• younger patients typically with open triradiate cartilage
• single transverse cut above the acetabulum through the ilium to sciatic notch • acetabulum hinges through the pubic symphysis • improves anterolateral coverage (can provide 20-25° lateral and 10-15° anterior coverage) • may lengthen leg up to 1cm
• 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 • improves anterolateral coverage
• triradiate cartilage must be closed in order to perform
• involves multiple osteotomies in the pubis, ilium, and ischium near the acetabulum •allows for improved 3D correction of the acetabulum configuration • technically the most challenging • posterior column and pelvic ring remain intact •patients are allowed to weight bear early
• osteotomy starts approximately 10-15mm above the AIIS and proceeds posteriorly to end at the level of the ilioischial limb of the triradiate cartilage (halfway between the sciatic notch and the posterior acetabular rim) •acetabulum hinges at the triradiate cartilage posteriorly and the symphysis pubis anteriorly •does not enter the sciatic notch and is therefore stable and does not need internal fixation • improves anterolateral coverage • reduces acetabular volume
• osteotomy from acetabular roof to triradiate cartilage (incomplete cuts through pericapsular portion of the innominate bone) • acetabulum hinges through the triradiate cartilage • does not enter the sciatic notch and is therefore stable and does not need internal fixation • improves anterior, central, or posterior coverage • reduces the acetabular volume
• leaves the medial wall or teardrop in its original position and is therefore intra-articular • spherical osteotomy
• add bone to the lateral weight-bearing aspect of the acetabulum by placing an extra-articular buttress of bone over the subluxed femoral head • depends on fibrocartilage metaplasia for successful results
• osteotomy starts above the acetabulum to the sciatic notch and ileum is shifted lateral beyond the edge of the acetabulum • depends on fibrocartilge metaplasia for successful results • medializes the acetabulum via iliac osteotomy
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A 4-week-old infant male is treated in a Pavlik harness for developmental dysplasia of the hip. Hip flexion is set to 125 degrees at the initial visit. At his 1-week follow-up appointment, ultrasound shows an alpha angle of 54 degrees and beta angle of 60 degrees. On physical exam, the patient is unable to kick his right leg and holds his knee in a flexed position. Which of the following is the most likely responsible for these findings?
Excessive hip abduction in Pavlik harness
Irreducible hip dislocation
Sciatic nerve palsy present before application of harness
Excessive hip flexion in Pavlik harness
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A newborn girl is referred for evaluation of suspected hip instability. What information from her history would place her in the highest risk category?
History of maternal diabetes mellitus
Frank breech presentation
Concomitant metatarsus adductus
What acetabular procedure for developmental dysplasia of the hip does not require a concentric reduction of the femoral head in the acetabulum?
Salter innominate osteotomy
Pemberton innominate osteotomy
Dega innominate osteotomy
Triple innominate osteotomy
Staheli shelf procedure
A newborn girl with an isolated unilateral dislocatable hip is placed in a Pavlik harness with the hips flexed 100 degrees and at resting abduction. Figure 23 shows an ultrasound obtained 2 weeks later. What is the next step in management?
Reposition the harness to hold the hips in 70 degrees of abduction
Closed reduction and arthrography under anesthesia
Open reduction and a spica cast
Continued harness treatment in the current position
A patient who underwent closed reduction of the hips as an infant now reports pain. An abduction internal rotation view shows an incongruous joint. Based on the findings shown in Figure 3, what is the most appropriate type of pelvic osteotomy for the right hip?
Ganz or Bernese periacetabular
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)
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
Figure A depicts an ultrasound of a newborn infant's hip. Which of the following structures (1 through 5) represents the labrum?
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?
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
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
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
Which of the following best describes the radiographic measurement labeled #1 on Figure A.
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
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
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
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