Role of ultrasound in the diagnosis and management of developmental dysplasia of the hip: an international perspective

Comparison of brace to observation in stable, radiological developmental dysplasia of the hip: a protocol for a global multicentre non-inferiority randomised trial

INTRODUCTION

Brace treatment is common to address radiological dysplasia in infants with developmental dysplasia of the hip (DDH); however, it is unclear whether bracing provides significant benefit above careful observation by ultrasound. If observation alone is non-inferior to bracing for radiological dysplasia, unnecessary treatment may be avoided. Therefore, the purpose of this study is to determine whether observation is non-inferior to bracing for infants with radiological dysplasia.

METHODS AND ANALYSIS

This will be a multicentre, global, randomised, non-inferiority trial performed under the auspices of a global prospective registry for infants and children diagnosed with DDH. Patients will be included if they present with radiological dysplasia (centred hip, alpha angle 43-60°, percent femoral head coverage greater than 35% measured on ultrasound) of a clinically stable hip under 3 months old. Patients will be excluded if they present with clinical hip instability, have received prior treatment or have known/suspected neuromuscular, collagen, chromosomal or lower-extremity congenital abnormalities or syndromic-associated hip abnormalities. Patients will be enrolled and randomised to undergo observation alone or brace treatment with a Pavlik harness for a minimum of 6 weeks. Follow-up visits will occur at 6 weeks, 1 year and 2 years post-enrolment. The primary outcome will be the norm-referenced acetabular index measured on the 2-year radiograph with a 3° non-inferiority margin. A total of 514 patients will be included.The study is anticipated to start in April 2024 and end in September 2028.The primary outcome will be compared between arms with a mixed-effects model with a random intercept for study centre, and a single covariate for the treatment group. If the lower bound of the 95% CI lies within 3° of the mean, we will treat this as evidence for non-inferiority.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the lead site's ethics board (University of British Columbia, Children's and Women's Research Ethics Board). Ethics approval will be obtained from the local ethics committees or institutional review boards at each institution prior to patient enrolment. It is intended that the results of this study shall be published in peer-reviewed journals and presented at suitable conferences.

TRIAL REGISTRATION NUMBER

NCT05869851.

Transgluteal Ultrasonography in Spica Cast in the Post-reduction Assessment of Hip Developmental Dysplasia

OBJECTIVE

Concentric circle reduction is one of the outcomes after reduction of developmental dysplasia of the hip (DDH). Radiography and magnetic resonance imaging (MRI) are used to confirm the reduction results. In this study, we evaluated the reduction results of the coronal section of the hip using transgluteal ultrasonography.

METHODS

We enrolled 46 children admitted to our hospital for closed or open reduction plaster fixation of DDH between January 2021 and December 2022. Thirty-eight patients had unilateral DDH, and eight patients had bilateral DDH. Transgluteal ultrasonography, radiography and MRI were done on the patients during the 7 d after reduction, and the results were interpreted by different radiologists. The covering of the femoral head and the distance between the medial margin of the femoral head and the acetabulum (HSD) were measured after calculating the maximum coronal surface of the iliac bone. MRI is regarded as the gold standard for determining hip reduction or dislocation. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasound and radiography were determined and compared.

RESULTS

The sensitivity, specificity, PPV and NPV of transgluteal ultrasonography were 100% (confidence interval [CI]: 69.2%-100%), 97.7% (CI: 88%-99.9%), 90.9% (CI: 59%-98.6%) and 100%, respectively, higher than those of radiography, which were 50% (CI: 18.7%-81.3%), 86.4% (CI: 72.6%-94.8%), 45.5% (CI: 24%-68.7%) and 88.4% (CI: 80.2%-93.5%), respectively. Ultrasonography had a higher sensitivity (100% vs. 50%, p < 0.01) and positive predictive rate (90.9% vs. 45.5%, p < 0.01) than radiography. Ultrasonography revealed that a distance between the head and socket (HSD) >8 mm indicated a strong suspicion for a poor reduction.

CONCLUSION

Transgluteal coronal ultrasound scan with semiquantitative assessment of acetabular femoral head coverage and measurement of HSD can effectively monitor the reduction relationship between the two in children after DDH reduction.

Outcomes of ultrasound-monitored treatment of divelopmental dysplasia of the hip graf type II

Introduction: The management of developmental dysplasia of the hips (DDH) type Graf IIa is still controversial. This study aims to examine the outcomes of ultrasound-monitored Pavlik harness treatment, as well as the effects of associated factors, such as gender, side of DDH, the age at the treatment start, and laterality on the treatment outcomes in different Graf type II subtypes. Methods: A cohort retrospective investigation was performed on 88 ultrasound-screened infants or 125 hips diagnosed with Graf type II dysplasia during a six-month period at a single institution, the University Clinic for Orthopedic Surgery, Skopje. Subsequently, 47 infants (18 boys, 29 girls) or 73 hips who underwent Pavlik harness treatment with at least one follow-up throughout treatment monitoring were included in this study. Results: The treatment success rate of the right DDH Graf type IIa (-) was higher (70.8%) compared to the rate of success (50%) in the treatment of left Graf type IIa (-) hips. The mean age of the infants at the treatment start in successfully treated Graf type IIa (-) hips was lower (9.12 ± 2.27 weeks) compared to the age of the infants with treatment failure at the last follow-up (11.33 ± 3.06 weeks), P = 0.04. Conclusion: The age of treatment initiation and the side of DDH were the most relevant factors related to the treatment outcome. Infants with maturational deficit hips, Graf type IIa (-), should undergo early initiated, carefully guided, and monitored Pavlik harness treatment.

Ultrasound techniques for the detection of developmental dysplasia of the hip: a systematic review and meta-analysis

BACKGROUND

Developmental dysplasia of the hip (DDH) encompasses a broad spectrum of hip pathologies, including femoral or acetabular dysplasia, hip instability, or both. According to the medical literature, ultrasonography is the most reliable diagnostic method for DDH. Several techniques for the assessment of hips in newborns and infants, using ultrasonography, have been described.

OBJECTIVE

To compare the accuracy of the Graf technique and other diagnostic techniques for DDH.

DESIGN AND SETTING

A systematic review of studies that analyzed ultrasound techniques for the diagnosis of DDH within an evidence-based health program of a federal university in São Paulo (SP), Brazil.

METHODS

A systematic search of relevant literature was conducted in the PubMed, EMBASE, Cochrane Library, CINAHL, and LILACS databases for articles published up to May 5, 2020, relating to studies evaluating the diagnostic accuracy of different ultrasound techniques for diagnosing DDH. The QUADAS 2 tool was used for methodological quality evaluation.

RESULTS

All hips were analyzed using the Graf method as a reference standard. The Morin technique had the highest rate of sensitivity, at 81.12-89.47%. The Suzuki and Stress tests showed 100% specificity. The Harcke technique showed a sensibility of 18.21% and specificity of 99.32%.

CONCLUSION

All the techniques demonstrated at least one rate (sensibility and specificity) lower than 90.00% when compared to the Graf method. The Morin technique, as evaluated in this systematic review, is recommended after the Graf method because it has the highest sensitivity, especially with the three-pattern classification of 89.47%.

REGISTRATION NUMBER

Identifier: CRD42020189686 at the International Prospective Register of Systematic Reviews (identifier: CRD42020189686).

Practice Essentials of Imaging in Early Diagnosis of DDH

INTRODUCTION

Developmental dysplasia of hip joint (DDH) is a dynamic progressive pathology which can tilt either way. The term strictly applies to primary dysplasia, where etiology is not clearly known. Secondary dysplasia can be due multiple causes, such as neuromuscular disorders, connective tissue disorders or skeletal syndromes.

METHODS

The etiology being multifactorial, it needs a multidisciplinary team to address the issue at hand. The management starts antenatally with a detailed history of any risk factors and a dedicated ultrasound of the foetus, since forewarned is forearmed. At birth, a paediatrician having a keen sense of DDH will perform Barlow's or Ortolani's manoeuvre and can be the first one to sound the alarm in the event of positive findings. How and when a Radiologist needs to step in will depend on inter-departmental discussions between the paediatrician and the orthopedician.

RESULTS

In the presence of positive clinical screening tests, and non-availability of ultrasound, a preliminary X ray pelvis AP view including both hip joints should be the requisitioned in a child of any age, particularly, if belonging to the high-risk group. If ultrasound is available, a screening exam till 6 months of age is recommended to rule out DDH.

DISCUSSIONS

India is known for its vast numbers and little babies with occult diseases are the first to bear the brunt of conditions which have very few symptoms to start with. DDH is one such condition which most unfortunately expresses itself as a symptom only when it's too late, i.e., most often when the child begins to walk. Ultrasound is the modality of choice in neonates; however, since India is a country of modest means, in majority of the regions, radiographs still remain the first line of investigation.

Effectiveness of different types of ultrasonography screening for developmental dysplasia of the hip: A meta-analysis

BACKGROUND

Infant hip screening for early detection of developmental dysplasia of the hip (DDH) is essential as early detection can enable less invasive treatments and achieve better long-term results. A previous meta-analysis assessed about 10,000 infants per group, which is insufficient for evaluating the effect of different infant hip screening strategies on early detection and treatment of DDH. Therefore, we conducted a systematic review and meta-analysis using both randomized controlled trials and cohort studies to determine the effects of universal hip ultrasonography screening (UHUS) and selective hip ultrasonography screening (SHUS) on the incidence of late-diagnosed DDH.

METHODS

A literature search of PubMed, EMBASE, and Cochrane databases was performed. The summary odds ratio (OR) with 95% confidence interval (CI) was calculated using fixed-effects models.

RESULTS

Meta-analysis of five studies that met the eligibility criteria revealed a significant difference in late-diagnosed DDH (OR 0.44, 95% CI 0.23-0.83) between infants screened using UHUS (n = 29,070) and those screened using SHUS (n = 30,442) in a fixed-effects model without heterogeneity among studies. In the subgroup analysis, meta-analysis of the randomized controlled trials showed no significant difference in late-diagnosed DDH (OR 0.52, 95% CI 0.20-1.39) between infants screened using UHUS (n = 11,453) and those screened using SHUS (n = 12,077) in a fixed-effects model with low heterogeneity among studies (I = 0.9%). However, meta-analysis of the cohort studies showed a significant difference in late-diagnosed DDH (OR 0.38, 95% CI 0.17-0.89) between infants screened using UHUS (n = 17,617) and those screened using SHUS (n = 18,345) in a fixed-effects model with low heterogeneity among studies. Sensitivity analysis revealed that the impact of each study on the summary results was not significant. There was no publication bias in our meta-analysis.

CONCLUSIONS

Our meta-analysis suggests that a statistically significant decrease in the incidence of late-diagnosed DDH is possible when UHUS is adopted compared with SHUS. Our study provides information about the effects of different infant hip screening strategies on the incidence of late-diagnosed DDH, which can help decide upon which strategy to apply.

Correlations between ultrasonographic and subsequent radiographic findings of developmental dysplasia of the hips

Purpose

The study aimed to investigate the utility of ultrasonographic (US) findings in predicting the subsequent radiographic parameters of developmental dysplasia of the hips.

Methods

In this 12-year retrospective cohort study, all new-born infants with a positive clinical examination or risk factors were included. They were scheduled for hip ultrasonography in the first 3 months, and subsequent radiographs at 1 year of life. The US images were evaluated using the Graf classification, Harcke’s dynamic screening method, and Terjesen’s femoral head coverage method. The radiographic images were evaluated using the acetabular index and femoral head position. The overall US or radiographic findings were considered abnormal if they were classified as abnormal for any of their respective parameters. The overall US and radiographic parameters were correlated.

Results

A total of 160 patients were included. The overall US and radiographic parameters showed no statistically significant difference (P=0.050). The sensitivity, specificity, and accuracy of the overall US parameters were 57.1%, 84.9%, and 81.3%, respectively. All three individual US parameters showed no statistically significant differences, with the overall radiographic findings and acetabular index (P>0.05). However, they showed a statistically significant difference, with the position of the femoral head (P<0.001), with the US parameters having an excellent negative predictive value of 100% for identifying an abnormal femoral head position.

Conclusion

The current study suggests that US findings evaluated in the first 3 months of life showed no statistically significant difference with radiographic findings evaluated at 1 year of life. The US parameters showed an excellent negative predictive value for abnormal femoral head position on radiographs.

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

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

The earliest timing of ultrasound in screening for developmental dysplasia of the hips

Purpose

The current study aimed to evaluate the results of ultrasound screening for developmental dysplasia of the hips (DDH) done at various weeks of life, to determine the earliest time that ultrasound screening can be performed reliably.

Methods

In this 17-year cohort study, all neonates who underwent ultrasound screening prior to the 12th week of life with subsequent follow-up radiography done at 1 year of life were included. The ultrasound images were evaluated according to the Graf classification, Harcke’s dynamic ultrasound screening method, and Terjesen’s femoral head coverage method. The radiographic images were evaluated according to the acetabular index and the femoral head position. The accuracy and correlation between the ultrasound findings from various weeks of life with the radiographic findings at 1 year of life were evaluated.

Results

A total of 348 neonates were included in the study, of whom 92 had abnormal ultrasound findings and 42 had abnormal radiographic findings at 1 year. Significant differences were identified between the findings of ultrasound screening examinations performed prior to the fourth week of life (day 21 and before) and the radiographic findings at 1 year of life (P<0.05). In contrast, no significant differences were identified when ultrasound screening was performed between the fourth and 12th weeks of life (day 22 and beyond) (P>0.05). The accuracy of ultrasound screening was 79.2% or higher when performed during or after the fourth week of life (day 22 and beyond).

Conclusion

The earliest that ultrasound screening for DDH can be performed reliably is during the fourth week of life (day 22 and beyond).

Ultrasound Diagnosis of Anterior Shoulder Dislocation

We describe the ultrasound evaluation technique and sonographic findings of a case of anterior shoulder dislocation. The sonographic features of anterior shoulder dislocation include: “sign of widening of subacromial space”, “sign of disappearance of humeral head”, “artery/vessel sign”, “humeral head below coracoid process sign” and “empty glenoid fossa sign”. It is a safe, real time, readily available, convenient, and well tolerated diagnostic technique. The time to confirming the diagnosis of anterior shoulder dislocation may be shortened and hence close reduction in a timely manner may be achieved. We suggest the use of high resolution ultrasound for confirmation of the diagnosis of anterior shoulder dislocation and relocation of the humeral head after close reduction. The potential of using ultrasonography to replace pre-reduction radiograph should be explored.

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.

What Risk Factors and Characteristics Are Associated With Late-presenting Dislocations of the Hip in Infants?

BACKGROUND

Most infants with developmental dysplasia of the hip (DDH) are diagnosed within the first 3 months of life. However, late-presenting DDH (defined as a diagnosis after 3 months of age) does occur and often results in more complex treatment and increased long-term complications. Specific risk factors involved in late-presenting DDH are poorly understood, and clearly defining an associated set of factors will aid in screening, detection, and prevention of this condition.

QUESTIONS/PURPOSES

Using a multicenter database of patients with DDH, we sought to determine whether there were differences in (1) risk factors or (2) the nature of the dislocation (laterality and joint laxity) when comparing patients with early versus late presentation.

METHODS

A retrospective review of prospectively collected data from a multicenter database of patients with dislocated hips was conducted from 2010 to 2014. Baseline demographics for fetal presentation (cephalic/breech), birth presentation (vaginal/cesarean), birth weight, maternal age, maternal parity, gestational age, family history, and swaddling history of patients were compared among nine different sites for patients who were enrolled at age younger than 3 months and those enrolled between 3 and 18 months of age. A total of 392 patients were enrolled at baseline between 0 and 18 months of age with at least one dislocated hip. Of that group, 259 patients were younger than 3 months of age and 133 were 3 to 18 months of age. The proportion of patients with DDH who were enrolled and followed at the nine participating centers was 98%.

RESULTS

A univariate/multivariate analysis was performed comparing key baseline demographics between early- and late-presenting patients. After controlling for relevant confounding variables, two variables were identified as risk factors for late-presenting DDH as compared with early-presenting: cephalic presentation at birth and swaddling history. Late-presenting patients were more likely to have had a cephalic presentation than early-presenting patients (88% [117 of 133] versus 65% [169 or 259]; odds ratio [OR], 5.366; 95% confidence interval [CI], 2.44-11.78; p < 0.001). Additionally, late-presenting patients were more likely to have had a history of swaddling (40% [53 of 133] versus 25% [64 of 259]; OR, 2.053; 95% CI, 1.22-3.45; p = 0.0016). No difference was seen for sex (p = 0.63), birth presentation (p = 0.088), birth weight (p = 0.90), maternal age (p = 0.39), maternal parity (p = 0.54), gestational age (p = 0.42), or family history (p = 0.11) between the two groups. Late presenters were more likely to present with an irreducible dislocation than early presenters (56% [82 of 147 hips] versus 19% [63 of 333 hips]; OR, 5.407; 95% CI, 3.532-8.275; p < 0.001) and were less likely to have a bilateral dislocation (11% [14 of 133] versus 28% [73 of 259]; OR, 0.300; 95% CI, 0.162-0.555; p = 0.002).

CONCLUSIONS

Those presenting with DDH after 3 months of age have fewer of the traditional risk factors for DDH (such as breech birth), which may explain the reason for a missed diagnosis at a younger age. In addition, swaddling history was more common in late-presenting infants. A high index of suspicion for DDH should be maintained for all infants, not just those with traditional risk factors for DDH. Further investigation is required to determine if swaddling is a risk factor for the development of hip dislocations in older infants. More rigorous examination into traditional screening methods should also be performed to determine whether current screening is sufficient and whether late-presenting dislocations are present early and missed or whether they develop over time.

LEVEL OF EVIDENCE

Level III, retrospective study.

DYSPLASIA OF HIP DEVELOPMENT: UPDATE

The term “developmental dysplasia of the hip” (DDH) includes a wide spectrum of abnormalities that affect the hip during its growth, ranging from dysplasia to joint dislocation and going through different degrees of coxofemoral subluxation. The incidence of DDH is variable, and depends on a number of factors, including geographical location. Approximately one in 1,000 newborn infants may present hip dislocation and around 10 in 1,000 present hip instability. Brazil has an incidence of five per 1,000 in terms of findings of a positive Ortolani sign, which is the early clinical sign for detecting the disorder. The risk factors for DDH include: female sex, white skin color, primiparity, young mother, breech presentation at birth, family history, oligohydramnios, newborns with greater weight and height, and deformities of the feet or spine. Hip examinations should be routine for newborns, and should be emphasized in maternity units. Among newborns and infants, the diagnosis of DDH is preeminently clinical and is made using the Ortolani and Barlow maneuvers. Conventional radiography is of limited value for confirming the diagnosis of DDH among newborns, and ultrasound of the hip is the ideal examination. The treatment of DDH is challenging, both for pediatric orthopedists and for general practitioners. The objectives of the treatment include diagnosis as early as possible, joint reduction and stabilization of the hip in a secure position. Classically, treatment options are divided according to different age groups, at the time of diagnosis.

Screening for developmental dysplasia of the hip in Hong Kong

PURPOSE

To review records of children referred to our hospital for developmental dysplasia of the hip (DDH) and evaluate the effectiveness of hip screening in Hong Kong.

METHODS

Records of children suspected of DDH and referred to our hospital between 1 January 2005 and 31 March 2010 were reviewed. The diagnosis was based on static and dynamic ultrasonography of the hips and/or radiographic features of hip subluxation, dislocation, and pelvic dysplasia. The age of the children at presentation was recorded. Late diagnoses were those presenting after the age of 6 months. Late presentations were those presenting after the walking age.

RESULTS

Of 213 referred children, 33 were diagnosed to have DDH. Their mean age at presentation was 90.8 (range, 9-559) days. The female-to-male ratio was 2.9:1, and the mean follow-up duration was 25.1 (range, 4.2-50.3) months. 30 of the DDH infants were diagnosed before the age of 6 months, one at 8 months, and 2 were late presenters. Hence, the failure rate of the hip screening was 0.09 per 1000 live births. The remaining 180 were confirmed to be normal and followed up until the walking age. The point prevalence of DDH on Hong Kong Island was 0.87/1000 live births.

CONCLUSION

In light of the low point prevalence of DDH in Hong Kong born children, the protocol of universal clinical assessment and selective ultrasonographic screening of suspected cases is justified.

Hip ultrasound

In newborns, US has an established role in the detection and management of developmental dysplasia of the hip. Later in childhood, when the limping child is a major diagnostic dilemma, US is extremely helpful in the identification of the varied disease processes underlying this condition, as transient synovitis, septic arthritis, Perthes disease and slipped femoral capital epiphysis. In adolescent practicing sporting activities, US is an excellent means to identify apophyseal injures about the pelvic ring, especially when avulsions are undisplaced and difficult-to-see radiographically. Later on, in the adulthood, US is an effective modality to diagnose tendon and muscle injuries about the hip and pelvis, identify effusion or synovitis within the hip joint or its adjacent bursae and guide the treatment of these findings. The aim of this article is to provide a comprehensive review of the most common pathologic conditions about the hip, in which the contribution of US is relevant for the diagnostic work-up.