Developmental dysplasia of the hip is a condition where the hip joint fails to form properly. It ranges from mild dysplasia to frank dislocation. The best outcomes are seen when treated before 6 months of age using a Pavlik harness. Between 6-18 months, closed or open reduction with spica casting is used. For older children, closed or open reduction with or without pelvic osteotomy is required. Complications include avascular necrosis, redislocation, and residual dysplasia if left untreated. Early diagnosis and treatment leads to the best long-term outcomes.

1. Developmental dysplasia of hip
Presenter: Dr souvik paul,
Dr Prince raina
Moderator: Prof. Dr. Shobha S Arora

2. Normal Development
• Embryonic
– 7th week - acetabulum and hip formed from same
mesenchymal cells
– 11th week - complete separation bet two
– Prox femur ossific nucleus - 4-7 months

3. Incidence
 Incidence per 1000 live births :0.06 in Africans
76.1 in Native Americans
0.47–9.2 # INDIANS
• Loder RT et al: higher centre edge angle in asians than white
race
• Clinical finding (2.3/100 births)
• Ultrasound abnormality (8/100 births)
# Singh M et al.Ind J Pediatr.2006;.
Gupta A.K.et al. Nat Med J India. 2002;

4. Etiology
• Multifactorial
– Genetics and Syndromes
• Ehler’s Danlos
• Arthrogryposis
• Larsen’s syndrome
– Intrauterine environmental factors
• Teratogens
• Positioning (oligohydramnios)
– Neurologic Disorders
• Spina Bifida

5. Pathoanatomy
• Ranges from mild dysplasia --> frank dislocation
• Bony changes
– Shallow acetabulum with superolateral slope to roof
– Degenerative changes lateral roof -subluxation
– Osteophytes and cysts along acetabular rim- labral tears
– Femoral anteversion & valgus neck shaft angle

6. Pathoanatomy
Intraarticular
– Inverted Labrum
– Hypertrophied & lengthened Lig. teres
– Pulvinar fat thickening
– Contracted transverse acetabular ligament
– Neolimbus
• Extraarticular
– Tight adductors, iliopsoas

7. Genetics in DDH
Susceptiblity genes subjects authors
GDFs (growth ⁄ differentiate
factor 5)
338 case and 620 control Dai et al.
TBX4 (T-box 4) 505 case subjects and 551 control Wang et al.
ASPN (Asporin) 370 case and 445 control Shi et al.
IL-6 & TGF-b1 28 case and 20 control Kolundzic et al.
PAPPA2( pregnancy-associated
plasma protein-A2)
310 case and 487 control Jia et al.
Li et al. : DDH locus in chromosome 17q21.31-17q22
Wei Tian et al. association study: positive association between HOXD9 gene
and DDH.

8. Diagnosis
• Family history, sibling history of DDH
• Birth history(breech delivery)
• History of birth asphyxia, fever, NICU admission history to
exclude other possibilities

9. Newborn screening
A. New born- routine examination:
– Warm, quiet environment with removal of diaper
– Ortolani’s and Barlow’s maneuvers with a thorough history and
physical
– Head to toe exam to detect any associated conditons (Torticollis,
Ligamentous Laxity etc.)
– Baseline Neuro and Spine Exam

10. Presenting symptoms at various ages
B. Infant-
1) Limited abduction
2) Galleazi sign
3) Proximal location of GT
4) Asymmetry of thigh folds
5) Pistoning of hip
6) Klisic test(B/L DDH)

11. • C. Toddler- Limp detected for the first time, unilat/bilat
• D. Older child- school going age
Limp
Incresed lumber lordosis
Peritrochanteric ( abductor fatigue) &Groin pain
Trendelenburg gait
Galeazzi's sign

12. Specific Clinical signs
• Telescopy: Gross telescopy, hyper mobile hip, moves in all
directions- Tomsmith hip
• Telescopy- moderately positive- ? DDH

13. Differential diagnosis
• Neonatal septic arthritis- infants and newborn
• Tb hip- walking children
• Untreated posterior dislocation hip
• Paralytic dislocation of hip- MMC, spastic CP
• Tomsmith hip

14. Choi classification of Tomsmiths’ hip

15. Neglected posterior dislocation hip
• Symp: pain, deformity, and limp
• O/E: Limb -flexion, adduction and internal rotation
Kumar S, Jain AK. Clin Orthop Relat Res.2005 Feb

16. Imaging
• X-rays
– Femoral head ossification center
• 4 -7 months
• Ultrasound
– Operator dependent, safe
• CT
• MRI
• Arthrograms

18. Radiological findings in older children
• Smaller or absent proximal femoral epiphysis
( equal size- ? Traumatic)
• Hypoplastic/ deformed proximal femur- Tomsmith choi type 1

19. Severin Classification

20. USG
• Sensitive and without radiation exposure
• Intersection of roofline and baseline forms the alpha angle.
• Intersection of the inclination line and baseline forms the beta
angle.

21. Graf classification
Class Alpha Angle Beta Angle Description Treatment
I > 60° < 55° Normal None
IIa 50°–60° 55°–77° Immature (<3
mo)
Observation
IIb >50°–60° 55°–77° >3 mo Pavlik harness
IIc 43°–49° >77° Acetabular
deficiency
Pavlik harness
IId 43°–49° >77° Everted labrum Pavlik harness
III <43° >77° Everted labrum Pavlik harness
IV Unmeasurable Dislocated Pavlik
harness/closed
vs. open
reduction

22. MRI
• Mao C et al. (Acta Radiol. 2016 Jun) :Compared with 3D CT, MRI is
more safe, precise, reliable and reproducible
• Fukiage K et al. (J Pediatr Orthop B.2015 Jul) found Femoral head
volume in 3D MRI :indicates severity of DDH
• Fukuda A et al. (J Child Orthop. 2016 Jun) Used ultrafast MRI to
diagnose DDH without sedation.
• E. G. MCNALLY et al. (J Bone Joint Surg 2007) MRI accurately
depicted acetabular anatomy and confirmed reduction in 12
patients.

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

26. Birth to Six Months
• Triple-diaper technique
– Prevents hip adduction
• Pavilk harness (1944)
– Very successful
– Allows free movement within
confines of restraints

27. Birth to Six Months
• Pavlik harness
– Indications
• Fully reducible hip
• Child not attempting to stand
• Close regular follow-up (every 1-2 weeks)
• For imaging and adjustments
• Duration
• Childs age at hip stability + 3 months

28. Pavlik Harness
• Failures
– Poor parent compliance
– Improper use by the physician
• Inadequate initial reduction
• Failure to recognize persistent dislocation
Treated with CR f/b hip spica after 3 weeks of Pavlik trial

29. Pavlik Harness
• Complications
– Avascular necrosis
• Forced hip abduction
Safe zone (Ramsey pl et al. JBJS Am 1976)
– Femoral nerve palsy
• Hyperflexion
25 to 30 degrees from
maximum abduction
50-90 degrees of flexion

30. Ucar d et al.
Journal of pediatric orthop.:march 2004
• prospectively studied results of pavlik harness f/b abduction
brace in patients of Graf type 2c/ severe hips.
• 22 hips :mean age 14.8(6-26) weeks
• follow up : 24.2(10-45) months.
• 90 % hip: reduced
• AVN :2 hips

31. Open Reduction
• Antero -lateral
– Smith-peterson
– Sartorius / TFL
• Medial approach(can be used)
– Pectineus / adductor longus + brevis
– Cannot address simeoultaneous bony work

32. 6 months - 2 years
– Closed reduction +/- adductor tenotomy
– Spica in position of 100 degrees flexion and about 55
degrees abduction (3 months)
– Abduction Orthosis 4 wks full time/4 wks nighttime
– Open reduction (if closed fails)

33. 2 Years of Age and Older
 Present a more difficult problem
– Prolonged dislocation
– Contracted soft tissue
Open redcution
• Tight - femoral shortening
• Stable - +/- pelvic osteotomy

38. Femoral shortening procedures
Indication:
1. excessive pressure needed on femoral head in
reduction
2.when a dislocated hip is reduced in a child older than 2
years of age#
• # Schoenecker PL et al.J Bone Joint Surg Am 1984

39. Femoral Shortening and
Derotation Osteotomy
Combined with Open
Reduction of the Hip
Intertrochanteric Varus
Osteotomy and Internal
Fixation with a Blade
Plate

40. Pelvic Osteotomy
• To reduce point loading by increasing contact area,
• Relaxing the capsule and muscles about the hip,
• Improving moment arm of hip,
• Normalizing the forces of weight bearing

42. Types: 1. Volume changing
– Pemberton
• Hinges on triradiate
• Requires remodeling of “new” incongruity
• Provides more anterolateral coverage
– Dega’s
– San Diego

43. Pelvic Osteotomy
• Redirecting
– Salter
• Osteotomy thru sciatic notch
• Hinge thru pubic symphysis
– Triple innominate
– Ganz
– Dial

44. Salvage or Shelf procedures
• Chiari
– Requires capsular metaplasia
– Pain - main indication
– Treatment of chronic hip pain in adolescents

46. • Prospectively study
• 75 hips with late-diagnosed DDH
• Group 1: < 6 months ,37 hips
• Group 2: 6–11 months ,17 hips
• Group 3: 12months –3years,21 hips
• follow-up: 11 (6–18) years
• Procedure: 68 reduced by CR,
OR +-Salter innominate osteotomy :17 hips

47. • acetabular angle improved rapidly in the younger children
:group A
• femoral head continued to grow irrespective of age at
reduction and became normal in almost all cases.
• Salter’s innominate osteotomy : excellent result in cases with
increasing acetabular angle.
• all but 2 patients were asymptomatic.

48. Complications
Untreated:
• persistent limp on the affected side
• premature osteoarthritis
• lower back or hip pain
Treated :
• AVN
• Redislocation
• Residual Acetabular Dysplasia

50. Mean age of onset of sec OA: 34.5 yrs :dysplastic DDH, 32.5 yrs:low
dislocation, 40.2 yrs:high dislocation
Classification: Crowe, Hartofilakidis, Eftekhar #
Center of hip :center of triangle-ASIS, ischial tuberosity ,obturator foramen
Cup: close to the teardrop
Acetabular screws: posterosuperior quadrant
#Crowe et al.JBJS1980. Wasielewski Rcet al. Clin Orthop Relat Res. 2005

51. Redislocation
Risk factors:
1. Insufficient release of anteromedial capsule ,inferior articular str &
transverse acetabular ligament
1. Greater pubic width
2. Decreased abduction in spica cast.
3. Dysplasia of femoral head
4. Insufficiently corrected femoral version
Procedures :
• 1.transfer and tenodesis of the ligamentum teres #
• 2.percutaneous K-wire to stabilize hip after reduction. ##
# Wenger DR et al. J Child Orthop. 2008
## Castañeda P et al. J Pediatr Orthop. 2015

52. Sankar WNJ Pediatr Orthop. 2011 Apr-May
Risk factors for failure after open reduction for DDH:
a matched cohort analysis
• Retrospective match-controlled study
• Cohort 1:22 successful OR for DDH
• Cohort 2:22 revision OR after redislocation

53. • Radiographs compared :acetabular index, pelvic width, triradiate cartilage
width, height of dislocation, size of ossific nucleus, abduction angle in the
spica cast, Tönnis grade, and Severin grade.
• Cohort 2 :significantly larger pelvic width and lower abduction angle
(mean 39 degrees vs. 51 degrees in grp 1) (P=0.003 ).
• Reasons for failure: dysmorphic femoral head and abnormal femoral
version.

54. 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
• Femoral shortening better than traction
• Pelvic osteotomies
– Dega, Pemberton
– Salter, triple innominate, Ganz
– Chiari

55. Thank you