Associated risk factors in children who had late presentation of developmental dysplasia of the hip

Developmental Dysplasia of the Hip and Laterality: The Importance of Graded Severity of the Contralateral Hip

Background

Laterality and bilaterality have been reported as prognostic variables in developmental dysplasia of the hip (DDH) outcomes. However, there is little clarity across the literature on the reporting of laterality in developmental dysplasia of the hip (DDH) due to the variability in severity of the condition. It is widely accepted that the left hip is most frequently affected; however, the true incidence of unilateral left, unilateral right and bilateral cases can be hard to quantify and compare across studies. The purpose of this study was to examine laterality accounting for graded severity in a multi-centre, international prospective observational study of infants with hip dysplasia to demonstrate the complexity of this issue.

Methods

A multi-centre, prospective hip dysplasia database was analyzed from 2010 to April 2015. Baseline diagnosis was used to classify patients into a graded laterality category accounting for hip status within the DDH spectrum.

Results

A total of 496 patients were included in the analysis; 328 were <6 months old at diagnosis and 168 were between 6 and 18 months old. Of these patients, 421 had at least one frankly dislocated hip. Unilateral left hip dislocations were most common, with 223 patients, followed by unilateral right and bilateral dislocations with 106 and 92 respectively. Stratifying these patients based on status of the contralateral hip, 54 unilateral left and 31 unilateral right dislocated patients also had a dysplastic or unstable contralateral hip. There were significantly fewer bilateral patients in the 6 to 18-month group (p = 0.0005). When classifying laterality by affected hip, bilaterality became the predominant finding, comprising 42% of all patients.

Conclusions

Findings from this multi-centre prospective study demonstrate the necessity to account for the graded severity in hip status when reporting DDH laterality. To accurately compare laterality across studies, a standardized, comprehensive classification should be established, as contralateral hip status may impact prognosis and treatment outcomes.

Level of Evidence

Level II Prognostic Study.

Interpretation and Natural History of Asymmetric Skin Folds in Infants With Developmental Dysplasia of the Hip

The association between asymmetric skin folds (ASFs) of the gluteal, groin, or thigh regions and ipsilateral developmental dysplasia of the hip (DDH) has not been elucidated yet. Why are ASFs formed in some infants with DDH? Do DDH-associated ASFs persist during childhood and adulthood? Is it possible for ASFs to emerge without DDH pathology? Three cases of acute and chronic hip pathology in adults are presented in an attempt to explain the formation and the natural history of ASFs in infants with DDH. It is suggested that ASFs are formed when the excess soft tissues of the thigh shrink over a short femur. On the other hand, ASFs disappear after the length of the thigh is restored and the soft tissues of the thigh are re-stretched. This telescoping mechanism of the formation and disappearance of ASFs is applicable regardless of the underlying hip pathology or the age of the patient.

Validation of parameters recommended for secondary screening for developmental dysplasia of the hip in Japan

BACKGROUND

Based on the Japanese Pediatric Orthopaedic Association's guidelines, secondary screening and imaging including ultrasonography and radiography, are recommended in infants with limited hip abduction (<70°) or in those with multiple risk factors including the following: asymmetrical skin creases, a family history of developmental dysplasia of the hip, female sex, and pelvic position at delivery. However, there is still little information regarding the usefulness of this guideline. The objective of this study was to investigate the association between the risk factors and developmental dysplasia of the hip diagnosed using ultrasound and radiography.

METHODS

A total of 356 infants (67 boys and 289 girls) underwent secondary ultrasonographic and radiological screening for developmental dysplasia of the hip in our hospital. Risk factors were documented from their medical records. The recommended item score, which we defined as an integrated value of the recommended item, was calculated for each patient. The limitation of hip abduction alone was a criterion for secondary screening; therefore, we defined the scores as follows: the limitation of hip abduction scored 2 points and other recommended scores were assigned 1 point. If the recommended item score was 2 points or more, we classified the infants as high-risk.

RESULTS

A total of 280 of 356 infants were included in the high-risk group, which showed a higher ratio of cases with abnormal imaging findings than the low-risk group. According to the multivariate logistic regression analyses among the recommended items, being female, skin asymmetry, and limb limitation were identified as independent risk factors for imaging abnormality and the need for Pavlik harness treatment.

CONCLUSIONS

The recommended items for secondary screening based on the Japanese Pediatric Orthopaedic Association's guidelines could be useful for screening infants in need of treatment.

Acetabular index as an indicator of Pavlik harness success in grade I developmental dysplasia of the hip: A retrospective study

Purpose

Some articles have focused on the effectiveness of the Pavlik harness treatment for unstable and dislocated hips, yet data on monitoring its effectiveness with the acetabular index remains elusive. Therefore, this study aimed to assess Pavlik harness effectiveness in infants ≤6 months diagnosed with grade I developmental dysplasia of the hip using acetabular index improvement and identify the possible predictors of successful Pavlik harness treatment.

Methods

A retrospective review of infants with grade I acetabular dysplasia treated with a Pavlik harness and monitored with anteroposterior pelvis X-rays at presentation and follow-up. Successful treatment was defined as achieving an acetabular index <30°.

Results

A total of 231 infants with acetabular dysplasia were treated with a Pavlik harness. A successful outcome was achieved in 135 infants (58.4%). Younger age, lower initial acetabular index, and patients with unilateral developmental dysplasia of the hip were significant predictors of a successful outcome. An age of 4.5 months or older was found to be the threshold for an unsuccessful result following Pavlik harness treatment, with a sensitivity of 65.2% and specificity of 57.3%. An initial acetabular index of 35.5° was found to be the threshold for an unsuccessful result, with a sensitivity of 83.7% and specificity of 61.5%.

Conclusion

Pavlik Harness's success in correcting the acetabular index in acetabular dysplasia patients was related to unilateral cases, a younger age at presentation, and a lower initial acetabular index. The thresholds for unsuccessful treatment were an age of 4.5 months or greater and an acetabular index of 35.5° or higher.

Multivariate analysis of the predictive value of asymmetric skin creases in diagnosis of decentralized developmental dysplasia of the hip

The aim of this study was to investigate the relationship of developmental dysplasia of the hip (DDH) with asymmetrical skin crease (ASC) in the inguinal, gluteal and thigh regions and to determine which ASC has the most predictive value for the diagnosis of hip dislocation in infants. This study was planned as a prospective, observational study and conducted between 1 October 2020 and 1 June 2021. Asymmetric distribution of skin creases was evaluated separately in three regions (inguinal, gluteal and thigh). Then, hip ultrasonography (USG) was performed and the Graf method was used to classify the cases as 'centralized' [Graf types I, IIa (-), IIb and IIc] and 'decentralized' (Graf types IId, III and IV). The relationship between the groups was evaluated using univariate and then multivariate analyses. A total of 241 patients were included in the study. The number of patients with ASC was 49 (21%). While 36 of these 49 patients had centralized hips, 13 had decentralized hips ( P  < 0.001). Sixty-five percent (13/20) of 20 infants with decentralized hips had ASC in at least one of the inguinal, gluteal or thigh regions. The presence of ASC in the inguinal ( P  < 0.001) and gluteal ( P  < 0.014) regions increased the risk of the decentralized hip in the child, whereas the presence of ASC in the isolated thigh region did not increase the risk of the dislocated hip ( P  = 0.534). Inguinal ASC and gluteal ASC are reliable findings in DDH screening, but the relationship of isolated thigh ASC with DDH could not be demonstrated statistically. Level of Evidence: Level II - diagnostic study.

The Global Research Trends and Hotspots on Developmental Dysplasia of the Hip: A Bibliometric and Visualized Study

Background: Developmental dysplasia of the hip (DDH) is a common musculoskeletal disorder in newborns and also one of the most common causes of hip arthritis in women. Many topics concerning DDH still remain controversial, and the global research trend in this field has not been well-studied yet. The aim of the present study was to illustrate the overall knowledge structure, development trends, and research hotspots of DDH.

Methods: The publications related to DDH from 1998 to 2020 were identified from the Web of Science Core Collection (WOSCC). Three bibliometric tools were used to conduct visualization and knowledge maps. Annual trends of publications, contributions of countries, institutions, authors, funding agencies and journals, and clustering of keywords were analyzed.

Results: A total of 2,691 publications were included. The annual number of DDH publications showed an increasing trend worldwide. The United States has made the greatest contribution, with the largest number of publications and the highest H-index. The most prolific institutions were Shanghai Jiao Tong University, Children's Hospital of Philadelphia, and Shriners Hospital for Children. Professors Tönnis D, Harris WH, Crowe JF, Graf R, and Salter RB have made great achievements in this field. However, the collaboration between international institutions or researchers was relatively low and mainly conducted in European and American countries. All the keywords could be divided into five clusters: hip osteoarthritis study, hip replacement study, hip ultrasound study, osteotomy surgery study, and etiology study. A trend of balanced and diversified development existed in these clusters. Keywords with the ongoing bursts, including clinical outcome, risk factor, femoroacetabular impingement, predictor, arthroscopy, morphology, and anteversion may continue to be the research hotspots in the near future.

Conclusions: There will be an increasing number of publications on DDH research, and the United States stay ahead in this field. International collaboration needs to be further strengthened. The information can provide helpful references for researchers to explore hot issues or target a specific field of DDH.

The Association of Asymmetric Skinfolds and the Diagnosis of Developmental Dysplasia of the Hip in Infants

BACKGROUND

The clinical finding of asymmetric skinfolds (ASF) in infants is used to indicate the possibility of developmental dysplasia of the hip (DDH). The association of ASF and a diagnosis of DDH remains unknown.

PURPOSE

To determine the association of ASF in the gluteal and femoral regions with a diagnosis of DDH.

METHODS

The correlation of ASF and other physical examination findings with DDH was compared retrospectively. The medical records of infants who underwent DDH screening in the clinic were analyzed. The physical examination findings were reviewed and categorized as ASF, clunk of the hip, limb-length discrepancy, hip abduction limitation, combined conditions of musculoskeletal disorders, and regular screening for DDH. The hip conditions were classified by Graf's ultrasound method. Type IIb and higher classifications were defined as DDH. The diagnosed rate and severity of DDH based on physical examination findings were calculated and compared.

RESULTS

Clinical data of 3266 infants aged up to 6 months were reviewed, and 194 infants were diagnosed with DDH by ultrasound examination. ASF was the most common indication for DDH screening (64.5%; 2107/3266). However, this was poorly correlated with a diagnosis of DDH (4.79%; P < .0001). No difference was found between the Graf classification severity and various indications (P = .079).

IMPLICATIONS FOR PRACTICE

Clinicians should recognize that, although ASF is the most common reason for DDH screening in infants, ASF does not correlate with a diagnosis of DDH.

IMPLICATIONS FOR RESEARCH

Additional research should examine the relationship between DDH and ASF in other populations.

Significance of Asymmetry of Groin and Thigh Skin Creases in Developmental Dysplasia of the Hip Revisited: Results of a Comparative Study

BACKGROUND

No high level of scientific evidence exists about the use of asymmetry of skin creases (ASC) on the groin and thigh regions in diagnosing developmental dysplasia of the hip. The aim of this comparative study was to revisit whether or not ASC was a significant clinical finding in developmental dysplasia of the hip.

METHODS

This was retrospective analysis of a prospectively collected data. Control group was composed of 1000 consecutive healthy infants (mean age, 46.7 d) whose both hips were considered Graf type I (normal). Study group (SG) was composed of 246 consecutive patients (mean age, 96.5 d) whose treatments by abduction bracing were initiated due to unilateral or bilateral Graf type IIa(-) and worse hips.

RESULTS

SG included 178 patients with bilateral or unilateral dysplastic hips [Graf type IIa(-), IIb, IIc] and 68 patients with at least 1 decentered hip (Graf type D, III, IV). ASC was seen in 63 of 101 patients (63%) having positive clinical finding(s). The rates of both ASC alone (P<0.001; odds ratio, 3.46) and ASC total (ASC with and without additional findings) (P<0.0001; odds ratio, 7.48) were significantly higher in SG than in control group. ASC was the only clinical finding in 31 patients and 24 of these 31 patients (77%) had unilateral or bilateral dysplastic hips. Sensitivity and specificity of ASC alone were 12.60% and 96.00%, respectively. ASC was accompanied by other clinical findings (mostly Galeazzi sign and limitation of abduction) in 32 patients and 23 of these 32 patients (72%) had at least 1 decentered hip. Sensitivity and specificity of ASC total were 25.61% and 95.60%, respectively.

CONCLUSIONS

ASC is a significant finding, as there is considerable increased risk of having dysplastic or decentered hips in infants having such a finding alone or associated with other findings. ASC alone is more commonly seen in patients with dysplastic hip(s) whereas ASC is mostly accompanied with other clinical finding(s) in patients with decentered hip(s). This study shows that, ASC can be introduced as a risk factor in selected newborn hip screening programs.

LEVEL OF EVIDENCE

Level II-diagnostic study.

Evaluation of vacuum phenomenon in dogs with coxofemoral degenerative joint disease using computed tomography

Background

Degenerative joint disease (DJD) is a common orthopedic lesion in the coxofemoral joint of canine patients. Concurrent with the sign of degeneration, the vacuum phenomenon (VP), or intra-articular gas, has been observed in several locations in both human and canine patients. A cadaveric study described VP in small breed dogs without DJD but with hip laxity. However, none of the canine VP reports mentioned coxofemoral DJD. Therefore, the aim of this retrospective study was to describe the distribution of coxofemoral VP revealed on computed tomography (CT) imaging in canine patients with DJD.

Results

A total of 282 dogs (564 coxofemoral joints), comprising 142 small, 85 large, and 55 medium breeds, were included in the present study. DJD was found in 31.02% of all dogs. The incidence of DJD was highest in large breed dogs (50%), followed by medium (31.81%) and small (19.36%) breed dogs. In addition, VP was detected with CT using the pulmonary window in 31 joints of 25 dogs that received a diagnosis of hip degenerative disease. VP was found most frequently at the laterodorsal area of the acetabulum. The incidences of VP in large, small, and medium breed dogs were 35.94%, 17.14% and 8.33%, respectively. The presence of coxofemoral VP was significantly and positively correlated with DJD (odds ratio = 17.58, 95% CI 2.32–133.42).

Conclusions

The presence of coxofemoral joint DJD and VP was more likely to be detected in large breed dogs, especially in those with established DJD. CT is an advanced diagnostic imaging modality that can be used to reveal VP lesions, most of which are reported at the laterodorsal acetabulum. Further studies, including comparisons of different patient positions, may reveal more information regarding coxofemoral VP.

Should paediatricians initiate orthopaedic hip dysplasia referrals for infants with isolated asymmetric skin folds?

PURPOSE

Asymmetric skin folds (ASFs) have been linked to developmental dysplasia of the hip (DDH) in select studies, leading to their inclusion in paediatric practice guidelines regarding orthopaedic referral for hip evaluation. The purpose of this study was to investigate the utility of isolated ASFs as a screening tool for DDH in a series of patient referrals evaluated at a single institution.

METHODS

We performed a retrospective review of consecutive patients between 0 and 12 months of age referred to orthopaedic clinics for isolated ASFs. We recorded radiographic findings (acetabular inclination or alpha angle), diagnosis rendered and treatment administered.

RESULTS

A total of 66 patients were included (mean age 6.4 months; 2.47 to 10.76). All patients received pelvic radiographs or ultrasound. In all, 36 patients (55%) were considered normal by their treating physician and 25 (38%) were considered dysplastic and underwent brace treatment. One hip with an isolated ASF was found to have a dislocated hip on radiograph prior to their initial orthopaedic visit. None of the patients in this study have required surgery to date.

CONCLUSION

Using ASFs as a reason for referral led to increased diagnosis of mild dysplasia resulting in orthotic treatment. Thus, in our particular clinical environment, isolated ASFs can be an indicator of mild dysplasia and warrant further workup or referral. Because treatment philosophies regarding recognition and treatment of mild dysplasia vary amongst centres, the value of screening with ASFs likewise depends on the treating orthopaedic surgeon's threshold for treatment of mild dysplasia.

LEVEL OF EVIDENCE

Level IV- Retrospective.

Late Presentation of Developmental Hip Dislocation: A Case Report

CASE

We describe a patient who was diagnosed with developmental hip dislocation at 21 months of age despite having had normal ultrasonography findings at 5 weeks of age.

CONCLUSION

This case report provides evidence that late developmental hip dislocation can occur despite normal clinical and sonographic findings early in life, and that it is difficult to know the cause of developmental hip dislocation when it presents late.

Developmental dysplasia of the hip: addressing evidence gaps with a multicentre prospective international study

There is a lack of high quality evidence available to guide clinical practice in the treatment and management of developmental dysplasia of the hip (DDH). Evidence has been limited by persistent confusion on diagnostic and classification terminology, variability in surgeon decision making and a reliance on single centre, retrospective studies with small patient numbers. To address gaps in knowledge regarding screening, diagnosis and management of DDH, the International Hip Dysplasia Institute began a multicentre, international prospective study on infants with hips dislocated at rest. This review discusses the current state of screening, diagnostic and management practices in DDH and addresses important unanswered questions that will be critical in identifying best practices and optimising patient outcomes. There is insufficient evidence to support universal ultrasound screening; instead, selective screening should be performed by 6-8 weeks of age on infants with risk factors of breech presentation, family history, or history of clinical hip instability. Follow-up of infants with risk factors and normal initial screening should be considered to at least 6 months of age. Brace treatment is a sensible first-line treatment for management of dislocated hips at rest in infants < 6 months of age. Early operative reduction may be considered as there is insufficient evidence to support a protective role for the ossific nucleus in the development of avascular necrosis.

The positive predictive value of asymmetrical skin creases in the diagnosis of pathological developmental dysplasia of the hip

Aims

The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH).

Patients and Methods

Between 1 January 1996 and 31 December 2016, all patients referred to our unit from primary or secondary care with risk factors for DDH were assessed in a "one stop" clinic. All had clinical and sonographic assessment by the senior author (RWP) with the results being recorded prospectively. The inclusion criteria for this study were babies and children referred with asymmetrical skin creases. Those with a neurological cause of DDH were excluded. The positive predictive value (PPV) for pathological DDH was calculated.

Results

A total of 105 patients met the inclusion criteria. There were 71 girls and 34 boys. Only two were found to have pathological DDH. Both also had unilateral limited abduction of the hip in flexion and a positive Galeazzi sign with apparent leg-length discrepancy. Thus, if the specialist examination of a patient with asymmetrical skin creases was normal, the PPV for DDH was 0%.

Conclusion

Isolated asymmetrical skin creases are an unreliable clinical sign in the diagnosis of pathological DDH. Greater emphasis should be placed on the presence of additional clinical signs to guide radiological screening in babies and children. Cite this article: Bone Joint J 2018;100-B:675-9.

How to use… Hip examination and ultrasound in newborns

Developmental dysplasia of the hip (DDH) ranges from a clinically detectable dislocation of the hip to radiologically diagnosed hip abnormalities. It is caused by both antenatal and postnatal factors. The Neonatal and Infant Physical Examination Screening Programme recommends that newborns should undergo a hip ultrasound (USS) when risk factor or clinical features suggestive of DDH are present. The aim of hip ultrasonography is to detect DDH early and prevent late complications through early treatment. Here, we discuss how to use hip examination and USS in newborns.

Late-presenting developmental dysplasia of the hip in Jordanian males. A retrospective hospital based study

Objectives:

To describe the pattern of developmental dysplasia of the hip (DDH) in late presenting Jordanian male patients and identify the risk factors and associated findings.

Methods:

This is a retrospective study of 1145 male patients who attended the Pediatric Orthopedic Clinic for a DDH check up. This study was carried out in the Orthopedic Section, Special Surgery Department, Faculty of Medicine, The University of Jordan, Amman, Jordan between March 2011 and October 2014. Data was collected from medical records, and x-ray measurements were evaluated.

Results:

Of the 1145 male patients, 43 (3.75%) with 70 involved hips were diagnosed with late- presenting DDH. Being a first-born baby resulted in 41.9% increased risk for DDH. Cesarian delivery was significantly associated with an increased risk of hip dislocation (p=0.004) while normal delivery was significantly associated with acetabular dysplasia (p=0.004). No predictable risk factors were found in 44.2% patients with DDH. Bilateral cases were more common than unilateral cases: (26 [60.5%] versus 17 [39.5%]). Limited abduction was a constant finding in all dislocated hips (p<0.001). Associated conditions, such as club foot and congenital muscular torticollis were not observed.

Conclusion:

Cesarian section is a significant risk for dislocated hips while normal delivery is significantly associated with acetabular dysplasia. Bilateral DDH is more common than the unilateral. Club foot and torticollis were not observed in this series.

Correlation between avascular necrosis and the presence of the ossific nucleus when treating developmental dysplasia of the hip

PURPOSE

This study assessed whether avascular necrosis (AVN) is correlated with the presence or absence of the ossific nucleus (ON) at the initiation of conservative treatment for developmental dysplasia of the hip (DDH). To date, the correlation between the presence of the ON and AVN manifestations remains ambiguous.

METHODS

The medical records of 148 patients with 234 dislocated hips who presented at our institution between January 2006 and December 2007 were reviewed. Based on ultrasound examination, the hips were classified according to Graf IIIa, IIIb, and IV criteria. Patients aged >6 months were simultaneously examined by standardized pelvis radiography.

RESULTS

The ON was present in 84 hips (35.9 %) at the beginning of treatment. Treatment was begun at a mean age of 5 months, with overhead traction for 2 weeks followed by arthrography and a spica cast for 4 weeks. Afterwards, we used a Tübingen hip-flexion splint. The mean age at final follow-up was 87 months. Hips were radiographically evaluated at last follow-up according to the Ogden-Bucholz AVN classification scheme. There was no significant difference in AVN prevalence between ON(-) versus ON(+) hips in children aged ≤10 months (P = 0.681), whereas when all age groups were analyzed together, AVN was significantly increased in ON(+) hips (P = 0.002). Clinical examination revealed no differences in limping, leg length inequality, and range of motion of hips in the ON(-) versus ON(+) groups.

CONCLUSION

We conclude that DDH treatment should be performed early without regard to the presence or absence of the ON. Reduction should not be delayed beyond >10 months of age because any delay in treatment increases the incidence of AVN.

Occlusal asymmetries in children with congenital hip dislocation

Developmental dysplasia of the hip (DDH) has been associated with other congenital postural deformities and associated with asymmetric features in the body. The aim of this study was to examine the associations between developmental DDH and malocclusions in preschool and school children. The subjects were 60 children (40 girls and 20 boys) born during 1997-2001 in Northern Ostrobothnia Hospital District and having developmental DDH and treated by Von Rosen method. The control group consisted of 71 Finnish children (46 girls and 25 boys) matched by age and gender. Children participated the cross-sectional study at the age of 5-10 years; the mean age of the DDH children was 8.0 (SD 1.4) and controls 7.9 (SD 1.4) years. Dental examinations, intra-oral photographs, and clinical examination including growth measurements were carried out. The DDH children had significantly more lateral crossbites than controls (30/9.9 per cent; P < 0.003). Overall, 77.8 per cent of cases were unilateral crossbites and found more on the right side (50 per cent) compared to the left side (22.2 per cent). Girls had more crossbite compared to boys (77.8/22.2 per cent; odds ratio 2.53). Children with congenital hip dislocation are more predisposed to the asymmetric growth of occlusion and the development of crossbite. The genetic and environmental factors including intrauterine conditions in addition to the splint therapy may be possible influencing factors. This study will give additional information of the development of occlusal asymmetries and the multifactorial nature of the aetiology of lateral malocclusions.