Developmental dysplasia of hip

Definition
• All case that clearly congenital and those that
are developmental, incorporating subluxation,
dislocation, and dysplasia of the hip

Morrisey RT, Weinstein SL. Lovel & Winter’s Pediatric orthopaedics, 6 th edition.
Developmental hip dysplasia and dislocation. Lippincot Williams & Wilkins. Atlanta,georgia.
2006.
 Epidemiology
• Incidence 1 per 1000 to 34 per 1000
• 1 :600 (girls) , 1:4000 (boys)
• Family history

Noordin S, Umer M, Hafeez K, Nawaz H. Develpmental dysplasia of the Hip.

Orthopaedic review 2010; vol 2:e19
 Etiology
• Ligament laxity
• Breech presentation
• Intrauterine crowding
• First born child
• Oligohydroamnion
• Post natal positioning ( wrapped with the hip
in extended position)

Noordin S, Umer M, Hafeez K, Nawaz H. Develpmental dysplasia of the Hip.

Orthopaedic review 2010; vol 2:e19
 Pathology
• Hip joint laxity  at the moment of birth 
the previous flexed hips  passively extended
 femoral head dislocate (relocate or remain
dislocate )  secondary change ( abnormal
development of acetabulum, increase femoral
neck anteversion, hypertrophy of the
elongated capsule, muscle contracture )

Salter RB. Textbook of disorder and injuries of the musculoskeletal system 3 rd edition.
Williams & Wilkins. Toronto. 1999
 Diagnosis
• Routine screening : the ortolani test and
barlow test
• Asymetric skin fold
• Leg length discrepency
• Galeazzi sign
• Limited abduction
• Trendelenberg sign
• Hyperlordosis
Gulati et al. Developmental dysplasia of the hip in the newborn : A systematic
review. World J Orthop. 2013. 18;4(2):32-41
 Screening for DDH
• 24 hour of birth, prior to hospital discharge, at
6 weeks, between 6-9 mo, and walking age
• UK programme  ultrasound screening of
high risk infant at six weeks
• Dutch programme  clinical & ultrasound
screening  3 – 5 mo of age
• Ortolani test  recognition of dislocation in
infants below the age 12 mo
Gulati et al. Developmental dysplasia of the hip in the newborn : A systematic
review. World J Orthop. 2013. 18;4(2):32-41
• Static test  asses morphology
• Pathological hip  femoral head cover by the
bony rim of the acetabulum <44% in girls and
<47% in boys
• Dynamic test asses stability
• Real time ultrasound  barlow manouevre

Sewell M.D, Eastwood D.M. screening and treatment in developmental dysplasia of

the hip – where do we go from?. International orthopaedic. 2011;35:1359-1367
Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.
Philadelphia.2013
 Imaging

Noordin S, Umer M, Hafeez K, Nawaz H. Develpmental dysplasia of the Hip.

Orthopaedic review 2010; vol 2:e19
Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.
Philadelphia.2013
Gulati V, Eseonu K et all.Developmental dysplasia of
the hip in the newborn : A sytematic review. 2013.
World J Orthop. 18;4(2):32-41
Severin classification of DDH
• Graf type III/IV  stable reduction decrease
after 3-4 wk duration

Gulati V, Eseonu K et all.Developmental dysplasia of the hip in the

newborn : A sytematic review. 2013. World J Orthop. 18;4(2):32-41
DDH - - - Define Treatment Group (by
age)

Birth to 6 months? successful tx likely

w/splinting (Pavlik
harness)

Seven to 18/24 months? closed reduction possible

>18/24 months? open reduction preferred

Scoenecker P.L.. 3rd POSNA
AGE

• 12 to 18 months: Closed reduction first

• 18 to 24 months: Gray zone
• 24 months and above: Primary open reduction
• 36 months and above: may require femoral
shortening osteotomy and acetabular
procedure with open reduction

Ken N kuo. 3rd POSNA

DDH
18 to 24 months

• Depending on the size, joint laxity, and the

station of the dislocation.
• If the dislocation is high and stiff, an open
reduction is advisable.

Ken N kuo. 3rd POSNA

DDH
 Treatment
(birth to 6 months)
 Treatment
6 to 18 months
 Newborn (birth to 6 mo)
• Observation
• Obtain reduction &
maintain  development
of the femoral head &
acetabulum
• Orthosis (pavlik harness)
• Followed bi-weekly
clinical & ultrasonography
• Discontinuation  6
weeks after clinal stability
Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.
Philadelphia.2013
 Pavlik harness treatment regimes
• Mean treatment duration 3.6 mo
(commenced before 1 mo) , 7.0 mo ( 1 -3 mo),
9.3 mo (3-9 mo)
• Succes rates  7%-99%
• Failure of device  poor compliance &
improper use  AVN (0%-28%)

Gulati V, Eseonu K et all.Developmental dysplasia of the hip in the newborn : A

sytematic review. 2013. World J Orthop. 18;4(2):32-41
 Child (1mo to 6mo)

• Prevention of
osteonecrosis of the
femoral head
• Closed reduction
• preoperative traction
• adductor tenotomy
• Hip spica cast
• Open reduction
Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.
Philadelphia.2013
 Toddler ( 18-36 months)
• Open reduction with • Femoral osteotomy –
femoral or pelvic Varus derotational
osteotomy, or both osteotomy
• Achieve reduction
without damaging the
femoral head
• Acetabular procedure
 judge stability at the
time of open reduction

Campbells operative Morisy, Raymond, Weinstein, Stuart. Lovell& Winter’s

orthopaedics 12 ed Pediatric Orthopaedic, 6th edition. 2006. Atlanta
 Child ( 3 to 8 yo)
• Adaptive shortening of • Pelvic osteotomy :
the periarticular salter innominate
structuress osteotomy, pamberton
• Structural alteration in acetabuloplasty, steel or
the femoral head and ganz osteotomy, shelf
the acetabulum procedure or Chiari
• Open reduction - osteotomy.
primary femoral
shortening , pelvic
osteotomy
Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.
Philadelphia.2013
Femoral varus derotation osteotomy

• Indications:
• -- well reduced hip with valgus and anteversion
of proximal femur
• -- As part of open reduction procedure in order
to contain the femoral head in acetabulum
• -- progressive lateral tilting of the capital
femoral epiphysis

DDH
 • Optimum outcome : 100 – 110 degree of neck-
shaft angle
• Problem after operation  trendelenberg gait
• remodelation  3 years
• Varus osteotomy  shifts the mechanical axis
to the medial knee

Arslan H, Kapukaya A, Bekler HI, Necmioglu S. Is Varus osteotomy necessary in one-stage

treatment of developmental dislocation of the hip in older children?. J child orthop.
2007;1:291-297
5 year old girl

DDH
DDH
DDH
DDH
 Pelvic osteotomies

• Redirectional  salter innominate osteotomy,

triple innominate osteotomy, periacetabular
osteotomy
• Reshaping  pamberton osteotomy, dega
osteotomy
• Salvage/ augmentation  chiari osteotomy,
slotted-shelf procedure

Gilliningham BL, Sanchez Anthony, Wenger Dennis R. Pelvic osteotomies for treatment of
hip dysplasia in children and young adult. J Am Acad orthop Surg. 1999;7:325-337
 Salter osteotomy
• Entire acetabulum
together with the pubis
and ischium  rotated
as unit, symphysis pubis
acting as a hinge
• Roof of acetabulum
shifted more
anteriorly&laterally

Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.

Philadelphia.2013
Salter Osteotomy

• Minimum 18 months old

• Congruity of the joint
• “Gold standard”
• Need posterior buttress

DDH
Salter Osteotomy-Advantages

• Provide coverage of the femoral head with

acetabulum consisted of hyaline cartilage.
• Does not disturb the growth of the
acetabulum.
• Maintain congruity and volume of the hip
joint.

DDH
Salter Osteotomy-Disadvantages

• Increased intra-articular pressure

• Increased tension of the muscles:
Iliopsoas tenotomy
Adductor
tenotomy
Femoral shortening
• Increase leg length
DDH
Salter Osteotomy-Disadvantages

• Limitation to the degree of correction, do

not perform Salter osteotomy if acetabular
index is more than 40 degrees.
• Does not centralize laterally displaced
femoral head.
• Create a relative posterior acetabular
deficiency.
DDH
Salter Osteotomy-Age limit

• Dislocation: from 18 months to 6 years

• Subluxation with dysplasia: up to 10
years

DDH
Salter osteotomy-Pre-requisites

• 1) Concentric reduction and congruity

of the hip joint.
• 2) Good range of motion.
• 3) Release of iliopsoas tendon and/or
• hip adductors.

DDH
DDH
DDH
Indication of Salter ost. in plain radiograph

30°≤ AI
(4~5 yr-old)

35°≤ AI Pembertom ost.

3rd POSNA-ASEAN Pediatric Seminar

 Pamberton acetabuloplasty
• The inclination of the
acetabular roof is
decreased by
pericapsuler osteotomy
of the ilium
• The triradiate cartilage
acts as hinge
• Acetabular roof rotated
anteriorly - laterally

Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.

Philadelphia.2013
Pemberton Procedure

• 1.5 to 6 years
• Excellent correction--closer to the
deformity
• No internal fixation necessary
• May reduce acetabular volume

DDH
Pembertom’s ost. (pericapsular ost.)

AI angle=37°

5 yrs. 2 mos. old

3rd POSNA-ASEAN Pediatric Seminar

3rd POSNA-ASEAN Pediatric Seminar
Post-op. 2 yrs

Post-op. 7 yrs
3rd POSNA-ASEAN Pediatric Seminar
3rd POSNA-ASEAN Pediatric Seminar
 chiari osteotomy
• Indication : painful,
subluxated hip
• Medialized of hip joint
• Increase femoral head
coverege
• Create immediate
acetabular overhang
• Complication : incomplete
medialization, transient
peroneal nerve palsy,
limited ROM, infection
Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.
Philadelphia.2013
 • Chiari osteotomy  last treatment option 
if there is lateral anterior or anterolateral
uncoverage femoral head
• Salvage procedure  does not violate the
articular cartilage & creating stiffness of the
hip joint

Karami Mohsen et all. The result of Chiari pelvic osteotomy in adolescents with a brief
literature review. J child orthop.2008. 2:63-68
 Advantages : • Disadvantages :
– Diminishing the load on • Narrowing of the pelvis
femoral head
• Sciatic nerve palsy
– Immediate formation of
a strong roof

Karami Mohsen et all. The result of Chiari pelvic osteotomy in adolescents with a brief
literature review. J child orthop.2008. 2:63-68
 Shelf procedure
• Indication : congruent
reduction imposible
• Create an extra articular
butress, preventing further
subluxation, increasing the
load –bearing area of the
hip
• Good clinical result 87% in
dysplastic hip
• Interposed capsular tissue
transform to fibrocartilage
Hirose S, Otsuka H, Morishima T, Sato K. Long term outcomes of shelf acetabuloplasty for
developmental dysplasia of the hip in adults: a minimum 20 year follow up study. J orthop sci.
2011; 16:698-703
Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.
Philadelphia.2013
 Treatment of DDH in the walking age

• Innominate osteotomy of salter  redirects

the acetabulum anterolaterally
• Double and triple pelvic osteotomies 
realign the acetabulum of the older patient
• Complex pericapsular osteotomies  redirect
the acetabulum  more refined

POSNA
 Adolescent and young adult (> 8 yo)

• Femoral head can’t repositioned distally to the

level of the acetabulum
• Salvaging operation
• Degenerative arthritic change
• Developmental coxa vara  when walking
begun, the forces that femoral neck must
withstand are increased neck is weak 
varus deform gradually develops
Canale ST, Beaty JH. Campbell’s Operative orthopaedics 12 edition. Elsevier.
Philadelphia.2013
• Older&heavier  deformity increase  greater
trochanter lies superior to the femoral head
pseudoarthrosis of the femoral neck  femoral
head wide separated from femoral neck
• Treatment : subtrochanteric osteotomy
• Time : 4 – 5 yo
• Indication : progresive deformity, painful,
unilateral, leg length discrepency
 Neglected DDH
• Difficulty  how to overcome the contratracted
soft tissue & stimulate the acetabular remodeling
ability
• One stage procedure  open reduction, femoral
shortening with or without VDRO, capsuloraphy,
pelvic osteotomy
• Pelvic osteotomy  salter , Tonnis acetabuloplasty
• Femoral shortening  the older the patient, the
greater need for shortening
El-Teyeby H.M. one stage hip reconstruction in late neglected developmental dysplasia of the
hip presenting in children above 8 years of age. J child orthop. 2009.3:11-20
 • If femoral head flatened or acetabulum
dysplastic, concentric reduction in older
children may chalange
• Increased femoral shortening reduced the risk
of osteonecrosis as well as facilitating better
reduction among the patients.

Dogan M, Agaoglu S, Ocguder A, Ugurlu M, Onem Y, Aksoy M. A comparison of the treatment

of DDH in the older children by femoral shortening with a) acetabular shelf and b) innominate
osteotomy plus shelf. Turk J med sci.2010; 40(1):83-89
DDH

• Once the patient requires closed

reduction
• and/or open reduction, it is necessary
• to follow them until skeletal maturity,
• or even beyond.

DDH
Treatment ddh in children the age
4 – 18 mo
 DDH…What are the Two Most Commonly
Occurring Complications of Tx?
• Re-dislocation does occur & in young pts w/
extreme ligamentous laxity
(reported as < 5%, probably much higher)

• AVN (should be <10%): etiology - either

compression of fem head (closed reduction) or
vessel injury to the medial
circumflex artery
(open reduction)
Thank you