Developmental dysplasia of the hip (DDH) is a condition where the hip joint is not properly formed or does not properly develop during fetal life or infancy. It ranges from shallow hip sockets to partial or complete dislocation of the hip joint. The goals of treatment are to reduce the femoral head into the acetabulum and maintain a concentric reduction to allow for normal hip development. Treatment depends on the age of presentation and severity, and may include use of a Pavlik harness, hip spica cast, closed or open surgical reduction, and osteotomies. Early diagnosis and treatment generally lead to better outcomes.

1. DR.Ammanullah

2.  Definition
 Dysplasia of the hip that develop during fetal life or
in infancy.
 It ranges from dysplasia of the acetabulum (shallow
acetabulum) to subluxation of the joint to complete
dislocation.
 The old name was ‘‘congenital dysplasia of the hip
(CDH).’’ The name has changed to indicate that not
all cases are present at birth and that some cases
can develop later on during infancy and childhood

3.  Types:
 DDH is classified into two major groups :
 Typical and teratologic .
 Typical DDH occurs in otherwise normal patients
or those without defined syndromes or genetic
conditions.
 Teratologic hip dislocations usually have
identifiable causes such as arthrogyposis or a
genetic syndrome and occur before birth.

4. 1. Complete hip dislocation.
2. Partial hip subluxation.
3. Hip dysplasia (incomplete development).

5.  Most newborn screening studies suggest that
some degree of hip instability can be detected in
1/100 to 1/250 babies, actual dislocated or
dislocatable hips are much less common, being
found in 1-1.5 of 1000 live births.
 There is marked geographic and racial variation
in the incidence of DDH.
 More inidence of DDH IN Sweden,Yugoslavia
and Canada.

6.  African and Asian
caregivers have traditionally
carried babies against their
bodies in a shawl so that a
child ’s hips are flexed,
abducted, and free to
move.
 This keeps the hips in the
optimal position for stability
and for dynamic molding of
the developing acetabulum
by the cartilaginous femoral
head.
 Children in Native
American and Eastern
European cultures, which
have a relatively high
incidence of DDH, have
historically been
swaddled in confining
clothes that bring their
hips into extension.
 This position increases
the tension of the psoas
muscle-tendon unit and
might predispose the hips
to displace and
eventually dislocate
laterally and superiorly.

7. Recommended
Not recommended

9. • A positive family history for DDH is found in 12-33% of
affected patients.
 DDH is more common among female patients (80%).
This is thought to be due to the greater susceptibility of
female fetuses to maternal hormones such as relaxin,
which increases ligamentous laxity
 Primigravida.
 Breech presentation(2-3%).
 Oligohydramnios ,primi gravida and large baby
( crowding phenomenon ).
 Adduction and Extension postnatally.

10. • Torticollis
• metatarsus adductus
• calcaneovalgus feet
Associated conditionsAssociated conditions

11.  The left hip is the most commonly affected hip
 In the most common fetal position, this is the hip
that is usually forced into adduction against the
mother’s sacrum.
 Girls are affected 5 times more than boys.

12.  IN NEWBORNS
 Usually asymptomatic and must be screened by
special maneuvers
 1) Barlow test.
It is a provocative test that attempts to dislocate an
unstable hip.
- Flexion ,adduction, posteriorly.
- “Clunk”

13. BARLOW’S TEST ( bahar lo)

14. BARLOW’S TEST ( bahar lo)

15.  2) Ortolani test
It is a maneuver to reduce a recently dislocated
hip.
 Flexion, abduction, anteriorly.
 We can`t use X-rays because the acetabulum and
proximal femur are cartilaginous and wont be
shown on X-ray.
 US is the best method to Dx.

16. ORTOLANI SIGN

17. ORTOLANI SIGN

18.  In infants:
 As the baby enters the 2nd and 3rd months of life,
the soft tissues begin to tighten and the Ortolani
and Barlow tests are no longer reliable.
 Shortening of the thigh, the Galeazzi sign , is
best appreciated by placing both hips in 90
degrees of flexion and comparing the height of the
knees, looking for asymmetry
 Asymmetry of thigh and gluteal skin folds.

19. •The most diagnostic sign is Ortolani’s limitation of
abduction.
•Abduction less than 60 degrees is almost
diagnostic.
•X-rays after the age of 3 months can be helpful esp.
after the appearance of the ossific nucleus of the
femoral head
•US is 100% diagnostic.

20. MOST RELIABLE SIGN

24.  In older children:
Complaints of limping, waddling (bilateral DDH),
lumbar lordosis, limitation of hip abduction, toe-
walking, wide perineum, etc…

26.  All neonates should have a clinical examination
for hip instability
 Risk factors :
◦ breech presentation
◦ family history
◦ torticollis
◦ oligohydramnios
◦ metatarsus adductus
USG SCREENING

27. CLINICAL USG
normal normal
&
normal ABnormal
REPEAT AT 6 WKS
normalABnormal
REPEAT AT 3 & 6 WKS
Clinical & USG normal
ABnormal
Closed / open reduction
F/U till maturity
ABnormal

28.  1. ULTRA SOUND
 In the Graf technique, the transducer is placed
over the greater trochanter, which allows
visualization of the ilium, the bony acetabulum,
the labrum, and the femoral epiphysis
 The angle formed by the line of the ilium and a
line tangential to the boney roof of the acetabulum
is termed the α angle and represents the depth
of the acetabulum.
 Values > 60 degrees are considered normal, and
those < 60 degrees imply acetabular dysplasia.

29.  The β angle is formed by a line drawn
tangential to the labrum and the line of the ilium;
this represents the cartilaginous roof of the
acetabulum.
 A normal β angle is < 55 degrees, as the
femoral head subluxates, the β angle increases.

31. Graf classification of DDH
[ simplified]
class Alpha angle Beta angle description
1 >60 <55 normal
2 43-60 55-77 Delayed
ossification
3 <43 >77 lateralization
4 unmeasurable unmeasurable dislocated

32.  von rosen view:
 hips abducted 45º &medially rotated.
 Anteroposterior.
 We draw a line through the central axis of the femoral
shaft.
in normal hip ( ossific nucleus )will be inside the
acetabulum.
in dislocated hip it will be above acetabulum.

35.  Horizontal line of Hilgenreiner:
drawn between upper ends of tri-radiate cartilage of
the acetabulum.
 Vertical line of perkins:
drawn from the lateral edge of the acetabulum vertical
to horizontal line.
 4 quadrants:
Normal hip: the ossification center of the femoral hip
lower medial quadrant.
Dislocated hip: upper lateral quadrant.

36. Pe

39.  Acetabular index:
angle between horizontal line of hilgenreiner and
the line between the two edges of the acetabulum.
normal hip 20º30
dilocated or dysplastic hip ≥ 30º
 Shenton’s line:
semicircle between femoral neck and upper arm
of obturator foramen, in dislocated hip this line is
broken.

41. • The earlier the better.
• Best time for treatment is in newborn period.
• It depends on the device and age of the patient.
• Goal is to:
1.Flex and abduct hips.
2.Reduce femoral head and maintaining it.

42.  The goals in the management of DDH are to
obtain and maintain a concentric reduction of
the femoral head within the acetabulum to
provide the optimal environment for the normal
development of both the femoral head and
acetabulum.
 The later the diagnosisof DDH is made, the
more difficult it is to achieve these goals, the
less potential there is for acetabular and
proximal femoral remodeling, and the more
complex are the required treatments

43.  From (1-6 months) use Pavlik Harness.
 From 6 months -2 year use hip spica.
 From the age of >2 year
traction , adductor tenotomy , surgical closed
reduction, salter innominate osteotomy.

44. First choice is
PAVLIK harness
Ensure hip > 90
degrees flexion

45.  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%.

46.  Standard of treatment worldwide
 Upto 6 months
 Contraindicated when there is major muscle
imbalance (myelomeningocele,ligamentous laxity)

48.  AVN
 Failure to reduce
 Femoral nerve
neuropathy
 Inferior dislocation
 Pavlik’s disease
(flattening posterolateral
acetabulum)

50.  Closed or open reduction + adductor tenotomy
 If closed reduction fails then surgeon should be
prepared for an open procedure

51. Force should be
avoided
Check for safe zone
Post reduction:
Spica change every six
weeks plus stability
check
Continue spica for 3-4
months

52. 20to 30 degrees from
maximum abduction
extended to below 90
degrees
without redislocation
Safe zone can be
improved
with adductor tenotomy

53. Management of DDH – Guidelines
0to 6 months
Pavliks Harness
6to 18 months 18to 36 months 3to 8 years
Traction
Closed reduction
Hip spica
Open reduction
Pri. open
reduction
Pelvic osteotomy
Pri, open
reduction with
Femoral
shortening
6weeks no
reduction
Arthrography
No reduction <1/3rd
head
visible

54. THANKS