Congenital Hip Dislocation with a Genu Recurvatum in Togo: A Case Report

Foli Yvon Agbeko 1,2* , Mawouto Fiawoo 1,3 , Rollin Arnaud Djomaleu 3 , Magnoulelem NZonou 4 , Sollim Talboussouma 5 , Manani Hemou 2 , Homba Daké Batalia 3 , Rachel Bayahou Kérékou 2 , Mazama Pakoudjare 2 , Kokouvi Evenyo Abalo 3 , Bayaki Saka 6 , Deladem Koffi Azoumah 6 , Edem Koffi Djadou 1,3 , Kokou Nadiedjoa Douti 1,2 , Komlatsè Gamedzi Akakpo-Numado 7 , Adama Dodji Gbadoe 1,4 , Yawo Dzayissé Atakouma 1,3


Introduction
A Congenital Hip Dislocation (CHD) is a loss of anatomical relationships between the articular surfaces of the femur and acetabulum that can be detected at birth [1]. In the majority of cases, it is an acquired disease due to an anomaly in the child's intrauterine positioning which may explain the association with other limb anomalies [1]. A CHD is a condition which, although frequent in pediatrics is rather related to Caucasian population [1,2], remains rare in the Black population [3] and exceptional in sub-Saharan Africa [4][5][6]. In South Africa, out of 16,000 black newborns examined, no case had been found [5]. In 1990 in Congo, after examination of 4,465 newborn babies, no case had also been found [6]. In 2003, out of 2,551 newborns examined, Wandaogo et al also failed to find any cases [4]. The aim of this work was to report this first Togolese case of bilateral congenital dislocation of the hip associated with genu recurvatum observed in a newborn baby received in consultation on the second day of life.

Patient Information
It was a female newborn transferred from the maternity ward of the Regional Hospital Center of Lomé-Commune for vicious lower limb attitude noted at the midwife's initial examination.
The mother, a 27-year-old primiparous, had 7 prenatal consultations. The last one was four weeks before delivery. The mother's HIV, syphilis, toxoplasmosis, and rubella serologies were negative. The Hepatitis B antigen test was also negative.
The delivery took place vaginally. The presentation was an incomplete breech. The gestational age was 37 weeks and 5 days. The Apgar score at birth was 8, 10, and 10 at the first, fifth, and tenth minute. The birth weight was 3,000g, height 50cm, and head circumference 35cm. The newborn had received basic care.

Clinical Findings
The pediatric examination had noted an extension of lower limbs. The thighs had a stiff bilateral genu recurvatum. The abduction of the thighs on the pelvis was considerably limited. The Barlow and Ortolani maneuvers showed a protrusion. There was also a camptodactyly of the thumb and a cleft palate. The rest of the examination was normal (Fig-1).

Diagnostic Assessment
An ultrasound of the hip showed a bilateral congenital dislocation of the hip with an estimated acetabular fundus of 7 mm on both the right and left sides. The ultrasound and radiography of the knees were normal (Fig-2).

Therapeutic Intervention
The baby had been monitored for 24 hours in the pediatric ward. then she was transferred to surgical ward, where she received orthopedic treatment for the hips.

Follow-up and Outcomes
The clinician-and patient-assessed outcomes: referred to surgery wards.

Discussion
Female patients are most often affected [6,7] as in our observation. The genetic and mechanical factors seem to be the most important risk factors [6]. A breech presentation such as incomplete breech, breech with bent knees and hip in external rotation, or tight thighs are important risk factors, but this involvement occurs at variable frequencies [4,6]. The newborn in our observation was in the incomplete breech with extended knees. Other factors such as primiparity in 50 to 60% of cases [8], oligohydramnios, twin pregnancy, and macrosomia are also involved [6] and can be explained by an interaction between the narrowed uterine cavity and the fetus.
A clinical examination of the hips at birth and in the first month of life is fundamental to the diagnosis of congenital hip dislocation [9]. Clinically, a congenital dislocation of the hip is characterized by an asymmetric attitude of the thighs: either the two thighs are brought together in adduction of less than 60° with hypertonic adductors, or there is a difference in the length of the knees when the child is lying down, with the hips bent, the knees bent and the feet on the examination table (Galleazi sign). There may also be a jump in the Barlow and Ortolani maneuvers [9,10]. In about 28% to 50% of cases, the damage can be bilateral [6,11]. A genu recurvatum of both knees may be associated in rare situation [6,12,13] with the pathology. The association with malformations such as abnormalities of the thoracic limb has not been found, but there was a cleft palate. This togolese clinical case could be part of arthrogryposis, a congenital disease manifested mainly by stiffness in various joints. It may be an independent disease or part of a syndrome associating other signs. More than 150 types have been described, including nearly 400 genetic abnormalities [14].
The paraclinical diagnosis is based on X-rays, but the best is ultrasound examination of the hip, which has the advantage of being more precise and less toxic [6]. The most commonly used techniques are the stitching technique, which measures the base of the acetabulum, so the dimension must be less than 5 mm [15]. The technique of de Graaf studies the acetabular cavity by frontal cuts passing through the centre [16]. Orthopaedic surgeons treat the patient. Total hip arthroplasty in congenital hip disease is generally considered as having higher failure rates [17]. It has to be stressed that the interpretation of results is difficult because in the majority of the studies all types of the disease are included, to a varying degree. Due to the fact that different reconstructive challenges are addressed in each type of the disease. Moreover, different techniques and implants are used, making the comparative evaluation of the results a difficult task [18].

Conclusion
CHD is a disease which is rare in the black population. The etiologies are various and can sometimes be multiple. In rare cases, it is associated with other abnormalities such as genu recurvatum. clinical examination at birth is the key step in diagnosis. A lot of studies are being carried out to improve screening through systematic clinical diagnosis and the evaluation of the coxofemoral joint in imaging. In situations where diagnosis is difficult, an ultrasound is of capital importance. The treatment is in the majority of cases orthopedic.