DEVELOPMENTAL DYSPLASIA OF HIP

Dr.Pugazhendhi. K
Professor
Department of Orthopaedics

2013 Chettinad Hospital & Research Institute

 It is formerly known as congenital dislocation of

hip.
It is defined as partial/complete displacement
of the femoral head from the acetabular
cavity present at birth or develops during
infancy or childhood.
Partial displacement- SUBLUXATION
Complete displacement- DISLOCATION

Genetic and environmental factors

appear to contribute to its
causation.
1. Genetic

factors may play a part in the Aetiology for

DDH-seems to run in families
2. Hormonal factors-High level of maternal estrogen,
progestrone and relaxin in the last few weeks of
pregnancy may produce ligamental laxity with
dislocation of hip.
3. Intra uterine mal position may be another factor in
the causation of DDH
4. Primary dysplastic development of the acetabulum.

 The acetabulum is shallow and mal directed

Structural inter position between the displaced
femoral head and acetabulum are common.
The iliopsoas tendon is insinuated between the
head of femur and acetabulum causing
depression in joint capsule-giving the joint
capsule a hour glass configuration.

 The Acetabular labrum is inverted into the

joint.
The ligamentum teres is enlarged.
Acetabulum may contain fat (pulvinar).
The proximal femur shows antetorsion and coxa
valga.

 With the baby on its back, hip and knee are

held flexed as the limb is slowly abducted at
the hip. In the dislocated hip, the head of the
femur is felt to slip into the acetabulum. This is
the Ortolani test of reduction.
Barlow test of exit is one which the head could
be pushed out of the acetabulum with a click,
with the hip in flexion and adduction.

 Ultrasonography, upto 4 months of age

Radiography, pelvis AP view, if the child is more
than 4 months of age
Arthrography
Magnetic Resonance Imaging

 In infants younger than 4 months of age, the

acetabulum and proximal femur are
predominantly cartilaginous and not visible on
plain radiographs and are best visualized with
ultrasonography
Ultrasonography is a valuable adjunct to the
detection of neonatal hip abnormalities
Very useful in detecting early treatment
failures when using the Pavlik harness

 Radiographs are recommended for an infant

once the proximal femoral epiphysis appears,
usually by 4 months of age
Hilgenreiner's line is drawn through the
triradiate cartilages.
Perkins line is drawn perpendicular to
Hilgenreiner's line at the lateral edge of the
acetabulum.

 The ossific nucleus of the femoral head should

be located in the medial lower quadrant of the
intersection of these two lines.
Shenton's line curves along the femoral
metaphysis and connects smoothly to the inner
margin of the pubis.
In a child with DDH, this line consists of two
separate arcs and therefore is described as
broken.

The acetabular index is the angle between a

line drawn along the margin of the acetabulum
and Hilgenreiner's line; in normal newborns, it
averages 27.5 degrees and decreases with age.

Cerebral palsy with spastic paralysis.

Congenital coxa vara.
Congenital short femur.
Arthrogryphosis
Myelomeningocele
Infantile coxa vara.
Idiopathic pelvic obliquity.
Stills diseases (Rheumatoid arthritis involving
the hips in children)

 Poliomyelitis, which adduction contracture may

develop, although abduction contracture is
more usual.
Congenital Scoliosis, which may result in an
elevation of the pelvis on one side and an
adducted position of the hip, which is
ordinarily not associated with actual limitation
of movement at the joints.

 Chondrodystrophy Morquios disease or

Hurlers syndrome, which limits abduction but
also causes other obvious clinical signs.
Scurvy or rickets which may result in painful
limbs and limited motion.
Obstetrical trauma-contusions, fractures and
dislocations.
Spina bifida-with weak hip abductors and
adduction contracture.
Hip joint infections pyogenic, TB etc.,

NEWBORNS AND INFANTS YOUNGER

THAN 6 MONTHS OF AGE
The Pavlik harness is used for all degrees of hip
dysplasia in otherwise normal newborns. Other
braces which are available include von Rosen
splint, Frejka pillow etc.
By maintaining the Ortolani-positive hip in a
Pavlik harness on a full-time basis for 6 wk, hip
instability resolves in 95% of cases.
The Pavlik harness may be used effectively till 6
months of age for any child with residual
dysplasia, subluxapion or complete dislocation.

 In a child younger than 6 months who has

complete dislocation, the Pavlik harness may
be used in a trial of ultra sound maintained
reduction. The infant should be checked at 7 to
10 days by clinical examination, Ultra sound and
Radiographs.

 Position
Hips at 100 -110 flexion
Lateral strap tightened to limit adduction not
force abduction
Knees should be able to adduct within 5 cm
of each other
Barlow test performed within harness to ensure
stability

 The Pavlik harness

is a dynamic splint
Allows a safe range
of hip motion while
maintaining the
desired flexedabducted posture
necessary to
prevent dislocation

 For children older than six months of age at

diagnosis, in the cases of failed trial of Pavlik
harness reduction,
under GA closed
reduction and spica cast immobilization, may
be preceeded by a period of skin or skeletal
traction for 1 to 2 weeks- the aim anatomical
reduction. An open or percutaneous adductor
tenotomy is usually necessary in this cases
because of secondary adduction contracture.

 The reduction should be maintained in well

moulded plaster cast (hip spica) in human
position-hyperflexion and limited abduction
for six weeks (Regardless of the patients age.
The reduction, after casting, should be
documented by radiography, CT scan, MRI scan,
or Ultrasonography.
Cut the Spica above the knee (or knees if
bilateral) to allow for some hip rotation and
ROM for the knee for additional 6 weeks.

Cast removal

Abduction Orthotic devices, full time basis

(except while bathing) for several months, then
part time, usually during night and napping
hours until acetabular development is caught
up with that of the opposite, normal side
(Generally 18 to 24 months) or till surgical
intervention is planned

OPEN REDUCTION
Indication patient 6 months to 2 years of age
if there is failure of closed reduction,
persistence subluxation, soft tissue inter
position, reducible but unstable reduction.
Post Operatively the hip is immobilized in a
functional position with minimal hip reflection
and some degree of abduction, usually for 6 to
8 weeks.

 Post Operatively one and half hips spica for

6 weeks.
Cut the spica above knee
Maintain with spica for another 6 weeks.

 After the cast removal

Patient is put on abduction orthosis
(as for the closed treatment)
After closed or open reduction the potential
for acetabular development is excellent and
continues for 4-8 years after reduction

 The most rapid improvement in acetabular

development occurs in the first 18 months after
surgery. Femoral anteversion and coxa valga
have an excellent chance to resolved during
this time.
However some surgeons think that every child
DDH older than 18 months should undergo
pelvic osteotomy accompanying open reduction
because of poor acetabular development
potential.

 In a child more than 2 years of age at the time

of diagnosis of DDH, open reduction is usually
necessary. In this age group the treating
surgeon must also consider whether to perform
concomitant femoral shortening with open
reduction.

 In this age group, the potential for acetabular

development is markedly diminished, many
surgeons recommend a concomitant acetabular
procedure like Salters innominate Osteotomy
or Pemberton Osteotomy either in conjunction
with open reduction or 6 to 8 week after it.

 Improves coverage of
the femoral head by
shifting the position
of the acetabulum
Single innominate
osteotomy (Salter)
Triple innominate
osteotomy (Steel)
Periacetabular
osteotomy (Ganz)

 Restoration of acetabular
morphology by changing
the shape of the
acetabulum
Should be used only in
skeletally immature as
the osteotomy hinges on
the triradiate cartilage
Pemberton osteotomy

 Indicated when congruent

reduction between the
femoral head and the
acetabulum cant be
obtained
Chiari osteotomy
Slotted-shelf procedure

 In this age group, the potential for acetabular

development is markedly diminished, many
surgeons recommend a concomitant acetabular
procedure like Salters innominate Osteotomy
or Pemberton Osteotomy either in conjunction
with open reduction or 6 to 8 week after it.

 In the reduced hips with residual dysplasia, the

problem is not one of deficiency of
acetabulum, but failure of peripheral
acetabular cartilage to ossify. In most cases an
arthrogram at the time of surgery shows
excellent coverage of femoral head by the
unossified acetabular cartilage. This cartilage
fails to undergo normal development either
because it is intrinsicaly abnormal or it was
damaged by the femoral head in the unreduced
position.

 Intervention should be undertaken after the

acetabulum has had the reasonable chance to
develop on its one.
Any Osteotomy of the iliac bone and the
neovascularity stimulated by it in healing may
increase the ossification of the otherwise
unossified acetabular cartilage.

 For the asymtomatic adolescent with minimal

radiographic evidence of dysplasia surgery can
be recommended at the onset of symptoms.
But in a adolescent with radiographic evidence
of subluxation, regardless of the symptoms,
surgical correction is recommended because
without treatment an adverse natural history is
certain.

 In extreme cases of degenerative joint disease

in the late teens or early adult years hip fusion
or total joint arthroplasty may be the only
treatment available. These circumstances are
rare in patient younger than 30 years.

Thank you!

2013 Chettinad Hospital & Research Institute