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DEVELOPMENTAL DYSPLASIA of

the HIP

Dr. Syafruddin, Sp. B

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CDH  DDH Klisic (1989)

Definition :
DDH : generic term describing a spectrum of
anatomic abnormalities of the hip, that may
be congenital or develop during infancy or
childhood
DDH : Unstable Hip :

1. Dislocated  Ortolani
test
2. Subluxated
Barlow test
3. Dislocatable
Incidence

• USA : (1-2) per 1000 lives birth


• ♀:♂ : (6-7) : 1
• Left hip > right hip = 80%
• 1 in 5 cases : bilateral = 20%
• Prevalent in certain area
In New York : Caucasian = 15.5 per 1000
Black = 4.9 per 1000
Lapps & North American Indians : (25-50) per 1000
Screening Unstable hips at birth
• Barlow :
• 1 out 60 newborn infants
• 60% : spontaneous recover in 1st week
• 88% : recover in 1st two months
• Health Dept.in UK :
• Hip instability at birth :
• 20 per 1000 births
• 80% resolve without Tx
• 10% persist as subluxated or dysplastic hip
• 10% dislocated
Etiology

Multifactorial :
1. Mechanical factor
2. Physiologic factor
3. Postnatal environmental factor
Mechanical factor
a. Fetal movement restriction
– prevent limb folding
• In 1st borns (60%)
• Oligohydramnion
• Fetal pelvis is trapped in maternal pelvis
b. Breech presentation (30-50)%
– Knees are extended
• genu recurvatum
• genu dislocation
Breech born :
– DDH 10x Vertex (Dunn)
– associate deformity (Mercer)
• mandibular = 22%
• torticollis = 20%
• postural scoliosis = 42%
• DDH = 50%
• genu recurvatum =100%
• talipes = 22%

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Physiologic factor

• Maternal estrogen  temporary laxity of


capsule
• Estrogen metabolism error 
• DDH familial
• inherited 20%
• ethnic
Environmental factor

1st month infant after delivery


• hip in flexion & mild abduction (physiologic)
 extended :
– swaddled  DDH  10x greater
– upside down in extended limbs
Pathomechanics

• Estrogen  capsule (hip joint)


• Fall out easily : reduced by Ortolani test
• Head in the acetabulum is : maintained 
normal hip
• If dislocation persist :
– soft tissue, bone will change
– difficult to reduce
• Muscles, acetabulum, head will change
Recognition and Diagnosis

1. in Newborn & infant


2. in Older child
Condition raising suspicion of DDH :
– breech
– female
– first born
– family history
– talipes
– torticollis
– other congenital anomalies (heart, kidney), any
syndrome.
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Newborn and Infant
The exam of the hip should conclude
• Normal
• Subluxatable
• Dislocatable – Barlow positive
• Dislocated :
a. reducable : Ortolani test position
b. not reducable : teratologic dislocation
Why is newborn DDH so often missed?

• crying baby
• tense baby
• hungry baby
• hurried doctor
• inexperienced doctor (tests)
• too firm in grip
Older child
The signs of DDH change with the infant’s age
Inspection :
• Skin fold
• Galeazzi’s sign
• Telescoping
• Trendelenburg’s test
• Trendelenburg gait
• Bilateral DDH :
– perineum widen
– hiperlordotic
– waddling gait
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Diagnostic Imaging

Radiology
• In newborn : seldom reliable (cartilaginous)
• Reliable at the age 6 weeks
Arthography
• By indication :
– unsatisfactory reduction
– hip redislocation
Ultrasonography (USG)
• Valuable under age 4 months (ossification of nucleus)
• Dynamic study of DDH (similar to Ortolani/Barlow)
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Treatment

Goal
• Reduce the head to normal position
• Maintained until stable
• Avoid avascular necrosis of the head
• Correction of residual dysplasia
Delay in diagnostic and problems in management
• Residual anatomic defect
• Subsequent degenerative arthritis
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Treatment
Hip instability in neonatal period

Barlow
• 60% : spontaneous recovery in the first week
• 88% : spontaneous recovery in the first 2 months
Soon after Dx was made : Tx by :
• triple diapers
• Frejka pillow
• Pavlic harness (the best)
“Pekeh” yes
“Bodong” no
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Reduction

Method of reduction depends on :


• Age of the infant
• Severety of DDH
A. Infant age (0-6) MO
– Hip instability or established dislocations
– Actively Tx until the hip clinically & radiologically normal
– initial Tx: brace (Pavlic harness the best)
B. Infant age (6-18) MO
– starts nonooperatively
– skin traction
– manipulation (anaesthesia) + adductor tenotomy
– spica cast in safezone position
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Reduction

C. Children age (18-36) MO


– Start by traction
– Open reduction :
• soft tissue release
• pelvic osteotomy (acetabular dysplasia)
• cast
D. Children age >36 MO
– open reduction
– + femoral shortening,
– + derotation osteotomy
– + pelvic osteotomy
• Treatment scheme for DDH
Developmental Dysplasia of the Hip

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Thank you for your attention

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