1. DevelopmentalDevelopmental
Dysplasia of the HipDysplasia of the Hip
Dr.HARDIK S PAWARDr.HARDIK S PAWAR
DEPARTMENT OF ORTHOPAEDICSDEPARTMENT OF ORTHOPAEDICS
CARE HOSPITALSCARE HOSPITALS
2. OverviewOverview
IntroductionIntroduction
Normal Development of the HipNormal Development of the Hip
Etiology and PathoanatomyEtiology and Pathoanatomy
Epidemiology and DiagnosisEpidemiology and Diagnosis
TreatmentTreatment
ComplicationsComplications
3. IntroductionIntroduction
Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip
Intracapsular displacementIntracapsular displacement
SubluxationSubluxation
Dislocation-usually posterosuperior (reducibleDislocation-usually posterosuperior (reducible
vs irreducible)vs irreducible)
DysplasiaDysplasia
Before, during or just after birthBefore, during or just after birth
4. HISTORYHISTORY
Chapple and davidson – 1941Chapple and davidson – 1941
Muller and seddon – 1953Muller and seddon – 1953
AR hodgson - 1959AR hodgson - 1959
Wilkinson - 1963Wilkinson - 1963
5. EPIDEMIOLOGYEPIDEMIOLOGY
1/1,000 born with dislocated hip1/1,000 born with dislocated hip
10/10,000 born with subluxation or dysplasia10/10,000 born with subluxation or dysplasia
5:1 Female:Male child5:1 Female:Male child
Left 60% (left occiput ant), Right 20%, both 20%Left 60% (left occiput ant), Right 20%, both 20%
Risk FactorsRisk Factors
Family history (6% one affected child, 12% oneFamily history (6% one affected child, 12% one
affected parent, 36% one child + one parent)affected parent, 36% one child + one parent)
OligohydramniosOligohydramnios
Breech (sustained hamstring forces)Breech (sustained hamstring forces)
Native Americans (swaddling cultures)Native Americans (swaddling cultures)
Torticollis or LE deformityTorticollis or LE deformity
6. Normal DevelopmentNormal Development
EmbryonicEmbryonic
7-87-8thth
th week - acetabulum and head formedth week - acetabulum and head formed
from same primitive mesenchymal cellsfrom same primitive mesenchymal cells
11th week - complete devlopement of hip11th week - complete devlopement of hip
Prox fem ossific nucleus - 4-7 monthsProx fem ossific nucleus - 4-7 months
Hip at risk of dislocation at 4 period :Hip at risk of dislocation at 4 period :
at 12at 12thth
weekweek
at 18at 18thth
weekweek
final 4 weeksfinal 4 weeks
post natal periodpost natal period
14. DiagnosisDiagnosis
Newborn screeningNewborn screening
Ortolani’s and Barlow’s maneuvers with aOrtolani’s and Barlow’s maneuvers with a
thorough history and physicalthorough history and physical
Warm, quiet environment with removal ofWarm, quiet environment with removal of
diaperdiaper
Head to toe exam to detect any associatedHead to toe exam to detect any associated
conditons (Torticollis, Ligamentous Laxityconditons (Torticollis, Ligamentous Laxity
etc.)etc.)
Baseline Neuro and Spine ExamBaseline Neuro and Spine Exam
16. Clinical Features : NeonatesClinical Features : Neonates
Delicate “clunk” thatDelicate “clunk” that
is palpable but notis palpable but not
audibleaudible
Repeat sequence 4-5Repeat sequence 4-5
times to be certain oftimes to be certain of
findingsfindings
If both signs negativeIf both signs negative
but pt is high risk :but pt is high risk :
follow up is essentialfollow up is essential
17. Clinical features : InfantsClinical features : Infants
Progression fromProgression from
instability to dislocationinstability to dislocation
is gradual processis gradual process
In some within a fewIn some within a few
weeksweeks
others the hipothers the hip
dislocation remainsdislocation remains
reducible up to 5 or 6reducible up to 5 or 6
months of age.months of age.
When the hip no longerWhen the hip no longer
reducible, specificreducible, specific
physical findingsphysical findings
appearappear
31. DiagnosisDiagnosis
Some cases still missedSome cases still missed
At risk groups should be further screenedAt risk groups should be further screened
AAPAAP
Recs further imaging (e.g. US) if exam isRecs further imaging (e.g. US) if exam is
“inconclusive” AND“inconclusive” AND
First degree relative + femaleFirst degree relative + female
BreechBreech
Positive provocative maneuver (Ortolani or Barlow)Positive provocative maneuver (Ortolani or Barlow)
Referral to OrthopaedistReferral to Orthopaedist
32. ImagingImaging
X-raysX-rays
Femoral head ossification centerFemoral head ossification center
4 -7 months4 -7 months
UltrasoundUltrasound
Operator dependentOperator dependent
CTCT
MRIMRI
ArthrogramsArthrograms
Open vs closed reductionOpen vs closed reduction
45. Centre – Edge Angle WibergCentre – Edge Angle Wiberg
6 – 13 years >19
degrees
>14 years > 25
degrees
46. ANDREN-von ROSENANDREN-von ROSEN
LINELINE
AP X-ray: hip in 45AP X-ray: hip in 45°abduction and IR°abduction and IR
Describes the longitudinal relationship betweenDescribes the longitudinal relationship between
long axis of femur and acetabulumlong axis of femur and acetabulum
47. Tear dropTear drop
AP X-rayAP X-ray
Lateral:wall ofLateral:wall of
acetabulumacetabulum
Medial:lesser pelvisMedial:lesser pelvis
Inferior :acetabularInferior :acetabular
notchnotch
Appears between 6-23Appears between 6-23
momo
[delayed in DDH][delayed in DDH]
48. Radiographs SummaryRadiographs Summary
Femoral head appears 4 - 7 monthsFemoral head appears 4 - 7 months
Shenton’s lineShenton’s line
Perkin’s and Hilgenreiner’s linesPerkin’s and Hilgenreiner’s lines
Inferomedial quadrantInferomedial quadrant
Center Edge Angle (< 20 abnormal)Center Edge Angle (< 20 abnormal)
Acetabular indexAcetabular index
Normal < 30 (Weintroub et al)Normal < 30 (Weintroub et al)
Tear drop*Tear drop*
Abnormal widening in DDHAbnormal widening in DDH
*may be only sign in mild subluxation*may be only sign in mild subluxation
49. ImagingImaging
UltrasoundUltrasound
Introduced in 1978 for eval of DDHIntroduced in 1978 for eval of DDH
Operator dependentOperator dependent
Useful in confirming subluxation, identifyingUseful in confirming subluxation, identifying
dysplasia of cartilaginous acetabulum,dysplasia of cartilaginous acetabulum,
documenting reducibilitydocumenting reducibility
Prox Femoral Ossification Center interferesProx Femoral Ossification Center interferes
Requires a window in spica cast (avoid)Requires a window in spica cast (avoid)
58. ArthrogramArthrogram
Severin [1941]Severin [1941]
Normal appearance:Normal appearance:
LABRUM:LABRUM:
*Thorn over the*Thorn over the
femoral headfemoral head
*A recess of joint*A recess of joint
capsule overlies thecapsule overlies the
thornthorn
60. Imaging ToolsImaging Tools
CT scan:CT scan:
Single section CT as check filmsSingle section CT as check films
Neglected C.D.H.Neglected C.D.H.
Adolescent and adultAdolescent and adult
MRI:MRI:
Equivalent to arthrographyEquivalent to arthrography
61. Natural HistoryNatural History
NewbornNewborn VariableVariable
> 6 months> 6 months more aggressive tx requiredmore aggressive tx required
due to more extensive pathology anddue to more extensive pathology and
decreased potential for acetabulardecreased potential for acetabular
remodelingremodeling
Abnormal Gait, Decreased Abduction andAbnormal Gait, Decreased Abduction and
Strength, Increased DJDStrength, Increased DJD
Unilateral worse than BilateralUnilateral worse than Bilateral
Subluxation worse than DysplasiaSubluxation worse than Dysplasia
62. Treatment OptionsTreatment Options
Age of patient at presentationAge of patient at presentation
Family factorsFamily factors
Reducibility of hipReducibility of hip
Stability after reductionStability after reduction
Amount of acetabular dysplasiaAmount of acetabular dysplasia
63.
64. Birth to Six MonthsBirth to Six Months
Triple-diaper techniqueTriple-diaper technique
Prevents hip adductionPrevents hip adduction
““Success” no different in someSuccess” no different in some
untreated hipsuntreated hips
Pavilk harness (1944)Pavilk harness (1944)
Experienced staff*Experienced staff*
Very successfulVery successful
Allows free movement withinAllows free movement within
confines of restraintsconfines of restraints
*posterior straps for preventing add. NOT producing abd.
65. Birth to Six MonthsBirth to Six Months
Pavlik harnessPavlik harness
IndicationsIndications
Fully reducible hip*Fully reducible hip*
Child not attempting to standChild not attempting to stand
FamilyFamily
• Close regular follow-up (every 1-2 weeks)Close regular follow-up (every 1-2 weeks)
• For imaging and adjustmentsFor imaging and adjustments
• DurationDuration
• Childs age at hip stability + 3 monthsChilds age at hip stability + 3 months
66. Pavlik HarnessPavlik Harness
FailuresFailures
Poor parent compliancePoor parent compliance
Improper use by the physicianImproper use by the physician
Inadequate initial reductionInadequate initial reduction
Failure to recognize persistent dislocationFailure to recognize persistent dislocation
Viere et al 1990Viere et al 1990
Bilateral dislocationBilateral dislocation
Absent Ortolani’s signAbsent Ortolani’s sign
> 7weeks of age> 7weeks of age
67. Pavlik HarnessPavlik Harness
ComplicationsComplications
Avascular necrosisAvascular necrosis
Forced hip abductionForced hip abduction
Safe zone (abd/adduction and flexion/extension)Safe zone (abd/adduction and flexion/extension)
Femoral nerve palsyFemoral nerve palsy
HyperflexionHyperflexion
*Be aware of Pavlik Harness Disease*Be aware of Pavlik Harness Disease
*Follow until skeletal maturity*Follow until skeletal maturity
68. Birth - Six monthsBirth - Six months
Closed reduction + SpicaClosed reduction + Spica
Failure after 3 weeks of Pavlik trialFailure after 3 weeks of Pavlik trial
69. Birth - Six monthsBirth - Six months
Closed reductionClosed reduction
General anesthesiaGeneral anesthesia
ArthrogramArthrogram
Safe zone - avoid AVNSafe zone - avoid AVN
+/- adductor tenotomy+/- adductor tenotomy
Open reduction if concentric reduction notOpen reduction if concentric reduction not
possiblepossible
Usually teratogenic hips in this age groupUsually teratogenic hips in this age group
70. Open reductionOpen reduction
Unable to achieveUnable to achieve
closed reductionclosed reduction
Widening of the jointWidening of the joint
spacespace
Unstable reductionsUnstable reductions
Loss of reduction onLoss of reduction on
follow upfollow up
Advanced ageAdvanced age
71. Open ReductionOpen Reduction
Medial approachMedial approach
Pectineus / adductor longus + brevisPectineus / adductor longus + brevis
Cannot address simeoultaneous bony workCannot address simeoultaneous bony work
Antero -lateralAntero -lateral
Smith-petersonSmith-peterson
Sartorius / Tensor Fascia lataSartorius / Tensor Fascia lata
74. Open Reduction with FemoralOpen Reduction with Femoral
derotation osteotomyderotation osteotomy
Pressure leads to risk of AVNPressure leads to risk of AVN
Better results than preoperative traction in olderBetter results than preoperative traction in older
children with less morbiditychildren with less morbidity
When to do??When to do??
Anticipated increased pressure on reduced femurAnticipated increased pressure on reduced femur
headhead
Recommended in child > 2yrs.Recommended in child > 2yrs.
distract the joint few millimeter per operativelydistract the joint few millimeter per operatively
Judge the tightness of soft tissues after reductionJudge the tightness of soft tissues after reduction
irreducible dislocationirreducible dislocation
77. 2 Years of Age and Older2 Years of Age and Older
For child 2 -3 years of age, during openFor child 2 -3 years of age, during open
reduction acetabular coverage ifreduction acetabular coverage if
insufficient warrants reorientationinsufficient warrants reorientation
osteotomyosteotomy
If coxa valga with excessive anteversion,If coxa valga with excessive anteversion,
VDRO may be done.VDRO may be done.
Children > 3 years usually need anChildren > 3 years usually need an
osteotomyosteotomy
78. Bilateral untreated dislocation upto 5Bilateral untreated dislocation upto 5
years:years:
Open reduction with femoral shorteningOpen reduction with femoral shortening
with salter / pemberton osteotomy withwith salter / pemberton osteotomy with
gap of 5-6 weeks.gap of 5-6 weeks.
Bilateral untreated subluxation upto 5-6Bilateral untreated subluxation upto 5-6
years:years:
Open reduction + salter osteotomy.Open reduction + salter osteotomy.
79. 6 months - 4 years6 months - 4 years
Present a more difficult problemPresent a more difficult problem
Prolonged dislocationProlonged dislocation
Contracted soft tissuesContracted soft tissues
6 - 18 months6 - 18 months
Closed reduction +/- adductor tenotomyClosed reduction +/- adductor tenotomy
Spica in human position of 100 degrees of flexion andSpica in human position of 100 degrees of flexion and
about 55 degrees abduction (3 months)about 55 degrees abduction (3 months)
Abduction Orthosis 4 wks full time/4 wks nighttimeAbduction Orthosis 4 wks full time/4 wks nighttime
Open reduction (if closed fails)Open reduction (if closed fails)
CapsulorraphyCapsulorraphy
CT scanCT scan
Spica for 6 wks followed by PTSpica for 6 wks followed by PT
80. 6 months - 4 years6 months - 4 years
18 months - 4 years18 months - 4 years
Closed reductionClosed reduction
Reducibile - check arthrogram andReducibile - check arthrogram and medial dye poolmedial dye pool
Irreducible - Open reductionIrreducible - Open reduction
Open redcutionOpen redcution
Tight - femoral shorteningTight - femoral shortening
Stable - +/- pelvic osteotomyStable - +/- pelvic osteotomy
81.
82.
83. Femoral osteotomyFemoral osteotomy
Schoenecker + Strecker 1984Schoenecker + Strecker 1984
Traction vs. Femoral shorteningTraction vs. Femoral shortening
56% AVN in traction group56% AVN in traction group
0% AVN in femoral shortening0% AVN in femoral shortening
87. Acetabular Reorientation-Acetabular Reorientation-
Innominate OsteotomyInnominate Osteotomy
Articular hyaline cartilage over femur headArticular hyaline cartilage over femur head
Types:Types:
SSalter’salter’s (innominate)(innominate)
SSutherland’s (double innominate)utherland’s (double innominate)
88. Salter’s OsteotomySalter’s Osteotomy
Redirects the entire acetabulumRedirects the entire acetabulum
Roof “covers” the femoral head anteriorlyRoof “covers” the femoral head anteriorly
and superiorlyand superiorly
Hinge at pubic symphysisHinge at pubic symphysis
Pre-requisitesPre-requisites
Congrous Concentric reductionCongrous Concentric reduction
No ContracturesNo Contractures
103. Salvage or Shelf proceduresSalvage or Shelf procedures
ChiariChiari
Requires capsular metaplasiaRequires capsular metaplasia
Pain - main indicationPain - main indication
Treatment of chronic hip pain in adolescentsTreatment of chronic hip pain in adolescents
112. Adolescent and young adult(olderAdolescent and young adult(older
then 8-10 yearsthen 8-10 years
If femoral head cannot be repositionedIf femoral head cannot be repositioned
distally to the level of acetabulum :distally to the level of acetabulum :
Salvage proceduresSalvage procedures
Degenertive arthritis and enough pain andDegenertive arthritis and enough pain and
limitation of movements – reconstructivelimitation of movements – reconstructive
operation (total hip replacement)operation (total hip replacement)
Arthodesis – rarely done, contraindiactedArthodesis – rarely done, contraindiacted
for bilateral dislocationfor bilateral dislocation
119. THR outcomes in DDHTHR outcomes in DDH
Charnley cemented hips:Charnley cemented hips:
5 of 38 loose at 11 years5 of 38 loose at 11 years
Bobak, Wroblewski et al 2000Bobak, Wroblewski et al 2000
Harris uncemented hips:Harris uncemented hips:
20% loose at 7 years20% loose at 7 years
46% loose at 12 years46% loose at 12 years
Jasty, Anderson, Harris, 1999Jasty, Anderson, Harris, 1999
121. Avascular NecrosisAvascular Necrosis
Most commonMost common
Not part of the natural history of DDHNot part of the natural history of DDH
IatrogenicIatrogenic
Etiology unknownEtiology unknown
Femoral head compressionFemoral head compression
Injury to blood supplyInjury to blood supply
Excessive abductionExcessive abduction
Sullivan et al 1997Sullivan et al 1997
SigSig ↓↓ blood flow w/ increasing abd angleblood flow w/ increasing abd angle
122. TX SummaryTX Summary
Best if treated before 6 weeks of ageBest if treated before 6 weeks of age
0 - 6 months of age0 - 6 months of age
PavlikPavlik
6 - 18 months6 - 18 months
Closed vs open reduction and spicaClosed vs open reduction and spica
18 - 48 months18 - 48 months
ClosedClosed
Open +/- osteotomiesOpen +/- osteotomies
123. SummarySummary
Femoral shortening better than tractionFemoral shortening better than traction
Pelvic osteotomiesPelvic osteotomies
Dega, PembertonDega, Pemberton
Salter, triple innominate, GanzSalter, triple innominate, Ganz
ChiariChiari