Developmental Dysplasia of the Hip (DDH)

Hip Anatomi

A few facts about DDH y developmental (not congenital) y subluxation / dislocation / instabilityy Subluxation incomplete contact between the articular surfaces y Dislocation complete loss of contact between the articular surface y Instability This consists of the ability to subluxate or dislocate the hip with passive

manipulation.

y typical vs. teratologic (Teratologic - refers to antenatal dislocation ofthe hip)

Causes of typical DDHy Physiological, Mechanical, & Postural Factors y ligamentous laxity y 9:1 female to male preponderance y first born (60%) y breech presentation (30-50%) y family history (20%) y associated conditions

Consequences of DDHy Acetabular dysplasia and maldirection y Excessive femoral anteversion (torsion) y Muscle contractures y Avascular necrosis of femoral head

Clinical Manifestationsy In the newborny limitation of hip abduction y absent normal knee flexion contracture y assymetric number of thigh skinfolds y Galleazi sign y apparent shortening of an extremity y Nelatons line: Tip of Greater trochanter

i i i p t i v v v a v d i

lies above the same y Schoemakers line below the umbilicus

Physical Exam Maneuversy A. Barlow Testy dislocates an unstable hip

y B. Ortolani Testy reduces a recently

dislocated hip y most likely to be positive at 1-2 mos.

Other Clinical Manifestationsy In older childreny limping, waddling, toe walking, Gluteus Medius lurch

(tredelenburg gait) y leg length discrepancy y Increase lumbar lordosis with prominent gluteal region y Out-toeing and short leg y Compensatory genu valgum at the knee. y Positive telescoping test y Positive trendlenburgs test.

Imagingy Ultrasoundy most useful during first four weeks of life y visualization of cartilage y recommended only as an adjunct to PE

y Radiography more useful by 4 to 6 months of age y cheap, less operator dependent

USG

Grafs classification of dislocation hip (1) Normal hip (2) Concentrically reduced but immature and delayed in ossification. (3) Hip is subluxated or has low dislocation. (4) Hip dislocation with interposing labrum.

Treatmenty Treatment is age specific y Neonatey Goal: maintain hip in flexed and abducted position to maintain

femoral head reduction and tighten ligamentous structures. y Pavlik harness or Frejka splint for 1-2 mos.

Arthrogram1. 2. 3. 4. 5.

Limbus - 'Rose thorn sign' of inverted labrum between femoral head & acetabulum Hour glass constriction of capsule - by psoas tendon Capsular distension Medial pooling of dye (normal = < 7mm) Confirms reduction after surgery

Treatmenty 1-6 monthsy Pavlik harness for 3-4 weeks. y Closed surgical reduction if harness fails.

y Safe Zoney Flexion 100-110 y Abduction 40-60

Treatmenty 6-18 mos.y Closed or open surgical reduction y Hip spica cast

Treatmenty 18 mos.-8 yearsy Open reduction with pelvic and/or femoral osteotomy

Optionsy Do nothing y Femoral osteotomies y Pelvic osteotomies y Combination

Pelvic osteotomiesy Chiari Osteotomy y Salter Osteotomy y Pemberton Osteotomy y Sutherland Osteotomy y Dega-Steele Osteotomy y Dial Osteotomy

Chiarry Osteotomy

Salter Innominate Osteotomy

Pemberton osteotomy

Dega Osteotomy

Femoral osteotomy (Shortening)

Surgical Treatment in Adults:1. Non-arthroplasty Options1. 2. 3. 4.

Pelvic Osteotomy Bernese Periacetabular Osteotomy Femoral Osteotomy Arthrodesis

2. Arthroplasty Options

Pelvic Osteotomy

2. Arthroplasty Options

Alternative methods

Complicationy The most common complication of treatment of DDH is

osteonecrosis of the femoral head y Growth disturbance of proximal femoral physis y Gait abnormality

Summaryy DDH is an evolving process y Proper serial exams are imperative to prevent deformity y Know clicks from clunks y Earlier treatment=better outcomes

CASE Female, 21 mo

DDH

DDH

DDH

DDH

DDH