Mead Minutes: Early prevention is key for DDH
Dr. Tim Mead at work
Greetings from the Philippines! After a night of rain, I awoke early to clear skies. The Southern Cross and Orion were constellations I knew shining dramatically against the inky, black sky. The air was fresh, humid, and not too hot. After all, we were in the cool “brrrr” months: Septembrrrrr, Octobrrrrr, Novembrrrrr, and Decembrrrrr. Taking into account that there are two seasons—hot and hotter—in the Philippines, cool is relative. The past few weeks, there has been much rain keeping the humidity high.
Recently, three children arrived with hips out-of-joint that needed reconstruction at Tebow CURE Hospital. The official term for this is developmental dislocation of the hip (DDH). Some children are born with unstable hips and hip cups (acetabulum) that are not quite right. X-rays and ultrasound often show vertical and shallow cups. If DDH is diagnosed early in life, we can place the infant in a special harness holding the hips in place to grow normally. In Kenya, the moms used to always carry the babies on their backs. This placed the hips in a great position for growth. Changes in the culture are modifying the practices of some and doctors are now seeing dislocated hips in children, a major step backwards.
All too often in the countries where CURE has hospitals, children come in with a painless limp that turns out to be a dislocation. Most kids older than 1½ years or so will need some form of surgery. The older the child, the more complex the surgery. After about 7-8 years of age, if they present their deformity, it eclipses my skills and cannot easily be reconstructed. We commonly will see teenagers and older presenting for initial evaluation. My heart breaks, but a shoe lift is probably their best option.
These kids were younger. We had a 2½ year old, a 3 year old, and a 4 year old present for reconstruction within the past 7 days. These are trying cases but need to be done. Do you want to read how? Okay. My methodology follows. There are other ways, of course.
First, we start with a deep breath and a prayer for the child and surgeons. Then, we make a smile, bikini incision over the front and side of the affected hip. The growth plate on the pelvic wing is split in line and the inner and outer sides of the pelvis are exposed well. We then pack it off with sponges to avoid bleeding. Now, the hip socket is way deep in the hole. We mobilize covering muscles and lengthen the hip flexor. The joint capsule is a whitish, somewhat shiny structure. It is very necessary to clearly define the borders.
Normally, the hip ball sits in the cup with a firm capsule adding stability. Here the capsule is stretched out following the femoral head up and proximally. The capsule is opened. The ligamentum teres is a structure that goes from the femoral head to the cup. We carefully release this stretched out structure and use it as a guide to the true acetabulum (cup). If the hip has been out a long time, the body will form a false acetabulum higher to the true. You must find the correct location.
Having resected the ligamentum, we clean out scar tissue and work on the cup to make sure it is ready for the ball. Now, put the head in the cup. The lateral head was not covered by the cup well. The tension in the joint was not excessive, so we did not need to shorten and realign the femur. So, the next step.
We did Salter pelvic osteotomies on all three children. This involved cutting the pelvis from front to back, changing the angle of the cup, harvesting a wedge of bone from the superior pelvis, and wedging it in where previously I cut and moved. Two pins hold the position. The operation was named in honor of Dr. Robert Salter who designed the procedure many years ago.
So, back to the hip joint. The ball was better covered and the hip more stable. The capsule needed to be reconstructed. The dislocation created a loose, redundant structure. When we opened the capsule, we placed firm sutures that were advanced and closed. Tissue was removed and moved to gain a firm closure. Hip stability was clinically good and portable X-rays confirmed the reduction.
Now for the truly nasty part: a spica cast. The cast goes from the ankle of the affected limb all the way up to the ribs and down the other thigh. We place a bar to reinforce the cast and hold position. Yes, we leave room for bathroom needs. The parents are truly angels for taking care of the kids in these casts.
If I never saw a child with DDH again, I would be thrilled. Once again, we see not only the need for the care provided by CURE, but also the need for education country-wide about checking newborn infants, diagnosing DDH early, and starting treatment early. The same is true of most pediatric deformities. Early diagnosis and early treatment is usually best. Exceptions exist, but they are truly exceptions.
CURE International, as a part of the ministry, does educational outreach. We teach the truth that the children are not “cursed, evil, or worthless.” We teach how to care for the children. We reach out to communities with information about treatment. Will CURE end neglected deformities in children? No, but we can do our part. Maybe you are called to help as well. The needs of the disabled children across the globe are many and the workers are few. Does something just not feel “right” to you and must change? That whisper may be your call to get up and go do something. What? Nothing changes if we all just sit comfortably and do nothing to affect change. Start an adventure! Travel the unknown in His grip.