DDH

1. DEVELOPMENT
DYSPLASIA HIP
DR.KHADIJAH NORDIN

2. Developmental Dysplasia Of The Hip (DDH)
• includes a wide spectrum of hip alterations:
• Neonatal instability;
• acetabular dysplasia;
• hip subluxation;
• true dislocation of the hip

3. • Syndromic types:
• DDH can be a part of many or only a sole manifestation of skeletal dysplasia,
or it may be present in conjunction with other malformations, e.g., pes -
equinovarus and acetabular labrum abnormalities.
• Syndromic dysplasia exists also in association with different pathologies such
as Down’s syndrome and neurogenic, renal or cardiovascular abnormalities.
• Non-syndromic DDH:
• diagnosed as an isolated condition
• genetic component
• These are mainly variants of genes whose products are structural factors of
connective tissue, genes involved in osteo- and chondrogenesis, genes
associated with the formation of joint structure and chemokine reseptors

20. •In older infant or child,
• Barlow and Ortolani examination is of limited utility due to
the development of contractures.
• These patients are observed for:
• leg length discrepancy, thigh-fold asymmetry, and limited hip
abduction.
• Leg length discrepancy should be assessed for with the infant in
the supine position with the pelvis flat on a level surface and the
hips and knees flexed to 90°. A discrepancy is indicated by
unequal knee heights, which is termed the Galeazzi sign
• in a child >3 months old is an assessment for asymmetric
diminished hip abduction

22. • The walking child may also present with:
• a Trendelenburg gait (trunk tilt toward the affected hip
when weight is applied) if there is a unilateral dislocation
• a waddling gait (trunk tilt toward the weight-bearing side,
alternating throughout the gait cycle) if there is bilateral
dislocation

37. Ultrasonography
• allows for the visualization of the femoral head location relative to the
acetabulum and specific anatomic parameters, such as the depth of
the acetabulum and inclination of the acetabular roof.
• can be performed in a static or dynamic manner:
• static study: examine the joint anatomy (the shapes and relations between
the femoral head, acetabulum, and labrum).
• dynamic ultrasonography, hip joint stability is assessed by performing the
manipulative stress maneuvers under direct imaging observation

38. • Key ultrasound measurements include
• the α (which is formed by the bony ilium and the bony roof of the
acetabulum)
• Values >60 degrees are considered normal, and those <60degree imply
acetabular dysplasia
• the β angle (which is formed by the bony ilium and the labral
fibrocartilage),
• Normal value <50degree, as the femoral head subluxates, the beta angle
increase
• the percentage of the femoral head covered by the bony roof of
the acetabulum.
• The α angle has more clinical significance than the β angle

40. Treatment
• the goal of the treatment is to achieve a concentric reduction of the
femoral head into the acetabulum and correct development of all
structures of the hip.
• This can be achieved according to three main principles:
• To achieve a concentric and stable reduction of the hip, avoiding
complications such an AVN.
• To confirm correction of acetabular dysplasia due to the stimulus provoked by
the stable and concentric position of the femoral head into the acetabulum.
• Pelvic or femoral osteotomies are indicated in two situations.
• First, when there is a residual dysplasia that previous reduction of the hip has not been
able to correct.
• Second, when the potential of correction after hip reduction is expected to be not
enough to correct the acetabular dysplasia due to the child’s age.

42. Pavlik Harness
• used for all degrees of hip
dysplasia in otherwise normal
newborns.
• Evolved as the clear method of
choice for treatment of infants
with developmental hip dysplasia
or dislocation
• Use of the Pavlik harness is
contraindicated:
• when there is major muscle
imbalance, as in myelomeningocele
(L2 to L4 functional level)
• major stiffness as in arthrogryposis;
• Ligamentous laxity, as in Ehlers-
Danlos syndrome.

43. 4 steps for application of the Pavlik harness
1. The chest halter is applied.
• The shoulder straps on the halter should
cross in the back to prevent them from
sliding over and down the child’s shoulders.
2. The leg stirrup straps are applied. The
strap for the proximal part of the leg
should be located just distal to the
popliteal fossa.
• This strap stabilizes and controls the knee
and, when properly positioned, prevents
bowstringing of the anterior and posterior
stirrup straps.
• With bowstringing, tightening of the
posterior stirrup straps often produces
internal rotation and adduction of the hip.

44. 3. The anterior stirrup straps are
attached to the chest halter.
• The attachment for the anterior
(flexor) stirrup straps should be
located at the anterior axillary line.
• If these straps are placed too far
medially, tightening them will cause
not only flexion but also adduction
of the hip.
4. Lastly, the 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 adduction
to prevent dislocation.

45. Treatment of the Infant with Acetabular
Dysplasia with or without Hip Subluxation
• Pavlik harness can be used for infants with limited hip abduction
and documented acetabular dysplasia with or without subluxation
• the infant with dysplasia should be removed from the harness daily
for baths and should be worn for 23 hours daily until the findings of
clinical and radiographic examination are normal

46. • To achieve this goal, the harness must
be worn :
• minimum of three months by children
<3mo old
• approximately double their age for children
>4mo old
• part-time during the last two months
• child approaches the walking age, an
alternative form of bracing such as a plastic
hip abduction brace

49. Abduction Orthosis
• Should be considered as an alternative to the Pavlik harness for
infants more than nine months of age who require continued
abduction positioning because of acetabular dysplasia and/or
subluxation.
• This device maintains abduction while allowing walking, and it is more
acceptable for the larger child.
• An abduction orthosis can be used for patients up to two and one-
half years of age.
• After about eighteen months of age, it is usually used only at night,
depending on the radiographic appearance of the hip.

50. Skin Traction Followed by Closed Reduction
• is the recommended treatment for older infants months of
age with a dislocated hip for which attempted reduction
with the Pavlik harness has failed or for children over nine
.
• This sequence of treatment decreases muscular
contractures and allows a safer, gentle closed reduction.

51. • After two to three weeks of skin
traction, an adductor tenotomy
is performed with the child
under general anesthesia, closed
reduction is attempted,
arthrography is performed
through a medial approach, and
a spica cast is applied.
• The cast is applied with the hip
held in 100° of flexion and 40° to
50° of abduction the so-called
human position

52. • The overall goals in the management of infants with developmental
dislocation of the hip are
• early diagnosis,
• safe and effective reduction of the hip,
• minimal inconvenience for the child and family,
• decreased cost by avoiding prolonged hospitalization,
• decreased risks by avoiding anesthesia and spica casts.
• The results indicate that these goals can best be achieved by
understanding Pavlik’s method (the correct use of his harness) and
using ultrasonography to aid in diagnosis and management.

53. Operative Treatment of Developmental Hip
Dislocation
• required for children between the ages of six and eighteen months
when treatment with a Pavlik harness and/or closed reduction
attempts have failed.
• The decision to perform an open reduction must be made in the
operating room following arthrography and failed closed reduction.

54. Anteromedial Open Reduction (in Children Six
to Twenty-four Months of Age)
• Clear anteromedial exposure allows:
• lengthening of the psoas tendon and
• opening of the constricted capsule, especially the capsule with an hourglass
constriction seen in most dislocated hips and
• released of the constricted transverse acetabular ligament at the acetabular base.
• The femoral head can then be safely reduced.
• stability is provided by application of the spica cast with the child in the
“human position”
• Problems with the anteromedial open reduction include:
• Capsulography cannot be performed
• redislocation (even in the spica cast),
• late avascular necrosis,
• and residual dysplasia.

55. Anterior Open Reduction Surgical Approach to
the Older Child (Two Years of Age and Older)
• This technique avoids the need for prolonged preliminary
traction and has proved to be as effective in younger children
as it is in three to four-year-old children
• single-stage approach to reduction in the older child, which
includes ;
• capsulorrhaphy,
• femoral derotational shortening,
• acetabuloplasty.

56. Open Reduction, Including Femoral Shortening
and Acetabuloplasty
• The goal of a one-stage reduction is :
• to safely reduce the dislocated hip and
• to surgically recreate normal anatomy (as closely as possible) that will
maintain the reduction
• allow rapid development of normal hip function.
• The patient is placed on a radiolucent operating table in a supine (but
30° oblique) position with a sandbag under the chest but not under
the hip as that prevents good skin preparation and good image-
intensifier views.

57. Capsule
Exposure

58. Capsulotomy

61. Acetabuloplasty
• perform this procedure in all patients treated with primary open
reduction and femoral shortening
• Salter procedure is that it redirects the acetabulum, thus immediately
improving anterolateral coverage of the femoral head
• With other types of acetabuloplasty(especially the Pemberton
acetabuloplasty),there is some risk of decreasing acetabular size
because the technique includes bending through the triradiate
cartilage

62. Cast Immobilization
• After the single-stage hip reduction is complete, suction drainage
tubes are placed in each wound and the wounds are closed, ending
with a cosmetic subcuticular suture.
• The child is placed in a hip spica cast with the hip flexed and abducted
30°
• The hip spica cast is maintained for six weeks and then is changed (as
a day-surgery procedure with the patient under general anesthesia)
to a second, more loosely fitting hip spica cast, which is worn for
another four to six weeks.

63. • A Petrie cast can be used for the second cast; however, in young
children (especially those who are overweight), such a cast produces
excessive stress at the osteotomy site.
• Therefore, a loosely fitting second hip spica cast is preferred. The
second cast is removed ten weeks after surgery, and no subsequent
bracing is required in the typical case.

64. Reference
• Developmental Hip Dysplasia and Dislocation: Part II,Stuart L.
Weinstein, Scott J. Mubarak and Dennis R. Wenger, J Bone Joint Surg
Am. 2003;85:2024-2035.
• Developmental Hip Dysplasia and Dislocation: Part II,Stuart L.
Weinstein, Scott J. Mubarak and Dennis R. Wenger, J Bone Joint Surg
Am. 2003;85:1824-1832.
• Developmental Dysplasia of the Hip :Scott Yang, a Natalie Zusman,, a
Elizabeth Lieberman, a Rachel Y. Goldstein, PEDIATRICS Volume 143,
number 1, January 2019
• Developmental dysplasia of the hip: update of management:EFORT
Open Rev 2019;4:548-556.
• Developmental Dysplasia of the Hip: A Review of Etiopathogenesis,
Risk Factors, and Genetic Aspects Stefan Harsanyi , Radoslav
Zamborsky, Lubica Krajciova, Milan Kokavec,Lubos Danisovic:Medicina
2020, 56, 153; doi:10.3390/medicina56040153