DDH Treatment Options

Graf Classification (Ultrasound)

Radiographic Measurements (Over 4-6 Months)

Treatment Algorithm by Age

0-6 Months: Pavlik Harness

• First-line treatment for dislocatable/dislocated hips
• Positioning: Flexion 100-110°, abduction 50-70°
• Wear 23 hours/day initially, wean over 2-4 months
• Monitor with ultrasound every 3-4 weeks
• Success rate: 95% for Graf III/IV detected early
• Discontinue if not reduced by 3-4 weeks (AVN risk)

6-18 Months: Closed Reduction

• Examination under anaesthesia with arthrogram
• Assess reduction quality and safe zone
• Adductor tenotomy if safe zone narrow (under 25°)
• Spica cast: 100° flexion, 40-50° abduction, neutral rotation
• Cast for 3 months, change at 6 weeks
• Success rate: 80-90% if adequate safe zone

18 Months-3 Years: Open Reduction

• Indicated when closed reduction fails
• Medial approach (Ludloff, Ferguson) under 12 months
• Anterior approach (Smith-Petersen) over 12 months
• Address obstacles to reduction
• May need femoral shortening if tight

Over 3 Years: Open Reduction + Osteotomy

• Open reduction always required
• Femoral varus and shortening osteotomy
• Pelvic osteotomy for residual dysplasia
• More complex, higher complication risk

This age-based approach ensures optimal outcomes while minimizing complications.

Detailed Treatment Options

Pavlik Harness Application

Indications:

• Graf Type III or IV (subluxed or dislocated)
• Age 0-6 months (maximum 6-7 months)
• Dislocatable hip on examination

Application:

• Chest strap: Around nipple line, snug but not tight
• Anterior strap: Controls flexion 100-110°
• Posterior strap: Controls abduction 50-70°
• Positioning: Hip flexed and abducted, allows active motion

Monitoring:

• Ultrasound every 3-4 weeks
• Check for reduction, assess Graf type improvement
• Adjust straps as needed

Discontinuation:

• If reduced: Gradually wean over 2-4 months
• If not reduced by 3-4 weeks: Discontinue to prevent AVN
• Switch to closed reduction if Pavlik fails

Complications:

• AVN (5-10%): From forced abduction, discontinue if not reduced
• Pavlik disease: Posterolateral acetabular wear from treatment in unreduced position
• Recurrence: ~10% after successful treatment

Proper application and monitoring are essential for success and AVN prevention.

Closed Reduction Technique

Indications:

• Failed Pavlik harness (not reduced by 3-4 weeks)
• Age 6-18 months
• Graf Type III/IV on ultrasound

Technique:

• Examination under anaesthesia
• Arthrogram to assess reduction quality
• Evaluate safe zone (abduction range maintaining reduction)
• Adductor tenotomy if safe zone narrow (under 25°)
• Apply spica cast in human position

Human Position:

• 100° flexion
• 40-50° abduction (NOT over 55° to prevent AVN)
• Neutral rotation
• This position minimizes AVN risk

Spica Cast:

• Duration: 3 months
• Change cast at 6 weeks
• Immediate MRI in spica to confirm reduction

Success Factors:

• Adequate safe zone (over 25°)
• Medial pooling reduces to under 5mm on arthrogram
• Proper positioning in human position

Understanding these principles ensures successful closed reduction while minimizing AVN risk.

Open Reduction Approaches

Indications:

• Failed closed reduction
• Age 18 months-3 years (up to 8 years unilateral, 6 years bilateral)
• Irreducible on arthrogram (medial pooling over 7mm)

Medial Approach (Ludloff/Ferguson):

• Age: 9-12 months
• Advantages: Bilateral surgery easy, adductor release part of approach, no abductor damage
• Disadvantages: AVN risk (10%), can't reduce high dislocations, can't do pelvic osteotomy
• Releases: Adductors, psoas, inferior capsule, pulvinar, ligamentum teres

Anterior Approach (Smith-Petersen):

• Age: Over 12 months
• Advantages: Better visualization, can do pelvic osteotomy, can address high dislocations
• Disadvantages: More soft tissue dissection, abductor risk
• Releases: All obstacles to reduction, capsular plication possible

Obstacles to Reduction:

• Psoas tendon (tight - release)
• Ligamentum teres (elongated - excise)
• Pulvinar (fibrofatty tissue - excise)
• Inverted limbus (labrum - may need release)
• Transverse acetabular ligament (tight - release)
• Capsule (hourglass constriction - incise)
• Adductors (tight - tenotomy)

Systematic addressing of all obstacles ensures successful reduction.

Pelvic and Femoral Osteotomies

Pelvic Osteotomies:

Salter Innominate Osteotomy:

• Redirectional osteotomy
• Hinges at pubic symphysis
• Provides anterosuperior/anterolateral coverage
• Age: Young children (under 8 years)
• NEVER in cerebral palsy

Pemberton Osteotomy:

• Reshaping osteotomy
• Hinges at triradiate cartilage (must be open)
• Reduces acetabular volume
• Age: Under 8 years
• Best for young DDH

Dega Osteotomy:

• Similar to Pemberton but extends to posterior
• Used in neuromuscular conditions
• Closes down posterior volume

Triple Osteotomy (Steele):

• Redirectional osteotomy
• Three cuts: ischium, pubis, ilium
• Age: Older children/adolescents

PAO (Ganz/Bernese):

• Periacetabular osteotomy
• Redirectional
• Age: Once triradiate closed (adolescent/adult)

Femoral Osteotomy:

• Varus derotation osteotomy (VDRO)
• Addresses femoral neck version and valgus
• May include shortening if tight
• Indicated: Over 3 years, residual dysplasia, version issues

Understanding osteotomy indications and techniques is essential for managing older DDH.

Avascular Necrosis (Most Devastating)

Incidence:

• Pavlik harness: 5-10%
• Closed reduction: ~20% (Salter type 1)
• Open reduction: 10-20% (medial approach 10%, anterior approach 10-20%)

Causes:

• Always results from treatment, not disease
• Forced abduction over 55°
• Extreme abduction with internal rotation and extension
• Multiple reduction attempts
• Early rigid casting

Kalamchi-MacEwen Classification:

• Class I: Nucleus only - will be normal
• Class II: Lateral physis - coxa valga from lateral physeal fusion
• Class III: Central - moderate deformity
• Class IV: Whole physis - severe deformity, poor outcomes

Prevention:

• Avoid abduction over 55°
• Use human position in spica (100° flexion, 40-50° abduction, neutral rotation)
• Discontinue Pavlik if not reduced by 3-4 weeks
• Gentle reduction technique
• Avoid multiple reduction attempts

Management:

• Established AVN: Containment procedures, may need later salvage
• Monitor for growth disturbance, coxa magna, coxa breva, coxa vara

AVN prevention is the most important principle in DDH treatment.

Additional Complications

Residual Dysplasia:

• May occur despite successful reduction
• Requires monitoring with serial radiographs
• May need later osteotomy if acetabular index remains elevated
• Acetabular index over 30° or center-edge angle under 20° indicates dysplasia

Redislocation:

• Occurs in 5-10% of closed reductions
• Risk factors: Inadequate safe zone, poor positioning, cast problems
• Management: Repeat closed reduction or open reduction

Stiffness:

• May occur after open reduction
• Usually improves with time and physiotherapy
• May require manipulation or arthrolysis if severe

Limb Length Discrepancy:

• May occur with unilateral DDH
• Usually mild (under 2cm)
• May require later equalization if significant

Early Osteoarthritis:

• Even successfully treated DDH has increased OA risk
• Late diagnosis correlates with worse outcomes
• May require THA in adulthood

Understanding and preventing these complications is essential for optimal outcomes.