DEVELOPMENT

DYSPLASIA OF THE
HIP
PRESENTED BY: D R A B H I S H E K R A S TO G I ( P G
RESIDENT)

MODERATOR: D R B H A R G AV ( S EN I O R
RESIDENT)
D E PA RT M E N T O F
O RT H O PA E D I C S
A B V I M S A N D D R R M L H O S P I TA L
DEVELOPMENT DYSPLASIA OF
THE HIP(DDH)
•Earlier known as congenital dislocation of the hip( CDH), presents in different
forms at different age, and not neccesarily occurring at birth.
•Basic pathology is that there is an instability of the hip with failure to
maintain the femoral head in the acetabulum
•Includes a wide spectrum of disorders
Subluxation of the femoral head
Dislocation of the femoral head
Acetabular dysplasia
•In a newborn child, the head can often be dislocated and reduced in the
acetabulum whereas in an older child secondary changes in the acetabulum
develops therefore the femoral head remains dislocated
SUBLUXATION

•Partial loss of contact between the

articular surfaces of the joint
•Widened tear drop femoral head
distance
•Break in the shenton line
DISLOCATION

•Complete displacement
between the articular surfaces
which forms a joint
•No contact between thee
original articular surfaces
DYSPLASIA

•Deficient development of the

acetabulum
•Loss of concavity
•Increased obliquity of the
acetabulum
•Intact shenton line
TERATOLOGIC DISLOCATIONS

•Dislocations present before birth and not reducible after

birth
•Have limited range of motions
•Usually associated with neuromuscular disorders especially
related to muscle paralysis(eg arthrogyposis), caudal
regression syndrome, sacral agenesis etc
EPIDEMIOLOGY

•Incidence of the disorder as per a meta analysis as revealed by

physical examinations by pediatricians is 8.6/1000 live births
•Incidence of 11.5 per 1000 revealed by orthopaedic screening
•Whereas 25/1000 was revealed by ultrasound examination
•Odds ratio:
5.5 for breech delivery
4.1 for female sex
1.7 for positive family history
RISK FACTORS

•4 F’S :
First born
Female gender
Family history positive for ddh
Foot first/ breech deliveries

• Common in white children as compared

to the black.
• Left side> right side

• Bilateral presentation in 35% cases

• Asociations with other musculoskeletal

abnormalities have been found such as
congential torticollis, metatarsus adductus,
and talipes calcaneovalgus

• The relationship between club foot and

ddh is controversial but many studies have
demonstrated little asociation
ETIOLOGY

•No single cause of DDH and therefore etiology is clearly

multifactorial. Several theories have been proposed
including :
Mechanical factors
Hormone induced joint laxity
Primary acetabular dysplasia
Genetic inheritance
Mechanical factors:
• Prenatal positioning
Breech presentation( frank/ complete footling
presentation)
The most common intrauterine position places the left
hip of fetus against the maternal sacrum, which could
partially explain the increased incidence of DDH in the
left hip

• Postnatal positioning
Swaddle positioning of the infants have higher
incidence of DDH possibly because of the placement of
the hip in full extension.
•Ligament laxity: it is believed to be due to the maternal
hormone relaxin which produces relaxation of the pelvis
during delivery which may cause enough ligament laxity in
child in utero and during neonatal period to allow dislocation
of the femoral head.
•Effect is much stronger in females
•Wynne davies in 1970s proposed heritable ligamentous laxity
was one of the two major mechanisms for inheritance of DDH.
•She believed it to be an autosomal dominant characteristic
with incomplete penetrance
Wynne- Davies criteria:

• >3/5 is
considered
to have a
ligamentous
laxity
Beightons score :

• Total score
given is out of
9
• Score of >6/9
indicates
ligamentous
laxity
CLINICAL
DETECTION OF
DEVELOPMENT
DYSPLASIA OF HIP
NEWBORNS

•Careful clinical examination mandatory

as radiographs are not always reliable in
the age group.
•Infant should be calm, relaxed and one
hip should be examined at a time
Hip should be first examined for limited
abduction, it is limited as compared to
the normal opposite side. Is the most
reliable sign of dislocated hip.
INSTABILITY EXAMINATION:

ORTOLANI TEST: PROVOCATIVE TEST OF BARLOW:

After 3months of age the barlow and ortlani tests become negative due to soft tissue contractures
Video
INFANTS

•As the child enters second and third

months of life other signs of DDH
appears
•Asymetry of thigh folds- not always
reliable
•Apparent shortening of the extremity
•Galeazzi /Allis sign
•Klisic sign
An inequality in the height of the knees is a positive Galeazzi sign
Bilateral dislocations may appear symmetrically abnormal

Klisic test
useful in case
of a bilateral
DDH
• As the child reaches 6- 18months of life several
factors in clinical presentation change

• First and most reliable feature is decrease in ability to

abduct the dislocated hip due to adductor muscle
contracture( 69% sensitivity)

• Inability to reduce the dislocated hip by abduction.

Therefore the the ortolani test is negative
Older children of walking age

•Trendlenberg pattern of gait

seen
•Increased lordosis of the spine
to compensate the shortening
•In case of bilateral
dislocations there is a
waddling type of gait and
there is hyperlordosis;
Natural history of the
disease
Dysplastic hip:

•Eventually leads to subluxation which is

inevitable
•Roof osteophytes at the synovial
attachment forms due to increased sheer
forces and a pseudo-acetabulum forms.
•Dysplastic hips without subluxation
usually becomes painful and develop
degenerative changes over time
Subluxated hip:

•Always lead to symptomatic degenerative arthritis with gradually

increasing pain in one or both hips

•Severe subluxation- symptoms in 2nd decade

•Moderate subluxation- symptoms in 3rd and 4th decade
•Mild subluxation- symptoms in 5th decade

•In a study, hips with well developed false acetabulum had highest
incidence of pain and disability
Complete dislocated hip:

•Symptoms much later than subluxated hip

•In some, the hip never become painful
•False acetabulum
Changes occurring in the acetabulum in
subluxated and dislocated hip:
•The changes occurring following DDH are initially reversible.
Relative gentle forces, persistently applied are probably the
cause of the deformations.
Postero-superior rim of acetabulum become blunt, flat and
thickened due to constant sliding in and out of the femoral
head.
This ridge of thickened articular cartilage called neolimbus is
then responsible for the clunk when head slides in and out
In hip that remains dislocated, secondary barriers to the
reduction develop.
◦ The pulvinar ( fatty tissue in the acetabulum) thicken and impede
reduction
◦ Ligamentum teres becomes elongated and thickens
◦ Labrum inverted
◦ TAL( transverse acetabular ligament) is hypertrophic impeding
reduction
◦ Inferior capsule takes an hourglass shape leading to decreased
opening for the femoral head
◦ Iliopsoas pulled tight across the isthmus contributing to the
narrowing
◦ Capsule narrowing by the Chinese finger trap mechanism
•Femoral changes are minimal and includes;

Increase in anterversion

Flattening of femoral head as it lies against the acetabulum

Note should be made to stretch/ release capsule to allow

head into acetabulum and not the acetabular cartilage as
the acetabular cartilage is needed for normal growth and
development of the acetabulum.
•As mentioned, that to a point the changes are
reversible, HARRIS suggested that hip reduced by 4yrs
could achieve satisfactory acetabular development. As
significant acetabular growth continued through 8 yrs.

•When a stable reduction is obtained, the acetabulum

remodels threby increasing the depth and acetabular
angle becoming horizontal.
RADIOLOGICAL
INVESTIGATIONS
PLAIN RADIOGRAPHY:
•Hilgenriener line(Y line/ tear drop line)
•Perkins line
•Shentons line
•Acetabular index/ acetabular angle :
◦ Upper limit for the acetabular angle/ acetabular index is
27+/- 4 degree
◦ Newborn 30 or less
◦ At 6m age is <25degree
◦ At 1 yr ~ 22 degree
Center edge angle of
Wiberg:
• Angle formed by
the center of
femoral head
• Not measured until
the ossific nucleus
present
• Normally >10 in
children
Increased acetabular index

Upward and lateral

displacement of femoral
head

Break in shentons line

Radiographic signs of DDH

1. Upward and lateral displacement of the femoral head

2. Late appearance of femoral ossific nucleus
3. Break in the shentons line
4. Acetabular dysplasia (Acetabular angle >30)
5. Center edge angle of Wiberg
4 radiological signs must be there in a >6month old child of
DDH
Radiological classification:

•Earlier given by Tonnis, who graded it into 4 categories.

•Modified later by the International Hip Dysplasia Institute.
•Uses the Hilgenreiners and perkins line to create 4
quadrants.
•Center of the proximal femoral metaphysis is used as a
reference point
Ultrasound

•Graf of Austria described the ultrasonographic anatomy of

the newborn hip and devised an ultrasonographic
classification of the hip dysplasia.
•Used as an adjunct to the physical examination and helpful
in measuring and documenting the response of hip to the
pavlik harness treatment.
•Observer dependent and is easy to overdiagnose dysplasia

•Ultrasound findings before 6 weeks can be questionable

because of ligament laxity in early newborn period.

•Treatment before 6wks should therefore be based on

physical examination rather than USG findings alone.
Screening in DDH

Routine Screening of a newborn with examination is recommended but

researches on ultrasound evaluation as a method of screening have mixed results.
The American Academy of Orthopedic Surgeons, developed clinical practice
guidelines in 2014 for detection and non operative management of pediatric DDH
in infants upto 6 months of age. Their recommendations to screening were;

Moderate evidence supports not performing universal ultrasound of newborn

infants
Moderate evidence supports performing imaging study before 6m age with one
or more risk factors like breech presentation, family history , history of clinical
instability.
Currently referral to an orthopedist is
recommended with a positive newborn
examination or a positive result at 2 week follow
up examination

Most helpful when manipulative reduction is

unstable or when the femoral head is not
concentrically seated within the acetabulum.
Arthrogram

•Usually done after induction of GA

•Uses:
Detects dysplasia
Subluxated /dislocated hip
Soft tissue interposition- medial pooling of dye
Condition and position of acetabular labrum(limbus)
Irreducible hip with the medial dye pool
3D IMAGING

MAGNETIC RESONANCE
COMPUTED TOMOGAPHY
IMAGING (MRI)
•Confirms maintenance of •Offers excellent visualization of
the reduction in the cast the anatomy with no radiation as
compared to the CT.
•In older children 3DCT useful
•Confirms a concentric reduction
to plan surgery
•Detects AVN
•Disadvantage: Takes more time
and increased cost
Management of DDH:
AIM OF TREATMENT

•Obtaining a concentric reduction

•Maintaining a concentric reduction
•Aid in the normal acetabular development
•Avoid complications like the Avascular necrosis of the head
of femur
Age Management
Neonatal hip instability(0-1 month) Positioning device to keep hip abducted
1 to 6 months Pavlik Harness, Rigid brace, CMR spica
6 months to 18 months Closed reduction and spica
Adductor tenotomy/ closed reduction and
spica
Open reduction if closed reduction fails
Medial approach/ Anterior approach
18 months to 3 years Open reduction
Innominate osteotomy
(Pemberton/Dega/Salter)
Femoral osteotomy
3 years to 8 years Open reduction
Femoral shortening
Pelvic osteotomy (Pemberton/Dega/Salter)

>8 years ??
Safe zone of Ramsey

•Range of abduction in which the Redislocation

hip is reduced
•Excess of abduction can lead to
AVN
•Less of abduction – redislocation AVN

•15°-20° of margin taken

Safe zone of Ramsey used to determine

acceptability of the closed reduction of
congenital dislocation of hip
TREATMENT( Birth to 6 months)

•Directed at stabilizing the hip that has a positive Ortolani or Barlow

test or reducing the hip that has a mild adduction contracture
•Treated successfully with a rate of 85-95% with Pavlic harness
during the first few months of life
•As there child ages, soft tissue contracture develops, along with
the secondary changes the success treatment of Pavlic harness
decreases.
•In teratologic dislocations too, the pavlic harness in unlikely to be
successful
PAVLIC HARNESS

•Dynamic flexion abduction

orthosis
•Produces excellent results in
treatment of dysplastic and Shoulder
strap
Chest
strap
dislocated hip in infants during
the first few months Stirrup

•limits adduction to within safe

zone and allows movement
within safe zone
•Hip is placed in flexion of 90° to 110° and the anterior flexion
strap is tightened to maintain this position
•Knees should 3-5cm apart at full abduction. Avoid forced
abduction.
•Worn 23-24 hrs/day until stability+
•Re-examine at 1-2 week interval
•A radiograph of the patient in the harness can help to confirm
that femoral neck is directed towards the triradiate cartilage.
•During the first few weeks, when hip seems stable clinically, USG
evaluation is sufficient to confirm reduction.
Complications:

•persistent dislocation in harness

•AVN (∼1%)
•Femoral nerve palsy, therefore quadriceps function should
noted at each examination
•Pavlick harness disease – on long term dislocation in
harness – changes occurs at head and acetabulum
(flattening of the posterior acetabulum) therefore reduction
becomes difficult
Risk factors for pavlic harness failure :
• Absent Ortolani test
• Bilateral hip dislocations
• Development of femoral nerve palsy during treatment
• Acetabular angle of 36 or more
• Initial coverage of 20% or less( by USG)
•If Pavlic harness treatment
fails, successful reduction has
been achieved by a trial with a
rigid abduction orthosis for a
few weeks.

Rigid abduction orthosis can be used

successfully in children in whom pavlic harness
failed to produce stable reduction.
TREATMENT(6 months- 18 months)

•Secondary adaptive changes occur therefore

reduction can be a problem.
•Limbus acetabuli hypertrophy
•Ligamentum teres hypertrophy and elongates
•Femoral head becomes reduced in size and
excessive anteversion
•Capsule becomes permanently elongates
•Femoral head migrates superiorly and
laterally
• Treatment in this age group includes
1. Preoperative traction
2. Adductor tenotomy
3. Closed reduction and arthrogram (f/b hip spica application)
4. Open reduction in children with failed closed reduction
Femoral shortening may be needed with high proximal dislocation
 Preoperative traction
The role of preliminary traction in reducing the incidence of
osteonecrosis and in improving reduction is controversial
although, some suggests if traction decreases the risk of
osteonecrosis even slightly, it may be considered.
 Adductor tenotomy
 Mild adduction contracture – percutaneous adductor tenotomy
 Severe adduction contracture – open adductor tenotomy through
small transverse incision is preferable.

 Arthrography and closed reduction

 Done with the child under GA
 Proposed criteria for acceptance of a reduction are a medial dye of
5mm or less and maintenance of reduction in acceptable safe zone.
 Acceptable closed reduction is sensation of clunk as femoral head
reduces in true acetabulum. Another indicator is increase in knee
flexion angle (popliteal angle).
Hip spica cast

•After confirmation of a stable hip reduction a hip spica cast is

applied.

•Hip joint is 95° flexion and 40°-45° of abduction (human

position as advocated by Salter), considered the best for
maintain the hip stability and minimizing the risk of
osteonecrosis
Following a closed reduction, 3D-imaging are used for confirmation
of the reduction
A comparison of MRI and CT found 100% sensitivity of both CT and
MRI and specificity of 96% in CT and 100% in MRI.

 Open reduction
it is indicated in whom closed reduction has failed and when
interposed soft tissues are to be corrected to reduce the head
concentrically in the acetabulum.
Approach for an open reduction can be an anterior or medial
approach and regardless of the approach chosen, open reduction
should correct as many as blocks to the reduction as possible
Comparison of the approaches

ANTERIOR APPROACH (SOMER-BIKINI

MEDIAL APPROACH (LUDLOF APPROACH)
APPROACH)
•Minimum dissection utilizes the •Required more anatomical
interval between iliopsoas and dissection and provides a better
pectineus exposure
•Exposes and higher risk to the medial
circumflex vessels leading to •Capsulorrhaphy can be performed
osteonecrosis (10-20%). and pelvic osteotomy can be
•Does not allow capsulorrhaphy performed through this approach.
•Recommended in infants of 6-18 •Recommended in older children
months old
Anterior bikini
incision made Capsulotomy of
extending iliac hip and use
crest to point ligamentum
midway between teres to find the
ASIS and midline true
of pelvis acetabulum

Interval between the

Sartorius and TFL
muscle Reduction and
capsulorrhaphy
after excision of
redundant
capsule

Anterior approach to the open reduction

 DDH of the right hip

After anterolateral open reduction Age at 7yrs, note remodelling

Incision transverse one
centered at the
anterior margin of
adductor longus
around 1 cm distal and
parallel to the inguinal
ligament
CONCOMITANT OSTEOTOMY
Use of concomitant osteotomy including the innominate osteotomy,
acetabuloplasty, proximal femoral varus derotation osteotomy or femoral
shortening osteotomy might increase the stability of open reduction
Zadeh et. al. used concomitant osteotomy to maintain stability of
reduction in which the following tests of stability after open reduction was
used;
Hip stable in neutral position – no osteotomy
Hip stable in ABD + flexion – innominate osteotomy
Hip stable in internal rotation and abduction – proximal femoral
derotational varus osteotomy
“double diameter” acetabulum with anterolateral def.- Pemberton type
osteotomy
Concomitant osteotomy
particularly, femoral shortening
osteotomy with or without
derotation should be done at
the time of open reduction
when necessary to maintain
stable safe reduction
TREATMENT IN TODDLER (18-36
months)

•For these children with well-established hip dysplasia, open

reduction with femoral or pelvic osteotomy or both is often
required.
•Persistent dysplasia can be corrected with redirectional proximal
femoral osteotomy in very young children
•If the primary dysplasia is acetabular, pelvic redirectional
osteotomy alone is more appropriate.
•However, in older children, both femoral and pelvic osteotomies
may be required if the deformity is significant
FEMORAL OSTEOTOMY

Good results in patients < 4years

Unpredicatable for age group 4-8 years due to development
of acetabulum
No benefit in > 8 years
Landmark to stop : arthrogram – good reduction in AB and
IR
• Varus osteotomy; hip remains stable in only wide
abduction

• Derotational osteotomy needed if there is anteroversion

requires significant internal rotation for reduction to be
stable.

• Varus derotational osteotomy; hip remains stable only in

abduction and IR

• Femoral shortening; high riding dislocation in older

children.
Femoral shortening
TREATMENT (3-8 years)

•By this age group, adaptive shortening of the periarticular

structures and structural alteration in the femoral head and
acetabulum has occurred and therefore, management in this
age group is difficult
•Preoperative skeletal traction should not be used as the only
means of achieving reduction because of high frequency of
osteonecrosis (54%) and redislocation (31%)
•Femoral shortening helps in reduction and decreases the
potential for complications
• Primary acetabular repositioning often needed;
Salter/Pemberton
• In >3 year-olds, an acetabular procedure needed to
adequately cover the head.
• Primary femoral shortening , anterior open reduction
and capsulorrhaphy with/without pelvic osteotomy
as indicated have been recommended in children 3
years or older.
PELVIC OSTEOTOMY

Abnormal acetabular Redirectional

angle osteotomy

Volume
Too large acetabulum reduction
osteotomy

Acetabular
Too small acetabulum
augmentation
Redirectional osteotomy (volume neutral)

•Salter innominate (most common); entire acetabulum with

ischium and pubic rotated as unit winging on pubic
symphysis
•Triple innominate of Steel or Tonnis
•Ganz periacetabular osteotomy (adolsecent) (after skeletal
maturity)
Salters innominate osteotomy

•entire acetabulum with ischium and pubic rotated as unit

winging on pubic symphysis.
•Redirects acetabulum; anterolateral coverage to femoral
head
•Corrects acetabular dysplasia
•Indications: DDH- 18months - 6 years; lateral and anterior
acetabular dysplasia
 Prerequisites;
•Concentric reduction of femoral head
•Open reduction of hip to obtain concentric reduction
•18 months to 6 years age
•ROM good – Flexion∼100°; abduction∼30°
•Contractures of iliopsoas and adduction must be realeased

Contraindications:
Non-concentric reduction
Severe acetabular dysplasia
>8 years
Stiff hip
 Graft taken from iliac
crest to fill wedge
and fixed with k wire

Incsision
taken from
greater sciatic
notch to AIIS

Distal
fragment
shifted
forward
downward
and
outward

Salters osteotomy
Open reduction with femoral
shorteing and salters osteotomy
Volume reduction osteotomy:

•Pemberton osteotomy
•Dega osteotomy
Pemberton acetabulplasty:

•Alter the shape of the acetabulum by osteotomy of ileium superior to

acetabular roof and levering the roof inferiorly
•Done in 18month – 8 years age
•Large acetabulum with small femoral head
•Anterolateral coverage
•Pre requisites:
• Good range of movements
• Age 18m – 8 yrs
• Open triradiate cartilage
• Anterolateral acetablular deficiency
Acetabular augmentation:
Shelf operation( Staheli ) – bone graft is put in the superior
margin of the acetabulum
Chiari osteotomy- innominate osteotomy with medial
displacement of the acetabulum.
Treatment in adolescents and young
adults (>8yrs)
•In unilateral dislocations: reduction strongly considered
• If femoral head cannot be positioned distally to level of
acetabulum- palliative salvaging operations are possible
• Rarely femoral shortening + pelvic osteotomy considered
•Bilateral dislocations: should be left untreated
•After some years when degenerative arthritis develop, when
they cause enough pain and limitation of movement,
reconstruction operations like THR done.
Old unreduced dislocation:

•Pelvic support osteotomy

•Ilizarov hip reconstruction/LRS
•THR
References:

Tachdjian’s pediatric orthopaedics 6th edition

Campbell ‘s operative orthopaedics 14th edition
Thank you!