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Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
DR HAMZA SHAIKH
Developmental dysplasia of hip (DDH)
Definition “Spectrum of disorders of development of the hip that present in different forms at
different ages”
Dislocation
Displacement of a joint with no contact b/w the articular surfaces
Subluxation
Displacement with some contact remaining b/w the articular surface
Dysplasia
Deficient development of the acetabulum
Teratologic dislocation
Distint form of the hip dislocation occur with other disorders
Dislocated before birth Have limited ROM Not reducibile on examination
Developmental dysplasia of hip (DDH)
Incidence
There is marked geographic and racial variation in the incidence of DDH
Higher incidences are reported when screening uses both clinical examination and ultrasonography
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Etiology
Ligamentous laxity (often inherited)
Breech position (especially footling)
Postnatal positioning (hips swaddled in extension)
Primary acetabular dysplasia (unlikely)
Developmental dysplasia of hip (DDH)
Ligamentous Laxity
Newborn response to maternal relaxin hormones
The newborn's response to maternal relaxin hormones may explain the higher incidence of DDH in girls.
Newborn with DDH have higher ratio of collagen III to collagen I suggesting connective tissue disorder
Developmental dysplasia of hip (DDH)
Wynne Davies criteria for ligamentous laxity
Developmental dysplasia of hip (DDH)
Prenatal positioning
Strong association
Breech positions have higher risk of DDH
Knees extended breech (20%) Footling breech (2% incidence)
A. Low incidence of DDHB. 2%C. 20%
Developmental dysplasia of hip (DDH)
Postnatal position
Increase risk in babies wrapped with hip extension
Developmental dysplasia of hip (DDH)
Racial Predilection
Certain ethnic groups seems to be predisposed to DDH, whereas others apper immune
Blacks and Asians have relatively low incidences of DDH, whereas whites and Native Americans have a higher incidence.
Developmental dysplasia of hip (DDH)
Associated conditions
Metatarsus adductus (1.5 – 10%)
Torticollis (15 -20%)
oligohydroamnios
Developmental dysplasia of hip (DDH)
Pathophysiology
Normal hip development Starts at 7th week of gestation Cartilaginous femoral head and acetabulum is
formed by 11th week of gestation Concavity of actabulum is determined by the
structure within the acetabulum
Neonatal acetabulum is composed of cartilage
Developmental dysplasia of hip (DDH)
Hip development in DDH
Gradually progressive disorder with distinct anatomic changes
At birth posterosuperior rim of the acetabulum loses its sharp margin and become flattened and ridge of thickened articular cartilage forms (neolimbus)
Some unstable hips become normal with complete resolution of anatomic changes other eventually remains out of the socket permanently
Developmental dysplasia of hip (DDH)
Pathology of unstable hip (subluxatable but not dislocatable)
• Loose hyperelastic capsule• Elongated ligamentum teres• Slight eversion of hypertrophied acetabular rim
Developmental dysplasia of hip (DDH)
Pathology of the dislocatable hip
• Capsule stretched out
• Ligamentum teres markedly elongated
• Labrum is definitely everted
• Neolimbus at the junction of labrum and hyaline cartilage
• Excessive acetabular antetorsion
Developmental dysplasia of hip (DDH)
Dislocated hip that is irreducible due to intra
articular obstacles
• Obstacles to reduction
• Inverted limbus• Ligamentum teres• Fibrofatty pulvinar
Developmental dysplasia of hip (DDH)
Iliopsoas tendon as an obstacle
• hourglass contriction forms capsular isthmus
Developmental dysplasia of hip (DDH)
Acetabulum gradually remodels after stable reduction ( increase depth / anteversion)
If hip remain dislocated, acetabulum becomes more anteverted and shallow
Acetabular growth continued through 8 yrs of age
Developmental dysplasia of hip (DDH)
Natural history
Neonatal hip instability
Fate of unstable hip remains an enigma
60% of hips that exhibit Barlow’s sigh at birth spontaneously corrected in the first week of life and 88% in first 2 months (Barlow -1962)
CLINICAL PRESENTATION
The clinical presentation of congenital dysplasia of the hip varies according to the age of the child. So the treatment is different in different age groups....
Neonate Child 6 month to 18 months Toddler 18mths to 36mths Child 3yrs to 8 yrs age
Developmental dysplasia of hip (DDH)
neonate
In newborns (≤6 months old), it is especially important to perform a careful clinical examination because radiographs are not reliable in making the diagnosis of congenital dysplasia of the hip in this age group.
Asymmetrical inguinal skin folds Ortolani test provocative maneuver of Barlow Klisic sign
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Asymmetry
• Asymmetric thigh, gluteal and popliteal fold
• Apparent shortening
Developmental dysplasia of hip (DDH)
Ortolani sign Barlow’s sign
Developmental dysplasia of hip (DDH)
Factors affecting reliablity of two test
Feel is quite delicate and requires just the right degree of relaxation on the part of the examiner as well as the infant
High pitched snap, often felt at the extremes of abduction – elicited by a circular motion
Originates in ligamentum teres / fascia lata / psoas tendon
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Klisic sign
• Line projects halfway between the umbilicus and the pubis
• Helpful in clinical assessment of bilateral dislocation
infant
Asymmetrical inguinal skin folds
Klisic sign
The first and most reliable is a decrease in the ability to abduct the dislocated hip because of a contracture of the adductor musculature.
Galeazzi sign is noted when the femoral head becomes
displaced not only laterally, but also proximally, causing an apparent shortening of the femur on the side of the dislocated hip . Bilateral dislocations may appear symmetrically abnormal.
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Reduce abduction
Developmental dysplasia of hip (DDH)
Galleazi’s sign
Apparent shortening of femur . Galeazzi test (If leg length discrepancy has been detected on measurement)Ask the patient to flex hips to about 45 o and knees to about 90 o . Make sure the heels are together on the couch, with medial malleoli touching. Look at the knees from the side to see if they are at the same level. If one is proximal to the other, there is femoral shortening; if one is distal to the other there is tibial shortening.
Developmental dysplasia of hip (DDH)
Walking child
Trendelenberg gait B/L dislocation- Waddling gait
Developmental dysplasia of hip (DDH)
Physical examination finding according to age
Neonates
Dislocatable
Reducible
Klisic’s sign
Infants Dislocatable
(occasionally)
Reducible (ocasionally)
Klisic’s sign
Decreased abduction
Galeazzi’s sign
• Walking Child
• Remains dislocated
• Klisic sign
• Decreased abduction
• Galeazzi’s sign
• Limp
• Short leg
• Wide perinium
• Increased lordosis (bilateral)
Developmental dysplasia of hip (DDH)
Ultrasonography
X rays fails to show head until primary ossification center is visible in the head by 3 - 6 months of life
Ultrasonography show the relationship of the femoral head and acetabulum very well
Graf recommended a lateral technique with tranducer placed over the greater trochanter.
Developmental dysplasia of hip (DDH)
Graf technique of U-sonography
Developmental dysplasia of hip (DDH)
Graf classification system
Baseline Inclination line Acetabular roofline Alpha angle Beta angle
Developmental dysplasia of hip (DDH)
R
B
Developmental dysplasia of hip (DDH)
Graf classification
Developmental dysplasia of hip (DDH)
Treatment of type II
Varies widely
Treatment decisions should be basd on ultrasonography examinations performed at 6 weeks of age rather than at birth
Developmental dysplasia of hip (DDH)
Literature regarding use of ultrasonography
More sensitive indicator of abnormality of the infant hip than radiography and screening with US does pick up clinically silent hips without increasing the rate of treatment for minor abnormalities that would resolve spontaneously
Too sensitive and results in overtreatment
Graf’s method is unreliable in children younger that 3 months of age
Ann R Coll Surg Engl 1996; 78:505. Radiology 1987; 165:647. J Bone Joint Surg Br 1989; 71:767.
Developmental dysplasia of hip (DDH)
Inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted US / clinical examination alone.
Cochrane Database Syst Rev. 2011 Sep 7;9:CD004595.
Developmental dysplasia of hip (DDH)
To conclude
Ultrasonography is a valuable adjunct to the detection of neonatal hip abnormalities
Should be used judiciously to avoid overtreatment of minor abnormalities
Very useful in detecting early treatment failure of Pavlic harness
Negative results on US does not preclude later abnormalities
Plain radiograph
Plain radiography of the pelvis usually demonstrates a frankly dislocated hip in individuals of any age.
. In newborns with typical DDH, however, the unstable hip may appear radiographically normal. As the child reaches 3 to 6 months of age, the dislocation will be evident radiographically
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Plain radiography
Hilgenreiner's line is a line through the triradiate cartilages.
Perkin's line, drawn at the lateral margin of the acetabulum, is perpendicular to Hilgenreiner's line
Shentons line
Useful when head is not ossified
Developmental dysplasia of hip (DDH)
Acetabular index
Acetabular index
27.5 at birth
23.5 degree at 6 months
20 degree by 2 years
Developmental dysplasia of hip (DDH)
Am J Orthop 29:773, 2000.)
• Superior gap H b/w proximal metaphysis and H line
• Medial gap D b/w femoral calcar and lateral pelvic wall
• H distance normally <7.5mm
• D distance normally<4-5mm
• If distance is more thanabove,then such case earlier treatment with closed / open reduction is advised..
Developmental dysplasia of hip (DDH)
Center edge angle of Wiberg
19 degree of children b/w 6 – 13 yrs of age
25 degree for 14 yrs or more In DDH ANGLE IS <20 DEG
Teardrop
Boundaries of teardrop true floor of acetabulum corresponds to
the radiographic teardrop teardrop lies in the inferomedial portion
of the acetabulum, just above the obturator foramen
the lateral and medial lips corresponds to the external and internal acetabular walls, respectively..
the medial portion of the teardrop represents the quadrilateral surface and the
lateral portion represents the medial aspect aspect of the acetabular floor)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Relation to Teardrops in AP view
Appears at 6 – 24 months in normal hip
Delayed appearance in DDH
Teardrop wider from superior to inferior in dislocated hip
Better outcome is observed in hips in which tear drops appear within 6 months of reduction
ARTHROGRAPHY
Because the radiograph of the hip in an infant or young child cannot yield all the information desired in diagnosing or treating congenital dysplasia, arthrography is helpful in determining
(1) whether mild dysplasia is present, (2) whether the femoral head is subluxated
or dislocated, (3) whether manipulative reduction has
been or can be successful, (4) to what extent any soft structures
within the acetabulum may interfere with complete reduction of the dislocation, Developmental dysplasia of hip
(DDH)
(5) the condition and position of the acetabular labrum (the limbus), and
(6)whether the acetabulum and femoral head are developing normally during treatment.
Their criteria for accepting a reduction are medial dye pool of 7 mm or less and maintenance of reduction in an acceptable safe zone
Developmental dysplasia of hip (DDH)
SAFE ZONE
The “safe zone” concept can be used in determining the zone of abduction and adduction in which the femoral head remains reduced in the acetabulum.
A wide safe zone (minimum of 20 degrees, preferably 45 degrees) is desirable, and a narrow safe zone implies an unstable or unacceptable closed reduction.
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Arthrography Done under GA
Subadductor approach with image intensification is preferred
needle is inserted below adductor longus 2 cm distal to its origin
Direction toward contralateral sternoclavcicular joint
Inject 1 ml
Obtained images for each position of the hip
Developmental dysplasia of hip (DDH)
Magnetic Resonance imaging
Excellent anatomic visualization of the infant hip
Not commonly used as required sedation and is expensive modality
Developmental dysplasia of hip (DDH)
Screening criteria
All neonates should be examined for hip instabilities
Infant with risk factors be examined by experienced person and possibly ultrasonography
Family Hx of DDH Breech Torticollis Metatarsus adductus Oligohydramnios
Screening with US remains controversial
Developmental dysplasia of hip (DDH)
Treatment Age based guidelines
Neonate Pavlic harness for 6 weeks
1 – 6 months Pavlic harness for 6 weeks after hip reduces
6 – 18 months traction / close reduction followed by cast for 3 months. Open reduction if close reduction fails
18 -24 months trial of close reduction / or primary open reduction +/- Salter osteotomy
24 months – 6 yrs open reduction + femur shortening +/- Salter osteotomy
Developmental dysplasia of hip (DDH)
Treatment of young child (1 to 6 months of Age)
Developmental dysplasia of hip (DDH)
Pavlic harness
the Pavlik harness is a dynamic flexion-abduction orthosis that can produce excellent results in the treatment of dysplastic and dislocated hips in infants approximately 4 to 6 months old.
It consist of: Chest band Shoulder strap Connecting strap Booties
Developmental dysplasia of hip (DDH)
The harness is applied with child in supine.
The hip is placed in flexion (90 to 110 degrees). The anterior flexion strap is tightened to maintain this position.
The lateral strap is loosely fastened to limit adduction, not to force abduction.
Excessive abduction to ensure stability is unacceptable.
The knees should be 3 to 5 cm at full adduction.
Developmental dysplasia of hip (DDH)
92% failure rate if the superior gap is 3 mm or less
94% failure rate if the medial gap is 10 mm or more, regardless of the type of splint used..
Developmental dysplasia of hip (DDH)
Four basic patterns of persistent dislocation have been observed after application of the Pavlik harness:
superior, inferior, lateral, and posterior.
Developmental dysplasia of hip (DDH)
If the dislocation is superior, additional flexion of the hip is indicated.
If the dislocation is inferior, a decrease in flexion is indicated.
A lateral dislocation in the Pavlik harness should be observed initially.
As long as the femoral neck is directed toward the triradiate cartilage, as confirmed by radiograph or ultrasound, the head may gradually reduce into the acetabulum
Developmental dysplasia of hip (DDH)
Duration of pelvic harness Depends upon patients age at time of
diagnosis and degree of instability. Full time wear = age of stability attended + 2 months Weaning time 2-4 hrs everyday To be doubled every 2
weeks
Developmental dysplasia of hip (DDH)
Follow up: it is essential to documentation of stability by….
USG Clinical examination: negative ortoloni
and barlow test X ray:immediately 1 month after weaning 6 month 12 month
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Ossification beneath the labrum – seen after successful early treatment of DDH
C/I to palvik harness
Child is walking age Hip cannot be centered towards to
triradiate cartilage with 90-110 flexion d/l develops after several weeks of birth d/l associated with muscle imbalance like meningomyelocele downs syndrome,marfan syndrome
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Craig splint Von Rosen splint
Rigid immobilisation and forced reduction should be avoided
Developmental dysplasia of hip (DDH)
Treatment of the child (6 month to 2 years of
Age)
Developmental dysplasia of hip (DDH)
General guidelines
Goal of the treatment are to obtain and maintain reduction of the hip without damaging the femoral head
Close / open reduction, may be preceded by period of traction
To reduce incidence of AVN To enable surgeon to obtain close reduction
Need for traction has been challenged
Developmental dysplasia of hip (DDH)
Despite many studies questioning its efficacy, traction continues to be used in many centers
Traditional traction Bryant’s traction
Developmental dysplasia of hip (DDH)
Home based traction mechanism. Applied for 2-3 weeks
Developmental dysplasia of hip (DDH)
Close reduction Should be performed in GA or deep sedation
Manipulation should be avoided
Reduction is achieved by flexion beyond 90 degrees and gradually abducting the hip, while lifting the greater trochanter
Minimal force should be applied
ROM to assess stability
Adduct to the point of redislocation. Extend to the point of dislocation and also note if it require internal rotation to maintain reduction.
Abduct the hip to 40 to 45 degrees, and flex it to about 95 degrees .
Excessive abduction should be avoided. We have found that the hips always are flexed less than they appear to be and are abducted more than they appear
Spica cast immobilization is continued for 4 months. The cast can be changed at 2 months
Radiographs or arthrograms can be obtained to ensure that the femoral head is reduced anatomically into the acetabulum.
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Safe zone
Wide safe zone i.e min of 20 degrees, preferably 45 degree, is desirable and narrow safe zone implies an unstable or unacceptable close reduction
Developmental dysplasia of hip (DDH)
Open reduction
Indications
Failure to obtain stable hip with close reduction
Unstable hips / excessive widening on arthrography (failed docking)
Approaches
Medial Anterior approach
Developmental dysplasia of hip (DDH)
Medial approach
First reported by ludloff (1913)
Good approach for children 1 year of age and younger
Disadvantages
Cannot do capsulorrhaphy Medial femoral circumflex vessel injury
optimal age for the medial approach: is of more value in the child younger than 18 months but older than 7 months
when this procedure is used in infants younger than 7 months, there may be a higher risk of AVN
Developmental dysplasia of hip (DDH)
- anatomical considerations: medial approach may occur either anteromedial (Ludloff Approach) posteromedial(Ferguson Approach) depending whether surgeon goes
anterior or posterior to adductor brevis; procedure may involve division of the
psoas tendon, since it can be an extra-articular barrier to reduction;
Developmental dysplasia of hip (DDH)
advantages: minimum dissection & blood loss;
allows direct approach to common obstacles to reduction (such as the psoas tendon); psoas tendon, capsular constriction, & transverse acetabular ligament
disadvantages: 1 poor access to acetabulum (neolimbus,
ligamentum teres, & pulvinar); 2 does not allow capsulorraphy (which is
required in older patients);
Developmental dysplasia of hip (DDH)
3 AVN: risk of AVN is about 15%; need for additional surgical procedures: 10-20%;
contra-indications:medial approach is usually not used once child who has begun to walk; medial approach not used when femoral head has migrated proximally;
Developmental dysplasia of hip (DDH)
Anterior approach
Somerville technique of anterior open reduction in congenital dislocation of hip.
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
o A, Bikini incision.
o B, Division of sartorius and rectus femoris tendons and iliac epiphysis.
o C, T-shaped incision of capsule.
o D, Capsulotomy of hip and use of ligamentum teres to find true acetabulum.
o E, Radial incisions in acetabular labrum and removal of all pulvinar from depth of true acetabulum.
o F, Reduction and capsulorrhaphy after excision of redundant
Developmental dysplasia of hip (DDH)
G, Developmental dislocation of right hip
. H, After anterolateral open reduction.
I, At age 7 years; note remodeling of femoral head and acetabulum.
Toddler 18months to 36 months
For these children with well-established hip dysplasia, open reduction with femoral or pelvic osteotomy, or both, often is required.
Persistent dysplasia can be corrected by a redirectional proximal femoral osteotomy in very young children.
If the primary dysplasia is acetabular, pelvic redirectional osteotomy alone is more appropriate.
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Open reduction with femoral shortening
• To reduce pressure on the femoral head
• Should be considered when hip is reduced in a child >2yrs of age
• Blade plate / simple lateral plate fixation may be used
• Derotation is considered when internal rotation positiion is severe during trial reduction
Developmental dysplasia of hip (DDH)
Open reduction with innominate osteotomy
Indicated if more than one third of the head is visible when hip is in extension and neutral rotation and abduction
Most children older than 18 months require osteotomy
Developmental dysplasia of hip (DDH)
Child 3 to 8 yrs of age
Challenging
Femoral head is more proximal Muscles are more severely contracted
Femoral shortening is an essential part of management
More likely need of primary acetabular reorienting osteotomy 2 – 3 yrs of age assess intraoperative regarding the need > 3 yrs usually needed
Posterior dislocation is a potential complication when combining an acetabular procedure with femoral shortening
Esp. if femur is derotated
Developmental dysplasia of hip (DDH)
Anteverted femur and acetabulum in untreated congenital dislocation of hip.
B, Redirection of femoral neck by snug anterior capsulorrhaphy.
C, Capsulorrhaphy and Salter innominate osteotomy.
D, Capsulorrhaphy, Salter innominate osteotomy, and full femoral derotation. Combined in excess, this sequence can produce posterior dislocation.
E, Open reduction, primary femoral shortening, derotation osteotomy, and Salter osteotomy produced fixed posterior hip dislocation in 5-year-old girl.
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Recommended osteotomies for DDH
Osteotomy Age Indication
Salter 18 months – 6 yrs Congrous hip reduction; <10-15 degrees of correction of acetabular index required
Pemberton 18 months – 10 yrs 10-15 degree correction of acetabular index required; small femoral head, large acetabulum
Steel/ Ganz Late adolescence to skeletal maturity
Residual acetabular dysplasia; symptoms; congrous joint
Shelf / chiari Adolescence to skeletal maturity
Incongruos joint;
Developmental dysplasia of hip (DDH)
Complications and pitfalls
AVN
Inadequate reduction and redislocation
Residual dysplasia
Developmental dysplasia of hip (DDH)
Avascular necrosis
Etiology
Iatrogenic problem – almost always preventable
Occurs when excessive pressure is applied for an extended time to the femoral head Extreme abduction / internal rotation
Can also occurs when the muscles crossing the hip are so contracted that they compress the reduced femoral head against the acetabulum
Excessive pressure can be avoided by femoral shortening
Developmental dysplasia of hip (DDH)
Diagnosis
1. Failure of initial appearance of the capital femoral ossification center during one year or longer following reduction.
2. Failure of continued chondro-osseous transformation and maturation of an existing epiphyseal ossification center during one year or longer following reduction.
3. Broadening of the femoral neck (metaphysis) during one year following reduction.
4. Increased radiographic density of the capital femoral ossification center followed by the radiographic appearance of fragmentation.
5. Residual deformity of the femoral head and neck when ossification is complete. Greater trochanter is not affected by
AVN and will continue to grow
Developmental dysplasia of hip (DDH)
Classification
Developmental dysplasia of hip (DDH)
Bucholz – Ogden system. A, Normal femoral head at 2 months (a), 1 year (b), and 9 years (c) of age.
B, Type I: a, sites of temporary vascular occlusion; b, irregular ossification in secondary center; c, normal epiphyseal contour, slight decrease in height of capital femoral ossification center.
C, Type II: a, probable primary site of vascular occlusion; b, metaphyseal and epiphyseal irregularities; c, premature fusion of lateral metaphysis and epiphysis.
Developmental dysplasia of hip (DDH)
D, Type III: a, sites of temporary vascular occlusion; b, impaired longitudinal growth of capital femoral epiphysis; c, irregularly shaped femoral head
. E, Type IV: a, sites of temporary vascular occlusion; b, impaired longitudinal and latitudinal growth; c, premature epiphyseal closure.
AVN remains a poorly understood complication of the treatment of DDH.
Conclusions about prevention and treatment
are difficult to reach because 1 the diagnostic and classification criteria
have not been validated. 2 controversies over time of reduction to
be attempted. 3 controversies over preoperative
traction. Developmental dysplasia of hip (DDH)
Treatment Kalamchi type I: Observation / Bracing. Kalamchi type II: Observation / Varus
osteotomy &/or proximal epiphysiodesis. Kalamchi type III/IV: Apophyseodesis or
distal trochanteric transfer for trochanteric overgrowth. Shoe lift or properly-timed epiphysiodesis for limb length inequality.
Developmental dysplasia of hip (DDH)
Potential sequence of AVN
femoral head deformity, acetabular dysplasia, lateral subluxation of the femoral
head, relative overgrowth of the greater
trochanter, and limb-length inequalities; osteoarthritis is a common late
complication
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Intervention
Anatomic effects can be altered by appropriate intervention
Trochanteric epiphysiodesis
Trochanteric advancement
Intertrochanteric double osteotomy
Lateral closing wedge valgus osteotomy with trochanteric advancement
Developmental dysplasia of hip (DDH)
Tip lies at the level of center of femoral head
Distance of a tip is 2 times the radius of femoral head
Developmental dysplasia of hip (DDH)
Trochanteric epiphysiodesis
Relative trochanteric overgrowth can be prevented by performing a trochanteric epiphysiodesis
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Trochanteric advancement
Considered when an objectionable abductor limp result from trochanteric overgrowth
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Lateral advancement of greater torchanter
Indicated when the neck is short and the trochanter has not grown above the femoral head with abductor limb
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Intertrochanteric double osteotomy
To improve the function of hip when the trochanter is markedly overgrown, abutting the pelvis and the femoral neck is very short
First step is to release hip adductors and iliopsoas through separate medial incision – necessary to relieve pressure on the head
Two osteotomies
At the base of greater trochanter at the level of upper border of the femoral neck
Through the upper end of the femoral shaft above the lesser trochanter
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Lateral closing wedge valgus osteotomy with trochanteric
advancement
Coxa vara with trochanteric overgrowth
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Reconstructive procedure for dysplasia
Dysplastic hips with concentric reduction
8-9 yrs of age
Salter innominate osteotomy Pemberton osteotomy
Older children / adolescents
Steel triple pelvic osteotomy Sutherland double ostetomy Ganz osteotomy (Bernese) Tonnis procedure Dega osteotomy
Dysplastic hips that cannot be cocentrically reduced
Chiari osteotomy Shelf procedure
Developmental dysplasia of hip (DDH)
Salter innominate osteotomy
Displaces acetabulum in an anterolateral direction
Salter's osteotomy of the innominate bone redirects the entire acetabulum so that its roof “covers” the femoral head anteriorly and superiorly.
Developmental dysplasia of hip (DDH)
Indications
Acetabular dysplasia persisting after primary treatment
Dysplasia discovered in an untreated child
Failure of the acetabular angle to improve within 2 years after reduction
Peristent dysplasia after 5 years of age
Appropriate for children b/w 2 – 9 year4
Children < 18 months usually do not have iliac wings that a thick enough to support the bone graft
Children > 9 yrs, not enough movement of the acetabular fragment is achieved to cover head
Prerequisites for success of osteotomy
1. The femoral head must be positioned opposite the level of the acetabulum. This may require a period of traction before surgery or primary femoral shortening.
2. Contractures of the iliopsoas and adductor muscles must be released. This is indicated in subluxations and dislocations. Open reduction is performed for hip dislocation, but usually is unnecessary for hip subluxation.
3. The femoral head must be reduced into the depth of the true acetabulum completely and concentrically. This generally requires careful open reduction and excision of any soft tissue, exclusive of the labrum, from the acetabulum.
4. The joint must be reasonably congruous.
5. The range of motion of the hip must be good, especially in abduction, internal rotation, and flexion.
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Approach
Bikini incision
Anterior approach
Rectus femors origin identified – landmark
Straight osteotomy with Gigli saw from AIIS to sciatic notch
Acetabular portion displaced in an anteroinferior with bone clamp Leg in figure of four
Bone graft in placed and fix with threaded pins
Hinge on symphysis pubis
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
• One and a half hip spica with hip in a stable position
• Radiograph in cast to assess the position of bone graft
• Ensure that it has not collapsed
• In older patients cancellous screw are used and spica cast is not necessary
• Cast removed at 6 weeks in G/A and pins removed
• ROM and weight bearing allowed with support
• FWB is resumed after 3 weeks
• When open reduction is combined with Salter osteotomy additional immoblization in abduction cast for 4 weeks is recommended
Developmental dysplasia of hip (DDH)
Complication Sciatic nerve injuries
Use of Gigle saw in the sciatic notch Always protect the cut with Hohman retracters
Femoral nerve injuries
Excessive retraction across pelvic brim
Loss of position of pins
Proper placement i.e two pins with one going behind the acetabulum and second should be placed over the acetabulum fixing the bone graft
Developmental dysplasia of hip (DDH)
Kalamchi modification of Salter osteotomy
• Distal fragment is placed in proximal notch
• Thus reduces pressure on femoral head
Developmental dysplasia of hip (DDH)
Pemberton acetabuloplasty
The term acetabuloplasty designates operations that redirect the inclination of the acetabular roof by an osteotomy of the ilium superior to the acetabulum followed by levering of the roof inferiorly
Reposition acetabulum to improve anterior and lateral coverage of femoral head
Osteotomy begins anteriorly at AIIS and proceed posteriorly to enter triradiate cartilage
Osteotomy hinges through triradiate cartilage and as it is opened, the fragment is pushed anterolaterally to fill with bone graft
Contraindicated if the acetabulum is small relative to the size of the femoral head
Complications
Premature closure of the triradiate cartilage Acetabular growth centers damage
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Dega osteotomy
Increase acetabular coverage anteriorly, centrally or posteriorly
Osteotomy starts above the acetabulum and proceed into the triradiate cartilage behind and beneath the acetabulum, leaving an intact hinge poseriorly
Placement of wedges determines the area of acetabular coverage
Developmental dysplasia of hip (DDH)
A, Skin incision.
B, Osteotomy line is marked on lateral cortex of ilium; guidewire is inserted to exit just above horizontal limb of triradiate cartilage.
C, Osteotome penetrates inner cortex.
D, View from inner side of pelvis shows intact posteromedial cortical hinge; length of intact inner cortex depends on amount of anterior and lateral coverage desired.
Developmental dysplasia of hip (DDH)
E, Osteotomy is levered open with osteotome or small lamina spreader.
F, Two grafts large enough to keep osteotomy open at premeasured height are inserted.
G, Larger graft is inserted anteriorly; posterior graft should be smaller to avoid loosening anterior graft.
Developmental dysplasia of hip (DDH)
Steel osteotomy Also known as Triple osteotomy
Osteotomies through the ilium and both pubic rami
Pubic ramus approached through transverse medial incision in the patient groin
Ischium is also approached through the same incision and is transected
Innominate osteotomy through another incision
Acetabular fragment is displaced and rotated to provide anterolateal coverage of the femoral head
Complications Nonunion of osteotomy sites Excessive external rotation of the acetabulum
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Ganz osteotomy
Indicated for all degree of dysplasia in skeletally mature individual
Advantage Single approach Large degree of correction in all planes Maintenance of blood supply to the acetabulum Intact posterior column Minimal disruption of hip abductors No alteration of pelvic birth outlet
When necessary, a femoral varus producing osteotomy may be obtained to establish optimal relationship
Developmental dysplasia of hip (DDH)
Procedure
Anterior approach / Ilio inguinal approach
First cut is the ischial cut – begin distal to acetabulum and direct posteriorly aiming to the ischial spine
Second cut is superior pubic ramus cut
Third cut is just inferior to ASIS – cut ends just lateral to pelvic brim
Fourth cut is made b/w first and third cut with curved osteotome
Schanz pin is then placed in acetabular fragment for positioning
Final fixation with 3.5 mm long cortical screw with 2 – 3 screws from proximal to distal
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Long and steep learning curve
complications
Excessive lateral displacement of the acetabular fragment with blocked hip abduction
Displacement of osteotomy with early weight bearing
Nonunion of pubic and ischial osteotomies
Lateral femoral cutaneous nerve damage (50%)
Femoral nerve palsy
Heterotopic ossification
Developmental dysplasia of hip (DDH)
Spherical acetabular osteotomy (dial osteotomy)
Technically challenging procedure
Allow rotational repositioning of the acetabulum through a wide range and are stable without disrupting the pelvic ring
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Chiari osteotomy
Indicated when it is no longer possible to achieve a concentric reduction of the hip
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Osteotomy is made just above the acetabulum, and curves to match the acetabular contour and slopes upward from lateral to medial
Acetabular fragment is displaced medially and is held there with pins or screw
Inaccurate placement of osteotomy – most frequent complication
Developmental dysplasia of hip (DDH)
Shelf procedures
Shelf procedures commonly have been performed to enlarge the volume of the acetabulum;
however, pelvic redirectional and displacement osteotomies have largely replaced this type of operation.
Indication
Hip in which concenteric reduction cannot be obtained and deficient acetabulum that cannot be corrected by redirectional pelvic osteotomy is the primary indication for this operation.
Developmental dysplasia of hip (DDH)
Before surgery, determine the center-edge angle of Wiberg from anteroposterior standing pelvic radiographs, and draw a normal center-edge angle (about 35 degrees) on the film
. Measure the additional width necessary to extend the existing acetabulum to achieve the normal angle.
This determines the width of the augmentation; this measurement added to the depth of the slot gives the total graft length.
Developmental dysplasia of hip (DDH)
Slotted acetabular augmentation (Staheli)
Developmental dysplasia of hip (DDH)
Developmental dysplasia of hip (DDH)
Wilson shelf procedure
Developmental dysplasia of hip (DDH)