Developmental dysplasia of the hip: impact of sonographic newborn hip screening on the outcome of early treated decentered hip joints-a single center retrospective comparative cohort study based on Graf's method of hip ultrasonography

Protective effect of modified lange "second position" for developing avascular necrosis following closed reduction for developmental dysplasia of the hip

BACKGROUND

Developmental Dysplasia of the Hip (DDH) is a condition affecting hip joint development in children, presenting multiple manifestations. Immobilization methods to ensure hip concentricity, such as the human position and modified Lange position, vary in effectiveness and risks, especially avascular necrosis. The purpose of this study was to identify whether closed reduction (CR), with two different immobilization techniques, is effective in avoiding complications such as residual hip dysplasia (RHD), re-dislocation, and Avascular Necrosis (AVN).

METHODS

A total of 66 patients with DDH (84 hips) were treated with two different techniques of immobilization (groups A and B); the mean age at the time of reduction was 8 (6-13) months. The rates of RHD, Re-dislocation, and AVN were determined with a minimum follow-up of 48 months in both techniques.

RESULTS

The Chi-square analysis conducted across the study groups unveiled that patients in Group B demonstrated a protective effect against AVN compared to those in Group A (OR: 0.248, 95% CI: 0.072-0.847, p = 0.026). However, no statistically significant differences were found between the groups concerning RHD (p = 0.563) and re-dislocation (p = 0.909).

CONCLUSIONS

After the initial Human Position immobilization, the second cast with the modified Lange "second position" demonstrated a protective effect compared with maintaining the Human Position immobilization throughout the immobilization period, reducing the likelihood of AVN development in patients undergoing closed reduction for developmental dysplasia of the hip.

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.

Ultrasonographic screening for developmental dysplasia of the hip: the Graf method revisited

Until the 1980s, the diagnosis of developmental dysplasia of the hip (DDH) was based on clinical examination and radiographic imaging. In 1980, Reinhard Graf developed his own ultrasonographic method for the examination of the infant hip joint. Graf's method evaluates the osseous and cartilaginous coverage of the femoral head by the acetabulum in the infantile hip joint by measuring the angles α and β. The validity of Graf method is that with these measurements the hip joint is further classified by Graf classification into types I to IV that guide treatment. Currently, Graf method is considered the gold standard examination for the diagnosis of DDH in many European countries. This review article aims to discuss the incidence, risk factors and pathophysiology of DDH, and to emphasize on the Graf method for the evaluation, classification, prevention and further management of this entity.

[Hip dysplasia]

BACKGROUND

Hip dysplasia is one of the most common malformations in childhood and has a significant impact on the further life of those affected. A distinction must be made between congenital and the much rarer acquired dysplasia. Early diagnosis and therapy are pivotal for further development of patients.

OBJECTIVES

The paper gives an overview of current radiological possibilities of diagnosis with focus on congenital hip dysplasia supplemented by insights into therapeutic options.

MATERIALS AND METHODS

Basic and review papers were analyzed.

RESULTS

Clinical examination of the newborn has low sensitivity and specificity in the diagnosis of hip dysplasia. The introduction of Graf ultrasound screening has significantly improved the early detection of dysplastic hips. With the help of sonography, but also magnetic resonance imaging (MRI), the shape of the acetabulum and the position of the femoral head in the socket can be precisely and quickly determined, while X‑ray examinations have their place especially in the context of follow-up examinations after treatment from the age of 1 year and in the diagnosis of secondary dysplasia. Therapeutic options range from spreading treatment to open reduction with fixation in the newborn as well as conversion osteotomy in older children.

CONCLUSION

Early detection of hip dysplasia is critical to the course of treatment. The right choice of examination method and correct performance are essential for further treatment.

Treatment perspective after failed open reduction of congenital hip dislocation. A systematic review

Background

Failure of open reduction of developmental hip dislocation is a serious complication and revision surgery appear to be technically demanding with high complication rates. Little attention has been given in literature to patients in whom open reduction of developmental hip dislocation has failed. We present a systematic review about current perspectives and timing when to perform surgical revision after failed open reduction of developmental hip dislocation in children.

Methods

Following the recommendations of the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) statements we performed a comprehensive search of the PubMed and Google Scholar bibliographic database in order to select all studies published between 1980 and 2022. Studies were screened for the reasons for failure of open reduction, timing when revision surgery was performed, and for the surgical techniques used for revision.

Results

A total of 10 articles including 252 patients and 268 hips has been recorded. The most common causes of re-dislocation after open reduction are inadequate exposure and failure to release the obstructing soft tissues inside and around the hip. In 90% of the cases the anterolateral approach was performed for revision surgery. Avascular necrosis occurred in 5%-67% of cases and was the most encountered complication.

Conclusion

Redislocation of developmental hip dislocation after an open reduction has poor long-term outcomes mainly due to a high rate of avascular necrosis of the femoral head. It is mandatory to obtain a stable reduction at the second surgery combining soft tissue release, capsulorrhaphy, pelvic and femoral osteotomies.

Factors for selective ultrasound screening in newborns with developmental dysplasia of the hip (DDH)

Background

Hip ultrasound screening for DDH provides better sensitivity compared to physical examination. Due to a lower prevalence and limited resources, selective hip ultrasound in newborns at risk could be considered a proper screening protocol in Thailand and Asian countries.

Objective

This study was aimed to evaluate risk factors and define criteria for selective screening.

Methods

A case-control study was conducted in 2020. All newborns with hip ultrasound screening were included. Cases were defined as newborns with abnormal hip ultrasounds, while controls were those with normal studies. Inter and intra-rater reliability were evaluated. All factors were analyzed using univariate and multivariate logistic regression. The model performance was tested by Hosmer-Lemeshow goodness of fit. Internal validity was performed by the split data method. Area under the receiver operating characteristic (ROC) curve was estimated.

Results

Ninety-five newborns (29 cases and 66 controls) were included. Eighty percent of cases and 58% of controls were female. The gestational age was 36.6 and 37.7 weeks in case and control, respectively. Female, breech presentation, positive Ortolani test, positive Barlow test, and limited hip abduction were significant factors with odds ratio of 2.82, 5.12, 34.21, 69.64, and 5.48, respectively. The final model included breech presentation, positive Ortolani test, and positive Barlow test. The model cut-off value 15.02 provided sensitivity (93.10%) and specificity were (80.30%). The area under the ROC curve was 0.9308. The split data remained significant internal validity for all factors with p-value < 0.05.

Conclusion

Careful history taking and physical examination are essential to identify the risk factors for DDH. Newborns with breech presentation, positive Ortolani test and positive Barlow test should be screened by hip ultrasound.

[Arthroscopic reduction of congenital hip dislocations in infants]

OBJECTIVE

Open reduction of congenital hip dislocations currently remains the standard treatment for those hip joints which are irreducible by closed means. The open reduction of the dislocated hip joint represents a relatively invasive surgical method. Thus, the goal was to develop a minimally invasive and safe procedure with a lower complication rate as an alternative to open reduction. This work presents the arthroscopically guided reduction of dislocated hip joints, first described in 2009, as a standardized surgical technique.

INDICATIONS

Failed closed reduction for congenital hip dislocation.

SURGICAL TECHNIQUE

Arthroscopic reduction of the dislocated femoral head using an arthroscopic two-portal technique, a high anterolateral and a medial subadductor portal. The arthroscope is inserted through the subadductor portal. The high anterolateral portal serves as working portal. Step-by-step identification and removal of obstacles to reduction such as the ligament of the femoral head, fat tissue, capsular constriction and psoas tendon. Reduction of the femoral head under arthroscopic control.

POSTOPERATIVE TREATMENT

The hip joint is retained in a hip spica cast with the legs in human position.

RESULTS

Arthroscopic hip reduction of 20 congenital hip dislocations: 13 girls and 3 boys with an average age at the time of operation of 5.8 months (3-9 months). All children had multiple, unsuccessful attempts of closed reduction by use of overhead traction, Pavlik harness or closed reduction and hip spica application. According to the Graf classification, there were 20 type IV hips. According to the radiological classification of Tönnis, there were 9 type 4, 7 type 3, and 4 type II grades. The obstacles to reduction were capsular constriction, hypertrophic ligament of the femoral head, and an extensively large pulvinar in the acetabulum. An inverted labrum was not seen in any of the cases. In contrast, in 2/3 of the cases, there was considerable retraction of the dorsal edge of the socket due to the ligament of the femoral head expanding right over it. In all cases, postreduction transinguinal ultrasound and MRI were used to check the femoral head position in the cast postoperatively. In all cases there was a deep reduction of the femoral head in the acetabulum. There were no intra- or postoperative complications such as bleeding, infections or nerve lesions. There were no cases of redislocation or decentering of the femoral head, which was also confirmed after an average follow-up of 15 months. The mean AC angle at follow-up was 24.5°. There was one coxa magna in the series and one avascular necrosis with a fragmented femoral head according to the Salter classification.

Clinical examination and patients' history are not suitable for neonatal hip screening

Purpose

To assess the percentage of missed developmental dysplasia of the hip, which escape the German criteria for newborn hip high-risk screening, we analyzed our data gained from the general neonatal sonographic hip screening performed at our department. The aim of the study was to determine the number of potentially belatedly treated developmental dysplasia of the hip.

Methods

The data from 1145 standardized newborn hip ultrasound examinations according to the Graf technique were analyzed retrospectively comparing findings for general neonatal sonographic hip screening and high-risk screening subgroups.

Results

We diagnosed developmental dysplasia of the hip in 18 of the 1145 newborns via ultrasound. A total of 10 out of 18 developmental dysplasia of the hip would have been missed by high-risk screening, which corresponds to a proportion of 55.6% false-negative results. The sensitivity of high-risk screening was only 44.4% and specificity, 78.3%. The positive predictive value was 3.2%. Family history as a screening criterion yielded false-negative results in 77.8% and false-positive results in 16.8%. In all, 83.3% of the children who were born with developmental dysplasia of the hip but not from breech position as a risk factor were false negative. The clinical examination was false negative in 88.9% and false positive in 0.6%.

Conclusion

High-risk screening detected less than every second developmental dysplasia of the hip, rendering the first month as the most effective treatment window unavailable for inapparent dysplastic hips, potentially resulting in the need for more invasive treatment. Due to the high sensitivity of ultrasound in the detection of developmental dysplasia of the hip, we recommend to replace the current German high-risk screening guidelines with a general newborn screening for all neonates using Graf ultrasound in the first week of life.

Level of evidence

Level II.

Comparison of treatment outcomes of stable and unstable developmental dysplasia of the hip with the Tübingen splint

BACKGROUND

The Tübingen splint was initially developed for the treatment of stable developmental hip dysplasia (DDH). Later on, some authors expanded its include for the treatment of unstable DDH, but there remain some controversies in the literature. This study aims to compare the outcome between stable and unstable DDH treated with a Tübingen splint.

METHODS

Epidemiological data and ultrasonographic data of all infants diagnosed with DDH and initially treated with a Tübingen splint at our institution between May 2017 and February 2020 were assessed retrospectively. We divided the population into stable and unstable hips using the Graf classification. Age at treatment initiation, duration of treatment, complications, and radiological outcome between 12 and 24 months were investigated.

RESULTS

We included a total of 45 patients (57 hips) affected by DDH treated with the Tübingen splint. Treatment has been successful in 93% of stable hips and only 40% of unstable hips. Radiological outcome at 1-year follow-up significantly correlated with initial Graf classification (p < 0.001).

CONCLUSION

The Tübingen splint is a safe and effective treatment for stable hips, nevertheless, for unstable hips, closed reduction, and spica cast remains the gold standard.

Staged reconstruction of unilateral neglected hip dislocation through total hip arthroplasty and subsequent intramedullary femoral lengthening

Background and purpose

Total hip arthroplasty (THA) is a successful approach to treat unilateral symptomatic neglected hip dislocation (NHD). However, the extensive leg length discrepancy (LLD) can hereby only be partially corrected. In case of residual LLD of more than 2 cm, subsequent femoral lengthening can be considered.

Patients/material/methods

Retrospective analysis of clinical data and radiographs of five patients (age 38.1 (28–51) years) with unilateral NHD who underwent THA with (n  = 3) or without (n = 2) subtrochanteric shortening osteotomy (SSO) and secondary intramedullary femoral lengthening through a retrograde magnetically-driven lengthening nail (follow-up 18.4 (15–27) months).

Results

LLD was 51.0 (45–60) mm before and 37.0 (30–45) mm after THA. Delayed bone union at one SSO site healed after revision with autologous bone grafting and plate fixation. Subsequent lengthening led to leg length equalisation in all patients. Complete consolidation was documented in all lengthened segments.

Conclusion

Staged reconstruction via THA and secondary femoral lengthening can successfully be used to reconstruct the hip joint and equalise LLD. The specific anatomical conditions have to be taken into consideration when planning treatment, and patients ought to be closely monitored.

Screening of Newborns and Infants for Developmental Dysplasia of the Hip: A Systematic Review

BACKGROUND

Developmental dysplasia of hip (DDH) is a common disorder of childhood and has a good prognosis when treated at an early age. In spite of being a significant concern, many children with DDH are not picked early and present late at walking age. In our country, it is presumed to be due to absence of a national policy for screening of DDH. Screening programmes including the combination of clinical and radiological methods in different ways have been suggested. However, the exact method of screening is controversial.

PURPOSE

To analyze effectiveness and cost-effectiveness of various screening methods for DDH.

STUDY DESIGN

Systematic review.

METHODS

This review was conducted in accordance with PRISMA guidelines. Medline database was explored for original case series and randomized clinical trials. Inclusion criteria were English language, screening for DDH in neonates, sample size more than 500, and studies with minimum duration of one year.

RESULTS

Thirty-four studies were selected to write the manuscript. This included 23 studies looking for effectiveness of a screening programme and 11 studies comparing various outcomes of different screening strategies. A trend favoring universal ultrasound screening was observed.

CONCLUSION

The literature supports universal ultrasound screening and has proved its cost-effectiveness. However, considering the logistic and financial challenges in our country, immediate implementation of universal ultrasound screening seems impractical. In the absence of any current guidelines for screening for DDH in India, we suggest professional organizations involved in the care of children and public health policy-makers to come together to develop national screening guidelines for DDH.

Importance of early diagnosis for developmental dysplasia of the hip: A 5-year radiological outcome study comparing the effect of early and late diagnosis

AIM

Australia utilises a selective ultrasound screening programme. The rate of late diagnosis of developmental dysplasia of the hip (DDH) in Australia is increasing. The aim of this study is to quantify the treatment required and compare the 5-year radiological outcomes between early and late diagnosis in children with DDH with frank dislocation.

METHODS

We performed a case-matched control study of children with frank DDH dislocations from 2000 to 2010 comparing three groups: children with an early diagnosis successfully treated in a Pavlik harness (SP), children with an early diagnosis who failed Pavlik harness treatment (FP) and children with a late diagnosis (LD). Minimum follow-up was 4 years.

RESULTS

A total of 115 hips were included. Patients in the LD group required significantly more open reductions (P < 0.001), acetabular osteotomies (P < 0.001) and femoral osteotomies (P < 0.001). LD was also associated with significantly higher rates of growth disturbance at 46.3%, compared to 20.6% in the FP group and 5% in the SP group (P < 0.001). Overall, there were excellent radiological outcomes in 58.5% of the LD group compared to 79.4% in the FP group and 100% in the SP group.

CONCLUSION

In Australia, high rates of LD in DDH persist in the context of selective ultrasound screening. While good radiological outcomes are achievable, a significantly greater level of surgical intervention is required and this is associated with significantly higher rates of growth disturbance. Optimisation of screening in Australia is vital.

Timing for closed reduction procedure for developmental dysplasia of the hip and its failure analysis

Background

It remains controversial whether the older age to perform closed reduction (CR) procedure for developmental dysplasia of the hip (DDH), the higher incidence of complications. The aim of this study is to evaluate the midterm outcome of CR for DDH among different age groups, and to analyze and identify risk factors for the failure of this procedure.

Methods

Clinical data of 107 DDH patients, who received CR, were retrospectively reviewed. Data were divided into three groups according to initial treatment age (Group I: younger than 12 months; Group II: 12 months to less or equal to18 months; Group III: older than 18 months). The presence of avascular necrosis (AVN), residual acetabular dysplasia (RAD), re-dislocation, and further surgeries (FS) were observed. The risk factors were identified for those outcomes aforementioned using univariable logistic regression models. For identified risk factor age, pre-op acetabular index (AI) and post-op AI, their prediction of CR failure were evaluated by receiver operating characteristics curve (ROC).

Results

A total of 107 patients (156 hips) undergoing CR procedure were evaluated with a median age at initial reduction of 13.0 ± 5.4 months (range, 4 to 28 mo). Mean follow-up time in this study was 6.7 ± 0.8 years (range, 3–8 years). The incidence of AVN, RAD and re-dislocation was 15.4% (24/156), 17.3% (27/156) and 14.7% (23/156) respectively. For AVN, RAD and re-dislocation, the significant risk factors are pre-op IHDI IV (p = 0.033), age ≥ 18 months (p = 0.012), and pre-op IHDI IV (p = 0.004) and walking (p = 0.011), respectively. The areas under the ROC curve of each type of failures were 0.841 (post-op AI), 0.688 (pre-op AI) and 0.650 (age).

Conclusions

Severe DDH patients older than 18 months with CR procedure may result in a high risk of RAD complication. Re-dislocation is significantly associated with pre-op IHDI IV and walking. Patients, who are older than 12.5 months or have a pre-op AI of 38.7° or a post-op AI of 26.4°, are also more likely to fail of CR procedure.

Evaluation of YouTube Video Content About Developmental Dysplasia of the Hip

Objective The purpose of this study is to investigate the quality and reliability of YouTube videos regarding developmental dysplasia of the hip (DDH). Background YouTube is one of the most popular websites used as a source of information, but the variety in authorship and lack of a peer-review process are problems. Methods The search string "developmental dysplasia of the hip" was inputted to the YouTube search engine, and the first 52 videos returned as a response were assessed. The Video Power Index (VPI) (like ratio*view ratio/100) was used to assess the popularity of the videos. Global Quality Score (GQS) and DDH scores (DDHS) were used to evaluate the quality and educational quality of the videos, and the Journal of the American Medical Association Score (JAMAS) was used to evaluate the accuracy of the source of information. Results According to our research, the mean duration time of the videos was 526 seconds (SD: 813), and the average view count of the videos was 34,644. The mean time since upload was 1,907 days (SD: 1,137). On average, the videos received 10.9 comments, 210.3 likes, and 6.8 dislikes. The mean like ratio and VPI were 92.9 (SD: 19.57) and 25.8 (SD: 53.43), respectively. The mean JAMAS, GQS, and DDHS of all videos evaluated were 1.37 (SD: 0.7), 2.46 (SD: 1.09), and 4.63 (SD: 5.00), respectively. The DDHS and GQS were positively correlated (p: 0.001; r: 65.8%). The GQS and the DDHS were higher in the academic group than in the commercial group (p: 0.01 and p: 0.037, respectively). Conclusions The videos regarding DDH on YouTube generally had poor quality. As a result, to maintain an optimal parent-physician or patient-physician relationship, we suggest that international health societies make their own educational videos for parents, patients, and fellow physicians. Level of evidence Level 3.

Using 3-dimensional ultrasound islice technology for the diagnosis of developmental dysplasia of the hip

OBJECTIVES

This study aimed to investigate the reliability of 3-dimensional (3D) ultrasound in screening for developmental dysplasia of the hip (DDH) by comparing the results with those of 2-dimensional (2D) ultrasound.

METHODS

One hundred five infants who were younger than 6 months were enrolled in this study. All of the infants underwent 2D and 3D ultrasound scanning for DDH by novices and experts, and the images were graded by a lead expert. The scanning time and image grades were analyzed by Student t tests (P < .05). The consistency of the α angle measurement between the novices and experts was evaluated by the intraclass correlation coefficient (ICC).

RESULTS

The 105 infants included 34 boys and 71 girls. On 2D scanning, there was agreement between the experts about the correct diagnosis, whereas in the novice group, 41 infants had misdiagnoses. There were no misdiagnoses with 3D scanning in either group. In the novice group, the mean image grades ± SD were 4.2 ± 1.3 (2D ultrasound) and 8.1 ± 0.7 (3D ultrasound; P < .05). In the expert group, the mean image grades were 7.4 ± 1.0 (2D ultrasound) and 8.2 ± 1.0 (3D ultrasound; P < .05). There was no statistically significant difference between the groups in the grades for 3D ultrasound (P = .83). The scanning time for 3D ultrasound was shorter than that for 2D ultrasound in both groups (P < .05). In the novice group, the ICC of the α angle between the 2D and 3D ultrasound results was 0.34, and in the expert group, it was 0.92. The ICCs were 0.35 and 0.84, respectively when comparing 2D and 3D ultrasound results in the groups.

CONCLUSIONS

Three-dimensional ultrasound required less time and showed greater inter-rater reliability than 2D ultrasound for detecting DDH.

Developmental dysplasia of the hip: real world data from a retrospective analysis to evaluate the effectiveness of universal screening

AIMS

Developmental dysplasia of the hip is an important cause of disability in children and young adult and it also has a significant socio-economic impact in our society. The main objective of our study is to evaluate, in our hospital, the effectiveness of a universal ultrasound screening protocol and to assess the general knowledge about the theme of pediatricians and neonatologists.

METHODS

Retrospective study of infants born from January 2016 to April 2019, evaluated with hip ultrasound (Graf method). Risk factors assessed were female gender, breech presentation at birth, positive family history and twin birth. For the secondary objective, an anonymous and validated questionnaire was distributed to all pediatricians and neonatologists.

RESULTS

Among the 4000 hips analyzed, on ultrasound examination, 98.8% hips resulted mature or immature but appropriate for age, while 1,2% hips were pathological. Analyzing the mature or immature hips, 2,4% were positive on clinical examination and 97,6% were negative. In relation to ultrasound pathological hips, 33,3% have positive clinical examination, while 66,7% negative. From the analysis of risk factors a significant association emerged between female sex, breech presentation and family history with the ultrasound pathological findings. The results of Survey showed that inadequate training about developmental dysplasia of the hip is done during medical school.

CONCLUSIONS

A universal ultrasound screening allowed us to identify developmental dysplasia of the hip in a number of children with normal clinical examination and no risk factors. Specific training courses should be implemented regarding Developmental Dysplasia of the Hip for neonatologists and pediatricians.

Comparison of arthroscopic and open reduction of conservatively irreducible dislocated hips of children

PURPOSE

Children with sonographic grade IV hip dysplasia according to Graf and with failed conservative treatment usually need surgical reduction afterwards. Surgical reduction of the hip can lead to severe complications, the occurrence of residual acetabular dysplasia, osteonecrosis, redislocation and other postoperative complications. This paper investigates whether arthroscopic reduction is a promising alternative to open reduction.

METHODS

We retrospectively examined 66 patients (78 hips) who were not older than two years at the first time of surgery. Arthroscopic reduction was performed on 17 children (19 hips) and open reduction on 49 children (59 hips). Patient records were used to determine redislocation, postoperative complication and residual dysplasia. Radiographs were used to determine Tönnis classification for osteonecrosis and pathological acetabular (AC) angle for residual dysplasia. We considered data up to a two-year follow-up. Statistical evaluation was performed with binary logistic regression.

RESULTS

After arthroscopic reduction, 6% showed osteonecrosis, compared with 20% with open reduction (p = 0.334). Redislocation was not observed after arthroscopic reduction but for 29% after open reduction (p = 0.005). An improvement of femoral head coverage was achieved with residual dysplasia of 23.5% after arthroscopic reduction, compared with 62% after open reduction (p = 0.002).

CONCLUSION

The arthroscopic procedure represents a meaningful alternative to the open procedure due to a lower complication rate, a safe setting, a lower rate of residual dysplasia, no observed redislocation and occurrence of osteonecrosis only once in the arthroscopic group of developmental dysplasia of the hip. The arthroscopic procedure should be tested in further studies and in other clinics in order to broaden the empirical base.

LEVEL OF EVIDENCE

Level III (retrospective cohort study).

Optimizing the Time for Developmental Dysplasia of the Hip Screening: Earlier or Later?

INTRODUCTION

Developmental dysplasia of the hip (DDH) is still a common and important disorder of childhood, with a prevalence of 0.1 to 2/1000 children. Using ultrasonography (US) in screening of DDH reduces the rates of open reductions and complications. In the current study, we aim to detect the optimal time for US examination for detecting DDH to prevent unnecessary repeating US examinations and treatments.

METHODS

Children referred to US examination for a healthy child screening program, according to the health policy of our country, are included in the current prospective study. Both hips of each child were sonographically examined by the same radiologist using Graf's method at 4th, 8th, 12th weeks of life.

RESULTS

A total of 2020 hips of 1010 children were examined. Fourth-week US results can predict 12th-week results (right hip: sensitivity 100%, specificity 75.7%; left hip: sensitivity 100%, specificity 78.3%). Eighth-week US results can predict 12th-week results (right hip: sensitivity 100%, specificity 87.5%; left hip: sensitivity 100%, specificity 83.9%). In predicting 12th-week US results, 8th-week results are found to be more successful than 4th-week results.

CONCLUSIONS

Late diagnosis of DDH might cause serious public health problems. On the other hand, early US examinations can result in false-positive diagnosis. Unfortunately, there is still confusion about the optimal time for DDH screening with US, especially among radiologists who are not specialized in DDH sonography. A US scan performed at eighth week of life can predict any pathology presence safely and correctly.

[Hip dysplasia-new and proven methods]

BACKGROUND

Hip dysplasia is one of the most common disorders in paediatric orthopedics. With the development of ultrasound techniques treatment has changed, and earlier diagnosis and treatment is possible. So, for more than 20 years diagnosis and treatment has been focused on ultrasound. Many papers reporting new diagnostic techniques like MRI have been published. Arthroscopic reduction is a new surgical procedure. However, established surgical procedures continue to play an important role in the treatment.

CURRENT TREATMENT

This paper presents new and established diagnostic techniques, conservative and surgical treatment options. Unfortunately, due to the great number of publications, not all aspects could be taken into account. In particular, we describe the diagnostic and treatment standards in German-speaking countries based on ultrasound hip screening. However, also international aspects of diagnostic and treatment options have been included.

Treatment of Graf Type IIa Hip Dysplasia: A Cut-off Value for Decision Making

Background:

The rate of spontaneous normalization in type IIa hips is reported to be high, whereas dysplsia persists or worsens in 5%-10% of cases.

Aims:

To evaluate the natural course of type IIa hips using Graf’s own perspective of physiological immaturity and maturational deficit.

Study Design:

A single center, retrospective cohort study.

Methods:

This was an institutional review board-approved retrospective review of all patients diagnosed with type IIa hip dysplasia at a single institution from 2012 to 2014. All patients included in the study had hip ultrasonography at about 6 weeks and 3 months of age. To assess reliability in α and β angles, ultrasonography measurements were carried out on the same image individually by all observers. The α and β angles were used as the main outcome measurements to evaluate hip maturation at the last follow-up. A receiver operating characteristics curve was drawn at the 3 month ultrasonography to evaluate the cut-off values for α and β angles for persistent dysplasia.

Results:

Sixty-four patients and 88 affected hips (63% unilateral and 37% bilateral) were included. The mean age at diagnosis was 6.4±2.7 weeks. Fifty-four hips were type IIa(+) (physiologically immature) and 34 hips were type IIa(-) (maturational deficit) at the initial ultrasonography evaluation. Improvement to type I was seen in 52 type IIa(+) and 17 type IIa(-) hips. Receiver operating characteristic analyses showed that patients do well if the α angle was >55° (area under the curve: 0.86; p<0.001 for the left hip and area under the curve: 0.72; p=0.008 for the right hip).

Conclusion:

The cut-off α angle value of 55° on initial ultrasonography should be considered to prevent future dysplasia. An α angle <55° on the initial ultrasonography was an independent predictor of worsening sonographic findings.

Diagnosing developmental dysplasia of the hip using the Graf ultrasound method: risk and protective factor analysis in 11,820 universally screened newborns

The essential role of ultrasound examinations in diagnosis and treatment of developmental dysplasia of the hip (DDH) is widely accepted while the weighting and correlation of protective factors and perinatal risk for DDH still give rise to debate. Our aim was to investigate the impact of single and twofold combined risk and protective factors on the newborns' hip maturity, assessed with the Graf ultrasound method. Therefore, data sets of 11,820 universally screened newborns were analyzed. Univariate and logistic regression analyses were performed to correlate risk and protective factors with mature or immature but appropriate for age and pathologic hip types. Thereby, female gender (OR 4.07 (95% CI 3.01-5.51), p < 0.001), breech presentation (4.98 (3.71-6.71), p < 0.001), and positive family anamnesis (5.05 (3.49-7.31), p < 0.001) as well as the combination of female gender with high birth weight (3.51 (2.45-5.03), p < 0.001) could be identified as independent predictive risk factors. Only low birth weight (0.27 (0.11-0.66), p = 0.004) could be identified as a single protective factor, while no combination of protective factors was significant.

CONCLUSION

The significance and the informative value of risk and protective factor combinations, e.g., for selective ultrasound surveys, are limited. Early universal ultrasound screening using the Graf method is advised to timely detect hip immaturity and pathologies and to provide the optimal approach for mature or immature but appropriate for age and pathologic hips. What is Known: • Ultrasound screening is essential for diagnosis and treatment of DDH in time while the weighting and correlation of protective factors and perinatal risk and their role for the ultrasound screening protocol still give rise to debate. What is New: • The effects of single risk and protective factors for DDH do not cumulate or counteract, resulting in a limited value of a selective screening protocol based on risk and protective factors. • A universal screening protocol using the Graf ultrasound method is recommended.

[Incidence and duration of therapy of pathological hip findings in U2 and U3 examinations (SNiP study)]

INTRODUCTION AND OBJECTIVES

Determination of the efficacy of an early ultrasound examination followed by immediate treatment of hip joint dysplasia as well as measuring the therapeutic success in a population-based cohort study of neonates.

MATERIAL AND METHODS

The Survey of Neonates in Pomerania (SNiP) study included 4,093 neonates which represents 95.1 % of the total neonatal population. Of these children 2,534 (61.9 %) underwent ultrasound examination of the hip joint during the U2 stage (3-10 days after birth). The mean gestational age was 38.9 weeks. The sonographic classification was performed according to Graf.

RESULTS

Initially (U2 stage) 42 (1.66 %) children were reported to be in need of therapy (stage IIc or higher according to Graf). The analysis showed a significantly higher incidence in girls (32 girls vs. 10 boys, p < 0.023, χ(2) test) and in children who had a breech birth (116, 4.6 %). A genetic predisposition was ascertained in 180 (7.1 %) children. The children could be subdivided into two groups: 1) children who underwent hip joint ultrasound during both U2 and U3 and 2) children who were first screened at the U3 stage. Of the 49 out of 54 neonates where the ultrasound findings were positive at the U2 examination the hip joint was matured in 32 children at U3 (4-8 weeks), 11 children had to be treated for 8-12 weeks 5 children were treated for over 3 months and1 child needed surgical correction.

CONCLUSION

The early diagnosis of hip maturation disorders and joint dysplasia facilitates early implementation of effective treatment. At our clinic over 60 % of the infants underwent the U2 check up and, given a pathological finding, could undergo early treatment. It was possible to successfully treat 78 % of these children with a Tübingen hip flexion splint in just 4-8 weeks. In contrast, infants who were first examined at the U3 stage needed treatment for 4-12 months. In our opinion, early diagnosis at the age of 3-10 days should be carried out for all newborns.

A modified surgical approach of the hip in children: is it safe and reliable in patients with developmental hip dysplasia?

PURPOSE

Treatment is easier and complications are less likely to occur if developmental dysplasia of the hip (DDH) is diagnosed early. In this study, we examined the early results of open reduction using a medial approach which we had modified for DDH and analyzed the success of this technique and the associated complication rates, with a focus on avascular necrosis (AVN).

METHODS

This is an Institutional Review Board-approved retrospective review of all patients diagnosed with DDH and treated with a modified medial approach at a single institution from July 1999 to December 2010. The patients' charts were analyzed for clinical and radiographic features.

RESULTS

Fifty-five hips of 41 patients, all of whom were treated by open reduction using a modified medial approach due to DDH, were evaluated retrospectively. The mean age of the patients at surgery was 19 (range 11-28) months, and the average follow-up was 5.5 (range 3-9.5) years. AVN was the most important complication in terms of radiological outcomes as assessed according to the Kalamchi-McEwen classification. Radiologic results were excellent or good in 51 hips (92.7 %) and fair-plus in four (7.3 %). Type 1 temporary AVN was detected in only two hips (3.6 %), and the lesions had disappeared completely in the final control graphs of these two patients. A secondary intervention was needed for two hips (3.6 %) of the same patients who were operated on due to bilateral DDH. No other complications, such as infection, re-dislocation, or subluxation, were seen in the operated patients.

CONCLUSIONS

We believe that treatment for DDH using a modified medial approach during early childhood is an effective and reliable method with low AVN rates. As shown here, this method achieves great success in radiological and clinical outcomes after a minimum 3-year follow-up.

Differences between the alpha angles measured manually and digitally from paediatric hip ultrasonograms

The aim of this study was to reveal whether a meaningful difference is caused by measuring the alpha angle in hip ultrasonography manually or digitally to help the early diagnosis and treatment of DDH and observe the treatment implications of any such difference. All ultrasound images were obtained by same orthopaedist, and each hip was measured twice by two investigators with different levels of experience. Standard images were taken, and a printout of the standard images were obtained. The alpha angle was measured digitally by using the sonography device. The alpha angle was also measured by pencil, ruler and goniometer on the printout after 2 days. One hundred and two hips of 51 babies, at a mean age of 14 weeks, were assessed. The mean alpha angle measured manually with a goniometer was 64.4° (±1.6°), while that measured on the ultrasonography device was 65.3° (±0.9°). This difference was found to be statistically different (p = 0.016). Typology changes occurred in a total of 10 hips out of 102 as a result of manual and digital measurements. However, this study showed reduction in alpha angle variation and considerable advantages for manual alpha angle measurement with pencil and goniometer on a printout compared to computer-based measurement; future studies are needed to understand these differences caused by each measurement method.

Applications of musculoskeletal ultrasonography in pediatric patients

Ultrasonography is an excellent adjunct to other musculoskeletal imaging tools utilized in the pediatric population and in some instances offers advantages over CT and MRI. It permits dynamic examination of anatomic structures and assists in guiding minimally invasive procedures. In the lower extremity, ultrasonography assists in screening for such disorders as developmental dysplasia of the hip and in detecting slipped capital femoral epiphysis and femoral acetabular impingement. In the neonatal spine, ultrasonography can identify unossified vertebral arches. Among other applications in the upper extremity, ultrasonography may be used in the evaluation and examination of peripheral nerve injuries and is a preferred modality for imaging the shoulder in infants with neonatal brachial plexus palsy. It is also considered an optimal adjunct for administration of botulinum toxin-A in children with cerebral palsy. The portability, relative low cost, lack of radiation, and absence of known contraindications enhances the utility of ultrasonography in pediatric orthopaedics.

Early articular cartilage degeneration in a developmental dislocation of the hip model results from activation of β-catenin

Developmental dislocation or dysplasia of the hip (DDH) is one of the most common deformities in children. Osteoarthritis (OA) is the most frequent long-term complication. The molecular mechanism of early articular cartilage degeneration in DDH is still unclear. It is well known that β-catenin plays a crucial role in articular cartilage degeneration. The objective of this study was to verify the relationship between β-catenin and DDH cartilage degeneration. We used a DDH model that was established by modification of swaddling position in newborn Wistar rats. The hips were isolated from the DDH model rats and untreated control group at the age of 2, 4, 6 and 8 weeks. β-Catenin gene and protein were investigated by quantitative (q)RT-PCR and immunohistochemistry. Collagen X and matrix metalloproteinase (MMP)-13, markers of early cartilage degeneration, were assessed by qRT-PCR. Primary chondrocytes were cultured from cartilage of two groups at the age of 8 weeks. Expression of β-catenin, collagen X and MMP-13 was detected. Continued high expression of β-catenin was observed in cartilage from DDH model rats. mRNA and protein expression of β-catenin was significantly increased in primary chondrocytes of the DDH model compared with the control group. Collagen X and MMP-13 expression was higher in the cartilage and chondrocytes from DDH model rats than the control group. Our findings suggest that early cartilage degeneration in DDH may result from activation of β-catenin signaling.

Use of ultrasonography in developmental dysplasia of the hip

PURPOSE

Ultrasonography has been used as a diagnostic tool in developmental dysplasia of the hip (DDH) during early infancy since the early 1980s. The aim of this review article is to summarise the technique, benefits and shortcomings of four infantile hip ultrasonography methods, focusing mainly on the Graf method, and to assess the effectiveness of ultrasonographic newborn hip screening programmes.

METHODS

Several infantile hip ultrasonography methods have been defined to assess the relationship between the femoral head and acetabulum. The Graf, Harcke, Terjesen and Suzuki methods are the universally known ones. The Graf method is composed of a quantitative classification system, while the Harcke and Suzuki methods have qualitative definitions and the Terjesen method contains both quantitative and qualitative descriptions.

RESULTS

Although the results of several studies assessing the sensitivity and consistency of the ultrasonography methods have still not proven a clear dominance of one of these techniques, the primary advantage of the Graf method is that it has a standardised examination technique, as well as a very well defined numeric hip typing system. The importance of newborn hip screening has been universally accepted, but there is still no strong evidence regarding the superiority of either universal (screening of all newborns) or selective (screening of high-risk newborns) ultrasonographic newborn hip screening programmes.

CONCLUSIONS

An effective ultrasonographic method should include simple, precise, quantitative and consistent definitions for a proper examination and diagnosis. Both universal and selective ultrasonographic newborn hip screening programmes have significantly decreased the rate of late detected DDH and lessened the need for surgical treatment.

Incidence and treatment of developmental hip dysplasia in Mongolia: a prospective cohort study

Background

In Mongolia, adequate early diagnosis and treatment of developmental hip dysplasia (DDH) have been unavailable and its incidence was unknown. We determined the incidence of ultrasonographic DDH in newborns and established adequate procedures for diagnosis and treatment of DDH at the largest maternity hospital in Ulaanbaatar, Mongolia.

Methodology/Principal Findings

During one year (Sept 2010 – Aug 2011) we assessed the hips newborns using ultrasound and Graf’s classification of DDH. 8,356 newborns were screened; median age at screening was 1 day. We identified 14,873 Type 1 (89.0%), 1715 Type 2a (10.3%), 36 Type 2c (0.2%), 70 Type D (0.4%), 14 Type 3 (0.08%), and 4 Type 4 hips (0.02%). Children with Type 1 hips (normal) were discharged. Children with Type 2a hips (physiologically immature) received follow-up ultrasounds at monthly intervals. Children with Type 2c to 4 (DDH; deformed or misaligned hip joint) hips were treated with a Tubingen hip flexion splint and also followed up. The hip abnormalities resolved to mature hips in all children who were followed up. There was no evidence for severe treatment related complications.

Conclusion/Significance

This study suggests that the incidence of DDH in Mongolian neonates is comparable to that in neonates in Europe. Early ultrasound-based assessment and splinting treatment of DDH led to mature hips in all children followed up. Procedures are feasible and will be continued.