Developmental dysplasia of hip

DEVELOPMENTAL DYSPLASIA
OF THE HIP
Dr.PONNILAVAN
ORTHO RESIDENT
PONDICHERRY

• Congenital dysplasia of hip includes
- subluxation (partial dislocation) of femoral head,
- acetabular dysplasia, &
- complete dislocation of femoral head from true acetabulum.
- In a newborn with true congenital dislocation of hip, femoral head can
be dislocated & reduced into & out of true acetabulum.
- In an older child, femoral head remains dislocated & secondary
changes develop in femoral head & acetabulum

• Historically, CDH Incidence - 1 in 1000 live births.
• Meta-analysis of literature
- incidence of DDH revealed by
 physical ex. done by pediatricians - 8.6 per 1000
 orthopaedic screening, 11.5 per 1000; and
 ultrasound examination, 25 per 1000.
- Left hip > right hip , and
- bilateral involvement is more common than involvement of right hip alone.

• More common in girls> boys
• Asso. With breech deliveries
• MacEwen and Ramsey in a study of 25,000 infants found the
combination of female infants & breech presentation to result in
congenital dysplasia of the hip in one out of 35 such births.
• Congenital dysplasia of the hip is more common in firstborn children
than in subsequent siblings.
• ETNICS - white children > black children.

Strong association also exists
with musculoskeletal
abnormalities, such as
congenital
torticollis
metatarsus
adductus, and
talipes
calcaneovalgus.

This theory has credibility because relaxin has been shown to cross placenta, and DDH is
more common in females who are presumably more susceptible to the influences of
relaxin.
The theory is that influence of the maternal hormone, relaxin, that produces relaxation of
the pelvis during delivery may cause enough ligamentous laxity in the child in utero &
during the neonatal period to allow dislocation of the femoral head.
Several authors have proposed ligamentous laxity as a contributing factor.

DIAGNOSIS AND CLINICAL PRESENTATION
Clinical presentation varies according to child’s age.
<6 mts old - perform a careful clinical examination because radiographs
are not always reliable in making the diagnosis.
Only one hip should be examined at a time. Examiner places his hand
around infants knees so that the thumb lies on the inner thigh and the
index and long fingers lie at the level of the greater trochanter.

Ortolani maneuver for routine screening of congenital dislocation of hip.
Examiner gently stabilizes infant’s left hip and lower extremity and places
left hand around right thigh and index and middle fingers over greater
trochanter.
The Ortolani test is
performed by gently
abducting the flexed hip
while applying an
anteromedially directed force
to the greater trochanter to
detect any reduction of the
femoral head into the true
acetabulum.

The provocative maneuver of Barlow detects any potential
subluxation or posterior dislocation of the femoral head by direct
pressure on the longitudinal axis of the femur while the hip is in
adduction.
A palpable, rather than an audible, clunk is felt as the femoral head
reduces into or subluxes out of the acetabulum.

A child may be born with
acetabular dysplasia without
dislocation of the hip, & the latter
may develop weeks or months
later.
Westin et al. reported the late
development of dislocation of the
hip in children with normal
neonatal clinical & radiographic
examinations; they termed this
developmental dysplasia as
opposed to congenital dysplasia of
the hip as it currently is known.

As the child reaches age 6 to 18 months, several factors in the clinical
presentation change. When femoral head is dislocated, & the ability to reduce
it by abduction has disappeared, several other clinical signs become obvious.
Limitation of abduction & asymmetrical skin folds are the two most common
findings.
Bilateral dislocations may appear symmetrically abnormal.

The first & most reliable
is a decrease in the
ability to abduct the
dislocated hip because
of a contracture of the
adductor musculature .

Galeazzi sign is noted when the
femoral head becomes displaced
not only laterally but also
proximally, causing an apparent
shortening of the femur on the
side of the dislocated hip.
Positive Galeazzi sign with
apparent shortening of right
lower extremity.

IMAGING
USG findings <
6 weeks of age
can be
questionable
because of
ligamentous
laxity in early
newborn
period.
Rx < 6 weeks
of age should
be based on
physical ex.
rather than
USG findings
alone.
USG diagnosis
of “acetabular
dysplasia” with
a stable hip
examination in
the early
postnatal
period may
result in
unnecessary
Rx.
USG often
helpful in
measuring &
documenting
response of
hip to Pavlik
harness Rx.

Although radiographs are not always reliable in making the
diagnosis of CDH in newborns.
Screening radiographs may reveal any severe acetabular
dysplasia or findings of a teratological dislocation.
As a child with a dislocated hip ages and the soft tissues
become contracted, radiographs become more reliable &
helpful in diagnosis & treatment.

TREATMENT
• Five age-related treatment groups have been designated:
• newborn (birth to 6 months old),
• infant (6 to 18 months old),
• toddler (18 to 36 months old),
• child (3 to 8 years old), and
• adolescent and young adult (>8 years old).

NEWBORN (BIRTH TO 6 MONTHS)
Rx is directed at stabilizing the hip
that has a positive Ortolani or
Barlow test
or reducing the dislocated hip
with a mild-to-moderate
adduction contracture.
Success rate of 85% to 95% -in
children treated in the Pavlik
harness
As the child ages & soft tissue
contractures develop, along
with secondary changes in the
acetabulum, the success rate of
the Pavlik harness decreases.

When properly applied and maintained, the
Pavlik harness is a dynamic flexion-abduction
orthosis that can produce excellent results in
the Rx of dysplastic & dislocated hips iinfants
during the first few months
The harness is difficult to use in children who
are crawling or who have fixed soft tissue
contractures and a fixed hip dislocation.
If a teratological dislocation is present, the Pavlik harness
should not be used

• Four basic patterns of persistent dislocation have been observed after
application of the Pavlik harness: superior, inferior, lateral, and
posterior.
• If the dislocation is superior, additional flexion of the hip is indicated.
• If the dislocation is inferior, a decrease in flexion is indicated.
• A lateral dislocation in the Pavlik harness should be observed initially

• If any of these patterns of dislocation or subluxation persist for more
than 3 to 6 weeks, treatment in the Pavlik harness should be
discontinued and a new program initiated; in most patients, this
consists of closed or open reduction and casting.
The Pavlik harness should be worn full-time until stability is attained, as
determined by negative Barlow and Ortolani tests.
During this time, the patient is examined at 1- to 2-week intervals and
the harness straps are adjusted to accommodate growth.

• Quadriceps function should be noted at each examination to detect a
femoral nerve palsy, and families should be instructed to remove the
legs from the brace daily to ensure that the infant is able to actively
extend the knee against gravity.
• If a femoral nerve palsy develops, the brace should be discontinued
until full motor function returns.
• The duration of treatment depends on the patient’s age at diagnosis
and the degree of hip instability. There are very few guidelines for
brace discontinuation.

• Recommendations vary from abrupt discontinuation of the Pavlik
harness 6 weeks after clinical stability has been obtained, to weaning
of up to 2 hours per week until the brace is worn only at night, to
transitioning to a night-time abduction orthosis for additional weeks
or months.
• Radiographic or ultrasound documentation can be used throughout
the treatment period to verify the position of the hip.

• USG evaluation is useful at the following times:
 immediately after the initiation of treatment,
after any major adjustment in the harness,
when the hip examination is stable after beginning Pavlik harness
treatment, and
6 weeks after the hip stabilizes clinically or at the time weaning
begins.
• Radiographs are useful at 6 months old, and at 1 year old

• Suggested risk factors for Pavlik harness failure include
• absent Ortolani sign at initial evaluation (irreducible dislocation)
• bilateral hip dislocations,
• the development of a femoral nerve palsy during Pavlik treatment
• In multiple series of dislocated hips reduced with the use of the Pavlik
harness, the more severe the dislocation, the higher the rates of failed
reduction and osteonecrosis, emphasizing the need for gentle
reduction and progression to further treatment when the harness fails.

INFANT (6 TO 18 MONTHS)
• When a child reaches crawling age (4 to 6 months old), success with
the Pavlik harness decreases significantly
• 18-month-old infant with a dislocated hip is likely to require either
closed or open reduction.
• Children in this age group often are seen initially with a shortened
extremity, limited passive abduction, and a positive Galeazzi sign. If
the child is walking, a Trendelenburg gait may be present.

• Radiographic changes include
-delayed ossification of the femoral head
- lateral and proximal displacement of the femoral head
- -shallow, dysplastic acetabulum.
- Treatment in this age group may include preoperative traction,
adductor tenotomy, and closed reduction and arthrogram or open
reduction in children with a failed closed reduction.

• Femoral shortening may be needed in a hip with a high proximal
dislocation.
• Preoperative traction, adductor tenotomy, and gentle reduction with
an acceptable “safe zone” are especially helpful in the prevention of
osteonecrosis of the femoral head .
• PREOPERATIVE TRACTION
• The role of preliminary traction in reducing the incidence of
osteonecrosis and in improving reduction is controversial.
• Disagreement exists about whether skin or skeletal traction should be
used, whether home or in-hospital traction is preferable, the amount
of weight that should be used, the most beneficial direction of pull,
and the duration of traction

• The objectives of traction or primary femoral shortening are to bring
the laterally and proximally displaced femoral head down to and
below the level of the true acetabulum to allow a more gentle
reduction.
• ADDUCTOR TENOTOMY
- A percutaneous adductor tenotomy under sterile conditions can be
performed for a mild adduction contracture. For a more severe
adduction contracture or one of long duration, an open adductor
tenotomy through a small transverse incision is preferable.

ARTHROGRAPHY AND CLOSED REDUCTION
• Arthrography is helpful in determining
• (1) whether mild dysplasia is present,
• (2) whether the femoral head is subluxated or dislocated,
• (3) whether manipulative reduction has been or can be successful,
• (4) to what extent any soft structures within the acetabulum may
interfere with complete reduction of the dislocation

• (5) the condition and position of the acetabular labrum (the limbus),
and
• (6) whether the acetabulum and femoral head are developing
normally during treatment.
• Because arthrograms are not always easy to interpret, the surgeon
must be thoroughly familiar with the normal and abnormal signs they
may reveal and with the technique of making arthrograms

• APPLICATION OF A HIP SPICA CAST-
-After confirmation of a stable reduction, a hip spica cast is applied
with the hip joint in 95 degrees of flexion and 40 to 45 degrees of
abduction.
Salter advocated this “human position” as best for maintaining hip
stability and minimizing the risk of osteonecrosis.

Place the anesthetized child on
the spica frame.
 Abduct the hip to 40 to 45
degrees, and flex it to about 95
degrees .
 The amount of hip flexion and
abduction required to keep the
hip in the most stable position
should be determined clinically
and checked by radiographs.
APPLICATION OF A HIP SPICA CAST-

After the correct position
of flexion and abduction
for stability is determined,
place a small towel in
front of the abdomen.
Cover the pelvis and
extremities with
stockinette.
Roll 2-inch (5-cm) Webril
from the level of the
nipples down to the
ankles

 Apply a third piece of felt over
the knee and. Place similar
pieces of felt over the opposite
knee and leg.
1
2
3
 Apply the first
pad over the
proximal end of
the spica, near
the nipple line
 Start a second piece of the same
size felt at the level of the right
groin, and carry it posteriorly
across the gluteal fold, over the
right iliac crest, in front of the
abdomen, over the lateral aspect
of the left thigh, and to the left
inguinal area
a fourth piece
above the
ankle over the
distal leg
4

 Apply a single layer of 4-inch (10-cm) plaster roll
from the nipple line to the level of the knees on
both sides.
 Apply four or five plaster splints back to front from
the nipple line to the back of the sacrum to
reinforce the back of the cast.
 At the same time, apply a short, thick splint over the
anterolateral aspect of the inguinal area
 Apply another splint. Starting from the right inguinal
area, carry it posteriorly across the gluteal region,
the iliac crest, the front of the abdomen, and back
the same way on the opposite thigh . This is a
reinforcing splint that attaches the thigh to the
upper segment.

Continue…
• ■ Apply another long splint from the level of the knee across the anterolateral
aspect of the inguinal area and up the chest wall . This splint is one of the main
anchors of the thigh to the body segment.
• ■ Follow this by a roll of 4-inch (10-cm) plaster from the nipple line to the knees.
This completes the proximal section of the spica.
• ■ Complete the cast from the knees down to the ankles. Do this by applying on
both sides a single roll of 3-inch (7.5-cm) plaster from the knee to the ankle level
and reinforcing this by two splints over the medial and lateral aspects of the
thigh, knee, and leg.

• Follow this by another roll of 3-
inch (7.5-cm) plaster. Shoulder
straps can be considered to
prevent pistoning of the child in
the cast but usually are
unnecessary with a snug cast .
• ■ Because the cast is reinforced
laterally around the hips, a
wide segment can be removed
from the front of the hips
without weakening the cast.
This permits better radiographs
of the hips

The final view of the spica cast
from inferiorly should appear ,
with about 40 to 45 degrees of
abduction.
The amount of abduction is
determined by the position of hip
stability. Excessive abduction
should be avoided.

• OPEN REDUCTION
• In children in whom efforts to reduce a dislocation without force have
failed, open reduction is indicated to correct the interposed soft
tissue structures and to reduce the femoral head concentrically in the
acetabulum.
• This surgical option is indicated by pathology rather than by age
because open reduction may be required in children younger than 6
months and closed reduction occasionally can be successful in
children 18 months old.

• Open reduction can be performed through an anterior, anteromedial,
or medial approach; the choice depends on the experience of the
surgeon and the particular dislocation.
• The anterior approach requires more anatomical dissection but
provides greater versatility because the pathological condition in the
anterior and lateral aspects is easily reached and pelvic osteotomy
can be performed through this approach if necessary.

• The anteromedial approach described by Weinstein and Ponseti
actually is an anterior approach to the hip through an anteromedial
incision.
• This approach is recommended for children 24 months old or
younger.
• Access to the lateral structures for dissection or osteotomy is
impossible with this approach.

• The medial (Ludloff) approach utilizes the interval between the
iliopsoas and the pectineus.
• This approach places the medial circumflex vessels at a higher risk
and has been reported to be associated with a higher incidence of
osteonecrosis (10% to 15%).
• Although the medial approach allows removal of the impediments to
reduction, it does not allow capsulorrhaphy and is, therefore,
generally recommended in infants 6 to 18 months old.

• CONCOMITANT OSTEOTOMY
• The use of a concomitant osteotomy of the ilium, acetabulum, or
femur at the time of open reduction remains controversial.
• Innominate osteotomy, acetabuloplasty, proximal femoral varus
derotation osteotomy, or femoral shortening osteotomy might
increase the stability of open reduction.
• However, in younger children (<12 months), acetabular remodeling
potential could render these procedures unnecessary.

• Zadeh et al. used concomitant osteotomy at the time of open
reduction to maintain stability of the reduction and reported
satisfactory results in 86% of 82 children (95 hips) in whom the
following test of stability after open reduction was used.
• 1. Hip stable in neutral position—no osteotomy
• 2. Hip stable in flexion and abduction—innominate osteotomy

• Concomitant osteotomy should be done at the time of open
reduction when necessary to maintain a safe, stable reduction.
• If open reduction is stable without an osteotomy, a bony procedure
for residual deformity should be considered at the time of the open
reduction in an older child (>18 months) and used with caution even
in younger infants when needed .

• TERATOLOGICAL DISLOCATIONS
• A teratological dislocation of the hip is one that occurs at some time
before birth, resulting in significant anatomical distortion and
resistance to treatment.
- It often occurs with other conditions, such as
- arthrogryposis,
- Larsen syndrome,
- myelomeningocele, and
- diastrophic dwarfism.

• OSTEONECROSIS
• The most serious complication associated with treatment of
congenital dysplasia of the hip in early infancy is the development of
osteonecrosis.
• Bucholz and Ogden and Kalamchi and MacEwen proposed
classification systems based on morphological changes in the capital
femoral epiphysis, the physis, and the proximal femoral metaphysis

• Estimated rates of osteonecrosis are 2.5 per 1000 infants referred for
treatment before 6 months of age and 109 per 1000 infants referred
after 6 months of age.
• Some authors have suggested that osteonecrosis is more frequent
when reduction is done before the appearance of the ossific nucleus
of the femoral head, whereas others have stated that waiting until
the ossific nucleus appears does not seem to affect the development
of osteonecrosis.

• Potential sequelae of osteonecrosis include
-femoral head deformity,
- acetabular dysplasia,
- lateral subluxation of the femoral head,
- relative overgrowth of the greater trochanter,
- limb-length inequalities;
- osteoarthritis is a common late complication.

• Children with osteonecrosis after treatment of congenital dislocation
of the hip should be followed to maturity with serial
orthoradiographs.
• Significantly better results have been reported in patients treated
early (1 to 3 years after the ischemic insult) with innominate
osteotomy than in patients treated later (5 to 10 years after the
ischemic insult) and patients without pelvic osteotomy.
• Patients treated early also had less pain and fewer gait disturbances
and required fewer additional procedures for limb-length inequality
or greater trochanteric overgrowth.

• Early innominate osteotomy has been suggested to induce spherical
remodeling of the femoral head, with a resultant congruous hip joint,
whereas with later osteotomy the femoral head was already
deformed, with little potential for remodeling.
• Significant limb-length inequality can be corrected by appropriate
techniques, usually a well-timed epiphysiodesis

• Symptomatic overgrowth of the greater trochanter can be treated in
older patients with greater trochanteric advancement, which
increases the abductor muscle resting length and increases the
abductor lever arm.

TODDLER (18 TO 36 MONTHS)
• Because of widespread screening of newborns, it is becoming less
common for DDH to go undetected beyond the age of 1 year.
• An older child with this condition has a wide perineum, shortened
lower extremity, and hyperlordosis of the lower spine as a result of
femoropelvic instability.
• For these children with well-established hip dysplasia, open
reduction with femoral or pelvic osteotomy, or both, often is
required.

TODDLER (18 TO 36 MONTHS)
• Persistent dysplasia can be corrected by a redirectional proximal
femoral osteotomy in very young children.
• If the primary dysplasia is acetabular, pelvic redirectional osteotomy
alone is more appropriate.
• Many older children require femoral and pelvic osteotomies,
however, if significant deformity is present on both sides of the joint

FEMORAL OSTEOTOMY IN DYSPLASIA OF THE HIP
• Surgeons who recommend femoral osteotomies advise an operation
on the pelvic side of the joint only after
• (1) the femoral head has been concentrically seated in the dysplastic
acetabulum by such an osteotomy,
• (2) the joint has failed to develop satisfactorily, and
• (3) the growth potential of the acetabulum no longer exists.

• Opinions differ widely as to the age at which the acetabulum loses its
ability to develop satisfactorily over a femoral head concentrically
located, although 8 years appears to be most frequently cited upper
age limit after which little benefit is derived from femoral osteotomy
alone
• Femoral osteotomy is most frequently indicated with primary femoral
shortening, but the technique is included here for completeness.

CHILD (3 TO 8 YEARS)
• The management of untreated congenital dislocation of the hip in a
child older than 3 years of age is difficult.
• By this age, adaptive shortening of the periarticular structures and
structural alterations in the femoral head and the acetabulum have
occurred.
• Dislocated hips in this age group require open reduction.
Preoperative skeletal traction should not be used because of the high
frequencies of osteonecrosis (54%) and redislocation (31%) reported
with its use alone.

• Femoral shortening aids in the reduction and decreases the potential
for complications but is technically demanding, as is treatment of the
dislocated hip, in this older age group.
• Primary femoral shortening, anterior open reduction, and
capsulorrhaphy, with or without pelvic osteotomy as indicated, have
been recommended in children 3 years old or older.

PELVIC OSTEOTOMY
• Operations on the pelvis, alone or combined with open reduction, are
useful in congenital dysplasia or dislocation of the hip to ensure or to
increase stability of the joint.
• The operations most often used are
• (1) osteotomy of the innominate bone (Salter),
• (2) acetabuloplasty (Pemberton),
• (3) osteotomies that free the acetabulum (Steel triple innominate
osteotomy or Ganz acetabular osteotomy),

• (4) shelf operation (Staheli), and
• (5) innominate osteotomy with medial displacement of the
acetabulum (Chiari).
• In an older child, one of these operations can be combined with
femoral osteotomy to correct femoral and acetabular abnormalitie
• Osteotomy of the innominate bone, an operation devised by Salter, is
useful only when any subluxation or dislocation has been reduced or
can be reduced by open reduction at the time of osteotomy in a child
18 months to 6 years old .

• Acetabuloplasty also is useful only when any subluxation or dislocation
has been reduced or can be reduced by open reduction at the time of
operation in children at least 18 months old.
• In acetabuloplasty, the inclination of the acetabular roof is decreased
by an osteotomy of the ilium made superior to the acetabulum .
• Pemberton described a pericapsular osteotomy of the ilium in which
the osteotomy is made through the full thickness of the bone from just
superior to the anterior inferior iliac spine anteriorly to the triradiate
cartilage posteriorly.

• The triradiate cartilage acts as a hinge on which the acetabular roof is
rotated anteriorly and laterally.
• This procedure decreases the volume of the acetabulum and
produces joint incongruity that requires remodeling.
• Osteotomies that free the acetabulum have been devised by Steel,
Eppright, and Ganz.
• These operations free part of the pelvis, creating a movable segment
of bone that includes the acetabulum.

• They are indicated in adolescents and skeletally mature adults with
residual dysplasia and subluxation in whom remodeling of the
acetabulum can no longer be anticipated.
• These operations are useful because they place articular cartilage
over the femoral head.
• The shelf operation and the operation of Chiari interpose capsular
fibrous tissue between the femoral head and the reconstructed
acetabulum.

• In the triple innominate osteotomy (Steel), the ischium, the superior
pubic ramus, and the ilium superior to the acetabulum all are divided
and the acetabulum is repositioned and stabilized by a bone graft and
metal pins.
• In the pericapsular dial osteotomy of the acetabulum (Eppright), the
entire acetabulum superiorly, posteriorly, inferiorly, and anteriorly is
freed by osteotomy and as a single segment of bone is redirected to
cover the femoral head appropriately.

• The Bernese periacetabular osteotomy (Ganz) creates a free
acetabular segment through a series of osteotomies in the ischium,
superior pubic ramus, and ilium while preserving the posterior
column of the pelvis.
• The shelf procedure (Staheli) is useful for subluxations and
dislocations that have been reduced and in which no other osteotomy
would establish a congruous joint with apposition of the articular
cartilage of the acetabulum to the femoral head.

• Innominate osteotomy with medial displacement of the acetabulum,
an operation devised by Chiari for patients older than 4 years old, is a
modified shelf operation that places the femoral head beneath a
surface of bone and joint capsule and corrects the pathological lateral
displacement of the femur.
• An osteotomy is made at the level of the acetabulum, and the femur
and the acetabulum are displaced medially. The inferior surface of the
proximal fragment forms a roof over the femoral head.

Recommended Osteotomies for Congenital or
Developmental Dislocation of the Hip
OSTEOTOMY AGE INDICATIONS
Salter innominate osteotomy 18 months-6 years Congruous hip reduction; <10-15
degrees correction of acetabular
index required
Pemberton acetabuloplasty 18 months-10 years >10-15 correction of acetabular
index required; small femoral head,
large acetabulum
Steel or Ganz osteotomy Late adolescence to skeletal
maturity
Residual acetabular dysplasia;
symptoms; congruous joint
Shelf procedure or Chiari
osteotomy
Adolescence to skeletal maturity Incongruous joint; symptoms; other
osteotomy not possible

ADOLESCENT AND YOUNG ADULT (>8 YEARS)
• In children older than 8 years old or in young adults in whom the
femoral head cannot be repositioned distally to the level of the
acetabulum, only palliative salvaging operations are possible.
• Rarely, a femoral shortening combined with a pelvic osteotomy could
be considered, but the chances of creating a hip to last a lifetime are
minimal.
• Reduction of a unilateral dislocation should be strongly considered,
even in children 6 years old.

• After some years, degenerative arthritic changes develop in the hip
joint.
• When these changes cause enough pain or limitation of motion to
require additional surgery, a reconstructive operation, such as a total
hip arthroplasty, may be indicated at the appropriate age
• Arthrodesis is now rarely indicated for old unreduced dislocations and
is contraindicated for bilateral dislocations.

Bilateral untreated congenital
dislocation of hip in 12-year-old girl.

• In bilateral dislocations in this age group, the hips should be left
unreduced , and total hip arthroplasties may be done during
adulthood.
• Degenerative joint disease is more likely to develop in early adulthood
in a dislocated hip with a false acetabulum in the wing of the ilium
than in a dislocated hip without formation of a false acetabulum.
• Patients with reduced femoral heads but painful acetabular dysplasia
can be treated with an appropriate pelvic osteotomy

• THANK U
• Source: Campbell's Operative Orthopaedics, 12thEdition

Developmental dysplasia of hip

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