Developmental

Dysplasia of the Hip

Dr. Bassel El-Osta

SpR Trauma & Orthopaedics
 Overview
Introduction
Normal Development of the Hip
Etiology and Pathoanatomy
Epidemiology and Diagnosis
Treatment
Complications
 Introduction
Developmental Dysplasia of the Hip
DDH - preferred term
Teratogenic hips
Subluxation
Dislocation-usually posterosuperior (reducible
vs irreducible)
Dysplasia
 Epidemiology
Risk Factors
1/1,000 born with dislocated hip
10/10,000 born with subluxation or dysplasia
80% Female
First born children
Family history (6% one affected child, 12% one
affected parent, 36% one child + one parent)
Oligohydramnios
Breech (sustained hamstring forces)
Native Americans (swaddling cultures)
Left 60% (left occiput ant), Right 20%, both 20%
Torticollis or LE deformity
 Normal Development
Embryonic
7th week - acetabulum and hip formed from
same mesenchymal cells
11th week - complete separation between the
two
Prox fem ossific nucleus - 4-7 months
 Normal Hip
Tight fit of head in
acetabulum
Transection of
capsule
Still difficult to
dislocate
Surface tension
 Pathoanatomy
Ranges from mild dysplasia --> frank
dislocation
Bony changes
Shallow acetabulum
Typically on acetabular side
Femoral anteversion
 Pathoanatomy
Soft tissue changes
Usually secondary to prolonged subluxation or
dislocation
Intraarticular
Labrum
Inverted + adherent to capsule (closed reduction with
inverted labrum assoc with increased Avascular Necrosis)
Ligamentum teres
Hypertrophied + lengthened
Pulvinar
Fibrofatty tissue migrating into acetabulum
 Pathoanatomy
Soft Tissue (Intraarticular)
Transverse acetabular ligament
Contracted
Limbus
Fibrous tissue formed from capsular tissue
interposed between everted labrum and acetabular
rim
Extraarticular
Tight adductors (adductor longus)
Iliopsoas
 Etiology and Epidemiology
Multifactorial
Genetics and Syndromes
Ehlers Danlos
Arthrogryposis
Larsens syndrome
Intrauterine environmental factors
Teratogens
Positioning (oligohydramnios)
Neurologic Disorders
Spina Bifida
 Diagnosis
Newborn screening
Ortolanis and Barlows maneuvers with a
thorough history and physical
Warm, quiet environment with removal of
diaper
Head to toe exam to detect any associated
conditons (Torticollis, Ligamentous Laxity etc.)
Baseline Neuro and Spine Exam
 Diagnosis
Key physical findings
Asymmetry
Limb length- Galeazzi
Abduction ROM
Skin folds
Limp
Waddilng gait /
hyperlordosis - bilateral
involvement
 Ortolanis Maneuver

*After3monthsofagetestsbecomenegative
Barlows Maneuver
 Diagnosis
Some cases still missed
At risk groups should be further screened
AAP
Recs further imaging (e.g. US) if exam is
inconclusive AND
First degree relative + female
Breech
Positive provocative maneuver (Ortolani or Barlow)
Referral to Orthopaedist
 Imaging
X-rays
Femoral head ossification center
4 -7 months
Ultrasound
Operator dependent
CT
MRI
Arthrograms
Open vs closed reduction
 Imaging
Radiographs
 Imaging
Radiographs
Helgenreiner'sLine
 Imaging
Radiographs
 Imaging
Radiographs

Shentonline
 Imaging
Acetabular Index
 Imaging
Acetabular Index
 Imaging
Acetabular Index

<30wnl
Imaging
Imaging
Imaging
Imaging
 Radiographs Summary
Femoral head appears 4 - 7 months
Shentons line
Perkins and Hilgenreiners lines
Inferomedial quadrant
Center Edge Angle (< 20 abnormal)
Acetabular index
Normal < 30 (Weintroub et al)
Tear drop*
Abnormal widening in DDH
*may be only sign in mild subluxation
 Imaging
Ultrasound
Introduced in 1978 for eval of DDH
Operator dependent
Useful in confirming subluxation, identifying
dysplasia of cartilaginous acetabulum,
documenting reducibility
Prox Femoral Ossification Center interferes
Requires a window in spica cast (avoid)
 Ultrasound
Femoralhead

Abductors

Ilium
 Ultrasound
Femoralhead

Abductors

Ilium
 Ultrasound
Femoralhead

Abductors

Ilium
 Ultrasound
Femoralhead

Abductors

Ilium
 Ultrasound
Grafsalpha
angle
 Ultrasound
Grafsalpha
angle

>60=normal

*linew/ilium
bisectshead50/50
 Natural History
Newborn Variable
> 6 months more aggressive tx required
due to more extensive pathology and
decreased potential for acetabular
remodeling
Abnormal Gait, Decreased Abduction and
Strength, Increased DJD
Unilateral worse than Bilateral
Subluxation worse than Dysplasia
 Treatment Options
Age of patient at presentation
Family factors
Reducibility of hip
Stability after reduction
Amount of acetabular dysplasia
 Tough Reductions
Obstacles to reduction
Extraarticular
Tight iliopsoas and
adductors
Intraarticular
Labrum
Ligamentum teres
Transverse acetabular
ligament
Pulvinar
Redundant capsule
(hourglass)
+/- limbus
 Birth to Six Months
Triple-diaper technique
Prevents hip adduction
Success no different in some
untreated hips
Pavilk harness (1944)
Experienced staff*
Very successful
Allows free movement within
confines of restraints

*posteriorstrapsforpreventingadd.NOTproducingabd.
 Birth to Six Months
Pavlik harness
Indications
Fully reducible hip*
Child not attempting to stand
Family
Close regular follow-up (every 1-2 weeks)
For imaging and adjustments
Duration
Childs age at hip stability + 3 months
 Pavlik Harness
Failures
Poor parent compliance
Improper use by the physician
Inadequate initial reduction
Failure to recognize persistent dislocation
Viere et al 1990
Bilateral dislocation
Absent Ortolanis sign
> 7weeks of age
 Pavlik Harness
Complications
Avascular necrosis
Forced hip abduction
Safe zone (abd/adduction and flexion/extension)
Femoral nerve palsy
Hyperflexion

*Be aware of Pavlik Harness Disease

*Follow until skeletal maturity
 Birth - Six months
Closed reduction + Spica
Failure after 3 weeks of Pavlik trial
 Birth - Six months

Closed reduction
General anesthesia
Arthrogram
Safe zone - avoid AVN
+/- adductor tenotomy
Open reduction if concentric reduction not
possible
Usually teratogenic hips in this age group
 Open Reduction
Medial approach
Pectineus / adductor longus + brevis
Cannot address simeoultaneous bony work
Antero -lateral
Smith-peterson
Sartorius / Tensor Fascia lata
Open Reduction
 6 months - 4 years
Present a more difficult problem
Prolonged dislocation
Contracted soft tissues
6 - 18 months
Closed reduction +/- adductor tenotomy
Spica in human position of 100 degrees of flexion and
about 55 degrees abduction (3 months)
Abduction Orthosis 4 wks full time/4 wks nighttime
Open reduction (if closed fails)
Capsulorraphy
CT scan
Spica for 6 wks followed by PT
 6 months - 4 years
18 months - 4 years
Closed reduction
Reducibile - check arthrogram and medial dye pool
Irreducible - Open reduction
Open redcution
Tight - femoral shortening
Stable - +/- pelvic osteotomy
 Femoral Shortening
Schoenecker + Strecker 1984
Traction vs. Femoral shortening
56% AVN in traction group
0% AVN in femoral shortening
 Pelvic Osteotomy
Persistent instability + dysplasia after
open reduction + femoral shortening
Requires concentric reduction of a
reasonably spherical femoral head
Usually based on surgeon preference
Salter and Pemberton 2 m/c in US
 Pelvic Osteotomy
Volume changing
Pemberton
Hinges on triradiate
Requires remodeling of new incongruity
Provides more anterolateral coverage
Degas
Pemberton
 Pelvic Osteotomy
Redirecting
Salter
Osteotomy thru sciatic notch
Hinge thru pubic symphysis
Triple innominate
Ganz
Dial
 Pelvic Osteotomy
Redirecting
Salter
Osteotomy thru sciatic notch
Hinge thru pubic symphysis
Triple innominate
Ganz
Dial
Salter Osteotomy
Salter Osteotomy
Salter Osteotomy
 Salvage or Shelf procedures
Chiari
Requires capsular metaplasia
Pain - main indication
Treatment of chronic hip pain in adolescents
Chiari Osteotomy
Chiari Osteotomy
Chiari Osteotomy
Chiari Osteotomy
Chiari Osteotomy
Avascular Necrosis
 Avascular Necrosis
Most common
Not part of the natural history of DDH
Iatrogenic
Etiology unknown
Femoral head compression
Injury to blood supply
Excessive abduction
Sullivan et al 1997
Sig blood flow w/ increasing abd angle
 TX Summary
Best if treated before 6 weeks of age
0 - 6 months of age
Pavlik
6 - 18 months
Closed vs open reduction and spica
18 - 48 months
Closed
Open +/- osteotomies
 Summary
Femoral shortening better than traction
Pelvic osteotomies
Dega, Pemberton
Salter, triple innominate, Ganz
Chiari
Thank You