management of DDH

1. Developmental Dysplasia
of Hip:Management

2. DDH..
• The older term congenital dislocation of the hip(CDH)
has gradually been replaced by developmental
dysplasia of hip(DDH) to include in the disorder infants
normal at birth but in whom hip dysplasia or dislocation
subsequently developed
• Developmental dysplasia of the hip as a condition in which
the femoral head has an abnormal relationship to
the acetabulum

3. Dysplasia: radiographic finding of increased
obliquity and loss of concavity of the
acetabulum, with an intact Shenton's
line(deficient development of
acetabulum)
Subluxation: femoral head is in partial contact
with the acetabulum
Dislocation:femoral head is not in contact with
the acetabulum

4. SCREENING..!!
• All neonates should have a clinical
examination for hip instability
• Risk factors :
– breech presentation
– family history
– torticollis
– oligohydramnios
– metatarsus adductus
USG SCREENING

5. Physical examination…!
NEONATE INFANT WALKING CHILD
Dislocatable
Reducible
Klisic sign
Dislocatable(occasionally)
Reducible(ocassionally)
Klisic sign
Decreased Abduction
Galleazi sign
Remains dislocated
Klisic sign
Decreased Abduction
Galleazi sign
Limp(Painless)
Shortening
Hyperlordosis

6. NEONATE..!!
BARLOW ORTOLANI

7. 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

8. Clinical features : Infants
• Progression from instability to dislocation is
gradual process
• In some within a few weeks-irreducible dislocation
,whereas in others the hip dislocation remains
reducible up to 5 or 6 months of age.
• When the hip is no longer reducible, specific
physical findings appear.

9. INFANT..!!
Limited Abduction
(most reliable)
Galeazzi's sign

10. INFANT..!!
Gluteal & thigh folds assymetry Klisic’s Test

11. WALKING CHILD…!!!
Trendelenburg gait Hyperlordosis

12. ULTRASONOGRAPHY..!!!
Lateral decubitus position
alpha & beta angles

13. GRAF CLASSIFICATION..!!
β decreased:better cartilagenous acetabulum
decreased:shallow acetabulum

14. RADIOGRAPHY…!!
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

15. Centre – Edge Angle of Wilberg…!!
6 – 13 years >19 degrees
>14 years > 25 degrees

16. AP X-ray: hip in 45°abduction and IR describes the longitudinal
relationship between long axis of femur and acetabulum
Von rosen view

17. FALSE PROFILE VIEW..!!

18. CLINICAL &
USG
normal normal
normal ABnormal
REPEAT AT 6 WKS
ABnormal normal
F/U till maturity
Clinical & USG normal
REPEAT AT 3 & 6 WKS
ABnormal
Closed / open reduction
ABnormal
TREATMENT :NEONATE

19. APPLYING PAVLIK HARNESS..!!
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.
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
JBJS:VOLUME 85-A OCTOBER 2003

20. Treatment:1 month – 6 months
Pavlik harness:1st choice
Continued till achieving stability
4 weeks
no reduction
discontinued
Reduced
Continue for 6 more weeks
Appearance of the notch predicts
better development of acetabulum

21. PROBLEMS WITH PAVLIK HARNESS..!!
Inferior dislocation of hip
Femoral neuropathy
Decrease Flexion
Avascular necrosis Decrease Flexion
Poor construction or fit Change size
Poor compliance Parent education
Pavlik disease
Discontinue harness if
no reduction in 3 weeks

22. Treatment:6 months-2 years
AIM: obtain & maintain concentric
reduction without damaging femoral
head
Closed/open reduction
Pre op traction ????
Femoral shortening &Innominate
osteotomy may be needed

23. 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

24. Closed reduction…!!

25. 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
Never keep the limb in
wide Abduction or >15°IR AVN

26. Closed reduction..!!
An infant in a cast in the human position
• Force should be avoided
• Check for safe zone

27. Ramsey “zone of safety”…!!
Wide zone of safety
Moderate zone of safety
Narrow zone of safety
Ramsey PL, Lasser S, MacEwen GD: Congenital dislocation of the hip: Use of the Pavlik harness
in the child during the first six months of life. J Bone Joint Surg Am 1976; 58:1000

28. ARTHOGRAPHY…!!
• 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
Good < 5mm
Fair 5-6 mm
Poor > 6mm

29. ARTHOGRAPHY…!!
Obstructions to reduction
Severin [1941]
Normal appearance:Labrum
*Thorn over the femoral head
*A recess of joint capsule overlies
the thorn

30. Post reduction ..!!
Cast in human position
6 weeks
Examination under GA
Stability assessment
Stable ,reduced Doubtful reduction
,unstable
Arthogram
6 weeks Cast in human position
3rd cast for
6 weeks &
discontinue
Abduction splinting
for 6 weeks
OR
Open Reduction

31. Open Reduction…!!
• Unable to achieve closed
reduction
• Widening of the joint
space
• Unstable reductions
• Loss of reduction on
follow up
• Advanced age

32. Approach…!
Medial
• Minimal dissection
• Obstructions
encountered directly
BUT..
• Limited view
• MFCA violation
• No capsulorrhaphy
Anterior
• Better exposure
• Capsulorrhaphy
• Pelvic osteotomy
possible
BUT..
• Blood loss
• iliac crest apophysis and
abductors damage
• Stiffness of hip

33. Open reduction: Medial approach

34. Medial approach…

35. Medial approach..

36. Anterior approach…!!
• Smith-Peterson anterior approach
• Stood the test of time
• More commonly used
• Bikini incision better cosmetic results

37. Technique: anterior approach..!!
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
JBJS:VOLUME 85-A OCTOBER 2003

38. Anterior approach…
Tensor-sartorius interval
Iliac apophysis split
Abductors elevated sub-periosteally
Elevation
Sectioning

39. T-capsulotomy..!!

40. Ligamentum teres
use of ligamentum teres to find true acetabulum

41. Radial incisions in
acetabular labrum
Removal of fibro-fatty tissue

42. Capsulorraphy..!!
Vest over pants capsulorraphy

43. Test of stability as an aid to
decide need for osteotomy…!!
H. G. Zadeh, Catterall,Hashemi-Nejad,Perry:J Bone Joint Surg [Br] 2000;82-B:17-27

44. Test of stability …!! Contd…

45. 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

46. 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

47. Open Reduction with Femoral
Shortening..!
Subtrochanteric cut
Overlap method to determine the
amount to shorten the femur.
Internal fixation with an
appropriate blade-plate

48. 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 acetabular
procedure

49. 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 years:
Open reduction + salter osteotomy.

50. Reorientation…!!
Acetabulum rotated into a better position

51. 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
Appropriate for children of 2-8 years
Before 2 yrs >8 yrs
Iliac wings too small symphysis pubis
to support graft less mobile

59. SALTER OSTEOTOMY..!!

60. MODIFIED SALTER..!!
Interlocking of the two segments of the osteotomy
prevents medial displacement and improves stability.
ALI KALAMCHI :JBJS VOL. 64-A, NO. 2. FEBRUARY 1982

61. SUTHERLAND’S OSTEOTOMY..!!
1. Can be done for
older child
2. Allows medial
displacement

62. Triple innominate osteotomy (Steel)..!!
Addition of ischial & pubic osteotomy to Salter allows increased
mobility of acetabulum for correction
Attached sacropelvic ligaments limit amount of correction

63. 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)

64. PEMBERTON..!!

65. Dega osteotomy..!
Osteotomy starts just above the anterior inferior iliac spine, curving gently cephalad and
posteriorly to reach a point superior to the midpoint of the acetabulum, and then continuing
posteriorly to end approximately 1 to 1.5 cm in front of the sciatic notch.

66. Dega osteotomy..!
Intact postero-medial cortical
hinge
If more anterior coverage desired ,inner cortex cut more
If more lateral coverage desired, inner cortex cut less

67. Dega osteotomy..!
A larger graft is inserted anteriorly. The posterior graft should be
smaller in order not to loosen the anterior graft.
JAN S. GRUDZIAK & W. TIMOTHY WARD :THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG VOLUME 83-A · NUMBER 6 · JUNE 2001

68. GANZ osteotomy..!
Larger corrections all directions(correction not
limited by sacro-pelvic ligaments)
Blood supply preserved
Shape of true pelvis unaltered
Technically demanding

69. SALVAGE(Augmentation)..!
Incongruent Hips
The deficient acetabulum is supplemented by a
buttress of bone to increase the area of support
for femoral head

70. SHELF ACETABULAR AUGMENTATION..!!!

72. SHELF ACETABULAR AUGMENTATION..!!!

73. Chiari Osteotomy

76. CROWE CLASSIFICATION..!!!
• Crowe classification uses the proximal femoral
head displacement from the line connecting
the distal borders of teardrops.
Type 1 Subluxation < 50%
Type 2 Subluxation 50% - 75%
Type 3 Subluxation 75-100%
Type 4 Subluxation >100%
DDH:ADULTS

77. The vertical height :pelvic wall
Line between tear drops
Femoral head diameter
Tuberositas ischium line
Head-neck line
CROWE CLASSIFICATION..!!!
D
M
Migration:M & Subluxation:M/D

78. DDH:ADULTS
Hartofilakidis classification..!!

79. FEMORAL CONSIDERATIONS FOR THR..!!
• The canal of the dysplastic femur is often narrow & exaggerated oval in cross
section
• If excessive femoral anteversion not recognized ,can lead to intraprosthetic
impingement, instability & in-toeing gait.
• Lenghtening of extremity by placing acetabulum in anatomic location : risks of
Sciatic & Femoral nerve palsies
• Restoration of ABDUCTOR FUNCTION Crucial
Abductors: underdeveloped & more transverse in nature
Proximal migration & excess anteversion:distortion of length & direction of
abductor muscles
Kevin I. Perry & Daniel J. Berry : Orthop Clin N Am 43 (2012) 377–386

80. FEMORAL CONSIDERATIONS FOR THR..!!
• Restoration of the hip to its true hip center & correction of
femoral neck anteversion can often provide more normal
abductor anatomy and function
• Subtrochanteric osteotomy & special uncemented stems
• Femoral Shortening

81. ACETABULAR CONSIDERATIONS FOR THR..!!
RANAWAT TRUE ACETABULAR REGION
Aim of the acetabular reconstruction is to place the acetabular component
in the area of the true acetabulum for purely mechanical reasons

82. ACETABULAR CONSIDERATIONS ..!!
• Placement of standard-sized acetabular components in a
dysplastic acetabulum may leave part of the component
unsupported by native bone.The native bone has to support at
least 70% of the surface area of component to give stability.
• Autogenous bone graft augmentation in association with
cemented acetabular components for hip dysplasia has provided
satisfactory early clinical results, but a higher rate of failure with
longer follow-up and with increasing revision rates due to graft
collapse, particularly when a large amount of the socket is
supported by graft, or due to socket loosening is observed.
• Better results have been reported when the hip center is
restored to its anatomic position, when the graft supports less
than 30% to 40% of the component, and when posterior as
well as superior support is provided.

83. ACETABULAR CONSIDERATIONS ..!!
• HIGH HIP CENTER: Proximal placement of the acetabular
component probably should be reserved for the elderly
patient in whom an anatomic position would otherwise
require grafts to most of the socket’s structural support.
• ACETABULAR COMPONENT MEDIALISATION: In subluxation,
slight medialization of hip center of rotation usually avoids the
use of bulk autograft for reconstruction
Michele R.Dapuzzo & Rafel.J Sierra:Orthop Clin N Am 43 (2012) 369–375

84. DDH: THR
does not solve all ills!
Right:
painless
Left:
severe pain

85. Thank You..!!!!!