Developmental Dysplasia of the Hip

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Developmental Dysplasia of the Hip

• Tina L Creekmore MD

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Definition

• Instability of the hip in the newborn including
  subluxated or dislocatable hips
• As the child grows it may progress to dislocation
  or poor acetabular coverage
• Evolves over time

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Associated factors

• Ligamentous laxity associated with family history
• Prenatal positioning and oligohydramnios
• Postnatal positioning
• Racial predilection

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Breech positioning

• Frank Breech presentation is associated with 20
  incidence of DDH

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Breech presentation

• Complete or footling breech have a much lower
  incidence of DDH (2)

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Breech presentation

• Lowry, et al, showed that breech infants
  delivered by elective caesarean section
  (pre-labor) had a lower incidence of DDH than
  those breech babies delivered vaginally

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Associated factors

• Cultures that wrap newborns with their hips and
  knees extended have a higher incidence of DDH
• Black and Asians have a low incidence of DDH and
  Caucasians and Native Americans have a higher
  incidence

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Associated Conditions

• Other positional abnormalities including
• Torticollis
• Metatarsus adductus
• Positional club foot
• Congenital Knee dislocation

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Barlows test

• Adduct and push posteriorly on the hip
• A positive test is feeling the hip push out of
  the acetabulum

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Ortolanis test

• Hold the knees and abduct the hip while lifting
  up on the greater trochanter
• A positive test is feeling the dislocated hip
  clunk into the acetabulum

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Diagnosis Physical exam

• May be limited abduction of affected hip
• Galeazzi sign affected femur appears shortened
  when hips and thighs are flexed
• Asymmetrical thigh folds

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Physical Exam older children

• The affected extremity is shortened so they toe
  walk on that side
• Trendelenburg gait
• Excessive lordosis

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Imaging

• For newborns, plain radiographs are difficult to
  interpret since most of the acetabulum is still
  cartilaginous, generally not accurate until 3-6
  months of age
• Look to see if the femoral heads point toward the
  triradiate cartilage
• Ultrasound is the test of choice because
  cartilage can be seen and real time images can be
  viewed

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Ultrasound

• Graf method measures alpha and beta angles
• Normal is alpha gt 60 and beta lt 55
• Some authors are concerned that it is too
  sensitive and may lead to over treatment

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Graf Classification
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Screening?

• Many mildly dysplastic hips, class IIa, IIb, and
  even some IIc, and D hips may spontaneously
  mature to normal without treatment so the
  concern is that routine screening can lead to
  over treatment
• However studies where routine screening was in
  use showed a significant decrease in
  hospitalization and surgical intervention

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Plain Radiographs

• Hilgengreiners line is across the triradiate
  cartilage
• Perkins line is vertical along the lateral border
  of the acetabulum
• Sheltons line

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Plain radiographs

• Acetabular index is the angle between the
  acetabulum and hilgenreiners line
• It should be less than 30 degrees in a newborn

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Plain Radiographs

• Center-edge angle of Wiberg cannot be measured
  until the ossific nucleus appears
• Normal is greater than 10 in children 6-13 yrs

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Computerized Tomography

• Not used very commonly for diagnosis
• Can be used to confirm reduction after closed
  reduction and casting

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Treatment

• Treatment methods are dependent on the age of the
  patient
• Generally, the younger the patient the less
  invasive the treatment and the better the results
• That is why early diagnosis is important

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Treatment Newborns

• Pavlic harness is mainstay of treatment for
  newborn hip dysplasia
• Avoid excessive flexion or abduction to avoid
  causing AVN
• 85-95 successful, ultrasound is generally used
  to assess progress

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Pavlic Harness

• Generally good results, but if no improvement in
  3-4 weeks, the harness should be stopped and
  either traction or closed reduction should be
  consider
• Even with good initial results, late
  complications such as AVN and residual acetabular
  dysplasia can occur, especially with abnormal
  echogenicity of the cartilage or alpha lt 43 deg

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Treatment Infants (6-18 mo)

• Closed reduction and casting /- preoperative
  traction
• Intraoperative arthrogram is important to comfirm
  reduction and to examine the amount of acetabular
  dysplasia or labral pathology
• If closed reduction cannot be achieved or is
  unstable, open reduction is indicated

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Treatment Infants

• If open reduction places excessive pressure on
  the femoral head, then a femoral shortening
  osteotomy is indicated
• Kuszkowski and Pucher suggested that if there is
  not an adequate safe zone that acetabular
  osteotomy should be considered at the time of
  open reduction even in younger children (6-24 mo)

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Treatment Toddlers (18-36 mo)

• Generally a femoral and/or acetabular osteotomy
  is necessaryFemoral shortening or varus
  osteotomyAt this age there is still significant
  remodeling potentialSpica casting is needed
  until osteotomies heal

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Treatment Child (3-8 yrs)

• At this age children usually need combined
  procedures
• Most recommend femoral shortening,
  capsulorrhaphy, and a pelvic osteotomy if
  indicated depending on acetabular index
• Important to correct soft tissue deformities

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Treatment Age gt8yrs

• Treatment becomes very difficult because it is
  often not possible to achieve a concentric
  reduction
• Can consider leaving bilateral dislocations out
  if asymptomatic
• Salvage procedure may be only option
• Will often need early arthroplasty

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Pelvic osteotomies

• Can be divided into complete and incomplete
• Incomplete osteotomies can only be used when the
  triradiate cartilage is open because most hinge
  on the triradiate cartilage
• In older patients, more complex, complete
  osteotomies are requried

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Pelvic osteotomies

• Incomplete Salter, Pemberton, Dega
• Complete Steel, Ganz, Chiari
• Other Shelf procedure (salvage procedure)

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Salter Osteotomy

• Osteotomy of the innominate bone which displaces
  the acetabulum in an anterolateral direction
• If the head is not concentrically reduced the
  procedure is not useful
• Hinges on the symphysis pubis

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Pemberton Osteotomy

• Osteotomy of the ilium which hinges on the
  triradiate cartilage
• The roof of the acetabulum is then rotated
  anterior and laterally
• Decreases this size of the acetabulum and
  produces joint incongruity so should only be done
  in younger children

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Dega Osteotomy

• Similar to Pemberton in that internal fixation is
  not required
• Incomplete osteotomy of the ilium in which the
  posteriomedial cortex remains intact
• A wegde of bone graft is used to push down the
  roof of the acetabulum

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Ganz and Steel Ostetomies

• These are triplane complete osteotomies that
  reposition the acetabulum
• Useful in older patients with residual dyplasia
• Done when a concentric reduction cannot be
  achieved

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Salvage procedures

• Used when a concentric reduction cannot be
  achieved
• Chiari osteotomy and shelf procedure
• Fibrocartilage covers the acetabulum

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Case presentation

• 4 yr old female referred to Shriners hospital
  for bilateral hip dyplasia
• She also has a history of cleft palate but
  otherwise past history is unremarkable
• Appears to be asymptomatic

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Bibliography

• Journals
• Alexiev V, Harcke T, Kumar S Residual dysplasia
  after successful pavlik harness treatment, early
  ultrasound predictors. J Pediatr Orthop
  20062616-23.
• Lowry C, Donoghue V, OHerlihy C et al Elective
  caesarean section is associated with a reduction
  in developmental dysplasia of the hip in breech
  term infants. J Bone Joint Surg Br
  200587(7)984-5.
• Roovers E, Boere-Boonekamp M, Mostert A et at
  The natural history of developmental dysplasia of
  the hip sonagraphic findings in infants of 1-3
  months of age. J Pediatr Orthop B
  200514325-330.
• Ruszkowski K, Pucher A Simultaneous open
  reduction and dega transiliac osteotomy for
  developmental dislocation of the hip in children
  under 24 months of age. J Pediatr Orthop
  200525695-701.
• Wirth T, Stratmann L, Hinrichs F Evolution of
  late presenting developmental dysplasia of the
  hip and associated surgical procedures after 14
  years of neonatal ultrasound screening. J Bone
  Joint Surg Br 200486-B585-9.

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Biliography

• Text
• Canale T Campbells Operative Orthopedics,
  Philadelphia, 2003, Mosby, Inc.
• Herring J, et al Tachdjians Pediatric
  Orthopedics, Philadelphia, 2002, W.B. Saunders
  Company
• Online
• http//orthoinfo.aaos.org/fact/thr_report.cfm?Thre
  ad_ID153topcategoryhip
• www.mgh.harvard.edu/ortho/Hip-dysplasia.htm