Younger patients typically with open triradiate cartilage
Single cut above acetabulum through the ilium to sciatic notch. Acetabulum hinges through the pubic symphysis. The redirectional osteotomy can provide 20-25° lateral and 10-15° anterior coverage (coverage limitations in anterolateral head). May lengthen leg up to 1 cm.
Favored in older children because their symphysis pubis does not rotate well. Performed when open triradiate cartilages are present
Salter osteotomy plus additional cuts through superior and inferior pubic rami. Acetabular reorientation procedure.
Triradiate cartilage must be closed in order to perform
Involves multiple osteotomies in the pubis, ilium, and ischium near the acetabulum. This allows improved three-dimensional correction of the acetabulum configuration. It is technically the most challenging. Posterior column and pelvic ring remain intact and patients are allowed to weight bear early
Osteotomy starts approximately 10 to 15 mm above the AIIS, proceeds posteriorly, and ends at the level of the ilioischial limb of the triradiate cartilage (halfway between the sciatic notch and the posterior acetabular rim). Osteotomy hinges at the triradiate cartilage posteriorly and the symphysis pubis anteriorly. This osteotomy does do not enter the sciatic notch and is therefore stable and does not need internal fixation. Reduces acetabular volume
Osteotomy from acetabular roof to triradiate cartilage (incomplete cuts through pericapsular portion of the innominate bone). The acetabular configuration changes by hinging through the triradiate cartilage. This osteotomy does do not enter sciatic notch and is therefore stable and does not need internal fixation. Reduces the acetabular volume
The dial or spherical osteotomy leaves the medial wall or teardrop in its original position and, as a result, is intra-articular.
Add bone to the lateral weight bearing aspect of acetabulum by placing an extra-articular buttress of bone over the subluxed femoral head. Depends on fibrocartilge metaplasia for successful results.
Make cut above acetabulum to sciatic notch and shift ileum lateral beyond edge of acetabulum. Depends on fibrocartilge metaplasia for successful results. Medializes the acetabulum via iliac osteotomy.
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Which of the following is true regarding the structure outlined in Figure A?
It is comprised of the iliopectineal eminence and quadrilateral surface
In normal hips, all children usually have this radiographic figure by 18 months of age
This figure is usually present in children with developmental dysplasia of the hip prior to reduction
The structure is a result of the radiographic superimposition of the ilioischial and Iliopectineal lines
It is comprised of the cotyloid fossa and iliopectineal eminence
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The structure outlined in Figure A is the acetabular teardrop and it is comprised of the quadrilateral surface and cotyloid fossa. In normal hips, all children have a teardrop figure by age 18 months of age.
Albicana et al retrospectively reviewed the radiographs of the pelvis and hips of 45 patients who had unilateral congenital dislocation of the hip treated with closed reduction and casting. The width, shape, and type of the teardrop were measured in the dislocated and contralateral, normal hips. They found that the hips with residual acetabular dysplasia had a v-shaped teardrop, widening of the superior width of the teardrop, and thickening of the acetabular floor which correlated with poorer prognosis in adult life.
Bowerman et al identified the structures responsible for teardrop figure by removing sections from the hemipelvis of an anatomic specimen with an electric saw. The normal and abnormal appearances of the teardrop shadow of the acetabulum of three patients were then demonstrated on both plain radiographs and CT scans.
Smith et al reviewed the radiographs of hips with 47 developmental dysplasia (DDH), and 25 normal hips, to determine the timing of the normal appearance of the acetabular teardrop figure and the value of teardrop development after reduction of the hip in predicting outcome. In normal hips, all children had a teardrop figure by age 18 months. In the 47 hips with DDH, no teardrop figure appeared until the hip was reduced. In terms of outcomes, they concluded that the appearance of the acetabular teardrop within 6 months after reduction of the hip is strongly associated with a favorable long-term outcome.
Albiñana J, Morcuende JA, Weinstein SL.
J Bone Joint Surg Am. 1996 Jul;78(7):1048-55. PMID: 8698722 (Link to Abstract)
Bowerman JW, Sena JM, Chang R.
Radiology. 1982 Jun;143(3):659-62. PMID: 7079492 (Link to Abstract)
Smith JT, Matan A, Coleman SS, Stevens PM, Scott SM.
J Pediatr Orthop. 1997 Mar-Apr;17(2):165-9. PMID: 9075089 (Link to Abstract)
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Average 3.0 of 41 Ratings
A 6-week-old female infant is referred to your practice for concerns of developmental dysplasia of the hip. On physical exam, you note a positive Ortolani test on the left side. Pavlik harness treatment is initiated. Which of the following imaging modalities should be utilized at the two week follow-up visit?
Magnetic Resonance Imaging (MRI)
Computed Tomography (CT)
Arthrogram and Dynamic Fluroscopy
Initial ultrasound is performed to confirm reduction of the hip in question (generally after 1 or 2 weeks) followed by repeat ultrasound 6 weeks later. Ultrasound is necessary to avoid leaving an infant in a harness with an unreduced hip which can erode the acetabulum.
Weinstein et al. provide a thorough overview of the presentation, evaluation, and treatment of DDH. The use of office-based ultrasound has helped to confirm hip reduction and proper acetabular development in children being treated with Pavlik harness.
Swaroop and Mubarak performed a retrospective, comparative study looking at children with Ortolani-positive hips who were treated with either Pavlik Harness and education or with Pavlik Harness, serial ultrasound exams, and a hip abduction orthosis upon failure of Pavlik harness. They achieved 93% success in the latter group.
Illustration A shows an illustration of a neonatal hip ultrasound looks like. The alpha angle is illustrated by the blue line which should be greater than 60 degrees in a normal hip. Illustration B demonstrates an ultrasound of a dysplastic hip showing a rounded corner on the lateral acetabular edge (arrow) and a subluxated femoral head. The alpha angle in this hip is approximately 45 degrees. Illustration C demonstrates an ultrasound of a normal hip. Notice the sharp, lateral acetabular edge (arrow) which is consistent with normal hip development and the well-reduced femoral head. The alpha angle here is closer to 65 degrees. Illustration D shows an AP pelvis radiograph showing asymmetric ossification of the proximal femoral epiphysis. An asymmetric lack of ossification (as seen on the left side) should raise suspicion for hip dysplasia.
Answer 1: MRI requires sedation in patients of this age and is not required as ultrasound can provide the needed information. MR can be useful in confirming closed reduction in older children (6-12 months).
Answer 2: CT exposes the child to unnecessary radiation and is not needed to confirm hip reduction in the harness. CT can be useful in confirming closed reduction in a spica cast.
Answer 4: Plain radiographs can help make the diagnosis of hip dysplasia however they do not provide as much information as ultrasound imaging as the femoral head is not yet ossified in infants.
Answer 5: Arthrogram and fluoroscopy require sedation as well and are more appropriate if a closed reduction in the operating room is required.
Weinstein SL, Mubarak SJ, Wenger DR.
Instr Course Lect. 2004;53:523-30. PMID: 15116641 (Link to Abstract)
Weinstein SL, Mubarak SJ, Wenger DR.
Instr Course Lect. 2004;53:531-42. PMID: 15116642 (Link to Abstract)
Swaroop VT, Mubarak SJ
J Pediatr Orthop. 2009 Apr-May;29(3):224-30. PMID: 19305270 (Link to Abstract)
Average 4.0 of 16 Ratings
Which of the following best describes the radiographic measurement labeled #1 on Figure A.
Radiographic line #1 on Figure A is consistent with Shenton's line.
Developmental dysplasia of the hip (DDH) refers to the the continuum of abnormalities involving the growing hip, (ranging from subluxation to dislocation of the hip joint). Shenton’s line is a projected arc from the inferior border of the femoral neck. Displacement of the femoral head or severe external rotation of the hip will result in a break in the continuity of Shenton’s line.
Guille et al, in a Level 5 article, state that Hilgenreiner’s line is a line drawn horizontally through each triradiate cartilage of the pelvis and Perkins’ line is drawn perpendicular to Hilgenreiner’s line at the lateral edge of the acetabulum. The femoral head should lie within the inferomedial quadrant formed by Hilgenreiner’s and Perkins’ lines.
Illustration A compares the parameters found in a normal and a dysplastic hip.
1. Tonnis line does not exist. Tonnis angle is an angle formed by a line drawn from point on the lateral triradiate cartilage to point on lateral margin of acetabulum and Hilgenreiners line
2. Galeazzi's line does not exist
3. Hilgenreiner's line is a horizontal line through right and left triradiate cartilage
4. Perkin's line is a perpendicular line to Hilgenreiner's through a point at lateral margin of acetabulum
Guille JT, Pizzutillo PD, MacEwen GD.
J Am Acad Orthop Surg. 2000 Jul-Aug;8(4):232-42. PMID: 10951112 (Link to Abstract)
Average 4.0 of 15 Ratings
A 15-year-old soccer player complains of bilateral hip pain. The pain is worse with activity and she notices that she has fatigue and pain that extends to the thighs and knees following a soccer match. She is nontender at the pubis symphysis and has no pain with resisted abdominal crunches. She has no pain with adduction of the hip. Hip flexion and rotation is normal. A radiograph of the right hip is shown in Figure A. Which of the following surgical interventions is best indicated?
Single innominate osteotomy (Salter)
Double innominate osteotomy
Peri-acetabular osteotomy (Ganz)
Triple innominate osteotomy (Steele)
The clinical presentation is consistent with DDH in a patient with a closed triradiate cartilage. A peri-acetabular osteotomy (Ganz) is the most appropriate treatment.
The peri-acetabular osteotomy (Ganz) is a reconstructive osteotomy for DDH patients with a closed triradiate cartilage. It allows for a large degree of three-dimensional correction because the cuts are close to the acetabulum, it preserves the abductor muscles and allows for inspection of the joint.
Karami et al. performed a Level 4 study of 20 patients with an average 12 years of follow-up that underwent a Chiari osteotomy. They found that the Sharp angle, center-edge angle and coverage of the femoral head all improved with the osteotomy but noted that there was a 25% rate of graft resorption.
Gillingham et al., in a level 5 study, emphasizes the timeline of osteotomy indications for DDH patients. A single innominate osteotomy (Salter) or Pemberton procedure is generally appropriate for a child between the ages of 2 and 10. A triple innominate osteotomy (Steel) is applicable for the older child or adolescent where the triradiate cartilage remains open. After triradiate is closed the Ganz periacetabular osteotomy is an option for DDH reconstruction.
Figure A demonstrates a skeletally mature individual with a center-edge angle that is abnormal and less than 20 degrees. Illustrations A-D are examples of the Salter (single nominate) , Ganz (Bernese periacetabular), Steel (Triple Inominate), and Chiari osteotomies, respectively. Illustration E shows a radiograph of the patient in Figure A following a Ganz osteotomy. Illustration F shows a modeling of the bone cuts utilized in a periacetabular osteotomy (Ganz).
Karami M, Fitoussi F, Ilharreborde B, Penneçot GF, Mazda K, Bensahel H.
J Child Orthop. 2008 Feb;2(1):63-8. Epub 2008 Jan 3. PMID: 19308604 (Link to Abstract)
Gillingham BL, Sanchez AA, Wenger DR
J Am Acad Orthop Surg. 1999 Sep-Oct;7(5):325-37. PMID: 10504359 (Link to Abstract)
Average 4.0 of 23 Ratings
Which of the following concepts regarding pediatric hips is true?
The proximal femoral physis and greater trochanteric apophysis develop from different cartilaginous physes
The proximal femoral physis grows at a rate of 9 mm per year
Normal infant femoral anteversion is between 10-20 degrees
The ossific nucleus of the proximal femur is visible on radiographs by 6 months of age in most children
Slipped capital femoral epiphysis (SCFE) typically occurs through the zone of proliferation
The ossific nucleus of the proximal femur is visible on radiographs by 6 months of age in most children.
The proximal femoral physis and greater trochanteric apophysis develop from the same cartilage physis in the infant which undergoes apoptotic division in the child. The distal femoral physis (not proximal) grows at a rate of 9 mm per year. The normal infant femoral anteversion is between 30-40 degrees. SCFE typically occurs through the zone of hypertrophy, not the zone of proliferation.
Vitale and Skaggs review the history, diagnosis, treatment, and outcome of developmental dysplasia of the hip.
Wientroub and Gill review the use of ultrasonography in the diagnosis and prognosis of developmental dysplasia of the hip. They recommend detection with ultrasound because of the delayed femoral head ossification (~5 months) and discuss the cost ineffectiveness of routine screening of all newborns.
Vitale MG, Skaggs DL
J Am Acad Orthop Surg. 9(6):401-11. PMID: 11730331 (Link to Abstract)
Wientroub S, Grill F.
J Bone Joint Surg Am. 2000 Jul;82-A(7):1004-18. PMID: 10901315 (Link to Abstract)
Average 4.0 of 33 Ratings
Failure to achieve reduction of a dislocated hip in an otherwise healthy 4 month old infant which did not reduce after 3 weeks in a Pavlik harness and 3 weeks in an abduction brace is best treated with which of the following?
Adjusting the harness to 75 degrees of abduction and maintaing 90 degrees of hip flexion
Adjusting the harness to 75 degrees of abduction and increasing hip flexion to 120 degrees
Closed reduction with hip arthrogram, adductor tenotomy if necessary, and hip spica casting
Open reduction and femoral shortening osteotomy
Open reduction, femoral shortening osteotomy, and pelvic acetabular osteotomy
A 4-month-old who fails Pavlik harness treatment is best treated with closed versus open reduction of the hip and spica casting. Continued harness treatment can be detrimental as there is risk of posterior acetabular erosion. Osteotomies are not necessary to achieve reduction in a patient of this age cohort.
In the review by Guille et al, he reports unsuccessful treatment of DDH with Pavlik Harness treatment if the hip does not become reduced within 2 weeks of treatment and recommends transitioning to alternative treatment options.
Mubarak, et al reports 12 failures in 18 infants with hip dislocations due to improper physician technique and/or inappropriate harness. Failure to recognize inadequate reduction portends worse clinical outcomes. Another option for failed Pavlik harness treatment in infants is a hip abduction brace.
Hedequist reports on 13 of 15 patients who failed Pavlik harness treatment, and went on to resolve DDH with an abduction brace avoiding the operating room and anesthesia for a closed reduction and spica casting.
Mubarak S, Garfin S, Vance R, McKinnon B, Sutherland D.
J Bone Joint Surg Am. 1981 Oct;63(8):1239-48. PMID: 7287794 (Link to Abstract)
Hedequist D, Kasser J, Emans J
J Pediatr Orthop. 23(2):175-7. PMID: 12604946 (Link to Abstract)
Average 4.0 of 21 Ratings
A 2-week-old infant girl is referred for a hip clunk noticed by the pediatrician. She has a history of a normal spontaneous vaginal delivery and is otherwise healthy. Examination demonstrates a right hip Ortolani sign. A coronal ultrasound is shown in figure A. What is the most appropriate next step in treatment?
Observation with repeat ultrasound in 1 month
Pavlik harness application
Closed reduction and spica casting
Open reduction and spica casting
Open reduction, acetabular osteotomy, femoral shortening, and spica casting
This patient has a right hip dislocation (DDH), as demonstrated by the positive Ortolani sign. Pavlik harness application is indicated for treatment. If the hip does not stay reduced within a few weeks, the next option is an arthrogram under anesthesia, closed reduction, and spica casting. Open reduction and casting is reserved for when closed reduction has failed. Acetabular osteotomy and femoral shortening are procedures used for children with DDH typically older than 1.5 years.
Average 3.0 of 29 Ratings
In patients older than 12-months of age with developmental dysplasia of the hip, all of the following physical exam findings are likely present EXCEPT?
Limited hip abduction
Positive Ortolani maneuver
Abnormal leg lengths on Galeazzi testing
There are many exam maneuvers which are used in the diagnosis of developmental dysplasia of the hip (DDH). Exam findings differ based on the age of the patient.
Vitale et al emphasize that physical exam findings associated with DDH in a child older than 12-months can be different than those seen in the newborn. Specifically, limited hip abduction, a positive Galeazzi test, a positive Trendelenburg gait, and asymmetry of hip abduction are all useful exams tests that are likely to be positive. The Barlow and Ortolani maneuvers are of limited use in older children (> 6 months) because the soft tissues about the hip tighten.
Illustration V demonstrate how the Barlow and Ortolani test are performed.
Average 4.0 of 17 Ratings
Figures A-E show a series of radiographic lines used in the assessment of a paediatric hip joint. Which of the following figures shows Perkin's line?
Figures A-E show a series of radiographic lines that overlay an AP pelvis x-ray of a patient with developmental dysplasia of the hip (DDH). Figure A shows Perkin's line.
Perkins line is used in the assessment of developmental dysplasia of the hip (DDH). It is a radiographic line drawn perpendicular to Hilgenreiner's line (Figure B) that intersects the most lateral aspect of the acetabular roof through the anterior inferior iliac spine. In the normal hip, the femoral head should be medial to Perkins line. The femoral head may be lateral to Perkins line in the setting of a hip dislocation.
Guille et al. reviewed the assessment and management of DDH in infants less than 6 months. They showed that plain radiographs are not useful in the first 6 months of life due to the lack of femoral head ossification for reliable estimation of position.
Weinstein et al. looked at the factors of contributing to DDH. The reported risk factors for DDH include: breech presentation (25% risk), family history (6-20%), foot deformities (2%), congenital torticollis (10-20%), skull-molding deformities (5-10%).
Illustration A is a diagram showing acetabular index angle, Hilgenreiner's line, Shenton's line, and Perkin's line
Answers 2: Figure B shows an AP radiograph of the hip with Hilgenreiner's line. This is a line connecting the superolateral margins of the triradiate cartilage. The femoral head is often migrated superior to this line in DDH.
Answer 3: Figure C shows an AP radiograph of the hip with Shenton's line. This is a line formed by the inferior surface of the superior pubic ramus and the medial surface of the proximal femoral metaphysis at the level of the lesser trochanter. In a normal hip it should create a smooth, curved line. In DDH it is often disrupted.
Answer 4: Figure D shows an AP radiograph of the hip with acetabular angle/index. This line represents the slope of the acetabular roof. It helps measure the angle between Hilgenreiner's line and the acetabulum. DDH usually has an increased angle, which does not improve unless the hip is reduced.
Answer 5: Figure E shows an an AP radiograph of the hip with Klein's line. It is used for the assessment of a slipped capital femoral epiphysis.
In infants with developmental dysplasia of the hip (DDH), anatomic closed reduction may be prevented by all of the following anatomic structure EXCEPT.
Interposition of gluteus medius
Limbus formed by fibrous tissue and hyaline cartilage
Ligamentum teres and prominent fibrofatty pulvinar tissue
Contracted transverse acetabular ligament
Inverted acetabular labrum
Interposition of gluteus medius is not associated with blocked reduction in patients with DDH.
The review article by Guille et al reviews the soft-tissue adaptations in DDH, and discusses the various blocks to reduction which include:
Answer 2: Fibrous tissue can merge with the hyaline cartilage of the acetabulum rim forming the limbus, which may then prevent concentric reduction of the hip.
Answer 3: The ligamentum teres and fibrofatty tissue, known as the pulvinar, may be found within the depths of the acetabulum and can also be an obstacle to reduction and are both depicted by the black arrows in Illustration B.
Answer 4: The transverse acetabular ligament at the caudal aspect of the acetabulum, contracts in patients with persistent hip dislocation and is a block to concentric reduction of the hip.
Answer 5: In the older infant with DDH, the acetabular labrum may be inverted and may mechanically block concentric reduction of the hip.
In addition, with long-standing dislocation, the stretched hip capsule becomes constricted by the contracted iliopsoas tendon to assume an hourglass configuration that prevents reduction as shown in Illustration A by the arrows.
Illustration C depicts the anatomy of these barriers to reduction in DDH.
A five-year-old boy with cerebral palsy presents to the clinic with a dislocated right hip, what quadrant of the acetabulum is most likely deficient?
Anterior-inferior and anterior-superior
In patients with cerebral palsy, the hip is normal at birth, but a combination of muscle imbalance and bony deformity leads to progressive hip dysplasia. The review article by Flynn notes that spasticity or contracture usually involves the adductor and iliopsoas muscles. Because of the pull of these muscles, the majority of hips subluxate in the posterosuperior direction. Because physical examination is unreliable, an AP of the pelvis is required for diagnosis.
Flynn JM, Miller F.
J Am Acad Orthop Surg. 2002 May-Jun;10(3):198-209. PMID: 12041941 (Link to Abstract)
Figure A depicts an ultrasound of a newborn infant's hip. Which of the following structures (1 through 5) represents the labrum?
Figure A depicts an ultrasound of a newborn infant, which is routinely used in the screening and monitoring for hip dysplasia. The structure labeled by the number 4 is the labrum.
Harke et al reviewed the management of congenital dislocation and dysplasia of the hip and the role of ultrasound (US). They concluded that US has distinct advantages over clinical and radiographic examination. As a “novel” technique for evaluation of infant hip dysplasia in 1991, they hoped US would provide a tool for screening and studying the natural history of the developmental disorders of the hip. Since that time, ultrasound has become very helpful in the evaluation of newborn and infant hips as the ossific nucleus of the femoral head is not visible on radiographs.
Illustration A depicts an ultrasound with structures abbreviated. Illustration B is a cartoon schematic of the hip. Il:ilium, Ac:acetabulum, L:labrum, G:gluteal muscles, C:capsule, GT:greater trochanter, H:femoral head, LT/P:ligamentum teres/pulvinar, Tr: triradiate cartilage.
Answer 1. Ilium is labeled is by the number 1
Answer 2. Femoral head is labeled is by the number 2
Answer 3. Triradiate cartilage is labeled by the number 3
Answer 5. Ischium is labeled by the number 5
Harcke HT, Kumar SJ.
J Bone Joint Surg Am. 1991 Apr;73(4):622-8. PMID: 2013607 (Link to Abstract)
Average 4.0 of 30 Ratings
HPI - Since childhood
How would you treat this 13 years old boy with neglected DDH?
HPI - The patient has had right hip pain for the past two years. The pain is worse with exertion.
What is the most likely primary cause of his symptoms?
HPI - patient comes to the consult at 10 years of age mother refers surgical procedure at the age of 5 months, unspecified surgery at 2005 (elsewhere), also did not specify why follow up was lost until now.
At this age, what treatment would you offer to this patient and parents?
HPI - -2 years ago proximal femoral shaft fracture, -Conservatively treated
-Minimal but progressive limping after the fracture
-For the last 3 months she has worsening pain and extreme difficulty while walking
The main pathologic abnormality is due to the deformity in the
HPI - 16-mos old female, normal developmental milestone and now walking normally, presents with border images and possible developmental hip dysplasia.
How would you treat this 16-mos female with borderline DDH?
HPI - No childhood trauma, no infection, no inflammatory diseases
What is the plan of management ?
HPI - this 4 yrs F is a known case of DDH diagnosed at age of walking ( 14 months old) & was treated 3 times by open reduction only & failed
what are the lines of management?
HPI - Girl with abnormal gait. Got treatment from "traditional healers " with out an X ray. Presented to us at her 8 yr of age because of pain.
What would be her management option?
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