Seminar on DDH

1. Developmental
Dysplasia of the Hip
Chair Person:
Dr.C.V.Mudgal
By: Dr.S.C.Hiremath

2. Adolph Lorenz, an early pioneer in the
treatment of developmental dislocation
of the hip

3. Overview
 Introduction
 Normal Development of the Hip
 Etiology and Pathoanatomy
 Epidemiology and Diagnosis
 Treatment
 Complications

4. Introduction:
• Developmental dysplasia of the hip is the
condition in which the femoral head has an
abnormal relationship to the acetabulum.
Developmental dysplasia of the hip includes
frank dislocation (luxation), partial
dislocation (subluxation), instability
wherein the femoral head comes in and out
of the socket, and inadequate formation of
the acetabulum.

5.  Previously known as congenital dislocation of
the hip implying a condition that existed at
birth
 developmental encompasses embryonic,
fetal and infantile periods
 includes congenital dislocation and
developmental hip problems including
subluxation, dislocation and dysplasia

6. Etiology and Epidemiology
 Multifactorial
 Genetics and Syndromes
○ Ehler’s Danlos
○ Arthrogryposis
○ Larsen’s syndrome
 Intrauterine environmental factors
○ Teratogens
○ Oligohydramnios)
○ breech
 Neurologic Disorders: Spina Bifida
 ligamentous laxity
familial trait

7.  Left : Right – 4 : 1
 Breech : DDH ≥ x 10
 Amniotic fluid↓ : moulded baby
- plagiocephaly
- scoliosis
- foot deformity
- skew pelvis

8. Postnatal positioning in extension, as in this child on
a Native American cradleboard, contributes to
developmental dysplasia of the hip

9. Normal Growth and
Development
 Embryologically the acetabulum, femoral
head develop from the same primitive
mesenchymal cells
 cleft develops in precartilaginous cells at 7th
week and this defines both structures
 11wk hip joint fully formed

10.  acetabular growth continues throughout
intrauterine life with development of
labrum
 By birth femoral head is deeply seated
in acetabulum by surface tension of
synovial fluid and very difficult to
dislocate
 in DDH this shape and tension is
abnormal in addition to capsular laxity

11.  The cartilage complex is 3D with triradiate medially
and cup-shaped laterally and interposed between
ilium above and ischium below and pubis anteriorly
 acetabular cartilage forms outer 2/3 cavity and the
non-articular medial wall form by triradiate cartilage
which is the common physis of these three bones
 fibrocartilaginous labrum forms at margin of
acetabular cartilage and joint capsule inserts just
above its rim

12.  articular cartilage covers portion articulating with femoral head
 opposite side is a growth plate with degenerating cells facing towards the
pelvic bone
 triradiate cartilage is triphalanged with each side of each limb having a
growth plate which allows interstitial growth within the cartilage causing
expansion of hip joint diameter during growth
 In the infant the greater trochanter, proximal femur and intertrochanteric
portion is cartilage
 By 4-7 months proximal ossification center appears which enlarges until
adult life when only thin layer of articular cartilage persists

15. Development cont..
 Experimental studies in humans with unreduced hips
suggest the main stimulus for concave shape of the
acetabulum is presence of spherical head
 for normal depth of acetabulum to increase several
factors play a role
 spherical femoral head
 normal appositional growth within cartilage
 periosteal new bone formation in adjacent pelvic
bones
 development of three secondary ossification centers
 normal growth and development occur through
balanced growth of proximal femur, acetabulum and
triradiate cartilages and the adjacent bones

16. DDH
 Tight fit between head and acetabulum is absent and head can
glide in and out of acetabulum
 hypertrophied ridge of acetabular cartilage in superior, posterior
and inferior aspects of acetabulum called “ neolimbus”
 98% DDH that occur around or at birth have these changes and
are reversible in the newborn
 2% newborns with teratologic or antenatal dislocations and no
syndrome have these changes

18.  Development in treated DDH different from normal hip
 goal is to reduce the femoral head to provide the stimulus
for acetabular development
 Concentric reduction maintainance is essential for
recovery and resumption of normal growth
 age at which DDH hip can still return to normal is
controversial and depends on
 age at reduction
 growth potential of acetabulum
 damage to acetabulum from head or during reduction

19. Epidemiology
 1 in 100 newborns examined have evidence of instability
( positive Barlow or Ortolani)
 1 in 1000 live births true dislocation
 Barlow stated that 60% stabilize in 1st week and 88%
stabilize in first 2 months without treatment remaining
12% true dislocations and persist without treatment

20. Incidence
-1 in 1000 live birth.
-male to female ratio 4:1
-family history 1:7

21. Normal Anatomy
 Hip starts from common mesenchymal
block of tissue
 7th week cleft forms to separate head
 11th week hip fully formed
 Acetabulum gets shallower close to birth

22. Normal Hip
 Tight fit of head in
acetabulum
 Transection of capsule
 Still difficult to dislocate
 Surface tension

23. Pathoanatomy
 Ranges from mild dysplasia --> frank
dislocation
 Bony changes
 Shallow acetabulum
 Typically on acetabular side
 Femoral anteversion

24. Pathoanatomy
 Soft tissue changes
 Usually secondary to prolonged subluxation or
dislocation
 Intra articular
 Labrum
○ Inverted + adherent to capsule (closed reduction with inverted
labrum assoc with increased Avascular Necrosis)
 Ligamentum teres
○ Hypertrophied + lengthened
 Pulvinar
○ Fibrofatty tissue migrating into acetabulum

25. Pathoanatomy
 Soft Tissue (Intra articular)
 Transverse acetabular ligament
○ Contracted
 Limbus
○ Fibrous tissue formed from capsular tissue
interposed between everted labrum and
acetabular rim
 Extra articular
 Tight adductors (adductor longus)
 Iliopsoas

28. Teratological DDH
 Irreducible
 False acetabulum
 Defective anterior acetabulum
“anteverted”
 Increased femoral neck
anteversion

29. Arthrogryposis with dislocations
& delivery fracture
False acetabulum

30. Associated
conditions
-torticollis
-metatarsus adducts
-calcaneo valgus
-talipus varus
-plagiocephaly

31. CLINACAL
PRESENTATION

32. Neonatal Presentation
 Exam one hip at a time
 Baby must be quiet
 Barlow’s sign: provocative maneuver
 Ortolani’s sign: reduces hip
 Other signs not helpful in newborn

33. Ortolani’s Maneuver
After 3 months of age
tests become negative

35. The Ortolani test for developmental dislocation of the hip in a
neonate.A, The examiner holds the infant's knees and
gently abducts the hip while lifting up on the greater trochanter with two
fingers.B, When the test is positive, the dislocated femoral head will fall
back into the acetabulum (arrow) with a palpable (but not audible) “clunk”
as the hip is abducted (Ortolani's sign). When the hip is adducted, the
examiner will feel the head redislocate posteriorly.

36. The Barlow test for developmental dislocation of the hip in a neonate.A, With the infant
supine, the examiner holds both of the child's knees and gently adducts one hip and
pushes posteriorly.B, When the examination is positive, the examiner will feel the femoral
head make a small jump (arrow) out of the acetabulum (Barlow's sign). When the
pressure is released, the head is felt to slip back into place.

37. Infant Presentation
 Skin fold asymmetry
 Limited hip abduction
 Unequal femoral lengths (Galeazzi’s
sign)
(Flex both hips and one side shows
apparent femoral shortening)

38. Skin fold asymmetry

39. Asymmetrical thigh folds

40. Galeazzi’s sign

43. Developmental dysplasia of the right hip. One physical
finding is limited abduction of the affected hip.

44. After Walking Age
 Trendelenberg gait
 Leg length discrepancy
 Increased lumbar lordosis in Bilateral
dislocation
Klisic test positive

45. The examiner places the middle finger over the greater trochanter, and the index
finger on the anterior superior iliac spine.A, With a normal hip, an imaginary line
drawn between the two fingers points to the umbilicus.B, When the hip is
dislocated, the trochanter is elevated and the line projects halfway between the
umbilicus and the pubis.

46.  hyperlordosis –
bilateral involvement

48. Which hip dysplasia
pain?
Complete dislocation with
no false acetabulum:
NO
Complete dislocation with
false acetabulum:
YES
Subluxation:
YES

49. Imaging
 X-rays
 Femoral head ossification center
○ 4 -7 months
 Ultrasound
 CT
 MRI
 Arthrograms
 Open vs closed reduction

50. Radiography

51. Hilgenreiner's line is drawn through the triradiate cartilages. Perkin's line is drawn
perpendicular to Hilgenreiner's line at the margin of the bony acetabulum.
Shenton's line curves along the femoral metaphysis and connects smoothly to the
inner margin of the pubis

52. Imaging
 Radiographs

53. Imaging
 Radiographs

54. Imaging
 Radiographs

55. Imaging
 Radiographs

56. Imaging
 Acetabular Index

57. The acetabular index is the angle between a line drawn along the margin
of the acetabulum and Hilgenreiner's line; it averages 27.5 degrees in
normal newborns and decreases with age.
 Acetabular Index

58. Imaging
 Acetabular Index < 30 wnl

59. Imaging

60. Imaging

61. Imaging

62. Imaging

63. Wilberg's center-edge angle, the angle between Perkin's line and a line drawn
from the lateral lip of the acetabulum through the center of the femoral head.
considered normal if greater than 10 degrees in children 6 to 13 years of age, and
it increases with age.

64. Radiographs Summary
 Femoral head appears 4 - 7 months
 Shenton’s line
 Perkin’s and Hilgenreiner’s lines
 Inferomedial quadrant
 Center Edge Angle of WILBERG (< 20
abnormal)
 Acetabular index
 Normal < 30 (Weintroub et al)

65. TEAR DROP SIGN
 Acetabular TEAR DROP SIGN appears
between 6 & 24 months in normal hip,
but later in case of ddh.
 Wall of acetabulum laterally, wall of
lesser pelvis medially,acetabular
notch inferiorly.
 U shaped teardrop
 V shaped teardrop- Dysplastic hips
and poor outcome

66. TEAR DROP

67. VON ROSEN VIEW
 Both hips abducted, intrernally rotated
and extended.
 NORMAL- Imaginary line from shaft of
femur extending upwards intersects the
acetabulum
 DDH- Line crosses above acetabulum

69. Imaging
 Ultrasound
 Introduced in 1978 for eval of DDH
 Operator dependent
 Useful in confirming subluxation, identifying
dysplasia of cartilaginous acetabulum,
documenting reducibility
 Prox Femoral Ossification Center interferes
 Requires a window in spica cast.

70. Ultra sound
 BOTH morphologic assessment and dynamic
 anatomical characteristics
○ alpha angle: slope of superior aspect bony
acetabulum
○ beta angle: cartilaginous component (problems with
inter and intraobserver error )
 dynamic
○ Observing events occuring with Barlow and ortolani
tests.
•Alpha angle = between line of ilium & bony acetabulum
•Beta angle (less important) = between line of ilium & anterior labrum

71. http://emedicine.medscape.com/article/408225
Measures acetabular depth.
Normal >60 degrees
Acetabular cartilaginous roof
coverage.
Normal <55 degrees
Smaller angle= better bony
coverage

72. Ultrasound
Femoral head
Abductors
Ilium

73. Ultrasound
Femoral head
Abductors
Ilium

74. Ultrasound
Femoral head
Abductors
Ilium

75. Ultrasound
Femoral head
Abductors
Ilium

76. Ultrasound
Graf’s alpha
angle

77. Ultrasound
Graf’s alpha
angle
>60 = normal
*line through
ilium bisects
head 50/50

78. • Type 1: mature hip joint with narrow, covering cartilaginous roof
• Type 2 (a+, a-, b, c, d): range from immature to dysplastic
• Type 3&4: both diplaced, range of severity
• *This classification system has good reliability with Type 1 hips,
but recently has been scrutinized regarding inter and intra-
observer reliability with all other Types.

79. Graf grading of DDH by
ultrasound

80. •Indications controversial due to high levels
of overdiagnosis and not currently
recommended as a routine screening tool
other than in high risk patients
•Best indication is to assess treatment
•Guided reduction of dislocated hip or check
reduction and stability during Pavlik harness
treatment

81. Arthrogram
Head shape
Cover
Congruity
Articular
cartilage
Labrum

82. Arthrogram
•Limbus - 'Rose thorn sign' of inverted
labrum between femoral head & acetabulum
•Hour glass constriction of capsule - by
psoas tendon
•Capsular distension

83. Arthrogram in DDH
SUBLUXATED HIP DISLOCATED HIP

84. •Eliciting Medial pooling of dye
•(normal = < 7mm)
•Confirms reduction after surgery
Dye pooling <7mm & complete reduction
with arthrogram = no need for open
reduction.

85. Natural History
in Newborns
 Barlow
 1 in 60 infants have instability ( positive Barlow)
 60% stabilize in 1st week
 88% stabilize in 2 months without treatment
 12 % become true dislocations and persist
 Coleman
 23 hips < 3 months
 26% became dislocated
 13 % partial contact with acetabulum
 39% located but dysplastic feature
 22% normal
 As it is not possible to predict the outcome, all
infants with instability should be treated

86. Adults
 Variable
 depends on 2 factors
 well developed false acetabulum ( 24 % chance good result vs 52 % if
absent)
 bilaterality
 in absence of false acetabulum patients maintain good ROM with little
disability
 femoral head covered with thick elongated capsule
 false acetabulum increases chances degenerative joint disease
 hyperlordosis of lumbar spine assoc with back pain
 unilateral dislocation has problems
 leg length inequality, knee deformity , scoliosis and gait
disturbance

87. Dysplasia and Subluxation
 Dysplasia (anatomic and radiographic def’n)
 inadequate development of acetabulum, femoral head or
both
 All subluxated hips are anatomically dysplastic
 Radiologically difference between subluxated and dysplastic
hip is disruption of Shenton’s line
 subluxation: line disrupted, head is superiorly,
superolaterally ar laterally
displaced from the medial wall
 dysplasia: line is intact
 Important because natural history is different

88. A 36-year-old woman with bilateral anatomically abnormal
(dysplastic) hips. The left hip is radiographically subluxated, with
the Shenton line disrupted, and the right hip is radiographically
dysplastic, with the Shenton line intact.

89. Seven years later, note the marked loss of joint space
in the secondary acetabulum of the left hip and very
early disruption of the Shenton line on the right.

90. Natural History Con’t
 Subluxation predictably leads to degenerative joint disease
and clinical disability
 mean age symptom onset 36.6 in females and 54 in men
 severe xray changes 46 in female and 69 in males
 Cooperman
 OUT OF 32 hips with CE angle < 20 without subluxation
 BY 22 years all had x ray evidence of Degenerative Joint
Disease
 no correlation between angle and rate of development
 concluded that radiologically apparent dysplasia leads to
DJD but process takes decades

91. Treatment Options
 Age of patient at presentation
 Family factors
 Reducibility of hip
 Stability after reduction
 Amount of acetabular dysplasia

92. Treatment 0 to 6 months
 Goal is TO obtain reduction and maintain reduction to provide
optimal environment for femoral head and acetabular
development
 Lovell and Winter
 Treatment should be initiated immediately on diagnosis
 AAOS (July,2000)
 subluxation often corrects after 3 weeks and may be
observed without treatment
 if persists on clinical exam or ultrasound beyond 3 weeks
treatment indicated
 actual dislocation diagosed at birth treatment should be
immediate

93. Treatment con’t
 Pavlik Harness preferred
 prevents hip extension and adduction but allows
flexion and abduction which lead to reduction and
stabilization
 success 95% if maintained full time six weeks
 In child > 6 months of age, success is < 50% as it is
difficult to maintain active child in harness

95. Pavlik Harness
 Chest strap at nipple line
 shoulder straps set to hold
cross strap at this level
 anterior strap flexes hip
100-110 degrees
 posterior strap prevents
adduction and allow
comfortable abduction
 safe zone arc of abduction
and adduction that is
between redislocation and
comfortable unforced
abduction

96. Pawlik harness

97. The transverse chest strap should be placed just below the
nipple line. The hips should be flexed to 120 degrees, and
the posterior straps should not produce forced abduction.

98. Pawlik contd..
 Indications include presence of reducible hip femoral head
directed toward triradiate cartilage on xray
 follow weekly intervals by clinical exam and US for two weeks
and if not reduced other methods are pursued
 once successfully reduced, harness is continued for childs age
at stability + 3 months
 end of weaning process---- xray pelvis obtained--- and if normal
discontinue harness

99. Complications
 Failure
 poor compliance , inaccurate position and persistence of
inadequate treatment
 subgroup where failure may be predictable
○ absent Ortolani sign
○ bilateral dislocations
○ treatment commenced after age 7 week
 NEXT Treatment is closed reduction and Spica
Casting
 Femoral Nerve Compression 2 to hyperflexion
 Inferior Dislocation
 Skin breakdown
 Avascular Necrosis

100. The Ilfeld or Craig splint

101. Von Rosen splint

102. Von Rosen splint

103. 6 months to 2 years age
 Closed reduction and spica cast immobilization
recommended
 traction controversial with theoretical benefit of gradual
stretching of soft tissues impeding reduction and neurovascular
bundles to decrease AVN
 skin traction preferred however vary with surgeon
 usually 1-2 weeks
 scientific evidence supporting this is lacking

104. Treatment contd..
 closed reduction preformed in OR under general anesthetic
manipulation includes flexion, traction and abduction
 percutaneous or open adductor tenotomy necessary
in most cases to increase safe zone which lessen incidence of
proximal femoral growth disturbance
 reduction must be confirmed on arthrogram as large portion of
head and acetabulum are cartilaginous
 dynamic arthrography helps with assessing obstacles to
reduction and adequacy of reduction

105. Treatment
 reduction maintained in spica cast well molded to greater
trochanter to prevent redislocation
 human position of hyperflexion and limited abduction
preferred
 avoid forced abduction with internal rotation as increased
incidence of proximal femoral growth disturbance
 cast in place for 6 weeks then repeat Ct scan to confirm reduction
 casting continued for 3 months at which point removed and xray
done then placed in abduction orthotic device full time for 2
months then weaned

106. Closed Reduction and Casting for Developmental
Dislocation of the Hip

111. Safe Zone
20 to 30 degrees from
maximum abduction
extended to below 90 degrees
without redislocation
Safe zone can be improved
with adductor tenotomy

112. Failure of Closed Methods
 Open reduction indicated if failure of closed reduction,
persistent subluxation, reducible but unstable other
than extremes of abduction
 variety of approaches
 anterior smith peterson most common
○ allows reduction and capsular plication and
secondary procedures
○ Disadvantages - more blood loss, damage to iliac
apophysis and abductors, stiffness

113. Open Reduction
 Medial approach ( between adductor brevis and magnus)
○ approach directly over site of obstacles with minimal soft
tissue dissection
○ unable to do capsular plication so depend on cast for post
op stability
 anteromedial approach Ludloff ( between neurovascular
bundle and pectineus)
○ direct exposure to obstacles, minimal muscle dissection
○ no plication or secondary procedures
○ increased incidence of damage to medial femoral
circumflex artery and higher AVN risk

114. Open Reduction

115. Follow-up after open reduction
 Abduction orthotic braces commonly used until acetabular
development is caught up to normal side
 in assessing development look for accessory ossification centers
to see if cartilage in periphery has potential to ossify
 secondary acetabular procedure rarely indicated < 2 years as
potential for development after closed and open procedures is
excellent and continues for 4-8 years
 most rapid improvement measured by acetabular index ,
development of teardrop occurs in first 18 months after surgery
 femoral anteversion and coxa valga also resolve during this time

116. Obstacles to Reduction
 Extra- articular
 Iliopsoas tendon
 adductors
 Intra-articular
 inverted hypertrophic labrum
 tranverse acetabular ligament
 pulvinar, ligamentum teres
 constricted anteromedial capsule in late cases
 neolimbus is not an obstacle to reduction and represents
epiphyseal cartilage that must not be removed as this impairs
acetabular development

117. Age greater than 2 years
 Open reduction usually necessary
 54% AVN and 32% redislocation with use of skeletal
traction in ages > 3
 For age > 3 open reduction and femoral
shortening and acetabular procedure is
recomended to avoid excess pressure on head
with reduction

118. Treatment con’t
 2-3-years gray zone
 potential for acetabular development is diminished
and therefore many surgeons recommend a
concomitant acetabular procedure with open
reduction or 6-8 weeks after
 Incidence of AVN is greater with simultaneous open
reduction and acetabular procedure

119. Treatment contd..
 Lovell and Winter advised to
 judge stability at time of reduction and if stable observe for
period of time for development
 if not developing properly with decreased acetabular
index, teardrop then consider secondary procedure
 most common osteotomy is Salter or Pemberton
 anatomic deficiency is anterior and Salter provides
this while Pemberton provides anterior and lateral
coverage

120. Natural Sequelae
 Goal of treatment is to have radiographically normal hip
at maturity to prevent DJD
 after reduction is achieved potential for development
continues until age 4.
 In child < 4 years minimal dysplasia may be observed but
if it is severe than subluxations and presence of residual
dysplasia should be corrected

121. Residual Dysplasia
 Determined by plain xray with measurement of CE
angle and acetabular index
 In young children deficiency is usually anterior and in
adolescents it can be global
 Deformities of femoral neck if significant it leads to
subluxation
 lateral subluxation with extreme coxa valga or
anterior subluxation with excessive anteversion
 usually DDH patients have a normal neck shaft
angle

122.  If there is Dysplasia for 2-3-years after reduction
proximal femoral derotation or varus osteotomy
should be considered
 varus osteotomy is done to redirect head to center of
acetabulum which stimulates normal development
 It must be done before age 4 as remodeling potential
goes down after this

123. Treatment in Adolescent or Adult
 Femoral osteotomy should only be used in
conjunction with pelvic procedure as there is
no potential for acetabular growth or
remodeling but changing orientation of femur
shifts the weightbearing portion
 Pelvic osteotomy considerations
 age
 congruent reduction
 range of motion
 degenerative changes

124. Femoral Shortening
 Schoenecker + Strecker 1984
 Traction vs. Femoral shortening
 56% AVN in traction group
 0% AVN in femoral shortening

125. Femoral shortening for
DDH
Hey-Groves
(1928)

126. Valgus/ extension
osteotomy
In AVN with
trochanteric
overgrowth
Better in
adduction and
flexion

127. Pelvic Procedures
 Redirectional
 Salter
 Sutherland double innominate osteotomy
 Steel ( Triple osteotomy)
 Ganz ( rotational)
 Acetabuloplasties ( decrease volume )
 Pemberton
 Dega
 Salvage
 depend on fibrous metaplasia of capsule
 Shelf and Chiari

128. Pelvic Osteotomy
 Done in Persistent instability + dysplasia
after open reduction and femoral
shortening
 Requires concentric reduction of a
reasonably spherical femoral head
 Usually based on surgeon preference

129. Pelvic Osteotomy
 Volume changing
 Pemberton
○ Hinges on triradiate
○ Requires remodeling of “new” incongruity
○ Provides more anterolateral coverage
 Dega’s

130. Pelvic Osteotomy
 Redirecting
 Salter
○ Osteotomy through sciatic notch
○ Hinge through pubic symphysis
 Triple innominate
 Ganz
 Dial

131. Salter
Innominate
osteotomy

132. Salter’s osteotomy

133. Salter’s osteotomy

134. Salter Single Innominate
•Age –18 months –6 years
•Requires concentrically reduced hip
–Open reduction at same time is possible
–Iliopsoas and adductor tenotomies often
required
•Covers antero-later alacetabular deficiency
–Up to 15 degree of acetabular index corrected

135. Salter
•Anterior approach to acetabulum
–Exposing inner and outer ilium
–Expose hip capsule if reduction needed
–Transverse osteotomy is done just above acetabulum
• Sciatic notch to Ant.Inf.iliac Spine
–Rotate on pubic symphysis in antero-lateral direction
–Hold correction with bone graft wedge & K-wires

138. Salter Osteotomy

139. K. E. 21 - 12 - 1999
Salter & femoral
osteotomy

140. Pemberton Acetabuloplasty
•Age –18 months –10 years
•Requires reduced hip
•Decreases acetabular volume
–Remodeling of acetabulum required
•Corrects >15 degree of Acetabular index
•Reduces antero-lateral acetabular defects
–Cuts altered to cover more anteriorly or laterally

141. Pemberton
•Anterior Approach -Exposure as for Salter
–Cut inner and outer table with small osteotome
– osteotomy 1cm above AIIS, staying 1 cm above
capsule
–Do not cut through to sciatic notch
–Lever through the cut until coverage is acceptable
•(Levers on tri-radiate cartilage)
–Hold correction with bone graft wedge

144. Dega Acetabuloplasty
•Similar to Pemberton
•Larger posterior hinge
–Hinges on horizontal tri-radiate limb
•Less inner table osteotomized for more lateral
coverage
(More inner table –more anterior coverage)

146. Steel Triple Innominate Osteotomy
•Age –Skeletally mature
•Requires congruent hip joint
•Divides ilium, ischium and superior ramus
–Acetabulum is rotationally free
–Indicated when other osteotomies not
possible
•Rotates to cover any acetabular defect

147. Steel
•Multiple incision technique
–Posteriorly between gluteus and hamstrings
•Allows osteotomy of ischium
–Anteriorly freeing medial attachments
•Allows Salter and superior ramus osteotomy
–Rotate acetabulum as desired
•Avoid externally rotating
–Bone graft wedge is fixed as per Salter type

149. Salvage or Shelf
procedures
 Chiari and Staheli osteotomies
 Requires capsular metaplasia
 Pain is the main indication
 Used in Treatment of chronic hip pain in
adolescents

150. Staheli Shelf Procedure
•Age –older child to skeletal maturity
•Salvage operation
•Indicated for non-concentric hips
•Augments supero-lateral deficency
–Slotted bone graft placed over capsule
deepening the acetablum

151. Staheli
•Anterior approach is used with outer wall exposure only
–Identify superior acetabular edge
–Create slot 1cm deep along edge in cephlad angle
–Remove 1 cm cortical strips from outer table
•Insert into slot, cutting at desired lateral overhang
•2nd layer inserted lengthwise
•Use remaining to fill in above slot edge
–Hold in place with reflected fascia and adductors

153. Staheli shelf

154. Chiari Medial Displacement
•Age –skeletally mature
•Salvage operation only
–Used when no other osteotomy possible
–Possible with subluxed hip
•Covers well laterally
–Anterior and posterior augmentation may be
necessary
•May be useful in other conditions
–Coxamagna, OA in dysplasichips

155. •Anterior approach –as per Salter
–Identify superior extent of capsule
–Cut from AIIS to notch following capsule
curve
•Angle osteotome10-20ocephlad
–Displace distal fragment medially 50-100%
•Ensure complete head coverage
•Leg abduction, hinges on pubic symphysis

157. Chiari Osteotomy

158. Chiari Osteotomy

159. Chiari Osteotomy

160. Chiari Osteotomy

161. Chiari osteotomy

162. Outcome of Chiari
osteotomy
236 of 388 osteotomies
reviewed at 25 years
51% good; 30% fair; 18% poor
Best results: ≤ 7 years; no OA
Femoral osteotomy: no better
(Windhager et al. JBJS
1991)

163. Schanz
osteotom
y
Very late
salvage

164. MANAGEMENT

165. Complications of Treatment
 Worst complication is disturbance of growth
in proximal femur including the epiphysis and
physeal plate
 commonly referred to as AVN however, no
pathology to confirm this
 may be due to vascular insults to epiphysis
or physeal plate or pressure injury
 occurrs only in patients that have been
treated and may be seen in opposite normal
hip

166. Necrosis of Femoral Head
 Extremes of position in abduction ( greater 60
degrees ) and abduction with internal rotation
 compression on medial circumflex artery as
passes the iliopsoas tendon and compression of
the terminal branch between lateral neck and
acetabulum
 “ frog leg position “ uniformly results in proximal
growth disturbance

167. Avascular Necrosis

168.  extreme position can also cause pressure
necrosis onf epiphyseal cartilage and
physeal plate
 severin method can obtain reduction but
very high incidence of necrosis
 multiple classification systems with Salter
most popular

169. Salter Classification
 1 failure of appearance of ossific nucleus
within 1 year of reduction2
 2 failure of growth of an existing nucleus
within 1 year
 3 broadening of femoral neck within 1
year
 4 increased xray density then
fragmentation of head
 5 residual deformity of head when re-
ossification complete including coxa
magna,vara and short neck

170. Treatment
 Femoral and/or acetabular osteotomy to
maintain reduction and shift areas of
pressure
 trochanteric overgrowth causing an abductor
lurch treated with greater trochanter physeal
arrest if done before age 8 otherwise distal
transfer
 early detection is key with 95% success rate
of treatment
 identify growth disturbance lines

174. THANK YOU