Dysplasia of the Hit

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A newer version of UpToDate is now available, and the information in this version may

no longer be current.Treatment and outcome of developmental dysplasia of the hip

AuthorNicholas A Waanders, MD, PhD Section Editors

William Phillips, MD

Joseph A Garcia-Prats, MD Deputy Editor

Mary M Torchia, MD

Last literature review version 19.1: January 2011 | This topic last updated: October 1,

2010 (More)

INTRODUCTION Developmental dysplasia of the hip (DDH) describes a spectrum

of conditions related to the development of the hip in infants and young children. The

spectrum of conditions includes abnormalities of stability (dislocation/dislocatability

and subluxation/subluxatability) and abnormalities of shape of the femoral head and

acetabulum (dysplasia). (See "Epidemiology and pathogenesis of developmental

dysplasia of the hip", section on 'Terminology'.)

Treatment of DDH is initiated with referral to a pediatric orthopedic surgeon or other

orthopedic surgeon who is familiar with the diagnosis and treatment of DDH. The

treatment and outcome of typical DDH will be reviewed here. The epidemiology,

pathogenesis, natural history, clinical features, and diagnosis are discussed separately.

(See "Epidemiology and pathogenesis of developmental dysplasia of the hip" and

"Clinical features and diagnosis of developmental dysplasia of the hip".)

GOALS OF TREATMENT The goals of treatment are to obtain and maintain

concentric reduction of the hip to provide an optimal environment for the development

of the femoral head and acetabulum.

The optimal environment requires that the cartilaginous surface of the femoral head be

in contact with the cartilaginous floor of the acetabulum. The acetabulum has the

capacity for growth and gradual resolution of dysplasia over time (months to years), ifconcentric reduction is maintained [1,2].

The goals of treatment are the same whether the child is diagnosed in the newborn

nursery or later. However, the therapies necessary to achieve those goals vary

depending upon age, stability, and severity [3,4].

NEWBORN The newborn nursery is a common place to discover hip instability or

recognize risk factors for DDH, especially breech positioning. Hip dislocation is rare in

newborns, but mild laxity (instability) or a shallow acetabulum (dysplasia) are common

findings [5]. It is controversial whether these findings should be labeled as pathologic or

as immaturity [6].


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joint, to confirm positioning within the cast. Casting is continued for three to four

months, usually with cast changes and repeat hip arthrography at six-week intervals.

Open reduction Open reduction is recommended if the hip cannot be reduced and

maintained with cast positioning. The timing for open reduction depends upon the

center. Some centers defer open reduction until there is evidence of adequate hipmaturity by the appearance of an ossific nucleus within the femoral head [20]. The risk

of osteonecrosis of the femoral head is lower when the ossific nucleus is present before

open reduction [21,22]. However, when factoring in the benefit of early therapy, other

centers proceed with open reduction whether or not the ossific nucleus is present [23].

As with closed reduction, the goal is to get the femoral head into the acetabulum and

hold it with a spica cast. If closed reduction cannot be accomplished, an incision is

made, and the hip capsule is opened to remove the obstacles to reduction that include

the inverted labrum, the neolimbus, the pulvinar, the hypertrophied ligamentum teres

and transverse acetabular ligament, and the tight iliopsoas tendon. After reduction,

casting is continued for three to four months, usually with cast changes and repeat hiparthrography at six-week intervals.

AGE 18 MONTHS AND OLDER In children 18 months and older, open reduction

is usually needed. Depending on other factors, additional tendon releases,

capsulorrhaphy, femoral shortening, and acetabular osteotomies also may be needed.

Risks for long-term problems including stiffness, failure of treatment, residual

dysplasia, and osteonecrosis are greater in older patients than in those who are treated

earlier.

In making treatment decisions, the risks of treatment are weighed against the untreated

natural history. In general, reduction of a unilateral dislocation is recommended until 10

to 12 years of age. Bilateral dislocations after age eight years are sometimes left

untreated, since results of treatment are likely to be less satisfactory than the untreated

natural history [24]. (See "Clinical features and diagnosis of developmental dysplasia of

the hip", section on 'Natural history'.)

LONG-TERM FOLLOW-UP The frequency and duration of long-term follow-up

depends upon the treating orthopedic surgeon. As a general rule, children treated for hip

dysplasia should have annual radiographs until they are at least six years old to look for

late complications, such as osteonecrosis and to ensure that the hip is developingnormally.

OUTCOME The long-term outcome of treated DDH depends upon the age of

diagnosis, the severity, and the success of treatment. The natural history of untreated

DDH serves as a baseline for comparison. (See "Clinical features and diagnosis of

developmental dysplasia of the hip", section on 'Natural history'.)

Most neonatal hips with instability or mild dysplasia resolve spontaneously. When

DDH is diagnosed in a newborn who has instability on examination or dysplasia on

ultrasonography, treatment with abduction splinting is successful in the majority of

patients [11,25]. Long-term follow-up is important to monitor residual dysplasia.


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Residual dysplasia, either following treatment or undiagnosed, may result in

progression to premature degenerative joint disease. A population-based study of 2.2

million children (1967 to 2004) found a 2.6-fold increase (95% CI 1.4-4.8) in total hip

replacements in young adults who had been diagnosed with neonatal hip instability

compared with those without neonatal hip instability [26]. The majority of young adults

who underwent hip replacement that was attributed to dysplasia were not known to haveneonatal hip instability.

SUMMARY AND RECOMMENDATIONS

The goals of treatment of developmental dysplasia of the hip are to obtain and maintain

concentric reduction of the hip to provide an optimal environment for the development

of the femoral head and acetabulum. (See 'Goals of treatment' above.)We recommend

treatment with abduction splinting for infants aged zero to six months of age with hip

dislocation or instability (Grade 1B). (See 'Dislocation or instability' above.)We suggest

abduction splinting for infants who have acetabular dysplasia without dislocation (Graf

Type IIa or worse) (figure 2) that persists beyond six weeks of age (Grade 2C). (See'Dysplasia without dislocation' above.)Closed or open reduction is usually necessary for

children who are older than six months of age at the time of diagnosis or initiation of

therapy. (See 'Age 6 to 18 months with dislocation' above and 'Age 18 months and

older' above.)Children who have been treated for DDH should be monitored for

osteonecrosis and other complications until they are at least six years old. The

frequency and duration of long-term follow-up depends upon the treating orthopedic

surgeon. (See 'Long-term follow-up' above.)The long-term outcome of treated DDH

depends upon the age of diagnosis, the severity, and the success of treatment. Treatment

with abduction splinting achieves and maintains hip reduction in the vast majority of

infants with DDH who are treated during the first six months of life. (See

'Outcome' above.)

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Dysplasia of the Hit