developemental dysplasia of hip

DevelopmentalDevelopmental
Dysplasia of the HipDysplasia of the Hip
Dr.HARDIK S PAWARDr.HARDIK S PAWAR
DEPARTMENT OF ORTHOPAEDICSDEPARTMENT OF ORTHOPAEDICS
CARE HOSPITALSCARE HOSPITALS

OverviewOverview
 IntroductionIntroduction
 Normal Development of the HipNormal Development of the Hip
 Etiology and PathoanatomyEtiology and Pathoanatomy
 Epidemiology and DiagnosisEpidemiology and Diagnosis
 TreatmentTreatment
 ComplicationsComplications

IntroductionIntroduction
 Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip
 Intracapsular displacementIntracapsular displacement
 SubluxationSubluxation
 Dislocation-usually posterosuperior (reducibleDislocation-usually posterosuperior (reducible
vs irreducible)vs irreducible)
 DysplasiaDysplasia
 Before, during or just after birthBefore, during or just after birth

HISTORYHISTORY
 Chapple and davidson – 1941Chapple and davidson – 1941
 Muller and seddon – 1953Muller and seddon – 1953
 AR hodgson - 1959AR hodgson - 1959
 Wilkinson - 1963Wilkinson - 1963

EPIDEMIOLOGYEPIDEMIOLOGY
 1/1,000 born with dislocated hip1/1,000 born with dislocated hip
 10/10,000 born with subluxation or dysplasia10/10,000 born with subluxation or dysplasia
 5:1 Female:Male child5:1 Female:Male child
 Left 60% (left occiput ant), Right 20%, both 20%Left 60% (left occiput ant), Right 20%, both 20%
 Risk FactorsRisk Factors
 Family history (6% one affected child, 12% oneFamily history (6% one affected child, 12% one
affected parent, 36% one child + one parent)affected parent, 36% one child + one parent)
 OligohydramniosOligohydramnios
 Breech (sustained hamstring forces)Breech (sustained hamstring forces)
 Native Americans (swaddling cultures)Native Americans (swaddling cultures)
 Torticollis or LE deformityTorticollis or LE deformity

Normal DevelopmentNormal Development
 EmbryonicEmbryonic
 7-87-8thth
th week - acetabulum and head formedth week - acetabulum and head formed
from same primitive mesenchymal cellsfrom same primitive mesenchymal cells
 11th week - complete devlopement of hip11th week - complete devlopement of hip
 Prox fem ossific nucleus - 4-7 monthsProx fem ossific nucleus - 4-7 months
 Hip at risk of dislocation at 4 period :Hip at risk of dislocation at 4 period :
at 12at 12thth
weekweek
at 18at 18thth
weekweek
final 4 weeksfinal 4 weeks
post natal periodpost natal period

GARDES OF DDHGARDES OF DDH
Grade 1 : subluxtable hip
Grade 2 : dislocatable
Grade 3 : severe

PathologyPathology
 Ranges from mild dysplasia --> frankRanges from mild dysplasia --> frank
dislocationdislocation
 Bony changes soft tissue chagesBony changes soft tissue chages
 Acetabulum capsuleAcetabulum capsule
 Head musclesHead muscles
 Femoral NeckFemoral Neck
 PelvisPelvis

PathoanatomyPathoanatomy
 Soft tissue changesSoft tissue changes
 Usually secondary to prolonged subluxation orUsually secondary to prolonged subluxation or
dislocationdislocation
 IntraarticularIntraarticular
 LabrumLabrum
 Inverted + adherent to capsule (closed reduction withInverted + adherent to capsule (closed reduction with
inverted labruminverted labrum assoc with increased Avascular Necrosis)assoc with increased Avascular Necrosis)
 Ligamentum teresLigamentum teres
 Hypertrophied + lengthenedHypertrophied + lengthened
 PulvinarPulvinar
 Fibrofatty tissue migrating into acetabulumFibrofatty tissue migrating into acetabulum

PathoanatomyPathoanatomy
 Soft Tissue (Intraarticular)Soft Tissue (Intraarticular)
 Transverse acetabular ligamentTransverse acetabular ligament
 ContractedContracted
 LimbusLimbus
 Fibrous tissue formed from capsular tissueFibrous tissue formed from capsular tissue
interposed between everted labrum and acetabularinterposed between everted labrum and acetabular
rimrim
 ExtraarticularExtraarticular
 Tight adductors (adductor longus)Tight adductors (adductor longus)
 IliopsoasIliopsoas

Tough Reductions…Tough Reductions…
 Obstacles to reductionObstacles to reduction
 ExtraarticularExtraarticular
 Tight iliopsoas andTight iliopsoas and
adductorsadductors
 IntraarticularIntraarticular
 LabrumLabrum
 Ligamentum teresLigamentum teres
 Transverse acetabularTransverse acetabular
ligamentligament
 PulvinarPulvinar
 Redundant capsuleRedundant capsule
(hourglass)(hourglass)
 +/- limbus+/- limbus

Etiology and EpidemiologyEtiology and Epidemiology
 MultifactorialMultifactorial
 Genetics and SyndromesGenetics and Syndromes
 Ehler’s DanlosEhler’s Danlos
 ArthrogryposisArthrogryposis
 Larsen’s syndromeLarsen’s syndrome
 Intrauterine environmental factorsIntrauterine environmental factors
 TeratogensTeratogens
 Positioning (oligohydramnios)Positioning (oligohydramnios)
 Neurologic DisordersNeurologic Disorders
 Spina Bifida ,CP , polio , myelomonigoceleSpina Bifida ,CP , polio , myelomonigocele

DiagnosisDiagnosis
 Newborn screeningNewborn screening
 Ortolani’s and Barlow’s maneuvers with aOrtolani’s and Barlow’s maneuvers with a
thorough history and physicalthorough history and physical
 Warm, quiet environment with removal ofWarm, quiet environment with removal of
diaperdiaper
 Head to toe exam to detect any associatedHead to toe exam to detect any associated
conditons (Torticollis, Ligamentous Laxityconditons (Torticollis, Ligamentous Laxity
etc.)etc.)
 Baseline Neuro and Spine ExamBaseline Neuro and Spine Exam

DiagnosisDiagnosis
 Key physical findingsKey physical findings
 AsymmetryAsymmetry
 Limb length- GaleazziLimb length- Galeazzi
 Telsescopic testTelsescopic test
 Limited AbductionLimited Abduction
 Skin foldsSkin folds
 LimpLimp
 TrendelenbergTrendelenberg
 Waddilng gait /Waddilng gait /
hyperlordosis - bilateralhyperlordosis - bilateral
involvementinvolvement
 Vascular sign of narathVascular sign of narath

Clinical Features : NeonatesClinical Features : Neonates
Delicate “clunk” thatDelicate “clunk” that
is palpable but notis palpable but not
audibleaudible
Repeat sequence 4-5Repeat sequence 4-5
times to be certain oftimes to be certain of
findingsfindings
If both signs negativeIf both signs negative
but pt is high risk :but pt is high risk :
follow up is essentialfollow up is essential

Clinical features : InfantsClinical features : Infants
Progression fromProgression from
instability to dislocationinstability to dislocation
is gradual processis gradual process
In some within a fewIn some within a few
weeksweeks
others the hipothers the hip
dislocation remainsdislocation remains
reducible up to 5 or 6reducible up to 5 or 6
months of age.months of age.
When the hip no longerWhen the hip no longer
reducible, specificreducible, specific
physical findingsphysical findings
appearappear

Limitation of AbductionLimitation of Abduction
MOST RELIABLE SIGNMOST RELIABLE SIGN

Galeazzi’s SignGaleazzi’s Sign

Asymmetric gluteal, thigh, labialAsymmetric gluteal, thigh, labial
foldsfolds

Klisic’s TestKlisic’s Test

Walking child:Walking child:
LLDLLD
↓↓AbductionAbduction
Tip-toe-walkingTip-toe-walking
Trendelenberg gaitTrendelenberg gait
Waddling [B/L]Waddling [B/L]
↑↑lumbar lordosislumbar lordosis

Clinical Features : WalkingClinical Features : Walking
ChildChild
 Trendelenburg's signTrendelenburg's sign
 Trendelenburg gaitTrendelenburg gait

BARLOW’S TEST (BARLOW’S TEST ( bahar lobahar lo))

ORTOLANI SIGNORTOLANI SIGN

Ortolani’s ManeuverOrtolani’s Maneuver

Barlow’s ManeuverBarlow’s Maneuver

DiagnosisDiagnosis
 Some cases still missedSome cases still missed
 At risk groups should be further screenedAt risk groups should be further screened
 AAPAAP
 Recs further imaging (e.g. US) if exam isRecs further imaging (e.g. US) if exam is
“inconclusive” AND“inconclusive” AND
 First degree relative + femaleFirst degree relative + female
 BreechBreech
 Positive provocative maneuver (Ortolani or Barlow)Positive provocative maneuver (Ortolani or Barlow)
 Referral to OrthopaedistReferral to Orthopaedist

ImagingImaging
 X-raysX-rays
 Femoral head ossification centerFemoral head ossification center
 4 -7 months4 -7 months
 UltrasoundUltrasound
 Operator dependentOperator dependent
 CTCT
 MRIMRI
 ArthrogramsArthrograms
 Open vs closed reductionOpen vs closed reduction

ImagingImaging
 RadiographsRadiographs

ImagingImaging
 Acetabular IndexAcetabular Index

ImagingImaging
 Acetabular IndexAcetabular Index
< 30° wnl

RadiographsRadiographs
Newborns 27.5 degrees
6 months 23.5 degrees
2 years 20 degrees

Centre – Edge Angle WibergCentre – Edge Angle Wiberg
6 – 13 years >19
degrees
>14 years > 25
degrees

ANDREN-von ROSENANDREN-von ROSEN
LINELINE
AP X-ray: hip in 45AP X-ray: hip in 45°abduction and IR°abduction and IR
Describes the longitudinal relationship betweenDescribes the longitudinal relationship between
long axis of femur and acetabulumlong axis of femur and acetabulum

Tear dropTear drop
AP X-rayAP X-ray
Lateral:wall ofLateral:wall of
acetabulumacetabulum
Medial:lesser pelvisMedial:lesser pelvis
Inferior :acetabularInferior :acetabular
notchnotch
Appears between 6-23Appears between 6-23
momo
[delayed in DDH][delayed in DDH]

Radiographs SummaryRadiographs Summary
 Femoral head appears 4 - 7 monthsFemoral head appears 4 - 7 months
 Shenton’s lineShenton’s line
 Perkin’s and Hilgenreiner’s linesPerkin’s and Hilgenreiner’s lines
 Inferomedial quadrantInferomedial quadrant
 Center Edge Angle (< 20 abnormal)Center Edge Angle (< 20 abnormal)
 Acetabular indexAcetabular index
 Normal < 30 (Weintroub et al)Normal < 30 (Weintroub et al)
 Tear drop*Tear drop*
 Abnormal widening in DDHAbnormal widening in DDH
*may be only sign in mild subluxation*may be only sign in mild subluxation

ImagingImaging
 UltrasoundUltrasound
 Introduced in 1978 for eval of DDHIntroduced in 1978 for eval of DDH
 Operator dependentOperator dependent
 Useful in confirming subluxation, identifyingUseful in confirming subluxation, identifying
dysplasia of cartilaginous acetabulum,dysplasia of cartilaginous acetabulum,
documenting reducibilitydocumenting reducibility
 Prox Femoral Ossification Center interferesProx Femoral Ossification Center interferes
 Requires a window in spica cast (avoid)Requires a window in spica cast (avoid)

UltrasoundUltrasound
Femoral head
Abductors
Ilium

Graf’s alpha
angle

Graf’s alpha
angle
>60° = normal
*line w/ ilium
bisects head 50/50

UltrasonographyUltrasonography
 lpha angle measures bony acetabuluBetalpha angle measures bony acetabuluBeta
angle measures cartilagenous acetabulumangle measures cartilagenous acetabulum

UltrasonographyUltrasonography
 Harcke & Kumar technique:Harcke & Kumar technique:
 Dynamic examination with stress views thatDynamic examination with stress views that
mirror Barlow’s & Ortolani’s maneuvermirror Barlow’s & Ortolani’s maneuver
Graf classification

ArthrogramArthrogram
Severin [1941]Severin [1941]
Normal appearance:Normal appearance:
LABRUM:LABRUM:
*Thorn over the*Thorn over the
femoral headfemoral head
*A recess of joint*A recess of joint
capsule overlies thecapsule overlies the
thornthorn

Arthrogram in DDHArthrogram in DDH
SUBLUXATED HIP DISLOCATED HIP

Imaging ToolsImaging Tools
 CT scan:CT scan:
 Single section CT as check filmsSingle section CT as check films
 Neglected C.D.H.Neglected C.D.H.
 Adolescent and adultAdolescent and adult
 MRI:MRI:
 Equivalent to arthrographyEquivalent to arthrography

Natural HistoryNatural History
 NewbornNewborn VariableVariable
 > 6 months> 6 months more aggressive tx requiredmore aggressive tx required
due to more extensive pathology anddue to more extensive pathology and
decreased potential for acetabulardecreased potential for acetabular
remodelingremodeling
 Abnormal Gait, Decreased Abduction andAbnormal Gait, Decreased Abduction and
Strength, Increased DJDStrength, Increased DJD
 Unilateral worse than BilateralUnilateral worse than Bilateral
 Subluxation worse than DysplasiaSubluxation worse than Dysplasia

Treatment OptionsTreatment Options
 Age of patient at presentationAge of patient at presentation
 Family factorsFamily factors
 Reducibility of hipReducibility of hip
 Stability after reductionStability after reduction
 Amount of acetabular dysplasiaAmount of acetabular dysplasia

Birth to Six MonthsBirth to Six Months
 Triple-diaper techniqueTriple-diaper technique
 Prevents hip adductionPrevents hip adduction
 ““Success” no different in someSuccess” no different in some
untreated hipsuntreated hips
 Pavilk harness (1944)Pavilk harness (1944)
 Experienced staff*Experienced staff*
 Very successfulVery successful
 Allows free movement withinAllows free movement within
confines of restraintsconfines of restraints
*posterior straps for preventing add. NOT producing abd.

Birth to Six MonthsBirth to Six Months
 Pavlik harnessPavlik harness
 IndicationsIndications
 Fully reducible hip*Fully reducible hip*
 Child not attempting to standChild not attempting to stand
 FamilyFamily
• Close regular follow-up (every 1-2 weeks)Close regular follow-up (every 1-2 weeks)
• For imaging and adjustmentsFor imaging and adjustments
• DurationDuration
• Childs age at hip stability + 3 monthsChilds age at hip stability + 3 months

Pavlik HarnessPavlik Harness
 FailuresFailures
 Poor parent compliancePoor parent compliance
 Improper use by the physicianImproper use by the physician
 Inadequate initial reductionInadequate initial reduction
 Failure to recognize persistent dislocationFailure to recognize persistent dislocation
 Viere et al 1990Viere et al 1990
 Bilateral dislocationBilateral dislocation
 Absent Ortolani’s signAbsent Ortolani’s sign
 > 7weeks of age> 7weeks of age

Pavlik HarnessPavlik Harness
 ComplicationsComplications
 Avascular necrosisAvascular necrosis
 Forced hip abductionForced hip abduction
 Safe zone (abd/adduction and flexion/extension)Safe zone (abd/adduction and flexion/extension)
 Femoral nerve palsyFemoral nerve palsy
 HyperflexionHyperflexion
*Be aware of Pavlik Harness Disease*Be aware of Pavlik Harness Disease
*Follow until skeletal maturity*Follow until skeletal maturity

Birth - Six monthsBirth - Six months
 Closed reduction + SpicaClosed reduction + Spica
 Failure after 3 weeks of Pavlik trialFailure after 3 weeks of Pavlik trial

Birth - Six monthsBirth - Six months
 Closed reductionClosed reduction
 General anesthesiaGeneral anesthesia
 ArthrogramArthrogram
 Safe zone - avoid AVNSafe zone - avoid AVN
 +/- adductor tenotomy+/- adductor tenotomy
 Open reduction if concentric reduction notOpen reduction if concentric reduction not
possiblepossible
 Usually teratogenic hips in this age groupUsually teratogenic hips in this age group

Open reductionOpen reduction
Unable to achieveUnable to achieve
closed reductionclosed reduction
Widening of the jointWidening of the joint
spacespace
Unstable reductionsUnstable reductions
Loss of reduction onLoss of reduction on
follow upfollow up
Advanced ageAdvanced age

Open ReductionOpen Reduction
 Medial approachMedial approach
 Pectineus / adductor longus + brevisPectineus / adductor longus + brevis
 Cannot address simeoultaneous bony workCannot address simeoultaneous bony work
 Antero -lateralAntero -lateral
 Smith-petersonSmith-peterson
 Sartorius / Tensor Fascia lataSartorius / Tensor Fascia lata

ApproachApproach
MedialMedial
Minimal dissectionMinimal dissection
ObstructionsObstructions
encountered directlyencountered directly
BUT..BUT..
Limited viewLimited view
MFCA violationMFCA violation
No capsulorrhaphyNo capsulorrhaphy
Secondary proceduresSecondary procedures
AnterolateralAnterolateral
Better exposureBetter exposure
CapsulorrhaphyCapsulorrhaphy
Pelvic osteotomyPelvic osteotomy
possiblepossible
BUT..BUT..
Blood lossBlood loss
Iliac crest apophysisIliac crest apophysis
and abductors damageand abductors damage
Stiffness of hipStiffness of hip

Open Reduction with FemoralOpen Reduction with Femoral
derotation osteotomyderotation osteotomy
 Pressure leads to risk of AVNPressure leads to risk of AVN
 Better results than preoperative traction in olderBetter results than preoperative traction in older
children with less morbiditychildren with less morbidity
When to do??When to do??
 Anticipated increased pressure on reduced femurAnticipated increased pressure on reduced femur
headhead
 Recommended in child > 2yrs.Recommended in child > 2yrs.
 distract the joint few millimeter per operativelydistract the joint few millimeter per operatively
 Judge the tightness of soft tissues after reductionJudge the tightness of soft tissues after reduction
 irreducible dislocationirreducible dislocation

Derotational femoral shorteningDerotational femoral shortening
osteotomyosteotomy

2 Years of Age and Older2 Years of Age and Older
 For child 2 -3 years of age, during openFor child 2 -3 years of age, during open
reduction acetabular coverage ifreduction acetabular coverage if
insufficient warrants reorientationinsufficient warrants reorientation
osteotomyosteotomy
 If coxa valga with excessive anteversion,If coxa valga with excessive anteversion,
VDRO may be done.VDRO may be done.
 Children > 3 years usually need anChildren > 3 years usually need an
osteotomyosteotomy

Bilateral untreated dislocation upto 5Bilateral untreated dislocation upto 5
years:years:
Open reduction with femoral shorteningOpen reduction with femoral shortening
with salter / pemberton osteotomy withwith salter / pemberton osteotomy with
gap of 5-6 weeks.gap of 5-6 weeks.
Bilateral untreated subluxation upto 5-6Bilateral untreated subluxation upto 5-6
years:years:
Open reduction + salter osteotomy.Open reduction + salter osteotomy.

6 months - 4 years6 months - 4 years
 Present a more difficult problemPresent a more difficult problem
 Prolonged dislocationProlonged dislocation
 Contracted soft tissuesContracted soft tissues
 6 - 18 months6 - 18 months
 Closed reduction +/- adductor tenotomyClosed reduction +/- adductor tenotomy
 Spica in human position of 100 degrees of flexion andSpica in human position of 100 degrees of flexion and
about 55 degrees abduction (3 months)about 55 degrees abduction (3 months)
 Abduction Orthosis 4 wks full time/4 wks nighttimeAbduction Orthosis 4 wks full time/4 wks nighttime
 Open reduction (if closed fails)Open reduction (if closed fails)
 CapsulorraphyCapsulorraphy
 CT scanCT scan
 Spica for 6 wks followed by PTSpica for 6 wks followed by PT

6 months - 4 years6 months - 4 years
 18 months - 4 years18 months - 4 years
 Closed reductionClosed reduction
 Reducibile - check arthrogram andReducibile - check arthrogram and medial dye poolmedial dye pool
 Irreducible - Open reductionIrreducible - Open reduction
 Open redcutionOpen redcution
 Tight - femoral shorteningTight - femoral shortening
 Stable - +/- pelvic osteotomyStable - +/- pelvic osteotomy

Femoral osteotomyFemoral osteotomy
 Schoenecker + Strecker 1984Schoenecker + Strecker 1984
 Traction vs. Femoral shorteningTraction vs. Femoral shortening
 56% AVN in traction group56% AVN in traction group
 0% AVN in femoral shortening0% AVN in femoral shortening

Residual DysplasiaResidual Dysplasia

Pelvic OsteotomyPelvic Osteotomy
 Persistent instability + dysplasia afterPersistent instability + dysplasia after
open reduction + femoral shorteningopen reduction + femoral shortening
 Requires concentric reduction of aRequires concentric reduction of a
reasonably spherical femoral headreasonably spherical femoral head

Salter OsteotomySalter Osteotomy

Acetabular Reorientation-Acetabular Reorientation-
Innominate OsteotomyInnominate Osteotomy
 Articular hyaline cartilage over femur headArticular hyaline cartilage over femur head
 Types:Types:
 SSalter’salter’s (innominate)(innominate)
 SSutherland’s (double innominate)utherland’s (double innominate)

Salter’s OsteotomySalter’s Osteotomy
Redirects the entire acetabulumRedirects the entire acetabulum
Roof “covers” the femoral head anteriorlyRoof “covers” the femoral head anteriorly
and superiorlyand superiorly
Hinge at pubic symphysisHinge at pubic symphysis
Pre-requisitesPre-requisites
Congrous Concentric reductionCongrous Concentric reduction
No ContracturesNo Contractures

K. E. 21 - 12 - 1999
Salter & femoral osteotomySalter & femoral osteotomy

Sutherland’s OsteotomySutherland’s Osteotomy
1. Can be done for older
child
2. Allows medial
displacement

Peri-acetabular OstetomiesPeri-acetabular Ostetomies
 Provide greater correction of acetabular indexProvide greater correction of acetabular index
 Reduce volume of hip jointReduce volume of hip joint
 Possibility of growth disturbancesPossibility of growth disturbances
TypesTypes
 PPemberton’semberton’s
 DDial (Eppright)ial (Eppright)
 WWagneragner
 DDega’sega’s
 GGanz osteotomy (Bernese)anz osteotomy (Bernese)

Pemberton’s OsteotomyPemberton’s Osteotomy

Pemberton’s OsteotomyPemberton’s Osteotomy
•Volume changing
•Hinges on triradiate
•Requires remodeling of
“new” incongruity
•Provides more anterolatera
coverage

Dega’s OsteotomyDega’s Osteotomy
1. Incomplete
2. Variable hinge
3. Allows anterio
lateral & poste
coverage

Ganz OsteotomyGanz Osteotomy
Larger corrections all dire
Blood supply preserved
Shape of true pelvis unalt
Technically demanding

Triple OsteotomiesTriple Osteotomies
Indication :Indication :
Adolescent requiring more than 25°Adolescent requiring more than 25°
correctioncorrection
Pre-requisite:Pre-requisite:
Functional range of motionFunctional range of motion
only mild subluxation acceptableonly mild subluxation acceptable
Types:Types:
 Steel (Inferior)Steel (Inferior)
 Tonnis (Posterior)Tonnis (Posterior)
 Tachdjian - subinguinal adductorTachdjian - subinguinal adductor

Triple OsteotomiesTriple Osteotomies
STEEL TONNIS TACHDJIAN’S

Salvage or Shelf proceduresSalvage or Shelf procedures
 ChiariChiari
 Requires capsular metaplasiaRequires capsular metaplasia
 Pain - main indicationPain - main indication
 Treatment of chronic hip pain in adolescentsTreatment of chronic hip pain in adolescents

Chiari OsteotomyChiari Osteotomy

Chiari osteotomyChiari osteotomy

Shelf ProcedureShelf Procedure

Adolescent and young adult(olderAdolescent and young adult(older
then 8-10 yearsthen 8-10 years
If femoral head cannot be repositionedIf femoral head cannot be repositioned
distally to the level of acetabulum :distally to the level of acetabulum :
Salvage proceduresSalvage procedures
Degenertive arthritis and enough pain andDegenertive arthritis and enough pain and
limitation of movements – reconstructivelimitation of movements – reconstructive
operation (total hip replacement)operation (total hip replacement)
Arthodesis – rarely done, contraindiactedArthodesis – rarely done, contraindiacted
for bilateral dislocationfor bilateral dislocation

Schanz
osteotomy
Very late
salvage

Radical salvageRadical salvage
 FusionFusion
 ReplacementReplacement
 ExcisionExcision

Hip arthrodesisHip arthrodesis
Consider forConsider for::
i. Young malei. Young male
ii. Unilateralii. Unilateral
iii. Infectioniii. Infection

Joint replacementJoint replacement
Consider for:Consider for:
 Severe arthritisSevere arthritis
 Failed “Failed “
conservative”conservative”
Rx.Rx.
 BilateralBilateral
diseasedisease

Severe arthritisSevere arthritis
DDHDDH
AVNAVN
OAOA

THR outcomes in DDHTHR outcomes in DDH
Charnley cemented hips:Charnley cemented hips:
5 of 38 loose at 11 years5 of 38 loose at 11 years
Bobak, Wroblewski et al 2000Bobak, Wroblewski et al 2000
Harris uncemented hips:Harris uncemented hips:
20% loose at 7 years20% loose at 7 years
46% loose at 12 years46% loose at 12 years
Jasty, Anderson, Harris, 1999Jasty, Anderson, Harris, 1999

Avascular NecrosisAvascular Necrosis
 Most commonMost common
 Not part of the natural history of DDHNot part of the natural history of DDH
 IatrogenicIatrogenic
 Etiology unknownEtiology unknown
 Femoral head compressionFemoral head compression
 Injury to blood supplyInjury to blood supply
 Excessive abductionExcessive abduction
 Sullivan et al 1997Sullivan et al 1997
 SigSig ↓↓ blood flow w/ increasing abd angleblood flow w/ increasing abd angle

TX SummaryTX Summary
 Best if treated before 6 weeks of ageBest if treated before 6 weeks of age
 0 - 6 months of age0 - 6 months of age
 PavlikPavlik
 Closed vs open reduction and spicaClosed vs open reduction and spica
 ClosedClosed
 Open +/- osteotomiesOpen +/- osteotomies

SummarySummary
 Femoral shortening better than tractionFemoral shortening better than traction
 Pelvic osteotomiesPelvic osteotomies
 Dega, PembertonDega, Pemberton
 Salter, triple innominate, GanzSalter, triple innominate, Ganz
 ChiariChiari

developemental dysplasia of hip

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