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Developmental Dysplasia of the Hip

Introduction

The term DDH is an acronym for Developmental Dysplasia of the Hip. This is a condition of the child's hip which may come to light in the neonatal period or during infancy and rarely during childhood where there is a dysplasia of the acetabulum and either subluxation or dislocation of the hip or only mild acetabular dysplasia.This can be either unilateral or bilateral. (Reference Needed)

This condition is usually Idiopathic, associated to the presentaion of fetus, sex (female > male) ,oligohydraminos etc.. (Reference Needed)

It can also occur in Neuromuscular problems, Syndromic conditions where it is called Teratologic Dislocation of Hip. This condition differs from the Idiopathic problem in the anatomy, pathogenesis, natural history and treatment.  (Reference Needed)

Anatomy

  • Acetabulum
  • Labrum
  • False Acetabulum
  • Unique Pathological Structures
  • Head and Neck of Femur
  • Ossification delay in Epiphysis
  • Capsule
  • Intra and Peri-articular Soft Tissues

Pathogenesis

Natural History

Natural history of Persistent acetabular dysplasia

Natural history of a Subluxed hip - unilateral and bilaeral

Natural history of a Dislocated hip - unilateral and bilateral

Clinical Presentation

Age of presentation can vary from just after birth to early childhood.

After birth the condition is usually picked up during routine examination by the Neonatologist / Paediatric Orthopaedic Surgeon. If that is not apparent at the time of birth, it becomes evident in Infancy when the mother usually comes with complaint that the child thigh folds are asymmetric or that there is limb length difference. The Mother may also complain that it is difficult for her to abduct the thighs for diaper change. Asymmetry however may be missed if the problem is bilateral and a decreased abduction may be all the complaint for which the parent comes.

In a child of walking age the presentation varies. In a unilateral dislocation, the child walks with an obvious limp and short limb on the affected side. In a bilateral dislocation, the child has a pronounced waddle due to the unstable pelvis and abductor lever arm loss. There may not be any limb length discrepancy in bilateral cases. The child may walk with excessive lordosis of the lumbar spine due to tight hip flexors.

A mild dysplasia without subluxation may be missed in childhood and the child will have abnormal edge loading of the acetabulum. There children may present during early adulthood with symptoms related to hip arthritis. In cases of bilateral untreated DDH in which the hips are frankly dislocated the onset of pain is delayed and usually they only have persistent painless waddle. (Reference Needed)

Imaging & Diagnostic Studies

Ultrasound Examination

  • Static
  • Dynamic
  • Probe and Technical Specifics
  • Discussion on Graf Method and Indexes

X-ray

  • Indices during Neonatal, Infantile and adult hips.

Arthrogram

  • Procedure notes
  • Technique guide
  • Evidences of Dysplasia, Subluxation, Dislocation on Arthrogram

CT- Scan

  • Pre-op and Post-op assessment of a CT
  • Relevence of 3D CT

MRI

  • Utility of MRI

Classification

Idiopathic

Teratologic / Neromuscular

Treatment

Primary Treatment Options for Idiopathic DDH:

  • Pavlik Harness
  • Closed reduction & arthrogram, Hip Spica
  • Open reduction & Hip Spica
  • Open Reduction, Femur Osteotomy and Acetabular Surgery
  • Salvage Procedures

Options for Treated DDH with Complications:* Redisclocation

  • Persistent acetabular dysplasia
  • Avascular Necrosis
    Treatment by age groups:
  • 0 - 6 Months
  • 6 - 1 Year
  • 1 - 2 Years
  • > 2 Years
  • Young Child
  • Young Adult

Outcome

Complications

  1. Irreducible hip
  2. Redislocation
  3. AVN
  4. Persistent Subluxation
  5. Persistent Acetabular Dysplasia
  6. Painful hip in adulthood

Pearls and Pitfalls

Controversy

References

Related Topics

Useful Internet Resources

Content

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