Developmental

dysplasia of the hip

Introduction
 Definition:
Dysplasia of the hip that develop during fetal life or in infancy
 The old name was congenital dysplasia of the hip(CHD).
The name changed to indicate that not all cases are present at birth and some cases can develop
later on during infancy and childhood.
DDH comprises a spectrum of disorders
including:
 Acetabular dysplasia
A shallow or underdeveloped acetabulum
 Subluxation
 Dislocation
 Teratologic hip
Dislocated in utero and irreducible on neonatal exam
Associated with neuromuscular conditions and genetic disorders,commonly seen with
arthogryposis,myelomengiocele.
Epidemiology
 Incidence
Most common orthopaedic disease in newborn
Dysplasia is 1:100
Dislocation is 1:1000
 Location
Most common in left hip in females
Bilateral in 20%
 Risk factors:
 First born
 Females ((6:1 over males)
 Breech
 Family history
 Oligohydraminos
Etiology and pathogenesis
Genetic factors
 Must be important for DDH tends to run in families and even in entire
populations.
 Two heritable features which could predispose to hip instability are:
1. generalized joint laxity is a dominant trait
2. shallow acetabular (a polygenic trait which mainly in girls and their
mothers
 Hormonal changes
Hormonal changes is pregnancy may aggregate ligamentous laxity in the
infant. This could account for the rarity of hip instability in premature
babies.
 Intrauterine malposition
Especially in a breech position with extended legs, would favour
dislocation.
Postnatal factors
Play a part in maintaining any tendency to instability.This may account
for the unusually high incidence of DDH in Inuit and Sami
people’s,who swaddle their babies and carry them with hips and knees
fully extended; compare with the rarity of DDH in African people's,
who carry their babies astride their backs with hips abducted.
Pathology
 The acetabulum is unusually shallow(shaped like a saucer instead of a cup)
 The femoral head slides out posteriorly and then rides upwards superiolaterally
 The capsule is stretched and the ligament there’s becomes elongated and
hypertrophied
 The acetabular labrum and it’s capsular edge may be pushed into the socket by
the dislocated femoral head; this fibrocartilage limbus may obstruct any
attempt at closed reduction of the femoral head
 Maturation of the acetabulum and femoral epiphysis is retarded And the
femoral neck is undule anteverted.
Clinical features
 The ideal, is to diagnose every case at birth. For this reason, every
newborn child should be examined for signs of hip instability.
 Where there is a family hx of congenital instability,and with breech
presentations or signs of other congenital abnormalities,extra care is
taken and the infant may have to be examined more than once.Even
then some cases are missed
 In the neonate there are several ways of testing for e.g Oryolanis
test, Barlow's test
Ortolani’s test
 In this test the baby’s thighs are held with the thumbs medially and
the fingers resting on the greater trochanters:the hips are flexed to
90°and gently abducted .Normally there is smooth abducton to
almost 90°.
 In congenital dislocation the movement is usually impeded but if
pressure is applied to the greater trochanters there is a soft “clink” as
the dislocation reduces
 If abduction stops halfway and there is no jerk of entry,there may be
an irreducible dislocation.
Barlow’s test
 This test is easily performed by adductingthe hipwhile applying light
pressure on the knee directing the force posteriorly.
 If the hip is dislocatable –that is, the hip can be popped out of the
socket with this maneuver- the test is considered positive.
 The ortolani maneuver is then used to confirm the positive finding
Ie that the hip is actually dislocated
 Every hip with signs of instability-however slight –should be examined by
ultrasonography.This shows the shape of the cartilaginous socket and the position of the
femoral head
 Late features –an observant mother may spot assymmetry,a clicking hip or difficulty
applying a diaper because of limited abduction
 With unilateral dislocation the skin creases look assymetrical and the leg is slightly
short(Galeazzi’s sign) and externally rotated;with bilateral fislocation there is an
abnormally wide perineal gap
 Abduction is decreased
 Contrary to popular belief late walking is not a marked feature;nevertheless, children who
do not walk by 18 mths must be excluded
 Likewisea limp or Trendelenburg gait or a wadding gait could be a sign of missed
dislocation.
Imaging
 Because the proximal femur at birthis all cartilaginous, radiographs
can not be used to position the head of the femur in relation to the
acetabulum.
 Ultrasound is used to assess the position of the head of femur until the
age of ,4-6mths when the ossific center of the proximal femur starts to
develop.
 Dynamic ultrasound: using ultrasound to assess the stability of the
head of the femur in the acetabulum during various movement of the
hip joint
 After the ossific center is formed (aroundb4-6mths),the ultrasound
waves cannot penetrate the ossific center.plain radiographs are used to
assess the hip joint
 Alpha angle
 It represents the bony acetabulum

Interpretation



Normal is more than 55°
of ultrasound of the hip
This indicated good bony coverage of the head of femur(deep acetabulum)
 Beta angle
 It represents the cartilaginous acetabulum
 Should be< 50°
 This indicated that the head of femur is not subluxated (Big Beta Bad)
Diagnosis of missed DDH at 6 mths
 Limited abduction of the affected hip
 Limb length discrepancy(positive Galeazzi sign)
 Limping for unilateral causes and waddling gait for bilateral cases
 Pain is never a symptom of untreated DDH until the development of hip
arthritis in the 4th decade of life
Radiographs of missed DDH
 The femoral head is ossified
 The femoral head is out of the acetabulum in the upper lateral quadrant formed by crossing of
Hilgereiner line and Perkin’s line
 Broken Shenton's line (imaginary line between the obturator foramen and lower border of the
neck of femur)
 Increased acetabular index ( normal acetabular index should be less than 24 degree at the age of
24 mths
 Delayed ossification of the femoral head(the affected side is smaller than the normal side).
Treatment
 Nonoperative
Abductiomsplinting/bracing(Pavlik harness)
Indications
 DDH < 6mthsof age and reducible hip.
 Is a dynamic splint that required normal muscle function for successful outcomes.
 Contraindicated in patients with terologic hip dislocations,Spina bifida or spasticity
Outcomes
 Overall Pavlik harness has success rate of 90%
 Dependent upon age at initiation of treatment and time spent in the harness
 Abandon pavlik harness treatment if not successful 3-4weeks
 If pavlik harness fails,convert to semi rigid abduction brace with weekly ultrasounds for an addiction 3-4 weeks
before considering further intervention.
 Closed reduction and spica casting
Indication
 DDH in6-18mths
 Failure of pavlik treatmet
Arthography performed at time of reduction
Medial dye pool >7mm associated with poor outcomes and
osteonecrosis.

Operative
 Open reduction and spica casting
Indications
 DDH in patient >18mths of age
 Failure of closed reduction
Open reduction and femoral osteotomy
Indications
 DDH > 2 years with residual hip dysplasia
 Anatomic changes on femoral side(e g.femoral anteversion coxa valga )
 Femoral head should be congruantly reduced with satisfactory. ROM, and reasonable femoral spericity
 Best in younger children (<4 years)
 After 4 yrs pelvic osteomies
Open reduction and pelvic osteotomy
Indications
 DDH>2years with residual hip dysplasia
 Severe dysplasia accompanied by significant radiographic changes
on the acetabular side.(Increased acetabular index)
 Used more commonly in older children (>4years)
 Decreased potential for acetabular remodeling as a child ages.
Complications

 Osteonecrosis
 Delayed diagnosis
Recurrence
 Approximstely 10%with appropriate treatment
 Requires radiographic follow-up until skeletal maturity
 Transient femoral nerve palsy