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Dragonas CG, Kottaridou E, Vampertzis T, Abbakr L, Taha N, Manoukian D. Length of treatment and ultrasound timing in infants with developmental dysplasia of the hip. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1079-1086. [PMID: 37934277 DOI: 10.1007/s00590-023-03771-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/23/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE Developmental dysplasia of the hip (DDH) joint is a complex condition that may lead to severe problems. Ultrasound scan (USS) in the first four-to-six weeks of life is considered the gold-standard for diagnosis while the Pavlik harness (PH) is a widely utilized method as first-line treatment. The purpose of this study is to compare clinical outcomes of infants with DDH in relation to the timing and frequency of USS following application of the PH. METHODS Retrospective data were collected over a 5-year period from February 2017 to February 2022. We included patients who underwent the first USS post-diagnosis and PH application in two, three, four and six weeks. Two-hundred-twenty-five patients were included and divided in four groups according to timing of the first follow-up: week-2, n = 13; week-3, n = 66; week-4, n = 95; and week-6, n = 51. For every patient Graf classification, treatment length and number of follow-ups were documented. RESULTS Week-3 and week-4 groups displayed a statistically significant shorter treatment length compared to week-6 group (p value < 0.001), while also demonstrating a lower number of sonographic follow-ups per patient compared to both week-6 (p value < 0.001) and week-2 (p value = 0.002 vs week-3; p value < 0.001 vs week 4). Week-4 group presented the highest treatment completion (56%) on first visit post-diagnosis. Conservative treatment with PH failed in 1.8% (4/225) and displayed no significant difference among all subgroups. CONCLUSIONS Differences in timing of first USS post-DDH diagnosis and initiation of treatment can lead to discrete outcomes with implications to the clinical outcome and cost effectiveness.
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Affiliation(s)
| | | | - Themistoklis Vampertzis
- The Royal London Hospital, Barts Health Trust, London, UK
- School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lina Abbakr
- Princess Alexandra Hospital NHS Trust, Hamstel Road, Harlow, Essex, CM20 1QX, UK
| | - Narmeen Taha
- Princess Alexandra Hospital NHS Trust, Hamstel Road, Harlow, Essex, CM20 1QX, UK
| | - Dimitrios Manoukian
- Princess Alexandra Hospital NHS Trust, Hamstel Road, Harlow, Essex, CM20 1QX, UK
- The Royal London Hospital, Barts Health Trust, London, UK
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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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Mulder FECM, Witlox MA, Dirksen CD, de Witte PB, de Vos-Jakobs S, Ham AMT, Witbreuk MMEH, Sakkers R, Drongelen MMMHPFV, Robben SGF, Mathijssen NMC. Active monitoring versus an abduction device for treatment of infants with centered dysplastic hips: study protocol for a randomized controlled trial (TReatment with Active Monitoring (TRAM)-Trial). BMC Pediatr 2023; 23:203. [PMID: 37120559 PMCID: PMC10148463 DOI: 10.1186/s12887-023-04012-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/13/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND Developmental Dysplasia of the Hip (DDH) is one of the most common pediatric orthopedic disorders, affecting 1-3% of all newborns. The optimal treatment of centered DDH is currently under debate. This randomized controlled trial aims to study the (cost-)effectiveness of active monitoring versus abduction treatment for infants with centered DDH. METHODS This is a multicenter, parallel-group, open-label, non-inferiority randomized controlled trial studying the (cost-)effectiveness of active monitoring versus abduction treatment for infants with centered DDH in fourteen hospitals in the Netherlands. In total, 800 infants with centered DDH (Graf IIa-/IIb/IIc), aged 10-16 weeks, will be randomly allocated to the active monitoring or abduction treatment group. Infants will be followed up until the age of 24 months. The primary outcome is the rate of normal hips, defined as an acetabular index lower than 25 degrees on an antero-posterior radiograph, at the age of 12 months. Secondary outcomes are the rate of normal hips at the age of 24 months, complications, time to hip normalization, the relation between baseline patient characteristics and the rate of normal hips, compliance, costs, cost-effectiveness, budget impact, health-related quality of life (HRQoL) of the infant, HRQoL of the parents/caregivers, and parent/caregiver satisfaction with the treatment protocol. DISCUSSION The outcomes of this randomized controlled trial will contribute to improving current care-as-usual for infants with centered DDH. TRIAL REGISTRATION Dutch Trial Register, NL9714, registered September 6, 2021. https://clinicaltrialregister.nl/en/trial/29596.
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Affiliation(s)
- Frederike E C M Mulder
- Department of Orthopedic Surgery, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.
| | - M Adhiambo Witlox
- Department of Orthopedic Surgery, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Carmen D Dirksen
- Department of Clinical Epidemiology and Medical Technology Assessment, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Pieter Bas de Witte
- Department of Orthopedics, Leiden University Medical Center, Leiden, the Netherlands
| | - Suzanne de Vos-Jakobs
- Department of Orthopedics and Sports Medicine, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arno M Ten Ham
- Department of Orthopedics, Sint Maartenskliniek, Nijmegen, the Netherlands
| | | | - Ralph Sakkers
- Department of Orthopedic Surgery, Wilhelmina Children's Hospital, University Medical Center, Utrecht, the Netherlands
| | | | - Simon G F Robben
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Nina M C Mathijssen
- Reinier Haga Orthopedic Center, Zoetermeer, the Netherlands
- Department of Orthopedics, Reinier de Graaf Hospital, Delft, the Netherlands
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Kanakamedala AC, Jejurikar NS, Castañeda P. Hip morphology on initial ultrasound predicts hip morphology at one year in developmental dysplasia of the hip. J Child Orthop 2022; 17:79-85. [PMID: 37034190 PMCID: PMC10080245 DOI: 10.1177/18632521221141085] [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] [Received: 03/12/2022] [Accepted: 11/03/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose: This study aimed to determine whether point-of-care ultrasound performed during the Pavlik method treatment of developmental dysplasia of the hip predicts acetabular morphology at 12 months of age. Methods: We reviewed the medical records, ultrasounds, and radiographs of patients treated successfully with the Pavlik method between 2017 and 2019. We performed sonographic measurements on point-of-care ultrasound at the initial presentation, the Pavlik discontinuation, and an additional sonographic follow-up. We measured the acetabular index on a plain anteroposterior radiograph of the pelvis obtained at a minimum of 12 months of age. Spearman’s rank correlation coefficient was used to analyze for correlation between sonographic measurements and the acetabular index. Results: A total of 72 patients were included in the final analysis. There were no residual or late dysplasia cases at the last radiographic follow-up (mean age = 14.8 ± 2.7 months). Sonographic parameters at the initial presentation significantly correlated with the acetabular index at the final radiographic follow-up (p < 0.001). Patients with worsening degrees of developmental dysplasia of the hip based on stability on sonographic testing (stable, unstable, or dislocated) had higher acetabular indices at the final radiographic follow-up (p < 0.05). Conclusion: Point-of-care ultrasound at initial presentation and the Pavlik discontinuation significantly correlate with acetabular morphology at 1–1.5 years of age. At initial presentation, hips that were unstable or dislocated on point-of-care ultrasound had significantly greater acetabular indices than stable hips at the final follow-up. Level of evidence: level IV case series.
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Affiliation(s)
| | | | - Pablo Castañeda
- Pablo Castañeda, Department of Orthopedic
Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 301 E. 17th
Street, Office 400B, New York, NY 10003, USA.
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Paulussen EMB, Mulder FECM, Mathijssen NMC, Witlox MA. Active monitoring versus immediate abduction as treatment of stable developmental dysplasia of the hip: a systematic review of the literature. BMJ Open 2022; 12:e057906. [PMID: 36123097 PMCID: PMC9486180 DOI: 10.1136/bmjopen-2021-057906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This systematic review aims to compare the effects of active monitoring and abduction treatment on the Graf alpha angle, Acetabular Index (AI) and femoral head coverage in infants with stable developmental dysplasia of the hip (DDH). DESIGN Systematic review reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES A search of the PubMed, Embase, Cochrane and Web of Science databases was performed in January 2020 and updated in January 2021. ELIGIBILITY CRITERIA (Non-)randomised studies comparing active monitoring with abduction treatment in infants younger than 4 months with stable DDH were included. DATA EXTRACTION AND SYNTHESIS All eligible articles were methodologically assessed using the Cochrane risk of bias tools. Data were extracted by summarising the study characteristics and results. RESULTS Of the six included studies, two randomised studies were of low risk and two of some concerns. Two non-randomised studies were of serious risk. In total, 544 dysplastic hips (439 infants) were investigated, of which 307 were observed and 237 were treated. Two studies reported a faster improvement of the alpha angle and average acetabular coverage in treated hips at 3 months. No differences in AI between the treatment and observation group after 3 months were reported. In total, 38 infants (12%) in the observation group switched to the treatment group. At the final radiograph, 21 observed hips and 32 treated hips were dysplastic. CONCLUSIONS There were no differences in AI between the treatment and observation group after 3 months in infants up to 4 months of age with stable DDH hips. The switch of 38 infants (12%) from the observation to the treatment group corroborates that not all infantile DDH hips will spontaneously progress into normal hips. The small study population sizes and methodological heterogeneity warrant a large randomised controlled trial to study this research question. PROSPERO REGISTRATION NUMBER CRD4202123300.
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Affiliation(s)
- Evy M B Paulussen
- Department of Orthopaedic Surgery, Maastricht University, Maastricht, The Netherlands
| | | | - Nina M C Mathijssen
- Department of orthopaedic surgery, Reinier Haga Orthopedic Center, Zoetermeer, The Netherlands
| | - M Adhiambo Witlox
- Department of Orthopaedic Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Andras LM, Whitlock PW, Abousamra O. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2022; 104:299-306. [PMID: 34932502 DOI: 10.2106/jbjs.21.01430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Principles of Bracing in the Early Management of Developmental Dysplasia of the Hip. Indian J Orthop 2021; 55:1417-1427. [PMID: 34785821 PMCID: PMC8582338 DOI: 10.1007/s43465-021-00525-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 09/13/2021] [Indexed: 02/04/2023]
Abstract
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.
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