1. DEVELOPMENT
DYSPLASIA OF THE HIP
PRESENTED BY:
MODERATOR:
DR ABHISHEK RASTOGI (PG RESIDENT)
DR BHARGAV (SENIOR RESIDENT)
DEPARTMENT OF ORTHOPAEDICS
ABVIMS AND DR RML HOSPITAL
2. DEVELOPMENT DYSPLASIA OF THE
HIP(DDH)
•Earlier known as congenital dislocation of the hip( CDH), presents in
different forms at different age, and not neccesarily occurring at birth.
•Basic pathology is that there is an instability of the hip with failure to
maintain the femoral head in the acetabulum
•Includes a wide spectrum of disorders
Subluxation of the femoral head
Dislocation of the femoral head
Acetabular dysplasia
•In a newborn child, the head can often be dislocated and reduced in the
acetabulum whereas in an older child secondary changes in the
acetabulum develops therefore the femoral head remains dislocated
3. SUBLUXATION
•Partial loss of contact between the
articular surfaces of the joint
•Widened tear drop femoral head
distance
•Break in the shenton line
7. TERATOLOGIC DISLOCATIONS
•Dislocations present before birth and not reducible after
birth
•Have limited range of motions
•Usually associated with neuromuscular disorders especially
related to muscle paralysis(eg arthrogyposis), caudal
regression syndrome, sacral agenesis etc
8. EPIDEMIOLOGY
•Incidence of the disorder as per a meta analysis as revealed by
physical examinations by pediatricians is 8.6/1000 live births
•Incidence of 11.5 per 1000 revealed by orthopaedic screening
•Whereas 25/1000 was revealed by ultrasound examination
•Odds ratio:
5.5 for breech delivery
4.1 for female sex
1.7 for positive family history
9. RISK FACTORS
•4 F’S :
First born
Female gender
Family history positive for ddh
Foot first/ breech deliveries
•Common in white children as compared
to the black.
10. • Left side> right side
• Bilateral presentation in 35% cases
• Asociations with other musculoskeletal
abnormalities have been found such as
congential torticollis, metatarsus
adductus, and talipes calcaneovalgus
• The relationship between club foot and
ddh is controversial but many studies have
demonstrated little asociation
11. ETIOLOGY
•No single cause of DDH and therefore etiology is clearly
multifactorial. Several theories have been proposed
including :
Mechanical factors
Hormone induced joint laxity
Primary acetabular dysplasia
Genetic inheritance
12. Mechanical factors:
•Prenatal positioning
Breech presentation( frank/ complete footling
presentation)
The most common intrauterine position places the left
hip of fetus against the maternal sacrum, which could
partially explain the increased incidence of DDH in the
left hip
•Postnatal positioning
Swaddle positioning of the infants have higher
incidence of DDH possibly because of the placement of
the hip in full extension.
13. •Ligament laxity: it is believed to be due to the maternal
hormone relaxin which produces relaxation of the pelvis
during delivery which may cause enough ligament laxity in
child in utero and during neonatal period to allow dislocation
of the femoral head.
•Effect is much stronger in females
•Wynne davies in 1970s proposed heritable ligamentous laxity
was one of the two major mechanisms for inheritance of
DDH.
•She believed it to be an autosomal dominant characteristic
with incomplete penetrance
17. NEWBORNS
•Careful clinical examination mandatory
as radiographs are not always reliable in
the age group.
•Infant should be calm, relaxed and one
hip should be examined at a time
Hip should be first examined for limited
abduction, it is limited as compared to
the normal opposite side. Is the most
reliable sign of dislocated hip.
18. INSTABILITY EXAMINATION:
ORTOLANI TEST: PROVOCATIVE TEST OF
BARLOW:
After 3months of age the barlow and ortlani tests become negative due to soft tissue contractures
20. INFANTS
•As the child enters second and third
months of life other signs of DDH
appears
•Asymetry of thigh folds- not always
reliable
•Apparent shortening of the extremity
•Galeazzi /Allis sign
•Klisic sign
21. An inequality in the height of the knees is a positive Galeazzi sign
Bilateral dislocations may appear symmetrically abnormal
Klisic test
useful in case
of a bilateral
DDH
22. • As the child reaches 6- 18months of life several
factors in clinical presentation change
• First and most reliable feature is decrease in ability to
abduct the dislocated hip due to adductor muscle
contracture( 69% sensitivity)
• Inability to reduce the dislocated hip by abduction.
Therefore the the ortolani test is negative
23.
24. Older children of walking age
•Trendlenberg pattern of gait
seen
•Increased lordosis of the spine
to compensate the shortening
25. •In case of bilateral
dislocations there is a
waddling type of gait and
there is hyperlordosis;
28. Dysplastic hip:
•Eventually leads to subluxation which is
inevitable
•Roof osteophytes at the synovial
attachment forms due to increased
sheer forces and a pseudo-acetabulum
forms.
•Dysplastic hips without subluxation
usually becomes painful and develop
degenerative changes over time
29. Subluxated hip:
•Always lead to symptomatic degenerative arthritis with gradually
increasing pain in one or both hips
•Severe subluxation- symptoms in 2nd decade
•Moderate subluxation- symptoms in 3rd and 4th decade
•Mild subluxation- symptoms in 5th decade
•In a study, hips with well developed false acetabulum had highest
incidence of pain and disability
31. Changes occurring in the acetabulum in
subluxated and dislocated hip:
•The changes occurring following DDH are initially reversible.
Relative gentle forces, persistently applied are probably the
cause of the deformations.
Postero-superior rim of acetabulum become blunt, flat and
thickened due to constant sliding in and out of the femoral
head.
This ridge of thickened articular cartilage called neolimbus is
then responsible for the clunk when head slides in and out
32.
33.
34. In hip that remains dislocated, secondary barriers to the
reduction develop.
◦The pulvinar ( fatty tissue in the acetabulum) thicken and
impede reduction
◦Ligamentum teres becomes elongated and thickens
◦Labrum inverted
◦TAL( transverse acetabular ligament) is hypertrophic impeding
reduction
◦Inferior capsule takes an hourglass shape leading to decreased
opening for the femoral head
◦Iliopsoas pulled tight across the isthmus contributing to the
narrowing
◦Capsule narrowing by the Chinese finger trap mechanism
35. •Femoral changes are minimal and includes;
Increase in anterversion
Flattening of femoral head as it lies against the acetabulum
Note should be made to stretch/ release capsule to allow
head into acetabulum and not the acetabular cartilage as
the acetabular cartilage is needed for normal growth and
development of the acetabulum.
36.
37.
38. •As mentioned, that to a point the changes are
reversible, HARRIS suggested that hip reduced by
4yrs could achieve satisfactory acetabular
development. As significant acetabular growth
continued through 8 yrs.
•When a stable reduction is obtained, the acetabulum
remodels threby increasing the depth and acetabular
angle becoming horizontal.
41. •Hilgenriener line(Y line/ tear drop line)
•Perkins line
•Shentons line
•Acetabular index/ acetabular angle :
◦ Upper limit for the acetabular angle/ acetabular index is
27+/- 4 degree
◦ Newborn 30 or less
◦ At 6m age is <25degree
◦ At 1 yr ~ 22 degree
42. Center edge angle of
Wiberg:
• Angle formed by
the center of
femoral head
• Not measured until
the ossific nucleus
present
• Normally >10 in
children
44. Radiographic signs of DDH
1. Upward and lateral displacement of the femoral head
2. Late appearance of femoral ossific nucleus
3. Break in the shentons line
4. Acetabular dysplasia (Acetabular angle >30)
5. Center edge angle of Wiberg
4 radiological signs must be there in a >6month old child of
DDH
45.
46.
47. Radiological classification:
•Earlier given by Tonnis, who graded it into 4 categories.
•Modified later by the International Hip Dysplasia Institute.
•Uses the Hilgenreiners and perkins line to create 4
quadrants.
•Center of the proximal femoral metaphysis is used as a
reference point
48.
49. Ultrasound
•Graf of Austria described the ultrasonographic anatomy of
the newborn hip and devised an ultrasonographic
classification of the hip dysplasia.
•Used as an adjunct to the physical examination and helpful
in measuring and documenting the response of hip to the
pavlik harness treatment.
50.
51. •Observer dependent and is easy to overdiagnose dysplasia
•Ultrasound findings before 6 weeks can be questionable
because of ligament laxity in early newborn period.
•Treatment before 6wks should therefore be based on
physical examination rather than USG findings alone.
52.
53.
54.
55. Screening in DDH
Routine Screening of a newborn with examination is recommended but
researches on ultrasound evaluation as a method of screening have mixed
results.
The American Academy of Orthopedic Surgeons, developed clinical practice
guidelines in 2014 for detection and non operative management of pediatric
DDH in infants upto 6 months of age. Their recommendations to screening were;
Moderate evidence supports not performing universal ultrasound of newborn
infants
Moderate evidence supports performing imaging study before 6m age with
one or more risk factors like breech presentation, family history , history of
clinical instability.
56. Currently referral to an orthopedist is
recommended with a positive newborn
examination or a positive result at 2 week follow
up examination
Most helpful when manipulative reduction is
unstable or when the femoral head is not
concentrically seated within the acetabulum.
57. Arthrogram
•Usually done after induction of GA
•Uses:
Detects dysplasia
Subluxated /dislocated hip
Soft tissue interposition- medial pooling of dye
Condition and position of acetabular labrum(limbus)
60. 3D IMAGING
COMPUTED TOMOGAPHY
•Confirms maintenance of
the reduction in the cast
•In older children 3DCT useful
to plan surgery
MAGNETIC RESONANCE
IMAGING (MRI)
•Offers excellent visualization of
the anatomy with no radiation as
compared to the CT.
•Confirms a concentric reduction
•Detects AVN
•Disadvantage: Takes more time
and increased cost
62. AIM OF TREATMENT
•Obtaining a concentric reduction
•Maintaining a concentric reduction
•Aid in the normal acetabular development
•Avoid complications like the Avascular necrosis of the head
of femur
63. Age Management
Neonatal hip instability(0-1 month) Positioning device to keep hip abducted
1 to 6 months Pavlik Harness, Rigid brace, CMR spica
6 months to 18 months Closed reduction and spica
Adductor tenotomy/ closed reduction and
spica
Open reduction if closed reduction fails
Medial approach/ Anterior approach
18 months to 3 years Open reduction
Innominate osteotomy
(Pemberton/Dega/Salter)
Femoral osteotomy
3 years to 8 years Open reduction
Femoral shortening
Pelvic osteotomy (Pemberton/Dega/Salter)
>8 years ??
64. Safe zone of Ramsey
•Range of abduction in which the
hip is reduced
•Excess of abduction can lead to
AVN
•Less of abduction – redislocation
•15°-20° of margin taken
Safe zone of Ramsey used to determine
acceptability of the closed reduction of
congenital dislocation of hip
Redislocation
AVN
65. TREATMENT( Birth to 6 months)
•Directed at stabilizing the hip that has a positive Ortolani or
Barlow test or reducing the hip that has a mild adduction
contracture
•Treated successfully with a rate of 85-95% with Pavlic harness
during the first few months of life
•As there child ages, soft tissue contracture develops, along with
the secondary changes the success treatment of Pavlic harness
decreases.
•In teratologic dislocations too, the pavlic harness in unlikely to
be successful
66. PAVLIC HARNESS
•Dynamic flexion abduction
orthosis
•Produces excellent results in
treatment of dysplastic and
dislocated hip in infants during
the first few months
•limits adduction to within safe
zone and allows movement
within safe zone
Chest
strap
Stirrup
Shoulder
strap
67. •Hip is placed in flexion of 90° to 110° and the anterior flexion
strap is tightened to maintain this position
•Knees should 3-5cm apart at full abduction. Avoid forced
abduction.
•Worn 23-24 hrs/day until stability+
•Re-examine at 1-2 week interval
•A radiograph of the patient in the harness can help to confirm
that femoral neck is directed towards the triradiate cartilage.
•During the first few weeks, when hip seems stable clinically, USG
evaluation is sufficient to confirm reduction.
68. Complications:
•persistent dislocation in harness
•AVN (∼1%)
•Femoral nerve palsy, therefore quadriceps function should
noted at each examination
•Pavlick harness disease – on long term dislocation in
harness – changes occurs at head and acetabulum
(flattening of the posterior acetabulum) therefore reduction
becomes difficult
69. Risk factors for pavlic harness failure :
• Absent Ortolani test
• Bilateral hip dislocations
• Development of femoral nerve palsy during treatment
• Acetabular angle of 36 or more
• Initial coverage of 20% or less( by USG)
70.
71.
72. •If Pavlic harness treatment
fails, successful reduction has
been achieved by a trial with
a rigid abduction orthosis for
a few weeks.
Rigid abduction orthosis can be used
successfully in children in whom pavlic harness
failed to produce stable reduction.
73. TREATMENT(6 months- 18 months)
•Secondary adaptive changes occur therefore
reduction can be a problem.
•Limbus acetabuli hypertrophy
•Ligamentum teres hypertrophy and elongates
•Femoral head becomes reduced in size and
excessive anteversion
•Capsule becomes permanently elongates
•Femoral head migrates superiorly and
laterally
74. • Treatment in this age group includes
1.Preoperative traction
2.Adductor tenotomy
3.Closed reduction and arthrogram (f/b hip spica application)
4.Open reduction in children with failed closed reduction
Femoral shortening may be needed with high proximal dislocation
Preoperative traction
The role of preliminary traction in reducing the incidence of
osteonecrosis and in improving reduction is controversial
although, some suggests if traction decreases the risk of
osteonecrosis even slightly, it may be considered.
75. Adductor tenotomy
Mild adduction contracture – percutaneous adductor tenotomy
Severe adduction contracture – open adductor tenotomy through
small transverse incision is preferable.
Arthrography and closed reduction
Done with the child under GA
Proposed criteria for acceptance of a reduction are a medial dye of
5mm or less and maintenance of reduction in acceptable safe zone.
Acceptable closed reduction is sensation of clunk as femoral head
reduces in true acetabulum. Another indicator is increase in knee
flexion angle (popliteal angle).
76. Hip spica cast
•After confirmation of a stable hip reduction a hip spica cast is
applied.
•Hip joint is 95° flexion and 40°-45° of abduction (human
position as advocated by Salter), considered the best for
maintain the hip stability and minimizing the risk of
osteonecrosis
77.
78. Following a closed reduction, 3D-imaging are used for confirmation
of the reduction
A comparison of MRI and CT found 100% sensitivity of both CT and
MRI and specificity of 96% in CT and 100% in MRI.
Open reduction
it is indicated in whom closed reduction has failed and when
interposed soft tissues are to be corrected to reduce the head
concentrically in the acetabulum.
Approach for an open reduction can be an anterior or medial
approach and regardless of the approach chosen, open reduction
should correct as many as blocks to the reduction as possible
79. Comparison of the approaches
MEDIAL APPROACH (LUDLOF APPROACH)
•Minimum dissection utilizes the
interval between iliopsoas and
pectineus
•Exposes and higher risk to the
medial circumflex vessels leading
to osteonecrosis (10-20%).
•Does not allow capsulorrhaphy
•Recommended in infants of 6-18
months old
ANTERIOR APPROACH (SOMER-BIKINI
APPROACH)
•Required more anatomical
dissection and provides a better
exposure
•Capsulorrhaphy can be performed
and pelvic osteotomy can be
performed through this approach.
•Recommended in older children
80. Anterior approach to the open reduction
Anterior bikini
incision made
extending iliac
crest to point
midway between
ASIS and midline
of pelvis
Interval between the
Sartorius and TFL
muscle
Capsulotomy of
hip and use
ligamentum
teres to find
the true
acetabulum
Reduction and
capsulorrhaphy
after excision of
redundant
capsule
81. DDH of the right hip
After anterolateral open reduction Age at 7yrs, note remodelling
82. Incision transverse one
centered at the
anterior margin of
adductor longus
around 1 cm distal and
parallel to the inguinal
ligament
83. CONCOMITANT OSTEOTOMY
Use of concomitant osteotomy including the innominate osteotomy,
acetabuloplasty, proximal femoral varus derotation osteotomy or femoral
shortening osteotomy might increase the stability of open reduction
Zadeh et. al. used concomitant osteotomy to maintain stability of
reduction in which the following tests of stability after open reduction
was used;
Hip stable in neutral position – no osteotomy
Hip stable in ABD + flexion – innominate osteotomy
Hip stable in internal rotation and abduction – proximal femoral
derotational varus osteotomy
“double diameter” acetabulum with anterolateral def.- Pemberton type
osteotomy
84. Concomitant osteotomy
particularly, femoral shortening
osteotomy with or without
derotation should be done at
the time of open reduction
when necessary to maintain
stable safe reduction
85. TREATMENT IN TODDLER (18-36 months)
•For these children with well-established hip dysplasia, open
reduction with femoral or pelvic osteotomy or both is often
required.
•Persistent dysplasia can be corrected with redirectional
proximal femoral osteotomy in very young children
•If the primary dysplasia is acetabular, pelvic redirectional
osteotomy alone is more appropriate.
•However, in older children, both femoral and pelvic osteotomies
may be required if the deformity is significant
86. FEMORAL OSTEOTOMY
Good results in patients < 4years
Unpredicatable for age group 4-8 years due to development
of acetabulum
No benefit in > 8 years
Landmark to stop : arthrogram – good reduction in AB and
IR
87. • Varus osteotomy; hip remains stable in only wide
abduction
• Derotational osteotomy needed if there is anteroversion
requires significant internal rotation for reduction to be
stable.
• Varus derotational osteotomy; hip remains stable only in
abduction and IR
• Femoral shortening; high riding dislocation in older
children.
90. TREATMENT (3-8 years)
•By this age group, adaptive shortening of the periarticular
structures and structural alteration in the femoral head and
acetabulum has occurred and therefore, management in this
age group is difficult
•Preoperative skeletal traction should not be used as the only
means of achieving reduction because of high frequency of
osteonecrosis (54%) and redislocation (31%)
•Femoral shortening helps in reduction and decreases the
potential for complications
91. • Primary acetabular repositioning often needed;
Salter/Pemberton
• In >3 year-olds, an acetabular procedure needed to
adequately cover the head.
• Primary femoral shortening , anterior open reduction
and capsulorrhaphy with/without pelvic osteotomy
as indicated have been recommended in children 3
years or older.
93. Redirectional osteotomy (volume neutral)
•Salter innominate (most common); entire acetabulum with
ischium and pubic rotated as unit winging on pubic
symphysis
•Triple innominate of Steel or Tonnis
•Ganz periacetabular osteotomy (adolsecent) (after skeletal
maturity)
94. Salters innominate osteotomy
•entire acetabulum with ischium and pubic rotated as unit
winging on pubic symphysis.
•Redirects acetabulum; anterolateral coverage to femoral
head
•Corrects acetabular dysplasia
•Indications: DDH- 18months - 6 years; lateral and anterior
acetabular dysplasia
95. Prerequisites;
•Concentric reduction of femoral head
•Open reduction of hip to obtain concentric reduction
•18 months to 6 years age
•ROM good – Flexion∼100°; abduction∼30°
•Contractures of iliopsoas and adduction must be realeased
Contraindications:
Non-concentric reduction
Severe acetabular dysplasia
>8 years
Stiff hip
100. Pemberton acetabulplasty:
•Alter the shape of the acetabulum by osteotomy of ileium superior to
acetabular roof and levering the roof inferiorly
•Done in 18month – 8 years age
•Large acetabulum with small femoral head
•Anterolateral coverage
•Pre requisites:
• Good range of movements
• Age 18m – 8 yrs
• Open triradiate cartilage
• Anterolateral acetablular deficiency
101.
102. Acetabular augmentation:
Shelf operation( Staheli ) – bone graft is put in the superior
margin of the acetabulum
Chiari osteotomy- innominate osteotomy with medial
displacement of the acetabulum.
103.
104. Treatment in adolescents and young
adults (>8yrs)
•In unilateral dislocations: reduction strongly considered
•If femoral head cannot be positioned distally to level of
acetabulum- palliative salvaging operations are possible
•Rarely femoral shortening + pelvic osteotomy considered
•Bilateral dislocations: should be left untreated
•After some years when degenerative arthritis develop, when
they cause enough pain and limitation of movement,
reconstruction operations like THR done.
the position of the hand should be such that the thumb be on the medial aspect of the thigh with the first web space around the knee and the fingers over the trochanter.
