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Developmental Dysplasia of the Hip

 Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) generally includes subluxation (partial dislocation) of the femoral head, acetabular dysplasia, and complete dislocation of the femoral head from the true acetabulum secondary to capsular laxity and mechanical factors.

Previously the disease was called congenital hip dysplasia (CDH), nowadays it’s called Developmental dysplasia of the hip (DDH).

The word developmental invokes the dimension of time, acknowledging that the dysplasia or dislocation may occur before or after birth, while dysplasia means an abnormality of development and encompasses a wide spectrum of hip problems.

Definition

Instability is the inability of the hip to resist an externally applied force without developing a subluxation or dislocation.

A subluxation is an incomplete dislocation with some residual contact between the femoral head and acetabulum.

A dislocation indicates complete displacement of the femoral head from the acetabulum.

Epidemiology

Bilateral Developmental dysplasia of the hip
Bilateral Developmental dysplasia of the hip

Etiology

The etiology of DDH is felt to be multifactorial, including both mechanical and physiological factors.

In utero, the hip is in a position of flexion and abduction that results in a tightened iliopsoas tendon and anterior–lateral orientation of the acetabulum.

The tight iliopsoas may push the femoral head out posteriorly with hip extension during kicking. The labrum (cartilaginous rim of the acetabulum) becomes everted and flattened.

The acetabulum and femoral head develop rapidly in the neonatal period. When the acetabulum and femoral head are in the correct position, each reinforces the development of the other by this physical contact:

In contrast, if a subluxation or dislocation persists, the femoral head becomes flattened on the posteromedial surface, the acetabulum becomes shallow and dysplastic, and femoral anteversion gradually increases. In addition, the muscles surrounding the hip may shorten and contract.

Risk factors

Several risk factors should arouse suspicion of Developmental Dysplasia of the Hip:

  1. Breech positioning.
  2. Female sex.
  3. Positive family history.
  4. Postnatal Positioning (swaddling with the hips in extension).
  5. Racial Predilection (whites and Native Americans).
  6. Firstborn child.
  7. Ligamentous laxity
DDH Postnatal positioning
Postnatal positioning
See Also: Developmental Dysplasia of the Hip Risk Factors

Associated Abnormalities

Developmental Dysplasia of the Hip is associated with multiple congenital deformities:

  1. Congenital torticollis: found in 8% , Boys more than girls.
  2. Metatarsus adductus.
  3. Talipes calcaneovalgus.
  4. Clubfoot deformity (Controversial): Screening hip physical examination and ultrasound evaluations for infants with clubfoot deformity is recommended.
DDH Associated Abnormalities
DDH Associated Abnormalities

Clinical Evaluation

Physical examination of Developmental dysplasia of the hip (DDH) varies based on the age of the child.

Newborns (<6 months old):

Three phases are commonly recognized in Barlow / Ortolani test:

Children > 3 months:

Walking child > 1 year:

Lumbar lordosis in Bilateral hip dislocation
Lumbar lordosis in Bilateral hip dislocation
See Also: Hip joint Special Tests

Imaging Evaluation

Dynamic Ultrasonography:

Ultrasonography Angles:

Angle α :

Angle β:

Radiographic:

Measurements:

The most commonly used lines of reference are the:

Normally, the femoral head lies within the inner lower quadrant of the reference lines noted by Perkins and Hilgenreiner.

DDH radiographic lines
DDH Radiographic lines

Acetabular index (AI):

Hip Acetabular index
Hip Acetabular index

The Wilberg center–edge angle:

Wilberg center–edge angle
Wilberg center–edge angle

Von Rosen view:

Von Rosen view
Von Rosen view

Acetabular Teardrop:

tear drop sign
Tear drop sign

Arthrography:

DDh Arthrography
DDh Arthrography

CT & MRI:

DDH Treatment

DDH Treatment is based on the child’s age:

Birth to 6 months:

Hips with normal exam but abnormal ultrasound findings:

Barlow-positive hips (reduced but dislocatable):

Ortolani-positive hips (dislocated but reducible): Should be treated with Pavlik harness.

Follow up check reduction after 3 weeks on ultrasonography:

Pavlik Harness:

Several series have documented the results of harness treatment. A review of a large European series of patients found that 95% of initially dysplastic hips were normal after treatment.

Risk factors for Pavlik Harness failure:

As the harness is discontinued, another AP radiograph is obtained to assess hip reduction and acetabular development. A notch above the acetabulum often appears after the hip is reduced, and this finding is usually followed by improved acetabular development. Acetabular development may be enhanced by abduction splinting, but controlled studies have not been conducted to confirm the efficacy of this common practice.

6 to 18 months:

18 months to 3 years:

Obstacles to reduction in developmental dysplasia of the hip:

  1. Transverse acetabular ligament.
  2. Pulvinar.
  3. In-folded labrum.
  4. Inferior capsular restriction.
  5. Psoas tendon.
DDH Obstacles to reduction
Pathology of the dislocated hip that is irreducible as a result of intraarticular obstacles. A, The hip is dislocated. B, The hip cannot be reduced on flexion, abduction, or lateral rotation. Obstacles to reduction are inverted limbus, ligamentum teres, and fibrofatty pulvinar in the acetabulum. The transverse acetabular ligament is pulled upward with the ligamentum teres.

3 to 8 years:

Older than 8 years:

Pelvic Osteotomy:

If the growth plate is open:

  1. Triple (Steele) Osteotomy.
  2. double pelvic (Southerland) Osteotomy.
  3. Staheli procedure

If the growth plate is closed:

pelvic osteotomy
Pelvic osteotomies

Adult Patient:

See Also: Hip Joint Osteoarthritis

Pelvic Osteotomy in treatment of developmental dysplasia of the hip:

OSTEOTOMYPROCEDUREREQUIREMENTINDICATIONS
Femoral Intertrochanteric osteotomy (Varus derotation osteotomy)Concentric reduction before the age of 8 years– High neck-shaft angle
– hip subluxation;
– usually performed in patients with cerebral palsy
Salter Open-wedge osteotomy through ileumConcentric reduction before the age of 8 years– Acetabular dysplasia without posterior wall loss; – redirection osteotomy
Pemberton Through acetabular roof to triradiate cartilage; does not enter sciatic notchConcentric reduction before the age of 8 years– Acetabular dysplasia with a patulous cup;
– volume-reducing osteotomy
Dega Through lateral ilium above acetabulum to triradiate cartilage; incomplete cuts through innominate boneConcentric reduction; favored in those with posterior acetabular deficiencyAcetabular dysplasia with patulous cup; – volume-reducing;
– favored in neuromuscular dislocations with posterior deficiency
Sutherland (double) Salter and pubic osteotomyConcentric reduction
Open triradiate cartilage
– More severe acetabular dysplasia;
– redirection procedure
Steel (triple)Salter and osteotomy of both ramiConcentric reduction
Open triradiate cartilage
– Most severe acetabular dysplasia;
– redirection procedure
Ganz Periacetabular osteotomySurgeon’s experience
Closed triradiate cartilage
Acetabular dysplasia in a skeletally mature patient
ChiariThrough ilium above acetabulum (makes new roof)Non-reconstructable acetabulumSalvage procedure for asymmetric incongruity
Shelf Slotted lateral acetabular augmentationNon-reconstructable acetabulumSalvage procedure for asymmetric incongruity
Pelvic Osteotomy Types

References

  1. Tachdjian Pediatric Orthopaedics 5th Edition Book.
  2. Millers Review of Orthopaedics, 7th Edition Book.
  3. Campbel’s Operative Orthopaedics 13th edition book.
  4. Mark Dutton, Pt . Dutton’s Orthopaedic Examination, Evaluation, And Intervention, 3rd Edition Book.
  5. Grill F, Bensahel H, Canadell J, Dungl P, Matasovic T, Vizkelety T. The Pavlik harness in the treatment of congenital dislocating hip: report on a multicenter study of the European Paediatric Orthopaedic Society. J Pediatr Orthop. 1988 Jan-Feb;8(1):1-8. doi: 10.1097/01241398-198801000-00001. PMID: 3335614.
  6. Nandhagopal T, De Cicco FL. Developmental Dysplasia Of The Hip. 2021 Jul 18. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 33085304.

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