Standardized diagnostic criteria for developmental dysplasia of the hip in early infancy

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

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.

Screening of Developmental Dysplasia of the Hip in Europe: A Systematic Review

BACKGROUND

Developmental dysplasia of the hip (DDH) is a prevalent orthopaedic disorder in children, and screening methods vary across regions due to local health policies. The purpose of this review is to systematise the different ultrasound screening strategies for detecting DDH in newborns in Europe.

METHODS

Eligible studies from the PubMed, Embase, and Scopus databases, published between 1 January 2018 and 18 March 2023, were included. The inclusion criteria specified a European origin, a focus on newborn human patients, and information on ultrasound for DDH detection.

RESULTS

In total, 45 studies were included, covering 18 countries. Among them, six nations (Austria, Bosnia and Herzegovina, Poland, Slovenia, the Czech Republic, and Germany) perform universal ultrasound screening. The timing of the first ultrasound varies, with Austria and the Czech Republic within the 1st week, Bosnia and Herzegovina on the day of birth, Poland between 1 and 12 weeks, and Germany before the 6th week. The Graf method is the most popular ultrasound technique used.

CONCLUSIONS

There is no consensus on the optimal DDH detection approach in Europe. Varied screening methods stem from epidemiological, cultural, and economic differences among countries.

Radiological long-term follow-up up to 12 years of initially ultrasound unstable hip types D, III and IV after treatment with the Tübingen splint worn as a plaster

INTRODUCTION

The treatment of ultrasound unstable hips with the Tübingen splint is currently under discussion. However, there is a lack of long-term follow-up data. This study presents to the best of our knowledge first radiological mid-term to long-term data of the successful initial treatment with the Tübingen splint of ultrasound unstable hips.

MATERIALS AND METHODS

From 2002 to 2022 the treatment of ultrasound unstable hips type D, III and IV (age ≤ 6 weeks, no severe limitation of abduction) with the Tübingen splint worn as a plaster is evaluated. Based on data derived from routine X-rays during the follow-up period, a radiological follow-up (FU) analysis until the age of 12 years was performed. The acetabular index (ACI) and center-edge angle (CEA) were measured and classified according to Tönnis as normal findings (NF), slightly (sliD) or severely dysplastic (sevD).

RESULTS

193 of 201 (95.5%) unstable hips could be successfully treated showing normal findings with an alpha angle > 65°. The few patients showing treatment failures were successfully treated applying a Fettweis plaster (human position) under anesthesia. The radiological FU of 38 hips showed a favorable trend with increase of normal findings from 52.8% to 81.1% and decrease of 38.9% to 19.9% of sliD respectively 8.3% to 0% of sevD hips. The analysis of avascular necrosis of the femoral head showed 2 cases (5.3%) of grade 1 according to Kalamchi and McEwen, which were improving over time in the further course.

CONCLUSIONS

The Tübingen splint as alternative to replace a plaster has proven a successful therapeutic option for ultrasound unstable hips type D, III and IV with favorable and over time improving radiological parameter up to the age of 12 years.

Feeling the clunk: Managing and attributing uncertainty in screening for developmental dysplasia of the hip in infancy

The management of uncertainty in clinical practice has been an enduring topic of sociological scholarship. However, little of this addresses how uncertainty and non-knowledge are attributed to the self and other actors. We take the example of checking for developmental dysplasia of the hip (DDH), part of infant screening in UK primary care, to examine the 'double contingency' of attributions of uncertainty and ignorance. Our data come from interviews with parents and General Practitioners (GPs), and observations of the six-week check conducted as part of a study to develop a checklist to aid GPs' diagnostic and referral decisions. Parents' pervasive uncertainties about managing with a new-born infant place them in a trusting relation to biomedicine, in which knowledge about infant hips is delegated to the clinical team: most described themselves as not-knowing about DDH. GPs focus on the uncertainties of applying sensory and experiential knowledge of infant bodies, in a consultation with more diffuse aims than screening for DDH. A prototype checklist, developed by orthopaedic specialists, was an explicit attempt to reduce uncertainty around thresholds for referral. However, using the checklist surfaced multiple logics of uncertainty. It also surfaced attributions of uncertainty and non-knowledge to other actors: orthopaedic specialists' assumptions about GPs' uncertain technical knowledge; GPs' assumptions about orthopaedic specialists' ignorance of the primary care setting; and clinicians' assumptions about the role of parental ignorance. This 'double contingency' of attributions of other actors' non-knowledge is a salient additional dimension to the uncertainty that infuses biomedical practice.

Testing of an Ultrasound-Limited Imaging Protocol for Pavlik harness Supervision (TULIPPS) in developmental dysplasia of the hip: a randomized controlled trial

AIMS

There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring.

METHODS

This study was a single-centre noninferiority randomized controlled trial. Infants aged under six months whose hips were reduced and centred in the harness at initiation of treatment (stable dysplastic or subluxable), or initially decentred (subluxated or dislocated) but reduced and centred within four weeks of PH treatment, were randomized to our current standard US monitoring protocol (every clinic visit) or to a limited-frequency US protocol (US only at end of treatment). Groups were compared based on α angle and femoral head coverage at the end of PH treatment, acetabular indices, and International Hip Dysplasia Institute (IHDI) grade on one-year follow-up radiographs.

RESULTS

Overall, 100 patients were included; 42 patients completed the standard protocol (SP) and 40 completed the limited protocol (LP). There was no significant difference in mean right α angle at the end of treatment (SP 70.0° (SD 3.2°) ; LP 68.7° (SD 2.9°); p = 0.033), nor on the left (SP 69.0° (SD 3.5°); LP 68.1° (SD 3.3°); p = 0.128). There was no significant difference in mean right acetabular index at follow-up (SP 23.1° (SD 4.3°); LP 22.0° (SD 4.1°); p = 0.129), nor on the left (SP 23.3° (SD 4.2°); LP 22.8° (SD 3.9°); p = 0.284). All hips had femoral head coverage of > 50% at end of treatment, and all were IHDI grade 1 at follow-up. In addition, the LP group underwent a 60% reduction in US use once stable.

CONCLUSION

Our study supports reducing the frequency of US assessment during PH treatment of DDH once a hip is reduced and centred.Cite this article: Bone Joint J 2022;104-B(9):1081-1088.

IMPACT (Information Medically Pertinent in Acute Computed Tomography) requests: Delphi study to develop criteria standards for adequate clinical information in computed tomography requests in the Australian emergency department

INTRODUCTION

Inadequate clinical information in medical imaging requests negatively affects the clinical relevance of imaging performed and the quality of resultant radiology reports. Currently, there are no published Australian guidelines on what constitutes adequate clinical information in computed tomography (CT) requests. This study aimed to determine specific items of clinical information radiologists require in CT requests for acute chest, abdomen and blunt trauma examinations, to support optimal reporting.

METHODS

A panel of 24 CT-reporting consultant radiologists participated in this e-Delphi consensus study. Panellists undertook multiple online survey rounds of open-ended, dichotomous and Likert scale questions, receiving feedback following each. Round 1 responses formulated lists for each CT examination. Round 2 set a threshold of 80% agreement after dichotomous scoring. Round 3 accepted items which averaged 4 or more on a 5-point Likert scale. Round 4 required panellists to rank items within the aggregated, accepted lists, based on panellists' perceived level of usefulness.

RESULTS

The large numbers of round 1 items (chest: 101, abdomen: 76, blunt trauma: 80) were rationalised and grouped into categories to facilitate efficiency during subsequent rounds. Twenty-three chest, 24 abdomen and 17 blunt trauma items met the 80% agreement threshold in round 2. Items below threshold were included in round 3; numbering 44, 19 and 23 for chest, abdomen and blunt trauma, respectively. Through the e-Delphi process, we formulated clinical information criteria standards for three CT types.

CONCLUSIONS

The developed standards will guide Australian referrers in providing adequate clinical information in CT requests, to support optimal reporting, diagnosis and treatment.

Development of a DDH Care Pathway for India: A Study Methodology to Guide Similar Efforts in Other Countries and for Other Conditions

PURPOSE

In India and other Global South countries, developmental dysplasia of the hip (DDH) is often diagnosed after walking age, leading to more invasive surgeries and long-term disability. DDH care pathways aim to enhance early detection and must be tailored to meet a country's needs and diverse practice settings. We describe a multi-phase methodology for context-specific DDH care pathway development, demonstrating its use in India.

METHODS

In Phase I, Orthopaedic surgeons, Pediatricians/Neonatologists, and Radiologists in India were surveyed regarding DDH screening. Seven relevant Indian organizations partnered together and assembled a multidisciplinary working group, which then met fortnightly to establish an evidence base and prepare for the subsequent consensus-building phase. During Phase II, panelists participated in a modified Delphi process to reach consensus on a list of DDH screening statements. Phase III applied the statements to develop the care pathway.

RESULTS

The Delphi process concluded after a preliminary survey and two Delphi rounds, reaching consensus on 47 statements, which were condensed into 35. The developed care pathway for India features periodic clinical hip examinations integrated with the country's immunization schedule and selective imaging screening, providing flexibility in the timing and modality of imaging.

DISCUSSION/CONCLUSION

In Global South countries, there is a need for DDH care pathways specific to local contexts. Successful care pathway development requires accounting for cultural differences in healthcare and strategies to facilitate engagement and to address country-specific barriers. This methodology was feasible in India and can be applied to other conditions and/or countries wishing to establish care pathways.

LEVEL OF EVIDENCE

Level III.

Results of slotted acetabular augmentation in adults with Crowe stage 1 and 2 hip dysplasia

To determine the survival of slotted acetabular augmentation in adult dysplasia, we reviewed all cases operated on between 2002 and 2020 with clinical and radiological assessment and a 2.63 year minimum of follow-up. Twenty-three patients were included, with 91% of Crowe 1 hip dysplasia. Seven patients underwent THA at a mean 6.0 ± 3.5 years; 15 retained SAA without THA at a mean 9.5 years' follow-up; 1 was lost to follow-up. There was a significant improvement in PMA and HHS scores, with decreased pain. WOMAC and SF12 quality-of-life scores were moderate due to frequent pain. The patients with preoperative osteoarthritis showed little progression at seven years 'follow-up. We concluded SAA is a corrective treatment for residual hip dysplasia. Its goal is to normalize joint loading by increasing the contact area and improving the lever arm of the hip. Its postponed onset of osteoarthritis and reduced pain, thereby allowing to postpone THA.

The Effects of Preterm Birth on Musculoskeletal Health-Related Disorders

Preterm birth is associated with various diseases and conditions which demand multidisciplinary medical care. Approximately 10% of all neonates are born prematurely with an increasing survival rate in almost all Western countries. This ongoing, yet desirable trend is creating new challenges for sufficient medical treatment regimens, which should be upheld throughout the patients’ lives. Orthopedic surgeons are focused on musculoskeletal disorders and the improvement of patients’ ability to cope with the challenges of everyday life. The most common conditions associated with preterm birth are cerebral palsy and a dysregulation of the calcium/phosphorus metabolism, which may lead to fractures. These diseases may vary greatly in their organic manifestation and clinical presentation. This demands multidisciplinary cooperation and parental support. Clinical management is aimed on the early enhancement of a patient’s physical, as well as neurological condition, and to prevent the development of secondary musculoskeletal disorders. In this article, we give an overview of the current literature on the most common musculoskeletal disorders associated with preterm birth and critically discuss state of the art diagnostic standards and treatment algorithms.

Understanding physician behaviour in the 6-8 weeks hip check in primary care: a qualitative study using the COM-B

OBJECTIVES

A compulsory hip check is performed on an infant at 6-8 weeks in primary care for the detection of developmental dysplasia of the hip (DDH). Missed diagnoses and infants incorrectly labelled with DDH remain an important problem. The nature of physician behaviour as a likely source of this problem has not been explored. The aims of this study were to make a behavioural diagnosis of general practitioners (GPs) who perform these hip checks, and identify potential behavioural change techniques that could make the hip checks more effective.

DESIGN

Qualitative study with in-depth semistructured interviews of 6-8 weeks checks. We used the Capability, Opportunity, Motivation and Behaviour model in making a behavioural diagnosis and elicited factors that can be linked to improving the assessment.

SETTING

Primary care.

PARTICIPANTS

17 GPs (15 female) who had between 5 and 34 years of work experience were interviewed.

RESULTS

Capability related to knowledge of evidence-based criteria and skill to identify DDH were important behavioural factors. Both physical (clinic time and space) and social (practice norms), opportunity were essential for optimal behaviour. Furthermore, motivation related to the importance of the 6-8 weeks check and confidence to perform the check and refer appropriately were identified in the behavioural diagnosis.

CONCLUSION

Aspects of capability, opportunity and motivation affect GPs' diagnosis and referral behaviours in relation to DDH. The findings from this work extend current knowledge and will inform the development of an intervention aimed at improving the diagnosis of DDH.

Paediatric hip ultrasound: uncertainties in examination and choice of treatment

PURPOSE

In Germany, neonates undergo hip sonography examination using the Graf method during the routine U3 screening examination, performed by consultant physicians four to five weeks after birth, and are referred to specialized orthopaedic departments if there are any uncertainties. This study evaluated the quality of sonographic screening in the outpatient sector and the treatment requirements of referred children.

METHODS

We performed a retrospective analysis of the patient data of 384 neonates collected in consultations performed between April 2016 and April 2019.

RESULTS

In total, 74% (n = 284) of neonates presented a hip type Ia/b. Treatment (abduction brace or Fettweis cast) was required in 32% (n = 122) of cases. The treatment duration was significantly correlated with age at first presentation (Pearson's r = 0.678; p = 0.001). The treatment duration for patients aged > 200 days old at first presentation was twice as long as those aged 100 days at first presentation. Patients with public health insurance require referral by a consultant. Developmental dysplasia of the hip as referral diagnosis could not be confirmed in control examination in 64% (n = 132) of cases. Of the public health insured children, 97% (n = 200) were referred through a consultant paediatrician.

CONCLUSION

We identified deficits in performing and interpreting the Graf method of ultrasound examination. A total of 64% of referred pathological hips turned out to be physiological configurations in our control examination. The future goal should be to increase anatomical knowledge of the newborn hip and ensure the correct use of Graf ultrasound method. Advanced training courses are recommended and necessary.

LEVEL OF EVIDENCE

IV.

Predictors of Hip Dysplasia at 4 Years in Children with Perinatal Risk Factors

While perinatal risk factors are widely used to help identify those at risk for developmental dysplasia of the hip (DDH) within the first 6 to 8 weeks of life, limited data exist about their association with radiographic evidence of dysplasia in childhood. The purpose of this study was to determine which perinatal risk factors are associated with acetabular dysplasia in children who are ≥2 years of age.

A Deep-Learning Aided Diagnostic System in Assessing Developmental Dysplasia of the Hip on Pediatric Pelvic Radiographs

BACKGROUND

Developmental dysplasia of the hip (DDH) is a common orthopedic disease in children. In clinical surgery, it is essential to quickly and accurately locate the exact position of the lesion, and there are still some controversies relating to DDH status. We adopt artificial intelligence (AI) to solve the above problems.

METHODS

In this paper, automatic DDH measurements and classifications were achieved using a three-stage pipeline. In the first stage, we used Mask-RCNN to detect the local features of the image and segment the bony pelvis, including the ilium, pubis, ischium, and femoral heads. For the second stage, local image patches focused on semantically related areas for DDH landmarks were extracted by high-resolution network (HRNet). In the third stage, some radiographic results are obtained. In the above process, we used 1,265 patient x-ray samples as the training set and 133 samples from two other medical institutions as the verification set. The results of AI were compared with three orthopedic surgeons for reliability and time consumption.

RESULTS

AI-aided diagnostic system's Tönnis and International Hip Dysplasia Institute (IHDI) classification accuracies for both hips ranged from 0.86 to 0.95. The measurements of numerical indices showed that there was no statistically significant difference between surgeons and AI. Tönnis and IHDI indicators were similar across the AI system, intermediate surgeon, and junior surgeon. Among some objective interpretation indicators, such as acetabular index and CE angle, there were good stability and consistency among the four observers. Intraclass consistency of acetabular index and CE angle among surgeons was 0.79-0.98, while AI was 1.00. The measurement time required by AI was significantly less than that of the doctors.

CONCLUSION

The AI-aided diagnosis system can quickly and automatically measure important parameters and improve the quality of clinical diagnosis and screening referral process with a convenient and efficient way.

Study protocol for evaluation of aid to diagnosis for developmental dysplasia of the hip in general practice: controlled trial randomised by practice

INTRODUCTION

In the UK, a compulsory '6-week hip check' is performed in primary care for the detection of developmental dysplasia of the hip (DDH). However, missed diagnoses and infants incorrectly labelled with DDH remain a problem, potentially leading to adverse consequences for infants, their families and the National Health Service. National policy states that infants should be referred to hospital if the 6-week check suggests DDH, though there is no available tool to aid examination or offer guidelines for referral. We developed standardised diagnostic criteria for DDH, based on international Delphi consensus, and a 9-item checklist that has the potential to enable non-experts to diagnose DDH in a manner approaching that of experts.

METHODS AND ANALYSIS

We will conduct a controlled trial randomised by practice that will compare a diagnostic aid against standard care for the hip check. The primary objective is to determine whether an aid to the diagnosis of DDH reduces the number of clinically insignificant referrals from primary care to hospital and the number of late diagnosed DDH. The trial will include a qualitative process evaluation, an assessment of professional behavioural change and a full health economic evaluation. We will recruit 152 general practitioner practices in England. These will be randomised to conduct the hip checks with use of the study diagnostic aid and/or as per usual practice. The total number of infants seen during a 15-month recruitment period will be 110 per practice. Two years after the 6-week hip check, we will measure the number of referred infants that are (1) clinically insignificant for DDH and (2) those that constitute appropriate referrals.

ETHICS AND DISSEMINATION

This study has approval from the Health Research Authority (16/1/2020) and the Confidentiality Advisory Group (18/2/2020). Results will be published in peer-reviewed academic journals, disseminated to patient organisations and the media.

TRIAL REGISTRATION NUMBER

NCT04101903; Pre-results.

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.

Routine screening for developmental dysplasia of the hip by chiropractors: a case report of late diagnosis in an infant

BACKGROUND

Developmental Dysplasia of the Hip (DDH) is a common musculoskeletal condition of infancy, but diagnosis can be delayed. In parts of Australia, after the four-month routine assessment, there is a 16-week interval before the next well-child assessment. This may result in a delay in diagnosing late developing DDH.

CASE PRESENTATION

This case report describes the diagnosis and management of an 18-week old infant with late-onset DDH who was successfully managed with simultaneous Pavlik harnessing with Denis Browne Bar.

SUMMARY

This case underscores the importance of routine ongoing hip joint screening, inter-professional collaboration of all health care practitioners, and the importance of appropriate training of all practitioners seeing infants, to reduce instances of undetected DDH, reduce medical burden, and prevent otherwise unnecessary surgical intervention.

Predicting developmental dysplasia of the hip in at-risk newborns

Background

The development of developmental dysplasia of the hip can be attributed to several risk factors and often in combination with each other. When predicting the likelihood of developing this condition, clinicians tend to over and underestimate its likelihood of occurring.

Therefore, the study aim is to determine among at-risk newborns how to best predict developmental dysplasia of the hip (DDH) within 8 weeks post-partum.

Methods

Prospective cohort study in secondary care. Patient population included newborns at-risk for DDH – we assessed 13,276 consecutive newborns for the presence of DDH risk factors. Only newborns with at least one of the predefined risk factors and those showing an abnormal examination of the hip were enrolled (n = 2191). For the development of a risk prediction model we considered 9 candidate predictors and other variables readily available at childbirth.

The main outcome measure was ultrasonography at a median age of 8 weeks using consensus diagnostic criteria; outcome assessors were blinded.

Results

The risk model includes four predictors: female sex (OR = 5.6; 95% CI: 2.9–10.9; P <  0.001); first degree family history of DDH (OR = 4.5; 95% CI: 2.3–9.0; P <  0.001), birthweight > 4000 g (OR = 1.6; 95% CI: 0.6–4.2; P = 0.34), and abnormal examination of hip (OR = 58.8; 95% CI: 31.9, 108.5; P <  0.001). This model demonstrated excellent discrimination (C statistic = 0.9) and calibration of observed and predicted risk (P = 0.35). A model without the variable ‘hip examination’ demonstrated similar performance.

Conclusion

The risk model quantifies absolute risk of DDH within 8 weeks postpartum in at-risk newborns. Based on clinical variables readily available at the point of childbirth, the model will enhance parental counselling and could serve as the basis for real time decisions prior to discharge from maternity wards.

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.

Clinical significance of asymmetric skin folds in the medial thigh for the infantile screening of developmental dysplasia of the hip

BACKGROUND

The presence of asymmetric skin folds in the medial thigh (ASM) is often used as one of the screening items for developmental dysplasia of the hip (DDH). However, few studies have evaluated the clinical relevance of ASM in DDH.

METHODS

We reviewed the data of 584 infants aged 4-12 months who were referred to our institute because of suspicious findings in periodic infantile DDH screenings. The reasons for referral were classified into ASM, gluteal asymmetry, limb-length discrepancy, limitation of hip abduction, and click/clunk of the hip. A simple radiograph and hip examination including stability assessment were evaluated in all the infants by an experienced pediatric orthopedic surgeon.

RESULTS

Most of the referred infants presented with ASM only (78.4%, 458/584), but none of them were diagnosed with DDH. On the other hand, about 18.3% of infants referred for other reason(s) were diagnosed with DDH.

CONCLUSION

Although the presence of ASM was the most common reason for referral, it had little clinical significance as a screening item for DDH in the infants aged 4-12 months. Therefore, ASM alone is not a clinical indicator of DDH.

Capsular arthroplasty for neglected developmental dysplasia of hip

INTRODUCTION

Treatment of developmental dysplasia of hip (DDH) diagnosed after 10 years of age is extremely difficult because of the soft tissue and bone deformities. In this study, we evaluated short-term results of a single-stage procedure performed with surgical hip dislocation, femoral shortening and capsular arthroplasty.

PATIENTS AND METHODS

A retrospective review of charts of five patients with DDH, older than 10 years, who underwent capsular arthroplasty at Ghurki Trust Teaching Hospital between 2013 and 2015 was performed. Post-operative functional evaluation was performed using modified McKay's scoring system and radiographic assessment using Severin's scoring method at a minimum of 2-year follow-up.

RESULTS

We present results of five patients (six hips) with a mean age of 18.16 years. All patients had limping gait and International Hip dysplasia Institute classification (IHDI) class 4 hip dislocation. Harris hip score showed a significant improvement (53.13 vs 84.16; p = 0.0001). Femoral shortening of 2-2.5 cm was done. Additional shelf procedure was required in one patient. This patient persistently has post-operative hip subluxation. All patients had good to excellent outcomes according to McKay classification. Post-operative Severin classification was 1A in all patients. No case of avascular necrosis of the femoral head was noted during the follow-up.

CONCLUSION

Capsular arthroplasty with subtrochanteric shortening is a useful procedure for neglected cases of DDH in patients older than 10 years.

Developmental Dysplasia of the Hip

Pediatricians are often the first to identify developmental dysplasia of the hip (DDH) and direct subsequent appropriate treatment. The general treatment principle of DDH is to obtain and maintain a concentric reduction of the femoral head in the acetabulum. Achieving this goal can range from less-invasive bracing treatments to more-invasive surgical treatment depending on the age and complexity of the dysplasia. In this review, we summarize the current trends and treatment principles in the diagnosis and treatment of DDH.

Musculoskeletal ultrasound: a useful tool for diagnosis of hip developmental dysplasia: One single-center experience

Developmental dysplasia of the hip (DDH) is one of the most common congenital abnormalities of the musculoskeletal apparatus in newborns. The aim of this study was to analyze the contribution of ultrasonography in the detection of DDH in newborns and infants, identifying the regional incidence of this pathology in the central area of Romania, emphasizing the risk factors that underlie DDH etiopathogenicity.This article represents a retrospective study of 847 newborns and infants examined in the Imagistic Department of a medical center from the central area of Romania, between January 1 and December 31, 2016. The ultrasound examinations were performed for the bilateral coxofemoral joints, using the method and technique described by Graf. For subjects born in the same medical center, data regarding mother's age, birth weights, and type of delivery (natural vs. caesarian section) were statistically analyzed.In our study group, the frequency of ultrasound diagnosis obtained from the examinations of right and left hips showed that the most frequent stage was type IA, and the rarest stage was III. The IA stage of right coxofemoral joints (87.3%) was higher than in the left coxofemoral joints (87.2%). The incidence of hip dysplasia (type III) diagnosed with ultrasound examinations in subjects from the central area of Romania was 0.2% (0.1% in both hips and 0.1% for the left coxofemoral joint).The musculoskeletal ultrasound examination is effective in early detection of hip dysplasia. The implementation of national and regional programs that promote indications, risk factors, and the screening age for DDH in both rural and urban areas could be a step forward in the early diagnosis of hip dysplasia for newborns and infants. The low incidence of DDH from our study group is not able to identify the role of advanced age of the mother, high birth weight of the newborn, or caesarean section as risk factors involved in the etiology of hip dysplasia. The implementation of national and regional programs that promote the musculoskeletal ultrasound as a screening imagistic investigation for DDH, in both rural and urban areas, could be a step forward in the early diagnosis of hip dysplasia for newborns and infants.

Ultrasonography of borderline and asymmetric infant hips - a challenge in the management of developmental dysplasia of the hip

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.

The influence of health policy on early diagnosis and surgical incidence of developmental dysplasia of the hip

Background

Hip screening is the standard approach for the early detection of developmental dysplasia of the hip (DDH). However, there is a lack of evidence regarding the effects of national policy on early diagnosis and later surgical incidence. The purpose of this national study is to estimate DDH incidence in the Taiwanese population through a new diagnosis definition and to examine whether a health promotion policy could reduce surgeries for DDH.

Methods and results

Six birth-year cohorts (2000–2005) were evaluated for DDH diagnosis and related surgeries using the database of the National Health Insurance Administration, which covers 99% of the population of Taiwan. Children with three or more sequential International Classification of Disease, Ninth Revision (ICD-9) diagnosis codes (754.3x) in the outpatient claim file or DDH-related surgeries were studied. The outcome of hip screening was evaluated with the ratio of early diagnosis (0–6 months) to late diagnosis (1–5 years) and the incidence of major surgeries for DDH. DDH incidence was 1.54 per thousand live births (2,255/1,462,539). After a hip screening promotion policy was implemented in 2002, ratios of early/late diagnosis increased from 1.06, 1.25, 1.38, and 1.5 to 1.75 for the years 2000 to 2005, respectively. Incidences of major surgery decreased from 0.41–0.47 per thousand before policy administration to 0.33–0.37 per thousand after policy administration.

Discussion

The DDH incidence of 1.54 per 1,000 in a geographically well-defined area offered epidemiological data for further studies in Asian populations. The results suggest that the health promotion policy is associated with an increase in early diagnosis and subsequently a decrease in surgeries for DDH.

[An ultrasonographic study of the correlation between developmental dysplasia of the hip and congenital muscular torticollis in children]

OBJECTIVE

To investigate the significance of early screening of pediatric developmental dysplasia of the hip (DDH) and congenital muscular torticollis (CMT) using ultrasonography and establish a simultaneous screening model for pediatric DDH and CMT.

METHODS

From January, 2013 to January, 2016, a total of 5060 pediatric patients with suspected DDH and CMT underwent ultrasonic examinations. The diagnostic results of the two diseases were classified into different clinical types, and Chi-square test was used to analyze the one-way relationship between different types of DDH and CMT; correspondence analysis was used for multivariate analysis of the variables. Chi-square test was used to analyze the difference between the detection rates in suspected CMT patients and the normal population.

RESULTS

GrafIIa type DDH was associated with mass-type CMT in the children (χ²=331.800, P<0.001). DDH of GrafIIb, GrafIIc, Graf III, and Graf IV types were related with non-tumor type of CMT. The children with a suspected diagnosis of CMT showed a significantly higher detection rate of DDH than the normal subjects (χ²=321.889, P<0.001).

CONCLUSION

DDH is closely related with CMT. Early simultaneous screening of DDH and CMT can help to improve the early diagnosis rate of CMT in children.

[An ultrasonographic study of the correlation between developmental dysplasia of the hip and congenital muscular torticollis in children]

OBJECTIVE

To investigate the significance of early screening of pediatric developmental dysplasia of the hip (DDH) and congenital muscular torticollis (CMT) using ultrasonography and establish a simultaneous screening model for pediatric DDH and CMT.

METHODS

From January, 2013 to January, 2016, a total of 5060 pediatric patients with suspected DDH and CMT underwent ultrasonic examinations. The diagnostic results of the two diseases were classified into different clinical types, and Chi-square test was used to analyze the one-way relationship between different types of DDH and CMT; correspondence analysis was used for multivariate analysis of the variables. Chi-square test was used to analyze the difference between the detection rates in suspected CMT patients and the normal population.

RESULTS

GrafIIa type DDH was associated with mass-type CMT in the children (χ2=331.800, P<0.001). DDH of GrafIIb, GrafIIc, Graf III, and Graf IV types were related with non-tumor type of CMT. The children with a suspected diagnosis of CMT showed a significantly higher detection rate of DDH than the normal subjects (χ2=321.889, P<0.001).

CONCLUSION

DDH is closely related with CMT. Early simultaneous screening of DDH and CMT can help to improve the early diagnosis rate of CMT in children.

Relative Risk and Incidence for Developmental Dysplasia of the Hip

OBJECTIVE

To determine the incidence and associated risk factors of developmental dysplasia of the hip (DDH) in a modern population without universal screening.

STUDY DESIGN

Children with DDH were identified from the Manitoba Centre for Health Policy's Data Repository by the use of International Classification of Diseases diagnosis codes as well as physician billing tariffs for surgical procedures for DDH for all children born between 1995 and 2012. To identify the outpatient-treated patients, ultrasound scans and radiographic imaging for DDH were reviewed for 2004-2012. Overall incidence was calculated on the basis of birth rate for the province per year. Relative risks of sex, first born, breech position, clubfoot deformity, multiple gestations, as well as regional health areas were analyzed with χ² tests.

RESULTS

We identified 1716 cases of DDH of 258 499 newborns. The incidence of DDH was calculated at 6.6/1000 newborns. Late-presenting DDH was detected in 2.2/1000 newborns. Female first-born children, clubfoot deformity, and breech position were associated significantly with an increased risk. Children with DDH born in rural areas of the Northern and Central part of Manitoba presented at a later age than those who are born in the urban areas (P < .0001) CONCLUSION: This study shows the need for improved early detection and awareness at well-baby clinics of risk factors and regional differences for DDH.

Retrospective Multicenter Analysis of the Accuracy of Clinical Examination by Community Physicians in Diagnosing Developmental Dysplasia of the Hip

OBJECTIVES

To determine among general practitioners (GPs) the most common clinical findings that raised concern for developmental dysplasia of the hip (DDH) and necessitated an orthopedic outpatient referral. In addition, we assessed the sensitivity and specificity of the most common of these clinical findings.

STUDY DESIGN

We performed a multicenter retrospective review of all referrals by GPs to local orthopedic outpatient departments for DDH over a 12-month period. All patients had undergone pelvic radiographs, and the acetabular index (AI) was measured. The AI was used as a reference test to assess the accuracy of the clinical examination in diagnosing DDH. Sensitivity and specificity of each clinical sign was calculated.

RESULTS

Twenty-six of 174 (14.9%) referred patients were diagnosed with DDH, defined as an AI score > 30. The most common indication for referral, per the GP letter was asymmetrical skin folds (97 patients, 45.8%), followed by hip click (42 patients, 19.8%), and limb shortening (34 patients, 16%). Sensitivities and specificities, respectively, among findings were asymmetric skin folds 46.2% (95% CI 26.6%-66.6%) and 42.6% (95% CI 34.5%-51.0%), hip click 23.1% (95% CI 9.0%-43.6%) and 75.7% (95% CI 67.9%-82.3%), limb shortening 30.8% (95% CI 14.3%-51.8%) and 82.4% (75.3%-88.2%), and reduced abduction 19.2% (95% CI 6.6%-39.4%) and 91.9% (95% CI 86.3%-95.7%). Using logistic regression analysis, no clinical sign was found to be a statistically significant indicator of an abnormal AI.

CONCLUSIONS

Clinical examination by GPs does not reliably detect radiographically-defined DDH. None of the clinical findings by the GP showed an acceptable level of sensitivity. Absence of reduced abduction and limb shortening are relevant negatives given the high level of specificity of these signs.

DEVELOPMENTAL DYSPLASIA OF THE HIP: DO THE RESPONSIBLE FOR SCREENING KNOW WHAT TO DO?

Objective:

To evaluate the knowledge on developmental dysplasia of the hip (DDH) by professionals involved in its diagnosis.

Methods:

This is a cross-sectional study using questionnaires to assess the knowledge about DDH. Orthopedic surgeons and pediatricians, residents and medical students from a tertiary teaching hospital were included in the study.

Results:

We evaluated 142 medical students, eight orthopedic residents, ten pediatric residents, seven pediatricians, and nine orthopedic surgeons; 50% declared not having examined any DDH case in the last year and only three had diagnosed more than 10 cases during their career. Regarding self-assessed knowledge (0-10), the average score was 4.25 [n=186; SD=2.43]. Nineteen percent of the participants ignored semiological tests and 26.1% of pediatricians (specialists and residents), were unaware of how to perform them. The most acknowledged and neglected risk factor was pelvic presentation (68%) and CMT (9.3%), respectively. None of the participants were able to identify all the risk factors. The average number of risk factors identified was two (n=186; SD=1.58). Forty seven point three percent of the participants failed to recognize the time of birth as the ideal moment for diagnosis; 17% reported it was after the first month. Regarding neglected severe DDH, 45.3% failed to recognize its natural history.

Conclusion:

Knowledge on DDH among health professionals who are involved in screening is flawed. Level of Evidence IV, Developing a Decision Model.

[Modified PemberSal osteotomy technique with lyophilized human allograft]

OBJECTIVE

PemberSal osteotomy to improve femoral head coverage by rotating the acetabular roof ventrally and laterally.

INDICATIONS

Insufficient coverage of the femoral head, and can be combined with other surgical procedures such as femoral intertrochanteric varus-derotation osteotomy and open reduction for developmental dysplasia and dislocation of the hip or to improve sphericity and containment in Legg-Calvé-Perthes disease. This specific acetabuloplasty can only be performed in patients with an open epiphyseal growth-plate.

CONTRAINDICATIONS

Increased bleeding tendency (e.g., inherited or iatrogenic); elevated anesthetic risk such as in cerebral palsy, arthrogryposis multiplex congenital, trisomies; syndromes require explicit interdisciplinary clarification to reduce perioperative risks; infections as in other elective surgeries; diseases/deformities making postoperative spica casting impossible or impractical (e.g., deformities of spinal cord or urogenital system, hernias requiring treatment); closed epiphyseal plate requires complex three-dimensional corrections of the acetabular roof (e.g., triple/periacetabular osteotomy).

SURGICAL TECHNIQUE

Osteotomy from the iliac bone to the posterior ilioischial arm of the epiphyseal growth-plate cartilage; controlled fracture of the cancellous bone without breaking the medial cortex of the iliac bone for ventrocaudal rotation of the acetabular roof. To refill and stabilize the osteotomy site, an allogenic bone-wedge is interponated and secured by a resorbable screw or kirschner wire. This method also allows more complex reconstructions of the acetabular roof, e.g., by including the pseudo-cup in a modified Rejholec technique.

POSTOPERATIVE MANAGEMENT

A spica cast is applied to immobilize the hip for 6 weeks. Afterwards physiotherapy can be performed under weight-bearing as tolerated. Radiographic check-ups every 6 months.

An index for diagnosing infant hip dysplasia using 3-D ultrasound: the acetabular contact angle

BACKGROUND

Developmental dysplasia of the hip (DDH) is a common condition that is highly treatable in infancy but can lead to the lifelong morbidity of premature osteoarthritis if left untreated. Current diagnostic methods lack reliability, which may be improved by using 3-D ultrasound.

OBJECTIVE

Conventional 2-D US assessment of DDH has limitations, including high inter-scan variability. We quantified DDH on 3-D US using the acetabular contact angle (ACA), a property of the 3-D acetabular shape. We assessed ACA reliability and diagnostic utility.

MATERIALS AND METHODS

We prospectively collected data from January 2013 to December 2014, including 114 hips in 85 children divided into three clinical diagnostic groups: (1) normal, (2) initially borderline but ultimately normal without treatment and (3) dysplastic requiring treatment. Using custom software, two observers each traced acetabula twice on two 3-D US scans of each hip, enabling automated generation of 3-D surface models and ACA calculation. We computed inter-observer and inter-scan variability of repeatability coefficients and generated receiver operating characteristic (ROC) curves.

RESULTS

The 3-D US acetabular contact angle was reproduced 95% of the time within 6° in the same scan and within 9° in different scans of the same hip, vs. 9° and 14° for the 2-D US alpha angle (P < 0.001). Areas under ROC curves for diagnosis of developmental dysplasia of the hip were 0.954 for ACA and 0.927 for alpha angle.

CONCLUSION

The 3-D US ACA was significantly more reliable than 2-D US alpha angle, and the 3-D US measurement predicted the presence of DDH with slightly higher accuracy. The ACA therefore shows promising initial diagnostic utility. Our findings call for further study of 3-D US in the diagnosis and longer-term follow-up of infant hip dysplasia.

The most relevant diagnostic criteria for developmental dysplasia of the hip: a study of British specialists

Background

Developmental dysplasia of the hip (DDH) is the most common orthopaedic disorder in newborns. Despite this considerable variation in practice exists. The aim of this study was to determine the clinical relevance and a ranking order for the diagnostic criteria in DDH amongst paediatric orthopaedic surgeons practicing in the UK.

Method

One hundred members of the British Society of Children’s Orthopaedic Surgery (BSCOS) were asked to rate the importance of 37 criteria useful in the diagnosis of DDH in newborns, using a 10 cm visual analogue scale. We determined the consistency among specialists in rating the criteria with the intraclass correlation coefficient (ICC) and compared the results to a group of international peers.

Results

Ortolani/Barlow tests, asymmetry in abduction ≥20° and a first-degree relative treated for DDH ranked among the top ten. Participants demonstrated poor consistency in rating the 37 criteria (ICC 0.39; 95 % CI 0.29, 0.52), but for clinical examination criteria alone their consistency improved (ICC 0.52; 0.35, 0.75). The importance ratings of members of BSCOS and members of the European Paediatric Orthopaedic Society differed for 15/37 (41 %) criteria (p <0.05).

Conclusions

Members of BSCOS had a preference for criteria relating to clinical examination and ultrasound.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0867-4) contains supplementary material, which is available to authorized users.

Imaging of Hip Pain: From Radiography to Cross-Sectional Imaging Techniques

Hip pain can have multiple causes, including intra-articular, juxta-articular, and referred pain, mainly from spine or sacroiliac joints. In this review, we discuss the causes of intra-articular hip pain from childhood to adulthood and the role of the appropriate imaging techniques according to clinical suspicion and age of the patient. Stress is put on the findings of radiographs, currently considered the first imaging technique, not only in older people with degenerative disease but also in young people without osteoarthritis. In this case plain radiography allows categorization of the hip as normal or dysplastic or with impingement signs, pincer, cam, or a combination of both.

Surgical treatment for young adult hip dysplasia: joint-preserving options

Developmental dysplasia of the hip (DDH) is a spectrum of disorders that results in anatomic abnormalities leading to increased contact stress in the joint and, eventually, secondary osteoarthritis. However, many patients with DDH become symptomatic before the severe degenerative changes of the hip because of abnormal hip biomechanics, mild hip instability, impingement, or associated intra-articular pathology. Early diagnosis and appropriate treatment for DDH are of the utmost importance. With the modification of techniques like pelvic osteotomy and capsular arthroplasty, and the introduction of intracapsular procedures such as arthroscopy and femoral head-neck junction osteochondroplasty, many young patients with symptomatic hip dysplasia may benefit from joint preservation procedures. We review the current development of these concepts and the associated surgical techniques.

Is prematurity a risk factor for developmental dysplasia of the hip? : a prospective study

The aim of this prospective study was to investigate prematurity as a risk factor for developmental dysplasia of the hip (DDH). The hips of 221 infants (88 female, 133 male, mean age 31.11 weeks; standard deviation (sd) 2.51) who were born in the 34th week of gestation or earlier, and those of 246 infants (118 female, 128 male, mean age 40.22 weeks; sd 0.36) who were born in the 40th week of gestation, none of whom had risk factors for DDH, were compared using physical examination and ultrasound according to the technique of Graf, within one week, after the correction of gestational age to the 40th week after birth or one week since birth, respectively. Both hips of all infants were included in the study. Ortolani's and Barlow's tests and restricted abduction were accepted as positive findings on examination. There was a statistically significant difference between pre- and full-term infants, according to the incidence of mature and immature hips (p < 0.001). The difference in the proportion of infants with an α angle < 60° between the two groups was statistically significant (p < 0.001). The incidence of pathological dysplasia (α angle < 50 º) was not significantly different in the two groups (p = 1.000). The Barlow sign was present in two (0.5%) pre-term infants and in 14 (2.8%) full-term infants. These results suggests that prematurity is not a predisposing factor for DDH.

The Development of Assessment Tools for Plastic Surgery Competencies

BACKGROUND

Objective tools to assess procedural skills in plastic surgery residency training are currently lacking. There is an increasing need to address this deficit in order to meet today's training standards in North America.

OBJECTIVES

The purpose of this pilot study was to establish a methodology for determining the essential procedural steps for two plastic surgery procedures to assist resident training and assessment.

METHODS

Following a literature review and needs assessment of resident training, the authors purposefully selected two procedures lacking robust assessment metrics (breast augmentation and facelift) and used a consensus process to complete a list of procedural steps for each. Using an online survey, plastic surgery Program Directors, Division Chiefs, and the Royal College Specialty Training Committee members in Canada were asked to indicate whether each step was considered essential or non-essential when assessing competence among graduating plastic surgery trainees. The Delphi methodology was used to obtain consensus among the panel. Panelist reliability was measured using Cronbach's alpha.

RESULTS

A total of 17 steps for breast augmentation and 24 steps for facelift were deemed essential by consensus (Cronbach's alpha 0.87 and 0.85, respectively).

CONCLUSION

Using the aforementioned technique, the essential procedural steps for two plastic surgery procedures were determined. Further work is required to develop assessment instruments based on these steps and to gather validity evidence in support of their use in surgical education.

Relationship between flexible flat foot and developmental hip dysplasia

PURPOSE

To evaluate the possible relationship between flexible flat foot and developmental hip dysplasia in children between six and 15 years of age.

METHOD

Cross-sectional study including 65 patients that had undergone surgery due to residual hip dysplasia or hip dislocation and compared against 75 healthy patients. Flexible flat foot prevalence was measured in each group, with the results showing that 61% of the group with residual hip dysplasia or hip dislocation had this condition, vs. 12% in the healthy group. The statistical analysis shows that the chances of suffering from flexible flat foot, are five times greater in the hip dysplasia or hip dislocation group, than in the healthy group.

DISCUSSION

There is no evidence in the literature showing a relationship between these two conditions, even though they have a common etiology. This study shows a potential measurable relation between this two conditions.

CONCLUSION

Patients with hip dysplasia or dislocation may have a higher chance of presenting flexible flat foot during late childhood, adolescence and adulthood, a fact that suggests a relationship between these two pathologies. Also, patients who seek assistance for the first time because of a flexible flat foot condition without having been evaluated during the first year of life for hip dysplasia, would be better off if evaluated for residual hip dysplasia.

Diagnostic yield of sonography in infants with suspected hip dysplasia: diagnostic thinking efficiency and therapeutic efficiency

OBJECTIVE

The purpose of this study is to determine the impact of sonographic information on surgeons' diagnostic thinking and decision making in the management of infants with a possible diagnosis of developmental dysplasia of the hip (DDH).

SUBJECTS AND METHODS

Five experienced orthopedic surgeons examined 66 hips of infants who were referred for a possible diagnosis of DDH and reported for each hip a confidence level about the diagnosis of DDH using a visual analog scale (VAS) before and after hip sonography was obtained. In addition, they reported a management plan. We determined the efficiency in diagnostic thinking by calculating the mean gain in diagnostic confidence as the percentage change in VAS scores and the impact of sonography on the management plan (therapeutic efficiency).

RESULTS

Sonography led to a change in diagnosis in 52% (34/66) of hips. The management plan changed in 32% (21/66) of hips. The mean gain in reported diagnostic confidence was 19.4% (95% CI, 17.3-21.5%), but it was 46.0% (95% CI, 30.5-60.8%) in cases where the management changed as a result of sonography (difference, 37.7%; p < 0.0001). The greatest yield of sonography was found in hips showing limited abduction. Sonography obviated further follow-up in 23% (15/66) of cases.

CONCLUSION

Sonography refined the diagnostic thinking of clinicians and led to a change in diagnosis in 52% of cases. Management plans changed in 32% of cases.

Weighted diagnostic criteria for developmental dysplasia of the hip

OBJECTIVE

To establish clinical diagnostic criteria for developmental dysplasia of the hip (DDH) that model the practices of expert clinicians.

STUDY DESIGN

Of 23 clinical criteria for the diagnosis of DDH, ranked in order of diagnostic importance by international consensus, the 7 most highly ranked were placed in all possible combinations to create unique case vignettes. Twenty-six experts rated 52 vignettes for the presence of DDH. We modeled the data to determine which of the 7 criteria were associated with a clinician's opinion that the vignette represented DDH. From the resulting regression coefficients, for each vignette we calculated a probability of DDH. An independent panel rated the same vignettes using a visual analog scale response. We correlated the visual analog scale ratings with probabilities derived from the model.

RESULTS

Our model identified 4 of 7 criteria as predictive of DDH (P < .001): Ortolani/Barlow test (β = 3.26), limited abduction (β = 1.48), leg length discrepancy (β = 0.74), and first-degree family history of DDH (β = 1.39). There was substantial correlation between the probability of DDH predicted by the model and that derived from an independent expert panel (r = 0.73; P < .001).

CONCLUSION

Weighted clinical criteria for inferring the likelihood of DDH produced consistent results in the judgment of 2 separate groups of experts. Using these weights, nonexperts could establish the probability of DDH in a manner approaching the practice of clinical experts.

Treatment and prevention of hip dysplasia in infants and young children

The diagnosis and treatment of developmental dysplasia of the hip in the infant are uniform, with consensus that diagnostic ultrasound and Pavlik harness management are standard procedures. Sequential procedures for failed early treatment, residual dysplasia and late diagnosis are dependent on the age and the severity of the dysplasia. This paper reviews the treatment of developmental dysplasia of the hip from birth to subsequent follow-up procedures, with particular reference to some of the senior authors' research and the Southampton approach to the management of hip dysplasia.

Variations in the use of diagnostic criteria for developmental dysplasia of the hip

BACKGROUND

Wide variation exists in reported prevalence estimates and management standards of developmental dysplasia of the hip (DDH). Discrepancies in diagnosticians' opinions may explain some of this variation.

QUESTIONS/PURPOSES

We sought to determine (1) the consistency with which pediatric orthopaedic surgeons rate the importance of diagnostic criteria for DDH, and (2) whether there were geographic differences in how the diagnostic criteria were rated by surgeons.

METHODS

One hundred ninety-seven of 220 members of the European Paediatric Orthopaedic Society and 100 of 148 members of the British Society of Children's Orthopaedic Surgery treating children with DDH participated in this cross-sectional study across 35 countries (15 regions). Each rated 37 items in four domains that specialists previously had identified as the most important features associated with DDH in early infancy. We determined consistency using the intraclass correlation coefficient (ICC; two-way random-effects model) interpreted as poor (0-0.40), acceptable (0.41-0.74), or good (≥ 0.75).

RESULTS

Poor consistency among surgeons was found in rating the 37 diagnostic criteria (ICC, 0.33; 95% CI, 0.24-0.45). Consistency was poor for three domains (patient characteristics/history: ICC, 0.29; 95% CI, 0.16-0.58; ultrasound: ICC, 0.26; 95% CI, 0.14-0.52; radiography: ICC, 0.34; 95% CI, 0.12-0.95) and acceptable for one (clinical examination: ICC, 0.50; 95% CI, 0.33-0.73). Surgeons in particular regions appeared to have a concept of DDH diagnosis that distinguished them from specialists of other regions; consistency in eight regions was greater (ICC ≥ 0.40) than consistency among all 15 regions.

CONCLUSIONS

The consistency of specialists in rating diagnostic criteria for DDH was lower than expected, and there was considerable geographic variation in terms of how specialists assigned importance ratings of the diagnostic criteria; these findings are somewhat counterintuitive, given the frequency with which this condition is diagnosed. These inconsistencies could explain, partly, the widely differing prevalence estimates and management standards of DDH.

Surgical technique: The capsular arthroplasty: a useful but abandoned procedure for young patients with developmental dysplasia of the hip

BACKGROUND

Codivilla in 1901, Hey Groves in 1926, and Colonna in 1932 described similar capsular arthroplasties--wrapping the capsule around the femoral head and reducing into the true acetabulum--to treat completely dislocated hips in children with dysplastic hips. However, these procedures were associated with relatively high rates of necrosis, joint stiffness, and subsequent revision procedures, and with the introduction of THA, the procedure vanished despite some hips with high functional scores over periods of up to 20 years. Dislocated or subluxated hips nonetheless continue to be seen in adolescents and young adults, and survival curves of THA decrease faster for young patients than for patients older than 60 years. Therefore, joint preservation with capsular arthroplasty may be preferable if function can be restored and complication rates reduced.

DESCRIPTION OF TECHNIQUE

We describe a one-stage procedure performed with a surgical hip dislocation and capsular arthroplasty. Various additional joint preservation procedures included relative neck lengthening for improved motion clearance and head size reduction, roof augmentation, and femoral shortening/derotation for containment and congruency.

METHODS

We retrospectively reviewed nine patients (one male, eight female; age range, 13-25 years) who had such procedures between 1977 and 2010. Function was assessed by the Harris hip score (HHS). Minimum followup was 1 year (median, 2 years; mean, 7.5 years; range, 1-27 years).

RESULTS

At latest followup, the mean HHS was 84 (n = 7) (range, 78-94). One patient underwent THA after 27 years. Complications included one deep vein thrombosis and one successfully treated neck fracture.

CONCLUSIONS

Our data in these nine patients suggest capsular arthroplasty performed with a surgical hip dislocation and other appropriate adjunctive procedures is useful to treat dislocated hips in young patients with few complications. It may postpone THA.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Prevention of hip dysplasia in children and adults

Klisic and Pajic summarized the history of early diagnosis and treatment of hip dysplasia when they wrote, Devising the preventive approach to developmental dysplasia of the hip (DDH) required much time.... Despite the 2400-year-old suggestion made by Hippocrates that children's hip dislocations are curable if treatment is started very early, the preventive approach was proposed by Roser only in 1879 [who] described early diagnosis in newborns and performed reduction by abduction... He also advocated early treatment by fixing babies' hips in abduction. However, surgeons did not readily accept these proposals, despite the good results shown by Froelich in 1906 and Le Damany in 1911. In 1927, Putti succeeded in interesting some orthopedic surgeons in the procedure by showing the results of early treatment. But the practical problem remained: ie, how to detect the DDH in patients at an early age. The turning point came in 1935 when pediatrician Ortolani introduced early detection of DDH by “early clinical search” shortly after a child's birth, instructing obstetricians, pediatricians, and midwives to perform the search. Rediscovering the diagnostic “segno della scatto,” ie, reducible displacement, he popularized the prophylactic approach to DDH by early detection and treatment. Fifteen years later, another pediatrician, Palmen, organized systematic screening in nurseries by pediatricians. Since Klisic and Pajic wrote this in 1993, the use of ultrasound, albeit still controversial in some ways, has influenced the treatment and prevention of DDH. Klisic's attempts to universally prevent the disease may still be able to be incorporated into further efforts at disease prevention through education and the systematic trials of hip abduction pillows or braces similar to his wide-diaper diapering technique. The goal of prevention is to eradicate a disease so that it does not present to the physician. For DDH, this goal may be tenable.

Does probe frequency influence diagnostic accuracy in newborn hip ultrasound?

Ultrasonography of the hip has gained wide acceptance as reliable method for diagnosing developmental hip dysplasia in infants. This blinded study was conducted to investigate the influence of two linear probes with different frequency on diagnostic accuracy and reproducibility. In 206 consecutive newborns, the bony roof angle (α-angle) and cartilage roof angle (β-angle) were assessed by three investigators according to Graf. The hips were measured twice both with a 7.5 MHz and a 12 MHz linear transducer (Sonoline G60S(®) ultrasound system; Siemens, Erlangen, Germany). Each investigator evaluated his sonograms 6 weeks later. Depending on the mean values for α-angle and β-angle, the hips were classified. Reproducibility of the Graf classification was not found to be influenced. In two of three investigators, we observed significant improvement concerning variation of the β-angle with the 12 MHz probe. The use of high-resolution transmitters may improve diagnostic accuracy in ultrasonography of the newborn's hip.