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DDH Treatment - Complete Summary (Campbell's Operative Orthopaedics, 15th Ed 2026)

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Overview of Treatment Principles

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STAGE 1: Newborn to 6 Months - Pavlik Harness

Mechanism

Success Rate

• 85% to 95% success rate in children treated during the first few months of life
• Success decreases as the child ages and soft-tissue contractures develop

Indications

• Dislocatable or dislocated hips in infants under 6 months
• DDH detected on clinical or ultrasound screening

Contraindications

• Teratologic dislocation (harness unlikely to succeed)
• Fixed contractures / older crawling infants
• Fixed dislocation with soft tissue adaptation

Application & Monitoring

• Applied with the hip in flexion >90° and abduction ~60° (within the "safe zone")
• Anterior strap prevents extension (maintains reduction); posterior strap prevents adduction
• Monitoring by physical exam and ultrasound every 2-4 weeks
• If no reduction in 3-4 weeks, the harness should be discontinued

Complications

• Femoral nerve palsy - from excessive hip flexion (>90-100°)
• Osteonecrosis of the femoral head - from excessive abduction and pressure on the medial circumflex artery
• Both complications occur in <1% of properly managed patients

AAOS Clinical Practice Guideline Notes

• Moderate evidence: do NOT perform universal ultrasound screening of all newborns
• Moderate evidence: perform imaging before 6 months if risk factors present (breech, family history, clinical instability)
• Limited evidence: ultrasound in infants <6 weeks with positive instability exam may guide brace decision

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STAGE 2: 6 to 18 Months - Closed or Open Reduction

Preoperative Traction (Controversial)

• Role is controversial; some advocate for skin traction to bring the femoral head down toward the true acetabulum before reduction
• Skeletal traction is not indicated at any age
• A few studies have failed to demonstrate benefit in reducing osteonecrosis or improving reduction rates
• Primary femoral shortening has largely replaced preoperative traction in older children

Adductor Tenotomy

• Percutaneous or open adductor tenotomy is often performed before closed or open reduction
• Releases the soft-tissue tension that prevents the femoral head from seating in the acetabulum

Closed Reduction + Arthrogram (Technique 32.1)

• Performed under general anesthesia with image intensification
• Hip arthrogram is injected (diatrizoate or iohexol contrast, 1-3 mL) to assess reduction quality
• Arthrogram shows the "medial dye pool" - a wide pool indicates interposed soft tissue (fibrofatty pulvinar, infolded labrum, hypertrophied ligamentum teres) preventing concentric reduction
• Safe zone of Ramsey: the arc between the position of dislocation and the position of impending excessive pressure - a wide safe zone favors success
• After reduction, a hip spica cast is applied in the "human position" (90-100° flexion, 40-55° abduction)
• 3D imaging (CT or MRI) post-cast is recommended to confirm concentric reduction

Open Reduction - Anterior Approach (Technique 32.3)

• Failed closed reduction
• Obstacles to reduction identified on arthrogram (medial dye pool, infolded labrum, hypertrophied pulvinar)
• Children >18 months

1. Anterior (Smith-Petersen type) or anterolateral approach (bikini incision in infants)
2. Iliopsoas tendon lengthening or tenotomy at the pelvic brim
3. T-shaped capsulotomy to enter the joint
4. Removal of obstacles: ligamentum teres, fibrofatty pulvinar (pulvinar of fat pad in the acetabular floor), transverse acetabular ligament sectioned to allow deeper seating
5. Capsulorrhaphy (tightening the redundant capsule) after reduction
6. Confirmed concentric reduction; spica cast applied (90-100° flexion, 40-55° abduction)
7. Spica cast changed at 5-6 weeks, removed at 10-12 weeks

Open Reduction - Medial Approach (Technique 32.4 - Ludloff)

• Transverse incision just distal to inguinal ligament
• Adductor longus divided, pectineus retracted superiorly
• Iliopsoas tendon divided at the lesser trochanter
• Transverse acetabular ligament sectioned
• Medial circumflex artery branch preserved (critical - supplies femoral head)
• Hip reduced and spica cast applied (8-12 weeks total)

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STAGE 3: 18 Months to 36 Months (Toddler) - Open Reduction + Osteotomy

• Open reduction (anterior approach, as above)
• Femoral osteotomy (varus derotational ± shortening)
• Pelvic osteotomy (if acetabular dysplasia persists)

Primary Femoral Shortening

• Used when the femoral head is high and proximally dislocated
• Reduces soft-tissue tension from contracted hamstrings, abductors, and neurovascular structures
• Has been shown to lower the risk of osteonecrosis by reducing pressure on the femoral head vasculature
• 1-2 cm of bone removed from proximal femoral shaft

Varus Derotational Osteotomy (VDRO) (Technique 32.7)

• Corrects coxa valga (excessive neck-shaft angle) and excessive anteversion
• Performed at the subtrochanteric level
• Fixed with pediatric hip screw, angled blade plate, or proximal femoral locking plate
• Reduces the force across the dysplastic hip and improves coverage

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Pelvic Osteotomies (Table 32.1 - Campbell's)

Salter Innominate Osteotomy

• Redirects the entire acetabulum anterolaterally to improve anterior and superior coverage
• A complete iliac osteotomy from sciatic notch to anterior inferior iliac spine; the fragment is displaced anterolaterally using a bone graft
• Does not cause acetabular retroversion
• Indications: DDH in children 18 months to 6 years; developmental subluxation in early adulthood
• Any dislocation/subluxation must be concentrically reduced before or at time of osteotomy
• Simultaneous capsulorrhaphy and adductor/iliopsoas release are performed as needed

Pemberton Acetabuloplasty

• Incomplete (hinge) osteotomy - the triradiate cartilage acts as the posterior hinge
• Allows greater correction of acetabular index than Salter
• Preferred when large correction is needed and in children <10 years (open triradiate cartilage)
• Can reduce the acetabular volume (risk if femoral head is large)

Ganz Periacetabular Osteotomy (PAO)

• For adolescents/adults with closed triradiate cartilage and residual acetabular dysplasia
• Three-dimensional reorientation of the acetabulum
• Preserves the posterior column for stability
• Used when hip is congruous but dysplastic

Chiari Osteotomy / Shelf Procedures

• Salvage procedures for incongruous joints
• Chiari: medial displacement osteotomy of the ilium just above the acetabulum - increases bony coverage by interposing the joint capsule
• Shelf: builds a bony "shelf" of bone graft over the superolateral acetabular rim
• Used when reconstructive osteotomies cannot achieve concentric reduction

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STAGE 4: Older Children and Adults - Total Hip Arthroplasty (THA)

Technical Challenges (from Campbell's 15th, Block 15 - Adult Hip Dysplasia)

• High hip center with small, shallow acetabulum
• Deficient anterosuperior acetabular bone stock
• Coxa valga and excessive femoral anteversion
• Shortened leg / small medullary canal
• Hypoplastic/absent abductor muscle strength

Surgical Strategy

• Acetabular reconstruction at or near the true acetabulum (not the false acetabulum)
• Structural or morselized bone grafting for acetabular deficiency
• Cementless press-fit acetabular components preferred
• Smaller cup sizes often needed
• Subtrochanteric femoral shortening osteotomy may be required to prevent excessive leg lengthening and neurovascular injury (peroneal nerve palsy risk with >4 cm lengthening)
• Modular or custom femoral stems for small/deformed medullary canals

Outcomes (Recent Evidence)

• DDH patients have higher complication rates (dislocation, leg length discrepancy, neurovascular injury)
• Overall implant survival is comparable at medium-term follow-up
• Dislocation risk is increased in DDH-THA; risk factors identified in a 2023 systematic review (Shahbazi P et al., PMID 37688602, Int Orthop): high Crowe type, excessive cup anteversion, abductor deficiency

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Complications of DDH Treatment (All Ages)

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Treatment Algorithm by Age (Summary)

Newborn – 6 months:      Pavlik Harness (1st line)
                         ↓ Failure at 3-4 weeks
6 – 18 months:           Closed Reduction + Arthrogram → Spica Cast
                         ↓ Failure / obstacles on arthrogram
                         Open Reduction (Anterior or Medial approach)
18 months – 3 years:     Open Reduction + Femoral Shortening/VDRO + Pelvic Osteotomy
3 – 8 years:             Open Reduction + Salter or Pemberton Osteotomy
Adolescent:              Ganz PAO (congruous joint) or Steel triple osteotomy
Adult:                   Total Hip Arthroplasty ± Subtrochanteric Shortening

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Recent Journal Evidence (2023-2024)

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Vascular vs Neurogenic Claudication - Complete Comparison

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Definitions

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Pathophysiology

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Clinical Features - Head-to-Head

Pain Location

Provocation & Relief (Most Diagnostically Useful)

The Classic "Shopping Cart Sign"

Bicycle Test

• Vascular claudication: Cycling reproduces symptoms - sustained muscle work demands blood flow regardless of position
• Neurogenic claudication: Cycling does NOT reproduce symptoms - the flexed hip/trunk posture on a bike opens the lumbar canal

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Physical Examination

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Treadmill Test Findings (Miller's Review of Orthopaedics, 9th Ed)

The standing treadmill test is a sensitive (>90%) provocative evaluation for neurogenic claudication. - Miller's Review of Orthopaedics, 9th Ed

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Summary Comparison Table (from Localization in Clinical Neurology, 8e)

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Investigations

Important caveat: Up to 21% of asymptomatic patients over age 65 have spinal stenosis on MRI - imaging must correlate with symptoms. - Symptom to Diagnosis, 4th Ed

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Quick Memory Anchor

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Clinical Pitfall

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• Localization in Clinical Neurology, 8th Ed - Differential of Neurogenic from Vascular Claudication (Table)
• Miller's Review of Orthopaedics, 9th Ed - Table 8.7, Treadmill Test Findings
• Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed - Table 7-9 + Evidence-Based Diagnosis section
• Textbook of Family Medicine, 9th Ed - Clinical Features of Spinal Stenosis
• Schwartz's Principles of Surgery, 11th Ed - Neurogenic Claudication