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Developmental Dysplasia of the Hip

DDH xray

DDH xray landmarks

DDH ultrasound picture

synonyms: DDH, congenital hip dislocation



  • 754
  • 754.30 unilateral dislocation
  • 754.31 bilateral dislocation
  • 754.32 unilateral subluxation
  • 754.33 bilateral subluxation
  • 754.35 dislocation of one hip, subluxation of the other

DDH Etiology / Epidemiology / Natural History

  • 1/1000 live births, left hip most common
  • More common in children of central European, Native Americans, Laplanders, and native Alaskan descents.
  • Etiology: multifactorial, genetic, intruterine mechanical environment,
  • Risk of DDH without family history = 0.2%
  • Risk of  DDH with a parent with DDH = 12%. First-born children are affected twice as often as subsequent siblings. Female infants have histest risk of DDH (@800% of affected infants are female).

DDH Risk factors (five f's)

  1. first born
  2. female
  3. family history
  4. feet( breech position)
  5. fluid(oligohydramnios)

DDH Anatomy

DDH Clinical Evaluation

  • Ortolani=out-reduces
  • Barlow=in-dislocates
  • Asymmetric gluteal folds
  • Galeazzi sign: apparent femoral length idscrepancy when the legs are held together with the hips and knees flexed.
  • Decreased hip abduction
  • Amubulatory Patient: flexion contracture, gluteus medius lurch, toe walking, increased lordosis if bilateral

DDH Xray / Diagnositc Tests

  • U/S=gold standard <4months, want Graf(alpha) angle >55 degrees, 50% or more head coverage. (Harcke HT, JBJS 1991;73A:622).
  • Patients will likely have severe arthritis if at maturity the lateral center edge angle is <16 degrees and the femoral head is uncovered >1/3.

DDH Classification / Treatment

  • Initial treatment for infants =Pavlic harness with weekly U/S f/u until hip is reduced.  Pavlic holds hip in flexion(100°) and abduction(limit adduction to neutral).If unreduced in 3-4wks>CR,arthrogram,spica+/-traction,+/-adductor tenotomy.  Post-op CT.  Cast changes Q6wks follow by night splinting vs Rhino brace
  • OR=fails CR, or >18months at presentation.  Generally ant approach.  Femoral shortening necessary if >24months.
  • acetabular index should be 22 degrees at 22 months
  • medial approach=can not do capsulorhaphy, higher risk of AVN(25%), <1y/o.  Invterval between pectineus and iliopsoas or between adductor brevis and magnus.  Risks=medial femoral circumflex vessels
  • anteriorleateral approach(Smith-Peterson)=allows capsuloraphy, bikini incision
  • Irreducible hip dislocation, moderate dysplasia, moderate subluxation withou complete obliteration of the joint space, preop center-edge angle >10°: Chiari pelvic osteotomy (Ito H, JBJS 2004;86A:1439)..

DDH Associated Anomalies

  • Metatarsus adductus
  • Hyperextended knees / congential knee dislocation
  • Torticollus

DDH Complications

  • Pavlik harness complications=femoral nerve palsy, AVN, post acetab wear, medial knee instability, brachial plexus palsy
  • Osteonecrosis
  • Persistent Acetabular dysplasia

DDH Follow-up Care

  • Frequent follow-up with repeat ultrasound/CT indicated to ensure maintenance of reduction.

DDH Review References

  • Guille JT, JAAOS 2000;8:232
  • Vitale MG, JAAOS 2001;9:401
  • Weinstein SL, JBJS 1979;61A:119
  • Hayes RJ, ICL 2001;50:535
  • Nemeth BA, Narotam V. Developmental dysplasia of the hip. Pediatr Rev. 2012 Dec;33(12):553-61. doi: 10.1542/pir.33-12-553. Review.
  • Lee CB, Mata-Fink A, Millis MB, Kim YJ. Demographic differences in adolescent-diagnosed and adult-diagnosed acetabular dysplasia compared with infantile developmental dysplasia of the hip. J Pediatr Orthop. 2013 Mar;33(2):107-11
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