‫ميحرلا نمحرلا هللا‬ ‫بسم‬

Developmental Dysplasia of The Hip

(DDH)
By
Hosam M. Khairy
2018

Contact us
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hosamkhairy@gmail.com
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Evidence Based Medicine
 References
• Campbell 8th - 13th Edition
• Tachdjian ( DDH – CP – Spina Bifida)
• Tachdjian CDH
• Tachdjian Atlas
• Tonnis
• Ortho- bullet
• AAOS
Definitions
Dislocation: complete displacement of
the joint, with no contact between the
original articular surfaces
Subluxation: displacement of the joint
with some contact remaining between
the articular surfaces
Dysplasia: Deficient development of the
acetabulum
DDH: is a spectrum of disorders of
development of the hip that present in
different forms at different ages.

DDH: is a disorder that evolves over

time.

Teratologic dislocation: is an intra-

uterine dislocation
Incidence
• Female : male (5:1)

• left > Right

• Dislocation (1.4/1000 births)

• Clinical finding(2.3/100 births)

Conditions associated with DDH
• Torticollis
• Metatarsus adductus
• Oligohydramnios
Etiology
The common etiology is excessive
laxity of the hip capsule, with
failure to maintain the femoral
head within the acetabulum
 Causes:
• Ligamentous laxity
• Breech presentation
• Postnatal positioning
• Primary acetabular dysplasia
Screening criteria (Risk factors)
• Family history of DDH
• Breech presentation
• Torticollis
• Oligohydramnios
• Metatarsus adductus
Pathology
 Capsule
• Laxity

• Hour glass constrictioin

• Pericephalic insertion of capsule

Hour glass capsule
Pericephalic insertion of the capsule
 Tight Muscles & Tendons
• Sartorius
• Rectus femoris
• Iliopsoas
• Adductor longus
 Acetabulum
• Limbus
• Pulvinar
• Transverse ligament
• Acetabular index
Acetabular changes
 Upper femur
• Antetorsion

• Coxa valga

• Coxa magna
 6 Obstacles to reduction
• Tight iliopsoas
• Hour glass capsule
• Inverted labrum
• Pulvinar
• Ligamentum teres
• Tight transverse ligament
Clinical features
 (Neonate)
1. Barlow test
2. Ortolani test
3. Klisic test
Ortolani test
Klisic test
 (Infant)
1. Barlow (Occasional)
2. Ortolani (Occasional)
3. Klisic
4. Asymmetrical skin folds
5. Decreased abduction
6. Galeazzi sign
Asymmetrical skin folds
Decreased abduction
Galeazzi sign
 (Walking child)
1. Klisic sign
2. Decreased abduction
3. Galeazi sign
4. Limping
5. Shortening
6. Lumbar lordosis (bilateral cases)
Ultrasonography
 Ultrasonography shows the soft anatomy of the
hip and the relationship of the acetabulum and
the femoral head very well.
Three question about hip US :
1. How often does US identify silent hip
2. Which US finding indicate that the hip must be
treated
3. Does US increase the rate of treatment for the
hips that would stabilize without such treatment
 Graf pioneered the use of US in
evaluation of hip anatomy he found:

• Hyaline cartilage of the hip has little echo

• Capsule and muscles has moderate echo
• Fibro cartilage and juncture of cartilaginous
upper femur and femoral neck had strong
echo
 Graf lines & angles
• Baseline: the line of the ilium as it intersects
the bony and cartilaginous acetabulum
• Inclination line: line along the margin of
cartilaginous acetabulum
• Acetabular roofline: bony roof of acetabulum
• Alpha angle: intersection of baseline and
roofline
• Beta angle: intersection of baseline and
inclination line
US
US
Graf classification
Radiography
Radiologic lines
 Radiologic lines
• Helignreiner's line
• Perkin's line
• Shenton's line
• Acetabular index
• Center edge angle
• Von Rosen views
• Acetabular teardrop
Shenton line
Radiologic lines
Acetabular index: angle between Helignreiner's
line and Acetabular roof
• Newborns: 27.5
• At 6 months: 23.5
• At 2 years: 20
Acetabular teardrop: formed laterally by
acetabular wall, medially by the wall of lesser
pelvis and inferiorly by Acetabular notch. It
appears between 4 and 24 months
When the hip is dislocated, the Acetabular
portion of teardrop loses its convexity and the
tear drop appears wider from above downwards.
When the teardrop appears within 6 months
after reduction this means better outcome
CT
Mostly beneficial with the cast
 CT indicated in:
• Postoperative to assess reduction
• Neglected cases (above 6 years)
• Revision cases
Arthrography
• In normal hip the free border of the labrum is
seen as a sharp thorn
• In DDH the capsule is enlarged over the
dislocated head with hour glass constriction
of the capsule by iliopsoas tendon
• Ligamentum teres may be seen outlined by
the dye
• A bulge of Acetabular cartilage may be seen
under the labrum (neolimbus)
MRI
MRI classification of DDH

• Group 1: sharp Acetabular rim

• Group 2: rounded Acetabular rim

• Group 3: inverted Acetabular rim

MRI
Treatment
• Neonates: place in Pavlik harness 6 w
• 1-6 months: place in Pavlik harness 6 w
after hip reduction
• 6-18 months: closed reduction+/- Add ten.
*If succeeded: spica cast for 3 m
* If failed: open reduction
<12 m medial approach
>12 m anterolateral approach
• 18-24 m: !trial closed reduction
Open reduction: anterolateral approach
Pelvic osteotomy

• 24m- 6 years:
Open reduction
Femoral osteotomy +shortening
Pelvic osteotomy
 Braces
• Pavlik Harnes
• Frijka pillow
• Triple Diapers
Pavlik harness
Closed Reduction
Stability after Closed Reduction
Open Reduction
Age limit
Medial
Anterior
Y. Nasr
Y-V Capsulotomy
Labrum
Concomitant Osteotomy
 Femoral Osteotomy
• Rotational
• Varus
• Shortening
Femoral Shortening
How to measure shortening
 Pelvic Osteotomies
• Reconstructive:
Redirectional
Single
Double
Triple
Reshaping (Acetabuloplasty)
Pemberton
Dega
Lance +Modified Lance Acetabuloplasty
• Salvage:
Chiari
Shelf operation
Pemberton osteotomy
Salter osteotomy
Dega osteotomy
Tonnis and Ganz
Residual Acetabular Dysplasia
 When to decide?
secondary pelvic osteotomy
• Lack of acetabular development 2 yrs post 0p
(Acetabular index > 35°)
• Presence of subluxation (broken shenton
line)
• Abnormal gait (Trendelenburg)
N B:
1- shortening is benificial
2- walking in abduction is also benificial
 Inadequate Reduction and
Redislocation (Revision DDH)
Long Term F Up
THANK YOU