Developmental Dysplasia of Hip Joint1

(DDH)
Definition:
Child that has only congenital dislocation of hip and is not as an associated
symptom in other syndromes (Otherwise DDH, the child is normal)
It is associated with:
(A) Insignificant delay in milestone.
(B) Normal bone anatomy.
(C) Normal muscle tone.
(D) Not associated with any other syndromic symptoms.
Stability2 of Hip mainly depends on the static (Bony stability), because the
acetabulum forms a semi-constrained joint with the femur.
Not all children are born with DDH, it can develop during the months of life as the
child grows due to congenital acetabular dysplasia3.
The most common type of dislocation in children is superior dislocation, that is
caused mainly by femoral adduction inside the uterus which is predisposed by:
1- First time of giving birth (Primiparas).
2- Oligohydramnios (It is a condition in pregnancy characterized by a
deficiency of amniotic fluid).
3- Twin Pregnancy.
4- Macrosomia. (Caused by GDM).

1
Mainly Unilateral, but 25% of cases are bilateral.
2
Femur is oriented upward and forward, while the acetabulum is oriented downward and forward; which make
the anterior part less covered and the superior part moderately covered and the posterior part well covered.
Although the anterior dislocation appears to be the most obvious type that can happen, it is not common in
children because the position to allow it is not feasible (It is extremely rare and predisposed by butt breech
presentation.
3
Means shallow acetabulum that allow the hip to subluxate then dislocate.
DDH is mainly common in white females4 more than males and in the left5 hip
more than the right hip.
For dislocation to happen, it requires:
1- Congenital acetabular6 dysplasia
2- Packing problem (High hip adduction or Butt breech presentation).
3- Ligamentous laxity.

Pathological anatomy:
(A) Bony and capsular:
1- Shallow dysplastic acetabulum.
2- Pulvinar (Pathological extrasynovial fibrous fatty tissue that occupy the
acetabulum).
3- Ligamentous teres stretch and thickening to adapt the new settings.
4- Inversion of transverse acetabular ligament inside the acetabulum.
5- Eversion, at dislocating hip, followed by inversion, at dislocating hip, the of
the labrum.
6- Stretched and capacious capsule that is wedged between the head of femur
and the ilium, causing capsular fibro-cartilaginous metaplastic changes
forming a false acetabulum.
7- Hourglass deformity of hip joint capsule, caused by iliopsoas tendon
constriction (True acetabulum medially and dislocated hip laterally)

4
Because of the ligamentous laxity.
The incidence of hip instability in girls stabilized after 21 days, after the metabolism of relaxin hormone in their
blood stream.
5
Because the most common position in uterus is left occipitoanterior presentation and freedom to do abduction
will be less because the pelvis is too tight to allow abduction on the left side.
6
The only mono-compartmental joint that have a ligament (ligamentum teres) in it.
 (B) Muscles:
Shortened hip adductors and flexors to adapt the new position which leads to
inability to stretch the muscles to the full passive range, which decrease the
stimulation of bone growth.
Why does in case of DDH flexion but not adduction deformity happen?
Although the same pathology exists, the ROM affected in extension arc of
motion is far more affected than the ROM affected in abduction arc of motion.
(The whole passive extension is lost, while not the whole passive abduction is
lost). The patient will suffer from flexion deformity and adductor tightness.
(C) Biomechanical:
1- Neck shaft angle7: Its main function is to widen the medial compartment to
allow more space for the adductor muscles (That represent 25% of the
lower limb muscles) and to make greater trochanter more lateral to
increase the lever arm of abductors and avoid pelvic drop. (Both of these
functions provide coronal plan balance during walking). In case in DDH and
obese and tall patient, it continues to be high (Persistently high).
2- Femoral anteversion8:
As the child learn to sit, he usually does weight bearing on both ischial
tuberosities and greater trochanters, which by the effect of shear forces
9
between weight bearing and ground reaction force it will decrease10.
So in case of DDH, there is persistently high femoral anteversion.
Clinical picture
(A) Infants:
1- Mother complains of inability to change diapers (Inability to passively
abduct the lower limb.
2- Skin creases over the thigh is crumbled(Asymmetric), caused by the
shorter dislocated leg.
7
At birth it is high and decrease with time till reaching normal, it decreases with standing and walking by the effect
of weight bearing and GRF with the start of standing by the action of shear forces on the femur and acetabulum.
8
High at birth to make the greater trochanter more lateral and decrease the widening of the pelvis. It decreases
with time to 15 degrees by sitting.
9
This extremely important deforming correcting forces is cancelled by W-shaped sitting, so parents are advised to
avoid it.
10
In case of obesity and high weight, coxa vara is common.
 3- Perineum on one side is different from the other side, because of the
adducted and flexed of hip caused by the dislocation.
(Β) Walker:
1- Pelvic is leveled during standing ( Despite the discrepancy), by making
Flexion in one hip, while the other is extended.
2- Physiological Trendelenburg sign (Using lateral trunk lurching). It is not
Diagnostic in the first 4 years because waddling11 is normal in the 1st 4
years.
3- Walk with backward lurching (Back hyperlordosis).

Clinical examination:
1- Barlow’s test: Adducting the hip.
2- Ortolani’s test: Abducting the hip, clunk sound is a positive sign.
3- Thomas test: For flexion deformity, patient is supine with both leg
extended and thighs are on the bed. Positive signs are hyper-lordosis of the
spine12(Masking of flexion deformity) or inability to maintain the hip
extended on the bed (flexion hip and knee).
To confirm, flex the non-affected hip till maximum ROM; the spine will flex
and loss hyper-lordosis and the affected hip will flex and you can measure
the deformity.
4- Prone test: Prone with the pelvis on the edge of the bed and legs are
hanging and knee flexed. Thigh is lift up.
Normally it can be lift till up to 20° without any buttocks elevation from the
bed.
Positive sign is Buttocks elevation from the bed (The angle then should be
measured).
5- Galeazzi sign: For assessing leg length discrepancy.
Hip is 90° flexed and knee is 45° extended, Hip and heels are at the same
level.
Parallel parts are the discrepant parts.

11
It is a sign of abductor insufficiency.
12
Pelvispinal motion: 1- Ipsidirectional: Spinal motion followed by the pelvic motion, 2- Contradirectional: Pelvic
motion followed by spinal motion
NB: DDH causes Apparent LLD.
Apparent Vs True LLD:
In both: Measure from ASIS or umbilicus to the tip of medial malleolus, Pelvis is
leveled.
If you measure from ASIS (A point that is lateral to the measured limb) apparent
lengthening of the affected limb will appear. While if you measured from
Umbilicus (A point that is medial to the measured limb), apparent shortening of
the affected limb will appear.
Apparent: The non-affected limb should be parallel to the affected side (Pelvis
leveled and limbs are parallel)
True: The limbs are identical in both aspects. (If one is directed to the left, direct
the other to the same direction) (Pelvis leveled and limbs are symmetrical).

Radiological examination:
(A) X-Ray (AP view): First, Identify the plane of
the pelvis, which is located through the
triradiate cartilages. It represents the
horizontal plan of the pelvis and is called
Hilgenreiner's line.
Draw a perpendicular line on the
horizontal line from the outer most point
of the acetabulum (It is called Perkin’s
line), this will divide the hip joint to 4
quadrants.

Observe:
1- Head of femur: Normally it is located in the Inferomedial quadrant, in
subluxed hip it will be in the inferolateral quadrant, and in dislocated hip
will be located in the superiolateral quadrant.
 2- Shenton’s line: It is a line from the tanged of superior pubic ramus to the
neck of femur. It will break in case of dislocation.
3- Acetabular index13: It is an angle that is between a
line drawn along the margins of the acetabulum
and Hilgenreiner's line. As it increases (More than
20°) as it indicates that the acetabulum is
shallow/dysplastic and does not cover the
acetabulum in a proper way that provides stability.
(B) Frog lateral X-ray (The limb flexed at
the knee approximately 30° to 40°,
and the hip abducted 45°) (It is the
radiographic equivalent of Ortolani’s
test):
Function: The main function of it is
to differentiate between reducible
(Head of femur return to its normal position) or irreducible.
How to do it?
1- Draw a line that represent the anatomical axis of femoral shaft, it is
called Von-Rosen line.
Normally and in reducible hip, it should point to the triradiate cartilage.
In case of irreducible dislocation: It will point to a point located above
the triradiate cartilage.

Management:
 Surgery is contraindicated when the patient is less
than 6 months.
 Double diapers are used till the age of 2 weeks, then
followed by Pavlic harness after 2 weeks to maintain
90° hip flexion and 40° abduction. It is worn for 23
hours daily.
 After 2 weekss, follow up to assess the child’s compliance.

13
It decreases with age which means more hip stability.
  After another 2 weeks, Frog lateral x-ray is done to assess hip reduction. If
reduced, continue pavlic harness till the acetabular index is neutralized on
AP x-ray. If not reduced>> Discard pavlic harness.
 In case of irreducible hip, after 6 months open reduction and
capsulorrhaphy (infero-medialization of the capsule).
 In case of the child is more than 2 years, acetabular osteotomy is
recommended to avoid Head of femur AVN. It is associated with adductor
tenotomy, to give the ability to the surgeon to put the hip in a much stable
position without the risk of developing
AVN by the squeezing action of
adductors on the joint (By increasing
the safe zone of abduction at the
expense of the dangerous zone).
NB: Zones of hip abduction:
1- Relative adduction: It is the dislocation zone.
2- Ramsey safe zone of hip abduction
3- Extreme Abduction: Stable but very dangerous and can lead to AVN by the
squeezing action of the adductors.
 Risk of surgeries after 4 years is high because of the dislocation has become
very high and need a lot of work to relocate the hip.
 Options after 4 years:
(A) Do a full job surgery (Bony reconstruction, soft tissue reconstruction,..)
But It has a lot of complications:
I. High incidence of post-operative complication.
II. High incidence of AVN.
III. High incidence of joint stiffness after the operation
IV. Needs a lot of time to adapt the new position and walk, so the parents
should consent the surgery.
(B) Wait till the patient reach 21 years old and make arthroplasty.
What are the recommendation of the surgeons after 4 years?
1- If the patient is female and the DDH is bilateral, recommendation is for
arthroplasty, it is the most tolerable case.
2- If the patient is male and DDH is bilateral or unilateral, full job is
recommended. It is the least tolerable case.
3- If the patient is female and unilateral, it is left for the preference of the
family, more tolerable to wait than the unilateral of bilateral male DDH.