Hip dysplasia (developmental dysplasia of the hip)

Children’s Hospital Boston’s hip sub-specialists provide comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care. How we’ll treat your child’s DDH depends on the complexity and severity of her condition—as well as her age, overall health, medical history and the expectations for the course of her condition as she grows.

The goal of all treatments for DDH is to put the femoral head back into the hip socket, so that the hip can develop normally. Treatment options may include:

• observation: If the socket of a child 6 months of age or younger is only slightly shallow and the instability is minor, the doctor will just follow the hip closely, since often the joint will form normally on its own.

• Pavlik harness: A Pavlik harness is used on babies up to 4 months of age to hold the hip in place, while allowing the legs to move a little. Your baby's doctor puts the harness on; the baby usually wears it full-time for at least six weeks, then part-time (12 hours per day) for another six weeks.
  
  During this time the doctor will see your baby frequently, to examine her hip and check the harness for proper fit. At the end of the treatment, x-rays (or an ultrasound) will check hip placement.
  
  The baby’s hip is usually successfully treated with the Pavlik harness, but sometimes it may continue to be partially or completely dislocated.
   
• traction or casting: If the hip continues to be partially or completely dislocated, traction or casting may be used. Traction—consisting of pulleys, strings, weights and a metal frame attached over or on the bed—applies force to stretch certain parts of the body in a specific direction.
  
  The purpose of traction is to stretch the soft tissues around the hip and allow the femoral head to move back into the hip socket. Traction can be set up either at home or in the hospital and is usually used for about 10 to 14 days.
   
• surgery and casting: If the other methods aren’t successful—or if DDH is diagnosed after the child is 2 – closed reduction surgery may be needed to put the hip back into place manually. After surgery, a spica cast (a cast that extends from the nipple line to the legs) is put on the baby to hold the hip in place.
  
  The baby wears the spica cast for about 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 (it may soften with daily wear). The cast remains on the hip until the hip achieves normal placement. Following casting, the baby may need a special brace and physical therapy exercises to strengthen the muscles around the hip and in the legs.

• surgery for toddlers and very young children: Non-surgical treatment is generally ineffective for a child older than walking age (especially if her hip isn’t developing properly or is dislocated). Open reduction surgery (in which the hip is repaired through an incision into the body) is usually needed, since by this time the child’s bones are usually enough “off-track” that they need to be repositioned in order for the hip to grow and function normally.
  
  The type of procedure for children of walking age (and older) depends on the problem that the surgery is treating, such as:

• re-shaping the hip socket: Surgery can reshape and re-direct the hip socket if it’s too shallow, or is pointed in the wrong direction. This is done by cutting above or around the socket to re-direct it within the pelvis.
   
• re-directing the femoral head: Surgery can re-direct the ball (femoral head) if it’s pointing in the wrong direction. The surgeon cuts the femur, points the femoral head in the correct position, and reconstructs the cut pieces with plates and screws until they heal.
   
• repair of a dislocation: With a complete dislocation,
  • the ball is put back into the socket
  • tight muscles (and/or obstructive fatty tissue) that are preventing the ball from going into the socket (“obstacles to reduction”) are cut away
  • ligaments to hold the ball in the socket are reconstructed
  • a cast keeps the ball in place in the socket during healing
     
• surgery for children older than 18 months of age: If the ball is out of the socket in a child older than 18 months, the socket is usually extremely shallow and hasn’t developed well. And the longer the ball stays out of the socket, the shallower the socket gets. In this situation, the surgeon will almost always need to:
  • put the ball into the socket
  • deepen the socket
  • re-orient the socket so it’s more stable
  • tighten the ligament
     
• surgery for children older than 2 ½ or 3 years of age: By this age the joint’s tissues (muscles and ligaments) are usually very tight, so in addition to the above, surgeons must also shorten the thigh bone (femur) to loosen the tissues. Loosening the tissues allows the ball to go into the socket, and relieves pressure on the cartilage and the small blood vessels that go to the ball.
   
• surgery for teens and adults:
  • Bernese periacetabular osteotomy (Bernese PAO) for teens and adults: At Children's, we’ve performed over 1,400 Bernese periacetabular osteotomies to correct dysplastic hips in teens and adults, whose hip sockets have finished growing.
    
    The PAO is the most complex and powerful procedure for repositioning the hip socket. Children’s is the most experienced center in the United States for the procedure – and the second-most experienced in the world. It’s our standard treatment for a hip socket that’s too shallow in a patient whose socket has finished growing – typically at ages 13 or 14 through adult – and whose hip is still viable enough to be repaired rather than replaced.
    
    The PAO involves rotating the shallow, dysplastic socket (acetabulum) by cutting it free enough from its attachments within the pelvis to be repositioned into a more stable alignment on the top of the head of the femur. In this new alignment, excessive pressure from the femoral head is more evenly distributed away from the sensitive rim area.
     

Care after surgery: tips if your child is in a cast or harness

• Keep your child’s cast clean and dry.
• Check for cracks or breaks in the cast.
• Put pads on rough edges to protect the skin from scratches.
• Don’t 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.
• Cover the cast while your child is eating to prevent food spills and crumbs 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.
• Encourage your child to move her toes to promote circulation
• Don’t use the abduction straps on a Pavlik harness to lift or carry your child.
   

Specialist care throughout your child’s growth period

Success rates are high for hip dysplasia treatments at Children’s. Even so, any child who’s been treated for hip dysplasia must still be followed periodically by her orthopedist until her skeletal growth is complete. The doctor will monitor the repaired hip, since it needs to grow normally through the whole growth period in order to be durable for a lifetime.

Coping and support
 

If your baby or child has hip dysplasia, the best thing you can do for her is to keep a positive attitude. Make a game out of keeping your small child’s cast dry during bathing. Start a countdown calendar for your older child to help her see progress toward recovery.

Still, we understand that a hospital visit can be difficult. So, we offer many amenities to make your child’s – and your own – hospital experience as pleasant as possible. Visit The Center for Families for all you need to know about:

• getting to Children’s
• accommodations
• navigating the hospital experience
• resources that are available for your family

In particular, we understand that you may have a lot of questions when your child is diagnosed with DDH. Will my child need surgery? How long will her recovery take? Will it affect my child long term? What should we do at home? Children’s can help you connect with extensive resources to help you and your family through this stressful time, including:

• patient education: From doctor’s appointments to treatment to recovery, our nurses and physical therapists will be on hand to walk you through your child’s diagnosis, treatment and recovery. And once your child is home, we’ll help you coordinate and continue the care and support she received at Children’s.
   
• parent-to-parent: Want to talk with someone whose child has been treated for hip dysplasia? We can often put you in touch with other families who’ve been through the same experience that you and your child are facing.
   
• faith-based support: If you’re in need of spiritual support, we’ll connect you with the Children’s chaplaincy. Our program includes nearly a dozen clergy—representing Protestant, Jewish, Muslim, Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
   
• social work: Our social workers and mental health clinicians have helped many other families in your situation. We can offer counseling and assistance with issues such as coping with your child’s diagnosis, stresses relating to coping with illness and dealing with financial issues.