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Developmental dysplasia of hip (DDH)

DR HAMZA SHAIKH

Developmental dysplasia of hip (DDH)

Definition

Spectrum of disorders of development of the hip that present in different forms at different ages Dislocation

Displacement of a joint with no contact b/w the articular surfaces

Subluxation

Displacement with some contact remaining b/w the articular surface

Dysplasia

Deficient development of the acetabulum

Teratologic dislocation

Distint form of the hip dislocation occur with other disorders


Dislocated before birth Have limited ROM Not reducibile on examination

Developmental dysplasia of hip (DDH)

Incidence

There is marked geographic and racial variation in the incidence of DDH Higher incidences are reported when screening uses both clinical examination and ultrasonography

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Etiology

Ligamentous laxity (often inherited)


Breech position (especially footling) Postnatal positioning (hips swaddled in extension) Primary acetabular dysplasia (unlikely)
Developmental dysplasia of hip (DDH)

Ligamentous Laxity

Newborn response to maternal relaxin hormones The newborn's response to maternal relaxin hormones may explain the higher incidence of DDH in girls. Newborn with DDH have higher ratio of collagen III to collagen I suggesting connective tissue disorder
Developmental dysplasia of hip (DDH)

Wynne Davies criteria for ligamentous laxity

Developmental dysplasia of hip (DDH)

Prenatal positioning

Strong association
Breech positions have higher risk of DDH

Knees extended breech (20%) Footling breech (2% incidence)

A. B. C. Developmental dysplasia of hip (DDH)

Low incidence of DDH 2% 20%

Postnatal position

Increase risk in babies wrapped with hip extension

Developmental dysplasia of hip (DDH)

Racial Predilection

Certain ethnic groups seems to be predisposed to DDH, whereas others apper immune Blacks and Asians have relatively low incidences of DDH, whereas whites and Native Americans have a higher incidence.

Developmental dysplasia of hip (DDH)

Associated conditions

Metatarsus adductus (1.5 10%) Torticollis (15 -20%) oligohydroamnios

Developmental dysplasia of hip (DDH)

Pathophysiology

Normal hip development

Starts at 7th week of gestation Cartilaginous femoral head and acetabulum is formed by 11th week of gestation Concavity of actabulum is determined by the structure within the acetabulum
Neonatal acetabulum is composed of cartilage

Developmental dysplasia of hip (DDH)

Hip development in DDH

Gradually progressive disorder with distinct anatomic changes At birth posterosuperior rim of the acetabulum loses its sharp margin and become flattened and ridge of thickened articular cartilage forms (neolimbus) Some unstable hips become normal with complete resolution of anatomic changes other eventually remains out of the socket permanently

Developmental dysplasia of hip (DDH)

Pathology of unstable hip (subluxatable but not dislocatable)

Loose hyperelastic capsule Elongated ligamentum teres Slight eversion of hypertrophied acetabular rim
Developmental dysplasia of hip (DDH)

Pathology of the dislocatable hip

Capsule stretched out Ligamentum teres markedly elongated Labrum is definitely everted

Neolimbus at the junction of labrum and hyaline cartilage Excessive acetabular antetorsion

Developmental dysplasia of hip (DDH)

Dislocated hip that is irreducible due to intra articular obstacles

Obstacles to reduction Inverted limbus Ligamentum teres Fibrofatty pulvinar

Developmental dysplasia of hip (DDH)

Iliopsoas tendon as an obstacle

hourglass contriction forms capsular isthmus

Developmental dysplasia of hip (DDH)

Acetabulum gradually remodels after stable reduction ( increase depth / anteversion) If hip remain dislocated, acetabulum becomes more anteverted and shallow Acetabular growth continued through 8 yrs of age

Developmental dysplasia of hip (DDH)

Natural history

Neonatal hip instability

Fate of unstable hip remains an enigma

60% of hips that exhibit Barlows sigh at birth spontaneously corrected in the first week of life and 88% in first 2 months (Barlow -1962)

Developmental dysplasia of hip (DDH)

CLINICAL PRESENTATION

The clinical presentation of congenital dysplasia of the hip varies according to the age of the child. So the treatment is different in different age groups.... Neonate Child 6 month to 18 months Toddler 18mths to 36mths Child 3yrs to 8 yrs age

Developmental dysplasia of hip (DDH)

neonate

In newborns (6 months old), it is especially important to perform a careful clinical examination because radiographs are not reliable in making the diagnosis of congenital dysplasia of the hip in this age group. Asymmetrical inguinal skin folds Ortolani test provocative maneuver of Barlow Klisic sign
Developmental dysplasia of hip (DDH)

Asymmetry

Asymmetric thigh, gluteal and popliteal fold

Apparent shortening

Developmental dysplasia of hip (DDH)

Ortolani sign

Barlows sign

Developmental dysplasia of hip (DDH)

Factors affecting reliablity of two test

Feel is quite delicate and requires just the right degree of relaxation on the part of the examiner as well as the infant High pitched snap, often felt at the extremes of abduction elicited by a circular motion
Originates in ligamentum teres / fascia lata / psoas

tendon

Developmental dysplasia of hip (DDH)

Klisic sign

Line projects halfway between the umbilicus and the pubis Helpful in clinical assessment of bilateral dislocation

Developmental dysplasia of hip (DDH)

infant

Asymmetrical inguinal skin folds Klisic sign

The first and most reliable is a decrease in the ability to abduct the dislocated hip because of a contracture of the adductor musculature. Galeazzi sign is noted when the femoral head becomes displaced not only laterally, but also proximally, causing an apparent shortening of the femur on the side of the dislocated hip . Developmental dysplasia of hip (DDH) may appear Bilateral dislocations

Reduce abduction

Developmental dysplasia of hip (DDH)

Galleazis sign
Apparent shortening of femur . Galeazzi test (If leg length discrepancy has been detected on measurement) Ask the patient to flex hips to about 45 o and knees to about 90 o . Make sure the heels are together on the couch, with medial malleoli touching. Look at the knees from the side to see if they are at the same level. If one is proximal to the other, there is femoral shortening; if one is distal to the other there is tibial shortening.

Developmental dysplasia of hip (DDH)

Walking child

Trendelenberg gait

B/L dislocationWaddling gait

Developmental dysplasia of hip (DDH)

Physical examination finding according to age

Neonates

Infants

Walking Child
Remains dislocated Klisic sign

Dislocatable Reducible

Dislocatable (occasionally) Reducible (ocasionally) Klisics sign Decreased abduction Galeazzis sign

Klisics sign

Decreased abduction
Galeazzis sign Limp Short leg Wide perinium Increased lordosis (bilateral)

Developmental dysplasia of hip (DDH)

Ultrasonography

X rays fails to show head until primary ossification center is visible in the head by 3 - 6 months of life

Ultrasonography show the relationship of the femoral head and acetabulum very well Graf recommended a lateral technique with tranducer placed over the greater trochanter.
Developmental dysplasia of hip (DDH)

Graf technique of U-sonography

Developmental dysplasia of hip (DDH)

Graf classification system

Baseline Inclination line Acetabular roofline Alpha angle Beta angle

Developmental dysplasia of hip (DDH)

B R

Developmental dysplasia of hip (DDH)

Graf classification

Developmental dysplasia of hip (DDH)

Treatment of type II

Varies widely Treatment decisions should be basd on ultrasonography examinations performed at 6 weeks of age rather than at birth

Developmental dysplasia of hip (DDH)

Literature regarding use of ultrasonography

More sensitive indicator of abnormality of the infant hip than radiography and screening with US does pick up clinically silent hips without increasing the rate of treatment for minor abnormalities that would resolve spontaneously
Too sensitive and results in overtreatment Grafs method is unreliable in children younger that 3 months of age
Ann R Coll Surg Engl 1996; 78:505. Radiology 1987; 165:647. J Bone Joint Surg Br dysplasia of hip Developmental 1989; 71:767.

(DDH)

Inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted US / clinical examination alone.

Cochrane Database Syst Rev. 2011 Sep 7;9:CD004595.


Developmental dysplasia of hip (DDH)

To conclude

Ultrasonography is a valuable adjunct to the detection of neonatal hip abnormalities

Should be used judiciously to avoid overtreatment of minor abnormalities


Very useful in detecting early treatment failure of Pavlic harness Negative results on US does not preclude later abnormalities

Developmental dysplasia of hip (DDH)

Plain radiograph

Plain radiography of the pelvis usually demonstrates a frankly dislocated hip in individuals of any age. . In newborns with typical DDH, however, the unstable hip may appear radiographically normal. As the child reaches 3 to 6 months of age, the dislocation will be evident radiographically

Developmental dysplasia of hip (DDH)

Plain radiography

Hilgenreiner's line is a line through the triradiate cartilages. Perkin's line, drawn at the lateral margin of the acetabulum, is perpendicular to Hilgenreiner's line Shentons line

Developmental dysplasia of hip (DDH)

Useful when head is not ossified

Acetabular index

Acetabular index

27.5 at birth 23.5 degree at 6 months 20 degree by 2 years

Developmental dysplasia of hip (DDH)

Superior gap H b/w proximal metaphysis and H line Medial gap D b/w femoral calcar and lateral pelvic wall H distance normally <7.5mm D distance normally<4-5mm If distance is more thanabove,then such case earlier treatment with closed / open reduction is advised..

Am J Orthop 29:773, 2000.)

Developmental dysplasia of hip (DDH)

Center edge angle of Wiberg

19 degree of children b/w 6 13 yrs of age 25 degree for 14 yrs or more In DDH ANGLE IS <20 DEG

Developmental dysplasia of hip (DDH)

Teardrop

Boundaries of teardrop true floor of acetabulum corresponds to the radiographic teardrop teardrop lies in the inferomedial portion of the acetabulum, just above the obturator foramen the lateral and medial lips corresponds to the external and internal acetabular walls, respectively.. the medial portion of the teardrop represents the quadrilateral surface and the lateral portion represents the medial aspect aspect of the acetabular floor)
Developmental dysplasia of hip (DDH)

Relation to Teardrops in AP view

Appears at 6 24 months in normal hip Delayed appearance in DDH Teardrop wider from superior to inferior in dislocated hip Better outcome is observed in hips in which tear drops appear within 6 months of reduction

Developmental dysplasia of hip (DDH)

ARTHROGRAPHY

Because the radiograph of the hip in an infant or young child cannot yield all the information desired in diagnosing or treating congenital dysplasia, arthrography is helpful in determining (1) whether mild dysplasia is present, (2) whether the femoral head is subluxated or dislocated, (3) whether manipulative reduction has been or can be successful, (4) to what extent any soft structures within the acetabulum may interfere with complete reduction of the dislocation,
Developmental dysplasia of hip (DDH)

(5) the condition and position of the acetabular labrum (the limbus), and (6)whether the acetabulum and femoral head are developing normally during treatment. Their criteria for accepting a reduction are medial dye pool of 7 mm or less and maintenance of reduction in an acceptable safe zone

Developmental dysplasia of hip (DDH)

SAFE ZONE

The safe zone concept can be used in determining the zone of abduction and adduction in which the femoral head remains reduced in the acetabulum. A wide safe zone (minimum of 20 degrees, preferably 45 degrees) is desirable, and a narrow safe zone implies an unstable or unacceptable closed reduction.

Developmental dysplasia of hip (DDH)

Arthrography

Done under GA Subadductor approach with image intensification is preferred needle is inserted below adductor longus 2 cm distal to its origin Direction toward contralateral sternoclavcicular joint

Inject 1 ml
Obtained images for each position of the hip

Developmental dysplasia of hip (DDH)

Magnetic Resonance imaging

Excellent anatomic visualization of the infant hip Not commonly used as required sedation and is expensive modality

Developmental dysplasia of hip (DDH)

Screening criteria

All neonates should be examined for hip instabilities Infant with risk factors be examined by experienced person and possibly ultrasonography

Family Hx of DDH Breech Torticollis Metatarsus adductus Oligohydramnios

Screening with US remains controversial

Developmental dysplasia of hip (DDH)

Treatment

Age based guidelines


Neonate 1 6 months 6 18 months

Pavlic harness for 6 weeks Pavlic harness for 6 weeks after hip reduces traction / close reduction followed by cast for 3 months. Open reduction if close reduction fails trial of close reduction / or primary open reduction +/- Salter osteotomy open reduction + femur shortening +/Salter osteotomy

18 -24 months 24 months 6 yrs

Developmental dysplasia of hip (DDH)

Treatment of young child to 6 months of Age)

(1

Developmental dysplasia of hip (DDH)

Pavlic harness

Developmental dysplasia of hip (DDH)

the Pavlik harness is a dynamic flexionabduction orthosis that can produce excellent results in the treatment of dysplastic and dislocated hips in infants approximately 4 to 6 months old. It consist of:
Chest band Shoulder strap Connecting strap Booties

Developmental dysplasia of hip (DDH)

The harness is applied with child in supine. The hip is placed in flexion (90 to 110 degrees). The anterior flexion strap is tightened to maintain this position. The lateral strap is loosely fastened to limit adduction, not to force abduction. Excessive abduction to ensure stability is unacceptable. The knees should be 3 to 5 cm at full adduction.
Developmental dysplasia of hip (DDH)

92% failure rate if the superior gap is 3 mm or less 94% failure rate if the medial gap is 10 mm or more, regardless of the type of splint used..

Developmental dysplasia of hip (DDH)

Four basic patterns of persistent dislocation have been observed after application of the Pavlik harness:

superior, inferior, lateral, and posterior.

Developmental dysplasia of hip (DDH)

If the dislocation is superior, additional flexion of the hip is indicated. If the dislocation is inferior, a decrease in flexion is indicated. A lateral dislocation in the Pavlik harness should be observed initially. As long as the femoral neck is directed toward the triradiate cartilage, as confirmed by radiograph or ultrasound, the head may gradually reduce into the acetabulum
Developmental dysplasia of hip (DDH)

Duration of pelvic harness Depends upon patients age at time of diagnosis and degree of instability. Full time wear = age of stability attended + 2 months Weaning time 2-4 hrs everyday To be doubled every 2 weeks

Developmental dysplasia of hip (DDH)

Follow up: it is essential to documentation of stability by. USG Clinical examination: negative ortoloni and barlow test X ray:immediately 1 month after weaning 6 month 12 month
Developmental dysplasia of hip (DDH)

Ossification beneath the labrum seen after successful early treatment of DDH

Developmental dysplasia of hip (DDH)

C/I to palvik harness

Child is walking age Hip cannot be centered towards to triradiate cartilage with 90-110 flexion d/l develops after several weeks of birth d/l associated with muscle imbalance like meningomyelocele downs syndrome,marfan syndrome

Developmental dysplasia of hip (DDH)

Craig splint

Von Rosen splint

Rigid immobilisation and forced reduction should be avoided


Developmental dysplasia of hip (DDH)

Treatment of the child (6 month to 2 years of Age)

Developmental dysplasia of hip (DDH)

General guidelines

Goal of the treatment are to obtain and maintain reduction of the hip without damaging the femoral head

Close / open reduction, may be preceded by period of traction


To reduce incidence of AVN To enable surgeon to obtain close reduction

Need for traction has been challenged

Developmental dysplasia of hip (DDH)

Traditional traction

Bryants traction

Despite many studies questioning its efficacy, traction continues to be used in many centers

Developmental dysplasia of hip (DDH)

Home based traction mechanism. Applied for 2-3 weeks


Developmental dysplasia of hip (DDH)

Close reduction

Should be performed in GA or deep sedation Manipulation should be avoided Reduction is achieved by flexion beyond 90 degrees and gradually abducting the hip, while lifting the greater trochanter Minimal force should be applied ROM to assess stability Adduct to the point of redislocation. Extend to the point of dislocation and also note if it require internal rotation to maintain reduction.
Developmental dysplasia of hip (DDH)

Abduct the hip to 40 to 45 degrees, and flex it to about 95 degrees . Excessive abduction should be avoided. We have found that the hips always are flexed less than they appear to be and are abducted more than they appear Spica cast immobilization is continued for 4 months. The cast can be changed at 2 months Radiographs or arthrograms can be obtained to ensure that the femoral head is reduced anatomically into the acetabulum.
Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Safe zone

Wide safe zone i.e min of 20 degrees, preferably 45 degree, is desirable and narrow safe zone implies an unstable or unacceptable close reduction

Developmental dysplasia of hip (DDH)

Open reduction

Indications

Failure to obtain stable hip with close reduction Unstable hips / excessive widening on arthrography (failed docking)

Approaches

Medial Anterior approach


Developmental dysplasia of hip (DDH)

Medial approach

First reported by ludloff (1913) Good approach for children 1 year of age and younger Disadvantages

Cannot do capsulorrhaphy Medial femoral circumflex vessel injury

Developmental dysplasia of hip (DDH)

optimal age for the medial approach: is of more value in the child younger than 18 months but older than 7 months

when this procedure is used in infants younger than 7 months, there may be a higher risk of AVN

Developmental dysplasia of hip (DDH)

- anatomical considerations: medial approach may occur either anteromedial (Ludloff Approach) posteromedial(Ferguson Approach) depending whether surgeon goes anterior or posterior to adductor brevis; procedure may involve division of the psoas tendon, since it can be an extra-articular barrier to reduction;
Developmental dysplasia of hip (DDH)

advantages:
minimum dissection & blood loss;

allows direct approach to common obstacles to reduction (such as the psoas tendon); psoas tendon, capsular constriction, & transverse acetabular ligament disadvantages: 1 poor access to acetabulum (neolimbus, ligamentum teres, & pulvinar); 2 does not allow capsulorraphy (which is
Developmental dysplasia of hip (DDH)

3 AVN: risk of AVN is about 15%; need for additional surgical procedures: 10-20%;

contra-indications: medial approach is usually not used once child who has begun to walk; medial approach not used when femoral head has migrated proximally;

Developmental dysplasia of hip (DDH)

Anterior approach

Somerville technique of anterior open reduction in congenital dislocation of hip.

Developmental dysplasia of hip (DDH)

o A, Bikini incision. o B, Division of sartorius and rectus femoris tendons and iliac epiphysis. o C, T-shaped incision of capsule. o D, Capsulotomy of hip and use of ligamentum teres to find true acetabulum.

oE, Radial incisions in acetabular labrum and removal of all pulvinar from depth of true acetabulum.

o F, Reduction and capsulorrhaphy aft excision of redundant


Developmental dysplasia of hip (DDH)

G, Developmental dislocation of right hip

. H, After anterolateral open reduction.


I, At age 7 years; note remodeling of femoral head and acetabulum.

Developmental dysplasia of hip (DDH)

Toddler 18months to 36 months

For these children with well-established hip dysplasia, open reduction with femoral or pelvic osteotomy, or both, often is required. Persistent dysplasia can be corrected by a redirectional proximal femoral osteotomy in very young children. If the primary dysplasia is acetabular, pelvic redirectional osteotomy alone is more appropriate.

Developmental dysplasia of hip (DDH)

Open reduction with femoral shortening

To reduce pressure on the femoral head


Should be considered when hip is reduced in a child >2yrs of age Blade plate / simple lateral plate fixation may be used Derotation is considered when internal rotation positiion is severe during trial reduction

Developmental dysplasia of hip (DDH)

Open reduction with innominate osteotomy

Indicated if more than one third of the head is visible when hip is in extension and neutral rotation and abduction
Most children older than 18 months require osteotomy

Developmental dysplasia of hip (DDH)

Child 3 to 8 yrs of age

Challenging
Femoral head is more proximal Muscles are more severely contracted

Femoral shortening is an essential part of management More likely need of primary acetabular reorienting osteotomy

2 3 yrs of age assess intraoperative regarding the need > 3 yrs usually needed

Posterior dislocation is a potential complication when combining an acetabular procedure with femoral shortening

Esp. if femur is derotated

Developmental dysplasia of hip (DDH)

Anteverted femur and acetabulum in untreated congenital dislocation of hip. B, Redirection of femoral neck by snug anterior capsulorrhaphy. C, Capsulorrhaphy and Salter innominate osteotomy. D, Capsulorrhaphy, Salter innominate osteotomy, and full femoral derotation. Combined in excess, this sequence can produce posterior dislocation.

Developmental dysplasia of hip (DDH)

E, Open reduction, primary femoral shortening, derotation osteotomy, and Salter osteotomy produced fixed posterior hip dislocation in 5year-old girl.

Developmental dysplasia of hip (DDH)

Recommended osteotomies for DDH


Osteotomy
Salter

Age
18 months 6 yrs

Indication
Congrous hip reduction; <10-15 degrees of correction of acetabular index required 10-15 degree correction of acetabular index required; small femoral head, large acetabulum Residual acetabular dysplasia; symptoms; congrous joint Incongruos joint;

Pemberton

18 months 10 yrs

Steel/ Ganz

Late adolescence to skeletal maturity Adolescence to skeletal maturity


Developmental dysplasia of hip (DDH)

Shelf / chiari

Complications and pitfalls

AVN Inadequate reduction and redislocation Residual dysplasia

Developmental dysplasia of hip (DDH)

Avascular necrosis

Etiology

Iatrogenic problem almost always preventable Occurs when excessive pressure is applied for an extended time to the femoral head Extreme abduction / internal rotation Can also occurs when the muscles crossing the hip are so contracted that they compress the reduced femoral head against the acetabulum
Excessive pressure can be avoided by femoral shortening
Developmental dysplasia of hip (DDH)

Diagnosis

1. Failure of initial appearance of the capital femoral ossification center during one year or longer following reduction. 2. Failure of continued chondro-osseous transformation and maturation of an existing epiphyseal ossification center during one year or longer following reduction. 3. Broadening of the femoral neck (metaphysis) during one year following reduction. 4. Increased radiographic density of the capital femoral ossification center followed by the radiographic appearance of fragmentation. 5. Residual deformity of the femoral head and neck when ossification is complete.

Greater trochanter is not affected by AVN and will continue to grow


Developmental dysplasia of hip (DDH)

Classification

Developmental dysplasia of hip (DDH)

Bucholz Ogden system


. A, Normal femoral head at 2 months (a), 1 year (b), and 9 years (c) of age.

B, Type I: a, sites of temporary vascula occlusion; b, irregular ossification in secondary center; c, normal epiphyseal contour, slight decrease in height of capital femoral ossification center.

C, Type II: a, probable primary site of vascular occlusion; b, metaphyseal and epiphyseal irregularities; c, premature fusion of lateral metaphysis and epiphysis.

Developmental dysplasia of hip (DDH)

D, Type III: a, sites of temporary vascular occlusion; b, impaired longitudinal growth of capital femoral epiphysis; c, irregularly shaped femoral head

. E, Type IV: a, sites of temporary vascular occlusion; b, impaired longitudinal and latitudinal growth; c, premature epiphyseal closure.
Developmental dysplasia of hip (DDH)

AVN remains a poorly understood complication of the treatment of DDH. Conclusions about prevention and treatment are difficult to reach because 1 the diagnostic and classification criteria have not been validated. 2 controversies over time of reduction to be attempted. 3 controversies over preoperative traction.

Developmental dysplasia of hip (DDH)

Treatment Kalamchi type I: Observation / Bracing. Kalamchi type II: Observation / Varus osteotomy &/or proximal epiphysiodesis. Kalamchi type III/IV: Apophyseodesis or distal trochanteric transfer for trochanteric overgrowth. Shoe lift or properly-timed epiphysiodesis for limb length inequality.

Developmental dysplasia of hip (DDH)

Potential sequence of AVN

femoral head deformity, acetabular dysplasia, lateral subluxation of the femoral head, relative overgrowth of the greater trochanter, and limb-length inequalities; osteoarthritis is a common late complication

Developmental dysplasia of hip (DDH)

Intervention

Anatomic effects can be altered by appropriate intervention


Trochanteric epiphysiodesis Trochanteric advancement Intertrochanteric double osteotomy Lateral closing wedge valgus osteotomy with trochanteric advancement
Developmental dysplasia of hip (DDH)

Tip lies at the level of center of femoral head Distance of a tip is 2 times the radius of femoral head

Developmental dysplasia of hip (DDH)

Trochanteric epiphysiodesis

Relative trochanteric overgrowth can be prevented by performing a trochanteric epiphysiodesis

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Trochanteric advancement

Considered when an objectionable abductor limp result from trochanteric overgrowth

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Lateral advancement of greater torchanter

Indicated when the neck is short and the trochanter has not grown above the femoral head with abductor limb

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Intertrochanteric double osteotomy

To improve the function of hip when the trochanter is markedly overgrown, abutting the pelvis and the femoral neck is very short First step is to release hip adductors and iliopsoas through separate medial incision necessary to relieve pressure on the head Two osteotomies

At the base of greater trochanter at the level of upper border of the femoral neck Through the upper end of the femoral shaft above the lesser trochanter

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Lateral closing wedge valgus osteotomy with trochanteric advancement

Coxa vara with trochanteric overgrowth

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Reconstructive procedure for dysplasia

Dysplastic hips with concentric reduction


8-9 yrs of age
Salter innominate osteotomy Pemberton osteotomy

Older children / adolescents


Steel triple pelvic osteotomy Sutherland double ostetomy Ganz osteotomy (Bernese) Tonnis procedure Dega osteotomy

Dysplastic hips that cannot be cocentrically reduced


Chiari osteotomy Shelf procedure

Developmental dysplasia of hip (DDH)

Salter innominate osteotomy

Displaces acetabulum in an anterolateral direction Salter's osteotomy of the innominate bone redirects the entire acetabulum so that its roof covers the femoral head anteriorly and superiorly.

Developmental dysplasia of hip (DDH)

Indications

Acetabular dysplasia persisting after primary treatment Dysplasia discovered in an untreated child Failure of the acetabular angle to improve within 2 years after reduction Peristent dysplasia after 5 years of age

Appropriate for children b/w 2 9 year4

Children < 18 months usually do not have iliac wings that a thick enough to support the bone graft Children > 9 yrs, not enough movement of the acetabular fragment is achieved to cover head

Developmental dysplasia of hip (DDH)

Prerequisites for success of osteotomy


1. The femoral head must be positioned opposite the level of the acetabulum. This may require a period of traction before surgery or primary femoral shortening. 2. Contractures of the iliopsoas and adductor muscles must be released. This is indicated in subluxations and dislocations. Open reduction is performed for hip dislocation, but usually is unnecessary for hip subluxation. 3. The femoral head must be reduced into the depth of the true acetabulum completely and concentrically. This generally requires careful open reduction and excision of any soft tissue, exclusive of the labrum, from the acetabulum. 4. The joint must be reasonably congruous. 5. The range of motion of the hip must be good, especially in abduction, internal rotation, and flexion. dysplasia of hip (DDH) Developmental

Approach

Bikini incision Anterior approach Rectus femors origin identified landmark Straight osteotomy with Gigli saw from AIIS to sciatic notch Acetabular portion displaced in an anteroinferior with bone clamp Leg in figure of four Bone graft in placed and fix with threaded pins Hinge on symphysis pubis

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

One and a half hip spica with hip in a stable position Radiograph in cast to assess the position of bone graft Ensure that it has not collapsed

In older patients cancellous screw are used and spica cast is not necessary Cast removed at 6 weeks in G/A and pins removed ROM and weight bearing allowed with support FWB is resumed after 3 weeks When open reduction is combined with Salter osteotomy additional immoblization in abduction cast for 4 weeks is recommended

Developmental dysplasia of hip (DDH)

Complication

Sciatic nerve injuries


Use of Gigle saw in the sciatic notch Always protect the cut with Hohman retracters

Femoral nerve injuries

Excessive retraction across pelvic brim

Loss of position of pins

Proper placement i.e two pins with one going behind the acetabulum and second should be placed over the acetabulum fixing the bone graft

Developmental dysplasia of hip (DDH)

Kalamchi modification of Salter osteotomy Distal fragment is placed in proximal notch Thus reduces pressure on femoral head

Developmental dysplasia of hip (DDH)

Pemberton acetabuloplasty

The term acetabuloplasty designates operations that redirect the inclination of the acetabular roof by an osteotomy of the ilium superior to the acetabulum followed by levering of the roof inferiorly Reposition acetabulum to improve anterior and lateral coverage of femoral head

Osteotomy begins anteriorly at AIIS and proceed posteriorly to enter triradiate cartilage

Developmental dysplasia of hip (DDH)

Osteotomy hinges through triradiate cartilage and as it is opened, the fragment is pushed anterolaterally to fill with bone graft Contraindicated if the acetabulum is small relative to the size of the femoral head

Complications

Premature closure of the triradiate cartilage Acetabular growth centers damage

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Dega osteotomy

Increase acetabular coverage anteriorly, centrally or posteriorly Osteotomy starts above the acetabulum and proceed into the triradiate cartilage behind and beneath the acetabulum, leaving an intact hinge poseriorly Placement of wedges determines the area of acetabular coverage
Developmental dysplasia of hip (DDH)

A, Skin incision. B, Osteotomy line is marked on lateral cortex of ilium; guidewire is inserted to exit just above horizontal limb of triradiate cartilage. C, Osteotome penetrates inner cortex. D, View from inner side of pelvis shows intact posteromedial cortical hinge; length of intact inner cortex depends on amount of anterior and lateral coverage desired.

Developmental dysplasia of hip (DDH)

E, Osteotomy is levered open with osteotome or small lamina spreader.

F, Two grafts large enough to keep osteotomy open at premeasured height are inserted. G, Larger graft is inserted anteriorly; posterior graft should be smaller to avoid loosening anterior graft.

Developmental dysplasia of hip (DDH)

Steel osteotomy

Also known as Triple osteotomy Osteotomies through the ilium and both pubic rami Pubic ramus approached through transverse medial incision in the patient groin Ischium is also approached through the same incision and is transected Innominate osteotomy through another incision

Complications

Acetabular fragment is displaced and rotated to provide anterolateal coverage of the femoral head Nonunion of osteotomy sites Excessive external rotation of the acetabulum
Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Ganz osteotomy

Indicated for all degree of dysplasia in skeletally mature individual Advantage

Single approach Large degree of correction in all planes Maintenance of blood supply to the acetabulum Intact posterior column Minimal disruption of hip abductors No alteration of pelvic birth outlet

When necessary, a femoral varus producing osteotomy may be obtained to establish optimal relationship
Developmental dysplasia of hip (DDH)

Procedure

Anterior approach / Ilio inguinal approach First cut is the ischial cut begin distal to acetabulum and direct posteriorly aiming to the ischial spine

Second cut is superior pubic ramus cut


Third cut is just inferior to ASIS cut ends just lateral to pelvic brim Fourth cut is made b/w first and third cut with curved osteotome Schanz pin is then placed in acetabular fragment for positioning Final fixation with 3.5 mm long cortical screw with 2 3 screws from proximal to distal
Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Long and steep learning curve complications

Excessive lateral displacement of the acetabular fragment with blocked hip abduction

Displacement of osteotomy with early weight bearing


Nonunion of pubic and ischial osteotomies Lateral femoral cutaneous nerve damage (50%) Femoral nerve palsy Heterotopic ossification

Developmental dysplasia of hip (DDH)

Spherical acetabular osteotomy (dial osteotomy)

Technically challenging procedure Allow rotational repositioning of the acetabulum through a wide range and are stable without disrupting the pelvic ring

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Chiari osteotomy

Indicated when it is no longer possible to achieve a concentric reduction of the hip

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Osteotomy is made just above the acetabulum, and curves to match the acetabular contour and slopes upward from lateral to medial

Acetabular fragment is displaced medially and is held there with pins or screw Inaccurate placement of osteotomy most frequent complication
Developmental dysplasia of hip (DDH)

Shelf procedures

Shelf procedures commonly have been performed to enlarge the volume of the acetabulum; however, pelvic redirectional and displacement osteotomies have largely replaced this type of operation. Indication Hip in which concenteric reduction cannot be obtained and deficient acetabulum that cannot be corrected by redirectional pelvic osteotomy is the primary indication for this operation.

Developmental dysplasia of hip (DDH)

Before surgery, determine the centeredge angle of Wiberg from anteroposterior standing pelvic radiographs, and draw a normal centeredge angle (about 35 degrees) on the film . Measure the additional width necessary to extend the existing acetabulum to achieve the normal angle.

This determines the width of the augmentation; this measurement added to the depth of the slot gives the total graft length.

Developmental dysplasia of hip (DDH)

Slotted acetabular augmentation (Staheli)

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)

Wilson shelf procedure

Developmental dysplasia of hip (DDH)

Developmental dysplasia of hip (DDH)