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Carol Berg

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Developmental

dysplasia of Hip

Dr Waqar HassanTMO Orthopedic Unit

HMC

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Objectives

Understand what is DDH

How to diagnose

Treatment

Research and cases in our unit

Conclusion & suggestion

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Definition

DDH is a spectrum of disorders. Hipcan be

Dislocated

Dislocatable

Subluxated

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Age

1. Teratological Dislocation (congenital dislocation of hip)

Typical DDH Child is otherwise normal

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Epidemiology

& risk factors Incidence 1 in 1000 live birth

Left hip 67%

Family history 20% In breech 30-50%

Bilateral 35%

Sex Ratio (Relaxin) F(4 - 6) : M(1)

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Risk factor

Environmental & Mechanical

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Risk factor

Geneticunknown genetic factor

Runs in familiesRisk to next child increases

Families with Generalised Ligament

Laxity Families with Acetabular Dysplasia

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Nursingrace

Rare in China, Asia, Africa (carrychildren with hips flexed andabducted)

High in native American (Used tonurse with legs extended)

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Aetiology-Ligamentous

LaxityMaternal Relaxin hormones

Induce hip capsule laxity in infant

Effect is much stronger in females

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PathologyBone

Soft tissues

Muscles

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Screening for DDH

Methods

Clinical

U.S. Scan

Aim of screeningEarly detection

Reduces late presentation

Reduces surgical intervention

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Clinical screening

Standard programme

Barlows/Ortolanis tests done on

every child at birth and then at 6-8weeks

Barlows/Ortolanis Tests

Specificity- 100%

Sensitivity- 60%

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Barlow Provocative Test

in neonate

Dislocates hip(exit)

Clunk

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Ortolani Maneuver

in neonate

Reducesdislocated hip(entry)

Abduction

Clunk

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Infant >3 Months

57 43

Limited abduction is key26

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Infant >3 Months

Asymmetricthigh folds

Limb-length

discrepancy

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Galeazzi test

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Toddler

Limping

waddling gaitLordosis

Deformity

Limited abduction and lateral rotationTelescoping

Leg length discrepancies

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Ultrasound Screening

High Specificity and Sensitivity: >90%

Helps in diagnosis of not onlySubluxated/ Dislocated hips but alsoDysplastic hips

Helps in Monitoring the treatment

Reduces the need for Arthrograms /Xrays.

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Radiology

Standard films AP of the pelvis withboth hip joint

frog-leg views

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Central edge

angle

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Von Rosens line

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Treatment

Aim

Proper reduction of femoral head

is important for development ofacetabulum and lowers incidenceof acetabular dysplasia

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According to Campbells

operative orthopedicsbirth to 6 months (New born)

6 to 18 months (Infant)18 to 36 months (toddler)

3 to 8 years (child)

Juvenile & Young adults-

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TREATMENT :

In newborn

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Denis Brown Abduction

Splint

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Von Rosen Splint

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Pavlik harness should not becontinued for more than 4 weeks if

failedComplicationAVN

Femoral nerve palsyPersistant dislocated hip can wear

away acetabulum (pavlik harnessdisease)

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Failure of Pavlik harness

6-8 weeks notstabilised

TractionClosed reduction&radiographicassesment

Open reduction ifnecessary

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Treatment: Infant 6 to 18

monthsClosed reduction & Spica

Must be gentle flex hip > 90

degree and in safe zone of 30 -60degree abduction

Arthrography is often useful

Adductor tenotomy

Open reduction if necessary

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Hip spica

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Aftercare

After close reduction

Spica for 4 months with cast

changes every 6 weeksCheck X-rays or CT scans

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Open reduction in 12 to 18

monthsAs child get older chance ofsuccessful close reduction

decreaseOpen reduction may be neededdue to soft tissues contracture

Seldom need bony procedure

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Open reduction

Structural obstacles to closereduction are

Hour glass capsular contractureLigamentum teres

Iliopsoas

PulvinarTransverse acetabular ligament

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Toddler 18-36months

Open reduction combined withfemoral osteotomy

Pelvic and femoral combinedosteotomies

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Oteotomy

Femoral osteotomyFemoral shortening

DerotationVarus

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Pelvic Osteotomies

Reconstructive

Salter 18m 6yPemberton18m 10y

Steel skeletal maturity

PAO (Ganz) skeletal maturity

SalvageChiari skeletal maturity

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Overview of Pelvic

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Overview of PelvicOsteotomies

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How to determine forosteotomy

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Juvenile & Young adults> 8 years

Palliative salvage procedures

Rarely femoral shortening &pelvic osteotomy

Bilateral: leave it alone

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Researh work in our unit

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Study in orthopedic unit

HMCPeriod : Sep2003 to July 2007

Ref no. : JPMI 2008 VOL22

NO.01:27-32Title : One stage surgery of

CDH/DDH in children of

2-5 years of age

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Results

Total no. of patients: 25Total hips operated: 30

Gender :

Female: 17Male: 8

Bilateral : 5 Cases

Left side : 18 casesMean age at surgery: 38.56months

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Radiological assessmentmodified Severin classification

Excellent I A CE angle>19 degree 9

Good I B

II

CE angle15-19 degree

Moderate deformity of femoral head

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10

Fair III Dysplastic hip, no subluxation CE

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Case -2

Irtiza

2 yr old

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Case-3

Alia

2 yr old

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Case- 4

Faiza

2 yr old

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Suggestion

Radiologist

Pediatrician

Gynecologist

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THANK YOU

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Ul d

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Ultrasound

Alpha > 60Slope of osseus

acetabulum

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