Clinical tests:

tests
Done within 2 days of birth
At discharge
6 weeks
6 9months
15 21 months
Risk factors are recorded

 If positive or if risk factors are

present:
X ray evaluation is done
U/S screening is done also at
follow up

Completely dislocated hip

Progress to degenerative joint disease in
well formed false acetabulum.
In B/L cases low back pain develops as
result of increased hyper-lordosis

In U/L cases secondary problems in back

can arise such as scoliosis, leg length
problems with gait disturbance, valgus
deformity of knee with OA of knee

(1) newborn, birth to 6 months of age,

(2) infant, 6 to 18 months of age,
(3) toddler, 18 to 36 months of age,
(4) child and juvenile, 3 to 8 years of age,
and
(5) adolescent and young adult, beyond 8
years of age.

Management of DDH Guidelines

0 to 6 months

Pavliks Harness
6 weeks no
reduction

6 to 18 months

18 to 36 months

Traction
Closed reduction
Hip spica
Arthrography
No reduction

Pri. open
reduction

3 to 8 years

Pri, open
reduction with
Femoral
shortening

>1/3rd head
visible

Open reduction
Pelvic osteotomy

 Stabilizing the hip that has a positive

Ortolani or Barlow test or
reducing the dislocated hip with a mild to
moderate adduction contracture.

 Pavlik harness is a dynamic flexion

abduction orthosis.
Evaluate carefully the direction of
dislocation, the stability, and the
reducibility of the hip before treatment
Pavlik harness should not be used in
teratological dislocation

 The Pavlik harness consists of a chest strap,

two shoulder straps, and two stirrups.
Each stirrup has an anteromedial flexion
strap and a posterolateral abduction strap.

 It is applied with the child in supine position

The chest strap is fastened first, allowing enough
room for 3 fingers to be placed between the chest
and the harness.
This strap is placed just below the nipple line.

 The shoulder straps are buckled to maintain

the chest strap at the nipple line.
The feet are then placed in the stirrups one
at a time.

 The hip is placed in flexion (90 to 110

degrees), and the anterior flexion strap is
tightened to maintain this position.
Hyper flexion of the hip may produce
femoral nerve palsy
Inferior dislocation of hip
Less than 90 flexion will fail to reduce the
hip

 Finally, the lateral strap is loosely fastened

to limit adduction,
Not to force abduction. It will occur by
gravity itself
Excessive abduction to ensure stability is
not acceptable.
The knees should be 3 to 5 cm apart at full
adduction in the harness

 The Barlow test should be performed within

the limits of the harness to ensure adequate
stability.
The child is then placed prone and the
greater trochanters are palpated; if
asymmetry is noted, a persistent dislocation
is present.

 X ray to confirm reduction femoral neck is

directed towards tri-radiate cartilage
After 3 weeks ultrasound can be used to
confirm reduction

4 basic patterns of persistent

dislocation
Superior
inferior
lateral and
posterior.

 Superior dislocation, additional flexion of

the hip is indicated.
Inferior, a decrease in flexion is indicated

 Lateral dislocation in the Pavlik harness

should be observed initially.
As long as the femoral neck is directed
toward the triradiate cartilage, as confirmed
by roentgenogram or ultrasound, the head
may gradually reduce into the acetabulum.

 Persistent posterior dislocation is difficult to

treat, and Pavlik harness treatment
frequently is unsuccessful
Posterior dislocation usually is
accompanied by tight hip adductor muscles
and may be diagnosed by palpation of the
greater trochanter posteriorly.

 If any of these patterns of dislocation or

subluxation persist for more than 3 to 6
weeks, treatment in the Pavlik harness
should be discontinued and a new
program initiated; in most patients, this
consists of optional traction, closed or open
reduction, and casting.

 The Pavlik harness should be worn fulltime until stability is attained.

Once or twice a week patient is examined
and the harness straps are adjusted to
accommodate growth.

 Duration of full-time harness wear

approximately equal to the age at which
stability is attained plus 2 months.
Weaning is then started by removing the
harness for 2 hours each day.
This time is doubled every 2 to 4 weeks until
the device is worn only at night.
Night bracing can be continued until the hip
is normal X ray wise

Radiological evaluation follow-up

1 month after weaning begins,

at 6 months of age, and
at 1 year of age.
Follow-up to skeletal maturity is
recommended

In one series 20% patients treated successfully in harness

Developed acetabular dysplasia during 8 to 15 year follow-up

 In European series 95% successful results

80% of these were dislocated and not initially
reducible
Rate of AVN in harness range from 0 to 15%
Higher the dislocation more is the risk of AVN

Problems and complications with

harness

AVN
Failure to reduce
Femoral nerve palsy
Pavlik disease

Pavlik disease
Jones and associates noted that positioning
of dislocated hip in flexion and abduction
potentiated dysplasia.
Flattening of postero-lateral acetabulum
occurred
Harness has to be discontinued and open
reduction done

Other splints
Von-rosens splint
Ilfeld or Craig splint
Use of Frejka pillow and triple diapers is to
be discouraged

6 months to 18 months
Closed Reduction

Open reduction

Pre operative traction

Objectives of traction
to bring the laterally and proximally
displaced femoral head down to and
below the level of the true
acetabulum to allow a more gentle
reduction.

Preoperative Traction
According to Coleman no significant
difference by using pre-op traction
Home skin traction program in children
with compliant and educated parents can
be used

Adductor Tenotomy.
A percutaneous adductor tenotomy under
sterile conditions can be performed for a
mild adduction contracture.
For an adduction contracture of long
duration, an open adductor tenotomy
through a small transverse incision is
preferable.

 Gentle closed reduction is accomplished

with the child under general anesthesia.

Arthrography
Criteria for accepting a reduction are a
medial dye pool of 7 mm or less and
maintenance of reduction in an acceptable
"safe zone."

Safe zone" concept of Ramsey, Lasser,

and MacEwen
zone of abduction and adduction in which
the femoral head remains reduced in the
acetabulum.
A wide safe zone (minimum of 20 degrees,
preferably 45 degrees) is desirable
narrow safe zone implies an unstable or
unacceptable closed reduction.

A careful clinical evaluation of the reduction

should be made before and after adductor
tenotomy and before the arthrogram.

Application of Hip Spica

Hip joint in 95 degrees of flexion and 40 to
45 degrees of abduction
Salter advocated this "human
position" as best for maintaining hip
stability and
minimizing the risk of avascular necrosis.

After treatment
Spica cast immobilization is continued for 4
months.
The cast can be changed at 2 months with
the patient under general anesthesia.
Roentgenograms or arthrograms can be
obtained to be sure that the femoral head is
reduced anatomically into the acetabulum.
Computed tomography (CT) scanning is
useful

Indications:
Failure of closed reduction
Teratologic dysplasia
Hour glass contracture, inverted labrum which
prevent closed reduction
Pathology rather than age is the
main indicator
Correct the offending soft tissue structures and to reduce the
femoral head concentrically in the acetabulum.

Approaches for open reduction

Anterior
Anteromedial
Medial approach

Anterior approach
More anatomical dissection
But provides greater versatility because
the pathological condition in the anterior
and lateral aspects is easily reached
Pelvic osteotomy can be performed if
necessary.

Somerville technique of anterior open reduction in congenital dislocation of hip. A, Bikini

incision. B, Division of sartorius and rectus femoris tendons and iliac epiphysis. C, T-shaped
incision of capsule. D, Capsulotomy of hip and use of ligamentum teres to find true
acetabulum. E, Radial incisions in acetabular labrum and removal of all pulvinar from depth
of true acetabulum. F, Reduction and capsulorrhaphy after excision of redundant capsule.

Anteromedial approach
Described by Weinstein and Ponseti
Actually is an anterior approach to the hip
through an anteromedial incision.
Hip is approached in the interval between the
pectineus muscle and the femoral
neurovascular bundle.
Access to the lateral structures for dissection
or osteotomy is not possible with this
approach.

The medial (Ludloff) approach

It is simpler and involves less dissection
But places the medial circumflex vessels at
a higher risk - higher incidence of avascular
necrosis.
Recommended in children aged 1year and
younger

Incision for medial (Ludloff) approach and open reduction.

After treatment
X rays or CT scans can be used to confirm
reduction of the femoral head into the acetabulum.
The spica cast is removed at 10 to 12 weeks.
Sequential X rays are used to assess development
of the femoral head and acetabulum
These are obtained on a regular basis until the
child reaches skeletal maturity.

Criteria Evaluation of Open

Reduction.
1.Hip stable in neutral positionno osteotomy
2.Hip stable in flexion and abductioninnominate
osteotomy
3.Hip stable in internal rotation and abduction
proximal femoral derotational varus osteotomy
4."Double-diameter" acetabulum with
anterolateral deficiencyPemberton-type
osteotomy

Earliest x ray sign

indicating stability of reduction
Appearance of the acetabular teardrop
figure after reduction of the hip in DDH
Tear appeared at an average of 6.5 months
after reduction

Teratological Dislocations
The acetabulum is small, with an oblique or
flattened roof,
the ligamentum teres is thickened, and
the femoral head is of variable size and may
be flattened on the medial side
The hip joint is stiff and irreducible, and
X rays show superolateral displacement

Treatment
Age to initiate treatment 3 to 6 months
Anterior open reduction and femoral
shortening produced the best results with
the fewest complications.
Older children may require pelvic
osteotomy in addition

Avascular Necrosis.
2.5/1000 in infants referred for treatment before 6
months of age and
109/1000 in those referred after 6 months of age.
Children with avascular necrosis after treatment of
congenital dislocation of the hip should be followed
to maturity with serial orthoroentgenograms

 Early innominate osteotomy induced spherical

remodeling of the femoral head, with a resultant
congruous hip joint.
Symptomatic overgrowth of the greater trochanter
can be treated in older patients with greater
trochanteric advancement,
which will increase the abductor muscle resting
length and increase the abductor lever arm

Open reduction
with femoral shortening or
pelvic osteotomy, or
both, often is required.

 Persistent dysplasia can be corrected by a

redirectional proximal femoral osteotomy in very
young children
If the primary dysplasia is acetabular, pelvic
redirectional osteotomy alone is more appropriate.
Older children, however, require both femoral and
pelvic osteotomies if significant deformity is
present on both sides of the joint.

Management after 3 years of age is difficult:

Adaptive shortening of periarticular
structures
Structural alterations in both femoral head
and acetabulum

Open reduction combined with

femoral shortening with or without

pelvic osteotomy

Femoral shortening

obtains predictable reduction, and

results in a low rate of avascular
necrosis.

Wenger recommends
primary femoral shortening,
anterior open reduction, and
capsulorrhaphy,
with or without pelvic osteotomy
Derotation or varus correction is not required as there is no
excessive anteversion or valgus

 Pelvic osteotomy may be required at an age

of 18 months and later .
The degree of acetabular coverage of the
femur when the head is placed in extension
and neutral rotation and abduction.
If more than 1/3rd is` seen in this position an
innominate osteotomy will provide better
coverage.

OPTIONS FOR OSTEOTOMY

Salters
Pembertons
Important points to be considered are:
1. Place the oteotomy high enough to avoid
damage to cartilaginous acetabular margin
2. If there is undue tension on reduction a
concomitant femoral shortening should be
considered.

Complication of combining pelvic

osteotomy with femoral shortening
Posterior Dislocation of the hip
Especially if hip is derotated

Age limit for reduction in U/L vs

B/L cases
U/L cases reduction should be attempted up
to 9 to 10 years if there is possibility of
restoring the acetabular coverage
B/L results are frequently unsatisfactory
in children more than 8 years old.
The natural outcome of untreated B/L
dislocation is better than in treated cases

Salter Innominate Osteotomy

Salter observed that the entire acetabulum
faces more anterolaterally (ANTETORSION)
than normal.
Salter's osteotomy of the innominate bone
redirects the entire acetabulum so that its roof
"covers" the femoral head both anteriorly and
superiorly.
It doesnot increase or decrease volume.

 Salter recommended his osteotomy in the primary

treatment of congenital dislocation of the hip in
children between the ages of 18 months and 6
years and
In the primary treatment of congenital subluxation
as late as early adulthood.
Secondary treatment of any residual or recurrent
dislocation or subluxation after other methods of
treatment

Prerequisites for Salters Osteotomy

The femoral head must be positioned opposite the level of the
acetabulum. (This may require a period of preop traction or
primary femoral shortening.)
Contractures of the iliopsoas and adductor muscles must be
released.
Open reduction is performed for hip dislocation but usually is
unnecessary for hip subluxation.
The femoral head must be reduced into the depth of the true
acetabulum completely and concentrically.
This generally requires careful open reduction and excision of
any soft tissue, exclusive of the labrum, from the acetabulum.
The joint must be reasonably congruous.
The range of motion of the hip must be good, especially in
abduction, internal rotation, and flexion.

AFTERTREATMENT.
At 8 to 12 weeks the spica cast is removed,
and with the patient under general or local
anesthesia the Kirschner wires also are
removed.
The position of the osteotomy and of the hip
is checked by roentgenograms.

Complications

Sciatic nerve injuries

Femoral nerve injuries
Loss of position
Pins placed into acetabulum, even into
femoral head
Post operative hip stiffness

Pemberton Acetabuloplasty
Pericapsular osteotomy of the ilium in
which an osteotomy is made through the
full thickness of the ilium,
Using the triradiate cartilage as the hinge
about which the acetabular roof is rotated
anteriorly and laterally.

Indications
Marked defeceincy of anterior and
superolateral wall of acetabulum
Marked laxity of capsule and hypermobility
of joint
Age 2 to 6 years

Advantages over Salters

Internal fixation is not required,and thus a
second, but minor, operation is avoided.
Furthermore, a greater degree of correction
can be achieved with less rotation of the
acetabulum in the
(because the fulcrum, the triradiate
cartilage, is nearer the site of desired
correction.)

Disadvantages
Technically more difficult to perform.
It alters the configuration and capacity of
the acetabulum and can result in an
incongruous relationship between it and the
femoral head

Anterior iliofemoral approach.

Letournel and Judet iliofemoral approach. A, Skin incision. B, Anterior aspect of

hip joint and anterior column are exposed by releasing sartorius and rectus
femoris and reflecting iliacus medially.

After treatment
At 8 to 12 weeks the cast is removed, and
Osteotomy is checked by roentgenograms.

Steel Osteotomy
provide more correction and
improve femoral head coverage.

 Triple innominate osteotomy developed by

Steel, the ischium, the superior pubic
ramus, and the ilium superior to the
acetabulum are all divided.
The acetabulum is repositioned and
stabilized by a bone graft and pins

 Joint must be congruous or become so once

the acetabulum has been redirected
Femoral shortening may be required

AFTERTREATMENT.
A spica cast is applied with the hip in 20 degrees
of abduction, 5 degrees of flexion, and neutral
rotation.
At 8 to 10 weeks the cast and pins are removed,
and active and passive motion of the hip are
started.
All three osteotomies usually unite by 12 weeks
after surgery, at which time progressive weightbearing on crutches is started.

Dega Osteotomy
Transiliac osteotomy for the treatment of
residual acetabular dysplasia secondary to
congenital hip dysplasia or dislocation.
osteotomy of the anterior and middle
portions of the inner cortex of the ilium

Shelf Operations
performed to enlarge the volume of the
acetabulum;
However, pelvic redirectional and
displacement osteotomies have largely
replaced this type of operation.

Indication
A deficient acetabulum that cannot be
corrected by redirec-tional pelvic osteotomy
is the primary indication for this operation.

Contraindication
Dysplastic hips with spherical congruity
suitable for redirectional osteotomy,
Hips requiring concurrent open reduction
that must have supplementary stability, and
patients unsuited for spica cast
immobilization.

 Before surgery the CE angle of Wiberg is

determined from anteroposterior standing
pelvic roentgenograms,
and a normal CE angle (about 35 degrees) is
drawn on the film.

 "bikini" skin incision 1 cm below and

parallel to the iliac crest.

Chiari Osteotomy
Capsular interposition arthroplasty and
should be considered only in those
instances when other reconstructions are
impossible,

 femoral head cannot be centered adequately

in the acetabulum
painfully subluxated hips with early signs of
osteoarthritis.
This procedure deepens the deficient
acetabulum by medial displacement of the
distal pelvic fragment and improves
superolateral femoral coverage.

Adolescent and Young Adult (Older

Than 8 to 10 Years of Age)
Palliative salvaging operations are possible
Rarely a femoral shortening combined with
a pelvic osteotomy could be considered, but
the chances of creating a hip to last a
lifetime are minimal.

Degenerative arthritis has set in:

Reconstructive operation such as a total
hip arthroplasty may be indicated at the
appropriate age
Arthrodesis
is now rarely indicated for old unreduced dislocations
and is contraindicated for bilateral dislocations.