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Developmental dysplasia of hip
1. Subject seminar
SRI SIDDHARTHA MEDICAL COLLEGE,TUMKUR
DEVELOPMENTAL DYSPLASIA OF HIP
CHAIRPERSON: PROF. & HOD Dr. Kiran Kalaiah
MODERATOR: PROF. & HOD Dr. Kiran Kalaiah
SPEAKER: Dr. G. ARUN SIVA RAM
2. Definition :
• Dysplasia of the hip that develop during fetal life or in infancy.
• It ranges from dysplasia of the acetabulum (shallow acetabulum) to
subluxation of the joint to complete dislocation.
• The old name was ‘‘congenital dysplasia of the hip (CDH).’’ The name
has changed to indicate that not all cases are present at birth and that
some cases can develop later on during infancy and childhood
5. INCIDENCE
• Most newborn screening studies suggest that some degree of hip
instability can be detected in 1/100 to 1/250 babies, actual dislocated
or dislocatable hips are much less common, being found in 1-1.5 of
1000 live births.
• There is marked geographic and racial variation in the incidence of
DDH.
• More inidence of DDH IN Sweden,Yugoslavia and Canada.
6. ETIOLOGY:
• A positive family history for DDH is found in 12-33% of affected
patients.
• DDH is more common among female patients (80%). This is thought
to be due to the greater susceptibility of female fetuses to maternal
hormones such as relaxin, which increases ligamentous laxity
• Primigravida.
• Breech presentation(2-3%).
• Oligohydramnios ,primi gravida and large baby ( crowding
phenomenon ).
• Adduction and Extension postnatally.
8. • The left hip is the most commonly affected hip
• In the most common fetal position, this is the hip that is usually
forced into adduction against the mother’s sacrum.
• Girls are affected 5 times more than boys.
9. TYPES
• DDH is classified into two major groups :
• Typical and teratologic .
• Typical DDH occurs in otherwise normal patients or those without
defined syndromes or genetic conditions.
• Teratologic hip dislocations usually have identifiable causes such as
arthrogyposis or a genetic syndrome and occur before birth.
15. NEONATE
• Exam one hip at a time
• Baby must be quiet
• Barlow’s sign: provocative maneuver
• Ortolani’s sign: reduces hip
• Other signs not helpful in newborn
16. NEWBORN
Usually asymptomatic and must be screened by special maneuvers
1) Barlow test.
It is a provocative test that attempts to dislocate an unstable hip.
- Flexion ,adduction, posteriorly
- . – “Clunk”
17. The Barlow test for developmental dislocation of the hip in a
neonate.A, With the infant supine, the examiner holds both of the
child's knees and gently adducts one hip and pushes posteriorly.B,
When the examination is positive, the examiner will feel the femoral
head make a small jump (arrow) out of the acetabulum (Barlow's sign).
When the pressure is released, the head is felt to slip back into place.
18. ORTOLANI TEST
It is a maneuver to reduce a recently dislocated hip.
• Flexion, abduction, anteriorly.
• We can`t use X-rays because the acetabulum and proximal femur are
cartilaginous and wont be shown on X-ray.
• US is the best method to Dx.
19. • The Ortolani test for developmental dislocation of the hip in a
neonate.A, The examiner holds the infant's knees and
gently abducts the hip while lifting up on the greater trochanter with
two fingers.B, When the test is positive, the dislocated femoral head
will fall back into the acetabulum (arrow) with a palpable (but not
audible) “clunk” as the hip is abducted (Ortolani's sign). When the hip
is adducted, the examiner will feel the head redislocate posteriorly.
20. CLINICAL MANIFESTATION- INFANT
• As the baby enters the 2nd and 3rd months of life, the soft tissues
begin to tighten and the Ortolani and Barlow tests are no longer
reliable.
• Shortening of the thigh, the Galeazzi sign , is best appreciated by
placing both hips in 90 degrees of flexion and comparing the height of
the knees, looking for asymmetry
21. • The most diagnostic sign is Ortolani’s limitation of abduction.
• Abduction less than 60 degrees is almost diagnostic.
• X-rays after the age of 3 months can be helpful esp. after the
appearance of the ossific nucleus of the femoral head
• US is 100% diagnostic.
22. INFANT PRESENTATION
• Skin fold asymmetry
• Limited hip abduction
•
• Unequal femoral lengths (Galeazzi’s sign)
• (Flex both hips and one side shows apparent femoral shortening)
27. After walking age
• Trendelenberg gait
• Leg length discrepancy
• Increased lumbar lordosis in Bilateral dislocation
• –Klisic test positive
28. • The examiner places the middle finger over the greater trochanter,
and the index finger on the anterior superior iliac spine.A, With a
normal hip, an imaginary line drawn between the two fingers points
to the umbilicus.B, When the hip is dislocated, the trochanter is
elevated and the line projects halfway between the umbilicus and the
pubis.
31. Screening
• All neonates should have a clinical examination for hip instability
• Risk factors :
– breech presentation – family history
– torticollis
– oligohydramnios
– metatarsus adductus
32. Imaging
• Xray femur head ossify at 4-7 months
• Usg
• Ct
• Mri
• arthrogram
33. Radiograph
• It is not reliable in early stages of DDH but new born screening may
reveal severe acetabular dysplasia or teratological dislocation.
• as child grows soft tissue become contracted and radiographs
become more helpful in diagnosis.
• Most common used lines of reference are vertical line of Perkins and
horizontal line of Hilgenreiner, both used to assess the position of
femoral head.
34. Von rosen view
• In this view both hips are Abducted, Internally Rotated and Extended.
• Line is drawn along femoral shaft, which intersect acetabulum.
• In dislocated hip, it crosses above the acetabulum.
35. Von rosen view
• AP X-ray: hip in 45°abduction and IR describes the longitudinal
relationship between long axis of femur and acetabulum
36. Xray
Horizontal line of Hilgenreiner:
drawn between upper ends of tri-radiate
cartilage of the acetabulum.
Vertical line of perkins:
drawn from the lateral edge of the acetabulum vertical to horizontal line.
4 quadrants:
Normal hip: the ossification center of the femoral
hip lower medial quadrant.
Dislocated hip: upper lateral quadrant.
37. Perkin line is through lateral margin of
acetabulum
• While hilgenreiner line is through triradiate cartilage.
• Shenton line is curved line that begins at lesser trochanter, goes upto
femoral neck, and connect with line along inner margin of pubis.
• In normal hip, medial beak of femoral metaphysis lies in lower inner
quadrant produced by junction of Perkin and hilgenreiner lines.
38. Dimensions H and D are measured to quantify proximal
and lateral displacement of the hip and are most useful
when the head is not ossified.
Acetabular index and the medial gap
39. Acetabular index:
angle between horizontal line of hilgenreiner and the line between the
two edges of the acetabulum.
normal hip 20 to 30*
dilocated or dysplastic hip ≥ 30*
Shenton’s line:
semicircle between femoral neck and upper arm of obturator foramen,
in dislocated hip this line is broken.
40. Acetabular index
The acetabular index is the angle between a line drawn along the margin of the acetabulum and
Hilgenreiner's line; it averages 27.5 degrees in normal newborns and decreases with age.
41. Centre edge angle
• It is useful to measure hip position.
• It is formed at the junction of Perkin line with line that connects
lateral margin of acetabulum to the center of femoral head.
• In children 6-13 yr. old, >19 degree is considered normal.
• • In children >=14 yr. old, >25 degree is considered normal.
44. AP X-ray
Lateral:wall of acetabulum
Medial:lesser pelvis
Inferior :acetabular notch
Appears between 6-23 mo
[delayed in DDH]
45. It significans is in the pronosis
• Hips in which teardrop appears within 6 months of reduction have
better outcome than in which it appears late.
• 4 types have been noted:-
• Open , closed , crossed and reversed.
• Also be describe as U- or V- shaped.
• V-shaped associated with poor outcome.
46. Diagnosis
1. ULTRA SOUND
• In the Graf technique, the transducer is placed over the greater
trochanter, which allows visualization of the ilium, the bony
acetabulum, the labrum, and the femoral epiphysis
• The angle formed by the line of the ilium and a line tangential to the
boney roof of the acetabulum is termed the α angle and represents the
depth of the acetabulum.
• Values > 60 degrees are considered normal, and those < 60 degrees
imply acetabular dysplasia.
47. • The β angle is formed by a line drawn tangential to the labrum and
the line of the ilium; this represents the cartilaginous roof of the
acetabulum.
• A normal β angle is < 55 degrees, as the femoral head subluxates, the
β angle increases.
48.
49.
50.
51. • In DDH , alpha angle decreases and beta angle increases, depending
upon femoral head subluxation.
• Depending upon alpha angle measurment he proposed a
classification system
53. MRI
• It gives excellent anatomical visualization of infant hip.
• Kashiwagi and associates proposed classification of hips with DDH.
• Group 1 hips had sharp acetabular rim, all were reducible with Pavlik
hareness.
• Group 2 hips had a rounded acetabular rim and almost all are
reducible with Pavlik hareness.
54. Group 3 hips have inverted acetabular rim,
and none was reducible with hareness.
• MRI findings includes :-
• Widening of iliac bone,
• Lateral drift of superior and posterior portions of acetabular floor,
• Overgrowth of acetabular cartilage,
• Convexity of posterior portion of cartilage
55. TREATMENT
Is divided in 5 age – related groups
1) newborn ( birth to 6 months old )
2) infant ( 6 to 18 months old )
3) toddler ( 18 to 36 months old )
4) child ( 3 to 8 yrs. Old )
5) adolescent and young adult ( > 8 yrs. Old )
56.
57. BIRTH TO SIX MONTHS
Triple-diaper technique
– Prevents hip adduction
– “Success” no different in some untreated hips
Pavilk harness (1944)
– Experienced staff*
– Very successful
– Allows free movement within confines of restraints
58. • Pavlik harness :- is used in first 6 months , shows excellent result in t/t
of DDH.
• It is dynamic flexion-abduction orthosis.
• c/I in children who are crawling or fixed soft tissue contracture, or
teratological dislocation present.
• After application, radiograph is taken and confirm the reduction. Hip
is placed in flexion of 110 and abduction to occur by gravity itself .
59. PELVIC HARNESS
Indications
• Fully reducible hip
• Child not attempting to stand
Close regular follow-up (every 1-2 weeks) • For imaging and
adjustments
Duration
• Childs age at hip stability + 3 months
60. APPLICATION
• A:The chest halter is applied. The shoulder straps on the halter should
cross in the back. B:The leg stirrup straps are applied
C:The attachment for the anterior (flexor) stirrup straps should be
located at the anterior axillary line
• D:posterior (abduction) stirrup straps should be attached over the
scapula. The position should be set to hold the hip in 90° of flexion
with the posterior straps limiting adductionto prevent dislocation.
61. How long pavlik harness should be continued
• After closed reduction and application of pavlik hareness. Patient is
follow up in every 1-2 weeks.
• At this time, hip stability is checked.
• Pavlik hareness is discontinued 6 weeks after clinically hip stability is
obtained.
• To weaning of up to 2 hrs. per week until brace is worn at night time.
62. Persistent dislocation of hip
• May be present after application of pavlik hareness , 4 basic pattern is
observed
• Superior, inferior , lateral and posterior.
• If present following manuvre should be done
• Superior – additional flexion is required,
• Inferior – flexion should be decreased,
• Lateral – closed observation to see for direction of femoral neck
towards triradiate cartilage.
63. Head may be gradually reduce and dock into
the acetabulum.
• Persistent posterior dislocation is difficult to treat. As tight hip
adductor muscle are present.
• If any of this persistent dislocation present for more than 3 to 6
weeks, pavlik hareness should be discontinued.
• t/t includes closed or open reduction and casting.
64. Pavlik Harness
FAILURES:
– Poor parent compliance
– Improper use by the physician
• Inadequate initial reduction
• Failure to recognize persistent dislocation
65. COMPLICATION
Avascular necrosis
• Forced hip abduction
• Safe zone (abd/adduction and flexion/extension)
Femoral nerve palsy
• Hyperflexion
*Be aware of Pavlik Harness Disease
*Follow until skeletal maturity
66. OTHER SPLINT
• Ilfeld and von rosen splint have high rate of success with fewer
complication but not superior to pavlik hareness.
• Frejka pillow and triple diaper are not used because of high rate of
AVN.
67.
68.
69.
70. Treatment:6 months-2 years
• AIM: obtain & maintain concentric reduction without damaging
femoral head
• Closed / open reduction
• Femoral shortening & innominate osteotomy may be needed
• pre op traction ??
71. Traction
• Pre-reduction traction was considered essential to reduce the
incidence of AVN and to enable the surgeon to obtain a closed
reduction
Salter et al 1969
Gage & winter 1972
Morel et al 1975
Langenskiold & Paavilainen 2000
• “The need for traction has been challenged by a number of studies
showing that hips can be safely reduced without preliminary traction”
Weinstein & Ponsetti 1979 Kahle et al 1990
Quinn et al 1994
• Current reccomendation: No traction
72. Closed reduction
• Stable: if leg could be adducted 30° from max abduction & extend to
below 90°
• Unstable: if wide abduction or more than 10 or 15 degrees of internal
rotation is required to maintain reduction
75. Arthrography
• An arthrogram obtained at the time of reduction is very helpful for
evaluating the depth and stability of the reduction
• Width of the medial dye pool to asses lateralisation
77. Open Reduction...!!
• Unable to achieve closed reduction
• Widening of the joint space
• Unstable reductions
• Loss of reduction on follow up
• Advanced age
78. Open reduction can be performed by
• Anterior
• Anteromedial
• Medial approach
• Anterior approach :- pathology in the anterior and lateral aspect of
hip can be easily reached and pelvic osteotomy can be easily
performed.
93. 2years and older
• For child 2 -3 years of age, during open reduction acetabular
coverage if insufficient warrants reorientation osteotomy
• If coxa valga with excessive anteversion, VDRO may be done.
• Children > 3 years usually need an acetabular procedure
• Femoral shortening is essential part of it’s management. In past , child
is put on skeletal traction but result of shortening are better and
morbidity is less.
94. Open reduction with femoral shortening
• Pressure leads to risk of AVN
• Better results than preoperative traction in older children with less
morbidity
95. When to do??
• Anticipated increased pressure on reduced femur head
• Recommended in child > 2yrs.
• distract the joint few millimeter per operatively
• Judge the tightness of soft tissues after reduction
• irreducible dislocation
96. How much shortening?
• Pre op: bottom of the femoral head to the floor of the acetabulum (a
to b)
• amount of overlap is noted after osteotomy • Tension of the soft
tissue
Derotation usually combined
• leaving 15 to 20 degrees of anteversion
101. Salter Single Innominate
•Age –18 months –6 years
•Requires concentrically reduced hip
–Open reduction at same time is possible
–Iliopsoas and adductor tenotomies often required
•Covers antero-later alacetabular deficiency
–Up to 15 degree of acetabular index corrected
102. Salter osteotomy
• Osteotomy: transverse & perpendicular to ilaic axis from just above
AIIS to sciatic notch
• Symphysis pubis :a flexible hinge for acetabular redirection to cover
anterolateral insuffiency in a concentrically reduced hip
103. Salter
• Anterior approach to acetabulum
–Exposing inner and outer ilium
–Expose hip capsule if reduction needed
–Transverse osteotomy is done just above acetabulum
• Sciatic notch to Ant.Inf.iliac Spine
–Rotate on pubic symphysis in antero-lateral direction –Hold correction
with bone graft wedge & K-wires
114. Pemberton acetauloplasty
•Age –18 months –10 years
•Requires reduced hip
•Decreases acetabular volume
–Remodeling of acetabulum required
•Corrects >15 degree of Acetabular index •Reduces antero-lateral
acetabular defects
–Cuts altered to cover more anteriorly or laterally
115. • Anterior Approach -Exposure as for Salter
–Cut inner and outer table with small osteotome
• – osteotomy 1cm above AIIS, staying 1 cm above capsule
–Do not cut through to sciatic notch
–Lever through the cut until coverage is acceptable •(Levers on tri-
radiate cartilage)
• –Hold correction with bone graft wedge
116.
117. Dega acetabuloplasty
•Similar to Pemberton
•Larger posterior hinge
–Hinges on horizontal tri-radiate limb
•Less inner table osteotomized for more lateral coverage
(More inner table –more anterior coverage)
118. • This is incomplete
involves osteotomy of anterior and middle portion of inner cortex of
ilium , leaving a intact hinge posteriorly consisting of intact
posteromedial iliac cortex and sciatic notch.
• At this osteotomy site , bone graft is placed.
123. If more anterior coverage desired ,inner cortex cut more If
more lateral coverage desired, inner cortex cut less
Intact postero-m,ediaql cortical hinge
124. A larger graft is inserted anteriorly. The posterior graft
should be smaller in order not to loosen the anterior graft.
125. GANZ OSTEOTOMY
Larger corrections all directions(correction not limited by
sacro-pelvic ligaments)
Blood supply preserved
Shape of true pelvis unaltered
Technically demanding
126. Steel Triple Innominate Osteotomy
• Age –Skeletally mature
•Requires congruent hip joint
•Divides ilium, ischium and superior ramus –Acetabulum is
rotationally free –Indicated when other osteotomies not possible
•Rotates to cover any acetabular defect
127. •Multiple incision technique
–Posteriorly between gluteus and hamstrings
•Allows osteotomy of ischium
–Anteriorly freeing medial attachments
•Allows Salter and superior ramus osteotomy
–Rotate acetabulum as desired
•Avoid externally rotating
–Bone graft wedge is fixed as per Salter type
128. • • Ischium, superior pubic ramus and ilium superior to acetabulum all
are divided and acetabulum is repositioned and stabilized by bone
graft and pins.
129.
130. Salvage or Shelf procedures
• Chiari and Staheli osteotomies
– Requires capsular metaplasia
– Pain is the main indication
– Used in Treatment of chronic hip pain in adolescents
131. Staheli Shelf Procedure
•Age –older child to skeletal maturity
•Salvage operation
•Indicated for non-concentric hips
•Augments supero-lateral deficency
–Slotted bone graft placed over capsule deepening the acetablum
132. Chiari Medial Displacement
•Age –skeletally mature
•Salvage operation only
–Used when no other osteotomy possible
–Possible with subluxed hip
•Covers well laterally
–Anterior and posterior augmentation may be necessary
•May be useful in other conditions
–Coxamagna, OA in dysplasichips
133. •Anterior approach –as per Salter
–Identify superior extent of capsule
–Cut from AIIS to notch following capsule curve
•Angle osteotome10-20* cephlad
–Displace distal fragment medially 50-100%
•Ensure complete head coverage
•Leg abduction, hinges on pubic symphysis
142. Complications of Treatment
• Worst complication is disturbance of growth in proximal femur
including the epiphysis and physeal plate
• commonly referred to as AVN however, no pathology to confirm this
• may be due to vascular insults to epiphysis or physeal plate or
pressure injury
• occurrs only in patients that have been treated and may be seen in
opposite normal hip
143. Necrosis of Femoral Head
• Extremes of position in abduction ( greater 60 degrees ) and
abduction with internal rotation
• compression on medial circumflex artery as passes the iliopsoas
tendon and compression of the terminal branch between lateral neck
and acetabulum
• “ frog leg position “ uniformly results in proximal growth disturbance
145. • extreme position can also cause pressure necrosis onf epiphyseal
cartilage and physeal plate
• severin method can obtain reduction but very high incidence of
necrosis
• multiple classification systems with Salter most popular
