- Children’s Orthopaedic & Spine Care Clinic
So your child has been diagnosed with DDH / a hip dislocation. While we understand that it is disturbing news for a parent, there is no need to panic. We offer solutions for this problem, and our clinic has the experience and the technical facilities to deal with dislocated hips.
Dr Sanjay Sarup is one the leading paediatric orthopaedic surgeons in India for the treatment of Hip Dysplasia. His clinic receives patients from all parts of the country. He has successfully treated a large number of children from Central Asia, from neighbouring countries, from the Middle east, and from Africa . Many of these children have already suffered failed surgeries and come for revision operations. Dr Sarup has pioneered new arthroscopic techniques in DDH to minimize the trauma of surgery and to reduce the avascular necrosis rate. He has more than 30 years of surgical experience in the treatment of this condition. His patients have participated in all physical activities, have participated in dance and sports competitions. Most of them lead a normal active life.
Here is an example of a DDH baby who has presented to us late – at 22 months of age. This is typical of how our patients present.
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Fig: 22 months old female child, both hips are dislocated.
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Fig: At age 5 years (3 years after surgery). Hips have become normal. The child is fully active.
If you suspect DDH, or a diagnosis has been made for you by a medical specialist, the first thing to do is to contact us and fix an appointment. The baby will be seen by Dr Sarup and his team members, and appropriate imaging will be advised. Once a diagnosis is confirmed, and depending upon the age of the child and the clinical examination and investigative findings – a plan of treatment will be made.
If a Pavlik Harness is recommended, the parents will be counselled and the harness will be fitted onto the baby at the next appointment. Fitting the harness takes 15 minutes. Follow up Ultrasound scans will be made to document the progress. These are usually repeated once in 3 weeks.
Should the baby need anything more than this, parents will be counselled. Standard Blood tests and a pre-anaesthesia check will be ordered. Children are admitted on the day of the surgery.
The procedure of closed reduction, arthrography, adductor tenotomy and hip spica is carried out as day care. That means that the baby gets to go home the same day, and appropriate follow up is maintained.
If surgery is required, the normal stay is 4 days in hospital. In bilateral cases, opposite side surgery is carried out after 10 days.
A hip spica is worn for 10 weeks after the operation, and on removal, a hip brace is fitted.
Should your child or you face any problem, you can always contact us by dropping us a whatsapp message. We will address your concern as soon as possible.
Here is some useful information for Parents whose children have to undergo or have undergone surgery at out clinic.
These guidelines are also the general care guidelines for children wearing a hip spica:
General care instructions for a hip spica:
To avoid wetting the cast with urine:
Frequently change position of the baby
This would have been taught in the hospital and must be followed at home every 2-3 hours.
When the baby is prone, back care can be given.
Inform us accordingly
A visit may be required to the hospital OPD to rectify these problems.
Red Flags for a hip Spica
Inform us immediately if any red flag signs are evident.
Fig: Left hip dislocation in a 7 month old/ Notice the ball of the thigh bone ( blue ring) is out of the socket ( marked in red ).
Hip Dysplasia means abnormal development of the hip joint. The abnormal development causes a defective articulation of the hip joint. This results in a hip subluxation, or a hip dislocation or an arthritis later in life. The older terminology was Congenital hip Dislocation (CDH), but now this condition is called Developmental Dysplasia of the Hip (DDH).
The hip Joint is one of the most critical joints of the body. It is not possible to walk normally or live a normal life without a hip joint. The disease ‘DDH’ destroys a hip joint in the long term. Early diagnosis and treatment of this condition will make the hip joint normal in nearly all children. Delay in treatment reduces the chances of making the hip normal.
If you are a parent who has had DDH yourself, or/and you have a first-born child who is a female, and was in the ‘Breech’ position in the uterus, you will need to have your child checked up by a paediatric orthopaedic surgeon. This is because there is higher than normal chance of your baby having a DDH.
Remember – an early diagnosis means quick easy non-surgical treatment with a very high success rate. More information on this condition is available as answers to Frequently Asked Questions below.
At our clinic, we have treated over 800 cases of DDH of various ages over the last 21 years. We have developed specialized techniques include arthroscopy to treat this condition. At the moment, we are the only clinc in India to utilize arthroscopic methods to improve outcomes in children who have DDH.
At our clinic, when DDH is detected at an ideal age, we offer a Pavlik Harness and surveillance of the hip through serial Ultrasound examinations.
Fig: Baby with both hips dislocated being treated without surgery in a Pavlik Harness. Babies are very comfortable once they get used to being in the harness.
When children are detected late, age 4 months and to 12-18 months of age, they need general Anaesthesia, Hip arthrography, adductor tenotomy, closed reduction and hip spica. Very rarely, a Hip arthroscopy may be required.
Fig: 6 months old child with right hip dislocation in hip spica cast under anaesthesia
Fig: Babies can be carried quite easily in a hip spica and are quite comfortable wearing one.
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Fig: Age 11 years after closed reduction and cast – hips are normal now
When children present in walking age and the hip is dislocated, we offer a one-time correction in order to normalise bony anatomy and offer the ideal environment in order for the hip to develop normally. The correction surgery involves;
The cup (Acetabulum) of a dislocated hip is full of vascular fibrofatty tissue. This tissue blocks the ball of the femur from back into its normal position. The arthroscopy is done by making a careful 5mm puncture in the hip capsule at a spot which will not disturb the blood supply.
Conventional techniques cut the capsule open, remove a portion and then stitch up the capsule tight (Capsulorrhaphy). This can disturb the entry point of blood vessels through the capsule and can be one of the causes of Avascular Necrosis of the Femoral Head.
Our techniques minimize the chances for developing Avascular Necrosis of the Hip, the most dreaded complication of treatment of a dysplastic hip.
This restores the bone alignment of the thigh bone and the femoral head points correctly into the depth of the acetabular cup once this operation is completed.
This restores the depth and the alignment of the Acetabular cup. The Acetabulum changes in shape from being like an asymmetrical saucer into a cup with depth. After surgery, it ‘locks’ the femoral head in place thereby stabilizing the reduced femoral head in the socket.
This technique has many advantages over conventional methods. This has been borne out by our experience with DDH over the last 30 years. The current technique was developed in 2004, and is applicable to all our patients up to 7 years of age or 35 kgs of weight.
Fig: . 8 - 2 year old female, left hip dislocation.
Fig- 9 – She underwent arthroscopy, pelvic osteotomy and femoral osteotomy
Fig- 10 - X-ray at age 5 years with a normal hip
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Fig: 11- 2 and half year-old baby girl with both hips dislocated. She underwent similar surgery of hip arthroscopy, pelvic osteotomy, femoral osteotomy.
Fig- 12 – Well developing hips at 5 years
Fig- 13 – Normal hips at age 11 years
For children over 35 kgs and 7 years of age, we carry out an open capsulorrhaphy instead of arthroscopy. The hips at this point are very deformed.
DDH (Developmental Dysplasia of the Hip) is a condition where the ball shaped head of the thigh bone – the femoral head – comes out of the hip joint. The condition is usually present at birth and was previously called the congenital dislocation of the hip.
It is now known that Hip Dislocation is a spectrum disorder. The severity ranges from mild with only flattening of the Acetabulum (the cup shaped socket of the Pelvic bone that articulates with the ball shaped femoral head), or Subluxation – with the femoral head sliding partially out of the socket, or in its most severe form – a Dislocation of the femoral head of the socket of the Acetabulum. Therefore, the condition is called Developmental dysplasia of the Hip. Dysplasia means incomplete development / formation.
The condition can occur spontaneously, or it can run in families:
Dysplasia (incomplete development and not necessarily a dislocation) occurs in 1 per 1000 babies. The incidence of frank dislocation is much less.
The condition is more common in babies who have a Breech position in the mother’s womb (head up rather than the normal head down position in the womb). It is more common in Females, and in first born children. It is more common in twins, in children of mothers who have suffered DDH, or if DDH is present in older siblings.
Communities that swaddle babies have higher incidence of DDH.
Overall, DDH is less common in India as compared to North European countries or North America.
When a baby is born, there may be no external evidence of DDH. However, suspicion should arise if
Fig: The left leg is shorter than the right. This is an indicator of a dislocated hip
Fig: 14- Same patient as in Fig 13. Ultrasound scan showing a dislocated Left hip.
15 - X-rays show a dislocated left hip.
The doctor should have a high index of suspicion if the baby is a first-born female, with a breech lie in the uterus. Also, there is higher chance of having DDH if there is a family history of the same problem in the mother, other siblings, or cousins, aunts, uncles or grandparents.
Contrary to popular belief, a hip dislocation is completely painless. So the child never complains of any pain or discomfort.
It is notoriously easy to miss a hip dislocation which is present in both hips – since there is no asymmetry in features. A child with bilateral hip dislocation walks near normally and therefore parents cannot detect anything abnormal till 2 to 3 years of age.
The diagnosis is made by a combination of a clinical examination and an imaging modality.
Clinical Assessment:
A detailed history taking and a careful clinical examination carried out by an experienced clinician (who is usually a paediatric orthopaedic surgeon or a paediatrician trained in this field) is mandatory.
Imaging modality:
When the baby is less than 4 months of age, the diagnosis is best confirmed by an Ultrasound examination. The Ultrasound examination must be carried out by an Ultrasonologist who is trained to examine hip with dysplasia. The Ultrasonologist not only confirms the diagnosis, but is also able to grade the severity of the problem.
At more than 4 months of age, the diagnosis can be confirmed on an AP view X-ray of the hips.
As the child becomes older, the diagnosis becomes more and more obvious, both on clinical examination and by an x-ray of the hips.
Mild dysplasia can correct itself in the first few weeks of life. The improvement needs to be carefully monitored by serial Ultrasound examinations under the supervision of a paediatric orthopaedic surgeon.
Once the articulation between the socket (The Acetabulum) and the ball (of the femoral head) is lost, the anatomy starts to change progressively. The socket (the acetabulum) changes from being a deep cup into a more flattened saucer shape, losing its shape and its grip on the femoral ball. The tissues that connect the two – the hip capsule and the internal ligament Teres – get stretched and are now unable to lock the ball and socket together. The femoral head, which is ball shaped, gets deformed and faces forwards (Anteverted). All of these changes get accentuated as the child becomes older. This making surgical treatment more extensive and difficult.
The asymmetry of the legs causes adverse effects on the spine, the opposite hip, and the knee joints. The spine can develop deformation which can become fixed and irreversible. The muscles around the affected hip become foreshortened and weak.
Over a period of time, the limping gets worse. Pain can develop and signal the onset of destruction of the hip joint. Premature arthritis develops in early adulthood.
Ultimately, the hip needs to be replaced. However, hip replacement in this setting is more challenging than straightforward hip replacements.
In an infant, Hip dysplasia can be treated without surgery. This is especially so if the dysplasia is mild, as determined by Ultrasound examination. Major surgery can be avoided in many cases up to age 12 months. After 18 months of age, surgery is always required. The magnitude of surgery increases as the child gets older.
In children less than 3 years, mild forms of dysplasia in children less than can be treated by hip abduction splints and exercises. Close observation is important; regular X-ray examination of the hip may have to be carried out to det
The type of treatment depends on age of the patient:
Age 0-6 months
The baby undergoes Ultrasound examination once in 3 weeks to determine progress. Once the Ultrasound shows stable hip with resolution of dysplasia, the harness is removed. This typically takes 2-3 months.
The baby is given exercises, and has regular check ups till 1st year of age when it is clearly determined that the hip development has achieved normalcy.
Age 3months – 12 months
This treatment can be carried out when the dislocation is diagnosed after 3 months of age, and can be usually applied till 12 to 15 months of age. This type of treatment does not involve any major surgery, but it does require a general anaesthesia.
Age 12 months – 18 months
The procedure depends on whether the hip is subluxated or dislocated, and whether the soft tissue around the hip is too tight to allow a gentle reduction. So the operations have to be tailored individually for children. The various options are:
The procedure is the same as in younger babies. It is done when reduction back into the socket is easily possible.
This is a time-honoured technique. The hip is opened, cleaned out and the hip capsule is tightly sutured to lock the femoral head into the acetabular cup. A hip spica is applied after the surgery.
Conventional treatment at this stage is open reduction of the hip. In this procedure, the hip joint is opened and cleaned out, the head of the femur is placed inside the socket, and the capsule of the hip joint is stitched back to hold the joint together.
In our department, the hip socket is cleaned out with an arthroscopic procedure. Once the socket is cleaned out, gentle closed reduction is carried out and hip spica is applied.
This arthroscopic procedure avoids the cutting and stripping of muscles and enables quick healing. The Hip Arthroscopic clearance also avoids the cutting of hip capsule and its subsequent suturing. The blood supply of the hip enters through the capsule. Cutting and tightly suturing the capsule strangulates the blood supply of the femoral head. Therefore, arthroscopic clearance reduces one of the dreaded complications of DDH surgery – namely Avascular Necrosis of the Femoral head.
Age 18 months and above.
The hip joint is cleaned out with an Arthroscopic clearance, without violating the hip capsule and thereby not potentially disturbing the blood supply to the femoral head. The femur bone is osteotomized and its forward angulation (anteversion) is corrected to normal. The ball of the femur head is placed in its normal position in the acetabulum after the clearance. The acetabulum is reshaped to restore normal anatomy by making it more horizontal in orientation and deepening the cup. A hip spica is applied at the end.