Developmental Dysplasia of the Hip (DDH) involves abnormal relationships between the femoral head and acetabulum, manifesting in conditions like dislocation and instability. The document discusses developmental etiology, diagnosis via physical exams and imaging, and treatment options, including harnessing and surgical methods. It emphasizes the importance of early intervention and the strategies for management based on the age of the patient and severity of the condition.

2. DDH
By Mostafa Raslan

3. Overview
Introduction
Normal Development of the Hip
Etiology and Pathoanatomy
Epidemiology and Diagnosis
Treatment
Complications

4. *Adolph Lorenz, an early
pioneer in the treatment of
developmental dislocation of
the hip
*FATHER of AVN

5. Introduction
Developmental dysplasia of the hip is the
condition in which the femoral head has an
abnormal relationship to the acetabulum.
Developmental dysplasia of the hip includes
frank dislocation (luxation), partial
dislocation (subluxation), instability
wherein the femoral head comes in and out
of the socket, and inadequate formation of
the acetabulum.

6. Distinct form of hip dislocation that usually occurs
with other disorders
DDX
Dislocated before birth,
have limited range of motion,
not reducible on examination.
Associated with other neuromuscular syndromes,
as myelodysplasia and arthrogryposis
Teratologic dislocation of the hip:

7. Multifactorial
Genetics and Syndromes
○ Ehler’s Danlos
○ Arthrogryposis
○ Larsen’s syndrome
Intrauterine environmental factors
○ Teratogens
○ Oligohydramnios)
○ breech
Neurologic Disorders: Spina Bifida
ligamentous laxity
Etiology and Epidemiology

8. BREECH presentation

9. *Postnatal positioning in extension, as in this
child on a Native American cradleboard, contributes
to developmental dysplasia of the hip

10. Embryologically the acetabulum, femoral
head develop from the same primitive
mesenchymal cells
cleft develops in precartilaginous cells at 7th
week and this defines both structures
11wk hip joint fully formed
Normal Growth and Development

11. •acetabular growth continues throughout
intrauterine life with development of
Labrum
•By birth femoral head is deeply seated
in acetabulum by surface tension of
synovial fluid and very difficult to
Dislocate
•in DDH this shape and tension is
abnormal in addition to capsular laxity

12. DDH
* Tight fit between head and acetabulum is absent
and head can glide in and out of acetabulum
* hypertrophied ridge of acetabular cartilage in
superior, posterior and inferior aspects of
acetabulum called “ neolimbus”
* 98% DDH that occur around or at birth have these
changes and are reversible in the newborn
* 2% newborns with teratologic or antenatal
dislocations and no syndrome have these changes

13. Development in treated DDH
different from normal hip
goal is to reduce the femoral head to provide the
stimulus for acetabular development
Concentric reduction maintainance is essential for
recovery and resumption of normal growth
age at which DDH hip can still return to normal is
controversial and depends on
age at reduction
growth potential of acetabulum
damage to acetabulum from head or during
reduction

14. Epidemiology
1 in 100 newborns examined have evidence
of instability ( positive Barlow or Ortolani)
1 in 1000 live births true dislocation
Barlow stated that 60% stabilize in 1st week
and 88% stabilize in first 2 months without
treatment remaining 12% true dislocations
and persist without treatment

15. Incidence
-1 in 1000 live birth.
-male to female ratio 4:1
-family history 1:7

16. Pathoanatomy
Ranges from mild dysplasia --> frank
dislocation
Bony changes
Shallow acetabulum
Typically on acetabular side
Femoral anteversion

17. Soft tissue changes
Usually secondary to prolonged subluxation or
dislocation
Intra articular
Labrum Inverted + adherent to capsule (closed
reduction with inverted labrum assoc with increased
Avascular Necrosis)
Ligamentum teres Hypertrophied + lengthened
Pulvinar Fibrofatty tissue migrating into
acetabulum

18. Transverse acetabular ligament Contracted
Limbus
Fibrous tissue formed from capsular tissue
interposed between everted labrum and
acetabular rim
Extra articular
Tight adductors (adductor longus)
Iliopsoas

20. -Torticollis
-Metatarsus adducts
-Calcaneo valgus
-Talipus varus
-Plagiocephaly
Associated conditions

21. CLINACAL
PRESENTATION

22. Neonatal Presentation
Exam one hip at a time
Baby must be quiet
Barlow’s sign: provocative maneuver
Ortolani’s sign: reduces hip
Other signs not helpful in newborn

23. * The Ortolani test 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.

24. The Barlow test With the 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.

25. Infant Presentation
Skin fold asymmetry
Limited hip abduction
Unequal femoral lengths (Galeazzi’s
sign)
(Flex both hips and one side shows
apparent femoral shortening)

26. Skin fold asymmetry

27. Asymmetrical thigh folds

28. Galeazzi’s sign

29. Developmental dysplasia of the right hip.
One physical finding is limited abduction of
the affected hip.

30. Trendelenberg gait and test
Leg length discrepancy
Increased lumbar lordosis in Bilateral dislocation
Klisic test positive
After Walking Age

31. Klisic test

32. Hyperlordosis – bilateral involvement

33. X-rays
Femoral head ossification center
○ 4 -7 months
Ultrasound
CT
MRI
Arthrograms
• Open vs closed reduction
Imaging

34. Radiography

35. The acetabular index is the angle between a line drawn along the margin
of the acetabulum and Hilgenreiner's line; it averages 27.5 degrees in
normal newborns and decreases with age.
Acetabular Index

37. Wilberg's center-edge angle, the angle between Perkin's line and a line
drawn from the lateral lip of the acetabulum through the center of the
femoral head. considered normal if greater than 10 degrees in children 6
to 13 years of age, and it increases with age.

38. Radiographs Summary
Femoral head appears 4 - 7 months
Shenton’s line
Perkin’s and Hilgenreiner’s lines
Inferomedial quadrant
Center Edge Angle of WILBERG (< 20 abnormal)
Acetabular index
Normal < 30

39. VON ROSEN VIEW
Both hips abducted, intrernally rotated and extended.
NORMAL- Imaginary line from shaft of femur extending upwards
intersects the acetabulum
DDH- Line crosses above acetabulum

40. Introduced in 1978
Operator dependent
Useful in confirming subluxation,
•Identifying dysplasia of cartilaginous acetabulum,
•documenting reducibility
Prox Femoral Ossification Center interferes
Ultrasound

41. BOTH morphologic assessment and dynamic
anatomical characteristics
○ alpha angle: slope of superior aspect bony acetabulum
○ beta angle: cartilaginous component
dynamic
○ Observing events occuring with Barlow and ortolani
tests.

42. Ultrasound (too sensitive)

43. As the femoral head subluxates:
decreased ALPHA angle increased BETA angle

44. Big Beta Bad

45. *Us of abnormal

47. Arthrogram
Head shape
Cover
Congruity
Articular cartilage
Labrum

48. • Limbus - 'Rose thorn sign' of inverted labrum between
femoral head & acetabulum
• Hour glass constriction of capsule – by psoas tendon
• Capsular distension
• Medial dye pooling

49. Eliciting Medial pooling of dye
•(normal = < 7mm)
•Confirms reduction after surgery
Dye pooling <7mm & complete
reduction with arthrogram = no need
for open reduction.

50. Treatment
The sonographic finding of most hips improve with age ,so
treatment dicisions should be based on US examination performed
at 6 weeks of age or later rather than at birth
tachdjan
Age of patient at presentation
Family factors
Reducibility of hip
Stability after reduction
Amount of acetabular dysplasia

51. American academy Of pediaterics (AAP)
Consider imaging before 6 months of age for male
or female infants with normal findings on physical
examination and the following risk factors:
•Breech presentation in third trimester
(regardless of cesarean or vaginal delivery)
•Positive family history
•History of previous clinical instability
•Parental concern
•Suspicious or inconclusive physical
examination

52. Treatment 0 to 6 months
Goal is TO obtain reduction and maintain reduction to provide
optimal environment for femoral head and acetabular
development
Lovell and Winter
Treatment should be initiated immediately on diagnosis
AAOS (July,2000)
subluxation often corrects after 3 weeks and may be
observed without treatment
if persists on clinical exam or ultrasound beyond 3 weeks
treatment indicated
actual dislocation diagosed at birth treatment should be
immediate

53. prevents hip extension and adduction but allows
flexion and abduction which lead to reduction
and stabilization
Success 95% if maintained full time six weeks
In child > 6 months of age, success is < 50% as it
is difficult to maintain active child in harness
Pavlik Harness

54. The hips should be flexed to 120 degrees, and
the posterior straps should not produce forced abduction

55. Indications include presence of reducible hip
Follow weekly intervals by clinical exam and US for
two weeks
and if not reduced other methods are pursued
Once successfully reduced, harness is continued for
childs age at stability + 3 months

56. Failure
poor compliance , inaccurate position
subgroup where failure may be predictable
○ absent Ortolani sign
○ bilateral dislocations
○ treatment commenced after age 7 week
NEXT Treatment is closed reduction and Spica
Casting
Femoral Nerve Compression 2 to hyperflexion
Inferior Dislocation
Avascular Necrosis
Complications

57. Von Rosen splint

58. Closed reduction and spica cast
immobilization recommended
6 months to 2 years age
Should not be done before apperance of
the osiffication center ( if done before
……increased incidance of AVN )
TACHDJAN

59. Traction
Traction is controversial with theoretical benefit of
gradual stretching of soft tissues impeding reduction
and neurovascular bundles to decrease AVN
skin traction preferred however vary with surgeon
usually 1-2 weeks to fascilitate closed reduction
scientific evidence supporting this is lacking
Poor compliance
Examples
Traditional position traction
Bryant traction

60. closed reduction preformed in OR under general
anesthetic
manipulation includes flexion, traction and abduction
Adductor tenotomy necessary
in most cases to increase safe zone
Reduction must be confirmed on arthrogram as large
portion of head and acetabulum are cartilaginous

61. Reduction maintained in spica cast well molded to
greater trochanter to prevent redislocation
Human position of hyperflexion and limited
abduction preferred
avoid forced abduction with internal rotation as
increased Risk of AVN.
Ct scan to confirm reduction
casting continued for 3 months changed after 6 weeks ,
then placed in abduction orthotic device full time for 2
months then weaned

63. Safe Zone
20 to 30 degrees from
maximum abduction
&flexion > 90

64. Closed reduction is considered
accepted when it is
safe and stable
If not……… do not accept and
go for open reduction

65. Criteria of safe & stable closed reduction
• wide safe zone
• Decreased abduction needed for reduction
• Decreased internal rotation needed for reduction
• Decreased medial dye pooling of arthrogram

66. Medial approach

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

68. Open reduction usually necessary
For age > 3 open reduction and femoral
shortening and acetabular procedure is
recomended to avoid excess pressure on head
with reduction
Age greater than 2 years

69. potential for acetabular development is diminished and
therefore many surgeons recommend a concomitant
acetabular procedure with open reduction
Incidence of AVN is greater with simultaneous open
reduction and acetabular procedure
2-3-years gray zone

70. • 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
Open Reduction with Femoral Shortening

71. 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

72. Re- orientation
Innominate
Periacetabular
Triple
Augmentation
Shelf procedures
Chiari
Pelvic osteotomy

73. • Articular hyaline cartilage over femur head
• Types:
– Salter’s (innominate)
– Sutherland’s (double innominate
Reorientation- Osteotomy

74. 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

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

76. • 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
Peri-acetabular Ostetomies

77. Pemberton’s Osteotomy
1. Incomplete
2. Hinges at triradiate cartilage

78. Dega’s Osteotomy
1. Incomplete
2. Variable hinge
3. Allows anterior,
lateral & posterior
coverage

79. Ganz Osteotomy
Larger corrections all
directions
Blood supply preserved
Shape of true pelvis unaltered
Technically demanding

80. Triple Oasteotomies
Indication :
Adolescent requiring more than 25° correction
Pre-requisite:
Functional range of motion
only mild subluxation acceptable
STEEL TONNIS TACHDJIAN’S

81. Shelf Procedure Chiari Osteotomy