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Developmental Dysplasia of the Hip From

Six Months to Four Years of Age

Michael G. Vitale, MD, MPH, and David L. Skaggs, MD

Abstract

Developmental dysplasia of the hip (DDH) denotes a wide spectrum of patho- hip because it more accurately
logic conditions, ranging from subtle acetabular dysplasia to irreducible hip dis- reflects the full spectrum of devel-
location. When DDH is recognized in the first 6 months of life, treatment with opmental abnormalities of the hip
a Pavlik harness frequently results in an excellent outcome. In children older joint. This condition can result in both
than 6 months, achieving a concentrically reduced hip while minimizing com- subluxation and dislocation of the
plications is more challenging. Bracing, traction, closed reduction, open reduc- hip and can predispose to the de-
tion, and femoral or pelvic osteotomies are frequently used treatment modalities velopment of early degenerative
for children aged 6 months to 4 years. In the past, treatment recommendations changes. A subluxated hip is one
have often been based on the patients age. However, recent practice has placed in which the femoral head is dis-
more emphasis on addressing the specific disorder and avoiding iatrogenic placed from its normal position but
osteonecrosis. The incidence of osteonecrosis of the femoral head has been still makes contact with a portion of
reduced by avoiding immobilization of the hip in extreme abduction and by the acetabulum. With a dislocated
using femur-shortening osteotomies when appropriate. Pelvic osteotomy con- hip, there is no articular contact
tinues to gain favor for the treatment of selected patients over 18 months of age. between the femoral head and the
J Am Acad Orthop Surg 2001;9:401-411 acetabulum.
Acetabular dysplasia is charac-
terized by an immature, shallow
acetabulum. Dysplasia can exist
Despite efforts to identify and treat less clear, however, whether this is with or without concomitant in-
all cases of developmental dysplasia due to subtle pathoanatomic changes stability of the hip and, if untreated,
of the hip (DDH) soon after birth, in that were not initially discernible on may lead to a poorly located, symp-
some children the diagnosis is examination but progressed with tomatic hip. An unstable hip is one
delayed, and they are 6 months of time, or represents the true develop- that is reduced in the acetabulum
age or older when they finally pre- ment of DDH in a previously normal but can be provoked to subluxate or
sent to the orthopaedic surgeon. hip. Ilfeld et al1 reported the cases of
The timing of diagnosis is important 15 patients with DDH who had doc-
because the treatment of DDH ini- umented normal physical examina-
tially diagnosed between 6 months tions during infancy but findings of Dr. Vitale is Assistant Professor of Ortho-
and 4 years of age differs consider- hip dysplasia at a subsequent exami- paedic Surgery, Childrens Hospital of New
ably from that of DDH diagnosed in nation. According to those authors, York, New York-Presbyterian Medical Center,
New York, NY. Dr. Skaggs is Assistant Pro-
the immediately postnatal period. the delayed finding of dislocation is fessor of Orthopedic Surgery, University of
These older children may present not evidence that an inadequate Southern California Keck School of Medicine,
for treatment of DDH for any of the physical examination of the hip was Los Angeles.
following reasons: a delay in diagno- performed.
sis, failure of Pavlik harness treat- Reprint requests: Dr. Skaggs, Division of
ment, and late development of the Orthopaedic Surgery, Childrens Hospital Los
Angeles, 4650 Sunset Boulevard, Mailstop 69,
pathologic changes of DDH with Definitions Los Angeles, CA 90027.
maturation. Normal physical exami-
nation findings during the immediate The term developmental dyspla- Copyright 2001 by the American Academy of
postnatal period do not preclude a sia of the hip has replaced the Orthopaedic Surgeons.
subsequent diagnosis of DDH. It is term congenital dislocation of the

Vol 9, No 6, November/December 2001 401


DDH From 6 Months to 4 Years

dislocate (i.e., Barlow positive). metrical motion and strength, gait tum teres, and an infolded labrum.
Teratologic hip dysplasia, which is disturbance, and knee disorders. An infolded labrum is rarely a prob-
outside the scope of this discussion, Patients with chronic subluxation lem once the other obstacles have
refers to the more severe fixed dislo- may experience symptoms earlier been addressed. A hypertrophied
cation that occurs prenatally, and is than those with true dislocation. transverse acetabular ligament,
usually seen in the setting of genetic Cooperman et al4 showed that de- located in the inferomedial portion
or neuromuscular disorders. generative joint disease developed of the acetabulum, may also be an
early in subluxated hips but later in absolute block to reduction. It
life in dysplastic hips without overt develops secondary to the pull of
Natural History subluxation. Most authors agree the ligamentum teres and may mi-
that subluxation will lead to early grate superiorly, decreasing the
The natural history of DDH in the degenerative disease, but that per- available volume of the inferome-
newborn is quite variable. Neo- sistent isolated acetabular dyspla- dial acetabulum and preventing the
nates with acetabular dysplasia sia has a less profound, yet equally femoral head from making contact
without instability may go on to predictable, effect on the develop- with the medial wall of the acetabu-
have normal hips without treat- ment of symptoms. lum. These obstacles to reduction be-
ment, but those with instability or come more fixed with increasing age.
frank dislocation often demonstrate The term neolimbus was
progressive radiographic changes Anatomy coined by Ortolani in 1948 and
and loss of motion, followed by refers to a ridge of cartilage tissue
pain. In contrast, spontaneous reso- A recent article by Guille et al 5 that develops in response to abnor-
lution of dysplasia without inter- included an extensive discussion of mal contact pressures. The neolim-
vention is unlikely in children over the general etiology, risk factors, bus divides the acetabulum into a
age 6 months. For a number of rea- and pathophysiology of DDH in the true and a false acetabulum. Some
sons, these children almost always newborn. The pathologic changes have advocated removing this ab-
require more aggressive treatment in the newborn are predominantly normal cartilage during surgery;
than younger children. This is re- related to a shallow acetabulum, however, removal of this epiphyseal
lated to the more extensive patho- laxity of the capsule, and soft-tissue
physiologic changes in older chil- interposition. Older children exhibit
dren, as well as the decreased more advanced changes in both the
potential for acetabular remodeling soft tissues and the osseous architec- Ligamentum teres
with increasing age. ture. There is a delay in the ossifica- elongated and
hypertrophied Inverted
Persistence of hip dysplasia into tion of the acetabulum, which is limbus
adolescence and adulthood may re- most often abnormally shallow,
sult in abnormal gait, decreased ab- anteverted, and deficient anterolat-
duction, decreased strength, and an erally. There is also a delay in ossi-
increased rate of degenerative joint fication of the femoral head and ex-
disease. Wedge and Wasylenko2 aggerated femoral anteversion.
reported that the presence of an The obstacles to a concentric re-
abnormal acetabulum was associ- duction may be classified as either
ated with adverse clinical outcomes. extra-articular or intra-articular
Stulberg and Harris3 demonstrated (Fig. 1). Extra-articular obstacles
that 50% of patients with idiopathic include a tight psoas tendon, which
osteoarthritis had associated pri- can constrict the anterior capsule so
Capsule Transverse acetabular
mary acetabular dysplasia, impli- as to create an hourglass narrow- ligament hypertrophied
cating dysplasia as a risk factor for ing of the capsule, which prevents
the onset of osteoarthritis. In gen- reduction. Tight adductor muscles Figure 1 Pathologic changes that present
eral, the natural history of adults may also prevent sufficient abduc- obstacles to reduction in children older
than 6 months with DDH. Note that the
with unilateral dislocations that tion for stable reduction of the elongated and hypertrophied ligamentum
have persisted since childhood is femoral head. teres is attached to the hypertrophied
less favorable than that for those Intra-articular obstacles that may transverse acetabular ligament. (Adapted
with permission from Tachdjian MO:
with bilateral dislocations; the for- impede reduction include a con- Pediatric Orthopedics. Philadelphia: WB
mer have the additional problems stricted joint capsule, the fibrofatty Saunders, 1990, vol 1, p 308.)
of limb-length inequality, asym- pulvinar, a hypertrophied ligamen-

402 Journal of the American Academy of Orthopaedic Surgeons


Michael G. Vitale, MD, MPH, and David L. Skaggs, MD

cartilage will impede acetabular


development and is not recom- Table 1
Radiographic Features in Normal and Dysplastic Hips*
mended.6

Radiographic Feature Normal Hip Dysplastic Hip


Diagnosis
Acetabular index, degrees
24 months 18-21 >24
Many of the diagnostic characteris-
3 months 20-25 >28
tics of DDH in children aged 6
Shentons line Continuous Discontinuous
months to 4 years are the same as
those seen in the newborn. The Ossific nucleus Present by 4-6 months Delayed, small
general aspects of diagnosis have
* Adapted with permission from Gillingham BL, Sanchez AA, Wenger DR: Pelvic
been well reviewed by Guille et al.5
There are, however, several unique osteotomies for the treatment of hip dysplasia in children and young adults. J Am
Acad Orthop Surg 1999;7:325-337.
features of the physical examination
of the older child with DDH. With
increasing age, the soft tissues about
the hip tighten. Thus, the Ortolani Skaggs et al8 have shown that, given years. 10,12 Although each patient
and Barlow tests usually lose their the intrinsic measurement error of should be treated with individual
utility after the first few months of the acetabular index in DDH, a dif- consideration, following a general
life. Abduction becomes more lim- ference of less than 12 degrees on treatment algorithm for the appro-
ited, and asymmetry of abduction successive radiographs should be priate age range is a helpful starting
becomes more apparent. The Ga- interpreted with caution. point for devising a logical treat-
leazzi test retains its usefulness in ment program (Figs. 3 and 4).
the older child. The ambulating
child will exhibit a Trendelenburg Treatment Closed Reduction
gait. In children with bilateral dislo- In children less than 6 months of
cated hips, symmetrical hip abduc- Treatment of children aged 6 age, closed reduction of a dislocated
tion and a normal Galeazzi test make months to 4 years who have DDH hip can usually be achieved by
the diagnosis more challenging. presents certain challenges and
However, a Trendelenburg sign, opportunities. Delay in concentric,
waddling gait, and decreased but stable reduction of the hip may re-
46
symmetrical hip abduction can be sult in irreversible changes in the
appreciated on careful examination. femoral head and acetabulum and 42 Age at reduction
Acetabular index, degrees

0-12 mo (56 hips)


In infants less than 4 to 6 months can adversely affect outcome. The 38 13-24 mo (81 hips)
of age, the femoral head is usually goal of treatment is to obtain and 34
>24 mo (48 hips)
not sufficiently ossified to be seen on maintain a stable, concentrically
30
a radiograph. Ultrasound is the pre- reduced hip joint at as early an age
ferred screening modality for DDH. as possible while minimizing com- 26
24
There are, however, a number of plications.9 22
helpful radiographic criteria for There is a well-established corre- 20
18
evaluating dysplastic hips7 (Table 1). lation between residual dysplasia 16
14
Ossification is normally evident by and age at reduction. Lindstrom et
the age of 6 months but is often de- al10 have shown that the acetabular 10
0 1 2 3 4 5 6 7 8
layed in patients with DDH. Serial index at follow-up is directly related
Interval after reduction, yr
radiographs showing increasing to the age at initial reduction (Fig. 2).
femoral head ossification are more Salter and Dubos11 have stated that Figure 2 Most acetabular remodeling
important than a single radiograph. acetabular remodeling cannot be occurs in the first 3 years after reduction.
The age at reduction is a critical determi-
It has been shown that variability of ensured after the age of 18 months. nant of the final radiographic outcome.
the acetabular index is greater in Others have suggested that remodel- (Adapted with permission from Lindstrom
dysplastic hips than in normal hips, ing may occur up to age 8 years.10,12 JR, Ponseti IV, Wenger DR: Acetabular
development after reduction in congenital
especially prior to definitive reduc- Remodeling of the acetabulum is dislocation of the hip. J Bone Joint Surg Am
tion. While it is important to note generally considered to be most pre- 1979;61:112-118.)
the direction of change over time, dictable in children younger than 4

Vol 9, No 6, November/December 2001 403


DDH From 6 Months to 4 Years

tion appears to potentiate acetabu-


Dislocated hip in patient lar dysplasia (particularly of the
aged 6-18 months
posterolateral rim) and may in-
crease the difficulty of subsequently
obtaining a stable closed reduc-
Closed reduction, tion.14 This situation has become
arthrography
adductor tenotomy known as Pavlik harness disease.

Closed Reduction and


Reducible Irreducible
Preoperative Traction
Closed reduction of the hip un-
der general anesthesia is typically
attempted in children aged 6 to 24
Arthrography
months who have a dislocated hip.
The use of traction before an at-
tempted closed reduction is contro-
<5- to 7-mm >5- to 7-mm
medial dye pool medial dye pool versial. Proponents of traction
believe that slow, gentle stretching
of both the neurovascular struc-
tures and the soft tissues about the
Stable reduction in Open reduction and
human position Reduction capsulorrhaphy, hip increases the likelihood of a
(ideally <55 abduction) not stable spica cast successful reduction and mini-
mizes the risk of osteonecrosis. A
frequently cited study by Gage and
Spica cast CT scan Winter15 seems to support the use
of traction, but the authors did not
account for differences in the de-
CT scan Spica cast gree of postreduction abduction
for 6 weeks between groups, a factor that may
affect the rate of osteonecrosis. In
Spica cast contrast, in a study of 210 hips,
for 3 months Physical therapy Brougham et al16 found that trac-
(range of motion)
tion did not influence the rate of
osteonecrosis. The available data
Brace (24 hr/day) are insufficient to definitively sup-
for 1 month
port or refute the effectiveness of
traction. In 1991, Fish et al17 reported
that most pediatric orthopaedic
Brace at night
for 2 months
surgeons still use prereduction
traction, although an informal poll
at the Pediatric Orthopaedic Society
Figure 3 Algorithm for treatment of DDH in children aged 6 to 18 months.
of North America meeting in 1998
suggested a trend toward decreas-
ing use of traction.
use of the Pavlik harness. Reported ness. Rates of failure exceed 50%, Traction is unlikely to affect some
success rates have generally been and there is, therefore, little role for of the major intra-articular structures
greater than 90%. After the age of 6 the use of such a harness in older prohibiting a closed reduction, such
months, it is difficult to immobilize patients. 13 However, in rare in- as the transverse acetabular liga-
the larger, increasingly active child stances, children who are small for ment, pulvinar, ligamentum teres,
with a Pavlik-type harness. Fur- their age may be treated with a and infolded labrum. As traction is
thermore, the degree of fixed patho- Pavlik harness. In hips that cannot generally applied in hip flexion, it
logic change in older children gen- be reduced with the Pavlik harness, does not seem logical that it would
erally precludes the achievement of continuation of the harness with the effectively elongate the psoas or sig-
reduction simply by use of a har- dislocated hip in flexion and abduc- nificantly lengthen the adductors, as

404 Journal of the American Academy of Orthopaedic Surgeons


Michael G. Vitale, MD, MPH, and David L. Skaggs, MD

is often necessary at the time of


closed reduction in the operating Dislocated hip in patient
room. Closed reduction should be aged 18-48 months
performed under general anesthesia
in the operating room with longitu-
dinal traction, flexion, and abduction Closed reduction,
arthrography,
of the affected hip, while lifting the
adductor tenotomy
greater trochanter anteriorly. It is
not unusual to find that a stable, gen-
tle, closed reduction can be achieved
Reducible Irreducible
with relative ease under general
anesthesia, even when the hip ap-
peared irreducible in the office.
Dynamic arthrography with fluo- Arthrography shows
<5- to 7-mm medial dye
roscopy is useful to assess the quali- pool and stable reduction
ty of reduction, the extent of cover- in human position
age of the femoral head, and the
optimal position for immobilization.
There is some debate as to whether Yes No Open reduction
and capsulorrhaphy
soft-tissue interposition (usually
acetabular fibrofatty tissue) between
the femoral head and the acetabu- Closed or open treatment
lum interferes with future develop- (closed is most common for If high dislocation significant
patients aged <24 months) pressure on reduction, do femoral
ment of the hip. If the femoral head shortening derotation
is not fully reduced in the acetabu- 10 to 15 varus

lum, an intraoperative arthrogram


will show a collection of dye medi-
ally (the medial dye pool) in the Unstable Stable
space between the femoral head and
the medial border of the acetabu-
lum. Race and Herring18 reported Pelvic osteotomy Pelvic osteotomy
that a medial dye pool of less than 5 is an option
to 7 mm indicated a concentric
reduction and was associated with a
good outcome in 11 of 13 hips. CT
Only 5 of 23 hips with a larger dye
pool had an acceptable outcome,
with a 57% incidence of osteonecro- Cast for 6 weeks
sis. As suggested in the algorithms,
a medial dye pool greater than 7
mm on arthrography is a potential Physical therapy
indication to proceed with open
reduction. One limitation of this Figure 4 Algorithm for treatment of DDH in children aged 18 to 48 months.
method is that magnification of
imaging can affect the size of the
dye pool; therefore, it is important
to rely on clinical judgment as well. the adduction contracture and thus closed reduction, a spica cast is
The safe zone is the range be- widen the safe zone by increasing applied in the human position of
tween maximum passive hip abduc- abduction. about 100 degrees of flexion and
tion and the angle of abduction at Salter and others have cautioned controlled abduction. In a study of
which the femoral head becomes against immobilization in a position 68 dislocated hips treated by closed
unstable. Adductor tenotomy, per- of extreme hip abduction, as this reduction, the development of
formed with either an open or a per- may be associated with the develop- osteonecrosis was statistically asso-
cutaneous technique, can decrease ment of osteonecrosis. 11,19 After ciated with hip-abduction angles

Vol 9, No 6, November/December 2001 405


DDH From 6 Months to 4 Years

greater than 55 degrees.19 Technical The length of postreduction cast hips. Fortunately, the acetabular
points that merit consideration immobilization is variable and index shows the least intraobserver
include use of a greater-trochanter should be adjusted for the individ- variability (95% CI, 5 degrees) in the
mold (Fig. 5, B) and maintenance of ual child. Currently, the spica cast is situation in which it is most use-
90 to 100 degrees of hip flexion, utilized for 3 months without chang- fulafter a closed reduction of a
despite the tendency of the hip to ing if it remains clean and is not too dysplastic hip.8
extend as padding and casting ma- tight, regardless of the age of the Many authors have reported that
terial are placed over the anterior child. After 3 months, an abduction a significant proportion of children
hip crease. Closed reduction and orthosis is applied for full-time wear will eventually require an additional
casting is as technically demanding for 4 weeks, followed by 4 weeks of procedure after closed reduction.
as open reduction, and should be nighttime-only use. There is little evi- Zionts and MacEwen21 reported on
performed only with adequate anes- dence to support a weaning period 42 children between 1 and 3 years of
thesia and assistance. from the brace. age who underwent a closed reduc-
Reduction of the hip is confirmed Acetabular development occurs tion and adductor tenotomy. Ar-
by using a limited computed tomo- most rapidly in the first 6 months thrography was not routinely used.
graphic (CT) or magnetic resonance after a closed reduction, and contin- An open reduction was required for
imaging study. A line drawn paral- ues at a slower pace over the next 25% of patients. Of the hips success-
lel to either of the pubic rami on a year (Fig. 2).10 Assessment of hip- fully reduced by closed reduction,
CT scan should intersect the proxi- joint maturation is generally accom- 66% required a secondary procedure
mal femoral metaphysis (Fig. 5, plished with serial radiographs. It a mean of 5 years after the reduction.
B).20 In a series of 68 hips treated has been suggested that if the Of the patients older than 18 months
by closed reduction, 6 of the 53 pa- acetabular angle has not decreased at the time of reduction, 74% re-
tients demonstrated a proximal at least 4 degrees during the first 6 quired a secondary procedure (most
femoral metaphysis below this months after reduction, abandon- commonly, femoral osteotomy).
line. Of these 6 patients, 4 had dis- ment of closed treatment should be Schoenecker et al22 reported that
located hips, and the other 2 eventu- considered.18 However, strict re- 12 (52%) of 23 hips in which closed
ally required further surgery.19 A liance on the acetabular index for reduction at 18 months of age was
reduced hip tends to sit posteriorly assessment of acetabular maturation successful required a femoral or
within the acetabulum (Fig. 5, B), in is problematic due to the variability pelvic osteotomy because of failure
contrast to a dislocated hip, which is of measurement. The 95% confi- to remodel. They also reported that
usually unequivocally posterior to dence interval for intraobserver 15 (79%) of 19 hips in children aged
the acetabulum (Fig. 5, A). readings is 12 degrees in dysplastic 18 to 21 months were successfully

A B

Figure 5 A, CT scan obtained after attempted closed reduction of a dislocated right hip. Line drawn parallel to the right pubic ramus
misses the proximal metaphysis. The hip was not reduced, and the patient was immediately taken back to the operating room. B, CT scan
obtained after open reduction. Note concentric reduction and well-molded cast (arrows). The small amount of posterior sag of the
femoral head is acceptable. Lines drawn along the pubic rami are now continuous with the proximal metaphyses on both sides.

406 Journal of the American Academy of Orthopaedic Surgeons


Michael G. Vitale, MD, MPH, and David L. Skaggs, MD

reduced, compared with only 8 tween the neurovascular bundle and Strecker26 compared preopera-
(42%) of 19 hips in children aged 22 and the pectineus muscle. tive skeletal traction with femoral
months or older. They concluded A medial approach potentially shortening in children over age 3
that children under the age of 22 endangers the blood supply to the who underwent open reduction of a
months have a higher likelihood of femoral head, and several authors developmentally dislocated hip.
a successful closed reduction. have noted an association between The incidence of osteonecrosis was
use of the medial approach and 54% in the 26 hips treated with trac-
Open Reduction increased rates of osteonecrosis. tion, compared with 0% in the 13
Although most often considered Although the incidence of osteone- hips treated with femoral shorten-
for children older than 18 months, crosis has been reported to be as ing. Femoral shortening should be
an open reduction is indicated for high as 43% at a mean follow-up utilized whenever hip reduction is
any hip in which a concentric, sta- interval of nearly 10 years, this has difficult or when it appears that
ble reduction cannot be achieved not been substantiated. 25 Never- undue force is being produced by
by closed means. A variety of ap- theless, concern regarding increased reduction of the hip. The amount of
proaches may be used; the location rates of osteonecrosis has con- shortening is determined on the
of the skin incision is of less impor- tributed to the decreased popularity basis of the amount of overlap of the
tance than the elements of the pro- of this approach. femoral segments after osteotomy
cedure relevant to the acetabulum. More important, the complete- with the hip reduced, and is most
The modified Smith-Petersen ness of the removal of obstacles to often in the range of 1 to 2 cm in this
anterolateral approach, performed reduction affects the outcome. A age group.
via a bikini incision, is the most common finding in a redislocated Femoral osteotomy is primarily
utilitarian approach and is used hip following an open reduction is indicated for shortening, but it also
when there is the possibility of a an intact transverse acetabular liga- presents an opportunity to correct
concomitant pelvic osteotomy. This ment that was not fully released at excessive femoral anteversion.
approach is particularly well suited the initial procedure. It is necessary However, derotational osteotomy
to open reduction in patients in to perform a complete release of the should be performed cautiously
whom there may be a high-riding hypertrophied transverse acetabular when combined with an anteriorly
femur with a lax capsule adherent ligament across the horseshoe- directed pelvic osteotomy, as exces-
to a false acetabulumstructures shaped acetabular notch at the base sive derotation may result in iatro-
that are not as well visualized of the acetabulum until a finger can genic posterior instability. Some
through a medial approach. be easily pushed past the inferior- authors question whether derota-
Inability to perform a pelvic os- medial rim. The acetabular origin tional osteotomy of the femur truly
teotomy or capsulorrhaphy via a of the ligamentum teres is just supe- changes the relationship of the
medial approach generally limits rior to the transverse acetabular lig- femur to the acetabulum or simply
its use to patients less than 12 to 18 ament and can serve as a guide for externally rotates the leg on the
months of age. However, a medial its identification. femur. However, many others
approach requires minimal dissec- Following open reduction and believe that proximal femoral os-
tion, avoids splitting the iliac apoph- capsulorrhaphy, a spica cast is teotomy redirects the femoral head
ysis, and allows direct access to the used for approximately 6 weeks into the acetabulum and is likely to
medial structures. with immobilization in about 30 stimulate remodeling in children
There are several medially based degrees of abduction, 30 degrees of who have acetabular remodeling
approaches. The true medial ap- flexion, and 30 degrees of internal potential (generally those who are
proach, as originally described by rotation. After cast removal, phys- 4 years of age or younger). Fem-
Ludloff, utilizes the interval be- ical therapy is often prescribed oral varus-producing osteotomies
tween the pectineus and the adduc- for hip mobilization and muscle have a role in the treatment of chil-
tor longus and brevis. Ferguson23 strengthening, especially in the dren with neuromuscular diseases,
popularized the use of this ap- older child. including cerebral palsy. However,
proach in the United States and varus osteotomy combined with
modified it to pass between the Femoral Osteotomy open reduction has little or no role
adductor longus and brevis anteri- Femoral shortening is thought to in the treatment of DDH.
orly and the adductor magnus and facilitate reduction and decrease the
gracilis posteriorly. Weinstein and rate of osteonecrosis by taking the Pelvic Osteotomy
Ponseti24 have described an antero- tension off the contracted soft tis- A pelvic osteotomy directly
medial approach that passes be- sues around the hip. Schoenecker addresses the insufficiency of ace-

Vol 9, No 6, November/December 2001 407


DDH From 6 Months to 4 Years

tabular coverage and may be indi- of the techniques of pelvic osteoto- In a thought-provoking article,
cated for persistence of acetabular mies for DDH was published in Lejman et al28 questioned the need
dysplasia or hip instability. There is 1999 by Gillingham et al.7 for capsulorrhaphy in open reduc-
considerable variability in clinical Our preference is to use a Dega tions with osteotomies. In this
practice with regard to pelvic os- osteotomy in children over age 18 prospective, randomized study of
teotomy in this age group. Some months with a steep acetabulum as 39 DDH patients aged 2 to 3 years,
reserve pelvic osteotomy for cases well as in children who exhibit in- the authors evaluated the results
in which open reduction and/or stability after open or closed reduc- after open reductions combined
femoral osteotomy has failed, tion. It is also frequently used in with femoral and pelvic osteotomies
whereas others commonly use children with neuromuscular con- with or without capsulorrhaphy. In
pelvic osteotomy in combination ditions because it improves posterior the 16 patients who underwent cap-
with open reduction as part of the acetabular coverage by cutting sulorrhaphy, there were three post-
initial procedure. For example, through the sciatic notch and leav- operative dislocations and one
Salter and Dubos11 have advocated ing the medial ilium intact as a instance of osteonecrosis. In 23 pa-
pelvic osteotomy as an index proce- hinge. When the Dega osteotomy tients who underwent capsulectomy,
dure for all patients with persistent is used to treat DDH, the cortex at the hip capsule was opened in a T
dysplasia who are older than 18 the sciatic notch is left intact as a fashion, with excision of the two tri-
months. Others recommend a pel- hinge, thus providing lateral and angles of capsule formed by the T.
vic osteotomy as the initial proce- anterior coverage.27 An advantage Patients with capsulectomies had no
dure only if there is residual insta- of the Dega osteotomy is the intrin- postoperative dislocations or osteo-
bility after reduction in children less sic stability, which obviates the necrosis. The authors stated that a
than 2 to 3 years of age. need for internal fixation with tight anterior hip capsule may push
The choice between femoral hardware, as well as the need for a the femoral head toward posterior
osteotomy and pelvic osteotomy second operation for hardware dislocation.
and among the various types of removal (Fig. 7). A spica cast is not
pelvic osteotomies may be based routinely necessary for postopera- Secondary Procedures
more on the surgeons training and tive immobilization, unless the One of the most difficult deci-
experience than on data comparing Dega osteotomy is combined with sions in the treatment of children
patient outcomes. Overall, the open reduction. with DDH is whether a secondary
innominate osteotomy of Salter
remains the most commonly used
pelvic osteotomy for patients in this
age group. 11 This is a complete
transverse osteotomy from the sciat-
ic notch to the ilium just above the
anterior inferior iliac spine. It relies
on rotation through the pubic sym-
physis in young patients and effec-
tively redirects the acetabulum
anterolaterally. In a review of 325
hips treated between 1958 and 1968,
Salter and Dubos11 reported 93.6%
excellent or good results in patients
aged 18 months to 4 years at an
average follow-up interval of 5.5
years.
Incomplete osteotomies, such as
those described by Pemberton and
Dega (Fig. 6), hinge through the
open triradiate cartilage, and are
also commonly used in skeletally
immature patients with DDH. A
useful comparison of the various Figure 6 Dega osteotomy for DDH, which leaves the sciatic notch intact.
reviews and a detailed discussion

408 Journal of the American Academy of Orthopaedic Surgeons


Michael G. Vitale, MD, MPH, and David L. Skaggs, MD

A B

Figure 7 A, Preoperative radiograph of a 2-year-old girl with bilateral DDH. B, Postoperative radiograph obtained 1 year after bilateral
Dega osteotomy. Both osteotomies were done at one sitting.

procedure is indicated (and if so, tioned well for many years despite femoral physis. This growth distur-
when). With the onset of walking, poor radiographic results. Overall, bance is not part of the natural his-
hips that appeared to have been function deteriorated with time tory of DDH, but is an iatrogenic
maturing appropriately after re- even in the absence of a growth complication observed with every
duction may begin to lateralize or disturbance of the proximal end of form of treatment, including the
dislocate; this is a definite indication the femur. Pavlik harness. Although not com-
for a secondary procedure. Arthrog- Despite encouraging intermediate- pletely understood, the cause of
raphy is helpful in this setting to term functional results, numerous osteonecrosis is believed to involve
determine whether a second open studies of the natural history have an interruption of the blood supply
reduction, combined with a pelvic established a strong link between to the femoral head. This may be
or femoral osteotomy, is necessary. persistent dysplasia and early de- caused by compression or stretch of
Race and Herring18 recommend that generative joint disease.2-4 Appre- vessels from excessive hip abduc-
if the acetabular index has not de- ciation of the predictably negative tion, direct injury to the vessels sup-
creased at least 4 degrees or if the natural history of hip dysplasia has plying the femoral head, or exces-
joint remains unstable 6 months been a driving force in the increas- sive mechanical pressure on the
after reduction, abandonment of ingly aggressive management of head after reduction.
closed treatment should be consid- this condition. However, the risk of The relationship between hip
ered after assessment by arthrog- the natural history of this disease abduction and blood-flow velocity
raphy. process must be carefully balanced in the femoral head has been estab-
against the possibility of iatrogenic lished with Doppler ultrasound. In
complications, particularly osteone- normal volunteers with their hips in
Functional Results crosis. neutral position, mean flow was 13
cm/sec; at 30 degrees of abduction,
In a 30-year follow-up study of 119 it was 10.3 cm/sec; and at 45 de-
DDH patients, the average Iowa Complications grees, 3.8 cm/sec.29 Clinical studies
hip rating was 91 of 100 points, have clearly shown the protective
even though 60% had a growth dis- The most devastating and, unfortu- effect of femoral shortening on de-
turbance of the proximal end of the nately, most common complication creasing joint pressure. Some au-
femur, and 43% had radiographic of treatment of DDH is osteonecro- thors30 have posited that the pres-
evidence of degenerative joint dis- sis of the femoral head, which has ence of the ossific nucleus confers a
ease.9 Patients who did not have also been referred to as a primary protective effect on the otherwise
such a growth disturbance func- growth disturbance of the proximal malleable femoral head, and may

Vol 9, No 6, November/December 2001 409


DDH From 6 Months to 4 Years

thus lead to lower rates of osteo- treatment, emphasizing the need for cy, some patients will present with
necrosis, but this has been refuted long-term follow-up of studies deal- DDH later in childhood. In an at-
by others. 31 Nevertheless, most ing with treatment of DDH. tempt to avoid a poor result, there
pediatric orthopaedists would argue The development of osteonecro- has been a gradual evolution to-
that the best overall results for DDH sis leads to a poor outcome. Al- ward earlier and more aggressive
are associated with as early a reduc- though some acetabular remodeling treatment of DDH. Concentric re-
tion as possible. may occur over time, the extent of duction as early as possible is essen-
Rates of osteonecrosis vary wide- remodeling is often even less than tial. Successful treatment of DDH in
ly from study to study. Thomas et that seen with osteonecrosis, which the older child demands an appreci-
al 32 have pointed out that the is due to a number of factors. Phy- ation of the pathoanatomy, the age-
marked variation in reported rates of sical therapy may be used in an dependent potential for acetabular
osteonecrosis reflects not only differ- attempt to maintain motion. Al- remodeling, the relative merits and
ences in patient populations but also though multiple treatment options pitfalls of various treatment options,
differences in the definition of this exist, they uniformly offer less than and recognition that iatrogenic os-
entity. Several systems of classifica- satisfactory results when the head is teonecrosis may occur. Early closed
tion of osteonecrosis have been de- severely involved. or open reduction, recognition of
veloped that encompass the range of the safe zone of immobilization,
disease, from temporary irregular os- femoral redirection and shortening,
sification to total head involvement Summary and well-conceived pelvic osteoto-
with growth disturbance. Studies mies all play an important role in
have shown that osteonecrosis may Despite rigorous efforts to identify improving the outcomes of older
first become apparent years after and treat all cases of DDH in infan- children with DDH.

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