Courtesy Dr Kishore Mulpuri , Dr Ashok Shyam, Ortho TV

 

 

Developmental Dysplasia of the Hip (DDH)

Introduction

Developmental dysplasia of the hip (DDH) represents a spectrum of abnormalities involving abnormal development of the hip joint.

The spectrum ranges from:

• Mild acetabular dysplasia
• Hip instability
• Subluxation
• Complete dislocation

Early diagnosis and appropriate management are critical to achieving a stable, concentric hip and preventing long-term complications.

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Epidemiology and Risk Factors

Important Risk Factors

Major risk factors include:

• Breech presentation
• Positive family history
• Female sex
• First-born child

These patients require careful screening and follow-up.

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Pathophysiology

DDH occurs due to abnormal development of:

• The acetabulum
• The femoral head relationship

Persistent instability prevents normal remodeling of the hip joint and may lead to progressive dysplasia and dislocation.

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PART 1: Early Diagnosis and Management (Birth–6 Months)

Importance of Early Diagnosis

Early detection allows:

• Non-operative treatment
• Better remodeling potential
• Reduced risk of surgery
• Lower complication rates

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Clinical Screening

Barlow Test

The Barlow test evaluates whether the hip can be:

• Dislocated posteriorly

A positive test indicates:

• Hip instability

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Ortolani Test

The Ortolani test assesses whether a dislocated hip can be:

• Reduced into the acetabulum

A palpable “clunk” suggests a reducible dislocation.

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Imaging

Ultrasound

Ultrasound is the preferred imaging modality in early infancy.

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Timing

Best performed at:

• Approximately 6–8 weeks of age

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Graf Classification

Ultrasound assessment commonly uses:

• Graf classification

to evaluate acetabular morphology and hip stability.

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Plain Radiographs

X-rays become more useful after:

• 4–6 months of age

when femoral head ossification begins to appear.

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Management in Early Infancy

Observation

Observation may be appropriate for:

• Mild dysplasia
• Stable hips with improving imaging findings

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Pavlik Harness

Indications

Pavlik harness is the standard treatment for:

• Reducible hips
• Early instability

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Principle

The harness maintains the hips in:

• Flexion
• Abduction

while allowing motion and promoting concentric reduction.

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Important Complication

A known complication is:

• Femoral nerve palsy

which occurs in approximately 5–6% of cases.

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Key Clinical Principle

Management decisions should always correlate:

• Clinical examination
• Imaging findings

Neither should be interpreted in isolation.

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PART 2: Surgical Management (6 Months–3 Years)

General Principles

The primary goals of treatment are:

• Stable concentric reduction
• Preservation of femoral head vascularity
• Normal hip development
• Prevention of avascular necrosis (AVN)

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Closed Reduction

Indications

Closed reduction is commonly used in children:

• Approximately 6–15 months old

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Arthrogram

An arthrogram is typically performed to assess:

• Concentric reduction
• Obstacles to reduction

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Important Principle

The quality of reduction is one of the most important determinants of long-term outcome.

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Open Reduction

Indications

Open reduction is indicated for:

• Failed closed reduction
• Irreducible hips
• Severe dislocation

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Medial Approach

Advantages

• Minimally invasive
• Direct access to obstructing structures

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Limitations

• Limited ability to perform corrective osteotomies

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Anterior Approach

Advantages

Provides:

• Wide exposure
• Ability to perform pelvic osteotomy simultaneously

Often preferred in older children.

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Pelvic Osteotomy

Indications

Pelvic osteotomy is used for:

• Residual acetabular dysplasia
• Inadequate acetabular coverage

It becomes increasingly necessary after:

• Approximately 18 months of age

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Femoral Osteotomy

Femoral Shortening

Femoral shortening helps:

• Reduce tension during reduction
• Lower risk of AVN

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Derotation Osteotomy

Performed to correct:

• Excessive femoral anteversion

and improve hip stability.

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Revision Surgery

Important Considerations

Revision procedures should be avoided whenever possible because they carry:

• Higher complication rates
• Increased stiffness
• Greater AVN risk

Careful primary treatment is essential.

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Complications

Potential complications include:

• Avascular necrosis (AVN)
• Residual dysplasia
• Redislocation
• Stiffness
• Limb length discrepancy
• Gait abnormalities

Long-term follow-up is important.

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Residual Dysplasia

Residual acetabular dysplasia is one of the most important determinants of:

• Long-term hip function
• Future degenerative arthritis

Continued surveillance during growth is essential.

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Key Clinical Pearls

• DDH represents a spectrum from dysplasia to dislocation.
• Early diagnosis significantly improves outcomes.
• Barlow and Ortolani tests are essential neonatal screening tools.
• Ultrasound is the preferred imaging modality in infants.
• Pavlik harness is effective for reducible hips.
• Quality of reduction is more important than the specific surgical technique.
• Forceful reductions increase the risk of AVN.
• Residual dysplasia strongly influences long-term outcome.

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Final Take-Home Message

Developmental dysplasia of the hip is a common pediatric hip disorder requiring early recognition and careful management.

Treatment depends on:

• Patient age
• Hip stability
• Severity of dysplasia

The ultimate goal is to achieve and maintain:

• Stable concentric reduction

while minimizing complications such as avascular necrosis and residual dysplasia.

Long-term follow-up is essential to ensure normal hip development and prevent early degenerative arthritis.