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Ömeroğlu H, Yüksel S, Demir P, Alexiev V, Alsiddiky A, Anticevic D, Bozinovski Z, Bytyqi C, Cosma D, Dučić S, Hegazy A, Kanashvili B, Koloyan G, Metaxiotis D, Şenaran H, Shahcheraghi GH, Shitrit R, Yazici M. An Eastern Europe and Middle East multinational expert Delphi consensus study on the prevention, diagnosis, and treatment of developmental dysplasia of the hip before walking age. INTERNATIONAL ORTHOPAEDICS 2024; 48:1373-1380. [PMID: 38150007 DOI: 10.1007/s00264-023-06077-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE The incidence of developmental dysplasia of the hip (DDH) is higher in Eastern Europeans and Middle Easterners. This study aimed to establish consensus among experts in this geographical area on the management of DDH before walking age. METHODS Fourteen experienced orthopedic surgeons agreed to participate in a four-round online consensus panel by the Delphi method. The questionnaire included 31 statements concerning the prevention, diagnosis, and treatment of DDH before walking age. RESULTS Consensus was established for 26 (84%) of 31 statements. Hip ultrasonography is the proper diagnostic tool under six months in DDH; universal newborn hip screening between three and six weeks is necessary; positive family history, breech presentation, female gender, and postnatal swaddling are the most important risk factors; Ortolani, Barlow tests, and limitation of abduction are the most important clinical findings; Pavlik harness is the first bracing preference; some Graf type IIa hips and all Graf type IIb and worse hips need abduction bracing treatment; the uppermost age limit for closed and open reductions is 12 months and 12-24 months, respectively; anatomic reduction is essential in closed and open reductions, postoperative MRI or CT is not always indicated; anterior approach open reduction is better than medial approach open reduction; forceful reduction and extreme positioning of the hips (> 60° hip abduction) are the two significant risk factors for osteonecrosis of the femoral head. CONCLUSION The findings of the present study may be useful for clinicians because a practical reference, based on the opinions of the multinational expert panel, but may not be applicable to all settings is provided.
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Affiliation(s)
- Hakan Ömeroğlu
- Faculty of Medicine, Dr. Ridvan Ege Hospital, Ufuk University, 06520, Ankara, Turkey.
| | - Selcen Yüksel
- Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Pervin Demir
- Faculty of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Venelin Alexiev
- University Orthopaedic Hospital, Sofia Medical University, Sofia, Bulgaria
| | | | - Darko Anticevic
- Faculty of Dental Medicine and Health, J.J, Strossmayer University of Osijek, Osijek, Croatia
| | | | - Cen Bytyqi
- University Clinical Center of Kosovo, University of Pristina, Pristina, Kosovo
| | - Dan Cosma
- Rehabilitation Clinical Hospital, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca-Napoca, Romania
| | - Siniša Dučić
- Medical Faculty, University Children's Hospital, University of Belgrade, Belgrade, Serbia
| | | | | | - Garen Koloyan
- Wigmore Hospital for Children, Yerevan State Medical University, Yerevan, Armenia
| | | | - Hakan Şenaran
- Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Reuven Shitrit
- Assof Harofe-Shamir Medical Center, Tel Aviv University, Tel Aviv, Israel
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Stavinoha TJ, Pun SY, McGlothlin JD, Uzosike MB, Segovia NA, Imrie MN. No Delay in Age of Crawling, Standing or Walking with Pavlik Harness Treatment: A Prospective Cohort Study. J Am Acad Orthop Surg 2024; 32:390-395. [PMID: 37862341 DOI: 10.5435/jaaos-d-21-00249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 09/15/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Pavlik harness treatment is the standard of care for developmental dysplasia of the hip in infants younger than 6 months. The effect of Pavlik harness treatment on the achievement of motor milestones has not previously been reported. METHODS In this prospective cohort study, 35 patients were prospectively enrolled to participate and received questionnaires with sequential clinical visits monitoring treatment of their developmental dysplasia of the hip. One-sample Student t -tests assessed differences in milestone attainment age, and the Benjamini-Hochberg procedure was conducted to decrease the false discovery rate. Post hoc power analyses of each test were conducted. The age of achievement of eight early motor milestones were recorded and compared with a previously published cohort of healthy infants. RESULTS Infants treated with a Pavlik harness achieved four early motor milestones markedly later than the reported age of achievement in a historical control group. These milestones included "roll supine" (5.3 vs. 4.5 months; P = 0.039), "roll prone" (5.7 vs. 5.0 months; P = 0.039), "sit" (6.4 vs. 5.2 months; P < 0.001), and "crawl on stomach" (7.7 vs. 6.6 months; P = 0.039). However, there was no difference in time to achievement of later motor milestones of "crawl on knees," "pull to stand," and "independent walking." CONCLUSION Several early motor milestones were achieved at a statistically significantly later time than historical control subjects not treated in a Pavlik harness. Despite statistical significance, the small delays in early motor milestones were not thought to be clinically significant. No differences were observed in the later motor milestones, including knee crawling, standing, and independent walking. Clinicians and parents may be reassured by these findings. LEVEL OF EVIDENCE Therapeutic Level II-prospective study.
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Affiliation(s)
- Tyler J Stavinoha
- From the Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Lucile Packard Children's Hospital at Stanford, Stanford, CA
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Volkan Çetin B, Bakırcıoğlu S, Çiftci S, Salih Söylemez M, Erkuş S, Turhan Y, Yalkın Çamurcu İ, Duman S, Yıldırım T, Memişoğlu K, Şenaran H, Ömeroğlu H. Management preferences of orthopedic surgeons in developmental dysplasia of the hip under 1 year of age in Türkiye: Results of a nationwide cross-sectional survey. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2023; 57:322-328. [PMID: 38131337 PMCID: PMC10837523 DOI: 10.5152/j.aott.2023.23080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/17/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE This study aimed to evaluate the diagnosis and treatment preferences of orthopedic surgeons in developmental dysplasia of the hip (DDH) cases under the age of 1 in Türkiye with a higher incidence of DDH, estimated to be around 5-15 per 1000 live births. METHODS This was a nationwide cross-sectional survey. A link for the online survey, including 16 multiple-choice questions, was sent to the email group of the National Orthopedic Society. RESULTS Among 233 filled-out surveys, 211 met the inclusion criteria. Half of the participants had experience of <10 years as orthopedic surgeons, managed <25% of pediatric patients in daily practice, and treated <25 DDH cases per year before walking age. Ninety-seven percent used more than one method, hip ultrasound the most common, for exact diagnosis of DDH under 6 months. Pavlik harness was the most commonly preferred brace, but the use of Tübingen orthosis increased among experienced surgeons. The uppermost age limit for bracing was higher in surgeons dealing with more pediatric patients and treating more DDH cases. Dislocated hips and hips requiring closed/open reduction were more commonly referred to other surgeons by less experienced surgeons in terms of years, number of pediatric patients, and treated DDH cases per year. The lowest age limit for intervention under general anesthesia was lower in surgeons treating >25 DDH cases per year. Over one-third used both anterior and medial approach open reduction, but a trend to anterior open reduction alone was more evident in surgeons treating >50 DDH cases per year. More experienced surgeons were more prone to check the intraoperative reduction with postoperative computed tomography or magnetic resonance imaging. Diagnosis and treatment ages of DDH cases did not significantly change during the coronavirus disease 2019 pandemic. CONCLUSION Management preferences of orthopedic surgeons in DDH before walking age primarily depend on the rate of pediatric patients in daily practice and the number of treated DDH cases per year.
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Affiliation(s)
- Baki Volkan Çetin
- Department of Orthopaedics and Traumatology, Harran University, Faculty of Medicine, Şanlıurfa, Turkey
| | - Sancar Bakırcıoğlu
- Department of Orthopaedics and Traumatology, TOBB Economy and Technology University, Ankara, Turkey
| | - Sadettin Çiftci
- Department of Orthopaedics and Traumatology, Selçuk University, Faculty of Medicine, Konya, Turkey
| | - Mehmet Salih Söylemez
- Department of Orthopaedics and Traumatology, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Serkan Erkuş
- Department of Orthopaedics and Traumatology, Medifema Hospital, İzmir, Turkey
| | - Yalçın Turhan
- Department of Orthopaedics and Traumatology, Düzce University, Faculty of Medicine, Düzce, Turkey
| | - İsmet Yalkın Çamurcu
- Department of Orthopaedics and Traumatology, Aritmi Osmangazi Hospital, Bursa, Turkey
| | - Serda Duman
- Department of Orthopaedics and Traumatology, Baltalimanı Metin Sabancı Bone Diseases Training and Research Hospital, İstanbul, Turkey
| | - Timur Yıldırım
- Department of Orthopaedics and Traumatology, İstanbul Nişantaşı University, İstanbul, Turkey
| | - Kaya Memişoğlu
- Department of Orthopaedics and Traumatology, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Hakan Şenaran
- Department of Orthopaedics and Traumatology, Bezmialem Vakif University, School of Medicine, İstanbul, Turkey
| | - Hakan Ömeroğlu
- Department of Orthopaedics and Traumatology, Ufuk University, Faculty of Medicine, Ankara, Turkey
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Grzybowski G, Bliven E, Wu L, Schaeffer EK, Gibbard M, Zomar BO, Casagrande Cesconetto A, Mundy C, Mulpuri K. Caregiver Experiences Using Orthotic Treatment Options for Developmental Dysplasia of the Hip in Children. J Pediatr Orthop 2023; 43:105-110. [PMID: 36607922 PMCID: PMC9812410 DOI: 10.1097/bpo.0000000000002312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Developmental dysplasia of the hip (DDH) is a common condition affecting 5 in 1000 newborns. The standard first line of treatment is the use of an orthotic, which has generally high success rates, but can pose substantial difficulties and put undue burden on caregivers. The general experience of caregivers using these orthotics has not been well documented on an orthotic-specific basis. The purpose of this study was to investigate caregiver experience using prescribed DDH orthotics to identify challenges, differences between treatment options, and areas of improvement. METHODS A survey assessing treatment prescription, respondent demographics, and caregiver experience was distributed online to caregivers whose child/children were treated for DDH with an orthotic. Seven-point positively phrased Likert scale statements and open-ended questions were included to assess caregiver experience. The results were analyzed using summary statistics and orthotics with more than 30 responses were selected for more in-depth analysis. RESULTS A total of 530 survey responses were collected with 63% (334/530) of respondents using a Pavlik harness, 45% (236/530) a Rhino brace, and 13% (67/530) a Denis Browne Bar. The overall weighted average score across all Likert Scale statements was positive for the Pavlik harness, Rhino brace, and Denis Browne Bar at 4.19 (95% CI, 3.83 to 4.54), 4.63 (95% CI, 4.27 to 4.99) and 4.91 (95% CI, 4.58 to 5.24), respectively. In the open-ended responses, all 3 orthotics were perceived as easy to use and not hindering child-caregiver bonding, but raised concerns of discomfort and skin irritation, as well as preventing the ability to cuddle their child the way they desired. The Pavlik harness respondents consistently brought up concerns regarding cleanability. CONCLUSIONS The results show that the DDH orthotics analyzed are generally easy to use and perceived positively by caregivers, but have orthotic-specific challenges that should be a focus of future improvement work. CLINICAL RELEVANCE This study evaluated opinions and attitudes of caregivers for children being treated with DDH orthotics, revealing experiences, concerns, and challenges associated with the use of commonly prescribed options.
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Affiliation(s)
| | | | - Luke Wu
- BC Children’s Hospital Research Institute
| | - Emily K. Schaeffer
- Department of Orthopaedics, University of British Columbia
- Department of Orthopaedic Surgery, BC Children’s Hospital, Vancouver, BC, Canada
| | | | - Bryn O. Zomar
- Department of Orthopaedics, University of British Columbia
- Department of Orthopaedic Surgery, BC Children’s Hospital, Vancouver, BC, Canada
| | | | | | - Kishore Mulpuri
- Department of Orthopaedics, University of British Columbia
- Department of Orthopaedic Surgery, BC Children’s Hospital, Vancouver, BC, Canada
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de Witte PB, van Bergen CJA, de Geest BL, Willeboordse F, van Linge JH, den Hartog YM, Margret M H P Foreman-van Drongelen M, Pereboom RM, Robben SGF, Burger BJ, Witlox MA, Witbreuk MMEH. Treatment of decentered developmental dysplasia of the hip under the age of 1 year: an evidence-based clinical practice guideline - Part 2. EFORT Open Rev 2022; 7:542-553. [PMID: 35924650 PMCID: PMC9458947 DOI: 10.1530/eor-21-0126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and purpose Materials and methods Results Interpretation
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Affiliation(s)
| | | | | | | | - Joost H van Linge
- Juliana Children's Hospital, The Hague & Reinier HAGA Orthopaedic Centre, Zoetermeer and Delft, the Netherlands
| | | | | | - Renske M Pereboom
- Dutch Hip Patient Association "Vereniging Afwijkende Heupontwikkeling", Nijkerk, the Netherlands
| | - Simon G F Robben
- Department Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Bart J Burger
- Department Orthopedic Surgery, North West Hospital Group, Alkmaar, the Netherlands
| | - M Adhiambo Witlox
- Department Orthopedic Surgery, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, the Netherlands
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Theunissen WW, van der Steen M, van Douveren FQ, Witlox AM, Tolk JJ. Timing of Repeat Ultrasound Examination in Treatment of Stable Developmental Dysplasia of the Hip. J Pediatr Orthop 2021; 41:203-208. [PMID: 33655899 PMCID: PMC8048726 DOI: 10.1097/bpo.0000000000001766] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Worldwide a wide variation exists in duration of Pavlik harness treatment for infants up to 6 months with stable developmental dysplasia of the hip (DDH). The purpose of this study was to evaluate whether shortening the time to first routine follow-up ultrasound after initiation of Pavlik harness treatment would reduce treatment duration and whether this influenced radiologic outcome at 1 year of age. Furthermore, predictors of higher acetabular index (AI) at 1 year of age were investigated. METHODS A retrospective study was conducted in infants with stable DDH (Graf IIb and IIc) diagnosed and treated between 2015 and 2017. Two groups were identified: first routine follow-up ultrasound at 12 weeks after Pavlik harness initiation (group I) and first routine follow-up ultrasound at 6 weeks after Pavlik harness initiation (group II). In both groups, treatment was continued until repeat ultrasound measurements (every 6 wk) showed a normalized hip. Radiologic outcome at 1 year of age was defined as residual dysplasia measured on an anteroposterior hip radiograph according to the Tönnis table. RESULTS A total of 222 infants were included. The median time of Pavlik harness treatment was 12 weeks (interquartile range, 11.9 to 12.3) in group I compared with 6.1 weeks (interquartile range, 6.0 to 7.5) in group II (P<0.001). Residual dysplasia at 1 year of age was detected in 20 infants (16.8%) in group I compared with 11 infants (10.7%) in group II (P=0.189). The multivariable prediction model showed that positive family history and lower baseline alpha angle correlate with a higher AI at 1 year of age. CONCLUSIONS First routine follow-up ultrasound can be safely brought forward from 12 to 6 weeks after Pavlik harness initiation. Furthermore, infants with a positive family history for DDH and an initial low alpha angle are at higher risk to have a higher AI at 1 year of age. LEVEL OF EVIDENCE Level III-retrospective study.
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Affiliation(s)
| | - Marieke van der Steen
- Department of Orthopaedic Surgery and Trauma, Máxima MC, Veldhoven
- Department of Orthopaedic Surgery, Catharina Hospital, Eindhoven
| | | | - Adhiambo M.A. Witlox
- Department of Orthopaedic Surgery and Trauma, Máxima MC, Veldhoven
- Department of Orthopaedic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jaap J. Tolk
- Department of Orthopaedic Surgery and Trauma, Máxima MC, Veldhoven
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Westacott DJ, Perry DC. The treatment of neonatal hip dysplasia with splints in the United Kingdom: time for consensus? J Child Orthop 2020; 14:112-117. [PMID: 32351623 PMCID: PMC7184644 DOI: 10.1302/1863-2548.14.190156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To understand the variation in the management of hip dysplasia identified from the United Kingdom neonatal selective screening programme. METHODS Having been designed and tested by the research committee of the British Society for Children's Orthopaedic Surgery (BSCOS), a nationwide online survey was conducted of BSCOS members to ascertain their treatment strategies for neonatal hip dysplasia. RESULTS There were 111 responses (60% of members), which illustrated wide variation in care. In all, 91 (over 80%) of respondents treat more than ten cases per year, yet only 61 (55%) work to an agreed protocol. A total of 90 (81%) use the Graf classification and 103 (93%) use the Pavlik harness initially. Consensus is lacking in key areas including duration of harness use, hours per day, clothing and weaning. Importantly, notable differences of opinion even exist regarding which hip pathologies need treatment. CONCLUSION This study quantifies the wide variation in many key elements of the initial treatment of neonatal hip dysplasia in the United Kingdom. This variation appears unnecessary and unacceptable as the Getting It Right First Time programme seeks to standardize care pathways. The charitable sector has called for consensus to mitigate parental anxiety, and it has been suggested that this could allow better integration of hip dysplasia into national screening pathways. Standardized care benefits patients and represents the platform from which we can begin understanding effectiveness and optimizing outcomes. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
| | - Daniel C. Perry
- Alder Hey Children’s Hospital, Liverpool, UK,Correspondence should be sent to Daniel C. Perry, Institute in the Park, Alder Hey Children’s Hospital, Liverpool, L12 2AP, UK. E-mail:
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Neal D, Beckwith T, Hines A, Lee WC, Kilinc BE, Jo C, Kim H. Comparison of Pavlik Harness treatment regimens for reduced but dislocatable (Barlow positive) hips in infantile DDH. J Orthop 2019; 16:440-444. [PMID: 31516214 DOI: 10.1016/j.jor.2019.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/30/2019] [Indexed: 11/17/2022] Open
Abstract
Objective Although the Pavlik Harness (PH) is the most utilized treatment for developmental dysplasia of the hip (DDH), the ideal treatment protocol (frequency of clinic visits in the first month and daily wear duration) for Barlow + hips (reduced but dislocatable) has yet to be defined. Methods This study compared DDH patients with Barlow hips who were treated with 23 vs 24 h per day PH wear and weekly vs every other week visits. Clinical success was defined as a stable hip that did not require closed or open reduction, or the use of an abduction orthosis prior to achieving clinical stability. Radiographic success was based on the acetabular index at 2-year follow up. Results Sixty-five patients (75 hips/58 females) with Barlow hips had a mean age of presentation of 15 ± 12 days (range 4-70) and mean follow-up of 33 ± 17 months (range 6-90). There was no difference in clinical or radiographic success rate between 23 h vs 24 h wear groups (p > 0.99 both) or the Frequently vs Infrequent visit groups (p = 0.49 both). Overall clinical success rate was 97% (73/75 hips) and radiographic success rate at 2 years was 97% (58/60 hips). Conclusion A strict, weekly clinic visit and 24-h PH regimen may not be necessary to obtain good clinical and radiographic outcomes in infants presenting <6 months of age with Barlow positive hips. Level of evidence Therapeutic, Level III.
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Affiliation(s)
- David Neal
- John Peter Smith Hospital, Fort Worth, TX, USA
| | - Terri Beckwith
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Adam Hines
- Irwin Army Community Hospital, Fort Riley, KS, USA
| | - Wei Chun Lee
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Bekir Eray Kilinc
- Health Science University, Fatih Sultan Mehmet Training and Research Hospital, Orthopaedics, Istanbul, Turkey
| | - ChanHee Jo
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Harry Kim
- Texas Scottish Rite Hospital for Children, Dallas, TX, USA
- Orthopedic Surgery Department at UT Southwestern Medical Center, Dallas, TX, USA
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Traction does not decrease failure of reduction and femoral head avascular necrosis in patients aged 6-24 months with developmental dysplasia of the hip treated by closed reduction: a review of 385 patients and meta-analysis. J Pediatr Orthop B 2019; 28:436-441. [PMID: 30585878 DOI: 10.1097/bpb.0000000000000586] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study aimed to investigate the effects of preliminary traction on the rate of failure of reduction and the incidence of femoral head avascular necrosis (AVN) in patients with late-detected developmental dysplasia of the hip treated by closed reduction. A total of 385 patients (440 hips) treated by closed reduction satisfied the inclusion criteria. Patients were divided in two groups according to treatment modality: a traction group (276 patients) and a no-traction group (109 patients). Tönnis grade, rate of failure reduction, AVN rate, acetabular index, center-edge angle of Wiberg, and Severin's radiographic grade were assessed on plain radiographs, and the results were compared between the two groups of patients. In addition, a meta-analysis was performed based on the existing comparative studies to further evaluate the effect of traction on the incidence of AVN. Tönnis grade in the traction group was significantly higher than in the no-traction group (P = 0.021). The overall rate of failure reduction was 8.2%; no significant difference was found between the traction (9.2%) and no-traction groups (5.6%) (P = 0.203). The rates of failure reduction were similar in all Tönnis grades, regardless of treatment modality (P > 0.05). The rate of AVN in the traction group (14%) was similar to that of the no-traction group (14.5%; P = 0.881). Moreover, the rates of AVN were similar in all Tönnis grades, regardless of treatment modality (P > 0.05). The meta-analysis did not identify any significant difference in the AVN rate whether preliminary traction was used or not (odds ratio = 0.76, P = 0.32). At the last follow-up visit, the two groups of patients had comparable acetabular indices, center-edge angles, and Severin's radiographic grades (P > 0.05). In conclusion, preliminary traction does not decrease the failure of reduction and the incidence of AVN in developmental dysplasia of the hip treated by closed reduction between 6 and 24 months of age.
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Voitl P, Sebelefsky C, Hosner S, Woditschka A, Diesner S, Böck A. Ultrasound of the infant hip: manual fixation is equivalent to Graf's technique regarding image quality-a randomized trial. BMC Pediatr 2019; 19:14. [PMID: 30630451 PMCID: PMC6327546 DOI: 10.1186/s12887-019-1392-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/03/2019] [Indexed: 11/10/2022] Open
Abstract
Background In Middle Europe ultrasonography is the standard method used to screen for developmental dysplasia of the hip in infants. Our aim was to determine whether manual fixation of the child is equivalent to Graf’s technique regarding image quality. Methods This randomized trial was conducted at a free-standing general pediatric outpatient clinic in Vienna, Austria. Healthy infants in the 1st and between the 6th and 8th week of life with no hip malalignment were included. After randomization, Group 1 was examined using Graf’s fixation device and participants in Group 2 were fixated on the examination couch by their parents. In a second step, all images underwent a blinded evaluation. Results A total of 117 babies (Group 1: n = 62, Group 2: n = 54, excluded: n = 1) were examined and 230 images (Group 1: n = 122, Group 2: n = 108) were evaluated, of which 225 were sonographically normal. Two images, showing a type IIa right hip and a type IIa + left hip respectively, were excluded. One participant had to be excluded as the respective images showed two pathologic hip joints. Two images in Group 1 and three in Group 2 were not evaluable. No statistical association between image quality (11 quality criteria and overall evaluability) and fixation technique (0.12 ≤ p ≤ 1.0 or constant) was found. Conclusions Considering sonographically normal hip joints, we found no evidence that manual fixation differed from Graf’s technique regarding image quality. In future studies, hip pathologies should be included and discomfort of infants and parents during the examination should be addressed. Trial registration German Clinical Trials Register, ID: DRKS00015694), registered retrospectively on October 7th, 2018.
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Affiliation(s)
- Peter Voitl
- First Vienna Pediatric Medical Center, Donau-City-Straße 1, 1220, Vienna, Austria.,Sigmund Freud Private University, Vienna, Austria.,Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Sebelefsky
- First Vienna Pediatric Medical Center, Donau-City-Straße 1, 1220, Vienna, Austria.
| | - Sara Hosner
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Astrid Woditschka
- First Vienna Pediatric Medical Center, Donau-City-Straße 1, 1220, Vienna, Austria
| | - Susanne Diesner
- First Vienna Pediatric Medical Center, Donau-City-Straße 1, 1220, Vienna, Austria
| | - Andreas Böck
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Vasilescu D, Cosma D, Vasilescu DE, Solomon CM, Corbu A, Dudea SM. Ultrasonography of borderline and asymmetric infant hips - a challenge in the management of developmental dysplasia of the hip. Med Pharm Rep 2018; 91:422-426. [PMID: 30564018 PMCID: PMC6296718 DOI: 10.15386/cjmed-1047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/19/2018] [Accepted: 07/02/2018] [Indexed: 12/04/2022] Open
Abstract
Background and aim Developmental dysplasia of the hip (DDH) is a potentially disabling disease. There are many diagnostic approaches, Graf method ultrasonography being the most popular imaging method. Although considered as a healthy condition, the existence of hips at the 60 degree limit or the asymmetries higher than 4 degrees between left and right side may be a source of unfavorable evolution and consequently of late diagnosed dysplasia cases. Methods The retrospective study was conducted in the Radiology Department of the Emergency Clinical County Hospital Cluj-Napoca, by retrospective analysis of the database containing 3013 records of the subjects presented for DDH assessment between January 2008 and December 2014. The study focuses on investigating two possible sources of missed cases by clinical-ultrasound management of DDH: borderline and asymmetric hips. Two conditions were studied in patients considered healthy according to Graf method: borderline hips (those with α angle value of 60° and 61°) and asymmetric hips (left to right difference between the α angle values exceeds 4°). Three study groups were formed: healthy subjects, asymmetric/borderline subjects and patients with immature or mild dysplasia. The incidence of risk factors, clinical suspicion and the success of therapy were evaluated. Results There were no significant differences between the three groups regarding the role of the risk factors in DDH pathogenesis. Data reveal a high suspicion rate after the clinical examination, in groups II and III, compared to the healthy population. This means that from this point of view, Group II might be considered having at least a dysplastic prognosis. An increased correlation in the therapeutic results was observed between Group II patients and those from mild delayed maturation subgroups from Group III (IIa−, IIa+). Conclusions Asymmetric and borderline hips should be approached similarly to immature hips, clinical suspicion and the therapeutic outcome being similar.
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Affiliation(s)
- Dan Vasilescu
- Radiology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dan Cosma
- Pediatric Orthopedic Surgery Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dana Elena Vasilescu
- Pediatric Orthopedic Surgery Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Carolina Maria Solomon
- Radiology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andrei Corbu
- Pediatric Orthopedic Surgery Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Sorin Marian Dudea
- Radiology Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Alves C, Truong WH, Thompson MV, Suryavanshi JR, Penny CL, Do HT, Dodwell ER. Diagnostic and treatment preferences for developmental dysplasia of the hip: a survey of EPOS and POSNA members. J Child Orthop 2018; 12:236-244. [PMID: 29951123 PMCID: PMC6005222 DOI: 10.1302/1863-2548.12.180034] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of this study was to elucidate developmental dysplasia of the hip (DDH) diagnosis and treatment preferences among members of the Pediatric Orthopaedic Society of North America (POSNA) and European Paediatric Orthopaedic Society (EPOS). METHODS A 54-question survey on DDH diagnosis and treatment preferences was distributed to POSNA and EPOS members. Descriptive statistics were performed. RESULTS A total of 459 responses were analyzed. Ultrasound was the preferred modality for diagnosing DDH in infants less than six months old; few surgeons preferred radiographs. In all, 57% of POSNA members had radiology technicians perform ultrasounds, only 7% of EPOS members did. The percent coverage defining a dislocated hip varied greatly, the most frequent response being < 20% for POSNA and < 40% for EPOS members. Pavlik harnesses were the most popular harness/brace, used by 90% of POSNA and 71% of EPOS members. POSNA members were more likely than EPOS members to use a rigid abduction brace following initial harness/brace failure. For residual acetabular dysplasia, POSNA members were twice as likely as EPOS members to institute hip abduction bracing. Most surgeons would not perform closed reduction at less than three months of age or open reduction at less than six months of age. Most EPOS -members used traction prior to reduction; few POSNA members did. Few POSNA and EPOS members believed that reduction should be delayed until the ossific nucleus was visible. CONCLUSION There is great variation in the preferred methods for diagnosing and treating DDH. This survey is the largest transcontinental survey to compile diagnostic and treatment preferences for DDH. With wide variations in practice, there is room for quality improvement.
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Affiliation(s)
- C. Alves
- Hospital Pediatrico - CHUC, EPE, Avenida Afonso Romao, 3000-602, Coimbra, Portugal
| | - W. H. Truong
- Gillette Children’s Specialty Healthcare, St Paul, Minnesota, USA
| | | | | | - C. L. Penny
- Hospital for Special Surgery, New York, New York, USA
| | - H. T. Do
- Hospital for Special Surgery, New York, New York, USA
| | - E. R. Dodwell
- Hospital for Special Surgery, New York, New York, USA, Correspondence should be sent to E. Dodwell, Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, United States. E-mail:
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Bin K, Laville JM, Salmeron F. Developmental dysplasia of the hip in neonates: evolution of acetabular dysplasia after hip stabilization by brief Pavlik harness treatment. Orthop Traumatol Surg Res 2014; 100:357-61. [PMID: 24797045 DOI: 10.1016/j.otsr.2014.03.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 02/17/2014] [Accepted: 03/06/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The recommended treatment duration in neonates with developmental dysplasia of the hip (DDH) varies depending on whether prolonged Pavlik harness therapy is believed to favourably affect the course of the acetabular dysplasia. According to one theory, several months of additional Pavlik harness therapy after achieving hip reduction contributes to correct the acetabular dysplasia. Another theory holds that hip dislocation induces the acetabular dysplasia, which corrects spontaneously once the femoral head is properly seated in the acetabulum. Here, we evaluated this second theory by studying outcomes after early brief Pavlik harness therapy. HYPOTHESIS Acetabular dysplasia associated with neonatal hip instability undergoes self-correction provided stable hip reduction is achieved very early after birth. Therefore, the duration of Pavlik harness therapy can be substantially shortened. MATERIALS AND METHODS We defined hip instability as either reducible hip dislocation or a very easily dislocatable hip with a soft clunk precluding determination of spontaneous hip position as dislocated or reduced. Static and dynamic ultrasound scans were obtained. Patients with ultrasonographic instability (pubo-femoral distance>5mm with less than 50% of coverage) underwent a second physical examination and received treatment. We re-evaluated 42 abnormal hips in 30 patients after a mean follow-up of 6.7 years (range, 5-14 years). Mean age at treatment initiation was 5 days (range, 1-15 days) and mean treatment duration was 34 days (range, 15-75 days). RESULTS Mean acetabular angle was 20° (range, 12°-30°) and mean Wiberg's lateral centre-edge angle was 30° (range, 22°-35°). Blunting of the lateral angle of the bony roof was noted in 8 hips at last follow-up. In 1 patient whose hip was stable clinically but unstable by ultrasonography at 21 days of age, recurrent dislocation occurred at 5 months of age. The Severin class was 1a in all patients. DISCUSSION Despite continuing controversy about whether hip dislocation induces dysplasia or vice versa, the need for early treatment is universally recognised. The optimal treatment duration, however, remains debated. Proponents of the familial determinism of DDH consider that acetabular shaping is genetically programmed when the femoral head is centred in the acetabular socket. Others advocate routine prolongation of Pavlik harness therapy for 2 months or longer, based on the opinion that this strategy decreases the dislocation recurrence rate and that mechanical hip unloading may promote correction of the dysplasia. Mean treatment duration in our population was 34 days and our sole objective was to treat the instability. The hip was reduced and held in its proper position long enough to allow sufficient capsule and ligament tightening to stabilise the hip. Under these conditions, the acetabular dysplasia underwent self-correction that was not related to treatment duration. CONCLUSION Very early Pavlik harness therapy to ensure rapid hip reduction and stabilisation optimises the potential of the acetabulum for spontaneous remodelling. LEVEL OF EVIDENCE Level IV, retrospective study.
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Affiliation(s)
- K Bin
- Service de Chirurgie Infantile, CHU Réunion, 97405 Saint-Denis, France
| | - J-M Laville
- Service de Chirurgie Infantile, CHU Réunion, 97405 Saint-Denis, France.
| | - F Salmeron
- Service de Chirurgie Infantile, CHU Réunion, 97405 Saint-Denis, France
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Staged weaning versus immediate cessation of Pavlik harness treatment for developmental dysplasia of the hip. J Pediatr Orthop B 2014; 23:103-6. [PMID: 24322535 DOI: 10.1097/bpb.0000000000000025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Outcomes of nonoperative treatment for developmental dysplasia of the hip were compared between two centres. Eighty children in Centre A underwent staged weaning of the Pavlik harness once three consecutive weekly ultrasounds showed Graf Grade I hips, whereas in 48 children in Centre B, the harness was removed immediately. No statistically significant difference was found in the rate of reintervention (repeat harness treatment, closed or open reduction), avascular necrosis or acetabular index between the two methods, although there was a nonsignificant trend towards higher reintervention rate and lower avascular necrosis rate with immediate harness removal. Age at start of treatment significantly impacted upon initial harness success, reinterventions and avascular necrosis.
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