SURGICAL CHALLENGES OF DEVELOPMENTAL DISLOCATION/DYSPLASIA

OF THE HIP (DDH) WITH DOWN SYNDROME UNDERGO OPERATIVE

TREATMENT UNDER ANESTHESIA IN TEACHING HOSPITAL: A CASE SERIES

Sulis Bayusentono1, Mika Kresna Prasetyo1

1
Departement of Orthopaedic dan Traumatology, Medical Faculty of Airlangga University /Dr Soetomo
General Academic Hospital Surabaya, Indonesia

ABSTRACT
INTRODUCTION
Down Syndrome often arises with its general laxity problematics, one of the things that are
often experienced by Down Syndrome patients who come to Dr Soetomo General Academic
Hospital is Developmental Dislocation/Dysplasia Of The Hip (DDH). In cases that are
handled late, surgery must be performed. Some complications can occur in the process of
anaesthesia with intubation and this is often mentioned in several journals.

METHODOLOGY
We report two cases, both of which are seven years old with patients in the first case
experiencing DDH and patients in the second case experiencing dislocation. Both cases were
carried out operatively, the first case was done by senior orthopaedics in the central operating
room for 2 hours electively using the method of Open Reduction in Capuslotomy, Internal
Fixation and Hemispica Installation. The second case was done by an orthopaedic resident in
the operating room of the emergency department on CITO for 3.5 hours with the method of
Closed Reduction and Hemispica Installation.

RESULT
The first patient experiences difficulty breathing one week after surgery, then the
tracheotomy is performed; while the second patient recovered a few days later and found no
problems, one week later the second case-patient was allowed to go home. In the first patient,
tracheotomy was performed for almost two months, and Hemispica was removed in
September 2019. After hemispica removal, the patients were then routinely controlled for
rehabilitation polyclinics and the results improved.
BRIEF DISCUSSION
Down syndrome patients with general laxity occur in all parts of the body especially in the
respiratory tract of the epiglottic region and aryepiglottic folds which form like an omega
symbol. Obstacles to surgery also increase the risk during and after anaesthesia. Intubation is
also thought to have difficulty due to airway obstruction and subglottic stenosis. Excessive
manipulation of this section will raise the potential for difficulties in intubating
anaesthetics. As a result of excessive manipulation will cause laryngomalacia which leads to
upper respiratory blockage. Laryngomalacia is a congenital abnormality in the laryngeal
cartilage. Dynamic lesions cause a collapse of the supraglottic structure at the time of
inspiration, causing airway obstruction. Besides this, morphological changes in the epiglottic
shape, degree of aryepiglottic fold, flaccidity and hypotonia in muscles can increase the
prevalence of laryngomalacia which leads to upper respiratory obstruction and stridor. Those
will lead the anesthesiologist to make the airway through tracheotomy.
Preparation for upper airway obstruction with an oral airway will decrease chances of
hypoxia on induction. In patients with subglottic stenosis, an LMA, or smaller endotracheal
tubes should be available during intubation to lessen the risk of airway trauma. Patients
should be monitored closely postoperatively until they have fully recovered from anesthesia.
Therefore, patients with DDH need to be aware of during the anaesthesia process. One of the
factors that influence this condition are resident of anesthesiologists who carry out intubation
procedure must be supervised by supervisors in performing anaesthesia in teaching
hospitals, another factor is operations that are "quick in-quick out".

KEYWORD: Developmental Dislocation Hip, Sindrom Down, Laryngomalacia

REFERENCES
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http://pediatrics.aappublications.org/content/pediatrics/105/4/896.full.pdf
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