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Developmental Dysplasia of the Hip (DDH) and Direct Subsequent Appropriate Treatment

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Developmental Dysplasia of the Hip (DDH) and Direct Subsequent Appropriate Treatment Scott Yang, MD, a Natalie Zusman, MD, a Elizabeth Lieberman, MD, a Rachel Y. Goldstein, MDb Developmental Dysplasiaabstract of the Hip Pediatricians are often the first to identify developmental dysplasia of the hip (DDH) and direct subsequent appropriate treatment. The general treatment principle of DDH is to obtain and maintain a concentric reduction of the femoral head in the acetabulum. Achieving this goal can range from less-invasive bracing treatments to more-invasive surgical treatment depending on the age and complexity of the dysplasia. In this review, we summarize the current trends and treatment principles in the diagnosis and treatment of DDH. Developmental dysplasia of the hip infancy and early childhood to prevent (DDH) encompasses a broad spectrum subsequent functional impairment. of abnormal hip development during A variety of methods are available infancy and early development. achieve the overarching goal of The definition encompasses a aDepartment of Orthopedics and Rehabilitation, obtaining a concentric hip reduction. Doernbecher Children’s Hospital and Oregon Health and wide range of severity, from mild b The treatment methods and goals Science University, Portland, Oregon; and Children’s acetabular dysplasia without hip Orthopaedic Center, Children’s Hospital Los Angeles, Los have not drastically changed in Angeles, California dislocation to frank hip dislocation. the past 20 years, although recent The etiology of DDH is multifactorial. developments within the past 5 to 10 Dr Yang conceptualized and drafted the initial Risk factors for DDH are breech years have been focused on optimal manuscript and edited the final manuscript; positioning in utero, female sex, Drs Zusman and Lieberman drafted the initial – surveillance methods, imaging manuscript; Dr Goldstein provided content guidance being firstborn,1 4 and positive family modalities to guide treatment, and edited and provided critical revisions to the history. Other conditions related outcomes assessment of treatment manuscript; and all authors approved the final to prenatal positioning, including methods, and refining indications for manuscript as submitted. metatarsus adductus and torticollis, treatment. It is important for both the DOI: https:// doi. org/ 10. 1542/ peds. 2018- 1147 are associated with DDH. Prolonged clinicians and families to understand Accepted for publication Sep 7, 2018 abnormal postnatal positioning via that the treatment of a dysplastic Address correspondence to Scott Yang, MD, swaddling also has been suggested as hip can be challenging and met with Department of Orthopedics and Rehabilitation, a risk factor in DDH because certain complications. Doernbecher Children’s Hospital, 3181 SW Sam ethnic populations that practice Jackson Park Rd, Mail Code CDW6, Portland, OR Although variations in treatment 97239. E-mail: [email protected] tight swaddling have a higher rate 5, 6 exist based on individual patient of DDH. The treatment algorithm PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, ’ characteristics, the following algorithm 1098-4275). in patients with DDH depends on is generally considered (Table 1). each patient s age and severity of the Copyright © 2019 by the American Academy of Infants up to 6 months of age who Pediatrics condition. The goal in the treatment are confirmed to have hip instability FINANCIAL DISCLOSURE: The authors have of DDH is to achieve and maintain a or dislocation are generally treated indicated they have no financial relationships concentric reduction of the femoral with a brace initially, such as a Pavlik relevant to this article to disclose. head in the acetabulum to allow for harness or abduction orthosis. Patients FUNDING: No external funding. continued normal development of the aged 6 to 18 months with dislocation POTENTIAL CONFLICT OF INTEREST: The authors hip. The natural history of residual can be treated with closed reduction have indicated they have no potential conflicts of DDH or dislocation into adulthood and the application of a hip spica cast. interest to disclose. has been associated with pain and Generally, patients >12 to 18 months early development of osteoarthritis. of age or those who fail to achieve a To cite: Yang S, Zusman N, Lieberman E, et al. Residual sequelae of DDH are 1 concentric hip reduction with closed Developmental Dysplasia of the Hip. Pediatrics. 2019;143(1):e20181147 of the leading causes of early7 hip methods are considered candidates osteoarthritis in adulthood. Hence, the for open surgical hip reduction. There goal is to improve hip development in are outliers to this general algorithm Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 143, number 1, January 2019:e20181147 STATE-OF-THE-ART REVIEW ARTICLE TABLE 1 General Treatment Algorithm for Hip Dislocation Age Treatment Comments <6 mo Abduction orthosis (ie, Pavlik harness) — 6–18 mo Closed reduction under general anesthesia with hip spica cast Closed reduction at <6 mo of age if abduction orthosis attempt fails >12–18 mo Open hip reduction Open reduction <1 y of age if previous closed-reduction attempt fails >2 y Open hip reduction with or without femoral shortening osteotomy Femoral shortening osteotomy may, but not always, be needed on the basis of the amount of tension that needs to be relieved to achieve a hip reduction. 3–8 y Open hip reduction with or without femoral shortening osteotomy and Pelvic osteotomy may, but not always, be needed to address residual with or without pelvic osteotomy acetabular dysplasia. >8 y Open hip reduction versus observation for eventual arthroplasty Controversial; poorer outcomes noted in attempting hip open reductions in those >8 y old because children <6 months old abducting the hips while applying may occasionally require closed anterior-directed pressure at the or open hip reduction if bracing greater trochanters. An Ortolani treatment fails. Osteotomies, such as maneuver is considered to have a femoral shortening osteotomy and positive result if the femoral head pelvic osteotomy, are considered relocates with a distinct clunk. An for hip dislocation in older patients Ortolani-positive hip is more severe to decrease tension on the hip than a Barlow-positive hip because reduction and those with a residual it indicates that the femoral head is shallow dysplastic acetabulum, dislocated at rest. The presence of a respectively. Adolescents and young subtler hip click during examination FIGURE 1 adults with residual symptomatic is a nonspecific finding and often 9,10 Galeazzi sign. With the pelvis level on a flat acetabular dysplasia are treated does not indicate true hip pathology. surface, the heights of the knees are asymmetric. with periacetabular osteotomy The 2 major limitations of these The right knee height is shorter, suggesting possible hip dislocation. (PAO) to preserve the native hip maneuvers are their dependence on joint and avoid hip arthroplasty. the skill of the examining provider Recent developments in each of these and the fact that these tests are more treatment methods will be discussed sensitive in younger infants, whose thigh folds and clinical examination in this article. soft tissues around the hip joint of limb length discrepancy are prone HIP EXAMINATION have yet to contract. Furthermore, to error and inaccuracy. The most a severely dislocated hip that is not sensitive examination for unilateral reducible may not have a Barlow hip dislocation in a child >3 months or Ortolani positive result. The old is an assessment for asymmetric Early identification of infants with 12, 13 sensitivity of Barlow and Ortolani diminished hip abduction (Fig 2). dysplastic hips can be performed on examination maneuvers alone in 11 The walking child may also present a routine basis from the newborn identifying DDH is at best 54%‍ ; physical examination and continue with a Trendelenburg gait (trunk tilt ’ 8 thus, adjunct imaging modalities for toward the affected hip when weight until the child reaches walking age. identification can be helpful. A newborn infant s hips should is applied) if there is a unilateral be evaluated by using the Barlow For the older infant or child, dislocation or a waddling gait (trunk and Ortolani physical examination Barlow and Ortolani examination tilt toward the weight-bearing side, maneuvers. The Barlow maneuver is of limited utility due to the alternating throughout the gait is performed by adducting the hip development of contractures. These cycle) if there is bilateral dislocation. to the midline and gently applying patients are observed for leg length For infants who are Ortolani- posterior force. A positive Barlow discrepancy, thigh-fold asymmetry, positive or older children with any result is when the femoral head and limited hip abduction. Leg length of the above examination findings, subluxes, and a clunk is felt. A discrepancy should be assessed for further diagnostic evaluation can be Barlow-positive hip indicates that with the infant in the supine position obtained, as described below. ° the femoral head is resting in the with the pelvis flat on a level surface DIAGNOSTICS: IMAGING STUDIES acetabulum but has pathologic and the hips and knees flexed to 90 . instability. With the thighs adducted A discrepancy is indicated by unequal and posteriorly depressed, the knee heights, which is termed the Ultrasonography is the recommended Ortolani maneuver is performed by Galeazzi sign (Fig 1). Asymmetric imaging modality in infants <4 Downloaded from www.aappublications.org/news by
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