Developmental dysplasia of the hip (DDH)

1. DEVELOPMENTAL DYSPLASIA OF
THE HIP
DR MUHAMMAD JUNAID
PGR ORTHOPAEDIC SURGERY
WARD 21

2. Introduction
dysplasia of hip that develop during fetal life or in infancy
Old name : CDH
Name changed because not
All cases present at birth,
Some cases may develop
Latter onduring infancy and
Childhood.

3. Spectrum of disease :
Dysplasia—shallow acetabulum
Subluxation
Dislocation
Teratologic—dislocated in utero and irreducible;
associated with neuromuscular conditions and genetic
abnormalities
Late dysplasia (adolescent and adult)

4. Risk factors:
4F :
FEMALE GENDER 85 %
FIRST BORN CHILD
FOOT FIRST (BREECH ) 30 TO 50%
FAMILY HISTORY >20%
DDH is observed most often in the left hip (67% of cases),
Also associated with postnatal positioning such as
swaddling with the hips in extension

5. • Causes:
Mechanical factors:
 transverse acetabular ligament,
pulvinar,
infolded labrum,
inferior capsular restriction,
Hypertrophied ligamentum teres,
psoas tendon
Hormones induced ligamentous laxity
Genetic inheretence
Most common intrauterine position of left hip over mother sacrum
Swaddle infants
Maternal hormone relaxin theory

6. Diagnosis:
Mother came with history difficulty in wearing
dippers to her baby.
Physical examination:
• Early diagnosis possible with Ortolani test
(elevation and abduction of femur relocates a
dislocated hip and Barlow test (adduction and
depression of femur dislocates a dislocatable
hip)
• All children should undergo screening via
physical examination.( 1ST DAY OF LIFE,6
WEEKS,3 MONTHS,6 MONTHS,& 1 YEAR)

7. Subsequent diagnosis is made with limitation of hip Abduction
Galeazzi sign
demonstrated by the clinical appearance
of foreshortening of the femur on the affected side
Other clinical findings
include asymmetric gluteal folds (less reliable)
And Trendelenburg stance (in older children),
increased lumbar lordosis,
and pelvic obliquity.

8. Dynamic ultrasonography before ossification of the femoral head (which
occurs at age 4–6 months)
On the coronal view, the normal α angle is greater than 60 degrees, and the
femoral head is bisected by the line drawn down the ilium.
acetabular roofline
inclination line

9. Radiographic studies and findings
older children >4-6 months
acetabular index normal <25 °
centre edge angle of Wiberg normal > 30°
Shenton line
IHDI CLASSIFICATION
TONIS CLASSIFICATION
(femoral head ossification begins to show between 4 and 6 months).

13. Fill the syringe with 5 mL of a 25% strength medically approved contrast agent such as diatrizoate or
iohexol solution and inject 1 to 3 mL through the needle into the joint with image intensification.

14. CT & MRI:
• Advanced imaging (CT, MRI) helpful after closed reduction to
determine concentric reduction

15. Birth to 6 months :
• In hips that have normal examination findings but abnormal
ultrasound findings, treatment recommendations are uncertain
•Children should have close follow-up.
• Repeat ultrasound at age 6 weeks, with treatment if continued signs
of dysplasia

16. Birth to 6 months :
• Pavlik harness
• All Ortolani-positive (dislocated but reducible) hips should be treated with
Pavlik harness.
• Barlow-positive (reduced but dislocatable) hips may stabilize without
treatment but should be watched closely; many writers advocate treating with
Pavlik harness with observation.
• If dislocated, reduction should be checked weekly with ultrasonography for 3
weeks.
• Not reduced: transition to rigid abduction orthosis versus closed reduction,
arthrography, and spica casting should be considered.
• Reduced: continue harness until findings of examination and ultrasonography
are normal.

17. Pavlik harness:
a chest strap, two shoulder straps, and
two stirrups.
Each stirrup has an anteromedial flexion
strap and a posterolateral abduction
strap.
 POSITION: SUPINE.
The chest strap is fastened first.
The shoulder straps are adjusted to
maintain the chest strap at the nipple
line.
hip is placed in flexion (90 to 110
degrees), with anteromedial strap.
lateral strap is loosely fastened to limit
adduction.
The knees should be 3 to 5 cm apart at

18. Pavlic harness is applied in about 90 to 110 degrees of flexion and mild
abduction (the “human position” [Salter position])
safe zoneof Ramsey (between maximum adduction before
redislocation and excessive abduction, which
increases risk of avascular necrosis [AVN]).
• Impingement of the posterosuperior retinacular
branch of the medial femoral circumflex artery
narrow safe zone (<40 degrees),

19. • The Pavlik harness should be worn 23 to 24 hours per day 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
• 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.
• discontinuation of the Pavlik harness 6 weeks after clinical
stability has been obtained.
RISK FACTORS:
• irreducible dislocation
• bilateral hip dislocations
• femoral nerve palsy
• AVN femoral head

20. 6 to 18 months:
percutaneous adductor tenotomy, closed reduction, and spica casting Postreduction CT or MRI
used to confirm concentric reduction
If closed reduction fails: open reduction
18 months to 3 years:
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
3 to 8 years:
• Osteotomy
Salter, Dega, Pemberton, or Staheli procedure
• Older than 8 years:
Osteotomy
• Growth plate open: triple (Steele), double pelvic
(Southerland), Staheli procedure
• Growth plate closed: shelf and Chiari procedures
• Total hip arthroplasty is performed when the child is an adult.

21. Closed and open reduction :
• Closed reduction :
• Performed for patients for whom Pavlik treatment fails and for patients 6
to 18 months of age
• Performed using general anesthesia; procedure includes a physical
examination, arthrography to assess reduction (look for thorn sign on
arthrogram, indicating normal labral position), and hip spica casting with the
legs flexed to at least 90 degrees and in the stable zone of abduction
• CT or MRI often performed to confirm that hip
is well reduced, especially in questionable cases

22. Open reduction :
• Reserved for children 6 to 18 months old in whom closed reduction fails, who have an
obstructive limbus, or who have an unstable safe zone
• Initial treatment for children 18 months and older.
• Anterior approach, especially for patients older than 12 months (less risk to medial
femoral circumflex artery)
• Capsulorrhaphy, adductor tenotomy, and femoral shortening can be performed to
take tension off the reduction, along with an acetabular procedure if severe dysplasia is
present
• Obstacles to reduction:
transverse acetabular ligament,
pulvinar,
infolded labrum,
inferior capsular restriction,
hypertrophied
ligamentum teres,
and psoas tendon

23. anterior approach
.requires more anatomic
dissection.
• pelvic osteotomy can be
performed through this
approach if necessary.
• The medial (Ludloff) approach
• Interval between the iliopsoas
and the pectineus.
• This approach places the medial
circumflex vessels at a higher
risk and associated with
osteonecrosis
• 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.

24. ANTERIOR APPROACH: (BEATY; AFTER SOMERVILLE)
anterior bikini incision ( middle of the iliac crest to midline of the pelvis)
Disect sartorius , tensor fasciae latae and rectus femoris tendons and iliac epiphysis (protect LFC nerve)
Perform psoas tendon recession tenotomy in its groove on the superior pubic ramus
Make a T-shaped incision from the most medial aspect of the capsule
 Identify and clear mechanical factors that hinder to stable reduction
 then head is reduced,if reduction is concentric then close the capsule, suturing the lateral flap of the T-shaped incision as
far medially as possible to eliminate any redundant capsule in the region of the false acetabulum
All layers closed in reverse manner ,double hip spica cast applied
Post op follow up:
Xray, ct scan or mri to check reduction
Spica is changed at 5-6 weeks
Final removal at 10-12 weeks

25. 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.

26. Zadeh et al. used concomitant osteotomy at the time of open
reduction to maintain stability of the reduction in which
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
3. Hip stable in internal rotation and abduction—proximal
femoral derotational varus osteotomy
4. “Double-diameter” acetabulum with anterolateral deficiency—
Pemberton-type osteotomy

32. Surgical risks :
• Osteonecrosis—the major risk associated with both open and closed
reductions; caused by direct vascular injury or impingement versus
disruption of circulation from osteotomies
• Damage to medial femoral circumflex can occur with medial approach to
hip; close association to psoas, which undergoes a tenotomy because it is a
block to reduction.
• Failure of open reduction is difficult to treat surgically because of the high
rates of complication after revision surgery (osteonecrosis in 50% and pain
and stiffness in 33% according to one study)
• Diagnosis after age 8 (younger in patients with bilateral DDH) may
contraindicate reduction because the acetabulum has little chance to
remodel, although reduction may be indicated in conjunction with salvage
procedures.