1. Developmental Dysplasia of the Hip
Dr.Abdulmonem Al Siddiky
Assistant professor & Consultant
Ped.Ortho.,Ped.Spine & Spinal deformities
KKUH , KSU

2. Overview Introduction Normal Development of the Hip
Etiology and Pathoanatomy
Epidemiology and Diagnosis
Treatment
Complications

3. Introduction Developmental Dysplasia of the Hip DDH - preferred term
Teratogenic hips
Subluxation
Dislocation-usually posterosuperior (reducible vs irreducible)
Dysplasia

4. Summary Risk Factors 1/1,000 born with dislocated hip
10/10,000 born with subluxation or dysplasia
80% Female
First born children
Family history (6% one affected child, 12% one affected parent, 36% one child + one parent)
Oligohydramnios
Breech (sustained hamstring forces)
Native Americans (swaddling cultures)
Left 60% (left occiput ant), Right 20%, both 20%
Torticollis or LE deformity

5. Normal Development Embryonic
7th week - acetabulum and hip formed from same mesenchymal cells
11th week - complete separation between the two
Prox fem ossific nucleus months

6. Normal Hip Tight fit of head in acetabulum Transection of capsule
Still difficult to dislocate
Surface tension

7. Pathoanatomy Ranges from mild dysplasia --> frank dislocation
Bony changes
Shallow acetabulum
Typically on acetabular side
Femoral anteversion

8. Pathoanatomy Soft tissue changes Intraarticular
Usually secondary to prolonged subluxation or dislocation
Intraarticular
Labrum
Inverted + adherent to capsule (closed reduction with inverted labrum assoc with increased Avascular Necrosis)
Ligamentum teres
Hypertrophied + lengthened
Pulvinar
Fibrofatty tissue migrating into acetabulum

9. Pathoanatomy Soft Tissue (Intraarticular) Extraarticular
Transverse acetabular ligament
Contracted
Limbus
Fibrous tissue formed from capsular tissue interposed between everted labrum and acetabular rim
Extraarticular
Tight adductors (adductor longus)
Iliopsoas

10. Tough Reductions… Obstacles to reduction Extraarticular Intraarticular
Tight iliopsoas and adductors
Intraarticular
Labrum
Ligamentum teres
Transverse acetabular ligament
Pulvinar
Redundant capsule (hourglass)
+/- limbus

11. Etiology and Epidemiology
Multifactorial
Genetics and Syndromes
Ehler’s Danlos
Arthrogryposis
Larsen’s syndrome
Intrauterine environmental factors
Teratogens
Positioning (oligohydramnios)
Neurologic Disorders
Spina Bifida

12. Diagnosis Newborn screening
Ortolani’s and Barlow’s maneuvers with a thorough history and physical
Warm, quiet environment with removal of diaper
Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity etc.)
Baseline Neuro and Spine Exam

13. Diagnosis Key physical findings Asymmetry Limb length- Galeazzi
Abduction ROM
Skin folds
Limp
Waddilng gait / hyperlordosis - bilateral involvement

14. Ortolani’s Maneuver
* After 3 months of age tests become negative

15. Barlow’s Maneuver

16. Diagnosis Some cases still missed
At risk groups should be further screened
AAP
Recs further imaging (e.g. US) if exam is “inconclusive” AND
First degree relative + female
Breech
Positive provocative maneuver (Ortolani or Barlow)
Referral to Orthopaedist

17. Imaging X-rays Ultrasound CT MRI Arthrograms
Femoral head ossification center
4 -7 months
Ultrasound
Operator dependent CT
MRI
Arthrograms
Open vs closed reduction

18. Imaging
Radiographs

19. Imaging
Radiographs

20. Imaging
Radiographs

21. Imaging
Radiographs

22. Imaging
Acetabular Index

23. Imaging
Acetabular Index

24. Imaging
Acetabular Index
< 30 wnl

25. Imaging

26. Imaging

27. Imaging

28. Imaging

29. Radiographs Summary Femoral head appears 4 - 7 months Shenton’s line
Perkin’s and Hilgenreiner’s lines
Inferomedial quadrant
Center Edge Angle (< 20 abnormal)
Acetabular index
Normal < 30 (Weintroub et al)
Tear drop*
Abnormal widening in DDH
*may be only sign in mild subluxation

30. Imaging Ultrasound Introduced in 1978 for eval of DDH
Operator dependent
Useful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum, documenting reducibility
Prox Femoral Ossification Center interferes
Requires a window in spica cast (avoid)

31. Ultrasound
Femoral head
Abductors
Ilium

32. Ultrasound
Femoral head
Abductors
Ilium

33. Ultrasound
Femoral head
Abductors
Ilium

34. Ultrasound
Femoral head
Abductors
Ilium

35. Ultrasound
Graf’s alpha angle

36. Ultrasound Graf’s alpha angle >60 = normal
*line w/ ilium bisects head 50/50

37. Natural History Newborn Variable
> 6 months more aggressive tx required due to more extensive pathology and decreased potential for acetabular remodeling
Abnormal Gait, Decreased Abduction and Strength, Increased DJD
Unilateral worse than Bilateral
Subluxation worse than Dysplasia

38. Treatment Options Age of patient at presentation Family factors
Reducibility of hip
Stability after reduction
Amount of acetabular dysplasia

40. Birth to Six Months Triple-diaper technique Pavilk harness (1944)
Prevents hip adduction
“Success” no different in some untreated hips
Pavilk harness (1944)
Experienced staff*
Very successful
Allows free movement within confines of restraints
*posterior straps for preventing add. NOT producing abd.

41. Birth to Six Months Pavlik harness Indications
Fully reducible hip*
Child not attempting to stand
Family
Close regular follow-up (every 1-2 weeks)
For imaging and adjustments
Duration
Childs age at hip stability + 3 months

42. Pavlik Harness Failures Poor parent compliance
Improper use by the physician
Inadequate initial reduction
Failure to recognize persistent dislocation
Viere et al 1990
Bilateral dislocation
Absent Ortolani’s sign
> 7weeks of age

43. Pavlik Harness Complications Avascular necrosis Femoral nerve palsy
Forced hip abduction
Safe zone (abd/adduction and flexion/extension)
Femoral nerve palsy
Hyperflexion
*Be aware of Pavlik Harness Disease
*Follow until skeletal maturity

44. Birth - Six months Closed reduction + Spica
Failure after 3 weeks of Pavlik trial

45. Birth - Six months Closed reduction General anesthesia Arthrogram
Safe zone - avoid AVN
+/- adductor tenotomy
Open reduction if concentric reduction not possible
Usually teratogenic hips in this age group

46. Open Reduction Medial approach Antero -lateral
Pectineus / adductor longus + brevis
Cannot address simeoultaneous bony work
Antero -lateral
Smith-peterson
Sartorius / Tensor Fascia lata

47. Open Reduction

48. 6 months - 4 years Present a more difficult problem 6 - 18 months
Prolonged dislocation
Contracted soft tissues
months
Closed reduction +/- adductor tenotomy
Spica in human position of 100 degrees of flexion and about 55 degrees abduction (3 months)
Abduction Orthosis 4 wks full time/4 wks nighttime
Open reduction (if closed fails)
Capsulorraphy
CT scan
Spica for 6 wks followed by PT

49. 6 months - 4 years 18 months - 4 years Closed reduction Open redcution
Reducibile - check arthrogram and medial dye pool
Irreducible - Open reduction
Open redcution
Tight - femoral shortening
Stable - +/- pelvic osteotomy

52. Femoral Shortening Schoenecker + Strecker 1984
Traction vs. Femoral shortening
56% AVN in traction group
0% AVN in femoral shortening

53. Pelvic Osteotomy
Persistent instability + dysplasia after open reduction + femoral shortening
Requires concentric reduction of a reasonably spherical femoral head
Usually based on surgeon preference
Salter and Pemberton 2 m/c in US

54. Pelvic Osteotomy Volume changing Pemberton Dega’s Hinges on triradiate
Requires remodeling of “new” incongruity
Provides more anterolateral coverage
Dega’s

55. Pemberton

56. Pelvic Osteotomy Redirecting Salter Triple innominate Ganz Dial
Osteotomy thru sciatic notch
Hinge thru pubic symphysis
Triple innominate
Ganz
Dial

57. Pelvic Osteotomy Redirecting Salter Triple innominate Ganz Dial
Osteotomy thru sciatic notch
Hinge thru pubic symphysis
Triple innominate
Ganz
Dial

58. Salter Osteotomy

59. Salter Osteotomy

60. Salter Osteotomy

61. Salvage or Shelf procedures
Chiari
Requires capsular metaplasia
Pain - main indication
Treatment of chronic hip pain in adolescents

62. Chiari Osteotomy

63. Chiari Osteotomy

64. Chiari Osteotomy

65. Chiari Osteotomy

66. Chiari Osteotomy

67. Avascular Necrosis

68. Avascular Necrosis Most common Not part of the natural history of DDH
Iatrogenic
Etiology unknown
Femoral head compression
Injury to blood supply
Excessive abduction
Sullivan et al 1997
Sig  blood flow w/ increasing abd angle

69. TX Summary Best if treated before 6 weeks of age 0 - 6 months of age
Pavlik
months
Closed vs open reduction and spica
months
Closed
Open +/- osteotomies

70. Summary Femoral shortening better than traction Pelvic osteotomies
Dega, Pemberton
Salter, triple innominate, Ganz
Chiari

71. Questions

72. Evaluation of a 4week infant who has a hip click reveals a positive Ortolani sign. Treatment should include:
A. traction, closed reduction, and spica casting.
B. triple diapers and reassessment in 1 month
C. an AP pelvis x-ray at age 4 months
D. Fitting of a Pavlik harness and reassessment in 2 weeks
E. an US of the hip, fitting of a Pavlik, and reevaulation in 3 months.

73. Evaluation of a 4week infant who has a hip click reveals a positive Ortolani sign. Treatment should include:
A. traction, closed reduction, and spica casting.
B. triple diapers and reassessment in 1 month
C. an AP pelvis x-ray at age 4 months
D. Fitting of a Pavlik harness and reassessment in 2 weeks
E. an US of the hip, fitting of a Pavlik, and reevaulation in 3 months.

74. A healthy 5-mo-old infant w/ DDH of the L hip has been treated in a Pavlik for 3 months. Exam shows limited ABD and a Galeazzi sign. Radiographs in harness were taken. Management should consist of:
A. an arthrogram and closed reduction
B. a change of the Pavlik to a Frejka pillow
C. no further Rx until the child is 6mos
D. Adjustment of the Pavlik and continuation of Rx
E. open reduction through a medial approach and spica

76. A healthy 5-mo-old infant w/ DDH of the L hip has been treated in a Pavlik for 3 months. Exam shows limited ABD and a Galeazzi sign. Radiographs in harness were taken. Management should consist of:
A. an arthrogram and closed reduction
B. a change of the Pavlik to a Frejka pillow
C. no further Rx until the child is 6mos
D. Adjustment of the Pavlik and continuation of Rx
E. open reduction through a medial approach and spica

77. A healthy 5-mo-old infant w/ DDH of the L hip has been treated in a Pavlik for 3 months. Exam shows limited ABD and a Galeazzi sign. Radiographs in harness were taken. Management should consist of:
A. an arthrogram and closed reduction
B. a change of the Pavlik to a Frejka pillow
C. no further Rx until the child is 6mos
D. Adjustment of the Pavlik and continuation of Rx
E. open reduction through a medial approach and spica

78. This is an x-ray of a 9-month-old infant who has intoeing
This is an x-ray of a 9-month-old infant who has intoeing. Exam of the hips show ABD of the Left hip to 75 degrees and the Right to 90 degrees. Both the Ortolani and Barlow signs are negative. Management should include:
A. observation
B. application of a Pavlik harness
C. closed reduction of the Left hip
D. open reductino of the Left hip
E. open reduction of the left hip with innominate osteotomy

82. This is an x-ray of a 9-month-old infant who has intoeing
This is an x-ray of a 9-month-old infant who has intoeing. Exam of the hips show ABD of the Left hip to 75 degrees and the Right to 90 degrees. Both the Ortolani and Barlow signs are negative. Management should include:
A. observation
B. application of a Pavlik harness
C. closed reduction of the Left hip
D. open reductino of the Left hip
E. open reduction of the left hip with innominate osteotomy

83. This is an x-ray of a 9-month-old infant who has intoeing
This is an x-ray of a 9-month-old infant who has intoeing. Exam of the hips show ABD of the Left hip to 75 degrees and the Right to 90 degrees. Both the Ortolani and Barlow signs are negative. Management should include:
A. observation
B. application of a Pavlik harness
C. closed reduction of the Left hip
D. open reductino of the Left hip
E. open reduction of the left hip with innominate osteotomy

84. The x-ray shows a AP pelvis of a 6yo girl who presents with a limp and intermittent pain in the right groin. Management should include:
A. A varus derotational osteotomy of the right femur
B. open reduction and adductor tenotomy
C. open reduction with femoral and pelvic osteotomies
D. PT for muscle strengthening and ROM exercises
E. longitudinal traction, closed reduction, and adductor tenotomy

86. The x-ray shows a AP pelvis of a 6yo girl who presents with a limp and intermittent pain in the right groin. Management should include:
A. A varus derotational osteotomy of the right femur
B. open reduction and adductor tenotomy
C. open reduction with femoral and pelvic osteotomies
D. PT for muscle strengthening and ROM exercises
E. longitudinal traction, closed reduction, and adductor tenotomy

87. The x-ray shows a AP pelvis of a 6yo girl who presents with a limp and intermittent pain in the right groin. Management should include:
A. A varus derotational osteotomy of the right femur
B. open reduction and adductor tenotomy
C. open reduction with femoral and pelvic osteotomies
D. PT for muscle strengthening and ROM exercises
E. longitudinal traction, closed reduction, and adductor tenotomy

88. Thank You