Developmental Dysplasia of the Hip is a disorder of abnormal development resulting in dysplasia, subluxation, and possible dislocation of the hip secondary to capsular laxity and mechanical instability.Diagnosis can be confirmed with ultrasonography in the first 4 months and then with radiographs after femoral head ossification occurs (~ 4-6 months). Treatment varies from Pavlik bracing to surgical reduction and osteotomies depending on the age of the patient, underlying etiology, and the severity of dysplasia.

1. DEVELOPMENTAL DYSPLASIA OF HIP
MODERATOR : DR. G C PAUL SIR
ASSISTANT PROFESSOR, DEPT. OF ORTHOPAEDICS
SILCHAR MEDICAL COLLEGE HOSPITAL
PRESENTER : DR. CH. RAKESH SINGHA
3RD YEAR PGT, DEPT. OF ORTHOPAEDICS
SILCHAR MEDICAL COLLEGE & HOSPITAL

2. INTRODUCTION
• Spectrum of disorder of abnormal
development of hip resulting in dysplasia,
subluxation, and possible dislocation of the
hip.
• Earlier “Congenital dysplasia of hip”.
• Dysplasia of hip that develop during fetal life
or in infancy.

3. INCIDENCE
• 1.4/1000 live births.
• Native Americans
• Left hip ~ 60%
• B/L hip ~ 20%
• Risk factors-
- First born
- Female child
- Family history
- Breech position

4. ETIOLOGY
1. Ligamentous laxity
2. Prenatal factors
3. Postnatal factors
4. Primary acetabular dysplasia.

5. 1. Ligamentous laxity
• Relaxin hormone
- Crosses placenta.
- Relaxation of muscles.
• Joint hypermobility syndrome
• Collagen III>I

6. 2. Prenatal factors
• Primigravida
• Breech position
• Oligohydramnios
• Large babies
3. Postnatal factors
• Swaddling
• Adduction & Extension of hip.

7. 4) Primary acetabular dysplasia
- Rare
- Adolescence
• Associated condition
- Torticollis (~20%)
- Metatarsus adducts (~5%)
- Calcaneo valgus
- Talipus varus

8. CLASSIFICATION
1. TYPICAL
• Idiopathic
• Most common
a. Subluxation
b. Dislocation
c. Dysplasia
2. TERATOGENIC
• Usually have identifiable causes
- Arthrogryposis
- Genetic conditions.
• Occurs before birth.

9. PATHOPHYSIOLOGY
Primary
instability
• Maternal, fetal laxity, genetic laxity, intrauterine and postnatal malpositioning
Dysplasia
• Anterolateral acetabulum abnormality
Subluxation
& gradual
dislocation
• Repetitive subluxation of the femoral head leads to the formation of a ridge of thickened
articular cartilage called the limbus
Chronic
dislocation
• Pulvinar thickens
• Ligamentum teres thickens and elongates
• Transverse acetabular ligament hypertrophies
• Hip capsule and iliopsoas form hourglass configuration.

11. CLINICAL FEATURES
A) NEONATES
Usually asymptomatic.
Screened by special manoeuvres:
• BARLOW TEST : Dislocatable hip
- Flexion, Adduction, Posterior
- “clunk”
• ORTOLANI TEST: Reducible hip
- Flexion, Abduction, Anterior
- “clunk”

12. BARLOW TEST ORTOLANI TEST

13. B) INFANT
• Occasionally Barlow & Ortolani test
positive
• Skin fold asymmetry
• Limited hip abduction (<60degree)
Galeazzi sign positive
- Unequal femoral length

14. C) CHILDREN
• Remain dislocated
• Trendelenberg gait(U/L)
• Lumbar lordosis

15. NEONATE INFANT CHILD
Barlow test (+) Barlow test (+)
(occasionally)
Remains Dislocated
Ortolani test (+) Ortolani test (+)
(occasionally)
Klisic sign (+) Klisic sign (+) Klisic sign (+)
Galleazi sign (+) Galleazi sign (+)
Decrease abduction Decreased abduction
Limp
Hyperlordosis

16. SCREENING
• All neonates should have a clinical
examination for hip instability.
• USG screening for high risk babies
- Family history
- Breech presentation
- Oligohydramnios
- Torticollis.

17. INVESTIGATION
1. ULTRASONOGRAPHY
2. PLAIN RADIOGRAPHS
3. ARTHROGRAPHY
4. CT SCAN
5. MRI

18. 1. ULTRASONOGRAPHY
• Primary imaging modality from birth to 4
months.
• Evaluates for - acetabular dysplasia
- hip dislocation
• Allows view of bony acetabular anatomy,
femoral head, labrum, ligamentum teres,
hip capsule

19. Measurements :
• Alpha angle (>60 degree)
- Bony acetabulum and the ilium.
• Beta angle (<55 degree)
-Labrum and the ilium.
• Femoral head is normally bisected by a
line drawn down from the ilium

21. 2. X-RAYS
• Older children (after age of 6 months)
• Vertical line of Perkins
• Horizontal line of Hilgenreiner
• Shenton line is disrupted in an older
child with a dislocated hip.

23. Acetabular index (AI) ~ <25degree
- Hilgenreiner's line &
- Lateral triradiate cartilage,
lateral margin of acetabulum
Center-edge angle (CEA) of wiberg
- Perkin's line &
- Femoral head to the lateral edge
of the acetabulum.

24. Acetabular Teardrop:
• AP radiographs
• Formed by several lines
Laterally – wall of acetabulum
Medially – wall of lesser pelvis
Inferiorly by curve line of acetabular notch
• 6month-2 years of age.
• Delayed in DDH

25. 3. ARTHROGRAM
- To confirm reduction after
closed reduction under anesthesia.
4. CT
5. MRI

26. TREATMENT
- Age of patient at presentation
- Family factors
- Reducibility of hip
- Stability after reduction
- Amount of acetabular dysplasia
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 years old )
5) Adolescence & young adult

27. Birth to Six Months
1. Triple-diaper technique
- Prevents hip adduction
2. Pavlik harness
- Dynamic flexion-abduction
orthosis
3. Von rosen splint

28. Pavlik harness
• Indications :
- Fully reducible hip.
• Contraindication :
- Children who are crawling
- Fixed soft tissue contracture.

29. • Chest halter
• Shoulder strap
• Anterior stirrup strap (flexion)
• Posterior stirrup strap (abduction)

30. Failures
- Poor parent compliance
- Inadequate initial reduction
Complications
- Avascular necrosis
Forced hip abduction
- Femoral nerve palsy
Hyperflexion

31. 6 to 18 months
• Closed reduction and spica casting.
+/- Percutaneous adductor tenotomy.
• Open reduction
- if closed reduction fails

32. • Closed reduction and spica casting
- Under general anesthesia
- CR using Ortolani maneuver
- Arthrogram to confirm the reduction
- Spica casting
Hip flexion 90-120 degree
Hip abduction 45 degree for 3 months

33. Open reduction
- Unable to achieve closed reduction
- Widening of the joint space
- Unstable reduction
- Loss of reduction on follow up
- Advance age
• Approach
- Medial approach
- Anterior approach

34. • Medial approach
- <1year of age.
- Interval between iliopsoas &
pectineus

35. • Anterior approach
- >1 year of age
- Decreased risk of injury to the
medial femoral circumflex artery
- Capsulorrhaphy can be
performed after reduction

37. 18-36months
• Trial closed reduction
• Primary open reduction
- Anterior approach
+/- Reorientation osteotomy.

38. 3-8 years
• Primary open reduction with femoral osteotomy
• Primary open reduction with pelvic osteotomy

39. Femoral osteotomy :
• Indications
- > 2 years old with residual hip dysplasia
- Anatomic changes on femoral side
• Femoral Varus DeRotational Osteotomy (VDRO)
• Correct excessive femoral anteversion and/or
valgus

40. Pelvic osteotomy :
RECONSTRUCTIVE OSTEOTOMY
1. Salter osteotomy
2. Triple osteotomy
3. Ganz osteotomy
4. Pamberton osteotomy
5. Dega osteotomy
SALVAGE OSTEOTOMY
1. Shelf osteotomy
2. Chiari osteotomy

41. 1. Salter osteotomy
- Transverse cut above the acetabulum
through the ilium to sciatic notch.
- Acetabular dysplasia.
2. Steel triple osteotomy
- Salter osteotomy with osteotomy both rami.
-Most severe acetabular dysplasia.

42. 3. Ganz osteotomy
- Periacetabular osteotomy
4. Pamberton osteotomy
- Through acetabular roof to triradiate cartilage
- For moderate to severe DDH

43. 5. Dega osteotomy
- Incomplete transiliac osteotomy
- Neuromuscular dislocations (CP)

44. 1. Shelf osteotomy
• Augments superolateral deficiency
• Salvage procedure for > 8 years old.
2. Chiari osteotomy
• Makes new roof through ilium above
acetabulum.
• Salvage procedure for patients with
inadequate femoral head coverage.

45. Adolescence & young adult
• Older than 8years – Pelvic osteotomy.
• Adult – Total hip arthroplasty

46. COMPLICATION
AVSCULAR NECROSIS
• Seen with all forms of treatment.
• Increased rates associated with
- Excessive or forceful abduction
- Previous failed closed treatment
- Repeated surgery.

47. • Broadening of the femoral neck.
• Increased density and fragmentation of ossified
femoral head.

48. CASE SCENARIO
6years old girl is brought to the consultation by her
mother with complains of limp since the age of
2years. Limp is not associated with pain.
No history of trauma or infection.
Developmental milestone are normal.
What are the differential diagnosis?

49. • What investigation will we advice?
• How will we treat this child?

50. THANK YOU