Developmental Dysplasia of the Hip

(DDH) : Treatment

GROUP I: IH / RR / DW / NR / PF

Introduction

The Term DDH is more likely than CDH (congenital Dysplasia of the Hip)

Girls are affected 5 times more than boys.The left hip is affected in 45%, right one 20% and

35% of the cases are bilateral.Two facts about DDH:

1) not all hip dislocation are present at birth. But they all occur before the age of 3 months2) newborns have hypotonic muscles in the 1st 6 wks till 3 months so not all cases of DDH can be diagnosed at that time.

Etiology

Generalized relaxation of the hip joint.

- Genetics- Hormonal Factors- Intrauterine Malformation- Postnatal factors

X-ray

Acetabular index: angle between horizontal line of

hilgenreiner and the line between the two edges of the acetabulum.

normal hip 20º30 dislocated or dysplastic hip ≥ 30ºShenton’s line: semicircle between femoral neck and

upper arm of obturator foramen, in dislocated hip this line is broken.

TREATMENT

The earlier the better.Best time for treatment is in newborn period.It depends on the device and age of the

patient.Goal is to:1.Flex and abduct hips.2.Reduce femoral head and maintaining it.

TREATMENT

From (1-6 months) use Pavlik Harness.From 6 months – 18 months use hip spika.From 18 months - 4 years : traction , adductor tenotomy , surgical

closed reduction, salter innominate osteotomy.

Treatment Options

Age of patient at presentationFamily factorsReducibility of hipStability after reductionAmount of acetabular dysplasia

Birth to Six Months

Triple-diaper techniquePrevents hip adduction“Success” no different in

some untreated hipsPavilk harness (1944)

Experienced staff*Very successfulAllows free movement

within confines of restraints

*posterior straps for preventing add. NOT producing abd.

Birth to Six Months

Pavlik harness

IndicationsFully reducible hip*

Child not attempting to standFamily

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

•Duration•Childs age at hip stability + 3 months

Pavlik Harness

Complications

Avascular necrosisForced hip abductionSafe zone (abd/adduction and flexion/extension)Femoral nerve palsyHyperflexion

*Be aware of Pavlik Harness Disease*Follow until skeletal maturity

Birth - Six months

Closed reduction + SpicaFailure after 3 weeks of Pavlik trial

Birth - Six months

Closed reductionGeneral anesthesiaArthrogramSafe zone - avoid AVN -/+adductor tenotomyOpen reduction if concentric reduction not possible

Usually teratogenic hips in this age group

6 months – 18 months

Present a more difficult problemProlonged dislocationContracted soft tissues

6 - 18 monthsClosed reduction +/- adductor tenotomySpica in human position of 100 degrees of flexion

and about 55 degrees abduction (3 months)Abduction Orthosis 4 wks full time/4 wks

nighttimeOpen reduction (if closed fails)

CapsulorraphyCT scanSpica for 6 wks followed by PT

18 months - 4 years

Closed reductionReducibile - check arthrogram and medial dye poolIrreducible - Open reduction

Open reductionTight - femoral shorteningStable - +/- pelvic osteotomy

Femoral Shortening

Schoenecker + Strecker 1984Traction vs. Femoral shortening56% AVN in traction group0% AVN in femoral shortening

Pelvic Osteotomy

1 )Persistent instability + dysplasia after open reduction + femoral shortening

2 )Requires concentric reduction of a reasonably spherical femoral head

3 )Usually based on surgeon preferenceSalter and Pemberton

Pelvic Osteotomy

Volume changing

Pemberton Hinges on triradiateRequires remodeling of “new” incongruityProvides more anterolateral coverage

Pemberton

Pelvic Osteotomy

RedirectingSalter

Osteotomy thru sciatic notchHinge thru pubic symphysis

Triple innominateGanzDial

Salter Osteotomy

Salter Osteotomy