Development Dysplasia of The

Hip

Andrianto Wisnu Nugroho

Orthopaedics & Traumatology Department
RSU Karsa Husada Batu
 Introduction
CDH DDH
Congenital : existed at birth
Developmental : organ growth and
differentiation includes embryonic, fetal
and infantile periods
 Causes of Developmental Dysplasia of the
Hip

The genetic effects : acetabular dysplasia, joint laxity,

or both
Intrauterine mechanical factors : breech positions,
oligohydramnions, neuromuscular mechanism (e.g.
meningochele)
First born child
Post natal influences
 Incidence

0.7 to 35 per 1000 live births

4.7 per 1000 live births unstable hips
16.8 per 1,000 live births dysplastic hips
Increasing numbers seen in paediatric
orthopaedic clinic but significant incidence
in adult females
 Incidence

female : male = 5 : 1
left hip : right hip = 3 : 1 (20% bilateral)
breech delivery (30-50%)
first born (60%)
family history (20%)
ligamentous laxity
other congenital abnormalities risk factor :
Torticolis
Metatarsus adductus
Oligohydramnion
 Pathology of DDH
Primary initiating factors excessive capsular laxity
& a shallow acetabulum at birth
- Femoral head pulled proximally & laterally by
Hip abductors
- Hip joint fills with fibrofatty debris
- Acetabular labrum enlarged along the superior,
posterior, and inferior rim infold into joint
limbus blocks reduction of femoral head
 Pathology of DDH
- - Acetabulum becames flattened ( dysplastic )
- Ligamentum teres becomes lengthened,
hypertrophic & redundant
- Transverse acetabular ligament pulled superiorly
- Capsule of hip joint expanded
- Muscles crossing the hip joint ( hamstring, hip
adductors & psoas ) become shortened & contracted
Psoas crosses acetabulum : blocking reduction
Arthrogram shows hour glass configuration
Pathology of DDH
 Consequences of DDH

Acetabular dysplasia and maldirection

Excessive femoral anteversion
Muscle contractures
Avascular necrosis of femoral head
 Clinical manifestation
limitation of hip abduction
absent normal knee flexion contracture
Asymetrical of thigh / groin skinfolds
uneven knee level affected side shorter (
Galeazzi sign )
apparent shortening of an extremity
Manifestations

Asymmetrical skin crease

 Other Clinical Manifestations

In older children ( age of 6 18 months )

limping, toe walking, waddling (trendelenberg gait)
increased lumbar lordosis
leg length discrepancy
Decrease in ability to abduct
the dislocated hip
PHYSICAL EXAM
 Physical Exam Maneuvers

A. Barlow Test
dislocates an unstable hip
stabilize pelvis with one hand, then flex and adduct
opposite hip with posterior pressure.
dislocation is felt as a clunk
release of posterior pressure spontaneously relocates
femoral head.
 Physical Exam Maneuvers

B. Ortolani Test
Reduces by gently a recently dislocated hip
flex and abduct the affected thigh to lift femoral head
into acetabulum
relocation clunk
most likely to be positive at 1-2 mos.
Physical Exam Maneuvers
 Investigation
Ultrasound
most useful during first four weeks of life
more accurate than radiograph (<6 mth) not useful after
9 months
non invasive
visualization of cartilage
reduces the need for arthrograms
at-risk infants with questionable clinical examination
follow-up for dysplastic hips
Hip ultrasound
Graf (1980)
Harcke and Grissom (1990) dynamic US
Hip Ultrasound
 Arthrogram

1. Limbus - 'Rose thorn sign' of inverted labrum

between femoral head & acetabulum
2. Hour glass constriction of capsule - by psoas
tendon
3. Capsular distension
4. Medial pooling of dye (normal = < 7mm)
5. Confirms reduction after surgery
6. Useful in assessing blocks to reduction
 Evaluation & Treatment

Neonatal Screening :
all newborns
examined clinically
unstable hips splinted
and reviewed in clinic
Dysplastic hips
followed up until
resolution
 Evaluation & Treatment

Neonatal Screening :
persistent hip clicks referred to clinic at 6 weeks
US for persistent hip clicks at 6 weeks
X-rays at 3 months for all hip clicks
 Principle of Treatment
Treatment is based on age
Aims :
1. concentric reduction
2. early acetabular development

Neonatal :
Goal: maintain hip in flexed and abducted position to
maintain femoral head reduction and tighten ligamentous
structures.
Pavlik-Harness or Frejka splint for 1-2 mth
 Principle of Treatment
1-6 months
Pavlik-Harness for 3-4
weeks Success rate of
85-95%
If the dislocation persist
after 4 weeks
discontinue the harness
and need Closed or open
reduction
 Pavlic Harness
Used in babies from 3 to 9
mth of age
Difficult for some
parents/caregivers to use
Compliance
Proper understanding & use
May require adductor
tenotomy
X-ray after 2-3 weeks
(45 flexion/45 abduction)
Stop if not successful
 Complications of Pavlik Harness

Pavlik Harness disease :

persistent postero-lateral dislocation
poor abduction
positive Galeazzi sign
prominent greater trochanter
Confirm with U/S or MRI

Inferior dislocation
Femoral nerve palsy
Avascular necrosis
Principle of Treatment
 Principle of Treatment
Infant (6-18 mth)
Preoperative traction 2-
3 weeks
Closed or open surgical
reduction w/ or w.o
adductor tenotomy
Closed or open
reduction w/ Hip spica
cast human
position
 Principle of Treatment
Save Zone of Ramsey

20-45
 Principle of Treatment
Toddler ( 18 - 48 months )
Open reduction with pelvic and/or femoral
osteotomy

Children ( 3 8 years )
Combined hip surgery :
- open reduction
- femoral shortening
- varus derotation osteotomy + pelvic
osteotomy
 Principle of Treatment

Juvenille & young adult (> 8 y.o)

Bilateral dislocation left unreduced
Unilateral dislocation many authors consider
for no intervention, but some authors
recommend Shelf procedure or Combined hip
surgery
 Option of Treatment

Do nothing
Closed/Open Reduction w/Hip Spica Cast
(fixed abduction orthotic device)
Femoral Osteotomy
Pelvic Osteotomy
Combination
 Principles of Surgical Treatment

Perform soft tissue releases (adductors and

ilio-psoas)
Find true acetabulum
Clear blocks to reduction
Achieve concentric reduction
Capsulorraphy
Bony procedures after 18 months
 Open Reduction
Medial approach
 Open Reduction
Anterolateral approach
- soft tissue release
- clear blocks to
reduction
Blocks to reduction

- Transverse ligament
- Pulvinar
Hip Spica Cast
 Femoral Osteotomy
(Shortening & Derotation)
Femoral shortening
if hip cannot be reduced
 Pelvic Osteotomy

Salters innominate Osteotomy most common

Pembertons Osteotomy
Osteotomies to free the acetabulum Steels &
Dega
Chiaris Dysplacement Osteotomy
Shelf procedure Osteotomy
 Salter Innominate Osteotomy

Innominate osteo-
tomy + open wedge
May lengthen the
affected leg up to 1
cm
Salter Innominate Osteotomy
 Salter Innominate Osteotomy
Post-op Management

6 weeks in hip spica

Remove pins and spica in OR
Self-mobilisation
 Pembertons Osteotomy
Through acetabular roof to triradiate cartilage
Steels & Dega Osteotomy
Steels & Dega Osteotomy
 Chiaris Osteotomy
Through ilium above
acetabulum (makes new
roof)
 Shelf Procedure Osteotomy

Slotted lateral
acetabular wall
Augmentation
 Complications of DDH

The most common complication of treatment

of DDH is osteonecrosis of the femoral head
Residual Femoral & Acetabular Dysplasia
Growth disturbance of proximal femoral
physis
Gait abnormality
THANK YOU