DDH is a leading cause og congenial and devlomental hip anomalies.if diagnosed early then results & outcome can be improved,

1. Developmental Dysplasia of the
Hip
Dr.NAVEEN RATHOR
(RESIDENT DOCTOR)
DEPT. OF ORTHOPEDICS
RNT MEDICAL COLLEGE
UDAIPUR

2. • Definition
• Dysplasia of the hip that develop during
fetal life or in infancy.
• It ranges from dysplasia of the acetabulum
(shallow acetabulum) to subluxation of the
joint to complete dislocation.
• The old name was ‘‘congenital dysplasia of
the hip (CDH).’’ The name has changed to
indicate that not all cases are present at
birth and that some cases can develop later
on during infancy and childhood

3. Developmental Dysplasia of the
Hip
1. Complete hip dislocation.
2. Partial hip subluxation.
3. Hip dysplasia (incomplete development).
4.Dislocatable hip

4. Dysplasia: radiographic finding of increased
obliquity and loss of concavity of the
acetabulum, with an intact Shenton's
line(deficient development of
acetabulum)
Subluxation: femoral head is in partial contact
with the acetabulum
Dislocation:femoral head is not in contact with
the acetabulum

5. Incidence
• Most newborn screening studies suggest that
some degree of hip instability can be detected in
1/100 to 1/250 babies, actual dislocated or
dislocatable hips are much less common, being
found in 1-1.5 of 1000 live births.
• There is marked geographic and racial variation in
the incidence of DDH.
• More inidence of DDH IN Sweden,Yugoslavia and
Canada.

6. Etiology
• A positive family history for DDH is found in
12-33% of affected patients.
• DDH is more common among female patients
(80%). This is thought to be due to the greater
susceptibility of female fetuses to maternal
hormones such as relaxin, which increases
ligamentous laxity
• Primigravida.
• Breech presentation(2-3%).
• Oligohydramnios ,primi gravida and large baby
( crowding phenomenon ).
• Adduction and Extension postnatally.

7. Associated
conditions
-torticollis
-metatarsus adducts
-calcaneo valgus
-talipus varus
-plagiocephaly

8. • The left hip is the most commonly affected hip
• In the most common fetal position, this is the hip
that is usually forced into adduction against the
mother’s sacrum.
• Girls are affected 5 times more than boys.

9. • Types:
• DDH is classified into two major groups :
• Typical and teratologic .
• Typical DDH occurs in otherwise normal patients
or those without defined syndromes or genetic
conditions.
• Teratologic hip dislocations usually have
identifiable causes such as arthrogyposis or a
genetic syndrome and occur before birth.

10. Teratological DDH
 Irreducible
 False acetabulum
 Defective anterior acetabulum
“anteverted”
 Increased femoral neck
anteversion

11. Pathoanatomy
• Soft tissue changes
– Usually secondary to prolonged subluxation or
dislocation
• Intra articular
– 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

12. Pathoanatomy
• Soft Tissue (Intra articular)
– Transverse acetabular ligament
• Contracted
– Limbus
• Fibrous tissue formed from capsular tissue interposed
between everted labrum and acetabular rim
• Extra articular
– Tight adductors (adductor longus)
– Iliopsoas

14. CLINACAL
PRESENTATION

15. Neonatal Presentation
Exam one hip at a time
Baby must be quiet
Barlow’s sign: provocative maneuver
Ortolani’s sign: reduces hip
Other signs not helpful in newborn

16. CLINICAL FINDINGS
• IN NEWBORNS
• Usually asymptomatic and must be screened
by special maneuvers
• 1) Barlow test.
It is a provocative test that attempts to
dislocate an unstable hip.
- Flexion ,adduction, posteriorly.
- “Clunk”

17. The Barlow test for developmental dislocation of the hip in a neonate.A, With the infant
supine, the examiner holds both of the child's knees and gently adducts one hip and
pushes posteriorly.B, When the examination is positive, the examiner will feel the
femoral head make a small jump (arrow) out of the acetabulum (Barlow's sign). When
the pressure is released, the head is felt to slip back into place.

18. • 2) Ortolani test
It is a maneuver to reduce a recently
dislocated hip.
• Flexion, abduction, anteriorly.
• We can`t use X-rays because the
acetabulum and proximal femur are
cartilaginous and wont be shown on X-ray.
• US is the best method to Dx.

19. The Ortolani test for developmental dislocation of the hip in a
neonate.A, The examiner holds the infant's knees and
gently abducts the hip while lifting up on the greater trochanter with
two fingers.B, When the test is positive, the dislocated femoral head
will fall back into the acetabulum (arrow) with a palpable (but not
audible) “clunk” as the hip is abducted (Ortolani's sign). When the hip is
adducted, the examiner will feel the head redislocate posteriorly.

20. Clinical Manifestations
• In infants:
• As the baby enters the 2nd and 3rd
months of life, the soft tissues begin to
tighten and the Ortolani and Barlow tests
are no longer reliable.
• Shortening of the thigh, the Galeazzi
sign , is best appreciated by placing both
hips in 90 degrees of flexion and
comparing the height of the knees,
looking for asymmetry

21. • The most diagnostic sign is Ortolani’s
limitation of abduction.
• Abduction less than 60 degrees is almost
diagnostic.
• X-rays after the age of 3 months can be
helpful esp. after the appearance of the
ossific nucleus of the femoral head
• US is 100% diagnostic.

22. Infant Presentation
Skin fold asymmetry
Limited hip abduction
Unequal femoral lengths (Galeazzi’s sign)
(Flex both hips and one side shows apparent
femoral shortening)

23. INFANT..!!
Limited Abduction
(most reliable)
Galeazzi's sign

24. Skin fold asymmetry

25. Asymmetrical thigh folds

27. After Walking Age
Trendelenberg gait
Leg length discrepancy
Increased lumbar lordosis in Bilateral
dislocation
–Klisic test positive

28. The examiner places the middle finger over the greater trochanter, and the
index finger on the anterior superior iliac spine.A, With a normal hip, an
imaginary line drawn between the two fingers points to the umbilicus.B, When
the hip is dislocated, the trochanter is elevated and the line projects halfway
between the umbilicus and the pubis.

29. WALKING CHILD…!!!
Trendelenburg gait Hyperlordosis

30. Physical examination…!
NEONATE INFANT WALKING CHILD
Dislocatable
Reducible
Klisic sign
Dislocatable(occasionally)
Reducible(ocassionally)
Klisic sign
Decreased Abduction
Galleazi sign
Remains dislocated
Klisic sign
Decreased Abduction
Galleazi sign
Limp(Painless)
Shortening
Hyperlordosis

31. Which hip dysplasia
pain?
•Complete dislocation with
no false acetabulum:
NO
•Complete dislocation with
false acetabulum:
YES
•Subluxation:
YES

32. • All neonates should have a clinical
examination for hip instability
• Risk factors :
– breech presentation
– family history
– torticollis
– oligohydramnios
– metatarsus adductus
USG SCREENING
SCREENING..!!

33. Imaging
• X-rays
– Femoral head ossification center
• 4 -7 months
• Ultrasound
• CT
• MRI
• Arthrograms
– Open vs closed reduction

34. Radiograph
• It is not reliable in early stages of DDH but new born
screening may reveal severe acetabular dysplasia or
teratological dislocation.
• as child grows soft tissue become contracted and
radiographs become more helpful in diagnosis.
• Most common used lines of reference are vertical
line of Perkins and horizontal line of Hilgenreiner,
both used to assess the position of femoral head.

35. Von Rosen view
• In this view both hips are Abducted,
Internally Rotated and Extended.
• Line is drawn along femoral shaft, which
intersect acetabulum.
• In dislocated hip, it crosses above the
acetabulum.

36. Von rosen view
AP X-ray: hip in 45°abduction and IR describes the longitudinal
relationship between long axis of femur and acetabulum

37. X-ray
 Horizontal line of Hilgenreiner:
drawn between upper ends of tri-radiate
cartilage of the acetabulum.
 Vertical line of perkins:
drawn from the lateral edge of the acetabulum
vertical to horizontal line.
 4 quadrants:
Normal hip: the ossification center of the femoral
hip lower medial quadrant.
Dislocated hip: upper lateral quadrant.

38. Perkin line is through lateral margin
of acetabulum
• While hilgenreiner line is through triradiate
cartilage.
• Shenton line is curved line that begins at
lesser trochanter, goes upto femoral neck, and
connect with line along inner margin of pubis.
• In normal hip, medial beak of femoral
metaphysis lies in lower inner quadrant
produced by junction of Perkin and hilgenreiner
lines.

39. RADIOGRAPHY…!!
Dimensions H and D are measured to quantify proximal
and lateral displacement of the hip and are most useful
when the head is not ossified.
Acetabular index and the medial gap

40. X-ray
Acetabular index:
angle between horizontal line of
hilgenreiner and the line between the two
edges of the acetabulum.
normal hip 20º30
dilocated or dysplastic hip ≥ 30º
Shenton’s line:
semicircle between femoral neck and
upper arm of obturator foramen, in
dislocated hip this line is broken.

41. Imaging
• Acetabular Index

42. The acetabular index is the angle between a line drawn along the margin of the
acetabulum and Hilgenreiner's line; it averages 27.5 degrees in normal newborns
and decreases with age.
• Acetabular Index

43. Imaging
• Acetabular Index < 30 wnl

44. Centre –Edge angle
• It is useful to measure hip position.
• It is formed at the junction of Perkin line
with line that connects lateral margin of
acetabulum to the center of femoral head.
• In children 6-13 yr. old, >19 degree is
considered normal.
• In children >=14 yr. old, >25 degree is
considered normal.

45. Centre – Edge Angle of Wilberg…!!
6 – 13 years >19 degrees
>14 years > 25 degrees

46. Acetabular tear drop
• It is seen in AP radiograph of pelvis.
• Formed by several lines ,
• Derived from – wall of acetabulum laterally,
• Wall of lesser pelvis medially,
• Curved line inferiorly and
• Acetabular notch.
• In normal hip it appears between 6-24 months
of age.

47. TEAR DROP

48. Tear drop
AP X-ray
Lateral:wall of
acetabulum
Medial:lesser pelvis
Inferior :acetabular
notch
Appears between 6-23
mo
[delayed in DDH]

49. It significans is in the pronosis.
• Hips in which teardrop appears within 6
months of reduction have better outcome
than in which it appears late.
• 4 types have been noted:-
• Open , closed , crossed and reversed.
• Also be describe as U- or V- shaped.
• V- shaped associated with poor outcome.

50. DIAGNOSIS
• 1. ULTRA SOUND
• In the Graf technique, the transducer is placed
over the greater trochanter, which allows
visualization of the ilium, the bony acetabulum,
the labrum, and the femoral epiphysis
• The angle formed by the line of the ilium and a
line tangential to the boney roof of the
acetabulum is termed the α angle and represents
the depth of the acetabulum.
• Values > 60 degrees are considered normal, and
those < 60 degrees imply acetabular dysplasia.

51. • The β angle is formed by a line drawn tangential
to the labrum and the line of the ilium; this
represents the cartilaginous roof of the
acetabulum.
• A normal β angle is < 55 degrees, as the femoral
head subluxates, the β angle increases.

52. ULTRASONOGRAPHY..!!!
Lateral decubitus position
alpha & beta angles

54. Ultrasound
http://emedicine.medscape.com/article/408225
Measures acetabular depth.
Normal >60 degrees
Acetabular cartilaginous roof
coverage.
Normal <55 degrees
Smaller angle= better bony
coverage

55. • In DDH , alpha angle decreases and beta
angle increases, depending upon femoral
head subluxation.
• Depending upon alpha angle measurment
he proposed a classification system

56. GRAF CLASSIFICATION..!!
β decreased:better cartilagenous acetabulum
decreased:shallow acetabulum

57. MRI
• It gives excellent anatomical visualization of
infant hip.
• Kashiwagi and associates proposed
classification of hips with DDH.
• Group 1 hips had sharp acetabular rim, all
were reducible with Pavlik hareness.
• Group 2 hips had a rounded acetabular rim and
almost all are reducible with Pavlik hareness.

58. Group 3 hips have inverted
acetabular rim, and none was
reducible with hareness.
• MRI findings includes :-
• Widening of iliac bone,
• Lateral drift of superior and posterior
portions of acetabular floor,
• Overgrowth of acetabular cartilage,
• Convexity of posterior portion of cartilage.

59. Treatment
• Is divided in 5 age – related groups
• 1) newborn ( birth to 6 months old )
• 2) infant ( 6 to 18 months old )
• 3) toddler ( 18 to 36 months old )
• 4) child ( 3 to 8 yrs. Old )
• 5) adolescent and young adult ( > 8 yrs.
Old )

60. Treatment Options
• Age of patient at presentation
• Family factors
• Reducibility of hip
• Stability after reduction
• Amount of acetabular dysplasia

61. Management of DDH – Guidelines
0 to 6 months
Pavliks Harness
6 to 18 months 18 to 36 months 3 to 8 years
Traction
Closed reduction
Hip spica
Open reduction
Pri. open
reduction
Pelvic osteotomy
Pri, open
reduction with
Femoral
shortening
6 weeks no
reduction
Arthrography
No reduction >1/3rd head
visible

62. 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
*posterior straps for preventing add. NOT producing abd.

63. • Pavlik harness :- is used in first 6 months ,
shows excellent result in t/t of DDH.
• It is dynamic flexion-abduction orthosis.
• c/I in children who are crawling or fixed soft
tissue contracture, or teratological dislocation
present.
• After application, radiograph is taken and
confirm the reduction. Hip is placed in flexion
of 110 and abduction to occur by gravity itself .

64. 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

65. APPLYING PAVLIK HARNESS..!!
A:The chest halter is applied. The shoulder straps on the halter should cross in the back.
B:The leg stirrup straps are applied
C:The attachment for the anterior (flexor) stirrup straps should be located at the anterior
axillary line
D:posterior (abduction) stirrup straps should be attached over the scapula. The
position should be set to hold the hip in 90° of flexion with the posterior straps limiting
adductionto prevent dislocation.
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
JBJS:VOLUME 85-A OCTOBER 2003

66. How long pavlik harness should be
continued
• After closed reduction and application of
pavlik hareness. Patient is follow up in every
1-2 weeks.
• At this time, hip stability is checked.
• Pavlik hareness is discontinued 6 weeks
after clinically hip stability is obtained.
• To weaning of up to 2 hrs. per week until
brace is worn at night time.

67. Persistent dislocation of hip
• May be present after application of pavlik
hareness , 4 basic pattern is observed
• Superior, inferior , lateral and posterior.
• If present following manuvre should be done
• Superior – additional flexion is required,
• Inferior – flexion should be decreased,
• Lateral – closed observation to see for direction
of femoral neck towards triradiate cartilage.

68. Head may be gradually reduce and
dock into the acetabulum.
Persistent posterior dislocation is difficult to
treat. As tight hip adductor muscle are
present.
If any of this persistent dislocation present for
more than 3 to 6 weeks, pavlik hareness
should be discontinued.
t/t includes closed or open reduction and
casting.

69. 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 Ortolani’s sign
• > 7weeks of age

70. 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

71. Other splint
• Ilfeld and von rosen splint have high rate of
success with fewer complication but not
superior to pavlik hareness.
• Frejka pillow and triple diaper are not used
because of high rate of AVN.

74. Treatment:1 month – 6 months
4 weeks
Pavlik harness:1st choice
Continued till achieving stability
no reduction
discontinued
Reduced
Continue for 6 more weeks
Appearance of the notch predicts
better development of acetabulum

75. Treatment:6 months-2 years
AIM: obtain & maintain concentric
reduction without damaging femoral
head
Closed/open reduction
Pre op traction ????
Femoral shortening &Innominate
osteotomy may be needed

76. Traction…!!
Pre-reduction traction was considered essential to
reduce the incidence of AVN and to enable the
surgeon to obtain a closed reduction
Salter et al 1969
Gage & winter 1972
Morel et al 1975
Langenskiold & Paavilainen 2000
“The need for traction has been challenged by a
number of studies showing that hips can be safely
reduced without preliminary traction”
Weinstein & Ponsetti 1979
Kahle et al 1990
Quinn et al 1994
Current reccomendation: No traction

77. Closed Reduction…!!
Stable: if leg could be adducted 30° from max
abduction & extend to below 90°
Unstable: if wide abduction or more than 10 or 15
degrees of internal rotation is required to maintain
reduction
Never keep the limb in
wide Abduction or >15°IR AVN

78. Closed reduction..!!
An infant in a cast in the human position
• Force should be avoided
• Check for safe zone

79. Ramsey “zone of safety”…!!
Wide zone of safety
Moderate zone of safety
Narrow zone of safety
Ramsey PL, Lasser S, MacEwen GD: Congenital dislocation of the hip: Use of the Pavlik harness
in the child during the first six months of life. J Bone Joint Surg Am 1976; 58:1000

80. ARTHOGRAPHY…!!
• An arthrogram obtained at the time of reduction is very
helpful for evaluating the depth and stability of the
reduction
• Width of the medial dye pool to asses lateralisation
Good < 5mm
Fair 5-6 mm
Poor > 6mm

81. Post reduction ..!!
Cast in human position
6 weeks
Examination under GA
Stability assessment
Stable ,reduced Doubtful reduction
,unstable
Arthogram
Cast in human position6 weeks
3rd cast for
6 weeks &
discontinue
Abduction splinting
for 6 weeks
OR
Open Reduction

82. Open Reduction…!!
• Unable to achieve closed
reduction
• Widening of the joint
space
• Unstable reductions
• Loss of reduction on
follow up
• Advanced age

83. Open reduction can be performed by
• Anterior
• Anteromedial
• Medial approach
• Anterior approach :- pathology in the
anterior and lateral aspect of hip can be
easily reached and pelvic osteotomy can be
easily performed.

84. Approach…!
Medial
• Minimal dissection
• Obstructions
encountered directly
BUT..
• Limited view
• Pelvic osteotomy not
possible
• No capsulorrhaphy
Anterior
• Better exposure
• Capsulorrhaphy
• Pelvic osteotomy
possible
BUT..
• Blood loss
• iliac crest apophysis and
abductors damage
• Stiffness of hip

85. Medial approach ;- interval between
iliopsoas and pectineus
• Medial circumflex vessel at higher risk.

88. Medial approach..

89. Anterior approach…!!
• Smith-Peterson anterior approach
• Stood the test of time
• More commonly used
• Bikini incision better cosmetic results

92. T-capsulotomy..!!

93. Ligamentum teres
use of ligamentum teres to find true acetabulum

94. Radial incisions in
acetabular labrum
Removal of fibro-fatty tissue

95. Capsulorraphy..!!
Vest over pants capsulorraphy

96. Test of stability as an aid to
decide need for osteotomy…!!
H. G. Zadeh, Catterall,Hashemi-Nejad,Perry:J Bone Joint Surg [Br] 2000;82-B:17-27

97. Test of stability …!! Contd…

98. 2 Years of Age and Older
• For child 2 -3 years of age, during open reduction
acetabular coverage if insufficient warrants
reorientation osteotomy
• If coxa valga with excessive anteversion, VDRO
may be done.
• Children > 3 years usually need an acetabular
procedure
Femoral shortening is essential part of it’s
management. In past , child is put on skeletal
traction but result of shortening are better and
morbidity is less.

99. Open Reduction with Femoral
Shortening..!
• Pressure leads to risk of AVN
• Better results than preoperative traction in older
children with less morbidity
When to do??
• Anticipated increased pressure on reduced femur head
• Recommended in child > 2yrs.
• distract the joint few millimeter per operatively
• Judge the tightness of soft tissues after reduction
• irreducible dislocation

100. How much shortening?
• Pre op: bottom of the femoral head to the floor of the
acetabulum (a to b)
• amount of overlap is noted after osteotomy
• Tension of the soft tissue
• Derotation usually combined
leaving 15 to 20 degrees of
anteversion

101. Open Reduction with Femoral
Shortening..!
Subtrochanteric cut
Overlap method to determine the
amount to shorten the femur.
Internal fixation with an
appropriate blade-plate

102. Primary femoral shortening

103. Pelvic Procedures
• Redirectional
– Salter
– Sutherland double innominate osteotomy
– Steel ( Triple osteotomy)
– Ganz ( rotational)
• Acetabuloplasties ( decrease volume )
– Pemberton
– Dega
• Salvage
– depend on fibrous metaplasia of capsule
– Shelf and Chiari

104. Salter Single Innominate
•Age –18 months –6 years
•Requires concentrically reduced hip
–Open reduction at same time is possible
–Iliopsoas and adductor tenotomies often
required
•Covers antero-later alacetabular deficiency
–Up to 15 degree of acetabular index corrected

105. Salter Osteotomy..!!
Osteotomy: transverse & perpendicular to ilaic axis from just
above AIIS to sciatic notch
Symphysis pubis :a flexible hinge for acetabular redirection to
cover anterolateral insuffiency in a concentrically reduced
hip
Appropriate for children of 2-8 years
Before 2 yrs >8 yrs
Iliac wings too small symphysis pubis
to support graft less mobile

106. Salter
•Anterior approach to acetabulum
–Exposing inner and outer ilium
–Expose hip capsule if reduction needed
–Transverse osteotomy is done just above acetabulum
• Sciatic notch to Ant.Inf.iliac Spine
–Rotate on pubic symphysis in antero-lateral direction
–Hold correction with bone graft wedge & K-wires

114. SALTER OSTEOTOMY..!!

115. Peri-acetabular Ostetomies
• Provide greater correction of acetabular index
• Reduce volume of hip joint
• Possibility of growth disturbances
Types
– Pemberton’s
– Dial (Eppright)
– Wagner
– Dega’s
– Ganz osteotomy (Bernese)

116. Pemberton Acetabuloplasty
•Age –18 months –10 years
•Requires reduced hip
•Decreases acetabular volume
–Remodeling of acetabulum required
•Corrects >15 degree of Acetabular index
•Reduces antero-lateral acetabular defects
–Cuts altered to cover more anteriorly or laterally

117. Pemberton
•Anterior Approach -Exposure as for Salter
–Cut inner and outer table with small osteotome
– osteotomy 1cm above AIIS, staying 1 cm above
capsule
–Do not cut through to sciatic notch
–Lever through the cut until coverage is acceptable
•(Levers on tri-radiate cartilage)
–Hold correction with bone graft wedge

118. PEMBERTON..!!

119. Dega Acetabuloplasty
•Similar to Pemberton
•Larger posterior hinge
–Hinges on horizontal tri-radiate limb
•Less inner table osteotomized for more lateral
coverage
(More inner table –more anterior coverage)

120. Dega osteotomy (transiliac)
 This is incomplete transiliac osteotomy ,
involves osteotomy of anterior and middle
portion of inner cortex of ilium , leaving a
intact hinge posteriorly consisting of intact
posteromedial iliac cortex and sciatic notch.
 At this osteotomy site , bone graft is placed.

121. Dega’s Osteotomy
1. Incomplete
2. Variable hinge
3. Allows anterior,
lateral & posterior
coverage

125. Dega osteotomy..!
Intact postero-medial cortical
hinge
If more anterior coverage desired ,inner cortex cut more
If more lateral coverage desired, inner cortex cut less

126. Dega osteotomy..!
JAN S. GRUDZIAK & W. TIMOTHY WARD :THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG VOLUME 83-A · NUMBER 6 · JUNE 2001
A larger graft is inserted anteriorly. The posterior graft should be
smaller in order not to loosen the anterior graft.

127. GANZ osteotomy..!
Larger corrections all directions(correction not
limited by sacro-pelvic ligaments)
Blood supply preserved
Shape of true pelvis unaltered
Technically demanding

128. Steel Triple Innominate
Osteotomy
•Age –Skeletally mature
•Requires congruent hip joint
•Divides ilium, ischium and superior ramus
–Acetabulum is rotationally free
–Indicated when other osteotomies not
possible
•Rotates to cover any acetabular defect

129. Steel
•Multiple incision technique
–Posteriorly between gluteus and hamstrings
•Allows osteotomy of ischium
–Anteriorly freeing medial attachments
•Allows Salter and superior ramus osteotomy
–Rotate acetabulum as desired
•Avoid externally rotating
–Bone graft wedge is fixed as per Salter type

130. Steel triple innominate osteotomy
• Ischium, superior pubic ramus and ilium
superior to acetabulum all are divided and
acetabulum is repositioned and stabilized by
bone graft and pins.

132. Salvage or Shelf procedures
• Chiari and Staheli osteotomies
– Requires capsular metaplasia
– Pain is the main indication
– Used in Treatment of chronic hip pain in
adolescents

133. Staheli Shelf Procedure
•Age –older child to skeletal maturity
•Salvage operation
•Indicated for non-concentric hips
•Augments supero-lateral deficency
–Slotted bone graft placed over capsule
deepening the acetablum

134. Staheli
•Anterior approach is used with outer wall exposure only
–Identify superior acetabular edge
–Create slot 1cm deep along edge in cephlad angle
–Remove 1 cm cortical strips from outer table
•Insert into slot, cutting at desired lateral overhang
•2nd layer inserted lengthwise
•Use remaining to fill in above slot edge
–Hold in place with reflected fascia and adductors

136. Staheli shelf

137. Chiari Medial Displacement
•Age –skeletally mature
•Salvage operation only
–Used when no other osteotomy possible
–Possible with subluxed hip
•Covers well laterally
–Anterior and posterior augmentation may be
necessary
•May be useful in other conditions
–Coxamagna, OA in dysplasichips

138. •Anterior approach –as per Salter
–Identify superior extent of capsule
–Cut from AIIS to notch following capsule
curve
•Angle osteotome10-20ocephlad
–Displace distal fragment medially 50-100%
•Ensure complete head coverage
•Leg abduction, hinges on pubic symphysis

140. Chiari Osteotomy

141. Chiari Osteotomy

142. Chiari Osteotomy

143. Chiari Osteotomy

144. Chiari osteotomy

147. Complications of Treatment
• Worst complication is disturbance of
growth in proximal femur including the
epiphysis and physeal plate
• commonly referred to as AVN however, no
pathology to confirm this
• may be due to vascular insults to epiphysis
or physeal plate or pressure injury
• occurrs only in patients that have been
treated and may be seen in opposite
normal hip

148. Necrosis of Femoral Head
• Extremes of position in abduction ( greater 60
degrees ) and abduction with internal
rotation
• compression on medial circumflex artery as
passes the iliopsoas tendon and compression of
the terminal branch between lateral neck and
acetabulum
• “ frog leg position “ uniformly results in
proximal growth disturbance

149. Avascular Necrosis

150. • extreme position can also cause pressure
necrosis onf epiphyseal cartilage and
physeal plate
• severin method can obtain reduction but
very high incidence of necrosis
• multiple classification systems with Salter
most popular

151. DDH: THR
does not solve all ills!
Right:
painless
Left:
severe pain

152. THANK YOU