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Maikku M, Valkama AM, Ohtonen P, Leppilahti J. Prevalence of Acetabular Dysplasia at a Mean age of 18 Years After Treatment for Neonatal hip Instability. J Pediatr Orthop 2024; 44:e478-e484. [PMID: 38630916 PMCID: PMC11302581 DOI: 10.1097/bpo.0000000000002673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND The long-term radiological outcomes after the treatment of neonatal hip instability (NHI) in developmental dysplasia of the hip are unclear. Therefore, the prevalence of acetabular dysplasia at a mean age of 18 years after treatment was investigated. The relationship between acetabular dysplasia and hip discomfort has also been poorly established. Therefore, the differences in pain, hip-related quality of life (QOL), and hip impingement tests in hips with and without acetabular dysplasia were assessed. METHODS All 127 patients treated for NHI from 1995 to 2001 at the study hospital and meeting the inclusion criteria were invited to participate in this population-based follow-up. Of these individuals, 88 (69.3%) participated. The lateral center-edge angle (LCEA), Sharp's angle (SA), and acetabular head index (AHI) were calculated for both hips from pelvic anterior-posterior radiographs. The Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire was completed for both hips separately; the total score, pain, and QOL subscores were calculated; and the impingement test was performed. RESULTS The prevalence of acetabular dysplasia, defined as an LCEA <20°, was 3.4%. Only the mean AHI (81.1%, SD 5.3) differed (-5.08, 95% CI -5.77 to -4.38, P <0.001) from previously described gender-specific and side-specific means, whereas the mean LCEA and SA did not. The odds ratio for a positive hip impingement test was 2.8 (95% CI: 1.11-7.05, P = 0.029) for hips with an LCEA <25° compared to hips with LCEA ≥25°. The hips with an SA ≥45° had a mean of 7.8 points lower for the HAGOS pain subscore (95% CI: 4.2-11.4, P <0.001) and a mean of 6.1 points lower for the HAGOS QOL subscore (95% CI: 2.1-10.2, P = 0.003) compared with hips with an SA <45°. CONCLUSIONS The prevalence of acetabular dysplasia was low after treatment for NHI. Acetabular dysplasia seems to be as common in the general population as for those treated for NHI based on the LCEA. Only an SA ≥45° resulted in slightly more pain and lower hip-related QOL.
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Affiliation(s)
- Mari Maikku
- Translational Medicine Research Unit, Medical Research Center Oulu, Oulu University Hospital, and University of Oulu, Oulu, Finland
| | - Arja Marita Valkama
- Department of Paediatrics, Oulu University Hospital, Wellbeing Services County of North Ostrobothnia, Pohde, Oulu, Finland
- Research Unit of Clinical Medicine and Medical Research Center Oulu, Oulu University Hospital, and University of Oulu, Oulu, Finland
| | - Pasi Ohtonen
- Translational Medicine Research Unit, Medical Research Center Oulu, Oulu University Hospital, and University of Oulu, Oulu, Finland
- Research Service Unit, Oulu University Hospital, Oulu, Finland
| | - Juhana Leppilahti
- Translational Medicine Research Unit, Medical Research Center Oulu, Oulu University Hospital, and University of Oulu, Oulu, Finland
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Saeed A, Bradley CS, Verma Y, Kelley SP. Resolving residual acetabular dysplasia following successful brace treatment for developmental dysplasia of the hip in infants. Bone Joint J 2024; 106-B:744-750. [PMID: 38945534 DOI: 10.1302/0301-620x.106b7.bjj-2023-1169.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Aims Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing. Methods This was a single-centre, prospective longitudinal cohort study of infants with DDH managed using a published, standardized Pavlik harness protocol between January 2012 and December 2016. RAD was measured at two years' mean follow-up using acetabular index-lateral edge (AI-L) and acetabular index-sourcil (AI-S), and at five years using AI-L, AI-S, centre-edge angle (CEA), and acetabular depth ratio (ADR). Each hip was classified based on published normative values for normal, borderline (1 to 2 standard deviations (SDs)), or dysplastic (> 2 SDs) based on sex, age, and laterality. Results Of 202 infants who completed the protocol, 181 (90%) had two and five years' follow-up radiographs. At two years, in 304 initially pathological hips, the prevalence of RAD (dysplastic) was 10% and RAD (borderline) was 30%. At five years, RAD (dysplastic) decreased to 1% to 3% and RAD (borderline) decreased to < 1% to 2%. On logistic regression, no variables were predictive of RAD at two years. Only AI-L at two years was predictive of RAD at five years (p < 0.001). If both hips were normal at two years' follow-up (n = 96), all remained normal at five years. In those with bilateral borderline hips at two years (n = 21), only two were borderline at five years, none were dysplastic. In those with either borderline-dysplastic or bilateral dysplasia at two years (n = 26), three (12%) were dysplastic at five years. Conclusion The majority of patients with RAD at two years post-brace treatment, spontaneously resolved by five years. Therefore, children with normal radiographs at two years post-brace treatment can be discharged. Targeted follow-up for those with abnormal AI-L at two years will identify the few who may benefit from surgical correction at five years' follow-up.
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Affiliation(s)
- Ayesha Saeed
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Catharine S Bradley
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Yashvi Verma
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Simon P Kelley
- Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
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Gahleitner M, Pisecky L, Gotterbarm T, Högler W, Luger M, Klotz MC. Long-term Results of Developmental Hip Dysplasia Under Therapy With Pavlik Harness. J Pediatr Orthop 2024; 44:135-140. [PMID: 38073187 DOI: 10.1097/bpo.0000000000002575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
INTRODUCTION The Pavlik harness is a commonly used treatment for developmental dysplasia of the hip (DDH) of types IIc or worse, based on the Graf classification. This study aimed to assess the long-term follow-up outcomes after treating DDH with the Pavlik harness. METHODS Between 1995 and 2006, ultrasound screening was conducted on 7372 newborns within the first days of life. Among them, 203 dysplastic hips in 152 patients, whose sonograms were Graf type IIc or worse, were treated with Pavlik harness. Treatment was discontinued if the measurement indicated Graf type Ia/b. More than 20 years later (mean: 20.46 y), patients were invited for clinical evaluation (Oxford Hips Score, Schulthess Hip Score, Harris Hip Score) and radiologic examination (center-edge angle according to Wiberg and the Severis classification, the rate of roofing of the femoral head via the Reimers migration percentage, and the Sharp angle). RESULTS Of the 152 patients, 60 (39.5%) participants with 80 (39.4%) affected hips (57.7% type IIc, 7.9% type D, and 15.6% type IIIa/b) were reexamined. The average follow-up duration was 20.5 years, with a maximum of 25.9 years. According to the Severin's classification, only 2 (3.77%) patients, each with one affected hip, showed slight residual dysplasia. The Reimer's migration percentage indicated an average of almost 90% canopy cover in the patient collective studied. No avascular necrosis was found, and the Sharp angle showed an average of almost 38 degrees. Only 4 participants with each one affected hip showed residual dysplasia according to the Sharp angle. The clinical results were quite satisfying, as none of the patients experienced hip pain that significantly limited their everyday activities or sports engagement, requiring medical attention before this study.Conclusions:Conservative therapy of DDH (Graf type IIc, D, III) with the Pavlik harness has demonstrated very good therapeutic success and a very low rate of residual dysplasia (2.81%). Both the radiologic and clinical outcomes were highly satisfactory. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | | | | | - Wolfgang Högler
- Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Kepler University Hospital GmbH, Linz, Austria
| | | | - Matthias C Klotz
- Department for Orthopaedics and Traumatology, Marienkrankenhaus Soest GmbH, Soest, Germany
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Aw AAL, Wong KPL, Lee NKL, Mahadev A. The utility of ultrasound and plain radiographs in the management of developmental dysplasia of the hip. J Pediatr Orthop B 2024; 33:9-15. [PMID: 36943691 DOI: 10.1097/bpb.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The purpose of this study is to assess the utility of follow-up radiological imaging in the management of developmental dysplasia of the hip (DDH) in patients successfully treated with the Pavlik harness. A retrospective review was conducted on all children under 6 months diagnosed with DDH at a tertiary pediatric hospital between January 2004 and December 2018. Inclusion criteria included successful Pavlik harness treatment following a standardized protocol with complete radiological documentation at 2 years of age. Ultrasonography was reviewed to measure the α and β angles and Graf classification. Anteroposterior pelvic radiographs were evaluated for the acetabular index and residual acetabular dysplasia. Seventy-eight hips from 57 infants were included in this study. The mean 6-month, 12-month and 2-year acetabular index of Graf I, IIa and IIc hips on ultrasound at 12 weeks were within the normal range according to age. There were no Graf IIb, IId, III and IV hips. All infants had normal radiographs at 2 years follow-up. The 6- and 12-month residual dysplasia rates in patients with DDH normalization at 12 weeks and 6 months range from 2.5 to 8.82%. Regardless of when the acetabular index normalized, all patients eventually had normal hip radiographs at 2 years of age. Following a standardized protocol, patients undergoing Pavlik harness treatment for DDH with Graf I and IIa hips at 12 weeks are likely to have normal plain radiographs at discharge. The incidence of residual dysplasia is very low and hence, radiographic surveillance is probably unnecessary until discharge at 2 years. Level II, retrospective study.
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Affiliation(s)
- Angeline Ai Ling Aw
- Faculty of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University
| | - Kenneth Pak Leung Wong
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Nicole Kim Luan Lee
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Arjandas Mahadev
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Li Y, Wang Z, Miao M, Xu Y, Shi J. Residual acetabular dysplasia after Pavlik harness treatment for Graf type II hips. J Child Orthop 2023; 17:306-314. [PMID: 37565002 PMCID: PMC10411375 DOI: 10.1177/18632521231182423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/29/2023] [Indexed: 08/12/2023] Open
Abstract
Purpose To evaluate the residual acetabular dysplasia in Graf type II hips after Pavlik harness treatment with a radiographic follow-up at 2 years of age. Methods We retrospectively reviewed the developmental dysplasia of the hip patients who were treated with the Pavlik harness between March 2018 and February 2022. Patients with Graf type II hip dysplasia who had at least one radiographic follow-up after 2 years of age were included. The following information, sex, laterality, affected side, age at harness initiation, treatment duration, α angle, and the morphology of bony roof, was collected and studied. We evaluated the radiographic acetabular index at the last follow-up and defined the value of greater than 2 standard deviations as residual acetabular dysplasia. Results A total of 33 patients (53 hips) met the criteria. The mean initial α angle was 53.4°; the mean age at Pavlik harness initiation was 10.9 weeks. The mean treatment duration was 10 weeks. The mean α angle at the last ultrasound follow-up was 64.9°. The mean age of the last radiographic follow-up was 2.6 years, and 26 hips had a residual acetabular dysplasia with acetabular indexes greater than 2 standard deviations above the mean. The morphology of the acetabular bony rim (odds ratio = 4.333, P = 0.029) and age of initial treatment <12 weeks (odds ratio = 7.113, P = 0.014) were seen as significant predictors for a higher acetabular index more than 2 years of age. Conclusions A notable incidence of residual acetabular dysplasia after Pavlik harness treatment in Graf type II hips, wherein the acetabular bony roof with a blunt rim at the end of treatment and initial age after 12 weeks were independent predictors associated with residual acetabular dysplasia. Levels of evidence Therapeutic studies, IV.
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Affiliation(s)
- Yuchan Li
- Department of Pediatric Orthopedics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhigang Wang
- Department of Pediatric Orthopedics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mingyuan Miao
- Department of Pediatric Orthopedics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yunlan Xu
- Department of Pediatric Orthopedics, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Shi
- Department of Radiology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Paranjape CS, Bomar JD, Upasani VV. Defining the Incidence of Residual Acetabular Dysplasia After Successful Reduction With a Harness. J Pediatr Orthop 2023; Publish Ahead of Print:01241398-990000000-00304. [PMID: 37311653 DOI: 10.1097/bpo.0000000000002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the rate of residual acetabular dysplasia (RAD), defined as an acetabular index (AI) of >90th percentile of age and sex-matched controls, in a cohort of infants successfully treated with the Pavlik harness (PH). METHODS We retrospectively studied typically developing infants at a single center, with at least 1 dislocated hip, that was successfully treated with a PH and had a minimum of 48 months follow-up. Hip dislocation was defined as <30% femoral head coverage at rest on pretreatment ultrasound or IHDI grade 3 or 4 on the pretreatment radiograph. RESULTS Forty-six dislocated hips (41 infants) were studied (4 males and 37 females). Brace treatment was initiated at an average age of 1.8 months (range: 2 d to 9.3 mo) and was maintained for an average of 10.2 months (range: 2.3 to 24.9 mo). All hips achieved IHDI grade 1 reduction. Five of 46 hips (11%) had an AI >90th percentile at the conclusion of bracing. Average follow-up was 6.5 years (range: 4.0 to 15.2 y). We found a 30% incidence of RAD (14/46 hips) on final follow-up radiographs. Of these hips, 13/14 (93%) had AI <90th percentile at the end of brace treatment. Comparing children with and without RAD, there were no differences in age at the initial visit or brace initiation, total follow-up, femoral head coverage at the initial visit, alpha angle at the initial visit, or total time in the brace (P > 0.09). CONCLUSION In a single-center cohort of infants with dislocated hips treated successfully with a PH, we observed a 30% incidence of RAD at a minimum 4.0-year follow-up. Normal acetabular morphology at the end of brace treatment did not result in normal acetabular morphology at the final follow-up in 13/41 hips (32%). We recommend that surgeons should pay close attention to the year-over-year change in both the AI and AI percentile. LEVEL OF EVIDENCE Level IV: case series.
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Affiliation(s)
- Chinmay S Paranjape
- Department of Orthopedics, Rady Children's Hospital, San Diego, San Diego, CA
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Residual dysplasia of the hip after successful ultrasound-monitored treatment: how does an infant's hip evolve? J Pediatr Orthop B 2022; 31:524-531. [PMID: 35502735 DOI: 10.1097/bpb.0000000000000984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite that normal values for the hip joint are reached at the end of ultrasound-monitored-treatment, the development of the acetabulum can be compromised during the growth phase. The acetabular index (AI) measured on a pelvic radiograph has been proven to be a reliable parameter. The aim of this study is to gain a better understanding of the dynamics of once-treated, residually dysplastic hips. This should be achieved by radiographically following these hips up to a milestone-examination at the end of preschool age. A total of 120 hips of consecutive 60 infants were included in this examination, each presenting with a residual developmental dysplasia of the hips (DDH) after successful ultrasound-monitored harness treatment. Radiographic follow-up was assessed retrospectively around 18 months, 3 years and 6 years of age, and the AI was measured. The age-dependent Tönnis classification was applied. The hips were assigned normal, mildly or severely dysplastic. Dependent t -test for paired samples indicated a highly significant improvement of the AI-values, including from the first to the second and from the second to the third follow-up. The percentage distribution into the Tönnis classification changed remarkably: in the first follow-up, 36 of the 120 hips were evaluated 'severely dysplastic', in the third follow-up only 1. On the other hand, three hips underwent acetabuloplasty. Even after normal values have been achieved at the end of ultrasound-monitored treatment, there remains a risk of residual dysplasia of the hips. Particularly, when the first radiographic examination shows nonphysiological findings, further close-meshed follow-up is recommended. Level of evidence: retrospective study of therapeutic outcome, consecutive patients, level II.
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Håberg Ø, Bremnes T, Foss OA, Angenete O, Lian ØB, Holen KJ. Children treated for developmental dysplasia of the hip at birth and with normal acetabular index at 1 year: How many had residual dysplasia at 5 years? J Child Orthop 2022; 16:183-190. [PMID: 35800653 PMCID: PMC9254022 DOI: 10.1177/18632521221106376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/28/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The purpose of the study was to assess the effect of further follow-up for children treated for developmental dysplasia of the hip, with normal clinical and radiological findings at 1-year time point. The effect was quantified by the number of hips with a pathologic deterioration up to 5 years. METHODS Among 47,289 children born in Sør-Trøndelag county in Norway between 2003 and 2015, 265 children had developmental dysplasia of the hip. Of these, 164 children (239 hips) treated for developmental dysplasia of the hip with normal clinical findings and normal acetabular index at the 1-year time point were included in the study. The number of hips with pathologic acetabular index at the 5-year time point were reported. The diagnostic uncertainty related to radiological measurements was quantified together with the effect of introducing a second radiographic measurement, the center edge angle. RESULTS A total of 239 treated hips were normal at the 1-year time point. At 5-year time point, 10 (4.2%) hips had a pathologic acetabular index measurement and none classified to have developmental dysplasia of the hip caused by measurement inaccuracy. Eight (3.3%) hips had pathologic center edge angle measurement. Four hips had both pathologic acetabular index and center edge angle measurements, with three later treated with surgery. The intra- and interobserver repeatability coefficients were within 3.1°-6.6°. CONCLUSION The repeatability coefficient of the acetabular index measurements was high and no hips could be classified to have developmental dysplasia of the hip at the 5-year time point when taking this repeatability into account. Hips classified as pathologic combining acetabular index and center edge angle measurements were likely to be treated with surgery for residual dysplasia. We recommend further follow-up for these children. LEVEL OF EVIDENCE level II.
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Affiliation(s)
- Øyvind Håberg
- Department of Orthopedic Surgery,
Kristiansund Hospital, Kristiansund, Norway,Institute of Neuromedicine and Movement
Science, Faculty of Medicine and Health Services, NTNU, Trondheim, Norway,Øyvind Håberg, Department of Orthopedic
Surgery, Kristiansund Hospital, Herman Døhlens vei 1, N-6508 Kristiansund,
Norway.
| | - Thomas Bremnes
- Department of Radiology and Nuclear
Medicine, St. Olav’s Hospital, Trondheim University Hospital, Trondheim,
Norway
| | - Olav A Foss
- Institute of Neuromedicine and Movement
Science, Faculty of Medicine and Health Services, NTNU, Trondheim, Norway,Department of Orthopedic Surgery,
Trondheim University Hospital, Trondheim, Norway
| | - Oskar Angenete
- Department of Radiology and Nuclear
Medicine, St. Olav’s Hospital, Trondheim University Hospital, Trondheim,
Norway,Institute of Circulation and Medical
Imaging, Faculty of Medicine and Health Services, NTNU, Trondheim, Norway
| | - Øystein B Lian
- Department of Orthopedic Surgery,
Kristiansund Hospital, Kristiansund, Norway,Institute of Neuromedicine and Movement
Science, Faculty of Medicine and Health Services, NTNU, Trondheim, Norway
| | - Ketil J Holen
- Institute of Neuromedicine and Movement
Science, Faculty of Medicine and Health Services, NTNU, Trondheim, Norway,Department of Orthopedic Surgery,
Trondheim University Hospital, Trondheim, Norway
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Maikku M, Ohtonen P, Valkama M, Leppilahti J. Treatment outcome of neonatal hip instability. Bone Joint J 2020; 102-B:1767-1773. [PMID: 33249896 DOI: 10.1302/0301-620x.102b12.bjj-2020-0266.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS We aimed to determine hip-related quality of life and clinical findings following treatment for neonatal hip instability (NHI) compared with age- and sex-matched controls. We hypothesized that NHI would predispose to hip discomfort in long-term follow-up. METHODS We invited those born between 1995 and 2001 who were treated for NHI at our hospital to participate in this population-based study. We included those that had Von Rosen-like splinting treatment started before one month of age. A total of 96 patients treated for NHI (75.6 %) were enrolled. A further 94 age- and sex-matched controls were also recruited. The Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire was completed separately for both hips, and a physical examination was performed. RESULTS The mean follow-up was 18.2 years (14.6 to 22.0). The HAGOS scores between groups were similar and met statistical and clinical significance only in the Symptoms subscale (mean difference 3.80, 95% confidence interval (CI) 0.31 to 7.29; p = 0.033). Those patients who had undergone treatment for NHI had a higher frequency of positive flexion-adduction-internal rotation test (odds ratio (OR) 2.6, 95% CI 1.2 to 5.6; p = 0.014), resisted straight leg rise test (OR 4.5, 95% CI 1.4 to 14.9; p = 0.014), and also experienced more pain in the groin during passive end range hip flexion (OR 2.5, 95% CI 1.2 to 5.3; p = 0.015) than controls. CONCLUSION NHI predisposes to hip discomfort in clinical tests, but no clinically relevant differences in experience of pain, physical function, and hip-related quality of life could be observed between the treated group and matched controls in 18 years of follow-up. Cite this article: Bone Joint J 2020;102-B(12):1767-1773.
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Affiliation(s)
- Mari Maikku
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland.,Medical Research Center, University of Oulu, Oulu, Finland
| | - Pasi Ohtonen
- Division of Operative Care, Research and Development, Oulu University Hospital, Oulu, Finland
| | - Marita Valkama
- Department of Pediatrics and Adolescence, Oulu University Hospital, Oulu, Finland.,PEDEGO Research Group, University of Oulu, Oulu, Finland
| | - Juhana Leppilahti
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland.,Medical Research Center, University of Oulu, Oulu, Finland
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Shin CH, Yang E, Lim C, Yoo WJ, Choi IH, Cho TJ. Which Acetabular Landmarks are the Most Useful for Measuring the Acetabular Index and Center-edge Angle in Developmental Dysplasia of the Hip? A Comparison of Two Methods. Clin Orthop Relat Res 2020; 478:2120-2131. [PMID: 32379138 PMCID: PMC7431232 DOI: 10.1097/corr.0000000000001289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 04/14/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The acetabular index and center-edge angle are widely used radiographic parameters. However, the exact landmarks for measuring these parameters are not clearly defined. Although their measurement is straightforward when the lateral osseous margin of the acetabular roof coincides with the lateral end of the acetabular sourcil, where these two landmarks disagree, recommendations have differed about which landmark should be used. Using a radiographic parameter with high reliability for predicting residual hip dysplasia helps avoid unnecessary treatment. QUESTIONS/PURPOSES We aimed to (1) compare two landmarks (the lateral osseous margin of the acetabular roof and the lateral end of the acetabular sourcil) for measuring the acetabular index and center-edge angle with respect to intraobserver and interobserver reliability and the predictability of residual hip dysplasia in patients with developmental dysplasia of the hip (DDH) and (2) evaluate longitudinal change in the acetabular edge's shape after closed reduction with the patient under general anesthesia. METHODS Between February 1985 and July 2006, we performed closed reduction with the patient under general anesthesia as well as cast immobilization in 116 patients with DDH. To be included in this study, a patient had to have dislocated-type DDH. We excluded patients with a hip dislocation associated with neuromuscular disease, arthrogryposis, or congenital anomalies of other organs or systems (n = 9); hips that underwent osteotomy within 1 year since closed reduction (n = 8); hips that underwent open reduction because of re-dislocation after closed reduction (n = 4); and hips with Type III or IV osteonecrosis according to Bucholz-Ogden's classification (n = 4). Ninety-one patients were eligible. We excluded 19% (17 of 91) of the patients, who were lost to follow-up before they were 8 years old, leaving 81% (74 of 91 patients) with full preoperative and most-recent data. Ninety-seven percent (72 patients) were girls and 3% (two patients) were boys. The mean ± standard deviation age was 14.0 months ± 6.4 months (range 3-40 months) at the time of closed reduction and 12.1 years ± 2.3 years (range 8.0-16.0 years) at the time of the latest follow-up examination, the duration of which averaged 11 years ± 2.2 years (range 6.5-15.4 years). To investigate whether longitudinal change in the acetabular edge's shape differed among hips with DDH, contralateral hips, and control hips, we identified control participants after searching our hospital's database for patients with a diagnosis of congenital idiopathic hemihypertrophy from October 2000 to November 2006 who had AP hip radiographs taken at 3 years old and then at older than 8 years. From 29 patients who met these criteria, we randomly excluded two male patients to match for sex because girls were predominant in the DDH group. We excluded another female patient from the control group because of a hip radiograph that revealed unacceptable rotation. Eventually, 26 patients were assigned to the control group. Control patients consisted of 24 girls (92%) and two boys (8%). The demographic characteristics of control patients was not different from those of 67 patients with unilateral DDH, except for laterality (left-side involvement: 64% [43 of 67] in the DDH group versus 38% [10 of 26] in the control group; odds ratio 1.7 [95% confidence interval, 1.0-2.8]; p = 0.035). The acetabular index and center-edge angle at 3 years old were measured using the lateral osseous margin of the acetabular roof (AIB and CEAB) and the lateral end of the acetabular sourcil (AIS and CEAS). The treatment outcome was classified as satisfactory (Severin Grade I or II) or unsatisfactory (Grade III or IV). The intraclass correlation coefficient (ICC) was used to compare the intraobserver and interobserver reliability of each method. We compared the predictability of residual hip dysplasia of each method at 3 years old as a proxy using the area under the receiver operating characteristic (AUC) curve. To evaluate longitudinal change in the acetabular edge's shape, we compared the proportion of hips showing coincidence of the two landmarks between 3 years old and the latest follow-up examination. To investigate whether the longitudinal change in the acetabular edge's shape differs among hips with DDH, contralateral hips, and control hips, we compared the proportion of coincidence among the three groups at both timepoints. RESULTS Intraobserver and interobserver reliabilities were higher for the CEAB (ICC 0.96; 95% CI, 0.94-0.98 and ICC 0.88; 95% CI, 0.81-0.92, respectively) than for the CEAS (ICC 0.81; 95% CI, 0.70-0.88 and ICC 0.69; 95% CI, 0.55-0.79, respectively). The AIB (AUC 0.88; 95% CI, 0.80-0.96) and CEAB (AUC 0.841; 95% CI, 0.748-0.933) predicted residual hip dysplasia better than the AIS (AUC 0.776; 95% CI, 0.67-0.88) and CEAS (AUC 0.72; 95% CI, 0.59-0.84) (p = 0.03 and p = 0.01, respectively). The proportion of hips showing coincidence of the two landmarks increased from 3 years old to the latest follow-up examination in hips with DDH (37% [25 of 67] to 81% [54 of 67]; OR = 8.8 [95% CI, 3.1-33.9]; p < 0.001), contralateral hips (42% [28 of 67] to 85% [57 of 67]; OR = 16.5 [95% CI, 4.2-141.9]; p < 0.001), and control hips (38% [10 of 26] to 88% [23 of 26]; OR = 14 [95% CI, 2.1-592.0]; p = 0.001). The proportion of coincidence in hips with DDH was not different from that in the contralateral hips and control hips at both timepoints. CONCLUSIONS Measuring the acetabular index and center-edge angle at 3 years old using the lateral osseous margin of the acetabular roof has higher reliability for predicting residual hip dysplasia than that using the lateral end of the acetabular sourcil in patients with DDH treated with closed reduction. Measuring the acetabular index and center-edge angle at an early age using the lateral end of the sourcil may lead to overdiagnosis of residual hip dysplasia and unnecessary treatment. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Chang Ho Shin
- C. H. Shin, E. Yang, C. Lim, W. J. Yoo, I. H. Choi, T-J. Cho, Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Eunkyu Yang
- C. H. Shin, E. Yang, C. Lim, W. J. Yoo, I. H. Choi, T-J. Cho, Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Chaemoon Lim
- C. H. Shin, E. Yang, C. Lim, W. J. Yoo, I. H. Choi, T-J. Cho, Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Won Joon Yoo
- C. H. Shin, E. Yang, C. Lim, W. J. Yoo, I. H. Choi, T-J. Cho, Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - In Ho Choi
- C. H. Shin, E. Yang, C. Lim, W. J. Yoo, I. H. Choi, T-J. Cho, Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Tae-Joon Cho
- C. H. Shin, E. Yang, C. Lim, W. J. Yoo, I. H. Choi, T-J. Cho, Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, Republic of Korea
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11
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Hines AC, Neal DC, Beckwith T, Jo C, Kim HKW. A Comparison of Pavlik Harness Treatment Regimens for Dislocated But Reducible (Ortolani+) Hips in Infantile Developmental Dysplasia of the Hip. J Pediatr Orthop 2020; 39:505-509. [PMID: 31599859 DOI: 10.1097/bpo.0000000000001052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Variation exists in the Pavlik harness (PH) treatment regimen for infantile developmental dysplasia of the hip (DDH). The purpose of this study was to determine if the daily PH wear duration (23 vs. 24 h) and frequency of follow-up visits affect the clinical and radiographic outcomes of infants with dislocated but reducible (Ortolani+) hips. METHODS This study reviewed prospectively enrolled patients with DDH in a single center who presented at age <6 months with Ortolani+ hips and were treated with PH. Recommended daily PH wear duration (23 vs. 24 h) and the frequency of clinic visits in first 4 weeks after the initiation of PH treatment were analyzed. The clinical success (stable hip that did not require closed or open reduction or the use of an abduction orthosis) and radiographic success based on the acetabular index at 2-year follow-up were compared between different PH regimen groups. RESULTS Sixty-two patients (74 hips, 53 females) with Ortolani+ hips had a mean age of presentation of 23±28 days (range, 4 to 128 d) and mean follow-up of 33.2±18.4 months (range, 8 to 85 mo). Overall clinical success rate of PH for Ortolani+ hips was 93% (69/74 hips) and radiographic success rate at 2 years was 84% (48/57 hips). There was no difference in clinical or radiographic success rate between the 23- and 24-hour wear groups (P>0.99, 0.73) or between hips assessed almost weekly compared with once or twice during the first 4 weeks of PH treatment (P>0.99 for both). CONCLUSIONS The 23- versus 24-hour PH regimen and frequency of clinic visits in the first 4 weeks of PH treatment did not affect the clinical or radiographic success rate of Ortolani+ hips in infantile DDH. A strict weekly clinic visit and 24-hour PH regimen may not be necessary to obtain stable reduced hips in infants presenting <6 months of age with Ortolani+ hips. LEVEL OF EVIDENCE Level III-therapeutic.
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Affiliation(s)
- Adam C Hines
- Center for Excellence in Hip Disorders, Texas Scottish Rite Hospital for Children
- Tripler Army Medical Center Orthopedic Surgery Service, Honolulu, HI
| | - David C Neal
- Center for Excellence in Hip Disorders, Texas Scottish Rite Hospital for Children
- Department of Orthopaedic Surgery, John Peter Smith Hospital, Fort Worth, TX
| | - Terri Beckwith
- Center for Excellence in Hip Disorders, Texas Scottish Rite Hospital for Children
| | - ChanHee Jo
- Center for Excellence in Hip Disorders, Texas Scottish Rite Hospital for Children
| | - Harry K W Kim
- Center for Excellence in Hip Disorders, Texas Scottish Rite Hospital for Children
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas
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12
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MRI reveals unrecognized treatment failures after application of Fettweis plaster in children with unstable hip joints. J Pediatr Orthop B 2019; 28:430-435. [PMID: 30807512 DOI: 10.1097/bpb.0000000000000604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
We evaluated the success of treatment of unstable hip joints with the Fettweis plaster followed by MRI to detect potential treatment failures. A total of 132 ultrasound-detected unstable hips of type D, III, or IV according to Graf were treated with closed reduction and Fettweis plaster, followed by MRI. We examined 19 type D, 55 type III, and 58 type IV. Mean age at diagnosis was 84.5 days (SD: ± 55.4). Treatment period was 63.2 days (SD: ± 22.2). In 13 cases, the MRI showed a poor reduction. After repetition of this treatment, all 13 showed a concentric reduction. The use of MRI detects 9.8% of treatment failures. We recommend an MRI examination after each closed reduction to ensure the success of the therapy.
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13
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Yang S, Zusman N, Lieberman E, Goldstein RY. Developmental Dysplasia of the Hip. Pediatrics 2019; 143:peds.2018-1147. [PMID: 30587534 DOI: 10.1542/peds.2018-1147] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Scott Yang
- Department of Orthopedics and Rehabilitation, Doernbecher Children's Hospital and Oregon Health and Science University, Portland, Oregon; and
| | - Natalie Zusman
- Department of Orthopedics and Rehabilitation, Doernbecher Children's Hospital and Oregon Health and Science University, Portland, Oregon; and
| | - Elizabeth Lieberman
- Department of Orthopedics and Rehabilitation, Doernbecher Children's Hospital and Oregon Health and Science University, Portland, Oregon; and
| | - Rachel Y Goldstein
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
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14
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Shaw KA, Moreland CM, Olszewski D, Schrader T. Late acetabular dysplasia after successful treatment for developmental dysplasia of the hip using the Pavlik method: A systematic literature review. J Orthop 2018; 16:5-10. [PMID: 30765927 DOI: 10.1016/j.jor.2018.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/10/2018] [Indexed: 12/22/2022] Open
Abstract
The Pavlik method is the most common method used for treatment of developmental dysplasia of the hip (DDH). Late acetabular dysplasia despite successful treatment, however, has had varied reporting. A systematic review was performed, investigating the long-term outcomes of DDH treated with the Pavlik method. Seventeen studies met inclusionary criteria, including 6029 hips treated with an average of 5.29 years follow-up. Radiographic evidence of late dysplasia was present in 280 hips, with 109 hips requiring additional surgery. A specified treatment algorithm had significantly decreased rates of radiographic dysplasia (3.8% vs 17.6%, p = 0.004). Level of evidence IV.
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Affiliation(s)
- K Aaron Shaw
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Colleen M Moreland
- Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Dana Olszewski
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Scottish Rite Campus, Atlanta, GA, USA
| | - Tim Schrader
- Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Scottish Rite Campus, Atlanta, GA, USA
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15
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Kubo H, Pilge H, Holthoff JP, Hufeland M, Westhoff B, Krauspe R. Poorer radiological outcome after delayed diagnosis and treatment in human position in Fettweis plaster cast in 93 unstable hip joints type D, III and IV according to Graf. J Child Orthop 2018; 12:590-598. [PMID: 30607206 PMCID: PMC6293336 DOI: 10.1302/1863-2548.12.180132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE In this study the course of unstable hips after successful treatment with Fettweis plaster of Paris (POP) is examined. Special focus will be given to age at beginning of treatment and initial hip type. METHODS The development of 93 unstable hips treated between November 2001 and April 2015 was examined. Inclusion criteria were: 1) unstable hips with successful treatment with Fettweis POP; 2) presence of two pelvic radiographs (12 to 24 months and 24 to 48 months). We analyzed: 1) the initial ultrasound hip type according to Graf; 2) the average age at first and second radiograph; 3) the Tönnis classification: normal findings (< 1 SD), slightly (1 SD to 2 SD) and severely dysplastic hips (> 2 SD). RESULTS In all, there were 14 hips type D, 41 hips type III and 38 hips type IV. Mean age of the first radiograph was 13.9 months and of the second 28.5 months. The first radiograph showed: (< 1 SD): 36, (1 SD to 2 SD): 34, (> 2 SD): 23 hips, the second radiograph: (< 1 SD): 33, (1 SD to 2 SD): 19, (> 2 SD): 30 hips. With subdivision at the start of treatment at age eight or fewer weeks 2/16 hips (12.5%) and with initiation of the treatment more than eight weeks 22/77 (26.0%) deteriorated. During the course between first and second radiograph a total of 35.7% of initial hip type D, 19.5% of type III and 23.7% of type IV deteriorated. CONCLUSION Radiograph controls after treatment with Fettweis POP show poorer outcome after delaying the start of treatment more than 8 weeks. These findings were independent of the initial ultrasound hip type. Regular radiograph controls of all hip types treated for unstable hips are justified to detect residual dysplasia. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- H. Kubo
- University of Düsseldorf, Medical Faculty, Department of Orthopaedics, Moorenstr. 5, D-40225 Düsseldorf, Germany,Correspondence should be sent to H. Kubo, University of Düsseldorf, Medical Faculty, Department of Orthopaedics, Moorenstr. 5, D-40225 Düsseldorf, Germany. E-mail:
| | - H. Pilge
- University of Düsseldorf, Medical Faculty, Department of Orthopaedics, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - J.-P. Holthoff
- University of Düsseldorf, Medical Faculty, Department of Orthopaedics, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - M. Hufeland
- University of Düsseldorf, Medical Faculty, Department of Orthopaedics, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - B. Westhoff
- University of Düsseldorf, Medical Faculty, Department of Orthopaedics, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - R. Krauspe
- University of Düsseldorf, Medical Faculty, Department of Orthopaedics, Moorenstr. 5, D-40225 Düsseldorf, Germany
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16
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Development of unstable hips after treatment with the Tübingen splint: mid-term follow-up of 83 hip joints. Arch Orthop Trauma Surg 2018; 138:629-634. [PMID: 29350271 DOI: 10.1007/s00402-018-2882-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Early diagnosis and treatment of hip dysplasia are widely accepted as major factors for beneficial outcome. However, modalities for reduction and retention as well as for imaging are currently under clinical investigation. Local and general risk factors, e.g., breech presentation and the family's desire to avoid in-hospital treatment are major concerns in the decision-making process and consultation. For treatment of unstable hips in newborns the treatment with the Tübingen splint has proven good results in recent studies. However, mid- and long-term outcome studies are missing. We report on clinical results and X-ray parameter of initially unstable hips after treatment with the Tübingen splint at two time points: 12-24 and 24-48 months of age. MATERIALS AND METHODS Included were newborns with 83 unstable hips (type D, III, IV according to Graf) which were successfully treated with the Tübingen splint-used as reduction splint 24 h per day/7 days per week-until type I hips were documented by ultrasound examination. Measurments are based on routine pelvic X-ray control at the age of 12-24 and 24-48 months. The acetabular angle was determined and according to the Tönnis-Classification evaluated into: normal findings (< 1 s), slightly dysplastic findings (1-2 s) and severely dysplastic findings (> 2 s). Children with secondary hip dysplasia were not included in this series. RESULTS In 2nd year of life, 45 hips (54.2%; initial hip type D: 47.4%, III: 63.2%, IV: 42.9%) of the formerly unstable hips show normal X-ray findings. Although final ultrasound showed normal findings, at this time point 28 hips (33.7%; initial hip type D: 34.2%, III: 31.6%, IV: 42.9%) were slightly dysplastic and 10 (12.0%%; initial hip type D: 18.4%, III: 5.3%, IV: 14.3%) still severely dysplastic. At the age of 24-48 months, the percentage of radiologic normal hips had increased to 61 hips (73.5%; initial hip type D: 68.4%, III: 81.6%, IV: 57.1%), the number of slightly (19 hips) and severely dysplastic (3 hips) hips had decreased 22.9% (initial hip type D: 28.9%, III: 15.8%, IV: 28.6%) respectively 3.6% (initial hip type D: 2.6%, III: 2.6%, IV: 14.3%). At this time no operative intervention was neccessary. CONCLUSIONS Our mid-term data show on the one hand a good development of unstable hips after successful treatment with the Tübingen splint. On the other hand despite successful therapy and normal ultrasound findings at the end of treatment further imaging by X-ray are mandatory to close follow-up and to detect those which might need surgical correction of residual dysplasia.
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17
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Swarup I, Penny CL, Dodwell ER. Developmental dysplasia of the hip: an update on diagnosis and management from birth to 6 months. Curr Opin Pediatr 2018; 30:84-92. [PMID: 29194074 DOI: 10.1097/mop.0000000000000574] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Our understanding of the epidemiology, diagnosis, and management of developmental dysplasia of the hip (DDH) is evolving. This review focuses on the most up-to-date literature on DDH in patients from birth to six months of age. RECENT FINDINGS Well known risk factors for DDH include family history, female sex, and breech positioning. Recent evidence suggests higher birth weight is a risk, whereas prematurity may be protective. Screening includes physical examination of all infant hips and imaging when abnormal findings or risk factors are present. Treatment in the first six months consists of a harness, with 70-95% success. Failure risk factors include femoral nerve palsy, static bracing, irreducible hips, initiation after seven weeks of age, right hip dislocation, Graf-IV hips, and male sex. Rigid bracing may be trialed if reduction with a harness fails and closed reduction is indicated after failed bracing. If the hip is still irreducible, nonconcentric, or unstable, open reduction may be required following closed reduction. Evidence does not support delaying hip reduction until the ossific nucleus is present. SUMMARY DDH affects 1-7% of infants. All infants should be examined and selective screening with imaging should be performed for abnormal physical exams or risk factors. Early treatment is associated with optimal outcomes.
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Affiliation(s)
- Ishaan Swarup
- Hospital for Special Surgery, New York, New York, USA
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