Bone maturation of MRI residual developmental dysplasia of the hip with discrepancy between osseous and cartilaginous acetabular index

The role of the cartilaginous to osseous acetabular angle ratio in children with developmental dysplasia of the hip

Purpose

This study aims to demonstrate the use of the cartilaginous to osseous acetabular angle ratio (AAR) in surgical decision-making for hip dysplasia.

Methods

Data were collected from patients who underwent an MRI of the hip after conservative treatment for developmental dysplasia of the hip between August 2019 and 2022. The data included demographic information as well as an anteroposterior pelvic radiograph. The osseous acetabular index (OAI) was measured using x-ray, while the cartilaginous acetabular index (CAI) and the cartilaginous acetabulum head index (CAHI) were measured using MRI. The square of the CAI to OAI, AAR, was calculated. The patients in the residual hip dysplasia (RHD) group were categorized as having an OAI above 20°. During the postoperative follow-up, we evaluated the patients in this group who underwent Bernese triple pelvic osteotomy. Data on surgical patients with an observation period that exceeded 1 year were collected and analyzed. The distribution of the AAR among the different groups was analyzed. A receiver operating characteristic (ROC) predictive model was constructed using the AAR of the patients in the normal and surgical groups to evaluate the need for surgery.

Results

It was found that there was a significant difference in the OAI, CAI, CAHI, and AAR between the RHD group (OAI 26.15 ± 3.90°, CAI 11.71 ± 4.70°, CAHI 79.75 ± 6.27%, and AAR 5.88 ± 4.24) and the control group patients (OAI 16.77 ± 5.39°, CAI 6.16 ± 3.13°, CAHI 85.05 ± 4.91%, and AAR 2.71 ± 2.08) (p < 0.001). A total of 93.5% of the control group patients had an AAR ≤5, while only 6.5% had an AAR >5. The results of postoperative imaging follow-up were "excellent" in 52 patients and "good" in 3, while the functional follow-up results were excellent in 53 and good in 2. In 15 patients, the observation period exceeded 1 year. The mean observation period was 633.1 ± 259.6 days and the preoperative CAHI was 71.7 ± 4.8%. Of the patients with an AAR >5, a substantial 94.8% (55/58) of them were reported to have undergone surgery, while all patients with an AAR less than or equal to 5 did not undergo surgery (91/91). Based on the ROC, a cutoff value of 5.09 was identified for the need for surgery in children with RHD.

Conclusions

A surgical decision for residual hip dysplasia can be based on the AAR. An AAR >5 may be a potential indicator for surgical intervention in patients with RHD.

Developmental Dysplasia of the Hip - Part 1

Developmental dysplasia of the hip (DDH) is a condition characterized by changes in joint formation within the last months of intrauterine life or the first months after birth. Developmental dysplasia of the hip presentation ranges from femoroacetabular instability to several stages of dysplasia up to complete dislocation. Early diagnosis is essential for successful treatment. Clinical screening, including appropriate maneuvers, is critical in newborns and subsequent examinations during the growth of the child. Infants with suspected DDH must undergo an ultrasound screening, especially those with a breech presentation at delivery or a family history of the condition. A hip ultrasound within the first months, followed by pelvic radiograph at 4 or 6 months, determines the diagnosis and helps follow-up. Treatment consists of concentric reduction and hip maintenance and stabilization with joint remodeling. The initial choices are flexion/abduction orthoses; older children may require a spica cast after closed reduction, with or without tenotomy. An open reduction also can be indicated. After 18 months, the choices include pelvic osteotomies with capsuloplasty and, eventually, acetabular and femoral osteotomies. The follow-up of treated children must continue throughout their growth due to the potential risk of late dysplasia.

A cross-sectional study evaluating patients' preferences for Salter innominate osteotomy

BACKGROUND

Residual acetabular dysplasia in children after reduction of hip dislocation is often treated using Salter innominate osteotomy to prevent future osteoarthritis. Preventive surgery for asymptomatic patients, which could result in overtreatment, should be carefully applied with consideration of patients' opinions. In this study, we aimed to describe opinions on Salter innominate osteotomy as preventive surgery for children among adult patients who had undergone periacetabular osteotomy for hip pain due to hip dysplasia.

METHODS

A mail-in questionnaire survey was conducted with 77 patients who underwent periacetabular osteotomy. Participants responded whether they would recommend Salter innominate osteotomy as preventive surgery for children and the reason for their opinion. We also performed a patient-based evaluation using the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire and assessed clinical outcome measures with the Japanese Orthopedic Association score. Their recommendations and reasons were evaluated, and associations between their opinions and demographic and clinical characteristics were analyzed.

RESULTS

Forty-three patients (56%) responded to the questionnaire. Of these, 10 (23%) patients recommended undergoing Salter innominate osteotomy, 28 (65%) patients did not, and 5 (12%) patients responded they were undecided. No significant association was observed between their opinions and demographic/clinical characteristics evaluated in the survey. The most frequent reason for why they do not recommend Salter innominate osteotomy was related to uncertainty about future hip pain.

CONCLUSIONS

In total, 65% of the study participants did not recommend Salter innominate osteotomy for children with risk of dysplasia in the future. Participants' preferences regarding preventive surgery were not influenced by demographic and clinical characteristics.

Cartilaginous predictors of residual acetabular dysplasia (RAD) in developmental dysplasia of the hip following closed or open reduction: A systematic review and meta-analysis

Object

This study was designed to analyze the cartilaginous predictors of residual acetabular dysplasia (RAD) after early treatment of developmental dysplasia of the hip and their diagnostic accuracy.

Study design

Databases such as PubMed, Embase, Cochrane, and Web of science were searched to screen the literature. The quality of the literature was assessed by the QUADAS-2 tool. Qualitative and quantitative synthesis of literature were performed based on extracted data. For quantitative synthesis studies, the sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC) curve with corresponding confidence intervals were calculated.

Results

For the cartilaginous acetabular index (CAI) group, the combined values of sensitivity, specificity, and DOR were 0.80 (95% CI = 0.54-0.93), 0.73 (95% CI = 0.57-0.84), and 10.62 (95% CI = 3.96-28.53), respectively. The corresponding values in the cartilaginous center-edge angle (CCE) group were 0.71 (95% CI = 0.57-0.82), 0.78 (95% CI = 0.66-0.87), and 8.64 (95% CI = 3.08-24.25), respectively. The area under the curve (AUC) of SROC was 0.82 (95% CI = 0.78-0.85) and 0.80 (95% CI = 0.76-0.83) for the CAI and CCE groups. The CAI group had higher sensitivity, DOR, and AUC than the CCE group.

Conclusion

Both of these two groups have good diagnostic accuracy, and CAI/L-AI has a little edge over CCE/L-CEA. However, there is still more research needed to determine whether they can be used as independent indications for secondary orthopedic surgery.Systematic review registration: [https://www.crd.york.ac.uk/PROSPERO/], identifier: [CRD42022338332].

Intra- and interobserver variability of novel magnetic resonance imaging parameters for hip screening and treatment outcomes at age 5 years

BACKGROUND

The outcome measure of neonatal hip screening is usually the radiographic acetabular index.

OBJECTIVE

To assess the feasibility of magnetic resonance imaging (MRI) without sedation and compare the utility of outcome parameters measured from MRI images.

MATERIALS AND METHODS

The invitation for MRI scanning at 5 years of age was incorporated into follow-up for babies who had more than one ultrasound examination during treatment or surveillance.

RESULTS

Diagnostic images were obtained in 132 of 134 children. The mean osseous acetabular index (standard deviation [SD]) was 16.6 (3.3) degrees for the right hip and 17.8 (3.2) for the left; the values for the cartilaginous acetabular index were 3.1 (3) and 3.4 (3.2). The mean downslope of a tangent to the lateral bony acetabular roof was 10.4 (4.5) and 9.0 (4.3) with respect to Hilgenreiner's line and that of a line drawn through the apex to the margin of the acetabulum was 3.7 (4.6) and 3.9 (4.7). Intra- and interobserver variation was greater for measures specific to the lateral acetabular roof than for ossific and cartilaginous indices. There was significant negative correlation between the downslope of the tangent to the lateral roof index and the age at onset of treatment on both sides, but no significant correlation for ossific or cartilaginous acetabular indices or apex-marginal index.

CONCLUSION

MRI without sedation at 5 years of age is feasible as an outcome measure for hip screening programmes. Parameters specific to the lateral acetabulum may better reflect acetabular sufficiency, despite having greater observer variation than cartilaginous and ossific acetabular indices.

Evaluation of Anterior Coverage in Children With Developmental Dysplasia of the Hip Using Transverse Magnetic Resonance Imaging at 2 Years Is Predictive of Future Radiographic Coverage

BACKGROUND

Although normal anterior acetabular coverage provides stability to the hip, acetabular retroversion leads to femoroacetabular impingement related to hip osteoarthritis. Previous studies have focused on acetabular version and anteroposterior coverage in children with developmental dysplasia of the hip (DDH); however, the correlation between anteroposterior coverage and acetabular development is unclear. We measured anteroposterior acetabular coverage in DDH patients using transverse magnetic resonance imaging (MRI) and subsequent bony acetabular growth, and evaluated the correlation of those findings.

METHODS

We evaluated 37 DDH (dislocations) in 36 patients who underwent MRI at 2 years of age. The mean age was 2.2±0.3 years at the time of MRI (1.6±0.4 y after reduction) and 6.0±0.1 years at the time of plain radiography for the Severin classification. On MRI scans, we measured the cartilaginous center-edge angle (CCEA) and cartilaginous acetabular-head index (CAHI) in the coronal plane and the anterior and posterior cartilaginous center-edge angles (AC-CEA and PC-CEA, respectively) in the transverse plane. Severin I or II was defined as a good outcome and III or IV as a poor outcome.

RESULTS

In the evaluations conducted at 2 years of age, the mean CCEA, CAHI, AC-CEA, and PC-CEA were 14±9 degrees, 66%±10%, 39±8 degrees, and 77±7 degrees, respectively; the CEA at 6 years of age was 13±7 degrees. Twelve and 25 hips were classified in the good and poor outcome groups, respectively. Although CCEA, CAHI, and AC-CEA were significantly associated with the outcome in a single regression analysis ( P <0.05), only AC-CEA was significant in the multiple regression analysis with a stepwise selection method ( P =0.018). The cutoff AC-CEA value for a good outcome was 38 degrees (sensitivity, 67%; specificity, 68%) using a receiver operating characteristic curve.

CONCLUSIONS

Among MRI findings for acetabular cartilaginous morphology, AC-CEA was strongly associated with the outcome. Anteroposterior coverage was correlated with bony acetabular growth in childhood, and anterior coverage was particularly important for subsequent acetabular growth.

LEVEL OF EVIDENCE

Level IV-case series.

Residual acetabular dysplasia in congenital hip dysplasia

Residual hip dysplasia may exist despite appropriate treatment of congenital hip dysplasia (CHD). The abnormalities chiefly affect the acetabulum and can lead to premature osteoarthritis. Although the main cause is delayed treatment of CHD, primary lesions are also possible and may be worsened by the initial treatment itself. Residual hip dysplasia must be detected during the follow-up of patients with CHD. The antero-posterior radiograph of the pelvis is the main diagnostic tool. However, the importance of non-ossified anatomical structures requires additional investigations such as arthrography and magnetic resonance imaging. The risk of premature osteoarthritis is difficult to predict based only on the imaging-study findings. Hip dysplasia is best treated before 5 years of age. The work-up at this age should allow determination of the best treatment. Surgery is required but should not be performed unnecessarily. The decision rests on the absence of improvement in the radiographic criteria and on the findings from additional imaging studies. The usual treatment is Salter's osteotomy, during which excessive anterior displacement should be avoided. At adolescence, the information provided by radiography in the coronal plane should be completed by a three-dimensional evaluation of the acetabulum and an assessment of the quality of the labrum. The shelf procedure has been proven to relieve pain and to significantly postpone the need for hip arthroplasty, when performed early, before the development of visible osteoarthritis, and on a congruent hip. Chiari's osteotomy has a role to play in complex dysplasia affecting both the acetabulum and the femur. Periacetabular osteotomy is getting more used thanks to cooperation between paediatric and adult orthopaedic surgeons. This osteotomy provides optimal correction in all three dimensions.

Application Value of Combined Diagnosis of Ultrasound, MRI, and X-Ray in Developmental Dysplasia of the Hip in Children

Objective

To explore the application value of the combined diagnosis of ultrasound, MRI, and X-ray in developmental dysplasia of the hip (DDH) in children.

Methods

Ninety children with suspected DDH admitted to our hospital from June 2017 to June 2020 were selected as the research objects to conduct a retrospective study. According to the age of the children, they were divided into a group with 0-6 months (group X), a group with 7-12 months (group Y), and a group older than 12 months (group Z), with 30 cases in each group. X-ray and high-frequency ultrasound were performed in all groups, and MRI examination was added to the children in groups Y and Z to compare the diagnostic value of the three imaging examinations in DDH children.

Results

No obvious differences in the general data and maternal risk factors were observed among the three groups (P < 0.05). The final comprehensive diagnostic results were taken as the gold standard, including 23 cases with acetabular dysplasia, 28 cases with subluxation of the femoral head, 31 cases with complete dislocation of the femoral head, and 8 non-DDH cases. The diagnostic accuracy of the three methods from high to low was MRI, high-frequency ultrasound, and X-ray, with obviously higher diagnostic accuracy of MRI than that of X-ray (P < 0.05). The ROC curves showed that the diagnostic efficacy from high to low was MRI + high-frequency ultrasound + X-ray, high-frequency ultrasound + X-ray, MRI, high-frequency ultrasound, and X-ray.

Conclusion

Ultrasound combined with X-ray has obvious advantages in the diagnosis of children at low months of age, while MRI has outstanding advantages in the diagnosis of children at high months of age. MRI combined with ultrasound and X-ray can significantly improve the diagnostic accuracy of DDH and provide objective data support for the clinical treatment of children.

Management and effects of residual limbus inversion following closed reduction in developmental hip dysplasia: Protocol for a multicenter randomized controlled trial

Closed reduction is a common treatment method for developmental dysplasia of the hip (DDH) in children aged 6-18 months. Residual acetabular dysplasia (RAD) is the most common complication associated with closed reduction. Residual limbus inversion (RLI) is a common condition following DDH closed reduction. Previously, we confirmed that when limbus inversion exceeds 32.2% of the acetabular depth after closed reduction, RLI persists and leads to RAD; however, this was based on a small cohort with a short-term follow-up period. The long-term fate of RLI and the correlation between RLI and RAD have yet to be verified. Therefore, this multicenter clinical study protocol was designed in three parts to investigate the effect of RLI on acetabular development after closed reduction of DDH (a multicenter retrospective cohort study), effect of RLI clearance on acetabular development (a multicenter retrospective and prospective randomized controlled study), and influence of inverted limbus clearance on acetabular development during DDH reduction (a multicenter prospective cohort study). Statistical analysis was performed by assessing the basic measures of acetabular development including the acetabular index and central-edge angle using frontal pelvic radiographs; the magnitude of limbus inversion, cartilaginous acetabular index, and T1ρ mapping values were measured using magnetic resonance imaging. The multicenter retrospective cohort studies required 5 years of follow-up period at minimum, and the prospective randomized controlled studies required reviews of frontal pelvic radiographs every 6 months as well as data pooling every 2 years to compare the short- and mid-term outcomes of hip joint morphological development between the two groups of pediatric patients. This research program is expected to verify that RLI following closed reduction of DDH can affect acetabular development and that limbus excision during DDH reduction can improve postoperative RAD. Therefore, the indication and timing of surgical intervention for RLI after closed reduction of DDH provide a basis for revising the acceptable criteria for utilizing closed reduction of DDH to reduce the incidence of osteoarthritis caused by RAD following DDH treatment. Clinical Trial: http://www.chictr.org.cn/showproj.aspx?proj=35045 (ChiCTR1900020996).

Hip morphology in mucopolysaccharidosis type IVA through radiograph, magnetic resonance imaging and arthrogram assessment

PURPOSE

This study examined the hip morphology of paediatric patients with mucopolysaccharidosis (MPS) type IVA (MPS IVA).

METHODS

This was a retrospective chart review of 42 hips in 21 children with MPS IVA. Pelvic radiographs and magnetic resonance imaging (MRI) scans of 42 hips and arthrograms of 13 hips were analysed. The bony, cartilaginous and labral coverage of the acetabulum was determined by acetabular index (AI), centre edge angle (CEA) and femoral head coverage (FHC).

RESULTS

The mean age at the time of radiography was 66.3 ± 21.7 months. The bony, cartilaginous and labral AI in the MRI assessment were 36.3 ± 5.3, 18.3 ± 4.7 and 12.1 ± 4.6 degrees, respectively. The inter-class correlation coefficients (ICCs) for the bony AI, CEA and FHC measurements on radiographs and MRI were 0.936, 0.879 and 0.810, respectively. In the MRI assessment, labrum in 12 of 42 hips appeared as a regular triangle, and it was flat on 30/42 hips. The average arthrographic AI (AAI) was 11.1 ± 2.7 degrees. The ICCs value of AAI versus cartilaginous and labral AI on MRI indicates good agreement but higher in labral AI.

CONCLUSION

Hips in MPS IVA exhibited obvious cartilage and labrum compensation in response to abnormal ossification of bony acetabulum. Cartilage in MPS IVA hip increases the thickness in the longitudinal direction, while the labrum becomes flatten in the horizontal direction. The AAI may represent intraoperative labrum coverage. The femora-acetabular harmony is difficult to determine using radiography only, and pre-operative MRI and an intraoperative arthrogram are very important in a hip assessment in MPS IVA.

[Hip dysplasia-new and proven methods]

BACKGROUND

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

CURRENT TREATMENT

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