Prof. Anisuddin Bhatti, Paediatric Orthopaedic Surgeon, Dr. Ziauddin University Hospital Clifton Karachi, presented webinar on Developmental dysplastic hip, series 1. on <meet.google.com> on 16.10.2020. Presentation mostly for trainees & jr. consultants. He explained in detail, pathoanatomy, screening protocols, ultrasonography & radiological evaluation of DDH cases.

2. 1_DDH Evaluation &
Screening Protocols
Prof. Anisuddin Bhatti
Founding Director, Paediatric Orthopaedic Registry, Pakistan
Focal Person, Ponseti International, Pakistan
President(Past), POA & Paediatric Orthopaedic Surgery,
Pakistan
Paediatric Orthopaedic & Orthopaedic Trauma
surgeon
Dr. Ziauddin University Hospital, Clifton, Karachi
DDH Webinar Series

3. The Expert Panel
ProfR. Nizamudin Jamele, JPMC. A Living legend
Who taught me DDH Rx Arthrogram & Orthopaedics
Prof. Imtiaz A HashmiPrd perfm
Dr. Idrees Shah
Profs. M Sohail Rafi, Nadeem A Baloch

4. Agenda
 Patho antomy
 Evaluation Tools
 Screening Protocols
 Ultrasonography
 Radiolographic evaluation
 Video Demonstarion:
Ortolani Barlow
manuvere
 Q&A

5. Pathoanatomy

6. DDH Spectrum:
DDH:refers to a spectrum of Cong. Hip problems:
 Unstable,
 Subluxated,
 Dislocated
 Dysplastic Acetabula & +/- Prx Fo Fem Def

7. DDH:
Pathoanatom
y
 Subluxation,
 Dysplastic
Acetabula

8. DDH:
Pathoanatom
y
 Dislocation

9. DDH: Soft tissues Abnormalities
 Thickened capsule
 Contracted muscles –
Iliopsoas, Rectus,
adductors and
hamstrings
 Horizontal /wrinkled
abductors
 Shortened Sciatic nerve
 Distorted Femoral nerve
and the Profunda femoris
“distorted anatomy,
especially in high
dislocations, affects most
of the soft tissues around
the hip.” Chandler H P

10. DDH: Structural Abnormalities
Coxa Valga Anteversa, Obtuse Acetabula
Acron shaped Head, Vertically oval
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 over hanged head
Fem Condyle axis

11. Caput Femoris: Acorn Shape
Seed of Oak
Tree
Vertically oval, Over hanged
caput
LT

12. • Capsule, Dumbbell elongated
• Ligamentum Teres, Thick elongated
• Capsule, Hypertrophied Redundant
• Pulvinar Fibrofatty layer
Thick Redundant
Capsule
Soft Tissue Obstacles
Caput femoris in
false acetabulum
Thick Elongated Ligamentum Teres

13. Pulvinar: Fibrofatty layer
Pulvinar
Pulvinar excised: True acetabulum
False acetabulum

14. Micro-Caput (Salter Type I AVN)

15. Clinical: Screening Protocols
Focused Clinical Examination
Imaging: Ultrasounographic
Radiographic
Arthrogam
Evaluation Tools

16. Early Diagnosis, Earliest
treatment
Early diagnosis is essential to
achieve best functional results”
Ortolani 1948
Because: with a longer period of
subluxation and dislocation, soft
tissue contractures & Coxa Valga
Anteversa increases.
That: typically results in a need for
multiple greater surgical intervention

17. Early Diagnosis, Earliest treatment
 Until early sixties it was just a dream (of
Ombredanni 1923)“TO ACHIEVE BEST
FUNCTIONAL RESULTS in CDH”.
 As: the CDH was the only deformity among
congenital anomalies that was un-
recognizable (in the majority) until a child
started crawling and walking”.
 “Best functional results can achieved
if treatment is started within first few
day after birth , any other time is not
early enough.” Ortolani 1948

18. The Most Obscure Congenital deformity.??

19. 1948-1967
 During mid sixties, certain screening
programme were introduced ……for early
detection of DDH & treatment before they start
crawling (7 months age).
 Thereafter, following challenges in treatment
were easy to address:
1.Screening protocol
2.Early treatment
3.Managing primary acetabular dysplasia
4.Managing OA in younger age DDH group.

20. Screening Protocols

21. Concept: NEONATAL
SCREENIN
Evolved after the publications of:
ORTOLANI (1948) & BARLOW (1963)
 They introduced “AT BIRTH SCREENING
PROTOCOL FOR NEWBORNS” performed
on babies with suspicion of DDH
diagnosed on basis of abnormal skin folds
and some other inconsistent findings.
SALTER (1963-72) …. Pelvic Osteotomy.
HARIS (1968-70) …. Acetabulum Development
Objective:
“Detect potential instability of hip,
subluxation or dislocation of the femoral
head.”

22. NEONATAL
SCREENING
MARINO ORTOLANI
(1948):
 Maneuver to reduce
dislocated hip by
flexion, abduction and
redirecting femoral
head to acetabulum.
 Feeling a gentle / fine
click with reduction of
hip indicate a positive
sign.
 Best time 0-8 wks age

23. ORTOLANI’s TEST:1948
Clunk of
Entry
(Reduction)
Felt on
Gentle
Abduction
Clunk
or
Click
???

24. NEONATAL
SCREENING
BARLOW, T G. 1962 :
Maneuver to dislocate a
dislocatable hip by
flexion, adduction,
pushing and
redirecting femoral
head away from
acetabulum.“The pathological changes occurring in a
CDH in a newborn are generally reversible
with a 95% success rate with simple
means (Abduction splints) of treatment”.
Barlow 1962

25. Clunk of
Exit
(Dislocation)
Felt on
Flexion
Adduction
Maneuver
BARLOW’S MANEUVER:1962

26. Ortolani - Barlows Maneuvers

27. Redesigned:
National Screening Programme:
UK++.
Adopted:
 Ortolani- Barlow test to Illicit
Unstable hip signs (click) :
1969
 Re-designed, with
addition of Ultra-
Sonographic imaging:
Graf 1980, Harcke 1986 &
Terjesen f/H coverage
2000

28. Ultrasonograpy

29. Coronal Illustration
AC- Acetabular cartilage
C – Capsule
GT – Gr. Troch
H- Head
IL – Ilium
LT/P – Ligamentum
Teres/Pulvinar
Tt- Triradiate Cartilage
Coronal View: Transducer is placed
Parallel to the lateral aspect of the hip

30. Transverse Flexion View
The Ultrasound transducer is
placed perpendicular to the
lateral aspect of the Hip
Transverse Ultrasound Image
G – Gluteus muscles
H – Head
IS – Ischium
L -Labrum
M – Metaphysis
FS- Femoral Shaft

31.  The baseline: along the ilium, through the
femoral head, to the point where perichondrium
unites with the Ilium.
 The roof line: along the acetabular roof
intersecting the baseline. From the lower edge
of the ilium at the triradiate cartilage to the
point where perichondrium units with Ilium
 The inclination line: across the top of the
femoral head, through the labrum and
intersecting the 1st two lines.
Ultrasonography– Graf 1980: 3
Lines

33. Graf’s Angle
 The alpha and beta angle: to
indicate the degree of
acetabular development
 The alpha angle determines the
type and beta angle determines
subtype.
ALPHA ANGLE reflects the
DEPTH / slope of the bony
acetabulum.
 Normally, the alpha angle is
greater than >60°.
 An angle less than 55 is

34. Graf’s Angle: Beta Angle <55
 The beta angle: the angle
formed between the
vertical cortex of the Ilium
and the triangular labral
fibrocartilage (echogenic
triangle).
 In reflects Cartilage
coverage
 Beta angle much more
variable than the alpha angle,
indicates subtypes.
 Beta angle is less than
<55.

35. Alpha angle is
greater than
>60°
An angle less
than 55 is
considered
abnormal.
Beta angle is less
than <55.
The increased beta
angle denotes the
subluxetion /
eccentrically placed
femoral head as it
elevates the labrum.

36. Decrease in Alpha angle &
Increase in Beta reflects subluxation to dislocation
AlphaBeta

37. Subluxated Hip Superiorly
• Rounded / indented Ilium-acetabular roof angle (Green)
• Abnormally elevated Labrum (Yellow / yellow)
• Femoral head (red circle) produce an abnormally shallow alpha
angle
Decrease in Alpha angle & increase in Beta denotes subluxation to dislocation

38. Graf Classification
 Type I: normal hip – α angle >60, β angle <55
 Type II < 3 months physiologic immaturity and > 3
months mild dysplasia:
- type II hip is immature or mildly dysplastic and
has a shallower acetabulum with a round rim;
- in children younger than 3 months, most of
these will spontaneously resolve;
- in children older than age 3 months, the
deformity is expected to persist without
treatment;
 Type II a: α angle >50-59 <3 months of age
 Type II b: α angle >50-59 >3 months of age
 Type II c: α angle >43-49, β angle 70-77 deg

39. Graf Classification
 Type III: dislocation: α angle < 43 deg
- acetabulum is shallow;
- cartilaginous roof is displaced with eversion of
labrum.
 Type IV: high dislocation
- acetabular cup is flat and has the worse
prognosis;
- femoral head is laterally and superiorly
displaced;
- labrum is interposed between the femoral
head and the lateral wall of the ilium

40. Limitations
AGE:
 If the baby is greater than 6 months, the hips
may be too ossified to examine adequately
with ultrasound.
 If the baby is 12 months or greater and
presents with limp, prominent GT or extra
crease, Radiographic evaluation be a better
option. That may include some specific views

41. Limitations
EQUIPMENT SELECTION
 Depends on the age (> 7 months) and size of the
child.
 In Newborn A 12Mhz linear array probe is used
 In 3 months age, a 7MHz will be required for
adequate penetration.
 If the tri-radiate cartilage cannot be seen,
decrease in the frequency is required.
 Better to perform when the ossification of the
proximal femoral epiphyses is not too far
advanced.
 A machine with cine capabilities and a foot switch
is helpful as you can keep your hands on the

42. Limitations
PATIENT PREPARATION
 Most accurate time to scan the baby is over 6
weeks .
This is because the hips are more mature
and not lax. Otherwise false positives can occur as
the baby's hips initially have some natural laxity.
 The nappy can be left on and just open the tabs
on the side you are scanning to get access to the
hip coronally.
 The parent can stay with the child at all times to
calm them.

43. RECOMMENDATIONS FOR U/S:
Health & MRC UK:
Ultrasonography in Neonatal Screening, Offered
to:
 Babies with risk factors:
- Strong family history
- Breech presentation
- Torticolis
- Congenital foot deformity
- Positive Hip Instability Signs
 All New born…Primary screening (Europe+)

44. NATIONAL SCREENING ROGRAMME:
UK ++
Since then (mid 80s) there has been
increasing use of Dynamic & Static
ultrasonograpy of hips of newborn babies
infants.
As a Result:
 ….. reduced the number of newborns
with unstable hips treated with
abduction splint by as much as 70%.
 ….Unnecessary use of Abduction
Splint & their Complications reduced
significantly
There were no late presentations /
Missed Dislocations after 2002.”

45. DDH in Walking / Crawling age
Missed dislocations
(2.5%-18% Plus)

46. Missed Dislocations
Hips that was stable at birth,
present later with dislocation
Missed Dislocations
They require a Sequential exams at
3 and 6 weeks, and 3 and 6
months. In high risk patients.
• Sequential clinical exam,
with support of U/S and
other Imaging Modalities as
per age at presentation

47. Missed dislocations: Signs
Less than full abduction
Asymmetric thigh folds
Long & Deep inguinal crease.
Negative Thomas test in CDH
(Thomas test is positive in a normal
hip till age 03 months +/-, as there is
15-20 degrees FFC at the normal hip)
LLD & Telescoping Sign

48. Missed dislocations: Signs
Galeazzi sign
Limited abduction
Asymmetric Thigh fold
Long & Deep inguinal crease

49. X-Ray in
Neonatal
Screening
No Role In Primary Screening
Positive Role in
1.Missed Dislocations
2.Secondary Radiological F.Up

50. Radiographic Evaluation
 Xray: ..a Reliable tool after 4 months
 Used for Diagnosis, Monitoring &
Follow-up.
 A SURROGATE MEASURE to
indicate long term results after 2yr
age.

53. Andren Von Rosen View:
Reliable after 3 Months age
• Hips abducted 450, Internaly rotated & Extended
• Line drawn along femoral shaft, intersect acetabulum
• In Dislocation axis line cross above the acetabulum

54. Von Rosen View:
Post Reduction Evaluation

55. Tonnis Hight of Dislocation
Shf 9 m
Sbc 19 m
Hjb 10 yr

56. Femoral head-Acetabulum
Relationship
CE angle of Wiberg
The Center-Edge angle (CE angle) was introduced
by Wiberg (1939) as a measure of acetabular development
and/or the degree of displacement of the femoral head.
Normal:
• 6-13 Yrs. >190
• > 13 yrs. >250
• Borderline dysplasia 20-250
• Dysplasia <200

57. Anteversion:
Frog leg Views

58. CT & MRI
 CT Scan: Measure Femoral
anteversion & Evaluation In
POP cast
 MRI: Adequacy of Reduction &
AVN
(Picture Courtesy: Prof. Javed Iqbal)

59. Imaging Modules: other than U/S
 Arthrography: Failure of
splintage, before & after
O.R.
 C Arm: Pre, per & post -
closed reduction evaluation

60. Xray &CT Scan: Evalutaion In POP cast
7months baby 4 Month in cast
CT Scan in
same cast
Von Rosen View in cast on same Xray
After removal of cast

61. Dream of ORTOLANI .…
in UK, Europe, USA etc
“… Because of widespread
screening of newborn, it is
becoming less common for
CDH to beyond age of 1year”
“.…Incidence 5-6%”
Beaty HGM 1999

62. Dream of ORTOLANI
in South East Asia, Africa …..
“.. Unfortunately, unrecognized or unsuccessfully
treated dislocation of the hip in older children is
not uncommon in less favored populations…
Dislocation is usually recognized when child starts
to walk” Karakas 1995 Turkey
“…it is not uncommon to see CDH in older children,
undetected, untreated & neglected till they develop
significant gait abnormalities….
Incidence Aprox. 25-40% and Half
of them are above 3 years age.
Zadeh & Catterral 2000, Bhatti etal JCPSP 1997.

63. Neonatal Screening

64. Neonatal Screening on
a DDH Model
 Plz follow link on my
Youtube
 Youtube/user/1orthojpm
c
or
 https://youtu.be/mv_kLq
ZSGdo
Upload video & play

65. If, sum mun book mun. Let Faculty proceed to discuss
Q & A Participants vs Faculty

66. This presentation is dedicated to
my mentor
Living legened
Prof. Niazamudin Jamele