2. Definition
• DDH (the abbreviation for developmental hip dysplasia) is a generic
term describing a spectrum of anatomic abnormalities of the hip
that may be congenital or develop during infancy or childhood.
• Spectrum: Shallow Acetabulum
Teratologic Dislocations
• DDH coined by Klisic in 1980s
3. Development
• Ossification of the ischium,
ilium, pubis, femoral shaft, and
distal femoral epiphysis occurs
before birth
• Acetabular growth
• Triradiate cartilage
• Acetabular epiphysis
4. • Femoral head and acetabulum develop from single cleft of
mesenchymal cells
• Femoral head begins to separate between 7-8 WOG and complete by
11-12 WOG
• 1st time at which dislocation may occur – 10 weeks( lower extremity
limb bud rotates medially
• At 18 WOG – muscular imbalance in neuromuscular disorder
Teratological dislocation
5. • Incidence
• 0.1% of infant
• 10% female – Transient abnormality of neonatal hip
• half of the women who develop degenerative arthritis have preexisting
acetabular dysplasia
6. Risk Factors
• Breech positioning(30% to 50%)
• positive family history(>=20%)
• female sex (85%)
• firstborn child are risk factors
• Postnatal positioning –Swaddling
with hip in extension
7.
8. Etiopathogenesis
A. Prenatal/intrauterine factors
(i) Epidemiologic
• 4–8:1 female/male incidence
• Breech position (especially after 30–34 weeks)
• Genu recurvatum/knee in extension
• oligohydramnios
• first child minimize chances of spontaneous version
• Twins
• Family history (genetic component)
• Relaxin
10. Etiopathogenesis
B. Postnatal factors
• Sudden passive extension of hips at birth and immediately postnatally
predisposes to subluxation and dislocation.
• Hips develop in utero in flexed position and are most stable in flexion
• Infants positioned postnatally with hips extended and adducted are
most prone to instability
11. Etiopathogenesis
• C. Temporal factors
(i) Prenatal onset
• hip imperfectly positioned in the third trimester- Left (67% )> right
• structural changes at birth are relatively marked; earlier the
malposition occurs, the worse the secondary changes
(ii) Perinatal onset
• hip structure at birth is normal
• capsular laxity that makes it dislocatable
12. (iii) Teratologic hip
• The more severe variants
(i) mesenchymal teratologic hip dysplasia:
• the abnormal hip occurs with other structural changes implying primarily a
mesenchymal cell defect
(ii) prenatal teratologic hip dysplasia:
• the hip development is normal until malposition occurs prenatally in the third
trimester with secondary changes occurring in utero
• more common
(iii) Developmental abnormalities and syndromes
• Ehlers Danlos syndrome, Down’s syndrome, Arthrogryposis
• Larsen syndrome
13. Clinical feature
• Associted with
• Torticollis(20%)
• Metatarsus adductus (10%)
• Club foot ??
Arthrogryposis Larsen Syndrome
15. Classification
1. Reduced and stable but
Dysplastic
• Clinically normal
• Balow –ve
2. Reduced but Dislocatable
• Barlow +ve
3. Dislocated but Reducible
• Ortolani +ve
4. Dislocated and Irreducible
• Ortolani -ve
16. Diagnosis
Neonatal examination
• Screening for signs of hip instability.
• Barlow manouevre
Provocation test
Adducting flexed hip and applying gentle
pressure to push femoral head
posterosuperiorly
• Ortolani techniques
Relocation manouevre
Abduction
Reduced hip produce palpable clunk
• Advanced Screening ?? Controversial
• Screening USG with significant RISK
Barlow Manoeuevre
Ortolani techniques
17. Diagnosis
Neonatal examination
• early infancy instability
• Later limitation of
abduction and shortening
bilateral dislocations
• Difficult to identify .
• If hip abduction is less than
about 60° on both sides, order
an imaging study.
Galeazzi sign
Limited hip abduction
18. Diagnosis
Galeazzi sign
• Knee flexion
• Feet touches surface
• Ankle touches buttock
• If knees are not in level
• Apparent LLD
• (DDH/Short femur)
19. Diagnosis
Bilateral DDH:
symmetry makes early diagnosis more
difficult. Note the typical lumbar
lordosis that occurs with high
dislocations
Mother’s intuition
20. Diagnosis -- Klisic Test
In Normal hip
imaginary line through tip of an index
finger placed on patient’s iliac crest and
tip of the long finger placed on patient’s
greater trochanter should point to
umbilicus.
In dislocated hip
line through two fingertips runs below
umbilicus because greater trochanter is
abnormally high.
22. Imaging- X Ray (>4-6 months)
• Shenton's curve :
smooth curved line connecting medial border of
femoral metaphysis with the superior border of the
obturator foramen
• Hilgenreiner's line :
horizontal line through the triradiate cartilage of the
acetabulum
• Perkin's line :
vertical line (perpendicular to Hilgenreiner's line)
from the lateral margin of the ossified acetabular
roof. Normally Ossific nucleus of femoral head-
medial (4-6 months)
• Acetabular angle :
angle that the acetabular line makes with
Hilgenreiner's line( Normal<25 degree)
23. Other X ray finding
Lateral displacement of femoral head
Increased Medial gap
Capital epiphyseal dysplasia
Pelvic ilium hypoplasia
Delayed fusion
Adduction attitude
24. Von Rosen View
• With 45 degrees of hip
abduction and internal rotation,
the line is drawn along the
longitudinal axis of the femoral
shaft.
• In normal hips, it intersects the
pelvis at the upper edge of the
acetabulum.
• In DDH line crosses above
acetabulum
25. Imaging- X Ray (>4-6 months)
Acetabular dysplasia
• Triangular shape of the tear drop
(red arrows).
• Joint space (orange line) widened.
• Shenton’s line (green lines) is
disrupted.
• The sourcil, or acetabular roof
sclerotic.
• left hip joint is higher than the
normal side.
26. Center.edge (CE) angle
• This child has a normal left hip
with a CE angle of 30°.
• The right hip aspherical and
subluxated, and the CE angle is
10°.
• Note that measures are made
with the pelvis level (white line).
33. Management
Objectives of management :
1. Early diagnosis
2. Reduction of the dislocation
3. Avoidance of avascular necrosis
4. correction of residual dysplasia.
• Age related
• Tailored to specific pathological condition
34. Birth to 6 months
• Close follow up
• Repeat USG at 6 wks
All Ortolani +ve
• Pavlik harness
Barlow +ve Hips
• Observation/Pavlik
harness
If dislocated –check reduction in 3wks(USG)
35. • Not reduced– rigid abduction orthosis/ closed reduction,arthrography
and spica casting
• Reduced – continue harness until findings of examination and USG
are normal
36. Pavlik Harness
• < 6 months infant
• Hip 100 degree flexion and mild abduction(Dynamic flexion abduction
orthosis)
• Position of Hip – Safe zone of Ramsey : between maximum
adduction before redislocation and excessive abduction, which
increases the risk of AVN
38. Pavlik Harness
• Worn full-time until stability is attained, as determined by negative
Barlow and Ortolani tests
• Worn 23 hours a day for at least 6 weeks after a reduction has been
achieved and then an additional 6 to 8 weeks part time (nights and
during naps)
39. Discontinuation of pavlik harness
• Failed reduction, persistent dislocation or subluxation for >3-6 weeks
• Femoral nerve palsy
• 6 weeks after clinical stability
abrupt discontinuation
• Weaning of upto 2 hrs/wk until brace is worn at night only, to
transitioning to a nighttime abduction orthosis for additional wks or
months
40. Complications of Pavlik harness
• Excessive flexion transient femoral nerve palsy.
• Failed reduction in 3 weeks Pavlik harness discontinued
(to prevent “Pavlik disease”: erosion of the pelvis superior to the
acetabulum and subsequent difficulty with closed reduction and
casting).
• Impingement of the posterosuperior retinacular branch of the medial
femoral circumflex artery has been implicated in osteonecrosis
associated with DDH treated in an abduction orthosis.
• Failed reduction
41. Pavlik Harness
Risk factor for pavlik harness failure
• Absent Ortolani sign at initial
evaluation
• Initial head coverage of <20%(USG)
• Bilateral hip dislocation
• Femoral nerve palsy during brace
• Acetabular angle >36 degree
• Treatment beyond 7 wks of age
Contraindication
• teratologic hip dislocations.
42. 6 to 18 months:
• Hip arthrography, percutaneous
adductor tenotomy,closed
reduction, and spica casting
• Postreduction CT scan used to
confirm concentric reduction
• If closed reduction fails: open
reduction
43. Hip Arthrogram
Helpful in determining:
• whether mild dysplasia is present
• whether manipulative reduction
has been or can be successful
• to what extent soft-tissue
structures within the acetabulum
may interfere with complete
reduction of the dislocation
• condition and position of the
acetabular labrum (the limbus
• whether the acetabulum and
femoral head are developing
normally during treatment Proposed Criteria for accepting reduction:
Medial dye Pool <=5mm
Maintenance of reduction in acceptable safe zone
45. 18 months to 3 years:
• Open reduction+ Osteotomy
46. • Zadeh et al. used concomitant osteotomy at the time of open
reduction to maintain stability of the reduction in which the following
test of stability after open reduction was used:
1. Hip stable in neutral position—no osteotomy
2. Hip stable in flexion and abduction—innominate osteotomy
3. Hip stable in internal rotation and abduction—proximal femoral
derotational varus osteotomy
4. “Double-diameter” acetabulum with anterolateral deficiency—
Pemberton-type osteotomy
47. 3 to 8 years:
• Osteotomy
• Salter, Dega, Pemberton, or
Staheli procedures
• Preop skeletal traction alone
for reduction:
• Osteonecrosis 54%
• Redislocation 31%
48. • Options for osteotomies of the
hip Procedure is shown in red.
• Orange lines show fibrocartilage
articulations.
49. Older than 8 years:
• Palliative salvaging operation
• Growth plate open: triple (Steele), double pelvic (Southerland),
Staheli procedure
• Growth plate closed: Ganz and Chiari procedures
• Arthrodesis??
• U/l dislocation- reduced
• B/l dislocation- Wait until the child is an adult to perform total
hiparthroplasty
2. Less intrauterine space accounts for the increased incidence
of DDH in firstborn children.
Pain, altered
function, and cosmetic problems often result from persisting hip deformity
due to DDH.
The infant should be quiet and comfortable so the muscles about the hip are relaxed.
Use no force. Test for instability in several positions.
Changing signs of DDH With increasing age, signs change.
Mother.s intuition This mother had DDH as a child. She suspected
that her son.s hip was abnormal, but the primary care physician found
nothing on examination. She insisted on a radiograph. This study
demonstrated a dislocation (red arrow). This scenario is not uncommon.
Asymmetrical thigh folds These occur in up to 20% of normal infants
Trendelenburg test This girl has DDH with weakness of the left hip abductors. When standing on her right leg, right hip abductors contract to
elevate the left pelvis to maintain the head centered over the body (green lines). When standing on the weaker left leg, abductor weakness allows the
right pelvis to fall (blue arrow). She must then shift her weight over the left leg (red lines).
Larger the angle deeper the acetabulum , stable the hip joint
Arthrogram of the right hip in the neural position in a 5-month-old boy shows contrast agent accumulating in the large recesses medial and lateral to the constriction produced by the orbicular ligament (arrow). Note the smoothness and even thickness of the cartilage covering the femoral head. (B) On the frog-lateral view, contrast is seen outlining the edge of the cartilaginous labrum (arrow). The ligamentum teres can be seen medial to the femoral head, extending from the inferior portion of the acetabulum.
There is accumulation of contrast agent in the stretched capsule (arrow), and the ligamentum teres is elongated. (B) In the frog-lateral position, the head moves more deeply into the acetabulum, but subluxation is still present.
Note the shallow acetabulum. (B) Arthrogram of the hip shows a deformed cartilaginous limbus and stretching of the ligamentum teres. The femoral head lies superior and lateral to the edge of the cartilaginous labrum. Note the accumulation of contrast agent in the loose joint capsule.
A patient with a narrow safe zone (less than 40 degrees) should be considered for an adductor tenotomy.
Check the fit after the parent applies the harness to assess problems before the parent leaves the clinic
The chest strap is fastened first, allowing enough room for three fingers to be placed between the chest and the harness. The shoulder straps are adjusted to
maintain the chest strap at the nipple line. The feet are placed in the stirrups one at a time. The hip is placed in flexion (90 to 110 degrees), and the anterior flexion strap is tightened to maintain this position. Finally, the lateral strap is loosely fastened to limit adduction, not to force abduction. Excessive abduction to ensure stability is unacceptable. The knees should be 3 to 5 cm apart at full adduction in the harness
During this time, the patient is examined at 1- to 2-week intervals and the harness straps are adjusted to accommodate growth.
Quadriceps function should be noted at each examination to detect a femoral nerve palsy, and families should be instructed to remove the legs from the brace daily to ensure that the infant is able to actively extend the knee against gravity.
Galeazzi sign +, Trendelenberg gait +, delayed ossification of femoral head, shallow acetabulum
Head on wt bearing- superiorly and laterally – capsule elongated , psoas tendon- block reduction, PM flattening, Coxa valga, excessive AV
Arthrogram of the right hip in the neural position in a 5-month-old boy shows contrast agent accumulating in the large recesses medial and lateral to the constriction produced by the orbicular ligament (arrow). Note the smoothness and even thickness of the cartilage covering the femoral head. (B) On the frog-lateral view, contrast is seen outlining the edge of the cartilaginous labrum (arrow). The ligamentum teres can be seen medial to the femoral head, extending from the inferior portion of the acetabulum.
There is accumulation of contrast agent in the stretched capsule (arrow), and the ligamentum teres is elongated. (B) In the frog-lateral position, the head moves more deeply into the acetabulum, but subluxation is still present.
Note the shallow acetabulum. (B) Arthrogram of the hip shows a deformed cartilaginous limbus and stretching of the ligamentum teres. The femoral head lies superior and lateral to the edge of the cartilaginous labrum. Note the accumulation of contrast agent in the loose joint capsule.
Open reduction Open reduction is often difficult, and obstruction must be corrected.
