What Is the Impact of Center Variability in a Multicenter International Prospective Observational Study on Developmental Dysplasia of the Hip?

Standardized In-harness Ultrasound Protocol Improves Success Rate of Brace Treatment for Dislocated Hips

OBJECTIVE

Infant hip dislocations benefit from early detection and treatment for optimal outcomes. Prior studies have identified that there remains wide variability in the success rate of bracing between institutions. Although there are standardized methods to screen infants for hip dysplasia, there are no clear guidelines regarding how to image a child being treated for a hip dislocation with a Pavlik harness. As a result, there is substantial variability in how treatment success or failure is monitored between and within institutions. The goal of our study is to determine whether a standardized in-harness imaging protocol improves outcomes and the likelihood of successful treatment for dislocated hips being treated with the Pavlik harness.

METHODS

All patients with hip dislocations and pretreatment ultrasound (US) were included from July 2018 to July 2022. A new institutional US protocol was implemented in July 2020, during which standardized in-harness imaging was obtained for patients with hip dislocations. Patients treated before the implementation of standardized in-harness imaging were categorized as nonstandardized and after implementation as a standardized group. Outcomes were compared between standardized and nonstandardized groups. P <0.05 determined the statistical significance.

RESULTS

One hundred twenty-eight hips met the inclusion criteria (n = 97 patients). The mean age at diagnosis was 41.6 ± 23.4 days and was predominantly female (85.6%). There was no significant difference between the patients' demographics and baseline clinical characteristics between the standardized and nonstandardized groups. Pavlik harness success rate was significantly higher in the standardized group (85% vs 60%, P = 0.0024). Twenty-eight hips in the nonstandardized group remained dislocated and were indicated for surgical treatment, whereas only 8 hips remained dislocated in the standardized group and necessitated closed or open reduction.

CONCLUSIONS

Standardization of in-harness imaging for patients undergoing treatment for developmental hip dislocations can significantly improve the Pavlik harness success rate. These findings emphasize the importance of obtaining images with the hip in flexion and abduction to prevent inadvertent stress during US evaluation for hips that have not yet stabilized, which may lead to premature cessation of the Pavlik harness.

LEVEL OF EVIDENCE

Level III.

Management preferences of orthopedic surgeons in developmental dysplasia of the hip under 1 year of age in Türkiye: Results of a nationwide cross-sectional survey

OBJECTIVE

This study aimed to evaluate the diagnosis and treatment preferences of orthopedic surgeons in developmental dysplasia of the hip (DDH) cases under the age of 1 in Türkiye with a higher incidence of DDH, estimated to be around 5-15 per 1000 live births.

METHODS

This was a nationwide cross-sectional survey. A link for the online survey, including 16 multiple-choice questions, was sent to the email group of the National Orthopedic Society.

RESULTS

Among 233 filled-out surveys, 211 met the inclusion criteria. Half of the participants had experience of <10 years as orthopedic surgeons, managed <25% of pediatric patients in daily practice, and treated <25 DDH cases per year before walking age. Ninety-seven percent used more than one method, hip ultrasound the most common, for exact diagnosis of DDH under 6 months. Pavlik harness was the most commonly preferred brace, but the use of Tübingen orthosis increased among experienced surgeons. The uppermost age limit for bracing was higher in surgeons dealing with more pediatric patients and treating more DDH cases. Dislocated hips and hips requiring closed/open reduction were more commonly referred to other surgeons by less experienced surgeons in terms of years, number of pediatric patients, and treated DDH cases per year. The lowest age limit for intervention under general anesthesia was lower in surgeons treating >25 DDH cases per year. Over one-third used both anterior and medial approach open reduction, but a trend to anterior open reduction alone was more evident in surgeons treating >50 DDH cases per year. More experienced surgeons were more prone to check the intraoperative reduction with postoperative computed tomography or magnetic resonance imaging. Diagnosis and treatment ages of DDH cases did not significantly change during the coronavirus disease 2019 pandemic.

CONCLUSION

Management preferences of orthopedic surgeons in DDH before walking age primarily depend on the rate of pediatric patients in daily practice and the number of treated DDH cases per year.

The Use of Visual Analysis for Gait and Foot Posture in Children with Developmental Dysplasia of the Hip

BACKGROUND

Developmental dysplasia of the hip (DDH) is recognized as a leading cause of significant long-term complications, including inaccurate gait patterns, persistent pain, and early regressive joint disorder, and it can influence families functionally, socially, and psychologically.

METHODS

This study aimed to determine foot posture and gait analysis across patients with developmental hip dysplasia. We retrospectively reviewed participants referred to the pediatric rehabilitation department of KASCH from the orthopedic clinic between 2016 and 2022 (patients born 2016-2022) with DDH for conservative brace treatment.

RESULTS

The foot postural index for the right foot showed a mean of 5.89 (n = 203, SD 4.15) and the left food showed a mean of 5.94 (n = 203, SD 4.19). The gait analysis mean was 6.44 (n = 406, SD 3.84). The right lower limb mean was 6.41 (n = 203, SD 3.78), and the left lower limb mean was 6.47 (n = 203, SD 3.91). The correlation for general gait analysis was r = 0.93, presenting the very high impact of DDH on gait. Significant correlation results were found between the right (r = 0.97) and left (r = 0.25) lower limbs. Variation between the right and left lower limb p-values was 0.88 (p < 0.05). DDH affects the left lower limb more than the right during gait.

CONCLUSION

We conclude that there is a higher risk of developing foot pronation on the left side, which is altered by DDH. Gait analysis has shown that DDH affects the right lower limb more than the left. The results of the gait analysis showed gait deviation in the sagittal mid- and late stance phases.

The management of developmental dysplasia of the hip in children aged under three months : a consensus study from the British Society for Children's Orthopaedic Surgery

AIMS

A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children's Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening.

METHODS

A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group.

RESULTS

A total of 60 statements were graded by 128 clinicians in the first round and 132 in the second round. Consensus was reached on 30 out of 60 statements in the first round and an additional 12 in the seond. This was summarized in a consensus statement and distilled into a flowchart to guide clinical practice.

CONCLUSION

We identified agreement in an area of medicine that has a long history of controversy and varied practice. None of the areas of consensus are based on high-quality evidence. This document is thus a framework to guide clinical practice and on which high-quality clinical trials can be developed.Cite this article: Bone Joint J 2023;105-B(2):209-214.

Demographic and Practice Variability Amongst Indian Centres in a Multicentre Prospective Observational Study on Developmental Dysplasia of the Hip

BACKGROUND

Since 2017, five Indian centres have enrolled into the International Hip Dysplasia Registry for prospective collection of data on Developmental Dysplasia of Hip (DDH).

AIMS

To assess how baseline patient characteristics and initial treatment modalities differ across these five centres.

METHODS

Registry data collected over 3 years were analyzed. Children with DDH that had radiograph-based diagnoses were included.

RESULTS

Collectively, there were 234 hips (181 patients), of which 218 had undergone surgery. Overall, median age at presentation was 25.3 months (IQR 16.8-46.0); female/male ratio was 2.6:1 (range 1.46-4.75:1); with 42%, 29%, and 29% unilateral left, bilateral and unilateral right hip dislocations respectively. Most were IHDI grade III and IV dislocations (94%). Closed reduction was performed at all but one centre, at median 15.3 months (IQR 9.6-21.1). Open reduction (OR) as a stand-alone procedure was performed at all centres, at median 20.8 months (IQR 15.4-24.9). Combination of OR with a single osteotomy, femoral (FO) or acetabular (AO), was performed at all centres at median 29.7 months (IQR 22.1-43.5). However, for the same age group, three centres exclusively performed FO, whereas the other two exclusively performed AO. The combination of OR with both FO and AO was used at all centres, at median 53.4 months (IQR 42.1-70.8).

CONCLUSIONS

The preliminary findings of this multi-centre study indicate similar patient demographics and diagnoses, but important differences in treatment regimens across the five Indian centres. Comparison of treatment regimens, using the 'centre' as a predictive variable, should allow us to identify protocols that give superior outcomes.

Repeated Pelvic Radiographs in Infants, After Harness Treatment for Developmental Dysplasia of the Hip, Carry Very Low Radiation Risk

OBJECTIVE

There are no data on the effect of X-Ray irradiation to the vulnerable pelvic organs of babies during DDH follow-up. This study aims to calculate, for the first time, the radiation exposure to infants during follow-up for DDH harness treatment, and thus quantify the lifetime risk of malignancy.

METHODS

Patients who had completed 5 years' follow-up following successful Pavlik harness treatment were identified from the hospital DDH database. The radiation dose was extracted from the Computerised Radiology Information System database for every radiograph of every patient. The effective dose (ED) was calculated using conversion coefficients for age, sex and body region irradiated. Cumulative ED was compared to Health Protection Agency standards to calculate lifetime risk of malignancy from the radiographs.

RESULTS

All radiographs of 40 infants, successfully treated in Pavlik harness for DDH, were assessed. The mean number of AP pelvis radiographs was 7.00 (range: 6-9, mode: 7). The mean cumulative ED was 0.25 mSv (Range: 0.11-0.46, SD: 0.07). This is far lower than the annual 'safe' limit for healthcare workers of 20 mSv and is categorised as "Very Low Risk".

CONCLUSION

Clinicians involved in the treatment DDH can be re-assured that the cumulative radiation exposure from pelvic radiographs following Pavlik harness treatment is "Very Low Risk". Whilst being mindful of any radiation exposure in children, this study provides a scientific answer that help addresses parental concerns.

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

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

Diagnostic and treatment preferences for developmental dysplasia of the hip: a survey of EPOS and POSNA members

PURPOSE

The aim of this study was to elucidate developmental dysplasia of the hip (DDH) diagnosis and treatment preferences among members of the Pediatric Orthopaedic Society of North America (POSNA) and European Paediatric Orthopaedic Society (EPOS).

METHODS

A 54-question survey on DDH diagnosis and treatment preferences was distributed to POSNA and EPOS members. Descriptive statistics were performed.

RESULTS

A total of 459 responses were analyzed. Ultrasound was the preferred modality for diagnosing DDH in infants less than six months old; few surgeons preferred radiographs. In all, 57% of POSNA members had radiology technicians perform ultrasounds, only 7% of EPOS members did. The percent coverage defining a dislocated hip varied greatly, the most frequent response being < 20% for POSNA and < 40% for EPOS members. Pavlik harnesses were the most popular harness/brace, used by 90% of POSNA and 71% of EPOS members. POSNA members were more likely than EPOS members to use a rigid abduction brace following initial harness/brace failure. For residual acetabular dysplasia, POSNA members were twice as likely as EPOS members to institute hip abduction bracing. Most surgeons would not perform closed reduction at less than three months of age or open reduction at less than six months of age. Most EPOS -members used traction prior to reduction; few POSNA members did. Few POSNA and EPOS members believed that reduction should be delayed until the ossific nucleus was visible.

CONCLUSION

There is great variation in the preferred methods for diagnosing and treating DDH. This survey is the largest transcontinental survey to compile diagnostic and treatment preferences for DDH. With wide variations in practice, there is room for quality improvement.