DDH New Developments and Timeless Classics

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Perry L. Schoenecker, MD St. Louis Shriners & St. Louis Children’s Hospitals; Washington University School of

Medicine, Department of Orthopaedic Surgery, St. Louis, Missouri, USA

DDH – New Developments and

Timeless Classics

The 59th Annual Edward T. Smith Orthopaedic Lectureship

Emerging Concepts in the Surgical Management of the Hip:

Deformity, Impingement and Fracture

DDH - - - Define Treatment Group

(by age)

Birth to 6 months? successful tx likely

w/splinting (Pavlik

harness)

Seven to 18/24 months? closed reduction possible

>18/24 months? open reduction preferred

DDH … Imaging Choice in 6wk old Infant?

Ultrasound –assess anatomy & stability up to 4-5 mos

old & monitor tx in Pavlik harness

2

Located

Ultrasound more sensitive than x-ray

Dislocated

Located

3

“…. maintaining the infant’s hip and knee in flexion,

abduction → reduction of the hip”

Pavlik Harness Tx

• Fit & check frequently

• Tx duration – until resolved on US

Hip Ultrasound

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Dislocated Pre- Pavlik

Post Pavlik Tx (6wks)Located

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7-2015

10-2015

6 mos of age

Reduces in Pavlik,

Planned Open Reduction

Post Pavlik Tx

12mos of age

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R hip

L hip

L hip 4wks of age

L hip 12wks of age, post Pavlik Tx

13 mos of age, No prev Tx

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• Postnatal (developmental): hip dysplasia noted much

later - - - - perhaps US screening would detect?

Presents at 20y/o

DDH - - - - Closed reduction

7 mos of age

failed Pavlik

Galeazzi sign

Limited abduction

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• Adductor tenotomy to widen the safe zone

• The safe zone assesses maximum ABD/ADD

Limited abduction

IN AT REST BUT DISLOCATABLE

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Positioning

Avoid Tight Reductions

The Worst Outcome Is AVN

Birth

J. Schoenecker, MD

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Birth

Metaphyseal

Vessels

Birth

Metaphyseal

Vessels

Avascular

Epiphysis

Birth

Metaphyseal

Vessels

Avascular

Epiphysis

Barrier to

Vascular

Anastomosis

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ChildSecondary

Ossification

Center

Child

Metaphyseal

Vessels

Secondary

Ossification

Center

Medial

Epiphyseal

Lateral

Epiphyseal

“Peri-physeal

Vessel”

• Reduction is confirmed by ?

Plain x-rays

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Spica cast/then Confirm w/Images

90º flex & <50º ABD

What other image check is helpful?

Spica cast/then Confirm w/Images

Dislocated posteriorly

(remove spica!)

CAT scan

Reduced

MRI now image of choice

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7 mos of age

b

c

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J. Schoenecker, MD

Abduction >60

J. Schoenecker, MD

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c

Abduction >60Abduction <60

7 mos of age

failed Pavlik18mos of age

subluxation post CR

Your Tx?

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18mos of age

subluxation post CR

A’gram → to assess if head

anatomically reduced

Capsule

Labrum

Proximal Femoral Ost.

18mos of age

subluxation post CR3 y/o, dysplasia resolved

Moseley, et alDeformed head

2+11“false acetabulum”

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•Anterior Iliofemoral approach

Tight psoas

• expose the capsule laterally, anteriorly &

medially critical!

Psoas

Tenotomy

Excise

Transverse

acetab. lig

Open capsule medially &

cut transverse ligament

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AC 3 y/o

walks w/ limp

AC 3 y/o

walks w/

limp

Doppler probe

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Take care w/lateral

capsulotomy & later w/

suture technique

Capsular closure

sutures are placed

very close to

lateral retinaculum

(& vessel) →

possible AVN

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20y/o

intermittent

L hip pain

• Osteotomy improves the stability achieved

w/ open reduction

• Not a substitute for a poorly performed

open reduction

Purpose of Osteotomy

What are the Upper Age Limits for Open Reduction?

Bilateral ≤6 y/o

6 y/o

B.T.

8 y/o

≤8 y/o

Unilateral

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Post Tx Follow-Up . . . How Long?

• Covered: Lat & Ant CE ≥25° <20% head uncovered

• Stable: Tonnis <10° & Shenton’s line intact

• Most Importantly → Optimally Congruent

- til normal hip noted . . . if not than indefinitely

FAILED PAVLIK

2mos

FAILED CLOSED

POST OPEN RED

2½y/o

2 yrs post OR

AI=33 AI=20

15 mo

6mo post

OR

Pelvic ost.?

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Relative Criteria for Observation

Progressive decrease in A-I& development of near normal

teardrop

Shenton’s line intact

Full ROM (abduction)

No limp

3 y/oAI=30° AI=15°

Tonnis D, 1987 Congenital dysplasia & dislocation of the hip in children & adults

Post reduction, acetabular

remodeling varies

Good acetabular response

3 y/o7y/o

observation only

13y/o16+7

Normal Hips

AI=30°

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Your Tx?

6y/o

5yrs post

CR

2½yrs

post CR

4mos

Relative Osteotomy Indicators(growing child)

• Min change in acetab index

6y/o

5yrs post

CR

31º

• Signs of instability:

limp, Trendelenberg

test or pain

• Shenton’s line persistently broken

Tonnis D, 1987 Congenital dysplasia & dislocation of the hip in children & adults

Post reduction, acetabular

remodeling varies

Poor acetabular response

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30º

Further observation was a bad idea

8y/o

6y/o

5yrs post

CR

31º

Any in acetabular depth is minimal after age

8 with hip dysplasia\subluxation

30º8y/o

16y/o

painful 13y/o

7+4

Post CR R & Open (Medial) L

Post PembertonPost PFO & Pemberton

Prognosis?

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8+11

14y/o

Recurrent valgus & acetab dys → subluxation

14y/o

8 y/o

Given Residual Acetabular Dysplasia . . .

• Select an age appropriate pelvic osteotomy

• Assure congruent reduction in a functional post

What is the “Correct” Ost.? . . . Must:

4 yrs old

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Assess Congruency in ABD/IR

8y/o ABD/IR

If the hip(s) do congruently reduce, then we can

redirect hyaline cartilage over hyaline cartilage

ABD/IR

Congruent Reduction into

Functional Acetabulum?

NO

Shelf

Chiari

YES

PFO

Salter

Pemberton

Dega

Triple

Ganz

8y/o

ABD/IR

+/-’s of Pelvic Osteotomies

Salter - - - - Limited correction

Pemberton - - - - Age restriction

Dega < 11-12 yrs

Ganz - - - - Preserves post. column,

lots of correction,

tech. more difficult

Triple - - - - More correction but

Innom. cuts thru post. column

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Complete vs. Incomplete:

Complete

(Salter)

Incomplete

(Pemberton/

Dega)

Complete (Salter) → less likely to over correct

3y/o 2 yrs

post CR

After

Salter Ost.

Incomplete (Pemberton, Dega) → Relatively easy to

over correct → restricts flexion, IR & abduction

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Dega Pemberton

Grudziak JS, Ward

WT. JBJS 83A:845-

854, 2001.

Pemberton P. JBJS 1965;

47A:65-86.

Dega Pemberton

S

S

D

D

P

P

C

C

4 yrs old

> 2 yrs . . . . most of deformity is acetabular

dysplasia . . . . 1st correct acetabular

deficiency, then +/- prox fem ost

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4 yrs old

Pemberton cut Opening ost.

4 yrs old Bone graft placed

>3 yrs & dysplastic/subluxated…Where is the Deformity?

8y/o

subluxated

7mos post

Pemb’s,

PFO’s

Reduces

congruently

→ acetab dysplasia & coxa

valga pelvic & fem ost.

2 yrs post

Pemb’s,

PFO’s

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5+4,

post tx

w/Pavlik

11y/o bilat

hip pain

Acetabulae are deficient

11y/o bilat

hip pain

Subluxated

dysplastic hip

11y/o

Don’t overcorrect . . . an “incomplete osteotomy”

AP False Profile

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Placing bone graft

Stabilizing bone graft

Hip

extension

Hip

flexion

Must assure >90º of hip flexion . .

If not ↓ correction

Now assess hip motion

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11y/o bilat

hip pain

8 mos post-op

pain resolved

Enough coverage?

3+6 bilat.

Dislocation

Bilat OR, PFO, Pemb

Enough coverage? Bilat AT, OR,

Pemb, PFO

6y/o

2 yrs post tx

10y/o

“lots” of coverage

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CS 17+9

↑↑pain 10°

5°

Surgical Tx → Must Address:

• Deficient lateral/anterior coverage

• Version

• Lateralization of joint center

• Acetabular (sourcil) slope

Ganz - - - - Preserves post. column,

lots of correction,

tech. more difficult

Triple - - - - More correction but

Innom. cuts thru post. column

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1- lateral tilt & adduction

2

2- medialization

3

3- anterior tilt Millis & Murphy. Periacetabular

Osteototmy. In: The Adult Hip 2nd Ed.,

vol I. 2007:795.

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18+6

16 mos

post-op

Ganz-PAO preferred

30° 26°

Hip Joint Center, typically

lateralized in acetabular dysplasia Assessed as distance between medial

fem head & ilio-ischial line

lateralized Normal

6-8mm

Clohisy, Schoenecker et. al. Iowa Orthop J 2004.

Ganz R, et. al. A new periacetabular osteotomy for the tx of hip dysplasia. Tech &

preliminary results. CORR 232, 1988:26-36.

Lateralized No Change Medialized

Hip Joint Center, as affected by PAO

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Ganz R, et al CORR 232, 1988

Should try to

Medialize

Pre-op R hip

Corrected w/

medialization

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“Unchanging” Essentials in Treating DDH

• Assure physiologic reduction of fem head w/in the true

acetabulum w/either Pavlik; closed reduction &/or open

reduction

Abduction >60

• Avoid circulatory embarrassment

− w/ closed reduction 2° to pressure

− w/open reduction direct injury


• Correct residual dysplasia w/ re-directional pelvic (&

femoral) osteotomies - - - - and assure satisfactory

residual hip motion

8y/o

subluxated

7mos post

Pemb’s,

PFO’s

→ acetab dysplasia & coxa

valga pelvic & fem ost.


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• Balance of coverage & congruency → minimize 2° FAI

Hip extension Hip flexion

Must assure >90º of hip flexion . .

If not ↓ correction


Residual Dysplasia - Tx Goals:

• Stable: Tonnis <10° & Shenton’s line intact

• & Most Importantly → Congruent w/Satis ROM

• Head Covered: Lat & Ant CE ≥25°...<20%head uncov

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13+10

Released for all sports

20y/o

↑↑ pain as Fed Ex driver

Pre

Now Can address noted problems of:

Impingement & Instability

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Pre Post PAOPost SHD

Pre-op

5 mos Post-op

Post

Pre

Major Correction of Problematic

Pathoanatomy Obtained

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15+9y/o ♂ ambulatory

diplegic w/↑↑hip pain/↓

function

Post-op: AT, PFO,

PAO, capsulorrhaphy,

ABD casting

Max ABD

Pre-op False Profile Post

Given Problematic Residual “Developmental” Hip

Dysplasia in the Skeletally Mature Patient

DDH 2° to acute

disease (LCP)

2° to NM

disease (CP)

Similar Outcome Goals of Surgical Tx

→ Congruency & stability w/ functional ROM

→ Optimal clinical outcome

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New Shriners

Hospital

St. Louis Shriners Hospital

St. Louis Children’s Hospital

Barnes-Jewish Hospital

• 16 consecutive hips (16 pts.)

• Av Age 21yrs (14-36)

• Mean Follow-up 32.6 mos (24-52)

Patient Population Study Group

• Study period 2006-2010 (30 other hips tx w/SDH

w/o PAO during this time)

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16 Hips Greater than 2 year

follow up post SHD / PAO

LCEA 11 32 21↑

ACEA 4 32 38↑

Tonnis angle 24 7 17↓

Pre Post Change

% Coverage 63% 93% 30%↑

Center (head)Trochanteric Distance

(CTD) -3 -1 2↓

HHS 62 87 25↑

Pre Post Change

Clinical Outcome

(hip pain & function in daily

living, best =100)

UCLA 8 9-10 no change (activity level, best =10)

2 failures: 2° to deep infection (1) & persistent pain (1)

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Enough coverage? Bilat AT, OR,

Pemb, PFO

6y/o

2 yrs post tx

10y/o

“lots” of coverage

13mos

Your

Tx?

• +/- Excise ligamentum teres,

transect transverse acetabular ligament

• Spica cast in 90° flexion, 45-50° ABD (12-18 wks)

Technique (by protocol)

• Transect adductor longus & dissect

between pectineus & brevis

• With hip reduced, iliopsoas

tenotomy, cruciate capsulotomy

Dislocated Reduced

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13mos

Post bilat

OR &

PFO

2y/o Pre-op

Your Tx? . . .

2yrs post

Open Red

I strongly recommend a pelvic ost.!

DDH New Developments and Timeless Classics

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