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7. Developmental Dysplasia of the Hip (DDH)

Developmental Dysplasia of the Hip (DDH)

What is DDH?
Developmental Hip Dysplasia is the term used to describe the varying degree of abnormal function of the hip joint.  This can occur in the utero and also can develop during infancy and childhood.  The hip joint is abnormal because the ball is not held firmly into the socket.

Who is affected?
One in 1000 live births are affected.  It runs in families.  It can be in one or both hips. The left hip is mostly affected.  High risk factors include being female, first born or breech position at birth.

When is the baby screened for DDH?
Babies are screen at birth and at well baby check ups by the Pediatrician. If the Pediatrician has concerns, he/she should refer the baby and parents to an orthopedic surgeon.

What if DDH is left untreated?
If DDH is left untreated, it can lead to pain and osteoarthritis in early adulthood.

What are the risk factors for developmental hip dysplasia?

• First born
• Family history of developmental hip dysplasia
• Positioning of the baby in uterus, especially breech position
• Having other orthopedic problems

What are the symptoms?

• The leg may appear shorter on the side of the dislocated hip
• The leg on the side of the dislocated hip may turn outward
• The folds in the skin of the thigh or buttocks may appear uneven
• The space between the legs may look wider than normal

Common Terms:
Congenital/Development Hip Dysplasia: abnormal hip development (involving the acetabulum, prox femur and adjacent soft tissues)
Subluxation: partial loss of contact between articular surfaces of femoral head and acetabulum
Dislocation: complete loss of contact between articular surfaces
Instability:  subluxable or dislocatable with passive manipulation (newborn); instability also occurs very subtly (later in life) 2 degrees to residual dysplasia.

Mechanical Factors:
Primiparous uterus tighter and can effect greater molding malformation; 1st born account for 50-60% of patients with DDH.

How is DDH Monitored?
Physical exam by an orthopedic surgeon.  They are looking for Ortoloni (limited abduction which is not seen until 3-4 months), Galeazzi sign, Trendelenburg sign (opposite side of pelvis dips during one legged stance).

What type is imaging is used?
Ultrasound:  most useful image study to confirm anatomy and stability up to 4 months of age
X-ray:  not accurate until patient is gestationally four months of age
Arthrogram:  dynamic study to assess quality of closd reduction
CT:  Used to assess a closd reduction; also define anatomy in older patients
MRI:  maybe used to reduce radiation to patient

Treatment Group by age:
Birth to 6 months:
Pavlik Harness

• Ensure proper alignment of harness
• Harness may be hand washed and either air dried or with a hair dryer
• Releasing harness to decrease risk of AVN (Avascular Necrosis of the femoral head) at least once a day to allow patient to "kick"
• Proper fit
  • Comfortable infrant
  • Chest strap below nipple line
  • Anterior straps hold hips in position
  • Posterior strap loose!
  • Hips and knees flexed to 90 degrees

IL Felt Brace
Used for children after the Pavlik harnes. This is when the child becomes to big or the Pavlik can no loner assist in the hips going to the right position.

Closed Reduction of the Hip
Patient is taken to the operatin groom for a closd reduction of the hip. The patient is put to sleep with the help of the anesthesia team. The patient does have x-rays in the room. 

Patient is placed into a SPICA cast.  They are in this cast for approximately 4-6 weeks initially.  The cast is changed at increments in the operating room.  The total cast time varies for each patient. The total cast time can last up to 3 months.  The patient is then transitioned into a brace.  The brace wear time is different for each child.  Occasionally, an arthrogram is performed. This is when the dye is injected into the hip to view the location of the closed reduction. This is often done in conjunction of a CT or MRI. 

Car seat Options with the Cast:  We always try your carseat from home first. Sometimes we have luck!  If not, we have a few loaner seats available.

6-18 months:
Diagnosis:

• x-ray of pelvis
• clinical exam per orthopedic surgeon
• listening to family

Treatment

* Closed reduction

* Open Reduction

* SPICA cast  

18-30 months:
Diagnosis

• AP x-ray of Pelvis
• Clinical Exam per orthopedic Surgeon

Treatment

*****Operative management is usually required

            Open reduction

Pemberton osteotomy

30 + months
Diagnosis

• x-ray of pelvis
• clinical exam per orthopedic surgeon

Treatment

• Operative Management