ORTHOPAEDIC SURGEON

1. DEVELOPMENTAL
DYSPLASIA OF THE HIP
KA Alatishe

2. OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• RELEVANT ANATOMY
• ETIOLOGY
• PATHOLOGY
• CLINICAL PRESENTATION
• INVESTIGATIONS
• CLASSIFICATION
• TREATMENT
• COMPLICATIONS
• FOLLOW-UP
• CONCLUSION

3. INTRODUCTION
• FORMERLY KNOWN AS CONGENITAL HIP DISLOCATION BUT
IMPRECISE AND CONFUSING
• SPECTRUM OF DEVELOPMENTAL DISORDERS OF THE HIP
• ACETABULAR DYSPLASIA, SUBLUXATION AND DISLOCATION
• MAY BE ASSOCIATED WITH OTHER CONGENITAL ANOMALIES( e.g
VACTERL)
• ALTHOUGH UNCOMMON IN THIS ENVIRONMENT, IT IS UNDER-
REPORTED ( LACK OF AWARENESS, NO ROUTINE SCREENING OF
NEWBORNS)

4. EPIDEMIOLOGY
• N. EUROPE 1:1000LIVE- BIRTH
• LAPPLANDERS AND NATIVE AMERICANS 25-50:1000
• AFRICANS 0:1000 ( Eldestein et al , 1966)
• GIRLS MORE THAN BOYS ( 7:1)
• LEFT HIP COMMONER THAN RIGHT (?LOA intrauterine position)
• BILATERAL IN 20% CASES
• COMMONER IN TERM BABIES THAN PRETERMS
• COMMON IN 1ST BORN BABIES AND BREECH PRESENTATION

5. EMBROLOGY OF HIP DEVELOPMENT
• THE FEMUR HEAD AND ACETABULUM ARISE FROM PRIMITIVE MESENCYMAL CELLS
• AT 7WEEK – CLEFT IN PRE-CARTILAGINOUS CELLS DEFINING THE FEMUR HEAD AND
ACETABULUM
• AT 11 WEEKS- HIP FULLY FORMED
• AT TERM – LEAST ACETABULAR COVERAGE OF THE HEAD
• POST-NATAL- LABRUM DEEPENS THE ACETABULUM
• AT AGE 1YR (DURING WALKING)- FEMUR HEAD FURTHER STIMULATES THE
DEVELOPMENT OF THE ACETABULUM

6. AETIOLOGY
• GENETIC THEORY
• FAMILY Hx
• PRIMARY ACETABULAR DYSPLASIA THEORY
• HORMONAL THEORY ( ESTROGEN, PROGEST., RELAXIN)…LIG LAXITY
• NEUROMUSCULAR THEORY e.g teratologic DDH
• MECHANICAL THEORY
• INTRA-UTERINE ( e.g breech – frank-20%; single footling-2%; packaging
disorders)
• POSTNATAL ( e.g backing position)

7. PATHOANATOMY
• PREDISPOSING FACTORS FOR HIP INSTABILITY( The “Fs”)
• HEAD GLIDES IN AND OUT OVER THE POSTEROSUPERIOR ACETABULAR RIM
• RIDGE forms on the hypertrophied acetabular cartilage( Neolimbus)
• LABRUM FLATTENED, EVERTED OR INVERTED (limbus)
• NON-CONCENTRIC ACETABULAR DEVELOPMENT SHALLOW & ANTEVERTED
• PERSISTENT DISLOCATION/ DIFFICULT RELOCATION

9. PATHOANATOMY
• STRETCHING OF THE JOINT CAPSULE LAX & REDUNDANT
• CAPSULE SQUEEZED BETWEEN THE EDGE OF ACETABULUM AND
ILIOPSOAS TENDON—hour glass appearance
• INTRA –ARTICULAR OBSTACLES
• FIBROFATTY TISSUE FILLING THE ACETABULAR CAVITY( Pulvinar)
• HYPERTROPHIED LIGAMENTUM TERES & TRANSVERSE ACETABULAR LIGAMENT
• ADAPTIVE SHORTENING OF PELVI-FEMORAL MUSCLES AND UPWARD
TRANSLATION OF THE PROXIMAL FEMUR->PSEUDOACETABULUM

11. CLASSIFICATION
• DYSPLASIA
• SUBLUXATABLE
• DISLOCATABLE
• DISLOCATED
• TERATOLOGIC DISLOCATION

12. CLINICAL FEATURES
• DEPENDS ON AGE AT PRESENTATION OR DIAGNOSIS
• Click during hip massage
• Difficulty with application of diapers
• Asymmetry groin skin creases
• Ortholani’s test-
• Barlow’s test
• Klisic test positive
• Limb discrepancy
• Limited abduction

13. Ortolani’s test
A, The examiner holds the infant's
knees and gently abducts the hip
while lifting up on the greater
trochanter with two fingers.
B, When the test is positive, the
dislocated femoral head will fall back
into the acetabulum (arrow) with a
palpable (but not audible) “clunk” as
the hip is abducted (Ortolani's sign).
When the hip is adducted, the
examiner will feel the head
redislocate posteriorly.

14. Barlow’s provocative test
A. Infant supine, the examiner holds
both of the child's knees and
gently adducts one hip and pushes
posteriorly.
B, When the examination is positive,
the examiner will feel the femoral
head make a small jump (arrow) out
of the acetabulum (Barlow's sign).
When the pressure is released, the
head is felt to slip back into place.

15. Klisic test
The examiner places the middle
finger over the greater trochanter,
and the index finger on the anterior
superior iliac spine.
A, With a normal hip, an imaginary
line drawn between the two fingers
points to the umbilicus.
B, When the hip is dislocated, the
trochanter is elevated and the line
projects halfway between the
umbilicus and the pubis.

16. Galeazzi's sign—apparent
shortening of the femur, as
shown by the difference in knee
levels as assessed in a child lying
on a firm table with the hips and
knees flexed at right angles.

17. Infant(sign)
Limitation of abduction, the
most reliable sign of a
dislocated hip, is best
appreciated by abducting
both hips simultaneously
with the child on a firm
surface.
A unilateral dislocation
produces a visible reduction
in abduction on the affected
side compared with the
normal side.

18. Wynne-Davies criteria for
ligamental laxity
.A. Flexion of the thumb to
touch the forearm.
B. Extension of the fingers
parallel to the forearm.
C.Hyperextension of the
elbow 15 degrees or more.
D. Hyperextension of the
knee 15 degrees.
E. Dorsiflexion of the ankle 60
degrees.

19. INVESTIGATIONS
• ULTRASONOGRAPHY
• RADIOGRAPHY
• MRI
• ARTHROGRAM
• CT-SCAN

20. ULTRASONOGRAPHY
• USES
• Screening
• Diagnosis
• Grading
• Monitoring progress of reduction during treatment
• Disadvantages
• Operator- dependent
• False positive

21. INVESTIGATIONS
• ULTRASONOGRAPHY
• directly visualizes the cartilaginous femoral head and surrounding soft-tissue
structures such as the labrum, capsule, ligamentum teres etc
• Screening recommended in “at risk” babies
• optimally performed when the infant is 4-6wks old
• Routine screening for all babies- expensive, risk of overtreatment and increase incidence
of AVN
• Two techniques: Static Graf method(emphasizes morphology)and Dynamic
Harcke technique(emphasizes stability of the femoral head)

22. Ultrasonography
The “baseline” is the line of the
ilium as it intersects the bony and
the cartilaginous portions of the
acetabulum.
The “inclination line” is the line
along the margin of the
cartilaginous acetabulum.
The third line is the “acetabular
roofline,” along the bony roof .
As the femoral head subluxates,
the alpha angle decreases and the
beta angle increases.

23. USS(Graf )classification system

24. RADIOGRAPHY
•USEFUL WHEN THE
FEMORAL EPIPHYSIS BEGINS
TO OSSIFY
•UNSTABLE HIP MAY APPEAR
NORMAL ON X-RAYS
•TO ASSESS ACETABULAR
DYSPLASIA & DISLOCATED
HIPS
CENTER-
EDGE ANGLE

25. X-ray findings in DDH
• Disruption of shenton line
• widened pelvic floor
• an absent teardrop figure
• Delayed appearance of the femoral ossific nucleus on the involved
side or dissimilar sizes of the ossific nuclei
• Ossific nucleus not located in the lower inner quadrant defined by the
Hilgenreiner and Perkins lines

26. Acetabular index &
medial gap
A measure of acetabular
dysplasia.
It averages 30 degrees in
normal newborns and
decreases with age.
Useful in when the head is
not yet ossified.

27. ASSESSING ACETABULAR DYSPLASIA
• Acetabular index (normally <30° at birth, 23° at 6 months and <20° by 2 years
of age)
• The acetabular index of the weight-bearing zone, or the sourcil angle
(of Tonnis) is normally <15°.
• horizontal line can be drawn from the inferior tip of the teardrop to
the lateral edge of the acetabulum to form the Sharp angle(normally
<40°)
• Center-edge angle of wilberg- useful after age 6yrs( anterior CEA
normally >15° @6-13yrs ,>20°@ 14yrs and > 25°in adult)

28. Wilberg’s center –edge
angle
It is a useful measure of hip
position in older children.
The angle is considered normal
if greater than 15 degrees in
children 6 to 13 years of age,
and it increases with age.

29. Severin classification

30. • MRI
• To identify cause of failed reduction such as intra-articular obstacles
• Evaluates the status of the femur head to rule out ischemic necrosis
• with gadolinium-contrast arthrography, an excellent tool for outlining
hip dysplasia

31. Kashiwagi et al MRI based classification of DDH
1. Group 1 hips: has a sharp acetabular rim, and all were reducible
with a Pavlik harness.
2. Group 2 hips: has a rounded acetabular rim, and almost all could
be reduced with a Pavlik harness.
3. Group 3 hips had an inverted acetabular rim, and none was
reducible with the harness.

32. TREATMENT
• Aims of treatment
• Achieve a concentric reduction.
• Maintain stability once concentric reduction is achieved.
• Promote normal growth and development of the hip.
• Minimize complications.

33. TREATMENT
• DEPENDS
• Age of the patient at diagnosis
• Degree of instability/ reducibility of the joint
• Technical know how
• Surgeon’s skills

34. Options of treatment
• Observation
• Splintage
• Closed reduction±arthrogram +Hip spica casting
• Open reduction+ Hip spica casting
• Osteotomies( acetabular, femoral or both)
• Salvage procedures
• Total hip replacement

35. Observation
• Hip instability( barlow test positive)
• Within 2-3weeks of birth ( controversial)- 80-90% resolves
spontaneously
• Re-examine weekly
• Make decision to splint

36. SPLINTAGE
• Flexion-Abduction orthosis
• Rigid( Craig’, Von Rosen splints) versus Dynamic ( Pavlik harness)
• Indicated in unstable hips btw birth-6months
• 3 Golden rules of splintage- reduction first, avoid extreme positions
and hips should be able to move.
• Monitor with Ultrasonography regularly
• Follow-up continues until child is walking

37. Rigid splints
Von-Rosen Splint Craig’s Splint

38. PAVLIK HARNESS
• Age< 6months
• Indicated in Barlow & Ortholani
positive hips
• Position- flexion of 90-120 degree,
some abduction and at full
adduction, there is a distance of 3-
5cm btw knees
• Treatment failure is predicted for
children older than 7 weeks,
bilateral hip dislocation and failure
of reduction (negative Ortolani
test)

39. CONTRA-INDICATIONS TO PAVLIK HARNESS
• Major muscle imbalance, such as myelomeningocele
• Major stiffness as in arthrogryposis
• Ligamentous laxity( as in Ehlers–Danlos syndrome)
• Severe respiratory compromise (a Craig splint may be useful in this
instance)
• Irreducible hip
• Age >6 months.

40. CARE&MONITORING UNDER PAVLIK HARNESS
• Frequent monitoring( initially weekly for 4weeks, then 2-4wkly for
12weeks and not more than 20weeks )
• Hygiene and care of pressure areas
• Clinically & with dynamic Ultrasound±MRI/radiography
• Discontinue after 4weeks of harness, if reduction is uncertain or hip
persistently dislocated
• Follow-up until skeletal maturity

41. COMPLICATIONS OF PAVLIK HARNESS
• Failure of reduction
• Damage to the posterior acetabular wall when there is a persistent
posterior dislocation( Pavlik harness disease)
• Avascular necrosis of the head of the femur 2.4%(range, 0–15%)
• Femoral nerve palsy
• Skin damage from pressure sore
• Brachial plexus injury
• Knee dislocation

42. CLOSED REDUCTION &HIP SPICA CASTING
• Indicated in patients above 6month- 18months
• Preliminary period of traction before closed reduction(controversial)
• Reduction done under anesthesia & C-ARM guidance
• Usually hip arthrogram is done( medial dye pool <7mm signifies
concentric reduction)
• ± adductor/iliopsoas tenotomy

43. CLOSED REDUCTION &HIP SPICA CASTING
• Hip spica casting after successful reduction is confirmed
• Position of the limb in spica cast- flexion-60; abduction-40, IR-20°(
safe zone of ramsey)
• Unsuccessful reduction-> Open reduction plus kwire plus hip spica
casting @ age 1yr
• Spica duration- until hip is stable, usually 6weeks -12weeks;
converted to splints(for 6months)

44. OPEN REDUCTION
• Done for persistent hip dislocation @ age 18months-4years
• or failed closed reduction ( usually delayed to age 1yr)
• Although, timing is controversial ( early versus delayed open reduction)
• Arthrogram very vital
• Approach- anterior( Smith- pertenson with a modified bikini incision) &
medial( Iowa, ludloff, fergusson)
• Procedure - removal of intra-articular obstacles, medial STR, hip reduction±
Osteotomies @ same sitting
• Splintage- Hip spica cast in 30-30-30 FABIR position for 6weeks-3months
• Follow-up until maturity

45. OSTEOTOMIES
• For persistent dislocation beyond 4years
• Limited internal rotation during open reduction esp >2yrs of age (DRVO
helps reduce hip pressure and achieve concentric reduction as well)
• types: femoral( VDRO), Pelvic( salter, pemberton, Dega) or both

46. FEMORAL OSTEOTOMY( shortening, varus,
derotation or combination)
• shortening osteotomy - to achieve reduction or reduce pressure in
the hip after a forceful reduction
• If the joint remains stable only in wide abduction, a varus osteotomy
is indicated.
• If there is excessive femoral anteversion and the reduction requires
significant internal rotation to be stable, then a derotation osteotomy
is needed.
• Ensure concentric reduction of femur head in 30 deg abduction and
max internal rotation before VDRO
• Intertrochanteric or subtrochanteric location

47. Open reduction, femoral shortening & derotation
osteotomy

48. PELVIC OSTEOTOMIES
• Re-directional- Salter innominate,Sutherland, Steel, Ganz
• Re-shaping- Dega, pemberton
• Salvage- Chiari, Shelf

49. SALTER’s OSTEOTOMY
• Redirects the acetabulum forward, producing more anterior and
lateral cover
• Osteotomy is hinged on the pubic symphysis
• useful in mild and moderate dysplasia but it may be harmful in
neuromuscular dysplasia, in which the posterior wall is usually
deficient.
• Indicated in acetabular dysplasia that persists after primary treatment
or discovered in an untreated child, failure of AI to improve after age
5years.

50. Single pelvic osteotomies
Salter innominate Osteotomy • More likely to succeed when CE
> 10deg
• provides about 15 degrees of
lateral coverage and 25 degrees
of anterior coverage
• improving the AI and CEA by
about 15° at the expense of
posterior cover.

51. GANZ OSTEOTOMY
• can be performed through a single anterior incision through an
abductor sparing approach, as against double incision in Steel
osteotomy
• Achieves good correction without breaking the posterior column
• does not affect the birth canal, which is an extra advantage in young
women
• However, contraindicated if the tri-radiate cartilage is still open (as it
interferes with the growth of the acetabulum)

52. GANZ –Periacetabular osteotomy, a
form of Triple osteotomy Steel- Triple osteotomy

53. DEGA OSTEOTOMY
• Re-shaping osteotomy
• provides lateral and posterior
cover, which is useful in
neuromuscular dysplasia
• semicircular cut through the lateral wall
of the ilium directed toward but not
through the medial cortex of the ilium

54. PEMBERTON
• Re-shaping osteotomy
• A low- volume pelvic osteotomy
• is ideal for bilateral or severe dysplasia in children under 6 years
• iliac osteotomy directed towards and hinged on tri-radiate cartilage(
hence, it must be open)
• Will only allow translation and not rotation of the acetabulum
• More stable and may not require hardware fixation
• Possible complications- damage to acetabular growth area,
premature closure of tri-radiate cartilage.

55. Pemberton

56. SALVAGE procedures
• Lateral Shelf
• Chiari
• Valgarization osteotomy
• Pelvic support osteotomy- schanz, lorenz

57. COMPLICATIONS OF DDH
• Persistent dislocation
• AVN femoral head( Kalamchi & MacEwen classification)
• Nerve palsies
• General surgical complications
• Complications specific to treatments

58. WEST AFRICAN PERSPECTIVES
• Paucity of expertise
• Late presentation of patients
• Late diagnosis by clinicians
• Rarity of condition in Africa
• Paucity/ scarcity of harness, splints, braces.
• Poverty

59. CONCLUSION
• Developmental hip condition with varying presentation
• Early diagnosis and Prompt attention to achieve successful outcome
• Main aim is concentric femoral head placement and continued
acetabular development
• Treatment varies from splints, closed or open reduction with or
without osteotomies around the hip
• Hip salvage may be the only option in some severe cases
• Arthroplasty in residual acetabular dysplasia in adult patients