Orthonotes
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Early detection with Barlow/Ortolani; ultrasound (Graf) guides treatment under 6 months. Pavlik harness is first‑line for reducible dislocation under ~6 months; avoid excessive extension/abduction to reduce AVN risk. Failed Pavlik → closed reduction and spica; if unstable/obstructed, open reduction with capsulorrhaphy and femoral shortening/derotation as needed. Residual acetabular dysplasia treated with pelvic osteotomies (Salter, Pemberton, Dega) based on age and pathology. Complications: AVN (Kalamchi‑MacEwen), redislocation, stiffness, femoral nerve palsy with Pavlik.
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Developmental dysplasia of the hip (DDH) encompasses a spectrum of hip pathology ranging from mild acetabular dysplasia to frank dislocation of the femoral head, all resulting from abnormal development of the acetabulum and proximal femur. The earlier the condition is detected and treated, the simpler and more effective the treatment — a fundamental principle that drives universal neonatal screening programmes. Untreated DDH leads to early hip osteoarthritis, pain, and significant functional disability.
| Test / Investigation | Technique | Positive Finding | Age / Context |
|---|---|---|---|
| Barlow test | Infant supine; hip at 90° flexion; adduct the hip while applying gentle posterior pressure along the femoral axis; feel for a `clunk` or `jerk` as the femoral head subluxes/dislocates posteriorly out of the acetabulum | A palpable `clunk` (not a `click`) = femoral head leaving the acetabulum = dislocatable hip (Barlow positive) | Neonates; tests for a reducible/dislocatable hip; becomes less reliable after 4–6 weeks (capsular laxity decreases; hip stiffens) |
| Ortolani test | Infant supine; hip at 90° flexion; abduct the hip while lifting the greater trochanter anteriorly; feel for a `clunk` as the posteriorly dislocated femoral head reduces back into the acetabulum | Palpable `clunk` = dislocated hip reducing = Ortolani positive (the hip was already dislocated before the test); high-pitched `click` without clunk = benign ligamentous click = does NOT indicate DDH | Neonates; tests for a dislocated reducible hip; becomes less reliable after 4–6 weeks; the clunk is a low-frequency palpable sensation, NOT an audible click |
| Hip abduction asymmetry | Assess hip abduction range with the infant supine, hips and knees flexed; limited abduction on one side (<45°) compared to the contralateral hip is abnormal | Asymmetric limited abduction = DDH suspect; in older infants and children (beyond 3 months) this becomes more important as Barlow/Ortolani become less reliable | Infants 2 months and older; walking children with limping |
| Galeazzi sign (Allis sign) | Infant supine; hips and knees at 90° flexion; feet flat on the table; observe the height of the knees — the knee on the dislocated side appears lower | Knee on the affected side lower (apparent limb shortening) = Galeazzi positive; in bilateral DDH, the sign may be symmetric and therefore missed — bilateral DDH is more commonly missed on clinical examination | Infants; children; also useful in unilateral cases at any age |
| Hip ultrasound (Graf classification) | Coronal ultrasound image of the hip; measures the alpha angle (bony acetabular roof inclination — normal >60°) and beta angle (fibrocartilaginous roof inclination); assesses femoral head coverage (percentage of femoral head covered by the bony acetabulum) | Graf Type I: normal (α >60°); Type IIa: immature (α 50–59°, physiological in infants <12 weeks); Type IIb: borderline dysplastic (α 50–59°, beyond 12 weeks — requires monitoring); Type IIc/D: critical zone; Type III/IV: dislocated hip; standard investigation for DDH 0–6 months of age | Preferred imaging under 6 months (before ossification of the femoral head); the femoral head is cartilaginous and not visible on plain X-ray; universal ultrasound in Germany; selective ultrasound in UK/USA (for high-risk groups: breech, family history, clinical instability) |
| AP pelvis plain X-ray | AP pelvis radiograph with the hips in neutral position; measure acetabular index (AI — normal <30° at 1 year, <25° at 2 years, <20° at adulthood), Shenton`s line continuity, lateral displacement of the femoral head | Acetabular index >30° at 1 year = dysplasia; disrupted Shenton`s line = subluxation/dislocation; `Hilgenreiner`s line` (horizontal through triradiate cartilages) + `Perkin`s line` (vertical through lateral acetabular margin) divide the hip into quadrants — normal femoral head ossification centre should be in the inferomedial quadrant | From 4–6 months onwards (once the ossification centre appears — usually by 4–6 months); standard follow-up imaging; the standard investigation beyond 6 months of age |
| Age at Diagnosis | First-Line Management | Second-Line / Escalation | Notes |
|---|---|---|---|
| Birth – 6 weeks | Pavlik harness (for dislocatable/dislocated hips with positive Barlow/Ortolani); double nappy only for borderline ultrasound (Graf IIa) — most resolve spontaneously; Graf IIb beyond 12 weeks → Pavlik harness | Rigid abduction splint (for Pavlik failure — see below) | Unstable hips detected at birth or neonatal check; Barlow/Ortolani positive = start Pavlik harness promptly; most unstable hips resolve within 2–4 weeks of harness |
| Birth – 6 months | Pavlik harness — maintains hip in approximately 100° of flexion and 60° of abduction (the `human position`); worn full-time initially; success confirmed by reduction on ultrasound at 2–3 weeks | If not reduced after 3 weeks → STOP Pavlik harness; prolonged use of an ineffective harness risks Pavlik harness disease (inferior dislocation + erosion of the posterior acetabulum — avascular necrosis risk); refer for closed reduction + arthrogram + spica cast | Overall Pavlik success rate ~85–90% for dislocatable hips; lower for true dislocations (~60–70%); stop if no reduction at 3 weeks to avoid Pavlik harness disease |
| 6 weeks – 6 months | Pavlik harness (if Ortolani/Barlow positive or ultrasound Graf IIb+); harness still effective in this age group | Closed reduction + arthrogram + hip spica cast under GA if Pavlik fails | Late-presenting DDH in this age group detected on selective ultrasound (high-risk groups) or clinical examination |
| 6 months – 18 months | Closed reduction under general anaesthesia + arthrogram (to confirm concentric reduction); hip spica cast (1.5–2 spica) for 3 months; confirm reduction with MRI or CT (not X-ray — femoral head cartilaginous); preliminary traction for 2–3 weeks may improve reduction success and reduce AVN risk | Open reduction (medial or anterior approach) if closed reduction fails or if arthrogram shows inadequate reduction (medial dye pool >5 mm); acetabular dysplasia requiring Salter osteotomy after age 18 months | Safe zone (Ramsey): the range of hip positions in the spica cast where the reduction is maintained without excessive force or AVN risk; cast in 30–45° of abduction; excessive abduction (>55–60°) = increased AVN risk |
| 18 months – 3 years | Open reduction (anterior approach — Smith-Petersen or modified Bikini incision) + capsulorrhaphy + Salter innominate osteotomy (if acetabular dysplasia present) + femoral shortening (if femoral head cannot reduce without undue tension); hip spica cast post-operatively | Femoral shortening/derotation osteotomy required in most cases over 18 months to decompress the reduction and reduce AVN risk; Pemberton acetabuloplasty as alternative to Salter for younger age | The most common age group for open reduction in the UK; missed diagnosis is common in this group; bilateral DDH may not be detected until the child begins walking (wide-based waddling gait, hyperlordosis) |
| 3 years – 8 years | Open reduction + femoral shortening/derotation osteotomy + pelvic osteotomy (Salter or Pemberton for younger; Dega osteotomy for more severe dysplasia; Tönnis triple osteotomy for older children >8 years with an open triradiate cartilage); hip spica post-operatively | Outcomes progressively less good with older age at treatment; risk of residual dysplasia and early OA increases; most surgeons still pursue reduction up to 8 years (open triradiate) for bilateral cases; unilateral cases in older children may accept one normal hip rather than risk AVN | Complex multi-stage surgery; higher AVN risk; requires specialist paediatric orthopaedic hip centre |
| Adolescent / adult | Periacetabular osteotomy (PAO — Ganz/Bernese) for symptomatic residual acetabular dysplasia with preserved cartilage; total hip arthroplasty for established end-stage OA; redirectional femoral osteotomy for residual femoral deformity | PAO is the gold standard for acetabular dysplasia in the young adult; redirects the entire acetabular fragment to improve coverage; requires intact or near-intact cartilage; delays or prevents THA | Late-presenting DDH is a common cause of early hip OA in young adults; femoro-acetabular impingement (FAI) is also a complication of under-treated DDH |
| Osteotomy | Principle | Age / Indication | Key Feature |
|---|---|---|---|
| Salter innominate osteotomy | Complete horizontal cut through the ilium above the acetabulum; the distal fragment (containing the acetabulum) rotates anterolaterally using the symphysis pubis as a hinge; improves anterior and lateral coverage | 18 months – 6 years; open triradiate cartilage; mild-to-moderate dysplasia; concurrent with open reduction | Reduces acetabular volume (may not be suitable for a very large acetabular deficiency); requires graft (often from excised iliac crest during the osteotomy itself) |
| Pemberton acetabuloplasty | Incomplete osteotomy through the supra-acetabular ilium (does not cross the triradiate cartilage); the acetabular roof is `hinged` down anterolaterally on the triradiate cartilage; reduces acetabular volume and redirects the roof | 1.5–8 years; open triradiate cartilage; moderate-to-severe dysplasia with shallow acetabulum; used when a larger correction is needed than Salter provides | Increases acetabular depth (reduces volume); appropriate for a shallow wide acetabulum; uses the elastic triradiate cartilage as a hinge — requires open triradiate |
| Dega osteotomy | Incomplete transiliac osteotomy; the posterior column and sometimes the posterior triradiate are used as the hinge; allows mainly posterior and lateral coverage improvement | 2–12 years; open triradiate; dysplasia with specific posterior deficiency (e.g., in neuromuscular DDH — cerebral palsy); flexible correction direction | Particularly useful in neuromuscular cases (CP hip) where posterior coverage is the main deficiency; technically less demanding than Salter for this specific pattern |
| Steel triple innominate osteotomy | Three separate cuts — through the ilium, ischium, and pubis — to fully mobilise the acetabular fragment; allows more correction than Salter | 8–16 years; open or recently closed triradiate cartilage; moderate-to-severe dysplasia requiring more correction than single innominate | Bridges the paediatric (Salter/Pemberton) and adult (Ganz PAO) procedures; less accurate than PAO; useful transition option |
| Ganz periacetabular osteotomy (PAO / Bernese osteotomy) | Four cuts around the acetabulum (ilium, ischium two cuts, pubis) leaving the posterior column intact; the large acetabular fragment is reoriented (anteversion, abduction, flexion) under direct vision to optimise femoral head coverage; precise and versatile correction | >15 years; closed or nearly closed triradiate; symptomatic acetabular dysplasia with preserved cartilage; the gold standard for young adult dysplasia | The most powerful and versatile adult pelvic osteotomy; preserves posterior column (hip stability + blood supply); large mobilisable fragment allows multiplanar correction; delays THA in young patients; requires significant surgical experience |
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