Developmental dysplasia of hip (DDH) is rare condition occurs in growing hip with structural abnormalities. Early finding and management provides the best possible result. Hip dysplasia into teens and later life may result in irregular gait, reduced the strength and generate many hip and knee disease. Developmental dysplasia should be treated soon after death. Different diagnostics test for Developmental dysplasia of hip were invented to treat with this condition. Radiography, ultrasonography and magnetic resonance imaging help to identify the dislocation. Surgical treatment usually consists of open reduction and hip reconstruction surgery. Review contains the current practicing for identifying the DDH and its treatment.
Keywords: Dysplasia; Children; Hip; Developmental dysplasia of the hip
Developmental dysplasia of the hip (DDH) describes entire range of deformities involving the growing hip including acetabulum, and dysplasia of the femoral head. During birth some children have a normal femoro acetabular relationship but later stage it generate dysplastic hip . Hip is unbalanced when the junction between the acetabulum and femoral get unstable and femoral head move up to some limit or enable to move . Inadequate contact between the acetabulum and articular surface of femoral head is called Subluxation of hip. Dislocation leads to various malformation like multiplex congentia, spinabifida, diastropic dwarfism etc. Some irregular muscle tension leads to inheritance of dysplasia of the hip . The classification developmental of dysplasia of the hip according to ultrasound system is termed Graf method which combines both alpha and beta angels in infant.
DDH etiology depends upon multiple factors. Various factors are responsible for inheritance of DDH is neuropediatric disorders with an abnormal muscle tension, including myelomeningocele, cerebral palsy and arthrogryposis and hereditary ligament laxity . Other than this breech presentation & postnatal positioning may also cause DDH in few cases. Female new-borns respond to relaxing hormones releasing from maternal placenta so they are more likely to develop hip displacement disorders [5-9]. Identical twins are more prone to development of hip dysplasia than fraternal twins. Presence of twins or multiple fetus causes intrauterine crowding which may disturb hip development
during fetal life. Methods of baby wrapping in extended position may lead to DDH more easily than the babies wrapped in abducted positions [10-13].
All new born should undergo a careful clinical examination especially those who are at risk of DDH. By using Ortolani test and Barlow maneuver routine screening of each hip should be done separately . For performing physical examination, a smooth, warm, comfortable surface is required in a calm environment and the child should be completely relaxed [15-18]. In new born infants, Hip instability was reported by Roserin 1879. After that, in 1910, a clinical test for hip instability was described by Le Damany and Saiget and this was emphasized by Ortolani in 1937 followed by the further tests to incite dislocation or subluxation was developed by Palmen and Barlow in 1961 and 1962.
In this test, place the baby in supine position with flexed hips at 90 degree. Index and long fingers of the examiner are kept laterally on the greater trochanter of the child and position the thumb medially near the groin crease . Stabilize the child’s pelvis by holding the contra lateral hip andusing opposite hand gently abducts the hip being tested by exerting an upward force simultaneously through the greater trochanter on lateral side. The perception of a palpable clunk indicates positive Ortolani test and along with this also represents the reduction of a dislocated hip into the acetabulum .
For performing this maneuver, stabilize the pelvis and
position the patient similar to the Ortolani test position i.e.
supine with leg flexed at 90 degrees. The Barlow’s test identifies
posterior sublimations or dislocation. It is performed by applying
a gentle downward force in the longitudinal axis of the femur but
after three to six months of age, contractures of soft tissue occur
that limit the motion of the hip even if it is dislocated (Figure
1). In case of an older child examination also includes careful
assessment, which consists of keen evaluation of extremities for
presence of asymmetric skin folds or discrepancy in length of
both legs especially in case of unilateral hip dislocation .
Also known as Allis sign. A positive Galeazzi sign is another
important indicator of hip dislocation. It is prompted by lying
down the child in supine position followed by flexing both the
knees so that feet touches the ground and the ankles touches
the buttocks . If an inequality in the height of the knees
appeared, it indicates a positive sign (Figure 2). In neglected
cases, DDH may be diagnosed when children attain walking age
with a sagging on the affected side.
During the neonatal period, baby is having largely
cartilaginous femoral head and acetabulum, so plain radiographs
are not much useful in diagnosis. In infants younger than 6
months of age, ultrasonography has much value to assess DDH.
Especially in starting 6 weeks of life, false diagnosis of DDH
may occur because this assessment is totally dependent upon
observer evaluation and as a result of false positive results infant
may undergo needless action . Routine ultrasonography
is recommended in many western countries. At the age of 3-6
months dislocation of hip will be apparent on x- rays, if evaluator
is aware about the immature pelvis landmarks (Figure 3).
In last era DDH treatment of was developed, it was first
anticipated by Lorenz, in this he focused on closed reduction
with application of plaster cast in stable maximal abduction.
Previously, it was very tough to diagnose babies until their
walking starts. After that in 1900’s introduction of radiograph
In babies, at age of 12 months diagnosis of dislocation was
firstly introduced by Ortolani, with help of a clinical test i.e.
known as Ortolani manoeuvre . He also gave an abduction
brace. Followed by this, a harness and stirrups system was came
in practice which is of huge use in today’s world known as Pavlik
harness. It is the most likely used method of orthosis of choice.
The Pavlik harness device made up of 2 shoulder straps
crossing over the back and secured to a wide thoracic belt on
the anterior side (Figure 4). Along with hips, holed at 90°
flexed position and the legs are fixed in drape shaving two ties.
The anterior strap used to keep the hips in flexion with some
extension and posterior strap are beneficial to stop the lower
limb breaking the midline to avoid adduction. It is suggested by
the Grill et al that position given in pavlik harness is like to the position of babies naturally carried on a mothers’ back position
involving thighs in flexed attitude.
The key aim of pavlik harness focus on regain of normal
improvement by atraumatic, repositioning and conservation
of the hip joint functions. Primarily, skilful reduction of the hip
depends on passive abduction and flexion . In few cases
which are having muscle imbalance like myelomening ocele,
arthrogryposis (major stiffness), Ehlers-Danlos syndrome i.e.
ligamentous laxity; Pavlik harness is contraindicated 14.
Different duration was suggested by various research studies.
A study conducted by Erlacher recommended his patients 6
month time period to wear the pavlik harness, other than this
Whilst Hirsch et al suggested duration of 3 months. Mubarak
et al.  added his concept and advised to wear harness
according to age i.e. less than 3 month baby should use it for 3
months and proposed approximately double time period for 4
month and older baby. All of these suggested about the follow
up care including harness adjustment and ultrasonography on
weekly basis. It is believed that new-born with true dislocation
regain hip stability in time period of three weeks.
Surgical regimes are taken when failure of closed reduction or
pavlik harness occur. This treatment of DDH focuses on open
reduction techniques along with osteotomy of femoral and
pelvic region . If femoral neck have excessive anteversion or
valgus deformity than femoral osteotomies remains beneficial.
Various type of osteotomies of pelvic region are available like
Pemberton pericapsular osteotomy, that likely to be chosen in
scenario where the acetabular index is more than 40˚and Salter
innominate osteotomy which is an open wedge osteotomy that
spreads the acetabulum around a fixed axis so that the femoral
head both superiorly and anteriorly covered by the acetabular
roof, Various complications of DDH surgical regimes occur
that are: damage of sciatic nerve, AVN, migration and breakage
of K-wire, epiphyseal centre damage, and fracture of femoral
Developmental dysplasias of the hip (DDH) describe entire
range of deformities involving the growing hip including
acetabulum, and dysplasia of the femoral head. Screening
programmes for DDH still vary worldwide and more largescale,
longitudinal studies are needed to allow standardisation
of policy across regions. Ultrasound imaging allows morbidity
can be reduced by doing appropriate management of DDH. The
Pavlik stimulate progress in the fruitful treatment of DDH with
a decline in developmental disturbance and short duration
complications. Follow up care including harness adjustment and
ultrasonography is required on weekly basis. Harness failure
can cause devastating AVN and femoral as well as acetabular
developmental disturbance. When harness treatment got failed
then surgical management is one and only last option for DDH
patients. Combination of both i.e. open reduction and femoral/
pelvic osteotomy have good prognosis.