Developmental Dysplasia of the Hip (DDH)

Hip Anatomi

A few facts about DDH

• developmental (not congenital)

• subluxation vs. dislocation vs. instability

• typical vs. teratologic

Causes of typical DDH

• Physiological, Mechanical, & Postural Factors

• ligamentous laxity

• 9:1 female to male preponderance

• first born (60%)

• breech presentation (30-50%)

• family history (20%)

• associated conditions

Consequences of DDH

• Acetabular dysplasia and maldirection

• Excessive femoral anteversion (torsion)

• Muscle contractures

• Avascular necrosis of femoral head

Clinical Manifestations

• In the newborn– limitation of hip abduction– absent normal knee flexion contracture– assymetric number of thigh skinfolds– uneven knee levels– apparent shortening of an extremity

Physical Exam Maneuvers

• A. Barlow Test– dislocates an unstable hip– stabilize pelvis with one hand, then flex and

adduct opposite hip with posterior pressure.– dislocation is felt as a “clunk”– release of posterior pressure spontaneously

relocates femoral head.

Physical Exam Maneuvers (con’t.)

• B. Ortolani Test– reduces a recently dislocated hip– flex and abduct thigh to lift femoral head into

acetabulum– relocation “clunk”– most likely to be positive at 1-2 mos.

Physical Exam Maneuvers (con’t)

Other Clinical Manifestations

• In older children– limping, waddling, toe walking– increased lumbar lordosis– leg length discrepancy

Clicks vs. Clunks

• Clicks– benign adventitial sounds– secondary to several causes– not predictive of DDH

• Clunks– feeling of true dislocation or reduction– positive examination

Imaging

• Ultrasound– most useful during first four weeks of life– visualization of cartilage– recommended only as an adjunct to PE

• Radiograph– more useful by 4 to 6 months of age– cheap, less operator dependent

Ultrasound

Radiograph

Treatment

• Treatment is age specific

• Neonate– Goal: maintain hip in flexed and abducted

position to maintain femoral head reduction and tighten ligamentous structures.

– Pavlik harness or Frejka splint for 1-2 mos.

Arthrogram

1. Limbus - 'Rose thorn sign' of inverted labrum between femoral head & acetabulum

2. Hour glass constriction of capsule - by psoas tendon

3. Capsular distension 4. Medial pooling of dye (normal = < 7mm) 5. Confirms reduction after surgery

Treatment

• 1-6 months– Pavlik harness for 3-4 weeks.– Closed surgical reduction if harness fails.

Save Zone Position

20-550

Treatment

• 6-18 mos.

– Closed or open surgical reduction

– Hip spica cast

Pathology

Treatment

• 18 mos.-8 years– Open reduction with pelvic and/or femoral

osteotomy

Pelvic osteotomies

• Salter’s innominate

• Pemberton

• Osteotomies to free the acetabulum - Steel & Dega

• Chiari displacement osteotomy

Options

• Do nothing

• Femoral osteotomies

• Pelvic osteotomies

• Combination

Salter Innominate Osteotomy

Pemberton osteotomy

Dega Osteotomy

Dega Osteotomy

Chiarry Osteotomy

Femoral osteotomy (Shortening)

Surgical Treatment in Adults:

1. Nonarthroplasty Options1. Pelvic Osteotomy

2. Bernese Periacetabular Osteotomy

3. Femoral Osteotomy

4. Arthrodesis

Pelvic Osteotomy

2. Arthroplasty Options

Alternative methods

Complication’s

• The most common complication of treatment of DDH is osteonecrosis of the femoral head

• Growth disturbance of proximal femoral physis

• Gait abnormality

Summary

• DDH is an evolving process

• Proper serial exams are imperative to prevent deformity

• Know clicks from clunks

• Earlier treatment=better outcomes