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Carol Berg

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Developmental
dysplasia of Hip

Dr Waqar Hassan
TMO Orthopedic Unit
HMC
Objectives

Understand what is DDH


How to diagnose
Treatment
Research and cases in our unit
Conclusion & suggestion

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Definition
DDH is a spectrum of disorders. Hip
can be
Dislocated
Dislocatable
Subluxated

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Age
1. Teratological Dislocation
 (congenital dislocation of hip)

Typical DDH
 Child is otherwise normal

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Epidemiology
& risk factors
• Incidence 1 in 1000 live birth
• Left hip 67%
• Family history 20%
• In breech 30-50%
• Bilateral 35%
• Sex Ratio (Relaxin) F(4 - 6) : M(1)

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Risk factor
Environmental & Mechanical

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Risk factor
Genetic
 unknown genetic factor
 Runs in families

 Risk to next child increases

 Families with Generalised Ligament


Laxity
 Families with Acetabular Dysplasia

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Nursing
race
Rare in China, Asia, Africa (carry
children with hips flexed and
abducted)

High in native American (Used to


nurse with legs extended)

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Aetiology-Ligamentous
Laxity
Maternal Relaxin hormones

Induce hip capsule laxity in infant

Effect is much stronger in females

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Pathology
Bone

Soft tissues

Muscles

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Screening for DDH
Methods
Clinical

U.S. Scan

Aim of screening
 Early
detection
 Reduces late presentation

 Reduces surgical intervention

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Clinical screening
Standard programme
 Barlow’s/Ortolani’s tests done on
every child at birth and then at 6-8
weeks

Barlow’s/Ortolani’s Tests
 Specificity- 100%

 Sensitivity- 60%

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Barlow Provocative Test
in neonate

Dislocates hip
(exit)

Clunk

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Ortolani Maneuver
in neonate

Reduces
Abduction
dislocated hip
(entry)

Clunk

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Infant >3 Months

57º 43º

Limited abduction is key


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Infant >3 Months

Asymmetric
thigh folds
Limb-length
discrepancy

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Galeazzi test

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Toddler

Limping
waddling gait
Lordosis
Deformity
Limited abduction and lateral rotation
Telescoping
Leg length discrepancies

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Ultrasound Screening
High Specificity and Sensitivity: >90%

Helps in diagnosis of not only


Subluxated/ Dislocated hips but also
Dysplastic hips

Helps in Monitoring the treatment


Reduces the need for Arthrograms /
Xrays.
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Radiology
Standard films AP of the pelvis with
both hip joint

frog-leg views

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Central edge
angle

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Von Rosen’s line

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Treatment
Aim

Proper reduction of femoral head


is important for development of
acetabulum and lowers incidence
of acetabular dysplasia

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According to Campbell’s
operative orthopedics
birth to 6 months (New born)
6 to 18 months (Infant)
18 to 36 months (toddler)
3 to 8 years (child)
Juvenile & Young adults-

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TREATMENT :
In newborn

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Denis Brown Abduction
Splint

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Von Rosen Splint

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Pavlik harness should not be
continued for more than 4 weeks if
failed
Complication
 AVN

 Femoral nerve palsy


 Persistant dislocated hip can wear
away acetabulum (pavlik harness
disease)
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Failure of Pavlik harness
6-8 weeks not
stabilised
Traction
Closed reduction
&radiographic
assesment
Open reduction if
necessary

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Treatment: Infant 6 to 18
months
Closed reduction & Spica
Must be gentle flex hip > 90
degree and in safe zone of 30 -60
degree abduction
Arthrography is often useful
Adductor tenotomy
Open reduction if necessary

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Hip spica

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Aftercare

After close reduction


Spica for 4 months with cast
changes every 6 weeks
Check X-rays or CT scans

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Open reduction in 12 to 18
months
As child get older chance of
successful close reduction
decrease
Open reduction may be needed
due to soft tissues contracture
Seldom need bony procedure

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Open reduction
Structural obstacles to close
reduction are
 Hour glass capsular contracture
 Ligamentum teres

 Iliopsoas

 Pulvinar

 Transverse acetabular ligament

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Toddler 18-36months

Open reduction combined with


femoral osteotomy
Pelvic and femoral combined
osteotomies

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Child 3 to 8 years of age

Open reduction combined with


femoral shortening osteotomy
Pelvic and femoral combined
osteotomies

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Oteotomy

Femoral osteotomy
 Femoral shortening
 Derotation

 Varus

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Pelvic Osteotomies
Reconstructive
Salter 18m – 6y
 Pemberton 18m – 10y
 Steel skeletal maturity
 PAO (Ganz) skeletal maturity
Salvage
 Chiari skeletal maturity

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Overview of Pelvic
Osteotomies

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How to determine for
osteotomy

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Juvenile & Young adults
> 8 years
Palliative salvage procedures
Rarely femoral shortening &
pelvic osteotomy
Bilateral: leave it alone

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Researh work in our unit

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Study in orthopedic unit
HMC
Period : Sep2003 to July 2007
Ref no. : JPMI 2008 VOL22
NO.01:27-32
Title : One stage surgery of
CDH/DDH in children of
2-5 years of age

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Results
Total no. of patients: 25
Total hips operated: 30
Gender :
 Female: 17
 Male: 8
Bilateral : 5 Cases
Left side : 18 cases
Mean age at surgery: 38.56
months
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Radiological assessment
modified Severin classification
Excellent IA CE angle>19 degree 9

Good IB CE angle15-19 degree 6


II Moderate deformity of femoral head 10

Fair III Dysplastic hip, no subluxation CE 5


angle<19

Poor IV Subluxation 0
V Head In false acetabulum 0
Redislocation 0
VI

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Functional results
modified MCKAY criterion
Grade No. %
of age
hip
s
Excellent Stable, no limp, full ROM , -ve trendlenberg 18 60

Good Stable, slight limp, slight decrease ROM ,-ve 7 23.3


trendlenberg

Fair Stable, limping, limitation of motion ,+ve 5 16.7


trendlenberg, some pain

poor Unstable ,painful , +ve trendlenberg 0 0


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Case -1

Sabiha
4 yr old

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Case -2

Irtiza
2 yr old

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Case-3

Alia
2 yr old

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Case- 4

Faiza
2 yr old

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Conclusion

The failure to diagnose and treat


DDH in neonatal period can result
in significant morbidity, including
closed treatment failure, the need
for open reduction, and the
eventual development of
osteoarthritis

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Suggestion
Radiologist
Pediatrician
Gynecologist

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THANK YOU

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Ultrasound

Alpha > 60º


Slopeof osseus
acetabulum
Graf classification system

Class Alpha angle Description

I >60 Normal

II 60-43 Immature/Dysplastic

III <43 Subluxed/Dislocated

IV Unmeasurable Dislocated