Developmental dysplasia of the hip (DDH) is a spectrum of disorders involving abnormal development of the hip joint that may present as dysplasia, subluxation, or dislocation. It results from excessive laxity of the hip capsule allowing the femoral head to slip out of the acetabulum. DDH is diagnosed through clinical examination including Ortolani and Barlow's tests in infants, and imaging such as ultrasound and x-rays. Treatment depends on the degree of hip involvement and age of presentation, ranging from bracing to closed or open reduction. Screening of newborns is important for early detection and management to prevent long-term complications.

2. DEVELOPMENTAL DYSPLASIA OF HIP
By
Dr. SUMAN KUMAR, JUNIOR RESIDENT
Dept. of ORTHOPEDICS
KURNOOL MEDICAL COLLEGE

3. CONTENTS:
INTRODUCTION
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
DIAGNOSIS
SCREENING
MANAGEMENT
COMPLICATIONS

4.  DEFINITION:
 A disorder of abnormal development resulting in dysplasia and possible subluxation or
dislocation of hip secondary to capsular laxity and other mechanical factors.
 Developmental dysplasia of the hip (DDH) is a spectrum of disorders of development of the
hip that present in different forms at different ages.
 The common etiology is excessive laxity of the hip capsule with a failure to maintain the
femoral head within the acetabulum.
INTRODUCTION:

5.  DDH is a disorder that evolves over time.
 The structures that make up the hip are normal during embryogenesis and gradually become
abnormal for a variety of reasons, the chief being the fetal position and presentation at birth (e.g.,
Malposition of the femoral head, abnormal forces acting on the developing hip) and the laxity of the
ligamentous structures around the hip joint.
 The older term congenital dislocation of the hip has gradually been replaced by developmental
dysplasia, which was introduced during the 1980s to include infants who were normal at birth but
in whom hip dysplasia or dislocation subsequently developed.

6.  In 1832, Guillaume Dupuytren described the condition of dislocation of the hip at birth and called it
“original or congenital dislocation of the hip.”
 At the turn of the twentieth century, Adolph Lorenz demonstrated his vigorous techniques of closed
reduction of the hip. However, because his reductions were so forceful that leading to osteonecrosis, he
has been called the “father of avascular necrosis”.
 Putti recommended early treatment, before the patient was 1 year old.
 In 1937, Ortolani—another person who is famously associated with hip dislocation—described both a
“click” or “jerk sign” of dislocation and a “click” or “jerk sign” of reduction.
 Probably one of the most important treatment advances was the introduction by Arnold Pavlik in 1946 of
the harness that bears his name.

7.  Actual dislocation is reported in 1/1,000 live births (But the incidence of positive clinical findings,
i.e. frank dislocations and lax dislocatable hips combined, is higher).
 Male: Female ratio is 1:5 (Female preponderance)
 It is bilateral in approximately one-third cases. Left hip involvement is more common (Left >
Bilateral > Right)
 The condition is more common in first born female child with fair complexion (whites or
Caucasians) who had a positive family history and at birth had a Faulty intrauterine position
(breech delivery)—“The Five F’s”.
 It is uncommon in India because mothers carry child straddled on the side of their waist with the
hips of child Abducted. This tends to reduce unstable hips because when the femur goes into
abduction, the head falls back into the acetabulum.
INCIDENCE:

8. Ligamentous laxity (often inherited)
Breech position (especially footling)
Postnatal positioning (hips swaddled in
extension)
Primary acetabular dysplasia (unlikely)
 Although there is no single cause of
DDH, a number of predisposing
factors have been identified, viz.,
ETIOLOGY

9. 1. LIGAMENTOUS LAXITY 2.PRENATAL POSITIONING:
In 1970, during an extensive genetic study of DDH
Wynne-davies proposed that heritable
ligamentous laxity was one of two major
mechanisms for the inheritance of DDH
 Prenatal positioning is strongly associated with DDH.
 Although only 2% to 3% of infants are born in breech
presentation, 16% of infants with DDH are born in breech
presentation
 The incidence of DDH is also higher in those pregnancies that
are complicated by oligohydramnios.
 These findings suggest that there is an intrauterine crowding
effect on the developing hip. This argument is supported by
the increased incidence of other postural abnormalities (e.g.,
Torticollis, metatarsus adductus) in children with DDH.

10. 3. POSTNATAL POSITIONING
Postnatal positioning is another factor that is associated with DDH. People who wrap their newborn babies in a
hip extended position (e.G., Native americans who use cradleboards have a much higher incidence of DDH as
compared with other populations.

11. Torticollis:
15%-20%
Metatarsus
adductus:
1.5%-10%
Oligohydramnios
Congenital knee
dislocation
Club foot has not
been shown to have
significant
association with
DDH.
Conditions associated with developmental dysplasia of the hip:

12.  The Initial instability is thought to be caused by maternal and fetal laxity, and intrauterine
and postnatal malpositioning. This instability leads to dysplasia, which further leads to
gradual dislocation.
PATHOPHYSIOLOGY:

13.  The hip joint begins to develop at approximately the seventh week of gestation.
 By eleventh week of gestation cartilaginous femoral head and acetabulum are formed.
 At birth, the neonatal acetabulum is completely composed of cartilage, with a thin rim of
fibrocartilage called the labrum.
 Whereas the proximal femur has a complex and often misunderstood growth pattern.
 In the normal femur, an ossification center appears in the center of the femoral head between the
fourth and seventh months of postnatal life.
 As the child matures, three acetabular epiphyseal centers develop and are responsible for the final
contours of the hip socket. The os acetabulum, which is the largest of the three, appears at
approximately 8 years of age and forms along the anterior wall as part of the pubis.
 Excessive pressure on the cartilaginous upper femur can cause a loss of vascular perfusion, which
results in the necrosis of the chondrocytes.
NORMAL HIP DEVELOPMENT

14. Hip development with developmental dysplasia :
 DDH is a gradually progressive disorder that is associated with distinct anatomic changes, many of
which are initially reversible.
 At birth, the affected hip will spontaneously slide into and out of the acetabulum. For this to occur, the
posterosuperior rim of the acetabulum has to have lost its sharp margin and become flattened and
thickened in the area over which the femoral head slides.
 As the head rides in and out of the socket, a ridge of thickened articular cartilage (called the neolimbus
by Ortolani) arises along the posterosuperior acetabular wall. The sliding of the head in and out
produces a “clunk.” The neolimbus is the structure that produces this feel as the head slides over it.
 While some of the hips that are unstable at birth become normal spontaneously, remaining are
irreducible due to the barriers,

18.  Barriers:
Inverted labrum
Hypertrophied
Ligamentum teres
Thickened Fibrofatty
Pulvinar
Hypertophied TAL
Hour glass capsule

19.  It is extremely important to realize that the acetabular structure is not impeding the femoral head
from entering the acetabulum. Rather, the constricted hip capsule is forcing the head against the
acetabular rim, and the capsule must be released or stretched to allow the head to move beneath
the acetabular rim and enter the acetabulum.
 The femoral head itself is usually deformed into a globular shape as a result of pressure against
the lateral portion of the acetabulum, and it may not be congruous with the acetabulum at the time
of reduction; however, this anatomic situation also eventually resolves if reduction is maintained.
 When a stable reduction is obtained, the acetabulum gradually remodels

20.  If the hip remains dislocated, additional changes occur during the growth and development of the
acetabulum. The acetabular roof becomes progressively more oblique, the concavity gradually flattens
and eventually presents a convex surface, and the medial wall of the acetabulum thickens.
 Medial twisting of the whole wing of the pelvis has been demonstrated by magnetic resonance imaging
(MRI) in patients with untreated DDH.
 Medial wall thickening is seen radiographically as a thickening and alteration of the shape of the
teardrop body.
 To a point, these changes are reversible, but the exact upper age at which hip reduction will result in
normal acetabular development is uncertain.
 Harris suggested that a hip reduced by the time a patient was 4 years old could achieve “satisfactory”
acetabular development.

21.  In adults, the fully dislocated femoral head may lie well above the acetabular margin in a markedly
thickened hip capsule; this is the so-called “high-riding dislocation”. The adult dislocated femoral head is
oval and flattened medially. The acetabulum is filled with fibrous tissue, hypertrophied ligamentum teres,
and thickened transverse acetabular ligament, and the articular cartilage is either atrophic or absent.
 Fully dislocated adult hips may remain free from degenerative changes for many years, even for the
individual’s lifetime.
 Subluxated hips have an unstable contact area that allows the head to slide proximally and distally against
a widened and oblique acetabular surface. This instability produces degenerative changes that often
become apparent during late adolescence and that usually progress rapidly within a few years to severe
degeneration. Late radiographic changes include subchondral sclerosis and cyst formation in the
acetabulum and the femoral head, osteophyte formation, and the loss of articular cartilage.

22.  Dysplasia refers to a radiographic finding of increased obliquity and the loss of the concavity of the
acetabulum, with an intact Shenton line.
 The term subluxation is used when the femoral head is not in full contact with the acetabulum. The
radiographic findings of subluxation include a widened teardrop femoral head distance, a reduced
center–edge angle, and a break in the Shenton line.
 The term dislocation specifies that the femoral head is not in contact with the acetabulum.
 Both subluxated and dislocated hips have dysplastic changes.

23.  C. Clinical presentation:
DDH is classified into
 Dislocated:
 Dislocatable: if Barlow positive
 Subluxatable: if Barlow suggestive
 Clinical presentation of DDH is variable based on age of presentation
REDUCIBLE
IRREDUCIBLE
ORTOLANI
POSITIVE
ORTOLANI
NEGATIVE

25.  Although no standard guidelines for screening of DDH exist, it is a general consensus that
all newborns must be screened for an unstable hip.
 Two conventional methods in practice for this are the Ortolani and Barlow’s tests.
 The hip examination of the neonate requires an artful approach in which the setting must
be controlled and the examiner experienced. The first requisite is a relaxed child.
 The “feel” of this examination is most important, and it is not like palpation of the liver.
Clinical Presentation In Neonates

26. Clinical Presentation In Neonates
BARLOW’S TEST : two parts—(1)
adduction and (2) abduction.
With the hips and knees flexed, grasp
thighs with fingers over greater trochanter
and thumb in front. Gently adduct the hip
and give slight outward pressure with
thumb to dislocate the hip, producing the
characteristic “clunk of dislocation”. This
occurs in unstable dislocatable hips, which
are not already dislocated. This part of test
is negative in already dislocated hip.
In second part, pressure is released and
hips abducted, Which will relocate the hip
and produce the “clunk of relocation”.
Clunk, and not click, is significant.
ORTOLANI TEST (abduction test): similar
to second part of Barlow’s test so can be
applied only to already dislocated hips.
The examiner holds the infant’s knees and
gently abducting the hip while lifting the
GT with two fingers.
When the test is positive, the dislocated
femoral head will fall back into the
acetabulum with a palpable clunk.
KLISIC SIGN: can be elicited in all age
groups with dislocated DDH.
In a supine child, place middle finger over
greater trochanter and index finger over
anterior superior iliac spine (ASIS).
Normally, an imaginary line through these
points crosses at umbilicus, but in
dislocation the line crosses below the
umbilicus. The sign is positive in both
unilateral and bilateral cases.

27. BARLOW’S TEST : ORTOLANI TEST: KLISIC SIGN:

28. Asymmetrical thigh folds/groin
creases and a wide perineum.
The affected limb is shortened
and externally rotated.
Restricted abduction (especially
in flexion) is one of the most
sensitive sign. (Sensitivity—
69%, specificity—54%).
There is excessive internal and
external rotation of the
dislocated hip
Ortolani and Barlow’s tests are
rarely positive after 3 months of
life because of soft tissue
contractures.
Galeazzi’s sign (allis sign) : child
lying supine with both hips and
knees flexed, the knee is lower
on affected side due to
shortening of the affected lower
extremity.
Vascular sign of NARATH may
be appreciated.
Lumbar lordosis may be
exaggerated (mostly in bilateral
cases)
In a walking child
Trendelenburg’s gait (abductor
lurch) and Trendelenburg’s test
may be positive. Children with
bilateral DDH walk with a
waddling gait/duck gait/
sailor’s gait.
Telescopy at hip is positive.
Clinical Presentation In Infant & Older Child

29. LIMITED ABDUCTION TEST GALEAZZI TEST

31. ULTRA
SONO
GRAPHY
RADIOGRAPHY ARTHROGRAM CT SCAN M.R.I
DIAGNOSIS

32.  Like clinical presentation, diagnosis of DDH is also influenced by age of the child.
 X-ray is of little value in a child less than 6 months. This is because the proximal femoral
epiphysis is not ossified at birth and hence not visible on x-rays for the first 6–12 months of life.
ULTRASONOGRAPHY:
 The investigation of choice (for screening as well as for diagnosis) for this age group (< 6 months old) is
ultrasonography (USG), although the best investigation for any age would be a magnetic resonance
imaging (MRI).
 Ultrasonography classifies DDH by Graf’s method. The radiologist measures two angles on hip
ultrasound—(1) alpha angle (between baseline of ilium and roof of bony acetabulum) and (2) beta angle
(between baseline of ilium and cartilaginous acetabular roof).
 Normally alpha angle is more than 60º and decreases with increasing severity while beta angle is less
than 55° and increases with increasing severity of DDH.

34.  Graf, who pioneered the use of ultrasonography for the evaluation of the infant hip, initially studied
cadaver hips and compared sonographic findings with radiographs and arthrograms to define the
sonographic anatomy of the hip. The hyaline articular cartilage of the hip had little echo, the capsule and
muscles had moderate echo, and the fibrocartilaginous labrum (as well as the juncture of the femoral neck
and the cartilaginous upper femur) had strong echo.
 The Graf classification has been modified several times, and it can be confusing. In its simplest form,
 class I hips are normal,
 class II hips are either immature or somewhat abnormal,
 class III hips are subluxated
 class IV hips are dislocated.

35.  a

36.  As the ultrasound findings commonly improve with age, so the decision to treat DDH should be based on USG
at 6 weeks and not at birth.
 Several authors have noted that universal screening with ultrasonography results in an increase in the
number of infants who require splinting but does not reduce the number of late dislocations. Hence when
clinical screening is of high quality there is no need of Universal screening with ultrasonography.
 Ultrasonography is also very useful for detecting early treatment failures when using the Pavlik harness.

37. RADIOGRAPHY:
 As the child reaches 3 to 6 months of age, the dislocation will be evident radiographically,
 X-rays are useful in relatively older children. Delayed appearance of upper femoral epiphysis
(normally it appears at 6 months) and delayed development (smaller size), shallow acetabulum, a
broken Shenton line (line from proximal medial neck to inferior border of superior pubic rami)
and lateral and upward displacement of ossific center of femoral head are some of the findings
that guide the diagnosis.
 Von rosen’s view may be especially useful in children under 1 year age. The view is taken with hips
abducted, internally rotated and extended. Normally, axis of the femoral shaft should intersect the
acetabulum. In dislocation, the line crosses above the acetabulum.

38.  Several classic lines are helpful when evaluating the immature hip. The Hilgenreiner line is a line
through the triradiate cartilages. The Perkin line, which is drawn at the lateral margin of the
acetabulum, is perpendicular to the Hilgenreiner line, making the each acetabulum into four
quadrants.
 The Shenton line is a curved line that begins at the lesser trochanter, goes up the femoral neck,
and connects with a line along the inner margin of the pubis.
 Normal position of femoral head (proximal metaphyseal beak more specifically if head is not
visible) is the inner lower quadrant whereas a dislocated head migrates into the upper outer
quadrant.
 The Shenton line is smooth in the normal hip whereas in the dislocated hip, the Shenton line is
broken because the femoral neck lies cephalic to the line from the pubis

41.  Acetabular index (AI) is calculated from these radiographs to know if the acetabulum is dysplastic or not.
The index is determined by measuring the angle between Hilgenreiner’s line and a line connecting triradiate
cartilage and lateral lip of acetabulum. Normally this angle is less than 30°. Greater values mean a more
vertical, shallow and dysplastic acetabulum.
Normal value of AI = 27.5° (mean in newborns)
at 6 months = 23.5°
at 2 years—decreases to less than 20°
 30° is the upper limit of normal hence for any age.
 Center edge angle of Wiberg (CEA) is another radiographic measurement to establish the diagnosis. The
angle is formed by a line drawn from the center of femoral head to the outer edge of the acetabular roof, and a
vertical line drawn through the center of femoral head. Normally this is greater than 20° and lesser values
indicate dislocated hip.

43.  The acetabular teardrop figure, as seen on an anteroposterior (AP) radiograph of the pelvis, is formed by
several lines. It is derived from the wall of the acetabulum laterally, the wall of the lesser pelvis medially, and
a curved line inferiorly, and it is formed by the acetabular notch. The teardrop appears between 6 and 24
months of age in a normal hip and later in a dislocated hip.
 The teardrops have also been described as U- or V-shaped, with a V-shaped teardrop being associated with a
dysplastic hip and a poor outcome.

44. ARTHROGRAPHY:
 used to confirm reduction after closed reduction under GA. Also used to identify the possible blocks to
reduction. (Inverted labrum, inverted limbus, transverse acetabular ligament, capsule, ligamentum teres &
pulvinar)
 In the normal hip, the free border of the labrum is easily seen as a sharp “thorn” overlying the femoral head.
A recess of joint capsule overlies this thorn. The capsule expands beyond this recess and is then constricted
by the ring like zona orbicularis. In a child with DDH, when the hip is in the dislocated position, the
acetabular edge is seen, and the capsule is enlarged as it extends over the femoral head. The capsule is
constricted at its middle portion into an hourglass shape by the iliopsoas tendon.
 Medial gap: this is the distance between the ossified proximal portion of the femur and lateral wall of
teardrop. Normal is less than 4 mm, 5 mm is suspicious and greater than or equal to 6 mm is dislocation.

45. ARTHROGRAM OF NORMAL HIP:

46.  CT scan: very rarely required. Used to evaluate reduction after the closed reduction and spica
casting.
 MRI: does not play a significant role in primary diagnosis.
 Kashiwagi and associates proposed an MRI-based classification of hips with DDH.
 Group 1 hips had a sharp acetabular rim, and all were reducible with a Pavlik harness.
 Group 2 hips had a rounded acetabular rim, and almost all could be reduced with a Pavlik harness.
 Group 3 hips had an inverted acetabular rim, and none was reducible with the harness

47. SCREENING:
 Hip screening in DDH does not meet most of the World Health Organization's criteria for an effective
screening programme and should only be considered as surveillance due to its low sensitivity and positive
predictive value (PPV).
 There is a significant risk of over diagnosis and over treatment. There is no International consensus on
screening in DDH.
 Hence most authors agree that infants with risk factors associated with DDH should receive more careful
screening that includes at least an examination by an experienced examiner and possibly ultrasonography at
around 4 to 6 weeks of age.

48. MANAGEMENT:
 Like clinical presentation and diagnosis, treatment too is dictated by the age at which the patient presents to
the doctor. Aim is achieving concentric and stable reduction of head into acetabulum and maintaining the
same.
0 To 6 Months Infant:
 In neonates and younger infants with unstable but reduced hips, place the child in a hip abduction splint for
6 weeks.
 In younger infant If the hips are already dislocated, close reduction under general anesthesia is done and
then child is placed in an abduction splint.

49. Management of DDH – AGEBASEDGuidelines
0 to 6 months
Pavliks Harness
6 to 18 months 18 to 24 months 2 to 6 years
Traction
Closed reduction
Hip spica
Open reduction
Trial of closed
reduction or
Primary open
reduction
Pelvic osteotomy
Primary open
reduction with
Femoral
shortening
6 weeks no
reduction
Arthrography
no reduction >1/3rd head
visible

50.  PAVLIK HARNESS

51. Pavlik Harness:
 The pavlik harness is the preferred method for the treatment of neonatal DDH. The first indication for
treatment is a hip that is dislocated and that can be reduced by the examiner (ortolani sign).
 Pavlik harness is applied by first placing the chest strap just below the nipple line. The child’s feet are placed
in the stirrups, the hips are placed in 120 degrees of flexion, and the straps are secured. The posterior straps
are fastened loosely to allow for the abduction of the hips to occur by gravity alone. Abduction should never
be forced by the straps on the harness.
 Excessive flexion must be avoided as it may lead to femoral nerve palsy when the nerve becomes
compressed by the diapers between the thigh and abdomen. Hyperflexion may also cause the femoral head to
dislocate inferiorly. Alternatively, inadequate flexion (i.e., <90 degrees) will fail to reduce the hip

52.  The progress of the hip can be monitored by repeating the ultrasonographic study after 3 weeks in the harness,
at which time the hip usually remains reduced. If the hip is unstable at 3 weeks, an abduction orthosis may be
substituted for the harness. On the other hand, if the hip remains dislocated after 3 to 4 weeks of harness wear,
the use of the harness should be discontinued, and the hip should be examined while the child is under
anesthesia and an arthrogram to be advised to evaluate the reasons for the persistence of dislocation.
 Four basic patterns of persistent dislocation have been observed after application of the pavlik harness:
superior, inferior, lateral, and posterior.
 If the dislocation is superior, additional flexion of the hip is indicated.
 If the dislocation is inferior, a decrease in flexion is indicated.
 If the dislocation is lateral, as long as the femoral neck is directed toward the triradiate cartilage, as confirmed
by radiograph or ultrasound, the head may gradually reduce and “dock” into the acetabulum.
 A persistent posterior dislocation is difficult to treat, and pavlik harness treatment frequently is unsuccessful.
 If any of these patterns of dislocation or subluxation persist for more than 3 to 6 weeks, treatment in the Pavlik
Harness should be discontinued and a new program initiated.

53.  After 6 weeks when the harness is being discontinued, another AP radiograph is obtained to assess hip
reduction and acetabular development. A notch above the acetabulum often appears after the hip is reduced,
and this finding is usually followed by improved acetabular development.
 Other types of abduction splints:
 Von rosen splint
 Ilfeld splint
 Frejka pillow splint

55.  VON ROSEN SPLINT Ilfeld or craig splint

56. Frejka Pillow splint:
 The frejka pillow is capable of forcefully abducting the hips of the infant, and it is associated with
an unacceptably high rate of AVN.

57. 6 Months To 2 Years Child:
 The goals of the treatment are to obtain and maintain the reduction of the hip without damaging the femoral
head. The two principal methods of treatment are closed reduction and open reduction, either of which may
be preceded by a period of traction.
 Traction: traditional prereduction traction is performed with the child’s hips placed in 20 to 30 degrees of
flexion by means of a frame or other immobilizing device in the crib, with traction applied via the use of
adhesive straps placed on the thighs and legs. Traction was continued until the head was below the
Hilgenreiner line;
 This often required patients to spend 3 weeks or more in the hospital.
 Others prefer the Bryant position, an alternative position in which the hips are flexed 90 degrees and the
knees are extended.

59.  Morel in France devised a newer method called “traction reduction”, which involves immobilizing the child in
bed and applying gradually increasing skin traction to bring the femoral head below the acetabulum. The
hips are then gradually abducted and internally rotated until the hip is reduced. At this point, the traction is
reduced, and a cast is applied. This approach often requires 6 or more weeks of in-hospital treatment and
results in little or no AVN.
 Other newer method is portable home traction, in which the child is placed in skin traction with the hip
flexed 90 degrees in a frame made of PVC pipe, which can easily be transported in a wagon or on a parent’s
lap.
 But 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
 At present there is no consensus on applying prereduction traction.

60. CLOSED REDUCTION:
 Should be performed with the use of general anesthesia or deep sedation.
 The reduction should be done with the hip flexed approximately 120 degrees.
 After the patient’s hip reduces, the surgeon evaluates its stability by extending the hip to the point of
redislocation and then adducting the hip to the point of redislocation.
 A reduction is considered stable if the hip can be adducted 20 to 30 degrees from maximal abduction and
extended to less than 90 degrees without redislocation.
 An arthrogram may be obtained at this time to further assess the adequacy of the reduction.
 If the adductors are tight on palpation with the hip in the reduced position, a tenotomy of the adductor
longus may be performed to reduce pressure on the hip

61.  The range of motion in which the hip remains reduced is compared with the maximum range of motion.
From this information, a “safe zone” is constructed.
 If the zone is relatively wide, the reduction is considered stable. Otherwise, if wide abduction or more than
10 or 15 degrees of internal rotation is required to maintain reduction, the reduction is considered unstable.
 Wide abduction and excessive internal rotation should be avoided as they are associated with higher
incidence of AVN.
 After attaining proper and stable reduction, a cast is applied to maintain the hip in Human position of more
than 90 degrees of flexion and enough abduction to maintain the reduction. Some internal rotation may be
used, but no more than 10 to 15 degrees, and never to the limit of internal rotation. Similarly, abduction to 30
or 40 degrees is acceptable as long as further abduction is available.
 An effective technique to prevent excessive abduction during cast application is to frequently abduct the hips
maximally and then return to a less abducted position to be certain of the position of the hips.

62.  Application of spica cast in human position:

63. RAMSEY ZONE OF SAFETY:

64. Post reduction ..!!
Cast in human position 6 weeks
Examination under GA
Stability assessment
Stable & Reduced Doubtful reduction &
Unstable
Arthogram
2nd Cast in Human
Position6 weeks
3rd cast for 6
weeks&
discontinue
Abduction splinting
for 6 weeks
OR
Open Reduction

65. OPEN REDUCTION:
 The primary indication for the open reduction of DDH is a failure to obtain a stable hip with a closed reduction.
 Failure may be evident at the time of the initial closed reduction, or it may become apparent when the hip
redislocates in the cast or at the time of a cast change.
 Open reduction can be performed from one of several medial approaches or from an anterior approach.
 The anterior (Smith Peterson) approach: Most commonly used due to decreased risk of injury to Medial Femoral
circumflex artery and Capsulorrhaphy can be performed after reduction and used if the child is > 12 months old.
 The Medial approach: Used if minimal dissection is required, and the obstructions to reduction are encountered
directly in a child < 12 months old. The disadvantages are a limited view of the hip, the possible interruption of the
medial femoral circumflex artery, the inability to perform a capsulorrhaphy and high incidence of AVN.
 Types: Ludloff - Medial (Between the Pectineus and Adductor longus & brevis)
Weinstein - Anteromedial (Between Neurovascular bundle and Pectineus)
Ferguson - Posteromedial (Between Adductor longus and Gracilis)

66.  Anterior approach:

67.  Medial approach:

68.  Open Reduction With Femoral shortening:
• Femoral shortening should be considered when an open reduction has been performed and if excessive pressure is
placed on the femoral head when it is reduced. It should also be considered when a dislocated hip is reduced in a
child who is older than 2 years.
 Femoral varus derotational osteotomy (VDRO): is indicated in femoral shortening with excessive anteversion
and/ or valgus deformity
• Used after femoral head is congruently reduced with satisfactory ROM and reasonable femoral sphericity
 Open Reduction With Innominate Osteotomy:
• As the child gets older, there is more likelihood of adding a pelvic osteotomy (Salter or Pemberton) to the primary
procedure. The need for a pelvic procedure is decided on the operating table; if after reduction and femoral
shortening the acetabular coverage of head is insufficient, a pelvic osteotomy is added. Pelvic osteotomies basically
decrease the acetabular index to better accommodate the head.

69.  Femoral varus derotational osteotomy:

70. 

71. 2 Years And Older Child:
 Treatment of children who are between 2 and 6 years old with hip dislocation is more challenging. Prereduction
traction is contraindicated, as the femoral head is usually in a more proximal location and the muscles that cross the
hip are more severely contracted. Femoral shortening is an essential part of the management of the older child.
 After the age of 18 months the development potential of acetabulum is no longer there. So even if the head is
reduced and maintained, once the maintenance brace is removed the head would dislocate again. So after 18
months of age, an open reduction is usually combined with either a femoral or an acetabular osteotomy to ensure
that the head stays in the acetabulum even if further development is not there.

72. PELVIC RECONSTRUCTION PROCEDURES
TYPE INDICATION TECHNIQUE
Salter • Younger patients typically with open triradiate
cartilage (18 months to 6 years)
• Single transverse cut above the acetabulum through the ilium to sciatic notch
• Acetabulum hinges through the pubic symphysis
• Improves anterolateral coverage (can provide 20-25° lateral and 10-15°
anterior coverage)
• May lengthen leg up to 1cm
Triple
(steel)
• Favored in older children because their
symphysis pubis does not rotate well
• Performed when open triradiate cartilages are
present
• Salter osteotomy plus additional cuts through superior and inferior pubic rami
• Acetabular reorientation procedure
• Improves anterolateral coverage
Ganz
(Bernese)
PAO
• Triradiate cartilage must be closed in order to
perform
• Involves multiple osteotomies in the pubis, ilium, and ischium near the
acetabulum
•Allows for improved 3D correction of the acetabulum configuration
• Technically the most challenging
• Posterior column and pelvic ring remain intact
•patients are allowed to weight bear early
Pemberton • For moderate to severe DDH
• Most versatile
•Triradiate cartilage must be open
Age group 18 months to 10 years
• Osteotomy starts approximately 10-15mm above the AIIS and proceeds
posteriorly to end at the level of the ilioischial limb of the triradiate cartilage
•Acetabulum hinges at the triradiate cartilage posteriorly and the symphysis
pubis anteriorly
•Does not enter the sciatic notch and is therefore stable and does not need
internal fixation
• Improves anterolateral coverage
• Reduces acetabular volume

73. TYPE INDICATION TECHNIQUE
Dega Favored in neuromuscular
dislocations (CP) and patients
with posterior acetabular
deficiency
•For severe cases
• Osteotomy from acetabular roof to triradiate cartilage
• Acetabulum hinges through the triradiate cartilage
• Does not enter the sciatic notch and is therefore stable and does not
need internal fixation
• Improves anterior, central, or posterior coverage
• Reduces the acetabular volume
Dial Technically difficult
• Rarely used
Leaves the medial wall or teardrop in its original position and is
therefore intra-articular
• Spherical osteotomy
SALVAGE PELVIC OSTEOTOMIES
Shelf
(Staheli)
salvage procedure performed in
patients > 8 years old
• add bone to the lateral weight-bearing aspect of the acetabulum by
placing an extra-articular buttress of bone over the subluxed femoral
head
• depends on fibrocartilage metaplasia for successful results
Chiari salvage procedure for patients
with inadequate femoral head
coverage and when a concentric
reduction can not be obtained (>8
years old)
osteotomy starts above the acetabulum to the sciatic notch and ileum is
shifted lateral beyond the edge of the acetabulum
• depends on fibrocartilage metaplasia for successful results
• medializes the acetabulum via iliac osteotomy

74.  Pelvic Osteotomies:

75.  Salter’s Innominate Osteotomy Dega Osteotomy

76.  Pemberton Pericapsular Osteotomy & Ganz Periacetabular Osteotomy:

77.  Steel Triple Innominate Osteotomy: Staheli Acetabular augmentation:

78. TERATOLOGIC DISLOCATIONS:
 A teratologic dislocation is commonly used to describe complex and “resistant to treat” forms of dislocations.
Actually, they are associated with other disorders that make the reduction difficult like arthrogryposis, Larsen
syndrome, myelomeningocele, and diastrophic dwarfism and myelodysplasia. The hips in these forms are
dislocated before birth and early intrauterine life with limited range of motion (ROM), complete acetabular
malformation and marked displacement of femoral head and they are not reducible on examination (barlow’s test)
due to short and tight soft tissues producing sort of fixed deformities

79.  Teratologic dislocations in this age-group represent a challenge, not that they are easy to manage even if identified
early but with the success of other methods in this age group their management is really frustrating for orthopedic
Surgeon.
 They are associated with significant anatomical changes in acetabulum and femoral head.
 The acetabulum is small, oblique and flat and the femoral head is of variable size and may be flattened on the
medial side. Typically the hip is stiff and irreducible with superolateral displacement of the head. • These
dislocations often accompany arthrogryposis, Larsen’s syndrome, myelomeningocele and diastrophic dwarfism.
While unilateral dislocations are treated aggressively, bilateral dislocation may be left as such. This is because of
high complication rates associated with open reduction for teratologic dislocation. Redislocation or subluxation
may be as high as 40% and rate of osteonecrosis may approach 70%. Typically, closed reduction is impossible and
open reduction should be accompanied with primary femoral shortening

80. COMPLICATIONS:
1. Osteonecrosis: Seen with all forms of treatment. Its occurrence increases with,
 Excessive of forceful abduction
 Excessive internal rotation under closed reduction
 Previous closed treatment.
 Repeat surgery.
 The greater trochanter is not affected by AVN, and it will continue to grow when capital epiphyseal
growth is arrested.

81.  Diagnosis of AVN is based on radiographic findings that include,
 Failure of appearance of growth of the ossific nucleus even after 1 year of reduction
 Broadening of femoral neck
 Increased density and fragmentation of ossified femoral head
 Residual deformity of proximal femur after ossification
 Interventions to alter the effects of AVN:
 Some of the anatomic effects of AVN can be altered by appropriate intervention. Procedures include trochanteric
Epiphysiodesis, Trochanteric Advancement, Intertrochanteric Double Osteotomy, and Lateral Closing Wedge Valgus
Osteotomy with trochanteric advancement.

82. 2. Inadequate reduction and redislocation:
 In current practice, the most common complication related to the management of DDH is the failure to obtain and
maintain the reduction. After closed reduction, single section CT is helpful for assessing the reduction while the hip
is in the cast. Failure to maintain the reduction is not in itself a major complication, but failure to recognize the
unreduced hip guarantees a poor result.
 If the hip has redislocated, a second attempt at reduction with the patient under anesthesia should be promptly
carried out.
 A more difficult situation arises when the hip is not well reduced after an open reduction. Most often, the surgeon
has not adequately exposed the acetabulum to obtain a deep reduction initially.

83. 3. Residual acetabular dysplasia:
 After the reduction of a dislocated hip, the acetabulum begins to remodel in response to the pressure exerted by the
femoral head. Usually this results in the gradual deepening of the acetabulum and the reduction of the obliquity of
the acetabular roof
4. Presenting late (delayed diagnosis):
 The more delayed the diagnosis, the lesser the chances of recovery with surgical modality. Hence if the child is
presenting after 6 to 8 years with either unilateral or bilateral ddh outcome with surgery is least.
5. Transient femoral nerve palsy:
 Seen with excessive flexion during Pavlik bracing.