Ddh residents

DevelopmentalDevelopmental
Dysplasia of the HipDysplasia of the Hip
Dr.Abdulmonem Al SiddikyDr.Abdulmonem Al Siddiky
Assistant professor & ConsultantAssistant professor & Consultant
Ped.Ortho.,Ped.Spine & Spinal deformitiesPed.Ortho.,Ped.Spine & Spinal deformities
KKUH , KSUKKUH , KSU

OverviewOverview
 IntroductionIntroduction
 Normal Development of the HipNormal Development of the Hip
 Etiology and PathoanatomyEtiology and Pathoanatomy
 Epidemiology and DiagnosisEpidemiology and Diagnosis
 TreatmentTreatment
 ComplicationsComplications

IntroductionIntroduction
 Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip
 DDH - preferred termDDH - preferred term
 Teratogenic hipsTeratogenic hips
 SubluxationSubluxation
 Dislocation-usually posterosuperior (reducibleDislocation-usually posterosuperior (reducible
vs irreducible)vs irreducible)
 DysplasiaDysplasia

SummarySummary
 Risk FactorsRisk Factors
 1/1,000 born with dislocated hip1/1,000 born with dislocated hip
 10/10,000 born with subluxation or dysplasia10/10,000 born with subluxation or dysplasia
 80% Female80% Female
 First born childrenFirst born children
 Family history (6% one affected child, 12% oneFamily history (6% one affected child, 12% one
affected parent, 36% one child + one parent)affected parent, 36% one child + one parent)
 OligohydramniosOligohydramnios
 Breech (sustained hamstring forces)Breech (sustained hamstring forces)
 Native Americans (swaddling cultures)Native Americans (swaddling cultures)
 Left 60% (left occiput ant), Right 20%, both 20%Left 60% (left occiput ant), Right 20%, both 20%
 Torticollis or LE deformityTorticollis or LE deformity

Normal DevelopmentNormal Development
 EmbryonicEmbryonic
 7th week - acetabulum and hip formed from7th week - acetabulum and hip formed from
same mesenchymal cellssame mesenchymal cells
 11th week - complete separation between the11th week - complete separation between the
twotwo
 Prox fem ossific nucleus - 4-7 monthsProx fem ossific nucleus - 4-7 months

Normal HipNormal Hip
 Tight fit of head inTight fit of head in
acetabulumacetabulum
 Transection ofTransection of
capsulecapsule
 Still difficult toStill difficult to
dislocatedislocate
 Surface tensionSurface tension

PathoanatomyPathoanatomy
 Ranges from mild dysplasia --> frankRanges from mild dysplasia --> frank
dislocationdislocation
 Bony changesBony changes
 Shallow acetabulumShallow acetabulum
 Typically on acetabular sideTypically on acetabular side
 Femoral anteversionFemoral anteversion

 Soft tissue changesSoft tissue changes
 Usually secondary to prolonged subluxation orUsually secondary to prolonged subluxation or
dislocationdislocation
 IntraarticularIntraarticular
 LabrumLabrum
 Inverted + adherent to capsule (closed reduction withInverted + adherent to capsule (closed reduction with
inverted labruminverted labrum assoc with increased Avascular Necrosis)assoc with increased Avascular Necrosis)
 Ligamentum teresLigamentum teres
 Hypertrophied + lengthenedHypertrophied + lengthened
 PulvinarPulvinar
 Fibrofatty tissue migrating into acetabulumFibrofatty tissue migrating into acetabulum

 Soft Tissue (Intraarticular)Soft Tissue (Intraarticular)
 Transverse acetabular ligamentTransverse acetabular ligament
 ContractedContracted
 LimbusLimbus
 Fibrous tissue formed from capsular tissueFibrous tissue formed from capsular tissue
interposed between everted labrum and acetabularinterposed between everted labrum and acetabular
rimrim
 ExtraarticularExtraarticular
 Tight adductors (adductor longus)Tight adductors (adductor longus)
 IliopsoasIliopsoas

Tough Reductions…Tough Reductions…
 Obstacles to reductionObstacles to reduction
 ExtraarticularExtraarticular
 Tight iliopsoas andTight iliopsoas and
adductorsadductors
 IntraarticularIntraarticular
 LabrumLabrum
 Ligamentum teresLigamentum teres
 Transverse acetabularTransverse acetabular
ligamentligament
 PulvinarPulvinar
 Redundant capsuleRedundant capsule
(hourglass)(hourglass)
 +/- limbus+/- limbus

Etiology and EpidemiologyEtiology and Epidemiology
 MultifactorialMultifactorial
 Genetics and SyndromesGenetics and Syndromes
 Ehler’s DanlosEhler’s Danlos
 ArthrogryposisArthrogryposis
 Larsen’s syndromeLarsen’s syndrome
 Intrauterine environmental factorsIntrauterine environmental factors
 TeratogensTeratogens
 Positioning (oligohydramnios)Positioning (oligohydramnios)
 Neurologic DisordersNeurologic Disorders
 Spina BifidaSpina Bifida

DiagnosisDiagnosis
 Newborn screeningNewborn screening
 Ortolani’s and Barlow’s maneuvers with aOrtolani’s and Barlow’s maneuvers with a
thorough history and physicalthorough history and physical
 Warm, quiet environment with removal ofWarm, quiet environment with removal of
diaperdiaper
 Head to toe exam to detect any associatedHead to toe exam to detect any associated
conditons (Torticollis, Ligamentous Laxityconditons (Torticollis, Ligamentous Laxity
etc.)etc.)
 Baseline Neuro and Spine ExamBaseline Neuro and Spine Exam

DiagnosisDiagnosis
 Key physical findingsKey physical findings
 AsymmetryAsymmetry
 Limb length- GaleazziLimb length- Galeazzi
 Abduction ROMAbduction ROM
 Skin foldsSkin folds
 LimpLimp
 Waddilng gait /Waddilng gait /
hyperlordosis - bilateralhyperlordosis - bilateral
involvementinvolvement

Ortolani’s ManeuverOrtolani’s Maneuver
* After 3 months of age tests become negative

Barlow’s ManeuverBarlow’s Maneuver

DiagnosisDiagnosis
 Some cases still missedSome cases still missed
 At risk groups should be further screenedAt risk groups should be further screened
 AAPAAP
 Recs further imaging (e.g. US) if exam isRecs further imaging (e.g. US) if exam is
“inconclusive” AND“inconclusive” AND
 First degree relative + femaleFirst degree relative + female
 BreechBreech
 Positive provocative maneuver (Ortolani or Barlow)Positive provocative maneuver (Ortolani or Barlow)
 Referral to OrthopaedistReferral to Orthopaedist

ImagingImaging
 X-raysX-rays
 Femoral head ossification centerFemoral head ossification center
 4 -7 months4 -7 months
 UltrasoundUltrasound
 Operator dependentOperator dependent
 CTCT
 MRIMRI
 ArthrogramsArthrograms
 Open vs closed reductionOpen vs closed reduction

ImagingImaging
 RadiographsRadiographs

ImagingImaging
 Acetabular IndexAcetabular Index

ImagingImaging
 Acetabular IndexAcetabular Index
< 30° wnl

Radiographs SummaryRadiographs Summary
 Femoral head appears 4 - 7 monthsFemoral head appears 4 - 7 months
 Shenton’s lineShenton’s line
 Perkin’s and Hilgenreiner’s linesPerkin’s and Hilgenreiner’s lines
 Inferomedial quadrantInferomedial quadrant
 Center Edge Angle (< 20 abnormal)Center Edge Angle (< 20 abnormal)
 Acetabular indexAcetabular index
 Normal < 30 (Weintroub et al)Normal < 30 (Weintroub et al)
 Tear drop*Tear drop*
 Abnormal widening in DDHAbnormal widening in DDH
*may be only sign in mild subluxation*may be only sign in mild subluxation

ImagingImaging
 UltrasoundUltrasound
 Introduced in 1978 for eval of DDHIntroduced in 1978 for eval of DDH
 Operator dependentOperator dependent
 Useful in confirming subluxation, identifyingUseful in confirming subluxation, identifying
dysplasia of cartilaginous acetabulum,dysplasia of cartilaginous acetabulum,
documenting reducibilitydocumenting reducibility
 Prox Femoral Ossification Center interferesProx Femoral Ossification Center interferes
 Requires a window in spica cast (avoid)Requires a window in spica cast (avoid)

UltrasoundUltrasound
Femoral head
Abductors
Ilium

Graf’s alpha
angle

Graf’s alpha
angle
>60° = normal
*line w/ ilium
bisects head 50/50

Natural HistoryNatural History
 NewbornNewborn VariableVariable
 > 6 months> 6 months more aggressive tx requiredmore aggressive tx required
due to more extensive pathology anddue to more extensive pathology and
decreased potential for acetabulardecreased potential for acetabular
remodelingremodeling
 Abnormal Gait, Decreased Abduction andAbnormal Gait, Decreased Abduction and
Strength, Increased DJDStrength, Increased DJD
 Unilateral worse than BilateralUnilateral worse than Bilateral
 Subluxation worse than DysplasiaSubluxation worse than Dysplasia

Treatment OptionsTreatment Options
 Age of patient at presentationAge of patient at presentation
 Family factorsFamily factors
 Reducibility of hipReducibility of hip
 Stability after reductionStability after reduction
 Amount of acetabular dysplasiaAmount of acetabular dysplasia

Birth to Six MonthsBirth to Six Months
 Triple-diaper techniqueTriple-diaper technique
 Prevents hip adductionPrevents hip adduction
 ““Success” no different in someSuccess” no different in some
untreated hipsuntreated hips
 Pavilk harness (1944)Pavilk harness (1944)
 Experienced staff*Experienced staff*
 Very successfulVery successful
 Allows free movement withinAllows free movement within
confines of restraintsconfines of restraints
*posterior straps for preventing add. NOT producing abd.

Birth to Six MonthsBirth to Six Months
 Pavlik harnessPavlik harness
 IndicationsIndications
 Fully reducible hip*Fully reducible hip*
 Child not attempting to standChild not attempting to stand
 FamilyFamily
• Close regular follow-up (every 1-2 weeks)Close regular follow-up (every 1-2 weeks)
• For imaging and adjustmentsFor imaging and adjustments
• DurationDuration
• Childs age at hip stability + 3 monthsChilds age at hip stability + 3 months

Pavlik HarnessPavlik Harness
 FailuresFailures
 Poor parent compliancePoor parent compliance
 Improper use by the physicianImproper use by the physician
 Inadequate initial reductionInadequate initial reduction
 Failure to recognize persistent dislocationFailure to recognize persistent dislocation
 Viere et al 1990Viere et al 1990
 Bilateral dislocationBilateral dislocation
 Absent Ortolani’s signAbsent Ortolani’s sign
 > 7weeks of age> 7weeks of age

Pavlik HarnessPavlik Harness
 ComplicationsComplications
 Avascular necrosisAvascular necrosis
 Forced hip abductionForced hip abduction
 Safe zone (abd/adduction and flexion/extension)Safe zone (abd/adduction and flexion/extension)
 Femoral nerve palsyFemoral nerve palsy
 HyperflexionHyperflexion
*Be aware of Pavlik Harness Disease*Be aware of Pavlik Harness Disease
*Follow until skeletal maturity*Follow until skeletal maturity

Birth - Six monthsBirth - Six months
 Closed reduction + SpicaClosed reduction + Spica
 Failure after 3 weeks of Pavlik trialFailure after 3 weeks of Pavlik trial

Birth - Six monthsBirth - Six months
 Closed reductionClosed reduction
 General anesthesiaGeneral anesthesia
 ArthrogramArthrogram
 Safe zone - avoid AVNSafe zone - avoid AVN
 +/- adductor tenotomy+/- adductor tenotomy
 Open reduction if concentric reduction notOpen reduction if concentric reduction not
possiblepossible
 Usually teratogenic hips in this age groupUsually teratogenic hips in this age group

Open ReductionOpen Reduction
 Medial approachMedial approach
 Pectineus / adductor longus + brevisPectineus / adductor longus + brevis
 Cannot address simeoultaneous bony workCannot address simeoultaneous bony work
 Antero -lateralAntero -lateral
 Smith-petersonSmith-peterson
 Sartorius / Tensor Fascia lataSartorius / Tensor Fascia lata

6 months - 4 years6 months - 4 years
 Present a more difficult problemPresent a more difficult problem
 Prolonged dislocationProlonged dislocation
 Contracted soft tissuesContracted soft tissues
 6 - 18 months6 - 18 months
 Closed reduction +/- adductor tenotomyClosed reduction +/- adductor tenotomy
 Spica in human position of 100 degrees of flexion andSpica in human position of 100 degrees of flexion and
about 55 degrees abduction (3 months)about 55 degrees abduction (3 months)
 Abduction Orthosis 4 wks full time/4 wks nighttimeAbduction Orthosis 4 wks full time/4 wks nighttime
 Open reduction (if closed fails)Open reduction (if closed fails)
 CapsulorraphyCapsulorraphy
 CT scanCT scan
 Spica for 6 wks followed by PTSpica for 6 wks followed by PT

6 months - 4 years6 months - 4 years
 18 months - 4 years18 months - 4 years
 Closed reductionClosed reduction
 Reducibile - check arthrogram andReducibile - check arthrogram and medial dye poolmedial dye pool
 Irreducible - Open reductionIrreducible - Open reduction
 Open redcutionOpen redcution
 Tight - femoral shorteningTight - femoral shortening
 Stable - +/- pelvic osteotomyStable - +/- pelvic osteotomy

Femoral ShorteningFemoral Shortening
 Schoenecker + Strecker 1984Schoenecker + Strecker 1984
 Traction vs. Femoral shorteningTraction vs. Femoral shortening
 56% AVN in traction group56% AVN in traction group
 0% AVN in femoral shortening0% AVN in femoral shortening

Pelvic OsteotomyPelvic Osteotomy
 Persistent instability + dysplasia afterPersistent instability + dysplasia after
open reduction + femoral shorteningopen reduction + femoral shortening
 Requires concentric reduction of aRequires concentric reduction of a
reasonably spherical femoral headreasonably spherical femoral head
 Usually based on surgeon preferenceUsually based on surgeon preference
 Salter and Pemberton 2 m/c in USSalter and Pemberton 2 m/c in US

 Volume changingVolume changing
 PembertonPemberton
 Hinges on triradiateHinges on triradiate
 Requires remodeling of “new” incongruityRequires remodeling of “new” incongruity
 Provides more anterolateral coverageProvides more anterolateral coverage
 Dega’sDega’s

 RedirectingRedirecting
 SalterSalter
 Osteotomy thru sciatic notchOsteotomy thru sciatic notch
 Hinge thru pubic symphysisHinge thru pubic symphysis
 Triple innominateTriple innominate
 GanzGanz
 DialDial

Salter OsteotomySalter Osteotomy

Salvage or Shelf proceduresSalvage or Shelf procedures
 ChiariChiari
 Requires capsular metaplasiaRequires capsular metaplasia
 Pain - main indicationPain - main indication
 Treatment of chronic hip pain in adolescentsTreatment of chronic hip pain in adolescents

Chiari OsteotomyChiari Osteotomy

Avascular NecrosisAvascular Necrosis

Avascular NecrosisAvascular Necrosis
 Most commonMost common
 Not part of the natural history of DDHNot part of the natural history of DDH
 IatrogenicIatrogenic
 Etiology unknownEtiology unknown
 Femoral head compressionFemoral head compression
 Injury to blood supplyInjury to blood supply
 Excessive abductionExcessive abduction
 Sullivan et al 1997Sullivan et al 1997
 SigSig ↓↓ blood flow w/ increasing abd angleblood flow w/ increasing abd angle

TX SummaryTX Summary
 Best if treated before 6 weeks of ageBest if treated before 6 weeks of age
 0 - 6 months of age0 - 6 months of age
 PavlikPavlik
 Closed vs open reduction and spicaClosed vs open reduction and spica
 ClosedClosed
 Open +/- osteotomiesOpen +/- osteotomies

SummarySummary
 Femoral shortening better than tractionFemoral shortening better than traction
 Pelvic osteotomiesPelvic osteotomies
 Dega, PembertonDega, Pemberton
 Salter, triple innominate, GanzSalter, triple innominate, Ganz
 ChiariChiari

Evaluation of a 4week infant who has aEvaluation of a 4week infant who has a
hip click reveals a positive Ortolani sign.hip click reveals a positive Ortolani sign.
Treatment should include:Treatment should include:
 A.A. traction, closed reduction, and spica casting.traction, closed reduction, and spica casting.
 B.B. triple diapers and reassessment in 1 monthtriple diapers and reassessment in 1 month
 C.C. an AP pelvis x-ray at age 4 monthsan AP pelvis x-ray at age 4 months
 D.D. Fitting of a Pavlik harness and reassessment in 2Fitting of a Pavlik harness and reassessment in 2
weeksweeks
 E.E. an US of the hip, fitting of a Pavlik, andan US of the hip, fitting of a Pavlik, and
reevaulation in 3 months.reevaulation in 3 months.

Evaluation of a 4week infant who has aEvaluation of a 4week infant who has a
hip click reveals a positive Ortolani sign.hip click reveals a positive Ortolani sign.
Treatment should include:Treatment should include:
 A.A. traction, closed reduction, and spica casting.traction, closed reduction, and spica casting.
 B.B. triple diapers and reassessment in 1 monthtriple diapers and reassessment in 1 month
 C.C. an AP pelvis x-ray at age 4 monthsan AP pelvis x-ray at age 4 months
 D.D. Fitting of a Pavlik harness and reassessment inFitting of a Pavlik harness and reassessment in
2 weeks2 weeks
 E.E. an US of the hip, fitting of a Pavlik, andan US of the hip, fitting of a Pavlik, and
reevaulation in 3 months.reevaulation in 3 months.

A healthy 5-mo-old infant w/ DDH of the L hipA healthy 5-mo-old infant w/ DDH of the L hip
has been treated in a Pavlik for 3 months.has been treated in a Pavlik for 3 months.
Exam shows limited ABD and a Galeazzi sign.Exam shows limited ABD and a Galeazzi sign.
Radiographs in harness were taken.Radiographs in harness were taken.
Management should consist of:Management should consist of:
 A.A. an arthrogram and closed reductionan arthrogram and closed reduction
 B.B. a change of the Pavlik to a Frejka pillowa change of the Pavlik to a Frejka pillow
 C.C. no further Rx until the child is 6mosno further Rx until the child is 6mos
 D.D. Adjustment of the Pavlik and continuation of RxAdjustment of the Pavlik and continuation of Rx
 E.E. open reduction through a medial approach and spicaopen reduction through a medial approach and spica

This is an x-ray of a 9-month-old infant whoThis is an x-ray of a 9-month-old infant who
has intoeing. Exam of the hips show ABD ofhas intoeing. Exam of the hips show ABD of
the Left hip to 75 degrees and the Right to 90the Left hip to 75 degrees and the Right to 90
degrees. Both the Ortolani and Barlow signsdegrees. Both the Ortolani and Barlow signs
are negative. Management should include:are negative. Management should include:
 A.A. observationobservation
 B.B. application of a Pavlik harnessapplication of a Pavlik harness
 C.C. closed reduction of the Left hipclosed reduction of the Left hip
 D.D. open reductino of the Left hipopen reductino of the Left hip
 E.E. open reduction of the left hip with innominateopen reduction of the left hip with innominate
osteotomyosteotomy

The x-ray shows a AP pelvis of a 6yo girl whoThe x-ray shows a AP pelvis of a 6yo girl who
presents with a limp and intermittent pain inpresents with a limp and intermittent pain in
the right groin. Management should include:the right groin. Management should include:
 A.A. A varus derotational osteotomy of the right femurA varus derotational osteotomy of the right femur
 B.B. open reduction and adductor tenotomyopen reduction and adductor tenotomy
 C.C. open reduction with femoral and pelvic osteotomiesopen reduction with femoral and pelvic osteotomies
 D.D. PT for muscle strengthening and ROM exercisesPT for muscle strengthening and ROM exercises
 E.E. longitudinal traction, closed reduction, and adductorlongitudinal traction, closed reduction, and adductor
tenotomytenotomy

The x-ray shows a AP pelvis of a 6yo girl whoThe x-ray shows a AP pelvis of a 6yo girl who
presents with a limp and intermittent pain inpresents with a limp and intermittent pain in
the right groin. Management should include:the right groin. Management should include:
 A.A. A varus derotational osteotomy of the right femurA varus derotational osteotomy of the right femur
 B.B. open reduction and adductor tenotomyopen reduction and adductor tenotomy
 C.C. open reduction with femoral and pelvicopen reduction with femoral and pelvic
osteotomiesosteotomies
 D.D. PT for muscle strengthening and ROM exercisesPT for muscle strengthening and ROM exercises
 E.E. longitudinal traction, closed reduction, and adductorlongitudinal traction, closed reduction, and adductor
tenotomytenotomy

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