DEVELOPMENTAL DYSPLASIA OF THE HIP

dr.Ongko Setunggal Wibowo

DEVELOPMENTAL DYSPLASIA OF THE HIP
The term developmental dysplasia of the hip
(DDH), coined by Klisic in the late 1980s, has
replaced the term congenital dislocation of
the hip (CDH) in order to re ect a spectrum
of abnormalities in the development of the
hip joint, ranging from mild acetabular
dysplasia to irreducible dislocation.
fl
Anatomy
EPIDEMIOLOGI
The true incidence is not known precisely although
there is probably some, at least transient, abnormality
of the neonatal hip in up to 10% of females, but
equipoise exists in terms of what needs to be treated
and what can be observed and which patients, or their
parents, can be reassured and discharged.
DDH CLASSIFICATION
Broadly, DDH can be classed into four groups on the
basis of a combination of clinical and sonographic
examination.

1. Reduced and stable but dysplastic

2. Reduced but dislocatable
3. Dislocated but reducible
4. Dislocated and irreducibile

PATHOPHYSIOLOGY
Embryonically the femoral head and acetabulum
develop from a single cleft of primitive mesenchymal
cells. The femoral head begins to separate between 7
and 8w and completed by 11–12 w
Postnatal development of the labrum further deepens
the socket to increase stability of the hip joint and
walking

PATHOPHYSIOLOGY
The first time at which dislocation may occur is 10
weeks when the lower extremity limb bud rotates
medially.

Neuromuscular disorders may cause muscular

imbalance leading to dislocation around 18 weeks’
gestation.

Dislocation at these early stages leads to abnormal

development of all parts of the hip joint and is thus
termed a teratological dislocation.

PATHOPHYSIOLOGY
During the final 4 weeks of gestation, mechanical
forces play a large part in the positioning of the hip
joint.

➤ Left occiput anterior (LOA)

➤ breech position
➤ oligohydramnio
➤ multiple fetuses

PATHOPHYSIOLOGY
In the subluxed position, the labrum is flattened under
the pressure of the femoral head and becomes flattened
or everted. In addition, the acetabulum develops non-
concentrically and does not deepen around the femoral
head, which leads to a shallow acetabulum and unstable
hip joint.

Dislocation of the femoral head leads to stretching of

the inferior capsule and adductors which, if untreated,
may lead to contractures and limited range of abduction.

PATHOPHYSIOLOGY
In addition to oligohydramnios and breech
positioning, the main risk factors for DDH are female
gender, firstborn children and family history. Three
percent of all births are breech position and of these
23% will have some degree of DDH. Other skeletal
abnormalities commonly associated with DDH
include torticollis and postural foot abnormality such
as metatarsus adductus.
DIAGNOSIS
The Barlow and Ortolani tests are the
mainstays in examination of the newborn hip.

DIAGNOSIS
The Barlow manoeuvre is a
provocation test conducted by
adducting the flexed hip and
applying gentle anterior to
posterior pressure in order to
push the femoral head
superior and posterior over
the edge of a shallow
acetabulum.

DIAGNOSIS
The Ortolani test is a
relocation manoeuvre
conducted by gently
manipulating the flexed hip
from adduction to
abduction to bring the
femoral head anteriorly
back into the acetabulum
from a dislocated position.

DIAGNOSIS
These manoeuvres are best performed with the
clinician’s palms over the infant’s knees and the
middle fingertip placed over the greater trochanter.

DIAGNOSIS
At a later stage, clinical examination findings may
include asymmetrical skin folds, although most
experts feel that these are generally not significant.
Once there is an established dislocation, one can
detect a leg-length discrepancy with a shorter affected
limb, positive Galeazzi test and reduced range of
abduction. Bilateral DDH is always more difficult to
diagnose as symmetrical changes are more difficult to
pick up.

DIAGNOSIS
At a later stage, clinical examination findings may
include asymmetrical skin folds, although most
experts feel that these are generally not significant.
Once there is an established dislocation, one can
detect a leg-length discrepancy with a shorter affected
limb, positive Galeazzi test and reduced range of
abduction. Bilateral DDH is always more difficult to
diagnose as symmetrical changes are more difficult to
pick up.

DIAGNOSIS
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Radiograph
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Radiograph
Center edge angle
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The introduction of ultrasound imaging, in the 1980s, allowed
visualization of the soft tissue components of the infant hip
including the cartilage of the femoral head and acetabulum, the
capsule and the labrum.

The use of multiplanar and dynamic ultrasound enables

visualization of the femoral head within the acetabulum and
assessment of the shape and depth of the acetabular cup.
Ultrasound is best used for children before 6 months of age, after
which ossi cation of structures makes plain radiographs
increasingly more helpful.
The most widely used ultrasonographic technique was
popularized by Graf.
fi

IMAGING
This technique uses static coronal images to determine
the depth and shape of the acetabulum by measuring
the alpha angle, an angle formed between the straight
edge of the ilium and the acetabular roof. A normal
alpha angle measurement is 60 degrees or greater.

In addition, Graf described the beta angle to measure

cartilaginous coverage of the femoral head, with a
normal angle measurement of 55 degrees, but this is
less helpful in clinical practice.

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MANAGEMENT AND TREATMENT
It is clear that treating DDH is more complicated with
a less favourable
Clinical screening is clearly sensible, but debate
persists on the specific benefits, compared to cost and
risk of over- treatment, of selective or universal
ultrasound screening.
Universal screening of infants using ultrasound is not
recommended in the UK.

MANAGEMENT AND TREATMENT

There is good evidence to support management in the
neonate. The treatment of Ortolani-positive hips,
dislocated at rest but reducible, should begin as soon as
practical.

Conversely, it is reasonable to delay treatment of

Barlow-positive hips for up to 2 weeks without
compromising the final outcome, as a large percentage of
such hips will stabilize within that period. At 2 weeks,
failure to improve either clinically or on the basis of an
ultrasound is an indication to commence treatment.

TERIMA KASIH