Ddh residents

Developmental Developmental Dysplasia of the HipDysplasia of the Hip

Dr.Abdulmonem Al SiddikyDr.Abdulmonem Al SiddikyAssistant professor & ConsultantAssistant professor & Consultant

Ped.Ortho.,Ped.Spine & Spinal deformitiesPed.Ortho.,Ped.Spine & Spinal deformities

KKUH , KSUKKUH , KSU

OverviewOverview

IntroductionIntroduction Normal Development of the HipNormal Development of the Hip Etiology and PathoanatomyEtiology and Pathoanatomy Epidemiology and DiagnosisEpidemiology and Diagnosis TreatmentTreatment ComplicationsComplications

IntroductionIntroduction

Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip DDH - preferred termDDH - preferred term Teratogenic hipsTeratogenic hips SubluxationSubluxation Dislocation-usually posterosuperior (reducible Dislocation-usually posterosuperior (reducible

vs irreducible)vs irreducible) DysplasiaDysplasia

SummarySummary

Risk FactorsRisk Factors 1/1,000 born with dislocated hip 1/1,000 born with dislocated hip 10/10,000 born with subluxation or dysplasia10/10,000 born with subluxation or dysplasia 80% Female80% Female First born childrenFirst born children Family history (6% one affected child, 12% one Family history (6% one affected child, 12% one

affected parent, 36% one child + one parent)affected parent, 36% one child + one parent) OligohydramniosOligohydramnios Breech (sustained hamstring forces)Breech (sustained hamstring forces) Native Americans (swaddling cultures)Native Americans (swaddling cultures) Left 60% (left occiput ant), Right 20%, both 20% Left 60% (left occiput ant), Right 20%, both 20% Torticollis or LE deformityTorticollis or LE deformity

Normal DevelopmentNormal Development

EmbryonicEmbryonic 7th week - acetabulum and hip formed from 7th week - acetabulum and hip formed from

same mesenchymal cellssame mesenchymal cells 11th week - complete separation between the 11th week - complete separation between the

twotwo Prox fem ossific nucleus - 4-7 monthsProx fem ossific nucleus - 4-7 months

Normal HipNormal Hip

Tight fit of head in Tight fit of head in acetabulumacetabulum

Transection of Transection of capsulecapsule Still difficult to Still difficult to

dislocatedislocate Surface tensionSurface tension

PathoanatomyPathoanatomy

Ranges from mild dysplasia --> frank Ranges from mild dysplasia --> frank dislocationdislocation

Bony changesBony changes Shallow acetabulumShallow acetabulum Typically on acetabular sideTypically on acetabular side Femoral anteversionFemoral anteversion


Soft tissue changesSoft tissue changes Usually secondary to prolonged subluxation or Usually secondary to prolonged subluxation or

dislocationdislocation

IntraarticularIntraarticular LabrumLabrum

Inverted + adherent to capsule (closed reduction with Inverted + adherent to capsule (closed reduction with inverted labruminverted labrum assoc with increased Avascular Necrosis) assoc with increased Avascular Necrosis)

Ligamentum teresLigamentum teres Hypertrophied + lengthenedHypertrophied + lengthened

PulvinarPulvinar Fibrofatty tissue migrating into acetabulumFibrofatty tissue migrating into acetabulum


Soft Tissue (Intraarticular)Soft Tissue (Intraarticular) Transverse acetabular ligamentTransverse acetabular ligament

ContractedContracted

LimbusLimbus Fibrous tissue formed from capsular tissue Fibrous tissue formed from capsular tissue

interposed between everted labrum and acetabular interposed between everted labrum and acetabular rimrim

ExtraarticularExtraarticular Tight adductors (adductor longus)Tight adductors (adductor longus) IliopsoasIliopsoas

Tough Reductions…Tough Reductions… Obstacles to reductionObstacles to reduction

ExtraarticularExtraarticular Tight iliopsoas and Tight iliopsoas and

adductorsadductors

IntraarticularIntraarticular LabrumLabrum Ligamentum teresLigamentum teres Transverse acetabular Transverse acetabular

ligamentligament PulvinarPulvinar Redundant capsule Redundant capsule

(hourglass)(hourglass) +/- limbus+/- limbus

Etiology and EpidemiologyEtiology and Epidemiology

MultifactorialMultifactorial Genetics and SyndromesGenetics and Syndromes

Ehler’s DanlosEhler’s Danlos ArthrogryposisArthrogryposis Larsen’s syndromeLarsen’s syndrome

Intrauterine environmental factorsIntrauterine environmental factors TeratogensTeratogens Positioning (oligohydramnios)Positioning (oligohydramnios)

Neurologic DisordersNeurologic Disorders Spina BifidaSpina Bifida

DiagnosisDiagnosis Newborn screeningNewborn screening

Ortolani’s and Barlow’s maneuvers with a Ortolani’s and Barlow’s maneuvers with a thorough history and physicalthorough history and physical

Warm, quiet environment with removal of Warm, quiet environment with removal of diaperdiaper

Head to toe exam to detect any associated Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity conditons (Torticollis, Ligamentous Laxity etc.)etc.)

Baseline Neuro and Spine ExamBaseline Neuro and Spine Exam

DiagnosisDiagnosis

Key physical findingsKey physical findings AsymmetryAsymmetry

Limb length- GaleazziLimb length- Galeazzi Abduction ROMAbduction ROM Skin foldsSkin folds Limp Limp Waddilng gait / Waddilng gait /

hyperlordosis - bilateral hyperlordosis - bilateral involvementinvolvement

Ortolani’s ManeuverOrtolani’s Maneuver

* After 3 months of age tests become negative

Barlow’s ManeuverBarlow’s Maneuver

DiagnosisDiagnosis

Some cases still missedSome cases still missed At risk groups should be further screenedAt risk groups should be further screened AAPAAP

Recs further imaging (e.g. US) if exam is Recs further imaging (e.g. US) if exam is “inconclusive” AND“inconclusive” AND First degree relative + femaleFirst degree relative + female BreechBreech Positive provocative maneuver (Ortolani or Barlow)Positive provocative maneuver (Ortolani or Barlow)

Referral to OrthopaedistReferral to Orthopaedist

ImagingImaging

X-raysX-rays Femoral head ossification centerFemoral head ossification center

4 -7 months4 -7 months

UltrasoundUltrasound Operator dependentOperator dependent

CTCT MRIMRI ArthrogramsArthrograms

Open vs closed reductionOpen vs closed reduction

ImagingImaging

RadiographsRadiographs

ImagingImaging

Acetabular IndexAcetabular Index

ImagingImaging

Acetabular IndexAcetabular Index

< 30° wnl

ImagingImaging

Radiographs SummaryRadiographs Summary

Femoral head appears 4 - 7 monthsFemoral head appears 4 - 7 months Shenton’s lineShenton’s line Perkin’s and Hilgenreiner’s linesPerkin’s and Hilgenreiner’s lines

Inferomedial quadrantInferomedial quadrant

Center Edge Angle (< 20 abnormal)Center Edge Angle (< 20 abnormal) Acetabular indexAcetabular index

Normal < 30 (Weintroub et al)Normal < 30 (Weintroub et al)

Tear drop*Tear drop* Abnormal widening in DDHAbnormal widening in DDH*may be only sign in mild subluxation*may be only sign in mild subluxation

ImagingImaging

UltrasoundUltrasound Introduced in 1978 for eval of DDHIntroduced in 1978 for eval of DDH Operator dependentOperator dependent Useful in confirming subluxation, identifying Useful in confirming subluxation, identifying

dysplasia of cartilaginous acetabulum, dysplasia of cartilaginous acetabulum, documenting reducibilitydocumenting reducibility

Prox Femoral Ossification Center interferesProx Femoral Ossification Center interferes Requires a window in spica cast (avoid)Requires a window in spica cast (avoid)

UltrasoundUltrasound

Femoral head

Abductors

Ilium


Graf’s alpha angle


Graf’s alpha angle

>60° = normal

*line w/ ilium bisects head 50/50

Natural HistoryNatural History

NewbornNewborn Variable Variable > 6 months> 6 months more aggressive tx required more aggressive tx required

due to more extensive pathology and due to more extensive pathology and decreased potential for acetabular decreased potential for acetabular remodelingremodeling

Abnormal Gait, Decreased Abduction and Abnormal Gait, Decreased Abduction and Strength, Increased DJDStrength, Increased DJD

Unilateral worse than BilateralUnilateral worse than Bilateral Subluxation worse than Dysplasia Subluxation worse than Dysplasia

Treatment OptionsTreatment Options

Age of patient at presentationAge of patient at presentation Family factorsFamily factors Reducibility of hipReducibility of hip Stability after reductionStability after reduction Amount of acetabular dysplasiaAmount of acetabular dysplasia

http://www.jaaos.org/content/vol8/issue4/images/large/0080232.ff023204.jpeg

Birth to Six MonthsBirth to Six Months

Triple-diaper techniqueTriple-diaper technique Prevents hip adductionPrevents hip adduction ““Success” no different in some Success” no different in some

untreated hipsuntreated hips

Pavilk harness (1944)Pavilk harness (1944) Experienced staff*Experienced staff* Very successfulVery successful Allows free movement within Allows free movement within

confines of restraintsconfines of restraints

*posterior straps for preventing add. NOT producing abd.

Birth to Six MonthsBirth to Six Months

Pavlik harnessPavlik harness IndicationsIndications

Fully reducible hip*Fully reducible hip* Child not attempting to standChild not attempting to stand FamilyFamily

• Close regular follow-up (every 1-2 weeks)Close regular follow-up (every 1-2 weeks)• For imaging and adjustmentsFor imaging and adjustments

• DurationDuration• Childs age at hip stability + 3 monthsChilds age at hip stability + 3 months

Pavlik HarnessPavlik Harness

FailuresFailures Poor parent compliancePoor parent compliance Improper use by the physicianImproper use by the physician

Inadequate initial reductionInadequate initial reduction Failure to recognize persistent dislocationFailure to recognize persistent dislocation

Viere et al 1990Viere et al 1990 Bilateral dislocationBilateral dislocation Absent Ortolani’s signAbsent Ortolani’s sign > 7weeks of age> 7weeks of age

Pavlik HarnessPavlik Harness

ComplicationsComplications Avascular necrosisAvascular necrosis

Forced hip abductionForced hip abduction Safe zone (abd/adduction and flexion/extension)Safe zone (abd/adduction and flexion/extension)

Femoral nerve palsyFemoral nerve palsy HyperflexionHyperflexion

*Be aware of Pavlik Harness Disease*Be aware of Pavlik Harness Disease

*Follow until skeletal maturity*Follow until skeletal maturity

Birth - Six monthsBirth - Six months

Closed reduction + SpicaClosed reduction + Spica Failure after 3 weeks of Pavlik trialFailure after 3 weeks of Pavlik trial

Birth - Six monthsBirth - Six months

Closed reductionClosed reduction General anesthesiaGeneral anesthesia ArthrogramArthrogram Safe zone - avoid AVNSafe zone - avoid AVN +/- adductor tenotomy+/- adductor tenotomy Open reduction if concentric reduction not Open reduction if concentric reduction not

possiblepossible Usually teratogenic hips in this age groupUsually teratogenic hips in this age group

Open ReductionOpen Reduction

Medial approachMedial approach Pectineus / adductor longus + brevisPectineus / adductor longus + brevis Cannot address simeoultaneous bony workCannot address simeoultaneous bony work

Antero -lateralAntero -lateral Smith-petersonSmith-peterson Sartorius / Tensor Fascia lataSartorius / Tensor Fascia lata

Open ReductionOpen Reduction

6 months - 4 years6 months - 4 years

Present a more difficult problemPresent a more difficult problem Prolonged dislocationProlonged dislocation Contracted soft tissuesContracted soft tissues

6 - 18 months6 - 18 months Closed reduction +/- adductor tenotomyClosed reduction +/- adductor tenotomy Spica in human position of 100 degrees of flexion and Spica in human position of 100 degrees of flexion and

about 55 degrees abduction (3 months)about 55 degrees abduction (3 months) Abduction Orthosis 4 wks full time/4 wks nighttimeAbduction Orthosis 4 wks full time/4 wks nighttime Open reduction (if closed fails)Open reduction (if closed fails)

CapsulorraphyCapsulorraphy CT scanCT scan Spica for 6 wks followed by PTSpica for 6 wks followed by PT

6 months - 4 years6 months - 4 years

18 months - 4 years18 months - 4 years Closed reductionClosed reduction

Reducibile - check arthrogram and Reducibile - check arthrogram and medial dye poolmedial dye pool Irreducible - Open reductionIrreducible - Open reduction

Open redcutionOpen redcution Tight - femoral shorteningTight - femoral shortening

Stable - +/- pelvic osteotomyStable - +/- pelvic osteotomy

Femoral ShorteningFemoral Shortening

Schoenecker + Strecker 1984Schoenecker + Strecker 1984 Traction vs. Femoral shorteningTraction vs. Femoral shortening 56% AVN in traction group56% AVN in traction group 0% AVN in femoral shortening0% AVN in femoral shortening

Pelvic OsteotomyPelvic Osteotomy

Persistent instability + dysplasia after Persistent instability + dysplasia after open reduction + femoral shorteningopen reduction + femoral shortening

Requires concentric reduction of a Requires concentric reduction of a reasonably spherical femoral headreasonably spherical femoral head

Usually based on surgeon preferenceUsually based on surgeon preference Salter and Pemberton 2 m/c in USSalter and Pemberton 2 m/c in US

Pelvic Osteotomy Pelvic Osteotomy

Volume changingVolume changing Pemberton Pemberton

Hinges on triradiateHinges on triradiate Requires remodeling of “new” incongruityRequires remodeling of “new” incongruity Provides more anterolateral coverageProvides more anterolateral coverage

Dega’sDega’s

PembertonPemberton

Pelvic OsteotomyPelvic Osteotomy

RedirectingRedirecting SalterSalter

Osteotomy thru sciatic notchOsteotomy thru sciatic notch Hinge thru pubic symphysisHinge thru pubic symphysis

Triple innominateTriple innominate GanzGanz DialDial

Salter OsteotomySalter Osteotomy

Salvage or Shelf proceduresSalvage or Shelf procedures

ChiariChiari Requires capsular metaplasiaRequires capsular metaplasia Pain - main indicationPain - main indication Treatment of chronic hip pain in adolescentsTreatment of chronic hip pain in adolescents

Chiari OsteotomyChiari Osteotomy

Avascular NecrosisAvascular Necrosis

Avascular NecrosisAvascular Necrosis

Most commonMost common Not part of the natural history of DDHNot part of the natural history of DDH IatrogenicIatrogenic Etiology unknownEtiology unknown

Femoral head compressionFemoral head compression Injury to blood supplyInjury to blood supply

Excessive abductionExcessive abduction Sullivan et al 1997Sullivan et al 1997 Sig Sig ↓↓ blood flow w/ increasing abd angle blood flow w/ increasing abd angle

TX SummaryTX Summary

Best if treated before 6 weeks of ageBest if treated before 6 weeks of age 0 - 6 months of age0 - 6 months of age

PavlikPavlik

6 - 18 months6 - 18 months Closed vs open reduction and spicaClosed vs open reduction and spica

18 - 48 months18 - 48 months ClosedClosed Open +/- osteotomiesOpen +/- osteotomies

SummarySummary

Femoral shortening better than tractionFemoral shortening better than traction Pelvic osteotomiesPelvic osteotomies

Dega, PembertonDega, Pemberton Salter, triple innominate, GanzSalter, triple innominate, Ganz ChiariChiari

QuestionsQuestions

Evaluation of a 4week infant who has a Evaluation of a 4week infant who has a hip click reveals a positive Ortolani sign. hip click reveals a positive Ortolani sign. Treatment should include:Treatment should include:

A.A. traction, closed reduction, and spica casting.traction, closed reduction, and spica casting. B.B. triple diapers and reassessment in 1 monthtriple diapers and reassessment in 1 month

C.C. an AP pelvis x-ray at age 4 monthsan AP pelvis x-ray at age 4 months D. D. Fitting of a Pavlik harness and reassessment in 2 Fitting of a Pavlik harness and reassessment in 2

weeksweeks E.E. an US of the hip, fitting of a Pavlik, and an US of the hip, fitting of a Pavlik, and

reevaulation in 3 months.reevaulation in 3 months.

Evaluation of a 4week infant who has a Evaluation of a 4week infant who has a hip click reveals a positive Ortolani sign. hip click reveals a positive Ortolani sign. Treatment should include:Treatment should include:

A.A. traction, closed reduction, and spica casting.traction, closed reduction, and spica casting. B.B. triple diapers and reassessment in 1 monthtriple diapers and reassessment in 1 month

C.C. an AP pelvis x-ray at age 4 monthsan AP pelvis x-ray at age 4 months D. D. Fitting of a Pavlik harness and reassessment in Fitting of a Pavlik harness and reassessment in

2 weeks2 weeks E.E. an US of the hip, fitting of a Pavlik, and an US of the hip, fitting of a Pavlik, and

reevaulation in 3 months.reevaulation in 3 months.

A healthy 5-mo-old infant w/ DDH of the L hip A healthy 5-mo-old infant w/ DDH of the L hip has been treated in a Pavlik for 3 months. has been treated in a Pavlik for 3 months. Exam shows limited ABD and a Galeazzi sign. Exam shows limited ABD and a Galeazzi sign. Radiographs in harness were taken. Radiographs in harness were taken. Management should consist of:Management should consist of:

A.A. an arthrogram and closed reductionan arthrogram and closed reduction B.B. a change of the Pavlik to a Frejka pillowa change of the Pavlik to a Frejka pillow C.C. no further Rx until the child is 6mosno further Rx until the child is 6mos D. D. Adjustment of the Pavlik and continuation of RxAdjustment of the Pavlik and continuation of Rx E.E. open reduction through a medial approach and spicaopen reduction through a medial approach and spica

This is an x-ray of a 9-month-old infant who This is an x-ray of a 9-month-old infant who has intoeing. Exam of the hips show ABD of has intoeing. Exam of the hips show ABD of the Left hip to 75 degrees and the Right to 90 the Left hip to 75 degrees and the Right to 90 degrees. Both the Ortolani and Barlow signs degrees. Both the Ortolani and Barlow signs are negative. Management should include:are negative. Management should include:

A.A. observationobservation

B.B. application of a Pavlik harnessapplication of a Pavlik harness C.C. closed reduction of the Left hipclosed reduction of the Left hip D.D. open reductino of the Left hipopen reductino of the Left hip E.E. open reduction of the left hip with innominate open reduction of the left hip with innominate

osteotomyosteotomy

The x-ray shows a AP pelvis of a 6yo girl who The x-ray shows a AP pelvis of a 6yo girl who presents with a limp and intermittent pain in presents with a limp and intermittent pain in the right groin. Management should include:the right groin. Management should include:

A.A. A varus derotational osteotomy of the right femurA varus derotational osteotomy of the right femur

B.B. open reduction and adductor tenotomyopen reduction and adductor tenotomy C.C. open reduction with femoral and pelvic osteotomiesopen reduction with femoral and pelvic osteotomies D.D. PT for muscle strengthening and ROM exercisesPT for muscle strengthening and ROM exercises E.E. longitudinal traction, closed reduction, and adductor longitudinal traction, closed reduction, and adductor

tenotomytenotomy

The x-ray shows a AP pelvis of a 6yo girl who The x-ray shows a AP pelvis of a 6yo girl who presents with a limp and intermittent pain in presents with a limp and intermittent pain in the right groin. Management should include:the right groin. Management should include:

A.A. A varus derotational osteotomy of the right femurA varus derotational osteotomy of the right femur

B.B. open reduction and adductor tenotomyopen reduction and adductor tenotomy C.C. open reduction with femoral and pelvic open reduction with femoral and pelvic

osteotomiesosteotomies D.D. PT for muscle strengthening and ROM exercisesPT for muscle strengthening and ROM exercises E.E. longitudinal traction, closed reduction, and adductor longitudinal traction, closed reduction, and adductor

tenotomytenotomy

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