hormones make both mom and baby's ligaments more lax around the time of delivery. We think that some infants may be more sensitive to those hormones. With females with more ligament laxity at baseline, going to the theology. Um we also understand that positioning they play a role with infants who have undergone swaddling techniques for mobilization and carrying them around, being more at risk for hip dysplasia, and that's been clearly shown. Whereas infants who are carried with their hips at a production have a lower incidence of hip dysplasia. This slide will show that there is um surgeon's name is bob psalter. He was up at Toronto at sick kids and he did a lot of research on hip disorders using pigs. So when pigs were casted in infancy with our hips and extension that developed hip dysplasia. When they were kept castes were removed, the hips went back to developing normally. Other risk factors that we know exists are breached positioning in the Agro first born female family history and illegal hydro news, illegal hydra meals, contributing most likely to positioning issues as the baby has less renting around. Additional associated conditions include toward Collis, which occurs in 12-20% of patients As well as metatarsals, seductive in 4-10% patients. This may be secondary to positioning issues. Um, early diagnosis is extremely important. We know this because the age at reduction correlates with outcomes With patients who are treated after 32 months having five times more likely uh residual displays us. That increases a 60% probability. If we can't get to the patient until they're 32 months or more, I'm going to go over a physical exam and I apologize that my clicker is advancing to slides at once. Hopefully if you're able to go back and review this, you'll get the other half of the presentation. Unless I can ask Gretchen to advance slide slide. Yes, you can just let me know what we can do. So if I'm going to go back to, could you advance to the next slide? Okay, so we'll go over some diagnoses next. So I mentioned that there's a importance of early diagnosis next. So we'll look at physical exam. Um one of the things that we're all taught to look for is stifled asymmetry and that's secondary to the more approximate location of the criminal head. If it is dislocated next, We also look for the galaxy sign and that's positive with me heights being a symmetric with hips flexed at 90 in the knees, flexed at 90 because one of the hips, the effective hip is dropped out the back of the acid tablet. So what we're seeing is an apparent thigh height, a symmetry when really it's the position of the hip, but that's the clear. That's on physical exam. We also look at the Barlow test. Barlow test helps us diagnose a hip that is unstable, meaning that it is located at rest but it can be pushed at the back of guest Fabulous. Rather the Ortolani diagnosed as the hip that is dislocated but relocate herbal with the abduction and forward pressure on the government to cancer. Next. So this is very important. A child cannot have both an Ortolani and Barlow. It is one of the or the other. Either it's dislocated at rest and relocate herbal or it is located at rest and dislocated. Yeah. So the hip click. We've all observed that babies. This is the audible click or pop that's heard when a baby's hip are being examined. There are many ligaments inside around the infants hip joint that can make that snapping or popping sound. A baby with a hip click should undergo serial examination. And then if there's a concern for dysplasia, we can evaluate them more closely with an ultrasound or an X ray, but most babies will have hip clicks that are completely normal after three months. The Ortolani test becomes negative because the ligaments around the hip tighten up and they're no longer have the flexibility to relocate. So we look at the hip a deduction after three months to clue us into whether or not there's a dislocation in a unilateral dislocation. We'll see that there's a symmetric reduction. Now in bilateral hip dislocations, the babies older than three months, we may see a symmetric abduction are that is slightly or significantly reduced. We also see hyper lord doses a waddling gait because hips are out of place and the muscles are working differently. And the Galbiati maybe negative as well if both hips are out next. Important to understand here that while we're performing our clinical exam we can detect dislocation or instability. We cannot detect assets have dysplasia. You'll see in the checkmark X ray that hip is going out of the joint. So that is a dislocated hip that child would have a positive Barlow or sorry, positive Galiazzo sign and on the right, the hip coverage is not full. But the exam may be totally normal nets dr Marcel. We have a question. Sure. Yes. At what ages do patients with bilateral dislocation typically present? So patients with bilateral dislocations typically present at or after the walking age. And that would be because once they're upright and see increased Lord. Oh sis you know that lumbar curvature or they persist in a waddling gait. That might be the first clinical tip off assuming that the baby didn't have any risk factors that result in us following them more closely. So that's why sometimes bilateral dislocations can be missed more easily looking at imaging. Um The hip ultrasound is very important Up to about the age of six months. The thermal head is cartilaginous and you can't see it on an X ray. So with ultrasound imaging, we can understand not just the position of the head in the metabolism, but then how that moves in real time. Next, this is an example of an ultrasound being performed and the image that it generates, we can see the Federal had is that large black dot with speckles in the middle and then we can see the depth of the assad tabl um and how well it's covered by the cartilage roof. Trying next this is an example of an ultrasound beginning on the bottom with the Federal habit is dislocated and then moving forward with the family. Had that locates and then finally is stable. I say 0-6 months is the best time to ultrasound because the child is small enough that we can penetrate the ultrasound and they don't fight us so much that we can still get enough. No. So this is an example of a normal ultrasound at six weeks we should have an alpha angle greater than 60 beta, less than 55 and federal hard coverage of greater than 55%. So we have some real good clear parameters what a normal hips should look like at six weeks. Next. Now comes the topic of screening. We recommend as does the ap selective screening performed based on risk factor. So family history being a big risk factor, breach positioning being a big risk factor. And then of course female and first born are also contributors. There's been several meta analysis that looked at ultra screening. Ultrasound screening universally versus selectively. So one of the issues is that risk factors don't always predict developmental hip dysplasia. What we noted in a couple of studies quoted below are that 85-88% previously, screen late presentation did not happen next. In terms of ultrasound screening, universal screening has resulted in higher rates of Pavlik harness embrace treatment. There are two randomized controlled trials that show no differences in the rate of late diagnosis whether we are selectively screening versus universally screen. Next, I'll discuss a little bit about radiography for the child who is four months of age or older. We start to see the federal had better and our other landmarks come into view such that an X ray will be helpful and I've drawn multiple lines on this X ray to show the various landmarks and markers and angles that we're measuring in relationships that were examining on an ap pelvis film. Next this is a demonstration of the thomas classification and this is a classification that correlates well with the outcome of treatment. This evaluates the station of the Federal head and that is where is the Federal head relative to the fantabulous? Is it located partially dislocated, dislocated or what we call high dislocation on the body? Next, another classification was developed to help us evaluate the station of the Federal head in cases where the Federal head has not supplied. This is important because in patients with significant displeasure dislocations that Federal had failed to justify and that can persist well into the 1st and 2nd year of life. So there are other things that we look at to help us understand exactly where the family has located, even when we can't see it. Yeah. I mentioned before that there's a difference between dysplasia and dislocation on this X ray, on the patient's right hip. We see that angle called Ai. That's acid tabular in that on the right side. We have a slightly abnormal ai. It's just a little steeper than it should be. That is a dis plastic that on the patient's left hip. The Ai is significantly increased and the federal head, which we can't see. But we know from radiographic measurements is now located outside of the asset. Next another example of a completely normal hip on the patient's left and the display plastic hit with an increased A. I. On the right. Yeah, we'll move on to treatment next five. So this is an overview for the treatment of a dislocated head At 0-6 months. We'll use a physical exam in an ultrasound to evaluate the hip and then treatment options for a dislocated hip include a Pavlik harness, a rigid brace or closed reduction, and spike a casting, followed by a rigid brace. Next for a patient who is 6-12 months, we'll look at a physical exam most likely X ray at that point and then closed reduction in spike a cast and followed by a rigid brace. This is where public harnesses are not indicated. Mhm. The next for 12 to 18 months, we look at the physical exam in the X ray. At this point we can attempt close reduction spiking casting but often times those tissues are too tight around the hips. And we have to move to open reduction At 18 months or older, again using the same p. e. and X. Ray. Now, we most often have to go with an open reduction. And sometimes we have to also include bony surgeries about both the hip and the femur to ensure a located him. No, this is the pilot card. It's so the reason that this is important is because it allows hip range of motion within the safety zone. That's where the hips are flexed most, no more than 100, And there are passively a deductible to neutral. So we want to be able to bring the patient's knees up together and then have them fallout in a deductive position. But we don't want them stuck out in the front position, the answer straps, control collection and the poster straps control. LTD. A deduction. That's so the logistics of treatment are that we rechecked the baby every two weeks when they're in a public park. We want to adjust for growth and perform follow up ultrasound. We instruct the family to check the baby and make sure that they're keeping both legs. If they're not, then we might need to worry about in front of your policy, particularly if the legs are flexed too severely. There's some variability on where schedules for an Ortolani positive hip hip that is dislocated and relocate herbal, the harnesses worn full time and it's against skin so the the family does not take it off our backs and you do not take it off to change for a Barlow a positive hip. They can remove the harness for bags, but where it at all. Other times Now will typically extend use of the father harness for 6-12 weeks after the ultrasound shows a clinically stable And we may have to brace longer than that. But the public unis harness use extends beyond the normalization by about 6-12. Next five, there are contra indications for use of the public if the patient has significant joint stiffness which is often a pathologic dislocation. Uh we cannot use it. And if there is muscle imbalance and that's what is causing the dislocation, we don't use it. So in patients with several policy or spina bifida, we would not use the pedal congress with. So next this is an example of a patient who was successfully treated with a polyp hornets. The first image shows a dislocated hip that ball with little speckles is sitting way up high, almost above the bright white line which is the iliac crest. Then on the right it's just moving a little bit deeper towards the sort of uh half circle bright light position on the bottom, on the next image below. It's located better on on the final image on the bottom, right. It's now normalized and this patient underwent through month treatment and demonstrated normal morphology right next. So we want to look at our outcome. What is the outcome of Pavlik harness treatment For Barlow hip is very successful. Um there's the study quoted here by Montanan and others that show about a 98% success rate for a Barlow positive hip just with public artistry for the Ortolani positive hip. There's a little bit more variability across studies, but we're still looking at a 63-83% positive outcome. And that is far better than what we can achieve closed reduction or, you know, production. No. So when do we start treating for a dislocated hip? That's Ortolani positive. We started media. And what we've learned in recent studies Is that if we don't start until the baby is four weeks, 6 weeks we may still have a high rate of success. Now I prefer to start the baby earlier because then there are public partners were time is Doesn't extend into 3, 4 months uh period and their childhood and parents like that they'd like to get the baby out of the harness when they're younger. So I prefer to start it right away. But the good thing about understanding this is that if there are any issues that result in not being able to start either because of health, because of issues with feeding, um we haven't really lost the opportunity to have a successful treatment with an Ortolani positive hip. So best to have them right away. But if we can't We still get them within 4-6 weeks. We have literature to back up that we can predict with success rate for a Barlow positive hip. To go back one We like to start at 4-6 weeks based on helping sound. So this is the hip that is stable at rest that dislocate herbal. And one of the reasons is that we know that a certain amount of those patients are going to stabilize on their own. So we like to push it out to four weeks max six so that we can avoid treating patients who would self stabilize in that perinatal time period for this plastic hips. We don't start treatment until six weeks. Oftentimes I have patients who come in and they've had an ultrasound at one week, two weeks and it shows dysplasia. If I get them at 46 weeks, I'll do an ultrasound and evaluate. Um but if I have them at two weeks dysplasia, then I'm not going to initiate treatment. I'm just gonna Next. So for the display plastic but stable hips, um I want to understand what happens to those hips. So in a randomized controlled trial of 128 patients, uh the study by Rosenthal showed that if we just follow the patients, half of them just with surveillance versus half of them treated with the public carnage In the surveillance group, we avoided treating 50%. So we understand from this that there definitely is a good portion these hips that are going to mature on their own, even though they showed initial dysplasia. Cicada in 99 showed us with 192 patients. But they looked at retrospectively that ultrasound less than four weeks had no predictive value when it looks at whether or not that patients going to develop dysplasia. So that's where you know that less than four week ultrasound for hip, that's not dislocated. It doesn't help direct treatment. So we want to push that out to more than six weeks. And then in another study, quoted lastly, there, in a prospective evaluation of 479 patients, 90% of the hips normalized without a splint. So again, we need to avoid are tendency to over treat by understanding exactly when we need to look. No. So then the longer term out Up to 30% of patients treated successfully with the public harness develop as a tabular dysplasia for six months. Or rather that dysplasia persists, I should say. So what this means is that we need to follow them longer In 5% with a successful reduction in public harness and the normal ultrasound after stabilization. We uh Alexia and his colleagues noted that there was persistent late hip dysplasia in this population. So again, we need to follow these babies more long term. So I tell my patients that I'm going to see them until they're potentially up until three years of age um longer for those who are dislocated. And that may mean just an ap pelvis film at each annual mark. But we definitely need to keep an eye on next. So what happens when the public harness doesn't? So we stop if the pip has not located after three weeks? The reason being that it continued to use the public harnessed, it just creates a situation where we're pushing the formal head into the pelvis and it's not going where it needs to go. That can cause erosion of the poster wildly asked problem can also cause a vascular process from too much pressure on the criminal head against pelvis. And this also narrows the seats up next. What happens to these kids? How do we predict failure? Well, if the present coverage on an early ultrasound less than 20% and the hip is not reducible, so it's Ortolani negative or if there are bilateral hip dislocations, those patients have a very high rate of public french failure. So that's a situation in which I would counsel the mother that we're going to start with a harness or going to continue for a period of four weeks. But we really you know, maybe at the second visit are going to start to talk about potentially having to move on to other treatments. White and colleagues noted that an increased beta angle as well as decreased federal health coverage and an inverted labrum or some of the soft tissues inverted into that stabbing were also predictors for public lewdness. No, I mentioned that we want to see the baby kicking. Another issue that can result from how the current treatment is the former owner of policy. This is typically associated with high degrees of flexion. So if the Pavlik harness has been adjusted by a caregiver, mom nanny grandma, daycare into a very high reflection angle that can pinch the femoral nerve, which then results in the baby's inability to find quadriceps and we won't see the kids um that formal nerves under increased pressure under the internal ligament. And this is also a higher risk for larger babies. Yeah, one of the issues from the nerve policy is it creates a pause and treatment for a length of time and a couple of studies that I quote here, look at how does that the successful use of the pilot aren't. So usually these criminal nerve policies present within a few days of the issue. Yes, if it resolves after three days of discontinuing use, Then there's about a 70% chance that we'll be able to go back and continue treatment and the treatment will be successful for this dislocated hip. If the policy persists greater than three days, we go down to a 70% chance of failure. And when a group of patients with palsy compared to non-policy group were evaluated, there was 47% success rate in the policy group recording stopped. So what this tells us is that we just need to be vigilant public heart issues and when I use it, I marked the harness each time to tell the parents. You know, if you have to remove it for some reason, if you're adjusting it, this is where you need to go back and I demonstrate the safe. So I'm just a lot of education and then getting feedback from your parents of the baby. Next. That's what. Okay, thank you. Um, they're also rigid abduction or theses that we used. These allow for a limited hip range of motion. We narrow down the safe zone and the child can fall and even walk with this phrase. So it's a path economy fails. After three weeks. We have some studies that have shown success with just transitioning to this and holding out a little bit longer to see if we can get a hip to locate next next time. Okay, thank you. So it is helpful, like I said in some have a cornice failure scenarios. Um, Sinker looked at retrospective use of 28 patients who embraced versus patients who had to undergo close reduction for Pavlik harness failure for dislocated hip. So all of these patients have had filmed public, 28 of them went into a brace. 22 of them had a surgical close reduction, 82% of patients treated with this particular race. The ill feld went on to successful reduction, 91% of the patients treated with surgical closed reduction also had a successful outcome. However, with the ill thought braids, there were no cases of a vascular necrosis and that is because of the positioning of the hip and that will felled versus the cast like a cast. So again, it's worth a trial. Is that how the carnage fails to see if we can still get the hip to locate without certain intervention next time and again, another study looking at the utility of a rigid abduction of fibrosis And we can try that for about another 3-4 weeks after Israel. Next one. So what happens if we have to move to close reduction? We performed several Uh parts of this procedure in one. So we'll do an arthur graham, inject some dye into the hip joint and that shows us exactly what's happening as the dye surrounds the federal head, which is cartilaginous. We can't see it on the next right and then we can see whether or not we can locate the hip and we can keep it located with him in the safe zone, meaning that we're not putting too much pressure on. Okay, then, if we are successful with that, will do a spiky cast with a really good mold in the safe zone. And then a post reduction verification of the ct or MRI. I do a post reduction verification with an MRI. Let the baby wake up in recovery, test out my cast a little bit with motion and then go down to the MRI scanner in the cast and have a quick limited hip MRI. And that can help me ensure that the patient hasn't fallen out the back hip hasn't subtly dislocated with just motion in. For patients who have a successful hip reduction, they'll have a cast change at six weeks and the total casting time is 12 weeks. Next line Question. So we had an audience member asked would you start treatment on an Ortolani hip based on Exa alone. My facility won't do ultrasounds until 4-6 weeks. So if you can repeat that based on on what alone I don't know if I'm butchering the word um Ortolani hip based exam. What? Let me spell it out. R. T. O. L. A. And I yeah I got that. If you could just read the whole question again then I'll put this all together. Sorry Would you start treatment on an Ortolani hit faced exam alone. My facility won't do ultrasounds until about 4-6 weeks. Yes. Now I have the good fortune of having an ultrasound machine and I do them myself. So my partner Dr Corey and I will do the ultrasound on our babies because it tells us real time what's happening to the hip. And then we can really see what's happening during the course of treatment. So I will do the ultrasound, get the information real time and then um institute treatment for an online and then we can do the ultrasounds that follow. So for the clothes reactions, this is a continuation of the description of clothes reactions. What we see here is we've injected dye into the joint and there's all sorts of white die in between where the federal head is and the deep socket of the ashtabula. The reason that is is because there are several things blocking the ability of the hips move into the title. There's something called an inverted Olympus soft tissue holding in the way there's ligaments and terry's that's crossing the capsule and blocking it off. There's the transfer sassy tabular ligament inside the assad tabula, and then just capsule construction, particularly for those frank breech babies. The hips have never been in those sockets. Those are babies where usually all of these things are creating issues and our blocks to production next time again, this demonstrates blocks to a close reduction, the capsule constriction and the other intervening soft tissues. And on the bottom right slide, that's the hip in the position that it should be in to um get a successful reduction. However, we note that there's a lot of dying between that criminal head and the establishment is not going. Yes. So that's where we have to move to an open reduction for a failed closed reduction at any age or 18 months older presentation typically will felt. Um We remove obstacles to the reduction in those open reduction. So we open up the hip. We release the translates as a tabula ligament. We remove the soft tissue between the federal head and the tablet of wall and then in patients. Um in the older age range, we may have to shorten the femur and then cut the pelvis to actually create a roof. And finally we tighten up the hip capsule to prevent it from distance. Excellent. So I mentioned a federal shortening Osti oddity on the X ray below. Um on the right we see a pelvis with a hip that is dislocated, that little blue ball is sitting up high outside the acetate look. And there are lines that show the distance between the top of the formal head, that little blue balls and the normal a spectacular. We cannot just pull that hip down. The soft tissues are constricted, the muscles are tight. So in order to put a hip in the appropriate location, we cut the femur down more into the shaft and remove an intervening segment of about that that hype that length that allows us to get the federal head into the asset autumn avoiding significant pressure on the head that might result in a P. S. Next time. So finally we'll talk about the late presentation. So eight years of age typically is the upper limit for reduction of a dislocated hip. Um On the table below, we can see that the results of an open reduction in that 1.5 to 2.5 range I have 85% um patients with excellent and good results. And then that deteriorates significantly with age. By the time they're eight results, about 17% patients who have a good to excellent results. Next one. So this is an example of a patient who presented very late and this patient presented with a significant limb length discrepancy and it was noted it was known that the hip was dislocated, but for various family reasons I had never been treated. So when we look at some of the studies evaluating how these patients do and late presentations, um There is one study that shows that the age of reduction of 10.8 you can get better outcomes but you know, this again is really pushing it. Um in terms of the quality of the hip joint, because you cannot predictably reshape the acid tabling to match the formal head even with the asset tabular, frosty autumn ease, the assets pabulum stops remodeling around 3 to 4 years of age to kind of our out of any possibility of having a really nice concentric ipso. This patient uh less than eight years old I think merits surgical intervention. But we have to counsel them that there is a very high level. They're going to need a total hip replacement later in life. We're just trying to push that out as far as possible and then make that easier by having a locator next slap. So I mentioned earlier bilateral dislocations. These can be very um there are multiple studies that have documented worse outcomes and bilateral dislocation In that actually have a patient who presented to me at 10 years of age with the complaint of having difficulty walking up the stairs. The reason is, as I said, very early on in the presentation that when the hip is dislocated, the muscles about the hip have to work a lot harder to move the leg around under the body. And so she was she could not get up the stairs without holding onto a railing and helping to pull herself up At this stage. With 10 years of age, bilateral missed uh dislocations. It really is no option for medical treatment. Unfortunately incidents to wait. Um And then some studies below by by dr wing showing 56 bilateral compared to 156 unilateral, noting that the the outcomes are worse than bilateral. Next one. So important. What about the located hip? That's dis plastic? I've kind of been highlighting that difference between this plastic and located and how do we catch the disc plastic hit? And what do we do to treat? Next line? So like I said, residual dysplasia. Now subluxation where the hip moves out of the joint. that will never improve spending formal head coverage can improve spontaneously, meaning that the hip is located, but the acid tablet is not covering it fully. There's a period of time early, early early in childhood where that can get better spontaneously. Thanks fine. So when we look at when does remodeling? And so that 24 months mark salter again, the a physician who was looking at a lot of peak studies Noted in human patients that that 24 months age you start to see a lot less remodeling. Um for patients who have undergone an open reduction at about the two year mark, we're going to see as much remodeling as possible. And then at 4-5 years after reduction al banana and all Noted that they did not seek any progression of um coverage of the hip, recurring 4-5 years after reduction next line. So when do we do a pelvic cost economy? Go Back one More. So if you go back one more. Okay, so when I've discussed, when does the hip stop for modeling? The reason that we're paying attention to that is we're trying to figure out is when is it that we've got everything we're going to get out of nature taking its course versus when we have to go in and actually perform a pelvic osteo to me to improve coverage service. So I mentioned that Really, there's not a whole lot more remodeling that's been occurring about that 4-5 year mark after reduction in hips. And so at that point, if a hip has been reduced And it does not have sufficient coverage and the child is 4-5 years old, or really at a point where we're going to need to do something more. And typically this is a case where we've done a reduction in that younger age group and we have not done about the past Academy at that time because they're young enough that we're gonna hope that the body does not need to do by itself. But at this 4-5 year mark after surgery, we know that we've got what we've got. We have to make decisions based on those x rays at that time. Next time this slide covers a few of the different public osteo to me that we have. So the type that we perform depends on the patient's age and the anatomy. We do public Osteo Khatami's to redirect. They asked traveling to cover the thermal head. And we also do them to reduce the volume of the thermal hat. And again, i on the far right where we're doing a reorienting osteo to me cutting the whole assad tabula um and moving it typically that's done an older patient. Whereas we can perform what we do. You know I'm saying slightly less invasive pelvic passed anatomy um less extreme in the younger child where there's still some remodeling potential next time. So the take home points of this talk is that residual dysplasia is correlated with arthritis. And so for our patients in adulthood who have residual displays and then potentially subluxation. Those patients do not do well and require him. Our replacements have a low threshold for screening with ultrasounds. So if we have risk factors of concerning physical exam, those are patients that we can screen with an ultrasound and we can determine whether or not it's normal hip or there's some dysplasia. We need to follow. The patient timing of public harness depends on the type of dysplasia. For an orderly positive. We'd like to start as soon as possible for Barlow positive. We're looking at 4-6 weeks, allowing it some time to see that tightens up on its own and for this plastic hip really no indications start doing anything before the six week mark you get your ultrasound and determine where you're at. Then. If the public treatment that we have to institute in certain cases fails, we'll move on to embrace for a few weeks and see if we can have improvement with that change in intervention. Yes, as tabular remodeling occurs to about the age of 4 to 6 years, years after the hip has been reduced. So if we just reduced the hip and we're not doing any Osti autumn ease, we can watch that hip until about the age of 46 and see if there's any more remodeling on its own model and be covered normally or it's going to lag behind. We may have to do something about it. There's worse outcome in bilateral dislocations and definitely with the delayed presentation. I did not talk a lot about the vascular process, but that is a very significant complication of the disease. And those certain kinds of treatment and patients with a vascular necrosis, the more severe that is that's correlated with worse outcomes next time. So there's a couple of really good resources for development of the dysplasia, both for the caregiver as well as the parents. Um and this is the uh international Hip Dysplasia Institute website has excellent, excellent content, particularly prepared for the next line, click again. So also the Ortho info site on the American Academy of Orthopedic surgeons. Again, good content for the provider as well as the parent and I don't have here. But at the Pediatric Orthopedic Society of North America website, there's also content they're appropriate for carol. Yeah, next time. Uh this is my contact and shiners. Contact information, odds, patient access line is there and I wanted to include also my email address and then um my phone contact. Should anyone want to get in touch with me? Um We're happy to talk about a patient. I'm happy to see your patients um or just answer questions and I believe that's the final sign. Thank you. Thank you everyone. Uh Just some closing comments. We do have one more question in the cube. So if you have any other comments or questions, let's use this time to chat. Uh type them into the chat box. So dr Marcel um when a patient comes out of cats, do they need any additional immobilization? Um in reference to your clothes reduction slide. Sure. So if the patient has undergone a closed reduction And that is successful. They'll be casted for a total of 12 weeks Having a change at six weeks in the operating. And then they will go into an abduction race. And that is because as some of my slides covered the hip should be located and stable. Active. Close reduction, but it still needs time for the acid tablet to a model over the top and so that requires him to be positioned in a production. So we do use a brace initially. That race will be used full time except for changing the baby and swimming and another such. But we recommend getting as close to full time as possible. And there's a paper that shows us that there is a dose dependent relationship between the amount of time spent in place and the outcome. Um As the hip normalizes, as we see that asset out of the index normalize. We can wean out of the abduction brace. Um, There's some debates on whether or not leaning makes a difference. Um, but I think that, you know, it's reasonable to lean slowly out of that price over the months that followed. Um, I do get a lot of questions from parents about whether or not their child would be delayed in their milestone Because they've been any cash, 12 weeks and then we're using brace treatment and treatment can continue for quite a number of months and I advise them that they will most likely have a delay. But if you have a child with otherwise normal muscle tone um and otherwise presenting normally that they will catch. Yeah. Okay, great. We have another one that's little abbreviated so I'm sorry if I butcher the question but Um, Breach is one reason to screen is the first born female sibling and parents with hip dysplasia or sub civilization and dislocation history. Another reason to screen? Yes, absolutely. We know that. Um, and I'm sorry that few of my slides in the beginning, um skipped over. We know that there is an increased incidence of hip dysplasia. If a sibling inside it, a parent has had it and it goes up quite a bit of a sibling and appearances. So we absolutely want to see patients who have a family history as well in addition to the first born female and breach. So you have to factor in if you're one of those risk factors, just being the first born female, I don't think is always a reason to screen if you have more than just that risk. And then I think you have to make some judgments about whether or not um you need to look at more than a physical exam and it looks like that was the last of our questions. So I'm gonna give everyone a few minutes back to their day and just a final thank you for joining us. And um oh sorry there is one more question we can answer it high level many of my patients are without insurance coverage. If there is a history of breach positioning, transient lee and third semester with vertex delivery and or latin Barlow are negative, is a hip ultrasound necessary? We don't have any ah studies that show us that breach positioning early on. Was a patient that turns um is a risk factor for hip dysplasia. And what about the last part of the question said at six weeks? Is hip ultrasound necessary at 65? Um I apologize but we in our field did not yet have good studies looking at patients that have been breached and then turn I think that just relatively speaking in terms of packaging and how much room that baby has. I think if breach positioning persists well into the third trimester that personally I would just See that baby at six weeks and screen because we don't have great information but and the first two trimesters and no no physical exam findings that are concerning. I don't think we have any hard and fast indications. Okay. And that looks to be about it. If there are any other questions audience you can email me and I connected with DR Maciel but for now this is our final thank you and I'll email everyone with directions on how to claim your CPU credits within the next couple of days. So thank you from everyone at T. G. H. And have a good rest of your day.
Presenters
