1. DEVELOPMENTAL DYSPLASIA OF THE HIP
DAMASCUS HOSPITAL
Dr.MHD BASHAR ALBOSHI

2. Definition:
Developemental?!! DDH is a disorder that evolves over time.
The left hip> right hip.
bilateral hips> right hip alone.

3. Etiology: تداخل عدة عوامل مشتركة (1) الرخاوة الرباطية
(2) ( الوضعية المقعدية داخل الرحم).
Generalized familial
hyperlaxity

4. Etiology: (3)وضعية البسط التام للوركين بعد الولادة. (4)العرق:
أعلى لدى القوقاز والأمريكان المحليين.
أقل عند السود والأسيويين

5. Associated Conditions
Torticollis (15% have DDH)
Metatarsus Adductus(1.5-10%have DDH)

6. PATHOPHYSIOLOGY( NORMAL HIP DEVELOPMENT):
The hyaline cartilage
( triradiate cartilages)

7. Pathophysiology (secondary obstacles):
النسج الشحمية(pulvinar thickens).
الرباط المدور (متسمك ومتطاول)
الرباط المعترض( متضخم)
المحفظة(شكل الساعة الرملية)
Iliopsoas

9. Fatty tissue(pulvinar thickens).

10. Teres ligament (elongated and thickened)
Docking the head

11. subluxated dislocated Labrum: Cartilaginous acetabular lip.
Neolimbus:a ridge of thickened articular cartilage

12. Transverse ligament (hypertrophic)

13. Hourglass shape of the capsule by the iliopsoas tendon

14. Pathophysiology (secondary obstacles):
progressive
Shortened of pelvifemoral muscles

15. Figure 15-17

16. CLINICAL PRESENTATION(THE NEONATE):
Ortolani,s or Barlow,s sign
Sonographic morphology.

17. CLINICAL PRESENTATION(THE NEONATE):

18. CLINICAL PRESENTATION(THE NEONATE):
Barlow Ortolani
clunk

19. CLINICAL PRESENTATION(THE INFANT):
Limited Abduction
Galeazzi Sign
Hips 90degrees

20. CLINICAL PRESENTATION(THE INFANT):
Asymmetric Folds

21. CLINICAL PRESENTATION(THE INFANT):
recognize a bilateral dislocation.
Klisic Test
Anterior superior iliac spine
Greater trochanter
Dislocation
Normal

22. CLINICAL PRESENTATION(THE WALKING CHILD):
FIG15-24

24. Femoral Neck Anteversion

26. IMAGING STUDIES(ULTRASOUND)
identify a silent hip

27. IMAGING STUDIES(ULTRASOUND)
15-28

28. IMAGING STUDIES(ULTRASOUND)
BASELINE: line of ilium which intersects the bony and the cartilaginous portions of the acetabulum.
15-29
As the femoral head subluxates:
ALPHA angle
BETA angle

29. IMAGING STUDIES(ULTRASOUND)
The Ultrasound ( before 3 mo. )
Ilium
Abductor M.

30. IMAGING STUDIES(ULTRASOUND)
TABLE15-2

31. IMAGING STUDIES(RADIOGRAPHY)

32. IMAGING STUDIES(RADIOGRAPHY)
عند الوليد الذي لديه DDHقد يظهر طبيعي على الصورة البسيطة.
عندما يصل لعمر 3-6 أشهر يظهر الخلع شعاعيا.

33. IMAGING STUDIES(RADIOGRAPHY)
Acetabulum
السقف( أكثر ميلانا)
التقعر(مسطح)
الجدار الانسي( متسمك)
إنقلاب أمامي شديد

34. IMAGING STUDIES(RADIOGRAPHY)

35. IMAGING STUDIES(RADIOGRAPHY)
lateral
broken

37. IMAGING STUDIES(RADIOGRAPHY)
figure15-33
Useful in newborns.
Decrease with age.

38. IMAGING STUDIES(RADIOGRAPHY)
figure15-34

39. IMAGING STUDIES(RADIOGRAPHY)
Figure15-35
teardrop body:
Losees its convexity
Wider.
The presence of a teardrop at 6 months after reduction predicted a satisfactory outcome in 93% of hips.

40. IMAGING STUDIES(Arthrography )
(1) عسر التصنع الخفيف
(2) الخلع وتحت الخلع
(3) الرد
(4) إندخال النسج الرخوة
labrum (5)
(6) المراقبة أثناء العلاج

42. Screening Criteria ultrasound + clinical examination
all babies with the risk factors
ultrasound + clinical examination

43. TREATMENT Neonate: Pavlic harness ((6 weeks)).
1 to 6 months: Pavlic harness(( 6 weeks)) after hip reduces.
6 to18 months: traction?
(1) Closed reduction( cast 3 months)
(2)Open reduction( unsuccessful closed reduction)
< 12 months (Medial approach)
> 12 months (anterolateral approach)
18 to 24 months: Trial of closed reduction?
Or primary open reduction (anterolateral approach)
(+/-A salter osteotomy )
24 months to 6 years: primary open reduction (anterolateral approach) + femoral shortening . ((+/-A salter osteotomy ))

44. TREATMENT( NEONATE-6 MONTHS)
PAVLIK harness for 6 weeks after hip reduction
Hip flexion(120degrees).

45. TREATMENT( NEONATE-6 MONTHS)
فحص سريري طبيعي عند وليد+ شذوذ على الإيكو-----إيكو بعد 6 أسابيع--- شذوذ---علاج
إذا حدث خلع بعد 3-4 أسابيع رد مغلق أو مفتوح.

46. TREATMENT( 6-18 MONTHS)
Skin traction for 2 – 3 weeks
90D

47. TREATMENT( 6-18 MONTHS)
Closed reduction
(spica cast for 3 mo.)
>90D flextion
abduction30-40D
Internal rotation 10-15D
open reduction if closed reduction is unsuccessful !

49. TREATMENT(AFTER 18 MONTHS)
Primary open reduction

50. OPEN REDUCTION Medial Approach: ‌محاسنه: شق صغير,مواجهة الرد مباشرة.
مساوئه: ساحة رؤية ضيقة, لا يمكن إنجاز رأب المحفظة, أذية الشريان المنعطف الفخذي الأنسي.
Anterior approach:
ساحة رؤية أفضل, إنجاز رأب المحفظة

53. Medial Approach(Ludloff)

54. Prefer<1 yrs.
5-7 cm
1cm distal and parellel to the inguinal crease.
Centered over the anterior margin of the adductor longus

55. If necessary can ligate and section saphenous vein.
The adductor longus is sectioned at its origin and reflected distally.
At the anterior margin of the adductor longus the pectineus are identified.

56. (A) the hip is approached anterior to the pectineus, between the muscle and the femoral sheath.
Expose the iliopsoas tendon at its insertion to the lesser trochanter.
The femoral circumflex vessels retracted laterally.

57. (B)the hip approach posterior and medial to the pectineus .

61. Flexion:100 degrees.
Abduction:30 degrees
Cast: 3 months.

63. Anterolateral Approach

64. Skin incision is oblique(bikini incision)
Skin incision is oblique(bikini incision).((excellent exposure and cosmesis))
Begin 2/3 the distance from greater trochanter to the iliac crest,crosses the inferior spine,and extends 1-2 cm beyond the inferior spine.

65. Anterior Approach Smith-Petersen

66. OPEN REDUCTION(Anterior Approach Smith-Petersen):
Begin the incision at the middle of the iliac crest or, for a larger exposure, as far posteriorly on the crest as desired.

71. Must determine:
(1) Depth of acetabulum and inclination of its roof.
(2) Shape of femoral head ,and smoothness ,cartilage.
(3) Degree of antetorsion of femoral neck.
(4) Stability of hip after reduction.

72. Suture:
iliac apophsis.
rectus femoris,sartorius to their origins
Cast: flexion
45 D abduction
20-30 medial rotation

74. THANK YOU

75. MoKazem.com
هذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل الأطباء المقيمين في شعبة الجراحة العظمية في مشفى دمشق, تحت إشراف د. بشار ميرعلي.
الموقع غير مسؤول عن الأخطاء الواردة في هذه المحاضرة.
This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali.
This site is not responsible of any mistake may exist in this lecture.
Dr. Muayad Kadhim
د. مؤيد كاظم