Correction of congenital

dislocation of the hip

Tsega T.
Menelik II Medical and Health Science College

8 July 2023
 Definition
• A progressive deformation of previously
normally formed structures during the
embryonic period
 Etiology
• Multifactorial :
-Mechanical Factors : all factors which tighten the space
available for the fetus in the uterus, like contracted pelvis
or tight unstretched uterine and abdominal musculature
which prevents free movement of the fetus.
-Hormonal Factors : maternal estrogens are increased
before
delivery to relax the pelvic muscles , this leads to laxity of
the capsule and instability of the hip.
-Postnatal environmental Factors : some people have
traditional habits of wraping the babies in positions which
do not secure the femoral head inside the acetabulum
 Pathology
• At the time of birth , the joint capsule is distended and elastic.
• After delivery the , the femoral head is loose within the joint
and free to fall out of the acetabulum .
• At this early stage the shape of the head and acetabulum and soft
tissues is very close to normal , so if the head is maintained within
the acetabulum for few weeks , the joint will return to its normal
configuration and become stable.
• If the dislocation is allowed to persist for long time, the bone
and soft tissues undergo adaptive changes , and the dislocation is
difficult to be reduced .
• The pathological changes may be in the acetabulum (shallow
acetabulum) , or the femoral head & neck, capsule and ligamentum
teres ( lax , redundant)
• Congenital dislocation of the hip occurs in a posterolateral and
proximal direction
 Clinical Diagnosis
• New Born:
• The mother may complain of asymmetric position of
lower limbs or lack of normal movement of one side

• The most reliable methods for diagnosis are :

-Ortolani Test :(Reduction Test),if the hip is dislocated,
the femoral head can be returned into the acetabulum ,
by abducting the hips and pushing the thighs anteriorly
(+ve sign ).
-Barlow Test : ( Dislocation Test) , if the hip is unstable
( dislocatable) , it can be pushed posteriorly out of the acetabulum after
flexing and adducting the thigh
 Older Infants & Children :
• -Limping during walking .
• In case of bilateral hip dislocation , waddling gait .
• -Shortening of affected lower limb, skin and subcutaneous
tissue are bunched up , extra skin folds are observed
• -Allis or Galeazi’s sign (shortening of affected thigh when
the knees are flexed ) .
• -Telescoping or Pistoning test (with the hip flexed, pushing
the thigh posteriorly no resistance is encountered )
• -Trendlenburg test : ( if the patient is standing on the
affected side ,pelvic tilt is observed)
 Neonatal Examination
• LOOK :
• External rotation attitude
• Lateralized contour
• Wide perineum ( in bilateral )
Asymmetric thigh folds
 Shortening ( not in neonates
• - Galeazzy sign
 FEEL :
• Empty groin
• Weak Femoral pulse
Neonatal Examination
Ortolani

Feel a Clunk
Not hear a click !
Neonatal Examination
Barlow
 Clinical Examination
The Walking Child
• Trendelenburgh: unilateral / bilateral (waddling)
 Radiographic Diagnosis
• Newborn :
In the first few days of life radiological diagnosis is almost
always negative
• After the age of 6 months pathological changes are evident :
- Shallow acetabulum ( Acetabulum Index), avarage 22-27 deg.
- Short Neck (Increased angle of antivervsion)
- Shenton’s Line
- Shoemaker’s Line
- Lateral migration of trochanter
- Delayed ossification of the head
 Treatment
Aims

• Obtain and Maintain concentric reduction

In an Atruamatic fashion Without disrupting
the blood supply
 Treatment
• Method depends on Age

• The earlier started, the easier the treatment

• The earlier started, the better the results

• Should be detected EARLY

 Treatment
• Birth to 6 months :
Pavlik harness or hip spica cast
• 6 months – 12 months :
closed reduction UGA and hip spica casts
• 12 months – 18 months :
possible closed / possible open reduction
• Above 18 months :
open reduction and ? Acetabuloplasty
• Above 2 years :
open reduction,acetabulplasty, and femoral osteotomy
• Above 8 years :
open reduction,acetabulplasty cutting three bones, and femoral
osteotomy
 Treatment
Hip instability in the neonatal period

Most resolve spontaneously

• Observation
• Pavlik harness
• Double /triple diapers ??
 Treatment
Birth – 6 months
Hip instability (dislocatable)
Established dislocation (reducible)
• Should be actively treated until hip is
normal clinically and radiographically
• Pavlik harness
• Hip Spica Cast
 Treatment
Birth – 6 months
Pavlik harness
 Treatment
Birth – 6 months

Other Devices
- Frejka pillow
- Craig

- Von Rosen splint

Soft abduction splints:

Not good enough

Rigid abduction splints:

Risk AVN
 Treatment
6 – 12 months
• Initially non operative – closed reduction
• Reduction under anesthesia and immobilization in hip
spica cast
• Position:
Human
Avoid severe abduction
Avoid Frog position
• Must be stable and concentrically reduced otherwise
needs open reduction

Better Picture
 Treatment
12 – 18 months
• Possibly closed reduction !!
when hip stable and concentrically reduced
• Probably open reduction
when hip unstable or not concentrically reduced
• Arthrography guided:
 Treatment
Above 3 years

• Open reduction

• And acetabulplasty

• And femoral shortening