Treatment of DDH

Treatment of Developmental Dysplasia of the Hip (DDH) at Shaare Zedek Medical Center
At Shaare Zedek Medical Center, thousands of newborns are born every month, most of whom are healthy, but some require treatment. In our clinic for hip dysplasia, we treat numerous cases of DDH. The initial treatment is provided in the infant department, where we offer guidance to families and refer them to continue treatment at our clinic or through their health fund. Our clinic's physicians are authorized to perform hip ultrasound examinations using the Graf method (a classification method for infant hip joints) and have experience in diagnosing and treating using this technique.

Please note that this is a general explanation page that provides initial information about the phenomenon and its treatment. It does not replace specific information about each child treated by our medical team.

The two main parts of the hip joint are the femoral head (hip bone) and the acetabulum of the pelvis. The acetabular margins are covered by the acetabular labrum, a ring-shaped cartilage that surrounds the head of the femur (you may hear this term during the ultrasound). Both parts are covered with joint cartilage, and the entire joint is enveloped by a capsule that is lined with synovial tissue.

Developmental dysplasia of the hip is a condition in which the relationship between the acetabulum and the femoral head is not normal, leading to improper development of the tissues around and within the joint. It occurs between the 12th week of pregnancy and six months of age and can result in subluxation, dislocation, or destruction of the hip joint during the child's development.

The development of the acetabulum begins around the 12th week of pregnancy. Proper development of the hip joint (a round femoral head and a well-formed acetabulum) depends on appropriate alignment of the two bones and proper movement within the womb. Two basic factors can negatively affect this process: general laxity, which is often familial and may lead to hip joint disorders after birth, and the formation of a shallow acetabulum. Both are familial tendencies that increase the risk of developing DDH.

The condition is reported to occur in approximately 1 to 6 cases per 1000 infants up to the age of one year. It is more common in females (1:9) and families with a previous history of the disease. It is also more prevalent in first-born children, in breech presentations, and when there are other skeletal deformities. DDH is more common (twice as much) in the left hip, but the reason for this is unclear. However, the most significant risk factor for the disease is a previous case of DDH in other family members. Therefore, it is important to inform family members if your child has DDH and carefully examine all infants born in the family (second and third-degree relatives).

Every newborn currently undergoes at least one manual examination before being discharged from the hospital. A further manual examination by a pediatrician is performed at child health stations (milk clinics). An ultrasound examination of the hip joint is the next step in the diagnostic process. Hospital pediatricians or pediatricians at the milk clinic may recommend an ultrasound if there are suspicious findings during the manual examination or if the newborn is in a risk group (family history of DDH, other skeletal deformities, breech presentation, syndromes, or recommendations for every first-born child). Currently, ultrasound for all newborns is performed in Israel only as part of research studies. In some European countries, it is more widely accepted as part of preventive measures.

External findings that may lead to suspicion of DDH during a physical examination include asymmetrical thigh folds, uneven leg positioning, unequal leg length, hip instability, other skeletal deformities identified before birth via ultrasound, renal abnormalities, and more. There are two specific tests for hip joint problems (named after Barlow and Ortolani) that aim to detect subluxation during abduction.

If suspicion of DDH arises, the next step is imaging evaluation. The most commonly used test in Israel for newborns and infants up to six months of age is the ultrasound (sonographic) examination. In Israel, the examination is performed using the Graf method, which relies on the fact that the hip joint contains a lot of cartilage until the age of one, making sonographic imaging possible. During the examination, various angles between the femoral head and the acetabulum are measured, and based on the results, the need for monitoring or treatment is determined. The examination is performed by orthopedic specialists in a clinic setting (usually covered by health funds). It is radiation-free and does not require anesthesia or medication, but it can only be performed using appropriate equipment, a suitable table, and knowledgeable staff for performing the imaging and measurements.

X-ray of the pelvis is another option, and it measures different angles that indicate the development of the hip joint. This test becomes more reliable as the child grows (as there is more fibrous tissue present), but it involves radiation and requires precise positioning of the baby, making obtaining a good image sometimes challenging. This method is less commonly used due to the convenience of the sonographic examination. Another option is using computed tomography (CT) or magnetic resonance imaging (MRI) for imaging, but these methods require sedation or anesthesia to prevent movement and are not widely used.

In cases of subluxation, an arthrography of the hip joint might be performed, which involves injecting contrast material into the joint under anesthesia. It allows imaging of the joint after injection to determine the best treatment approach.

If DDH is confirmed during the imaging evaluation, treatment with the Pavlik harness or a similar device should be initiated. The harness is suitable for use until around six months of age. After applying the harness, it is essential to confirm through ultrasound that it stabilizes the joint properly and continues monitoring throughout the treatment. If harness treatment is not successful, a closed reduction (placing the femoral head into the acetabulum) may be performed under anesthesia, and a Spica cast (made of plaster) will be applied to the hip. This cast immobilizes the legs in a position similar to the Pavlik harness. At the end of treatment, an X-ray of the cast is necessary to confirm proper repositioning of the hip. The baby will remain in the cast (with regular replacements) until the hip joint is stable and the acetabulum develops properly. In cases where the acetabulum does not develop properly and in cases that were not diagnosed until later (over one year old), surgical interventions may be required, such as releasing tendons and ligaments to allow the femoral head to return to its place and cleaning the acetabulum from the fibrous material filling it. In some cases, surgical intervention may include cutting the pelvis and sometimes the femur to create a new acetabulum and a proper structure for both bones.

Like any disease, DDH can lead to several complications, including problems arising from the disease itself, such as hip joint inflammation and pain, limping, limited movement, unequal leg length, pelvic tilt, and hip tilting.

Other problems may result from the combination of the disease and its treatment. During the use of harnesses or Spica casts, avascular necrosis of the femoral head can occur. During surgery, there may be damage to muscles, tendons, nerves, bones, and skin, which can lead to various complications.