1. Michael Albert, MD
Bio:
Chief of Orthopaedics, Dayton Children’s Hospital
Attended Wright State University School of Medicine
Expertise in spinal deformity
“I went to medical school thinking I wanted to become a pediatrician, but once I did surgery and orthopedics, I decided to combine my dedication and love of children's health with orthopedic surgery.”

2. hip disorders from birth to maturity
22nd annual pediatric orthopaedic symposium
hip disorders from birth to maturity
developmental dysplasia of the hip
Michael C. Albert, M.D.
Chief of Orthopaedics
Dayton Children’s Hospital
September 27, 2019

3. disclosure
I have no disclosures related to the following topic.

4. case presentation
13 month old female presents with Limb Length Inequality
Mother’s first baby
Full term, vaginal delivery
No breech presentation AP
3/21/2017

5. treatment Open reduction Anterior approach
Adductor and iliopsoas tenotomy
Spica cast
4/18/17

6. 3/19/2019

7. DDH Spectrum of abnormalities of the growing hip
“Immature hip”
Dysplasia (malformed anatomy)
Subluxable hip
Dislocatable hip
Reducible hip dislocation
Chronically subluxed or dislocated hip
Disruption of normal tight fit between the femoral head and acetabulum
Growth and development of acetabulum depend on femoral head within
10/1000 positive physical exam, 1/1000 dislocated hip

8. DDH Etiology multifactorial Risk factors Mechanical (breech)
Genetic (family history)
Hormonal (female)
Risk factors
Left hip
80% of patients (40% on right)
Female
80% of pts
Family history
1.5X risk
Breech
7X risk
Others: firstborn, prematurity, oligohydramnios, torticollis, metarsus adductus

9. detection and screening
Physical exam
All newborns
Ortolani, Barlow, Galeazzi
Positive exam (clunk, asymmetry) should be referred to orthopaedic surgeon
with or without ultrasound
Equivocal exam (click, mild asymmetry) re-examine at 2 weeks
Hip clicks do not correlate with hip dysplasia
If exam at 2 weeks negative or equivocal, consider risk factors
Older child (>3 months)
Asymmetric/decreased abduction
Galeazzi sign, asymmetric skin folds,
Abductor lurch

10. detection and screening
Physical Exam - Bilateral Dislocation
Limited Abduction
Wide Perineal Space
Prominemt Gr. Trochs.
Lumbar Lordosis
Waddling Gait
Broad Flat Buttocks 12

11. imaging Plain Radiography Ultrasonography Arthrography CT SCAN/MRI
Michael C. Albert, MD 14

12. ultrasound All aspects of use in hip dysplasia controversial
High inter and intra-observer variability
Excessive sensitivity
Uncertain natural history
Static and dynamic exam
Static coronal exam for coverage and angle
Dynamic transverse exam for subluxation

13. ultrasound Screening of all newborns not recommended
Most sensitive test
As many as 21 percent of newborns with normal physical exam have abnormal ultrasound
Cannot differentiate between immaturity and early DDH

14. ultrasound recommendations
Ultrasound recommended for equivocal exam or patients risk factors
Females with family history (44/1000)
Males and females with breech presentation (26/1000 and 120/1000)
Screening at 6 weeks of age
Monitor treatment

15. natural history Newborn natural history is variable DDH
Many patients improve spontaneously
DDH
Not painful during childhood
May have little or no functional disability
Does not delay development
Not worsened by parent behavior or positioning
Swaddling in extension

16. natural history
Hip pain and early degenerative hip disease in adulthood
20-50% of hip DJD

17. treatment
Goal: obtain and maintain reduction of femoral head to promote normal development of the hip and reverse pathologic changes
Acetabulum and femoral head remodel for many years after reduction
Early treatment  more potential for remodeling  better anatomic result  lower risk of DJD
No treatment option is entirely benign
Avascular necrosis of the hip
Poor natural history

18. pathological findings
Birth: Minimal
Continued Dislocation:
Soft Tissue Contracture
Deformation of Head/Acetabulum
Inverted Labrum
Constriction Inferior Capsule 15

19. treatment guidelines Acetabular dysplasia: Treatment controversial
May improve or resolve
Newborn: mild dysplasia or “immaturity” resolve in greater than 95% of patients
Remodeling possible in young child
Uncertain risk of DJD
Should at least be observed: some will go on to subluxation or dislocation

20. treatment guidelines Subluxation and Dislocation
0-6 months: Pavlik harness/abduction brace
6 months – 2 years, failed bracing: closed reduction, possible open reduction
> 2 years: open reduction
>3 years: open reduction with femoral and pelvic osteotomy
Persistent subluxation or dysplasia after reduction
Pelvic/acetabular osteotomy

21. Pavlik Harness Prevents Hip Extension, Adduction Dynamic Splint
Flexion Straps Degrees
Abduction Straps Degrees
Confirm Reduction by U.S.
Do Not Use Over 3 wks if Irreducible

22. Pitfalls in the Use of the Pavlik Harness for Treatment of CDH Mubarak, et al JBJS 198121

23. Pavlik Harness Contraindications Teratologic Arthrogryposis
Spina Bifida
Ehlers-Danlos
Poor Family Dynamics
Age Over 9 mos. 22

24. success with Pavlik
>95% in Newborn 85% in mos. 50% in mos. 23

25. summary
Developmental dysplasia of the hip is a spectrum of abnormalities of the growing hip
Dysplasia  Subluxation  Dislocation
Natural history: hip pain and DJD in early adulthood
All newborns screened with physical exam
Early detection  early reduction  hip remodeling  better results
Early recognition also allows simpler treatment

26. Thank you!