Management of Irreducible Hip Dislocations in Infants With Developmental Dysplasia of the Hip Diagnosed Below 6 Months of Age

Failure of Pavlik Harness Treatment in Infants Under 6 Months Old with Dislocated Hips: Short- and Intermediate-Term Results of Subsequent Treatment Modalities

Objective

This study aimed to determine the short- and medium-term outcomes of hip dislocation in infants who failed Pavlik harness therapy and were subsequently treated with brace, closed reduction (CR) or open reduction (OR) before 6 months of age.

Methods

Fifty infants (66 hip dislocations) who failed Pavlik harness therapy between 2000 and 2018 and were treated with a rigid abduction brace or undergoing a CR or OR/cast were evaluated. All demographic data obtained from the medical system, developments and complications during the follow-up and treatment process were recorded and evaluated.

Results

Fifty infants (66 hips) with dislocated hips failed Pavlik harness therapy. Of these, 9 infants (12 hips) underwent rigid abduction splint therapy: 9 hips were successful, 2 hips had CR and 1 had OR. Thirty-eight infants (51 hips) had index CR, of which 3 (3 hips) failed and had OR. Radiographs of 49 hips (44 patients) were normal at the final evaluation. Pavlik harness therapy starting after 3 weeks (P = 0.028) and unilateral dislocations (P = 0.028) increased the risk of needing operating room. There was an association between OR and avascular necrosis (P = 0.025), but not between OR and other complications-dysplasia and re-dislocation/subluxation (P = 0.257 and P = 0.508, respectively).

Conclusion

Closed treatment of hip dislocation is possible in most babies who fail Pavlik treatment. Babies who are started on Pavlik therapy after 3 weeks of age may be at increased risk of needing an operating room.

Level of Evidence

IV.

Refining Risk Factors for Developmental Dysplasia of the Hip in Neonates: A Cross-Sectional Study in a Tertiary Referral Center

Background

Developmental dysplasia of the hip (DDH) is used to describe a spectrum of structural abnormalities that involve the growing hip. Early diagnosis and treatment are critical to providing the best possible functional outcome. This study aimed to evaluate the prevalence of DDH in neonates with and without risk factors and determine the role of ultrasound screening on the initial diagnosis.

Methods

This prospective cross-sectional study was conducted on 399 infants at the Pediatric Treatment Center, Tehran University of Medical Sciences, between December 2015 and June 2016. Infants with suspected DDH who underwent hip ultrasonography were included, and the presence or absence of each risk factor was documented according to the checklist. The ultrasound findings were also registered in the checklists. The odds ratio (OR) of each risk factor for DDH was calculated. The collected data were analyzed by SPSS software version 18 at a 0.05 significance level.

Results

In 16 months of study, 174 (43.6%) male and 225 (56.4%) female infants under the age of 18 months were studied. Risk factors were detected in the medical history of 329 infants. Out of them, 230(57.6%) were firstborn children, 7 (1.75%) had a positive family history of DDH, and 26 (6.5%) had limb anomalies. There was also a history of breech presentation in 16 (4.01%) and a history of oligohydramnios in 21 (5.1%) of infants. The prevalence of DDH was 25.8% in infants with risk factors and 2.8% in those without risk factors. (OR = 11.84, P < 0.05).

Conclusion

In this study, the frequency of DDH was significantly higher in infants with risk factors. The female gender and limb anomalies were stronger risk factors for DDH. Overall, ultrasound showed great potential for DDH screening.

Risk factors of developmental dysplasia of the hip in infants: A meta-analysis based on cohort studies

INTRODUCTION

Developmental dysplasia of the hip (DDH) is a prevalent condition in children. Currently, the exact etiology of DDH remains uncertain. The objective of this study was to conduct a meta-analysis to investigate the risk factors associated with DDH in infants. The findings would provide a theoretical foundation for targeted early screening and diagnosis.

HYPOTHESIS

Several indicators, such as gender, intrauterine position, family history of DDH, gestational age, delivery mode, amniotic fluid levels, swaddling, parity, fetus number, combined musculoskeletal deformities, birth weight, and physical examination results, may serve as risk factors for DDH.

MATERIALS AND METHODS

Cohort studies investigating the risk factors of DDH in infants through logistic regression analysis were searched in the Wanfang, VIP citation, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc, Excerpta Medica Database (Embase), PubMed, and Cochrane Library databases up to May 2023. After extracting the data from eligible literature and assessing them using the Newcastle-Ottawa Scale (NOS), articles were selected based on pre-established inclusion and exclusion criteria.

RESULTS

A total of eleven literature reports covering 979,757 infants were included in this meta-analysis. The publication bias did not significantly influence the results. The incidence rate of DDH was 47.99‰ among infants with risk factors compared to 3.21‰ in the general population. Risk factors for DDH included being female (OR=6.97, 95% CI: 5.18-9.39, p<0.001), breech delivery (OR=4.14, 95% CI: 3.09-5.54, p<0.001), positive family history (OR=4.07, 95% CI: 2.20-7.52, p<0.001), cesarean section (OR=1.11, 95% CI: 1.01-1.21, p=0.032), oligohydramnios (OR=3.93, 95% CI: 1.29-12.01, p=0.016), swaddling (OR=6.74, 95% CI: 1.25-36.31, p=0.026), firstborn status (OR=1.84, 95% CI: 1.49-2.53, p<0.001), combined musculoskeletal malformations (OR=2.27, 95% CI: 1.58-3.27, p<0.001), and physical signs of DDH (OR=8.71, 95% CI: 2.44-31.07, p=0.001). Premature delivery (OR=0.91, 95% CI: 0.88-0.95, p<0.001) was a protective factor for DDH. The relationship between multiple pregnancies (OR=0.58, 95% CI: 0.33-1.02, p=0.060) and low birth weight (OR=0.62, 95% CI: 0.14-2.76, p=0.529) in relation to DDH remained uncertain.

DISCUSSION

This meta-analysis shows that female, breech delivery, positive family history, cesarean section, firstborn status, oligohydramnios, swaddling and combined musculoskeletal malformations are associated with DDH. Premature delivery appeared to be a protective factor against DDH. Nevertheless, the other factors need more research to reach more conclusive results.

LEVEL OF EVIDENCE

III; meta-analysis.

Comparison of outcomes of different Graf grades of developmental dysplasia of the hip in infants treated with Tubingen splint versus Pavlik harness - A systematic review

This systematic review was designed to compare the outcomes of the two braces against each other classified by the Graf method. The databases sources included PubMed, Embase, and Google Scholar. The keywords included "DDH Tubingen versus Pavlik" and Tubingen and Pavlik separately. Included papers provided specific data regarding success and failure rate, avascular necrosis (AVN), duration, and age of intervention. The excluded studies discussed surgeries, diagnosis and mechanism, and ones that weren't in English. Total of 20 papers were included, resulting in 1243 Tubingen and 420 Pavlik samples. It was seen that the Tubingen splint had a statistically significant greater success rate and lower failure rate for Graf 2, D, and 3 hips, while both braces were not very successful for Graf 4 at success rates less than 60 %. Tubingen also had a lower incidence of AVN. Both braces shared similar ages of intervention, duration, and time per day. Both braces are very comparable to each other, each having better success rates for lower Graf grades, which points to the importance of bracing earlier to improve the success rates. The Tubingen splint had a higher success rate, lower failure rate, and lower AVN rate compared to the Pavlik harness. This points to the Tubingen splint potentially being the preferred option for bracing in infants.

Femoral and obturator neuropathies

The femoral and obturator nerves both arise from the L2, L3, and L4 spinal nerve roots and descend into the pelvis before emerging in the lower limbs. The femoral nerve's primary function is knee extension and hip flexion, along with some sensory innervation to the leg. The obturator nerve's primary function is thigh adduction and sensory innervation to a small area of the medial thigh. Each may be injured by a variety of potential causes, many of them iatrogenic. Here, we review the anatomy of the femoral and obturator nerves and the clinical features and potential etiologies of femoral and obturator neuropathies. Their necessary investigations, including electrodiagnostic studies and imaging, their prognosis, and potential treatments, are discussed in this chapter.

Changes of Age-related Auricular Cartilage Plasticity and Biomechanical Property in a Rabbit Model

OBJECTIVES

Ear molding is an emerging technique that can correct auricular deformities. Treatment initiation time is the most important prognostic determinant of ear molding. Here, we aimed to examine why auricular cartilage plasticity appeared to diminish with age. Thus, we characterized age-related changes in the biomechanical, biochemical, and morphological properties of auricular cartilage.

METHODS

New Zealand rabbits were used as the experimental animal. We examined immature [postnatal 0 day (P0), 5 days (P5), 15 days (P15)], young [2 months (2M)], and mature [6 months (6M)] rabbits. Rabbits' ears were splinted and folded using adhesive fixation strips. Folding duration ranged from 1 day to 5 days to 10 days. Photographs were taken to calculate the retained fold angle. Cartilage morphology and extracellular matrix (ECM) content were examined histologically (using hematoxylin-eosin, Safranin O, elastic Van Gieson, and Masson's trichrome). Water content, DNA content, and cell density were also analyzed. Biomechanical properties were measured using a Nano indenter.

RESULTS

Immature ears had smaller angles after strip removal, and the angled deformation lasted a longer time. Cartilage matrix compositions, including glycosaminoglycan (GAG), elastin fiber, and collagen, increased over development. The water content, DNA content, and cell density decreased with age. Young's modulus was significantly higher in mature cartilage.

CONCLUSIONS

Here, we successfully established an animal model of ear molding and demonstrated that immature cartilage was associated with better plasticity. We also found that the cartilage's biomechanical property increased with the accumulation of ECM. The biomechanical change could underlie age-related shape plasticity.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:88-94, 2023.

Residual Hip Dysplasia in Children With Unilateral Hip Dislocation-Does Side Matter?

BACKGROUND

Developmental dysplasia of the hip (DDH) is the most common musculoskeletal abnormality in infants and young children. Despite the fact that the left hip is most frequently affected, literature and clinical experience suggest a poorer outcome for right-sided hip dislocation in DDH. On the basis of this hypothesis, we studied the outcomes (residual dysplasia, number of surgeries, and complication rate) of right-sided unilateral hip dislocation in comparison with left-sided unilateral hip dislocation in DDH up to 8 years follow-up.

METHODS

We identified all patients with unilateral hip dislocation at Erasmus MC Sophia Children's Hospital from 2002 to 2012, diagnosed with DDH before the age of 1 year and with a minimum follow-up of 8 years. The primary outcome was residual dysplasia (based on an acetabular index (AI) >18 degrees and center-edge angle of Wiberg (CEA) <15 degrees) at the age of 8 years. Secondary outcome measures were residual dysplasia at the ages of 1, 2, and 5 years, successful surgical reduction rates, additional surgery, and complication rates.

RESULTS

Out of a consecutive series of 555 patients, 298 could be included (17 males; median age at diagnosis 4.0 [IQR 3.0 to 5.5] months): 107 patients (35.9%) had right-sided unilateral hip dislocation. There was no significant difference in residual dysplasia between the unilateral left-sided and unilateral right-sided hip dislocation groups, respectively, at 1-year follow-up (34.0% vs. 24.2%, P =0.107), 2-year follow-up (74.1% vs. 70.1%, P =0.565), 5-year follow-up (74.1% vs. 66.2%, P =0.261), and 8-year follow-up (65.3% vs. 53.8%, P =0.199). There was no significant difference in surgical interventions between the left-sided and right-sided hip dislocation groups, respectively: additional surgical reduction (14.7% vs. 15.0%, P =0.945) and additional surgery for residual dysplasia (8.9% vs. 10.3%, P =0.695). There was no significant difference in complication rate between the unilateral left-sided and unilateral right-sided hip dislocation groups, respectively: avascular necrosis (19.4% vs. 15.9%, P =0.454) and redislocation (11.5% vs. 9.3%, P =0.561).

CONCLUSIONS

The results of our study suggest that in patients with DDH, unilateral right-sided hip dislocation does not have poorer outcomes compared with unilateral left-sided hip dislocation during an 8-year follow-up.

LEVEL OF EVIDENCE

Level III - retrospective follow-up study.

Radiological predictors associated with success of treatment for developmental dysplasia of hip using the Pavlik harness: A retrospective study

BACKGROUND

While various predictors of treatment outcome of Pavlik harness have been reported, appropriate indications for treatment and relationships between patient characteristics and outcome are unclear. The present study aimed to identify radiological predictors for successful Pavlik harness treatment of DDH at the initiation of treatment and investigate the progression of radiological characteristics after successful treatment.

METHODS

One-hundred-forty-two of 527 infants who visited our hospital for secondary screening of DDH were treated with the Pavlik harness. One-hundred-eight hips of 108 infants experienced successful treatment and could be followed up until 3 years of age (group S); treatment was unsuccessful within the first 2 weeks for 22 hips of 21 infants (group F). We investigated the Graf classification and radiological parameters.

RESULTS

We observed the ipsilateral-side measurements of distance A and B as defined by Yamamuro and Chene's method to be significantly smaller and greater, respectively, in group F compared with those of group S. Group F tended to exhibit the smaller distance A and larger distance B compared to the group S among the same Graf type. The cut-off values for successful treatment at were >7.4 mm at initiation of treatment for distance A and <11.2 mm for distance B. The acetabular index (AI) of the ipsilateral side at the initiation of treatment was significantly correlated with that at 1 and 3 years of age. Patients with an AI of >32° at the initiation of harness treatment were more likely to exhibit hip dysplasia at 3 years of age.

CONCLUSIONS

Radiographic parameters prior to the Pavlik harness could be predictors of treatment failure and DDH in the future. This study showed that AI at the initiation of treatment is associated with residual acetabular dysplasia, suggesting that radiographic assessment may be useful even considering the risks associated with radiation exposure.

A Survey of Parents' and Carers' Perceptions of Parenting a Child With Developmental Dysplasia of the Hip

PURPOSE

To explore parents' and carers' perceptions of parenting a child with developmental dysplasia of the hip (DDH).

METHODS

A retrospective analysis of a questionnaire of parents and carers of children with hip dysplasia. Data analysis was guided by qualitative content analysis.

RESULTS

There were 753 responses describing a range of parenting experiences. Three themes emerged: arduous parenting , detailed the parenting challenges, both practical and emotional posed by the management of DDH; insufficient understanding , described the social disconnection experienced by the respondents due to a lack of empathy from others; inconsistent guidance , encompassed respondents' reliance on health professionals for information and support, yet frustration at variability in the management of DDH.

CONCLUSIONS

Overall, having to care for a child with DDH has a negative effect on the practice of parenting. Health professionals can support parenting and provide consistent education to assist parents' understanding of the complex nature of DDH management. What this study adds to the evidence: Despite a good prognosis, the diagnosis of hip dysplasia has a negative effect on of parenting. Parents and carers of children with hip dysplasia rely on the support of health professionals but find the associated loss of parenting autonomy distressing.

Can Medialization of Acetabular Rim Be a Prognostic Factor in Treatment of Developmental Dysplasia of Hip?

OBJECTIVES

To investigate if acetabular rim medialization (ARM) can be used as a new parameter in determining the treatment choice and duration in Graf type III and IV hips.

METHODS

Among the 12,300 infants who underwent hip ultrasound (US) according to Graf's method between 2015 and 2019, 26 infants (9 had bilateral pathology hence 35 hips) with type III and IV hips, whose follow-up data could be obtained were included in the study. Age of the infants at the initial diagnosis, ARM measurement, the duration of harness treatment, and the treatment results were noted. To determine the extent of ARM, distance between a line that is drawn tangential to the iliac wing and acetabular rim was measured.

RESULTS

In cases with poor prognosis, ARM measurement was 6 to 8.5 mm on the right hip and 4 to 9 mm on the left hip. Bilaterality or unilaterality, left or right pathology, and gender did not have a significant effect on the prognosis (P >.05). Age at the initial diagnosis and ARM had significant effects on treatment success (P = .04, P = .00, respectively). In predicting the prognosis, ARM was found to be more successful than age (AUC = 0.95 versus AUC = 0.68). When these two variables were evaluated together, the success in predicting the prognosis significantly increased (AUC = 0.98).

CONCLUSIONS

ARM measurement may have an important role in determining the treatment method and duration in Graf type III and IV hips. It can be used as a prognostic factor alone or in combination with treatment initiation time. When the two factors are combined, prognostic value significantly increases.

Morphological Development of the Hip in Normal Infants Under Six Months of Age by the Graf Ultrasound Method

OBJECTIVE

This large-sample observational study aims to analyze the morphological development of the hip joint in Chinese normal infants under 6 months of age by the Graf ultrasound method.

METHODS

The clinical and ultrasound data of infants who underwent early screening for developmental dysplasia of the hip (DDH) in the authors' clinic from January 2011 to December 2019 were analyzed retrospectively. The standard Graf method was used to measure the hip joint α angle, β angle and femoral head coverage (FHC). The infants with Graf type I or IIa hips were included in this study. All infants were grouped by age. FHC, α and β angles were compared among different study groups.

RESULTS

A total of 3,067 infants (6,134 hips) were included in the study. There were 1,164 males and 1,903 females with an average age of 77 days (1-180 days). The mean α angle was 62.4 ± 3.6° on the left and 63.2 ± 3.5° on the right (P < 0.001). The mean β angle was 55.6 ± 4.5° on the left and 54.8 ± 4.5° on the right (P < 0.001). The average FHC was 54.2 ± 4.6% and 54.8 ± 4.2%, accordingly (P < 0.001). The α angle and FHC of females was significantly smaller than that of males (P < 0.001). While the left β angle in females was slightly larger than males (P = 0.014), there were no significant differences in the right β angle between the two sexes (P = 0.150). During the first 3 postnatal months, the α angle and FHC increased while β angle decreased with age. However, the α and β angles and FHC were stable at a relatively constant level from the 4 to the 6^th postnatal month.

CONCLUSIONS

The normal infant hip reveals progressive maturation during the first 3 months after birth, and then enters a plateau period during the 4 to 6^th month. The development of hip joint in females and of the left side slightly lags behind that in males and of the right side, which is consistent with the observation that DDH is more common in females and on the left hips.

Docking phenomenon and subsequent acetabular development after gradual reduction using overhead traction for developmental dysplasia of the hip over six months of age

PURPOSE

This study aimed to explore the docking of the femoral head into the acetabulum after gradual reduction (GR) using traction for developmental dysplasia of the hip (DDH) and the impact on subsequent acetabular development.

METHODS

A total of 40 patients with DDH (42 hips) undergoing GR using overhead traction and spica casting were retrospectively reviewed. The presence of inverted labrum and the coronal and axial femoral-acetabular distances (FADs) were compared between MRI immediately and five weeks after spica casting. The change in the acetabular index on anteroposterior pelvic radiographs were compared between hips with inverted labrum (residual group) and with normally-shaped labrum (normalized group) on follow-up MRI.

RESULTS

The mean age at reduction was 13.1 months (7 to 33) and the mean follow-up duration was 7.7 years (4 to 11). The rate of inverted labrum and the FADs significantly decreased between the MRI scans (all p-values < 0.001), and previous Pavlik harness failure had no negative effect on these decreases. The acetabular indices at the ages of three and five years in the residual group were significantly larger than those in the normalized group (both p-values < 0.001). Residual acetabular dysplasia was seen in 84.2% of the residual group compared with 34.8% of the normalized group (p = 0.002).

CONCLUSION

The docking phenomenon can occur during spica casting following GR using traction in children with DDH between the ages of six months and three years. The remaining inverted labrum at the cast removal may negatively affect subsequent acetabular development.

LEVEL OF EVIDENCE

III - retrospective comparative study.

Principles of Bracing in the Early Management of Developmental Dysplasia of the Hip

Bracing is considered a gold standard in treating Developmental Dysplasia of the Hip (DDH) in infants under 6 months of age with reducible hips. A variety of braces are available that work on similar principles of limiting hip adduction and extension. This paper summarises the current evidence regarding bracing in DDH. Most of the literature pertains to the Pavlik harness (PH) and there are few studies for other brace types. Bracing eliminates dislocating forces from the hamstrings, the block to reduction of the psoas and improves the muscle line of pull to stabilise the hip joint. Recent studies have shown no benefit in bracing for stable dysplasia. The rates of PH treatment failure in Ortolani-positive hips have been reported to be high. Barlow positive hips have lower Graf grades and are more amenable to PH treatment. There is consensus that the earlier the diagnosis of DDH and initiation of PH treatment, the better the outcome. Failure rates due to unsuccessful reduction and AVN are higher with treatment initiated after age 4-6 months. Studies have shown no benefits of staged weaning of braces. While there is no maximum time in brace, current consensus suggests a minimum of 6 weeks. The key to successful bracing lies in education and communication with the family.

What Are the Rate and Risk Factors for Developing a Complication With the Pavlik Method for the Treatment of Hip Dysplasia?

BACKGROUND

The Pavlik method for the treatment of developmental dysplasia of the hip (DDH) has been proven successful for over 85 years. The high success rate and reproducibility have made it the mainstay of treatment.

METHODS

We performed a retrospective cohort study of patients with DDH treated with the Pavlik method between September 2016 and August 2018 with at least 24 months of follow up in a single academic center. We excluded patients with neuromuscular conditions, teratologic dislocations, and arthrogryposis. We identified and included a total of 307 patients in the analysis. There were 66 patients with dysplasia, 97 with instability, and 144 with a dislocation. Data collected included age at initiation of the Pavlik method, diagnosis (isolated dysplasia, subluxation, or dislocation), duration of treatment, follow up duration and any complication. At final follow up, anteroposterior radiographs of the pelvis were used to determine the Severin classification.

RESULTS

Major complications were proximal femoral growth disturbance (5.8%) and femoral nerve palsy (0.98%). Multivariate analysis showed that an initial diagnosis of a dislocated hip (odds ratio, 2.20; P<0.01), was significantly associated with developing a complication. At final follow up, we found Severin type I or II radiographic findings in 100% of patients with dysplasia, 95% of patients with instability and 54% of patients with dislocation (P=0.001).

CONCLUSIONS

Complications are not entirely uncommon when the Pavlik method is used for the treatment of DDH. The overall rate of major complications was 7%. The Pavlik method is safe, and independent risk factors for complications were being over 5 months of age and having a dislocated hip at initial presentation.

LEVEL OF EVIDENCE

Level IV-cohort study.

An Inverted Acetabular Labrum Is Predictive of Pavlik Harness Treatment Failure in Children With Developmental Hip Dysplasia

INTRODUCTION

The failure rate of Pavlik harness treatment for developmental dysplasia of the hip (DDH) has been reported as high as 55%. The purpose of this study is to investigate the effect of an inverted acetabular labrum on outcomes of Pavlik harness treatment for DDH.

METHODS

A retrospective review was conducted on DDH patients at a tertiary care pediatric hospital from 2004 to 2016. DDH patients that underwent index treatment with Pavlik harness and had minimum 12 months follow-up were included. Medical charts were reviewed for demographics, treatment, and outcomes. Outcomes were compared between patients with an inverted labrum versus those without an inverted labrum.

RESULTS

A total of 156 patients with 229 dysplastic hips were included. The mean age at initiation of Pavlik harness treatment was 1.9±1.4 months and mean follow-up was 37.7±23.0 months. Bilateral DDH was diagnosed in 46% (73/156) of patients. In all, 37% (75/229) of hips failed Pavlik harness index treatment. Second-line treatment was rigid hip abduction bracing in 91% (68/75) of hips, closed reduction in 5% (4/75) of hips, and open reduction in 4% (3/75) of hips. An inverted labrum was present in 10% (22/229) of all hips. The incidence of Pavlik harness treatment failure was 91% (20/22) in the inverted labrum group compared with 27% (55/207) in the control group (P<0.001). Closed or open reduction was required in 86% (15/22) of the inverted labrum group compared with 3% (7/207) of hips in the control group (P<0.001). The incidence of avascular necrosis was 18% (4/22) in hips with an inverted labrum compared with 0.4% (1/207) in the control group (P<0.001).

CONCLUSIONS

In children with DDH undergoing index treatment in a Pavlik harness, the presence of an inverted acetabular labrum is strongly predictive of treatment failure. Dysplastic hips with an inverted labrum also have a significantly higher risk of requiring closed or open reduction and developing avascular necrosis compared with those without an inverted labrum.

LEVEL OF EVIDENCE

Level III.

There is No Link Between Birth Weight and Developmental Dysplasia of the Hip

AIMS

Developmental Dysplasia of the Hip (DDH) has been linked to high birth weight and packaging disorders, though the evidence is limited. This has implications on screening strategies. The aim of this study was to establish whether birth weight was truly associated with the incidence of DDH.

PATIENTS AND METHODS

This cohort study analysed the birth weights of all babies born at our institution over a 24 month period, between 01/01/2017 and 01/01/2019. Babies with DDH and those without DDH were compared. Babies were excluded if born before 38 weeks, had incomplete data or were a non-singleton pregnancy. Sub-analysis was performed for DDH severity (dysplastic versus subluxed/dislocated hips), breech presentation, gestational age, gender and ethnicity. Statistical analysis was performed using SPSS.

RESULTS

There were 10,113 babies born at our institution during the selected timeframe, of which 884 were excluded for prematurity, 336 for being non-singleton and 19 for incomplete data. This left 8874 for analysis, of which 95 babies had confirmed DDH. Both the Non-DDH and DDH data sets had normal distribution (Shapiro-Wilkes, p = 0.308 and 0.629, respectively), with mean birth weights of 3477.7 g with DDH and 3492.8 g without DDH. No difference in birth weight was found (Independent T test, p = 0.789). Females had a lower birth weight than males (3293.1 g versus 3416.6 g (p < 0.001)) yet have a higher incidence of DDH (ratio 6:1 in this dataset). No significant difference was found between birth weights of females with and without DDH (p = 0.068), nor between males with and without DDH (p = 0.513). There were no significant differences in birth weights even when only displaced hips were analysed (p = 0.543), nor according to breech presentation (p = 0.8). Longer gestation babies weighed more (p < 0.00001), yet showed no increase in DDH incidence (p = 0.64).

CONCLUSION

This study discredits the belief that DDH may be related to higher birth weight, thus casting doubt on the link to DDH being a packaging problem in utero. This, therefore, allows future research to prioritise the investigation of alternative aetiologies.

Is It Possible to Treat Developmental Dysplasia of the Hip with Anterior Open Reduction and Pemberton Osteotomy Under 18 Months of Age?

PURPOSE OF THE STUDY

The purpose of the present study is to determine the outcome success of anterior open reduction with Pemberton osteotomy in patients under 18 months of age with developmental dysplasia of the hip.

METHODS

We retrospectively reviewed the clinical and radiological results of 27 developmental hip dysplasia patients under 18 months of age (26 girls, 1 boy) who underwent anterior open reduction with Pemberton osteotomy. Bilateral surgery was performed in 18 patients and unilateral in nine patients. At the final follow-up, the clinical results were evaluated according to the McKay's clinical evaluation criteria, the radiological results according to the Severin's radiological evaluation criteria, and the presence of avascular necrosis according to the Kalamchi-MacEwen's classification criteria.

RESULTS

We treated 36 hips of 27 patients who were younger than 18 months of age (range 10-18 months) at the time of surgery and followed up a minimum of 5 years (mean 6.5 years). At the final follow-up, 34 (94.4%) were assessed clinically as excellent, one hip (2.7%) as good and one hip (2.7%) as fair according to the McKay's clinical classification. Radiological classification revealed that, 97.2% of the hips were Severin Type-1 and 2.8% Severin Type-3. Avascular necrosis was observed in 5 of 36 hips (13.8%). Two hips were assessed as Type-2, two hips Type-3 and one hip Type-4 according to the Kalamchi-MacEwen's classification.

CONCLUSION

We conclude that Pemberton osteotomy with anterior open reduction is useful technique for developmental hip dysplasia treatment of patients under the age of 18 months with good clinical and radiological results as well as with low complication rates.

Risk Factors for Failure of Pavlik Harness Treatment in Infants With Dislocated Hips That Are Evaluated by Dynamic Sonography

BACKGROUND

Frankly dislocated hips occur in ∼1% to 3% of infants with developmental dysplasia of the hip and are often difficult to treat. In the most severely dislocated hips, the femoral head is positioned outside the posterior/lateral rim of the acetabulum and is irreducible, that is, the femoral head will not reduce by positioning the leg. The purpose of this study was to determine risk factors, using univariate and multivariate analyses, for Pavlik harness failure in infants who initially presented with irreducible/dislocated hips (confirmed by dynamic sonography).

METHODS

Following institutional review board approval, 124 infants (170 hips) with frankly dislocated hips treated using a Pavlik harness between 2000 and 2018 were evaluated. Patients' demographic characteristics, clinical findings, dynamic sonographic findings (dislocated-fixed vs. dislocated-mobile), age at onset of Pavlik harness treatment, duration of harness usage, and follow-up treatments were recorded. Univariate analyses were used to determine risk factors for treatment failure.

RESULTS

In frankly dislocated hips (confirmed by dynamic sonography to be positioned outside the posterior/lateral rim of the acetabulum), Pavlik harness treatment was successful in 104 of 170 hips (61%) while it failed in 66 hips. Mean follow-up was 4.86±4.20 years. Univariate analysis determined the risk factors to be onset of treatment after the seventh week of age (P=0.049) and initial mobility (dislocated-fixed group) (P<0.001) by dynamic sonography. In addition, multivariate analysis (P=0.007) showed infants of multigravida mothers (non-firstborn) to be another risk factor for failure. Six percent of hips with no risk factors failed Pavlik harness treatment, those with 1 risk factor had 42% failure, 2 risk factors had 69% failure, and all 3 risk factors had 100% failure.

CONCLUSIONS

In our patients with frankly dislocated irreducible hips, 39% of hip failed Pavlik harness treatment. Independent multivariate, logistic regression analysis, and multivariate analysis determining the risk factors for failure of Pavlik harness treatment were onset of treatment after the seventh week of age, infants of multigravida mothers, and initial hip mobility (fixed-dislocated hips) by dynamic sonography.

LEVEL OF EVIDENCE

Level III.

The feasibility of ultrasound Graf method in screening infants and young children with congenital hip dysplasia and follow-up of treatment effect

BACKGROUND

Congenital hip dysplasia is a common limb deformity in infants and young children. This study aimed to clarify the feasibility of ultrasound Graf method in screening congenital hip dysplasia of infants and young children, and its application value in follow-up treatment.

METHODS

A total of 1,313 infants and young children with clinically suspected congenital hip dysplasia in our hospital from December 2016 to January 2018 were selected as the participants and were examined by ultrasound Graf method. The acetabulum shape and the measured values of α and β angles of the participants were observed. The development of the hip joint and distribution of congenital hip dysplasia were analyzed, and the treatment effect was followed up.

RESULTS

Among 1,313 infants and young children with suspected congenital hip dysplasia, the positive rate of congenital hip dysplasia was 6.02% (79/1,313). The lesions were located on both sides in 14 cases, on the left side in 67 cases, and on the right side in 26 cases. The α angle of cases with congenital hip dysplasia was significantly lower than that of normal cases, and the β angle was significantly higher than that of normal cases (P<0.05). Ultrasound follow-up results showed that out of 24 cases who underwent hip abduction exercises, 22 (91.67%) returned to normal, and the remaining 2 returned to normal after Pavlik sling treatment. Among 46 cases treated with Pavlik sling, 42 (91.30%) returned to normal, and the remaining 4 cases returned to normal after closed reduction and plaster fixation. A total of 9 participants underwent plaster fixation after closed reduction, all of which returned to normal.

CONCLUSIONS

Ultrasound Graf method can be used as the first choice for screening infants and young children with congenital hip dysplasia. It can be followed up to observe the clinical treatment effect, and it has high clinical application value.

Predicting Hip Dysplasia in Teenagers with Cerebral Palsy in order to Optimize Prevention and Rehabilitation. A Longitudinal Descriptive Study

OBJECTIVE

To develop a predictive model of neuromuscular hip dysplasia (NHD) in teenagers with cerebral palsy (CP) to optimize rehabilitation.

DESIGN

A longitudinal, multicenter, double-blinded, descriptive study of one hundred and two teenagers with CP (age 16.5 ± 1.2 years, range 12-18 years). Data on etiology, diagnosis, spasticity, epilepsy, clinical history, and functional assessments were collected from 2005 to 2017 and entered in the prediction model "PredictMed."

RESULTS

Poor walking abilities [p < .001; Odd Ratio (OR) Infinity], scoliosis (p 0.01; OR 3.22), trunk muscles' tone disorder (p 0.002; OR 4.81), spasticity (p 0.006; OR 6.6), poor motor function (p 0.02; OR 5.5), and epilepsy (p 0.03; OR 2.6) were predictors of NHD development. The accuracy of the model was 77%.

CONCLUSION

Trunk muscles' tone disorder, severe scoliosis, epilepsy, and spasticity were predictors of NHD in teenagers with CP. Based on the results we have developed appropriate preventative rehabilitation interventions.

The diagnosis and management of common childhood orthopedic disorders: An update

Musculoskeletal illness represents a significant portion of office visits to primary and urgent care clinicians. Despite this, little emphasis is placed on learning pediatric orthopaedics during medical school or residency. The focus of this paper is to provide a systematic approach to this general musculoskeletal physical exam and to assist in the recognition of what conditions are normal development and what conditions require observation, workup and referral to an experienced pediatric orthopaedist.