Outcome of surgical management of developmental dysplasia of hip in children between 18 and 24 months

Modified Center-Edge Angle in Children with Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) is a prevalent developmental condition that necessitates early detection and treatment. Follow-up, as well as therapeutic decision-making in children younger than four years, is challenging because the center-edge (CE) angle of Wiberg is not reliable in this age group. The authors propose a modification of the CE angle (MCE) to achieve comparable reliability with the CE among children younger than four and set diagnostic thresholds for the diagnosis of DDH. 952 anteroposterior pelvic radiographs were retrospectively reviewed. The MCE is defined on X-ray pelvic overview images as the angle between the line connecting the epiphyseal joint center and the outer edge of the acetabulum, and perpendicular to the Hilgenreiner line. The MCE angle exhibited high sensitivity and specificity, as well as intrarater variability comparable to the CE among children younger and older than four years. The authors recommend cut-off values for the MCE angle; for children under four years old, the angle should be equal to or greater than 15 degrees; for those under eight years old, it should be equal to or greater than 20 degrees; and for those eight years old and older, it should be equal to or greater than 25 degrees. However, the MCE angle's reliability diminishes around the age of nine due to the curvature of the growth plate, which complicates accurate measurement. This study showed that the MCE angle can be used adequately in children under four years and could be used as a progression parameter to diagnose DDH.

The Evolution of DDH Management in India

BACKGROUND

Developmental dysplasia of hip (DDH) is a relatively common disorder of the paediatric age group and can have a significant impact on the quality of life, if left untreated. Some research has been done in this field from India over the past many decades, thereby helping to attain the present state of knowledge about DDH. Through this review, an attempt was made to identify and acknowledge important contributions in this field from India.

PURPOSE

To provide some historical aspects and summarise the evidence developed in India concerning different facets of DDH since 1920.

METHODS

Information about the evolution of DDH management in India was collated from recollections of the senior author (ANJ), from existing records, and contributions from senior Paediatric Orthopaedic surgeons of the country. The Medline database was searched for Indian literature concerning different aspects of DDH. All studies published in English language were included. Included studies were categorised into original studies, reviews, book chapters, case series and case reports, and their contribution to the understanding of DDH was highlighted.

RESULTS

The analysis showed 63 published studies on DDH from India. The majority of publications occurred between 2011 and 2020. Retrospective cohort studies and reviews comprised 46% of the published literature.

CONCLUSION

There is a scarcity of research on DDH from India, with many knowledge gaps still prevalent. The overall quality of published literature is poor, with very few good quality original research. However, an increasing trend for research on different aspects of DDH was observed.

The Incidence, Diagnosis, and Treatment practices of Developmental Dysplasia of Hip (DDH) in India: A Scoping Systematic Review

PURPOSE

To identify literature on variations and knowledge gaps in the incidence, diagnosis, and management of developmental dysplasia of hip (DDH) in India.

METHODS

Following standard methodology and PRISMA-ScR guidelines, a scoping systematic review of literature on incidence, diagnosis, and treatment of DDH in India was conducted. Studies conducted in India, published in indexed or non-indexed journals between 1975 and March 2021, were included in the search.

RESULTS

Of 57 articles which met the inclusion criteria, only 33 studies (57.8%) were PubMed-indexed. Twenty-eight studies (49%) were published in Orthopaedic journals and majority had orthopaedic surgeon as the lead author (59.6%). Sixteen studies were mainly epidemiological, 20 reported screening/diagnosis, and 21 reported treatment of DDH. Almost 90% of the studies (51) were Level 4 or 5 according to the levels of evidence in research. There is lack of clarity in the definition of hip dysplasia and screening/diagnostic guidelines to be used. The incidence of hip dysplasia in India is reported to be 0-75 per 1000 live births, with true DDH between 0 and 2.6/1000. Late-presenting DDH is common in India, with most studies reporting a mean age of > 20 months for children presenting for treatment. The treatment is also varied and there is no clear evidence-based approach to various treatment options, with lack of long-term studies.

CONCLUSION

This systematic scoping review highlights various knowledge gaps pertaining to DDH diagnosis and management in India. High-quality, multicentric research in identified gap areas, with long-term follow-up, is desired in future.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Orthopaedic Surgeons in India

BACKGROUND

We evaluated screening, referral and treatment practices for developmental dysplasia of the hip (DDH) in India by surveying Orthopaedic surgeons who treat patients with DDH. The survey assessed the timing of DDH presentation, resource availability, and current state of screening and diagnosis, which would help in the development of a DDH care pathway for India.

METHODS

An online survey was distributed to Orthopaedic surgeons practicing in India via email and administered onsite to those attending the annual conference of the Pediatric Orthopaedic Society of India in 2019.

RESULTS

173 completed surveys were received from surgeons practicing in a predominantly urban setting. 68.8% of respondents had performed initial evaluations on children with DDH aged over 1 year in the past 12 months, and 49.1% had assessed children with DDH aged > 2 years on initial presentation. There was no consistent use of established guidelines, with only 30% of respondents stating that a care pathway was in place at their institution. However, 91.9% would support the implementation of a care pathway developed in India, to decrease the incidence of delayed diagnosis and facilitate earlier intervention. 85% of respondents had ready access to ultrasound scans and 95.4% had access to X-rays.

CONCLUSIONS

In India, there is still a large number of late-presenting cases of DDH, which could be improved with effective screening. The development of a care pathway for DDH in India is well-supported by Orthopaedic surgeons and may help decrease the incidence of late presenting cases; potentially improving outcomes, decreasing morbidity, and upskilling local practitioners.

Duration of immobilization after developmental dysplasia of the hip and open reduction surgery

BACKGROUND

There is no consensus about the duration of post-operative immobilization in the treatment of DDH (developmental dysplasia of hip). Our aim in this study is to compare between two post-operative immobilization protocols for patients undergoing open reduction.

MATERIALS AND METHODS

Thirty-eight hips in 32 patients assigned to group A were immobilized in hip spica for four weeks followed by abduction brace application which was gradually weaned through the periods of several months and 29 hips in 24 patients assigned to group B immobilized in hip spica for 12 weeks without further bracing. Both groups were surgically reduced using anterior approach between the ages of 12-24 months.

RESULTS

There were non-significant statistical difference between both groups as regards clinical and radiological outcome but there is significant statistical difference as regards AVN (avascular necrosis) on follow-up between both groups. The rate of AVN cannot be related to the method of immobilization, as there are many factors can lead to AVN of the hip as immobilization in an extreme position and tight reduction.

CONCLUSION

Group A post-operative immobilization protocol is safer and associated with less complications and more comfortable to the patient and parents than that used in group B. Early removal of hip spica cast and application of hip abduction brace does not increase the rate of re-dislocation.

LEVEL OF EVIDENCE

Level III Retrospective comparative study.

Clinical evaluation of ultrasound screening in follow-up visits of infants with cerebral palsy at high risk for developmental dysplasia of the hip

The aim of the study was to assess the clinical value of ultrasound screenings for the developmental dysplasia of the hip (DDH) and explore its etiology in high-risk infants with cerebral palsy in follow-up visits. A group of 98 cases of infants at high-risk of cerebral palsy who received rehabilitation treatment between July, 2009 and July, 2010 were selected. Infants included 58 men and 40 women, aged <6 months and not lost to follow-up visits. Ultrasound (using Graf static inspection) screening of hips was performed and the infants with abnormalities were given clinical intervention, and 1- to 2-year-old infants were given outpatient follow-ups. The results were analyzed and there were 40 abnormal cases among the 98 cases of infants at high risk of cerebral palsy, including 18 cases of unstable hip joint, and 22 cases of DDH (12 cases of hip dysplasia, 3 cases of hip subluxation and 7 cases of hip dislocation). Early clinical intervention for infants with hip dysplasia and outpatient follow up for infants aged 1–2 years was carried out and had ischemic necrosis of femoral head, with the exception of 1 case of femoral detorsion that was poorly restored. In conclusion, the probability of DDH was higher in infants at high-risk of cerebral palsy compared to the normal infants. Hip ultrasound is a safe, simple, and effective screening method for these infants, which is of great clinical significance for an earlier diagnosis and treatment of DDH in infants with cerebral palsy.