1. • Dr. Sushil Paudel Management of
Developmental
Dysplasia of Hip

2. Developmental dysplasia of the hip (DDH) :
spectrum of disorders of development of hip that
present in different forms at different ages
Structures that make up hip are normal during
embryogenesis and gradually become abnormal
for a variety of reasons, chiefly fetal position and
presentation at birth (malposition of the femoral
head, abnormal forces acting on developing hip)
and laxity of ligamentous structures about hip
joint

3.  Evolves over time
 Syndrome in newborn:
instability of hip;
subluxated or dislocated,
dislocated position and
be reducible on
examination
 Over time, femoral head
becomes fully dislocated
and cannot be reduced by
changing position of the
hip

4.  Teratologic dislocation of the hip: distinct
form of hip dislocation that usually occurs
with other disorders
Dislocated before birth, have limited range of
motion, and are not reducible on examination.
Associated with other neuromuscular
syndromes, as myelodysplasia and arthro-
gryposis

5. PATHOGENESIS
Affected hip slides in &out
Flattenened posterior border NEOLIMBUS
of acetabulum (CLUNK)
birth Loose capsule
Everted labrum
corrected uncorrected
DOCKING OF THE
Secondary
FEMORAL HEAD
barriers

6. SECONDARY
BARRIERS
PULVINAR
LIGAMENTUM TERES
TR.ACETABULAR LIG
INVERTED LABRUM
CAPSULE
ILIOPSOAS
REDUCED-DOCKING
HOURGLASS CONSTRICTION
POINT OF REDUCIBILITY:?
HARRIS et al: 4 yrs “CHINESE FINGER TRAP”

7. ACETABULAR
UNREDUCED CHANGES
ACETABULAR ROOF FLATTENING
THICKENED MEDIAL WALL
DYSTROPHIC CARTILAGE
SUBCHONDRAL CYSTS
LOSS OF CARTILAGE
OSTEOPHYTES

8. Management

9. Making the Diagnosis
High index of suspicion
Identifying risk factors
Careful physical
examination
Provactive dynamic
tests
Risk baby evaluation by
USG
Radiological evaluation

10. Clinical Features : Neonates
BARLOW’S TEST ( bahar lo)

11. Clinical Features : Neonates
BARLOW’S TEST ( bahar lo)

12. Clinical Features : Neonates
ORTOLANI SIGN

13. Clinical Features : Neonates
ORTOLANI SIGN

14. Clinical Features : Neonates
Delicate “clunk” that is
palpable but not
audible
Repeat sequence 4-5
times to be certain of
findings
If both signs negative
but pt is high risk :
follow up is essential

15. Clinical features : Infants
 Progression from
instability to dislocation is
gradual process
 In some within a few
weeks
 others the hip dislocation
remains reducible up to 5
or 6 months of age.
 When the hip no longer
reducible, specific
physical findings appear

16. Limitation of Abduction
MOST RELIABLE SIGN

17. Galeazzi’s Sign

18. Asymmetric gluteal, thigh, labial folds

19. Telescopy

20. Klisic’s Test

21. Walking child:
LLD
↓Abduction
Tip-toe-walking
Trendelenberg gait
Waddling [B/L]
↑lumbar lordosis

22. Clinical Features : Walking Child
• Trendelenburg's sign
• Trendelenburg gait

23. Radiological evaluation
Dysplasia
Subluxation
Dislocation
Each stage has a different radiological
presentation

24. Ultrasonography
– lpha angle measures bony acetabuluBeta angle
measures cartilagenous acetabulum

25. Ultrasonography
• Harcke & Kumar technique:
– Dynamic examination with stress views that
mirror Barlow’s & Ortolani’s maneuver
Graf classification

26. Newborns 27.5 degrees
Radiographs 6 months
2 years
23.5 degrees
20 degrees

27. Centre – Edge Angle Wiberg
6 – 13 years >19 degrees
>14 years > 25 degrees

28. ANDREN-von ROSEN LINE
 AP X-ray: hip in 45 abduction and IR
 Describes the longitudinal relationship between
 long axis of femur and acetabulum

29. Imaging
• Radiographs

30. Imaging
• Radiographs

31. Imaging
• Radiographs

32. Imaging
• Radiographs

33. Imaging
• Acetabular Index

34. Imaging
• Acetabular Index

35. Imaging
• Acetabular Index
< 30 wnl

36. Tear drop
AP X-ray
Lateral:wall of acetabulum
Medial:lesser pelvis
Inferior :acetabular notch
Appears between 6-23 mo
[delayed in DDH]
V-shaped in DDH

37. False Profile view

38. Arthrogram
Severin [1941]
Normal appearance:
LABRUM:
*Thorn over the
femoral head
*A recess of joint
capsule overlies the
thorn

39. Arthrogram in DDH
SUBLUXATED HIP DISLOCATED HIP

40. Imaging Tools
• CT scan:
– Single section CT as check films
– Neglected C.D.H.
– Adolescent and adult
• MRI:
– Equivalent to arthrography

41. Diagnosis
Reduction
maintain
Intervene adverse natural history
Ensure normal adult hip

42. Screening
• All neonates should have a clinical
examination for hip instability
• Risk factors :
– breech presentation USG SCREENING
– family history
– torticollis
– oligohydramnios
– metatarsus adductus

43. CLINICAL & USG
normal normal
normal ABnormal
ABnormal
F/U till maturity
REPEAT AT 6 WKS
ABnormal normal
Clinical & USG normal
REPEAT AT 3 & 6 WKS ABnormal
Closed / open reduction

44. Infant 1 – 6 months of Age
First choice is PAVLIK
harness
Ensure hip > 90 degrees
flexion
AP radiograph
Does not have to be
reducible initially

45. Infant 1 – 6 months of age
weekly clinical examination & USG
By 3 weeks stable reduction must
Continue till radiographs show normal
acetabulum
Results :
 95% of initially dysplastic hips normal
 80% dislocated and not initially reducible were successfully reduced
 Higher dislocations had a higher failure rate
 The rate of AVN was 2.38%.
Grill F, Bensahel H, Canadell J, et al: J Pediatr
Orthop 1988; 8:1.

46. Pavlik harness
Standard of treatment worldwide
Upto 6 months
Contraindicated when there is major muscle
imbalance (myelomeningocele, AMC or
ligamentous laxity)

47. Complications of Pavlik Harness
• AVN
• Failure to reduce
• Femoral nerve
neuropathy
• Inferior dislocation
• Pavlik’s disease (flattening
posterolateral acetabulum)

48. Follow up
The child should be followed till
skeletal maturity
Increased risk of asymmetric physeal closure
Valgus deformity of the neck

49. Child 6 months to 2 years of age
• Closed or open reduction + adductor
tenotomy
• If closed reduction fails then surgeon should
be prepared for an open procedure

50. Closed reduction
Force should be avoided
Check for safe zone
Post reduction:
 Spica change every six
weeks plus stability
check
 Continue spica for 3-4
months

51. Safe Zone
20 to 30 degrees from
maximum abduction
extended to below 90 degrees
without redislocation
Safe zone can be improved
with adductor tenotomy

52. Open reduction
Unable to achieve
closed reduction
Widening of the joint
space
Unstable reductions
Loss of reduction on
follow up
Advanced age

53. Approach
Medial Anterior
 Minimal dissection  Better exposure
 Obstructions encountered  Capsulorrhaphy
directly  Pelvic osteotomy possible
 BUT..
 BUT..  Blood loss
 Limited view  Iliac crest apophysis and
 MFCA violation abductors damage
 No capsulorrhaphy  Stiffness of hip
 Secondary procedures

54. Medial approach

55. Anterior approach
• Smith-Peterson anterior
approach
• Stood the test of time
• More commonly used
• Bikini incision better
cosmetic results

58. Open Reduction with Femoral
Shortening
• Pressure leads to risk of AVN
• Better results than preoperative traction in older
children with less morbidity
When to do??
• Anticipated increased pressure on reduced femur
head
• Recommended in child > 2yrs.
• distract the joint few millimeter per operatively
• Judge the tightness of soft tissues after reduction
• irreducible dislocation

59. How much shortening?
• Pre op: bottom of the femoral head to the
floor of the acetabulum (a to b)
• amount of overlap is noted after osteotomy
• Tension of the soft tissue
• Derotation usually combined
leaving 15 to 20 degrees of
anteversion

60. Derotational femoral shortening osteotomy

61. 2 Years of Age and Older
• For child 2 -3 years of age, during open
reduction acetabular coverage if insufficient
warrants reorientation osteotomy
• If coxa valga with excessive anteversion, VDRO
may be done.
• Children > 3 years usually need an osteotomy

63. Bilateral untreated dislocation upto 5 years:
Open reduction with femoral shortening with
salter / pemberton osteotomy with gap of 5-6
weeks.
Bilateral untreated subluxation upto 5-6 years:
Open reduction + salter osteotomy.

64. Residual Dysplasia
Pelvic
osteotomy
Re- orientation Augmentation
Innominate Periacetabular Triple
Shelf
Chiari
procedures

65. Acetabular Reorientation-Innominate
Osteotomy
• Articular hyaline cartilage over femur head
• Types:
– Salter’s (innominate)
– Sutherland’s (double innominate)

66. Salter’s Osteotomy
Redirects the entire acetabulum
Roof “covers” the femoral head anteriorly and
superiorly
Hinge at pubic symphysis
Pre-requisites
 Congrous Concentric reduction
 No Contractures

67. Salter’s osteotomy

68. Salter’s osteotomy

69. Sutherland’s Osteotomy
1. Can be done for older
child
2. Allows medial
displacement

70. Peri-acetabular Ostetomies
• Provide greater correction of acetabular index
• Reduce volume of hip joint
• Possibility of growth disturbances
Types
– Pemberton’s
– Dial (Eppright)
– Wagner
– Dega’s
– Ganz osteotomy (Bernese)

71. Pemberton’s Osteotomy

72. Pemberton’s Osteotomy
1. Incomplete
2. Hinges at
triradiate cartilage

73. Dega’s Osteotomy
1. Incomplete
2. Variable hinge
3. Allows anterior,
lateral & posterior
coverage

74. Ganz Osteotomy
Larger corrections all directions
Blood supply preserved
Shape of true pelvis unaltered
Technically demanding

75. Triple Osteotomies
Indication :
Adolescent requiring more than 25° correction
Pre-requisite:
Functional range of motion
only mild subluxation acceptable
Types:
• Steel (Inferior)
• Tonnis (Posterior)
• Tachdjian - subinguinal adductor

76. Triple Osteotomies
STEEL TONNIS TACHDJIAN’S

77. Shelf Procedure

78. Chiari Osteotomy

80. Adolescent and young adult(older then 8-
10 years
If femoral head cannot be repositioned
distally to the level of acetabulum : Salvage
procedures
Degenertive arthritis and enough pain and
limitation of movements – reconstructive
operation (total hip replacement)
Arthodesis – rarely done, contraindiacted for
bilateral dislocation

81. Very late
salvage
Schanz
osteotomy

82. Joint replacement
Consider for:
 Severe arthritis
 Failed “
conservative” Rx.
 Bilateral disease