Developmental dysplasia
of the Hip (DDH)
Natural history,
management and outcomes
West Bank, Autumn 2009
Aetiology
 Genetic: polygenic
syndromic
sex-linked
 Hormonal: oestrogen ; relaxin
 Mechanical: breech
liquor deficiency
Mechanical
 Left : Right – 4 : 1
 Breech : DDH ≥ x 10 (N.B. frank)
 Liquor ↓ : moulded baby
- plagiocephaly
- scoliosis
- foot deformity
- skew pelvis
Genetic / mechanical
Joint laxity
Acetabular and femoral version
Birth pathology in DDH
Simple:
Acetabulum normal
Femoral head normal
Labrum normal
Capsule stretched
Neonatal DDH
Ligamentum
teres
True socket
Teratological DDH
 Irreducible
 False acetabulum
 Defective anterior acetabulum
“anteverted”
 Increased femoral neck anteversion
False acetabulum
Arthrogryposis with dislocations
& delivery fracture
Untreated dysplasia without
dislocation in the Navajo
18 children
 15 became normal
 3 stayed dysplastic
Pratt, Freiberger, Arnold. CORR; 1982
Which hip dysplasia
pain?
• Complete dislocation with
no false acetabulum:
NO
• Complete dislocation with
false acetabulum:
• Subluxation:
YES
YES
Wedge, Wasylenko. CORR, 1978
45-year old
• Subluxation
• False
acetabulum
• Severe OA
... and adult unrecognised dysplasia?
Early treatment
• Diagnose!
• Splint
• Review
Ortolani test
Ultra
Sound
!
UK Screening Committee:
the problems
• Poor science
• Poor testers
• No national training
• No national audit
• Litigation
programme
U.K. National Screening
Committee (2006)
• Universal U.S. not recommended
• Clinical exam.
•
by properly trained
( at birth & 6 weeks)
Refer “at risk” babies
The extended role
practitioner
&
orthopaedic team working
Annie: extended role physio.
Oxford experience
• 1500 new screenings / year
• 700 follow-up screenings / year
• 95% successful splints
Challenges in hip dysplasia
• Subluxation
• Incongruity
• Early arthritis
The older child
Closed reduction
• E.U.A.
• Adductor tenotomy
• Safe position in POP
Open reduction
• Bikini incision
• Psoas tenotomy
• Ligamentum teres?
• Transverse ligament
• Limbus?
• Capsulorraphy
Arthrogram
• Head shape
• Cover
• Congruity
• Articular cartilage
• Labrum
DDH: what influences
arthritis risk?
• Age at treatment
• Quality of reduction
• Stability
• AVN
Oxford DDH follow-up
Results - Arthritis
Opposite hips
4%: moderate/
severe OA
Affected hips
40%: moderate/
severe OA
Femoral operation
• Shortening
• Varus/valgus +/- rotation
• Trochanteric transfer
• Neck lengthening
Femoral shortening for DDH
Hey-Groves
(1928)
Valgus/ extension osteotomy?
AVN with
trochanteric
overgrowth
Better in
adduction and
flexion
Neck-shaft angle
after femoral osteotomy
Pelvic operation
Re-alignment:
simple e.g. Salter
complex e.g. Bernese
Re-shaping:
e.g. Pemberton
Augmentation:
e.g. shelf
Chiari
Salter
Innominate
osteotomy
Salter & femoral osteotomy
K. E. 21 - 12 - 1999
Staheli shelf
Chiari osteotomy
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)
Very late
salvage
Schanz
osteotomy
Radical salvage
•
•
•
Fusion
Replacement
Excision
Hip arthrodesis
Consider for:
i. Young male
ii. Unilateral
iii. Infection
Joint replacement
Consider for:
i. Severe arthritis
ii. Failed “ conservative” Rx.
iii. Bilateral disease
Joint replacement
•
•
•
May be complex
+/- femoral shortening
+/- acetabular grafting
Severe arthritis
DDH
AVN
OA
End-stage O.A.
High,
painful
DDH
DDH: THR
does not solve all ills!
Right:
painless
Left:
severe pain
THR outcomes in DDH
• Charnley cemented hips:
5 of 38 loose at 11 years
Bobak, Wroblewski et al 2000
• Harris uncemented hips:
20% loose at 7 years
46% loose at 12 years
Jasty, Anderson, Harris, 1999