Developmental Dysplasia of Hip/ DDH is common among newborns, so it is important to screen all newborns for DDH

1. By: Dr. Daniel Joseph Augustine
MOSC Medical College, Kolenchery

2. ANATOMY OF HIP JOINT
 It is a multiaxial ball and socket joint designed for stability
and weight bearing.
 Movements at the joint include flexion, extension,
abduction, adduction, medial and lateral rotation, and
circumduction.
ARTICULAR SURFACES:
 Head of femur articulates with acetabulum of hip bone to
form hip joint
 Head of femur- more than ½ a sphere, covered with
hyaline cartilage
 Acetabulum- lunate shape –notch & fossa

3.  Except for
the fovea,
the head of
the femur is
also
covered by
hyaline
cartilage

5. LIGAMENTS OF HIP JOINT
1. Fibrous Capsule
2. Acetabular labrum
3. Ligaments:
 Iliofemoral
 Pubofemoral
 Ischiofemoral
 Ligament of the head of the femur
 Transverse ligament of the acetabulum

7. BLOOD SUPPLY
 Obturator .A, two circumflex femoral .A, two gluteal.A
 Retinacular br.
NERVE SUPPLY
 Femoral .N
 A/D of obturator .N, Accessory obturator .N
 Nerve to Quadratus femoris
 Superior gluteal .N

9. STABILITY OF HIP JOINT
 Depth of acetabulum
 Tension and strength of ligaments & surrounding
muscles
 Length & obliquity of the neck of femur
High degree of stability & mobility

10. DDH
 DDH is defined as partial or complete
displacement of the femoral head from the
acetabular cavity since birth
 It comprises a spectrum of disorders including
acetabular dysplasia without displacement,
subluxation and dislocation
 Incidence: Females affected 7 times more
 The left hip is more often affected than the right, B/L
involvement in 1 in 5 cases

11. Theories of Etiology
 GENETIC- hereditary predisposition- generalized joint
laxity and shallow acetabula
 HORMONAL – common in females, maternal relaxin,
high E & P levels – aggravate laxity
 INTRAUTERINE MALPOSITION: extended breech -
favour D/L- “packaging d/o”
 POST NATAL FACTORS: uncommon in Asia and India

12. PATHOLOGY
 Dislocated at birth (classic DDH) or dislocatable after
birth (underlying laxity)
Following changes seen:
 Femoral head is d/l upwards & laterally, epiphysis is small
& ossifies late
 Femoral neck- excessively anteverted
 Acetabulum shallow, ligamentum teres HP
 Labrum may be folded into the cavity
 Capsule is stretched, Hip muscles undergo adaptive
shortening

13. CLINICAL FEATURES
 Detected at birth or soon after when child starts
walking
 Birth –Routine screening for suggestive signs in every
newborns especially those at high risk
 Early childhood- Asymmetry of groin fold, click,
limitation of movement
 Older child- peculiar gait, no pain

14. CLINICAL TESTS
For infants :
 Look for asymmerty of groin crease, limitation of movt
or audible click
 Special tests include Barlow’s and Ortolani’s

15. Barlow’s Test
 To assess DDH in neonate.
 The Barlow maneuver identifes the unstable hip that is
in a reduced position that the clinician can passively
dislocate
 Here the hip is started reduced and the test will
dislocate the hip

17. Ortolani Test
 Ortolani maneuver is performed following Barlow's
test to determine if the hip is actually dislocated
 Here the hip is started dislocated and the test will
reduce the hip

19.  For Older Child:
 Limitation of hip abduction, limb short & ext rotated
 Higher buttock fold, asymmetrical thigh fold, lordosis
of the lumbar spine
 Galeazzi’s sign: Hips flexed to 70o
,knees flexed-compare
level –lowering on affected side
 Ortolani’s may be +ve
 Trendelenberg’s Test is +ve
 U/L D/L –trendelenberg gait
 B/L D/L- waddling gait

21. INVESTIGATIONS
Radiological Imaging
 Ultrasonography has replaced radiography for
imaging hips in the newborn. Sequential assessment
allows monitoring of the hip during a period of
splintage.
 Plain X-rays: X-ray examination is more useful after
the first 6 months, and assessment is helped by
drawing lines on the x-ray.

22. X-ray findings:
 Delayed appearance of ossification center of head of
femur
 Retarded development of ossification center
 Sloping acetabulum
 Lateral and upward displacement of ossification centre
of femoral head
 A break in Shenton’s line.

23. Hilginreiner’s line
Perkins line
Shenton’s line

26.  Aim is to achieve reduction of the head into the
acetabulum and maintain it until the hip becomes
clinically stable and a “round” acetabulum covers the
head
 Most cases closed reduction possible, else open
reduction done
MANAGEMENT OF DDH

27. Birth to 6m:
Where facilities for ultrasound scanning are
available, all newborn infants at risk are examined by
USG.
1. If hip is reduced and has a normal cartilaginous
outline, no treatment is required, observe for 3-6m
2. If acetabular dysplasia or hip instability, the hip is
splinted in a position of flexion and abduction and
USG done at intervals

28. Splintage
 Splintage The object of splintage is to hold the hips
somewhat flexed and abducted maintainence of reduction)
 Von Rosen’s splint is an H-shaped splint
 The Pavlik harness is more difficult to apply but gives the
child more freedom while still maintaining position
3 golden rules of splintage are:
 the hip must be properly reduced before it is splinted;
 extreme positions must be avoided;
 the hips should be able to move.

30.  If ultrasound is not available: nurse them in double
napkins or an abduction pillow for the first 6 weeks
and observe for first 6m for devpt of acetabular roof

31. Persistent Dislocation : 6-18m
 The hip must be reduced – preferably by closed
methods but if necessary by operation – and held
reduced until acetabular development is satisfactory.
 Closed reduction : suitable after 3m and is performed
under G/A with an arthrogram to confirm a concentric
reduction.
 Failure to achieve concentric reduction should lead to
abandoning this method in favour of an operative
approach at approximately 1 year of age

32. Splintage
 Held in a plaster spica at 60 degrees of flexion, 40
degrees of abduction and 20 degrees of internal
rotation.
 After 6 weeks the spica is changed & stability assessed
 If satisfactory, spica retained for 6w, then abduction
splint for 6m
 If concentric reduction is not achieved, open operation
is done

33.  The psoas tendon is divided; obstructing tissues are
removed and the hip is reduced.
 It is usually stable in 60 degrees of flexion, 40 degrees
of abduction and 20 degrees of internal rotation. A
spica is applied and the hip is splinted

34. Persistent Dislocation 18m to 4y:
 In older children, arthrography and OR preffered over CR
 Traction: help to loosen the tissues and bring the femoral
head down opposite the acetabulum.
 Arthrography: anatomy of hip, degree of acetabular
dysplasia
 Acetabular reconstruction procedures- If there is marked
acetabular dysplasia, either a
 Pericapsular reconstruction of the acetabular roof
(Pemberton’s operation)
 An innominate (Salter) osteotomy

35.  Salter’s osteotomy
Osteotomy of iliac bone, so that
acetabulum becomes more
horizontal and covers the head
 Chiari’s Osteotomy: Iliac bone
transversly divided avobe
acetabulum & medially
displaced for additional depth
 Pemberton’s osteotomy:
The roof is deflected over the
femoral head.

36. Splintage
 After operation, the hip is held in a plaster spica for 3
months and then left unsupported

37. D/L in children >4yr:
 U/L D/L in the child over 8 years often leaves the child
with a mobile hip and little pain. This justifies non-
intervention, though the child must accept the fact
that gait is distinctly abnormal.
 B/L D/L the deformity –waddling gait – is symmetrical
and therefore not so noticeable;
 Operation avoided unless the hip is painful or
deformity unusually severe.

38. COMPLICATIONS
 Failed reduction: The acetabulum remains
undeveloped, the femoral head may be deformed, the
neck is usually anteverted and the capsule is thickened
and adherent.
 AVN: ischaemia of the immature femoral head. It may
occur at any age and any stage of treatment and is
probably due to vascular injury or obstruction d/t
forceful reduction and hip splintage in abduction.

39. To avoid AVN
 Traction should be gentle and in the neutral position;
 Soft-tissue release (adductor tenotomy) should
precede closed reduction;
 If difficulty is anticipated open reduction is preferable

40. Persistent D/L in Adults:
 If disability is severe enough - total joint replacement.