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DDH
1. • Dr. Sushil Paudel Management of
Developmental
Dysplasia of Hip
2. Developmental dysplasia of the hip (DDH) :
spectrum of disorders of development of hip that
present in different forms at different ages
Structures that make up hip are normal during
embryogenesis and gradually become abnormal
for a variety of reasons, chiefly fetal position and
presentation at birth (malposition of the femoral
head, abnormal forces acting on developing hip)
and laxity of ligamentous structures about hip
joint
3. Evolves over time
Syndrome in newborn:
instability of hip;
subluxated or dislocated,
dislocated position and
be reducible on
examination
Over time, femoral head
becomes fully dislocated
and cannot be reduced by
changing position of the
hip
4. Teratologic dislocation of the hip: distinct
form of hip dislocation that usually occurs
with other disorders
Dislocated before birth, have limited range of
motion, and are not reducible on examination.
Associated with other neuromuscular
syndromes, as myelodysplasia and arthro-
gryposis
5. PATHOGENESIS
Affected hip slides in &out
Flattenened posterior border NEOLIMBUS
of acetabulum (CLUNK)
birth Loose capsule
Everted labrum
corrected uncorrected
DOCKING OF THE
Secondary
FEMORAL HEAD
barriers
6. SECONDARY
BARRIERS
PULVINAR
LIGAMENTUM TERES
TR.ACETABULAR LIG
INVERTED LABRUM
CAPSULE
ILIOPSOAS
REDUCED-DOCKING
HOURGLASS CONSTRICTION
POINT OF REDUCIBILITY:?
HARRIS et al: 4 yrs “CHINESE FINGER TRAP”
7. ACETABULAR
UNREDUCED CHANGES
ACETABULAR ROOF FLATTENING
THICKENED MEDIAL WALL
DYSTROPHIC CARTILAGE
SUBCHONDRAL CYSTS
LOSS OF CARTILAGE
OSTEOPHYTES
9. Making the Diagnosis
High index of suspicion
Identifying risk factors
Careful physical
examination
Provactive dynamic
tests
Risk baby evaluation by
USG
Radiological evaluation
14. Clinical Features : Neonates
Delicate “clunk” that is
palpable but not
audible
Repeat sequence 4-5
times to be certain of
findings
If both signs negative
but pt is high risk :
follow up is essential
15. Clinical features : Infants
Progression from
instability to dislocation is
gradual process
In some within a few
weeks
others the hip dislocation
remains reducible up to 5
or 6 months of age.
When the hip no longer
reducible, specific
physical findings appear
36. Tear drop
AP X-ray
Lateral:wall of acetabulum
Medial:lesser pelvis
Inferior :acetabular notch
Appears between 6-23 mo
[delayed in DDH]
V-shaped in DDH
40. Imaging Tools
• CT scan:
– Single section CT as check films
– Neglected C.D.H.
– Adolescent and adult
• MRI:
– Equivalent to arthrography
41. Diagnosis
Reduction
maintain
Intervene adverse natural history
Ensure normal adult hip
42. Screening
• All neonates should have a clinical
examination for hip instability
• Risk factors :
– breech presentation USG SCREENING
– family history
– torticollis
– oligohydramnios
– metatarsus adductus
43. CLINICAL & USG
normal normal
normal ABnormal
ABnormal
F/U till maturity
REPEAT AT 6 WKS
ABnormal normal
Clinical & USG normal
REPEAT AT 3 & 6 WKS ABnormal
Closed / open reduction
44. Infant 1 – 6 months of Age
First choice is PAVLIK
harness
Ensure hip > 90 degrees
flexion
AP radiograph
Does not have to be
reducible initially
45. Infant 1 – 6 months of age
weekly clinical examination & USG
By 3 weeks stable reduction must
Continue till radiographs show normal
acetabulum
Results :
95% of initially dysplastic hips normal
80% dislocated and not initially reducible were successfully reduced
Higher dislocations had a higher failure rate
The rate of AVN was 2.38%.
Grill F, Bensahel H, Canadell J, et al: J Pediatr
Orthop 1988; 8:1.
46. Pavlik harness
Standard of treatment worldwide
Upto 6 months
Contraindicated when there is major muscle
imbalance (myelomeningocele, AMC or
ligamentous laxity)
48. Follow up
The child should be followed till
skeletal maturity
Increased risk of asymmetric physeal closure
Valgus deformity of the neck
49. Child 6 months to 2 years of age
• Closed or open reduction + adductor
tenotomy
• If closed reduction fails then surgeon should
be prepared for an open procedure
50. Closed reduction
Force should be avoided
Check for safe zone
Post reduction:
Spica change every six
weeks plus stability
check
Continue spica for 3-4
months
51. Safe Zone
20 to 30 degrees from
maximum abduction
extended to below 90 degrees
without redislocation
Safe zone can be improved
with adductor tenotomy
52. Open reduction
Unable to achieve
closed reduction
Widening of the joint
space
Unstable reductions
Loss of reduction on
follow up
Advanced age
53. Approach
Medial Anterior
Minimal dissection Better exposure
Obstructions encountered Capsulorrhaphy
directly Pelvic osteotomy possible
BUT..
BUT.. Blood loss
Limited view Iliac crest apophysis and
MFCA violation abductors damage
No capsulorrhaphy Stiffness of hip
Secondary procedures
55. Anterior approach
• Smith-Peterson anterior
approach
• Stood the test of time
• More commonly used
• Bikini incision better
cosmetic results
56.
57.
58. Open Reduction with Femoral
Shortening
• Pressure leads to risk of AVN
• Better results than preoperative traction in older
children with less morbidity
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
59. 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
61. 2 Years of Age 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 osteotomy
62.
63. Bilateral untreated dislocation upto 5 years:
Open reduction with femoral shortening with
salter / pemberton osteotomy with gap of 5-6
weeks.
Bilateral untreated subluxation upto 5-6 years:
Open reduction + salter osteotomy.
65. Acetabular Reorientation-Innominate
Osteotomy
• Articular hyaline cartilage over femur head
• Types:
– Salter’s (innominate)
– Sutherland’s (double innominate)
66. Salter’s Osteotomy
Redirects the entire acetabulum
Roof “covers” the femoral head anteriorly and
superiorly
Hinge at pubic symphysis
Pre-requisites
Congrous Concentric reduction
No Contractures
70. Peri-acetabular Ostetomies
• Provide greater correction of acetabular index
• Reduce volume of hip joint
• Possibility of growth disturbances
Types
– Pemberton’s
– Dial (Eppright)
– Wagner
– Dega’s
– Ganz osteotomy (Bernese)
80. Adolescent and young adult(older then 8-
10 years
If femoral head cannot be repositioned
distally to the level of acetabulum : Salvage
procedures
Degenertive arthritis and enough pain and
limitation of movements – reconstructive
operation (total hip replacement)
Arthodesis – rarely done, contraindiacted for
bilateral dislocation
