DDH 2 - Compressed

CHAPTER 13
Developmental Dysplasia Harrry K.W. Kim and John A. Herring

of the Hip
Pediatrics defines DDH as a condition in which the femoral

Chapter Contents head has an abnormal relationship to the acetabulum.1 The
abbreviation DDH has been used to denote both dislocation
Definition 422 and dysplasia of the hip, and it is used in both senses in this
Incidence 422 chapter. Dislocation is defined as the complete displace-
Etiology 423 ment of a joint, with no contact between the original articu-
Associated Conditions 425 lar surfaces. Subluxation is defined as the displacement of
Pathophysiology 425 a joint with some contact remaining between the articular
Natural History 430 surfaces. Dysplasia refers to the deficient development of
Clinical Features 431 the acetabulum.
Radiographic Findings 434 Teratologic dislocation of the hip is a distinct form of hip
Screening Criteria 442 dislocation that usually occurs with other disorders. The
Treatment 442 hips of patients with this condition are dislocated before
Complications and Pitfalls 453 birth, have a limited range of motion, and are not reducible
Reconstructive Procedures for Dysplasia 461 on examination. Teratologic dislocation of the hip is usu-
Teratologic Dislocation of the Hip 471 ally associated with other neuromuscular syndromes, espe-
cially those related to muscle paralysis (e.g., myelodysplasia,
arthrogryposis). The pathologic process, natural history,
and management of teratologic dislocation are discussed
Definition separately.
In 1832, Guillaume Dupuytren described the condi-
Developmental dysplasia of the hip (DDH) is a spec- tion of dislocation of the hip at birth and called it “origi-
trum of disorders of development of the hip that present nal or congenital dislocation of the hip.”62 At the turn
in different forms at different ages. The common etiol- of the 20th century, Adolph Lorenz demonstrated his
ogy is excessive laxity of the hip capsule with a failure to vigorous techniques of closed reduction of the hip175;
maintain the femoral head within the acetabulum. The however, because his reductions were so forceful, he
syndrome in the newborn consists of instability of the hip has been called the “father of avascular necrosis.” Putti
such that the femoral head can be displaced partially (sub- recommended early treatment, before the patient was 1
luxated) or fully (dislocated) from the acetabulum by an year old.232
examiner. The hip may also rest in a dislocated position In 1937, Ortolani—another person who is famously
and be reducible on examination. Over time, the femo- associated with hip dislocation—described both a “click”
ral head becomes fully dislocated and cannot be reduced or “jerk sign” of dislocation and a “click” or “jerk sign” of
by changing the position of the hip. In some infants, the reduction.220 LeDamany161 actually described something
clinical examination results are negative, but abnormalities similar in 1912.
found with the use of ultrasonography and radiographic Probably one of the most important treatment
studies portend later hip dysplasia. The syndrome may advances was the introduction by Arnold Pavlik in 1946
manifest later during childhood or adolescence as a dislo- of the harness that bears his name. The simple stirrup
cated hip or during adolescence as a hip with poorly devel- device allowed for active movement to guide the dislo-
oped acetabular coverage; the latter is termed dysplasia cated hip into the socket. Pavlik’s work was stimulated by
of the hip. dissatisfaction with the rates of avascular necrosis (AVN)
DDH is a disorder that evolves over time. The structures that he saw with existing treatment methods. In 1959, he
that make up the hip are normal during embryogenesis and reported the management of 1424 hips without a single
gradually become abnormal for a variety of reasons, the case of AVN.226
chief being the fetal position and presentation at birth (e.g.,
malposition of the femoral head, abnormal forces acting on
the developing hip) and the laxity of the ligamentous struc- Incidence
tures around the hip joint.
The older term congenital dislocation of the hip has The incidence of DDH is difficult to determine because of
gradually been replaced by developmental dysplasia, which disparities in the definition of the condition, the type of
was introduced during the 1980s to include infants who examinations used to detect hip abnormalities, the differing
were normal at birth but in whom hip dysplasia or disloca- skill levels of examiners, and the populations being studied
tion subsequently developed.55 The American Academy of (Box 13.1). Estimates of the incidence of some degree of
422
CHAPTER 13 Developmental Dysplasia of the Hip 423
Box 13.1 Incidence of Developmental Table 13.1 Incidence of Developmental Dysplasia of

Dysplasia of the Hip the Hip.
Dislocation: 1.4 per 1000 births Geographic Area: Incidence per

Clinical finding: 2.3 per 100 births Study, Year Population Thousand
Ultrasound abnormality: 8 per 100 births Walker, 1973305 Island Lake Region 188.5
(Manitoba, Canada):
Canadian Indians
hip instability in the newborn have ranged from a low of Klisic, 1975a Belgrade, Yugoslavia 75.1
1 per 1000 to a high of 3.4 per 100. Higher incidences are
reported when screening involves both clinical examination Coleman, 195646 Utah 20.0
and ultrasonography.238 Hiertonn and James, Adademiska Sju- 20.0
The data regarding the incidence of actual dislocation of 1968 lchuset, Uppsala,
the hip are more consistent, with reports ranging from 1.0 Sweden
to 1.5 cases per 1000 live births.a Stanisavljevic, 1961b Detroit, Michigan 10.0
Geographic and racial variations in the incidence of DDH
are marked; some areas of the world have a high endemic Paterson, 1976c Adelaide, Australia 6.2
incidence, whereas in other areas the condition is virtually Von Rosen, 1962d Malmö, Sweden 1.7
nonexistent. The reported incidence on the basis of geog-
raphy ranges from 1.7 per 1000 live births in Sweden332 to Barlow, 196214 Salford, England 1.5
75 per 1000 live births in what was then Yugoslavia143 to Hoaglund et al, Hong Kong: Chinese 0.1
188.5 per 1000 live births in a certain district in Manitoba, 1981104
Canada (Table 13.1).305 An interesting study of more than
Edlestein, 1966 Africa: Bantus 0.0
6000 specimens from a medieval British cemetery found
evidence of DDH in 2.7 “cases” per 1000, which is a rate aKlisicP. Congenital dysplasia of the hip in the first year of life: inci-
similar to that found by modern studies.196 Certain racial dence, diagnosis, and spontaneous evolution [in Serbian]. Srp Arh Celok
Lek. 1968;96:961.
groups have a low incidence of DDH (e.g., African Bantu, bStanisavljevic S. Clinical findings in examination of hips in newborn
Chinese), whereas other groups have a high incidence (e.g., babies. Henry Ford Hosp Med Bull. 1962;10:245.
Navajo Native American children).46 cPaterson D. The early diagnosis and treatment of congenital dislocation
of the hip. Aust N Z J Surg. 1976;46:359.

dvon Rosen S. Diagnosis and treatment of congenital dislocation of the
hip joint in the new-born. J Bone Joint Surg Br. 1962;44:284.

Etiology
Although there is no single cause of DDH, a number of
predisposing factors have been identified (Box 13.2). These Box 13.2 Etiology of Developmental
factors include ligamentous laxity, prenatal positioning, Dysplasia of the Hip
postnatal positioning, and racial predilection. The etiology Ligamentous laxity (often inherited)
of DDH is clearly multifactorial, and it is influenced by hor- Breech position (especially footling)
monal and genetic elements. Postnatal positioning (hips swaddled in extension)
Primary acetabular dysplasia (unlikely)
Ligamentous Laxity
Ligamentous laxity is related to DDH in several ways. The study of Navajo families, hip dysplasia in one family mem-
condition is associated with the development of DDH when ber increased the risk for other family members fivefold.46
laxity is a familial trait. In fact, the racial incidence of laxity Newborns with DDH have also been found to have a higher
may parallel racial predilections for DDH. The newborn’s ratio of collagen III to collagen I as compared with control
response to maternal relaxin hormones may explain the subjects, which suggests a connective tissue abnormality in
higher incidence of DDH among girls. These hormones, those with DDH.119 In a study of laxity by distraction of the
which produce the ligamentous laxity that is necessary for symphysis pubis, infants with DDH had twice the amount
the expansion of the maternal pelvis, cross the placenta and of distraction of the symphysis pubis as compared with con-
induce laxity in the infant. This effect is much stronger in trol subjects.9
female than in male children. Several animal studies are relevant to the issue of laxity
In 1970, during an extensive genetic study of DDH, of the hip capsule. When the hip capsule and the ligamen-
Wynne-Davies proposed that heritable ligamentous laxity tum teres were removed from dogs, the animals frequently
was one of two major mechanisms for the inheritance of developed dislocated hips.258 Dislocation would also result
DDH (Fig. 13.1).326 She believed that this was an autoso- if the capsule was mechanically stretched but not removed.
mal dominant characteristic with incomplete penetrance. Alternatively, removal of the acetabular roof resulted not in
The fact that the risk of DDH is 34% in identical twins hip dislocation but only in a shallower acetabulum than nor-
(i.e., both twins having DDH) but only 3% in fraternal mal. In a classic study of male and female newborn rabbits,
twins also suggests a genetic influence.110 In Coleman’s only the female rabbit hips dislocated when the knees were
splinted in extension; this observation supports the concept
a References 14, 40, 73, 74, 121, 304, 316. of hormonally induced laxity.322
424 SECTION II Anatomic Disorders
E
A B
C D
FIG. 13.1 Wynne-Davies’ criteria for ligamentous laxity. (A) Flexion of the thumb to touch the forearm. (B) Extension of the fingers parallel
to the forearm. (C) Hyperextension of the elbow of 15 degrees or more. (D) Hyperextension of the knee of 15 degrees. (E) Dorsiflexion of
the ankle of 60 degrees.
section (3.7%) as compared with those delivered vaginally

(8.1%).176
Experimental studies in which newborn rabbits’ knees
were splinted in extension showed a high incidence of hip
dislocation.189 If, in the same rabbits, the hamstring ten-
dons were transected, the hips did not dislocate; this sug-
gests that the pull of the hamstring across the flexed hip was
the dislocating factor. The hip is affected by intrauterine
position, and delivery by cesarean section does not alter the
likelihood of hip dislocation.60 The incidence of DDH is
also higher among first-born children and in those pregnan-
A B C cies that are complicated by oligohydramnios.36,59,60 These
findings suggest that there is an intrauterine crowding effect
on the developing hip. This argument is bolstered by the
increased incidence of other postural abnormalities (e.g.,
torticollis, metatarsus adductus) in children with DDH. In
FIG. 13.2 The breech position, which is associated with develop-
addition, the left hip is more often involved than the right.
mental dysplasia of the hip (DDH). (A) A double breech position
is associated with a low incidence of DDH. (B) A single footling
Because the most common intrauterine position has the left
breech is associated with a 2% risk of DDH. (C) A frank breech, hip adducted against the maternal sacrum, some authors
especially with the knee(s) extended, is associated with a 20% risk believe that this position places the left hip at greater risk
of DDH. for dislocation as compared with the right hip.59,60
Prenatal Positioning Postnatal Positioning

Prenatal positioning is strongly associated with DDH. Postnatal positioning is another factor that is associated
Although only 2% to 3% of infants are born in breech pre- with DDH. People who wrap their newborn babies in a hip-
sentation, 16% of infants with DDH are born in breech extended position (e.g., Native Americans who use cradle-
presentation.203 Neonates who were carried in certain boards: Fig. 13.3) have a much higher incidence of DDH as
breech positions in utero have a significantly higher risk of compared with other populations.46,158,233 The mechanism
DDH (Fig. 13.2). The breech effect is most notable when of action is believed to be the placement of the hips in full
the knees are extended, with an incidence of 20% seen extension against the normal neonatal hip flexion contrac-
for a single or frank breech.272 Alternatively, the footling ture. An archaeologic study of prehistoric adults found a
breech position, in which the hips are flexed, is associated high incidence of DDH (46/1000) which correlated with
with only a 2% incidence of DDH. Lowry and co-workers head molding from cradleboard immobilization.22 By con-
have shown a significant reduction in the incidence of trast, people who usually carry their infants astride the hip
DDH when the baby is delivered preterm by cesarean or in a wrap that flexes and abducts the hips have a lower
Box 13.3 Conditions Associated With

Developmental Dysplasia of the Hip
Torticollis: 15%–20%
Metatarsus adductus: 1.5%–10%
Oligohydramnios
FIG. 13.3 Postnatal positioning in extension, as seen in this child

on a Native American cradleboard, contributes to developmental
dysplasia of the hip.
incidence of DDH as compared with other groups.36 A

group studied more than 40,000 children in Malawi where
FIG. 13.4 Torticollis should alert the examiner to the possibility
a back-carry position similar to the Pavlik position is uni-
of developmental dysplasia of the hip; up to 15% of infants with
versally used. Over a 10-year period no cases of DDH were torticollis have hip instability.
found.88 Postnatal positioning programs have been consid-
ered. In one such approach, new parents were given a set
of “abduction pants” and wide diapers; a 65% decrease in likelihood of DDH ranges from 5% to 20%; this is thought
the incidence of DDH was noted and attributed to the to result from intrauterine crowding.b A relationship has
program.146 also been noted between DDH and metatarsus adductus
The primary failure of acetabular development has been (Fig. 13.5), with the incidence of concurrence ranging from
proposed as a cause of DDH. Early cadaver studies noted 1.5% to 10%.111,154 Clubfoot has not been shown to have a
that the acetabulum is shallower at birth than during the ear- significant relationship with DDH.319,327 Pregnancies that
lier fetal period162,234,240; full coverage does not occur until are complicated by oligohydramnios have been associated
3 years of age.201 Beals believes that acetabular dysplasia is with an increased incidence of DDH.59,60 First-born white
inherited and that it may be a precursor of dislocation.15 infants have a higher incidence of DDH.c First-term hyper-
After birth, the acetabulum becomes deeper throughout thyroidism has also been associated with increased inci-
childhood, and it eventually covers the head completely. dence of DDH.114
However, other authors have rejected the primary acetabu-
lar dysplasia hypothesis.58,159
Pathophysiology
Racial Predilection Normal Hip Development
Racial predilection apparently plays a role; certain ethnic The hip joint begins to develop at approximately the sev-
groups seem to be predisposed to DDH, whereas others enth week of gestation, when a cleft appears in the mes-
appear to be somewhat immune. Blacks and Asians have enchyme of the primitive limb bud (Fig. 13.6). These
relatively low incidences of DDH (0.1 per 1000 to 5 per precartilaginous cells differentiate into a fully formed carti-
1000),10,104 whereas whites and Native Americans have laginous femoral head and acetabulum by the eleventh week
higher incidences (15 per 1000).10 of gestation.267,268,307 The concave shape of the acetabulum
is determined by the structure (femoral head) within the
acetabulum. If there is a failure during the normal embryo-
Associated Conditions genesis of the hip, the consequence is a major anomaly (e.g.,
proximal femoral focal deficiency).77
Certain conditions, particularly postural abnormalities, are
associated with DDH more commonly than chance alone
would dictate (Box 13.3). The association of DDH with tor- b References 2, 108, 116, 120, 139, 194, 223, 297.
ticollis is strong (Fig. 13.4). In a child with torticollis, the c References 6, 11, 12, 35, 36, 60.
At birth, the neonatal acetabulum is completely com-

posed of cartilage, with a thin rim of fibrocartilage called
the labrum (Fig. 13.7). The hyaline cartilage of the ace-
tabulum is continuous with the triradiate cartilages, which
divide and interconnect the three osseous components
of the pelvis (i.e., the ilium, the ischium, and the pubis).
The surface of the acetabular cartilage, which abuts the
bone of the pelvis, is made up of epiphyseal cartilage in
the shape of a hemisphere; it functions as a major growth
plate. The growth of this physis is essential for acetabular
development, and any damage to the periacetabular area
may induce a growth disturbance.96,230,231 The labrum also
contributes significantly to the development of acetabular
depth; thus any excision of the labrum during the treat-
ment of DDH is ill advised. The majority of acetabular
shape development is determined by approximately 8
years of age. Late acetabular development during adoles-
cence is enhanced by the growth of the secondary acetabu-
lar centers such as the os acetabulum.317
FIG. 13.5 There is an association between metatarsus adductus The proximal femur has a complex and often misun-
and developmental dysplasia of the hip, with up to 10% of infants derstood growth pattern. In the neonate, the entire upper
with metatarsus adductus having developmental dysplasia of the femur is a cartilaginous structure in the shape of a femoral
hip. head and the greater and lesser trochanters. The develop-
ment of the proximal segment of the femur occurs through
A B C
D E F
FIG. 13.6 Embryology of the hip joint. (A) The highly cellular blastema in the proximal and central portion of the limb bud will later form
the cartilage model of the hip joint. (B) At 8 weeks, the cartilage model of the acetabulum and the femoral head has begun to form. (C) The
femur forms in the shape of a truncated cone. The disk-shaped masses mark the development of the anlagen of the ilium, ischium, and pu-
bis. (D and E) Note the spherical configuration of the femoral head and the acetabulum. The limbus and the transverse acetabular ligament
are well-formed structures. (F) At 16 weeks of fetal life (100 mm), the lower limbs are positioned in flexion, adduction, and lateral rotation.
(From Watanabe RS. Embryology of the human hip. Clin Orthop Relat Res. 1974;98:8.)
Ligamentum
teres
Acetabular
cartilage Labrum
FIG. 13.7 Photomicrograph of a labrum (hematoxylin-eosin,
original magnification ×9). Note the fibrous structure covering the
cartilaginous labrum and projecting toward the true joint cavity.
Distinct tissue planes are lacking. Small blood vessels are present
in the different layers of the limbus. The femoral head and the
ligamentum teres are to the right of the illustration. (Courtesy the
Armed Forces Institute of Pathology, Bethesda, MD.)
FIG. 13.8 The acetabular epiphysis is seen as a ring of ossification
along the lateral margin of the acetabular rim (arrow).
a combination of appositional growth on the surfaces of the
upper femur and epiphyseal growth at the juncture of the Hip Development With Developmental
cartilaginous upper femur and the femoral shaft.256 In the Dysplasia of the Hip
normal femur, an ossification center appears in the center of
the femoral head between the fourth and seventh months of DDH is a gradually progressive disorder that is associated
postnatal life. This center grows until physeal closure dur- with distinct anatomic changes, many of which are initially
ing late adolescence; at this time, it has become the adult reversible. It is a malformation of anatomic structures that
femoral head, and it is covered with a thin layer of articular have developed normally during the embryologic period.
cartilage. During the period of growth, the thickness of the Relatively gentle forces, persistently applied, are probably
cartilage surrounding this bony nucleus gradually decreases, the cause of such deformations.60 At birth, the affected hip
as does the thickness of the acetabular cartilage. The thick- will spontaneously slide into and out of the acetabulum. For
ness of the cartilage accounts for the widened radiographic this to occur, the posterosuperior rim of the acetabulum
appearance of a normal hip in a child. has to have lost its sharp margin and become flattened and
As the child matures, three acetabular epiphyseal cen- thickened in the area over which the femoral head slides
ters develop and are responsible for the final contours of (Fig. 13.9). As the head rides in and out of the socket, a
the hip socket (Fig. 13.8). The os acetabulum, which is the ridge of thickened articular cartilage (called the neolimbus
largest of the three, appears at approximately 8 years of by Ortolani) arises along the posterosuperior acetabular wall
age and forms along the anterior wall as part of the pubis. (Fig. 13.10). The sliding of the head in and out produces a
The acetabular epiphysis, which also ossifies at approxi- “clunk.” The neolimbus is the structure that produces this
mately 8 years of age, forms along the superior edge of the feel as the head slides over it.212,219,230,231
acetabulum as part of the ilium; it fuses when the child Some hips that are unstable at birth spontaneously
is approximately 18 years old. The third center is a small reduce and become normal, with complete resolution of the
epiphysis in the posterior or ischial area, which develops aforementioned anatomic changes. Other hips eventually
when the child is 9 years old and fuses when he or she is remain out of the socket permanently, and many second-
17 years old. ary anatomic changes take place gradually. The frequency of
Excessive pressure on the cartilaginous upper femur spontaneous reduction as compared with progressive dislo-
can cause a loss of vascular perfusion, which results in the cation is not known.
necrosis of the chondrocytes. Various portions of the femo- In those hips that remain dislocated, secondary barriers
ral head and growth plate can be injured, with the result- to reduction develop. In the depths of the acetabulum,
ing patterns of deformity corresponding with the areas of the fatty tissue known as the pulvinar thickens and may
injury. The greater trochanteric area is usually unaffected; impede reduction (Fig. 13.11). The ligamentum teres also
it will continue to grow normally, gradually becoming more elongates and thickens, and it may take up valuable space
proximal than the femoral head. This “trochanteric over- within the acetabulum. The transverse acetabular ligament
growth” is actually normal trochanteric growth in the pres- is often hypertrophic as well, and it may impede reduc-
ence of upper femoral “undergrowth.”78,221,247 tion.113 More important, the inferior capsule of the hip
Muscle imbalance can also significantly affect the growth assumes an hourglass shape, eventually presenting an open-
and morphology of the upper femur. Excessive adductor ing that is smaller in diameter than the femoral head. The
pull or inadequate abductor muscle function results in a val- iliopsoas, which is pulled tight across this isthmus, con-
gus deformity of the upper femur.78,221,247 tributes to this narrowing (Fig. 13.12). The capsule also
Normal attachment Labrum slightly everted

of capsule and hypertrophic
Capsule Femoral head

spherical
Capsule stretched
and loose
Ligamentum teres elongated

A B
FIG. 13.9 Pathology of the unstable hip that is subluxatable but not dislocatable. (A) Normal hip. (B) Subluxatable hip. Note the loose hy-
perelastic capsule, the elongated ligamentum teres, and the slight eversion of the hypertrophied acetabular rim. The femoral head is normal
in shape. Excessive femoral and acetabular antetorsion may be present, which causes the anatomic instability of the hip joint.
Labrum everted
Capsule stretched
and loose
Femoral head
Labrum inverts
spherical
and everts
Acetabulum
Acetabulum
Ligamentum teres
elongated
Ligamentum teres
elongated
A B
FIG. 13.10 Pathology of the dislocatable hip. (A) Unstable hip. The capsule is stretched out and very loose, the ligamentum teres is mark-
edly elongated, and the labrum is definitely everted. (B) Complete displacement of the femoral head out of the acetabulum. At the fibrocar-
tilage–hyaline junction of the labrum with the acetabulum, there may be inversional hypertrophic changes (neolimbus; arrows). The femoral
head is spherical. Acetabular antetorsion is usually excessive.
narrows through a “Chinese finger- trap” mechanism.113 capsule must be released or stretched to allow the head to
The femoral changes are minimal and include an increase move beneath the acetabular rim and enter the acetabulum.
in anteversion and some flattening of the femoral head as Clinicians often use the term labrum for this blocking struc-
it lies against the ilium. ture, and sometimes they excise it. However, the actual
When an attempt is made to reduce the hip against the labrum is a thin fibrocartilaginous rim around the periphery
narrowed hip capsule, the femoral head abuts the cartilagi- of the acetabular cartilage. The blocking structure encoun-
nous acetabular lip, and it tends to push this rim into the tered in patients with DDH is not only the labrum but also
acetabulum. It is extremely important to realize that the a significant portion of the cartilaginous acetabulum itself.
acetabular structure is not impeding the femoral head from This vital cartilaginous acetabular anlage is essential for the
entering the acetabulum. Rather, the constricted hip cap- normal growth and development of the acetabulum, and it
sule is forcing the head against the acetabular rim, and the should not be excised.
Labrum inverted
Ligamentum teres
elongated
Labrum from posterior and

superior border of acetabulum
interposed between femoral
epiphysis and acetabulum,
preventing reduction of femoral Capsular
head adhesions
A Capsule
Transverse acetabular
ligament pulled upward
Ligamentum teres
B
Fibrofatty pulvinar
in acetabulum
FIG. 13.11 Pathology of the dislocated hip that is irreducible as a result of intraarticular obstacles. (A) The hip is dislocated. (B) The hip
cannot be reduced on flexion, abduction, or lateral rotation. Obstacles to reduction are inverted limbus, ligamentum teres, and fibrofatty
pulvinar in the acetabulum. The transverse acetabular ligament is pulled upward with the ligamentum teres.
head to seat deeply. Known clinically as “docking the head,”

this phenomenon was described by Severin in 1941.252 The
femoral head itself is usually deformed into a globular shape
as a result of pressure against the lateral portion of the ace-
tabulum, and it may not be congruous with the acetabulum
at the time of reduction; however, this anatomic situation
also eventually resolves if reduction is maintained.113
When a stable reduction is obtained, the acetabulum
gradually remodels. This remodeling increases the depth of
the acetabulum, and the acetabular angle gradually becomes
more horizontal. During the acetabular remodeling period,
secondary ossification centers often appear prematurely in
A B the acetabulum.317
If the hip remains dislocated, additional changes occur
during the growth and development of the acetabulum.
FIG. 13.12 The iliopsoas tendon as an obstacle to closed reduction. The acetabular roof becomes progressively more oblique,
(A) Anterior view. The iliopsoas tendon traverses the anteromedial the concavity gradually flattens and eventually presents
aspect of the hip joint before inserting into the lesser trochanter.
a convex surface, and the medial wall of the acetabulum
With lateral and superior displacement of the femoral head (dotted
line) and lesser trochanter, the iliopsoas tendon is stretched taut
thickens. The acetabulum has been noted to be excessively
across the medial and anterior aspect of the hip capsule. (B) Lateral anteverted in patients with DDH, thus providing dimin-
view showing external pressure and indentation of the capsule by ished coverage of the femoral head.161,177 Medial twisting of
the iliopsoas tendon. This hourglass constriction of the capsule the whole wing of the pelvis has been demonstrated by mag-
with the formation of the capsular isthmus markedly reduces the di- netic resonance imaging (MRI) in patients with untreated
ameter of the acetabular orifice and is a barrier to closed reduction. DDH.271 Medial wall thickening is seen radiographically as a
The dotted line indicates the acetabulum. thickening and alteration of the shape of the teardrop body.
Although acetabular anteversion is present in the young hip,
After the femoral head has been reduced, the acetabular retroversion of the acetabulum has been found in adoles-
rim may still impede the deep seating of the femoral head cents and adults with hip dysplasia.
because the rim has become thicker than normal. If the To a point, these changes are reversible, but the exact
head is maintained within the acetabulum, this thickened upper age at which hip reduction will result in normal ace-
cartilage will usually flatten out gradually and allow the tabular development is uncertain. Harris suggested that a hip
In some untreated hips, the femoral head retains some

contact with the acetabulum. These subluxated hips have
an unstable contact area that allows the head to slide proxi-
mally and distally against a widened and oblique acetabular
surface. This instability produces degenerative changes that
often become apparent during late adolescence and that
usually progress rapidly within a few years to severe degen-
eration. Late radiographic changes include subchondral scle-
rosis and cyst formation in the acetabulum and the femoral
head, osteophyte formation, and the loss of articular carti-
lage. The reorientation of the acetabulum and the redirec-
tion of the forces across the hip can ameliorate degenerative
changes if they are performed before severe degeneration
occurs.
FIG. 13.13 Untreated bilateral developmental dysplasia of the hip
diagnosed when the patient was 9 years old.
Natural History
Neonatal Hip Instability
The fate of the unstable hip remains an enigma. How often
an unstable hip spontaneously reduces—or, alternatively,
becomes dislocated, subluxated, or dysplastic—remains a
Gluteus medius and subject of controversy. A primary problem is the definition
minimus muscles of an unstable hip. Traditionally, instability has been defined
shortened
by a positive result on the Ortolani or Barlow test. How-
ever, the classification has been complicated by the inclu-
Femoral head dislocated
above and lateral to
sion of hips that are clinically stable but that have abnormal
acetabulum ultrasonographic characteristics. Thus the criteria that an
investigator uses to define abnormal hips must be taken into
consideration when evaluating any study of hip instability.
Barlow found 1 hip in 60 that he examined to exhibit his
Adductors instability sign; 60% normalized within 1 week, and 88%
shortened
were corrected within 2 months without treatment.14 Cole-
man’s natural history study in Navajo children found that 5
of 23 Ortolani-positive hips spontaneously corrected, with
the remainder being dysplastic, subluxated, or dislocated.46
Yamamuro followed 52 newborns with untreated instability.
Three of 12 Ortolani-positive hips resolved, and 24 of 42
subluxatable hips also resolved.329
Dysplasia, Subluxation, and Dislocation After

the Neonatal Period
FIG. 13.14 The pelvifemoral muscles become shortened and
contracted and involve the progressive upward displacement of the The term dysplasia refers to a radiographic finding of
femoral head with long-established developmental dysplasia of the increased obliquity and the loss of the concavity of the ace-
hip. Arrows represent the direction of muscle forces. tabulum, with an intact Shenton line (Fig. 13.15). The term
subluxation is used when the femoral head is not in full
reduced by the time a patient was 4 years old could achieve contact with the acetabulum (Fig. 13.16). The radiographic
“satisfactory” acetabular development.94 He found that sig- findings of subluxation include a widened teardrop femoral
nificant acetabular growth continued through 8 years of age.94 head distance, a reduced center–edge angle, and a break in
In adults, the fully dislocated femoral head may lie well the Shenton line. The term dislocation specifies that the
above the acetabular margin in a markedly thickened hip femoral head is not in contact with the acetabulum. Both
capsule; this is the so-called “high-riding dislocation” (Fig. subluxated and dislocated hips have dysplastic changes.
13.13). The adult dislocated femoral head is oval and flat- Dysplasia is a direct result of abnormal forces across the
tened medially. The acetabulum is filled with fibrous tissue, acetabulum. The lateralization of the femoral head results in
hypertrophied ligamentum teres, and thickened transverse increased forces over a smaller unit area with an increase in
acetabular ligament, and the articular cartilage is either atro- the sheer vector. Increased sheer vectors affect the physes
phic or absent.190 The muscles that insert at the proximal of the acetabulum. With an acetabular inclination of more
femur are foreshortened and more horizontally oriented than 15 degrees, the sheer and lateralization forces exceed
(Fig. 13.14). Fully dislocated adult hips may remain free the medialization forces, and progressive subluxation is
from degenerative changes for many years, even for the inevitable. Roof osteophytes will form at synovial attach-
individual’s lifetime. ment sites. These progress, forming a pseudoacetabulum
of the hip are the result of subluxation or residual acetabular

dysplasia.d The only guarantee of a lifetime of normal hip
function is a completely normal radiographic appearance of
the hip.
The subluxated hip always leads to symptomatic degen-
erative hip disease.50,181,309,312,313 The affected individual
often presents with gradually increasing pain in one or both
hips but no history of hip symptoms or treatment. After
the pain begins, it tends to progress rapidly over a period of
months. Severe subluxation leads to symptoms during the
second decade of life, moderately subluxated hips become
painful during the third and fourth decades, and the least
severely subluxated hips become symptomatic during the
fifth and sixth decades.308,309 In one study, the hips with
well-developed false acetabula had the highest incidence of
pain and disability.309
A completely dislocated hip causes symptoms much
later than a subluxated hip; in some individuals, these hips
FIG. 13.15 Acetabular dysplasia. The image shows a dysplastic left never become painful. No strict linear relationship between
hip in which the acetabulum is more oblique than normal with an
center–edge angle, acetabular angle, and osteoarthritis
increased acetabular index.
has been found.50,129 Hip, knee, and back pain have been
noted in approximately half of the patients with untreated
DDH.97 Other studies have emphasized cases in which
there were no symptoms or few symptoms despite lifelong
hip dislocation.97,305,313
Other degenerative and functional problems develop in
people with untreated dislocated hips.296,308,309,312,314 Uni-
lateral dislocations cause limb length inequality, ipsilateral
valgus knee deformity, an abnormal gait, decreased agility,
and postural scoliosis. Bilateral cases are associated with sig-
nificant back pain as a result of increased lumbar lordosis.
Clinical Features
Neonate
DDH in the neonate is diagnosed by eliciting Ortolani or
FIG. 13.16 A subluxated and dysplastic left hip. There is only Barlow sign or from significant changes seen in the sono-
partial contact of the femoral head with the acetabulum, and the graphic morphology of the hip. The unstable hip may either
acetabulum is oblique and shallow. stabilize spontaneously or become dysplastic or dislocated
over a period of several months.
that increases the contact surface area of fibrocartilage at The hip examination (Box 13.4) of the neonate requires
the acetabular margin. Joint contact area determines the an artful approach in which the setting must be controlled
cartilage stress. Stress may rise from 20 to 320 kp/cm2. and the examiner experienced. The first requisite is a
An abductor lurch is an effective adaptation in that the relaxed child. To achieve this, the infant may need a bottle;
abductor forces are reduced to the point that only body the examination surface should be warm and comfortable,
weight forces are carried through the hip. When the pelvis and the room should be reasonably quiet. A firm examina-
drops, however, the head coverage decreases, and this has a tion surface is best, but if the parent’s lap keeps the child
negative biomechanical effect. more comfortable, it will suffice.
Dysplastic hips without subluxation usually become The “feel” of this examination is most important, and it
painful and develop degenerative changes over time. These is not unlike palpation of the liver. Movement of the hip in
hips often become subluxated as the degenerative disease and out of the socket is a delicate event that is best appreci-
progresses. Cooperman and associates reported that all dys- ated with a very light touch. The examiner holds the child’s
plastic hips without subluxation with a center–edge angle of knees, one in each hand, and examines one hip at a time.
less than 20 degrees sustained osteoarthritic changes over In the test for Barlow sign, the examiner attempts to slide
22 years of follow-up50; however, no direct correlation of the femoral head out of the acetabulum (Fig. 13.17). The
the center–edge angle with the development of arthritis was hip is adducted, and a gentle push is applied to slide the hip
demonstrated. It has been shown that a hip with an acetabu- posteriorly. The examiner’s fingers are positioned over the
lar angle of 35 degrees or more 2 years after reduction has greater trochanter, and the trochanter is allowed to move
an 80% probability of becoming a Severin class III or IV laterally. In a positive test, the hip will be felt to slide out of
hip, which will likely require later hip replacement.1 It is
estimated that 20% to 50% of cases of degenerative arthritis d References 71, 126, 148, 182, 184, 211, 261, 316.
Box 13.4 Physical Examination Findings by

Age for Developmental Dysplasia of the Hip
NEONATE
Dislocatable
Reducible
Klisic sign
INFANT A
Dislocatable (occasionally)
Reducible (occasionally)
Klisic sign
Decreased abduction
Galeazzi sign
WALKING CHILD
Remains dislocated
Klisic sign
Decreased abduction
Galeazzi sign
Limp B
Short leg
FIG. 13.18 The Ortolani test for developmental dislocation of the
Increased lordosis (bilateral)
hip in a neonate. (A) The examiner holds the infant’s knees and
gently abducts the hip while lifting up on the greater trochanter
with two fingers. (B) When the test is positive, the dislocated
femoral head will fall back into the acetabulum (arrow) with a
palpable (but not audible) “clunk” as the hip is abducted (Ortolani
sign). When the hip is adducted, the examiner will feel the head
redislocate posteriorly.
manner. During the newborn period, there are usually no

other signs of abnormality.
A This examination is subject to many factors that can
affect its effectiveness and reliability. The hurried exam-
iner usually fails to appreciate the instability. It is possible
to examine a hip throughout 15 maneuvers and to feel the
instability only the sixteenth time that the hip is moved. The
explanation is that this “feel” is quite delicate and requires
just the right degree of relaxation on the part of the exam-
iner as well as the infant. Many examiners report a “click”: a
high-pitched snap, often felt at the extremes of abduction.
This click may originate in the ligamentum teres or occa-
B sionally in the fascia lata or psoas tendon, and it usually does
FIG. 13.17 The Barlow test for developmental dislocation of the not indicate a significant hip abnormality130; however, one
hip in a neonate. (A) With the infant supine, the examiner holds study122 reported a 9.35-fold increase in the incidence of
both of the child’s knees, gently adducts one hip, and pushes poste- abnormal results on ultrasonography in children with simple
riorly. (B) When the examination is positive, the examiner will feel clicks, and another found a 1.5% incidence of DDH when
the femoral head make a small jump (arrow) out of the acetabulum a click was the only finding.25 One study of 256 patients
(Barlow sign). When the pressure is released, the head is felt to slip
found no abnormalities with this finding.83
back into place.
It is important to plan appropriate follow-up for children
after the initial evaluation. Occasionally, patients who had
the acetabulum. As the examiner relaxes the proximal push, a negative clinical examination during the neonatal period
the hip can be felt to slip back into the acetabulum. present at an older age with dysplasia (Fig. 13.19). Imaging
The Ortolani test is the reverse of the Barlow test: the studies—ultrasonography for the infant and pelvic radiog-
examiner attempts to reduce a dislocated hip (Fig. 13.18). raphy for the child who is older than 6 months—should be
The examiner grasps the child’s thigh between the thumb done in children with risk factors that include breech pre-
and the index finger and, with the fourth and fifth fingers, sentation in a girl and positive family history. Whether imag-
lifts the greater trochanter while simultaneously abducting is necessary for all children who are referred remains
ing the hip. When the test result is positive, the femoral unclear.
head will slip into the socket with a delicate “clunk” that is
palpable but not audible. The examiner should repeat this Infant (Video 13.1)
sequence four or five times to be certain of the findings,
alternating the Barlow test and the Ortolani test in a gentle As the child enters the second and third months of life,
arc of motion. The other hip is then examined in the same other signs of DDH appear (see Box 13.4). It is important
40°
80°
FIG. 13.20 Developmental dysplasia of the right hip. One physical

finding is limited abduction of the affected hip.
A
FIG. 13.21 The Galeazzi sign. There is an apparent shortening

of the femur as demonstrated by the difference in knee levels as
B assessed for a child lying on a firm table with the hips and knees
FIG. 13.19 (A) Anteroposterior radiograph of the pelvis of a flexed at right angles.
9-month-old girl who had a negative physical examination when
she was 2 weeks old. The left hip shows significant dysplasia. (B)
An arthrogram of the left hip shows subluxation of the femoral is foreshortened, there will be more thigh folds on the
head with adduction and mild axial pressure. In the neutral position affected side than on the normal side (Fig. 13.22). Although
the hip was well reduced. The child was treated with a one-and- this sign is always present with a unilateral dislocation, extra
one-half-hip spica cast for 6 weeks. The arthrogram after that cast thigh folds are a common normal variant and do not neces-
showed no subluxation. A second cast was applied for another 6 sarily indicate hip dislocation.
weeks to encourage acetabular development and hip stability. A potentially perilous situation for the unwary examiner
is the child with bilateral hip dislocation. This child has no
to recall that the progression from instability to dislocation asymmetry of abduction, and the flexed knees are at the
during the newborn period is a gradual process. In some same level. Combined abduction is limited, but this is dif-
children, an irreducible dislocation develops within a few ficult to detect because the limitation is symmetric. One
weeks, whereas in others the hip dislocation remains reduc- test that can help the examiner to recognize a bilateral dis-
ible until they are 5 or 6 months old. When the hip is no location is the Klisic test, in which the examiner places the
longer reducible, specific physical findings appear, including third finger over the greater trochanter and the index finger
limited abduction, shortening of the thigh, proximal loca- on the anterior superior iliac spine. An imaginary line drawn
tion of the greater trochanter, asymmetry of the thigh folds, between the fingers should point to the umbilicus. When
and pistoning of the hip. the hip is dislocated, the more proximal greater trochanter
The limitation of abduction, which is the most reliable causes the line to point approximately halfway between the
sign of a dislocated hip, is best appreciated by abducting umbilicus and the pubis (Fig. 13.23).
both hips simultaneously with the child on a firm surface These examinations are capricious, and the clinician
(Video 13.2). A unilateral dislocation produces a visible should use imaging studies to evaluate infants with ques-
reduction in abduction on the affected side as compared tionable findings and those with risk factors that are associ-
with the normal side (Fig. 13.20). Shortening of the thigh ated with DDH. These risk factors include a family history
(Galeazzi sign) is best appreciated by placing both hips in of DDH, breech position, oligohydramnios, torticollis, and
90 degrees of flexion and comparing the height of the knees, metatarsus adductus. The significantly higher frequency
again looking for asymmetry (Fig. 13.21). Because the thigh of DDH among girls as compared with boys must also be
considered. The reexamination of a child a few months later dislocated hip adducts, and the child leans over the dislo-
helps to decrease the possibility of missing a dislocation. It is cated hip; this is known as an abductor lurch or Trendelen-
imperative that experienced orthopaedic practitioners pro- burg gait (Fig. 13.24). When the child attempts to stand on
vide education to primary care providers regarding examina- that foot with the other elevated off of the floor, he or she
tion for DDH. leans toward the affected side (Trendelenburg sign). As in
the younger child, there is limited abduction on the affected
side, and the knees are at different levels when the hips are
Walking Child
flexed (Galeazzi sign).
The unilateral dislocated hip produces distinct clinical signs In the walking child, bilateral dislocation is more diffi-
in a walking child (Video 13.3; see Box 13.4). Although cult to recognize than unilateral dislocation. There is usually
some authors have suggested that children with DDH a lurching gait on both sides, but some children mask this
are late to start walking, more recent studies have shown rather well, showing only an increase in the dropping of the
no significant delay.61,127 The affected side appears to be pelvis during the stance phase. Excessive lordosis is com-
shorter than the normal extremity, and the child toe-walks mon, and it is often the presenting complaint (Fig. 13.25).
on the affected side. With each step, the pelvis drops as the The lordosis is the result of hip flexion contracture, which is
usually present. The knees are at the same level, and abduc-
tion is symmetric but limited. There is usually an excessive
internal and external rotation of the dislocated hips.
Radiographic Findings
Ultrasonography
The neonate’s hip is a difficult structure to image with stan-
dard radiographic techniques because the hip is composed
primarily of cartilage and soft tissue. Ultrasonography is a
modality which gives the examiner a detailed view of soft
and hard tissues about the hip, both in static and mobile
modes. A number of technics are in use and many stud-
ies have defined parameters of normal, and indications for
treatment.
Graf in 198085 first described his technique using a lat-
eral imaging technique with the transducer placed over the
greater trochanter (Fig 13.26). He subsequently developed
a classification of abnormalities which is in use today (Table
13.2).86
Harcke and Kumar in the 1980s reported dynamic stud-
ies in which the hip is moved to reproduce the Barlow
FIG. 13.22 With developmental dysplasia of the right hip, there
and Ortolani maneuvers, and the degree of subluxation is
may be asymmetry of the thigh folds and of the popliteal and glu-
teal creases, with apparent shortening of the extremity on the right
documented with ultrasonography.92,93 During the first few
which is the affected side. days of life, 4 to 6 mm of motion is considered normal,
FIG. 13.23 The Klisic test for developmental dysplasia of

the hip. The examiner places the middle finger over the
greater trochanter and the index finger on the anterior
superior iliac spine. (A) With a normal hip, an imagi-
nary line drawn between the two fingers points to the
umbilicus. (B) When the hip is dislocated, the trochanter A B
is elevated, and the line projects halfway between the
umbilicus and the pubis.
A B
FIG. 13.24 Trendelenburg sign and gait. The Trendelenburg test
is positive on the dislocated right side. (A) As the child stands with
the weight on the normal side, the pelvis is maintained in the
horizontal position by the contraction and tension of the normal
hip abductor muscles. (B) As the child shifts weight to the side FIG. 13.25 Bilateral hip dislocation. Note the excessive lordosis that
of the dislocated hip, the pelvis on the opposite and normal side occurs as a result of hip flexion contracture.
drops as a result of the weakness of the hip abductor muscles on
the affected side. This is termed a positive Trendelenburg sign. The
sideways lean of the body toward the affected side in gait is known In the Graf classification class I hips are normal, class II
as the Trendelenburg gait. hips are either immature or somewhat abnormal, class III
hips are subluxated, and class IV hips are dislocated. Class
and definite treatment indications developed on the basis of I hips need no follow-up, whereas class III and IV hips usu-
stress views are still evolving.93,135 ally require treatment. Class II hips form the group in which
Tersen in 1989 described an ultrasonic measure of femo- the degree of abnormality and the need for treatment are
ral head coverage which has also had wide usage, with a 50% less clear. Graf subdivided class II in several ways in dif-
coverage considered to be normal.281 ferent publications (see Table 13.2). He noted that stage
A number of recent reviews have compared the several IIc is the most important to identify because it represents
classification systems and their reproducibility.69,216 a preluxation- phase hip that will subsequently dislocate.
He emphasized that the probe should be perpendicular to
Graf Technique the acetabulum as well as to the cut in the center of the
Graf ’s classification system is based on the angles formed acetabulum.85,86,87
by the sonographic structures of the hip (Fig. 13.26D). The Treatment philosophies regarding abnormalities in
“baseline” is the line of the ilium as it intersects the bony Graf class II hips vary widely (some authors treat only
and cartilaginous portions of the acetabulum. The “inclina- those hips with clinical instability), regardless of sono-
tion line” is the line along the margin of the cartilaginous graphic findings. Others treat all class II hips with abduc-
acetabulum. The third line is the “acetabular roofline” along tion devices. Exact treatment guidelines are lacking. Graf
the bony roof. The intersection of the roofline and the base- recommends treating IIa hips, while others begin treat-
line forms the alpha angle, whereas the intersection of the ment for IIb hips but not IIa.216 In the newborn period
inclination line and the baseline forms the beta angle. A the ultrasound images show transient abnormalities,
smaller alpha angle indicates a shallower bony acetabulum. and in most centers the most useful exam is done at age
A smaller beta angle indicates a better cartilaginous acetabu- 6 weeks. There is wide agreement that treatment deci-
lum. In other words, as the femoral head subluxates, the sions should be based on ultrasonography examinations
alpha angle decreases, and the beta angle increases.86 The performed at 6 weeks of age or later to allow for hip
classification is illustrated in Table 13.2. maturity.
Femoral
Abductor Cartilaginous head
muscle acetabulum
β
Abductor muscle
Bony
acetabulum
Capital
Ilium epiphysis
C
Ilium
Ischium
D α
FIG. 13.26 Ultrasonographic evaluation of the infant hip. (A) The sonogram should be obtained with the child in the lateral decubitus posi-
tion. (B) Ultrasonographic scan showing hip structures in a child. (C) Highlights of the anatomic structures shown on the sonogram. (D)
Measurement of alpha (α) and beta (β) angles on ultrasonography scans to establish Graf class. The alpha angle is the angle between the
baseline and the roof of the bony acetabulum. The beta angle is the angle between the baseline and the cartilaginous acetabular roof.
The Harcke Method The Terjesen Method

The Harcke method uses four views, the frontal neutral The main finding of the Terjesen method is the percentage
view, the frontal flexion view, the transverse neutral view, of coverage of the femoral head. The lower normal limit
and the transverse flexion view. With his method the insta- for the coverage value is 50% in infants older than 1 month
bility is evaluated with a combination of two perpendicular of age. In addition, the alpha angle of Graf is measured,
planes, with and without stress. Thus the position, stability, and the shape of the lateral bony rim is defined as normal,
and morphology of the hip joint are assessed. The findings defective, or rounded. The exact percentage of head cover-
are reported as normal, subluxated, slightly dislocated, or age which requires treatment is as yet not clearly defined
dislocated.216 (Figs. 13.27 and 13.28).
Table 13.2 Graf Classification System of Developmental Dysplasia of the Hip on the Basis of the Sonographic Angles of
the Hip.
Class Alpha Angle Beta Angle Description Treatment
Standard Classification
I >60° <55° Normal None
IIa 50°–60° 55°–77° Immature (<3 mo) Observation
IIb >50°–60° 55°–77° >3 mo Pavlik harness
IIc 43°–49° >77° Acetabular deficiency Pavlik harness
IId 43°–49° >77° Everted labrum Pavlik harness
III <43° >77° Everted labrum Pavlik harness
IV Unmeasurable Unmeasurable Dislocated Pavlik harness/closed vs. open

reduction
Simplified Classification
I >60° <55° Normal None
II 43°–60° 55°–77° Delayed ossification Variable
III <43° >77° Lateralization Pavlik harness
IV Unmeasurable Unmeasurable Dislocated Pavlik harness/closed vs. open

reduction
Treatment Implications hip exams are normal, but whose ultrasound exams show
Bialik and colleagues provided some useful guidelines for definite abnormality.187 Studies suggest that screening with
the use of ultrasonography with their protocol to reduce the ultrasonography does pick up clinically silent hips without
number of hips that are treated unnecessarily by delaying increasing the rate of treatment for minor abnormalities that
the start of treatment pending sonographic reexamination.18 would resolve spontaneously.42,259 The exact indications for
Neonates with hips that were stable during their initial treatment by ultrasonographic criteria are still being refined.
examination were reexamined clinically and with ultraso- Ultrasonography is also very useful for detecting early
nography at 6 weeks of age, whereas those with unstable treatment failures when using the Pavlik harness or other
hips were reexamined at 2 weeks of age. If the ultrasono- treatment modalities. It is important to note that a normal
graphic study showed no improvement of the unstable hips result with ultrasonography does not completely preclude
at the second examination, treatment with the Pavlik har- later abnormalities. Several cases of dysplasia at walking age
ness was begun. At the end of the established waiting peri- have been reported in children who had normal ultrasono-
ods, 90% of the abnormal hips had become normal without graphic findings during the neonatal period.146 Imre studied
treatment. Only 3% of the Graf IIa hips failed to normalize 300 babies who were born breech; of those with normal
without treatment, whereas 17% of Graf III hips and 25% examinations and ultrasound studies, 29% later had abnor-
of Graf IV hips failed to normalize. Slightly more than half mal radiographs of the hips at 5 months of follow-up.112
of the hips treated had no clinical instability. Their outcome, Thus we also must conclude that a “normal” ultrasound at
had they not been treated, remains speculative. A review of 6 weeks of age does not guarantee a normal hip later in life.
5 years of experience with a universal screening program in
Germany found that the need for surgical treatment was
Radiography
reduced but not eliminated for children with DDH.298
Other authors have reported a more dramatic reduction in Plain radiography of the pelvis usually demonstrates a
surgical rates in response to universal screening.325 frankly dislocated hip in individuals of any age. In newborns
A number of authors believe that ultrasonography is too with typical DDH, however, the unstable hip may appear
sensitive and results in the overtreatment of hips that would radiographically normal. As the child reaches 3 to 6 months
otherwise develop normally.331 Screening studies have of age, the dislocation will be evident radiographically, but
shown that only 0.012% of hips that are normal on clini- the examiner must be familiar with the landmarks of the
cal examination have evidence of dysplasia later195 and that immature pelvis to recognize the abnormality. In the infant,
most Graf IIa hips normalize without treatment.294 When the upper femur is not ossified, and most of the acetabu-
ultrasonography was used for screening, the treatment rate lum is cartilaginous. The triradiate cartilage lies between the
doubled as compared with using clinical findings alone.238 ilium, the ischium, and the pubis.
Another study found that only 9.5% of infants with abnor- Several classic lines are helpful when evaluating the
mal ultrasound scans had clinical signs of DDH. immature hip (Figs. 13.29–13.31). The Hilgenreiner line is a
It is now clear that ultrasonography is a valuable adjunct line through the triradiate cartilages. The Perkin line, which
to the detection of neonatal hip abnormalities. The expe- is drawn at the lateral margin of the acetabulum, is perpen-
rienced examiner will frequently encounter babies whose dicular to the Hilgenreiner line. The Shenton line is a curved
A 30fps 5cm B
RT HIP CORONAL NON–STRESS _
C LT HIP CORONAL NON–STRESS OOH_ D

FIG. 13.27 Ultrasound evaluation of a 6-week-old girl with a positive Barlow sign of the left hip. (A) Ultrasound of the right hip shows well
covered femoral head, alpha angle 57 degrees. (B) Ultrasound of the left hip shows 10% coverage of the femoral head and an alpha angle
of 37 degrees. Pavlik harness treatment was initiated. (C) Ultrasound after 3 weeks in the harness, shows 60% left femoral head coverage
and an alpha angle of 60 degrees. After 6 weeks of Pavlik harness treatment the ultrasound findings remained unchanged and the harness
was discontinued. (D) Pelvis radiograph at age 5 months showing well reduced hips with developing ossific nuclei of the femoral head.
Residual dysplasia is evident and will be followed for possible future intervention.
line that begins at the lesser trochanter, goes up the femoral Fig. 13.30). In normal newborns, the acetabular index aver-
neck, and connects with a line along the inner margin of ages 27.5 degrees. At 6 months of age, the mean is 23.5
the pubis. In a normal hip, the medial beak of the femoral degrees. By 2 years of age, the index usually decreases to 20
metaphysis lies in the lower, inner quadrant produced by degrees. Thirty degrees is considered the upper limit of nor-
the juncture of the Perkin and Hilgenreiner lines. The Shen- mal.100,142,158 The acetabular index of the weight-bearing
ton line is smooth in the normal hip. In the dislocated hip, zone or the sourcil is normally less than 15 degrees.204,285
the metaphysis lies lateral to the Perkin line; the Shenton In the older child, the center–edge angle is a useful mea-
line is broken because the femoral neck lies cephalic to the sure of hip position (see Fig. 13.31). This angle is formed
line from the pubis. at the juncture of the Perkin line with a line that connects
Another useful measurement is the acetabular index, the lateral margin of the acetabulum to the center of the
which is an angle formed by the juncture of the Hilgen- femoral head. In children who are 6 to 13 years old, an angle
reiner line and a line drawn along the acetabular surface (see of more than 19 degrees has been reported as normal; in
Hip Angle 51.7° Hip Angle 50.7°
A Rt Hip Coronal Non-Stress B Lt Hip Coronal Non-Stress

5.0cm 5.0cm
Hip Angle 66.7° Hip Angle 63.8°
C Rt Hip Coronal Non-Stress

5.0cm
D Lt Hip Coronal Non-Stress
5.0cm
FIG. 13.28 An 8-week-old girl, born breech with a twin delivery, was evaluated for hip dysplasia. Her hips were stable to examination but
there were abnormalities of the ultrasound exam. (A) An ultrasound at 8 weeks of age shows excellent coverage of the right hip, alpha angle
52 degrees. (B) There is 33% coverage of the left hip, alpha angle 50 degrees. No treatment was instituted. (C) An ultrasound at 10 weeks
of age shows maintained coverage of the right hip with 55% coverage, alpha angle 64 degrees. (D) At 10 weeks the left hip coverage is now
52%, alpha angle is 63.8 degrees. This case emphasizes that the exact indications for treatment of mild ultrasonic dysplasia have not been
fully established.
children who are 14 years old and older, an angle of more within 6 months of reduction have a better outcome than
than 25 degrees is considered normal.253 hips in which the teardrop appears later.257 Four types of
A helpful radiographic projection is the Von Rosen view, teardrop bodies have been noted: open, closed, crossed, and
in which both hips are abducted, internally rotated, and reversed.4 The teardrops have also been described as U-or
extended.299 In the normal hip, an imaginary line extended V-shaped, with a V-shaped teardrop being associated with a
up the femoral shaft intersects the acetabulum. When the dysplastic hip and a poor outcome (Fig. 13.32).
hip is dislocated, the line crosses above the acetabulum. Another measure of acetabular dysplasia is the acetabu-
The acetabular teardrop figure, as seen on an anteropos- lar index of depth to width in which the depth of the cen-
terior (AP) radiograph of the pelvis, is formed by several tral portion of the acetabulum is divided by the width of the
lines. It is derived from the wall of the acetabulum laterally, acetabular opening, with normal being more than 38%.204
the wall of the lesser pelvis medially, and a curved line infe- The femoral head extrusion index represents the percent-
riorly, and it is formed by the acetabular notch. The tear- age of the femoral head that lies outside of the acetabulum.
drop appears between 6 and 24 months of age in a normal The false-profile radiographic view represents a lateral
hip and later in a dislocated hip. In a study by Smith and view of the acetabulum, and it is especially useful for evalu-
associates,257 the teardrop did not appear until hips were ating anterior acetabular dysplasia.38,164,165 The patient is
reduced, but the teardrop was present in dislocated hips positioned 65 degrees obliquely to the x-ray beam, with the
by 29 months of age in a study by Albiñana and associates.4 foot parallel to the cassette. The extent of anterior coverage
When the hip is dislocated or subluxated, the acetabular is represented by a dense line of ossification known as the
portion of the teardrop loses its convexity, and the tear- sourcil, the limit of which is sometimes difficult to define.
drop is wider from the superior to the inferior directions. An acetabular angle can be constructed; the mean value
The reduced hip remodels the acetabulum, and the tear- is 32.8 degrees, with a range of 17.7 to 53.6 degrees (Fig.
drop gradually narrows. Hips in which the teardrop appears 13.33).51
Perkin line
Hilgenreiner
D line Perkin line
Shenton Center–edge angle

line of Wilberg
FIG. 13.31 The Wilberg center–edge angle, which is the angle that
FIG. 13.29 Radiographic measurements that are useful for evaluat- is formed between the Perkin line and a line drawn from the lateral
ing developmental dysplasia of the hip. The Hilgenreiner line is lip of the acetabulum through the center of the femoral head. This
drawn through the triradiate cartilages. The Perkin line is drawn angle, which is a useful measure of hip position in older children, is
perpendicular to the Hilgenreiner line at the margin of the bony considered normal if it is more than 19 degrees in children between
acetabulum. The Shenton line curves along the femoral metaphysis the ages of 6 and 13 years. It increases with age.
and connects smoothly to the inner margin of the pubis. Dimen-
sion H (height) is measured from the top of the ossified femur to
the Hilgenreiner line. Dimension D (distance) is measured from
the inner border of the teardrop to the center of the upper tip of
the ossified femur. Dimensions H and D are measured to quantify
proximal and lateral displacement of the hip and are most useful
when the head is not ossified.
Hilgenreiner A
line
25° 33°
Acetabular Acetabular
index index
(normal) (abnormal)
B
Medial gap
FIG. 13.32 A wide teardrop body in a 10-year-old girl who under-
went closed reduction when she was 18 months old. (A) Anteropos-
FIG. 13.30 Acetabular index and the medial gap. The acetabular terior radiograph showing bilateral acetabular dysplasia. Note the
index is the angle between a line drawn along the margin of the wide teardrop body bilaterally, which is an indication of inadequate
acetabulum and the Hilgenreiner line; it averages 27.5 degrees in acetabular deepening since reduction. (B) Anteroposterior radio-
normal newborns, and it decreases with age. graph obtained 4 years after Salter osteotomies. Acetabular coverage
has improved, but the widened teardrop persists. It is likely that
degenerative changes will develop, particularly in the left hip.
The Severin classification has been used for many years
to specify outcome in hips that have been treated for DDH increase in carcinogenic risks from the cumulative radio-
(Table 13.3).248 However, in 1997, Ward and associates graphs taken to manage an average DDH case have been
reported poor levels of intraobserver and interobserver reli- estimated to be less than 1%.26
ability when the system was used.306 The interpretive ambi-
guities and lack of objective measures emphasize the need
Arthrography
for a more reliable scheme.
Although parents may become concerned about radiation The arthrographic anatomy of the hip was well described
exposure during the course of their child’s management, the by Severin in 1941.252 In the normal hip, the free border
V
A
FIG. 13.33 (A) The false-profile view is made

with the patient standing 65 degrees oblique
to the x-ray beam with the foot parallel to
the cassette. (B) From the false-profile radio-
graph, the center–edge angle is constructed
from the intersection of a vertical line (V )
through the center of the femoral head (C )
with a line (A) from the anterior edge of the
A B sourcil to the center of the femoral head.
Table 13.3 Severin Classification System of

Developmental Dysplasia of the Hip.
Radiographic Center–Edge Angle
Class Appearance (Age)
Ia Normal >19° (6–13 yr)
>25° (≥14 yr)
Ib Normal 15°–19° (6–13 yr)
20°–25° (≥14 yr)
IIa Moderate deformity of Same as class I

femoral head, femoral
neck, or acetabulum
III Dysplasia without sub- <15° (6–13 yr) FIG. 13.34 Anteroposterior arthrogram of a normal hip in a neutral
luxation position. Note the sharp lateral acetabular margin (the “thorn
<20° (≥14 yr)
sign”) with a recess of joint capsule overlying it.
IVa Moderate subluxation ≥20°
IVb Severe subluxation <0°
V Femoral head articulates When the hip is placed into a reduced position, it may
with pseudoacetabulum reduce fully against the acetabular wall, or it may “dock”
in superior part of original against the labrum and the capsular constriction of the ilio-
acetabulum psoas (see Fig. 13.48B). When the reduction is deep, the
labrum lies flat over the head and has a sharp border. When
VI Redislocation
the head is docked, the labrum is blunted and interposed
between the head and the acetabular wall. The ligamentum
teres is seen within the joint, and it may be outlined by con-
of the labrum is easily seen as a sharp “thorn” overlying the trast material. A bulge in the acetabular cartilage beneath
femoral head (Fig. 13.34). A recess of joint capsule overlies the labrum (the neolimbus) may be seen. If the reduction
this thorn. The capsule expands beyond this recess and is is stable and the hip is immobilized in a safe position, then
then constricted by the ringlike zona orbicularis. In a child the femoral head will gradually overcome the capsular tight-
with DDH, when the hip is in the dislocated position, the ness. Arthrography repeated 6 weeks later shows the head
acetabular edge is seen, and the capsule is enlarged as it as being well seated in the acetabulum.
extends over the femoral head. The capsule is constricted Arthrography should usually be performed with
at its middle portion into an hourglass shape by the iliopsoas the patient under general anesthesia. We prefer the
tendon. median, subadductor approach with image intensification
Affected hip flexed and the hip joint. Disruption and tears of the labrum, cartilage
abducted 90° delamination, and articular cartilage loss can be identified
with this technique.133,166
Adductor longus muscle
Screening Criteria
All neonates should undergo a clinical examination for hip
instability. Beyond that recommendation, there is a lack of
consensus with regard to the need for further screening.
Direction of needle
for arthrography
Most authors agree that infants with risk factors associ-
ated with DDH should receive more careful screening that
Cartilaginous roof includes at least an examination by an experienced exam-
iner and an ultrasound study of the hip. These risk factors
Cul-de-sac include first-born female, a family history of DDH, and
of synovium
breech birth position. Clinical findings of torticollis, meta-
Limbus tarsus adductus, and oligohydramnios may be associated
with an increased incidence of hip instability with some
studies showing a relationship and others not.108,111,116,154.
First-born whites also have an increased risk for DDH rela-
tive to other racial groups.e
The need for screening with ultrasonography remains
controversial. In addition to the added cost, the disadvantage
FIG. 13.35 Subadductor approach for the insertion of a needle for of ultrasound screening of all newborns is the identification
arthrography of the hip. Inset, Normal limbus (aka labrum) as seen of a large number of children with sonographic abnormali-
with arthrography.
ties for which there are no firm treatment guidelines. Some
authors recommend ultrasonography in combination with
(Fig. 13.35). The needle is inserted just beneath the adduc- clinical examination for all infants with appropriate risk fac-
tor longus, approximately 2 cm distal to its origin. If the tors, although others found a low yield of significant abnor-
starting point is too close to the adductor’s origin, the nee- malities in the absence of clinical findings, even in hips that
dle will encounter the inferior portion of the acetabulum were considered to be at risk.224 The American Academy
rather than the joint itself. The needle is directed medially of Pediatrics has issued a practice guideline that recom-
and aimed toward the contralateral sternoclavicular joint. mends radiographic screening (ultrasonography) for female
When resistance is encountered, the position of the nee- infants who were either carried in the breech position or
dle is noted on the image. The needle should be directed have a positive family history of DDH.1 Alternatively, the
toward the joint space. A small amount of contrast material US Preventive Services Task Force—in accordance with a
is injected to be certain that the joint has been entered; the best-evidence review—concluded that the “net benefits” of
contrast agent should flow freely around the femoral head. screening could not be determined; they found that there
Another 1 mL of contrast agent is injected, and the needle was a high rate of spontaneous resolution of the abnormality
is removed. Permanent films should be obtained for each and a lack of evidence of the effectiveness of intervention
significant position of the hip. It is important to note the on functional outcome.254
positions of maximum stability and instability.
Treatment
Magnetic Resonance Imaging
Treatment of the Neonate
MRI affords excellent anatomic visualization of the infant
hip, but it is not commonly used because of the expense Pavlik Harness
involved and the need for sedation. Kashiwagi and associates The Pavlik harness is the preferred method for the treat-
proposed an MRI-based classification of hips with DDH.131 ment of neonatal DDH (Box 13.5). The first indication for
Group 1 hips had a sharp acetabular rim, and all were reduc- treatment is a hip that is dislocated and that can be reduced
ible with a Pavlik harness. Group 2 hips had a rounded ace- by the examiner (Ortolani sign). We recommend that all
tabular rim, and almost all could be reduced with a Pavlik such hips should be treated in a harness, beginning at the
harness. Group 3 hips had an inverted acetabular rim, and time the diagnosis is made. We also recommend immediate
none was reducible with the harness. MRI findings include Pavlik harness treatment for hips that are located but that
the widening of the iliac bone, the lateral drift of the supe- can be subluxated by the examiner (Barlow sign). Some of
rior and posterior portions of the acetabular floor, the over- these hips will spontaneously stabilize, and some clinicians
growth of the acetabular cartilage, and the convexity of the prefer to wait a few weeks and reexamine the child before
posterior portion of the acetabular cartilage.27,89 initiating treatment. When observation is chosen, steps
MRI with gadolinium-contrast arthrography is an impor- should be taken to ensure follow-up because some of these
tant tool for the evaluation of the adolescent patient with hip hips will subsequently dislocate if they are left alone.14,46
dysplasia and pain. This technique allows for the evaluation
of the condition of the labrum and the articular cartilage of e References 6, 11, 12, 35, 36, 60.
Box 13.5 Age-Based Guidelines for the

Treatment of Developmental Dysplasia of the
Hip
Neonate: Place the patient in a Pavlik harness for 6 weeks.
1–6 months: Place the patient in a Pavlik harness for up to 6
weeks after the hip reduces.
6–18 months: Treat the patient with traction and closed reduc-
tion. If closed reduction is successful, place the hip in a cast
for 3 months. If closed reduction is unsuccessful, perform
open reduction. Open reduction is performed via a medial
approach in children who are younger than 12 months old
and via an anterolateral approach in children who are older
than 12 months.
18–24 months: Treat the patient with a trial of closed reduc-
tion or primary open reduction (anterolateral approach). A
Salter or Pemberton osteotomy may or may not be part of
the procedure.
24 m
onths to 6 years: Perform primary open reduction (ante-
rolateral approach) and femoral shortening, with or without
a Salter or Pemberton osteotomy.
Less certain are the indications for the treatment of hips

that are normal on clinical examination but abnormal on
ultrasonography. Currently in patients with a normal physi-
cal examination we institute Pavlic harness treatment for
hips with Graf IIb findings and those with less than 30% FIG. 13.36 The Pavlik harness. The transverse chest strap should
coverage of the head (Terjesen method). As noted in the be placed just below the nipple line. The hips should be flexed to
previous discussion of sonographic examinations, Graf class 120 degrees, and the posterior straps should not produce forced
II hips are more likely to improve without treatment than abduction.
are Graf class IIb, III, or IV hips. Similarly, the Graf clas-
sification is also predictive of likely success with Pavlik
treatment, with 97% success for Graf class III hips and 50% The progress of the hip can be monitored by repeat-
success for class IV hips in one series in which the hips were ing the ultrasonographic studies. If the ultrasound remains
not initially reducible.201 abnormal 3 weeks, an abduction orthosis may be substi-
The Pavlik harness is applied by first placing the chest tuted for the harness. Swaroop and co-workers reported
strap just below the nipple line (Fig. 13.36). The child’s feet a 93% success rate without AVN when hips that were
are placed in the stirrups, the hips are placed in 120 degrees unstable after 3 weeks of Pavlik harness treatment were
of flexion, and the straps are secured. The posterior straps switched to an abduction device and monitored with serial
are fastened loosely to allow for the abduction of the hips ultrasound examinations.274 After 6 weeks of treatment,
to occur by gravity alone. Abduction should never be forced the hip is examined with the child out of the harness, and
by the straps on the harness.288 In fact, the hips should be ultrasonography is performed. If sonography shows a well-
able to adduct to almost a neutral position with the straps located hip and the clinical examination is negative, then
in place. Excessive flexion must be avoided; it will occur the harness is discontinued. (Some authors prefer to wean
if the harness is not properly adjusted as the child grows. the infant from the harness with a period of part-time
Hyperflexion of the hips may produce a femoral nerve palsy wear that occurs over several weeks or months.) The child
as the nerve becomes compressed by the diapers between is then followed clinically. When the patient is 6 months
the thigh and abdomen.202 Hyperflexion may also cause the old, a radiograph of the pelvis is obtained. If the hip is
femoral head to dislocate inferiorly.237 Alternatively, inad- normal, the child is seen when he or she is 1 year old,
equate flexion (i.e., <90 degrees) will fail to reduce the hip and a standing radiograph is obtained. If the radiograph is
(Fig. 13.37). negative, subsequent follow-up is either annual or bien-
The use of the harness is most effective when there is a nial. Follow-up to the point of skeletal maturity is recom-
strong support system to educate the parents and to moni- mended, because there is a small but significant incidence
tor the neonate’s progress closely. We see the infant every of late asymmetric epiphyseal closure that results in valgus
week while the harness is being used. Reliable parents are of the femoral head and reduced coverage of the hip. In
taught to remove and replace the harness for bathing. If the one series, 20% of patients who were successfully treated
social setting is poor, we prefer to have the parents keep in the harness developed acetabular dysplasia during 8 to
the infant in the harness and return weekly with the child 15 years of follow-up.291 Another found a 10% incidence
for bathing and harness change. Most infants outgrow the of AVN at more than 14 years of follow-up.213 Kitoh and
initial harness after 3 to 4 weeks, and a larger harness is associates found that an abduction contracture before
then fitted. treatment was associated with an increased risk of AVN.141
A B
C D E
FIG. 13.37 Use of the Pavlik harness in a child presenting at age 5 months with a dislocated left hip. (A) Anteroposterior (AP) radiograph
obtained at presentation when patient was 5 months old shows a dislocated left hip. (B) AP radiograph of patient in the harness with
inadequate flexion. (C) AP radiograph obtained 2 weeks later shows adequate flexion of the hip, although the hip is still dislocated. (D) AP
radiograph obtained 1 month later shows that the hip has been reduced. (E) AP radiograph obtained when patient was 5 years old shows
good acetabular development. (today ultrasound would have been used rather than radiographs).
If the hip remains dislocated after 3 to 4 weeks of har- The plan of treatment is similar to that for younger
ness wear, the use of the harness should be discontinued, infants, but management must be continued until hip stabil-
and the hip should be examined while the child is under ity is assured (see Fig. 13.37). The child is examined weekly,
anesthesia. An arthrogram may show the cause of the insta- and reduction is evaluated by clinical and ultrasonographic
bility, and the hip should be managed with either closed or examinations. If reduction is not obtained within 3 to 4
open reduction. If the hip is reduced at 3 weeks but dislo- weeks, the harness should be discontinued and other treat-
cates during examination, the harness should be worn for ment begun. If reduction is confirmed, the harness should
3 to 6 more weeks until the hip stabilizes. An abduction be continued for approximately 6 weeks after stability is
orthosis may be used for hips that have not stabilized after 3 established. When harness treatment is completed, some
or more weeks of treatment in the harness.98 clinicians elect to place the child in an abduction splint for
several more months. We recommend treating older chil-
dren for a longer time to encourage acetabular develop-
Treatment of the Young Child (2 to 6 Months ment. For example, a 6-month-old child may be treated for
Old) a total of 3 to 4 months. However, precise guidelines for the
Pavlik Harness stoppage of treatment are lacking.
As the harness is discontinued, another AP radiograph
Treatment Plan is obtained to assess hip reduction and acetabular develop-
The child who presents between 2 and 6 months of age may ment. A notch above the acetabulum often appears after
have an unstable hip that is similar to that seen in the neo- the hip is reduced, and this finding is usually followed by
nate, or the hip may remain dislocated. The Pavlik harness is improved acetabular development (Fig. 13.38). Acetabular
the first choice of treatment for this age group. To be effec- development may be enhanced by abduction splinting, but
tive, the harness must hold the hips in more than 90 degrees controlled studies have not been conducted to confirm the
of flexion, with the position of the upper femoral metaphy- efficacy of this common practice.
sis pointed toward the triradiate cartilage. If the hip cannot Several series have documented the results of harness
be placed in this position, the harness is unlikely to relocate treatment. A review of a large European series of patients
the hip. The hip does not have to be reducible at the time of found that 95% of initially dysplastic hips were normal after
the clinical examination to be successfully treated with the treatment.90 Eighty percent of hips that were dislocated
harness, but higher dislocations are less likely to reduce than and not initially reducible were successfully reduced with
lower ones. Children who are treated with the harness have the harness. Higher dislocations had a higher failure rate.
not shown evidence of developmental delay.333 The rate of AVN was 2.38%. A Japanese study found that
FIG. 13.39 The Ilfeld or Craig splint.
FIG. 13.38 Radiographic appearance in a 7-month-old child after

the successful treatment of developmental dysplasia of the hip
with a Pavlik harness. The notch (arrow) at the lateral margin of the
acetabulum represents ossification beneath the labrum and is often
seen after successful early treatment of developmental dysplasia of
the hip.
infants who were hospitalized for harness treatment had a

28% incidence of AVN, whereas those who were managed
at home had a 7.2% rate of AVN.117 The explanation for this
outcome was that the children in the hospital were handled
less and immobilized more than those at home, thus pre-
disposing them to AVN. Other studies have confirmed that
high dislocations are less likely to reduce and more likely
to have a higher rate of AVN as compared with low dislo-
cations. With high dislocations, slightly more than 50% of
the hips in the harness reduced, and the rate of AVN was
as high as 27%.273 Overall, the reported rate of AVN when
the Pavlik harness is used ranges from 0% to 15%.29,125,284
Factors that are associated with the failure of Pavlik har- FIG. 13.40 The Von Rosen splint.
ness treatment include patient age of more than 7 weeks
at treatment, bilateral hip dislocation, and an absent Orto- Other Splints and Braces
lani sign.295 Whenever the harness is used, Pavlik’s credo A variety of other splints and braces have also been used
should be remembered: “The main aim of the treatment is to treat DDH. When selecting a treatment method, it is
to achieve concentric reduction and to prevent AVN, which important to remember that the splint should position the
cripples the child for the whole of his life.”227 hips so that reduction can occur spontaneously. The hips
must never be rigidly immobilized, and forced positions
Problems and Complications Associated With the Pavlik should not be used. Wide abduction and forced internal
Harness rotation must always be avoided because these positions
Problems and complications other than AVN that can arise cause AVN of the soft femoral head. The Ilfeld splint
from the use of the harness include the failure to reduce the has been reported to have a high rate of success with few
hip, femoral nerve palsy, and the so-called Pavlik harness dis- complications (Fig. 13.39),136 as has the Von Rosen splint
ease (Video 13.4). Pavlik harness disease was reported by (Fig. 13.40).239
Jones and associates, who found that prolonged positioning of
the dislocated hip in flexion and abduction potentiated dys- Frejka Pillow and Triple Diapers
plasia and resulted in a hip that was likely to require an open The Frejka pillow is a semi-soft abduction device that has
reduction.123 They noted a flattening of the posterolateral been in use for many years. The Frejka pillow is capable of
acetabulum in these hips and recommended discontinuing forcefully abducting the hips of the infant, and in several
the harness if reduction had not occurred after 3 or 4 weeks. reports has been associated with an unacceptably high rate
Long-term follow-up is recommended for treated hips.291 of AVN (Fig. 13.41). One report found that AVN developed
FIG. 13.42 Traditional traction position with a frame in the bed

and the hips flexed 30 degrees (inset). (Redrawn from Tachdjian
MO, ed. Congenital Dislocation of the Hip. New York: Churchill
Livingstone; 1982.)
FIG. 13.41 Avascular necrosis after the use of the Frejka pillow.
Anteroposterior radiograph obtained when patient was 16 years
old shows a shortened femoral neck with trochanteric overgrowth.
The valgus tilt of the femoral head indicates a lateral physeal injury
from avascular necrosis.
in half of grade II dislocated hips with the use of the Fre-

jka pillow284; another study reported a 14% rate with the
pillow.152,153 The use of triple diapers should also be aban-
doned. On the other hand Czubak and co-workers found a
rate of 12% with the Frejka compared to 7% with Pavlik har-
ness, and the pillow was more likely to gain hip reduction in
children over 6 months of age.52 Tegnander and colleagues
also reported good results with the Frejka pillow with a sin-
gle case (0.9%) of AVN.280 Triple diapers do not effectively
position the hips, and their use may falsely suggest to par-
ents that something positive is being accomplished. FIG. 13.43 The Bryant traction position. The child lies in a bed
or crib with the hips flexed 90 degrees and the knees extended.
Treatment of the Child (6 Months to 2 Years (Redrawn from Tachdjian MO, ed. Congenital Dislocation of the Hip.
Old) New York: Churchill Livingstone; 1982.)
General Guidelines
The child who is between 6 months and 2 years old who Traction
presents with a dislocated hip and the child in whom ini- For many years pre-reduction traction was widely used, ini-
tial splintage has failed are managed in the same manner. tially done as an in-patient event, and later adapted to trac-
The goals of the treatment are to obtain and maintain the tion at home (Figs. 13.42–13.44). Earlier studies suggested
reduction of the hip without damaging the femoral head. that traction decreased the rate of AVN,f but more recent
The two principal methods of treatment are closed reduc- work has not shown a beneficial effect.249,269,282 Sucato and
tion and open reduction, either of which may be preceded co-workers reviewed 342 cases and found no difference in
by a period of traction. AVN rates (18% with traction, 8% without traction) and
Some authors have recommended that closed or open no difference in achieving successful closed reduction.269 A
reduction of the dislocated hip should not be performed until review by Schur and colleagues found a higher rate of AVN
the ossific nucleus of the femoral head has appeared.34,250 in the patients treated with traction compared to those not
Others have refuted this finding and found that hips so treated.249
reduced after the appearance of the nucleus had more than Several aspects of the current treatment of DDH that
twice as many subsequent operative procedures as those have contributed to a reduced frequency of AVN include
reduced before the nucleus was seen.43,178 Cooke and col- the use of gentle reduction, the use of the human position
leagues reported good results regardless of the presence of when maintaining reduction, and avoiding the temptation to
an ossific nucleus.49 We concur with their opinion that one hold the hip reduced at any cost. A comprehensive traction
should not wait to treat a hip until the nucleus appears. The method has been reported by Morel in France, who used
growth potential of the acetabulum declines with age, and traction not only to stretch the soft tissues around the hip
hips that are reduced later will likely not remodel as well as
those that are reduced earlier. f References 30, 53, 56, 151, 163, 199, 310, 335.
At times, an adductor tenotomy will increase the safe

zone by allowing for a wider range of abduction. However,
very wide abduction should not be used because this may
cause AVN. Excessive internal rotation may cause AVN. An
arthrogram obtained at the time of reduction is very helpful
for evaluating the depth and stability of the reduction. Ben-
son has shown that the information gained from an arthro-
gram often changes the treatment plan.149 The positions of
reduction and dislocation are noted on the arthrogram, and
a “live” observation of the reduction shows the depth of
reduction and the obstacles encountered. Some infolding or
blunting of the labrum after reduction is commonly noted,
as are the constriction of the capsule by the iliopsoas and the
presence of the ligamentum teres between the femoral head
and the acetabular wall. The width of the medial dye pool
on a standard AP radiograph indicates the likely stability of
the reduction and can be rated as good, fair, or poor.233 A
narrow rim of contrast agent indicates that the femoral head
FIG. 13.44 Portable home traction frame of PVC pipe. The “little is well seated and stable, and the reduction can be classified
red wagon” is an essential part of the treatment. as good. A fair reduction has a 5-to 6-mm dye pool and
is easily held reduced (Fig. 13.46). A poor reduction has a
medial space that is wider than 6 mm, and the reduction is
but to reduce the femoral head.199 This “traction reduction” difficult to hold (Figs. 13.47 and 13.48).
method involves immobilizing the child in bed and applying A number of factors help the clinician to determine
gradually increasing skin traction to bring the femoral head whether a hip is stable or unstable. In addition to range-of-
below the acetabulum. The hips are then gradually abducted motion considerations, there is a certain “feel” to the reduc-
and internally rotated until the hip is reduced. At this point, tion. A stable hip remains reduced throughout most of the
the traction is reduced, and a cast is applied. This approach range of motion of the hip and dislocates only in adduc-
often requires 6 or more weeks of in-hospital treatment and tion or extension. An unstable hip redislocates easily, and
results in little or no AVN. A similar approach reported from the examiner must continue lifting up the greater trochan-
Japan resulted in 92% of hips being reduced by traction over ter to maintain the reduction. If a reduction is difficult to
an average duration of 8 weeks; in this series, almost half of maintain, closed reduction should be abandoned, and open
children had residual subluxation at follow-up when they reduction can then be performed. The forceful mainte-
were older than 6 years old.328 A recent report from Japan nance of an unstable reduction is likely to cause AVN. In
detailed a similar traction-reduction method in which 72 many cases, the femoral head “reduces” to a stable posi-
hips were successfully reduced with an AVN rate of only tion at the entrance of the acetabulum, abutting the labrum
2.7%. and the iliopsoas but not actually making contact with the
acetabular medial wall. If stability can be maintained in a
Closed Reduction (Video 13.5) physiologic position, the hip may be immobilized, and it will
Closed reduction of the hip should be performed with the usually become well seated over a 6-week period.252 This
use of general anesthesia (see Plate 13.1 on page 472). The phenomenon was described in Severin’s classic 1941 article
inexperienced orthopaedist should be wary of this seemingly as well as by others, and our experience with this approach
simple procedure; the proper performance and interpreta- has also been successful.33,233,253,264
tion of the closed reduction is difficult and requires experi- Other authors believe that any widening of the joint is
ence. The hip is reduced by placing it in flexion beyond 90 unacceptable and that the femoral head should not be used as
degrees and gradually abducting it while gently lifting the a sound to dilate the acetabular opening.39,173,236,315 Leveuf
greater trochanter, as is done during the Ortolani maneuver. found that hips in which the labrum was pressed upward
Minimal force should be applied. After a palpable reduc- against the pelvis did well with closed reduction and that
tion is felt, the hip is examined to determine the stability those in which the labrum was inverted between the femo-
of the reduction. The flexed hip is adducted to the point ral head and the acetabulum required open reduction.168,169
of redislocation, and that position is noted. The hip is again If the reduction is deemed stable, the child is then
reduced and then extended until it dislocates, and the point immobilized in a spica cast in a safe and stable position. The
of dislocation is noted. If the hip requires internal rotation cast should maintain the hip in a position of more than 90
to maintain reduction, this is also noted. degrees of flexion and enough abduction to maintain the
The range of motion in which the hip remains reduced reduction. Some internal rotation may be used, but no more
is compared with the maximum range of motion. From this than 10 to 15 degrees, and never to the limit of internal rota-
information, a “safe zone” is constructed, as described by tion. Similarly, abduction to 30 or 40 degrees is acceptable
Ramsey and associates (Fig. 13.45).235 If the zone is rela- as long as further abduction is available. Abduction to the
tively wide, the reduction is considered stable. Alterna- limit of abduction should be avoided. An experienced per-
tively, if the hip is only stable in wide abduction or if more son should hold the hip in a proper position while the cast is
than 10 or 15 degrees of internal rotation is required to being applied. An effective technique to prevent excessive
maintain reduction, the reduction is considered unstable. abduction during cast application is to frequently abduct the
Point of redislocation
(adduction) Safe zone
Marginal
0 15° Marginal
30°
Redislocation on
Safe zone adduction
Aseptic necrosis on
maximal abduction
65°
Marginal
80°
90° Maximal abduction
Point of redislocation
A 0 Marginal
25°
35°
Safe zone
60° Marginal
65°
B
0 Point of redislocation
37° Safe zone

40°
Marginal
55°
58°
90°
Hip is flexed 90°
C Femoral head relocates
50° in acetabulum
Hip is flexed 50°
Femoral head dislocates
FIG. 13.45 Zones of safety. (A) Wide zone of safety. (B) Moderate zone of safety. (C) Narrow zone of safety. (D) Femoral head dislocates.
hips maximally and then return to a less abducted position reduction in a cast, as has MRI.293 With MRI, the vascular
to be certain of the position of the hips. status of the femoral head as well as the reduction can be
After the cast is applied, an intraoperative radiograph evaluated.320
is obtained. After the procedure, single-section computed After 6 weeks of immobilization, the cast is removed
tomography (Fig. 13.49) may be used to confirm the reduc- with the patient under anesthesia, and the hip is gently
tion.101,102 Ultrasonography has also been used to confirm examined for stability. No effort is made to dislocate the
A B
C D
E F
FIG. 13.46 Girl with left-sided developmental dysplasia of the hip. (A) Anteroposterior (AP) radiograph taken when the patient was 1 year
old shows left-sided developmental dysplasia of the hip. (B) Arthrogram obtained after 2 weeks of traction. In the “human” position, the
labrum is blunted, and the dye pool is 5-mm wide. (C) Arthrogram obtained with the hip in internal rotation shows better seating of the
femoral head. This would be classified as a fair reduction. (D) Arthrogram obtained at a cast change 6 weeks later shows better seating
of the femoral head with persistent blunting of the labrum. (E) AP radiograph obtained when the patient was 6 years old shows a well-
developed femoral head and acetabulum. (F) AP radiograph obtained when the patient was 15 years old shows well-developed hips.
hip, but stability is assessed by putting the hip through a Other clinicians accept a perfect closed reduction but rec-
moderate range of motion. An AP radiograph of the pelvis ommend an open reduction if there is any widening of the
is obtained, and, if the hip is reduced, a new cast is applied joint space between the femoral head and the acetabulum.
again with the hip in the human position. If there is any The more common approach is to accept closed reductions
question regarding reduction (either during the examination that are stable with mild to moderate widening of the joint
or on the radiograph), arthrography should be performed. and to perform open reductions for unstable hips and those
After 6 weeks, the second cast is also removed with the that are excessively wide on arthrography.
patient under anesthesia, and the surgeon must make a Open reduction can be performed from one of sev-
decision about the need for further immobilization. We usu- eral medial approaches or from an anterior approach. The
ally apply a third cast for another 6 weeks and discontinue medial approach is preferred by many surgeons because
immobilization at the end of that period. Others prefer to minimal dissection is required, and the obstructions to
begin abduction splinting after 12 weeks in a cast, and this reduction are encountered directly. The disadvantages of
approach may be equally efficacious. Prolonged abduction the medial approach are a limited view of the hip, the pos-
splinting has not proved efficacious, but the practice is rec- sible interruption of the medial femoral circumflex artery,
ommended in some centers. and the inability to perform a capsulorrhaphy. Others prefer
the anterior approach because it affords better exposure and
Open Reduction allows the surgeon to perform a capsulorrhaphy. The choice
The primary indication for the open reduction of DDH is a of a medial or anterior approach is also related to the pres-
failure to obtain a stable hip with a closed reduction. Fail- ence of ligamentous laxity that requires capsulorrhaphy, the
ure may be evident at the time of the initial closed reduc- patient’s age, and the surgeon’s training and experience.
tion, or it may become apparent when the hip redislocates
in the cast or at the time of a cast change (see Fig. 13.48). In Medial Approach
some centers, an open reduction is the preferred treatment Although the medial approach has been successfully used
method, and a closed reduction is usually not attempted. in children who are up to 3 years old, we recommend it for
children who are 1 year old and younger. This strategy is sup- a mean age of 17 months.215 In the older child, we pre-
ported by a long-term follow-up study that demonstrated fer an anterior approach, which allows a capsulorrhaphy to
that the mean age of patients with a good result from medial be performed.184,313 Although the anatomic details of the
open reduction was 9 months; those with poor results had medial approach are uncomplicated, the procedure itself
can become difficult because the exposed area is narrow,
and the child is often small and chubby (see Plate 13.2 on
page 474). The medial femoral circumflex vessels cross the
operative field and should be carefully retracted. A small
amount of bleeding from these vessels makes the operation
difficult because of the narrow exposure, and damage to the
vessels could produce AVN. In short, this is not an opera-
tion for the inexperienced surgeon. The iliopsoas is tran-
sected, and the hip capsule is incised to expose the joint.
The thickened and constricted medial capsule is often the
1
most important obstacle to reduction. The removal of the
2
3
FIG. 13.47 Example of a poor reduction. The femoral head is pre-

vented from entering the acetabulum by the narrowed hip capsule
FIG. 13.49 Computed tomography scan after a closed reduction;
beneath the iliopsoas. This causes the femoral head to compress
the patient is in a cast. Persistent dislocation of the hip is apparent
the labrum which further narrows the opening to the acetabulum.
on the scan.
1, Zona orbicularis; 2, infolded labrum; 3, ligamentum teres.
A B C
D E F
FIG. 13.48 A girl diagnosed with developmental dysplasia of the hip at the age of 21 months. After a period of skin traction, she under-
went a closed reduction. (A) Anteroposterior radiograph at the time of presentation showing a dislocated hip. (B) Intraoperative arthrogram
showing reduction of the hip with blunting of the labrum. (C) A perfusion magnetic resonance image scan taken with the patient in a spica
cast immediately after the hip was reduced. Blood flow to the head appears to be minimal. (D) A perfusion magnetic resonance image scan
taken after reapplication of the cast in less abduction and less internal rotation. Blood flow to the head is restored. (E) Follow-up radiograph
taken when the patient was 34 months old shows normal development of the femoral head and mild acetabular dysplasia.
ligamentum teres significantly increases the exposure and Anterior Open Reduction
allows for a deeper reduction of the femoral head. A radio- The anterior approach to the open reduction of the hip has with-
graph is obtained to assess reduction. If the head is not ossi- stood the test of time59,186 (Video 13.6; see Plate 13.3 on page
fied, a radiographic marker (e.g., a fine wire rolled into a 479). When this procedure is performed through an oblique
disk shape) may be placed over the femoral head to locate it and almost transverse incision (i.e., the “bikini” incision), the
more precisely on the intraoperative radiograph. cosmesis is excellent.244 Wider exposure of the hip is achieved
Some children less than a year of age may have a dis- as compared with the medial approach, but exposure of the
location in which the femoral head is quite high-riding. In depths of the acetabulum may be difficult, especially with a
these cases it may be impossible to bring the femoral head high dislocation. After the obstacles to reduction are removed,
down for a reduction when a medial approach is used. The a capsulorrhaphy should be performed to increase the stability
surgeon may evaluate reducibility with an attempted reduc- of the reduction. The procedure should not be attempted by
tion under anesthesia before an incision is made. When it anyone who has not had adequate training in the technique.
is difficult to bring the femoral head down to the level of A number of factors can make anterior open reduction dif-
the acetabulum, the anterior approach is preferred, because ficult. When the femoral head is well above the acetabulum,
the tension of the soft tissues can be relieved by sliding the the muscles around the hip are also displaced in a lateral and
abductors on the iliac wing. cephalic direction. Considerable dissection and retraction are
A variation of this approach involves the transection of necessary to expose the acetabulum. Many surgeons have mis-
the adductor longus and the iliopsoas and the evaluation taken the more easily exposed false acetabulum for the true
of the reduction with an intraoperative arthrogram. If the acetabulum and have thus failed to reduce the hip. A radio-
reduction is satisfactory, the operation is concluded. If the graph should be obtained after the femoral head has been
reduction is imperfect, the joint is opened to complete the reduced to confirm that the head abuts the triradiate cartilage.
reduction. One series reported successful reductions in 91% Before the radiograph is taken, the surgeon should remove the
of cases, with an AVN rate of 19.5%.20 Other authors have wedge from beneath the hip to level the pelvis; this is a step
reported the performance of open reduction with the mini- that allows for the more accurate evaluation of the reduction.
open release of the iliopsoas and the arthroscopic excision of If considerable force is required to reduce the hip and the
the ligamentum teres and the pulvinar.30 reduction seems tight, the surgeon should perform a shorten-
After the open reduction, we place the child in a below- ing femoral osteotomy to decompress the joint.
knee spica cast in the human position, with the hip in more After the hip is reduced and the capsulorrhaphy is per-
than 90 degrees of flexion and moderate abduction (i.e., formed, a spica cast is applied with the hip in an extended,
well short of maximal abduction). An intraoperative radio- abducted, and mildly internally rotated position. We apply
graph is obtained to confirm the reduction. A limited CT the cast to below the knee on the affected side and to above
or MRI scan after the procedure confirms the maintenance the knee on the contralateral side, and we incorporate a bar
of reduction. The MRI may be performed with contrast to between the legs.106 Bilateral open reductions may be per-
assess vascularity. The cast is changed after 6 weeks, and an formed during the same operative procedure by an expe-
above-knee cast is applied with the hip in the same posi- rienced surgical team, or the second hip may be operated
tion. Thereafter, some clinicians use abduction splinting for several weeks later. We have also used a high (above the nip-
another 3 to 6 months, depending on the development of ple line) cast for the first open reduction, and 2 weeks later
the acetabulum; however, the necessity of further splinting have performed the second side open reduction through a
remains controversial. wide window in the cast. When the procedure is complete,
Some authors have reported good results with the the entire cast is removed and a bilateral spica cast applied.
medial approach, with a less than 5% incidence of After the procedure, a limited CT is used to confirm
AVN.311 One report documents the rapid improvement the reduction. MRI and ultrasound may also be used to
of the acetabular angle over the course of the first year confirm the reduction of the hip in the spica cast.48,63
after operation, with gradual improvement to normal by MRI studies with perfusion may allow for the determi-
7 years after surgery.217 Others, however, have reported nation of femoral head vascularity in the postoperative
more frequent AVN, especially among older children, cast.283 After 6 weeks, the hip is examined with the
and they recommend that this procedure not be used for patient under anesthesia, and, if the reduction is satisfac-
patients who are older than 2 years. Reported rates of tory, a second cast is applied. Some surgeons use a spica
AVN after anteromedial open reduction have ranged from cast, whereas others use long-leg plasters with a bar to
0% to 66%.g Current reports have shown rates of AVN maintain abduction and internal rotation. These “Petrie
between 3.6% and 24%.h Novais reported AVN rates of casts” allow for flexion and extension and are used for 4
18.7% for medial open reduction and 19.6% for anterior to 6 more weeks. The choice between the two is based on
open reduction.210 Tarassoli found AVN in 12% of medial the perceived stability of the hip.
and 18% of anterior open reduction hips.278 The subse-
quent function of the iliopsoas muscle after lengthening Open Reduction With Femoral Shortening (Videos
has been evaluated. Although minor degrees of weakness 13.7 and 13.8)
have been documented, no functional deficits have been Femoral shortening should be considered when an open
reported.218,330 reduction has been performed and if excessive pressure is
placed on the femoral head when it is reduced (Figs. 13.50–
g References 50, 95, 171, 205, 260, 309, 321. 13.52) see also Plate 13.4 on page 486).79,246 It should also
h References 3, 7, 41, 70, 82, 118, 210, 278. be considered when a dislocated hip is reduced in a child
A B C
FIG. 13.50 Child with left-sided developmental dysplasia of the hip. (A) Anteroposterior (AP) radiograph obtained at presentation when
the patient was 2 years 3 months old shows a high dislocation of the left hip. (B) AP radiograph obtained after open reduction and femoral
shortening osteotomy. (C) AP radiograph obtained when the patient was 8 years 2 months old shows excellent acetabular development.
A B C
FIG. 13.51 Child with unilateral developmental dysplasia of the hip. (A) Anteroposterior (AP) radiograph obtained at presentation when
the patient was 8 years old shows a high dislocation of the left hip. (B) AP radiograph obtained after anterior open reduction and femoral
shortening. (C) AP radiograph obtained when the patient was 15 years old shows good hip development.
A B
C D
FIG. 13.52 A girl examined for excessive lordosis and found to have bilateral dislocation of the hips. (A) Anteroposterior (AP) radiograph ob-
tained at presentation when the patient was 6 years 7 months old shows bilaterally dislocated hips. (B) AP radiograph obtained after staged
open reductions, femoral shortenings, and Salter innominate osteotomies. Both hips are reduced. Note the widened teardrop body on the
right, which may portend a poor long-term prognosis. (C) AP radiograph obtained 4 years after reduction. The teardrop body remains wide
on the right. (D) AP radiograph obtained 10 years after reduction, when the patient was 16 years old. Acetabular development is better on
the left than on the right. Note the valgus deformity of the femoral head on the neck bilaterally, probably as a result of early lateral physeal
closure. The valgus reduces the coverage of the hip; when this is recognized early, it may be an indication for varus femoral osteotomy. This
patient subsequently had a periacetabular osteotomy on the right side.
who is older than 2 years. One way to assess the tightness reduction. If the acetabular coverage is insufficient, a pelvic
of the reduction is to attempt to distract the femoral head osteotomy should be performed. The Salter and Pemberton
away from the acetabulum after reduction. If the reduction procedures are the most commonly used techniques, and
is safe, the surgeon should be able to distract the joint a few they are usually successful, with little additional operative
millimeters without much force. We prefer to perform the time or morbidity. Children who are older than 3 years at
shortening through a separate lateral incision. A blade plate reduction usually need an acetabular procedure to cover the
or a simple lateral plate fixation may be used with an inter- femoral head adequately.144,145,318
trochanteric or subtrochanteric osteotomy (see Plate 13.5 A potential complication when combining an acetabular
on page 487). procedure with a femoral shortening procedure is the pos-
In the past, femoral osteotomies were also used to reduce terior dislocation of the hip. Dislocation is most likely to
anteversion and to place the femoral neck into a varus posi- occur when the femur is derotated. During surgery, how-
tion. However, we have not found excessive anteversion ever, there is usually little increase in true anteversion. Thus
or valgus of the upper femur to be common; therefore we derotation is unnecessary, and it may predispose the hip to
do not usually do either derotation or varus correction. A posterior dislocation if it is performed.
follow-up study by Spence and colleagues showed better Current results in older children are encouraging com-
acetabular development in patients after innominate oste- pared with outcomes obtained in the past, when complica-
otomy as compared with varus derotational osteotomy.262 tions were frequent. Good results with femoral shortening
A reduction of anteversion in combination with innominate and acetabular procedures have been reported in 66% to
osteotomy may result in the posterior dislocation of the 88% of children, with low rates of AVN.79,246,332
femoral head. There is some debate regarding the upper age at which a
successful reduction can be carried out (see Figs. 13.51 and
Open Reduction With Innominate Osteotomy 13.52). The guidelines differ for unilateral and bilateral hip
An innominate osteotomy may be indicated at the time of dislocations because gait asymmetry and function are more
an open reduction, especially in children who are 18 months markedly affected in patients with unilateral dislocations.
old or older. The surgeon can assess the need for added cov- However, the complication rate is considerably higher when
erage by noting the degree of acetabular coverage of the both hips must be reduced. For unilateral dislocations, reduc-
femoral head when the hip is placed in extension and neu- tion is probably reasonable for children who are up to 9 or 10
tral rotation and abduction. If more than one-third of the years old if there is reasonable acetabular development. For
head is visible in this position, an innominate osteotomy will bilateral dislocations, the results are frequently unsatisfactory
provide better hip coverage. among children who are older than 8 years. The rationale for
In some centers, most children who are older than 18 not treating the child after the age of 8 years is that, in most
months undergo a concomitant innominate osteotomy at cases, the natural outcome of untreated bilateral dislocations
the time of reduction, whereas other surgeons prefer to per- is likely to be better than the results of the reduction of both
form acetabular augmentation (if necessary) when the child hips. It should be noted that some authors have reported sat-
is older. We perform an innominate osteotomy in patients isfactory results in patients who are older than 8 years old
who are older than 18 months, primarily when coverage is at treatment. Zhao and colleagues from China report one-
in doubt; it is used in probably two-thirds of these cases. stage treatment with open reduction, femoral shortening
We prefer the Salter innominate osteotomy, whereas others and derotation, and pelvic osteotomy for an older group of
choose the Pemberton or another periacetabular procedure. patients. In patients over age 10.5 at treatment they report
Whichever procedure is used, it is important to place the 54% excellent and 33% good results for bilateral cases, and
osteotomy high enough to avoid injury to the cartilaginous 57% excellent and 28% good results for unilateral cases. They
margin of the acetabulum, which is a major growth center for emphasize three-dimensional CT scanning of femur and pel-
the acetabulum. If there is undue tension on the reduction, a vis to obtain hip congruity.334 Ok and co-workers reported
concomitant femoral shortening should be considered. on nine patients (including two with bilateral dislocations)
who were treated at an average age of 11 years.214 Treatment
consisted of open reduction, femoral shortening, varus oste-
Treatment of the Older Child (2 Years Old and
otomy, and, in some cases, Chiari pelvic osteotomy. Eight
Older)
of the nine patients recovered nearly full range of motion
Treatment of children who are between 2 and 6 years old without pain, and one redislocated. El Tayeb reported on 19
with hip dislocation is more challenging. The femoral head patients who were older than 8 years old with hips that were
is usually in a more proximal location in the older child, treated with one-stage reduction; good results were reported
and the muscles that cross the hip are more severely con- in 84%, with 16% considered fair or poor according to Sev-
tracted. Femoral shortening is an essential part of the man- erin criteria.65,144
agement of the older child, and, with higher dislocations,
greater shortening is necessary. In the past, long periods of
skeletal traction were used in this age group, but femoral Complications and Pitfalls
shortening has produced better results with less morbidity. Avascular Necrosis
In addition, the older child is more likely to need a primary
acetabular reorienting osteotomy (e.g., a Salter or Pember- Etiology
ton procedure). AVN is a major cause of long-term disability after the treat-
For children who are between 2 and 3 years old, the sur- ment of DDH. It is a problem that is directly associated
geon should evaluate the stability of the hip during the open with treatment; careful technique should prevent the more
serious varieties of AVN. AVN occurs when excessive pres- hip are so contracted that they compress the reduced fem-
sure is applied for an extended time to the femoral head, oral head against the acetabulum. AVN can be prevented
thereby occluding its vascular perfusion. The most common by avoiding extreme positions and by performing femoral
cause is immobilization in a position that places excessive shortening when the reduction is too tight. Traction has been
pressure on the femoral head, such as extreme abduction or effective in reducing the tightness of the hip musculature.
internal rotation. Internal rotation increases pressure on the
femoral head, and it may also contort the capsular vessels. Diagnosis
In addition, AVN may occur when the muscles crossing the AVN is diagnosed when the femoral head fails to ossify or to
grow within 1 year after being reduced. Other findings that
indicate the presence of AVN are the widening of the femo-
ral neck within 1 year of reduction, changes in the bone
ATD L density of the femoral head, and residual deformity that
suggests growth disturbance.245 The unique anatomy of the
R proximal femur in the young child allows complex changes
to occur if growing areas are injured. Before the ossification
of the femoral head, the entire upper femur is one cartilagi-
nous structure that includes the greater and lesser trochan-
ters as well as the femoral head. The avascular insult may
involve only a part of the upper femoral segment, or it may
affect the entire femoral epiphysis. The greater trochanter
is not affected by AVN, and it will continue to grow when
capital epiphyseal growth is arrested (Fig. 13.53).
Classification
There are several classification systems for AVN, with the
FIG. 13.53 Diagram showing the upper end of a normal femur. In Bucholz-Ogden system being the most widely used.31 With
the normal hip, the distance (length [L]) from the greater trochant- type I AVN, changes are limited to the femoral head, and the
er to the center of the femoral head is two times the radius of the metaphysis is not involved (Fig. 13.54). These hips usually heal
head (L = 2 × R). The tip of the greater trochanter is at or slightly without significant growth disturbance, and their outcome is
below the center of the femoral head. The articulotrochanteric not compromised. The hallmark of this type is the irregular
distance (ATD) normally measures 10 to 25 mm. ossification of the femoral head, with no abnormalities of the
PS PS PS
PI PI PI
A 2 months 1 year 9 years
B 2 months 1 year 9 years

FIG. 13.54 (A) The normally developing hip in a patient at 2 months, 1 year, and 9 years of age. PS represents the posterosuperior branch
of the medial femoral circumflex artery; PI is the posteroinferior branch. Closed arrows indicate normal blood flow from the posterosuperior
and posteroinferior vessels. (B) A hip with a Bucholz-Ogden type I pattern of ischemic necrosis at the same ages showing irregular ossifi-
cation in the capital femoral epiphysis without subsequent growth disturbance. Dashed lines indicate normal conformation. Open arrows
indicate temporary blood flow disturbances.
Metaphyseal
changes
FIG. 13.55 Bucholz-Ogden type
II pattern of avascular necrosis at
2 months, 1 year, and 9 years of
age. The ischemic event probably
occurs laterally (open arrows), and
there is lateral epiphyseal closure,
Osseous which produces a valgus deformity
bridge
of the head on the neck of the fe-
mur. Dashed lines represent normal
development. Closed arrows repre-
2 months 1 year 9 years sent the site of growth arrest.
reflects changes that are confined to the ossific nucleus,

grade 2 involves the lateral growth plate, grade 3 involves
the central physis, and grade 4 indicates total physeal and
head injury. A comparison of the Kalamchi-MacEwen and
Bucholz-Ogden systems shows that Kalamchi- MacEwen
grade 1 is the same as Bucholz-Ogden type I; Kalamchi-
MacEwen grade 2 is the same as Bucholz-Ogden type II;
and Kalamchi-MacEwen grade 4 is the same as Bucholz-
Ogden type III (Table 13.4).
A Other Manifestations of Avascular Necrosis
A disturbing late abnormality that may be a manifesta-
tion of AVN is the closure of the lateral portion of the
capital femoral growth plate during adolescence. Closure
can occur in a hip that has shown no early evidence of
a vascular insult, and the true etiology is unclear. Often
the femoral head, which has been relatively well cov-
ered by the acetabulum, appears to gradually drift lat-
erally.138,181,198,332 Radiographs obtained during the
early teen years show early closure of the lateral por-
tion of the growth plate, with progressive valgus tilting
B of the femoral head on the metaphysis. The inclination
of the epiphyseal plate becomes more horizontal or even
FIG. 13.56 Bucholz-Ogden type II lateral avascular necrosis after
reverses its tilt over time.138,181,198,332 When this occurs,
closed reduction. This occurred after traction when the patient was
progressive dysplasia of the hip may follow. Corrective
2 months old that was followed by 3 months in a spica cast. (A)
When the patient was 2 years old, early lucency can be seen in the treatment options include varus femoral osteotomy and a
metaphysis. (B) When the patient was 4 years old, valgus tilt and redirectional acetabular procedure (e.g., a triple innomi-
uncovering are seen because of lateral growth arrest as a result of nate osteotomy). If this complication is recognized early,
avascular necrosis. the surgeon could consider some form of arrest of the
medial portion of the growth plate, but this has not been
described to date.
ossification of the metaphysis. An early growth arrest line may In the normal hip, the tip of the greater trochanter is
indicate the symmetric growth of the metaphysis, which sug- slightly distal to or level with the center of the femoral
gests that no growth injury has occurred.211 With type II, the head. The relationship of the femoral head to the trochan-
lateral metaphysis shows evidence of injury, and the femoral ter can be measured radiographically as the articulotro-
head will grow into a valgus deformity after premature lateral chanteric distance, the value of which becomes negative
epiphyseal closure (Figs. 13.55 and 13.56). With type III, the when the trochanter is proximal to the upper portion of
entire metaphysis is affected, and the femoral neck will be the head of the femur (see Fig. 13.53).64 The relative
extremely short, with marked trochanteric overgrowth (Figs. height of the greater trochanter and the length of the
13.57 and 13.58). With type IV, a radiolucent defect along femoral neck determine the biomechanical function of the
the medial metaphysis may be seen early, thereby indicat- gluteus medius and minimus muscles. As explained by the
ing a growth disturbance of the medial growth plate that will Blix curve, muscle fiber tension is proportional to muscle
cause the femoral head to grow into a varus deformity (Figs. fiber length at the moment of excitation.23 When a muscle
13.59 and 13.60). With types II, III, and IV, there is relative fiber is shortened to less than 60% of its resting length, its
overgrowth of the greater trochanter that in time may result contractile force is lost. In the hip, when the tip of the tro-
in an abductor limp. chanter reaches the level of the femoral head, the abduc-
Another classification of AVN is that developed by tor muscle tension is altered, and the patient will usually
Kalamchi and MacEwen.125 In their system, grade 1 develop an abductor limp.157
FIG. 13.57 Bucholz-Ogden type III avascular

necrosis at 2 months, 1 year, and 9 years of
age. The ischemic effect is noted across the
entire physis (open arrows), with disturbance
of the complete growth of the epiphysis.
Dashed lines indicate normal anatomy; closed Metaphyseal changes
arrows indicate metaphyseal changes. 2 months 1 year 9 years
A B
C D E
FIG. 13.58 Bucholz-Ogden type III severe central avascular necrosis in a boy who was treated elsewhere with closed reduction and casting
without traction when he was 2 months old. (A) Anteroposterior (AP) radiograph obtained when the patient was 11 months old shows
central metaphyseal lucency (arrow) and fragmentation of the femoral head, which indicate extensive avascular necrosis. (B) Frog-leg lateral
radiograph obtained when the patient was 11 months old shows central metaphyseal lucency (arrow). (C) AP radiograph obtained when
the patient was 21 months old shows extensive metaphyseal change (arrow), which is indicative of avascular necrosis. (D) AP radiograph
obtained when the patient was 8 years old shows a short femoral neck with early trochanteric overgrowth. This is an appropriate age for
trochanteric epiphysiodesis. (E) AP radiograph obtained when the patient reached maturity shows trochanteric overgrowth.
Another factor that contributes to the abductor limp is Interventions to Alter the Effects of Avascular Necrosis
the shortening of the femoral neck. The effectiveness of Some of the anatomic effects of AVN can be altered by
the abductor muscles is decreased as the lever arm (i.e., the appropriate intervention. Procedures include trochanteric
femoral neck) shortens. In addition, the direction of pull epiphysiodesis, trochanteric advancement, intertrochan-
of the abductors is steeper when the femoral neck is short- teric double osteotomy, and lateral closing wedge valgus
ened, which also decreases their function.225 osteotomy with trochanteric advancement.
Metaphyseal
changes FIG. 13.59 Bucholz-Ogden type
IV avascular necrosis at 2 months,
1 year, and 9 years of age. The
primary ischemia occurs medially
(open arrow), thereby producing
early closure of the medial portion
of the physis with resultant growth
Osseous into a varus deformity. Dashed
bridge lines indicate normal anatomy.
Closed arrows indicate intact blood
2 months 1 year 9 years supply.
A B C
FIG. 13.60 Bucholz-Ogden type IV medial avascular necrosis, with late varus developing in the untreated hip. The child underwent treat-
ment of the left hip with traction and closed reduction when he was 4 months old, and this was followed by abduction splinting. The
following findings were noted in the right hip, which was initially normal. (A) When the patient was 3 years old, an irregularity of the medial
portion of the physis was noted. (B) When the patient was 12 years old, the femoral head was tilted into a varus position relative to the
femoral neck. (C) When the patient was 18 years old, the varus tilt of the femoral head had increased. The patient had no symptoms. The
long-term significance of this abnormality is unknown.
Trochanteric Epiphysiodesis
Table 13.4 Classification Systems of Avascular Necrosis
of the Proximal Femur. Relative trochanteric overgrowth can be prevented by per-
Degree Characteristics
forming a trochanteric epiphysiodesis at the appropriate
time (see Plate 13.6 on page 491). This procedure should
Bucholz-Ogden System be performed when major AVN is recognized and the ossific
Type I Irregular ossification nucleus of the greater trochanter is present. Studies have
Femoral head only shown this procedure to be most effective if it is performed
Normal growth
when the child is approximately 5 years old; it has been
found to be ineffective if it is performed when the child is
Type II Lateral head and metaphysis much older than 8 years old.78,115,157 A recent report rela-
Caput valgus during adolescence tive to Legg Perthes showed partial effectiveness of trochan-
teric arrest in children between 8.5 and 10 years of age.140
Type III Whole head and metaphysis
Our preferred technique is to, under direct vision, ablate
Short femoral neck the physis of the trochanter through a small incision using
Trochanter high image intensification.
Type IV Medial head and metaphysis Trochanteric Advancement
Kalamchi-MacEwen System Trochanteric advancement may be considered when an
Grade 1 Head only objectionable abductor limp results from trochanteric over-
Normal development growth (Fig. 13.61; see also Plates 13.7 and 13.8 on pages
Grade 2 Lateral head and metaphysis 497 and 504). The surgeon should consider a trochanteric
transfer when the greater trochanter has reached the level
Caput valgus during adolescence
of the top of the femoral head; when there is a congruous
Grade 3 Central head and metaphysis and concentric reduction of the hip; when the Trendelen-
Grade 4 Whole head
burg sign can be elicited; and when the child is older than
8 years.19,173,180 Significant subluxation or dysplasia of the
Short neck
hip causes a similar limp, and trochanteric advancement in a
Trochanter high dysplastic hip will not improve the patient’s gait.
short302 (see Plate 13.9 on page 506). A double osteotomy

of the femoral neck is performed with the use of a portion
of the base of the trochanter to elongate the femoral neck.
This operation creates several moving parts and requires
excellent fixation by an experienced hip surgeon.
Lateral Closing Wedge Valgus Osteotomy With
Trochanteric Advancement
Coxa vara with trochanteric overgrowth may also be cor-
rected with a valgus osteotomy at the intertrochanteric level
in combination with a trochanteric transfer (see Plate 13.10
on page 508). A lateral closing wedge osteotomy is per-
formed at the base of the greater trochanter and combined
with a trochanteric osteotomy. The osteotomy site is closed
by aligning two Kirschner wires, whereas the neck–shaft and
A greater trochanteric fragments are aligned and fixed with a
prebent trochanteric hook plate.
Inadequate Reduction and Redislocation

In current practice, the most common complication related
to the management of DDH is the failure to obtain and main-
tain the reduction. After closed reduction, single-section
CT is helpful for assessing the reduction while the hip is in
the cast. Failure to maintain the reduction is not in itself a
major complication, but failure to recognize the unreduced
hip guarantees a poor result. If the hip has redislocated, a
second attempt at reduction with the patient under anes-
thesia should be promptly carried out. A repeated attempt
at closed reduction is occasionally successful, but the sur-
geon should be prepared to perform an open reduction if
the hip is not stable.
B A more difficult situation arises when the hip is not well
FIG. 13.61 Avascular necrosis of the left femoral head with result- reduced after an open reduction. Most often, the surgeon
ant coxa breva and relative overgrowth of the greater trochanter has not adequately exposed the acetabulum to obtain a
treated by distal and lateral advancement of the greater trochanter. deep reduction initially. The intraoperative radiographs are
(A) Preoperative anteroposterior radiograph of both hips showing often misread, and what appears to be minor widening of
the short femoral neck, coxa vara, and relative overgrowth of the the space between the femoral head and the acetabulum is
greater trochanter. The patient has a marked gluteus medius lurch often the difference between a well-reduced hip and a hip
and a 4-cm shortening of the femur. (B) Postoperative anteropos- that remains dislocated. A repeated attempt at open reduc-
terior radiograph of the hips showing the apparent elongation of
tion is usually necessary after redislocation, although, in cer-
the femoral neck after greater trochanteric transfer. (From Kelikian
tain circumstances, a closed reduction may be successful.
AS, Tachdjian MO. Greater trochanteric advancement. In: The Hip
Society Awards Papers. St. Louis, MO: Mosby; 1983.) The wise surgeon will seek an experienced assistant before
repeating the procedure. The hip in which open reduction
has failed is difficult to treat, especially if there is a great
Wagner recommended lateral (as opposed to distal) deal of scarring or if much time has passed since the reduc-
transfer of the greater trochanter when the neck is short tion. Reported series find that only one-third to one-half of
and when the trochanter has not grown above the femoral these cases have acceptable results, and the rate of AVN can
head.302 The indications again include an abductor limp and be as high as 44%.28,53,128,185
a congruous hip reduction. Occasionally a hip that has been well reduced and immo-
In several reports, the abductor limp either improved bilized for an appropriate time redislocates or, more com-
or resolved in most patients who underwent a trochanteric monly, becomes subluxated. If there is significant widening
advancement procedure.134,277,302 However, the results of of the joint, an open reduction and capsulorrhaphy will
trochanteric advancement are frequently unsatisfactory if probably be necessary. In some cases, the subluxated hip
there is residual hip dysplasia.173 The surgeon should realize responds to prolonged splinting, and this may be a treat-
that it is often difficult to advance the trochanter as far as ment option if the hip is concentrically reduced. If the hip
would be ideal and that fixation is sometimes inadequate. is dislocated, an open reduction is necessary.
Intertrochanteric Double Osteotomy
Residual Acetabular Dysplasia
Wagner described a procedure to improve the function of
the hip when the trochanter is markedly overgrown and After the reduction of a dislocated hip, the acetabulum
abutting the pelvis and when the femoral neck is very begins to remodel in response to the pressure exerted by the
σ max 18.0 σ max 22.9

kp/cm2 kp/cm2
A B
σ max 49.4 σ max 225.0

kp/cm2 kp/cm2
FIG. 13.62 Magnitude of joint pressure in rela-

tion to the extent of area transmitting the load.
Drawings show the gradual increase in articular
pressure with progressive subluxation of the hip.
C D (A) Normal hip. (B–D) Gradual subluxation. Note
the increased pressure across the joint.
femoral head (Fig. 13.62). Usually this results in the grad- reduction if the hip is reduced before the patient is 4 years
ual deepening of the acetabulum and the reduction of the old.170 There is good evidence that if, after treatment of
obliquity of the acetabular roof. Many times, however, this the dislocation, acetabular obliquity is still present when
process is incomplete, and the acetabulum remains shallow the patient is 5 years old, further acetabular development
and the roof inclined. The development of the sourcil or will be inadequate. Thus if significant dysplasia persists until
“eyebrow” is a reliable indicator of acetabular development the age of 5 years, a pelvic osteotomy should be performed
(see Fig. 13.69B). Often the acetabular roof appears to pro- to ensure the adequate development of the hip. Some
vide adequate femoral head coverage even if the sourcil is authors recommend a varus- derotational femoral osteot-
oblique and shallow. True coverage of the femoral head is omy in younger patients with acetabular dysplasia.24,132,197
represented by the position of the sourcil rather than by the A study by Spence and associates showed better acetabu-
apparent acetabular roof. The widening of the joint by more lar results with Salter osteotomy as compared with femoral
than 6% has been shown to be predictive of the failure of osteotomy.262
acetabular development in 4-and 5-year-old children, and
an up-sloping sourcil was a predictor of future dysplasia.137
Acetabular Dysplasia Presenting Late
Albiñana and others noted that 80% of hips with an acetabu-
lar index of 35 degrees or more 2 years after reduction had A number of patients present with hip complaints during ado-
a poor outcome.5 lescence. Some of these patients have a history of the treat-
Early reports stated that acetabular development was ment of hip dislocation, but many are unaware of any prior
completed by 18 months of age.241 Others have found that hip problems. The affected patient complains of aching pain;
the acetabulum continues to develop for up to 8 years after this may be either pain in the groin (indicating pain coming
A B
FIG. 13.63 False-profile radiographs. (A) The right hip demonstrates the lack of anterior coverage of the femoral head. The ventral center–
edge angle measures −5 degrees. (B) The left hip demonstrates a near-normal ventral center–edge angle with good anterior femoral head
coverage.
from the hip joint) or lateral hip pain (usually indicating lat- of the hip is best documented by comparing the distance
eral abductor fatigue pain). The pain is worse with exertion from the medial acetabular wall to the femoral head on the
and long periods of walking or standing, and it may result involved and uninvolved sides. A subluxated femoral head
in a decrease in activity. The patient limps when he or she is displaced proximally as well as laterally, and the Shenton
is tired or uncomfortable. After these symptoms start, they line is broken. Degenerative disease is indicated by the pres-
usually increase steadily in frequency and severity, often over ence of sclerosis and cyst formation on both sides of the
a relatively short time. The physical findings are usually mini- joint and the narrowing of the cartilage joint space. Osteo-
mal. Some patients have a Trendelenburg limp or a delayed phyte formation is a late manifestation of degenerative dis-
Trendelenburg sign, and there may be some discomfort at the ease. Any of these abnormalities may be present separately
extremes of hip motion. The surgeon should be alert to signs or in combination with one another.
of snapping or popping, which may be caused by a tear in the The treatment strategy is based on whether the hip
labrum. More commonly, degeneration of the labrum is pres- can be concentrically reduced. This is first assessed radio-
ent as a result of overload from a deficient bony acetabular graphically with the patient supine and the hip abducted
coverage. In these situations, the pain is exacerbated when and internally rotated. If the femoral head can be reduced
the hip is maximally flexed, internally rotated, and adducted against the medial acetabular wall, a redirectional procedure
(i.e., the impingement test). Gadolinium- enhanced MRI is recommended. These procedures reorient the acetabulum
arthrography may demonstrate labral pathology.167 When so that the femoral head is better covered with acetabular
there is a labral tear, an arthrotomy is necessary, and the torn articular cartilage. If concentric reduction is not possible,
portion is debrided or excised. a salvage procedure in which the femoral head is not cov-
The radiographic assessment should include a stand- ered by preexisting articular cartilage is indicated. There
ing AP pelvic radiograph, an abduction–internal rotation are intermediate cases that do not appear to be reduced on
view, and false-profile radiographs of the hip. The abduc- the abduction–internal rotation radiograph but that may
tion–internal rotation view should demonstrate a concen- be reduced as part of the surgical procedure. For example,
tric reduction of the hip, which indicates that a rotational these hips may be reduced with a femoral redirectional pro-
acetabular procedure is appropriate. The false-profile radio- cedure or even an open reduction and then covered with a
graph is performed in a way that is similar to a standing redirectional acetabular procedure.
lateral radiograph of the hip. However, the unimaged hip is When acetabular dysplasia is detected and the patient
rotated 25 degrees out of the plane to allow for full visual- is asymptomatic, the treatment decision is difficult. If a
ization of the involved acetabulum. From the false-profile repositioning procedure will restore near-normal acetabular
radiograph, the anterior acetabular coverage is assessed with alignment, we recommend performing such a procedure in
the use of the ventral center–edge angle, which should be the absence of symptoms, with the goal of preventing future
more than 25 degrees (Fig. 13.63). In addition, the width of degenerative disease. This decision is based on the high like-
the posterior column of the acetabulum can be assessed in lihood that the patient will later develop symptoms and on
preparation for a periacetabular osteotomy. On the AP pel- the evidence that better acetabular coverage—preferably
vic radiograph, it is important for the surgeon to specifically while the child is still growing—allows the hip to remodel.
distinguish among dysplasia, subluxation, and degenerative Alternatively, a salvage procedure is usually not indicated if
disease. Acetabular dysplasia is defined by a loss of concav- the patient has no symptoms. These procedures are usually
ity of the acetabular roof, an excessive lateral inclination of recommended only when the patient has significant symp-
the roof, and a widening of the teardrop body. Subluxation toms that interfere with activities.
Procedures such as the Salter innominate osteotomy and Table 13.5 Pelvic Osteotomy for Developmental
the Pemberton osteotomy are used for dysplastic hips that Dysplasia of the Hip.
are concentrically reduced in children who are younger than
8 or 9 years old. Greater improvement in acetabular coverage Type of Osteotomy Comments
may be achieved with a Pemberton or Dega procedure. With With Concentric Reduction
these procedures, there is a possibility of reducing the size Younger than 8 yr old
of the acetabulum to a degree that will cause impingement
on the femoral head.174,222 In older children and adolescents, Salter Redirects acetabulum
the acetabulum must be displaced to a greater degree to pro- Pemberton Restructures acetabulum,
vide coverage of the hip. Procedures that are used for this slight decreased volume
age group include the Steel triple pelvic osteotomy,265,266 the
Sutherland double osteotomy,270 the Ganz osteotomy,80 the 8–15 yr old (triradiate open)
Tönnis procedure,286,288 and the Dega osteotomy.275 When Triple innominate (Steel) Greater redirection of acetabu-
the triradiate cartilage is open, we prefer a triple innominate lum
osteotomy (either Steel or Tönnis). However, for adolescent
Triple innominate, Tonnis Greater acetabular mobility
and young adult hip dysplasia, our preferred osteotomy is the
Ganz (Bernese) periacetabular osteotomy because it provides Dega Produces lateral and posterior
the greatest ability for acetabular correction while limiting acetabular coverage
the surgical and soft tissue dissection. Spherical osteotomies Older than 15 yr old
as described by Wagner and Eppright and others may be used (triradiate closed)
to cover severely dysplastic hips.66,191,301,303 However, these
procedures are technically very difficult to perform, and they Triple innominate Greater redirection of acetabu-
lum
are sometimes complicated by the inadvertent penetration of
the acetabulum by the osteotomy. In addition, the acetabular Ganz (Bernese) Maximum acetabular redirec-
fragment depends on the hip capsule for its vascular supply, tion; achieves stable pelvis;
and acetabular AVN may develop after a spherical osteotomy. difficult
Hips that cannot be concentrically reduced may be Spherical (Wagner, Eppright, Maximum acetabular redirec-
improved with the use of procedures that cover the fem- Ninomiya) tion; difficult
oral head with structures that will become fibrocartilage.
Without Concentric Reduction
The Chiari osteotomy and the shelf procedure are two such
Shelf (Staheli)
approaches.57,263 For both procedures, the femoral head is
covered with a layer of hip capsule that is buttressed by Chiari
bone. The Chiari osteotomy accomplishes this by displac-
ing the femoral head medially beneath a pelvic osteotomy,
whereas the shelf procedure adds bone laterally over the The osteotomy begins anteriorly at the anterior inferior iliac
head. After either procedure, the hip capsule undergoes spine and proceeds posteriorly and inferiorly to enter the
gradual metaplasia to fibrocartilage, and the overlying bone triradiate cartilage posterior to the acetabulum. The path of
hypertrophies and remodels to conform to the femoral the osteotome is controlled with image-intensified radiog-
head. Because it moves the hip medially, the Chiari oste- raphy. As the osteotomy is opened, the acetabular fragment
otomy is believed to improve the biomechanics of the hip. is pried into an anterolateral position and held there with
a bone graft. This osteotomy is quite stable and does not
require fixation. The osteotomy hinges through the triradi-
Reconstructive Procedures for Dysplasia ate cartilage, which reduces the volume of the acetabulum
Simple Pelvic Osteotomies That Reposition the and makes this procedure especially appropriate for cases in
Acetabulum which the acetabulum is capacious. At the same time, this
operation is contraindicated if the acetabulum is small rela-
Most of these pelvic osteotomies can be performed through tive to the size of the femoral head. In such cases, the pro-
a bikini incision and an anterior tensor–sartorius interval cedure may prevent the proper seating of the femoral head.
approach as described by Salter (Table 13.5).241 This inci- A potential complication of the Pemberton osteotomy is the
sion results in minimal scarring. Because the traditional premature closure of the triradiate cartilage caused by the
Smith-Petersen skin incision leaves a wide and deep scar osteotomy’s passage through the triradiate cartilage.209 This
and offers no better exposure, the procedure should be complication has been reported, but it is extremely rare.
abandoned. Cast immobilization after these procedures Another possible complication of the procedure is damage
depends on the stability of the fixation and the patient’s to the acetabular growth centers caused by an osteotomy
age. Casts are used after all osteotomies in which an open that is made too close to the acetabulum.
reduction has been performed and in most children who are
younger than 7 years old. Salter Innominate Osteotomy (Video 13.10)
Salter initially recognized the anterolateral deficiency of the
Pemberton Osteotomy (Video 13.9) acetabulum in patients with DDH and proposed correcting
The Pemberton osteotomy repositions the acetabulum to the deficiency with a pelvic osteotomy that displaces the
improve the anterior and lateral coverage of the femoral acetabulum in an anterolateral direction (see Plate 13.12
head (Fig. 13.64); see Plate 13.11 on page 512).68,228,279,300 on page 520; Fig. 13.65 and Fig. 13.66).241,242,243 The first
A B
C D E
FIG. 13.64 Results of the Pemberton osteotomy in a 16-month-old girl who presented with a limp. (A) Anteroposterior (AP) radiograph
showing acetabular dysplasia in the left hip. The patient underwent a closed reduction after several weeks of home traction. (B) AP radio-
graph obtained when the patient was 5 years old shows persistent acetabular dysplasia. (C) Radiograph obtained 6 weeks after the perfor-
mance of the Pemberton osteotomy. (D) AP radiograph obtained 6 months after the Pemberton osteotomy. (E) AP radiograph obtained 3
years after surgery showing good acetabular coverage.
prerequisite for the procedure is that the hip be concentri- cover the femoral head adequately. It has been reported that
cally reduced. When the hip is not well reduced, the sur- the acetabular angle will be improved by an average of 10
geon must first obtain a concentric reduction. If the hip is degrees with the use of the Salter osteotomy.200,292 Older
subluxated, simply placing the hip in abduction and internal children should undergo a complex osteotomy, especially
rotation may reduce the hip. If the hip does not concentri- when the dysplasia is severe.
cally reduce, an open reduction is necessary. If a concentric The hip is approached through a bikini incision that leads
reduction is not achieved, the osteotomy will be of no ben- to the tensor–sartorius interval. The rectus femoris origin
efit to the child. During the early years after Salter’s initial is identified, and both the inner and outer tables of the
report, many surgeons failed to observe this vital point. As a iliac wing are exposed. A straight osteotomy is made with a
result, many children underwent “Salters” in which the hip Gigli saw from the anterior inferior iliac spine to the sciatic
remained dislocated and the long-term outcome was very notch. The acetabular portion is displaced in an anteroin-
poor. The reduction of the hip must be perfect: any compro- ferior direction with the use of traction on a bone clamp
mise ensures failure. placed over the acetabulum. The displacement may be facil-
The indications for the Salter osteotomy are acetabular itated by placing the patient’s leg into a figure-four position
dysplasia that persists after primary treatment and acetabu- when the capsule is intact. The displacement is fixed by
lar dysplasia discovered in an untreated child. The failure placing a triangular bone graft taken from the anterior supe-
of the acetabular angle to improve within 2 years after rior iliac spine area into the osteotomy and fixing it there
reduction and persistent dysplasia after the age of 5 years with threaded pins or screws. When properly displaced, the
are definite indications for the procedure. Young children osteotomy is closed at the sciatic notch, with the distal frag-
with acetabular dysplasia are asymptomatic and function ment anteriorly displaced a few millimeters on the proximal
normally, which makes the decision to perform surgery fragment. If the osteotomy remains open posteriorly, the
difficult. However, the likelihood of degenerative disease acetabulum will not be correctly repositioned.
without treatment is high, and the treatment is effective. The Salter osteotomy increases the tension on the mus-
Thus children who meet the indications should undergo an cles that cross the hip anteriorly, and it mildly increases the
osteotomy. The Salter osteotomy is appropriate for chil- limb length. The iliopsoas is routinely lengthened with an
dren who are between 2 and 9 years old. Children who are intramuscular tenotomy at the pelvic brim. Occasionally
younger than 18 months old usually do not have iliac wings the adductors may also need to be lengthened. In the older
that are thick enough to support the bone graft. For children child, the femur should be shortened as part of the open
who are older than 9 or 10 years, the surgeon may not be able reduction procedure to relieve the pressure from the con-
to achieve enough movement of the acetabular fragment to tracted muscles.
A B C
D E F
G H I
FIG. 13.65 Imaging appearance in a girl with bilateral developmental dysplasia of the hip that was diagnosed when she was 18 days old
after subsequent poor parental compliance with the treatment program. (A) Anteroposterior (AP) radiograph obtained when the patient
was 18 days old showing bilaterally dislocated hips. The Hilgenreiner and Perkin lines help to delineate the dislocated hips. (B) AP radio-
graph obtained at presentation when the patient was 6 weeks old shows bilateral dislocations. The infant was treated in a Pavlik harness for
6 weeks and in an abduction splint thereafter. The grandmother later confided that the mother did not comply with treatment instructions
and did not use the devices very much at all. (C) Arthrogram obtained when the patient was 5 months old shows good reductions. (D) AP
radiograph obtained when the patient was 12 months old shows bilateral subluxation that is worse on the left side. AA, Acetabular angle;
CE, center-edge angle. (E) Standing AP radiograph obtained when the patient was 2 years old shows persistent bilateral subluxation. (F)
Arthrogram obtained when the patient was 2 years old shows mild subluxation with good reduction. (G) The patient underwent a left Salter
osteotomy. (H) AP radiograph obtained when the patient was 5 years old (i.e., 3 years after the Salter osteotomy) shows good acetabular
development. (I) Final radiograph, obtained when the patient was 15 years old, shows good development bilaterally (slightly better on the
left side).
Complications are often the result of a lack of atten- it may displace posteriorly. The posterior edges of the
tion to the details of the procedure. Sciatic nerve inju- osteotomy should be well visualized before the surgeon
ries have occurred during the passage or use of the Gigli pins the osteotomy to prevent the misplacement of the
saw in the sciatic notch. This cut should always be pro- fragment.
tected by Hohmann retractors. We prefer first to pass a Pins have been placed into the acetabulum, and pins have
soft tape through the notch. The tape is then tied to the even been inserted into the femoral head. Needless to say,
Gigli saw, and the saw is pulled through the notch with care must be taken to place the fixation pins correctly, and
the tape. This maneuver is safer than grasping the saw appropriate radiographs must be obtained to ensure proper
in the depths of the notch. Femoral nerve injuries have placement. Palpating the acetabulum when the hip is open
occurred, usually as a result of excessive retraction across may identify intraarticular pins, but pins in the subchondral
the pelvic brim. Loss of position may occur, especially position may be missed. Postoperative hip stiffness is rare
when the fixation pins are not appropriately placed. One in the treatment of DDH and may be the result of the fail-
pin should go behind the acetabulum, and the second pin ure to shorten the femur when there is excessive pressure
should be placed over the acetabulum to fix the bone after reduction. Hip stiffness will occur when the hip has
graft. If the distal fragment is not held in proper position, not been concentrically reduced.
A B C
D E F
G
FIG. 13.66 Bilateral Salter osteotomies. (A) Anteroposterior (AP) radiograph showing bilateral developmental dysplasia of the hip in a
14-month-old girl. (B) Arthrogram of the right hip obtained during the closed reduction after 2 weeks of home traction. The reduction is
good. (C) Arthrogram of the left hip shows a fair reduction with a small medial space between the head and the acetabulum. (D) AP radio-
graph obtained when the patient was 4 years 9 months old shows bilateral acetabular dysplasia. (E) AP radiograph obtained after bilateral
Salter osteotomies that were performed in a single operative setting. (F) AP radiograph obtained 1 year after the Salter osteotomies shows
good acetabular coverage. (G) AP radiograph obtained when the patient was 14 years 4 months old shows excellent hip development
bilaterally.
Although reported outcomes of the Salter procedure determines the area of acetabular coverage that is improved.
have varied,285 we have found that the Salter procedure is an Thus, if wedges are placed posteriorly, posterior acetabu-
appropriate addition to the open reduction, when necessary. lar coverage is augmented, as is often necessary in patients
Kalamchi modified the Salter procedure by displacing with neuromuscular-related hip dislocations. If the wedges
the distal fragment into a posterior notch in the proximal are placed anteriorly and superiorly, coverage is improved
fragment to avoid increasing the pressure on the femoral anterolaterally, much as it is with the Pemberton osteotomy.
head.124 Results have been comparable with those of the The acetabular volume may be decreased by the displace-
original procedure. ment of the osteotomy.
Dega Osteotomy
Complex Osteotomies That Reposition the
The Dega osteotomy allows the surgeon to increase ace- Acetabulum
tabular coverage anteriorly, centrally, or posteriorly. The
osteotomy starts above the acetabulum and proceeds into Steel Osteotomy
the triradiate cartilage behind and beneath the acetabulum. The Steel procedure includes osteotomies through the
The acetabular fragment is then pried downward and held ilium and through both pubic rami (Fig. 13.67).67,91,265,266
in place with bone wedges. The placement of the wedges The pubic ramus is approached through a transverse
A B C
FIG. 13.67 Radiographic appearance in a 20-year-old female track athlete with a 2-year history of pain in the right hip. She had no history
of hip abnormalities. (A) Anteroposterior radiograph shows right hip dysplasia with an increased acetabular index. (B) Frog-leg lateral radio-
graph shows the sourcil of the right hip, which is more oblique than the apparent acetabular contour. (C) Radiograph obtained after a Steel
triple innominate osteotomy. The acetabular fragment has been rotated anterolaterally and translated medially to improve hip coverage and
mechanics.
medial incision in the patient’s groin. A dissection that is

made proximally up the pectineus allows for ready access
to the ramus, which is then divided. The ischium is also
approached through the same incision. This dissection inter-
val is posterior to the adductor magnus. After the ischium
is transected, this wound is closed, and an innominate oste-
otomy is made, similar to that performed for the Salter pro-
cedure. The acetabular fragment is displaced and rotated to
provide anterolateral coverage of the femoral head. Greater
acetabular repositioning can be obtained with the triple
osteotomy than with the innominate osteotomy alone. The
surgeon may use large pins that are placed in the distal frag-
ment as handles to displace and rotate the acetabulum. The
osteotomy is fixed with screws or threaded pins. The triple Tönnis Osteotomy Lines
innominate osteotomy provides considerable mobility for FIG. 13.68 The sites of the three osteotomies are shown in a model
repositioning the acetabulum. The acetabular fragment is of the human pelvis. (Redrawn from Tönnis D, Behrens K, Tscharani
rotated anteriorly and laterally, and it may also be displaced F. A modified technique of the triple pelvic osteotomy: early results.
medially to a limited degree at the ischial osteotomy. Com- J Pediatr Orthop. 1981;1:243.)
plications include the painful nonunion of osteotomy sites286
and the excessive external rotation of the acetabulum.75
A polygonal osteotomy150 has been reported to obtain Ganz osteotomy, thus allowing for a wide range of improved
good clinical and radiographic results, to be easier than the hip coverage (Fig. 13.68).8
Ganz osteotomy, and to allow for medialization as well as
for the repositioning of the acetabulum.251 Ganz Osteotomy
The Ganz osteotomy, which is also known as the Bernese
Tönnis Osteotomy periacetabular osteotomy, has gained popularity because
Tönnis modified the triple innominate osteotomy. With it allows for the greater displacement and medialization
this method, the ischium is approached directly, with the of the acetabulum while maintaining an intact posterior
patient in the prone position.287–289 A long ischial cut con- column (Fig. 13.69).44 It is indicated for all degrees of
nects the obturator foramen with the sciatic notch so that acetabular dysplasia in a hip that can be concentrically
the cut finishes proximal to the sacrospinous ligament, reduced, either with standard radiographs or with fluo-
thereby preventing it from tethering the acetabular frag- roscopy and repositioning. The advantages, as noted by
ment during correction. The long cut provides good contact Ganz and colleagues, include a single approach, a large
after displacement to prevent pseudarthrosis. The iliac cut degree of correction in all planes, the maintenance of
is slightly curved, and the pubis is cut, as in the Steel pro- blood supply to the acetabulum, an intact posterior col-
cedure, from a medial approach. Fixation is obtained with umn, the minimal disruption of the hip abductors, and
the use of several screws and by attaching a cerclage wire no alteration of the pelvic birth outlet (Videos 13.11
from a screw in the pubis to a pin in the ilium. Tönnis and and 13.12).80 The procedure is indicated for symptom-
colleagues reported that 58% of their patients were pain atic acetabular dysplasia in the skeletally mature indi-
free after the procedure and that another 32% had mild to vidual. The degree of dysplasia should be evaluated on
moderate residual pain.289 Nine percent had improvements both standing AP radiographs and false- profile views.
in the degrees of their arthrosis, and 73% had no change Acetabular anteversion can be estimated with the use of
over an average follow-up period of 7 years. Amien and the AP view.183 The femoral head should be able to be
co-workers have shown that the Tönnis osteotomy results concentrically reduced, although the presence of a false
in freedom of movement that is comparable to that of the acetabulum is not a contraindication. When necessary, a
A B
C D E
FIG. 13.69 Ganz osteotomy in a 15-year-old girl who presented with increasing hip pain but no history of hip problems. (A) Anteroposterior
radiograph of the pelvis. The left hip is subluxated and dysplastic. (B) Abduction internal rotation radiograph showing improved seating of
the femoral head with restoration of the Shenton line but some lateralization. (C) False-profile radiograph showing marked anterior uncov-
ering of the femoral head. (D) Postoperative anteroposterior radiograph showing considerable improvement in acetabular coverage. (E)
Postoperative false-profile radiograph showing improvement in anterior acetabular coverage.
femoral osteotomy (usually varus producing) may be per- cuts can be nicely visualized during surgery with a false-
formed to obtain an optimal relationship of the femoral profile fluoroscopic image on a radiolucent operating room
head with the acetabulum.45 table.103,187 The second cut is the superior ramus cut, which
During the performance of the operation, a single inci- is made after subperiosteal dissection around the obtura-
sion is made along the iliac crest, and it can be extended tor foramen and protection with the Hohmann retractors
slightly over the anterior aspect of the thigh. An anterior of the obturator neurovascular bundle. A sharp Hohmann
superior iliac spine osteotomy is created to allow for the retractor is placed medial to the cut to allow for full visu-
retraction of the sartorius and the fascia of the tensor fasciae alization of this angled cut, which begins just medial to the
latae. The direct and indirect heads of the rectus femoris iliopectineal eminence (see Fig. 13.70B). The third cut is
are dissected sharply, and the iliocapsularis muscle is sharply made just inferior to the anterior superior iliac spine, and a
dissected off of the anterior and medial capsule. small lateral window is made via the subperiosteal resection
The first cut is the ischial cut, which is approached of the abductors to allow the saw to penetrate the lateral
through the iliopsoas–capsule interval; it is made down to cortex. The cut ends just lateral to the pelvic brim at the
the ischium at the infracotyloid groove. A 50-degree–angled apex between the third and fourth cuts, midway between
special osteotome is then used to create this cut, which the posterior aspect of the posterior column and the poste-
begins distal to the acetabulum and which is directed posterior wall of the acetabulum (see Fig. 13.70C). The fourth
riorly, aiming toward the ischial spine (Fig. 13.70A). The cut cut is made with a curved osteotome, and it travels down
ends just at the posterior aspect of the acetabulum, and it the posterior column to meet with the first cut (see Fig.
will connect with the distal extent of the fourth cut. These 13.70D). This cut should be visualized under fluoroscopy
B C D
FIG. 13.70 The Ganz surgical technique. (A) The first cut is seen on the false-profile view (left) with the curved Ganz osteotome beginning
the cut at the infracotyloid groove and aiming toward the base of the ischial spine. The anteroposterior view (right) demonstrates the appro-
priate position of the osteotome directed straight posterior and slightly proximal. (B) The second cut. A sharp Hohmann retractor is placed
in the superior ramus and used to retract soft tissues to allow the osteotomy to begin just medial to the iliopectineal eminence. The blunt
Hohmann retractors in the obturator foramen are not shown. (C) The third cut. The osteotome is marking the posterior and medial extent
of the third cut ending just lateral to the pelvic brim. (D) The fourth cut. The osteotome is directed down the posterior pelvic column while
staying posterior to the acetabulum.
with the use of a false-profile–type trajectory of the image perform the varus osteotomy at the same sitting, before the
intensifier. Ganz osteotomy so that the rotation of the acetabulum can
A Schanz pin is then placed into the acetabular fragment be dialed into the new position of the femoral head.
to assist with its positioning. The first step in positioning All series report excellent improvement in symptoms
the acetabular fragment is to move the superior ramus and function after the Ganz osteotomy.80,81,188,193,229 Pre-
proximally and slightly posteriorly to allow the fragment operative evidence of impingement of the femoral head
to rotate around the center of rotation of the hip center with a lack of concentricity and joint-space narrowing are
and to ensure that normal version is maintained during the associated with poor results and are considered contraindi-
correction. The fragment is then provisionally fixed, and cations to the procedure.45
radiographs are obtained to ensure that the correct medi- Our experience demonstrates a significant improvement
alization of the joint center, the normalization of the lateral in the lateral center–edge angle from −4 to 23 degrees and
and anterior acetabular coverage, and the maintenance of in the ventral center–edge angle from −2 to 33 degrees,
version are seen (Fig. 13.71). Final fixation involves the use with functional improvements in Harris hip scores from 76
of 3.5-mm–diameter long cortical screws, with two or three to 90 points at 2 years. Gait analysis demonstrated improve-
screws running proximal to distal and one screw going from ments at 2 years in walking speed, hip adductor moment
the acetabular fragment toward the posterior column. impulse, and maximum hip abductor torque, which reflect
A proximal femoral osteotomy is indicated less often an improvement in the medialization of the hip joint
today when a Ganz osteotomy is performed. The general center.255
indications are when significant valgus is seen in the proxi- An issue of some disagreement is the need to open the
mal femur and when severe acetabular dysplasia is seen in hip capsule to evaluate the labrum and the articular cartilage.
which the reorientation of the acetabulum fails to result in Although preoperative MRI arthrography reveals a labral
normal hip congruency. The decision to perform the varus pathologic process in many cases, many authors believe that
osteotomy should be made before surgery, and we generally inspection of the labrum is necessary to detect labral tears,
A B C
FIG. 13.71 Intraoperative imaging after positioning of the fragment in Ganz osteotomy. (A) The preoperative anteroposterior radiograph
demonstrating bilateral hip dysplasia. (B) Intraoperative anteroposterior radiograph after acetabular reorientation with provisional fixation
demonstrating improvement in lateral and anterior acetabular coverage, medialization of the hip joint center, and maintenance of acetabu-
lar version. (C) Final intraoperative radiographs after permanent fixation with 3.5-mm diameter cortical screws.
Bone graft
Line of Resection
osteotomy of bone
A B C
FIG. 13.72 Ninomiya acetabular osteotomy which is used in Japan. The freed acetabulum should be shifted anterolaterally, medially, and
downward. (A) Preoperative view. (B) Anterolateral shift (arrow). (C) Downward shift (curved arrow) and medial shift (straight arrow) after
removal of the excess bone.
detachment, and articular cartilage delamination. Although called a dial osteotomy.66 For many years, these procedures
these lesions may be repaired, the success of these repairs is were used primarily in the centers where they were described
not completely known at this point.81,192,193 because the operations were perceived to be technically
Complications of the Ganz osteotomy can be serious, challenging. There has been renewed interest in a spherical
and the learning curve for this procedure has been described approach, and several authors have introduced variations of
as “long and steep.”290 Early weight bearing may displace this operation.107,191 Ninomiya reported a spherical osteot-
the osteotomy, and delayed union has occurred.80 Other omy that produced excellent results in hips with acetabular
complications include the nonunion of the pubic and ischial angles of up to 60 degrees (Fig. 13.72).207,208 This group
osteotomies and the loss of fixation; lateral femoral cutane- from Japan reported excellent results at 13-year follow-up
ous nerve damage is common, having occurred in as many for a combined approach of valgus femoral osteotomy and
as 50% of patients.109,229 Femoral nerve palsy, ectopic bone spherical acetabular osteotomy in patients ranging in age
formation, and necrosis of the acetabular fragment have from 11 to 36 years.206 Hsieh and co-workers described a
also been reported.54,109 A significant (77%) decrease in spherical osteotomy through a transtrochanteric exposure
blood flow after the separation of the acetabular fragment that allows for intraarticular inspection of the hip, and they
has been reported99; however, avascular changes within the reported excellent results with few complications.107
acetabulum are rare. The surgeon is well advised to obtain as Spherical osteotomies allow for the rotational reposition-
much instruction and practice in the laboratory as possible ing of the acetabulum through a wide range, and they are
before undertaking this surgical procedure. stable without disrupting the pelvic ring. Medialization of
the acetabulum is difficult if not impossible, but Hsieh and
Shih reported the achievement of some medial displace-
Spherical Acetabular Osteotomy
ment.107 With the anterior rotation of the acetabulum,
A spherical acetabular osteotomy to allow for acetabular there is usually a loss of flexion after surgery. Necrosis of the
repositioning was introduced by Wagner in 1976.248,301,303 acetabular fragment is occasionally reported, and it is more
Eppright also described a spherical osteotomy, which he likely if the cuts are close to the acetabular wall. Pain relief
A B
C D
FIG. 13.73 Chiari osteotomy. (A) Anteroposterior radiograph of 10-year-old girl who underwent a closed reduction when she was 2 years
old that subsequently failed. Note the wide subluxation of the femoral head. (B) Anteroposterior radiograph obtained when the patient was
14 years old that shows sclerosis and joint space narrowing, which are signs of early degenerative disease. The patient now had daily hip
pain. (C) Intraoperative radiograph shows the Chiari osteotomy with screw fixation. (D) Anteroposterior radiograph taken when the patient
was 16 years old. The femoral head was now better covered, and the patient’s symptoms had decreased.
and improvement of the acetabular coverage of the femoral pin or screw fixation. If anterior coverage is inadequate after
head are reported in most patients after spherical osteoto- the displacement of the osteotomy, a bone graft from the
mies. In all series, the majority of patients experienced the iliac wing should be placed anteriorly over the femoral head
stabilization or improvement of radiographic degenerative and fixed there. If the angle of inclination of the osteotomy
changes. Favorable results in one series were related to the is too horizontal, the displaced fragment will not support
degree of acetabular cover and were more likely when the the femoral head. If the inclination is too steep, the frag-
femoral head was spherical.147 ment will abut the head.
Reported results are good or excellent in two-thirds of
Osteotomies That Augment the Acetabulum patients, with most experiencing pain relief and increased
function.13,37 Macnicol and co-workers found that four of
Chiari Osteotomy five hips were still functioning without hip replacement at
The Chiari osteotomy is indicated when it is no longer an average of 18 years after surgery.179 Total hip replace-
possible to achieve a concentric reduction of the hip. It ment was more likely among patients who were 25 years old
is, in essence, a controlled fracture through the ilium, or older. The pelvis did not remodel, and hip coverage was
with medial displacement of the acetabular fragment and maintained as long as 30 years after surgery.179
the intact hip capsule under the ilium (Fig. 13.73). Over The most frequent complications occur as a result of
time, the hip capsule transforms into fibrocartilage, which the inaccurate placement of the osteotomy. Both the start-
becomes the new acetabular coverage. Because the femoral ing point and the slope of the osteotomy are critical to the
head is covered by fibrocartilage rather than repositioned successful displacement of the acetabulum. An osteotomy
acetabular cartilage, the Chiari osteotomy is considered a with a high starting point provides no support to the femoral
salvage procedure. head, and an osteotomy that enters the sacroiliac joint can-
The Chiari osteotomy is made just above the acetabu- not be displaced. If the angle of the osteotomy is too great,
lum, in the region of insertion of the hip capsule.i The oste- the displaced fragment will impinge on the femoral head.
otomy curves to match the acetabular contour, and it slopes Failure to add an anterior bone graft may leave the femoral
upward from lateral to medial. The level of the osteotomy head uncovered.
and the slope of the cut must be precise for the displaced
iliac wing to cover the femoral head without impinging on Shelf Procedures
it. The acetabular fragment is displaced medially almost the Numerous varieties of shelf procedures have been used for
full width of the ilium at that level, and it is held there with severe acetabular dysplasia (Figs. 13.74 and 13.75).j The
i References 16, 17, 32, 72, 105, 155, 324. j References 21, 73, 85, 93, 177, 190, 264, 270, 304, 321, 332.
35°
wa
gl
A B C
D E F
G H I
FIG. 13.74 Slotted acetabular augmentation. (A) The reflected head of the rectus femoris is sectioned in its anterior part, elevated, and
reflected posteriorly. Note the exposure of the thickened capsule of the hip joint in its anterior, superior, and posterior aspects. (B) The site
of the slot is exactly at the margin of the acetabulum. It is made by multiple drill holes that are joined with a narrow rongeur. The slot is 5
mm wide and 10 mm deep; its length varies, depending on the amount of coverage required. (C) The width of augmentation (wa) is that
amount of bone needed to provide the patient with a normal center–edge angle. Adding the width of augmentation to the slot gives the
graft length (gl). (D) Harvesting of thin strips of cortical and cancellous bone graft from the lateral wall of the ilium. The graft strips are long,
and they extend from the iliac crest to the upper margin of the slot. The inner wall of the ilium is left intact. (E) First layer of augmentation.
The thin strips of bone graft are placed radially into the slot with the concave side down. (F) The second layer of augmentation is perpendic-
ular to the first layer and parallel to the acetabular margin. (G) The first and second layers of bone graft are held in place by reattaching the
tendon of the reflected head of the rectus femoris. A capsular flap may be used as an additional measure, if necessary. (H and I) The third
layer of the bone graft consists of small pieces of bone that are packed above the reflected head of the rectus femoris. This layer of bone is
held in place by reattaching the hip abductor to the iliac crest. (Redrawn from Staheli LT. Slotted acetabular augmentation. J Pediatr Orthop.
1981;1:321.)
indications for a shelf procedure are similar to those for is constructed over the femoral head, particularly ante-
the Chiari osteotomy: chiefly, a hip in which a concentric riorly and laterally. It is created by using local shavings of
reduction cannot be obtained. In addition, some surgeons iliac bone along with a large segment of bone from the iliac
augment another acetabular procedure (e.g., the Salter pro- wing. A concave slab of bone is fixed over the femoral head
cedure) with a shelf procedure in an attempt to gain addi- and placed over the hip capsule and beneath the reflected
tional hip coverage. Shelf procedures that do not have an head of the rectus femoris. A buttress of cancellous bone is
adequate buttress of bone that is continuous with the pelvis then constructed between this slab and the pelvis, over the
will gradually resorb or “melt” away. acetabulum. As the shelf matures, the contour will remodel
The Staheli procedure can provide increased coverage from the pressure of the femoral head, and the bone of the
for a hip that cannot be concentrically reduced. The shelf shelf will hypertrophy.
A B C D
FIG. 13.75 Developmental hip dysplasia in a 15-year-old girl who was treated with the Staheli acetabular augmentation procedure. (A) Pre-
operative radiograph. (B) Immediate postoperative radiograph. (C and D) Radiographic appearance 1 year after surgery. Note the excellent
coverage of the femoral head. (From Staheli LT. Slotted acetabular augmentation. J Pediatr Orthop. 1981;1:321.)
A B C
FIG. 13.76 Teratologic dislocation of the right hip. (A) AP radiograph at age 5 months of a girl with arthrogryposis. (B) Medial open reduc-
tion was performed at age 5 months. Intraoperative radiograph shows reduced femoral head. Small rolled wire is temporarily placed in the
acetabulum with the head reduced to allow radiographic confirmation of reduction. (C) AP pelvis radiograph at age 15 months showing
maintenance of reduction with acetabular dysplasia. (D) Postoperative radiograph following Pemberton osteotomy at age 7 years.
Teratologic Dislocation of the Hip extremities and reasonable trunk control, and most of these
hips should be reduced. Occasionally, a child with arthro-
Teratologic hip dislocation, which is also called antenatal gryposis has almost total motor paralysis and may not ben-
dislocation of the hip, is defined by a fixed dislocation at efit from hip reduction.
birth, with limited range of motion of the hip (Fig. 13.76). The closed treatment of teratologic hip dislocation is
Most children who have teratologic dislocations have an usually unsuccessful. Our choice for management has been
associated syndrome or other musculoskeletal abnormali- an open reduction from an anteromedial approach when
ties. The most common coexisting conditions are arthro- the child is 6 months old.91 These hips tend to remain sta-
gryposis, myelomeningocele, chromosomal abnormalities, ble without capsulorrhaphy, and the medial approach has
diastrophic dwarfism, and lumbosacral agenesis. not caused excessive stiffness. Szoke and associates have
Through the 1950s and 1960s, treatment programs for reported 80% good results in children with arthrogryposis
teratologic dislocations were often unsuccessful. As a result, who were treated with medial open reduction at approxi-
many authors suggested leaving these hips untreated.76,84 mately 9 months of age.276 In the young child, femoral
Modern treatment has been more successful, and the major- shortening is usually not required. In the older child, ante-
ity of such hips should be reduced.47,172,323 For patients rior open reduction with femoral shortening, if necessary,
with neuromuscular conditions (e.g., myelomeningocele), is the preferred approach. LeBel and Gallien reported the
the motor level should be considered, and high paralytic results of the treatment of 18 patients with teratologic hips
levels may be best left untreated. with open reduction at 1 year of age followed by femoral
When addressing the decision to treat, the surgeon varus derotational osteotomy 6 weeks later; they found
should consider the functional level of the patient and the that 76% had good functional results; Two cases of AVN
prognosis for ambulation. Most children with arthrogrypo- resulted.160
sis have a restricted but adequate range of hip flexion and
extension, with limited rotation and abduction. Most of References
these children also have some motor ability in the lower For References, see expertconsult.com.
Plate 13.1 Closed Reduction and Casting for Developmental Dislocation of the Hip (see Video 13.5)
(A) The first step of this procedure—evaluating the reduc- she should hold the hips to maintain the reduction while
tion of the hip—is probably the most important. With the avoiding extremes of abduction or internal rotation.
infant completely anesthetized, the surgeon gently per- (C) A rolled towel or stockinette is placed over the
forms the Ortolani maneuver by grasping the infant’s thigh, child’s abdomen and later removed to allow for breathing
applying mild longitudinal traction, lifting the greater tro- room in the cast.
chanter with the fingers, and abducting the hip to reduce (D) Cast padding is applied around the abdomen in a
the femoral head. The reduction should be done with the figure-eight pattern around the groin and then down the
hip flexed approximately 120 degrees. After the patient’s legs. The first cast is usually applied to the middle of the
hip reduces, the surgeon evaluates its stability by extend- calf of the affected extremity and to above the knee on the
ing the hip to the point of redislocation and then adducting contralateral leg. If available, a layer of moisture-control
the hip to the point of redislocation. A reduction is consid- material (e.g., Gore-Tex) may be placed against the skin
ered stable if the hip can be adducted 20–30 degrees from to prevent wetness. Casting material (usually fiberglass)
maximal abduction and extended to less than 90 degrees is then rolled over the areas to be enclosed. During the
without redislocation. An arthrogram may be obtained at entire procedure, the surgeon must continually assess the
this time to further assess the adequacy of the reduction. infant’s hip position by abducting the hips maximally and
If the adductors are tight on palpation with the hip in the then “backing off ” by at least 15 degrees to prevent the
reduced position, a tenotomy of the adductor longus may hip from sagging into full abduction.
be performed to reduce pressure on the hip. (E) The infant is taken off of the table, and the cast is
(B) After the reduction is established, the patient windowed for perineal access. Radiographs are obtained
is placed on the infant spica table for cast application. at this point to ensure reduction. If any doubt remains
The head of the table is raised to assist with keeping the regarding reduction, minimal-cut computed tomography
perineum against the center post. At this point, the sur- or MRI scan is useful to confirm the hip’s position.
geon should be certain of the reduction of the hip. He or (F) Side view of the finished cast.
C D
E F
Plate 13.2 Medial Approach for Open Reduction of the Developmentally Dislocated Hip
The patient is placed supine, and the ipsilateral hip, the The deep fascia is divided. The surgeon should be care-
hemipelvis, and the entire lower limb are prepared and ful not to injure the saphenous vein; however, if necessary,
draped in the usual fashion, which allows for the free the vein can be ligated and sectioned.
mobility of the limb during surgery. (B and C) The hip is approached anterior to the pec-
We prefer a transverse skin incision because it affords tineus, between that muscle and the femoral sheath.
better access to the hip and results in better cosmesis than With this approach, the pectineus muscle is retracted
a longitudinal incision. The hip is approached anterior to medially and inferiorly and the femoral vessels and nerve
the pectineus with the traditional Ludloff technique. An are retracted laterally, thereby exposing the iliopsoas
alternative approach—posterior to the pectineus—is also tendon as it passes toward the lesser trochanter. The
described. femoral circumflex vessels cross the field and are care-
fully retracted.
Transverse Skin Incision With Surgical (D) Transverse section showing the approach to the hip
Approach Anterior to the Pectineus anterior to the pectineus.
(A) The preferred approach is through a transverse

oblique skin incision that is 5–7 cm long, centered over
the anterior margin of the adductor longus, and approxi-
mately 1 cm distal and parallel to the inguinal crease.
Transverse skin incision
Adductor longus muscle
Lymph
Femoral vessels nodes
Line of
and nerve retracted
sectioning of
laterally
iliopsoas tendon
B Saphenous vein ligated

and sectioned
Access route to lesser trochanter

anterolateral to pectineus muscle to
release iliopsoas tendon
Iliopsoas
Adductor longus Adductor longus tendon
muscle detached muscle detached
and retracted and retracted
C
Pectineus muscle Adductor
Adductor brevis muscle
retracted medially brevis muscle
Pectineus
muscle
D Lesser trochanter
Continued on following page

Plate 13.2 Medial Approach for Open Reduction of the Developmentally Dislocated Hip—cont’d
Approach Posterior to the Pectineus (H and I) The inferior part of the capsule and the trans-
verse ligament are pulled upward with the femoral head.
(E and F) The hip can also be approached by a route that
The capsule may adhere to the floor of the acetabulum, and
is posterior to the pectineus muscle. The pectineus mus-
the ligamentum teres is enlarged and usually needs to be
cle is retracted laterally to protect the femoral vessels and
removed to better visualize and reduce the femoral head.
nerve, and the adductor brevis muscle is retracted medi-
(J) The capsule is opened with an incision that is paral-
ally, thereby bringing the iliopsoas tendon into view at its
lel to the acetabular margin. It is best to make a small stab
insertion to the lesser trochanter. A Kelly clamp is passed
in the capsule, insert a small hemostat, and then complete
under the iliopsoas tendon and opened slightly, and the
the incision using the hemostat to protect the femoral
tendon is sectioned.
head. In the drawing, a cruciate cut is shown; however, a
(G) With all of the medial approaches, the psoas ten-
single incision parallel to the acetabular margin is usually
don is sectioned and allowed to retract proximally, and the
sufficient.
iliacus muscle fibers are gently elevated from the anterior
aspect of the hip joint capsule.
Femoral
vessels
and nerve
retracted
laterally
Pectineus Line of
muscle sectioning Access route to lesser trochanter
retracted of iliopsoas posteromedial to pectineus muscle to
laterally muscle release iliopsoas tendon
Pectineus muscle
Adductor
longus muscle
detached Iliopsoas
E and retracted tendon
Adductor
brevis muscle Adductor
brevis
muscle
Adductor
magnus
muscle
Lesser
trochanter
F
Relation of iliopsoas tendon

to capsule
Line of sectioning of Capsule adhering to floor

G H of acetabulum
iliopsoas tendon
Transverse cut (optional) Capsule incised along

to create cruciate incision axis of femoral neck
Ligamentum teres excised

if large and hypertrophied
Iliospoas muscle
elevated and
reflected proximally
Femoral vessels
Capsule adhering to and nerve retracted
floor of acetabulum laterally
I J
Adductor Adductor longus muscle
magnus muscle detached and retracted

Plate 13.2 Medial Approach for Open Reduction of the Developmentally Dislocated Hip—cont’d
Transverse acetabular
ligament sectioned
Ligamentum teres excised

if large and obstructive
K
(K) The transverse acetabular ligament is sectioned, (L) A one-and-one-half-hip spica cast is applied with
and the ligamentum teres is excised. The hypertrophied the hip in 100 degrees of flexion, 30 degrees of abduction,
pulvinar is also removed. and neutral rotation. During the application and setting
After this step, the femoral head should be eas- of the cast, medially directed pressure is applied over the
ily reduced underneath the limbus. If the head does greater trochanter with the palm. The surgeon should be
not reduce easily, the medial capsule and the transverse certain that the hip is not placed in maximal abduction to
acetabular ligament should be released more thoroughly. avoid excess pressure on the femoral head.
Reduction can be maintained by holding the hip in 30
degrees of abduction, 90–100 degrees of flexion, and neu-
Postoperative Care
tral rotation. It is not necessary to repair the capsule. The
wound is closed in the usual fashion. The cast is changed at 6-week intervals, with a total dura-
tion of cast immobilization of approximately 3 months.
Plate 13.3 Open Reduction of Developmental Hip Dislocation Through the Anterolateral Approach
Operative Technique exposure and cosmesis. The anterior inferior iliac spine is
palpated and marked. The incision begins approximately
(A) The patient is placed supine with a roll under the hip.
two-thirds of the distance from the greater trochanter to
The entire lower limb and the affected half of the pelvis
the iliac crest, crosses the inferior spine, and extends 1 or
are prepared and draped to allow for the free motion of
2 cm beyond the inferior spine.
the hip.
(B) The incision is then retracted over the iliac crest,
The skin incision is an oblique “bikini” incision. The
and the dissection is carried down to the apophysis of the
incision formerly used over the iliac crest produces an
crest.
unsightly scar, whereas the bikini incision affords excellent
Skin incision
Anterior inferior
iliac spine
Anterior superior
iliac spine
Lateral femoral
cutaneous nerve
CAUTION:
Avoid injury to nerve

Plate 13.3 Open Reduction of Developmental Hip Dislocation Through the Anterolateral Approach—cont’d
(C) Anteriorly, the tensor–sartorius interval is bluntly procedure easier. Further subperiosteal dissection clears
dissected beginning distally and working proximally. The the sartorius medially and the tensor laterally, thus expos-
lateral femoral cutaneous nerve appears just medial to this ing the rectus femoris as it arises from the anterior inferior
interval and just distal to the inferior iliac spine, and it spine.
should be protected. The interval is widened with blunt (E) The rectus femoris is elevated from the hip cap-
dissection, and the rectus femoris is identified as it inserts sule, and the straight and reflected heads are identified,
on the anterior inferior iliac spine. tagged, and sectioned. The hip capsule is exposed laterally,
(D) The iliac apophysis is now split with a scalpel or first with the aid of a periosteal elevator to clear muscle
cautery down to the bone of the crest. With the help of attachments from the capsule. Next, the medial portion of
periosteal elevators, the iliac crest is exposed subperioste- the capsule is exposed, again by using a periosteal elevator
ally. The surgeon must be careful to keep the periosteum to dissect between the capsule and the iliopsoas tendon.
intact because it protects the iliac muscles and prevents Flexing the hip relaxes the iliopsoas and helps with the
bleeding. Bleeding points on the iliac wings should be con- gaining of medial exposure. The capsule beneath the ilio-
trolled with bone wax, even if the bleeding points appear psoas is exposed, and strong medial retraction with Army-
to be small. A dry wound makes subsequent steps in the Navy retractors is necessary to access the true acetabulum.
Iliac apophysis
Deep incision in Gluteus medius and split
cartilaginous minimus muscles elevated Periosteal
Gluteus iliac apophysis subperiosteally from elevator
medius muscle ilium to level of
sciatic notch
Ilium
Anterior
inferior
iliac spine
Tensor Tensor
fasciae fasciae
latae muscle latae muscle
Hemostat developing
groove between muscles Sartorius muscle Sartorius muscle
C D Capsule of hip
Rectus
Rectus femoris muscle
femoris muscle
Iliac apophysis
split
Periosteal
elevator
Ilium
Capsule
of hip
Gluteus medius and

minimus muscle attachments
freed from capsule
with periosteal elevator
Sartorius muscle
Rectus femoris muscle detached and
detached and reflected
E reflected

(F) If the iliopsoas tendon cannot be retracted, it may the greater trochanter. A second capsular incision is made
need to be sectioned. down the femoral neck to form a T.
(G) When medial exposure is adequate, the capsule is (H) The capsule edges are grasped with Kocher clamps,
opened with a knife. A hemostat is inserted into the cap- and a blunt probe is inserted to visualize the acetabulum.
sule, and the capsule is opened over the instrument and The hip should be flexed and externally rotated to open
parallel to the acetabular margin, leaving a 5-mm margin of up the acetabulum. The ligamentum teres is elevated with
capsule. This incision should extend medially all the way a right-angle clamp and followed to the depths of the ace-
to the transverse acetabular ligament and laterally to above tabulum. This step is essential; many a surgeon has mis-
taken a false acetabulum for the true acetabulum.
Iliopsoas muscle elevated

off anterior capsule
Transverse incisions
to lengthen iliopsoas
muscle
F
Limbus
Capsule
opened
Excision of
ligamentum
teres
Iliopsoas muscle
T-shaped incision of
capsule along axis of
femoral neck and limbus
G of acetabulum H

(I) The ligamentum teres is cut free from its base in its free edges. The capsule should also be tightened medi-
the acetabulum with scissors. The labrum of the acetabu- ally and anteriorly with a vest-over-pants closure. If this
lum may initially appear to be folded into the acetabulum, closure is too lax and redundant, a portion may be excised.
especially when the head is reduced. This usually indicates With the hip dislocated, nonabsorbable sutures are passed
that the medial obstacles to reduction (i.e., the capsule, through the medial portion of the capsule, which is still
the iliopsoas, and the transverse ligament) have been inad- attached above the acetabulum. The needles are left on
equately released. After more thorough release medially, the sutures and held with clamps. The hip is reduced, and
the head should be reducible beneath the labrum, which the superolateral segment of the capsule is brought medi-
will elevate the labrum out of the acetabulum. The exci- ally and distally with a Kocher clamp; this holds the hip
sion of the labrum is almost never necessary. internally rotated and deeply seated in the acetabulum.
Next, the surgeon inspects and determines (1) the The sutures are passed through the capsule in this position
depth of the acetabulum and the inclination of its roof; and tied. Any redundant capsule is imbricated over this
(2) the shape of the femoral head and the smoothness and closure with nonabsorbable sutures. The two halves of the
condition of the articular hyaline cartilage covering it; (3) iliac apophysis are sutured together over the iliac crest.
the degree of antetorsion of the femoral neck; and (4) the The rectus femoris and sartorius muscles are resutured to
stability of the hip after reduction. The femoral head is their origins. The wound is then closed in routine man-
placed in the acetabulum under direct vision by flexing, ner. An AP radiograph of the hips is obtained to ensure a
abducting, and medially rotating the hip while applying concentric reduction before a one-and-one-half-hip spica
traction and gentle pressure against the greater trochan- cast is applied. The roll beneath the patient’s hip should
ter. This maneuver is reversed to redislocate the hip. The be removed when the radiograph is made to obtain a true
position of the hip when the femoral head comes out of AP view of the pelvis. The cast is applied with the hip in
the acetabulum is determined and noted in the operative approximately 45 degrees of abduction, 60–70 degrees of
report. If necessary, sterile 4-0 or 5-0 suture wire is rolled flexion, and 20–30 degrees of medial rotation. The knee is
into a circle and placed against the cartilaginous femoral always flexed at 45–60 degrees to relax the hamstrings and
head to delineate it, the hip is reduced, and radiographs to control rotation in the cast.
are obtained; the wire is then removed. If the hip joint
is unstable or if, after reduction under direct vision, the
Postoperative Care
femoral head is insufficiently covered superiorly and ante-
riorly, the surgeon should decide whether to perform a The patient is immobilized in a one-and-one-half-hip spica
Salter innominate osteotomy or a derotation osteotomy of cast for 6 weeks. After 6 weeks, the patient is examined
the proximal femur at this time. under anesthesia, and a Petrie type of cast is applied. This
(J and K) A careful capsuloplasty is performed next. consists of long-leg plasters that are connected by one or
It is very important to keep the femoral head in its ana- two bars, with the hips abducted 45 degrees and internally
tomic position in the acetabulum. With the femoral head rotated 15 degrees. The cast allows for the flexion and
reduced, the hip joint is held by a second assistant in 30 extension of the hips while the reduction is maintained by
degrees of abduction, 30–45 degrees of flexion, and 20–30 the abduction and internal rotation. The cast is removed
degrees of medial rotation throughout the remainder of in the clinic after 4 weeks. Weight bearing is allowed while
the operation. The degree of medial rotation depends on the child is in the cast. If stability is uncertain, a second
the severity of antetorsion. spica cast may be appropriate.
The large, redundant, superior pocket of the capsule
should be obliterated via the plication and overlapping of
Removal of fibrofatty
tissue with curet
Repair of capsule
K
Plate 13.4 Femoral Shortening and Derotation Osteotomy Combined With Open Reduction of the Hip
(see Videos 13.7 and 13.8)
A femoral shortening and derotation osteotomy proce- also be placed transversely through the femur above and
dure is performed through a separate lateral longitudi- below the proposed osteotomy.
nal incision, although other surgeons may use different (B) The femur is transected just below the lesser tro-
approaches. The exposure of the upper femoral shaft chanter. The hip is reduced, and the distal femoral shaft is
through a separate longitudinal incision of the upper thigh aligned with the proximal shaft. The amount of overlap is
is technically simpler; there is less bleeding, and the scars noted, which gives the surgeon the final estimate of short-
are aesthetically more attractive. It is vital to expose a suf- ening necessary; this is usually between 1 and 2 cm. This
ficient length of the upper femoral shaft subperiosteally. overlap is marked on the distal fragment, and the femoral
With an irreducible dislocation, femoral shortening shaft is transected again at that level. A four-hole plate is
facilitates reduction; when reduction is difficult because attached to the proximal fragment, and the distal shaft is
of increasing pressure on the femoral head, it also decom- held to the plate with a Verbrugge clamp.
presses the hip. (C) The reduction is completed and assessed with
regard to femoral rotation and adequacy of shortening. As
Operative Technique a rule, the degree of hip decompression is adequate if the
(A) Femoral shortening is necessary to reduce pressure on surgeon can, with a moderate force, distract the reduced
the reduced femoral head, which is known to cause avas- femoral head 3 or 4 mm from the acetabulum. With the
cular necrosis of the hip. The amount of shortening may rotation marks aligned, the position of the lower extrem-
be estimated from the preoperative supine radiograph by ity should be in moderate internal rotation. Derotation is
measuring the distance from the bottom of the femoral done only when the internal rotation position is severe.
head to the floor of the acetabulum (a–b). The distance The remaining screws are placed to fix the plate to the
from b to c must equal the distance from a to b. With distal fragment.
higher dislocations, however, this may overestimate the The lateral thigh wound is closed in the usual manner.
needed shortening. The dissection for the open reduction, The repair of the hip capsule as well as other steps are
including clearing the acetabulum, is performed before the illustrated in Plate 13.3 on page 479.
transection of the femur. A trial reduction gives the sur-
geon a feel for the tightness of the muscles and other fore-
Postoperative Care
shortened structures, thus allowing for another estimate of
the amount of shortening needed. Postoperative care is similar to that which occurs after
A longitudinal mark is made with the saw along the open reduction of the hip. The plate can be removed after
anterior aspect of the femoral shaft. This serves as an ori- 6 months, when the osteotomy has solidly healed.
entation mark for femoral rotation. Steinmann pins may
Steinmann
pin
b Lesser
trochanter
c
Bone to be removed
ab = bc Bottom two
Plate applied with top screws inserted
two screws placed,
engaging medial cortex
Steinmann pin
A B C
Plate 13.5 Intertrochanteric Varus Osteotomy and Internal Fixation With a Blade Plate
Operative Technique distally parallel to the femur for a distance of 10–12 cm.
The subcutaneous tissue is divided in line with the skin
(A) The operation is performed with the child supine on a
incision.
radiolucent operating table. It is imperative to have image-
(B) The fascia lata is exposed by deepening the dissec-
intensifier radiographic control. Some surgeons prefer to
tion. It is first divided with a scalpel, and it is then split
operate on an older child on a fracture table because it is
longitudinally with scissors in the direction of its fibers.
technically easier to obtain a lateral radiograph of the hip.
The fascia lata should be divided posterior to the tensor
A straight, midlateral, longitudinal incision is made begin-
fasciae latae to avoid splitting the muscle.
ning at the tip of the greater trochanter and extending
Skin incision
A
Greater trochanter
Tensor fasciae latae muscle
Division of fascia lata

Plate 13.5 Intertrochanteric Varus Osteotomy and Internal Fixation With a Blade Plate—cont’d
Splitting of
vastus lateralis muscle
Greater
trochanteric
apophysis
Exposed femoral shaft

D
(C) With retraction, the vastus lateralis muscle is vastus lateralis muscle fibers are elevated from the lateral
visualized. Next, the anterolateral region of the proxi- intramuscular septum and the tendinous insertion of the
mal femur and the trochanteric area are exposed. It is gluteus maximus.
vital to not injure the greater trochanteric growth plate. (D) The lateral femoral surface is exposed by sub-
The origin of the vastus lateralis muscle is divided trans- periosteal dissection. The greater trochanteric apophysis
versely from the inferior border of the greater trochan- should not be disturbed.
ter down to the posterolateral surface of the femur. The
(E and F) The femoral head is centered concentrically the patient. This is a very dependable and simple method
in the acetabulum by abducting and medially rotating the for properly orienting the proximal femur.
hip, and its position is checked with an image intensifier. (G) The chisel for the blade plate is placed at an angle
Immediately distal to the apophyseal growth plate of the that is determined as follows: if the chisel paralleled
greater trochanter, a 3- mm Steinmann pin is inserted the guide pin, the 90-degree blade plate would produce
through the lateral cortex of the femoral shaft parallel to a 90-degree neck–shaft angle. In this case, we sought to
the floor of the operating room and at a right angle to the produce a neck–shaft angle of 105 degrees. Thus a chisel
median plane of the patient. The pin is drilled medially placed 15 degrees off of the guide pin’s axis adds 15
along the longitudinal axis of the femoral neck and stops degrees to a 90-degree neck–shaft angle, thereby resulting
short of the capital femoral physis. This position of the in a 105-degree final angle.
proximal femur can be reproduced at any time during the (H) The osteotomy cuts are made while the chisel is in
operation by placing the Steinmann pin horizontally paral- place. The proximal osteotomy is parallel to the chisel, and
lel to the floor and at 90 degrees to the longitudinal axis of the distal osteotomy is perpendicular to the femoral shaft.
Head of femur concentrically

reduced in acetabulum
Head of femur (head is covered)
uncovered
Greater Pin in center of femoral
trochanteric neck and stopped short of
apophysis capital femoral epiphysis
Steinmann pin
Line of osteotomy
E F Leg abducted and

Physis of medially rotated
femoral head
Proximal osteotomy
parallel to chisel
15°
Guide pin along
axis of neck
Chisel removed
Chisel placed 15°
off axis of neck
Distal osteotomy
perpendicular to
femoral shaft
G H
Leg adducted and
medially rotated

Plate 13.5 Intertrochanteric Varus Osteotomy and Internal Fixation With a Blade Plate—cont’d
(I) After the osteotomized triangle is removed, the (K) The vastus lateralis and fascia lata are closed with
chisel is removed, and the blade plate is inserted. Careful running sutures. Subcutaneous and skin closure with
control of the proximal fragment and clear visualization absorbable sutures completes the procedure.
of the entry site of the chisel facilitate the placement of
the blade.
(J) The blade plate is fully seated and secured with
Postoperative Care
screws that are drilled and tapped. The angulation of the
plate produces medial displacement of the femoral shaft, The osteotomy is stable when the bone is of normal
which is extremely important to the biomechanics of strength. In reliable patients, cast immobilization is not
the hip. Failure to displace the distal fragments medially necessary. For less reliable children, those with osteopenic
results in the lateral prominence of the plate and the wid- bone, and always when an open reduction has been per-
ening of the groin. formed, 6 weeks in a spica cast are required.
Medial Screw fixation

displacement
of distal
fragment
I J
Blade plate inserted
K
Closure of vastus
lateralis muscle
Plate 13.6 Greater Trochanteric Epiphysiodesis156
Operative Technique the distal transfer of the greater trochanter is anticipated

in the future.
(A) The child is placed supine with a sandbag under the
(B) The site of origin of the vastus lateralis from the
ipsilateral hip. The entire lower limb, hip, and pelvis are
upper part of the intertrochanteric line, the anteroinferior
prepared and draped to permit the free passive motion
border of the greater trochanter, the lateral tip of the glu-
of the hip. A transverse incision that is 5–7 cm long is
teal tuberosity, and the upper part of the lateral tip of the
centered over the epiphysis of the greater trochanter. If
linea aspera are shown.
desired, a longitudinal incision may be made, especially if
Transverse incision centered

over greater trochanter
Piriformis muscle
Gluteus Obturator
medius muscle internus muscle
A
Gemelli muscles
Quadratus
femoris muscle Gluteus
minimus muscle
Adductor Vastus
magnus muscle lateralis muscle
Gluteus
maximus muscle

Plate 13.6 Greater Trochanteric Epiphysiodesis156—cont’d
(C) The subcutaneous tissue is divided in line with the the Keith needle and the growth plate. (Many surgeons
skin incision, and the wound edges are retracted. A longi- will perform the arrest by removing the physeal cartilage
tudinal incision is made in the fascia of the tensor fasciae with a curet that is controlled with radiographic image
latae muscle. intensification.)
(D) The tensor fasciae latae muscle is retracted anteri- (F) The periosteum is divided by one longitudinal
orly, and the origin of the vastus lateralis is detached and and two horizontal incisions. The dotted rectangle marks
elevated extraperiosteally. the bone plug to be removed and turned around. This
(E) A Keith needle is inserted into the soft growth rectangle is 2 cm long and 1.25 cm wide. In a smaller
plate of the greater trochanteric epiphysis. Anteropos- child, the rectangle is 1 cm (2⁄5 inch) long and 0.6 cm (1⁄5
terior radiographs are obtained to verify the position of inch) wide.
Longitudinal incision
in fascia of tensor Tensor fasciae latae muscle
fasciae latae muscle retracted
Detachment of
vastus lateralis
muscle
extraperiosteally
Gluteus
medius
muscle
Greater
trochanter
C D
Gluteus
maximus muscle

Keith needle inserted
into growth plate Periosteum
reflected
Vastus
lateralis
muscle
E F
Apophyseal plate
of greater trochanter

(G and H) With straight osteotomies, the bone plug is to not enter the trochanteric fossa and injure the circula-
removed. Note that the growth plate is in the proximal tion to the femoral head.
third of the rectangle. (J) With a curved osteotome, cancellous bone is
(I) A diamond- shaped drill and curets are used to removed from the proximal femoral shaft and packed into
destroy the growth plate. The operator should be careful the defect at the site of the growth plate.
Osteotomes removing rectangular Bone plug removed; plug

piece of bone plug at site of includes part of apophyseal plate
greater trochanter
G H
Growth plate destroyed with

diamond-shaped drill and curets
I J
Cancellous bone (from
proximal femoral shaft)
placed in cleared
growth plate defect
(K and L) The bone plug is rotated 180 degrees, Postoperative Care

replaced in the defect in the greater trochanter, and, with
The patient is allowed out of bed on the first postopera-
an impactor and mallet, securely seated.
tive day as soon as he or she is comfortable. The patient is
(M) The muscles are resutured to their insertion sites, and
discharged home within a few days and instructed to pro-
the vastus lateralis is attached to the gluteus medius and min-
tect the limb that was operated on by using a three-point
imus tendons at their insertion sites after the closure of the
crutch gait for 3–4 weeks.
periosteum. The fascia lata is closed with interrupted sutures,
and the wound is closed with interrupted and subcuticular
sutures. It is not necessary to immobilize the hip in a cast.
Bone plug (rotated 180°)

replaced in greater trochanter
Bone plug
firmly impacted
K L
Vastus lateralis muscle sutured

to insertion of gluteus
medius muscle
Gluteus minimus, obturator,
and gemelli muscles
resutured to insertion
site
Periosteum sutured
M
Plate 13.7 Distal and Lateral Transfer of the Greater Trochanter
Operative Technique in profile and not superimposed on the femoral neck. It is

crucial to see the trochanteric fossa. The affected hip and
(A and B) The patient is placed on the fracture table with
the upper two-thirds of the thigh are prepared and draped
the affected hip in a neutral position with regard to adduc-
in the usual manner.
tion and abduction and in 20–30 degrees of medial rota-
A straight, lateral, longitudinal incision is made from
tion to bring the greater trochanter forward to facilitate
the tip of the greater trochanter and extended distally for
exposure. The opposite hip is placed in 40 degrees of
10 cm. The subcutaneous tissue is divided in line with the
abduction. Image-intensifier anteroposterior fluoroscopy
skin incision.
is used to show the femoral head and neck, the greater
(C) The fascia lata is split longitudinally in the direction
trochanter, and the upper femoral shaft. The hip should
of its fibers.
be rotated medially so that the greater trochanter is seen
Incision
Enlarged greater trochanter

above normal alignment with
center of femoral head
A B
Fatty tissue

fibers split longitudinally
Tensor fasciae
latae muscle
Vastus lateralis muscle
Gluteus medius muscle

Fascia lata
Incision of posterolateral
margin at tensor fasciae
C latae muscle

Plate 13.7 Distal and Lateral Transfer of the Greater Trochanter—cont’d
(D and E) The vastus lateralis is detached proxi- from the femoral shaft for 5–7 cm. The vastus lateralis
mally from the abductor tubercle by a proximally based should be elevated over its entire width.
horseshoe-
shaped incision and elevated subperiosteally

Line of detachment
of vastus lateralis Vastus lateralis muscle
muscle
Base of greater trochanter
Lateral intermuscular septum
Gluteus medius muscle Gluteus maximus muscle
Fatty tissue elevated
Capsule of hip
Greater trochanter
Gluteus medius
muscle
Femur
E Gluteus maximus muscle

(F) The anterior border of the gluteus medius is identi- the level of the abductor tubercle; it points to the trochan-
fied, and a blunt elevator retractor is introduced beneath teric fossa along a line that is continuous with the upper
its deep surface; it is pointed in the direction of the tro- cortex of the femoral neck. Radiography with image inten-
chanteric fossa. sification verifies the proper level and depth of the guide
(G) At this time, to orient the plane of the trochanteric wire. The point of the Kirschner wire must not protrude
osteotomy properly, a smooth Kirschner wire is inserted at through the medial cortex into the trochanteric fossa.
Chandler elevator
Gluteus medius
muscle Vastus lateralis muscle
F
Fibers of gluteus maximus muscle
retracted posteriorly, providing
exposure to greater trochanter
and subtrochanteric region
of femur
Gluteus medius muscle
Kirschner wire drilled at lower border

of greater trochanter in direction
of upper cortex of femoral neck,
stopping short of trochanteric fossa

(H) A blunt, flat retractor is placed beneath the poste- trochanteric fossa must be avoided to prevent necrosis of
rior border of the greater trochanter to protect the soft tis- the femoral head.
sues. The previously applied anterior retractor protects the (I) Next, a 3- mm-wide flat osteotome is driven
soft tissues ventrally. With a 2-to 3-cm-wide reciprocating through the osteotomy cleft, and the osteotomy site is
saw, the greater trochanter is divided in the anteroposterior wedged open by moving the handle of the osteotome
direction, following the proximal border of the Kirschner craniad. By applying leverage with the osteotome in
wire. The cut is stopped 3 mm short of the medial cor- the cleft, the operator produces a greenstick fracture of
tex of the trochanteric fossa. Injury to the vessels in the the medial cortex.
STOP! DO NOT CUT INNER CORTEX

DO NOT INJURE
RETINACULAR
VESSELS
Oscillating saw performing

osteotomy on proximal side
of Kirschner wire without cutting
opposite cortex
Flat 3-cm-wide osteotome

wedging open osteotomy
cleft; cortex at trochanteric
fossa cracked by wedging action
I
(J) A large periosteal elevator is placed deep into the resistance, it means that further adhesions are present
osteotomy cleft; this cleft is opened up medially by gen- that must be freed.
tly levering the handle up and down. The trochanteric (K) After sufficient mobilization of the greater trochan-
fragment is lifted superolaterally with a Lewin bone ter, the recipient site on the lateral surface of the upper
clamp, and adhesions between the joint capsule and the femoral shaft is prepared with a curved osteotome to cre-
medial aspect of the greater trochanter are released. ate a flattened surface. The surgeon should not remove too
This must be done very carefully to avoid injuring reti- much bone laterally. Next, the greater trochanter is dis-
nacular blood vessels in the capsule. Do not fracture the placed distally and laterally; with excessive femoral antetor-
greater trochanter. Mobilization is sufficient when, with sion, it may be moved slightly forward. If additional distal
lateral and distal traction placed on the greater trochan- advancement is desired, the hip may be abducted on the
ter, the muscle response is elastic; if there is still muscle fracture table.
Periosteal elevator releasing

all adhesions and soft tissue
between subjacent joint capsule
Greater trochanter and greater trochanter
pulled laterally
Segment of greater trochanter

J removed to facilitate
attachment to receptor site
Line of
section
Receptor site prepared

with osteotome and rasp
to create flattened surface

(L and M) The trochanter is held in the desired posi- the femur. We do not recommend internal fixation with the
tion and temporarily fixed to the femur with two threaded use of this method because screw fixation is more stable.
Kirschner wires of adequate size that are drilled upward However, in an obese or uncooperative patient, threaded
and medially. At this point, the accuracy of the position Kirschner wires may be used in addition to screw fixation.
of the greater trochanter is verified with image-intensifier Alternatively, a tension wire band may be used as described
radiography. As stated previously, the tip of the greater tro- in Plate 13.8 on page 504, “Lateral Advancement of the
chanter should be level with the center of the femoral head Greater Trochanter.”
and at a distance from it of two to two-and-one-half times (P) Final intraoperative radiographs are obtained to
the radius of the femoral head. If there are problems with ensure that the trochanter has been advanced to the
proper visualization, a long Kirschner wire is placed hori- desired site. Next, the detached origin of the vastus late-
zontally and parallel to both anterior superior iliac spines so ralis is firmly sutured to the tendinous insertion of the
that it crosses the center of the femoral head; the position gluteus medius and minimus muscles. This tension-band
of the tip of the greater trochanter is then checked. suture absorbs the pull of the hip abductors and reinforces
(N) Before osteosynthesis, the gluteal muscle is split in the the internal fixation of the greater trochanter. A suction
direction of the fibers to expose the bone and to avoid muscle drain is inserted, and the remainder of the wound is closed
necrosis. The greater trochanter is fixed to the lateral sur- in routine fashion. The skin closure is subcuticular.
face of the upper femur with two lag screws (each equipped
with a washer), which are directed medially and distally at
Postoperative Care
45-degree angles to counteract the pull of the hip abductors.
For large trochanters, 6.5-mm cancellous screws with drill The patient is placed in split Russell traction or on an abduc-
bits of appropriate size are used; with smaller trochanters, tion pillow with each hip in 35–40 degrees of abduction.
3.2-mm screws are used. The outer cortex of the greater tro- Active assisted exercises are begun as soon as the patient
chanter may be overdrilled. The tapping of the outer cortex is comfortable. Adduction and excessive flexion of the hip
is optional. The washers increase the surface area, help the should be avoided. Hip abduction exercises are performed
operator to avoid cutting through the cortex, ensure more with the patient in a supine position, which eliminates the
secure fixation, and allow for early motion. After both screws effect of gravity. Sitting should be allowed gradually and
are inserted, the initial Kirschner wires are removed. with care because, with 60–90 degrees of hip flexion, the
(O) Alternatively, fixation can be achieved with two posterior fibers of the gluteus medius muscle exert a strong
heavy, threaded Kirschner wires directed medially and lateral rotary force on the greater trochanter and may
upward. The resultant pull of the hip abductors through loosen its fixation.
the direction of the wires provides a force that will com- The patient is allowed out of bed on crutches when
press the greater trochanter against the lateral surface of comfortable and should be instructed to walk using a
Trochanter shifted laterally

and distally and aligned so
tip is at same level as center
Normal alignment of greater of femoral head
trochanter tip with center of
femoral head
2r
Temporary Kirschner wires

to hold fragments
L M
three-point gait with partial weight bearing to protect the good with regard to motor strength and until the Tren-
recently treated limb. The patient is discharged as soon as delenburg sign is absent.
he or she is independent and secure on crutches. Three The screws are removed 3–6 months after surgery. Dur-
weeks after surgery, side- lying hip abduction exercises ing screw removal, the operator should be very careful to
are started, and the child is allowed to sit and return to not damage the gluteus medius and minimus muscle fibers.
school. At 6 weeks, bony consolidation is usually adequate After the removal of the screws, the hip is protected by
to begin the use of one crutch on the opposite side (to three-
point partial weight bearing on crutches for 2–3
protect the operated hip) and to perform standing Tren- weeks. Side- lying hip abduction exercises and standing
delenburg exercises. One- crutch protection should be Trendelenburg exercises are performed to regain the motor
continued until the hip abductor muscles are normal or strength of the hip abductor muscles.
Gluteus medius muscle fibers

separated to allow placement Alternative fixation with two
of screws and washers heavy Kirschner wires directed
medially and upward
Two lag screws with

washers directed from
above downward and
medially to engage
N medial cortex of femur O
Capsule of hip
Gluteus minimus
muscle
Detached origin of vastus

lateralis muscle firmly
sutured to insertion of
Gluteus medius gluteus medius muscle
muscle
P Gluteus maximus
muscle
Plate 13.8 Lateral Advancement of the Greater Trochanter
Operative Technique (C) Internal fixation is augmented by a taut tension

(A) The surgical exposure of the greater trochanter and band of heavy wire suture that extends from the neck of
the upper femoral shaft is similar to that for the distal and each trochanteric screw to a small unicortical screw that
lateral transfer of the greater trochanter (see Plate 13.7, is anchored 6 cm distally in the femur. This wire tension
A–K, on page 497). band counteracts the pull of the hip abductors.
(B) The tip of the greater trochanter is at its normal (D) The detached vastus lateralis is then sutured to the
level, so it is not necessary to advance it distally. It is kept insertion of the gluteus medius. The subcutaneous tissue
horizontally level with the center of the femoral head, and and the skin are closed in the usual manner.
its position is maintained by two wide-thread positional
cancellous screws. The screws are inserted horizontally
Postoperative Care
and perpendicular to the osteotomized lateral surface of
the upper femur. The threads of these “positioning” screws Postoperative care is similar to that used after the distal
grip the trochanter as well as the intertrochanteric region and lateral transfer of the greater trochanter (see Plate
of the femur without compression. The cleft between the 13.7 on page 497)
greater trochanter and the femur is filled with autogenous
cancellous iliac bone, which is taken through a separate
incision over the iliac apophysis.
Shortened femoral neck Greater trochanter shifted

shortens distance laterally; position maintained
between tip of trochanter by two wide-thread screws
and center of femoral
head Tip of trochanter
is maintained
Tip of trochanter horizontal to
at normal level center of femoral head
Line of
osteotomy
Cleft between femur and
trochanter filled with
autogenous cancellous bone
A B

sutured to insertion of
Tight tension-band gluteus medius muscle on
wires stretched from relocated greater trochanter
screw necks in greater to maintain tension band
trochanter to small screw
secured distally in shaft
of femur
C D
Plate 13.9 Wagner Intertrochanteric Double Osteotomy
The first step of the operation is a soft tissue release femoral fragment is then pulled laterally so that the medial
of the hip adductors and the iliopsoas muscle through cortex of the upper end of the femoral shaft serves as a
a separate medial incision. Compressive forces between buttress to the inferomedial corner of the femoral neck.
the femoral head and the acetabulum should be relieved This maneuver elongates the femoral neck.
because elongation of the femoral neck will increase (C) When the femoral head and neck and the femoral
intraarticular pressure. The objectives are to elongate shaft have been brought into the correct position, three
the femoral neck, to restore the neck–shaft angle to nor- smooth Kirschner wires are used to transfix and tempo-
mal, and to displace the greater trochanter laterally and rarily hold the fragments. Next, the greater trochanter is
distally. transferred distally and laterally and fixed to the femoral
The bony procedure consists of two horizontal osteoto- neck with the threaded pin that was previously inserted in
mies: the first is at the base of the greater trochanter at its middle portion. Radiographs are obtained to check the
the level of the upper border of the femoral neck, and realignment of the three fragments and the correction that
the second is through the upper end of the femoral shaft has been achieved.
(above the lesser trochanter) and level with the lower (D) Osteosynthesis is performed with the use of a
margin of the femoral neck. The double osteotomy creates molded semitubular plate that is prepared as follows.
three fragments that can be moved and redirected inde- With a powerful wire cutter, a vertical slot is cut out from
pendently of each other. the plate’s upper end to the first screw hole. The bifur-
cated limbs are trimmed at their tips to sharp points and
then bent inward to form hooks. The semitubular plate
Operative Technique is reshaped to fit the superolateral surface of the upper
femur. The hooks are inserted into the tip of the greater
(A) The proximal part of the femur is exposed through trochanter and deep into cancellous bone for firm anchor-
a lateral longitudinal approach as described for distal and age. The diagonally inserted Kirschner wires transfix the
lateral transfer (see Plate 13.7, steps A–K, on page 497). neck and shaft and prevent the medial shifting of the fem-
First, a heavy threaded Steinmann pin is inserted in oral neck on the buttress provided by the upper medial
the center of the axis of the femoral head. The pin should cortex of the femoral shaft. All the screws are inserted,
stop short of the capital femoral physis. The level of the and the spaces between the fragments are packed with
two horizontal osteotomies is determined under image- autogenous cancellous bone obtained from the ilium
intensification radiography. The first should be at the base through a separate incision.
of the greater trochanter, and the second should be at Some surgeons may prefer to use other methods of
the upper end of the femoral shaft, immediately distal to internal fixation, such as a 90-or 130-degree AO right-
the base of the femoral neck. These levels are marked by angle plate as well as the stabilization of the fragments
inserting smooth Kirschner wires into bone. with multiple screws.
(B) A heavy threaded Steinmann pin is inserted into
the middle portion of the greater trochanter, stopping
Postoperative Care
short of its medial cortex. Next, the two horizontal oste-
otomies are performed under image-intensification radio- Osteosynthesis is secure, and it allows for active assisted
graphic control. It is vital to avoid the injury of the vessels exercises to take place 3 or 4 days after surgery. The
in the trochanteric fossa and the retinacular vessels. The patient is kept in bilateral split Russell traction for 3
deep ends of the osteotomies should stop short of the weeks, until the hip develops a functional range of
medial cortex, where a greenstick fracture is made. First, motion. At this point, partial weight bearing is permitted
the greater trochanter is pulled cephalad to facilitate expo- with three-point crutch gait protection. Bone healing is
sure. Next, the femoral neck fragment is pushed down- usually solid after 3 months, at which time full weight
ward and medially into the desired position. The distal bearing is allowed.
Note enlarged greater trochanter,

short femoral neck, and undersized
Upper line femoral head
of osteotomy
Neck fragment
Steinmann pin redirected medially
in relation to distal
(femoral) fragment
Lower line
of osteotomy
Buttress
Steinmann pin
used to maneuver
femoral neck
Distal (femoral) fragment
moved laterally
A B
Trochanter moved distally

and laterally with tip level
with center of femoral head
Gluteus
medius
muscle
Autogenous
cancellous
Permanent Kirschner wire bone chips
Kirschner wires to Molded semitubular

hold fragments plate
C D
Plate 13.10 Lateral Closing Wedge Valgization Osteotomy of the Proximal Femur With Distal and Lateral
Advancement of the Greater Trochanter
The greater trochanter and the upper femoral shaft are osteotomy. The apex of the osteotomy stops 1 cm short
exposed with the use of the technique described in Plate of the medial cortex. The length of the base of the wedge
13.7, steps A–K, on page 497. If the hip adductors are depends on the degree of correction of the coxa vara that
taut, they are released through a separate medial incision. is required. The wedge of bone is resected with an oscil-
lating saw.
Operative Technique (C) With a straight osteotome and leverage from
the pins anchored in the femur, a greenstick fracture is
(A and B) First, the greater trochanter is osteotomized produced in the medial cortex, thereby converting the
with the use of the technique described for distal and lat- osteotomy to a short-stemmed Y.
eral advancement. Next, two threaded Steinmann pins are
inserted to serve as guides for the level and angle of the
Gluteus medius and minimus muscles

Greater trochanter
insertion on greater trochanter
Steinmann pin
Wedge
excised
Lines of
osteotomy
Steinmann pin
A B
Greenstick fracture
through cortex converting
osteotomy to a Y

Plate 13.10 Lateral Closing Wedge Valgization Osteotomy of the Proximal Femur With Distal and Lateral
Advancement of the Greater Trochanter—cont’d
(D) The osteotomy gap is closed by bringing the two (F) The three fragments are then fixed with a prebent
Steinmann pins together and by aligning the neck, shaft trochanteric hook plate and screws.
and the greater trochanter at a preoperatively determined
angle.
Postoperative Care
(E) The greater trochanter is transfixed with a
threaded Steinmann pin that is driven into the neck of Care after this operation is similar to that provided after
the femur. the Wagner intertrochanteric double osteotomy.
Osteotomy gap closed

by bringing Steinmann
pins parallel
Greater trochanter advanced

distally and transfixed
with threaded Steinmann pins
Trochanteric bifurcated hook
transfixing femoral and greater
trochanteric osteotomy
E F
Plate 13.11 Pemberton Osteotomy (see Video 13.10)
The skin of the affected side of the abdomen and pelvis their origin and reflected. The iliopsoas tendon is length-
and the entire lower limb is prepared with the patient ened by transverse incisions, and the Pemberton iliac osteot-
lying on his or her side, and the patient is draped to allow omy lengthens the pelvis. Division of the psoas tendon (not
for free hip motion during surgery. Next, the patient is the iliacus muscle) decreases the pressure over the femoral
placed completely supine. The operation is performed on a head.
radiolucent operating table. It is imperative to have image- (B) The ilium is exposed subperiosteally all the way pos-
intensification fluoroscopic and radiographic control. teriorly. The interval between the greater sciatic notch and
the hip joint capsule posteriorly is developed gently and
Operative Technique cautiously. The periosteal elevator meets resistance at the
posterior limb of the triradiate cartilage. Chandler elevator
(A) The medial and lateral walls of the ilium and the hip retractors are placed in the greater sciatic notch medially
joint are exposed through an anterolateral iliofemoral and laterally to protect the sciatic nerve and the gluteal ves-
approach. The cartilaginous apophysis of the ilium is split sels and nerves. On the inner wall of the pelvis, the peri-
in accordance with the Salter technique. The sartorius osteum and the cartilaginous apophysis may be divided
muscle is sectioned at its origin from the anterior superior anteriorly to posteriorly at the level of the anterior inferior
iliac spine, tagged with 2-0 Mersilene suture, and reflected iliac spine as far as the sciatic notch; this will facilitate the
distally. Both heads of the rectus femoris are divided at opening up of the osteotomy.
Medial wall of ilium exposed
Anterior superior
iliac spine
Inguinal ligament
Anterior inferior
iliac spine
Chandler elevator in
greater sciatic notch
Capsule of hip joint

thoroughly exposed
Iliopsoas muscle
lengthened by
transverse incisions
Sartorius muscle sectioned

at origin and reflected
A
Subperiosteal exposure of Iliac apophysis split

outer and inner surfaces
of ilium
All soft tissue

removed from
both iliac spines
Chandler elevators in
greater sciatic notch
laterally and medially to
protect sciatic nerve and
inferior gluteal vessels
Gluteus medius and

minimus and tensor
fasciae latae muscles
elevated subperiosteally
Anterior inferior
iliac spine

Plate 13.11 Pemberton Osteotomy (see Video 13.10)—cont’d
(C to E) The osteotomy is first performed on the outer to the greater sciatic notch and posterior to the hip joint
table of the ilium. The cut is curvilinear, and it describes a margin. The next cut is made on the inner wall of the ilium,
semicircle around the hip joint on the lateral side at a level and it should be inferior to the level of the outer cut. The
that is 1 cm above the joint, between the anterior supe- more distal the level of the inferior cut, the greater the
rior and anterior inferior iliac spines. It is best to mark the extent of lateral coverage. If more anterior than superior
line of the osteotomy with indelible ink. The sharp edge of coverage is required, then the medial and lateral cuts in the
a thin osteotome is used to make the cut. The osteotomy ilium are parallel. The importance of sectioning the ilium as
ends at the posterior arm of the triradiate cartilage; this is far posterior and inferior to the triradiate cartilage as pos-
most difficult to see if the exposure is inadequate. Image- sible cannot be overemphasized. It is vital to not violate the
intensification fluoroscopy helps to determine the terminal articular cartilage of the acetabulum and enter the hip joint.
point of the cut at the triradiate cartilage, which is anterior
Medial wall of ilium Lateral wall of ilium
Inner pericapsular
cut in ilium Outer pericapsular
Full thickness of ilium cut in ilium
sectioned as far posteriorly
and inferiorly as triradiate
Posterior arm of cartilage
triradiate cartilage
Note: Triradiate
cartilage is open
C D
Lateral wall of ilium
Outer pericapsular
cut in ilium with
curved osteotome
DO NOT ENTER
HIP JOINT

(F) With sharp curved osteotomes, the cuts of the inner (G) If necessary, a lamina spreader may be used to sep-
and outer table of the ilium are joined. Periosteal elevators arate the iliac fragments. However, the operator should be
are used to mobilize the osteotomized fragments, and the very gentle; he or she should steady the upper segment of
inferior segment of the ilium is leveled laterally, anteriorly, the ilium and push it distally. Care should be taken not to
and distally. fracture the acetabular segment by forceful manipulation
or crushing with the lamina spreader.
Iliac apophysis split Iliac crest
Cuts in medial and lateral

walls of ilium connected
with curved osteotome
Anterior inferior
iliac spine
Medial wall
of ilium
Inner pericapsular
F cut in ilium
Upper segment of ilium

held steady and
pushed distally
Lamina
spreader
Acetabular segment
rotated with rake retractor
G anteriorly, laterally, and
distally

(H and I) Next, a triangular wedge of bone is resected the hip, and to prevent joint stiffness. The sartorius mus-
from the anterior part of the iliac wing. In the young child, cle is reattached to its origin, the split iliac apophysis is
we remove the wedge of bone more posteriorly and avoid sutured, and the wound is closed in the usual fashion. A
the anterior superior iliac spine; this gives greater stabil- one-and-one-half-hip spica cast is applied.
ity to the iliac fragments. The wedge of bone graft may
be shaped into a curve to fit the graft site. Pemberton
Postoperative Care
and Coleman recommend that grooves be made on the
opposing cancellous surfaces of the osteotomy. The graft is The cast is removed after 6 weeks, and the healing of the
impacted into the grooves, and the osteotomized fragment osteotomy is assessed with the use of anteroposterior and
is sufficiently stable to obviate internal fixation. We do oblique lateral radiographs. When joint motion and the
not recommend cutting grooves because of the associated motor strength of the hip extensors, quadriceps, and tri-
problems of splintering and the weakening of the acetabu- ceps surae muscles are good, the child is allowed to ambu-
lum. The fragments are fixed internally with two threaded late. In the older patient, a three-point crutch gait with toe
Kirschner pins or cancellous screws. The internal fixation touch on the limb that was operated on is used to protect
allows the surgeon to remove the cast sooner, to mobilize the hip until the Trendelenburg test is negative.
Triangular full-thickness
iliac graft
Trangular bone
graft removed
from iliac crest
Triradiate
cartilage
Bone graft inserted between
oseotomized iliac fragments
and firmly impacted
If fragments are not

fixed internally with screws,
hip is immobilized in a one-
and-one-half-hip spica cast for
4 to 6 weeks
H I
Plate 13.12 Salter Innominate Osteotomy (see Video 13.9)
(A to D) The Salter innominate osteotomy is based on the chest, and the affected half of the pelvis can be draped
redirection of the acetabulum as a unit by hinging and rota- to the midline anteriorly and posteriorly; the entire lower
tion through the symphysis pubis, which is mobile in chil- limb is also prepared and draped to allow for the free
dren. It is performed by making a transverse linear cut above motion of the hip during the operation. The patient is
the acetabulum at the level of the greater sciatic notch and placed supine with a roll beneath the buttock.
the anterior inferior iliac spine. The whole acetabulum with The skin incision is an oblique bikini incision. The
the distal fragment of the innominate bone is tilted down- incision that was formerly used over the iliac crest
ward and laterally by rotating it. The new position of the dis- produces an unsightly scar, whereas the bikini incision
tal fragment is maintained by a triangular bone graft that is results in excellent exposure and cosmesis. The anterior
taken from the proximal portion of the ilium and inserted inferior iliac spine is palpated and marked. The incision
into the open-wedge osteotomy site. Internal fixation is pro- begins approximately two-thirds of the distance from the
vided by two threaded Kirschner wires. Through the rota- greater trochanter to the iliac crest and extends across
tion and redirection of the acetabulum, the femoral head is the inferior spine and 1 or 2 cm beyond the inferior
covered adequately with the hip in a normal weight-bearing spine. The incision is then retracted over the iliac crest,
position. In other words, the reduced dislocation or sublux- and the dissection is carried down to the apophysis of the
ation that was previously stable in the position of flexion and crest. Anteriorly, the tensor–sartorius interval is bluntly
abduction is now stable in the extended and neutral position dissected, beginning distally and working proximally. The
of weight bearing. lateral femoral cutaneous nerve appears just medial to
(E) The skin is prepared with the patient in the side- this interval and just distal to the inferior iliac spine, and
lying position so that the abdomen, the lower part of the it should be protected.
Congenitally
Normal hip
dislocated hip
Kirschner
wires
Bone for
graft Innominate
osteotomy
Bone graft
Hip dislocated in
weight-bearing position
A B
Hip stable in
abduction and internal rotation
Kirschner
wires
Innominate
Bone graft
osteotomy
C D E

Plate 13.12 Salter Innominate Osteotomy (see Video 13.9)—cont’d
(F) With a scalpel, the cartilaginous iliac apophysis is split the anterior inferior iliac spine and the reflected one from
in the middle down to the bone from the junction of its the superior margin of the acetabulum—are divided at their
posterior and middle thirds to the anterior superior iliac origin, marked with whip sutures, and reflected distally.
spine. With the use of blunt dissection, the groove between Next, on the deep surface of the iliopsoas muscle, the
the tensor fasciae latae and the sartorius and rectus femoris psoas tendon is exposed at the level of the pelvic rim. The
muscles is opened and developed. With a broad and long- iliopsoas muscle is rolled over so that its tendinous portion
handled periosteal elevator, the surgeon strips the lateral can be separated from the muscular portion. If identifica-
part of the iliac apophysis and the tensor fasciae latae and tion is in doubt, a nerve stimulator is used to distinguish
gluteus medius and minimus muscles subperiosteally and the psoas tendon from the femoral nerve. A Freer elevator
the greater sciatic notch posteromedially. is passed between the tendinous and muscular portions of
(G) Next, the periosteum is elevated from the medial and the iliopsoas muscle, and the psoas tendon is sectioned at
lateral walls of the ilium all the way posteriorly to the sci- one or two levels. The divided edges of the tendinous por-
atic notch. It is vital to stay within the periosteum to prevent tion retract, and the muscle fibers separate, thus releasing
injury to the superior gluteal vessels and the sciatic nerve. the contractures of the iliopsoas without disturbing the
A common pitfall is the inadequate surgical exposure of the continuity of the muscle.
sciatic notch, which makes it difficult to pass the Gigli saw Two medium-sized Hohmann elevator retractors—one
behind the notch. The space on the lateral wall of the ilium introduced from the lateral side and the other from the
is packed with sponge to dilate the interval and to control the medial side of the ilium—are placed subperiosteally in the
oozing of blood. The periosteum is then elevated from the sciatic notch. This step is crucial: in addition to keeping the
inner wall of the ilium in a continuous sheet to expose the neurovascular structures out of harm’s way, the Hohmann
sciatic notch medially. Again, it is important to stay in the retractors maintain the continuity of the proximal and dis-
subperiosteal plane to avoid injury to the vessels and nerves. tal innominate segments at the sciatic notch.
The medial space is packed with sponge. The sartorius mus- A right-angle forceps is passed subperiosteally from the
cle can usually be reflected medially with the medial half of medial side of the ilium and guided through the sciatic
the cartilaginous iliac apophysis. If it is difficult to do so or notch to the outer side with the index finger of the sur-
if more distal exposure is desired, the origin of the sartorius geon’s opposite hand. The Gigli saw is most easily passed
muscle is detached from the anterior superior iliac spine, its by first passing an umbilical tape through the notch. The
free end is marked with whip sutures for later reattachment, end of the tape is tied to the Gigli saw. The tape is grasped
and the muscle is reflected distally and medially. The two with the right-angle clamp and pulled through the notch;
heads of origin of the rectus femoris—the direct one from it in turn pulls the saw through the notch.
Iliac apophysis split
Sartorius muscle
Gluteus medius
muscle
Hip joint capsule
Iliopsoas muscle white

F fibers divided Rectus femoris muscle
Forceps grasping umbilical

tape to which is tied the
Gigli saw
Iliac
apophysis
split
Anterior inferior iliac spine
Tensor fasciae
latae muscle
Hip joint capsule

not opened Sartorius muscle
Gigli saw Iliopsoas muscle lengthened

by transverse incision in
tendinous portion
G detached and reflected

(H) The osteotomy line extends from the sciatic notch fragment is grasped with a second stout towel forceps.
to the anterior inferior iliac spine, and it is perpendicular The affected hip is placed in 90 degrees of flexion, maxi-
to the sides of the ilium. It is vital to begin the osteotomy mal abduction, and 90 degrees of lateral rotation; a second
well inferiorly in the sciatic notch; the tendency is to start assistant applies distal and lateral traction to the thigh.
too high. The handles of the Gigli saw are kept widely With the second towel clip placed well posteriorly on the
separated and in continuous tension to keep the saw from distal fragment, the surgeon rotates the distal fragment
binding in the soft cancellous bone. The osteotomy, which downward, outward, and forward, thereby opening the
emerges anteriorly immediately above the anterior inferior osteotomy site anteriorly. The site must be kept closed
iliac spine, is completed with the Gigli saw. The use of an posteriorly. Leaving it open posteriorly displaces the hip
osteotome may subject the superior gluteal artery and the joint distally without adequate rotation and redirection of
sciatic nerve to iatrogenic damage. the acetabulum at the symphysis pubis; furthermore, it
(I) The Hohmann retractors are kept constantly at the will lengthen the lower limb unnecessarily. Another tech-
sciatic notch by an assistant to prevent the posterior or nical error to avoid is opening the osteotomy site with a
medial displacement of the distal segment and the loss mechanical spreader (e.g., a laminectomy spreader, a self-
of bony continuity posteriorly. A triangular full-thickness retaining retractor) because that may move the proximal
bone graft is removed from the anterior part of the iliac fragment upward and the distal fragment downward with-
crest with a large, straight, double- action bone cutter. out rotating the distal fragment through the symphysis
The length of the base of the triangular wedge represents pubis. The acetabular maldirection will not be corrected
the distance between the anterior superior iliac spine and unless such rotation of the distal fragment takes place.
the anterior inferior iliac spine. The portion of bone to be The posterior and medial displacement of the distal frag-
removed as a bone graft is held firmly with a Kocher for- ment should be avoided.
ceps; the operator must be sure that this portion does not When the periosteum on the median wall of the ilium
fall on the floor or get contaminated. is taut, the cartilaginous apophysis of the ilium is divided
The proximal fragment of the innominate bone is at two or three levels; this will help with the rotation of
held steady with a large towel-clip forceps, and the distal the acetabulum.
Hohmann elevators in
Donor site of graft greater sciatic notch laterally
and medially to protect
sciatic nerve and inferior
gluteal vessels
Gigli saw
Line of osteotomy
Gigli saw
Proximal segment
held stationary
Note continuity of
proximal and distal
segments at the
sciatic notch
Bone graft
inserted
I
Distal segment pulled
downward, outward, and forward
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(J) Next, the bone graft is shaped with bone cutters to A radiograph of the hips through the cast is obtained
the appropriate size to fit the open osteotomy site. The before the child is discharged from the hospital. Another
graft is usually about the correct size for the size of the set of radiographs is obtained 2–3 weeks after surgery to
patient because the base of the triangular graft represents ensure that the graft has not collapsed, that the pins have
the distance between the anterior superior iliac spine and not migrated, and that there is no medial displacement
the anterior inferior iliac spine. The surgeon should avoid of the distal segments. In the older cooperative patient,
using a large graft and hammering it in to fit snugly into when cancellous screws are used for internal fixation, a
the osteotomy site because this will open the site poste- hip spica cast is not necessary.
riorly. With the osteotomy site open anteriorly and the
distal segment rotated, the bone graft is inserted into the
Postoperative Care
opened-up osteotomy. The distal fragment of the innomi-
nate bone should be kept slightly anterior to the proximal The cast is removed after 6 weeks with the child under
fragment. When traction is released, the graft is firmly general anesthesia, and the pins are removed through a
locked by the two segments of the bone. portion of the original incision. Range-of-motion exercises
A stout threaded Kirschner wire is drilled from the are begun, and the patient is allowed to ambulate with
proximal segment across the osteotomy site, through the support. Older children can use crutches; those who are
graft, and into the distal segment posteri or to the ace- younger than 5 years old use a walker. Full weight bear-
tabulum, thereby preventing any future displacement of ing is resumed after 3 weeks if the range of motion of
the graft or the distal segment. The first wire should be the knee is more than 90 degrees. When an open reduc-
directed posterior to the acetabulum. Radiographs are tion has been combined with a Salter osteotomy, a second
obtained to check the adequacy of correction of the acetab- period of immobilization in abduction casts (Petrie casts)
ular maldirection and the position of the Kirschner wire. for approximately 4 weeks is recommended. This allows
A second Kirschner wire is then drilled parallel to the the hips to regain flexion and extension, and the abducted
first to further stabilize the internal fixation of the position maintains hip reduction.
osteotomy. In the older child, we use a third threaded
Kirschner wire or two cancellous positional screws to
ensure the security of internal fixation. The inadequate
penetration of the wires into the distal fragment will
result in the loss of alignment of the osteotomy. The
wires may bend or break, or, if they are excessively heavy, Two heavy Kirschner
they may fracture the graft or the innominate bone; the wires transfixing graft
importance of choosing the correct diameter of wire or
cancellous screw cannot be overemphasized. The pen-
etration of the wires into the hip joint may cause chon-
drolysis of the hip, or it may cause the wire to break at
the joint level. An anteroposterior radiograph of the hips
is obtained to check the depth of the Kirschner wires
and the degree of correction that has been obtained.
The two halves of the cartilaginous iliac apophysis are
sutured together over the iliac crest. The rectus femoris
and sartorius muscles are reattached to their origins, and Graft placed
the wound is closed in a routine manner. Skin closure
should be with continuous subcuticular 00 nylon suture.
The Kirschner wires are cut so that their ends are in the
subcutaneous fat and easily palpable. CAUTION: Do not penetrate hip joint.
A one-and-one-half-hip spica cast is applied with the Note that pins are drilled posteriorly.
hip in a stable weight-bearing position. Immobilization in
a forced or extreme position should be avoided because
it will cause the excessive and continuous compression of
articular cartilage, osteonecrosis, permanent joint stiff-
ness, and eventual degenerative arthritis. In the cast,
the knee is bent to control the position of hip rotation.
When there is excessive femoral antetorsion, the hip is
immobilized in slight medial rotation. A common pitfall
is immobilization in marked medial rotation; this mistake
J
will result in posterior subluxation or dislocation of the
femoral head. With femoral retrotorsion, the hip should
be immobilized in slight lateral rotation.

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CHAPTER 13

Developmental Dysplasia Harrry K.W. Kim and John A. Herring

Pediatrics defines DDH as a condition in which the femoral

Box 13.1 Incidence of Developmental Table 13.1 Incidence of Developmental Dysplasia of

Dislocation: 1.4 per 1000 births Geographic Area: Incidence per

of the hip. Aust N Z J Surg. 1976;46:359.

hip joint in the new-­born. J Bone Joint Surg Br. 1962;44:284.

section (3.7%) as compared with those delivered vaginally

Prenatal Positioning Postnatal Positioning

Box 13.3 Conditions Associated With

FIG. 13.3 Postnatal positioning in extension, as seen in this child

incidence of DDH as compared with other groups.36 A

At birth, the neonatal acetabulum is completely com-

Normal attachment Labrum slightly everted

Capsule Femoral head

Ligamentum teres elongated

Labrum from posterior and

head to seat deeply. Known clinically as “docking the head,”

In some untreated hips, the femoral head retains some

Dysplasia, Subluxation, and Dislocation After

of the hip are the result of subluxation or residual acetabular

Box 13.4 Physical Examination Findings by

manner. During the newborn period, there are usually no

FIG. 13.20 Developmental dysplasia of the right hip. One physical

FIG. 13.21 The Galeazzi sign. There is an apparent shortening

FIG. 13.23 The Klisic test for developmental dysplasia of

The Harcke Method The Terjesen Method

IIa 50°–60° 55°–77° Immature (<3 mo) Observation

IIb >50°–60° 55°–77° >3 mo Pavlik harness

IIc 43°–49° >77° Acetabular deficiency Pavlik harness

IId 43°–49° >77° Everted labrum Pavlik harness

III <43° >77° Everted labrum Pavlik harness

IV Unmeasurable Unmeasurable Dislocated Pavlik harness/closed vs. open

II 43°–60° 55°–77° Delayed ossification Variable

III <43° >77° Lateralization Pavlik harness

IV Unmeasurable Unmeasurable Dislocated Pavlik harness/closed vs. open

C LT HIP CORONAL NON–STRESS OOH_ D

Hip Angle 51.7° Hip Angle 50.7°

A Rt Hip Coronal Non-Stress B Lt Hip Coronal Non-Stress

Hip Angle 66.7° Hip Angle 63.8°

C Rt Hip Coronal Non-Stress

Shenton Center–edge angle

FIG. 13.33 (A) The false-­profile view is made

Table 13.3 Severin Classification System of

>25° (≥14 yr)

Ib Normal 15°–19° (6–13 yr)

20°–25° (≥14 yr)

IIa Moderate deformity of Same as class I

IVb Severe subluxation <0°

Box 13.5 Age-­Based Guidelines for the

Less certain are the indications for the treatment of hips

FIG. 13.39 The Ilfeld or Craig splint.

FIG. 13.38 Radiographic appearance in a 7-­month-­old child after

infants who were hospitalized for harness treatment had a

FIG. 13.42 Traditional traction position with a frame in the bed

in half of grade II dislocated hips with the use of the Fre-

At times, an adductor tenotomy will increase the safe

90° Maximal abduction

90° Maximal abduction

hip joint in the new-born. J Bone Joint Surg Br. 1962;44:284.

FIG. 13.33 (A) The false-profile view is made

Box 13.5 Age-Based Guidelines for the

FIG. 13.38 Radiographic appearance in a 7-month-old child after

FIG. 13.57 Bucholz-Ogden type III avascular