DDH / CDH
So your child has been diagnosed with DDH or 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.
22 months old female child, both hips are dislocated.
At age 5 years (3 years after surgery). Hips have become normal. The child is fully active.
My Child has DDH – What should I do?
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. For more information , please read below:
Information for Parents – DDH / CDH
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. Arthritis will develop in such a hip later in life.
The older terminology for this condition 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 including arthroscopy to treat this condition.
We are the only clinic in India to utilize arthroscopic methods to improve outcomes in children who have DDH.
At our clinic, when DDH is detected at an ideal early age, we offer a Pavlik Harness and surveillance of the hip through serial Ultrasound examinations.
2 Month Old Baby with
both hips dislocated
Treated without surgery in a Pavlik Harness. Babies are very comfortable once they get used to being in the harness.
2 Month Old Baby with both hips dislocated being Treated 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 onwards up to 12-18 months of age, they need general Anaesthesia and-
Hip arthrography (where some contrast material is injected into the hip joint to see it better),
Adductor tenotomy (these are tight muscles on the inside of the thigh and releasing them is important to aid the relocation of the hip joint),
Closed reduction (the gentle relocation of the hip joint with the baby asleep under anaesthesia) and
Hip spica (The cast to hold the joint in place till it heals).
Very rarely, a Hip arthroscopy may be required. That means that most of the babies in this age group are treated by minor surgery, with no pain or discomfort and minimal time in hospital.
same child with right hip dislocation in hip spica cast
6 month old child with right hip dislocation in Spica cast
Babies can be carried quite easily in a hip spica and are quite comfortable wearing one
After closed reduction and hip spica cast in infancy. Child is now 11 years old and hips are normal.
When children present in walking age and the hip is dislocated, we offer a one-time corrective surgery in order to normalise bony anatomy. The surgery reduces the head of the femur back into its correct position. This creates the ideal environment in order for the hip to develop normally.
The correction surgery involves;
Hip Arthroscopy
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 involves the instruction of tiny camera into the hip joint, along with specialized instruments to clear the hip joint of all the tissue that has filled the cup of the acetabulum. 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.
Femoral Osteotomy
The femur (thigh bone) is deformed at the top end – it faces too far forwards (High degree of Anteversion) in these cases.
Osteotomy (cutting of bone, realigning it and fixing the new position with a plate) is done.
The bone alignment of the thigh bone is normalized and the femoral head points correctly into the depth of the acetabular cup once this operation is completed.
Pelvic Osteotomy
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.
2 year old female, left hip dislocation.
She underwent arthroscopy, pelvic osteotomy and femoral osteotomy
At 5 years age - the hip is normal now
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 and the arthroscopic technique is not suitable after age 7 years.
Information for Parents whose children have to undergo surgery for DDH
Preoperative preparation
- A hip abduction brace is ordered. These are customized to the baby and take 5 working days to make. The brace has to be worn after the plaster is removed at 3 months following the surgery.
- The child undergoes the following blood tests before surgery:
- Urine Routine and Microscopy
- COVID RTPCR is done one day before surgery at the hospital.
- The child should not have any cough or cold, or any other infection at the time of surgery. A pre-anaesthesia check is carried out 1 day before surgery by the Anaesthesia team to determine fitness for surgery and to determine any special needs that the child may have.
Day of Surgery
- The child is admitted on the day of surgery, usually early morning.
- Children 6 months – 12 months are advised to stop feeding 6 hours before surgery. Clear fluid like water and clear apple juice are allowed till 3 hours before surgery.
- Older children are fasted for 6 hours before surgery.
- The child is shifted to preop holding area where an IV cannula is inserted, and the consent forms for surgery and anaesthesia are signed. Preoperative sedation may be given to relieve anxiety.
- When the child is shifted to the Operating room, parents have to leave the holding area.
Care after Surgery
- Once the surgery is over, the parents are informed so that they are present in the post-operative area to be with the child. The child comes out wearing a hip spica.
- A diaper is applied to the private parts to prevent stool soiling
- A small dressing is placed at the place of surgery for releasing adductor tendon. This may show a blood spot but this is normal.
- Xray imaging is carried out once the child is sufficiently awake.
- For a closed reduction, adductor tenotomy and hip spica, the children are discharged from hospital the same day or the next morning.
Care at Home after hip dislocation surgery
- The child should be comfortably rested at home after discharge.
- We encourage 2-4 hourly turning of the baby from supine position (Baby lying on the back) to prone position over a pillow (Baby lying on the tummy).
- Hip spica care is very important.
Caring for the plaster cast - Hip Spica:
These guidelines are also the general care guidelines for children wearing a hip spica:
Please follow all instructions given to you at the time of discharge.
General care instructions for a hip spica:
- The hip spica should not get wet. Usual cause of a wet spica is leaking of urine into the hip spica.
- When washing hair or upper body, do not allow water to enter the cast
- You can also wet sponge clean the baby’s trunk area to avoid the cast getting wet.
- Do not insert any object into the cast. It can remain inside and will cause a sore (An infected wound).
- Make sure that the baby does not insert any objects into the cast.
- Do not scratch inside the cast. Deep scratches can get infected.
- Give frequent small meals when in hip spica. Large meals should be avoided.
- Do not pour a lot of talcum powder into the hip spica. It will cake up inside and can cause a local infection
To avoid wetting the cast with urine:
- Correct size diaper (Usual brand name – Huggies) must be used.
- Change the diaper when wet
- Do not stuff the diaper into the hip spica. That will deliver the urine into the hip spica if diaper gets fully soaked
- Raise the head end of the bed so that the baby’s bed has a downward slope towards the foot end. This will encourage the urine to flow down and away from the hip spica.
- If the lining of the hip spica gets wet; Blow dry the wet areas with a hair dryer using cold air. It is very important to keep the heating switch in off The baby’s skin can be damaged from hot air, and the child will suffer burns.
- A wet spica liner promotes contact dermatitis. The skin of the baby can become red, ulcerated, and infected if the wetness is allowed to persist.
- To avoid contact dermatitis, a parent can regularly apply RASH-FREE cream to area under the diaper.
Frequently change position of the baby
- Position is changed from supine to prone, and vice-e-versa.
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.
- Inspect the back – look for a rash
- Look for any wetness in the plaster liner – dry it as described above.
- Look for any areas under pressure from the edge of the cast. The skin may be red, or the child may cry if there is pain from the plaster edge.
Inform us accordingly:
- A visit may be required to the hospital OPD to rectify these problems.
Red Flags for a hip Spica
- The child is vomiting persistently. This happens a day or two after application of the cast. Inform your doctor immediately.
- Foul smell coming from the cast – indicates a skin infection
- Red rash on the cast edge or the diaper area. This is usually due to prolonged contact with urine. It is also called a diaper rash.
- Any persistent swelling of the feet indicating a tight cast.
- Any Blue discolouration or white discolouration of the feet accompanied by incessant crying.
There is more information given in the FAQ (Frequently Asked Questions) section below.
What is Congenital Hip Dislocation/ DDH/ Hip dislocation?
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 Dysplasia and 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 out of the socket of the Acetabulum. Therefore, the condition is called Developmental dysplasia of the Hip. (Dysplasia means incomplete development / formation).
What causes congenital dislocated hip?
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.
What are the signs of hip dysplasia?
When a baby is born, there may be no external evidence of DDH. However, suspicion should arise if
- One leg appears to be shorter.
- There is asymmetry of the thigh folds or creases
- One leg spreads (abducts) less than the other
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.
- As the child starts walking, a shortening of the leg becomes evident.
- The child limps while walking.
Contrary to popular belief, a hip dislocation is completely painless. 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.
How is congenital hip dislocation diagnosed?
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.
Can hip dysplasia fix itself?
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.
What happens if hip dysplasia is left untreated?
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.
Do you need surgery for hip dysplasia or can it be treated without surgery?
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 determine improvement.
What is the treatment for congenital hip dislocation?
The type of treatment depends on age of the patient:
Age 0-4 to 6 months
- Non-surgical treatment – PAVLIK HARNESS. When hip dislocation is diagnosed in a new born, treatment is highly successful without the need for surgery. We treat the babies with a Pavlik harness. The harness is applied in the out-patient / consulting room. The baby can go home immediately afterwards, and usually needs a pacifier to settle into the harness.
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 4months – 12 months
- Non- surgical treatment – HIP SPICA & HIP ABDUCTION BRACE.
This treatment can be carried out when the dislocation is diagnosed after 4 months of age, and can be usually applied till 12 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:
- Closed reduction, adductor tenotomy and hip spica.
The procedure is the same as in younger babies. It is done when reduction back into the socket is easily possible.
- Open reduction of the hip.
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.
- MINIMALLY INVASIVE SURGERY – HIP ARTHROSCOPY with or without femoral osteotomy.
- Beyond 8 months of age, the muscles around the hip start to become stronger, the cup shaped Acetabulum fills up with fibrous tissue. It acts as an obstruction to the return of the femoral head into its correct position. The Acetabulum remains flattened or actually becomes even more flat. The ball shaped femoral head starts to lose its shape. The soft tissues holding the joint together (the capsule) becomes even more loose and elongated.
- All these factors prevent the relocation of the femoral head into its normal position. At this stage, in order to relocate the femoral head, the cup shaped acetabulum needs to be cleaned out.
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.
- We are the only centre in India to offer arthroscopic treatment of DDH.
Age 18 months and above.
- At this stage, the anatomy is significantly changed. There are severe dysplasia changes in the acetabulum. The cup is filled with fibrous tissue, it is flattened, and its inclination is more vertical. The femoral neck is highly anteverted, and the femur sits high, well above its normal position in the acetabulum.
- Surgery offered at this stage is a combined procedure. We call it the Arthroscopic triple procedure. It consists of a Hip Arthroscopic clearance, a Pelvic Osteotomy, and a Femoral osteotomy.
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.