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Developmental Dysplasia of the Hip

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(Redirected from Hip Dysplasia)

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

  • First described by Hippocrates in 400 BCE[1]
  • Illustrations in scientic literature date back to Ambrroise Pare and William Adams in the 15th and 18th century respectively
  • A widely cited case series was published by Putti in 1933[2]

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[3]
  • 8 fold more common in females than males[4]
    • 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

Indices used to assess developmental dysplasia of the hip (DDH) on plain radiographs. The centre edge angle (CEA) is the angle from the lateral wall of the acetabulum to the centre of the femoral head relative to the vertical. The acetabular index (AI) is the angle between Hilgenreiner’s line and a line drawn from the triradiate cartilage to the lateral edge of the acetabulum. The centre head distance discrepancy (CHDD) is the percentage difference between D and d[5]
Radiograph showing a dislocation of the left hip

General

  • Dysplasia of the hip (DDH) which represents abnormal development of the hip resulting in dysplasia, subluxation, and possible dislocation

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[6]
    • 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

Anatomy of the Hip Joint

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[7]
    • Use of swaddling, cradle boards
  • Neurological
  • Other
    • Family history of DDH[8]
    • Susceptible genes: GDF5, TBX4, ASPN, IL-6, TGF-β1, and PAPPA2[9]

Differential Diagnosis

Differential Diagnosis Hip Pain

Clinical Features

Illustration of the barlow and ortolani tests
Illustration of Klisic Test

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%)[10]

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

Reference lines and angles used to evaluate in DDH[11]
The acetabular angle is a plain film measurement used when evaluating developmental dysplasia of the hip (DDH) which is measured between Hilgenreiner's line and a line parallel to the acetabular roof. At birth it should be less than 28 degrees, and should progressively reduce with maturation of the hip.[12]
Pelvic radiographs at 1 and 3 years show progressive dyplastic left hip with dislocation associated with a neuromuscular disorder[13]
Frontal pelvic xray demonstrates lateral subluxation of the left hip. The acetabulum has a sloping roof and is shallow. Asymmetry of the femoral head, particularly the medial portion of the head with flattening. Associated widening of the femoral metaphysis.[14]

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[15])
    • 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[16])
    • 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
  • Hilgenreiners Line
    • Line drawn horizontally through the superior aspect of both triradiate cartilages.
    • Normal: It should be horizontal.
  • Perkins 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.
  • Shentons 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[17]
    • 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[17]
  • Dislocatable: Barlow-positive
  • Dislocated: Ortolani-positive early when reducible; Ortolani-negative late when irreducible

Management

Pavlik Harnesss[18]
Treatment algorithm for DDH according to age[11]
Treatment algorithm for residual AD[11]

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[19]

6 months to 2 years

  • Procedure: Closed reduction under general anesthesia
  • Possible arthrogram in operating room
  • Application of Hip 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 Hip Spica Cast which remains on for 6-12 weeks

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Not applicable

Prognosis and Complications

Prognosis

  • General
    • Depends on age of diagnosis, severity of dysplasia, timeliness of intervention
  • Mild cases
    • Detected early by exam or ultrasound, often resolve spontaneously
    • Up to 90% resolve spontaneously in early infancy without intervention[20]
  • Before 3 months of age
    • Treatment with a removable hip brace is effect in about 90% of cases with excellent long term outcomes[21]
  • Delayed Diagnosis after 4-6 months
    • Often necessities surgical intervention with associated increased risk of complications
  • Late diagnosis/ inadequate treatment
    • Leading cause of early hip osteoarthritis[22]
    • May account for up to 10% of all hip replacements, 1/3 of those in individuals under 60
  • Long term follow up study by Wong et al[23]
    • 83% of hips treated with closed reduction achieve good radiographic outcomes at skeletal maturity
    • Older age at reduction, high acetabular index predict poor prognosis

Complications

See Also

Internal

External

References

  1. ↑ Price, Charles T., and Brandon A. Ramo. "Prevention of hip dysplasia in children and adults." Orthopedic Clinics of North America 43.3 (2012): 269-279.
  2. ↑ Putti, Vittorio. "Early treatment of congenital dislocation of the hip." JBJS 11.4 (1929): 798-809.
  3. ↑ 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.
  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. ↑ Feeley, I. H., et al. "International variance in the treatment of developmental dysplasia of the hip." Journal of children's orthopaedics 8.5 (2014): 381-386.
  6. ↑ Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Pediatrics. 2000;105:E57.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ Shi D, Dai J, Ikegawa S, Jiang Q. Genetic study on developmental dysplasia of the hip. Eur J Clin Invest. 2012;42:1121-1125.
  10. ↑ Castelein RM, Korte J. Limited hip abduction in the infant. J Pediatr Orthop. 2001;21:668-670.
  11. ↑ 11.0 11.1 11.2 Bakarman, Khaled, et al. "Developmental dysplasia of the hip (DDH): etiology, diagnosis, and management." Cureus 15.8 (2023).
  12. ↑ Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 2714
  13. ↑ Image courtesy of radiologyassistant.nl
  14. ↑ Case courtesy of Bahman Rasuli, Radiopaedia.org, rID: 161483
  15. ↑ Graf R. Classification of hip joint dysplasia by means of sonography. Arch Orthop Trauma Surg. 1984;102:248-255.
  16. ↑ American College of Radiology (ACR) appropriateness criteria. Developmental dylsplasia of the hip-child. www.acr.org/Quality-Safety/Appropriateness-Criteria. Accessed March 21, 2014.
  17. ↑ 17.0 17.1 https://www.orthobullets.com/pediatrics/4118/developmental-dysplasia-of-the-hip-ddh
  18. ↑ Ucpunar, Hanifi, et al. "Effect of the Pavlik harness used in the treatment of developmental dysplasia of the hip on unaided sitting and independent walking age." Journal of Children's Orthopaedics 18.1 (2024): 79-84.
  19. ↑ Novacheck TF. Developmental dysplasia of the hip. Pediatr Clin North Am. 1996;43:829-848.
  20. ↑ Mulpuri, Kishore, et al. "Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 23.3 (2015): 202-205.
  21. ↑ Singh, Abhinav, et al. "Does this infant have a dislocated hip?: The rational clinical examination systematic review." JAMA 331.18 (2024): 1576-1585.
  22. ↑ Shaw, Brian A., et al. "Evaluation and referral for developmental dysplasia of the hip in infants." Pediatrics 138.6 (2016).
  23. ↑ Wong, Janus Siu Him, et al. "Prognosticating residual dysplasia at skeletal maturity following closed reduction for developmental dysplasia of the hip: a long-term study with an average 20-year follow-up." JBJS (2021): 10-2106.
  24. ↑ 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
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John Kiel on 5 July 2019 08:51:17
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