This document discusses developmental dysplasia of the hip (DDH). It defines DDH and explains how it occurs due to ligamentous laxity and breech positioning. Risk factors include female sex, family history, and oligohydramnios. DDH can present as a dysplastic, subluxated, or dislocated hip. Diagnosis is made through clinical examination and imaging like ultrasound and x-rays. Treatment depends on age and may include Pavlik harness, closed or open reduction, and hip spica casting. Complications include failure of reduction or avascular necrosis.

1. BY : G T SAI PRASANTH
MODERATOR: DR VENKATDASS K
02-01-2015
GANGA HOSPITAL
DEVELOPMENTAL
DYSPLASIA OF THE HIP

3. The early pioneers in DDH

4.  What is DDH ?
 How does it occur ?
 Why does it occur ?
 When does it occur ?
 What are the various presentations of DDH ?
 How to identify DDH in children ?
 What are the various management principles of
treating DDH ?

5. Dysplastic hip:
Increased obliquity and loss of concavity
of the acetabular roof
Excessive lateral inclination of the roof
Widening of the teardrop
Intact Shenton’s line
Subluxated hip:
Widened tear drop femoral head distance
Break in Shenton’s line
Femoral head not in full contact
Reduced centre-edge angle
Dislocated hip :
The femoral head is not in contact
with acetabulum at all.

6. What is DDH ?
 The AAP defines it as a condition in which the femoral head
has an abnormal relationship to the acetabulum.
 It is a spectrum of disorders of abnormal hip development.
 Can present in varied forms at different ages.
 Can present as a dislocation, subluxation, dysplasia of the
acetabulum or as a component of other syndromes
(Teratologic dislocation of the hip)

7. Why does DDH occur ? ( Etiology )
 Predisposing factors for development of DDH
include :
 Ligamentous laxity
 Breech position (esp. the frank breech )
 Postnatal positioning of the child
 Primary acetabular dysplasia (unlikely)
 Racial predilection

8. Ligamentous laxity
as described
by Wynn - Davies
The maternal Relaxin hormones cross the placenta and induce
ligamentous laxity, female child more affected.
Newborns with DDH have a higher ratio of Collagen III to
Collagen I.
DDH is found in families with laxity as a trait.

9. Prenatal positioning is strongly
associated with DDH
16% of infants with DDH are born
in breech postion
Frank breech with flexion at hip & knees in complete extension
are most predisposed to develop DDH.
The pull of hamstrings can predispose to the dislocation.
Oligohydramnios
Intrauterine Crowding
Involvement of left hip more than right
First born child

10.  Postnatal positioning in cradle boards be predisposing
factor, while abducting them can be protective.
 Whites and Native Americans have a higher incidence
 Association of DDH with other conditions like :
 Metatarsus adductus
 Torticollis
 Hyperthyroidism in pregnancy

11. How does DDH occur ? (Pathophysiology)
 The affected hip
 spontaneously
 slides out.

 subluxatable hip
 Posterosuperior rim of acetabulum loses its sharp margin,
becomes flat & thickened.
 The capsule becomes loose and more elastic.
 The ligamentum teres elongates.

12. Neolimbus of Ortolani
Produces the *clunk*
Dislocatable hip
Hip out of
acetabulum
Hips that are dislocated have
20
Barriers to Reduction :
Thickened pulvinar
Elongated ligamentum teres
The inferior capsule
hour glass
Dislocated hip

13. Iliopsoas attaching to the lesser
trochanter narrows the opening
acting like a * Chinese Finger trap*.
Chronic long standing dislocated hips have
acetabular muscular and femoral head changes.
The acetabulum becomes excessively anteverted,
the roof becomes convex, medial wall thickens
The femoral head becomes oval and medially flat.
High riding dislocation
The muscles become short and contribute to the
upward pull

14. How does DDH present ? (Clinical features)
 In a Neonate :
 Ortolani or Barlows Sign
 Ultrasonographic features
 Hip examination in a neonate :
 Relaxed child (well fed, calm, mothers lap, quiet room)
 Experienced examiner
 * Feel* of the hip movements – a delicate event
 Examine one hip at a time
 Very light touch
 Spending adequate time with the patient

15. Barlow’s sign
Attempt to dislocate / subluxate the femoral head from the acetabulum
Hip is ADDUCTED, a gentle push applied to slide the hip POSTERIOR
Thumb medially, apply a postero-
lateral force
Hip felt to slide out of acetabulum
POSITIVE
Once the force stopped, the hip
slides back

16. Ortolani’s sign
Reverse of Barlow’s test.
Attempt to reduce a dislocated hip
Thigh held b/w thumb and index
finger
With the other fingers gently lift
the GT and simultaneously abduct
the hip
Positive result – Femoral head slips into
the socket with a palapable CLUNK
Repeat both the tests to be sure
of the findings

17.  In an Infant :
 The signs of DDH in the infant depends on whether the
hip is reducible or non reducible.
 Limitation of abduction
 Galeazzi’s sign
 Looking for the number of thigh folds
Affected hip

18. Klisic’s test for B/L dislocation
B/L hip dislocation in a child can be confusing due to the symmetry
in findings.
Symmetry on abduction
Knees at the same level
KLISIC’S test to differentiate :
Index finger on ASIS
Middle finger on G T
Imaginary line drawn should point
to umbilicus
Dislocated hip the G T comes more
proximally shifting the line below
the umbilicus

19.  In a Walking child :
 Trendelenberg test positive
 Galeazzi’s sign positive
 Exgg lumbar lordosis in B/L cases
 Waddling gait
 Limited abduction in dislocated hips
 Excessive rotations

20. How to identify DDH ? (Radiology findings)
 Various radiographic techniques used :
 Ultrasonography
 Arthrography
 X rays
 Magnetic resonance Imaging

21. The role of Ultrasonography in DDH
Shows the soft anatomy
& relationship of femoral head
with acetabulum.
Pioneered by GRAF
Articular cartilage little echo
Capsule, muscles moderate echo
Fibrocartilagenous labrum
strong echo
Lateral imaging technique
Examination at 6 weeks of age
found to be most sensitive

22. BASELINE
ACETABULAR
ROOFLINE
INCLINATION
LINE
The intersection of the baseline and the acetabular
roofline forms the ALPHA angle
The intersection of the baseline with the inclination line
forms the BETA angle
As the alpha angle decreases the acetabular
wall becomes more shallow.
Lesser the alpha angle and greater the
beta angle - subluxated femoral head
GRAF CLASSIFICATION:
Graf I – normal
Graf II – immature/ somewhat abnormal
Graf III – subluxated
Graf IV – dislocated hips

23. Advantages and disadvantages of using Ultrasonography
to diagnose unstable hips
Advantages :
• A very sensitive indicator of infant hip abnormality as compared to
radiography.
• Picks up cases that are clinically silent and will dislocate in future
• Can be performed on all within 2-3 minutes
Disadvantages :
• It is too oversensitive and results in overtreatment of hips that
would otherwise develop normally
• In infants younger than 3 months old, the Graf method is unreliable
as the reference points are indistinct.
• Some ultrasonographically normal hips also may dislocate.
CONSENSUS :
USG is a valuable adjunct to clinical exmn and radiography and must
be used judiciously.

24. The role of X rays
Features of an Unossified pelvis:
• Upper femur is not ossified.
• Most of the acetabulum is cartilagenous
in the form of Triradiate Cartilage
• Hilgenreiner’s Line :
A line through the triradiate cartilages
• Perkins line :
A line perpendicular to the first, at the
lateral margin of the bony acetabulum.
• Shenton’s Line
• In a normal hip, the medial beak of femoral metaphysis lies in lower
inner quadrant.

25.  Measurements of Acetabular Index:
 Angle formed by junction of HG line with a line drawn from the
acetabular surface.
 Newborns : Avg 27.5 0
, 6 months 23.5 0, 2 yrs 20 0
 Older child the center-edge angle is used .
 Junction of Perkin’s line with a line from the centre of femoral
head to lateral margin of acetabulum.
 6-13 yrs : >19 0 normal, >14 yrs : 25 0(SEVERINS Classification)

26. Acetabular teardrop :
• Appears normally b/w 6-24 months in normal hip and later
in dislocated hip.
• Teardrop in a dislocated/subluxated hip is wider and loses its
convexity
Acetabular Index of Depth :
Depth of the centre
Width of the opening
>38% is normal
Femoral head extrusion Index
False profile view : For evaluating the
anterior acetabular dysplasia

27. The role of Arthrography & MRI
 Severin pioneered the description of the arthrographic anatomy
of the hip joint.
 Patient under GA, median subadductor approach used.
 Insert the needle 2 cm distal to origin to the adductor longus,
direct the needle medially towards the opposite Sternoclavicular
joint.
 A small amount of contrast injected.
 If in the joint the contrast should
flow freely around the femoral head.
 Xray films should be taken in all
directions of joint movement

28. • The free margin of acetabular labrum is seen as a ‘ Sharp thorn’
overlying the femoral head.
• In dislocated position of the
femoral head, the capsule is
enlarged over the femoral head
& ‘hourglass’ constriction seen.
USE OF MRI:
• Excellent anatomical view of
the infant hip.
• The downsides being the cost and the need for sedation in infants.
• MRI classification of Kishiwagi for DDH hips :
• Group I : Sharp acetabular rim, reducible with Harness
• Group II : Rounder acetabular rim, may be reduced with Harness
• Group III : Inverted acetabular rim, not reducible

29. How to treat this patient ??
 Depending on the age of the patient at the time of diagnosis
and treatment :
 Treatment of the neonate
 Treatment of the young child ( 1 – 6 months old )
 Treatment of the child ( 6 months to 2 yrs old)
 Treatment of an older child (> 2 yrs old )

30. Treatment of the Neonate
 PAVLIK HARNESS is the preferred treatment
 Indications :
 Positive Ortolani’s Sign
 Positive Barlow’s sign
 USG abnormal at birth Repeat at 6 weeks
If found abnormal Harness
How to put a Pavlik’s Harness ?
 Chest strap just below the nipple line
 Feet placed in the stirrups & hips placed in 120 0 of flexion
 Posterior strap to be applied loose, let the abduction occur with
gravity
 Never force abduction by the straps

31. • Hyperflexion of the hips produces femoral nerve palsy due to
compression
• Hyperflexion can also cause femoral head to dislocate inferiorly.
• Inadequate flexion will fail to reduce the hip
• Forceful abduction can cause avascular necrosis of femoral head
due to compression.
• Educate the parents regarding the care of the baby with Harness.
• Repeat clinical exmn and USG at the end of 6 weeks of treatment
• If clinical exmn is negative and USG shows a well reduced hip,
then discontinue the harness and follow clinically
• If the hip remains dislocated, discontinue the harness, examine
the hip under anesthesia & arthrography to ascertain the cause.

32.  Treatment of the Young Child (1-6 months)
 PAVLIK HARNESS
 The first choice of treatment for dislocated/subluxated hips
 Maintain flexion more than 90 0
 Examine the child weekly with clinico-USG exmn & after 3-4
weeks;
 If reduction obtained, continue the Harness for 6 more weeks.
 If reduction not obtained, discontinue Harness and try for
other treatment methods.
 A P radiograph of the hip and look for a
notch above the acetabulum.
 The presence of this notch is a good sign & it
indicates good acteabular development.

33. Problems and complications of Pavlik Harness
• Failure of reduction of the hip joint, especially the high dislocations
• Avascular necrosis of the joint :
• Hospital treated children have higher chances than those
treated at home
• High dislocations treated with Harness.
• Forceful abduction and reduction
• Femoral nerve palsy
• Pavlik Harness Disease:
• Prolonged positioning of the hip in flexion and abduction
potentiated dysplasia
• Flattening of posterolateral acetabulum
• Discontinue Harness after 3-4 weeks if reduction not achieved.
• Factors leading to Harness failure :
• > 7 weeks at presentation, b/l hip dislocation, absent Ortolani’s
sign.

34. Treatment of the child ( 6 months to 2 years old)
 Either the child presents first time with a dislocated hip or
he/she were initially treated with splintage which failed.
 Goals of the treatment :
 Obtain and maintain reduction without AVN.
 Methods of treatment:
 Closed reduction +/- Traction
 Open reduction +/- Traction

35. Use of Traction for reduction
• The need for traction as a prerequisite for reduction has been a
controversial area.
• The need for traction has been challenged by the fact that hips can
reduced safely without preliminary traction.
• Different application methods of traction exist :
Bryant’s traction position
(hip at 900 flexion )
Traditional traction position (hip
at 300flexion)

36. CLOSED REDUCTION
• Done under GA / deep sedation
• It is a seemingly simple procedure but, the proper performance
and interpretation needs experience.
• The method of closed reduction :
Flex the hip beyond 90 0
Gradually abduct the limb while gently lifting the greater trochanter
After palpable reduction is felt, move the hip to determine its ROM
The Hip is moved in all planes till the point of redislocation
Compare the reduced ROM with the maximum ROM

37. From this construct a * SAFE ZONE *, the range of movements
during which the hip remains in the acetabulum.
A wide safe zone indicates a stable hip
A wide abduction or the need for 10-15 0 of internal rotation to
maintain reduction, indicates an unstable hip
Obtain an Arthrogram at the time of reduction to evaluate the depth
& stability of reduction.
The width of the medial dye pool on an AP radiograph indicates the
likely stability.
Good reduction – narrow rim of contrast
Fair reduction – 5-6 mm of dye pool
Poor reduction - > 6 mm dye pool

38. • A stable hip has wide SAFE ZONE and gets dislocated only at the
periphery of movements
• An unstable hip redislocates easily and has a narrow safe zone.
• Open reduction must be performed for cases where closed
reduction is not able to hold the hip in reduction.
• Casting can be done for stable hips for 6 weeks and the acetabular
development is good, femur becomes well seated.

39. HIP SPICA CAST
 The Hip Spica cast should maintain more than 900 flexion,
30-400 abduction, around 10-150 internal rotation.
 The most experienced must hold the position of
immobilization.
 Extreme abduction/ internal rotation can cause AVN.
 After cast, take an intraop X ray/ CT to see the reduction.
 MRI can also be performed as it gives additional information
about the femoral head vascularity.
 After 6 weeks remove the spica, Exmn Under Anaesthesia is
performed.
 Put the hip through moderate range of movements and look
for the stability

40.  Repeat the AP X ray and look for reduction. Reapply the cast if
the reduction is good.
 After 6 weeks the second cast is also removed and the child
examined again.
 A third cast may or may not be applied for 6 weeks/ abduction
splint may be used.

42. OPEN REDUCTION
• The primary indication for open reduction is failure to obtain a
stable hip with closed reduction.
• Open reduction of the hip is done either through :
• Medial approaches
• Anterior approach
• The medial approach has the advantages of minimal dissection &
viewing the obstructions to reduction directly.
• The disadvantages include a limited view of the hip joint and
damage to MFCA.
• The anterior approach provides good exposure and
Capsulorrhaphy can be done.

43. Medial Approach to open reduction
 Not a surgery for the inexperienced surgeon as the chances of
causing AVN to the femoral head are high.
 Recommended for children 1 year or younger.
 The MFCA vessels cross the operative field and have to be
retracted to safety.
 Transect the iliopsoas+/- adductor longus , incise the medial hip
capsule and reach the joint.
 Removal of thickened & constricted medial capsule + removal of
ligamentum teres allows reduction.
 Take a radiograph to assess the reduction.
 Post operatively, place the child in a below knee hip spica cast.
 Convert it to above knee spica after 6 weeks if reduction
maintained.

45. Anterior Approach to open reduction
 Has stood the test of time.
 Pros being a wider exposure of the hip joint as compared to the
medial, good cosmesis (using the bikini incision), ability to
perform capsulorrhaphy but difficult to expose the depths of
acetabulum.
 In cases of high dislocation of femoral head, the technique can be
challenging as the muscles are constricted.
 Take a radiograph after the joint has been reduced. If reduction
is too tight do a femoral shortening and capsulorraphy if the
capsule is too lax.
 Apply a hip spica cast after reduction with a bar in between.
 Take a radiograph after 6 weeks and reapply the cast.

47. • Treatment of the Older child ( 2 yrs and older ):
• Problems faced in the older child :
• Femoral head is usually in a more proximal position
• Hip muscles are severely contracted
• Femoral shortening is needed & higher the dislocation more is the
shortening needed.
• Primary acetabular reorientation osteotomy may be needed.
• Children between 2-3 yrs of age, pelvic osteotomy is needed if the
acetabular coverage is not adequate.
• Children who are older than 3 yrs at reduction usually need an
acetabular procedure.

48.  A potential complication of combining acetabular procedure with
femoral shortening is ‘Posterior dislocation of hip’
 Occurs usually during the derotation.

49. Age based guidelines for the treatment of DDH
 Neonate - Place the patient in Pavlik harness for 6 weeks
 1 to 6 months – Place the patient in a Pavlik harness for 6 weeks
after the hip reduces
 6 to 18 months – Treat he patient with taction & closed
reduction. Closed reduction successful – hip spica for 3 months
Closed reduction unsuccessful – Open reduction medial
approach(<12months), anterolateral approach (>12 months)
 18-24 months – Treat the patient with a trial of closed reduction
or open reduction ( anterolateral approach)
 24 months- 6yrs – Primary open reduction ( AL approach) +
femoral shortening ,+/- Salters Osteotomy

50. Complications and Pitfalls of the available treatment
 Avascular necrosis of femoral head
 Inadequate reduction and redislocation
 Residual acetabular dysplasia

51. Avascular necrosis of femoral head
 Excessive pressure application to the femoral head :
 Immobilization in extreme abduction or internal rotation
 Contraction of the muscles crossing the hip
 Increases the pressure on the femoral head & occludes the
vascularity
 Diagnosed when the femoral head fails to ossify or grow even
after 1 year of reduction.
 Widened femoral neck, bone density changes.
 Measurements in a normal femur:
 L = 2 x R
 Tip of GT slightly below the centre of head
 Auriculotrochanteric distance = 10-25 mm.

52. Classification systems:

53. • In B-O type I AVN, changes are limited to femoral head, & the
metaphyses isn’t involved. Irregular ossification of the head.
• In B-O type II AVN, the lateral metaphysis sustains injury -- leading
to an early closure of the lateral epiphysis – VALGUS deformity.
• In B-O type III AVN, the entire metaphysis is affected – premature
closure of the physis -- extremely short femoral neck.
• In B-O type IV AVN, growth disturbance of the medial growth plate
-- VARUS deformity.
• With B-O types II,III,IV there is relative overgrowth of GT &
reversal of auriculotrochanteric distance leading to abductor limp.
• Abductor limp : shortening of femoral neck (decreases the lever arm)
, lengthening of GT causing decreased abductor action.

54. Interventions to treat AVN affected hips :
 Trochanteric Epiphysiodesis can prevent overgrowth of GT, best for
children around 5 yrs, presence of ossific nucleus of GT
 Trochanteric advancement can be performed in the presence of an
abductor limp due to GT overgrowth. Lateral transfer is better &
usually done at 8 yrs of age.
 Intertrochanteric Double Osteotomy performed when the trochanter
is markedly overgrown & abutting the pelvis. Double osteotomy of
the femoral neck is done. Technically very challenging.
 Lateral Closing Wedge Valgus Osteotomy with Trochanteric
Advancement usually used for coxa vara with trochanteric overgrowth.

55. Inadequate Reduction & Redislocation
 Most common complication of managing DDH patients is
failure to obtain and maintain the reduction.
 Failure to recognize a dislocated hip after a closed reduction
warrantes a poor outcome.
 A redislocation after an open reduction is a difficult situation.
 The tissues around the hip are very much constricted and
scarred.
 Closed reduction/ repeat open reduction of a failed open
reduction can be performed.

56. Residual Acetabular Dysplasia
 Post – reduction the actebulum remodells in response to the
pressure exerted by the reduced femoral head.
 If this process is incomplete, certain parts of acetabulum remain
dysplastic.
 The development of the “sourcil” or eyebrow indicates proper
acetabular development.
 Indicators of improper acetabular development:
 Widening of joint more than 6%
 up-sloping sourcil

57. Late presenting Acetabular Dysplasia
 The patients may present with hip complaints late in
adolescence.
 Aching pain, pain in the groin region (hip jt) or lateral hip pain
(abductor fatigue).
 Presence of limp, positive Trendelenberg test and Trendelenberg
sign.
 Labral tears and degeneration due to deficient acetabular
coverage pain is provocated by Impingement test
(flexion,internal rotation and adduction)
 AP radiograph, false profile view, abduction internal rotation
view & Gad enhanced MRI arthrogram may be used.
 Gd-MR-arthrogram demonstrates labral pathology.

58.  Abduction-internal rotation view shows concentric reduction of
hip
 False profile view : for assessing the anterior acetabular coverage
 AP radiograph to differentiate between subluxation, dislocation
and dysplasia.

59. Treatment strategy for late presenting acetabular
dysplasias
Take a supine X ray of the hip in abduction + internal rotation
Assess whether hip can be concentrically reduced
Yes No
Perform redirectional Salvage procedure performed
procedures that reorient Femoral head is not covered by
acetabulum & increase the preexisting articular cartilage
femoral head coverage

60. Reconstructive procedures for Dysplasia

61. Pemberton’s Osteotomy
 aka pericapsular osteotomy of the ilium
 Redirects the inclination of the acetabular roof by an osteotomy
of the ilium superior to the acetabulum followed by levering the
roof inferiorly
 The triradiate cartilage acts as a hinge on which the acetabular
roof is rotated anteriorly & laterally
 Recommended for dysplastic hips b/w 1 yr to 12 yrs in the
presetting of concentric reduction of femoral head
 Advantage over Innominate osteotomy is that :
 Internal fixation not always required
 No need of implant removal
 Greater degree of correction can be achieved

62. Pemberton’s Osteotomy

63. Salter Innominate Osteotomy
 Salter observed that on extending these hips there is a deficient
cover anteriorly and on adducting superior deficiency
 Salter’s osteotomy of the innominate bone – redirection of the
acetabulum for better anterior and superior coverage
 Prerequisites for success :
 Femoral head opposite the acetabulum
 No contractures of iliopsoas & adductor
 Concentric reduction of femoral head in the acetabulum
 Congrous joint
 Good range of hip movements

64. Salter Innominate Osteotomy

65. Dega Osteotomy
 Dega’s Osteotomy allows allows the surgeon to increase
acetabular coverage anteriorly, centrally, or posteriorly.
 The osteotomy starts above the acetabulum and proceeds into
the triradiate cartilage behind and beneath the acetabulum.
 The acetabular fragment is then pried downward and held in
place with bone wedges.
 The placement of the wedges determines the area of acetabular
coverage that is improved.
 If wedges are placed posteriorly, posterior acetabular coverage is
augmented, as is often necessary in neuromuscular-related hip
dislocations.

67. Ganz osteotomy
 Triplanar periacetabular osteotomy.
 Adolescents and adults who require correction of congruency
and containment of the femoral head
 Proximal femoral osteotomy can be combined when femoral
degenerative changes are present. This helps to achieve
uninvolved wt bearing surfaces
 Advantages :
 Only one approach
 Large amount of correction can be performed
 Correction in all planes can be performed
 Acetabular blood supply preserved
 Posterior column of pelvis remains intact, immediate weight
bearing can be started

68. Chiari Osteotomy
 Chiari Osteotomy is performed when concentric reduction of hip
is impossible.
 It is an Osteotomy that augments the acetabulum.
 A controlled fracture through the ilium – medial displacement of
the acetabular fragment & the intact hip capsule
 Improves the superolateral femoral coverage
 It is a salvage procedure & places the femoral head under a
surface of cancellous bone with capacity for regeneration
 Indications : coxa magna after AVN/Perthes disease
 congenital subluxations 4-6 yrs of age, untreated DDH > 4 yrs
 Dysplastic hips with osteoarthritis
 Paralytic dislocations caused by muscle weakness

69. Teratologic dislocation of the hip
 Also known as Antenatal Dislocation of the hip
 Fixed dislocation at birth, with restriction of ROM
 Most of these children have an associated syndrome/ MSK
abnormality
 Arthrogryposis, myelomeningocoele, chromosomal
abnormalities, diastrophic dwarfism, lumbosacral agenesis.
 The treatment of these hips depends on the nervous system
functioning, prognosis of ambulation post reduction, muscle
power in lower extremities etc.
 Closed reduction is usually unsuccessful
 Open reduction when the child is around 6 months old.
 Medial/ anteromedial approach to the hip is preferred choice of
tretament.

70. Bibliography
 Tachdjian’s Pediatric Orthopaedics 4th edition
 Tachdjian’s Pediatric Orthopaedics 5th edition
 Who’s Who of Orthopaedics
 Campell’s Orthopaedics 12th ed
 Internet

71. Thank you