DDH

Dr Vikas Rai
PG Resident 3
Christian Medical College, Ludhiana
Adolph Lorenz, an early pioneer in the treatment of
developmental dislocation of the hip
Overview
• Introduction
• Normal Development of the Hip
• Etiology and Pathoanatomy
• Epidemiology and Diagnosis
• Treatment
• Complications
Introduction:
• Developmental dysplasia of the hip is the
condition in which the femoral head has an
abnormal relationship to the acetabulum.
Developmental dysplasia of the hip includes
frank dislocation (luxation), partial
dislocation (subluxation), instability
wherein the femoral head comes in and out
of the socket, and inadequate formation of
the acetabulum.
• Previously known as congenital dislocation of the
hip implying a condition that existed at birth

• developmental encompasses embryonic, fetal and

infantile periods

• includes congenital dislocation and developmental

hip problems including subluxation, dislocation
and dysplasia
Etiology and Epidemiology
• Multifactorial
• Genetics and Syndromes
• Ehler’s Danlos
• Arthrogryposis
• Larsen’s syndrome
• Intrauterine environmental factors
• Teratogens
• Oligohydramnios)
• breech
• Neurologic Disorders: Spina Bifida
• ligamentous laxity
familial trait
Left : Right – 4 : 1
Breech : DDH ≥ x 10
Amniotic fluid↓ : moulded baby
- plagiocephaly
- scoliosis
- foot deformity
- skew pelvis
Postnatal positioning in extension, as in this child on a Native American
cradleboard, contributes to developmental dysplasia of the hip
 Normal Growth and Development

• Embryologically the acetabulum, femoral head

develop from the same primitive mesenchymal
cells

• cleft develops in precartilaginous cells at 7th week

and this defines both structures

• 11wk hip joint fully formed

• acetabular growth continues throughout intrauterine life
with development of labrum

• By birth femoral head is deeply seated in acetabulum by

surface tension of synovial fluid and very difficult to dislocate

• in DDH this shape and tension is abnormal in addition to

capsular laxity
• The cartilage complex is 3D with triradiate medially
and cup-shaped laterally and interposed between
ilium above and ischium below and pubis anteriorly

• acetabular cartilage forms outer 2/3 cavity and the

non-articular medial wall form by triradiate cartilage
which is the common physis of these three bones

• fibrocartilaginous labrum forms at margin of

acetabular cartilage and joint capsule inserts just
above its rim
• articular cartilage covers portion articulating with femoral head
• opposite side is a growth plate with degenerating cells facing towards the pelvic
bone

• triradiate cartilage is triphalanged with each side of each limb having a growth
plate which allows interstitial growth within the cartilage causing expansion of hip
joint diameter during growth

• In the infant the greater trochanter, proximal femur and intertrochanteric portion
is cartilage

• By 4-7 months proximal ossification center appears which enlarges until adult life
when only thin layer of articular cartilage persists
Development cont..
• Experimental studies in humans with unreduced hips suggest the main stimulus for
concave shape of the acetabulum is presence of spherical head
• for normal depth of acetabulum to increase several factors play a role
• spherical femoral head
• normal appositional growth within cartilage
• periosteal new bone formation in adjacent pelvic bones
• development of three secondary ossification centers
• normal growth and development occur through balanced growth of proximal femur,
acetabulum and triradiate cartilages and the adjacent bones
DDH
• Tight fit between head and acetabulum is absent and head can
glide in and out of acetabulum

• hypertrophied ridge of acetabular cartilage in superior, posterior

and inferior aspects of acetabulum called “ neolimbus”

• 98% DDH that occur around or at birth have these changes and
are reversible in the newborn

• 2% newborns with teratologic or antenatal dislocations and no

syndrome have these changes
• Development in treated DDH different from normal hip
• goal is to reduce the femoral head to provide the stimulus for
acetabular development
• Concentric reduction maintainance is essential for recovery and
resumption of normal growth
• age at which DDH hip can still return to normal is controversial
and depends on
• age at reduction
• growth potential of acetabulum
• damage to acetabulum from head or during reduction
Epidemiology
• 1 in 100 newborns examined have evidence of instability (
positive Barlow or Ortolani)

• 1 in 1000 live births true dislocation

• Barlow stated that 60% stabilize in 1st week and 88% stabilize in
first 2 months without treatment remaining 12% true
dislocations and persist without treatment
Incidence
-1 in 1000 live birth.
-male to female ratio 4:1
-family history 1:7
Normal Anatomy
Hip starts from common mesenchymal block of tissue
7th week cleft forms to separate head
11th week hip fully formed
Acetabulum gets shallower close to birth
Normal Hip
• Tight fit of head in
acetabulum
• Transection of capsule
• Still difficult to dislocate
• Surface tension
Pathoanatomy
• Ranges from mild dysplasia --> frank dislocation
• Bony changes
• Shallow acetabulum
• Typically on acetabular side
• Femoral anteversion
Pathoanatomy
• Soft tissue changes
• Usually secondary to prolonged subluxation or dislocation
• Intra articular
• Labrum
• Inverted + adherent to capsule (closed reduction with inverted
labrum assoc with increased Avascular Necrosis)
• Ligamentum teres
• Hypertrophied + lengthened
• Pulvinar
• Fibrofatty tissue migrating into acetabulum
Pathoanatomy
• Soft Tissue (Intra articular)
• Transverse acetabular ligament
• Contracted
• Limbus
• Fibrous tissue formed from capsular tissue interposed between everted labrum and
acetabular rim
• Extra articular
• Tight adductors (adductor longus)
• Iliopsoas
Teratological DDH

 Irreducible
 False acetabulum
 Defective anterior acetabulum “anteverted”
 Increased femoral neck anteversion
 False acetabulum

Arthrogryposis with dislocations

& delivery fracture
Associated
conditions

-torticollis
-metatarsus adducts
-calcaneo valgus
-talipus varus
-plagiocephaly
CLINACAL PRESENTATION
Neonatal Presentation
Exam one hip at a time
Baby must be quiet
Barlow’s sign: provocative maneuver
Ortolani’s sign: reduces hip
Other signs not helpful in newborn
Ortolani’s Maneuver

After 3 months of age tests

become negative
The Ortolani test for developmental dislocation of the hip in a neonate.A, The
examiner holds the infant's knees and gently abducts the hip while lifting up on
the greater trochanter with two fingers.B, When the test is positive, the
dislocated femoral head will fall back into the acetabulum (arrow) with a
palpable (but not audible) “clunk” as the hip is abducted (Ortolani's sign).
When the hip is adducted, the examiner will feel the head redislocate
posteriorly.
 The Barlow test for developmental dislocation of the hip in a neonate.A, With the infant supine,
the examiner holds both of the child's knees and gently adducts one hip and pushes
posteriorly.B, When the examination is positive, the examiner will feel the femoral head make a
small jump (arrow) out of the acetabulum (Barlow's sign). When the pressure is released, the
head is felt to slip back into place.
Infant Presentation
Skin fold asymmetry
Limited hip abduction
Unequal femoral lengths (Galeazzi’s sign)
(Flex both hips and one side shows apparent femoral shortening)
Skin fold asymmetry
Asymmetrical thigh folds
Galeazzi’s sign
Developmental dysplasia of the right hip. One physical
finding is limited abduction of the affected hip.
After Walking Age
Trendelenberg gait
Leg length discrepancy
Increased lumbar lordosis in Bilateral dislocation

•Klisic test positive

The examiner places the middle finger over the greater trochanter, and the index finger
on the anterior superior iliac spine.A, With a normal hip, an imaginary line drawn
between the two fingers points to the umbilicus.B, When the hip is dislocated, the
trochanter is elevated and the line projects halfway between the umbilicus and the
pubis.
hyperlordosis –
bilateral involvement
 Which hip dysplasia pain?
•Complete dislocation with
no false acetabulum: NO
•Complete dislocation with
false acetabulum: YES
•Subluxation: YES
Imaging
• X-rays
• Femoral head ossification center
• 4 -7 months
• Ultrasound
• CT
• MRI
• Arthrograms
• Open vs closed reduction
Radiography
Hilgenreiner's line is drawn through the triradiate cartilages. Perkin's line is drawn perpendicular to Hilgenreiner's
line at the margin of the bony acetabulum. Shenton's line curves along the femoral metaphysis and connects
smoothly to the inner margin of the pubis
Imaging
• Radiographs
Imaging
• Radiographs
Imaging
• Radiographs
Imaging
• Radiographs
Imaging
• Acetabular Index
The acetabular index is the angle between a line drawn along the margin of the acetabulum and Hilgenreiner's
line; it averages 27.5 degrees in normal newborns and decreases with age.

• Acetabular Index
Imaging
• Acetabular Index < 30 wnl
Imaging
Imaging
Imaging
Imaging
Wilberg's center-edge angle, the angle between Perkin's line and a line drawn from the
lateral lip of the acetabulum through the center of the femoral head. considered normal
if greater than 10 degrees in children 6 to 13 years of age, and it increases with age.
Radiographs Summary
• Femoral head appears 4 - 7 months
• Shenton’s line
• Perkin’s and Hilgenreiner’s lines
• Inferomedial quadrant
• Center Edge Angle of WILBERG (< 20 abnormal)
• Acetabular index
• Normal < 30 (Weintroub et al)
TEAR DROP SIGN
• Acetabular TEAR DROP SIGN appears between 6 & 24 months in
normal hip, but later in case of ddh.
• Wall of acetabulum laterally, wall of lesser pelvis
medially,acetabular notch inferiorly.
• U shaped teardrop
• V shaped teardrop- Dysplastic hips and poor outcome
TEAR DROP
VON ROSEN VIEW
• Both hips abducted, intrernally rotated and extended.
• NORMAL- Imaginary line from shaft of femur extending upwards
intersects the acetabulum
• DDH- Line crosses above acetabulum
Imaging
• Ultrasound
• Introduced in 1978 for eval of DDH
• Operator dependent
• Useful in confirming subluxation, identifying dysplasia of cartilaginous
acetabulum, documenting reducibility
• Prox Femoral Ossification Center interferes
• Requires a window in spica cast.
 Ultra sound
• BOTH morphologic assessment and dynamic
• anatomical characteristics
• alpha angle: slope of superior aspect bony acetabulum
• beta angle: cartilaginous component (problems with
inter and intraobserver error )
• dynamic
• Observing events occuring with Barlow and ortolani
tests.

•Alpha angle = between line of ilium & bony acetabulum

•Beta angle (less important) = between line of ilium & anterior labrum
 Ultrasound
Acetabular cartilaginous roof
coverage.
Normal <55 degrees
Smaller angle= better bony
coverage

Measures acetabular depth.

Normal >60 degrees

http://emedicine.medscape.com/article/408225
Ultrasound
Femoral head

Abductors

Ilium
Ultrasound
Femoral head

Abductors

Ilium
Ultrasound
Femoral head

Abductors

Ilium
Ultrasound
Femoral head

Abductors

Ilium
Ultrasound
Graf’s alpha
angle
Ultrasound
Graf’s alpha
angle

>60 = normal
*line through
ilium bisects head
50/50
 Graf Classification

• Type 1: mature hip joint with narrow, covering cartilaginous roof

• Type 2 (a+, a-, b, c, d): range from immature to dysplastic
• Type 3&4: both diplaced, range of severity
• *This classification system has good reliability with Type 1 hips,
but recently has been scrutinized regarding inter and intra-
observer reliability with all other Types.
Graf grading of DDH by ultrasound
•Indications controversial due to high levels of
overdiagnosis and not currently recommended
as a routine screening tool other than in high
risk patients

•Best indication is to assess treatment

•Guided reduction of dislocated hip or check

reduction and stability during Pavlik harness
treatment
Arthrogram
•Head shape
•Cover
•Congruity
•Articular cartilage
•Labrum
Arthrogram

•Limbus - 'Rose thorn sign' of inverted

labrum between femoral head & acetabulum

•Hour glass constriction of capsule - by

psoas tendon

•Capsular distension
Arthrogram in DDH

SUBLUXATED HIP DISLOCATED HIP

•Eliciting Medial pooling of dye
•(normal = < 7mm)

•Confirms reduction after surgery

Dye pooling <7mm & complete reduction
with arthrogram = no need for open
reduction.
Natural History
in Newborns
• Barlow
• 1 in 60 infants have instability ( positive Barlow)
• 60% stabilize in 1st week
• 88% stabilize in 2 months without treatment
• 12 % become true dislocations and persist
• Coleman
• 23 hips < 3 months
• 26% became dislocated
• 13 % partial contact with acetabulum
• 39% located but dysplastic feature
• 22% normal
• As it is not possible to predict the outcome, all infants with
instability should be treated
 Adults
• Variable
• depends on 2 factors
• well developed false acetabulum ( 24 % chance good result vs 52 % if absent)
• bilaterality
• in absence of false acetabulum patients maintain good ROM with little disability
• femoral head covered with thick elongated capsule
• false acetabulum increases chances degenerative joint disease
• hyperlordosis of lumbar spine assoc with back pain
• unilateral dislocation has problems
• leg length inequality, knee deformity , scoliosis and gait
disturbance
Dysplasia and Subluxation
• Dysplasia (anatomic and radiographic def’n)
• inadequate development of acetabulum, femoral head or both
• All subluxated hips are anatomically dysplastic

• Radiologically difference between subluxated and dysplastic hip is

disruption of Shenton’s line
• subluxation: line disrupted, head is superiorly,
superolaterally ar laterally
displaced from the medial wall
• dysplasia: line is intact

• Important because natural history is different

A 36-year-old woman with bilateral anatomically abnormal (dysplastic) hips. The left hip is
radiographically subluxated, with the Shenton line disrupted, and the right hip is radiographically
dysplastic, with the Shenton line intact.
Seven years later, note the marked loss of joint space in the secondary acetabulum
of the left hip and very early disruption of the Shenton line on the right.
Natural History Con’t
• Subluxation predictably leads to degenerative joint disease and clinical disability
• mean age symptom onset 36.6 in females and 54 in men
• severe xray changes 46 in female and 69 in males
• Cooperman
• OUT OF 32 hips with CE angle < 20 without subluxation
• BY 22 years all had x ray evidence of Degenerative Joint Disease
• no correlation between angle and rate of development
• concluded that radiologically apparent dysplasia leads to DJD but process takes
decades
Treatment Options
• Age of patient at presentation
• Family factors
• Reducibility of hip
• Stability after reduction
• Amount of acetabular dysplasia
Treatment 0 to 6 months
• Goal is TO obtain reduction and maintain reduction to provide optimal
environment for femoral head and acetabular development

• Lovell and Winter

• Treatment should be initiated immediately on diagnosis

• AAOS (July,2000)
• subluxation often corrects after 3 weeks and may be observed
without treatment
• if persists on clinical exam or ultrasound beyond 3 weeks
treatment indicated
• actual dislocation diagosed at birth treatment should be
immediate
Treatment con’t
• Pavlik Harness preferred

• prevents hip extension and adduction but allows flexion and abduction which lead to
reduction and stabilization

• success 95% if maintained full time six weeks

• In child > 6 months of age, success is < 50% as it is difficult to maintain active child in
harness
Pavlik Harness
• Chest strap at nipple line
• shoulder straps set to hold cross strap at
this level
• anterior strap flexes hip 100-110 degrees
• posterior strap prevents adduction and
allow comfortable abduction
• safe zone arc of abduction and
adduction that is between redislocation
and comfortable unforced abduction
Pawlik harness
The transverse chest strap should be placed just below the nipple line. The hips
should be flexed to 120 degrees, and the posterior straps should not produce forced
abduction.
Pawlik contd..
• Indications include presence of reducible hip femoral head directed
toward triradiate cartilage on xray

• follow weekly intervals by clinical exam and US for two weeks and if
not reduced other methods are pursued

• once successfully reduced, harness is continued for childs age at

stability + 3 months

• end of weaning process---- xray pelvis obtained--- and if normal

discontinue harness
Complications
• Failure
• poor compliance , inaccurate position and persistence of
inadequate treatment
• subgroup where failure may be predictable
• absent Ortolani sign
• bilateral dislocations
• treatment commenced after age 7 week
• NEXT Treatment is closed reduction and Spica Casting
• Femoral Nerve Compression 2 to hyperflexion
• Inferior Dislocation
• Skin breakdown
• Avascular Necrosis
The Ilfeld or Craig splint
Von Rosen splint
Von Rosen splint
6 months to 2 years age
• Closed reduction and spica cast immobilization recommended

• traction controversial with theoretical benefit of gradual stretching of

soft tissues impeding reduction and neurovascular bundles to decrease
AVN

• skin traction preferred however vary with surgeon

• usually 1-2 weeks

• scientific evidence supporting this is lacking

Treatment contd..
• closed reduction preformed in OR under general anesthetic
manipulation includes flexion, traction and abduction

• percutaneous or open adductor tenotomy necessary in most

cases to increase safe zone which lessen incidence of proximal femoral
growth disturbance

• reduction must be confirmed on arthrogram as large portion of head

and acetabulum are cartilaginous

• dynamic arthrography helps with assessing obstacles to reduction and

adequacy of reduction
Treatment
• reduction maintained in spica cast well molded to greater trochanter to
prevent redislocation

• human position of hyperflexion and limited abduction preferred

• avoid forced abduction with internal rotation as increased incidence of

proximal femoral growth disturbance

• cast in place for 6 weeks then repeat Ct scan to confirm reduction

• casting continued for 3 months at which point removed and xray done
then placed in abduction orthotic device full time for 2 months then
weaned
Closed Reduction and Casting for Developmental Dislocation of the Hip
Safe Zone

20 to 30 degrees from
maximum abduction

extended to below 90 degrees

without redislocation
Safe zone can be improved
with adductor tenotomy
Failure of Closed Methods
• Open reduction indicated if failure of closed reduction, persistent subluxation, reducible
but unstable other than extremes of abduction

• variety of approaches
• anterior smith peterson most common
• allows reduction and capsular plication and secondary procedures
• Disadvantages - more blood loss, damage to iliac apophysis and abductors,
stiffness
Open Reduction
• Medial approach ( between adductor brevis and magnus)
• approach directly over site of obstacles with minimal
soft tissue dissection
• unable to do capsular plication so depend on cast for
post op stability

• anteromedial approach Ludloff ( between neurovascular

bundle and pectineus)
• direct exposure to obstacles, minimal muscle dissection
• no plication or secondary procedures
• increased incidence of damage to medial femoral
circumflex artery and higher AVN risk
Open Reduction
Follow-up after open reduction

• Abduction orthotic braces commonly used until acetabular development is

caught up to normal side

• in assessing development look for accessory ossification centers to see if

cartilage in periphery has potential to ossify

• secondary acetabular procedure rarely indicated < 2 years as potential for

development after closed and open procedures is excellent and continues
for 4-8 years

• most rapid improvement measured by acetabular index , development of

teardrop occurs in first 18 months after surgery

• femoral anteversion and coxa valga also resolve during this time
 Obstacles to Reduction
• Extra- articular
• Iliopsoas tendon
• adductors

• Intra-articular
• inverted hypertrophic labrum
• tranverse acetabular ligament
• pulvinar, ligamentum teres
• constricted anteromedial capsule in late cases

• neolimbus is not an obstacle to reduction and represents epiphyseal

cartilage that must not be removed as this impairs acetabular
development
Age greater than 2 years
• Open reduction usually necessary

• 54% AVN and 32% redislocation with use of skeletal traction in ages > 3

• For age > 3 open reduction and femoral shortening and acetabular procedure is
recomended to avoid excess pressure on head with reduction
Treatment con’t
• 2-3-years gray zone

• potential for acetabular development is diminished and

therefore many surgeons recommend a concomitant
acetabular procedure with open reduction or 6-8 weeks
after

• Incidence of AVN is greater with simultaneous open

reduction and acetabular procedure
Treatment contd..
• Lovell and Winter advised to
• judge stability at time of reduction and if stable observe for period of time for development
• if not developing properly with decreased acetabular index, teardrop then consider
secondary procedure

• most common osteotomy is Salter or Pemberton

• anatomic deficiency is anterior and Salter provides this while Pemberton provides
anterior and lateral coverage
 Natural Sequelae

• Goal of treatment is to have radiographically normal hip at

maturity to prevent DJD

• after reduction is achieved potential for development continues

until age 4.

• In child < 4 years minimal dysplasia may be observed but if it is

severe than subluxations and presence of residual dysplasia
should be corrected
Residual Dysplasia
• Determined by plain xray with measurement of CE angle and acetabular index

• In young children deficiency is usually anterior and in adolescents it can be global

• Deformities of femoral neck if significant it leads to subluxation

• lateral subluxation with extreme coxa valga or anterior subluxation with excessive
anteversion
• usually DDH patients have a normal neck shaft angle
• If there is Dysplasia for 2-3-years after reduction
proximal femoral derotation or varus osteotomy
should be considered

• varus osteotomy is done to redirect head to center of

acetabulum which stimulates normal development

• It must be done before age 4 as remodeling potential

goes down after this
Treatment in Adolescent or Adult
• Femoral osteotomy should only be used in
conjunction with pelvic procedure as there is no
potential for acetabular growth or remodeling but
changing orientation of femur shifts the weightbearing
portion

• Pelvic osteotomy considerations

• age
• congruent reduction
• range of motion
• degenerative changes
Femoral Shortening
• Schoenecker + Strecker 1984
• Traction vs. Femoral shortening
• 56% AVN in traction group
• 0% AVN in femoral shortening
Femoral shortening for DDH

Hey-Groves
(1928)
Valgus/ extension osteotomy

In AVN with
trochanteric
overgrowth

Better in
adduction and
flexion
Pelvic Procedures
• Redirectional
• Salter
• Sutherland double innominate osteotomy
• Steel ( Triple osteotomy)
• Ganz ( rotational)
• Acetabuloplasties ( decrease volume )
• Pemberton
• Dega
• Salvage
• depend on fibrous metaplasia of capsule
• Shelf and Chiari
Pelvic Osteotomy
• Done in Persistent instability + dysplasia after open reduction and
femoral shortening
• Requires concentric reduction of a reasonably spherical femoral head
• Usually based on surgeon preference
Pelvic Osteotomy
• Volume changing
• Pemberton
• Hinges on triradiate
• Requires remodeling of “new” incongruity
• Provides more anterolateral coverage
• Dega’s
Pelvic Osteotomy
• Redirecting
• Salter
• Osteotomy through sciatic notch
• Hinge through pubic symphysis
• Triple innominate
• Ganz
• Dial
 Salter
Innominate
osteotomy
Salter’s osteotomy
Salter’s osteotomy
Salter Single Innominate

•Age –18 months –6 years

•Requires concentrically reduced hip
–Open reduction at same time is possible
–Iliopsoas and adductor tenotomies often required
•Covers antero-later alacetabular deficiency
–Up to 15 degree of acetabular index corrected
Salter

•Anterior approach to acetabulum

–Exposing inner and outer ilium
–Expose hip capsule if reduction needed
–Transverse osteotomy is done just above acetabulum
• Sciatic notch to Ant.Inf.iliac Spine
–Rotate on pubic symphysis in antero-lateral direction
–Hold correction with bone graft wedge & K-wires
Salter Osteotomy
Salter & femoral osteotomy

K. E. 21 - 12 - 1999
Pemberton Acetabuloplasty

•Age –18 months –10 years

•Requires reduced hip
•Decreases acetabular volume
–Remodeling of acetabulum required
•Corrects >15 degree of Acetabular index
•Reduces antero-lateral acetabular defects
–Cuts altered to cover more anteriorly or laterally
Pemberton

•Anterior Approach -Exposure as for Salter

–Cut inner and outer table with small osteotome

– osteotomy 1cm above AIIS, staying 1 cm above capsule

–Do not cut through to sciatic notch
–Lever through the cut until coverage is acceptable
•(Levers on tri-radiate cartilage)
–Hold correction with bone graft wedge
Dega Acetabuloplasty

•Similar to Pemberton
•Larger posterior hinge
–Hinges on horizontal tri-radiate limb
•Less inner table osteotomized for more lateral
coverage

(More inner table –more anterior coverage)

Steel Triple Innominate Osteotomy
•Age –Skeletally mature
•Requires congruent hip joint
•Divides ilium, ischium and superior ramus
–Acetabulum is rotationally free
–Indicated when other osteotomies not possible
•Rotates to cover any acetabular defect
Steel
•Multiple incision technique

–Posteriorly between gluteus and hamstrings

•Allows osteotomy of ischium
–Anteriorly freeing medial attachments
•Allows Salter and superior ramus osteotomy
–Rotate acetabulum as desired
•Avoid externally rotating
–Bone graft wedge is fixed as per Salter type
Salvage or Shelf procedures
• Chiari and Staheli osteotomies
• Requires capsular metaplasia
• Pain is the main indication
• Used in Treatment of chronic hip pain in adolescents
Staheli Shelf Procedure
•Age –older child to skeletal maturity
•Salvage operation
•Indicated for non-concentric hips
•Augments supero-lateral deficency
–Slotted bone graft placed over capsule
deepening the acetablum
Staheli
•Anterior approach is used with outer wall exposure only
–Identify superior acetabular edge
–Create slot 1cm deep along edge in cephlad angle
–Remove 1 cm cortical strips from outer table

•Insert into slot, cutting at desired lateral overhang

•2nd layer inserted lengthwise

•Use remaining to fill in above slot edge

–Hold in place with reflected fascia and adductors
Staheli shelf
Chiari Medial Displacement
•Age –skeletally mature
•Salvage operation only
–Used when no other osteotomy possible
–Possible with subluxed hip
•Covers well laterally
–Anterior and posterior augmentation may be necessary
•May be useful in other conditions
–Coxamagna, OA in dysplasichips
•Anterior approach –as per Salter
–Identify superior extent of capsule
–Cut from AIIS to notch following capsule curve
•Angle osteotome10-20ocephlad
–Displace distal fragment medially 50-100%
•Ensure complete head coverage
•Leg abduction, hinges on pubic symphysis
Chiari Osteotomy
Chiari Osteotomy
Chiari Osteotomy
Chiari Osteotomy
Chiari osteotomy
Outcome of Chiari osteotomy

• 236 of 388 osteotomies

reviewed at 25 years
• 51% good; 30% fair; 18% poor
• Best results: ≤ 7 years; no OA
• Femoral osteotomy: no better

(Windhager et al. JBJS 1991)

Very late
salvage
Schanz
osteotomy
MANAGEMENT
Complications of Treatment
• Worst complication is disturbance of growth in
proximal femur including the epiphysis and
physeal plate
• commonly referred to as AVN however, no
pathology to confirm this
• may be due to vascular insults to epiphysis or
physeal plate or pressure injury
• occurrs only in patients that have been treated
and may be seen in opposite normal hip
Necrosis of Femoral Head
• Extremes of position in abduction ( greater 60
degrees ) and abduction with internal rotation

• compression on medial circumflex artery as passes

the iliopsoas tendon and compression of the
terminal branch between lateral neck and
acetabulum

• “ frog leg position “ uniformly results in proximal

growth disturbance
Avascular Necrosis
• extreme position can also cause pressure necrosis
onf epiphyseal cartilage and physeal plate

• severin method can obtain reduction but very

high incidence of necrosis

• multiple classification systems with Salter most

popular
Salter Classification
•1 failure of appearance of ossific nucleus within 1
year of reduction2
•2 failure of growth of an existing nucleus within 1
year
•3 broadening of femoral neck within 1
year
•4 increased xray density then
fragmentation of head
•5 residual deformity of head when re-
ossification complete including coxa
magna,vara and short neck
Treatment
• Femoral and/or acetabular osteotomy to maintain
reduction and shift areas of pressure
• trochanteric overgrowth causing an abductor lurch
treated with greater trochanter physeal arrest if
done before age 8 otherwise distal transfer
• early detection is key with 95% success rate of
treatment
• identify growth disturbance lines
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