DEVELOPMENTAL DYSPLASIA OF THE HIP

To be presented
by
DR AJAYI ADEKUNLE
OUTLINE
• INTRODUCTION
• ANATOMY OF THE HIP JOINT
• CLASSIFICATION
• PATHOLOGY
• EVALUATION-
– History
– Examination
– Radiological evaluation
• TREATMENT -
– Conservative
– Surgical Management
• PROGNOSIS
• CONCLUSION
INTRODUCTION

• Developmental dysplasia of the hip (DDH) intially called

Congenital dislocation of the hip (CDH).
• DDH covers a spectrum of hip dysplasia and instability,
presenting from birth to early childhood.
• Result of both genetic and environmental factors, so that
family history is a risk factor but so also is breech birth
Definations of terms
• Dislocation : is defined as complete displacement of a
joint, with no contact between the original articular
surfaces.
• Subluxation : is defined as displacement of a joint with
some contact remaining between the articular surfaces.
• Dysplasia: is a radiographic finding of increased obliquity
and loss of concavity of the acetabulum, with an intact
Shenton's line
• Teratologic dislocation of the hip is a distinct form of hip
dislocation that usually occurs with other disorders.
INTRODUCTION

Spectrum of DDH
1.Complete Hip dislocation
2.Partial Hip Subluxation
3.Hip Dysplacia
4 Dislocatable hip
• Important features of the natural history of the condition:
Not all cases are found at birth; some develop during the 1st
year of life.
Not all hips are dislocated; some have only a shallow or
dysplastic acetabulum.
INCIDENCE:

• The neonatal hip instability in northern Europe is

approximately 1 per 1000 live births,
• Barlow (1962) described an incidence of 1:60; however
60 per cent stabilized by one week and 88 per cent by 8
weeks.
Girls : boys = 7:1.
left hip > right hip
1 in 5 cases is bilateral.
TYPES of DDH
• Classified into two
– TYPICAL
– TERATOLOGIC
• Typical DDH occurs in otherwise normal patients or those without defined
syndromes or genetic conditions
• Teratologic hip dislocations usually have identifiable causes such as arthrogyposis
or a genetic syndrome and occur at birth
-Irreducible
-False Acetabulum
-Defective Anterior Acetabulum “anteverted”
-Increase Femoral neck Antevertion
Aetiology and pathogenesis

• A positive family history for DDH is found in 12-33% of

affected patients.
• DDH is more common among female patients (80%). This
is thought to be due to the greater susceptibility of female
fetuses to maternal hormones such as relaxin, which
increases ligamentous laxity
Aetiology and pathogenesis
Intrauterine malposition
• Primigravida.
• Breech presentation (2-3%)
with extended legs favours
dislocation; this socalled
‘packaging disorder’
• Oligohydramnios ,primi
gravida and large baby
( crowding phenomenon ).
• Adduction and Extension
postnatally.
Aetiology and pathogenesis

Genetic factors.
• DDH tends to run in families and even in entire
populations .
• Two heritable features predispose to hip instability:
 Generalized joint laxity (a dominant trait)
 Shallow acetabula (a polygenic trait which is seen mainly
in girls and their mothers).
 4 out of 5 cases only one hip is dislocated.
Aetiology and pathogenesis
Wynne Davies criterial for ligamentous laxity
Hormonal factors
• high levels of maternal
(oestrogen, progesterone
and relaxin in the last few
weeks of pregnancy)
• may aggravate
ligamentous laxity in the
infant.
• Instability in premature
babies is rare.
Aetiology and pathogenesis

Others conditions
associated with high
incidence of DDH including
• Plagiocephaly,
• Congenital torticollis
• Postural foot deformities.
Aetiology and pathogenesis
Postnatal factors :
• Dislocation is very common in
Lapps and North American Indians
who swaddle their babies
• Rare in southern Chinese and
African Negroes who carry their
babies astride their backs with legs
widely abducted.
• Experimental evidence that
simultaneous hip and knee
extension leads to hip dislocation
during early development
(Yamamuro and Ishida, 1984).
Pathology
• 2 important mechanisms of normal hip development:
1. The proportionate growth of the acetabular triradiate
cartilages
2. The presence of a concentrically located femoral head.

• At birth the hip, though unstable, is probably normal in

shape but the capsule is often stretched and redundant.
Pathology

Changes in infancy occurs,

• Reflecting a primary dysplasia of the acetabulum
• The proximal femur adaptation to persistent instability and
abnormal joint loading
• The femoral head dislocates posteriorly but, with
extension of the hips, it comes to lie first posterolateral
and then superolateral to the acetabulum.
Pathology

• The cartilaginous socket is shallow and anteverted.

• The cartilaginous femoral head is normal in size but the
bony nucleus appears late and its ossification is delayed
throughout infancy.
• The capsule is stretched and the ligamentum teres
becomes elongated and hypertrophied.
Pathology
• Superiorly the acetabular
labrum and its capsular
edge may be pushed into
the socket by the
dislocated femoral head
• Fibrocartilaginous limbus
may obstruct any attempt
at closed reduction of the
femoral head.
Pathology

In the older child who has started bearing weight.

• Both the acetabulum and the femoral neck remain
anteverted and the pressure of the femoral head induces
a false socket to form above the shallow acetabulum.
• The capsule, squeezed between the edge of the
acetabulum and the psoas muscle, develops an
hourglass appearance.
• In time the surrounding muscles become adaptively
shortened.
Clinical features

Soon after birth

• Usually asymptomatic and must be screened
• Use of clinical tests of neonatal hip instability
supplemented by the selective use of ultrasound
examination.
• Ideally, the examination should be performed by an
experienced examiner.
• Ortolani test.
• Barlow test.
Clinical features

• BARLOW TEST
It is a provocative test
that attempts to dislocate
an unstable hip. Clinical Features
Ortolani's Test
Clinical features

INFANCY
• Difficulty in wearing diaper
• Skin fold asymmetry
• Limited hip abduction
Clinical features

• Unequal femoral lengths

(Shortening of the thigh,
the Galeazzi Sign ,by
placing both hips in 90
degrees of flexion and
comparing the height of
the knees.
Assymetric thigh fold Klisic Test

ASI
S
G
T
 Clinical Features Walking child
• Remains dislocated
• Klisic's sign
• Decreased abduction
• Galeazzi's sign
• Limp
• Short leg
• Increased lordosis (bilateral) FFD @ Hips
Trendelenburg's sign.
• There usually is excessive
internal and external
rotation of the dislocated
hips
INVESTIGATION Baselin
e

Ultrasonography
Acetabula
Roof
• 100% Diagnostic. r Line
• Static and dynamic ultrasound.
• Sequential assessment is straightforward
and allows monitoring of the hip during a
period of splintage. Acetabulu
• Alpha angle m Roo
• Beta angle f
• Bony coverage
1.< 50% coverage of the capital femoral
epiphysis.
2.Alpha angle < 60 degrees.
3.Blunted acetabular margin.
Inclination
Line
A, Standard static coronal (A) and transverse (B)
ultrasound
 blunting of bony
acetabulum pulvinar fat
hypertrophy

US image in 1-month-old girl with DDH shows α angle

US image shows measurement of α angle (thin (dashed line) is abnormal, measuring 43°. Acetabulum
diagonal line) in normal hip in 1-month-old boy, which is is shallow and femoral head is laterally dislocated.
more than 60°; β angle (thick line) is also within normal
range
Investigation

Plain x-rays
• X-rays of infants are difficult
to interpret and in the
newborn.
• Useful after the first 6
months
– Horizontal line of Hilgenreiner
– Vertical Perkins line
– Shenton line
Acetabular index,
 (A) with normal acetabular roof with weight bearing forces applied over entire surface and 24-year-old
woman (B) with dysplastic shallow acetabular roof with weight bearing forces distributed over smaller
area. Arrows indicate acetabular roof and arcs indicate weight bearing forces
Von Rosen view

In this view both hips are

Abducted, internally rotated
and extended
• Line is drawn along femoral
shaft, which intersect the
acetabulum
• In dislocated hip, it crosses
above the acetabulum
Investigation
• Center edge angle of Wilberg
In children 6 to 13 years of age, an angle
greater than 19 degrees has been reported as
normal, whereas in children 14 years of age
and older, an angle
greater than 25 degrees is considered normal
Investigation

The acetabular teardrop

• Appears betw 6 and 24 months of age in a normal hip, later in a
dislocated hip.
• D D Hip:the acetabular portion of the teardrop loses its
convexity and the teardrop is wider from superior to inferior
• Hips in which the teardrop appears within 6 months of
reduction have a better outcome than hips in which the teardrop
appears later.
•4 types have been noted:-
•Open , closed , crossed and
reversed.
•Also describe as U- or V-
shaped.
•V- shaped associated with
dysplatic hip and poor
outcome.
Investigation

Arthrography
• Subadductor approach with image intensification.
• Needle beneath the adductor longus, about 2 cm distal to
its origin.
• The needle is directed medially, aimed toward the
contralateral sternoclavicular joint
• 1 mL of contrast agent is injected.
• Help to access the depth and stability of reduction post
intervention
Investigation - Arthrography
Investigation
Magnetic Resonance Imaging
• Widening of iliac bone,
• Lateral drift of superior and
posterior portions of
acetabular floor,
• Overgrowth of acetabular
cartilage
• Convexity of posterior
portion of cartilage.
Kashiwagi and associates proposed an
MRI-based classification of hips with
DDH.
• Group 1 hips had a sharp acetabular
rim, and all were reducible with a
Pavlik harness.
• Group 2 hips had a rounded acetabular
rim, and almost all could be reduced
with a Pavlik harness.
• Group 3 hips had an inverted
acetabular rim, and none was
reducible with the harness
Screening
• Neonatal screening in dedicated centres has led to a
marked reduction in missed cases of DDH.
• Risk factors
- family history
- breech presentation
- oligohydramnios
- Presence of other congenital abnormalities are taken into
account in selecting newborn infants for special
examination and ultrasonography.
Complications of untreated DDH

• Degenerative hip disease – In Dysplastic & Subluxated hip

• Abductor lurch
• Unilateral dislocations cause limb length inequality.
• Ipsilateral valgus knee deformity
• Decreased agility
• Postural scoliosis
• Bilateral cases are associated with significant back pain
secondary to increased lumbar lordosis
Management

Is divided in 5 age related groups

1. Newborn (birth to 6months)
2. Infant 6 to 18month
3. Toddler 18 to 36months
4. Child 3 to 8years
5. Adolescent and young adult ( > 8 yrs. old)
Management
• Age of patient at presentation
• Family factors
• Reducibility of hip
• Stability after reduction
• Amount of acetabular dysplasia
Management

Splintage
• objective:
To hold the hips somewhat flexed and abducted; extreme
positions are avoided and the joints should be allowed some
movement in the splint.
• Golden rules of splintage:
(1) the hip must be properly reduced before it is splinted;
(2) extreme positions must be avoided;
(3) the hips should be able to move.
Management

Newborn
• Triple Diaper technique
Prevents hip adduction
“Success” no different in
some untreated hips
• Pavilk harness (1944)
Experiance staff
Very Successful
Allow for movement within
confine restrains
 Management- Pavlik harness
• Used in first 6 months , shows • Indication
excellent result in t/t of DDH. Fully reducible Hip
• It is dynamic flexion-abduction Child not attempting to stand
orthosis. Family
• c/i in children who are crawling or
• Close follow up 1-2wks for imaging and
fixed soft tissue contracture, or
adjustment
teratological dislocation present.
• Duration
• After application, radiograph is taken
Child age at hip stability + 3month
and confirm the reduction. Hip is
placed in flexion of 110 and abduction
Pavlik hareness is discontinued 6 weeks
to occur by gravity itself .
after clinically hip stability is obtained
Management

• Von Rosen’s splint is an H-shaped malleable splint.

• The Pavlik harness is more difficult to apply but gives the
child more freedom while still maintaining position
• Ilfeld and Von Rose Splint have high success rate with
fewer complication but not superior topavlik hareness
• Frejka pillow and triple diaper are not used because of
high rate of AVN
Management

Persistent dislocation of hip • .

• May be present after application of pavlik hareness , 4
basic pattern is observed
• Superior, inferior , lateral and posterior.
• If present following manuvre should be done
• Superior – additional flexion is required,
• Inferior – flexion should be decreased,
• Lateral – closed observation to see for direction of
femoral neck towards triradiate cartilage.
Management

THE FIRST 3–6 MONTHS

• US finding of the hip is reduced and has a normal cartilaginous
outline, no treatment is required but the child is kept under
observation for 3–6 months.
• Acetabular dysplasia or hip instability, the hip is splinted in a
position of flexion and abduction
• US is repeated at intervals until stability and normal anatomy
are restored or a decision is made to abandon splintage in
favour of more aggressive treatment.
Management

THE FIRST 3–6 MONTHS

• Absence USS :all infants with a high-risk background or a
positive Ortolani or Barlow test, as ‘suspect’ and to nurse them
in double napkins or an abduction pillow for the first 6 weeks

• Drawbacks to this approach:

(1) the sensitivity of the clinical tests is not high enough to ensure
that all cases will be spotted (Jones, 1994);
(2) those hips that are unstable at birth, 80–90 per cent will
stabilize spontaneously in 2–3 weeks
Management

Follow-up
• Whatever policy is adopted, follow-up is continued until the
child is walking.
• Sometimes, even with the most careful treatment, the hip may
later show some degree of acetabular dysplasia.
Management

PERSISTENT DISLOCATION: 6–18 MONTHS

• Failed early treatment, with incompletely reduced, or if the
child presents late with a ‘missed’ dislocation,
• The hip must be reduced – preferably by closed methods
• Open operation – and held reduced until acetabular
development is satisfactory.
Management

Closed reduction:Suitable after the age of 3 months

• Performed under general anaesthesia with an arthrogram to
confirm a concentric reduction.
• Lift the greater trochanter with the fingers, and abduct the hip
to reduce the femoral head – Hip flexion 120
• Stable Reduction - if the hip can be adducted 20 to 30 degrees
from maximum abduction and extended to below 90 degrees
without redislocation.
Management

Closed reduction:
• To minimize the risk of avascular necrosis, reduction must be
gentle and may be preceded by gradual traction to both legs.
• The hips should be stable in a safe zone of abduction, which
may be increased with a closed adductor tenotomy. Splintage
Management TRACTION
• Aim is to bring the femoral head to a “station” below
Hilgenreiner's line.
• Lorenz or Lange position of extreme abduction without
preliminary traction - 30% incidence of AVN.
• Same cast position was used after preliminary traction - 15%
rate of AVN.
• Child was placed in the “human position” of 90 degrees of
flexion and mild abduction, rate of AVN fell to 5%.
Traditional traction Bryant's traction
Management

Closed reduction:
• The concentrically reduced hip is held in a plaster spica at 60
degrees of flexion, 40 degrees of abduction and 20 degrees of
internal rotation.
• After 6 weeks the spica is changed and the stability of the hips
Surgical management

Indications
• Failure of concentric reduction of the femoral head in the
acetabulum
• Failure to obtain a stable hip with a closed reduction.
• Widening of the joint space between the femoral head
and the acetabulum after closed reduction.
• Unstable reductions
• Loss of reduction on follow up
• Advanced age
Open Surgery

Open reduction can be performed by

• Anterior
• Anteriomedial
• Medial
Anterior Approach Medial Approach

Better exposure Limited view

Calpsulorraphy No Calpsulorraphy

Pelvic Osteotomy possible Pelvic osteotomy not posible

Blood loss from extensive disection Minimal dissection

Stiffness of the joint Obstruction encouter directly

Surgical Management - Femoral Shortening
• In irreducible hip, femoral shortening facilitates reduction
• If considerable force is required to reduce the hip and the
reduction seems tight, the surgeon should perform a
shortening femoral osteotomy to decompress the joint.
• Femoral shortening should be considered when a
dislocated hip is reduced in a child older than 2 years of
age.
• Perform the shortening through a separate lateral incision.
• Blade plate or simple lateral plate fixation may be used
with an intertrochanteric or subtrochanteric osteotomy.
 Surgical Management - Femoral Shortening
• Preoperative supine radiograph by
measuring the distance from the
bottom of the femoral head to the
floor of the acetabulum (a to b). The
distance from b to c must equal the
distance from a to b.
• As a rule, the degree of hip
decompression is adequate if the
surgeon can, with a moderate
force, distract the reduced femoral
head 3 or 4 mm from the
acetabulum.
• Intertrochanteric Varus Osteotomy
and Internal Fixation with a Blade
Plate
Reconstructive Procedures for Dysplasia
Management - SURGICAL method
• A spica cast is applied and the
hip is splinted as described at
60* flexion, 30* abduction and
20* internal rotation.
• If stability can be achieved
only by markedly internally
rotating the hip, a corrective
subtrochanteric osteotomy of
the femur is carried out, either
at the time of open reduction
or 6 weeks later.
• In young children this usually
gives a good result
Surgical management
Peri- acetabular osteotomy

• Provides greater correctional acetabur index

• Reduce volume of Hip hoint
• Possibility of Growth disturbance
• Types
– Pemberton's
– Dial (Eppright)
– Wagner
– Dega's
– Genz osteotomy Bernese
Surgical Management

• Marked acetabular dysplasia,

acetabuloplasty – either a
-Pericapsular reconstruction of
the acetabular roof
(Pemberton’s operation)
- An innominate (Salter's
osteotomy which repositions
the entire innominate bone and
acetabulum.
 Surgical Management
PEMBERTON OSTEOTOMY
• Repositions the acetabulum to
improve anterior and lateral
coverage of the femoral head.
• Osteotomy is quite stable and
does not require fixation.
• Reduces the volume of the
capacious acetabulum.
• Contraindicated if the
acetabulum is small rela tive to
the size of the femoral head.
Management
• PERSISTENT DISLOCATION: 18 MONTHS – 4 YEARS
• Older child, closed reduction is less likely to succeed.
• Many surgeons would proceed straight to arthrography
and open reduction.
• Traction.
• Arthrography : clarify the anatomy of the hip and show
whether there is an inturned limbus or any marked degree
of acetabular dysplasia.
Management

• DISLOCATION IN CHILDREN OVER 4 YEARS

• Reduction and stabilization become increasingly difficult with advancing age.
• Children between 4 and 8 years – especially if the dislocation is unilateral – it
is still worth attempting,
• Risk of avascular necrosis and hip stiffness is reported as being in excess of
25 per cent.
• Unilateral dislocation in the child over 8 years often leaves the child with a
mobile hip and little pain.
• This is the justification for non-intervention, though in that case the child must
accept the fact that gait is distinctly abnormal.
• If reduction is attempted it will require an open operation and acetabular
reconstruction
Important Point

• Do not excise labrum only release of hip capsule during

reduction of irreducible femoral head.
• Labrum is essential for normal development of acetabulum.
• After the femoral head has been reduced
Gradual remodeling of Acetabulum Acetabular angle gradually becomes more
horizontal

Thickened cartilage will usually flatten out gradually

and allow the head to seat deeply.
“Docking the head”
• Harris suggested that a hip reduced by 4 years of age could
achieve “satisfactory” acetabular development. He found that
significant acetabular growth continued through 8 years of age

Complication
• Failed Reduction
• Avascular Necrosis
• High-riding dislocation:
Management

• Persistent dislocation in adults Adults their thirties or forties but

with increasing discomfort due to an unreduced congenital
dislocation.
• Walking becomes more and more tiring and backache is
common.
• Bilateral dislocation the loss of abduction may hamper sexual
intercourse in women.
• Severe Disability justify total joint replacement.
• The operation is difficult and should be undertaken only by
those with experience of hip reconstructive surgery.
Conclusion
• DDH intially refer to as CHD is a spectrum of disorder
which ranges from simiple joint instability, Hip dislocation,
Subluxation and Acetabula Dysplasia
• All neonate should be assess early to detect any
abnormalty in the hip joint and treatment should be
instituted.
• Reduction and Splintage are form of management which if
failure to achieve concentrically reduce femoral head may
require surgical intervention
Refeences
• APLEY'S SYSTEM OF ORTHOPEDIC AND FRACTURE
9TH EDITION
• DEVELOPMENTAL DYSPLASIA OF THE HIP BY
DR.NAVEEN RATHOR (RESIDENT DOCTOR) DEPT. OF
ORTHOPEDICS RNT MEDICAL COLLEGE UDAIPUR