Prof. Anisuddin Bhatti, Paeds Orthopaedic surgeon, Dr. Ziauddin University Hospital Clifton Karachi, Pakistan, delivered lecture on Developmental Dysplastic Hips Treatment principles, protocols and procedures on 21.11.2020. he elaborated on principles /protocols of Open reduction. elaborated in detail on Catteral test of stability, Salters osteomy & Pemberton Osteotomy.He also gave example of disaster if principles of open reduction are violated.this lecture series on DDH was mostly for trainees and young Orthop surgeons.

1. DZU Webinar Series Lecture_3
Developmental Dysplastic Hips
Saturday, 21st November 2020, @09:00–10:00

2. 3_DDH RX.
PRINCIPLES & PROTOCOLS
FOR
OPEN REDUCTION
IN
WALKING AGE GROUP
Prof. Anisuddin Bhatti
President(Past), Paediatric Orthopaedic Society, Pakistan
Chairman, Paediatric Orthopaedic Registry, Pakistan
Focal Person, Ponseti International, Pakistan
Paediatric Orthopaedic & Orthopaedic Trauma Surgeon
Dr. Ziauddin University Hospital, Clifton, Karachi

3. DDH:
•If undetected…
leads to an
unacceptable
disability.
•If Mishandled…
leads to more
devastating
complication.. Life
long disability, than
it is left alone
AVN
AVN / OA

4. AGENDA: RX IN AGE GROUP 1- 5 YEARS
Aims & Objectives:
• Principles of Rx
• Protocols of Rx
• Indicationss & OR &
approaches
• Steps Open Reduction
Catterall’s Test of stabilty
Additional osteotomies
Video
Demonstartion:
oTest of Stability
oPelvic osteotomies:
Salter
Pemberton

5. Principles & Protocol
OPEN REDUCTION
3500 Year old arches of old Buirut

6. BASIC PRINCIPLE:
To achieve an Anatomical,
Concentric, Stable hip,
without significant pressure on
Femoral head, Risk of Re-
subluxation & AVN.

7. OBJECTIVE
 Provide optimal conditions for
mutual growth stimulating effect of
femoral head & acetabulum for the
normal development of a hip. (Harris
1967)
•To prevent progressive deformation
of hip elements whic may leads to
early degenerative changes.
• Goal: to achieve a painless mobile hip at
maturity.

8. RATIONAL APPROACH
Careful clinico-radiological evaluation &
planning for accurate/effective treatment that
shall be
tailored according to
• Age… 12-36 months, 3-8Yrs, 8-13yrs &
above.
• Severity of dysplasia… Height of d’location,
femoral & acetabular abnormalities.
• Position of stability at O.R, to achieve Good

9. 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)

10. •PMID: 759420

12. REDUCTION OF DDH: IMPLICATION FOR
THE NEED FOR FUTURE SURGERY
Scott E luhman etal 2003
Delayed the reduction untill appearance of Ossific
Nucleus, more than doubles the need of secodary
surgery to make the hip as anaotomical as ossible
Scott E Luhman et al. JBJS: 2003. 85 (2):239-243
153 hips. 44 Open Reductions. 109 CR. 7 yrs FU

13. PROTOCOL: RX TAILORED TO AGE
• “ Principle of Rx are not
significantly different then those
for a newborn…. i.e Anatomical
Concentric Reduction & without significant
pressure
• …. the protocol do vary grossly
than younger age.”
(Klisic, Williamson)

14. PROTOCOL: NEWBORN TO 12 MONTHS
1 day to 6 months
• Reduction & maintenance
with +Abd Splint.. Pavlik
Harness
•6 to 9 months
•In Reducible Hip Fixed HAB..
Craig Splint, Boston Brace
•Golden Period: 6-18
Months:
•Closed Reduction with
adductor Tenotomy
•A’Scope assisted CR
•O R Medial approach
•Cast in Safe Zone position

15. PROTOCOLS OF RX UNDER 1 YR AGE:
UPDATE
• In age group over 6 months with failed HAB
treatment, the currently preferred method is
closed reduction under general anesthesia or
Arthroscopic assisted Closed reduction. MRI to
confirm that reduction. Confirmation with Per
operative arthrography or MRI
• Very few reports OR in very young age (>6 months)
through Medial Ludloff’s or medial Weinstein’s approach.
Koizumi W, etal (Ludloff’s approach) J Bone Joint Surg [Br] 1996;78-B:924-9.
Morcuende JA et al, (Weinstein approach). J Bone Joint Surg [Am] 1997;79-A:810
McCarthy & McEwen, Orthopedics 2007. Bulut ,Arthroscopy 2005., .Eberhardt JBJS 2012.

16. PROTOCOLS RX UNDER 1 YR AGE:
UPDATE AVN
• AVN with OR Medial approach upto 69% due to injury to
Medial circumflex artery.
• Kouzomi 2019 Reports: AVN 43% with medial approach.
• 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.
• Zadeh JBJS 2000. Ezimik, 2015… reports delayed effect of
AVN that may not be seen earlier but @ adolescent as a Coxa
valga, vara & Breva

17. PROTOCOLS OF RX UNDER 1 YR
AGE: UPDATE
• 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 until about 1-
year i.e OR after age of 1 year gives the best
results.
• 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. Zadeh & Nejad JBJS 2000
References:
Zadeh & Nejad JBJS 2000, Kelley n Campbel 13th Ed.,
Bache CE, et al. 2008, Citlak A, Saruhan S, Baki C. 2013

18. PROTOCOL:: RX TAILORED TO AGE
12 MONTHS TO 36 MONTHS:
Open Reduction +/- Pelvic &
femoral DR osteotomy.
• Release offending soft tissues
contractures & correct
structural abnormalities, Coxa
Valga Anteversa, Dysplastic
Acetabulum.
• To solve all hip problems under
a single operative procedure.

19. RX TAILORED TO SEVERITY OF DYSPLASIA:
HIGHT OF DISLOCATION & ACETABULUM
OBTUSITY & SHAPE
Duoble Diameter Acetabulum
Tonnis hight of Dislocation

20. RX PROTOCOL: SEVERITY OF DYSPLASIA /
PATHOLOGY
• Tight Hip @ Open
reduction
oCerebral Palsy
oTeratogenic Hip:
Arthrogryposis
• Paralytic Hips
• Failed Closed
Reduction with
Persistent Instability

21. OPEN REDUCTION
to achieve objectives
Anatomical, Concentric, Stable
reduction, without risk of Re-
subluxation & AVN to prevent
subsequent deformation of the
hip joint at adulthood

22. OPEN REDUCTION
TO
• Release Sot tisssue obstacles
• Correction structural abnormalities
• One stage combined procedure.

23. SOFT TISSUES OBSTACLES
• Contracted muscles –
Iliopsoas, Rectus Femoris,
Adductors, Tensor Fascia
Lata & Hamstrings
• Thickened capsule:
Dumbbell
“distorted anatomy, especially in
high dislocations, affects most of
the soft tissues around the hip.”
Chandler H P
Distorted anatomy Horizontal
abductors, Shortened Sciatic nerve
& Tortuous Femoral nerve and the
Profunda femoris artery.

24. STRUCTURAL ABNORMALITIES
Coxa Valga Anteversa, Obtuse
Acetabula
Excessive anteversion of the femoral
neck and posterior displacement of
the trochanter
Posterior position of the greater
trochanter and the crooked proximal
aspect of the femur. Acron shaped
head.

25. OPEN REDUCTION: APPROACHES
• Anterior Approach
- Somerville – Bikini Incision approach
- Smith Petersen Iliofemoral Incision approach
Advantage: Greater versatility of age group, easily approachable anterior,
superior and lateral structures & pelvic osteotomy, with minimum chances of
AVN
• Antero-Medial approach
Weinstein-Ponseti… < 2yr age
• Medial approach
(Ludloff / Ferguson) < 18 months age
AVN with with medial approachs …. 43% . (Kouzomi 2019)
“Choice depends on experience of surgeon & particular
dislocation”

26. OPEN REDUCTION:
ANTERIOR APPROACH
Smith Petersen Approach
Ilio-femoral Incision
Somerville Approach
Bikini Incision

27. OPEN REDUCTION: PATHOANATOMY

28. SOMERVILLE APPROACH BIKINI
INCISION
Capsulorraphy
in internal
rotation

29. OPEN REDUCTION
LUDLOFF MEDIAL & IOWA ANTERIO-MEDIAL APPROACH
LUDLOFF’S MEDIAL APPROACH
•performed between the pectineus and
adductor longus and brevis
WEINSTEIN ANTEROMEDIAL APPROACH
• performed between neurovascular bundle
and pectineus
FERGUSON POSTEROMEDIAL
APPROACH
• performed superficially between the
adductor longus and gracilis, and
deep between the adductor brevis and
adductor magnus
INDICATIONS:
• Age 6-15 months
• Failed HAB & CR

30. OPEN REDUCTION
LUDLOFF’S MEDIAL APPROACH
Superficial dissection from posterior margin of Adductor longu
Then between Adductor longus & Gracilis
Deep Dissection:
• in interval between
Adductor brevis &
Adductor magnus,
• Feel lesser trochanter.
• Place retractors to
save NV bundle of Ant.
Division obturator that
supply Add Long &
Gracilis

31. OPEN REDUCTION
Ludloff medial & IOWA anteromedial approach
LUDLOFF’S MEDIAL APPROACH
Deep Dissection: interval between
Adductor brevis, (supplied by Ant division
Obturator) & Adductor magnus (adductor
portion supplied by post div. Obturator n
and Ischial portion by sciatic N).
Deep Dissection:
• Place retractors to save NV bundle
• Cut Psoas tendon
• Capsule is exposed
• Release capsular constriction by
incising capsule, Transv. Acetab
ligament & Pulvinr
• Release Rectus Femoris
• Reduce caput femoris in
acetabulum under C-arm control.
• Apply Spica cast

32. OPEN REDUCTION
WEINSTEIN-IOWA ANTERO-MEDIAL APPROACH
• Interval B/W
Sartorius &
add Longus
• Interval
between NV
bundles &
Pectineus
• Feel Lessor
Trochchanter

33. PER-OPERATIVE TEST OF STABILITY
Catterall A. 1991
Z a d e h , H . G . , C a t t e r a ll , A . , H a s h e m i - N e j ad , A . , Pe r r y, R . E . J B J S . B r. J a n . 2 0 0 0
Youtube.com/user/1orthojpmc OR
https://youtu.be/sgHbCZyBrgU

34. PER-OPERATIVE TEST OF STABILITY
CATTERRAL 1991
•To identify the position of
maximum stability of the hip at
open reduction.
•To evaluate the need for an
appropriate osteotomy
•To evaluate the level of osteotomy:
Femoral (derotational and/or
varus). Pelvic or both

35. TEST OF STABILITY I.
• STABLE POSITION I
• Hip stable in
Neutral position (2%,
Young)
• RECONSTRUCTION
• O.R., Capsuloraphy
•No osteotomy

36. TEST OF STABILITY II.
• STABLE POSITION II
• Hip stable in Internal
rotation & Abduction
(66%, Young Age)
• RECONSTRUCTION
•Upper femoral
varus
derotational
osteotomy

37. TEST OF STABILITY III
HIP STABLE IN FLEXION & ABDUCTION
(14% OLDER CHILDREN)
Innnominate Osteotomy

38. TEST OF STABILITY IV.
• STABLE POSITION IV
• Hip stable in Flexion, Internal
rotation & abduction (14%,
Older children)
• RECONSTRUCTION
• Innominate
osteotomy
• Upper femoral varus
derotational osteotomy

39. TEST OF STABILITY V.
• STABLE POSITION V
• Double diameter acetabulum with
antrolateral deficiency (4%, Age>
3Yr.)
• RECONSTRUCTION
•Pemberton
osteotomy

40. TEST OF STABILITY VI.
• STABLE POSITION VI
• Tight reduction.
Unreduced & High
dislocation
(5% -25% Age > 3 Yr.)
• RECONSTRUCTION
• One stage combined
procedure with FEMORAL
SHORTENING

41. TEST OF STABILITY: POST SALTER &
PEMBERTON VDEO MODULES
Youtube.com/user/1orthojpmc OR https://youtu.be/sgHbCZyBrgU

42. CASE EXAMPLE OR +
CAPSULORRAPY +/- DRO

43. MAZ, 19 MONTHS,
BILATERAL CDH,
TONNIS III
Or+Capsuloraphy +
DD-Rotation
Osteotomy
6 YR FOLLOW-UP

44. MAZ 6 YR FOLLOW-UP, FUNCTIONAL
RESULTS

45. CASE EXAMPLE OR + CAPSULORRAPY. @ 18 MON
4 YEAR FU
AI 200,CEA 200, BHATTI SCOR EXCELLENT

46. PELVIC OSTEOTOMIES
Objectives:
• To improve femoral head coverage
• To provide Coxofemoral joint stability.

47. PELVIC OSTEOTOMIES
Types:
o Re-orientation [Reconstructive] osteotomies: Salter and
Pol le Coeur triple osteotomy
o Peri-Capsular Acetabuloplasties [Reshaping]: Pemberton
and Dega.
o Salvage Osteotomies: Chiari’s & Stahli’s Shelf
acetabuloplasty

48. PELVIC OSTEOTOMIES
• REORIENTATION OSTEOTOMIES. These are
complete osteotomies that redirect the entire
acetabulum. types described depending on the
location and number of lines: Salter innominate
osteotomy, double osteotomy, triple osteotomy: Steel,
Wenger, Pol Cour
• ACETABULOPLASTIES: These are incomplete
osteotomies redirected by a hinge located at the
triradiate cartilage. Dega acetabuloplasty and
Pemberton acetabuloplasty.
• CHIARI OSTEOTOMY. an osteotomy of the ilium that
enlarges the acetabulum by medializing the
coxofemoral joint.J. Sales de Gauzy. Pelvic reorientation osteotomies and acetabuloplasties in children. Surgical technique.
Orthopaedics & Traumatology: Surgery & Research. 2010.96:793-799

49. SALTER’S INNOMINATE OSSTEOTOMY
• Salter osteotomy uses a single
osteotomy line located at the
inferior gluteal line.

50. TRIPLE PELVIC OSTEOTOMIES
• Pol Le Coeur triple pelvic osteotomy combines innominate
osteotomies of the iliopubic and ischiopubic rami via a
genitofemoral approach (inguinal).
• In these two reorientation osteotomies, the acetabulum tilts in
retroversion, improving the anterior and lateral coverage but
reducing the posterior coverage.
• Wenger’s Triple Osteotomy: Three cuts, Rotation & Salter’s
Graft
Pol Le Coeur triple PO
Dennis R Wenger PO
Wenger

51. PEMBERTON’S PERICAPSULAR
ACETABULOPLASTY
• Pemberton acetabuloplasty, the osteotomy line is incomplete. It begins
anteriorly between the iliac spines and ends posteriorly immediately
above the triradiate cartilage. The posterior part of the ilium remains
intact.
• The Pemberton acetabuloplasty causes retroversion and plicature of
the acetabulum responsible for reducing its diameter.
• Anterior and lateral coverage of the femoral head is improved and
posterior coverage remains unchanged.

52. DEGA PERICAPSULAR ACETABULOPLASTY
• Dega acetabuloplasty, the
osteotomy line is incomplete. It
begins laterally above the
acetabulum and terminates
just above the triradiate
cartilage.
• The medial part of the ilium
remains intact.
• The Dega acetabuloplasty
reduces the diameter of the
acetabulum and improves
overall femoral head coverage
(anterior, lateral, and posterior).

53. PELVIC OSTEOTOMIES AS PER AGE GROUP

54. SALTER’S INOMINATE
OSTEOTOMY

55. SALTER’S OSTEOTOMY:
INDICATIONS
•18 months to 6 years.
•Hip is re-locatable
concentrically.
•Unstable hip on extension and
adduction.
•Acetabular index correction
required for less than 15

56. SALTER’S OSTEOTOMY
PREREQUISITES
•Concentric relocation.
•Release of soft tissue.
•Good range of motion.
•Pubic symphysis is
mobile.

65. SALTER OSTEOTOMY

66. CASE EXAMPLE
OR + SALTERS OSTEOTOMY
8 YEARS FU

67. 2 YRS SBCA: LEFT TONNIS IV DDH
OR + SALTER + DDRO
OP. DECEMBER 2012, LAST FU OCTOBER 2020
6 years FU

68. 2 YRS SBCA: LEFT TONNIS IV DDH
OR + SALTER + DDRO
6 YEARS F U:
BHATTI’S FUNCTIONAL SCORING.. GOOD

69. SZA 2YR +, TONNIS III
OR + SALTER

70. PEMBERTON’S PERICAPSULAR
ACETABULOPLASTY

71. PEMBERTON’S PERICAPSULAR
ACETABULOPLASTY: INDICATIONS
• Age Less than 7 years, (18 months -7 years).
• Incongruent (double acetabulum)
acetabulum.
• Un-stable, Re-locatable hip.
• Moderate to severe deformity
• Triradiate cartilage must be open
• Most versatile

72. PRINCIPLES OF PEMBERTON’S
PERICAPSULAR ACETABULOPLASTY
Reduces acetabular inclination.
Acetabular roof is rotated
anteriorly and laterally.
Tri-radiate cartilage acts as a
hinge.
Requires remodeling.
Difficult to perform (Expertise &
instruments).

73. • Osteotomy line begins slightly superior to anterior
inferior Iliac spine & curving into triradiate cartilage.
• Posterior Sciatic ridge remains intact (incomplete pelvic
osteotomy). Fig A
• Osteotomy completed with acetabular roof directed in
corrected position and wedge of bone impacted into
open osteotomy site. Fig B,C
PEMBERTON ACETABULOPLASTY: STEPS

74. PEMBERTON OSTEOTOMY

75. 3 YEARS OLD
BILATERAL DDH, TONNIS IV,
DOUBLE ACETABULUM

76. capsuletomy Femoral head n false acetabulum
True Acetabulum
Prox. Femur exposed for Osteotomy

77. Prox. Femoral osteotomy, Osteosynthesis
After shortening & test of stability

78. Pemberton procedure Steps

79. 2
6
27

80. Summary Pelvic Osteotomies

81. Pemberton module https://youtu.be/PnVyTFjO0IM
Salter Bone module https://youtu.be/nHSMd2WFKIU
Salter Live module https://youtu.be/T_wp4C2oSB8
SALTER ON PELVIS MODEL &
PEMBERTON LIVE MODULES
VIDEOS
YOUTUBE.COM/USER/1ORTHOJPMC

82. • With a prolonged dislocation significant soft tissue
contracture & structural changes occurs. That
include Coxa valga anteversa, progressively
increases. In Acetabulum index.
• Haence, over 3 years the concomitant femoral
shortening osteotomy become invariably
necessary to achieve the stability and decrease
compressive forces on the femoral head.
• These children yield better with ONE STAGE
COMBINED osteotomy procedure recommended by
Jankovic & Klisic i.e Femoral shortening & Pelvic
osteotomy. (Zadeh JBJS 2000)
PROTOCOL: AGE 3 YEARS-7YEARS

83. ONE STAGE COMBINED PROCEDURES
Ombredanne 1923.. Stromjivonic 1959
• I. Klisic P, Jancovic I. Approach 1976 :
o Single lateral incision
o Transfemoral approach
o Inferior capsulotomy
• II. Wenger’s Modification of Klisic approach 1984:
o Two incsion approach
o Anterior..O.R., Capsuloraphy & In. Osteotomy
o Lateral…S/T Fem. Shortening, VDRO

84. KLISIC P, JANCOVIC I.
Single stage
lateral incision approach:
AVN: 3.3% - 7%
Predrag Klisic
Yugoslavia

86. FIG 1-A 6 YEARS AGED GIRL HAVING LEFT SIDED TONNIS GRADE
4 CDH, WAS OPERATED IN 1994 WITH KLISIC APPROACH. 10
YEARS POST OP, HER HIP IS CONTAINED WITH EXCELLENT
SCORE ON KLISIC RATING.
JCPSP, 19 (1): 43-48. 2009
Influence of Age on the Outcome of Single stage Reconstructive surgery for
Congenital Dislocation of the Hip Joint. (Orignal article),
Anisuddin Bhatti, A.R. Jamali, Ghulam Mehboob.

87. Maq 8yrs
1yr Pop
Maq 7yrs
Maq 10yr postop
Maq 18 yrs
10yrs postop
Lt
Lt
10 yr Pop
Lt

88. Single stage
Two Incision approach:
OR with Anterior Smith Petersen approach
Femoral shortening DRO through Lateral etterbox approach

89. 3YR WARDA OP 2005

90. 10YR WARDA 7 YR
FU (OP 2005)

91. 3.6 YEAR AGED
TONNIS IV
OR + SHORTENING + SALTER
12 YEAR FU

92. 3 YEARS OLD
BILATERAL DDH, TONNIS IV, DOUBLE
ACETABULUM

93. CASE EXAMPLES
Deviation From Principles
Pre-operation traction &
Tight reductions
Short cuts in Surgery
Early Osteoarthritis

94. SHF: 19+ YRS
D.O.B. DECEMBER 1991
C/o: Pain, Limitation of
Movement & LLD
• At age 3 yr 1st Procedure:
• 6 wks traction followed by
CR + K wire + PoP cast >3
months.
• At age 6 yrs 2nd attempt was
made……..?

95. OCT 1996, BEFORE 2ND
PROCEDURE,
PRE-OPERATIVE TRACTION
+ OR BUT NO OSTEOTOMIES

96. AT 6 YRS AGE, 2ND PROCEDURE (NOVEMBER
1996):
4 WEEKS TRACTION, FOLLOWED BY OR+
NO OSTEOTOMIES. POP CAST
4 WKS POST OP X-RAY

97. 2 & 4 MONTHS AFTER 2ND SURGERY
REDISLOCATION

98. MARCH 1998, IMMEDIATE POST OP AFTER
3RD SURGERY:
OR+D’rotation Osteotomy.
No Pelvic Osteotomy
4 months after 3rd surgery
with AVN

99. 17 months after 3rd surgery
Progressive s’luxation +
degeneration
24 months 3rd surgery Post
op. Progressive s’luxation +
degeneration. Age 9+ yrs

100. Progressive s’luxation +
degeneration, PMEF, AVN.
Age 15 yrs
Pain, shortness, stiffness,
limp, LLD > 2 inch

101. AT AGE 20 YEARS: SEPTEMBER 2011
Stable Painful Hip,
Limited ROM LLD > 3inches

102. SHF: 19+ YRS
Problem: Pain, Limitation
of Movement & >3” LLD
Pit Fall: 1:Traction followed by Closed
& Open Reduction at age > 3 years
2: No Femoral shortening & Pelvic
Osteomy at 4 & 6 years age
Result: OA, LLD & ROM problem Pain

103. TREATMENT OUTCOME FACTORS
•Age at the time of Primary Tx.
•Quality of initial reduction
•Surgical expertise
•Compliance to treatment
•Followup duration

104. 0 6m
Spica
Pavlik
Harness
Closed Reduction
+ Adductor
Tenotomy
Open
Reduction
Femoral Derotation
Osteotomy
Salter
Derotation + Femoral
Shortening
Salter Dega Triple
Open
Reduction
Open
Reduction
18
m
3y
6y3y
SUMMARY
Open
Reduction
Derotation + Femoral
Shortening

105. TAKE HOME MASSAGE
•No shortcut in surgery:
No Tight reductions
•Good Initial Reduction
can only be achieved if
the principles of
treatment are followed
in letter & Sprit

106. THIS LECTURE IS DEDICATED TO
MY MENTOR
LATE PROF. SAGHIR AHMED: 2012

107. EXPERTS COMMENTS

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

110. Thank you