Developmental Dysplasia of Hip

1. Department of Orthopaedics
AFMC, Pune
PG SEMINAR
DEVELOPMENTAL DYSPLASIA
OF HIP
Maj Rohit Vikas
Resident

2. CDH/ DDH
Instability of the hip in the newborn
Includes
Dislocatable hips
Acetabular dysplasia
Subluxation of femoral head
Dislocated Femoral head
As the child grows it may
Progress to dislocation or poor acetabular
coverage
Secondary changes develop in head and
acetabulum
Process is not restricted to congenital abnormalities
of the hip, and includes some hips that were normal
at birth and subsequently became abnormal.

3. DEVELOPMENTAL DYSPLASIA
OF HIP
DEFINITIONS

4. Which is an Unstable Hip?
Positive Barlow/ Ortolani Tests
Clinically stable but abnormal USG
Acetabular Index
Lateral displacement of femoral
beak in relation to Perkin’s line

5. What is Dysplasia?
Radiographic finding
Increased obliquity of acetabulum
Loss of acetabular concavity
Intact Shenton line

6. What is Subluxation?
Femoral head not fully in contact
with acetabulum
Widened Teardrop – femoral head
distance
Reduced CE angle
Break in Shenton line
Dysplastic changes in acetabulum

7. What is Dislocation?
Femoral head not in contact with
acetabulum
Dysplastic changes in acetabulum

8. Teratologic / Antenatal Dislocations
Fixed dislocation at birth with limited range of motion at hip
During gestation the hip is at risk of dislocation
during the 12th week when the lower limb rotates medially,
during the 18th week as the hip muscles develop.
Dislocations during these developmental stages are termed teratologic and are
the result of congenital abnormal neuromuscular development.
Treatment unsuccessful
Open Reduction at 6 months of age

9. Secondary Hip Dysplasia
Strictly, DDH applies to idiopathic hip dysplasia
Secondary Hip dysplasia
Neurological conditions
Myelomeningocele
Cerebral palsy
Connective tissue diseases
Ehlers-Danlos syndrome
Myopathic disorders
Arthrogryposis multiplex congenita.

10. DEVELOPMENTAL DYSPLASIA
OF HIP
ETIOPATHOGENESIS

11. INCIDENCE
Breech delivery
Frank Breech
20% incidence
of DDH
Left hip > Bilateral > Right hip
Complete or
Lowry, et al, showed that breech infants footling breech
delivered by elective caesarean section (pre- lower incidence
labor) had a lower incidence of DDH than of DDH (2%)
those breech babies delivered vaginally

12. ASSOCIATED CONDITIONS
Other positional abnormalities including:
Torticollis (20%)
Metatarsus adductus (10%)
Positional club foot
Congenital Knee dislocation

13. THEORIES
Mechanical factors
Hormone induced ligamentous laxity
Primary acetabular dysplasia
Genetic inheritance

14. DEVELOPMENTAL DYSPLASIA
OF HIP
CLINICAL DETECTION OF DDH
BIRTH TO 6 MONTHS

15. Asymmetrical Thigh Folds
Indicative of Abnormal hips
Also seen in infants with normal hips
Widened perineum
Prominent Greater trochanter

16. Galeazzi’s / Allis sign
Limited Abduction
In bilateral hip abnormality, asymmetry may not
be a feature

17. Ortolani’s sign
(Ortolani 1937, 1976).
Hold the knees and abduct the hip while lifting
up on the greater trochanter
A positive test is feeling the dislocated hip
clunk into the acetabulum

18. Barlow’s Provocative Test
(Barlow,1962)
Adduct and push posteriorly on the hip
A positive test is feeling the hip push out of the
acetabulum

19. Klisic sign in bilateral DDH
The Ortolani and Barlow manoeuvres are the mainstay of clinical diagnosis in
the first months of life
Even in the best hands physical examination can fail to detect DDH, and after 3 months
of age the Ortolani and Barlow tests become negative due to progressive soft tissue
contractures.

20. DEVELOPMENTAL DYSPLASIA
OF HIP
CLINICAL DETECTION OF DDH
OLDER CHILD

21. Abduction becomes more limited which is particularly noticeable when there is
unilateral disease.
Femoral shortening (positive Galeazzi test) may be apparent but this can be difficult
to appreciate with bilateral disease.
Ambulatory children will have a Trendelenburg gait in addition to limited hip
abduction
Trendelenburg sign
Telescopy positive
Exaggerated lumbar lordosis

22. DEVELOPMENTAL DYSPLASIA
OF HIP
NATURAL HISTORY

23. What happens to a Dysplastic hip without subluxation ?
Usually become painful
Degenerative Arthritis over time
Often subluxate as degeneration progresses
Hips with Acetabular index > 35 will likely require hip replacement later
If these hips are well reduced after primary treatment of DDH, with a greater
than normal CE angle, risk of Degenerative arthritis decreases

24. What happens to a Subluxated hip?
Always lead to symptomatic degenerative arthritis
Rapid progression
Severe subluxation – symptoms in 2nd decade
Moderate subluxation – in 3rd to 4th decade
Mild subluxation – in 5th to 6th decade

25. What happens to a completely dislocated hip?
Symptoms much later than a subluxated hip
May never become painful
False acetabulum
False acetabulum

26. Consequences of Persistent Dysplasia
Abnormal gait
Restricted abduction
Reduced strength
Increased rate of degenerative joint disease.
Outcome of untreated unilateral DDH is less favorable compared with bilateral
disease
Limb length discrepancy,
Asymmetrical movement, strength
Ipsilateral valgus knee.
Degenerative joint disease tends to present earlier in subluxated hips than in
dysplastic hips without subluxation

27. Natural History
Over the age of 6 months spontaneous resolution of dysplasia is unlikely
Usually more aggressive treatment is required compared with younger children.
Older children tend to have more advanced changes in the soft tissues and bony
structures.
Changes in acetabulum
Ossification is delayed
Shallow,
Anteverted
Deficient anterolaterally.
Changes in Femoral Head
Delayed ossification
Exaggerated femoral anteversion.

28. Natural History
A 16y /F with longstanding “missed” left DDH.
The left femoral head articulates with a neo-acetabulum in the iliac bone.
The left femoral shaft is reduced in diameter and there is wasting of the thigh muscles

29. Natural History

30. Natural History

31. DEVELOPMENTAL DYSPLASIA
OF HIP
PLAIN RADIOLOGY

32. Normal Hip
Perkins’ line
acetabular
index
Hilgenreiner’s line
Shenton’s line

33. Normal Hip
Acetabular index
Angle between the acetabulum
and hilgenreiner’s line
It should be < 30 degrees in a
newborn
Center-edge angle of Wiberg
Cannot be measured until the ossific
nucleus appears
Normal is > 10 degrees in children 6-
13 yrs

34. DDH
Ossification centre
Head of femur
2 and 7 months

35. DDH
8 month /F with left DDH.
Left acetabulum is shallow and the
hip is dislocated.
Left proximal femoral ossification
centre is small compared with the
normal right side.
The normal right acetabulum has a
central depression and well-defined
lateral edge.
The acetabular teardrop is
developing on the right but not on
the dysplastic left side

36. DEVELOPMENTAL DYSPLASIA
OF HIP
ULTRASOUND

37. L
β
Iliac Wing Femoral Head
α
T
Bony
Diagram showing hip anatomy on standard coronal US plane and lines Acetabular
used to evaluate hip dysplasia using the Graf method. roof
Femoral head (FH) is centred over the hypoechoic triradiate cartilage
(T). The promontory is at the junction of the iliac wing (IL) and the
bony acetabular roof (A). L, labrum.
The alpha angle reflects the depth of the bony acetabular roof and is Standard coronal ultrasound of the normal
formed by the intersection of the baseline (BL) and acetabular roof infant hip joint. The promontory is sharply
line (AL). In a normal mature hip the alpha angle is greater than 60°.
defined and the bony acetabular roof is
The beta angle reflects cartilaginous coverage and is formed by the steep. The ossification centre for the femoral
intersection of the baseline with the labral line (LL). A normal beta head has not yet developed
angle is less than 55°

38. SONOGRAPHIC CLASSIFICATION

39. DEVELOPMENTAL DYSPLASIA
OF HIP
ARTHROGRAPHY

40. Not routinely performed
Either performed before surgery or intraoperatively.
Goal of arthrography in DDH is to demonstrate the position of the femoral head with
respect to other joint structures both at rest and during reduction or stress manoeuvres
It also outlines any deformities or obstructions to concentric reduction
Inverted limbus,
Capsular constriction,
Pulvinar Hypertrophy
Hypertrophied ligamentum teres

41. Arthrogram, made after
fifteen days of overhead
traction, showing the hip
to be reduced. A square-
shaped limbus (arrow) at
the superior pole of the
epiphysis and marked
capsular distension are
evident.

42. DEVELOPMENTAL DYSPLASIA
OF HIP
COMPUTED TOMOGRAPHY

43. Two main indications for CT in DDH:
To document hip reduction post-
operatively if a child is placed in a spica
cast
Pre-operative planning in severely
dysplastic hips that require corrective
procedures.
Axial CT scan following open reduction of the left hip.
The left femoral metaphysis is not aligned with the
acetabulum and the femoral head is displaced
posteriorly.
The spica cast was removed and patient underwent
further manipulation under anaesthesia to achieve
successful reduction

44. DEVELOPMENTAL DYSPLASIA
OF HIP
MRI

45. Distinct advantages over both CT and arthrography in pre-operative imaging in
patients with DDH.
Ability to differentiate between different types of soft tissue which enables
visualisation of unossified cartilage, ligaments, fat, muscle and fluid including those soft
tissues that present an obstruction to concentric reduction such as pulvinar, the labrum
and joint capsule.
Lack of ionising radiation
MR imaging is more time-consuming than CT or arthrography.
In newborns and infants sedation may be required, except if patents are in a spica cast
since this limits movement.
The main disadvantages of MR imaging is increased cost and limited availability

46. DEVELOPMENTAL DYSPLASIA
OF HIP
SCREENING

47. General Examination
-Plagiocephaly,
-Sternomastoid Tumour (Torticollis),
-Feet for any congenital deformity

48. Hip Examination
Barlow’s test (<3-4 months of age)
Ortolani’s test (<3-4 months of age)
Limitation of Abduction
Leg length discrepancy (Galleazi test)
Asymmetry of thigh folds
Limp in a walking child

49. Radiology
Children <6 months - Ultrasound using Graf
classification system
Class Alpha angle Description
I >60 Normal
II 60-43 Immature/Dysplastic
III <43 Subluxed/Dislocated
IV Unmeasurable Dislocated
Children >6 months - Xrays.

50. Criteria for Screening
Clinical Screening for all neonates for Hip Instability.
Careful screening for infants with risk factors:
Family history of DDH
Breech
Torticollis
Metatarsus adductus
Oligohydomnios
Screening with USG
Controversial
As per AAP guidelines
Female infants delivered breech
Family history of DDH +

51. DEVELOPMENTAL DYSPLASIA
OF HIP
TREATMENT
BIRTH – 6 MONTHS

52. DEVELOPMENTAL DYSPLASIA
OF HIP
PAVLIK HARNESS

53. Indications
All Dislocated hip that can be reduced (Ortolani’s sign)
Start harness at the time of diagnosis
Hips that are located but can be subluxated (Barlow’s sign)
Some may spontaneously stabilize, some may dislocate.
Re-examine after few weeks before starting treatment
Hips that are normal on clinical examination but abnormal on USG
Close observation
Repeat USG at 6 weeks of age
Abnormal hips treated
Graf II hips more likely to improve without treatment than Graf III/ IV hips
Irreducible hips
Likely to fail treatment if initial coverage was < 20%

54. Application
Flexion – 120°
Hyper flexion
Femoral nerve palsy
Inferior dislocation of head
Inadequate flexion < 90°
Fails to reduce hip
Abduction by gravity
1
4
3
2

55. Follow Up
Weekly Follow up during harness treatment
Change size after 3-4 weeks
USG at 3-4 weeks
If unreduced – discontinue treatment
Examine under anaesthesia
Arthrogram for cause of instability
If hip reduced but can be dislocated
Continue harness for 3-6 more weeks
After 6 weeks of harness – USG with child out of harness.
If reduced head – Wean/ discontinue harness
X rays at 3-4 months
X rays at 1 yr
Annual Follow up
Follow up till skeletal maturity
(Late asymmetric epiphyseal closure – valgus femoral head and reduced coverage
Acetabular dysplasia in 20%)

56. Problems in Harness
If reduction not achieved with harness in 3 – 4 weeks then discontinue harness and
other treatment started.
PAVLIK DISEASE
Prolonged positioning of dislocated hip in flexion and abduction
Dysplasia increased - Flattening of posterior acetabulum
Open reduction needed
Femoral nerve palsy

57. DEVELOPMENTAL DYSPLASIA
OF HIP
TREATMENT
6 – 18 MONTHS

58. Goal of Treatment
Obtain and maintain reduction without damaging femoral head
Closed Reduction
Open Reduction
Problems
Risk of Avascular Necrosis
Growth potential of acetabulum declines with age (and hence remodelling
potential)

59. Role of Pre Reduction Traction
Reduced risk of Avascular Necrosis
30% without Traction
15% with prereduction traction
< 5% in Human position
(flexion 90 and mild abduction)
Reduced need for Open reduction
Portable Home Traction
for 2 – 3 weeks

60. Role of Pre Reduction Traction
Bryant’s Traction

61. Closed Reduction
Gentle positioning
Determine Stability – Wider Zones of Safety

62. Adductor Tenotomy
Increases the Zones of Safety by allowing wider range of abduction

63. Hip Spica Cast
Flexion > 90
Abduction 30 – 40 acceptable as long as
further abduction possible
Slight internal rotation (10 – 15)

64. Hip Spica Cast
Intraop radiograph
Confirm reduction – USG/ CT Scan
MRI – reduction and vascular status of head can both be assessed
Remove cast after 6 weeks under anesthesia
Assess stability through moderate range of motion/ do not dislocate.
Xray AP pelvis to confirm reduction
Reapply second cast for 6 weeks.
Third cast/ Abduction splinting
Usually applied for 6 more weeks and discontinue immobilization

65. Obstacles to Reduction
• Extra- articular
– Iliopsoas tendon
– adductors
• Intra-articular
– inverted hypertrophic labrum
– tranverse acetabular ligament
– pulvinar, ligamentum teres
– constricted anteromedial capsule espec in late cases
• neolimbus is not an obstacle to reduction and represents epiphyseal cartilage
that must not be removed as this impairs acetabular development

66. Open Reduction +/- Capsulorrhaphy
For unstable hips
Widened joint space
Approaches
Medial Approch v/s Anterior approach
Minimum dissection Better exposure
Obstructions approached directly Capsulorrhaphy can be performed
Limited exposure
Medial femoral Cx Artery
< 1 yr of age in older children

67. Open Reduction + Femoral Shortening
If there is excessive pressure on femoral head when it is reduced
Consider in a dislocated hip in > 2 yrs age
To correct excessive anteversion
To place femoral head into Varus position
Intertrochanteric/ Subtrochanteric
osteotomy

68. Open Reduction + Innominate Osteotomy
If there is need for added coverage
Assess need:
Hip in extension – neutral rotation –
abduction
If > 30% head visible then innominate
osteotomy required
Innominate osteotomy in > 18 months.
Salter / Pemberton
Consider femoral shortening for
excessive pressure on head

69. DEVELOPMENTAL DYSPLASIA
OF HIP
TREATMENT
18 – 36 MONTHS

70. Open Reduction
Evaluate stability of hip during open reduction
Assess need for added coverage
Salter/ Pemberton pelvic osteotomy
For Children > 3 yrs, usually an acetabular procedure is needed to cover femoral
head adequately

71. Varus Derotational Femoral Osteotomy

72. DEVELOPMENTAL DYSPLASIA
OF HIP
TREATMENT
3 – 8 YEARS

73. Problems
Proximal head location
Contracted muscles
Femoral shortening required, greater shortening required for higher dislocations
Primary acetabular repositioning osteotomy often needed
Salter/ Pemberton
In > 3 yr, an acetabular procedure needed to adequately cover the head

74. Open Reduction
Upper age for Successful Reduction
Unilateral dislocations
Open reduction should be attempted till 9 – 10 yrs of age
Gait asymmetry
Bilateral dislocations
Upto 8 yrs
Increased complication if both hips reduced
Natural outcome of untreated B/L Dislocation better than results of treatment

75. PELVIC OSTEOTOMIES
Simple osteotomies that Reposition the Acetabulum
Salter Innominate Ostetomy
Pemberton’s Acetabuloplasty
Dega Osteotomy
Complex Osteotomies that Reposition the Acetabulum
Steel osteotomy
Tonnis Osteotomy
Ganz Osteotomy
Spherical Acetabular osteotomy
Osteotomies that Augment the Acetabulum
Chiari Osteotomy
Shelf Procedures
Staheli Slotted Acetabular Augmentation

76. PELVIC OSTEOTOMIES

77. Salter Innominate Osteotomy
Prerequisite – concentrically reduced hip
Acetabular dysplasia
Failure of acetabular index to improve within 2 yrs after
reduction
Persistent dysplasia after 5 yrs of age
Likely hood of Degenerative osteoarthritis high
For 2 – 9 yrs of age
(< 2 yrs – not enough iliac wings that are thick enough to
support bone graft,
> 9 yrs – acetabular fragment not adequately mobilized.
Improves Acetabular index by avg 10°.

78. Salter Innominate Osteotomy

79. Salter Innominate Osteotomy

80. Pemberton’s Acetabuloplasty
Improves anterior and lateral coverage of femoral head
Stable osteotomy, does not require Internal Fixation
Hinges through triradiate cartilage, reduces the volume
of acetabulum
Contraindicated if acetabulum is small relative to femoral
head.
Complication
Closure of triradiate cartilage (very rare)
Damage to acetabular growth areas if
osteotomy too close to acetabulum

81. Pemberton’s Acetabuloplasty

82. Pemberton’s Acetabuloplasty
6-year-old child underwent
open reduction with
capsular placation, femoral
shortening, and a pelvic
(Pemberton) osteotomy.

83. Dega Osteotomy
Increases acetabular coverage anteriorly, centrally and posteriorly.
Placement of wedges determine the areas of coverage to be improved

84. Dega Osteotomy
Residual acetabular
dysplasia on right
side.

85. Steel Triple Osteotomy
Osteotomies through ilium and both pubic rami.
Increases anterolateral coverage
(More than Salter)

86. Chiari Osteotomy
Used when other procedures cannot
achieve a concentric reduction of hip.
Controlled fracture through ilium with
medial displacement of acetabular
fragment and the intact hip capsule
under the ilium.
Over time the hip capsule converts into
fibrocartilage and becomes the new
acetabular coverage.
A Salvage surgery

87. Chiari Osteotomy

88. Shelf Operations
Slotted Acetabular
Augmentation (Staheli)

89. Staheli Acetabular Augmentation

90. DEVELOPMENTAL DYSPLASIA
OF HIP
TREATMENT
> 8 YEARS

91. If Femoral head cannot be repositioned distally to the level of Acetabulum
Palliative Salvage Surgeries
Rarely, Femoral shortening + Pelvic Osteotomy
Degenerative Arthritic Painful Hip
Total Hip Replacement
Role of Arthrodesis
Rarely used now for old unreduced dislocations
Contraindicated in bilateral dislocations
Bilateral Dislocations
Leave hip unreduced
Later do THR
Reduced hip but painful acetabular dysplasia
Pelvic osteotomy

92. DEVELOPMENTAL DYSPLASIA
OF HIP
COMPLICATIONS

93. Complications
Avascular Necrosis of Femoral Head
Trochanteric overgrowth
Inadequate Reduction and Redislocation
Residual Acetabular Dysplasia
Acetabular dysplasia Presenting late

94. Avascular Necrosis

95. THANK YOU