1

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

4

Dislocated Pre- Pavlik

Post Pavlik Tx (6wks)Located

5

7-2015

10-2015

6 mos of age

Reduces in Pavlik,

Planned Open Reduction

Post Pavlik Tx

12mos of age

6

R hip

L hip

L hip 4wks of age

L hip 12wks of age, post Pavlik Tx

13 mos of age, No prev Tx

7

• 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

8

• Adductor tenotomy to widen the safe zone

• The safe zone assesses maximum ABD/ADD

Limited abduction

IN AT REST BUT DISLOCATABLE

9

Positioning

Avoid Tight Reductions

The Worst Outcome Is AVN

Birth

J. Schoenecker, MD

10

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

12

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

13

7 mos of age

b

c

14

J. Schoenecker, MD

Abduction >60

J. Schoenecker, MD

15

c

Abduction >60Abduction <60

7 mos of age

failed Pavlik18mos of age

subluxation post CR

Your Tx?

16

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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20

Take care w/lateral

capsulotomy & later w/

suture technique

Capsular closure

sutures are placed

very close to

lateral retinaculum

(& vessel) →

possible AVN

21

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?

26

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

1

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.

35

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

“Unchanging” Essentials in Treating DDH

• 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.

“Unchanging” Essentials in Treating DDH

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• Balance of coverage & congruency → minimize 2° FAI

Hip extension Hip flexion

Must assure >90º of hip flexion . .

If not ↓ correction

“Unchanging” Essentials in Treating DDH

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

42

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)

44

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

45

13mos

Post bilat

OR &

PFO

2y/o Pre-op

Your Tx? . . .

2yrs post

Open Red

I strongly recommend a pelvic ost.!