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Sharanayya Hiremath, profile picture
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Ddh 1

Developmental dysplasia of the hip (DDH) refers to abnormal development of the hip joint during infancy. It ranges from mild hip instability to complete dislocation. Risk factors include breech positioning, family history, and neuromuscular disorders. Diagnosis is made through clinical examination and imaging studies like ultrasound and x-rays. Treatment depends on the severity and may include closed or open reduction and casting or bracing. Complications can include degenerative joint disease, leg length discrepancy, and back pain if left untreated.

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Developmental Dysplasia of the Hip Chair Person: Dr.C.V.Mudgal By: Dr.S.C.Hiremath
Adolph Lorenz, an early pioneer in the treatment of developmental dislocation of the hip
Overview  Introduction  Normal Development of the Hip  Etiology and Pathoanatomy  Epidemiology and Diagnosis  Treatment  Complications
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.
 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
Etiology and Epidemiology  Multifactorial  Genetics and Syndromes ○ Ehler’s Danlos ○ Arthrogryposis ○ Larsen’s syndrome  Intrauterine environmental factors ○ Teratogens ○ Oligohydramnios) ○ breech  Neurologic Disorders: Spina Bifida  ligamentous laxity familial trait
 Left : Right – 4 : 1  Breech : DDH ≥ x 10  Amniotic fluid↓ : moulded baby - plagiocephaly - scoliosis - foot deformity - skew pelvis
Postnatal positioning in extension, as in this child on a Native American cradleboard, contributes to developmental dysplasia of the hip
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
 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
 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
 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
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
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
 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
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
Incidence -1 in 1000 live birth. -male to female ratio 4:1 -family history 1:7
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
Normal Hip  Tight fit of head in acetabulum  Transection of capsule  Still difficult to dislocate  Surface tension
Pathoanatomy  Ranges from mild dysplasia --> frank dislocation  Bony changes  Shallow acetabulum  Typically on acetabular side  Femoral anteversion
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
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
Teratological DDH  Irreducible  False acetabulum  Defective anterior acetabulum “anteverted”  Increased femoral neck anteversion
Arthrogryposis with dislocations & delivery fracture False acetabulum
Associated conditions -torticollis -metatarsus adducts -calcaneo valgus -talipus varus -plagiocephaly
CLINACAL PRESENTATION
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
Ortolani’s Maneuver After 3 months of age tests become negative
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.
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.
Infant Presentation  Skin fold asymmetry  Limited hip abduction  Unequal femoral lengths (Galeazzi’s sign) (Flex both hips and one side shows apparent femoral shortening)
Skin fold asymmetry
Asymmetrical thigh folds
Galeazzi’s sign
Developmental dysplasia of the right hip. One physical finding is limited abduction of the affected hip.
After Walking Age  Trendelenberg gait  Leg length discrepancy  Increased lumbar lordosis in Bilateral dislocation Klisic test positive
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.
 hyperlordosis – bilateral involvement
Which hip dysplasia pain? Complete dislocation with no false acetabulum: NO Complete dislocation with false acetabulum: YES Subluxation: YES
Imaging  X-rays  Femoral head ossification center ○ 4 -7 months  Ultrasound  CT  MRI  Arthrograms  Open vs closed reduction
Radiography
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
Imaging  Radiographs
Imaging  Radiographs
Imaging  Radiographs
Imaging  Radiographs
Imaging  Acetabular Index
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
Imaging  Acetabular Index < 30 wnl
Imaging
Imaging
Imaging
Imaging
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.
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)
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
TEAR DROP
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
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.
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
http://emedicine.medscape.com/article/408225 Measures acetabular depth. Normal >60 degrees Acetabular cartilaginous roof coverage. Normal <55 degrees Smaller angle= better bony coverage
Ultrasound Femoral head Abductors Ilium
Ultrasound Femoral head Abductors Ilium
Ultrasound Femoral head Abductors Ilium
Ultrasound Femoral head Abductors Ilium
Ultrasound Graf’s alpha angle
Ultrasound Graf’s alpha angle >60 = normal *line through ilium bisects head 50/50
• 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.
Graf grading of DDH by ultrasound
•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
Arthrogram Head shape Cover Congruity Articular cartilage Labrum
Arthrogram •Limbus - 'Rose thorn sign' of inverted labrum between femoral head & acetabulum •Hour glass constriction of capsule - by psoas tendon •Capsular distension
Arthrogram in DDH SUBLUXATED HIP DISLOCATED HIP
•Eliciting Medial pooling of dye •(normal = < 7mm) •Confirms reduction after surgery Dye pooling <7mm & complete reduction with arthrogram = no need for open reduction.
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
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
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
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.
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.
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
Treatment Options  Age of patient at presentation  Family factors  Reducibility of hip  Stability after reduction  Amount of acetabular dysplasia
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
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
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
Pawlik harness
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.
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
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
The Ilfeld or Craig splint