Vietnam doctors struggle to treat congenital hip dislocation

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     A nurse cares a newborn baby at Tu Du, the leading obstetrics hospital in Ho Chi Minh City. The hospital was the first to recognize the congenital hip dislocation in 1997 and has been treating patients aged less than four months. Photo: Thanh Tung

The Ho Chi Minh City Orthopedics Hospital last June admitted a 14-year-old boy who had difficulty walking and pain in his hip area.

Doctors performed a five-hour surgery on him, fixing a congenital hip dislocation that had never been treated.

They said they could only make the hip more stable and not make it normal since the bones were deformed after so long.

Researches have found that between 0.5 and 2 percent of children are born with the unstable hip condition, also known as dysplasia of the hip which causes inability to walk, and can result in paralysis as it damages the sciatic nerve.

Nguoi Lao Dong newspaper reported that doctors have warned about a lack of expertise in the country as well as little knowledge among people who do not notice the condition early enough to save their children from life-long difficulty.

The condition starts with abnormal formation of the hip joint during the early stages of fetal development, and it worsens as the child grows.

The ball-and-socket hip joint may dislocate regularly, with the ball slipping out of the socket during movement.

Nguyen Thi Phuong Tan, head of rehabilitation at HCMC's leading obstetrics hospital, Tu Du, said discovering the condition early means a 96 percent chance of recovery and prevention of disability.

"Ideally the intervention should happen before the child is one month old, and physical therapy should be provided by the fourth month," Tan said, adding that babies sleep most of the time during their first month and do not move much, which makes treatment highly effective.

She said after one year children start walking and surgery then becomes the only way to cure them.

The condition is fairly new for healthcare practitioners in Vietnam, with none treating it until around 20 years ago, she said.

Her hospital was the first to recognize the condition in 1997 and has been treating patients aged less than four months, she said.

The risks are higher in case of girl babies, the first child, multiple births, breech delivery, and other kinds of deliveries in which the head does not emerge first.

It also depends on the mother's endocrine system which decides the density of bursa the fluid-filled sac that reduces friction around joints and the strength of hip ligaments.

The condition also has other consequences for females such as spinal cord problems during pregnancy and delivery difficulties.

Dr. Deborah Pate, an American chiropractor, said that congenital hip dislocation is eight times more common in girls than in boys, the left hip is twice as likely as the right to be affected, and bilateral dislocation occurs in more than 25 percent of affected children.

The condition is common in Mediterranean and Scandinavian countries, but almost unknown in countries like China, "possibly due to the custom of carrying the infant on the mother's back with the child's hips flexed and abducted," he said.

Phan Van Tiep, head of pediatrics at the HCMC Orthopedics Hospital, said his department receives 40 to 50 patients with congenital hip dislocation every year, and though it admits people as young as four months old, most of them are brought in late when they are already walking.

Most parents only notice the abnormality when a child starts to walk.

He said when a child is hospitalized early, they will wear a cast or brace for three months to hold the hip in place and put the head of the thigh bone in the correct position in the hipbone cavity.

If that does not work, doctors wait until the child is eight months old to perform a surgery, which is less complicated and offers a higher chance of recovery than when the child is older.

Late treatment also leaves the baby with a higher risk of necrosis of bone components, "the condition's most fearful complication," he said.

The necrosis occurs in bones due to inadequate blood supply, leading to the collapse of bone structures, then bone destruction, pain, and loss of joint function.

Hospitals in developed countries screen for the condition when a baby is born, but only a few obstetrics hospitals like Tu Du do that in Vietnam, he said.

The screening done before the third month, includes a number of reflex exercises called Ortolani and Barlow maneuvers.

In the Ortolani test, the doctor applies forward pressure to each femoral head to move a dislocated head forwards into the hipbone socket. Palpable movement, with a "clunk" sound, suggests that the hip is dislocated.

The Barlow test applies backward pressure to the head of each femur, and partial or complete displacement can suggest a dislocation, which needs to be confirmed with radiographs.

Dr. Nguyen Van Thanh of the HCMC Orthopedics Hospital said parents can notice the dislocation by observing a baby lying on its chest.

Any hip dislocation will cause the folds in the skin of the thigh or buttocks to appear uneven; when the two legs are stretched, the one on the dislocated side would appear shorter, he said.

Thanh said for many patients the dislocation was discovered when they came to the hospital for a different problem.

Sometimes parents do notice their children's abnormal gait, but lack the money or medical knowledge to realize it is a symptom of a severe condition, he said.

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