2. Adolph Lorenz, an early pioneer in the
treatment of developmental dislocation
of the hip
3. Overview
Introduction
Normal Development of the Hip
Etiology and Pathoanatomy
Epidemiology and Diagnosis
Treatment
Complications
4. Introduction:
• Developmental dysplasia of the hip is the
condition in which the femoral head has an
abnormal relationship to the acetabulum.
Developmental dysplasia of the hip includes
frank dislocation (luxation), partial
dislocation (subluxation), instability
wherein the femoral head comes in and out
of the socket, and inadequate formation of
the acetabulum.
5. Previously known as congenital dislocation of
the hip implying a condition that existed at
birth
developmental encompasses embryonic,
fetal and infantile periods
includes congenital dislocation and
developmental hip problems including
subluxation, dislocation and dysplasia
8. Postnatal positioning in extension, as in this child on
a Native American cradleboard, contributes to
developmental dysplasia of the hip
9. Normal Growth and
Development
Embryologically the acetabulum, femoral
head develop from the same primitive
mesenchymal cells
cleft develops in precartilaginous cells at 7th
week and this defines both structures
11wk hip joint fully formed
10. acetabular growth continues throughout
intrauterine life with development of
labrum
By birth femoral head is deeply seated
in acetabulum by surface tension of
synovial fluid and very difficult to
dislocate
in DDH this shape and tension is
abnormal in addition to capsular laxity
11. The cartilage complex is 3D with triradiate medially
and cup-shaped laterally and interposed between
ilium above and ischium below and pubis anteriorly
acetabular cartilage forms outer 2/3 cavity and the
non-articular medial wall form by triradiate cartilage
which is the common physis of these three bones
fibrocartilaginous labrum forms at margin of
acetabular cartilage and joint capsule inserts just
above its rim
12. articular cartilage covers portion articulating with femoral head
opposite side is a growth plate with degenerating cells facing towards the
pelvic bone
triradiate cartilage is triphalanged with each side of each limb having a
growth plate which allows interstitial growth within the cartilage causing
expansion of hip joint diameter during growth
In the infant the greater trochanter, proximal femur and intertrochanteric
portion is cartilage
By 4-7 months proximal ossification center appears which enlarges until
adult life when only thin layer of articular cartilage persists
13.
14.
15. Development cont..
Experimental studies in humans with unreduced hips
suggest the main stimulus for concave shape of the
acetabulum is presence of spherical head
for normal depth of acetabulum to increase several
factors play a role
spherical femoral head
normal appositional growth within cartilage
periosteal new bone formation in adjacent pelvic
bones
development of three secondary ossification centers
normal growth and development occur through
balanced growth of proximal femur, acetabulum and
triradiate cartilages and the adjacent bones
16. DDH
Tight fit between head and acetabulum is absent and head can
glide in and out of acetabulum
hypertrophied ridge of acetabular cartilage in superior, posterior
and inferior aspects of acetabulum called “ neolimbus”
98% DDH that occur around or at birth have these changes and
are reversible in the newborn
2% newborns with teratologic or antenatal dislocations and no
syndrome have these changes
17.
18. Development in treated DDH different from normal hip
goal is to reduce the femoral head to provide the stimulus
for acetabular development
Concentric reduction maintainance is essential for
recovery and resumption of normal growth
age at which DDH hip can still return to normal is
controversial and depends on
age at reduction
growth potential of acetabulum
damage to acetabulum from head or during reduction
19. Epidemiology
1 in 100 newborns examined have evidence of instability
( positive Barlow or Ortolani)
1 in 1000 live births true dislocation
Barlow stated that 60% stabilize in 1st week and 88%
stabilize in first 2 months without treatment remaining
12% true dislocations and persist without treatment
21. Normal Anatomy
Hip starts from common mesenchymal
block of tissue
7th week cleft forms to separate head
11th week hip fully formed
Acetabulum gets shallower close to birth
22. Normal Hip
Tight fit of head in
acetabulum
Transection of capsule
Still difficult to dislocate
Surface tension
23. Pathoanatomy
Ranges from mild dysplasia --> frank
dislocation
Bony changes
Shallow acetabulum
Typically on acetabular side
Femoral anteversion
24. Pathoanatomy
Soft tissue changes
Usually secondary to prolonged subluxation or
dislocation
Intra articular
Labrum
○ Inverted + adherent to capsule (closed reduction with inverted
labrum assoc with increased Avascular Necrosis)
Ligamentum teres
○ Hypertrophied + lengthened
Pulvinar
○ Fibrofatty tissue migrating into acetabulum
25. Pathoanatomy
Soft Tissue (Intra articular)
Transverse acetabular ligament
○ Contracted
Limbus
○ Fibrous tissue formed from capsular tissue
interposed between everted labrum and
acetabular rim
Extra articular
Tight adductors (adductor longus)
Iliopsoas
32. Neonatal Presentation
Exam one hip at a time
Baby must be quiet
Barlow’s sign: provocative maneuver
Ortolani’s sign: reduces hip
Other signs not helpful in newborn
35. The Ortolani test for developmental dislocation of the hip in a
neonate.A, The examiner holds the infant's knees and
gently abducts the hip while lifting up on the greater trochanter with two
fingers.B, When the test is positive, the dislocated femoral head will fall
back into the acetabulum (arrow) with a palpable (but not audible) “clunk”
as the hip is abducted (Ortolani's sign). When the hip is adducted, the
examiner will feel the head redislocate posteriorly.
36. The Barlow test for developmental dislocation of the hip in a neonate.A, With the infant
supine, the examiner holds both of the child's knees and gently adducts one hip and
pushes posteriorly.B, When the examination is positive, the examiner will feel the femoral
head make a small jump (arrow) out of the acetabulum (Barlow's sign). When the
pressure is released, the head is felt to slip back into place.
37. Infant Presentation
Skin fold asymmetry
Limited hip abduction
Unequal femoral lengths (Galeazzi’s
sign)
(Flex both hips and one side shows
apparent femoral shortening)
43. Developmental dysplasia of the right hip. One physical
finding is limited abduction of the affected hip.
44. After Walking Age
Trendelenberg gait
Leg length discrepancy
Increased lumbar lordosis in Bilateral
dislocation
Klisic test positive
45. The examiner places the middle finger over the greater trochanter, and the index
finger on the anterior superior iliac spine.A, With a normal hip, an imaginary line
drawn between the two fingers points to the umbilicus.B, When the hip is
dislocated, the trochanter is elevated and the line projects halfway between the
umbilicus and the pubis.
51. Hilgenreiner's line is drawn through the triradiate cartilages. Perkin's line is drawn
perpendicular to Hilgenreiner's line at the margin of the bony acetabulum.
Shenton's line curves along the femoral metaphysis and connects smoothly to the
inner margin of the pubis
57. The acetabular index is the angle between a line drawn along the margin
of the acetabulum and Hilgenreiner's line; it averages 27.5 degrees in
normal newborns and decreases with age.
Acetabular Index
63. Wilberg's center-edge angle, the angle between Perkin's line and a line drawn
from the lateral lip of the acetabulum through the center of the femoral head.
considered normal if greater than 10 degrees in children 6 to 13 years of age, and
it increases with age.
64. Radiographs Summary
Femoral head appears 4 - 7 months
Shenton’s line
Perkin’s and Hilgenreiner’s lines
Inferomedial quadrant
Center Edge Angle of WILBERG (< 20
abnormal)
Acetabular index
Normal < 30 (Weintroub et al)
65. TEAR DROP SIGN
Acetabular TEAR DROP SIGN appears
between 6 & 24 months in normal hip,
but later in case of ddh.
Wall of acetabulum laterally, wall of
lesser pelvis medially,acetabular
notch inferiorly.
U shaped teardrop
V shaped teardrop- Dysplastic hips
and poor outcome
67. VON ROSEN VIEW
Both hips abducted, intrernally rotated
and extended.
NORMAL- Imaginary line from shaft of
femur extending upwards intersects the
acetabulum
DDH- Line crosses above acetabulum
68.
69. Imaging
Ultrasound
Introduced in 1978 for eval of DDH
Operator dependent
Useful in confirming subluxation, identifying
dysplasia of cartilaginous acetabulum,
documenting reducibility
Prox Femoral Ossification Center interferes
Requires a window in spica cast.
70. Ultra sound
BOTH morphologic assessment and dynamic
anatomical characteristics
○ alpha angle: slope of superior aspect bony
acetabulum
○ beta angle: cartilaginous component (problems with
inter and intraobserver error )
dynamic
○ Observing events occuring with Barlow and ortolani
tests.
•Alpha angle = between line of ilium & bony acetabulum
•Beta angle (less important) = between line of ilium & anterior labrum
78. • Type 1: mature hip joint with narrow, covering cartilaginous roof
• Type 2 (a+, a-, b, c, d): range from immature to dysplastic
• Type 3&4: both diplaced, range of severity
• *This classification system has good reliability with Type 1 hips,
but recently has been scrutinized regarding inter and intra-
observer reliability with all other Types.
80. •Indications controversial due to high levels
of overdiagnosis and not currently
recommended as a routine screening tool
other than in high risk patients
•Best indication is to assess treatment
•Guided reduction of dislocated hip or check
reduction and stability during Pavlik harness
treatment
84. •Eliciting Medial pooling of dye
•(normal = < 7mm)
•Confirms reduction after surgery
Dye pooling <7mm & complete reduction
with arthrogram = no need for open
reduction.
85. Natural History
in Newborns
Barlow
1 in 60 infants have instability ( positive Barlow)
60% stabilize in 1st week
88% stabilize in 2 months without treatment
12 % become true dislocations and persist
Coleman
23 hips < 3 months
26% became dislocated
13 % partial contact with acetabulum
39% located but dysplastic feature
22% normal
As it is not possible to predict the outcome, all
infants with instability should be treated
86. Adults
Variable
depends on 2 factors
well developed false acetabulum ( 24 % chance good result vs 52 % if
absent)
bilaterality
in absence of false acetabulum patients maintain good ROM with little
disability
femoral head covered with thick elongated capsule
false acetabulum increases chances degenerative joint disease
hyperlordosis of lumbar spine assoc with back pain
unilateral dislocation has problems
leg length inequality, knee deformity , scoliosis and gait
disturbance
87. Dysplasia and Subluxation
Dysplasia (anatomic and radiographic def’n)
inadequate development of acetabulum, femoral head or
both
All subluxated hips are anatomically dysplastic
Radiologically difference between subluxated and dysplastic
hip is disruption of Shenton’s line
subluxation: line disrupted, head is superiorly,
superolaterally ar laterally
displaced from the medial wall
dysplasia: line is intact
Important because natural history is different
88. A 36-year-old woman with bilateral anatomically abnormal
(dysplastic) hips. The left hip is radiographically subluxated, with
the Shenton line disrupted, and the right hip is radiographically
dysplastic, with the Shenton line intact.
89. Seven years later, note the marked loss of joint space
in the secondary acetabulum of the left hip and very
early disruption of the Shenton line on the right.
90. Natural History Con’t
Subluxation predictably leads to degenerative joint disease
and clinical disability
mean age symptom onset 36.6 in females and 54 in men
severe xray changes 46 in female and 69 in males
Cooperman
OUT OF 32 hips with CE angle < 20 without subluxation
BY 22 years all had x ray evidence of Degenerative Joint
Disease
no correlation between angle and rate of development
concluded that radiologically apparent dysplasia leads to
DJD but process takes decades
91. Treatment Options
Age of patient at presentation
Family factors
Reducibility of hip
Stability after reduction
Amount of acetabular dysplasia
92. Treatment 0 to 6 months
Goal is TO obtain reduction and maintain reduction to provide
optimal environment for femoral head and acetabular
development
Lovell and Winter
Treatment should be initiated immediately on diagnosis
AAOS (July,2000)
subluxation often corrects after 3 weeks and may be
observed without treatment
if persists on clinical exam or ultrasound beyond 3 weeks
treatment indicated
actual dislocation diagosed at birth treatment should be
immediate
93. Treatment con’t
Pavlik Harness preferred
prevents hip extension and adduction but allows
flexion and abduction which lead to reduction and
stabilization
success 95% if maintained full time six weeks
In child > 6 months of age, success is < 50% as it is
difficult to maintain active child in harness
94.
95. Pavlik Harness
Chest strap at nipple line
shoulder straps set to hold
cross strap at this level
anterior strap flexes hip
100-110 degrees
posterior strap prevents
adduction and allow
comfortable abduction
safe zone arc of abduction
and adduction that is
between redislocation and
comfortable unforced
abduction
97. The transverse chest strap should be placed just below the
nipple line. The hips should be flexed to 120 degrees, and
the posterior straps should not produce forced abduction.
98. Pawlik contd..
Indications include presence of reducible hip femoral head
directed toward triradiate cartilage on xray
follow weekly intervals by clinical exam and US for two weeks
and if not reduced other methods are pursued
once successfully reduced, harness is continued for childs age
at stability + 3 months
end of weaning process---- xray pelvis obtained--- and if normal
discontinue harness
99. Complications
Failure
poor compliance , inaccurate position and persistence of
inadequate treatment
subgroup where failure may be predictable
○ absent Ortolani sign
○ bilateral dislocations
○ treatment commenced after age 7 week
NEXT Treatment is closed reduction and Spica
Casting
Femoral Nerve Compression 2 to hyperflexion
Inferior Dislocation
Skin breakdown
Avascular Necrosis
103. 6 months to 2 years age
Closed reduction and spica cast immobilization
recommended
traction controversial with theoretical benefit of gradual
stretching of soft tissues impeding reduction and neurovascular
bundles to decrease AVN
skin traction preferred however vary with surgeon
usually 1-2 weeks
scientific evidence supporting this is lacking
104. Treatment contd..
closed reduction preformed in OR under general anesthetic
manipulation includes flexion, traction and abduction
percutaneous or open adductor tenotomy necessary
in most cases to increase safe zone which lessen incidence of
proximal femoral growth disturbance
reduction must be confirmed on arthrogram as large portion of
head and acetabulum are cartilaginous
dynamic arthrography helps with assessing obstacles to
reduction and adequacy of reduction
105. Treatment
reduction maintained in spica cast well molded to greater
trochanter to prevent redislocation
human position of hyperflexion and limited abduction
preferred
avoid forced abduction with internal rotation as increased
incidence of proximal femoral growth disturbance
cast in place for 6 weeks then repeat Ct scan to confirm reduction
casting continued for 3 months at which point removed and xray
done then placed in abduction orthotic device full time for 2
months then weaned
111. Safe Zone
20 to 30 degrees from
maximum abduction
extended to below 90 degrees
without redislocation
Safe zone can be improved
with adductor tenotomy
112. Failure of Closed Methods
Open reduction indicated if failure of closed reduction,
persistent subluxation, reducible but unstable other
than extremes of abduction
variety of approaches
anterior smith peterson most common
○ allows reduction and capsular plication and
secondary procedures
○ Disadvantages - more blood loss, damage to iliac
apophysis and abductors, stiffness
113. Open Reduction
Medial approach ( between adductor brevis and magnus)
○ approach directly over site of obstacles with minimal soft
tissue dissection
○ unable to do capsular plication so depend on cast for post
op stability
anteromedial approach Ludloff ( between neurovascular
bundle and pectineus)
○ direct exposure to obstacles, minimal muscle dissection
○ no plication or secondary procedures
○ increased incidence of damage to medial femoral
circumflex artery and higher AVN risk
115. Follow-up after open reduction
Abduction orthotic braces commonly used until acetabular
development is caught up to normal side
in assessing development look for accessory ossification centers
to see if cartilage in periphery has potential to ossify
secondary acetabular procedure rarely indicated < 2 years as
potential for development after closed and open procedures is
excellent and continues for 4-8 years
most rapid improvement measured by acetabular index ,
development of teardrop occurs in first 18 months after surgery
femoral anteversion and coxa valga also resolve during this time
116. Obstacles to Reduction
Extra- articular
Iliopsoas tendon
adductors
Intra-articular
inverted hypertrophic labrum
tranverse acetabular ligament
pulvinar, ligamentum teres
constricted anteromedial capsule in late cases
neolimbus is not an obstacle to reduction and represents
epiphyseal cartilage that must not be removed as this impairs
acetabular development
117. Age greater than 2 years
Open reduction usually necessary
54% AVN and 32% redislocation with use of skeletal
traction in ages > 3
For age > 3 open reduction and femoral
shortening and acetabular procedure is
recomended to avoid excess pressure on head
with reduction
118. Treatment con’t
2-3-years gray zone
potential for acetabular development is diminished
and therefore many surgeons recommend a
concomitant acetabular procedure with open
reduction or 6-8 weeks after
Incidence of AVN is greater with simultaneous open
reduction and acetabular procedure
119. Treatment contd..
Lovell and Winter advised to
judge stability at time of reduction and if stable observe for
period of time for development
if not developing properly with decreased acetabular
index, teardrop then consider secondary procedure
most common osteotomy is Salter or Pemberton
anatomic deficiency is anterior and Salter provides
this while Pemberton provides anterior and lateral
coverage
120. Natural Sequelae
Goal of treatment is to have radiographically normal hip
at maturity to prevent DJD
after reduction is achieved potential for development
continues until age 4.
In child < 4 years minimal dysplasia may be observed but
if it is severe than subluxations and presence of residual
dysplasia should be corrected
121. Residual Dysplasia
Determined by plain xray with measurement of CE
angle and acetabular index
In young children deficiency is usually anterior and in
adolescents it can be global
Deformities of femoral neck if significant it leads to
subluxation
lateral subluxation with extreme coxa valga or
anterior subluxation with excessive anteversion
usually DDH patients have a normal neck shaft
angle
122. If there is Dysplasia for 2-3-years after reduction
proximal femoral derotation or varus osteotomy
should be considered
varus osteotomy is done to redirect head to center of
acetabulum which stimulates normal development
It must be done before age 4 as remodeling potential
goes down after this
123. Treatment in Adolescent or Adult
Femoral osteotomy should only be used in
conjunction with pelvic procedure as there is
no potential for acetabular growth or
remodeling but changing orientation of femur
shifts the weightbearing portion
Pelvic osteotomy considerations
age
congruent reduction
range of motion
degenerative changes
124. Femoral Shortening
Schoenecker + Strecker 1984
Traction vs. Femoral shortening
56% AVN in traction group
0% AVN in femoral shortening
128. Pelvic Osteotomy
Done in Persistent instability + dysplasia
after open reduction and femoral
shortening
Requires concentric reduction of a
reasonably spherical femoral head
Usually based on surgeon preference
129. Pelvic Osteotomy
Volume changing
Pemberton
○ Hinges on triradiate
○ Requires remodeling of “new” incongruity
○ Provides more anterolateral coverage
Dega’s
130. Pelvic Osteotomy
Redirecting
Salter
○ Osteotomy through sciatic notch
○ Hinge through pubic symphysis
Triple innominate
Ganz
Dial
134. Salter Single Innominate
•Age –18 months –6 years
•Requires concentrically reduced hip
–Open reduction at same time is possible
–Iliopsoas and adductor tenotomies often
required
•Covers antero-later alacetabular deficiency
–Up to 15 degree of acetabular index corrected
135. Salter
•Anterior approach to acetabulum
–Exposing inner and outer ilium
–Expose hip capsule if reduction needed
–Transverse osteotomy is done just above acetabulum
• Sciatic notch to Ant.Inf.iliac Spine
–Rotate on pubic symphysis in antero-lateral direction
–Hold correction with bone graft wedge & K-wires
139. K. E. 21 - 12 - 1999
Salter & femoral
osteotomy
140. Pemberton Acetabuloplasty
•Age –18 months –10 years
•Requires reduced hip
•Decreases acetabular volume
–Remodeling of acetabulum required
•Corrects >15 degree of Acetabular index
•Reduces antero-lateral acetabular defects
–Cuts altered to cover more anteriorly or laterally
141. Pemberton
•Anterior Approach -Exposure as for Salter
–Cut inner and outer table with small osteotome
– osteotomy 1cm above AIIS, staying 1 cm above
capsule
–Do not cut through to sciatic notch
–Lever through the cut until coverage is acceptable
•(Levers on tri-radiate cartilage)
–Hold correction with bone graft wedge
142.
143.
144. Dega Acetabuloplasty
•Similar to Pemberton
•Larger posterior hinge
–Hinges on horizontal tri-radiate limb
•Less inner table osteotomized for more lateral
coverage
(More inner table –more anterior coverage)
145.
146. Steel Triple Innominate Osteotomy
•Age –Skeletally mature
•Requires congruent hip joint
•Divides ilium, ischium and superior ramus
–Acetabulum is rotationally free
–Indicated when other osteotomies not
possible
•Rotates to cover any acetabular defect
147. Steel
•Multiple incision technique
–Posteriorly between gluteus and hamstrings
•Allows osteotomy of ischium
–Anteriorly freeing medial attachments
•Allows Salter and superior ramus osteotomy
–Rotate acetabulum as desired
•Avoid externally rotating
–Bone graft wedge is fixed as per Salter type
148.
149. Salvage or Shelf
procedures
Chiari and Staheli osteotomies
Requires capsular metaplasia
Pain is the main indication
Used in Treatment of chronic hip pain in
adolescents
150. Staheli Shelf Procedure
•Age –older child to skeletal maturity
•Salvage operation
•Indicated for non-concentric hips
•Augments supero-lateral deficency
–Slotted bone graft placed over capsule
deepening the acetablum
151. Staheli
•Anterior approach is used with outer wall exposure only
–Identify superior acetabular edge
–Create slot 1cm deep along edge in cephlad angle
–Remove 1 cm cortical strips from outer table
•Insert into slot, cutting at desired lateral overhang
•2nd layer inserted lengthwise
•Use remaining to fill in above slot edge
–Hold in place with reflected fascia and adductors
154. Chiari Medial Displacement
•Age –skeletally mature
•Salvage operation only
–Used when no other osteotomy possible
–Possible with subluxed hip
•Covers well laterally
–Anterior and posterior augmentation may be
necessary
•May be useful in other conditions
–Coxamagna, OA in dysplasichips
155. •Anterior approach –as per Salter
–Identify superior extent of capsule
–Cut from AIIS to notch following capsule
curve
•Angle osteotome10-20ocephlad
–Displace distal fragment medially 50-100%
•Ensure complete head coverage
•Leg abduction, hinges on pubic symphysis
162. Outcome of Chiari
osteotomy
236 of 388 osteotomies
reviewed at 25 years
51% good; 30% fair; 18% poor
Best results: ≤ 7 years; no OA
Femoral osteotomy: no better
(Windhager et al. JBJS
1991)
165. Complications of Treatment
Worst complication is disturbance of growth
in proximal femur including the epiphysis and
physeal plate
commonly referred to as AVN however, no
pathology to confirm this
may be due to vascular insults to epiphysis
or physeal plate or pressure injury
occurrs only in patients that have been
treated and may be seen in opposite normal
hip
166. Necrosis of Femoral Head
Extremes of position in abduction ( greater 60
degrees ) and abduction with internal rotation
compression on medial circumflex artery as
passes the iliopsoas tendon and compression of
the terminal branch between lateral neck and
acetabulum
“ frog leg position “ uniformly results in proximal
growth disturbance
168. extreme position can also cause pressure
necrosis onf epiphyseal cartilage and
physeal plate
severin method can obtain reduction but
very high incidence of necrosis
multiple classification systems with Salter
most popular
169. Salter Classification
1 failure of appearance of ossific nucleus
within 1 year of reduction2
2 failure of growth of an existing nucleus
within 1 year
3 broadening of femoral neck within 1
year
4 increased xray density then
fragmentation of head
5 residual deformity of head when re-
ossification complete including coxa
magna,vara and short neck
170. Treatment
Femoral and/or acetabular osteotomy to
maintain reduction and shift areas of
pressure
trochanteric overgrowth causing an abductor
lurch treated with greater trochanter physeal
arrest if done before age 8 otherwise distal
transfer
early detection is key with 95% success rate
of treatment
identify growth disturbance lines