eMedicine Specialties > Orthopedic Surgery > Hip

Developmental Dysplasia of the Hip: Treatment

Author: James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;
Contributor Information and Disclosures

Updated: Sep 23, 2009

Treatment

Medical Therapy

The treatment of hip dysplasia begins with a careful examination of the newborn. If evidence of instability is present, a Pavlik harness should be considered and, if used, fitted appropriately.44,45,46,47 The Pavlik harness should be placed such that the chest strap is at the nipple line, with 2 fingerbreadths of space between the chest and strap. The anterior strap is at the midaxillary line and should be set such that the hips are flexed to 100-110º. Excessive hip flexion can lead to femoral nerve compression and inferior dislocations. Quadriceps function should be determined at all clinic visits.

The posterior abduction strap should be at the level of the child's scapula and adjusted to allow for comfortable abduction. This should prevent the hips from adducting to the extent that the hips dislocate. Excessive abduction should be avoided because of concern regarding the development of avascular necrosis. The fitting of the harness should then be checked clinically within the first week and then weekly thereafter. Carefully monitoring the patient to ensure the harness fits and the hips are reduced is important.

Ultrasonography is an excellent means of documenting the reduction of the hip in the Pavlik harness and should be performed early in the course of treatment.48 If the hip is posteriorly subluxed, then the Pavlik harness therapy should be discontinued. Using the Pavlik harness for guided reduction, which occurs when the hip does not completely reduce initially but is pointed toward the triradiate cartilage, is controversial.

When the harness is used for guided reduction, the physician should obtain a radiograph after the Pavlik harness is placed to determine if the femoral heads are pointing toward the triradiate cartilage. An ultrasonogram should be obtained to determine the success, or lack thereof, of the guided reduction.

The overall duration of Pavlik harness therapy has not been universally agreed upon.49,50 If the hip is reduced satisfactorily in the harness, then the author maintains this treatment at least until the hip is stable clinically and based on ultrasound findings with the patient out of the brace. Abduction splinting is maintained thereafter if radiographic evidence of residual dysplasia is present. The use of an abduction brace after a failure of the Pavlik harness has been suggested. In one study, 13 of 15 patients were treated successfully in this manner, and the remaining 2 patients had a successful closed reduction.51

When the patient is older than 6 months, the success rate with a Pavlik harness is less than 50%; therefore, this therapy should not be used in patients older than 6 months.52 If the child is diagnosed when older than 6 months or if the Pavlik harness is determined to be unsuccessful, a closed reduction is attempted. Often, traction is performed for a 2- to 3-week period before closed reduction is attempted. Traction (usually skin traction) can be performed either at home or in the hospital. This must be monitored carefully to ensure the integrity of the skin. The overall benefit of traction is quite controversial, although most pediatric orthopedic surgeons do use skin traction.53,54

Closed reduction is typically performed with the aid of arthrography, which is used to determine the adequacy of the reduction. A medial dye pool and an interposing limbus are both associated with a poor prognosis. If, on the other hand, a sharp or even a blunted limbus and no medial dye pooling are present, the prognosis is good.55 Also, the safe zone of Ramsey, which is the angle between the maximum abduction and minimum abduction in which the hip remains reduced, should be at least 25º and can be increased with release of the adductor longus.

The cone of stability—a cone that involves hip flexion, abduction, and internal and/or external rotation—has also been defined. If this cone measures greater than 30º, it is considered satisfactory.55 A spica cast is placed, with care taken in molding over the posterior aspect of the greater trochanter of the ipsilateral limb. After this is performed, a CT scan is then obtained to ensure that no evidence of posterior subluxation is present. The cast is typically worn for 6-12 weeks, at which time the hip is reexamined, and, if found to be stable, the patient is placed in an abduction brace. If the hip remains unstable, the patient is again placed in a spica cast.

Surgical Therapy

Open reduction is the treatment of choice for children older than 2 years at the time of the initial diagnosis or for children in whom attempts at closed reduction have failed. In children with teratologic hips, with failure at a much younger age, open reduction can be performed through a medial approach. The medial approach has a number of advantages, as follows:

  • Both hips can be reduced at the same time (in a patient with bilateral DDH).
  • The obstacles to reduction (eg, psoas tendon) are easily identified.
  • The adductor longus can be sectioned through the same incision.
  • The hip abductor muscles are not at risk for injury, and, therefore, residual weakness is unlikely to occur.
  • The iliac apophysis is not at risk for injury.
  • The incision has a very good cosmetic result.

Problems with this approach include the following:

  • The possibility of increased avascular necrosis
  • The potential lack of familiarity of surgeons with this approach
  • The inability to perform capsular placation or a pelvic procedure through this incision.

With the use of a medial approach, the cast plays a much more important role.

Most often, especially in older children, the standard anterolateral or Smith-Petersen approach is used. This can be combined with a capsule placation, if needed, and/or an acetabular procedure. In a child older than 3 years, femoral shortening is typically performed instead of traction (see Image 3).56 At that time, if proximal femoral dysplasia is present, such as that observed with significant anteversion or coxa valga, this can also be corrected. However, whether traction or femoral shortening should be performed in children aged 2-3 years is controversial.

Radiographs from a 6-year-old child who underwent...

Radiographs from a 6-year-old child who underwent open reduction with capsular placation, femoral shortening, and a pelvic (Pemberton) osteotomy.

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Radiographs from a 6-year-old child who underwent...

Radiographs from a 6-year-old child who underwent open reduction with capsular placation, femoral shortening, and a pelvic (Pemberton) osteotomy.


Pelvic osteotomy may be needed for residual hip dysplasia.26,57,58,59 When this should be performed is, again, somewhat controversial. Some authors suggest pelvic osteotomy in children as young as 18-24 months, whereas others suggest waiting until the children are aged at least 4 years. If open reduction is performed in a child older than 4 years with significant hip dysplasia, an acetabular procedure should be considered at the time of open reduction. If a closed reduction is performed earlier, at least 12-18 months of acetabular remodeling should be allowed before an acetabular procedure is undertaken. At that time, if no evidence of acetabular modeling is noted, a pelvic osteotomy should be considered.

Postoperative Details

When open reduction is performed, the patient wears a spica cast for 6 weeks; then, the patient is placed in an abduction orthosis.

Follow-up

The duration that a child remains in a hip orthosis is quite controversial and depends on the treating physician's experience and the individual patient.

Complications

Numerous possible complications can occur, including redislocation, stiffness of the hip, infection, blood loss, and, possibly the most devastating, necrosis of the femoral head. The rate of femoral head necrosis varies significantly; depending on the study, the rate ranges from 0% to 73%.60 Numerous studies demonstrate that extreme abduction, especially combined with extension and internal rotation, results in a higher rate of avascular necrosis.61,62,63

More on Developmental Dysplasia of the Hip

Overview: Developmental Dysplasia of the Hip
Workup: Developmental Dysplasia of the Hip
Treatment: Developmental Dysplasia of the Hip
Follow-up: Developmental Dysplasia of the Hip
Multimedia: Developmental Dysplasia of the Hip
References
Further Reading
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Further Reading

Related eMedicine topics

 Developmental Dysplasia of the Hip (Radiology)

Fracture, Hip (Emergency Medicine)

Dislocation, Hip (Emergency Medicine)

Hip Dislocation (Sports Medicine)

Hip Fracture (Sports Medicine)


Clinical guidelines
Screening for developmental dysplasia of the hip: recommendation statement. United States Preventive Services Task Force - Independent Expert Panel. 2006. 10 pages. NGC:004705

ACR Appropriateness Criteria® developmental dysplasia of the hip - child. American College of Radiology - Medical Specialty Society. 1999 (revised 2007). 7 pages. NGC:007008

Clinical studies

 Treatment for Mild Hip Dysplasia in Newborns

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Keywords

developmental dysplasia of the hip, DDH, developmental dislocation of the hip, congenital dislocation of the hip, CDH, hip dysplasia, hip subluxation, hip dislocation, teratologic hip dislocation, hip instability, displaced hip, dislocated hip, cerebral palsy, myelomeningocele, arthrogryposis, Larsen syndrome, proximal femoral focal deficiency, Charcot-Marie-Tooth disease, Ortolani maneuver, Galeazzi sign

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Contributor Information and Disclosures

Author

James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;
James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

Medical Editor

B Sonny Bal, MD, Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine
B Sonny Bal, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

B Sonny Bal, MD, Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine
B Sonny Bal, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

William L Jaffe, MD, Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases
William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, Eastern Orthopaedic Association, and New York Academy of Medicine
Disclosure: Stryker Orthopaedics Consulting fee Speaking and teaching

 
 
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