Developmental Dysplasia of the Hip, Infant, Toddler, Child

Developmental Dysplasia of the Hip, Infant, Toddler, Child

Travis Matheney

Closed Reduction

Operative Indications

  • Unilateral or bilateral infant hip dysplasia or dislocation in those younger than 18 months having failed conservative/bracing treatment


  • Request neuromotor relaxation

  • Local anesthetic available if an adductor tenotomy is performed

Examination Under Anesthesia

  • Complete muscle relaxation

  • Examine for Ortolani and Barlow signs

  • Assess for presence/size of “stable zone”; want at least 25 (ideally more) degree zone of adduction/abduction of the hip(s) where hip is felt to be reduced


  • Utilized to confirm examination under anesthesia (EUA) findings

  • Limited sterile prep of groin(s) with prep solution and wide area of sterile towels to facilitate a sterile working space

  • A 20-gauge spinal needle inserted under adductor longus aiming roughly at the ipsilateral axilla

  • In dislocated hip, try to insert into the vacant acetabulum in the inferior side (Figure 20.1)

    • If you happen to not be in the joint, when you inject contrast material, it will decrease the chances that you create an aberrant “dust cloud” over your areas of interest

  • In subluxated/dysplastic hips, flex hip and aim for the proximal portion of the inferior femoral neck

  • Once in cast, if position of the hip is in question, after sterile swab of the exposed groin, you can repeat the arthrogram in cast (Figure 20.2)

Intraoperative Contrast-Enhanced Ultrasound*

  • Ultrasound can be utilized intraoperatively to assess both hip reduction and hip perfusion

  • Hip reduction is assessed both prior to casting and in spica cast via an anterior/transinguinal approach (Figures 20.3,20.4,20.5)

  • This imaging has been validated against cross-sectional imaging1

  • Proximal femoral perfusion can be assessed using intravenous contrast

    • Perfusion can be graded as “good,” “partial decrease,” or “global decrease” in perfusion

    • Assessment is performed before attempted reduction and after casting as part of the reduction assessment (Figures 20.6 and 20.7)

    • Preliminary data points to a strong correlation between decreases in perfusion and eventual development of proximal femoral growth disturbance (PFGD)

    • Technique requires prior agreement with your radiology department and access to appropriate ultrasound machine and intravenous contrast agent


  • Supine on radiolucent operating table

  • Fluoroscopy is positioned on the opposite side of operative hip if unilateral

  • If a radiolucent casting table is available, you can consider positioning on this for reduction to facilitate immediate transition to casting once you affect a reduction

Technique in Steps

  • Apply cast liner (stockinette or water-resistant liner)

  • Affected hip is flexed and abducted with pressure behind greater trochanter to position deemed most stable on arthrography

  • Assess “safe zone” of the reduction—the range of adduction to abduction where hip is stable, ideally more than 25° arc

    • If the safe zone is small and the adductor longus feels tight, consider lengthening of the adductor longus to improve the safe zone

    • This can be accomplished either percutaneously with a #15 or #11 blade or through small 1.5-cm transverse incision directly over the longus tendon following sterile prep of that area

  • Spica cast is applied with cotton Webril and either fiberglass (our preferred method) or plaster (see Spica casting tips below)

    • A well-made cast is at least half of this procedure

    • Cast must have snug contact with

      • Iliac crests

      • Greater trochanters—caution not to apply the “SuperMold” as this may lead to pressure-induced femoral head ischemia

      • Ischial tuberosities

    • In-cast fluoroscopy or plain radiographs are obtained of the operative hip(s) in both anteroposterior (AP) and iliac oblique Judet views for comparison to in-clinic imaging obtained postoperatively (Figures 20.8 and 20.9)

Postoperative Care

  • Patient and family are admitted for recovery and spica cast care teaching

  • Car seat evaluation with current car seat to assure proper fit

  • Postoperative in cast radiographs can be taken within 10 to 14 days to assure no late displacement in the cast

  • Total anticipated casting time is typically 3 months

  • Cast change in the operating room either monthly or at 6 weeks with cast removal in clinic at 3 months

  • Post cast bracing at the discretion of the surgeon

    • Where persistent instability or dysplasia is a concern, use of an abduction splint may be beneficial

Postoperative Imaging

  • Postoperative multiplanar imaging in spica is commonly used to confirm hip reduction in cast after this child recovers from anesthesia

  • Both computed tomography (CT) and magnetic resonance imaging (MRI) have been utilized to confirm hip reduction in spica cast

  • Evidence suggests that “global decreased enhancement” of the femoral epiphysis and/or hip abduction in cast greater than 60° correlates with the development of PFGD2 (Figures 20.10 and 20.11)

    • What if there is globally decreased enhancement? Assess the amount of hip abduction, amount of trochanteric molding, and relative difficulty maintaining the reduction

    • If any of the above are present, consider remaking the cast and/or conversion to open reduction