Fig. 54

SURGICAL TREATMENT FOR CONGENITAL DISLOCATION OF
THE HIP IN CHILDREN
Thesis
Submitted for partial fulfillment of the requirements of M. D. degree in Orthopaedics
and Traumatology
By
med Omar Youssef
M.B.B.Ch., Ms.D.
Supervised by
Prof. Dr. Hussein Abd EI-Salam Nazim Prof. Dr. Yehia Nour El-Din Tarraf
Prof of Orthopaedics and Traumatology Prof of Orthopaedics and Traumatology
Faculty of Medicine - El-Minia University Faculty of Medicine - Cairo University
Prof. Dr. Nady Saleh EI-Said Dr. Mohamed Mohamed Fouad Abd El -Latef
Prof of Orthopaedics and Traumatology Assist Prof of Orthopaedics and Traumatology
Faculty of Medicine - El-Mink, University Faculty of Medicine - El-Minia University
El-Minia university
2002
) 2

t
e
a
k
t
i
l
d
i
l
l
i
t
t
o
m
e
r
c
i
t
L
-
4
/
i
t.
c
p
t
o
d
i
l
i
s
A
l
411 j
s
u
a
(Fr) 4
1
1
4
1
4
1
1
2
.
0
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t

TO
MY MOTHER
SPIRITS OF MY FATHER
MY WIFE
MY SON MAHMOUD

Acknowledgments
To THE _ALMIGHTY MERCIFUL ALLAH, whose celestial
assistance has offered me the great chance to be instructed by such most
respectable scientists and honorable professors.
To Prof Hussein Abdel S
alam
Nazim, Professor of Orthopaedic
Surgery & Traumatology, Faculty of Medicine, M
ELtribute
of what can words convey of gratitude together with love and
inia
University, I give
admiration, for without his enthusiastic help, care, and encouragement, this
work would not have come to light. Let me admit, that through his remarks,
guidance, and moralism, I have been able to get valuable experience,
information and avoid glaring errors. His valuable advice and support are
beyond acknowledgment.
To Prof Y
ehia
Nour El-Din T
art*
*
,
Professor of Orthopaedic Surgery
& Traumatology, o
Faculty Cairo University, it is a great honor-for
me to take this opportunity to express my sincere appreciation and my deep
respect
fMedicine
or his intellectual guidance, his valuable advice, and his peerless efforts
throughout the whole work, also he has kindly directed me and offered a
great help in finishing this study

A special "Thank you is owed to Prof I
Vadi
S
aleh
El-Sayed, Professor
of Orthopaedic Surgery & Traumatology, Faculty of Medicine, E
University, for his full support, careful supervision, constant enthusiasm, in
exhaustive efforts, valuable advice, sustained encouragement, endless
meticulous supply of the most recent knowledge, valuable discussions which
highlighted the main core of this work. Also, deepest thanks and gratitude to his
patience throughout the completion of this thesis and my appreciation to his
ideas in organizing its main items.
To Dr. Mohamed Mohamed Fouad a
bd-El-Latef,
Assistant Professor of
Orthopaedic Surgery & Traumatology, Faculty of Medicine, E
University, to whom I am indebted for his patience, kind guidance, continuous
constructive criticism, valuable and generous advice, and great endless
encouragement, his assistance was indispensable throughout this work
To all staff members of Orthopaedic Surgery & Traumatology
Department, Faculty of Medicine, E
valuable times to help me during my work
l-A/
I
- U
lla
University, who dedicated their
Last but not least, I would like to thank my patients for their c
ooperation.
Ahmed Omar Youssef
2002
l-Minia
l-Minia

LIST OF CONTENTS
Contents Page
INTRODUCTION
AIM OF THE WORK 3
REVIEW OF L
Historical review
ITERATURE
Anatomy of the hip joint 9
Development of human hip joint 16
Pathomechanics 24
Pathology 28
Incidence and etiology 37
Clinical diagnosis of DDH 50
Radiographic examination 60
Computed tomography (CT) 70

Magnetic resonance imaging (MRI) 72
Arthrography 74
Treatment 78
Complications of treatment 98
MATERIAL AND METHODS 109
RESULTS 142
CASES PRESENTATION 171
DISCUSSION 199
SUMMARY 223
CONCLUSION 229
REFERENCES 231
ARABIC SUMMARY
tt

LIST OF FIGURES
Figure Page
Fig. 1: The bench of Hippocrates. 5
Fig. 2: Right hip joint from the front. 11
Fig. 3: The hip joint from behind. 12
Fig. 4: Left hip joint, opened by removing the floor of the acetabulum
from within the pelvis. 13
Fig. 5: Hip joint, front view. The capsular ligament has been largely
removed. 14
Fig. 6: Structures surrounding right hip joint 15
Fig. 7: Diagram of right innominate bone. 20
Fig. 8: Infant proximal femur. 22
Fig. 9: Adaptive soft tissue changes in DDH. 31
Fig. 10: Abnormal capsular adhesions. 31
Fig. 11: Hourglass constriction of the capsule. 32
Fig. 12:The pelvifemoral muscles. 33
Fig. 13: Eversion of the acetabulum. 34
Fig. 14: Associated deformities with DDH. 49
Fig. 15: Newborn at risk of DDH. 51
Fig. 16: Ducklike waddle or sailor's gait in bilateral hip dislocation. 53
Fig. 17: Physical finding suggesting DDH. 54
Fig. 18: Limited abduction. 55
Fig. 19: Piston Mobility or telescoping. 56
Fig. 20: Absence of femoral head. 56
Fig. 21: Nelaton' line. 57
Fig. 22: Trendelenbug test. 58
Fig. 23: Bilateral hip dislocation. 59
III

Fig. 24: Diagram showing Hilgenreiner's line or the Y line and vertical
Perkins's line. 62
Fig. 25: Method of measuring lateral displacement of the femoral head.63
Fig. 26: Measurement of superior displacement. 64
Fig. 27: Schematic diagram of radio-graphic types of tear drops. 66
Fig. 28: Acetabular index. 67
Fig. 29: CE angle. 68
Fig. 30: The Tonnis grades of dislocation. 69
Fig. 31: Drawing of medial pooling ratio calculation. 77
Fig. 32: The three groups of pelvic osteotomies. 82
Fig. 33: Salter innominate osteotomy. 85
Fig. 34: Pemberton acetabuloplasty. 87
Fig. 35: Steel's triple innominate osteotomy. 89
Fig. 36: Staheli osteotomy. 91
Fig. 37: Chiari pelvic osteotomy. 92
Fig. 38: Femoral anteversion in CDH and the effect of capsulorraphy,
derotation osteotomy and Salter osteotomy. 97
Fig. 39: The 4 types of ischemic necrosis of the proximal femur. 102
Fig. 40: sex incidence. 110
Fig. 41: Side affected. 110
Fig. 42: Bikini incision. 122
Fig. 43: Iliofemoral incision. 123
Fig. 44: Incision in the deep fascia. 124
Fig. 45: Dissection between tensor fasciae latae and sartorius muscle. 124
Fig. 46: Iliac apophysis split and subperiosteal release of tensor fasciae
latae, gluteus medius and minimus muscles. 125
Fig. 47: Distal reflection of sartorius and two heads of rectus femoris
muscles. 126
Fig. 48: Iliopsoas tendon recession. 127

Fig. 49: T-shaped capsular incision. 128
Fig. 50: Inspection for intra-articular barriers to reduction and excision of
ligamentum teres. 128
Fig. 51: Removal of fibrofatty tissue from the acetabulum. 128
Fig. 52: Technique of capsulorraphy. 131
Fig. 53: Technique of d
erotation
osteotomy and femoral shortening. 133
Fig. 54: Technique of spica cast application. 136
Fig. 55: Clinical result. 145
Fig. 56: Radiological results. 148
Fig. 57: Results and age at operation. 151
Fig. 58: Comparison between results in unilateral and bilateral cases. 154
Fig. 59: Results and side affected. 156
Fig. 60: Results and gender. 158
Fig. 61: Incidence of avasular necrosis. 159
Fig. 62: Incidence of complete and partial avasular necrosis. 160
Fig. 63: AVN and age at operation. 162
Fig. 64: AVN and surgical procedure. 164
Fig. 65: AVN and hip stiffness. 165
Fig. 66: Case number 1. 171
Fig. 67: Case number 6. 176
Fig. 68: Case number 7. 180
Fig. 69: Case number 12. 183
Fig. 70: Case number 16. 186
Fig. 71: Case number 22. 189
Fig. 72: Case number 28. 192
Fig. 73: Case number 31. 194
Fig. 75: Case number 35. 197

LIST OF TABLES
Table Page
Table 1: DDH high-risk group factors. 51
Table 2: Advantages of AP and lateral arthrograms. 77
Table 3: Recommended osteotomies for congenital dislocation of the hip. 84
Table 4: Classification of ischemic necrosis of femoral head after
treatment of DDH. 104
Table 5: Complication reported by Williamson, 1989. 108
Tab. 6: Sex incidence. 110
Tab. 7: Side affected. 110
Table 8: Complaint. 115
Table 9: Associated congenital anomalie. 118
Table 10: Material and methods. 140, 141
Table 11: Criteria for clinical evaluation. 143
Table 12: Clinical result. 144
Table 13: Severin classification (1941). 146
Table 14: Radiological results. 147
Table 15: age distribution. 149
Table 16: Results and age at operation. 150
Table 17: Comparison between results in unilateral and bilateral cases. 153
Table 18: Results and side affected. 155
Table 19: Results and gender. 157
Table 20: Incidence of avasular necrosis. 159
Table 21: Incidence of complete and partial avasular necrosis. 160
Table 22: AVN and age at operation. 161
Table 23: AVN and surgical procedure. 163
vi

Table 24: AVN and hip stiffness. 163
Table 25: complications other than vascular necrosis. 168
Table 26: Results. 169, 170
VII

CDH
DDH =
=
Bil. = Bilateral.
B.Sym =
LIST OF ABBREVIATIONS
Congenital hip dislocation.
Developmental dysplasia of the hip.
Bilateral symmetrical.
Wad. = Waddling gait.
OR = open reduction.
Trend. =
PFO =
=
Trendelenbug gait.
Proximal femoral osteotomy (Femoral derotation and shorterning).
delayed walking.
Asym. = Asymmetrical.
LH = ligamentous hyperlaxity.
Tort. = Torticollis.
Abd. =
Abduction.
Cal.Val. = Calcaneovalgus foot.
Gr. Troch. = Greater trochanter.
Trend sign = Trendelenburg sign.
Asso. =
Anom. associated congenital anomalies.
=
SWI Superficial wound infection
FF =
supracondylar fracture femur
THS & PHS = Transient and persisted hip stiffness
LLD =
Significant limb-length discrepancy
MP = Meralgia parathetica
CV = Coxa v
ary
VIII

INTRODUCTION
INTRODUCTION
There has been a recent trend in the pediatric orthopedic literatures
(
d
to change the terminology from congenital dislocation of hip to
developmental of the hip (DDH). The term congenital implies
ysplasia
that the condition existed at birth. The term developmental includes the
embryonic, fetal and infantile period. Dislocation of the hip refers to the
hip in which a complete loss of contact occurs between the femoral head
and the acetabulum, but hip dysplasia is often used to include the entire
spectrum of congenital hip abnormalities from instability to dislocation.
So the Pediatric Orthopedic Society of North America, the American
Academy of Orthopedic Surgeons, and the American Academy of
Pediatrics have endorsed the name change from CDH to DDH
(Weinstein, 1996; G
uille
et al, 2000; No authors listed, 2000).
The presenting complaint of developmental dysplasia of the hip
varies according to the degree of displacement, whether the hip is
subluxatable,
patient (Tachdjian, 1997).
dislocatable, or dislocated, as well as on the age of the
DDH falls into two major categories: Teratologic (atypical) which
is associated with other severe malformations such as arthrogryposis
multiplex congenita, m
chromosomal a
normal infant (
Tachdjian,
bnormalities,
,
yelomeningocele,
lumbosacral agenesis, and
and Typical, which occurs in an otherwise
1997).
CDH)

INTRODUCTION
The fundamental treatment goals of DDH are the same regardless
of patient age. The main goal is to obtain and maintain concentric
reduction to provide an optimum environment for femoral head and
acetabular development. (Weinstien, 1992) The acetabulum has potential
for development for many years after reduction as long as the reduction is
maintained (Lindstrom et al, 1979) and femoral anteversion well also
remodel if the reduction maintained (Malvitz, and Weinstein, 1994).
The later the diagnosis of DDH is made, the more difficult it is to
achieve a concentric reduction, the less potential there is far acetabular
and proximal femoral remodeling, and the more complex are the required
treatment. With increased age and complexity of treatment, the greater
the risks of complications and the more likely the patient will eventually
develop degenerative joint disease (Lindstrom et al., 1979).
2

AIM OF THE WORK
AIM OF THE WORK
Evaluation of surgical treatment for congenital dislocation of the hip
in children aged from 18 to 48 months, by open reduction and occasionally
proximal femoral osteotomy, in El-Minia University Hospital and Cairo
University Children's Hospital.

with a f
REVIEW OF L
HISTORICAL REVIEW
Congenital dislocation of the hip is a classic orthopaedic condition
acinating
history.
Dislocation of the hip joint was referred to as. early as in the oldest
medical documents. Even Hippocrates (460 —370 B.C.) gives a detailed
description of dislocation of various joints and mentions that a dislocation
of the hip may be congenital, caused by an injury to the mother's
abdomen (Lowegren, 1909).
Hippocrates also gives detailed directions concerning the manual
reduction of various dislocations, with or without means of assistance
(Palmen, 1984).
Fig. 1 shows an illustration from the 16th century of the "bench of
Hippocrates".
ITERATURE'S
4

Fig. (1): The bench of Hippocrates (Palmen, 1984).
REVIEW OF LITERATURES
In writings from the 16th and 17th centuries occasional references are
made to dislocations of the joint. Ambroise Pare in Paris, the " father of
surgery", note in 1578 that hip dislocation may be hereditary. He also
mentioned that a shallow a
head at reduction.
cetabulum
impedes retention of the femoral
The first post—mortem pathological—anatomical description of a
dislocated hip joint was given by Paletta in Vienna in 1783, concerning a
bilateral dislocation in a boy aged 15 days.
Dupuytren's dissertation on hip joint dislocation, written in Paris in
1826, is well known. He described the underdeveloped acetabulum at
dislocation and remarked that treatment had no prospect of success
(Palmen, 1984).

REVIEW OF LITERATURES
It is generally held that the first definite case of successful reduction of a
dislocation of the hip joint was that reported by Pravaz in Lyon in 1836,
in a 7 year old boy with unilateral dislocation.
During the middle decades of the 19th century new interest in dislocation
of the hip joint arose, owing to the establishment of orthopaedic hospitals,
providing schools for the surgeons of the time.
Prolonged traction therapy preceding attempts at reduction was used in
the 1860's to 1880's in the U.S.A Brown, 1885 and in England Adams,
1888 (Palmen, 1984).
The year 1895 was a notable year in the history of orthopaedics, when
Lorenz in Vienna published his method of closed reduction of congenital
hip dislocation (Lorenz, 1920).
With the discovery of X-rays in 1895 the primarily encouraging result
could be verified and Lorenz's method quickly became widespread.
During the last three decades of the 19th century surgical operations were
introduced for correction of t
dislocation, Guerin, Konig and Paci
(1888) and Hoffa (1897). These consisted m deepening of the
acetabulum
with a view to facilitating retention of the femoral head, a
method also used by Lorenz (1895). However, the results were
by

REVIEW OF LITERATURES
disappointing. Infections, sometimes fatal, were not unusual and
subsequent joint contractures occurred. Many warned against the
operations, and the late results were always discouraging (
Palmen,
1984).
It is of interest from the historical viewpoint that Ortolani's examination
method had already been described in exactly the same way in 1912 by
Le Damany in France. But the latter author did not realize its importance
and the method fell into obscurity (Le D
amany,
1912).
Hilgenreiner (1925) in Prague described his 10 years experiences of
treating dislocation in infants that treatment was best started at the age of
4-6 months. He favored an abduction splint.
In Bologna Putti introduced early treatment for congenital hip
dislocation. He presented the first 24 cases at the orthopaedic conference
in London in 1929, and in his publication of 1933, he reported on 119
treated cases (Putti, 1935).
Ortolani, a paediatrician in Ferrara in northern Italy started to apply the
principle of early diagnosis and treatment. His diagnostic criterion was
the "click" which occurs when the femoral head, if subluxated or
dislocated, slips back into the acetabulum on abduction of the legs, flexed
at the hip joints. For treatment, he used a pillow to keep the hip joints
flexed and abducted (Ortolani, 1976).
7

REVIEW OF LITERATURES
In the U.S.A. Chapple (1935) reported that he had treated 3 infants with
a hip spica before the age of 3 years with encouraging results (Chapple,
1935).
In Czechoslovakia, Frejka (1941) used the same type of pillow as
Ortolani. It is known as a Frejka pillow and is used in many countries
including Scandinavia (
Frejka,
1941).
Pelvic osteotomies as developed by Salter (1961) and by Chiari (1963)
have become standered operations. Pemberton (1965) decribed his
acetapuloplasty. Steel (1973) developed his osteotomy, modified by
Sutherland (1977).
8

REVIEW OF LITERATURES
ANATOMY OF THE HIP JOINT
This articulation is an enarthrodial or ball-and-socket joint, formed by the
reception of the head of the femur into the cup-shaped cavity of the acetabulum.
The articular cartilage on the head of the femur, thicker at the center than at
the circumference, covers the entire surface with the exception of the fovea
capitis femoris, to which the ligamentum teres is attached; that on the
acetabulum forms an incomplete marginal ring, the lunate surface. Within the
lunate surface there is a circular depression devoid of cartilage, occupied in the
fresh state by a mass of fat, covered by synovial membrane (Gray, 1978).
The ligaments of the joint are:
• The articular capsule.
• The iliofemoral
• The pubocapsular.
• The ischiocapsular.
• The ligamentum teres f
• The l
glenoidal
• The transverse acetabular.
abrum.
emoris.
9

REVIEW OF LITERATURES
The Articular Capsule (capsula articularis; capsular ligament)
The articular capsule is strong and dense. Above, it is attached to the margin of
the acetabulum; 5 to 6 mm beyond the glenoidal labrum behind; but in front, it
is attached to the outer margin of l
the and opposite to the notch where
the margin of the cavity is deficient, it is connected to the transverse ligament,
and by a few fibers to the edge of the obturator foramen. It surrounds the neck
of the femur, and is attached, in front, to the intertrochanteric line; above, to the
base of the neck; behind, to the neck, about 1.25 cm. above the intertrochanteric
crest; below, to the lower part of the neck, close to the lesser trochanter.
From its femoral attachment some of the fibers are reflected upward along the
neck as longitudinal bands, termed retinacula.
The capsule is much thicker at the upper and forepart of the joint, where the
greatest amount of resistance is required; behind and below, it is thin and loose.
It consists of two sets of fibers, circular and longitudinal:
The circular fibers, zona orbicularis, are most abundant at the lower and back
part of the capsule, and form a sling or collar around the neck of the femur.
The longitudinal fibers are greatest in amount at the upper and front part of the
capsule, where they are reinforced by distinct bands, or accessory ligaments, of
which the most important is i
the ligament. The other accessory
bands are known as , the pubocapsular and the ischiocapsular ligaments.
The external surface of the capsule is rough , covered
liofetnoral
abrum,
by numerous muscles
1 0

(
iliocapsularis
REVIEW OF LITERATURES
muscle), and separated in front from the psoas major and iliacus
by a bursa, which not infrequently communicates by a circular aperture with the
cavity of the joint (Ward et al, 2000).
Fig. 2:
Right hip joint from the front showing iliofemoral and pubocapsular
ligaments (
1933).
Spalteholz,
I
(
The Ligament
of Bigelow) Fig. 2
The iliofemoral ligament is a band of great strength, which lies in front of
liofemoral
ligamentum
iliofemorale;
Y-ligament;
ligament
the joint; it is intimately connected with the capsule, and serves to strengthen it
in this situation.
It is attached, above,
to the lower part of the anterior inferior iliac spine; below,
it divides into two bands, fixed to the upper and lower parts of the

REVIEW OF LITERATURES
intertrochanteric line. Between the two bands is a thinner part of the capsule
(Coleman, 1978).
Fig. 3: The hip joint from behind showing ischiocapsular ligament
(Spalteholz, 1933).
The Pubocapsular Ligament (ligamentum pubocapsulare; pubofemoral
ligament): This ligament is attached, above, to the obturator crest and the
superior ramus of the pubis; below, it blends with the c
surface of the vertical band of the iliofemoral ligament (Gray, 1978).
The I
schiocapsular
apSule
and with the deep
Ligament (ligamentum ischiocapsulare; ischiocapsular
band; ligament of Berlin): The ischiocapsular ligament consists of a triangular
band of strong fibers, which spring from the ischium below and behind the
acetabulum, and blend with the circular fibers of the capsule (Gray, 1978).
Fig. 3
12

S
1.
+
4
r I
Iti,
fentcirqf
(
ivarn41e
REVIEW OF LITERATURES
The Ligamentum Teres Femoris (Fig. 4): The ligamentum teres femoris is a
triangular, somewhat flattened band implanted by its apex into the antero-
superior part of the fovea capitis femoris; its base is attached by two bands, one
into either side of the acetabular notch, and between these bony attachments it
blends with the transverse ligament. It is ensheathed by the synovial membrane
(Gray, 1978).
Ant,
if r
,
inf.
no
Fig. 4: Left hip joint, opened by removing the floor of the acetabulum from
within the pelvis showing ligamentum teres femoris (Spalteholz, 1933).
The Glenoidal Labrum (labrum c
glenoidale; ligament): Fig. 5
The glenoidal labrum is a fibrocartilaginous rim attached to the margin of the
acetabulum, the cavity of which it deepens. It bridges over the notch as the
transverse ligament, and thus forms a complete circle, which closely
surrounds the head of the femur and assists in holding it in its place. It is
triangular on section, its base being attached to the margin of the acetabulum,
while its opposite edge is free and sharp (Coleman, 1978).
otyloid
13

REVIEW OF LITERATURES
Fig. 5: Hip joint, front view. The capsular ligament has been largely removed
showing cotyloid ligament (Spalteholz, 1933).
The Transverse Acetabular Ligament t
(ligamentum acetabuli;
transverse ligament): This ligament is in reality a portion of the glenoidal
labrum, though differing from it in having no cartilage cells among its fibers. It
consists of strong, flattened fibers, which cross the acetabular notch, and
convert it into a foramen through which the nutrient vessels enter the joint
(Coleman, 1978).
Synovial Membrane: The synovial membrane is very extensive. Commencing
at the margin of the cartilaginous surface of the head of the femur, it covers the
portion of the neck which is contained within the joint; from the neck it is
reflected on the internal surface of the capsule, covers both surfaces of the
glenoidal labrum and the mass of fat contained in the depression at the bottom
of the acetabulum, and ensheathes the ligamentum teres as far as the head of the
femur. The joint cavity sometimes communicates through a hole in the capsule
ransversum
14

Pito:
Amnia
teN
ft M
Obertmtor
Ori,
1%
-
liciammAt
a n
al
wrr”
.
Irvt,
ear»
,
I Sciatic N
iltrcrlatcs
C
l'e.
a.
wyst
rts
40
eund-oharri.
,9
we'ta
,
REVIEW OF LITERATURES
between the vertical band of the iliofemoral ligament and the pubocapsular
ligament with a bursa situated on the deep surfaces of the psoas major and
iliacus (Last, 1973).
The muscles in relation with the joint are, in front, the psoas major and iliacus,
separated from the capsule by a bursa; above, the reflected head of the rectus
femoris and gluteus minimus, the latter being closely adherent to the capsule;
medially, the e
obturator and pectineus; behind, the piriformis, gemellus
superior, obturator internus, gemellus inferior, obturator extemus, and
quadratus femoris (Last, 1973). Fig. 6
xtemus
Fig. 6: Structures surrounding right hip joint (Spalteholz, 1933).
The nerves are articular branches from the sacral plexus, sciatic, obturator,
accessory obturator, and a filament from the branch of the femoral supplying
the rectus femoris.
Movements: The movements of the hip are very extensive, and consist of
flexion, extension, adduction, abduction, circumduction, and rotation (Last,
1973).
rre
15

REVIEW OF LITERATURES
DEVELOPMENT OF HUMAN HIP JOINT
To comprehend the etiology and pathogenesis of DDH, it is
necessary to understand the development of the human hip joint. Many
detailed comprehensive studies of the developing hip have been reported
by Badgley, 1943; Gardner and Gray, 1950; Lauenson, 1965; Strayer,
1971; Watanabe, 1974 and others helped to expand and further our
understanding of hip joint development.
1- Prenatal development of the hip:
The prenatal development of the hip has been arbitrarily divided into
the embryonic and fetal periods.
The embryonic period involves the first 2 months after
fertilization. At 4 weeks of gestation the embryo is about 5 mm in crown-
rump length and the limb buds can be seen as folds along the ventro
lateral aspect of the body. At this stage the hip shows little differentiation,
however, the knee joint, feet, and toes already show some early evidence
of development.
When the length of the fetus is 10 mm (5 to 6 weeks), the os
innominatum blastema begins to separte into three masses, representing
the ilium, ischium, and pubis. At the 12 mm stage (6 weeks) the femoral
16

REVIEW OF LITERATURES
shaft begins to show precartilage cells and assumes a somewhat " club-
shaped" appearance.
Development of the acetabulum were the same as for those ultimately
contributed by the corresponding portions of the i
nnominate
bone in the
adult, namely, two fifths ischium, two fifths ilium , and one fifth pubis.
During this acetabular formation, which can be observed as early as 6 to 7
weeks of gestation (length, 15 mm), the femoral head can be seen to
develop in situ as a globular structure within the primitive cartilage of
the hip joint.
When the fetus has reached 20 mm in length (7 1/2 weeks of gestation )
this interzone differentiates into three layers. The middle layer or zone
represents the first evidence of the synovial membrane, and the outer
layers represent the perichondrium of the a
cetabulum
and femoral head.
At 2 months of gestation the embryo measures about 30 mm in length;
during this period the circulation to the limb is established and the hip
joint becomes completely formed in cartilage, with an identifiable
femoral head, acetabulum, capsule, synovial membrane, and ligamentum
teres.
The fetal period begins at the conclusion of the embryonic stage and
continues at the final prenatal development at term. It is during this time
that the complex c
development of the human hip take place
and the features of the hip that relate to antenatal dysplasia and
dislocation are established.
haracteristic'
17

REVIEW OF LITERATURES
The hip joint forms from a single mass of plastema, which forms the
cartilage model of the components of the joint. The femoral head and
acetabulum are well formed prior to the formation of the joint space. The
joint space forms at the age of 11 weeks. C
dngenital
dislocation of the hip
cannot occur prior to the twelfth week since the joint is not formed at this
time.
The degree of femoral anteversion measures near the neutral point during
the first half of fetal life. It then increases to 35 degree at the time of
birth.
The legs lie in a position of flexion, abduction and external rotation
during fetal life and the hip joint is most stable in this position. The
sudden extension of the hip joint in the presence of a dysplastic
acetabulum will result in the actual complete dislocation of the hip.
At the age of 20 weeks, the ossification has progressed in the femoral
shaft, ilium, ischium and the pubis. The femoral head remains entirely
cartilaginous at this stage. Acetabular development continues through
intra-uterine life particularly by growth and development of the labrum
(Watanabe 1974).
2- Development after birth
At birth the femoral head is deeply seated in the acetabulum and
held within its confines by the surface tension of , the
something of a suction cup phenomenon. Even if the hip joint capsule is
synovial
fluid,
18

REVIEW OF LITERATURES
divided, it is extremely difficult to dislocate a normal infant hip (Ponseti,
1978).
Hence, hips in newborn with DDH are not merely normal hips with
capsular laxity, but pathologically abnormal. The growth of the
acetabular cartilage complex and the proximal femur are interdependent,
and their continued growth after birth are important for the ongoing
development of the hip joint (Watanabe, 1974).
The acetabular cartilage complex (Fig. 7) is a three-dimensional
structure that is triradiated medially and cup-shaped laterally. This
complex is interposed between the ilium above, the li
the pubis anteriorly.
schium
below, and
The outer two thirds of the acetabular cavity is formed by the acetabular
cartilage. Portions of the triradiate cartilage and a portion of the ilium
above, and the ischium below form the nonarticular medial wall of the
acetabulum. The acetabular cavity is separated from the pubic bone by
thick cartilage from which a secondary ossification center, the os
acetabulum, will develop in early adolescence (Ponseti and Frigerio,
1959).
At the margin of the acetabular cartilage is the fibro-cartilaginous labrum.
l
p
The joint capsule inserts just above the and is continuous with the
labrum below and the of the pelvic bones above.
eriosteum
The triradiate cartilage is a three—limbed structure. One limb is oriented
horizontally between the ilium and ischium. A second limb is oriented
abrum
19

vertically and interposed between the i
limb is located anteriorly and slanted s
the pubis.
schium
uperiorly
REVIEW OF LITERATURES
and the pubis. The third
between the ilium and
Acetabular cartilage growth occurs through interstitial growth within the
cartilage and appositional growth under the p
erichondrum.
If this area is
injured during surgery, further acetabular growth may be jeopardized .
Fig. 7: Diagram of right innominate bone showing development of the
acetabulum. (OS) os acetabulum, (AE) acetabular epiphsis (Ponseti,
1978).
Each limb of the triradiate cartilage is composed of very cellular hyaline
cartilage containing many cartilage canals. Each limb has a growth plate
20

REVIEW OF LITERATURES
in either side. The hip joint expands its diameter during growth by
interstitial growth within the triradiate cartilage.
Volume (diameter and depth) of the acetabulum is enhanced by
development of the 3 ossification centers and interstitial growth within
the triradiate cartilage. The lateral lip of the acetabulum and lateral
extension of its roof are developed from the l
the ilium (Siffert, 1981).
abrum
and ossific center of
In the infant the entire proximal end of the femur is composed of
cartilage. Between the fourth and seventh months of life the proximal
femoral ossification center appears. This bony Centrum continues to
enlarge but at a slowly decreasing rate, along with its cartilaginous
analogue, until adult life, when only a thin layer of articular cartilage
remains The greater trochanter and the proximal femur enlarge by
appositional cartilage cell proliferation.
Three main growth areas are present in the f
proximal
plate, the growth plate of the greater trochanter, and the femoral neck
isthmus (Siffert, 1981).
emur,
the physeal
For the normal configuration of the proximal femur and the relationship
between the proximal femur and the greater trochanter as well as the
overall neck width, a balance between the growth rates of these various
centers must exist. The growth of the proximal femur is affected by the
forces transmitted across the hip joint by weight bearing, normal joint
nutrition, circulation, muscle pull, and muscle tone, also may be
stimulated by hyperemia secondary to surgery or inflammatory conditions
(Siffert, 1981; Schofield and Smibert, 1990). Alternation in any of these
21

REVIEW OF LITERATURES
factors may cause profound changes in development of the proximal
femur (Reynolds, 1986).
During infancy a small i
cartilaginous connects the trochanteric
and femoral growth plates along the lateral border of the femoral neck
and is a reflection of their previous common origin. This growth cartilage
contributes to the lateral width of the femoral neck and remains active
until skeletal maturity. Fig. 8
Fig. 8: Infant proximal femur showing c
trochanter and proximal femur physeal plate
sthinus
artilagenous
(Ponseti, 1978).
isthmus connecting
22

REVIEW OF LITERATURES
The main conclusions derived from a review of the development of the
hip joint in relation to DDH are:
1) The hip joint is an anatomical and functional unit derived from a
common primitive blastema.
2) Primitive condensed s
clerotomic
mesenchyme transforms into
cartilage that shapes in a genetically determined pattern to form the femur
and os innominatum in continuity.
3) The joint space develops by autolytic degeneration in the 7-8 weeks
embryo. By the 1 1 th week, the joint cavity, evolved in the capsule lined
internally by synovium, has a well-differentiated labrum and l
teres with the basic morphology of a developed hip joint. Only after this
stage is displacement possible.
4) Depth (and stability) of the acetabul um increase with development of
the glenoid labrum and cartilaginous rim (incomplete only in its inferior
portion). Here a fibrous band (transverse ligament) offers less resistance
to displacement, but occasions are an anatomic barrier to concentric
reduction.
5) In the early fetal period, the a
cetabulum
is a deep-set cavity, becoming
shallower at the time of birth. Femoral head coverage at birth is more
deficient than at any other previous or subsequent of development.
(Torrelles et al., 1990).
igamentum
23

PATIMMECHANICS
REVIEW OF LITERATURES
The mechanism of congenital dislocation is probably quite simple.
Near the time of birth, the joint capsule is distended and elastic
(McKibbin, 1970). After delivery, the femoral head is loose within the
joint and free to "fall' out" of the acetabulum (Salter, 1968). If the
dislocation is recognized in the newborn period, the femoral head can
easily be returned to its normal position (reduced). At this early stage, the
shape of the joint and soft tissue structures is close to normal (Salter,
1968). Thus, for a stable hip to develop it is only necessary to maintain
the normal relationship between the femoral head and the acetabulum for
a few weeks while the joint capsule returns to its normal configuration. In
this case, the hip has the potential for an excellent long-term result.
If the dislocation is allowed to persist, however, the soft tissue and bone
adjacent to the joint gradually undergo adaptive changes, the dislocation
becomes more difficult to a
reduce,
successful long-term result diminishes significantly.
nd
the chance for obtaining a
The rate of growth in the newborn period is rapid, with the infant
doubling in size in the first 5 to 6 months, and tripling in size in the first
year. Thus, the earlier the reduction is accomplished, the fewer are the
5 .
adaptive changes that will have occurred and the shorter is the time
required for the joint components to return to their normal configuration.
During the first year of life, the potential exists for the hip to be

REVIEW OF LITERATURES
remodeled so that it appears normal roentgenographically. If the
dislocation is not treated, the simple problem becomes more complex.
The longer the hip is dislocated, the more the normal muscle action will
increase the proximal and lateral migration of the femoral head along the
pelvis (
Kalamchi
CAPSULAR LAXITY
and MacFarlane, 1982).
The stability of joints depends on the integrity of the soft tissues
(mainly the joint capsule and i
the shape of the joint surfaces.
Capsular laxity can take one of two forms:
liofemoral
ligament in front) rather than on
Firstly, the laxity of the whole of the capsule which allows an increased
range of movement in all directions but not necessarily displacement.
Such capsular laxity may not be a cause of displacement but there is no
doubt that where severe generalized laxity exists correction of a
dislocated hip may prove very difficult and the prognosis may be poor.
Dislocated hips associated with severe degrees of E
are probably better left alone.
hlers—
Danlos
disease
Secondly, laxity as the result of stretching may develop in a part of the
capsule, while the rest remains normal or even contracted. It is in this
type of laxity that displacement is more likely to occur (Somerville,
1978).
25

REVIEW OF LITERATURES
Andren and Palmen, 1963 suggested that capsular laxity might be
caused by the effect of the maternal relaxing hormones present in the
bloodstream at birth, and that this might well affect the ligaments of the
child's joints before, during, and after birth for a short time.
There are several factors, which make the theory attractive, because they
fit in with known facts:
1) It is beyond doubt that the capsule is stretched in the congenitally
displaced hip, whether dislocated or subluxated, because the head
remains within it, whereas in traumatic displacement the capsule is
ruptured.
2) The capsule in a normal hip at birth is a strong structure, and attempts
at dislocation in the stillborn child result in fracture of the femur rather
than displacement of the hip. It seems that the capsule must be
abnormally stretchable in those children who are at risk.
3) Whatever it is that causes the weakening of t
he'capsule
must have only
a transient effect, because of the strong tendency for the instability to
resolve spontaneously in the first week of life in the great majority of
cases and the ease with which the rest respond to treatment. This could
only happen if the laxity were a temporary phenomenon.
It is difficult to think of anything, which fits the facts better than the
hormonal hypothesis (Somerville, 1978).
26

Mechanism of displacement:
REVIEW OF LITERATURES
Capsular laxity cannot cause displacement, it can only allow it to
occur. Some mechanism of displacement is r
The baby compression 'in utero as in cases of oligohydramnois. The
mechanism of displacement was pressure on the flexed knee while the hip
joint flexed and adducted forcing the head of the femur out through the
back of the a
cetabulum.
The problem lay in the psoas muscle, which had shortened so that when
equirqd:
the hip was forcibly extended the tight psoas acted as a fulcrum about
which the head was levered out of the acetabulum. Such a mechanism
would force the head of the femur against the posterosuperior part of the
acetabulum, and if strong enough would produce a dislocation or
subluxation (Somerville, 1978).
Direction of Displacement:
In the literature there are descriptions of the'displacement occurring
posteriorly, superiorly, inferiorly and anteriorly, each direction being
associated with a different mechanism (Somerville, 1978).
27

Mechanism of displacement:
REVIEW OF LITERATURES
Capsular laxity cannot cause displacement, it can only allow it to
occur. Some mechanism of displacement is required:
The baby compression :in utero as in cases of oligohydramnois. The
mechanism of displacement was pressure on the flexed knee while the hip
joint flexed and adducted forcing the head of the femur out through the
back of the acetabulum.
The problem lay in the psoas muscle, which had shortened so that when
the hip was forcibly extended the tight psoas a
cted
as a fulcrum about
which the head was levered out of the acetabulum. Such a mechanism
would force the head of the femur against the posterosuperior part of the
acetabulum, and if strong enough would produce a dislocation or
subluxation (Somerville, 1978).
Direction of Displacement:
In the literature there are descriptions of athe
occurring
posteriorly, superiorly, inferiorly and anteriorly, each direction being
associated with a different mechanism (Somerville, 1978).
isplaCement
27

PATHOLOGY
REVIEW OF LITERATURES
If the golden opportunity for early diagnosis and treatment has
been missed and displacement of the head of the femur persists, whether
small or great, secondary structural changes will develop, which can
become permanent as the damage will be irreversible increases with
continuing duration of displacement (Hasegawa and Iwata, 2000).
Initially, displacement may be so small in amount no more than an
eccentricity of movement of the head of the femur within the acetabulum.
Even this will, with time, lead to a progressive deterioration of the joint,
so that there will be some acetabular dysplasia which will be secondary.
But more severe degrees of displacement may be present from the start,
which will lead to greater changes (Hasegawa and Iwata, 2000).
The changes, all of which are secondary to the displacement, are to
be found in:
1)The ossification.
2) The soft tissues.
3) The acetabulum.
4) The upper end of the femur.
28

posteromedial
OSSIFICAION
REVIEW OF LITERATURES
There is delay in the ossification of the whole joint. This will be
shown by delay in appearance and underdevelopment of the ossific
nucleus in the head of the femur, and an apparent sloping of the
acetabular roof.
While instability is one cause for the delay in ossification in the capital
ossific nucleus there is a further reason for its small size in some cases:
the blood supply is from two leashes of vessels. The larger lies
posterolaterally and supplies the anterolateral part of the femoral ossific
nucleus. The second leash lies posteromedially and supplies the
vessels.
part. There is little if any a
nastomosis
between these
In the dislocated position it is the posteromedial part of the head of the
femur, which is in contact with the pelvis and will knock against the side
of the pelvis in movement, and this will endanger the patency of the
posteromedial leash of vessels, which enter the bone at this point. If it is
damaged, in part or in whole, the development of the posteromedial part
of the nucleus will be impaired or delayed (Somerville, 1953).
SOFT TISSUES
The changes in soft tissues are purely adaptive. Some are
adaptively shortened and some are stretched, while others are simply
distorted (Tachdjian, 1990).
29

Ligamentum
The joint capsule:
REVIEW OF LITERATURES
The hip joint capsule becomes enlarged to a varying degree
depending on how high up the ilium the femoral head comes to lie. As the
dislocation persists, the capsule narrows at the isthmus, the area where
the iliopsoas crosses to the lesser trochanter. Fig. 9
The capsular isthmus eventually becomes narrower than the diameter of
the femoral head. At this point a complete closed reduction becomes
impossible because of the capsular constriction (hourglass constriction).
Fig. 11 Although this is more likely to occur in older children, it may
occasionally be the case of the young child.
Abnormal capsular adhesions may occur; around the femoral neck,
across the acetabular floor, along the lateral wall of ilium; preventing
reduction. Fig. 10
teres:
The ligamentum teres becomes longer and thicker. In a few cases
the ligamentum teres loses contact with the femoral head and atrophies.
Fig. 9
Transverse acetabular ligament:
The transverse acetabular ligament, which is the inferior
continuation of the l
acetabular is pulled superiorly with the
capsule, contracting and blocking the lower portion of the a
abrum,
(Fig. 9). The posterior insertion of the transverse acetabular ligament can
be transformed into ,a toothlike bony prominence making complete
reduction impossible. It can be detected by CT scan or intraoperative
cetabulum
30

• " .
0.
:
Itittl.
:
Epitif
.
6 . 1
1:
m.
4
t, .
•••
•
•••
•
4
-
.
•
.
,
i.
3049.
1<
otc.
.
.
,
,
Ort■S
.
.
•
!
i:
c•i•41
f
, :
01
11
:
1951.
•
REVIEW OF LITERATURES
palpation, and can be corrected by pushing it back with a punch under
palpatory control (Brunner, 2002).
Pulvinar:
In the depths of the acetabulum, the pulvinar the small amount of
fibrofatty tissue that normally presents within the joint becomes
hypertrophic. Fig. 9
Fig. 9: Adaptive soft tissue changes in DDH; stretched capsule,
hypertrophied ligament= teres and p
ulvinar(
Tac
gn.
lotrtailrh
djian,
. h
1990).
Fig. 10: Abnormal capsular adhesions: A) to the lateral wall of ilium, B)
to the acetabular floor, and C) around the femoral neck (Tachdjian,
1990).
31

REVIEW'OF
LITERATURES
Fig. 11: Hourglass constriction of the capsule by tight iliopsos tendon. A)
Anterior view, B) Lateral view (Tachdjian, 1990).
False acetabulum:
Late in the course of events a false acetabulum forms, the false
acetabulum pathologically is an indentation in the wall of the ilium that
articulates with the femoral head. The false a
cetabulum
is lined with
fibrocartilage that may clinically resemble articular cartilage but has poor
weight — bearing characteristic, this fibrocartilage probably originates
from metaplasia of the hip capsule interposed between the femoral head
and the ilium. Fig. 9
Pelvifemoral muscles:
rectus f
The pelvifemoral muscles (the iliopsoas, hip adductors, gluteals,
emoris
and the hamstrings) will become shortened and prevent
lowering of the femoral head to the level of the acetabulum These
muscles should be elongated to allow reduction w
ithotit
increased
32

'.
tPuiee,
s
:
'
Yeirturus
rerhoral
Try *
ietabiJkiJr)
medifrs
I:
f
head
dletec"
ei.
eq
ond:
REVIEW OF LITERATURES
tension. The older the child and the higher the dislocation, the greater is
the severity of myostatic contractures and the more resistance to pulling
down the femoral head. Fig. 12
The end result of dislocation, usually late in adulthood is the formation of
degenerative changes of the femoral head and a
cetabulum
when there is
no contact between the femoral head and acetabulum (Tachdjian, 1990).
Fig. 12: The pelvifemoral muscles b
(Tachdjian, 1990).
eCome
short and contracted
33

DEFORMITY OF THE ACETABULUM
•
6
•f
• n
ap
tqc.
:
r/
s13!
A;
;
:
tqu
REVIEW OF LITERATURES
Deformity of a
the depends on the degree of
displacement and even more on the type of movement which the
displacement, and the soft tissue adaptation to it, allows.
cetabulum
In subluxation the head of the femur, which is in acetabulum, is the
center of movement but the center of the head is not, because there is
laxity of the soft tissues allowing the head to slip about in the a
This is eccentric movement. When the head of the femur is moving in an
eccentric manner it will gradually mould the lip of the a
outwards (eversion). Fig. 13
Fig. 13: A) Normal hip. B) Subluxatable hip. Note eversion of the
acetabulum (Tachdjian, 1990).
1•
+
1010!
0;
j1,
,
3i:
firist:
if!
p
cetabulum
cetabulum
"
fltitEtivi!
.
416d-
34

REVIEW OF LITERATURES
In dislocation the femoral head is no longer the center of movement,
and as shown the center of movement is somewhere in the
intertrochanteric region, perhaps closely related to the psoas, on which
the femur may well swing. With every movement the head of the femur
grinds against the side of the pelvis and will do most damage to the most
prominent part, which will be the lip of the a
superiorly. The lip of the a
cetabulum
cetabulum
posteriorly and
or limbus is fibrocartilaginous, soft
and malleable, and under repeated pressure it become deformed and
turned into the joint leading to different degrees of inversion, which may
be encountered. Fig. 9
It is the active kicking of child, which causes the deformity of the limbus.
In those cases where the dislocation is associated with some form of
paralysis, so that active kicking is nil or restricted, the limbus is rarely
deformed at all.
It is interesting that while the eversion of the limbus in subluxation takes
place slowly, it may take 2 or 2 1 /
2 years before it reaches a degree of
significance; the inversion of the limbus takes place rapidly and may be
established within a few months (Somerville, 1953 and 1957).
UPPER END OF THE FEMUR
While there may be changes in ,
the angle between one
case and another, they are of only minor degree at birth and probably of
neck-shaft
35

REVIEW OF LITERATURES
no significance. The main deformity is to be found in the angle of
anteversion.
The usual angle of anteversion at birth is about 25° - 35°. In the presence
of displacement the angle increases to 70°, 80°, or even 90° at times, so
that there must be some mechanism, which causes this increase.
In dislocation the posterior aspect of the head and neck of the femur are
against the hard wall of the pelvis, whereas the anterior aspect is only in
contact with soft tissue. The leg lies in some lateral rotation and each time
the child tries to rotate the leg medially pressure will be applied to the
posterior aspect of the head and neck, which will mould it progressively
into increasing a
nteversion
because the upper end of the femur at this
early age is growing rapidly and is very malleable (Somerville, 1953;
Sugano et al., 1998).
36

Incidence
REVIEW OF LITERATURES
INCIDENCE AND ETIOLOGY
There is great geographic and r
acia)
variation in the incidence of
DDH. Certain areas of the world have an endemically high incidence,
whereas in other areas it is virtually nonexistent. Among 16,000 black
African Bantu babies, Edelstein 1966 found not a single case of
congential dislocation of the hip, whereas in the Island Lake Region in
Manitoba, Canada, Walker 1973 reported an incidence of 188.5 per
thousand.
The incidence of DDH is reported as 0.1 per thousand in Chinese children
in Hong Kong (Hoaglund and associates, 1981), 1.5 per thousand in
Salford, England, (Barlow, 1962); 1.7 per thousand in Sweden (von
Rosen, 1962), and 75 per thousand in Belgrade, Yugoslvia (Klisic, 1976).
Some other reports of the incidence of DDH are 1: 50, by Coleman in
1956; 1:50, by Hiertonn and James in 1968; 1: 60 by Dunn in 1971; 1:
100, by Stanisavljevic in 1961, and 1: 160, by Paterson in 1976.
37

Factors responsible for incidence variability of DDH:
REVIEW OF LITERATURES
This difference in incidence of DDH among disparate groups is
explained by genetic and environmental factors. Another important
consideration is the age of the infant at the time of examination. The
congenitally dysplasic hip is observed more frequently in the newborn
than in the four week old infant (Tachdjian, 1990).
Barlow found that about one infant in 60 was born with instability of one
or both hips, and that of these 60 per cent recovered in the first week of
life, and 88 per cent in the first two months. The remaining 12 per cent,
an incidence of 1.55 per thousand, were typical congenital dislocation and
persisted (Barlow, 1962).
These findings of Barlow indicate that unstable and dislocatable hips
have a tendency to stabilize themselves spontaneously by tautening of the
lax capsule. The age of the baby at the time of examination is, therefore,
an important factor affecting the reported incidence of DDH.
The experience and ability of the examiner and clincial signs used for
criteria in making the diagnosis are other factors that determine the
reported incidence of congenital hip dislocation (Tachdjian, 1990).
PERIODS AT WHICH THE HIP MAY BE DISLOCATED
In the intrauterine life of the fetus there are three periods during
which the hip is at risk for dislocation: (1) the twelfth week, (2) the
eighteenth week, and (3) the final four weeks of gestation.
38

acetabuluum.
REVIEW OF LITERATURES
The period around the twelfth week of in utero development is the first
period of risk for hip dislocation because the first major positional change
of the lower limb takes place — the limb rotates medially, using the hip
joint as the pivot point. The joint capsule is weak, providing little
resistance to lateral displacement of the femoral head, and the femoral
neck is short and retroverted.
Failure of synchonized development of neuromuscular units will result in
abnormal muscle pull, and this coupled with an insufficiency of the
acetabular labrum will result in an unstable hip that is unable to tolerate
the torque of medial rotation of the lower limb. As a result the femoral
head is displaced out of the a
cetabulum
and remains dislocated until birth.
With rapid growth all elements of the hip joint quickly become abnormal:
the acetabulum becomes shallow, the capsule distends, the femoral head
and greater trochanter remain small because compressional loading is
lacking, and a false acetabulum develops. Pathologic changes observed at
birth are the most severe.
During the eighteenth week of gestation (the second period), the
musculature around the hip joint is fully developed, and active motion of
the hip begins. If there is anatomic instability of the hip joint such as
capsular weakness, insufficiency and shallowness of the acetabulum, or
abnormal muscle pull due to n
onsrichronous
•
development of
neuromusular units — the femoral head will be ' drwan out of the
During this period the pull of the iliopsoas muscle may
displace the femoral head anteriorly.
39

REVIEW OF LITERATURES
The third period is the last four weeks of gestation, when the hip joint
with all its muscles is fully developed. The factors producing hip
dislocation at this time are abnormal mechanical forces due to intrauterine
malposture of the fetus such as breech p
osition•with
extended knees or
oligohydramnios (lack of the normal amount of amniotic fluid). This is
the type of congenital hip dysplasia most commonly encountered at birth.
The hip joint may also be dislocated at birth and postnatally (Tachdjian,
1990).
Etiology:
Many factors are involved in causing congenital dislocation of the
hip: ligamentous hyperlaxity, mechanical forces resulting from anatomic
instability of the hip and intrauterine malposture, genertic influences, and
postnatal environmental factors (Tachdjian, 1990).
1- LIGAMENTOUS LAXITY:
Laxity and insufficiency of the capsule of the hip joint and its
associated ligaments are the prime factors in the pthogenesis of typical
congenital dislocation of the hip. The capsular and ligamentous laxity
may be hereditary, hormonal, or mechanical (Tachdjian, 1990).
Andren in 1960 has demonstrated abnormal laxity of the pelvic
ligaments in infants born with congenital dislocation of the hip, as shown
by distraction of the symphysis pubis twice as great as in normal control
cases.
The exact cause of excessive joint laxity and its predominance in the
female has not yet been determined. A decrease in the collagen content of
40

REVIEW OF LITERATURES
connective tissue of children with dislocated hips was found in studying
the umbilical cords of babies born with congenital dislocation of the hip
and comparing them with those of normal babies (Jensen et al., 1986).
DDH is frequent in extremely rare conditions characterized by excessive
laxity such as Down, E
1994).
hlers-Danlos,
and Marfan syndromes (Weinstein,
2- THE CONCEPT OF PRIMARY ACETABULAR DYSPLASIA
In the past there has been much discussion and controversy
regarding the etiologic importance of a
cetabular
dysplasia. Does it
represent a primary feature of congenital dislocation of the hip or is it a
secondary adaptive defect?
In recent years the support for primary acetabular dysplasia has waned,
and it has become evident that the dysplasia of the acetabulum is the
result and not the cause of congenital dislocation of the hip.
Acetabular dysplasia is minimal in the newborn with perinatal congenital
dislocation of the hip. This is shown by findings at autopsy of newborn
babies with the defect, observations at surgery during open reduction and
radiographic and arthrographic studies.
Reversal of acetabular dysplasia following concentric reduction
contradict the hypothesis of a primary developmental defect in the
acetabulum (Tachdjian, 1990).
41

3- MECHANICAL FACTORS
REVIEW OF LITERATURES
The mechanical factors that predispose to the typical dislocation
occur primarily in the last trimester of pregnancy. All such factors have
the effect of restricting the space available for the fetus in the uterus. It is
believed that the pelvis of the fetus becomes trapped in the maternal
pelvis. The fetus is unable to kick and change positions, which prevents
the normal flexion of the hip and knee, or "limb folding". If, in addition,
the knees are extended (frank breech), the increased tension in the
hamstrings further contributes to the hip instability (Dunn, 1976; Artz et
al. 1975).
Breech Presentation:
The incidence of breech presentation in infants born with
congenital dislocation of the hip is 15.7 per cent in the neonatal series and
8.3 per cent in the late diagnosis series of Bjerkreim and Van Der
Hagen (1974); 17.3 per cent in that of Carter and Wilkinson (1964);
and 30 per cent in that of Hass (1951).
The incidence of breech presentation in the general population is about 3
per cent (Hsieh et al., 2000).
Ramsey and associates (1976), in a study of 25.000 newborns, reported
the incidence of true congenital dislocation of the hip to be one out of 35
births in females born by breech presentation. A fetus in breech position
in utero is at high risk for hip dislocation.
42

Birth Order:
REVIEW OF LITERATURES
There is greater incidence of hip dislocation in firstborn children.
This appears to be related to intrauterine malposture caused by an
unstretched uterus and taut abdominal muscles (Wynne-Davies, 1970).
Oligohydramnios:
Amniotic fluid protects the fetus from pressure and permits it
mobility and freedom of exercise. As the fetus gets longer and larger, the
volume of amniotic fluid diminishes, and the fetus is subjected to
mechanical pressure from the uterus and abdominal wall.
Congenital dislocation of the hip is extremely rare in fetuses aborted
before 20 weeks gestation. Before 20 weeks, the fetus is very small and
not subject to intrauterine pressure sufficient to produce a mechanical
effect on the developing hip (Dunn, 1977).
Side Involved:
Approximately 60 per cent of congenital dislocations of the hip are
on the left, 20 per cent are on the right, and in 20 per cent involvement is
bilateral. The great frequency of left side involvement is due to the fetus's
tendency to lie with its back toward its mother's left side twice as often as
it does toward her right side. The fetal lower limb lying posteriorly
against the mother's back forcing the hip into a posture of flexion and
adduction (Artz et al., 1975).
43

4- GENETIC FACTORS
Familial Incidence:
REVIEW
OF LITERATURES
Wynne—Davies (1970) carried out a detailed survey of genetic and
other etiologic factors in 589 index patients With congenital dislocation of
the hip and their families.
According to her findings the risk to subsequent members of the family
when dislocation is present is:
(1) normal parents with one affected child, risk to subsequent
children 6 per cent,
(2) one affected parent, risk 12 per cent, and
(3) one affected parent with one affected child, risk 36 per cent.
Wynne —Davies (1970) suggested that genetic predisposition operates
through two separte heritable systems:
• the first is the development of acetabular dysplasia , which is
inherited as a polygenic system and is responsible for a large
proportion of the cases diagnosed late,
• the second system is generalized joint laxity, which is inherited as
a dominant trait is responsible for a large proportion of neonatal
cases.
The best evidence for genetic influences on the development of DDH
comes from a study by Idelberger, 1951 who investigated 138 pairs of
twins, if one child had congenital dislocation of the hip, there was a
42.7% likelihood of dislocation in the other twin. In the dizygous twins
evaluated there was a 2.8% cross over rate.
44

REVIEW OF LITERATURES
Muller and Seddon, 1953 found that 2.2% of siblings of patients with
DDH were affected and 1.3% of parents had DDH.
Coleman, 1956 found that hip dysplasia was five times more common in
those children with a positive family history of dysplasia than in those
without such a history.
Another study evaluated collagen content of umbilical cords and found
that the ratio of collagen III to collagen I was higher in babies with DDH
than in the controls (Jensen et al., 1986). .
Sex Incidence:
There is a definite preponderance of females affected by congenital
dislocation of the hip, its incidence being 5-8 times as great in girls as in
boys (Borges et al., 1995).
5- POSTNATAL ENVIRONMENTAL FACTORS
Postnatal environmental factors also may contribute to the
development of hip instability and dislocation. In the first months after
delivery, the normal physiologic position of the hip is that of flexion and
abduction. In sociaties (Northern Italy, Germany) where infants are
customarily wrapped to a cradleboard or swaddled to maintain the legs
together, hips and knees fully extended, the incidence of DDH is 10 times
greater than normal. DDH is rare in Chinese and African Negroes who
carry their babies astride their backs with legs widely abducted (Salter,
1968).
45

6- SEASONAL INFLUENCE
REVIEW OF LITERATURES
Several authors have explored the unusual observation that there is
a seasonal element in the incidence of DDH. Andren and Palmen, 1963
have shown that the incidence of DDH is increased for those children
born in the fall and winter months in temperate climates. This observation
has been explained in a variety of ways, including such as seasonal
hormonal changes and the heavy clothing on the infant that holds the
lower limbs in an a
dduct'ed
7- HORMONAL FACTORS
and extended position.
Higher incidences of congenital hip instability in children of
mothers with symptoms of pelvic girdle relaxation in pregnancy. Pelvic
girdle relaxation has previously been associated with increased serum
relaxin level. This could account for the rarity of instability in premature
babies, born before the hormones reach their peak (Tachdjian, 1997).
In contrary, Vogel et al., 1998 in their study did not show an association
of serum relaxin with neonatal hip instability. It was suggested that
detectable serum relaxin levels found in samples from the umbilical cord
only when these were contaminated with maternal blood.
ASSOCIATED CONGENITAL ANOMALIES (Fig. 14)
Bjerkreim and Van Der Hagen in 1974 reported 9 per cent of
patients with concomitant anomalies in neonatal diagnosis. In late
46

opulation
. p
REVIEW OF LITERATURES
diagnosis of congenital hip dislocation the same author reported 14 per
cent.
The common associated anomalies are the folowing:
A- Plagiocephaly:
This condition was noted in 32 per cent of the patients with
congenital dislocation of the hip by Wynne—Davies 1970. The left and
right sides were equally involved, and there was no correlation with the
side of the dislocatd hip.
B- Pes Calcaneovalgus;
This deformity of the feet was found to be associated with
congenital dislocation of the hip in 25 per cent of the cases (Paterson,
1976).
C- Torticollis:
The incidence of congenital musclar torticollis in the newborn
is 4 per thousand and that of congenital dislocation of the hip
1.5 per thousand, the probable incidence of coexistence of the two
conditions is 0.06 per thousand (
Tachdjian,
1990).
47

REVIEW OF LITERATURES
This relationship between torticollis and congenital dislocation of the hip
is significant, the presence of torticollis should serve as a warning to look
for congenital dislocation of the hip. A careful clinical, ultrasonographic,
and radiographic examination of both hip joints is in order (Tien et al.,
2001).
D- Metatarsus Varus:
A much higher incidence of congenital hip dysplasia in infants
with metatarsus varus than in the general population.
E- Generalized Laxity of Joints:
Commonly found in patients with congenital dislocation of the hip,
the lax ligaments as a rule tauten with skeletal growth; flexible pes
planovalgus, however, is an almost universal problem in children with
congenital dislocation of the hip.
F- Other rare m
usculoskeletal
deformities:
Coexisting with congenital dislocation of the hip may be talipes
equinovarus, congenital convex pes valgus (vertical talus), congenital
defects (e.g., longitudinal deficiency) of upper and lower limbs, infantile
scoliosis, congenital, dislocation of the knee and shoulder, and radioulnar
syno sto s is.
48

Lt
ieavatgus
REVIEW OF LITERATURES
Fig. 14: Associated deformities with DDH; plagiocephaly,
torticollis, talipes varus, metatarsus Yarns and calcaneovalgus
(Tachdjian, 1997).
Some visceral anomalies found concomitant with congenital dislocation
of the hip include pyloric stenosis, patent ductus arteriosus, malformation
of the urinary and gastrointestinal tracts, and undescended testicles.
It behooves the orthopedic surgeon and pediatrician to examine not just
the hip but the entire infant. Conversely an infant that has a deformity or
malformation of the musculoskeletal or visceral system should have a
thorough examination of the hips to rule out congenital dislocation
(Tachdjian, 1990).
Tot:
110Als
)
.
tacjilsoept.
afy
- !
49

HISTORY
REVIEW OF LITERATURES
CLINICAL DIAGNOSIS OF DM
It is important to emphasize the value of recording the history of
the patient with DDH.
The physician should determine first whether the infant was full term or
not; whether the gestation was uneventful; whether the birth was normal;
whether the infant was firstborn or not; and whether the infant was
delivered by breech or cephalic presentation.
The physician should know whether there was anything unusual about the
birth and neonatal history, whether the dislocation existed at birth
(antenatal), and whether there is, or was, a family history of DDH. These
types of historical data should help to identify whether one patient is a
member of the high-risk group (Hensinger, 1987; Omeroglu and
Koparal, 2001) (Table 1 and Fig. 15).
PHYSICAL EXAMINATION
General evaluation
As a part of the physical examination, a complete general
orthopedic evaluation must be made, t
including neck, spine, upper
limbs, and lower limbs, as well as an appropriate neurologic examination.
h6
50

Table 1: DDH high-risk group factors (any combination)
First-born female.
Breech presentation.
Knee has been in extended posture in utero.
REVIEW OF LITERATURES
A cesarean section has been performed because of abnormal presentation
Positive family history
Oligohydramnios
Intrauterine crowding has occurred because of twins or multiple
pregnancy
Fig. 15: Newborn at high risk of DDH. A) Family history and first born
female. B) Caesarian section for Breech presentation. C) o
D) Multiple pregnancy. D) Frank Breech presentation (Tachdjian, 1997).
ligohydrammnios.
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REVIEW OF LITERATURES
During these examinations any associated abnormalities in the
musculoskeletal system I should be carefully considered. Their presence
should alert the pediatrician to the possible presence of hip dislocation, or
other more complex problems, such as teratologic syndrome associated
with DDH (Hensinger, 1987).
Clinical findings
These vary with the age of the infant, the degree of displacement of
the femoral head whether subluxatable, dislocatable, or dislocated.
After walking age
1- Gait
Gluteus medius lurch, characterized by that in the standing phase
of each step on the dislocated hip by a contralateral tilt of the pelvis,
lateral deviation of the spine toward the affected side.
In bilateral dislocation the gait has been described as a "duck like
waddle" or "sailor's gait". Fig. 16
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REVIEW OF LITERATURES
Fig. 16: Ducklike waddle or sailor's gait in bilateral hip dislocation
(From Tachdjian, 1990).
2- Asymmetrical thigh folds and popliteal creases; they are due to
pelvic obliquity with abduction contracture of one hip and sometimes
adduction contracture of a varying degree of the opposite hip
(Tachdjian, 1997; and Hennrikus, 1999). Fig. 17 A, and B
3- Apparent shortening of the femur (positive Galeazzi sign) is usually
found in dislocated hip. A congenital short femur should not be
misdiagnosed as a dislocation hip because of a positive Galeazzi sign
(Tachdjian, 1997). Fig. 17 C
4- Asymmetry of inguinal folds. Normally the inguinal folds are
symmetric and they stop short of the anal aperture posteriorly. When
the femoral head is dislocated posteriorly and displaced superiorly, the
inguinal folds are asymmetric. On the involved side the inguinal fold
53

REVIEW OF LITERATURES
extends posteriorly and laterally beyond the anal aperture. When both
hips are dislocated, the inguinal folds may be symmetric, but they
extend posteriorly beyond the anal aperture (Ando, and Gotoh, 1990).
Fig. 17 D, E, F, and G
Fig. 17: Physical f
inding
suggesting DDH. A, B) Asymmetrical thigh folds and
popliteal creases. C) Galeazzi sign. D, E) Normal and asymmetric inguinal
folds. F) Positive right. G) Positive both sides (Tachdjian, 1997).
54

REVIEW OF LITERATURES
5-Adduction contracture of the hip. The range of passive abduction of
the dislocated hip in 90 degrees of hip flexion is progressively limited.
The position of reduction and dislocation should be noted. These can
be conceptualized relative to the safe zone of Ramsey and associates
(Ramsey et al, 1976). Fig. 18
Fig. 18: Limited abduction (Tachdjian, 1990).
6-Positive telescoping sign or piston mobility. Test the adducted hip in
flexion and extension. To elicit this sign the examiner grasps the distal
thigh and knee with one hand, places the index finger of the other hand
over the greater trochanter, and splays the thumb and other fingers over
the ilium. Up and down movements of the greater trochanter can be felt
(Tachdjian, 1990). Fig. 19
55

Fig. 19: Piston Mobility or telescoping (Tachdjian, 1990).
Ant. Sup. Iliac
Ing.
Lig.
Fern. Art.
Pub. Tub.
Spine
REVIEW OF LITERATURES
7-The femoral head is absent from its normal site anteriorly in the
groin beneath the femoral artery at about the middle of Poupart's
ligamint. Fig. 20
Fig. 20: Absence of femoral head (Tachdjian, 1990).
56

REVIEW OF LITERATURES
8-The Klisic line is drawn between the tip of the greater trochanter and
the anterior superior iliac spine and extended superomedially toward
the umbilicus. In the normal hip the line bisects the umbilicus, whereas
in the dislocated hip it passes inferior to the umbilicus (Tachdjian,
1997).
9-Nelaton's line is drawn between the ischial tuberosity and anterior
superior iliac spin. Determine the position of the greater trochanter. In
the normal hip the tip of the greater t
rochanter
lies at or below
Nelaton's line, whereas in the dislocated hip it lies superior to
Nelaton's line (Tachdjian, 1997). Fig. 21
Fig. 21: Nelaton' line. A) Normal hip; the greater trochanter lies below the Nelaton's
line. B) Dislocated hip; the greater trochanter lies above the Nelaton's line.
(Tachdjian, 1990).
10- Trendelenburg test
The Trendelenburg test is positive, as the child stands on the
dislocated hip, the pelvis drops on the opposite normal side because of
57

REVIEW LOF
the weakness of hip abductors. In the normal hip; on standing, the pelvis
is maintained in the horizontal position by contraction and tension of
normal hip abductors (MacEwen and Ramsey, 1978; Trendelenburg,
1998). Fig. 22
Fig. 22: Trendelenbug test. A) Negative test in normal hip. B) Positive
test in dislocated hip (Tachdjian, 1990).
11- In bilateral dislocation the perineal space is widened and the greater
trochanters are prominent, but the buttocks are broad and flat.
ITERATURES
58
.

REVIEW OF LITERATURES
Hyperlordosis is present, caused by backward displacement of the
femoral heads and increased foreword inclination of the pelvis. Fig. 23
With increasing adduction contracture of the hips, there is compensatory
genu valgum (Sharrard, 1979; Tachdjian, 1997).
Fig. 23: Bilateral hip dislocation A) Prominent greater trochanter. B)
severe hyperlordosis (Tachdjian, 1997).
59

REVIEW OF LITERATURES
RADIOGRAPHIC EXAMINATION
Radiographic assessment of the newborn hip if normal may be
misleading and deceptive. A negative radiogram does not rule out the
presence of d
islocation.
Much of the newborn pelvis is cartilaginous and
therefore not visible in the routine radiogram; the femoral head is not
ossified at birth, and its exact relationship to the acetabulum is hard to
determine (Broughton et al., 1989; Hubbard, 2001).
In the newborn the femoral head will easily move into and out of the
acetabulum. The dislocated hip may be reduced at the time the radiogram
is made. Positioning for the Von Rosen view (which is made with the
hips in abduction and medial rotation) may itself reduce the dislocation
and make the radiographic study of no value.
Another pitfall is to make radiograms in the frog-leg lateral position, a
position of flexion-abduction that also reduces the dislocation. The
radiograms show the hip reduced, but in neutral position it will be
dislocated.
Improper positioning of the infant's hips may cause problems. A common
mistake is to make the radiograms with the hips rotated laterally; this
disrupts the radiographic landmarks.
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REVIEW OF LITERATURES
Side-to-side tilting of the pelvis will give an abnormal acetabular index
and cause the femoral head to appear uncovered. Posterior pelvic rotation
decreases the acetabular index, whereas foreword tilting of the pelvis may
increase it
The flexion contractures of the hips corrected by pressing the thighs
against the X-ray plate causes the pelvis to tilt foreword. Contractures of
the newborn hip must be taken into account when the infant is positioned
for hip radiography. The hips are flexed 30 degrees so that the pelvis is
positioned flat on the X7
ray
cassette.
A restrained, crying, feisty baby will automatically contract the hip
abductors-flexors muscles and spontaneously reduce the dislocation.
A single true anteroposterior view of the pelvis made with the hips in 20
to 30 degrees of flexion will serve as a baseline examination and rule out
other congenital deformities that may simulate congenital dislocation of
the hip, such as congenital coxa vara, congenital short femur, or proximal
femoral focal deficiency (Tachdjian, 1990).
A positive radiographic study is helpful, but a normal radiogram in the
presence of a positive Ortolani or B
(Garvey et al., 1992).
arlOW
test is of no significance
X-ray Technique: The X-ray is taken in the supine position with the
lower limbs extended, the patellae point* upward and the distal end of
the feet rotated slightly internally to correct the anteversion of the femoral
neck. The central rays is directed into the median line of the body slightly
61

REVIEW OF LITERATURES
above the symphysis pubis, with the film focus distance generally set at
1- 1.15 m.
In the properly made anteroposterior radiogram of the hip one assesses
the lateral and upward displacement of the head of femur and
development of the acetabulum. Since ossification centers are not present,
the following lines and determinations are made:
Hilgenreiner's line, or the Y line, is a horizontal line drawn through the
top of the clear areas in the depth of the acetabula, which represents the
triradiate or Y cartilage (Hilgenreiner, 1925).
Ombredanne's vertical line, or Perkins's line, is drawn downward
from the most lateral ossified margin of the roof of a
perpendicular to and through the Y line to form quadrants (Perkin,
1928).
The medial margin of the ossified proximal metaphysis of femur lies
medial to Perkins's line; if it lies lateral to the Perkins's line, the femoral
head is laterally d
isplaeed
Y line) or dislocated (above Y line). Fig. 24
Fig. 24: Diagram H
showing
Perkins's line (Tachdjian, 1990).
and the hip considered to be subluxated (below
ilgenreiner's
line or the Y line and vertical
cetabulum
62

Lateral displacement may be measured by t
which is the distance f
rom
REVIEW OF LITERATURES
he.
Y
coordinate (Ponseti),
midsacrum to the center of ossified nucleus of
the femoral head; or the medial protruding tip of the ossified femoral
neck may be used as a lateral point of reference. The inner border of the
teardrop shadow, the floor of acetabular socket, or the lateral wall of
ischium may be used as a medial point of reference. Fig. 25
These reference points may be altered by changes in the position of
pelvis, and care should be taken to focus the X-ray tube directly over the
middle of and a little above the symphysis pubis to ensure symmetry of
both halves of the pelvis.
Medial gap, a measure of separation between the proximal femur and a
line drawn perpendicular to the lateral margin of ischium, over 5 mm is
suspicious and over 6 mm is indicative of dislocation.
A B C
Fig. 25: Method of measuring lateral displacement of the femoral head.
A) By Y coordinate line. B) By inner wall of tear drop. C) By lateral wall
of ischium (From Tachdjian, 1990).
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REVIEW OF LITERATURES
Superior displacement of the proximal femur is measured by Shenton's
or Menard's line, which is drawn between the medial border of the neck
of femur and the superior border of the obturator foramen. In a normal
hip, this line is an even arc of continuous contour; in the dislocated hip
with proximal displacement of the femoral head, it is broken and
interrupted. Fig. 26
Superior displacement (H distance) may be also ;
determined by
measuring the distance between the proximal end of the ossified femoral
neck and the Y line of both hips. Fig. 26
Fig. 26: Measurement of superior displacement by: A) Shenton' line. B)
H distance (Tachdjian, 1990).
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REVIEW OF LITERATURES
The position of unossified femoral head is suggested by the location and
direction of the proximal femur in relation a
to Both hips are
fully extended, abducted 45 to 50 degrees, and laterally rotated fully. In
normal hip, a longitudinal line drawn through the center of femoral shaft
bisects the outer corner of the acetabulum, whereas in a dislocated hip, it
points above the lateral edge of the a
superior iliac spine.
cetabulum,
cetabulum.
bisecting the anterior
In the Von Rosen view both hips are extended, abducted 45 to 50
degrees, and medially rotated. Medial rotation may reduce the
dislocation; the Von Rosen view is therefore not recommended in the
neonate and early infancy. Diagnostically it is much more helpful to
rotate the hips laterally.
The U figure or teardrop of Koehler is delayed in ossification in
developmental subluxation or dislocation of the hip because of lack of or
inadequate stimulation from the capital epiphysis. The teardrop ossifies
normally when the infant is a few months old. In persisting hip dysplasia
the width of the teardrop shadow is greater than normal, and its lateral
border, which corresponds to the inner wall of the acetabulum, does not
ossify (Tachdjian, 1997).
Albinana et al., 1996 studied the evolution of the teardrop in children
from the time of the initial diagnosis of DDH to skeletal maturity. The
time of the appearance of the teardrop as well as its width, shape (V and
U), and type (open, closed, crossed, and reversed) were associated with
the radiographic appearance of the hip at maturity. The closed teardrop is
the most frequently seen type in normal hips at an early age, but it
gradually evolves into the crossed and reversed types in adolescents. The
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REVIEW OF LITERATURES
continued presence of a v-shaped teardrop with widening of its superior
width and thickening of the acetabular floor are suggestive of residual
acetabular dysplasia. With concentric reduction, the width of the teardrop
decreases. Fig. 27
Fig. 27: Schematic diagram of radio-graphic types of tear drops A) Open
B) Closed C) Crossed D) Reversed (Albinana et al., 1996).
The acetabular notch appears as a cup-shaped defect in the lateral
iliac wall immediately above the acetabulum; the notch is demarcated
medially by a line of sclerotic bone. When present with a steeply inclined
acetabular roof, it indicates an unstable or subluxated hip (Portinaro et
al., 1994).
D
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REVIEW OF LITERATURES
Acetabular index: The acetabular index is measured by the angle
formed between the Y line and a line passing through the depth of the
acetabular socket at the Y line to the most lateral ossified margin of the
roof of the a
cetabulum
(Sharp, 1961; Skaggs et al., 1998) Fig. 28. Agus
et al., 2002 described a modified method for measurement of the
acetabular angle, the lateral margin of the sourcil (subchondral bony
condensation in the acetabular roof) was used as a landmark. They
concluded that this method probably produce better understanding of the
radiographic anatomy in dysplastic hips.
Normal Acetabular Angles (Caffey, 1992)
AP radiograph of pelvis
Age Acetabular Angle
Female (Degrees)
AcetabularAngle
Male (Degrees)
Newborn 28.8 ± 4.8 26.4 ± 4.4
3 Month Old 25 ±3.5 22 ±
Six Month Old 23.2 ± 4.0 20.3 ± 3.7
One Year Old 21.2 ±
3.8 19.8 + 3.6
Two Year Old 18 4 ±
+ 19
Fig. 28: Acetabular index (Ozonoff, 1992)
4
3.6
67

Center-Edge Angle (Wiberg)
REVIEW OF LITERATURES
The center edge angle is used to evaluate the relationship of the
femoral head to the acetabulum. It is defined as the angle formed by a
line drawn through the center of the femoral head and the edge of the
acetabulum and another line perpendicular to a line drawn through the
center of the femoral heads. The value of this is limited if the femoral
head is deformed or if the ossific center is small or eccentric. Fig. 29
Normal Center-Edge Angles (Ozonoff, 1992)
Age Center Edge Angle (Degrees)
3 months 18-20
2 years 30
Lowest limit of normal, age 5 to 8 y 19
Lowest limit of normal, age 9 to 12y 25
Lowest limit of normal, age 13 to 20y 26-30
Fig. 29: CE angle (Ozonoff, 1992).
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REVIEW OF LITERATURES
Tonnis (1982) has classified DDH by the position of the ossific nucleus,
and this classification is useful in evaluating treatment programs. Fig. 30
Fig. 30: The Tonnis grades of dislocation: grade 1-nucleus medial to
Perkins line; grade 2-nucleus lateral to Perkins line and below the
acetabular rim; grade 3-nucleus at the level of the superior rim; grade 4-
nucleus above the superior rim (Tonnis, 1982).
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REVIEW OF LITERATURES
COMPUTED TOMOGRAPHY [CB
Because of the transverse orientation of the hip, CT is of great help in
the assessment of pathologic anatomy of congenital dislocation of the hip
and in the planning of its treatment. The following parameters can be
determined from CT:
1-Concentricity of reduction:
After closed or open reduction and cast application, the
relationship of the femoral head to a
cetabulum
is determined by
anteroposterior and true lateral radiograms of the hips (the latter is
sometimes difficult to obtain, even with good visibility through the
cast), CT can solve this problem.
CT interpretation:
• The distance of the hook of the femoral neck from the floor of
acetabulum measures the degree of lateral displacement of the
femoral head.
• Superior displacement is detected by the appearance of the
femoral head of dislocated hip before that of the opposite
normal hip as the scan cuts move inferiorly from above.
• Posterior dislocation of the femoral head is determined as
follows: first draw the i
schial
line, which is horizontal line
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REVIEW OF LITERATURES
tangent to the ischial spines. In posterior dislocation, the
femoral head is projected posterior to the ischial line, and the fat
plane anterior to gluteus m
aximus
is displaced backward.
2- Constriction of the capsule by the i
taut CT scan will
visualize the indentation and hourglass constriction of the capsule
by the iliopsoas tendon, caused by the lateral and upward
displacement of the femoral head.
3- Intra-articular barriers to concentric reduction:
The pulvinar is a fibrofatty tissue, and because of its adipose
content, it can be clearly visualized on CT scan.
The hypertrophic l
igamentum
teres and inverted limbus usually are
not adequately depicted; their visualization can be improved by
combination of CT a
and
Pin protrusion into joint following Salter or other innominate
osteotomy can be detected in CT scan.
4- Femoral
torsion (femoral anteversion):
rthrography.
Determination of femoral torsion by CT scan is simple and
accurate. It measures the angle directly and obviates the need for
trigonometric calculation. The proximal section is made to visualize
the femoral neck and the distal section is made to visualize the
femoral condyles.
liopsoas:
71

5- Configuration of the a
cetabulum:
RE VIEW OF LITERATURES
The CT scan will determine the depth of acetabulum, the thickness of
the floor, and the size of its anterior and posterior walls. The scan also
will determine the degree of acetabular torsion (Peterson et al., 1981;
Browning et al., 1982; Edelson, 1984; Moen and Lindsey, 1986;
Kim et al., 1999).
Kim and Wenger, 1997 reported that DDH were evaluated by using
three-dimensional computed tomographic (3DCT) imaging to clarify
the nature and degree of acetabular and femoral head deformity. They
noted four types of dysplastic acetabulae: type I, subtle deficiency of
the acetabulum with a mild break in S
henton's
line (24%); type II,
anterosuperior deficiency (29%); type III, midsuperior deficiency
(38%); and type IV, global deficiency (9%). The 3DCT method
produced a topographic "contact map" that replicates the contact
relation between the a
cetabulum
and the femoral h
1998; Frick et al., 2000; Kim et al. 2000).
MAGNETIC RESONANCE IMAGING I
ead,
(
Takashi
MRI1
et al.,
MRI is performed to delineate the cartilaginous and soft tissue
pathology of the hip, the adequacy of reduction, and any ischemic process
of the femoral head or neck (Greenhil et al., 1993; Bos et al., 1988;
Aoki, 1999).
A transverse plane was the most useful for assessing the relationship
between the femoral head and acetabulum, the ossific nucleus is
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REVIEW OF LITERATURES
identified as a low-signal structure within the high-signal unossified
hyaline cartilage. The ossified areas of the anterior and posterior columns
are also seen as intermediate to low-signal structure, separated by a band
of high signal representing the triradiate cartilage (Omeroglu, 1998).
The coronal section on some patients is performed but these are not
necessary for assessing the position of the femoral head. The relationship
of the femoral head to the acetabulum is easily assessed. An imaginary
line is drawn joining both triradiate cartilage. When reduced, the ossific
nucleus of the femoral head should lie anterior to this line. If the
contralateral hip is normal, comparison is often helpful (McNally et al.,
1997; Nakanishi et al., 1999; Tennant et al. 1999).
The three-dimensional magnetic resonance imaging (3-D MR) proved
useful in demonstrating the extent of anterior and posterior acetabular
coverage. In conclusion, both 3-D CT and 3-D MR demonstrate the
extent of anterior and posterior acetabular coverage. 3-D CT and 3-D MR
facilitate the diagnosis of DDH and the choice of treatment modality
during preoperative planning in selected problem cases. 3-D CT appears
to be the imaging method of choice in children > 6 months of age because
of its superior spatial resolution, lack of artifacts, and, compared to MR,
fewer computing requirements for image generation. 3-D MR seems to be
particularly helpful in children less than 6 months of age with nonossified
cartilaginous femoral heads and, because of its lack of irradiation, in
those patients in whom several follow-up examinations may be required
(Lang et al., 1988; Philipp et al., 1989).
73

ARTHROGRAPHY
REVIEW OF LITERATURES
A commonly performed procedure in the past, is being replaced by the
.newer imaging technology-ultrasonography, (CT) scan, and (MRI). Some
surgeons still prefer to use it because it is helpful in determining:
(1) Whether mild dysplasia is present,
(2) Whether the femoral head is subluxated or dislocated,
(3) Whether manipulative reduction has been or can be successful,
(4) To what extent any soft structures within the acetabulum may
interfere with complete reduction of the dislocation, or an "hourglass"
constriction obstructing reduction,
(5) The condition and position of the acetabular labrum (the limbus), and
(6) Whether the a
cetabulum
during treatment (Mitchell, 1963; Beaty, 1992).
The drawback of a
rthrography
and femoral head are developing normally
is that it is an invasive procedure that
requires general anesthesia (Hughes, 1982; Ando et al., 1992).
Because a
rthrograms
are not always easy to interpret, the surgeon must be
thoroughly familiar with the normal and abnormal signs they may reveal
and with the technique of making a
rthrograms.
74

REVIEW OF LITERATURES
The use of image intensification in arthrography makes insertion of the
needle much easier. The danger of damaging the articular surfaces by the
needle is decreased, and the possibility of injecting the contrast medium
directly into the ossific nucleus or the physis is prevented. When such
equipment is not available, brief but careful use of an ordinary
fluoroscope can aid in properly centering the needle (Mitani et al., 1997).
TECHNIQUE:
With supine child under general anesthesia sterile preparation and
draping of the hip or hips performed. With a gloved fingertip locate the
hip joint immediately inferior to the middle of the inguinal ligament and
one fingerbreadth lateral to the pulsating femoral artery. As an
alternative insert the needle medially, anterior to the adductor
musculature.
With the assistance of image intensification insert a 22-gauge needle, to
which is attached a 5 ml syringe filled with normal saline solution, until it
enters the hip joint; resistance will be met as the needle passes through
the joint capsule.
Next, inject the saline solution into the joint; this is easy at first but
becomes more difficult as the joint becomes distended. Release the
plunger of the syringe; if the joint has been successfully entered, the
saline solution that is under pressure in it will reverse the plunger and
fluid will escape into the syringe. Aspirate the saline solution from the
joint and remove the syringe from the needle.
75

REVIEW OF LITERATURES
Then, fill the syringe with 5 ml of a 25% strength Hypaque solution and
inject I to 3 ml through the needle into the joint with image
intensification. Rapidly withdraw the needle, and while the hip is still
unreduced, have an arthrogram made. Before developing it, gently reduce
the hip into a stable position and have a second arthrogram made.
Maintain reduction until both arthrograms have been developed and
studied (Beaty, 1992).
Classification of A
rthrograms
Several authors have proposed arthrographic classifications. These
classifications can be used to indicate the type of treatment and predict
outcome.
In 1983, Race and Herring established criteria for evaluating hip
development and the quality of the reduction. According to these criteria,
closed reduction should be accepted if the medial dye pooling is 7 mm or
less in the initial arthrogram and 3 mm or less in the repeat a
Forlin et al., 1992 considered the width of the medial dye pooling
unreliable, and believed that the medialization ratio was the important
measurement in evaluation and a significant prognostic factor in their
series.
Jason et al., 1996 reported that besides concentricity of reduction, 2
additional parameters were observed:
(1) The medial pooling ratio is the percentage of the widest horizontal
distance of the contrast medium in the floor of the acetabulum to the
radius of the femoral head; and
.
rthrogram.
76

REVIEW OF LITERATURES
(2) Acetabular limbus-the outer edge of a normal acetabular limbus
should be sharply outlined, pointed, and directed distally. Fig. 31
Fig. 31: Drawing of medial pooling ratio calculation (Jason et al., 1996).
Mitani et al., 1997 have used a lateral view of the arthrogram as well as
an AP view to judge the accuracy of the reduction. They investigated,
retrospectively, the correlation between the information obtained from the
two views and the results of treatment. Table 2
Table 2: Advantages of AP and lateral a
sometimes visible, X invisible) (
Mitani
rthrograms
et al., 1997)
l
Obstacles to reduction Visible in arthrogram ?
AP view Lateral view
Tight iliopsoas tendon
Adhesion around the post capsule
Inversion of the limbus
A
Ant part X 0
Sup part 0 X
Post part X 0
Contracted transverse ligament A X
Hypertrophied teres 0 A
Hypertrophied fibro-fatty pulvinar 0 A
igamentum
(0 visible; A,
77

TREATMENT
REVIEW OF LITERATURES
Management of DDH varies according to the degree of
displacement of the femoral head subluxatable, dislocatable, or dislocated
and the age of the child (Tachdjian, 1997).
Treatment Goals:
• To achieve and maintain a concentric reduction of hip joint;
• Concave acetabulum cannot develop without concentric force
exerted by the reduced femoral head;
• Up to age 1 year, concentric reduction generally results in normal
hip;
• Up to age 4 years, reduction along with operative correction of
acetabular dysplasia or correction of femoral anteversion can lead
to normalization of the hip (Wheeless, 1996; Weinstien, 1997).
78

REVIEW OF LITERATURES
TREATMENT AFTER WALKING AGE
In this age group, the intra-articular and extra-articular obstacles to
reduction become greater. The capsular constriction by the iliopsoas
tendon is stiffer and more severe. The femoral head is displaced more
superiorly and the capsule is adherent to the lateral wall of the ilium. The
transverse acetabular ligament with the inferior anterior capsule of the hip
is pulled against the acetabulum, thereby preventing concentric reduction.
The labrum is thicker and more deformed and in folded. In order to
achieve concentric reduction, these obstacles must be overcome. It is
important to individualization each case and not to make decisions based
solely on the age of the, patient.
An important decision to make in this, age group is whether
prereduction traction should be used. This is an individual decision that
the surgeon must make. In a high dislocation that is rigid and, on the
telescoping maneuver, has no mobility, femoral shortening is indicating.
This facilitates concentric reduction, reduces compressive forces on the
femoral head, and diminishes the risk of avascular necrosis. The older the
child and the more rigid the dislocation, the greater the need for femoral
shortening at the time of open reduction of the hip. These cases should
not have preoperative traction (
Tachdjian,
1997).
For these children with well-established hip dysplasia, open reduction
with femoral or pelvic osteotomy, or both is often required (Beaty, 1992).
79

1- OPEN REDUCTION
REVIEW OF LITERATURES
Open reduction is indicated for failure to obtain a closed reduction,
failure to maintain a closed reduction, or an unstable reduction. During
the open reduction, each obstacle to reduction must be addressed. The
most common obstacle is the tight a
nteromedial
joint capsule, which must
be released. The transverse acetabular ligament often requires sectioning,
and the ligamentum teres may need to be removed. A true inverted
limbus should never be excised but only radially incised because excision
of this tissue may interfere with the normal growth and development of
the acetabulum. If an open reduction is necessary, it can be done through
a variety of surgical approaches (Weinstein, 1994; Akazawa et al.,
1998).
The anterolateral approach for open reduction of the hip is rarely
indicated in a child less than 1 year of age except when it is an antenatal
dislocation or when the acetabulum is very deficient and acetabuloplasty
is indicated to stabilize the hip. It is the most commonly used because it is
a standard approach to the hip joint and is thus familiar to most surgeons.
The disadvantages may include greater blood loss than other approaches,
possible damage to the iliac crest apophysis and the hip abductors, and
postoperative stiffness (Salter et al., 1984).
80

innominate
2-Pelvic osteotomies
REVIEW OF LITERATURES
The options available for treatment of residual dysplasia are
traditionally divided into three groups.
The first group is those osteotomies of the pelvis that redirect the entire
acetabulum to provide coverage of the femoral head by acetabular
articular catilage. These o
osteotomy, the Sutherland double i
steotomies
nnominate
include the Salter innominate
osteotomy, and the triple
osteotomies of Tonnis, among others. These procedures
involve complete cuts through varying numbers of the pelvic bone and
then rotating of the acetabulum (Salter and Dubos, 1974; Eppright,
1976; Kalamchi et al., 1982; Sutherland and Moore, 1991; Tonnis,
1990; Tonnis et al., 1994).
The second group is those of acetabuloplasties that involve incomplete
cuts and hinge on the triradiate cartilage include the acetabular
procedures described by Pemberton and Dega, which hinge on different
aspects of the triradiate cartilage. These procedures have the capability of
decreasing the volume of the a
cetabulum
by virtue of the fact that they
hinge on the triradiate cartilage (Dega et al., 1959; Pemberton, 1965;
Lloyd-Roberts et al., 1985; Faciszewski et al., 1993; Grudziak and
Ward, 2001).
The third group is the group of acetabular reconstructive procedures that
place bone over the hip joint capsule on the uncovered portion of the
femoral head. These procedures provide coverage for the femoral head by
capsular fibrous metaplasia and include the various shelf procedures and
the medial displacement o
steotomy
described by Chiari. Although it
81

REVIEW OF LITERATURES
seems better to cover the femoral head with articular cartilage than to rely
on fibrous metaplasia, it is not certain whether long-term results of shelf
arthroplasties will not yield good results, because no such long-term
results currently exist (Chiari, 1963 and 1974; Bailley and Hall, 1985;
Hiranuma et al., 1992).
Three groups of pelvic osteotomies •
Redirectional Shape changing Augmentation
Salter Pemberton Chiari
Sutherland Albee Staheli shelf
Steel Dega
Tonnis
Ganz
Eppright
Wagner
Fig. 32: The three groups of pelvic osteotomies (Hensinger, 1987).
Choice of operation:
When acetabular anteversion is severe in a child 18 months of age
or older and not responding to orthotic management, this condition is
corrected by Salter's innominate osteotomy. It provides coverage of the
femoral head, which is biologically physiologic. A definite advantage of
Salter's innominate osteotomy is that it does not disturb growth of the
82

REVIEW OF LITERATURES
acetabulum at the triradiate cartilage or the growth zone of the acetabular
rim. Concentric reduction of the hip is a requisite, and the hip should
have nearly normal range of motion with no myostatic contracture of
iliopsoas muscle or hip adduction. The Salter i
nnominate
osteotomy is a
derotation osteotomy and does not change the capacity of the acetabulum
(Salter, 1961; Utterback and MacEwen, 1974; ,
1999).
Gillingham
et al.,
When the acetabulum is shallow and deficient in a child 2 to 5 year of
age, a pericapsular acetabuloplasty is performed to provide coverage of
the head (Hughes, 1982).
Pemberton's periacetabular innominate osteotomy corrects the deficiency
of the anterior and superolateral walls of a
the The advantage
of the procedure is that it tautens the marked laxity of the capsule and
stiffens the hyper mobile hip joint. The osteotomy extends to the posterior
rim of the triradiate cartilage, but the fulcrum of the rotation and
angulation is located at the triradiate cartilage. This is a drawback
because of the risk of growth arrest of the triradiate cartilage. Because of
this potential problem, some surgeons do not favor this method of
correction of the shallow deficient acetabulum. The patient should be
between 2 and 6 years of age (Pemberton, 1965).
When the acetabulum is deficient and the femoral head is large, an Albee
shelf arthroplasty is performed which covers the head anteriorly and
laterally. Bone graft inserted at the o
of the acetabulum, thereby enlarging the a
steotomy
cetabulum
cetabulum.
site extend beyond the rim
so that it can cover
the large femoral head fully. A danger of this procedure is disturbance of
growth of the rim of the a
cetabulum
(Albee, 1915).
83

Dial or Steel osteotomy Skeletal maturity
Shelf procedure or
Chiari osteotomy
.
.
.
.
.
.
.
.
.
.
Ado le scent--skeletal
maturity
REVIEW OF LITERATURES
Table 3: Recommended osteotomies for congenital dislocation of the hip
(Beaty, 1992).
Osteotomy
Salter innominate
osteotomy
Pemberton
acetabuloplasty
Age
18 mo-6 yr
Salter innominate osteotomy: Fig. 33
Indications
Congruous hip reduction; 10-15 degrees correction of acetabular
index required; small femoral head, large
acetabulum
Residual acetabular dysplasia; symptoms;
congruous j
Incongruous joint; symptoms; other
osteotomy not possible
During open reduction of congenital dislocations of the hip, Salter
observed that the entire acetabulum faces more a
oint
s
nterolaterally
than
normal. Thus when the hip is extended, the femoral head is insufficiently
"covered" anteriorly, and when it is adducted, there is insufficient
coverage superiorly. Salter's osteotomy of the i
the entire a
cetabulum
anteriorly and superiorly.
nnominate
bone redirects
so that its roof "covers" the femoral head both
If indicated to correct acetabular dysplasia, d
any or subluxation
must be reduced concentrically before this operation is performed; if not,
open reduction is carried out at the time of osteotomy. During the
operation any associated contractures of the adductor or iliopsoas muscles
are released by t
enotomy,
elongated, a capsulorrhaphy is carried out.
is
. location
and in dislocations when the capsule is
84

Fig. 33: Salter innominate o
steotomy
.
r4.
0:
11:
10?
-4;
ti
norzttet.
drafkx.
.
inq
Kie.
sairibt
1 ∎
••
.
, (
111
&icsr
.
REVIEW OF LITERATURES
fy
(Tachdjian, 1990).
Salter recommends his osteotomy in the primary treatment of congenital
dislocation of the hip between the ages of 18 months and 6 years.
The following prerequisites are necessary for the success of this
operation:
1. The femoral head must be positioned opposite the level of the
acetabulum. This may require a period of traction before surgery or
primary femoral shortening
2. Contractures of the iliopsoas a
and must be
released. This is indicated in subluxations as well as in
dislocations. Open reduction is performed for hip dislocation but
dductoi
usually is unnecessary for hip subluxation.
- muscles
85

REVIEW LOF
3. The femoral head must be reduced into the depth of the true
acetabulum completely and concentrically. This generally requires
careful open reduction and excision of any soft tissue, exclusive of
the labrum, from the a
4. The joint must be reasonably congruous.
cetabulum.
5. The range of motion of the hip must be good, especially in
abduction, internal rotation, and flexion.
(Salter, 1961, 1966, 1972, 1974, and 1984; Hosny and Fattah, 1998;
Morin et al., 1998).
Pemberton acetabuloplasty: Fig. 34
The term acetabuloplasty designates operations that redirect the
inclination of the acetabular roof by an osteotomy of the ilium superior to
the acetabulum followed by levering of the roof inferiorly.
Pemberton devised an acetabuloplasty that he called p
osteotomy of the ilium ' in which an osteotomy is made through the full
thickness of the ilium, using the triradiate cartilage as the hinge about
which the acetabular roof is rotated anteriorly and laterally.
ITERATURES
ericapsular
86

Fig. 34: Pemberton a
cetabuloplasty
(
Tachdjian,
REVIEW OF LITERATURES
1990).
87

REVIEW OF LITERATURES
Pemberton recommends this procedure for any dysplastic hip in patients
between the age of 1 year and the age when the •
triradiate cartilage
becomes too inflexible to serve as a hinge (about 12 years of age in girls
and 14 years in boys) (Coleman, 1974; Pemberton 1965 and 1974; Eye-
Brook et al., 1978; Trousdate et al., 1995; Vedantom et al., 1998).
Steel osteotomy: Fig. 35
The Pemberton pericapsular osteotomy is. limited by the mobility
of the triradiate cartilage, and hinging on this cartilage can cause
premature physeal closure. Although the Salter i
nnominate
osteotomy can
be used in older patients, its results depend on the mobility of the
symphysis pubis, and the amount of femoral head coverage is limited.
Other, more complex o
steotomies,
such as those of Steel and Eppright,
can provide more correction and improve femoral head coverage.
i
a
In the triple developed by Steel, the ischium, the
superior pubic ramus, and the ilium superior to the are all
nnominate
osteotomy
divided, and the acetabulum is repositioned and stabilized by a bone graft
and pins (Steel, 1973).
The objective of this procedure is to establish a stable hip in anatomical
position for dislocation or subluxation of the hip in older children when
this is impossible by any one of the other osteotomies.
cetabulum
88

Fig. 35: Steel's triple innominate o
steotomy
REVIEW OF LITERATURES
7
.6
iintifil
at:
ifofij,
. N
014
(From Tachdjian, 1990).
For the operation to be successful the articular surfaces of the joint must
be congruous or become so once the acetabulum has been redirected so
that a functional, painless range of motion will be achieved and a
Trendelenburg gait will be absent (Guille et al., 1992).
Steel, 1973 reviewed 45 patients in whom 52 of his operations had been
performed. The results were satisfactory in 40 hips and unsatisfactory in
12. The unsatisfactory hips were painful and easily fatigued; in two the
Trendelenburg test was positive, and in one significant motion had been
lost.
Before surgery skeletal traction must be used until the femoral head is
brought distally to the level of the acetabulum or femoral shortening must
be performed; if necessary, any contracted muscles about the hip are
released surgically.
89

REVIEW OF L
Ganz et al., 1988 developed ta
periacetabular osteotomy for
adolescents and adults with dysplastic hips that require correction of
riplanar,
congruency and containment to the femoral head. If significant
degenerative changes involving the weight-bearing surface of the femoral
head are present, a proximal femoral o
steotomy
ITERATURES
can be added to provide
uninvolved acetabular and proximal femoral weight-bearing surfaces.
The reported advantages of periacetabular osteotomy include
(1) Only one approach is used,
(2) A large amount of correction can be obtained in all directions,
including the medial and lateral planes,
(3) Blood supply to the acetabulum is preserved,
(4) The posterior column of the h
emipelvis
remains mechanically intact,
allowing immediate crutch walking with minimal internal fixation,
(5) The shape of the true pelvis is unaltered, permitting a normal child
delivery, and
(6) It can be combined with trochanteric osteotomy if needed.
Shelf operations:
Shelf procedures have commonly been performed to enlarge the
volume of the acetabulum; however, pelvic redirectional and
displacement osteotomies have largely replaced this type of operation.
90

REVIEW OF LITERATURES
The redirectional osteotomies are inappropriate in hips in which the
femoral head and acetabulum are misshapen but still congruent, since
redirection may cause incongruity (Fong et al., 2000).
Staheli, 1981 described a slotted acetabular augumentation procedure to
create a congruous acetabular extension in which the size and position of
the augmentation can be easily controlled. A deficient a
cannot be corrected by redirectional pelvic osteotomy is the primary
indication for this operation. Contraindications include dysplastic hips
with spherical congruity suitable for redirectional osteotomy, hips
requiring concurrent open reduction that must have supplementary
stability, and patients unsuited for spica cast immobilization (Staheli
1981 and 1992). Fig. 36
Fig. 36: Staheli osteotomy (Beaty, 1992).
cetabulum
that
91

The Chiari o
steotomy
is a capsular interposition .a
REVIEW OF LITERATURES
rthroplasty
and should
be considered only in those instances when other reconstructions are
impossible: when the femoral head cannot be centered adequately in the
acetabulum or in painfully subluxated hips with early signs of
osteoartbritis.
This procedure deepens the deficient acetabulum by medial
displacement of the distal pelvic fragment and improves superolateral
femoral coverage ( Chiari, 1963 and 1974). Fig. 37
Fig. 37: Chiari pelvic osteotomy. A) O
displacement of the distal fragment (Beaty, 1992).
steotomy
site. B) Medial
The Chiari procedure is an operation that places the femoral head beneath
a surface of cancellous bone with the capacity for regeneration and
corrects the lateral pathological displacement of the femur. An o
of the pelvis is performed at the superior margin of the acetabulum, and
steotomy
92

REVIEW OF LITERATURES
the pelvis inferior to the osteotomy along with the femur is displaced
medially.
The superior fragment of the osteotomy ,
,
then
becomes a shelf, and the
capsule is interposed between it and the femoral head. After using this
operation on more than 600 patients, 400 of whom have been observed
for more than 2 years, Chiari 1974 recommends the operation as follows:
1. For congenital subluxations in patients 4 to 6 years old or older,
including adults. These include subluxations persisting after
conservative treatment of dislocations and those previously not
treated.
2. For untreated congenital dislocations in patients over 4 years old,
soon after open or closed reduction.
3. For dysplastic hips with osteoarthritis.
4. For paralytic dislocations caused by muscular weakness or
spasticity.
5. For coxa magna after Perthes disease or avascular necrosis after
treatment of congenital dysplasia.
These indications are broader than those usually accepted by most
pediatric orthopaedists For children younger than about 10 years of age
the osteotomy is not recommended in subluxations or in dislocations that
can be reduced either surgically or conservatively and in which
osteotomy of the innominate bone, acetabuloplasty, or osteotomies that
free the acetabulum would result in a competent acetabulum.
93

REVIEW OF LITERATURES
Some surgeons recommend the operation for patients in the second and
later decades who have symptomatic early subluxation of the hip with
acetabular dysplasia too severe to be treated by other pelvic osteotomies;
for them innominate osteotomy with medial displacement is preferred to a
shelf operation. The procedure also has been used in older children with
underlying neuromuscular disorders and acetabular dysplasia.
Chiari's operation is a capsular arthroplasty because the capsule is
interposed between the newly formed acetabular roof and the femoral
head. Because the biomechanics of the hip are improved by displacing the
hip nearer the midline, a Trendelenburg limp often is eliminated (Colton,
1972; Hoffman et al., 1974; Mitchell, 1974; Salvati and Wilson 1974;
Betz et al., 1988; MatsunonT et al, 1992; Fong et al., 2000).
3-Proximal femoral osteotomies
The goals are to correct deformity of the proximal femur, to
enhance hip joint stability, and to improve femoral head coverage, by
derotation femoral osteotomy and to diminish soft tissue tension on the
reduced hip by femoral shortening (Wagner 1976 and 1978; Atecs and
Omeroglu, 1996).
Varus derotation o
steotomy:
Deformities of the femoral neck assume significance when they
lead to subluxation of the joint. Lateral subluxation with extreme coxa
valga, or anterior subluxation with excessive anteversion (Tonnis, 1990).
94

REVIEW OF LITERATURES
Ordinarily, with splinting of the hips in abduction and flexion, femoral
anteversion corrects up to the age of 4 to 5 years. Femoral derotation
osteotomy is being performed less and less (Tachdjian, 1997).
Varus derotation osteotomy, if used to "stimulate" more normal
acetabular development, must be used in patients younger than 4 years
(Tonnis, 1990; Wenger et al., 1995).
The proximal femur in DDH usually has a normal neck-shaft angle. Thus,
when varus o
steotomy
is performed, abnormal v
arus
is introduced. This
yams improving acetabular development, but if excessive, it will cause an
abductor limp and shortening. Mild varus angulation frequently remodels
to a normal neck-shaft angle in younger child.
Several techniques are described for performing varus derotation
osteotomies. Some surgeons prefer an o
steotomy
below the lesser
trochanter, but the intertrochanteric level is better because it is
accompanied by femoral shaft medialization. If osteotomy is the more
distal, lateralization of the femur occurs and p
ioduces
a deformity that
may not remodel, posterior displacement of the lesser trochanter, and
mechanical abnormalities at the knee (Weinstein, 1996).
Pre-Requities for Osteotomy:
• Hip should be reducible on radiographs when placed in abduction,
internal rotation, and in flexion.
• A deficient lateral acetabulum along with a deficient lateral
acetabular labrum (as judged by arthrogram), may indicate the
need for concomitant pelvic osteotomy.
95

REVIEW OF LITERATURES
More than 15 degrees of correction will cause leg length discrepancy
(Weeless, 1996).
Femoral shortening
Primary femoral shortening is recommended for children aged 3
years and older and for children aged 18 to 36 months when a traction
program has failed or when preoperative traction is not feasible
(Schoenecker and Strecker, 1984; Beaty, 1992).
At present, when femoral shortening is carried out in an young child with
a delayed diagnosis of DDH, derotation of the proximal femur is
simultaneously performed to correct antetorsion (Wenger, 1989).
4-Combined pelvic and femoral procedures
During the last decade the combination of primary open reduction
and femoral shortening, with or without pelvic o
steotomy,
accepted method of treatment of DDH in older children.
has become an
This approach avoids expensive in-hospital traction, obtains predictable
reduction, and produces a low rate of avascular necrosis (Beaty, 1992).
While a little excessive varus will remodel if avascular necrosis does not
occur, too much "correction of anteversion" can result in a hip which
dislocates posteriorly, especially if a Salter innominate osteotomy is
performed. Fig. 38
Ryan et aL, 1998 reviewed the result of operative treatment of DDH in
96

Artt
,:
. a
ter
-$
.
.
4.
>
pe.
:
Ics
C.
:
REVIEW OF LITERATURES
twenty-five hips. They suggest that a one stage operative procedure
consisting of open reduction, femoral shortening, and pelvic o
(if necessary) for previously untreated DDH in children who are three to
ten years old can result in remodeling of the acetabulum and a functional
hip.
:
`
, .
.
.
.
.
.
„
.
.
.
.
.
.
.
:
''.
.
.
.
'
i :
.
,
.
.
.
.
7
— "
---.
.
,
,
&•;
StiV:
:
VJ
, '
,
.
.
.
.
.
,
.
.
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--.
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N
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„
fa
14,
.
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rth
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-
-7
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Pe.
-a
oesitt:
,
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:
r0
i
azi(
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,
r
m.
:
0
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a .
. 0
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A
'4,
/
Fig. 38: A, Anteverted 'femur and acetabulum in untreated DDH of hip. B,
Redirection of femoral neck by snug anterior capsulorrhaphy. C, Capsulorrhaphy and
Salter innominate osteotomy , D, Capsulorrhaphy, Salter innominate osteotomy, and
full femoral derotation. Combined in excess, this full femoral derotation. Combined in
excess, this sequence can produce posterior dislocation (Beaty, 1992).
i
1
I.
i
/
Ant.
,
.
.
s,
,
,
,
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97

REVIEW OF LITERATURES
COMPLICATIONS OF TREATMENT
1- ISCHEMIC NECROSIS OF THE FEMORAL HEAD
The most serious complication associated with treatment of
congenital dysplasia of the hip in early infancy is the development of
avascular necrosis.
AVN is reported to occur in 6-30% of patients undergoing closed
reduction, but in some series the incidence can be as high as 45%;
children older than age of 2-3 years are most at risk for AVN.
This is an iatrogenic complication caused by excessive hip abduction and
rotation of the hip in spica cast or splint, forceful manipulation, and
inadvertent division of the retinacular ,
surgery.
r
o
circumflex vessels during
Marked abduction of the hip compresses the medial circumflex artery
between the taut iliopsoas tendon and either the hip adductors or the
pubic ramus. Extreme abduction of the hip compresses the
posterosuperior branches of the medial circumflex artery as the greater
trochanteric fossa impinges on the rim of the acetabulum.
Extreme medial rotation of the hip stretches and occludes the medial
circumflex vessels. These extreme positions of the hip do not affect the
98

REVIEW OF LITERATURES
lateral circumflex vessels, and the blood supply of the greater trochanter
is unaffected (Ogden and Southwick, 1973; Ogden, 1974;
Gregosiewicz and Wosko, 1988; Thomas et al., 1989).
Potential sequelae of avascular necrosis include femoral head deformity,
acetabular dysplasia, lateral subluxation of the femoral head, relative
overgrowth of the greater trochanter, and limb length inequalities;
osteoarthritis is a common late complication.
The deformities produced by i
schemia
depend upon the age of the patient,
the anatomic site of vascular occlusion, and whether the capital epiphysis
or physis or both are affected (Tachdjian, 1997).
Bucholz and Ogden 1978, as well as Kalamchi and MacEwen 1980,
have proposed classification systems based on morphological changes in
the capital femoral epiphysis, the physis, and the proximal femoral
metaphysis. These classifications are useful in determining proper
treatment and prognosis for a particular patient; however, the proper
classification may not be identifiable on roentgenograms until the child is
4 to 6 years of age.
Bucholz and Ogden's classification (1978):
Type I. Complete fragmentation of the capital femoral ossific nucleus.
Physis shows no irregularities and no propensity to premature closure.
Minimal to mild residual deformity.
99

REVIEW OF LITERATURES
Type II. The physis became irregular in its lateral aspect soon after
fragmentation of the ossification center. Localized premature fusion of
the superolateral portion of the plate. This premature fusion is not evident
until the patients are 7 to 12.5 years of age, with the mean age of
roentgenographically evident partial premature fusion being 9 years.
Type III. The entire physis is irregular, and premature fusion of the
entire plate occurred at an average age of 7.5 years. Marked coxa vara
with a variably deformed femoral head, an extremely short femoral neck,
and severe overgrowth of the greater trochanter.
Type IV. Variable abnormalities that seem to affect the medial
epiphyseal ossification center and to a lesser degree, the medial
metaphysis. Severe coxa magna with shortening of the femoral neck.
Kalamchi and MacEwen, 1980 described 4 patterns: Fig. 39
GROUP I: Changes Affecting the Ossific Nucleus
Only the femoral head is involved. There is delay of ossification or
temporary fragmentation of the capital femoral ossific nucleus. It is
caused by temporary interruption of blood supply by the medial
circumflex d
artery to extracapsular occlusion. The capital epiphysis
reossifies rapidly with minimal deformity. There may be slight coxa
ue:
magna and/or decreased height of the epiphysis.
GROUP II: Lateral Physeal Damage
100

REVIEW OF LITERATURES
The lateral segment of the capital physis is affected by occlusion of
the posterosuperior branches of the medial circumflex artery. The lateral
part of the growth plate arrests prematurely, whereas its medial part is
open. This . asymmetric growth arrest of the capital physis causes valgus
tilting of the femoral head out of the a
the femoral head, and a short femoral neck.
GROUP III: Central Physeal Damage
cetabulum
marked uncovering of
This is characterized by central closure of the capital physis and
symmetric growth retardation a short femoral neck (coxa breva). The
femoral head remains round and contained in the acetabulum, and the
femoral neck-shaft angle remains normal; there is no coxa vara. With
cessation of growth from the capital femoral physis, progressive
shortening (1/8 inch per year) and moderate limb length disparity of the
lower limbs occur. Relative overgrowth of the greater trochanter is
present, along with gluteus medius insufficiency and T
lurch.
GROUP IV: Total Damage to the Head and the Physis
The entire blood supply of both the proximal femoral epiphysis and
physis is obstructed. The resultant deformation of the upper femur is
severe, with marked delay in ossification of the femoral head with coxa
magna, flattening of the femoral head, and hip joint incongruity. The
sequela is severe osteoarthritis of the hip in young adult life.
An alternate scheme was proposed by Salter as shown in table 4.
rendelenburg

Fig. 39: The 4 types iof
(Tacdjian, 1990).
schernic
REVIEW OF LITERATURES
necrosis of the proximal femur

REVIEW OF LITERATURES
Treatment should be directed toward the clinical problems associated
with each roentgenographic classification group. Many patients will not
require any treatment during adolescence and young adulthood. In a few,
femoral head deformity and acetabular dysplasia predisposing the hip
joint to incongruity and persistent subluxation can be treated with either
femoral osteotomy or appropriate pelvic o
Treatment summary:
Kalamchi type I: Observation / Bracing.
steotomy,
or both.
Kalamchi type II: Observation / Vans osteotomy &/or proximal
epiphysiodesis.
Kalamchi I
type Apophyseodesis or distal trochanteric transfer for
trochanteric overgrowth. Shoe lift or properly-timed epiphysiodesis for
limb length inequality
II/
IV:
Children with avascular necrosis after treatment of congenital dislocation
of the hip should be observed to maturity with serial roentgenograms.
Significant limb length inequality can be corrected by appropriate
techniques, usually a well-timed epiphysiodesis. Symptomatic
overgrowth of the greater trochanter can be treated in older patients with
greater trochanteric advancement; which will increase the abductor
muscle resting length and increase the abductor lever arm.
The presence of avascular necrosis of a significant degree produces major
problems for the patients. Those with a short femoral neck and
trochanteric overgrowth will have an a
bdUctor
limp. There will be some
103

REVIEW OF LITERATURES
shortening of the lower extremity, but severe leg-length inequality dos
not occur because of the minor contribution to leg length of the capital
growth plate. Often, the changes in the upper femur associated with
avascular necrosis aggravate the dysplasia of the hip. Trochanteric arrest
and trochanteric transfer are operative procedures commonly used to
ameliorate the effect of avascular necrosis (Ogden and Southwick,
1973; Fletcher and Johnson, 1985).
Table 4: Classification of ischemic necrosis of femoral head
after treatment of DDH
Salter Kalamachi and MacEwen
Type I
Delayed ossification of femoral head.
No increase in density and no
deformity
Type II
1- Failure of the femoral head ? 1 year
after reduction.
2- Failure of growth in an existing
ossific nucleus ? 1 year after
reduction.
3- Broadening of the femoral neck.
4- Increased radiographic density
followed by radiographic appearance
5- Residual
of fragmentation.
deformity of the femoral
head and neck when ossification is
coin i lete.
2- REDISLOCATIOIN
Group
Changes confined to ossific nucleus.
Group II
Group I plus damage to lateral physis
Group III
Group I plus damage to central physis
Group IV
Group I plus damage to whole physis
Redislocation may occur after closed or open reduction. When
redislocation is discovered at a cast change after a closed reduction,
another closed reduction with arthrography may be immediately
performed. The surgeon should always be prepared for this contingency
and handle it as a known complication rather than as a disaster. In fact, a
redislocation usually can be managed with no long-term adverse effects.
104

REVIEW OF LITERATURES
shortening of the lower extremity, but severe leg-length inequality dos
not occur because of the minor contribution to leg length of the capital
growth plate. Often, the changes in the upper femur associated with
avascular necrosis aggravate the dysplasia of the hip. Trochanteric arrest
and trochanteric transfer are operative procedures commonly used to
ameliorate the effect of avascular necrosis (Ogden and Southwick,
1973; Fletcher and Johnson 1985).
Table 4: Classification of i
necrosis of femoral head
after treatment of DDH
schemic
Salter Kalamachi and MacEwen
Type I
Delayed ossification of femoral head.
No increase in density and no
deformity
Type II
1- Failure of the femoral head ? 1 year
after reduction.
2- Failure of growth in an existing
ossific nucleus ? 1 year after
reduction.
3- Broadening of the femoral neck.
4- Increased radiographic density
followed by radiographic appearance
5- Residual
of fragmentation.
deformity of the femoral
head and neck when ossification is
com i lete.
2- REDISLOCATIOIN
Group I
Changes confined to ossific nucleus.
Group'1,
I1
Group I plus damage to lateral physis
Group III
Group I plus d
to central physis
Group IV
Group I plus damage to whole physis
Redislocation may occur after closed or open reduction. When
redislocation is discovered at a cast change after a closed reduction,
another closed reduction with arthrography may be immediately
performed. The surgeon should always be p
repar
. ed
amage
for this contingency
and handle it as a known complication rather than as a disaster. In fact, a
redislocation usually can be managed with no long-term adverse effects.
104

REVIEW OF LITERATURES
A redislocation following an open reduction usually presents a
more difficult problem. If the child's skin is in good condition, a repeat
open reduction may be performed at the time of the cast change.
Achieving a stable reduction and repeating the capsulorrhaphy may be
difficult the second time around (Hensinger, 1987).
3- ACETABULAR DYSPLASIA
Acetabular dysplasia and subluxation are most common problems
in the further development of the hip after reduction. In the early phases,
continued abduction splinting may help resolved the problem, although
no control studies exit to prove the efficacy of this modality. Subluxation
is a more serious problem, and if it does not resolve quickly with closed
measures, operative intervention is necessary. Progressive subluxation is
always an indication for operative treatment.
Tucci et al., 1991 reported the appearance of radiographic dysplasia in 17
% of 74 hips treated for DDH with an average follow-up age of 12 years
and suggested caution and need for long-term follow-up for treated
patients. This group had normal radiographic appearance at age of 5
years, which subsequently deteriorated.
4- CHONDROLYSIS AND CARTILAGE NECROSIS
Chondrolysis of the hip often presented clinically by gradual onset
of pain and progressive loss of range of motion with hip flexion
contracture. Chondrolysis may or may not be associated with
radiographic evidence of osteonecrosis of the femoral head. Since the
105

simple and should be considered before the o
femoral head level.
REVIEW OF LITERATURES
trochanter
reaches the
Gage and Cary, 1980 found that the Operation was effective for total
avascular necrosis when performed around age 5
relatively ineffective if done after the age of 8 years.
.1
They found it was
When the trochanter has reached or exceeded the level of the femoral
head because of relative overgrowth, a transfer of the trochanter distally
and laterally may be considered. The purpose of the procedure is to
reduce or eliminate the Trendelenburg lurch from the gait. Distal transfer
is not a simple procedure, and it is sometimes difficult to move the
trochanter as far distally as desired. Lloyd-Roberts, 1985 reported that in
five of eight patients the Trendelenburg limp was resolved following
trochanteric transfer in DDH.
7-ACETABULAR NECROSIS
The risk of acetabular necrosis that occurs after the iliac osteotomy,
overall in smaller children in home the isthmus of the iliac bone is
sectioned. The nutritional iliac artery for the inferior part of the ilium
(acetabular roof) can be transected by bone cut and the final outcome is
an increase in the verticalization of the a
the redislocation of the femoral head (Redon, 1996).
cetabulum
which further permit
8- SEPARATION OF THE PROXIMAL FEMORAL EPIPHYSIS
Lahoti et al., 1998 reported separation of the proximal femoral
epiphysis in 2 cases after varus o
steotomy
of the femur. Stated that this
107

REVIEW OF LITERATURES
procedure imposes high shear stress on the femoral epiphysis, depending
on the degree of varus obtained. Such epiphyseal slip may or may not be
symptomatic.
Williamson et al., 1989 in their series of surgical treatment of DDH in
38 children (45 hips) reported the following complications as shown in
table 5.
Table 5: Complication reported by Williamson, 1989.
Avascular necrosis 5
Supracondylar fracture 4
Coxa vara 3
Wound infection 2
Lateral physeal fusion 1
Meralgia paraesthestica 1
Pressure sore 1
Femoral fracture
Total 18
108

MATERIAL AND METHODS
MATERIAL AND METHODS
This study includes thirty-six children with forty-four
dislocated hips. Their age ranged from 18 to 48 months with a mean
of 25.5 months at the time of surgery. There were 30 girls and 6
boys with a ratio of 5: 1 as shown in table 6 and figure 40. The left
hip was affected in 21 cases, the right was affected in 7 cases, while
bilateral affection was encountered in 8 cases as shown in table 7
and,figure 41.
They were managed surgically in El-Minia University Hospital and
Cairo University Children's Hospital from September 1997 to
January 2001.
No patients with neuromuscular disease, teratological dislocation,
septic arthritis, or recurrent dislocation included in this study.
109

Tab. 6: Sex incidence
Right Left
19.4% 58.3%
Fig. 41 : Side affected
MATERIAL AND METHODS
Sex No. of patients Percentage
Female 30 83.3 %
Male 6 16.7 %
Tab. 7: Side affected
Male
16.7%
Female
83.3%
Fig. 40: sex incidence
Side No. of patients Percentage
M Female
Male
Left 21 58.3 %
Right 7 19.4 %
Bilateral 8 22.2 %
110

HISTORY
Personal history
Name:
Age:
Sex:
Address:
Gestational history
First borne.
Breech presentation.
Cesarean section.
Oligohydramnio s.
Family history
Positive Consanguinity
Positive family history of CDH.
Case Sheet
Positive family history of ligamentous hyperlaxity of joints.
COMPLAINT
Delayed walking.
Abnormal gait.
Short one lower limb.
CLINICAL EXAMINATION
Side: Unilateral Right
Bilateral
Left
Gait: Trendelenburg gait.
Waddling gait.
MATERIAL AND METHODS
111

Asymmetrical thigh and popliteal folds.
Inguinal folds: Asymmetrical.
Symmetrical but extends beyond anal aperture.
Limited abduction: Asymmetrical.
Galeazzi sign.
Symmetrical (less than 60 degrees).
Exaggerated lumber lordosis, protuberant a
trochanter.
Telescoping.
Trendelenburg sign.
Associated congenital anomalies.
ROENTGENOGRAPHIC EXAMINATION
Delayed appearance of ossified femoral epiphysis:
❑ Four quadrant test:
❑ Tonnis classification grade:
❑ Shenton line:
❑ Acetabular index:
❑ Center- edge angle (CE angle):
bdomin
MATERIAL AND METHODS
and prominent greater
112

SURGICAL TREATMENT
❑
None
Grade I
Grade II
Grade III
Grade IV
Open reduction.
o Concomitant proximal femoral osteotomy.
Operative notes:
FOLLOW UP
Clinical evaluation:
Pain
Limp
Stability
Trendlenburg sign
Range of movement
Radiological evaluation:
CE angle
Acetabular index
Assessment o
fAVN:
MATERIAL AND METHODS
113

History:
• First borne in 9 cases (25 %
• Breech presentation in 6 cases (16.7 %).
• Cesarean section in 3 cases (8.3 %).
• Oligohydramnios in one case (2.8 %).
• Family history:
)
.
Positive consanguinity in 9 cases (25 %).
MATERIAL AND METHODS
Positive family history of DDH in one case (2.8 %).
• All patients give no history of previous treatment either
conservative or surgical.
Complaint:
• Delayed walking in 7 cases (19.4 %).
• Abnormal gait in 29 cases (80.6%).
• Shortening in one lower limb in unilateral cases. ,
114

Table 8: Complaint
MATERIAL AND METHODS
Complaint No. of cases Percentage
Delay walking 19.4 %
Abnormal gait 29 80.6 %
Shortening in one lower limb 28 77.8 %
Clinical Examination:
I- Gait:
• Delay walking in 7 cases (4 unilateral and 3 bilateral cases).
• Gluteus medius lurch or Trendelenburg gait in unilateral cases
characterized by a contralateral tilt of the pelvis, lateral
deviation of the spine toward the affected side.
• "Duck like waddle" or "waddling gait" in bilateral cases.
II- Asymmetrical thigh and popliteal creases in 26 of unilateral
cases.
III- Inguinal folds: were asymmetrical in unilateral cases and
symmetrical in bilateral cases, but they extend posteriorly beyond
the anal aperture.
115

IV- Limited abduction:
MATERIAL AND METHODS
The child must be calm and relaxed; abduction was examined
in 90 degrees hip flexion.
Unilateral limitation of hip abduction was found in 27 of unilateral
cases, by comparison with contralateral n
ormal'
hip.
Bilateral symmetrical limitation of hip abduction was found in 6 of
bilateral cases. Hip abduction was found to be less than 60 degrees.
The three cases associated with ligamentous hyperlaxity, abduction
was normal.
V- Galeazzi sign:
Apparent shortening of the femur as shown by the difference
of the knee levels with the hips and knees flexed at right angles and
the child lying on a firm table. Positive Galeazzi sign was found in
unilateral cases.
VI- Associated signs in bilateral cases: Wide perineal space,
prominent greater trochanters, hyperlordosis of lumber spine, and
protuberant abdomen.
VII- Telescoping:
To elicit this sign, test the adducted hip in flexion and

MATERIAL AND METHODS
extension, the examiner grasps the distal thigh and knee with one
hand, places the index finger of the other hand over the greater
trochanter, and splays the thumb and other fingers over the ilium. Up
and down movements of the greater trochanter can be felt.
Telescoping is positive in 18 cases (21 hips).
VIII-Trendelenburg sign:
The Trendelenburg test was positive, as the child stands on the
dislocated hip, the pelvis drops on the opposite normal side because
of the weakness of hip abductors.
Trendelenburg sign was positive in 29 cases (80.6%). The remaining
7 cases (18.4 %) were the cases of delayed walking and standing, so
it was difficult to elicit the test. (Cases number 4, 6, 7, 15, 19, 30 and
34).
IX-Associated congenital anomalies:
• Three cases (8.3 %) associated with Wipes equinovarus (Cases
number 1, 6 and 17).
Three cases (8.3 %) associated with ligamentous h
of the joints (Cases number 12, 19 and 29).
• Two cases (5.6 %) associated with congenital torticollis (Cases
number 23 and 25).
yperlaxity
117

MATERIAL AND METHODS
• Two cases (5.6 %) associated with congenital calcaneovalgus
(Cases number 11 and 27).
• One case (2.8 %) associated with congenital scoliosis (Case
number 1).
Table 9: Associated congenital anomalies
Associated congenital anomalies No. of cases
Talipes equinovarus 3 8.3%
Ligamentous hyperlaxity of the joints 3 8.3%
Congenital torticollis 2 5.6%
Congenital calcaneovalgus 2 5.6%
Congenital scoliosis 1 2.8%
118

Roentgenographic examination
MATERIAL AND METHODS
Standard anteroposterior and frog-leg lateral radiographs were
taken to establish the diagnosis.
All the forty-four hips were complete dislocations. The ossified
nucleus of the femoral head lies laterally to the Perkins's line and
above Y line in 39 hips.
The other 5 hips (
caseS
number 6, 7 and 25) the ossified nucleus not
yet developed and the medial margin of the ossified proximal
metaphysis of femur lies laterally to the Perkins's line and above Y
line.
grade 4.
According to Tonnis classification (1982) all our cases were
Shanton line: was disrupted in all affected hips.
119

Surgical treatment
MATERIAL AND METHODS
Open reduction and capsulorraphy through the anterolateral
approach were done in the forty-four hips.
In seven hips (cases number 1, 10, 16, 22, 26 and 33R) proximal
femoral o
steotomy
was done to accomplish reduction.
(femoral shortening and derotation osteotomy)
120

Surgical technique of open reduction
Anesthesia: General anesthesia.
MATERIAL AND METHODS
Positioning: The patient was placed supine in the operating table
with a small pad beneath the affected hip.
Sterilization: Betadine was used for sterilization of the surgical
field starting from the lower chest, abdomen, iliac region, perineum,
down to include the entire affected lower limb. The lower limb
draped free to be moved during operation.
Adductor tenotomy:
The affected hip was flexed 70 to 80 degrees, abducted, and laterally
rotated by the assistant. A small incision was made over the adductor
tendons transversely about 1 cm distal and parallel to the inguinal
crease, dissecting the deep fascia in the same plane with the incision.
The fascial sheath over the adductor longus was incised
longitudinally. The anterior and posterior margins of the adductor
longus muscle are delineated, and the muscle was sectioned over a
right angled forceps at its origin and retracted distally. The adductor
brevis muscle was retracted anteriorly, and the anterior branches of
the obturator nerve and vessels are visualized but not disturbed.
121

MATERIAL AND METHODS
Release the gracilis muscle was done if abduction was still limited
(less than 60 Hdegrees).
was then secured and the wound
packed to be closed with the other wound at the end of operation.
Open reduction:
aemostasis
Incision: bikini incision extends from the middle of the iliac crest to
a point midway between the anterosuperior iliac spine and the
midline of the pelvis. The anterosuperior iliac spine should be at the
midpoint of the incision, which can be placed 1 cm below the iliac
crest. Fig. 42
Fig. 42: Bikini incision Beaty, 1992).
122

Or i
liofemoral
MATERIAL AND METHODS
incision extends from the junction of the posterior
and middle thirds of the iliac crest to the anterior superior iliac spine
and then distally into the thigh for about 7 to 10 cm in the groove
between the tensor fasciae latae and the sartorius muscles. Fig. 43
Fig. 43: Iliofemoral incision (Tachdjian, 1990).
The deep fascia was incised over the iliae crest, and the fascia lata
was opened in line with the skin incision.' The lateral femoral
cutaneous nerve was identified; it crosses the sartorius muscle 2.5
cm. distal to the anterior superior iliac spine and lies close to the
muscle's lateral border. The nerve was retracted medially. Fig. 44
123

Fig. 44: Incision in the deep fascia (
Tachdjian,
MATERIAL AND METHODS
1990).
Blunt dissection was used to open the groove between the tensor
fasciae latae muscle laterally and the sartorius and rectus femoris
muscles medially, and the fatty layer of tissue that covers the front
of the capsule of the hip joint was exposed. The ascending branches
of the lateral femoral circumflex vessels cross the midportion of the
wound. If they were in the way, they were isolated, clamped, ligated
and cut. Fig. 45
Fig. 45: Dissection ; between tensor fasciae latae and sartorius
muscle (Tachdjian, 1990).
124

•:
,
440.
:
01.
464.
:
.
:
.
T. f c
isciap
•
.
.
MATERIAL AND METHODS
With a scalpel, the cartilaginous iliac apophysis was splited through
the middle down to bone from the junction of its posterior and
middle thirds to the anterior superior iliae spine. With a broad
periosteal elevator, the lateral part of the apophysis and the tensor
fasciae latae and the gluteus medius and minimus muscles were
subperiosteally stripped and reflected as a continuous sheet to the
superior rim of the acetabulum anteriorly and the greater sciatic
notch posteriorly. Fig. 46
Fig. 46: Iliac apophysis split and s
ubperiosteal
:
release of tensor
fasciae latae, gluteus medius and minimus muscles (Tachdjian,
1990).
Next, the origin of the sartorius muscle was detached from the
anterior superior iliac spine, and its free e
nd'was
marked with 2-0
Vicryl sutures for later reattachment. The sartorius muscle was
reflected distally and medially. The two heads of r
the
the direct one from the anterior inferior iliac spine and the reflected
ectus
femoris-
125

Ire i
3
. i
rem•eop
lc . . • . •
:
.
• •
• •
• .
.
urkl:
ri
, i
lecto
.
•
14.
MATERIAL AND METHODS
a
V
one from the superior margin of the were divided at
their origin, marked with 2-0 sutures, and reflected distally.
Fig. 47
icryl
Fig. 47: Distal reflection of sartorius and two heads of rectus
femoris muscles (Tachdjian, 1990).
The hip was then flexed, abducted, and laterally rotated, exposing
the iliacus muscle fibers, iliopsoas tendon, and lesser trochanter. A
retractor was placed along the medial aspect of the anteroinferior
spine onto the superior pubic ramus. The psoas tendon was
identified in its groove on the superior pubic ramus (a right angle
forceps was used to isolate t
the
tenotomy was done. Fig. 48
endinaps
cetabulum-
portion) and a recession
126

Fig. 48: Iliopsoas tendon recession (Tachdjian, 1990).
MATERIAL AND METHODS
At this point an attempt was made to reduce the dislocated hip in
order to determine the factors obstructing closed reduction.
Manipulation should not be forcible. If reduction was not possible,
either there were intracapsular obstructing factors or all obstructing
extracapsular factors had not been relieved, or both.
Next, the capsule s
and were incised parallel to the superior
and anterior margins of the acetabulum. Enough rim (usually 1/4 to
ynovium
3/8 inch) of the capsule should be left medially with the acetabulum
and marked with 2-0 PDS sutures for capsuloplasty later.
Superiorly, a longitudinal incision was made parallel with the neck
of the femur, converting the capsular incision into a T. The free
edges of the capsule were marked with 2-0 PDS sutures for traction
and later plication. Any adhesions fond around the femoral neck
were dissected. Fig. 49
127

T.
‘
Oi6p6ci
cnp
fhmPtol.
nack
sitios
.
tetrgiulUro
along
inclstari 0
Fig. 49: T-shaped capsular incision Tachdjian, 1990).
unetfiirkbv
(
: .
:
MATERIAL AND METHODS
The hip joint was inspected for intra-articular factors obstructing
reduction. The l
igamentum
teres was usually elongated and
enlarged and may prevent anatomic reduction; if so, it should be
excised. First, the femoral head end of the ligamentum teres was
divided, and the opposite end was traced to the a
the lower part of the true a
cetabulum,
cetabular
notch at
where it was divided. Release
the transverse acetabular ligament, which was displaced superiorly
with the inferior part of the capsule to enlarge the most inferior
aspect of the acetabulum. Fig. 50
Fig. 50: Inspection for intra-articular, barriers to reduction and
excision of ligamentum teres (Tachdjian 1990).
128

MATERIAL AND METHODS
Next, the acetabulum was inspected. It may be filled with fibrofatty
tissue, which may interfere with optimal seating of the femoral
head within the socket; if so, it was excised with curet or small bone
nippler. One should be cautious, however, not to remove articular
cartilage with it. Fig. 51
Fig. 51: Removal of fibrofatty tissue from the acetabulum
(Tachdjian, 1990).
If a hypertrophied l
abrum
was present, several radial, T-shaped
incisions laterally and superiorly were done to make enlargement of
the true acetabulum easier.
Next, inspection of the joint was done to determines (1) the depth of
the acetabulum and the inclination of its roof, (2) the shape of the
femoral head and the smoothness and condition of the articular
hyaline cartilage covering it, (3) the degree of anteversion of the
femoral neck, and (4) the stability of the hip after reduction. The
femoral head was placed in the acetabulum under direct vision by
flexing, abducting, and medially rotating the hip while applying
thigh. traction and gentle pressure over the greater trochanter. This
129

MATERIAL AND METHODS
maneuver was reversed to redislocate the hip. The position of the
hip when the femoral head comes out of the acetabulum was
determined.
Femoral derotation osteotomy (FDO) were done in these cases
where internal rotation more than 30 degrees were needed to
maintain the femoral head in the stable zone. .
Femoral shortening was done in these cases due to excessive soft
tissue tension and excessive tension on the femoral head after
reduction.
A careful capsulorraphy was performed. With the femoral head
reduced, the hip joint was held by a second assistant in 30 degrees
of abduction, 30 to 45 degrees of flexion, and 20 to 30 degrees of
medial rotation throughout the remainder of the operation.
The large, redundant superior pocket of capsule should be
obliterated by plication and overlapping of its free edges. The
capsule should also be tightened medially and anteriorly by a vest-
over-pants closure. If it was too lax and redundant, a portion may be
excised. First, the medial part of the capsule that was left attached to
the margin of the a
cetabulum
was everted by pulling the previously
placed PDS sutures anteriorly and superiorly. Next, the
superolateral segment of the T was brought inferomedially and
sutured with interrupted sutures to the inner surface of the capsule
130

MATERIAL AND METHODS
there. Then the inferolateral segment was brought up and over the
superolateral segment and sutured with i
nterrupted
sutures to the
inner superoposterior surface of the medial part of the capsule.
Next, the capsule was tautened anteriorly and medially, bringing the
medial segment over the lateral segments and suturing it to them by
interrupted PDS sutures. Fig. 52
Fig. 52: Technique of capsulorraphy (Tachdjian, 1990).
The two halves of the iliac apophysis were sutured together over the
iliac crest. The rectus femoris and sartorius muscles were resutured
to their origins.
Femoral shortening and derotation osteotomy
Through lateral incision from the greater trochanter distally 8 to 12
cm, the iliotibial band was incised, and the vastus lateralis muscle
was reflected to expose the lateral aspect of the femur.
131

MATERIAL AND METHODS
A transverse line was done in the femoral cortex with an osteotome
to mark the level of the osteotomy at the level slightly distal to the
lesser trochanter.
Next, longitudinal orientation line on the anterior femoral cortex to
determine correct rotation; this line was positioned so that it can be
seen through the plate holes or around the plate.
The plate (four-hole one-third tubular AO plate) was positioned on
the femur with the o
steotomy
site in the middle. The plate was fixed
to the proximal segment loosely with one screw and drilling was
done only for the second screw (3.5mm cortical screws).
Next, osteotomy was done at the transverse line on the cortex with
an oscillating power saw. The amount of shortening needed was
determined by the amount of overlap after the first o
amount of shortening required was ranged from 1 to 3 cm.
Next, the first screw was tightened, and a second one was applied to
the proximal segment.
Using the longitudinal mark in the femoral cortex as a guide, the
femur was rotated as needed to correct femoral anteversion (usually
15 to 30 degrees).
steotomy.
The
132

MATERIAL AND METHODS
The plate was secured to the distal femoral shaft with reduction
clamp and the other two screws were applied in the distal fragment.
Fig. 53
The wound was closed in layers over a suction drain and hip spica
was applied.
Fig. 53: Technique of derotation osteotomy and femoral
shortening (Tachdjian, 1997).
133

Technique of spica cast application
MATERIAL AND METHODS
The anesthetized child was placed on the spica frame. The hip was
abducted 40 to 45 degrees and flexed to about 95 degrees. Fig. 54-A
A small towel was placed in front of the abdomen. 2-inch (5 cm)
Webril or cotton was rolled from the level of the nipples down to the
ankles. Fig. 54-B
The bony prominence was padded. The first pad was applied over
the proximal end of the spica, near the nipple line (Fig. 54-C). A
second piece was applied at the level of the right groin and carried
posteriorly across the gluteal fold, over the right iliac crest, in front
of the abdomen, over the lateral aspect of the left thigh, and then to
the left inguinal area (Fig. 54-C). A third piece was applied over the
knees (Fig. 54-D) and a fourth piece was applied over the ankles.
The plaster was done in two sections: a proximal section from the
nipple line to the knees and a distal section from the knees to the
ankles.
A single layer of (10cm) plaster roll was applied from the nipple line
to the level of the knees on both sides.
Four or five plaster splints were applied back to front from the
nipple line to the back of the sacrum to reinforce the back of the cast.
At the same time a short, thick splint was applied over the
134

MATERIAL AND METHODS
anterolateral aspect of the inguinal area (Fig. 54-E). Another splint
was applied: starting from the right inguinal area, carried posteriorly
across the gluteal region, the iliac crest, the front of the abdomen,
and back the same way on the opposite thigh (Fig. 54-E).
This was a reinforcing splint that attaches the thigh to the upper
segment. Another long splint was applied from the level of the knee
across the anterolateral aspect of the inguinal area and up the chest
wall (Fig. 54-F). This splint was one of the main anchors of the
thigh to the body segment. This was followed by a roll of (10cm)
plaster from the nipple line to the knees. This completes the
proximal section of the spica.
Next, the cast was completed from the knees down to the ankles.
This was done by applying on both sides a single roll of (7.5cm)
plaster from the knee to the ankle level and this was reinforced by
two splints over the medial and lateral aspects of the thigh, knee, and
leg. This was followd by another roll of (7.5cm) plaster, then
shoulder straps were applied to prevent pistoning of the child in the
cast (Fig. 54-G).
Since the cast was reinforced laterally around the hips, a wide
segment can be removed from the front of the hips without
weakening the cast. This permits better roentgenograms of the hips
(Fig. 54-G).
135

MATERIAL AND METHODS
The final view of the spica from inferiorly should appear as shown
in Fig. 54-H, with about 40 to 45 degrees of abduction. The amount
of abduction is determined by the position of hip stability.
Fig. 54: Technique of spica cast application (Beaty, 1992).
136

Aftertreatment
MATERIAL AND METHODS
• Spica cast immobilization was continued for 12 weeks. The
cast changed at 2 months postoperatively, with the patient
under general anesthesia in 3 cases (cases number 5, 10, and
18).
• Roentgenograms were done postoperatively in all cases to be
sure that the femoral head was reduced anatomically into the
acetabulum.
• CT scan was done postoperatively to be sure that the femoral
head is reduced anatomically into the acetabulum in 4 cases
(cases number 1, 5, 9, and 20).
• After removal of spica cast, radiographs of the hips were
taken. The child was allowed to m
ove
his lower limbs
actively. Passive exercises should be avoided, as they stretch
the shortened retinacular vessels. As soon as functional range
of motion of the hips was obtained, partial weight- bearing
was begun. Full weight-bearing was started within 8 to 12
weeks, following removal of the solid cast.
137

Operative Notes
MATERIAL AND METHODS
• Blood transfusion: 250- 300 cc of blood transfusion was
needed in cases with concomitant femoral shortening and
denotation o
steotomy.
• Skin incision: Bikini incision (ilioinguinal incision) was used
in 24 hips and iliofemoral incision in 20 hips.
• The shape of the femoral head was noted to be spherical in
18 hips and deformed in 26 hips.
• Capsular adhesions were found around the femoral neck in
20 hips, adherent to lateral acetabular wall in 36 hips, and
adherent across the acetabular floor in 8 hips. The adhesions
must be dissected from the femoral neck cautiously to avoid
damage of blood supply to the femoral head. Adhesions to
lateral acetabular wall were dissected and reflected to augment
the capsulorraphy. Adhesions across the acetabular floor were
dissected to facilitate reduction.
• l
The teres was noted to be hypertrophic in 34
hips and was reflected.
igamentum
138

MATERIAL AND METHODS
• In 36 hips the transverse acetabular ligament was found to
be enlarged causing narrowing of the inferior part of
acetabulum and it was divided.
• The neolimbus was found to be inverted and hypertrophic
causing acetabular narrowing in 20 hips and radial release
incisions were done.
• Skin closure was done by subcuticular stitches using 2-0
Vicryl as it found to be more cosmetic and to avoid cast
damage or change during stitch removal.
• In bilateral cases, the other hip was operated upon after an
average period of one month (ranged from 3 to 6 weeks) in
seven of them, in the other case (number 1) 6 months elapsed
between surgeries.
139

wi'"
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Table 10: Material and methods
MATERIAL AND METHODS
Complaint Clinical Examination Operative
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Delay
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140

MATERIAL AND METHODS
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24 .
.
_
Trend +
-
-
+
-
-
OR
#
Shaded cases are cases of group II (37-42 M).
B.Sym = Bilateral symmetrical.
OR = open reduction.
P
F
O
= Proximal femoral osteotomy (Femoral derotation and s
h
o
r
t
e
r
n
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n
g
LH = ligamentous hyperlaxity. Tort. = Torticollis.
Cal. Val. = Calcaneovalgus foot.
Trend sign = Trendelenburg sign.
Asso. Anom. = associated congenital anomalies.
Bil. = Bilateral.
Wad. = Waddling gait.
Trend. = Trendelenbug gait.
= delayed walking.
Asym. = Asymmetrical.
Abd. = Abduction.
Gr. Troch. = Greater trochanter.

Follow-up
Results
RESULTS •
The patients were followed-up regularly in the out patient clinic in
the following manner:
* every month interval in the first three postoperative months, then
* every three months for one year, then
* every six months till the end of the study.
The follow-up period ranged from 12 to 36 months with a mean of
22.7 months.
In each follow-up visit the patients undergone clinical examination
and anteroposterior and frog-leg lateral roentgenograms on the
pelvis and both hips.
Statistics were done using statistical program SPSS version 10.
Groups were compared using the Chi-square test (X 2 ) and Fisher
exact test. Significant results were considered when P value less than
0.05.
142

Clinical evaluation:
RESULTS
The clinical notes were reviewed for possible complications of
treatment as well as for any mention of pain in the hip, limited range
of motion, Trendelenburg sign, or limb-length discrepancy at the
final follow-up visit.
The clinical evaluation was done according to the criteria described
by Barrett et al., 1986, as shown in table 11.
Table 11: Criteria for clinical evaluation (Barrett et al., 1986)
Excellent Stable, painless hip, no limp, negative
Trendelenburg
sign, full range of movement
Good Stable, painless hip, slight limp, negative
Trendelenburg
sign, slight loss of hip movement
Fair Stable, painless hip, limp, positive Trendelenburg
sign, moderate stiffness
Poor Unstable and / or painful hip
According to this criteria, excellent results were reported in 9 hips
(20.5%), good results in 25 hips (56.8 %), fair results in 6 hips (13.6
%) (cases number 9, 22, 25 left, 29 bilateral and 30), and poor
results in 4 hips (9.1 %) (cases number 10, 16 and 32 bilateral) as
shown in table 12 and figure 55.
143

RESULTS
The satisfactory (excellent and good) results in 34 hips (77.3%),
unsatisfactory (fair and poor) results in 1
Table 12: Clinical result
Frequency Percent
Statistics•
Excellent 9 20.5
Good 25 56.8
Fair 6 13.6
Poor 4 9.1
Total 44 100.0
0
hips (22.7%).
144

Fig. 55: Clinical results
Excellent Good Fair Poor
El
No. of hips •
%
RESULTS
145

Radiological evaluation:
RESULTS
Radiological evaluation was done according to the criteria described
by Severin 1941.
Table 13: Severin c
Grade I
(Excellent)
Grade II
(Good)
Grade III
(Fair)
Grade IV
(Poor)
Grade V
(Poor)
Grade VI
(Poor)
lass:
ification
(1941)
-E
CriteriaC
Angle
Normal hip CE angle >15° ( 5 to 13 years)
Moderate deformity of
the femoral head, neck,
or acetabulum
Dysplastic hip or
moderate deformity of
femur or acetabulum
Subluxation
Articulation in false
acetabulum
Redislocation
CE angle >20° (> 14 years)
CE angle >15° ( 5 to 13 years)
CE angle >20° (> 14 years)
CE angle 15° ( 5 to 13 years)
CE angle 14 years)
The acetabular index was regarded as the most valuable parameter .
of development of the hip in children who are less than 5 years old at
the time of most recent follow-up. As measurements of CE angle in
this young patients are not consistently reproducible.
146

Table 14: Radiological results
Radiological results Statistics
Frequency Percent
Excellent 7 15.9
Good :
27 61.4
Fair 6 13.6
Poor 4 9.1
Total 44 100.0
RESULTS
According to this criteria, excellent results were reported in 7 hips
(15.9%), good results in 27 hips (61.4 %), fair results in 6 hips (13.6
%) (cases number 9, 22, 25 left, 29 bilateral and 30), and poor
results in 4 hips (9.1%) (cases number 10, 16 and 32 bilateral) as
shown in table 14 and figure 56.
The satisfactory (excellent and good) results in 34 hips (77.3%),
unsatisfactory (fair and poor) results in 10 hips (22.7%).
147

Fig. 56 : Radiological results
Excellent Good Fair Poor
No. of M
hips %
RESULTS

Results and age at operation
RESULTS'
Twenty-seven cases (32 hips) were reduced when the patient 18 to
36 months old (group I), and nine cases (12 hips) were reduced
when the patient 37 to 48 months old (group II) as shown in table
15.
Table 15: age distribution
Age group Group I
(18- 36 M)
Group II
(37- 48 M)
No. of cases No. of hips
27 32
9 12
Total 36 44
In group I, excellent results were reported in 7 hips {
21.
9
%), good
results in 19 hips (59.4 %), fair results in 5 hips (15.6 %) (cases
number 9, 25 left, 29 bilateral and 30), and poor results in one hip
(3.1 %) (case number 16) as shown in table 16 and figure 57.
The satisfactory results in 26 hips (
results in 6 hips (18.7%).
81.
3%
)
,
and unsatisfactory
In group II, good results were reported in 8 hips (66.7 %), fair
results in one hip (8.3 %) (case number 22), and poor results in 3
hips (25%) (case number 10 and 32 bilateral) as shown in table 16
and figure 57.
149

The satisfactory results in 8 hips (
results in 4 hips (33.3%).
Table 16: Results and age at operation
Age
group
Group I
(18-36 M)
Group II
(37-48 M)
66.
7%
)
,
and unsatisfactory
Results Total
Excellent Good Fair Poor
7 (21.9%) 19 (59.4%) 5 (15.6%) 1 (3.1%) 32
0 (0%) 8 (66.7%) 1 (8.3%) 3 (25%) 12
Total 7 ((15.9%) 27 (61.4%) 6 (13.6%) 4 (9.1%) 44
X = Z635 P value = 0.05
This may be explained by:
• The severe secondary adaptive changes caused by persistent
dislocation during rapid growth.
• The older child might require more surgical intervension.
• The older child's hip will be remodel during a period of
decreasing growth velocity.
RESULTS'
150

Fig. 57: Results and age at operation
0 Group 1 (18-36 M) I
I
Group 11 (37-48 M)
RESULTS

Results in bilateral cases
RESULTS
Eight cases with bilateral developmental dysplasia of the hip were
reviewed in this study. Before surgery, there was no significant
difference clinically and radiologically between the right and left
hips for all patients. Surgical procedures (open reduction ± proximal
femoral osteotomy) required for both hips also were the same in all
patients except case number 33 (right open reduction + proximal
femoral o
steotomy
and left open reduction only).
However, asymmetrical outcome occurred in one case (12.5%) (case
number 25).
Comparison between results in unilateral and bilateral cases
Twenty-eight unilateral cases and eight bilateral cases were
reviewed in this study.
In unilateral cases, excellent results were reported in 5 hips (17.9
%), good results in 18 hips (64.3 %), fair results in 3 hips %
(10.7
and poor results in 2 hips (7.1%) as shown in table 17 and figure 58.
)
,
Results in unilateral cases were satisfactory in 23 hips (82.2%) and
unsatisfactory in 5 hips (17.8%).
152

RESULTS
In bilateral cases, excellent results were reported in 2 hips (12.5%),
good results in 9 hips (56.2 %), fair results in 3 hips (18.8 %), and
poor results in 2 hips (12.5%) as shown in table 17 and figure 58.
Results in bilateral cases were satisfactory in 11 hips (68.7%) and
unsatisfactory in 5 hips (31.3%).
Table 17: Comparison between results in unilateral and bilateral
cases
Results Total
Excellent Good Fair Poor
Unilateral cases 5 (17.9%) 18 (64.3%) 3 (10.7%) 2 (7.1%) 28
Bilateral cases 2 (12.5%) 9 (56.2%) 3 (18.8%) 2 (12.5%) 16
Total 7 ((15.9%) 27 (61.4%) 6 (13.6%) 4 (9.1%) 44
X = 1.1 P value = 0.9
153

Fig. 58: Comparison between results in unilateral and
bilateral cases
80
60
40
200 Excellent Good Poor
Fair
0 Unilateral M
Bilateral
RESULTS
154

Results and side affected
In this series, surgical treatment was done in twenty-nine left hips
(21 unilateral and 8 bilateral cases) and fifteen right hips (7
unilateral and 8 bilateral cases).
In left hip, excellent results were reported in 5 hips (17.2%), good
results in 17 hips (58.6 %), fair results in 4 hips (13.8 %), and poor
results in 3 hips (10.3%) as shown in table 18 and figure 59.
Results in left hips were satisfactory in 22 hips (75.8%) and
unsatisfactory in 7 hips (24.1 %).
In right hip, excellent results were reported in 2 hips (13.3%), good
results in 10 hips (60.7 %), fair results in 2 hips (13.3 %), and poor
results in one hip (6.7%) as shown in table 18 and figure 59.
Results in right hips were satisfactory in 12 hips (80%) and
unsatisfactory in 3 hips (20%).
Table 18: Results and side affected
Excellent Good Fair Poor
Results•
Side Left 5 (17.2%) 17 (58.6%) 4 (13.8%) 3 (10.3%) 29
Right 2 (13.3%) 10 (66.7%) 2 (13.3%) 1 (6.7%) 15
Total 7 (15.9%) 27 (61.4%) 6 (13.6%) 4 (9.1%) 44
X =
0.34 P value = 0.9
RESULTS.
Total

Fig. 59: Results and side affected

Results and gender '
RESULTS
This series include thirty females (34 hips) and six males (10 hips).
In females, excellent results were reported in 5 hips (14.7%), good
results in 23 hips (67.6 %), fair results in 2 hips (5.9 %), and poor
results in 4 hips (11.8%) as shown in table 19 and figure 60.
Results in female's hips were satisfactory in 28 hips (82.3%) and
unsatisfactory in 6 hips (17.7%).
In males, excellent results were reported in 2 hips (20%), good
results in 4 hips (40 %), fair results in 4 hips (40 %) as shown in
table 19 and figure 60.
Results in male's hips were satisfactory in 6 hips (60%) and
unsatisfactory in 4 hips (40%).
Table 19: Results and gender
Results Total
Excellent Good Fair Poor
Sex Females 5 (14.7%) 23 (67.6%) 2 (15.9%) 4 (11.8%) 34
Males 2 (20%) 4 (40%) 4 (40%) 0 (0%) 10
Total 7 ((15.9%) 27 (61.4%) 6 (13.6%) 4 (9.1%) 44
X = 8.87 P value= 0.03
157

Fig. 60: Results and gender
RESULTS

Incidence of avacular necrosis (AVN)
Positive
18.2%
Negative
81.8%
M
Negative
Positive
Fi . 61: Incidence of avascular necrosis
RESULTS.
The criteria for assessing avascular necrosis and proximal physeal
damage were conducted according to Kalamchi and MacEwen
1980.
According to these criteria, eight hips (18.2 %) d
e
vi e
loped
avascular
necrosis. Seven hips (15.9 %) were partial AVN grade I in six hips
(cases number 1 right, 9, 25 left, 29 bilateral, and 30) and grade III
in one hip (case number 35). Only one hip (2.3%) developed
complete AVN grade IV (case number 10) as shown in table 20, 21
and figure 61, 62.
Table 20: Incidence of avasular necrosis
Avascular necrosis Statistics
Frequency Percent
Negative 36 81.8
Positive 8 18.2
Total 44 100.0
159

Table 21: Incidence of complete and partial avasular necrosis
Type of avascular necrosis Statistics
Partial Complete
15.9% 2.3%
Fig. 62: Incidence of complete
and partial AVN
E
la
o
Negative
Partial
Complete
Negative
81.8%
RESULTS
Frequency Percent
Negative 36 81.8
Partial 7 15.9
Complete 1 2.3
Total 44 100.0

Avascular necrosis and age at operation:
In group I, 5 hips (15.6 %) developed avascular necrosis (cases
number 9, 25 left, 29 bilateral and 30), all were grade I.
In group II, 3 hips (25 %) developed avascular necrosis, one hip
was grade I (cases number 1 right), one hip was grade III (case
number 35), one hip was grade IV (case number 10) as shown in
table 22 and figure 63.
Table 22: A
VN
RESULTS•
and age at operation
Avascular necrosis Total
Negative Positive
27 (84.4%) 5 (15.6%) 32
,
Age group Group I
(18-36 M)
Group II
(37-48 M)
9 (75%) 3 (25%) 12
Total 36 (81.8%) 8 (18.2%) 44
X 0.5 P value = 0.3
This may be attributed to muscular contractures in chronically
dislocated hips may put the vessels at an increased risk of being
stretched and compressed, external to the joint itself. Surgical release
of the adductors and iliopsoas would reduce this risk.
Also, the need for more surgical intervension in group II may
increase the incidence of medial circumflex artery injury.
The more dysplastic acetabulum in group II, may require increased
flexion and abduction in spica cast postoperatively to secure hip
stability. A position which increase the incidence of vascular stretch
and compression.
161

Fig. 63: AVN and age at operation
AVN negative
O Group 1 (18-36 M) I
I
----
AVN positive
7
,
77
I -
Group 11 (37-48 M)
RESULTS
162

AVN and surgical procedure
RESULTS
Six out of thirty-seven hips managed by open reduction developed
AVN (16.2%). While two out of seven hips managed by open
reduction, derotation osteotomy and femoral shortening developed
AVN (28.6%) as shown in table 23 and figure 64.
Table 23: AVN and surgical procedure
Surgical
procedure
.
Avascular necrosis Total
Negative Positive
Open reduction 31 (83.3%) 6 (16.2%) 37
Open reduction &
Proximal femoral osteotomy
5 (71.4%) 2 (28.6%) 7
Total 36 (81.8%) 8 (18.2%) 44
AVN and hip stiffness;
X = 0.6 P value = 0.3
Seven out of eight hips had persisted hip stiffness after spica cast
removal developed A
65.
VN
Table 24: AVN and hip stiffness
(87.5%) as shown in table 24 and figure
Avascular necrosis Total
Negative Positive
Hip stiffness Negative 35 (97.2%) 1 (2.8%) 36
Positive 1 (12.5%) 7 (87.5%) 8
•Total
36 (81.8%)
X2 = 31.6 P value = 0.0001
8 (18.2%) 44
163

Fig. 64: AVN and surgical procedure
100
80
60
40
200
Open reduction R
AVN negative
AVN positive
Open reduction & Proximal femoral osteotomy
RESULTS
164

100
50
Fig. 65 .
0
Hip stiffness negative
❑
AVN and hip stiffness
AVN negativeM
Hip stiffness positive
AVN positive
RESULTS
165

Complications other than AVN:
1-Redislocation:
RESULTS.
Redislocation was encountered in three hips (cases number 16
and 32 bilateral). To repeat open reduction and Salter 's
innominate osteotomy were required.
2- Superficial wound infection:
Superficial wound infection occurred in 4 cases, it was
managed by dressings only.
3- Supracondylar fracture:
4- Hip
Pathological fracture in osteoporotic bone happened in
supracondylar femoral region after trivial fall on the ground due
to disuse bone atrophy after prolonged immobilization. It
occurred in 3 cases and managed by above knee cast for 4 weeks.
stiffness:
Stiffness of the hip after spica cast removal was encountered in
10 hips, it was transient and improved within 3 months in 2 hips,
and was persisted stiffness in 8 hips.
166

5- Significant leg-length discrepancy:
RESULTS
Significant leg-length discrepancy (> 2 cm) was reported in
only one case (case number 10), in which grade IV AVN
occurred.
6- Coxa magna:
Coxa magna is frequent after open operations on the developing
hip and should be distinguished afrom
necrosis by the lack
of fragmentation and growth arrest. It occurred in only one case in
our study (case number 28).
7- Coxa vara:
Neck-shaft angle less than 110 degrees, it occurred in one hip
only (case number 35) due to development of grade III AVN.
8- Meralgia parathetica:
Pain in the anterolateral aspect of the thigh developed in one
case n(case
It was due to entrapment of the lateral
cutaneous nerve of the thigh. It was managed by non-steroidal anti-
umber14)
.
inflammatory drugs and neurotonics, it disappeared after one year.
vascular
167

Table 25: complications other than avascular necrosis:
Complication No. of hips
Redislocation 3
Superficial wound infection 4
Supracondylar fracture 3
Hip stiffness J 10
Significant leg-length discrepancy 1
Coxa magna 1
Coxa vary
Meralgia parathetica
RESULTS •
168

Case Sex Side Age
(M)
Followup
duration
iM)
Operative
Procedure
Table 32: Results
Clinical
result
(Barret)
-----:
:
.
:
.
.
--.
Radiological
result
(severin)
Avascular
necrosis
Complications
Other than
AVN
2 F L 24 24 OR Excellent II -- --
3 M R 20 36 OR Good II -- --
4 F L 18 24 OR Excellent I -- --
5 F L 20 12 OR Good II -- --
6 M Bil. 18 36 OR B.Excellent B.I -- L. FF
7 F R 18 24 OR Excellent I -- --
8 F L 30 18 OR Good II-
--
9 M L 28 24 OR Fair III Grade I PHS, SWI
.
:
.
11 F L 18 12 OR Good II -- --
12 F L 18 24 OR Excellent I-
--
13 F R 20 18 OR Good II -- --
I
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r
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8
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II-
B.II-
-
1 5 F L 18 24 OR Good -- --
16 F L 24 12 OR Poor IV SWI
17 F L 18 36 OR Good --
18 F Bil. 24 24 OR B.Good --
19 M Bil. 18 12 OR B.Good B.II -- L. FF
20 F R 24 18 OR Good II --
21 F L 18 24 OR Excellent I -- --
4PF0
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,
.
,
RESULTS
169

• '
ff
ii v
v
23 F L 24 24 OR Good II
--
24
25
F L 24
18
36
24
OR
OR
Good
R. Good
II
R. II
--
L. Grade I
--
L.PHS,
L. Fair L. III
L. SWI
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--
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28 F L 18 24 OR Good II
THS, Coxa
-- magna
29 M Bil. 1-8 - 24 OR . B. Fair B. III B. I B. PHS
30 F R 24 18 OR Fair III Grade I PHS
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(
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36 F L 24 24 OR Good II-
# Shaded cases are cases of group II
OR open reduction.
PR) = Proximal femoral
M).
= wound infection
FF = supracondylar fracture femur
SWI
uperficial
THS & P
HS
steotomy.
37
= Transient and persisted hip stiffness
LLD = Significant limb-length discrepancy
MP = Meralgia parathetica
CV = Coxa vara
7
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RESULTS
170

Bilatqral
Fig. 66: Case number 1:
Four years old girl presenting with bilateral C
Complaint:
Abnormal gait.
Clinical examination:
- Waddling gait.
DH.
- Symmetrical inguinal folds but extends posteriorly beyond anal
aperture.
- Bilateral symmetrical limited abduction.
CASES PRESENTATION
- Exaggerated lumber lordosis, protuberant abdomen and prominent
greater trochanter.
- Negative telescoping test.
- Positive Trendelenbug's sign.
- Associated congenital anomalies: Bilateral CTEV and dorsal spine
scoliosis.
Surgical treatment:
Bilateral open reduction, femoral s
Final result according to Severin c
grade II (good).
hortening
lassification
, and
derotation osteotomy.
(1941):
171

(A)
(B)
CASES PRESENTATION
A and B: A-P and frog-leg lateral radiographs showing
bilateral congenital hip dislocation.
172

CASES P
C: Immediate postoperative CT scan while the patient in hip spica,
showing concentric reduction of the right hip.
D: Postoperative A-P radiograph, after removal of hip spica,
showing concentric reduction of the right hip.
RESENTATION
1 7
3

CASES PRESENTATION
E: Immediate postoperative CT scan while the patient in hip spica. Showing
concentric reduction of both hips and grade I avascular necrosis of right hip.
F: Postoperative A-P radiograph, after removal of hip spica.
Showing concentric reduction of both hips.
174

(G)
ell
CASES PRESENTATION
(H)
G and H: 3 years postoperative A-P and frog-leg lateral radiographs
showing concentric reduction of both hips, acetabular coverage,
w
well development of the femoral ossific nucleus and acetabulum, but
the femoral neck is relatively shorter and broader in the right hip than
left one.
175

Fig. 67: Case number 6:
Eighteen months old boy presenting with bilateral CDH.
Complaint:
Delayed walking.
Clinical examination:
-Symmetrical inguinal folds but extends posteriorly beyond anal
aperture.
- Bilateral symmetrical limited abduction.
CASES PRESENTATION
- Exaggerated lumber lordosis, protuberant abdomen and prominent
greater trochanter.
- Positive telescoping test.
- Associated congenital anomalies: Bilateral CTEV.
Surgical treatment:
Bilateral open reduction.
Final result according to Severin classification (1941):
Bilateral grade I (excellent).
176

(A)
CASES PRESENTATION
(B)
A and B: A-P and frog-leg lateral radiographs showing bilateral
congenital hip dislocation
fi
77

CASES PRESENTATION
C: Postoperative A-P radiograph, after removal of hip spica. Showing
concentric reduction of both hips.
178

(D)
CASES PRESENTATION
(E)
D and E: 3 years postoperative A-P and frog-leg lateral
radiographs showing concentric reduction of both hips, well
acetabular coverage, well development of the femoral ossific
nucleus and acetabulum.
479

Fig. 68: Case number 7:
Eighteen months old girl presenting with right CDH.
Complaint:
- Delayed walking.
- Short right lower limb.
Clinical examination:
- Asymmetrical thigh folds and popliteal creases.
CASES PRESENTATION
- Aymmetrical inguinal folds, the right side extends posteriorly beyond
anal aperture.
- Limited abduction of the right hip.
- Positive Galeazzi sign.
- Positive telescoping test.
Surgical treatment:
Right hip open reduction.
Final result according to Severin classification (1941):
grade I (excellent).
180

A: A-P radiograph showing right congenital hip dislocation.
CASES PRESENTATION
181

(B)
CASES PRESENTATION
(C)
B and C: 1 year postoperative A-P and frog-leg lateral radiographs showing
reduction of the right hip, well acetabular coverage, well
of the femoral ossific nucleus and acetabulum.
concentric
develop
- t
ient
182

Fig. 69: Case number 12:
Eighteen months old girl presenting with left CDH.
Complaint:
- Abnormal gait.
- Short left lower limb.
Clinical examination:
- Trendelenburg gait.
- Asymmetrical thigh folds and popliteal creases.
CASES PRESENTATION
Aymmetrical inguinal folds, the left side extends posteriorly beyond
anal aperture.
- Normal abduction.
- Positive Galeazzi sign.
- Positive telescoping test.
- Positive Trendelenbug's sign.
- Associated congenital anomalies: Ligamentous hyperlaxity of joints.
Surgical treatment:
Left hip open reduction.
Final result according to Severin classification (1941):
Grade I (Excellent).
183

(A)
CASES PRESENTATION
(B)
A and B: A-P and frog-leg lateral radiographs showing
left congenital hip dislocation.
184

CASES PRESENTATION
C: Postoperative A-P radiograph, after removal of hip spica.
Showing concentric reduction of the left hip.
D : 2 years postoperative A-P radiographs showing concentric
reduction of the left hip, well acetabular coverage, well
development of the femoral ossific nucleus and acetabulum.
185

Fig. 70: Case number 16:
A 2 years old girl presenting with left CDH.
Complaint:
4imping.
-Short left lower limb.
Clinical examination:
-Trendelenburg
gait.
- Asymmetrical thigh folds and popliteal creases.
CASES PRESENTATION
- Aymmetrical inguinal folds, the left side extends posteriorly beyond
anal aperture.
- Limited abduction of the left hip.
- Positive Galeazzi sign.
- Negative telescoping test.
- Positive Trendelenbug's sign.
Surgical treatment:
Left hip open reduction, femoral shortening and derotation osteotomy.
Final result according to Severin classification (1941):
Grade VI (poor).

(A)
CASES PRESENTATION
(B)
A and B: A-P and frog-leg lateral radiographs showing left congenital hip
dislocation
187

(C)
(
D)
CASES PRESENTATION
C and D: 1 year postoperative A-P and frog-leg lateral radiographs
showing redislocation of the femoral head.
88

Fig. 71: Case number 22:
Forty-two months old girl presenting with left CDH.
Complaint:
-limping.
-Short left lower limb.
Clinical examination:
-Trendelenburg
gait.
CASES PRESENTATION
- Asymmetrical f
thigh and popliteal creases.
inguinal folds, the left side extends posteriorly beyond
yrnmetrical
- A
anal aperture.
olds
- Limited abduction of the left hip.
- Positive G
aleazzi
sign.
- Negative telescoping test.
- Positive Trendelenbug's sign.
Surgical treatment:
Left hip open reduction, femoral shortening and derotation osteotomy.
Final result according to Severin c
Grade III (fair).
lassificatibn
(1941):

4
A: A
-P
CASES PRESENTATION
radiograph showing left congenital hip dislocation.
190

(B)
CASES PRESENTATION
(C)
B and C: 1 year postoperative A-P and frog-leg lateral
radiographs. Showing concentric reduction of the
femoral head, but the acetabulum still dysplastic. Note
difficult positioning in A-P radiograph due to persisted
hip stiffness.
191

Fig. 72: Case number 28:
Eighteen months old girl presenting with left CDH.
Complaint:
- Abnormal gait.
-Short left lower limb.
Clinical examination:
-Trendelenburg
gait.
- Asymmetrical thigh folds and popliteal creases.
CASES PRESENTATION
- Aymmetrical inguinal folds, the left side extends posteriorly beyond
anal aperture.
- Limited abduction of the left hip.
- Positive Galeazzi sign.
- Positive telescoping test.
- Positive Trendelenbug's sign.
Surgical treatment:
Left hip open reduction.
Final result according to Severin classification (1941):
Grade II (good).
192

CASES PRESENTATION
A: A-P radiograph showing left congenital hip dislocation.
B: 2 years postoperative A. radiographs showing concentric
reduction of the left hip, well acetabular coverage, and coxa
magna.
193

Fig. 73: Case number 31:
Four years old girl presenting with left CDH.
Complaint:
- Abnormal gait.
- Short left lower limb.
Clinical examination:
- Trendelenburg gait.
- Asymmetrical thigh folds and popliteal creases.
- A
ymmetrical
anal aperture.
- Left hip limited abduction.
- Positive Galeazzi sign.
- Negative telescoping test.
CASES PRESENTATION
inguinal folds, the left side extends posteriorly beyond
- Positive Trendelenbug's sign.
Surgical treatment:
Left hip open reduction.
Final result according to Severin classification (1941):
Grade II (good).
194

CASES PRESENTATION
.A: A-P radiograph showing left congenital hip dislocation
B: Postoperative A-P radiograph, after removal of hip spica. Showing
concentric reduction of the left hip.
195

CASES PRESENTATION
C: 2 years postoperative A-P radiographs showing concentric reduction of the
left hip, well acetabular coverage, well development of the femoral ossific
nucleus and acetabulum.
196

Fig. 74: Case number 35:
Four years old girl p
Complaint:
- Abnormal gait.
- Short right lower limb.
Clinical examination:
-Trendelenburg gait.
respnting
with right CDH.
- Asymmetrical thigh folds and popliteal creases.
CASES PRESENTATION
Aymmetrical inguinal folds, the right side extends posteriorly beyond
anal aperture.
- Limited abduction of the right hip.
-
Positive Galeazzi sign.
- Negative telescoping test.
- Positive Trendelenburg sign.
Surgical treatment:
Right hip open reduction.
Final result according to Severin classification (1941):
grade II (good).
197

A: A-p radiograph showing right congenital hip dislocation.
CASES PRESENTATION
B: 2 years postoperative radiograph, showing concentric reduction of right hip,
well devepment of a
the decrease femoral head height, short
femoral neck, coxa vara and relative overgrowth of the greater trochanter
(grade I
AVN).
II
cetabulinn,
19g

Discussion
DISCUSSION
There is a definite preponderance of females affected by congenital
dislocation of the hip. Congenital dislocation of the hip is
approximately five to eight times more common in girls than boys.
Girls are especially susceptible to the maternal hormone relaxin,
which may contribute to ligamentous laxity with the resultant
instability of the hip (Barges et al., 1995).
In this series there were 30 females and 6 males with a ratio of 5:1.
The left hip is involved 3 times as commonly as the right hip,
perhaps related to the left occiput anterior positioning of most
nonbreech newborns. In this position, the left hip resides posteriorly
against the mother's spine, potentially limiting abduction (No
authors listed, 2000).
The left hip was affected in 21 cases (58.3%), the right was
affected in 7 cases (19.4%), and there were 8 bilateral cases
(22.2%%).
There is greater incidence of hip dislocation in firstborn children.
This appears to be related to intrauterine malposture caused by an
199

DISCUSSION
unstretched uterus and taut abdominal muscles (Wynne-Davies,
1970). In this study there were 9 firstborn children (25%).
A fetus in breech position in utero is at high risk for hip dislocation.
The frank breech position of hip flexion and knee extension places a
newborn or infant at the highest risk. The incidence of breech
presentation in the general population is about 3 per cent (Hsieh et
al., 2000).
The incidence of breech presentation in infants born with congenital
dislocation of the hip is 15.7 per cent in the neonatal series and 8.3
per cent in the late diagnosis series of Bjerkreim and Van Der
Hagen (1974); 17.3 per cent in that of Carter and Wilkinson
(1964); and 30 per cent in that of Hass (1951).
From the history taken from our cases there was history of
breech presentation in 6 cases (16.7%).
The mechanical factors that predispose to dislocation occur
primarily in the last trimester of pregnancy. All such factors have the
effect of restricting the space available for the fetus in the uterus. It
is believed that the pelvis of the fetus becomes trapped in the
maternal pelvis. The fetus is unable to kick and change positions,
which prevents the normal flexion of the hip and knee, or "limb
folding". (Artz et al., 1975; Dunn, 1976).
200

scoliosis.
DISCUSSION
In this study there were history of cesarean section in 3 cases
(8.3%) and oligohydramnios in one case (2.8%).
Other abnormalities are known to occur in association with
congenital dislocation of the hip. Patients having any of these
abnormalities are termed high-risk infants. They include talipes
equinovarus, metatarsus varus, calcaneovalgus foot, congenital knee
dislocation, scoliosis, spina bifida, and generalized laxity of joints
(Tachdjian, 1997; Gercovich, 1999; Tien et al., 2001).
In this study there were three cases (8.3 %) associated with talipes
equinovarus, three cases (8.3 %) associated with ligamentous
hyperlaxity of the joints, two cases (5.6 %) associated with
calcaneovalgus,
congenital torticollis, two cases (5.6 %) associated with congenital
one case (2.8 %) associated with congenital
Clinical findings of DDH vary with the age of the infant, the degree
of displacement of the femoral head whether subluxatable,
dislocatable, or dislocated (Tachdjian, 1997).
After walking age this findings include asymmetry of the thigh or
gluteal folds (better observed when the child is prone), relative
shortness of the femur with the hips and knees flexed (called the
Allis or Galeazzi sign) and a discrepancy of leg lengths.
201

DISCUSSION
Asymmetrical skin folds are commonly mentioned as a sign to look
for, but unfortunately this sign is not always reliable because normal
children may have asymmetrical skin folds, and children with
dislocated hips may h
aVe
symmetrical folds (Morey, 2001).
In this study, 26 of unilateral cases (92.9%) had asymmetrical
thigh and gluteal folds.
Inguinal fold assessment was recommended as a useful adjunct to
other screening methods for congenital dysplasia of the hip in old
infants and we suggest that asymmetrical or abnormally long
inguinal folds are indications for further evaluation (Ando and
Gotoh, 1990; Tachdjian, 1997).
In this series, abnormal injuinal folds were found in all cases. It
was asymmetrical in unilateral cases and symmetrical in bilateral
cases but extend posteriorly beyond the anus.
Weil , 1978 reported that normally 37.5% of all children start to
walk between the 9th and the 12 th month of life; 84.7% started
between 13 t h and 15 th month, and 100% are walking between the 16 th
and 19 th month.
Walking was delayed in seven patients (19.4%), their age were 18
months.
202

DISCUSSION
In a child of walking age with an undetected dislocated hip, families
describe a "waddling" type of gait, indicating dislocation of the
femoral head and a Trendelenburg gait pattern (Morey, 2001).
Radiographic assessment of the newborn hip if normal may be
misleading and deceptive. A negative radiogram does not rule out
the presence of dislocation. Much of the newborn pelvis is
cartilaginous and therefore not visible in the routine radiogram; the
femoral head is not ossified at birth, and its exact relationship to the
acetabulum is hard to determine (Hubbard, 2001).
All the hips in this study were graded radiologically as complete
dislocation, and according to Tonnis classification (1982) all our
cases were grade 4.
The American Academy of Pediatrics (AAP) has developed a
clinical practice guideline on the early detection of developmental
dysplasia of the hip (DDH), which includes frank dislocation, partial
dislocation, instability and inadequate formation of the acetabulum.
The accompanying algorithm gives an overview of the
recommendations for DDH screening in infants (
2000; Morey, 2001).
NO
authors listed,
Despite the introduction of screening programs to detect congenital
dislocation of the hip in the newborn, children still present later in
childhood with established dislocation (Williamson et al., 1989).

This study conducted in t
months at the time of surgery.
hirty-six
DISCUSSION
patients aged between 18 to 48
The goal of treatment in congenital dislocation of the hip is to return
the femoral head to within the acetabulum, and to maintain this
position until the pathological changes have reversed. Early
reduction implies that fewer adaptive changes have taken place, and
reduces the time required for the femoral head, acetabulum and
capsular structures to return to their normal configuration
(Hensinger, 1985).
The treatment of congenital dislocation of the (
hip has
undergone a steady evolution. As early as 1936, Gill recognized that
no one method of treatment would be satisfactory for all cases of
CDH.
At first, closed methods of treatment were favored, but later it was
realized that the results were variable and that poor results with
closed treatment tended to be associated with avascular necrosis
and/or residual subluxation. Decompression of the femoral head by
prereduction traction, soft tissue releases, and moderate position in a
spica cast could largely circumvent the problem of avascular
necrosis. However, residual subluxation continued to be a problem.
Following the advent of hip a
rthrograpliy,
it was realized that many
hips were reduced with soft tissue interposition (Powell et al.,
1986).
CDH)
204

DISCUSSION
Renshaw, 1981 in his review of arthrography of closed reduction,
found that interposed soft tissue remained in the joint and obstructed
reduction. This was against S
everin,
1950 who suggested that soft
tissue would yield to bone, and, therefore, soft tissue interposition
would eventually melt away.
Thus, it became clear that soft tissue interposition with attempted
closed reduction was an indication for open reduction. Persisting
with conservative therapy may then lead to a permanently defective
joint.
The earliest age at which an open reduction, can safely be carried out
is contentious (Zionts and MacEwen, 1986). Chuinard, 1972
stated that Wolf's law operates across a joint; if this is true then the
earlier a concentric reduction is obtained, the better the prognosis.
After 18 to 24 months of age, the risk of avascular necrosis and
failure to maintain reduction by closed means increases, so that open
reduction is generally preferred (Galpin et al., 1989; Weinstein,
1994; Terry Canale et al., 1996).
In this study, open reduction and capsulorraphy through the
anterolateral approach were done in the all forty-four hips.
205

DISCUSSION
The anterolateral approach is the most commonly used because it is
a standard approach to the hip joint and is thus familiar to most
surgeons. The disadvantages may include greater blood loss than
other approaches, possible damage to the iliac crest apophysis and
the hip abductors, and postoperative stiffness (Salter et al., 1984).
Open reduction through the anterolateral approach generally is used
to expose and correct the soft-tissue abnormalities responsible for
failure of closed reduction. This procedure includes excision of the
ligamentum teres, removal of the fibro-fatty tissue from the
acetabular fossa, division of the transverse acetabular ligament,
reduction of the femoral head into the acetabulum, and
capsulorrhaphy.
The anterolateral approach also facilitates femoral shortening which
may be necessary to accomplish reduction in the older child
(Weinstein, 1996).
The medial approach should be restricted to children under
approximately 24 months of age who have not responded to
abduction splintage or in whom a stable closed reduction cannot be
accomplished. This approach has not been satisfactory in patients
with teratologic dislocations (e.g.,arthrogryposis and high stiff
dislocations) and following previous surgery (Martin et al., 1993).
The medial approach for open reduction of the hip has been reported
to have a risk of osteonecrosis due to interruption of the medial
206

DISCUSSION
circumflex artery. This can be largely avoided by carefully
preserving the vessels, but the surgeon must be skilled in order to do
so. Also it provides poor access to a
cetabulum
(neolimbus,
ligamentum teres, and pulvinar) and does not allow capsulorraphy
(which is required in older patients) (
Bikini incision (
iliofemoral
ilioinguinal
Wheeless,
1996).
incision) was used in 24 hips and
incision in 20 hips. It was found that Bikini incision
was more cosmetic for the patient and provides the same exposure
as i
liofemoral
incision.
Skin closure was done by subcuticular stitches using V2-0
it found to be more cosmetic and to avoid cast damage or change
during stitch removal.
Somerville and Scott, 1957 advocated a limited anterolateral
arthrotomy and excision of the limbus in hips which would n
reduce concentrically after traction in abduction. In their Oxford
series, degenerative changes were one third as common if reduction
could be achieved without limbectomy, and the rate of deterioration
in radiographic grades I and II was faster after adolescence in
patients who were limbectomised than in those who were not.
This suggests that even in limbectomised hips, which appeared to
develop satisfactorily in childhood, uncovering of the femoral head
was followed by degenerative changes in adolescence and early
icryl
as
ot
.
207

adulthood (Sherlock et a
Blockey, 1984).
l.
,
DISCUSSION
1957; Somerville and Scott, 1957;
O'Hara, 1989 concluded that excision of the limbus appears to be
directly responsible for the deterioration in the acetabular cover,
which occurs after adolescence in previously sound limb. Excision
of the limbus is thus avoidable, undesirable, and unnecessary.
Excision of the labrum is discouraged; if infolded, it should be
'turned out or radially incised but preserved (O'Hara, 1989).
In this study, the neolimbus was found to be inverted and
hypertrophic causing acetabular narrowing in 20 hips and radial
release incisions were done.
Williamson and Benson, 1988 had found that uncovered femoral
head with relatively low acetabular angle can be treated satisfactorily
by derotation femoral osteotomy. A shallow acetabulum with
relatively large acetabular angle greater than 27 degrees precludes
good results, and pelvic o
steotomy
should be considered.
Varus derotation osteotomy, if used to "stimulate" more normal
acetabular development, must be used in-patients younger than 4
years (Tonnis, 1990).
Regardless the neck-shaft angle immediately after the osteotomy, the
femur predictably remodels toward a more normal neck-shaft angle.
208

DISCUSSION
Limb-length inequality does not seem to be a complication of this
procedure. Presumably, the shortening caused by the varus
osteotomy is offset by stimulation of growth of the involved
extremity (Schoenecker et al., 1995).
Several techniques are described for performing varus derotation
osteotomies. Some surgeons prefer an osteotomy below the lesser
trochanter, but the intertrochanteric level is better because it is
accompanied by femoral shaft medialization. If o
steotomy
is the
more distal, lateralization of the femur occurs and produces a
deformity that may not remodel, posterior 'displacement of the lesser
trochanter, and mechanical abnormalities at the knee (Weinstein,
1996).
In contrary, Reichel and Hein, 1996 recommended derotation and
shortening • to be done subtrochanterically and recommended
intertrochanteric osteotomies to be done only in exceptional cases,
such as extremely high dislocated hips in older children.
Galpin et al., 1989 used preoperative skin traction in children until
the age of two years or until a weight of 11.3 kilograms (twenty-five
pounds) has been reached, or both. The efficacy of preoperative
traction, particularly for young children, has been demonstrated in
many reviews (Barlow, 1966; Coleman, 1978; Lindstrom, 1979;
Race et al., 1983).
209

DISCUSSION
Although prereduction traction is still used by 95% of pediatric
orthopedic surgeons in North America, its use is a somewhat
controversial topic. In methods (skin traction versus skeletal
traction), direction (overhead versus divarication versus
longitudinal), and duration (days versus months). Whether traction
can be applied effectively in the home or whether it should be used
in the hospital (Weinstein, 1997-A).
In older children, the m
ore
rigid contractures of the soft tissues may
prevent reduction or may cause it to be unstable. This tightness also
results in major pressure on the capital femoral ossified nucleus if
reduction is obtained (King and Coleman, 1980).
Femoral shortening allows all of the muscles that cross the
osteotomy site to function as if they were lengthened. It has other
advantages • as well; it may be combined with open reduction, it
avoids the prolonged hospitalization and risks of skeletal traction,
and it allows more adequate decompression of the joint than can be
achieved by the conventional surgical r
eleitse
(Galpin et al., 1989).
Primary femoral shortening is recommended for children aged 3
years and older and for children aged 18 to 36 months when a
traction program has failed or when preoperative traction is not
feasible (Beaty, 1992).
In this study, additional surgical procedures (femoral shortening
and denotation osteotomy) were done in seven hips to accomplish
210

eduction.
DISCUSSION
Femoral derotation osteotomy (FDO) were done in those cases as
internal rotation more than 30 degrees were needed to maintain
the femoral head in the stable zone.
Femoral shortening through was done in those cases due to
excessive soft tissue tension and excessive tension on the femoral
head after reduction.
The patient's notes were reviewed and clinical evaluation was done
according to Barrett et al., 1986.
According to this criteria, excellent results were reported in 9 hips
(20.5%), good results in 25 hips (56.8%), fair results in 6 hips (13.6
%), and poor results in 4 hips (9.1 %).
The satisfactory (excellent and good) results in 34 hips (77.3%),
unsatisfactory (fair and poor) results in 10 hips (22.7%).
Radiological evaluation was done according to the criteria
described by Severin, 1941.
Severin first used this classification system in 1941 to describe the
radiographic appearance of the hip a
congenital hip dislocation.
fte'r
the closed treatment of
211

DISCUSSION
The system includes six main categories. Clinicians who use the
Severin system appear to have reached a consensus that class I
indicates an excellent result; class II a good result; class III a fair
result; and classes IV, V, and VI a poor result (Ward et al., 1997).
Acetabular index was regarded as the most valuable parameter of
development of the hip in children who are less than 5 years old at
the time of most recent follow-up. As measurements of CE angle in
this young patients are not consistently reproducible.
According to these criteria, excellent results were reported in 7 hips
(15.9%), good results in 27 hips (61.4%), fair results in 6 hips (13.6
%), and poor results in 4 hips (9.1 %).
The satisfactory (excellent and good) results in 34 hips (77.3%),
unsatisfactory (fair and poor) results in 10 hips (22.7%).
Comparing our results with other series; Massie and
Howorth, 1951 reported 21% satisfactory results in 58 hips
managed by open reduction and usually femoral o
age ranged from 2 to 8 years.
steotomy,
patient
Salter and Dubos, 1974 reported 67% satisfactory results in 30 hips
managed by open reduction and innominate osteotomy, patient age
ranged from 4 to 10 years.
212

DISCUSSION
Pozo, Cannon and Catterall, 1987 reported 78% satisfactory
results in 50 hips managed by open reduction and capsular
arthroplasty, patient age ranged from 3 to 10 years.
Klisic, 1982 reported 59% satisfactory results in 93 hips managed by
open reduction, pelvic and femoral s
age was greater than 7 years.
hortening
osteotomy,
patient
Kasser et al., 1985 reported 81% satisfactory results in 16 hips
managed by open reduction and femoral osteotomy in children who
were less than 5 years of age.
Williamson et al., 1988 reported 51 % satisfactory results in 45 hips
managed by open reduction and femoral or pelvic o
age ranged from 3 to 9 years.
steotomy,
patient
Nazim et al., 1993 reported 94.4% satisfactory results in 18 hips
managed by combined open reduction, femoral and pelvic
osteotomy, patient age ranged from 3 to 13 years.
In this study we had poor results in 4 hips, three due to redislocation,
revision of open reduction and Salter innominate o
required, in these cases the a
cetabulum
steotomy
were
was very shallow (acetabular
index was greater than 27 degrees). The 4 th hip due to development
of grade IV avascular necrosis.
213

DISCUSSION
There is strong correlation between results and the patient age at
the time of operation.
In group I, satisfactory results were reported in 26 hips (81.3%),
and unsatisfactory results in 6 hips (18.7%).
In group II, satisfactory results were reported in 8 hips (66.7%),
and unsatisfactory results in 4 hips (33.3%).
The difference between the two groups results were statistically
significant, P value was 0.05.
This may be explained by: the more severe secondary adaptive
changes that are caused by persistent dislocation during rapid
growth, the older child might require more surgical intervension, and
the older child's hip will be remodeling during, a period of
decreasing growth velocity.
Asymmetric outcome is a potential risk after surgical treatment of
bilateral developmental dysplasia of the hip in children (Viere et al.,
1990).
Eight cases with bilateral developmental dysplasia of the hip
were reviewed in our study. Before surgery, there was no
significant difference clinically and radiologically between the
right and left hips for all patients. Surgical procedures (open
reduction ± proximal femoral osteotomy) required for both hips
also were the same in all patients except one case (right open
214

DISCUSSION
reduction + proximal femoral osteotomy and left open reduction
only).
However, asymmetrical outcome occurred in one case (12.5%).
Moussa and A
l
- O
thman,
2001 reviewed fifteen patients who were
2 years of age or older and had bilateral developmental dysplasia of
the hip. Thirty hips had required open reduction combined with
osteotomy on the pelvic or femoral side or both as necessary.
Asymmetric outcome occurred in four (27%) patients, three of who
were older than 5 years.
Children with bilateral dislocations are symmetric in their gait and
deformity, and for them to get benefit from treatment, the surgeon
must achieve excellent results with two hips, not just one. A patient
who ends up with one excellent hip and one dysplastic arthritic hip
will have significant pain and disability, and the excellent result in
the good hip will be for naught. This fact means that the upper age
limit for performing open reduction is younger in bilateral
dislocations than in unilateral ones, and bilateral open reduction
should be avoided after fifth birthday. Open reductions of unilateral
dislocations should be avoided in children after their eighth birthday.
Such patients are better off with no treatment at all (Moseley, 2001).
Bilateral dislocation is a major frisk
for failure of treatment
(Viere et al., 1990). Twenty-eight unilateral cases and eight bilateral
cases were reviewed in our study.
aCtor
215

DISCUSSION
Results in unilateral cases were satisfactory in 23 hips (82.2%) and
unsatisfactory in 5 hips (17.8%).
Results in bilateral cases were satisfactory in 11 hips (68.7%) and
unsatisfactory in 5 hips (31.3%).
The difference between the two groups results were statistically
insignificant, P value was 0.9.
Surgical treatment on the right hip has better outcome than left
hip (Thomas et al., 1989).
In this series, surgical treatment was done in twenty-nine left hips
(21 unilateral and 8 bilateral cases) and fifteen right hips (7
unilateral and 8 bilateral cases).
i
Results left hips were satisfactory in 22 hips (75.8%) and
unsatisfactory in 7 hips (24.1 %).
n.
Results in right hips were satisfactory in 12 hips (80%) and
unsatisfactory in 3 hips (20%).
The difference between the two groups results were statistically
insignificant, P value was 0.9.
This may be explained by small number of right hips included in this
study and the longer immobilization period of right hips in bilateral
cases as we usually started surgery on them.
216

DISCUSSION
The prognosis of surgical treatment for developmental dysplasia of
the hip was worse in boys than girls. Closed and open reduction of
the hip is associated with higher rate of complications in boys than
in girls. Acetabular remodeling does not occur after open reduction
alone, and it may be prudent to perform an innominate osteotomy to
augment the a
al., 1995).
cetabulum
at the time of the open reduction (Borges et
This series include thirty females (34 hips) and six males (10 hips).
Results in female's hips were satisfactory in 28 hips (82.3%) and
unsatisfactory in 6 hips (17.7%).
Results in male's hips were satisfactory in 6 hips (60%) and
unsatisfactory in 4 hips (40%).
The difference between the two groups results were statistically
•
significant, P value was 0.03.
This May be explained by the more rigid deformity in males than
females.
The most serious complication associated with treatment of
congenital dysplasia of the hip in early infancy is the development of
avascular necrosis (Thomas et a
1.
,
1989)
.
?
217

DISCUSSION
The incidence of avascular necrosis reported in the literatures varies
widely, ranging from 0% to 67%. The age at reduction, the severity
of dislocation, the ease of reduction, the position of postoperative
immobilization, and the concurrent performane of femoral or pelvic
osteotomies have been reported to influence the frequency of this
complication.
This is an iatrogenic complication thought to be related to excessive
pressure on the soft chondroepiphyseal cartilage during reduction,
occlusion of femoral b
ead
blood supply by excessive abduction, or
injury to the medial femoral circumflex vessels during open
reduction (Bassett et al., 1997).
Criteria for assessing avascular necrosis and proximal physeal
damage were done according to Kalamchi and I
VIacEwen
1980.
According to these criteria, eight hips (18.2 %) developed
avascular necrosis. Seven hips (15.9 %) were partial AVIV, grade I
in six hips and grade III in one hip. Only one k
complete AVN grade IV.
ip
(2.3%) developed
Massie and Howorth, 1951 reported 41 % rate of avascular
necrosis in their patients managed by open reduction and femoral
derotation osteotomy.
Salter and Dubos, 1974 reported 6% rate of avascular necrosis in
their patients managed by open reduction and innominate o
steotomy.
218

DISCUSSION
Pozo, Cannon and Catterall, 1987 reported 2% rate of avascular
necrosis in their patients managed by open reduction and capsular
arthroplasty.
Klisic and Jankovic, 1976 reported 30% rate of a
vascular
necrosis
in their patients managed by open reduction, pelvic and femoral
shortening osteotomy.
Williamson et al., 1988 reported 1 1% rate of avascular necrosis in
their patients managed by open reduction and femoral or pelvic
osteotomy.
There is strong correlation between development of A
patient age at the time of operation (Dhar et al., 1990).
VN
and the
In group I, 5 hips (15.6 %) developed avascular necrosis, all were
grade I.
In group II, 3 hips (25 %) developed avascular necrosis, one hip
was grade I, one hip was grade III, one hip was grade IV.
The difference between the two groups results were statistically
insignificant, P value was 0.3.
This may be attributed to muscular c
ontractures
in chronically
dislocated hips may put the vessels at an increased risk of being
219

DISCUSSION
stretched and compressed, external to the joint itself. Surgical release
of the adductors and iliopsoas would reduce this risk.
Also, the need of more surgical intervension in group II may
increase the incidence of medial circumflex artery injury.
The more dysplastic acetabulum in group II, may require increased
flexion and abduction in spica cast postoperatively to secure hip
stability. A position which increase the incidence of vascular stretch
and compression.
The incidence of A
procedures (Dhar et al, 1990).
VN
was higher w
ith
multiple surgical
Six out of thirty-seven hips managed by open reduction developed
AVN (16.2%). While two out of seven hips managed by open
reduction, derotation osteotomy and femoral shortening developed
AVN
(28.6%).
The difference between the two groups results were statistically
insignificant, P value was 0.3.
In contrary, Pawell et al., 1986 concluded that addition of femoral
osteotomy does not increase the incidence of AVN. However,
addition of Salter osteotomy tincrease
of AVN. He reported
incidence of 46.7% in Salter osteotomy group compared with 26.5%
in open reduction and femoral osteotomy group.
he•rate
220

DISCUSSION
The earliest sign of AVN may be clinical. Persisted stiffness of the
hip after removal of the plaster is an indication, even without early
radiological signs of AVN, that all is not well and that the hip should
be observed (Thomas et al., 1989).
Seven out of eight hips had persisted hip s
removal developed AVIV (87.5%).
tiffness
after spica cast
The difference between the two groups results were statistically
highly significant, P value was 0.0001.
Superficial wound infection occurred in 4 cases, it w
dressings only.
as
managed by
Pathological fracture in osteoporotic bone happened in
supracondylar femoral region after trivial fall on the ground due to
disuse bone atrophy after prolonged immobilization. It occurred in 3
cases and managed by above knee cast f
or4
weeks.
Significant leg-length discrepancy (> 2 cm) was reported in only
one case, in which grade IV AVN occurred.
Coxa magna is frequent after open operations on the developing hip
and should be distinguished from avascular necrosis by the lack of
fragmentation and growth arrest. It occurred in only one case (2.3%)
in this study.
221

DISCUSSION
Coxa vara with neck-shaft angle less than 110 degrees, occurred in
one hip due to development of grade III AVN.
Meralgia p
arathetica,
pain in the anterolateral aspect of the thigh
developed in one case n
(case It was clue to entrapment of
the lateral cutaneous nerve of the thigh. It was managed by non-
steroidal anti-inflammatory drugs and n
after one year.
Williamson et al., 1989 reported s
umberl4)
.
upracondylar
euroton
i es, it disappeared
fracture in 4 cases,
coxa vara in 4 cases, wound infection in 2 cases, pressure sore in one
case, and meralgia parathetica in one case.
222

SUMMARY
SUMMARY
There is great geographic and racial variation in the incidence of
congenital dislocation of the hip. Certain areas of the world have an
endemically high incidence, whereas in other areas it is virtually
nonexistent.
In this series, abnormal inguinal folds were found in all cases. It
was asymmetrical in unilateral cases and symmetrical in bilateral
cases but extend posteriorly beyond the anus.
In a child of walking age with an undetected dislocated hip, families
describe a "waddling" type of gait, indicating dislocation of the femoral head
and a Trendelenburg gait pattern (Morey, 2001).
Radiographic assessment of the newborn hip if normal may be misleading
and deceptive. (Hubbard, 2001).
The goal of treatment in congenital dislocation of the hip is to return the
femoral head to within the acetabulum, and to maintain this position until the
pathological changes have reversed. Early reduction i
mplies
that fewer
adaptive changes have taken place, and reduces the time required for the
femoral head, acetabulum and capsular structures to return to their normal
configuration (Hensinger, 1985).
223

SUMMARY
Despite the introduction of screening programs to detect congenital
dislocation of the hip in the newborn, children still present later in childhood
with established dislocation (Williamson et al., 1989).
t
f
This study includes children with dislocated hips.
Their age ranged from 18 to 48 months with a mean of 25.5 months at the
hirty-six
time of surgery. There were 30 girls and 6 boys with a ratio of 5: 1. The
left hip was affected in 21 cases; the right a
was
bilateral affection was encountered in 8 cases.
orty-four
ffected
in 7 cases, while
They were managed surgically in El-Minia University Hospital and Cairo
University Pediatric Hospital from September 1997 to January 2001.
No patients with neuromuscular t
disease,
arthritis, or recurrent dislocation included in this study.
apsulorraphy
eratological
dislocation, septic
c
a
Open reduction and through the approach
were done in the forty-four hips. In seven hips proximal femoral osteotomy
(femoral shortening and d
reduction.
erotation
osteotomy)
nterolateral
was done to accomplish
Bikini incision (ilioinguinal incision) was used in 24 hips and iliofemoral
incision in 20 hips.
The patient's notes were reviewed and clinical evaluation was done
according to Barrett et al., 1986.
224

SUMMARY
According to this criteria, excellent results were reported in 9 hips (20.5%),
good results in 25 hips (56.8%), fair results in 6 hips (13.6 %), and poor
results in 4 hips (9.1%).
Radiological evaluation was done according to the criteria described by
Severin, 1941.
According to this criteria, excellent results were reported in 7 hips (15.9%),
good results in 27 hips (61.4%), fair results in 6 hips (13.6 %), and poor
results in 4 hips (9.1%).
In this study we had poor results in 4 hips, three due to redislocation,
revision of open reduction and Salter i
nnominate
osteotomy were required,
in these cases the acetabulum was very shallow (acetabular index was
greater than 27 degrees). The 4 th hip due to development of grade IV
avascular necrosis.
In group I (18- 36 months), satisfactory results were reported in 26 hips
(81.3%), and unsatisfactory results in 6 hips (18.7%).
In group II (37- 48 months), satisfactory results were reported in 8 hips
(66.7%), and unsatisfactory results in 4 ( hips .The difference between the two groups results were statistically significant,
P value was 0.05.
Eight cases with bilateral d
developmental of the hip were
reviewed in our study. Before surgery, there was no significant
ysplasia
33.
3%
)
225

difference clinically and radiologically between the right and left hips
for all patients. Surgical procedures (open reduction ± proximal
femoral osteotomy) required for both hips also were the same in all
patients except one case (right open reduction + proximal femoral
osteotomy and left open reduction only).
However, asymmetrical outcome occurred in one case (12.5%).
Twenty-eight unilateral cases and eight bilateral cases were reviewed
in this study.
Results in unilateral cases were satisfactory in 23 hips (82.2%) and
unsatisfactory in 5 hips (17.8%).
Results in bilateral cases were satisfactory in 11 hips (68.7%) and
unsatisfactoryin 5 hips (31.3%).
The difference between the two groups results were statistically
insignificant, P value was 0.9.
In this series, surgical treatment was done in twenty-ti i
left hips (21
unilateral and 8 bilateral cases) and fifteen right hips (7 unilateral and
8 bilateral cases).
Results in left hips were satisfactory in 22 hips (75.8%) and
unsatisfactory in 7 hips (24.1%).
Results in right hips were satisfactory in 12 hips (80%) and
unsatisfactory in 3 hips (20%).
ne
SUMMARY
226

SUMMARY
The difference between the two groups results were statistically
insignificant, P value was 0.9.
This series include thirty females (34 hips) and six males (10 hips).
Results in female's hips were satisfactory in 28 hips (82.3%) and
unsatisfactory in 6 hips (17.7%).
Results in male's hips were satisfactory in 6 hips (60%) and
unsatisfactory in 4 hips (40%).
The difference between the two groups results were statistically significant,
P value was 0.03.
Criteria for assessing avascular necrosis and proximal physeal damage
were done according to Kalamchi and MacEwen, 1
According to• these criteria, eight hips (18.2 %
)
980.
developed a
necrosis. Seven hips %
(15.9 were partial AVIV, grade iI
)
n
vascular
six hips
and grade III in one hip. Only one hip (2.3%) developed complete
AVN grade IV.
In group I (18- 36 months), 5 hips (15.6 %) developed avascular
necrosis, all were grade I.
In group II (37- 48 months), 3 hips (25 %) developed avascular
necrosis, one hip was grade I, one hip was grade III, one hip was
grade IV.
The difference between the two groups results were statistically
insignificant, P value was 0.3.
227

AVN
Six out of thirty-seven hips managed by open reduction developed
(16.2%). - While two out of seven hips managed by open
reduction, derotation osteotomy and femoral shortening developed
AVN (28.6%).
SUMMARY
The difference between the two groups results were statistically
insignificant, P value was 0.3.
Seven out of eight hips had persisted hip stiffness after silica cast
removal developed AVN (87.5%).
The difference between the two groups results were statistically highly
significant, P value was 0.0001.
Other complications include superficial wound b
length discrepancy in one case, coxa magna in one case, c
case, and meralgia parathetica in one case.
yection
in 4 cases, leg-
o_va
vara
in one
228

CONCLUSION
CONCLUSION
❑ Inguinal fold assessment was recommended as a useful adjunct to other
screening methods for congenital dysplasia of the hip in old infants.
Open reduction through the anterolateral approach is an effective method of
treatment for congenital hip dislocation in children aged from 18 to 48 months.
Provided that there is no soft tissue tension on the femoral head and internal
rotation required less than 30 degrees during open reduction.
❑ Bikini incision was more cosmetic for the patient and provides the same
exposure as iliofemoral incision.
❑ Femoral derotation osteotomy (FDO) were done. in those cases as internal
rotation more than 30 degrees were needed to maintain the f
stable zone.
emoral
head in the
Femoral shortening through separate lateral approach was done in these cases
due to excessive soft tissue tension and excessive tension on the femoral head
after reduction.
❑ There is strong correlation between results and the patient age at
the time of operation.
❑ Asymmetric outcome is a potential risk after surgical treatment of bilateral
developmental dysplasia of the hip in children
229

o Bilateral dislocation is a major risk factor for failure of treatment
Surgical treatment on the right hip has better outcome than left hip
CONCLUSION
The prognosis of surgical treatment for developmental dysplasia of the hip was
worse in boys than girls.
❑ There is strong correlation between development of AVN and the patient age at
the time of operation
❑ The incidence of AVN was higher with multiple surgical procedures
❑ The earliest sign of AVN may be persisted stiffness of the hip after removal of
the plaster.

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