About Hip Dysplasia
Hip dysplasia is a condition where the hip joint socket (acetabulum) is too shallow. Hip dysplasia causes abnormal loading of the cartilage and labrum (soft tissue socket) and can lead to early arthritis. Some mild dysplasia problems may be treated arthroscopically, while others are more suitable for open procedure surgery (periacetabular osteotomy).
Developmental Dysplasia of the Hip (DDH)
What is DDH?
Developmental dysplasia of the hip is a congenital (present at birth) condition of the hip joint. It occurs once in every 1,000 live births. The hip joint is created as a ball and socket joint. In DDH, the hip socket may be shallow, letting the "ball" of the long leg bone, also known as the femoral head, slip in and out of the socket. The "ball" may move partially or completely out of the hip socket.
The greatest incidence of DDH occurs in first-born females with a history of a close relative with the condition.
What causes DDH?
Hip dysplasia is considered a "multifactorial trait." Multifactorial inheritance means that many factors are involved in causing a birth defect. The factors are usually both genetic and environmental.
Often, one gender (either male or female) is affected more frequently than the other in multifactorial traits. There appears to be a different "threshold of expression," which means that 1 gender is more likely to show the problem than the other gender. For example, hip dysplasia is more common in females than males.
One of the environmental influences thought to contribute to hip dysplasia is the baby's response to the mother's hormones during pregnancy. A tight uterus that prevents fetal movement or a breech delivery may also cause hip dysplasia. The left hip is involved more frequently than the right due to intrauterine positioning.
What are the risk factors for DDH?
First-born babies are at higher risk since the uterus is small and there is limited room for the baby to move; therefore affecting the development of the hip. Other risk factors may include the following:
Family history of developmental dysplasia of the hip, or very flexible ligaments
Position of the baby in the uterus, especially with breech presentations
Associations with other orthopedic problems that include metatarsus adductus, clubfoot deformity, congenital conditions, and other syndromes
What are the symptoms of DDH?
The following are the most common symptoms of DDH. However, each baby may experience symptoms differently. Symptoms may include:
The leg may appear shorter on the side of the dislocated hip
The leg on the side of the dislocated hip may turn outward
The folds in the skin of the thigh or buttocks may appear uneven
The space between the legs may look wider than normal
A baby with developmental dysplasia of the hip may have a hip that is partially or completely dislocated, meaning the ball of the femur slips partially or completely out of the hip socket. The symptoms of DDH may resemble other medical conditions of the hip. Always consult your baby's doctor for a diagnosis.
How is DDH diagnosed?
Developmental dysplasia of the hip is sometimes noted at birth. The pediatrician or newborn specialist screens newborn babies in the hospital for this hip problem before they go home. However, DDH may not be discovered until later evaluations. Your baby's doctor makes the diagnosis of developmental dysplasia of the hip with a clinical examination. During the examination, the doctor obtains a complete prenatal and birth history of the baby and asks if other family members are known to have DDH.
Diagnostic procedures may include:
X-ray. A diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
Ultrasound (also called sonography). A diagnostic imaging technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels.
Treatment for DDH
Specific treatment for DDH will be determined by your baby's doctor based on:
Your baby's gestational age, overall health, and medical history
The extent of the condition
Your baby's tolerance for specific medications, procedures, or therapies
Expectations for the course of the condition
Your opinion or preference
The goal of treatment is to put the femoral head back into the socket of the hip so that the hip can develop normally.
Treatment options vary for babies and may include:
Nonsurgical positioning device or placement of a Pavlik harness. The Pavlik harness is used on babies up to 6 months of age to hold the hip in place, while allowing the legs to move a little. The harness is put on by your baby's doctor and is usually worn one to two months. Your baby is seen frequently during this time so that the harness may be checked for proper fit and to examine the hip. At the end of this treatment, X-rays (or an ultrasound) are used to check hip placement. The hip may be successfully treated with the Pavlik harness, but sometimes, it may continue to be partially or completely dislocated.
Casting. If the hip continues to be partially or completely dislocated, casting, or surgery may be required.
Surgery. If the other methods are not successful, or if DDH is diagnosed at age 6 months to 2 years, surgery may be required to put the hip back into place manually, also known as a "closed reduction." Children older than 2 years may require an "open surgery" to realign the hip, followed by spica cast. If successful, a special cast (called a spica cast) is put on the baby to hold the hip in place. The spica cast is worn for approximately three to six months. The cast is changed from time to time to accommodate the baby's growth and to ensure the cast's rigidity, as it may soften with daily wear.
The cast remains on the hip until the hip returns to normal placement. Following casting, a special brace and/or physical therapy exercises may be necessary to make the muscles around the hip and in the legs stronger.
What is a short leg hip spica cast?
A short leg hip spica cast is applied from the chest to the thighs or knees. This type of cast is used to hold the hip in place after surgery to allow healing.
Cast care instructions
Keep the cast clean and dry.
Check for cracks or breaks in the cast.
Rough edges can be padded to protect the skin from scratches.
Do not scratch the skin under the cast by inserting objects inside the cast.
Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast.
Do not put powders or lotion inside the cast.
Cover the cast during feedings to prevent spills from entering the cast.
Prevent small toys or objects from being put inside the cast.
Elevate the cast above the level of the heart to decrease swelling.
Do not use the abduction bar on the cast to lift or carry the baby.
When to call your baby's doctor
Contact your baby's doctor or other health care provider if your baby develops one or more of the following symptoms:
Increased swelling above or below the cast
Drainage or foul odor from the cast
Cool or cold toes
Long-term outlook for a baby with DDH
While newborn screening for DDH allows for early detection of this hip condition, starting treatment immediately after birth may be successful. Many babies respond to the Pavlik harness, and/or casting. Additional surgeries may be necessary since the hip dislocation can reoccur as the child grows and develops. If left untreated, differences in leg length or a duck-like gait, and a decrease in agility may occur. In children 2 years or older with DDH, deformity of the hip and osteoarthritis may develop later in life. DDH can also lead to pain and osteoarthritis by early adulthood.
Frequently Asked Questions and Answers about Hip Dysplasia
- What is hip dysplasia?
- What are common symptoms with dysplasia?
- What happens inside a dysplastic hip?
- How do I know if I need surgery?
- Does pain correlate with dysplasia?
Dysplasia can also be referred to as developmental dysplasia of the hip (DDH); it is a condition through a child’s early development where the hip socket (acetabulum) doesn’t form normally. The socket is usually too shallow and the femoral head (ball) is partially uncovered; sometimes it can be facing more backward than forward (retroversion).
Many people, especially women, have dysplasia and don’t know it until their mid to late twenties or thirties. Most of the time, individuals will start to feel pain in the front of their hip (groin) after prolonged sitting or walking, such as a dull ache in the groin or catching or popping. Walking up or downhill can also be difficult.
Since the weight-bearing surface of the acetabulum (socket) is smaller or more shallow, it has to withstand more force and tends to wear out faster than if it shared the forces with more of the acetabulum. The cartilage and labrum are the cushion between the ball and socket (clear space on x-rays), and this can get damaged and start to degenerate (develop small tears and arthritis). If left untreated the majority of dysplastic hips need hip replacement (total hip arthroplasty) at some time in their life.
You may want to consider surgery if you have a pain that is in the front groin (anterior) that affects daily activities and prevents you from doing the things you want to. Also if x-rays show dysplasia with early degenerative changes (mild arthritis), but still evidence of good cartilage, you may be a candidate for an osteotomy.
Not necessarily. Sometimes people have significant dysplasia without significant symptoms to warrant a big surgery. In those patients we observe the hips over time with x-rays and re-evaluate their symptoms every year or two.
Frequently Asked Questions and Answers about Periacetabular Osteotomy
- What does “periacetabular osteotomy” mean?
- What is involved in a periacetabular osteotomy (PAO)?
- What other surgical options are there?
- Will I need a blood transfusion?
- How long will I be in the hospital?
- What physical therapy do I have to do?
- What are the major risks to the surgery?
- What happens when I leave the hospital?
- What do I do at home while recovering?
- How long do I take narcotics?
- When can I drive?
- When do I see my doctor after surgery?
- Who do I call if I'm having problems after surgery?
- How long will it take to fully recover from this surgery?
- How long will the PAO last? Will I need another surgery?
- What lifelong activities can I do or not do?
“Peri” means around, “acetabular” means the hip socket and “osteotomy” means to cut bone. Thus the surgery involves cutting out or carving around the hip socket to move it to a new and better location.
The surgeon goes through an incision over the front of the hip about 6-8 inches long, separating muscles to get to the pelvis, then with x-ray guidance (fluoroscopy) carefully cuts through the three pelvic bones (ischium, pubis, ilium) around the acetabulum to free it from its original position. Next the acetabulum is fixed in its new location with screws (usually three to six); a bone graft is used if needed.
Sometimes if the angle made by the femur and head is too low (varus) or too high (valgus), then an osteotomy of the femur may be needed. This helps the femoral head to be in a more normal position to preserve it from wearing out. This surgery is called a proximal femoral osteotomy.
You may. We recycle the blood you lose at surgery and give it back to you if there is enough. But sometimes you will need a transfusion of 1–2 units after surgery. We usually like you to donate your own blood if you are able, but if not, the blood bank is very safe and we can use that.
Usually, the hospital stay is two to three days after surgery.
Starting the day after surgery you will have physical therapy twice a day that includes gentle exercises, learning to sit, stand and walk with partial weight-bearing and crutches. You may take a few steps the first day around your room, and the second day out into the hallway and so on. After you leave the hospital, the only important therapy you have to do is walk, rest and let your surgery heal. We do not want formal physical therapy for the first six weeks; after that we evaluate your needs on an individual basis.
The major risks include the following:
- Blood clot We reduce risk of this by using a blood thinner, T.E.D. hose (compressive stockings) and compression boots on your feet to increase circulation.
- Infection You are given IV antibiotics before surgery, which is continued for 24 hours after; then keep a close watch of the incision for redness or drainage, especially in the groin.
- Nerve palsy A sensory nerve called the lateral femoral cutaneous nerve is right where we do surgery. We do our best to identify it and protect it but there is a 50% chance you will have some numbness over the front of your thigh; over time sensation usually returns. There are also bigger nerves, the femoral and sciatic nerves, which are deeper and can get stretched with a big correction/surgery, but this is very rare (less than 1%).
- Failure to heal This is also uncommon but always a concern, especially if you smoke. If the bone doesn’t heal, the screws can break and the socket can move. An additional surgery to increase bone healing could be needed, but very rarely.
Usually, you will need 24 hour help for a week. Or if you don't have adequate help at home, you could consider a rehabilitation center. The final plans will be made while you are recovering in the hospital.
Recovery involves the following:
First six weeks: Finish taking blood thinners (aspirin for six weeks), wear T.E.D. hose, walk with crutches (partial weight bearing), keep wound clean.
Next six weeks: Transition to one cane or crutch as instructed by your physician until three months after surgery; may start gentle stretching or strengthening exercises; walk.
After three months: Return to work part time or full time as tolerated (two to three months from surgery); continue to walk and return to gentle exercise.
After six months: You may return to full activity (when the bone cuts are completely healed) except for running/jumping activities.
The best lifelong activities are walking, swimming, biking to preserve your hip’s health.
Only as long as you need to, about 7 to 21 days from surgery. Be aware that sometimes anti-inflammatories (NSAIDS) can slow down bone healing, but Tylenol is not a problem.
Usually three to four weeks after surgery (when you’re safe enough to not be at fault if you get in an accident and off narcotics).
You will probably have staples and should see your doctor in two weeks, then again six weeks after surgery for x-rays, then three months, six months, one year and every year or two so we can see how the hip progresses.
You can call the orthopedic clinic and ask for the nurse/MA who works with your surgeon; she will get back to you within a business day; otherwise, call the orthopedic resident on-call.
You will be walking within a couple days of surgery, but on one to two crutches for three months, and it usually takes 9–12 months to feel fully recovered.
We hope to prolong the time between now and when you need a hip replacement (total hip arthroplasty). But the exact time in years is unknown and based on the amount of arthritis in your hip already.
We advise patients to resume what they can tolerate, especially walking, swimming and bicycle riding. We discourage repetitive jumping, running and heavy manual labor and lifting. These activities tend to wear out your hip faster.
ACL Reconstruction, Femoroacetabular Impingement, Hip Arthroscopy, Hip Preservation, Knee, Knee Preservation, Labral Tear, Minimally Invasive Joint Surgery, Orthopaedic Surgery, Pediatric Orthopaedic Surgery, Sports Medicine
|Pediatric Orthopaedics||(801) 662-5600|
|University Orthopaedic Center||(801) 587-0989|
Adult Reconstruction, Femoroacetabular Impingement, Hip Arthroscopy, Hip Preservation, Hip Replacement, Joint Replacement, Knee Replacement, Minimally Invasive Joint Surgery, Orthopaedic Surgery, Periacetabular Osteotomy, Physician Assistant, Surgical Dislocation
|University Orthopaedic Center||(801) 587-7028|
ACL Reconstruction, Cartilage Restoration, Femoroacetabular Impingement, Hip Arthroscopy, Hip Preservation, Minimally Invasive Joint Surgery, Orthopaedic Surgery, Pediatric Orthopaedic Surgery, Sports Medicine
|Primary Children's Hospital||(801) 662-5600|
|South Jordan Health Center||(801) 213-4500|
|University Orthopaedic Center||(801) 587-7109|
Adult Reconstruction, Direct Anterior Hip Replacement, Femoroacetabular Impingement, Hip Arthroscopy, Hip Dysplasia, Hip Instability, Hip Preservation, Hip Replacement, Hip Revision, Joint Infection, Joint Replacement, Knee Preservation, Knee Replacement, Knee Revision, Labral Tear, Minimally Invasive Joint Surgery, Orthopaedic Surgery, Oxford Partial Knee Replacement, Patello-Femoral Arthroplasty (PFA), Periacetabular Osteotomy, Surgical Dislocation, Uni-Compartmental Knee Arthroplasty, Unicompartmental Knee Replacement
|University Orthopaedic Center||(801) 587-7109|
Adult Reconstruction, Femoroacetabular Impingement, Hip Dysplasia, Hip Preservation, Hip Replacement, Hip Revision, Joint Replacement, Knee Replacement, Labral Tear, Minimally Invasive Joint Surgery, Orthopaedic Surgery, Periacetabular Osteotomy, Surgical Dislocation, Uni-Compartmental Knee Arthroplasty
|University Orthopaedic Center||(801) 587-7109|