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Developmental Dysplasia of the Hip

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Other Names

  • Developmental Dysplasia of the Hip (DDH)
  • Congenital Dislocation of the Hip (CDH)

Background

  • This page refers to Developmental dysplasia of the hip (DDH) which represents abnormal development of the hip resulting in dysplasia, subluxation, and possible dislocation

History

Epidemiology

  • Most common orthopedic disorder of newborns (need citation)
  • Dysplasia (1:100) is about 10x more common than dislocation (1:100) (need citation)
  • DDH 5.5 per 1000 children using US at 2 days of life, which drops to 0.5 per 1000 at 2 weeks[1]
  • 8 fold more common in females than males[2]
    • Suspected to be due to increased estrogen increasing ligament laxity
  • 60% of cases are seen in left hip (need citation)
    • Due to in utero position: left occiput anterior, left hip adducted against mothers spine
  • Up to 20% are bilateral (need citation)

Pathophysiology

  • DDH encompasses
    • Dysplasia: shallow, underdeveloped acetabulum
    • Subluxation: displacement of joint with some articular contact
    • Dislocation: complete displacement with no articular contact
    • Teratogenic hip: dislocated in utero with abnormal acetabular development, i.e. pseudoacetabulum
      • Associated with genetic disorders including arthrogryposis, myelomeningocele, Larsen's syndrome, Ehlers-Danlos
    • Late: adolescent form which is mechanically stable with laxity
  • Initial instability leads to dysplasia
    • Dysplasia leads to subluxation, gradual dislocation
    • Chronic dislocation can lead to barriers of reduction, anatomic changes

Etiology

  • Often no clear cause
  • Complex interaction of genetic risk factors, maternal and fetal laxity, intrauterine and postnatal malpositioning

Screening

  • AAP guidelines[3]
    • Newborns: Screening with physical exam, US not recommended
      • Positive: referral to orthopedics
      • Equivocal: repeat in 2 weeks
    • Two weeks of age
      • Normal: follow up routine child visits
      • Positive: referral to orthopedics
      • Equivocal: referral to orthopedics or order US for week 3-4

Pathoanatomy

Associated Conditions

Risk Factors

  • Race
    • Increased risk among Canadians, Native Americans, Laplanders
    • Decreased risk among African, Chinese individuals
  • Prenatal/Neonatal
    • Breech position at birth
    • First born baby in a primagravida
    • Oligohydromnios[4]
    • Use of swaddling, cradle boards
  • Neurological
  • Other
    • Family history of DDH[5]
    • Susceptible genes: GDF5, TBX4, ASPN, IL-6, TGF-β1, and PAPPA2[6]

Differential Diagnosis

Clinical Features

  • History
    • Clinical manifestation depends on the age of the child
    • Newborn may present with limited abduction
    • Toddler may present with antalgic gait
    • In an adult, hip pain, degenerative arthritis
  • Physical Exam (<3 months)
  • Physical Exam (3 months to 1 year)
    • Look for positive Klisic Test, leg length discrepancy
    • Limited hip abduction may be only finding in babies over 3 months of age (Se 69%, Sp 54%)[7]
  • Physical Exam (1 year and older)
  • Special Tests
    • Ortolanis Sign: In newborn, with ips and knees flexed to 90° , gently abduct hips
    • Barlow Sign: In newborn, apply posterolateral pressure to patient in attempt to dislocation hip
    • Geleazzi Sign: hips flexed to 45°, knee flexed to 90°, look for asymmetry at the level of the knees
    • Klisic Test: Place both index fingers on ASIS, middle fingers on greater trochanter, line should pass through umbilicus

Evaluation

Ultrasound

  • Useful up to 4-6 months of age
    • Operator dependent, requires experience
    • Current recommendation is to perform at 4 weeks to avoid high false positive rate when performed earlier
  • Static Acetabular Images (Graf[8])
    • Measures: alpha angle (osseous acetabular roof angle), beta angle (position of the echogenic acetabular labrum)
    • Classification
      • Normal hip: No need for intervention
      • Immature hip: Needs follow-up
      • Progressive unstable hip or frankly dislocated hip
  • Dynamic Stress Images (Harcke[9])
    • Perform the Barlow and Ortolani maneuver and observe the relationship between the femoral hip and the acetabulum in real time

Radiographs

  • Standard Radiographs Hip, Standard Radiographs Pelvis
    • Of limited value in first 3 months, femoral head is mostly cartilage
    • More useful at 4-6 months of age
  • Indications
    • Assess the hips in children with a clinical diagnosis of DDH
    • To monitor hip development after treatment
    • To assess long-term outcomes
  • Hilgenreiner’s Line
    • Line drawn horizontally through the superior aspect of both triradiate cartilages.
    • Normal: It should be horizontal.
  • Perkin’s Line
    • Drawn perpendicular to Hilgenreiner's Line, passes thorough the lateral- most aspect of the acetabular roof
    • Femoral head should be seen in the inferomedial quadrant, lie below Hilgenreiner’s line, and medial to Perkin’s line.
    • If ossified nucleus of the femoral head is not visible, the femoral metaphysis should be used.
    • Lateral or superior displacement of the femoral head occurs in DDH.
  • Shenton’s line
    • Line passes from the medial border of the femoral neck to the superior border of the obturator foramen
    • Normal hip: continuous
    • DDH: line contour will be interrupted
    • Note: intact in “subluxation”, disrupted in “dysplasia.
  • Acetabular index
    • Angle formed between Hilgenreiner’s line and a tangential line to the lateral ossific margin of the roof of the acetabulum.
    • The acetabular index is helpful in measuring the development of the osseous roof of the acetabulum.
    • Normal values: <35° at birth; <25° at 1 year; <20° between 1 and 3 years.

Arthrogram

  • Used to confirm reduction under general anesthesia
  • Can be used to find blocks to reduction including[10]
    • Inverted labrum
    • Inverted limbus
    • Transverse acetabular ligament
    • Hip capsule is constricted by iliopsoas tendon
    • Pulvinar
    • Ligamentum teres

MRI

  • Often used after closed reduction, casting to minimize radiation exposure (compared to CT)

CT

  • Historical study of choice to evaluate hip after closed reduction, falling out of favor for MRI

Classification

  • Subluxable: Barlow-suggestive[10]
  • Dislocatable: Barlow-positive
  • Dislocated: Ortolani-positive early when reducible; Ortolani-negative late when irreducible

Management

Prognosis

0 to 6 months

  • Pavlik Harness with success rates of 85% - 95%
    • Most commonly used and considered gold standard
    • Purpose: maintain the hip in flexion and abduction position
    • This brings the femoral head as close to the acetabular ring as possible
    • Plaster > Fiberglass > soft cast
    • Immediately after placement, radiograph needs to be performed to confirm position
    • Two weeks after placement, US to confirm stability of hip
    • Recommendations to discontinue vary from weening over time to removal at 6 weeks
    • Should repeat XR at 6 months and 12 months
  • Alternative splint options: Rosen Splint, Wagner Stocking
  • Use of double or triple diapers is not recommended under 1 year[11]

6 months to 2 years

  • Procedure: Closed reduction under general anesthesia
  • Possible arthrogram in operating room
  • Application of Spica Cast which remains on for 3 months
  • Failure of closed reduction requires need for open reduction

Older than 2 years

  • Procedure: Open reduction alongside, possibly femoral or pelvic osteotomies
  • Application of Spica Cast which remains on for 6-12 weeks

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications

  • Delayed Diagnosis
    • can be seen in bilateral cases
  • Recurrence
  • Transient Femoral Nerve Palsy
  • Avascular Necrosis
    • Most devastating complication of pavlik harness
    • Incidence estimates range from 0 to 26%[12]
  • Postoperative
    • Hip stiffness
    • Hypertonicity of musculature

See Also

References

  1. ↑ Bialik V, Bialik GM, Blazer S, Sujov P, Wiener F, Berant M. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics. 1999;103:93-99.
  2. ↑ Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006;117:e557-e576.
  3. ↑ Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Pediatrics. 2000;105:E57.
  4. ↑ Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006;117:e557-e576.
  5. ↑ Wynne-Davies R. Acetabular dysplasia and familial joint laxity: two etiological factors in congenital dislocation of the hip. A review of 589 patients and their families. J Bone Joint Surg Br. 1970;52:704-716.
  6. ↑ Shi D, Dai J, Ikegawa S, Jiang Q. Genetic study on developmental dysplasia of the hip. Eur J Clin Invest. 2012;42:1121-1125.
  7. ↑ Castelein RM, Korte J. Limited hip abduction in the infant. J Pediatr Orthop. 2001;21:668-670.
  8. ↑ Graf R. Classification of hip joint dysplasia by means of sonography. Arch Orthop Trauma Surg. 1984;102:248-255.
  9. ↑ American College of Radiology (ACR) appropriateness criteria. Developmental dylsplasia of the hip-child. www.acr.org/Quality-Safety/Appropriateness-Criteria. Accessed March 21, 2014.
  10. ↑ 10.0 10.1 https://www.orthobullets.com/pediatrics/4118/developmental-dysplasia-of-the-hip-ddh
  11. ↑ Novacheck TF. Developmental dysplasia of the hip. Pediatr Clin North Am. 1996;43:829-848.
  12. ↑ Tiruveedhula M, Reading IC, Clarke NM. Failed Pavlik harness treatment for DDH as a risk factor for avascular necrosis [published online June 24, 2014]. J Pediatr Orthop. 2014 Jun 24
Created by:
John Kiel on 5 July 2019 08:51:17
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Last edited:
5 October 2022 13:10:32
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