Prof. Anisuddin Bhatti, Paeds Orthopaedic Surgeon @ Dr. Ziauddin University Hospital, Clifton Karachi Pakistan, delivered a lecture on Developmental Dysplastic Hip: Principles & protocols of Rx in age less than a year. This was a second lecture in Webinar series of DZU on DDH.third lecture on Principles of DDH surgery shall be delivered after fortnight on Friday November 20th, 2020 @ 09:00-10:00 on DZU webinar through google.

2. 2_DDH Rx. Principles & Protocols
Age 0-12 months
Prof. Anisuddin Bhatti
President(Past), Paediatric Orthopaedic Surgery,
Pakistan & POA
Chairman, Paediatric Orthopaedic Registry, Pakistan
Focal Person, Ponseti International, Pakistan
Paediatric Orthopaedic & Orthopaedic Trauma
surgeon
Dr. Ziauddin University Hospital, Clifton, Karachi
DZU_DDH Webinar Series
Friday, 6th November 2020. 09:00-10:00 am

3. Profs. Chirag M Khan, Ghulam Mahboob, Imtaiz Hashmi, Sohail Rafi, Idrees Shah
Experts Pannel

4. Agenda: Rx in 0-12 months age
 Aims & Objectives of Rx
 Principles of Rx
 Protocols of Rx
 Hip Abduction Brace
 Hip Spica cast: Indicationss &
Method
 Arthrogram & arthroscopic Assisted
CR
 Video PH Module: PH Bracing
application

5. DDH:
•Undetected…
leads to an
unacceptable
disability.
BUT / IF / WHEN
•Mishandled…
leads to more
devastating
complication (AVN)
than it is left alone

6. Mishandling & Short Cut (in surgical
procedures) always invite a disaster

7. Management
Principles &
Protocols in DDH
“Pakistan Superstition exposed.”
Pakistani mothers bury their children in mud during Solar
eclipse in Karachi Pakistan.
DAWN 2014

8. Principle 1: Age vs Results
 “...Younger the age at treatment, better
the results at skeletal maturity”.
AGE Clinico- radiological results
Years Excellent to Good **
 < 2 95%
 2 - 4 80%
 4 - 8 63-70%
 8 - 17 47-42%
______________________________________
**Low rate of AVN & Re-dislocation
( Zadeh & Catterall 2000 JBJS)

9. Principle 2:
2.1 GOALS:
Anatomical, Concentric, Stable hip:
to provide Optimal conditions for
Mutual Growth Stimulating Effect
of Femoral Head & Acetabulum
for the Normal development of a
Hip.
2.2 TREATMENT TAILORED TO:
 Age
Specific Pathological Status.

10. Earliest treatment, Best the
Results
50% babies with DDH diagnosed
at birth become normal within few
months without treatment” Tonnis
Germany
Initiation of treatment with splint
appliances before 8 weeks is more
likely to be success”
Diana Albourne 2002
Neonates responds well to
abduction splints…. with no

11. Treatment Tailored to Age
Newborn to 6 months:
Protocol:
Gentle closed reduction
No pressure on vessels &
femoral head.
Maintenance in abduction splint
& monitoring
Goals: Anatomical, Concentric, Stable hip in
abduction splint.

12. Protocol: Newborn to 06
month
HIP abduction Splints: Dynamic / fixed

13. HIP Abduction Splints
Dynamic <6 months age
Static / fixed > 6 month age
Pavlik Harness; Success rate 85-95%, decreases with each additional months of age
Pavlik
Craig
Von Rosen
Boston

14. Dynamic Abduction Brace:
Pavlik Harness
The Pavlik harness is the standard
therapy for infants age 6 months or
younger.
The principle is to
hold the hip in a
flexed, abducted
position that will
allow gentle
reduction and
stabilization.

15. Dynamic abduction Brace:
Pavlik Harness
The standard position for
the PH brace is
approximately 100 of
flexion set by the anterior
strap of the harness.
The posterior strap should
be adjusted to allow
adduction the leg only to a
neutral position.

16. Dynamic abduction Brace:
Pavlik Harness
This position minimizes the risks
associated with over abduction and
hyperflexion, which are associated
with osteonecrosis and femoral nerve
Palsy.
The harness is initially worn 24 hours
a day, until the hip is believed to be
stable without support. Later it is worn
part time until Acetabular remodeling

17. Dynamic abduction Brace:
Pavlik Harness
Mothers Training: Ortolani’s click -
Barlow test, Klisic test: palpation of
greater trochannter.
Duration: Stability + 2 months.
Weaning: 2 hrs / day, doubled every
wk, until normal.
Monitoring: A dislocated hip is
monitored weekly using
ultrasonography until the hip is
located and stable .

18. Pavlik Harness
 P H FAILURE RISK FACTORS:
-Delay in to apply P H beyond 7 Wks.
-Negative Ortolani at initial Reduction
-Bilateral d’location.
 Warning:
Treatment of a hip in a dislocated position
for more that 3 weeks can lead to flattening
of the posterior wall which makes the
subsequent closed reduction much more
difficult
 Pavlik H Failure is a surgical indication

19. Monitoring & Follow-up: Mandatory
Improper Use, improper foot
pads Vendors application
Proper Use, always check
after vendors application
proper foot padsImproper foot pads

20. Pavlik Harness Monitoring
• Proper application
• Training parents
• Weekly US n PH &
FU
• Fortnightly visit
• In brace check-up
Proper
Wrong: Feet pads

21. Case examples: Rx Pavlik Harness

22. Pkz 4 months, Rigt side DDH, Tonnis II
Dynamism Indicated By Abduction

23. Comfort in P Harness
04th october2010
Three months F. Up Five months Follow-up

24. Pkz
Assessments
at 5/12 month
Follow-up

25. PKZ 6 YR FU

26. Abd CHN Bilateral DDH
PH Failure (Rt)
CR @ 9m age. 20m fU
CR cast@9m age
@14m age, Salter 1 Avn
20m age FU & Video

27. Abd CHN
Bilat.DDH PHF to CR cast
@ 9 mon
Boston HAB for next 4 months
2 yrs FU
@ 2Yrs age FU.
AVN Full recoverd
Bilateral Ac Indx Rt. 22 & Lt.180
@13m age n Boston brace & without Brace
@ 20 mo age FU.
@ 2Yrs age FU

28. Swaddling

29. Fixed Abduction splint
Indication: Failed PH, age >6mon

30. Fixed Abduction splint
 If the Pavlik harness
fails to proved
adequate reduction
within 3 to 4 weeks,
 or if the child is
larger than the
average 6- month
old………
a rigid abduction
orthosis or cast

31. Fixed DDH Brace: Von Rosen
 For unstable hips early
closed treatment using
appropriate rigid abduction
bracing leads to excellent
long term out comes.
 When patient is older than
6 months…. Monitoring
every 2 to 4 weeks to
assses the reduction.
 Use Ultrasonographic in
Orthosis. (radiographic)
follow up

32. Transition Period Monitoring
However, prolonged use of
rigid orthosis in persistent
dislocation / subluxation leads
to development of Acron /
Saddle shaped head, difficult
to reduce with CR.Saddle shaped head a sequalae of
Kalamchi 3 ( central necrosis)

33. DDH: What has changed in the last 20
years?
Pavel Kotlarsky, et al. WJO. 2015
 Although there are few comparative studies,
all the three braces are superior to no
treatment.
 The Craig and the Von Rosen splints
might be slightly superior to the Pavlik
harness (>6m age), but the Pavlik
harness remains the standard
treatment for the majority of children
younger than 6 months
 As in Pavlik Hr patient is the most
thoroughly examined, and found to be safe

34. DDH: What has changed in the last 20
years?
Pavel Kotlarsky, et al. WJO. 2015
Continuation of the harness with the
dislocated hip may potentiate:
Acetabular dysplasia, which may
increase the difficulty of subsequent
closed reduction.
“Pavlik Harness Disease”
Higher rates of AVN.
• AVN % is generaly low with Pavlik < Craig
< Von Rosen.
Ref. WJO. 2015 & AAOS

35. Pavlik Hr HARNESS DISEASE: AVN (K3)
Hyper-abduction Syndrome:
Cause: Lack of Monitoring, long duration PH & no weaning
Rx Somewhere else
12 months in PH
K-III AVN
@ 2 yr FU AVN
apeared

36. Rx Protocols: Age > 6 months

37. Rx Protocol: 6 to 12 months
GOLDEN PERIOD: 06 to 18 Months, to
obtain very satisfactory results.
 Closed or Open Reduction and Spica
Cast.
 Indication:
o Bracing fails to provide adequate
reduction
o Infant is older than age 6-9 months and
the hip is not easily reducible using the
Ortolani maneuver.

38. Rx Protocol: 6 to 12 months
Traction… Preliminary gradual
abduction
C. R / O.R with Adductor Tenotomy
& Orthography to confirm reduction.
• Avoid tight reduction, to prevent AVN
& re-dislocation… Ref. AGMC

39. Rx Protocol: 06 to 12 months
 Preliminary gradual abduction
traction
+/- Adductor tenotomy
 Gentle closed reduction … GA
+/_ Arthrography or MRI, aimed
to….
Good Quality of initial reduction.
 Casting in Good position … Safe
Zone.

40. Rx. Protocol: 6 to 12 months:
Update:
Travis H Matheney, young J Kim OKU-AAOS 2008: 715-720
 In the past closed reduction
were attempted after a period of
traction and were not performed
until the child has reached 18
months to 2 years of age.
The currently preferred
method is closed
reduction under general
anesthesia and
arthrography / MRI to
confirm that reduction.

41. Safe Zone Concept: Must be
observed
Acceptable position of closed reduction.
Abduction 200-450 & Flexion 1000
To prevent R’d’location & AVN

42. Ramasey “Zone of Safety”
Ramsey Pl et al. Pavlik harness in the child during the first six months of
life.

43. Age > 6 Months: Complications
 Cast is applied in the safe position,
which is approximately 100 degree of
flexion and an abduction angle <450 within
the stable zone. Flx >1000 ..
Neuroparaxia
 Abduction greater than 55 degree has
been associated with the development
of osteonecrosis.

44. Case Examples : Closed Reduction

45. ARZ, 7 months at presentation
 At 5 month –
closed reduction
and cast
Unnoticed failure of
reduction
Failure of reduction
detected at 7
month on looking
at C.T. Scan
5 month age
7 month age

46. 12 month age

47. Shfa Bilateral DDH: DOB 13.01.2020
PH failure. CR + Arthrogram

48. Shfa Bilateral DDH
PH failure. CR + Arthrogram
 Ortolony – Barlows Positive.
 Placed in Pavlik Harness
 @ 6m age. U/ sound 20.6 2020. No hypertrophied
Liagment, No subluxation Normal alpha Beta
Angles
 Alpha: 55/55
 Beta: 67 /68
 Impression No DDH
 Advised by Surgeon OR
on clinical grounds & Xray
 They refrained.

49. Shfa Bilateral DDH
PH failure. CR + Arthrogram
 Ortolony – Barlows Positive.
 @ 6m age. U/ sound No DDH
despite Dorderline decreased Alpha
& increased Beta angle
 Consulted @ ZHC:
 My impression Bilateral DDH Tonnis
Rt.III/lt.II
 U/ Sound & Xray AP.
 Adv fixed Brace (VR splint / Craig
splint.
 Left to 3rd surgeon who fixed Pavlik
H again

50. Shfa Bilateral DDH
PH failure. CR + Arthrogram
 Ortolony – Barlows Positive.
 @ 9m age. U/ sound no gross
subluxation Increased Alpha RT.63
& deccreased Beta angle 34. Left
alpha 67, beta 56.
 In brace Lt alpha 77, Beta 45
 Caput visualized & within
acetabulum
 Consulted @ ZHC:
 Advised Closed Reduction GA

51. Shfa Bilateral DDH
PH failure. CR + Arthrogram
 Ortolony – Barlows Positive.
 Re-consulted @ ZHC @ 10m
age.
 Xray were done @ 9 mon:
Reprort DDH wih no
interposition of soft tissues
 Advised Closed Reduction +
adductor tenotomty, under GA,
Arthrogram & Cast @ 10
months age.
 They agreed & CR done
14.09.2020

52. Shfa:PH failure. CR + Arthrogram
 Closed Reduction + adductor
tenotomty, under GA,
Arthrogram & Cast @
26.09.2020.

53. Open reduction: < 12 months age

54. Open Reduction in < 1 yr Age:
update
 Indication::: Failed Closed reduction
 Timing of surgery & Approach are
controversial.
Ref. Tonnis 1984 & Senaren 2007 J Pediatr Orthop
 Early reduction can be expected to lead to normal
development of hip. and thus, if required, OR be
done as early as possible.
Ref. Senaren 2007 J Pediatr Orthop.
 Very few reports OR in very young age (>8
months) through Medial Ludloff’s or medial
Weinstein’s approach.
Ref. Koizumi W, etal (Ludloff’s approach) J Bone Joint Surg [Br]
1996;78-B:924-9.

55. Open Reduction in < 1 yr Age:
update
Zadeh, Catterall & Nejad 2000 Reports:
 There is currently a vogue for open reduction
carried out by a medial approach in the first few
months of life.
 Deliberate Delayed open reduction was until
about one year.
 The results have been acceptable (Severin I and
II) in 94% of hips when this procedure was carried
out in children under the age of two years.
 It could therefore be argued that when open
reduction is required the operation is best
delayed until the child is about one year old.
Zadeh & Catterall et al 2000 br. J Bone Joint Surg

56. Open Reduction in < 1 yr Age:
update
Arthroscopic assisted OR
 Minimum age reported in Recent
Literature:
> 6 months BUT that too is, Arthroscopic
assisted OR
 11-14 months. (McCarthy & McEwen… Orthopedics 2007 &
Bulut …Arthroscopy 2005).
 6-7 months. (O.Eberhardt JBJS 2012).
 Chao Feng 2019: 7 months

57. Complications:
OR in Age < 1 yr Age
 AVN with OR Medial approach upto 69% due to
injury to Medial circumflex artery.
 Arthroscopic reduction has less chance
of AVN as capsular release is more
superolateral less chance of damage to
Med Circumflex Artery
McCarthy & McEwen… Orthopedics 2007 & Bulut
…Arthroscopy 2005. O.Eberhardt JBJS 2012.
 Kouzomi 2019: AVN 43% with medial approach.
 Zadeh JBJS 2000: effect of AVN may not be seen
earlier but @ adocesent as a Coxa valga, vara &

58. Arthroscopic Assisted
Closed Reduction

59. Arthroscopic Reduction of DD in
Age < 1 yr Age
 Two portal Technique used
on supine lying child.
 Medial sub-adductor portal
1cm lateral & anterior to
Ischeal tuberosity.
 Anterolateral portal 2cm
distal to ASIS 1cm lateral to
line from ASIS to Patella
 Cannulated Arthroscopic
system inserted over Flexible
guide wire used
McCarthy & McEwen… Orthopedics 2007 & Bulut …Arthroscopy 2005. O.Eberhardt JBJS 2012.

60. Arthroscopic Reduction
DDH in Age < 1 yr Age
 Obstacle removed:: Pulvinar, Hypertrophic Ligamnt
Teres, transverse Ligament, Capsular constriction,
Psoas tenotomy
O.Eberhardt JBJS 2012

61. 8 hips with failed CR
Age 4-7 months
Two Portal technique
Medial sub-adductor
2.7 mm, 700 A/Scope
Antero Lateral portal
For Instrumentation
Intra articular
structures
Pulvinar
Hypertrophic T. lig.
Excised. Capsular
constriction released

62. Arthroscopic DDH Reduction
O Eberhardt. JBJS(B) 2012 96(6):824-7
 All hips were reduced by a single
arthroscopic procedure, the reduction being
confirmed on MRI scan.
 None of the hips had an inverted labrum.
 The greatest obstacle to reduction was a
constriction of the capsule.
 Study demonstrates
 arthroscopic reduction is feasible
 Longer follow-up studies are necessary to
evaluate the functional results.

63. Arthroscopic DDH Reduction
O Eberhardt. JBJS(B) 2012 96(6):824-7
FOLLOW-UP:
Mean follow-up of 13.2 months (9 to 24),
All eight hips remained stable.
Three developed avascular necrosis.
The mean acetabular index decreased from Pre-
op AI
from 35.5 to 23.30 to 17 to 28°

64. Arthroscopic DDH Reduction
O Eberhardt. JBJS(B) 2012 96(6):824-7
Conclusion:
 The timing of surgery and the surgical approach
are controversial.
 Early reduction can be expected to lead to normal
development of the hip, and thus, if required,
open reduction should be performed as early as
possible.
 An arthroscopic procedure might be a suitable
alternative to open surgery, but there are only a
few studies on arthroscopic or arthroscopically-
assisted procedures in children and infants.

65. Safety angle significantly
reduced
Medialization FH 127%
compared to Preop 72%
Stiffness significantly
reduced

66. Complex DDH Cases
• DDH with TEV
• DDH with CDK
• DDH n AGMC

67. Complex DDH + TEV
• Ponseti casting+ PCT
• Ponseti casting FAB + PH

68. Complex DDH with CDK: Sm Sh
PH could be not b maintained.
Improvise Frejka type pillow
That worked Excellent
• CDK Serial casting: Chen Chung method
• PC Quad Tenotomy
• Final VY Plasty @ 6months +
• Hips contained well on Frejka type Pillow made by her
mother
REF. Anisuddin Bhatti. The Earliest Age Limit for Manipulation and Casting in Idiopathic C K D. J.Pak
Orthop Assoc. 2018, 30(3): 57-81

69. Complex DDH with CDK: SM Sh
PH could be not b maintained
Improvise Frejka type pillow
That worked Excellent
CDK Serial casting:Chen Chung method
PC Quad Tenotomy
Final VY Plasty
Hips contained well on Frejka Type Pillow
Xray @ 12 m FU
@ 6 m FU Before V-y P
@ 12 m FU
REF. Anisuddin Bhatti. The Earliest Age Limit for Manipulation and
Casting in Idiopathic C K D. J.Pak Orthop Assoc. 2018, 30(3): 57-81

70. Es: DDH+Club Foot
Tonnis-2
Von Rosen veiw
In P Harness
Exclnt Result

71. Pavlik H application: Video
Module

72. This Lecture is Dedicated to
Our Mentor
Late Prof Yunis H Soomro

74. If, sum mun book mun. Let me reply urs un-asked questions
Q & A Participants vs Faculty

75. Faculty Discussion