I chose to search for and present novelties in the treatment of congenital hip dislocation, on the one hand because I am a person who loves children and who wants to contribute, in some way, to their evolution and harmonious growth, and on the other hand because I had the opportunity to meet and work with adults whose condition was detected late, or the evolution of the disease was not properly monitored during growth and they were left with a locomotor deficiency, which in other conditions could have avoid.
Congenital dislocation of the hip is one of the serious malformations of the lower limbs, relatively frequently encountered, which leaves particularly important functional sequelae, difficult to treat and with a high degree of disability. From birth to 7-8 months, we encounter luxating hip dysplasia, a condition in which the cotyledons are dysplastic, the femoral heads are not completely contained by the cotyloid cavities, being placed in front of them and most of the time the femoral neck is anteversal . Exceptionally rare dislocation can appear from birth bearing the name of teratological dislocation. At birth, the coxofemoral joint has small bones and a large cartilage content, and the percentage of the femoral head covered by the acetabulum is smaller, therefore the first 6 weeks of the child’s life are critical for the development of anomalies in the joint.
From the point of view of top therapy, kinetoprophylaxis is considered very important, due to the possibility of avoiding a post-natal installation of congenital hip dislocation, but also due to the low costs. in this sense it is currently recommended:
- Young people who have cases in the family are recommended to avoid efforts and traumas.
- During birth, maneuvers that require strong traction of the lower limbs will be avoided, as much as possible.
- If the newborn needs to be resuscitated, the head-down suspension maneuver will be avoided, the maneuver that favors dislocation through the capsular distension it produces at the level of the hips.
- Children with other malformations, but especially congenital crooked leg (especially talus valgus) will have to be carefully examined at the level of the hips as well.
- Prophylaxis is particularly important, parents should know that swaddling with tight legs (from the people or from mothers and grandmothers) is traumatic and favors hip dislocation.
- Swaddling the baby in the first 3 months of life with two diapers one on top of the other – I advise the parents of newborns to put on them a special panty or two diapers, one on top of the other, to fix the thighs apart, which makes it easier to restore the normal anatomical position of the coxofemoral joint and also helps to prevent a postnatal dislocation.
- It is recommended that babies be laid in a ventral position (on their stomachs) with the lower limbs in abduction and slight internal rotation – It has been found that congenital hip dislocation is less common in American infants, this fact is primarily due to the habit Americans to put their children to sleep in the ventral position and in slight abduction, this position favoring the maintenance of the femoral head in the acetabulum.
- The pre-walker is totally contraindicated in children with congenital dislocation of the hip, but should be avoided in healthy children as well.
Currently, the treatment of congenital hip dislocations depends on the age of the patient and the success of the previous techniques, but up to the age of 3 the disease can be considered cured. Children under 6 months with instability on examination are treated with a form of limb rod and harnesses, especially Pavlik. The child will be held with the thighs in abduction and internal rotation, a position in which the femoral head is well centered in the pelvis. The indications for surgery depend on the severity of the disease, bilaterality and the formation or not of a false acetabulum. in congenital dislocations of the hip, it was found that kinetotherapeutic treatment is necessary regardless of the age of the patient, the stage of the disease, whether the hip was surgically or only orthopedically intervened, and regardless of whether the patient is in one of the forms of immobilization, or apparently stability, mobility the hip and the strength of its muscle groups were regained, the kinetic program being structured according to the objectives targeted at the time.
Balance stability is obtained through free positions, fixed positions, manipulations. The increase in balance mobility is obtained through: tractions, mobilizations (passive, active-passive and active) and F.N.P.s. The increase in muscle tone is obtained through global and analytical exercises on all hip muscle groups.
Personal experience in the field:
- I found that for a better collaboration with children, it is good to avoid wearing the classic, white uniforms by the physiotherapist, because it is known that the little ones have a phobia towards the white coat and in this sense the colors are preferred more vivid, which attract the little ones, for example the color red.
- I have obtained better results in the field if in the first 6-12 months after the orthopedic or surgical treatment of congenital hip dislocations, I performed physical therapy sessions, daily, especially when this period corresponded to the period of growth and initiation of walking.
- Regarding the methods of assessing the balance function, I noted that they must be done sequentially at the beginning, during the course and at the end of the recovery program. This appreciation is coded analytically through joint and muscle testing or synthetically through the ability to perform a series of usual actions.
- From my experience in the field, patients who have been instituted a preoperative recovery program have a better and faster postoperative evolution in terms of mobility and toning of the hip muscles, which had congenital dislocation.
- I have noticed that pain is often encountered in patients with congenital dislocation of the hip, especially when it was not operated or reduced correctly and they need anti-inflammatory and anti-algesic medication, and the physiotherapy sessions should be carried out without loading.< /li>
- From my experience, patients who failed to detect the congenital dislocation of the hip in time or to respect their recovery programs after its reduction, have secondary coxarthrosis as a late sequel. That is why patients, in addition to the kinetic program, are required to follow a series of orthopedic hip hygiene rules, which will be followed throughout their lives.
I am of the opinion that a great deal of emphasis must be placed on kinetoprophylaxis, to avoid congenital hip dislocations, especially the postnatal one, by wrapping the infant in double diapers, lying in a prone position with the lower limbs in abduction and slight internal rotation, but also by avoiding the use of pedestrians.
I think it is important that in the recovery of congenital dislocation of the hip, the exercises should be performed slowly, rhythmically, without abruptness and should be based on stable, solid starting positions, which allow maximum muscular work.
Opposite the period of the kinetic maintenance program, it is recommended until post-puberty (because osteonecrosis of the femoral head can occur at puberty) as a degenerative process.
It is good that in the case of children positioned in a Spica Cast, during the physical therapy sessions, the lifting of the bar between the legs or only the upper part of the body should be avoided.
Among the postural methods, very important for patients with congenital hip dislocation, the most used in the whole world and the most effective at the same time is the Pavlik Harness.
It is good that during the recovery sessions after congenital dislocation of the hip, it is good to place great emphasis on the recovery of hip stability, as well as on the toning of the abductor and extensor muscles.
I recommend that in late bilateral hip dislocations the Wileams program should be used.
- Don’t forget that adults who have a properly treated congenital dislocation of the hip should work, from a kinetic point of view, in the same way as in coxarthrosis, because it is known that it occurs secondary in these situations.
- I recommend that patients who have had a hip arthroplasty start the kinetic program from the second day and, in addition to the specific, post-operative physical therapy, perform exercises to improve breathing.
- I also believe that the fight against edema is also necessary postoperatively for congenital hip dislocation and in this sense, anti-slope postures, dorsiflexion and plantar flexion mobilizations of the leg, knee mobilizations and massage of the lower limb are useful.
- I am of the opinion that during the period of immobilization the massage is indispensable in order to maintain tonicity and trophicity as close as possible to the re-education normal.
- Antalgic thermotherapy and electrotherapy should not be neglected in the treatment of adults with congenital hip dislocations operated for analgesic and decontracting purposes.
Hannemaria Strete