Comparison of brace to observation in stable, radiological developmental dysplasia of the hip: a protocol for a global multicentre non-inferiority randomised trial.

INTRODUCTION: Brace treatment is common to address radiological dysplasia in infants with developmental dysplasia of the hip (DDH); however, it is unclear whether bracing provides significant benefit above careful observation by ultrasound. If observation alone is non-inferior to bracing for radiological dysplasia, unnecessary treatment may be avoided. Therefore, the purpose of this study is to determine whether observation is non-inferior to bracing for infants with radiological dysplasia. METHODS AND ANALYSIS: This will be a multicentre, global, randomised, non-inferiority trial performed under the auspices of a global prospective registry for infants and children diagnosed with DDH. Patients will be included if they present with radiological dysplasia (centred hip, alpha angle 43-60°, percent femoral head coverage greater than 35% measured on ultrasound) of a clinically stable hip under 3 months old. Patients will be excluded if they present with clinical hip instability, have received prior treatment or have known/suspected neuromuscular, collagen, chromosomal or lower-extremity congenital abnormalities or syndromic-associated hip abnormalities. Patients will be enrolled and randomised to undergo observation alone or brace treatment with a Pavlik harness for a minimum of 6 weeks. Follow-up visits will occur at 6 weeks, 1 year and 2 years post-enrolment. The primary outcome will be the norm-referenced acetabular index measured on the 2-year radiograph with a 3° non-inferiority margin. A total of 514 patients will be included.The study is anticipated to start in April 2024 and end in September 2028.The primary outcome will be compared between arms with a mixed-effects model with a random intercept for study centre, and a single covariate for the treatment group. If the lower bound of the 95% CI lies within 3° of the mean, we will treat this as evidence for non-inferiority. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the lead site's ethics board (University of British Columbia, Children's and Women's Research Ethics Board). Ethics approval will be obtained from the local ethics committees or institutional review boards at each institution prior to patient enrolment. It is intended that the results of this study shall be published in peer-reviewed journals and presented at suitable conferences. TRIAL REGISTRATION NUMBER: NCT05869851.

An in-depth analysis of young adults with osteonecrosis secondary to developmental dysplasia of the hip who underwent total hip arthroplasty.

BACKGROUND: Patients with osteonecrosis of the femoral head secondary to DDH frequently require total hip arthroplasty (THA), but it is not well understood which factors necessitate this requirement. We determined the incidence of THA in patients who have osteonecrosis secondary to DDH and factors associated with need for THA. METHODS: We included patients who received closed or open reductions between 1995 and 2005 with subsequent development of osteonecrosis. We determined osteonecrosis according to Bucholz and Ogden; osteoarthritis severity (Kellgren-Lawrence), subluxation (Shenton's line); neck-shaft angle; and acetabular dysplasia (centre-edge and Sharp angles). We also recorded the number of operations of the hip in childhood and reviewed case notes of patients who received THA to describe clinical findings prior to THA. We assessed the association between radiographic variables and the need for THA using univariate logistic regression. RESULTS: Of 140 patients (169 hips), 22 patients received 24 THA (14%) at a mean age of 21.3 ± 3.7 years. Associated with the need for THA were grade III osteonecrosis (OR 4.25; 95% CI 1.70-10.77; p = 0.0019), grade IV osteoarthritis (21.8; 7.55-68.11; p < 0.0001) and subluxation (8.22; 2.91-29.53; p = 0.0003). All patients who required THA reported at least 2 of: severe pain including at night, stiffness, and reduced mobility. Acetabular dysplasia and number of previous operations were not associated with the need for THA. CONCLUSIONS: We identified a 14% incidence of THA by age 34 years in patients with osteonecrosis secondary to DDH. Grade III osteonecrosis (global involvement femoral head and neck) was strongly associated with THA, emphasising the importance to avoid osteonecrosis when treating DDH.

Risk factors for avascular necrosis of the femoral head after developmental hip dislocation reduction surgery and construction of Nomogram prediction model.

BACKGROUND: To analyze the risk factors for the development of avascular necrosis (AVN) of the femoral head after reduction surgery in children with developmental hip dysplasia (DDH), and to establish a prediction nomogram. METHODS: The clinical data of 134 children with DDH (169 hips) treated with closure reduction or open reduction from December 2016 to December 2019 were retrospectively analyzed. Independent risk factors for AVN after DDH reduction being combined with cast external immobilization were determined by univariate analysis and multivariate logistic regression and used to generate nomograms predicting the occurrence of AVN. RESULTS: A total of 169 hip joints in 134 children met the inclusion criteria, with a mean age at surgery of 10.7 ± 4.56 months (range: 4-22 months) and a mean follow-up duration of 38.32 ± 27.00 months (range: 12-94 months). AVN developed in 42 hip joints (24.9%); univariate analysis showed that the International Hip Dysplasia Institute (IHDI) grade, preoperative development of the femoral head ossification nucleus, cartilage acetabular index, femoral head to acetabular Y-shaped cartilage distance, residual acetabular dysplasia, acetabular abduction angle exceeding 60°, and the final follow-up acetabular index (AI) were associated with the development of AVN (P < 0.05). Multivariate logistic regression analysis showed that the preoperative IHDI grade, development of the femoral head ossification nucleus, acetabular abduction angle exceeding 60°, and the final follow-up AI were independent risk factors for AVN development (P < 0.05). Internal validation of the Nomogram prediction model showed a consistency index of 0.833. CONCLUSION: Preoperative IHDI grade, preoperative development of the femoral head ossification nucleus, final AI, and acetabular abduction angle exceeding 60° are risk factors for AVN development. This study successfully constructed a Nomogram prediction model for AVN after casting surgery for DDH that can predict the occurrence of AVN after casting surgery for DDH.

Specific pelvic shape in patients with developmental dysplasia of the hip on 3D morphometric homologous model analysis.

PURPOSE: To clarify the morphological factors of the pelvis in patients with developmental dysplasia of the hip (DDH), three-dimensional (3D) pelvic morphology was analyzed using a template-fitting technique. METHODS: Three-dimensional pelvic data of 50 patients with DDH (DDH group) and 3D pelvic data of 50 patients without obvious pelvic deformity (Normal group) were used. All patients were female. A template model was created by averaging the normal pelvises into a symmetrical and isotropic mesh. Next, 100 homologous models were generated by fitting the pelvic data of each group of patients to the template model. Principal component analysis was performed on the coordinates of each vertex (15,235 vertices) of the pelvic homologous model. In addition, a receiver-operating characteristic (ROC) curve was calculated from the sensitivity of DDH positivity for each principal component, and principal components for which the area under the curve was significantly large were extracted (p<0.05). Finally, which components of the pelvic morphology frequently seen in DDH patients are related to these extracted principal components was evaluated. RESULTS: The first, third, and sixth principal components showed significantly larger areas under the ROC curves. The morphology indicated by the first principal component was associated with a decrease in coxal inclination in both the coronal and horizontal planes. The third principal component was related to the sacral inclination in the sagittal plane. The sixth principal component was associated with narrowing of the superior part of the pelvis. CONCLUSION: The most important factor in the difference between normal and DDH pelvises was the change in the coxal angle in both the coronal and horizontal planes. That is, in the anterior and superior views, the normal pelvis is a triangle, whereas in DDH, it was more like a quadrilateral.

Resolving residual acetabular dysplasia following successful brace treatment for developmental dysplasia of the hip in infants.

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.

Residual Acetabular Dysplasia at Walking Age: A Study of 470 Hips Treated With Pavlik Harness.

BACKGROUND: This study aims to report on the acetabular indices of walking age children following successful DDH treatment with Pavlik harness and investigate risk factors for residual acetabular dysplasia (RAD). METHODS: We retrospectively reviewed the data for children treated for DDH at a single centre between 2015 and 2020. Acetabular indices (AI) measured on pelvic radiographs taken at 2- and 4-year follow-up visits were referenced against age-matched and sex-matched normal data. Values ≥90th percentile were considered to represent RAD. RESULTS: A total of 305 children with 470 hips were suitable for inclusion. The mean age at treatment initiation was 7.0±4.5 weeks and mean treatment duration was 15.9±4.3 weeks. Overall, 27% and 19% of hips were found to have RAD at 2- (n=448) and 4-year (n=206) follow-up, respectively. The χ 2 test for independence demonstrated that the difference in the proportion of hips with RAD at both time points was significant ( P =0.032). Patients with RAD at 2 years were found to have been treated for longer ( P =0.028) and had lower alpha angles on final ultrasound assessment ( P <0.001). Patients with RAD at 4 years were older at initiation of treatment ( P =0.041), had lower alpha angles on final ultrasound assessment ( P <0.001) and were more likely to have had RAD at 2 years ( P <0.001). Multivariate analysis identified lower alpha angles on final ultrasound to be predictive for RAD at 2 years ( P =0.011), and presence of RAD at 2 years to be predictive for RAD at 4 years ( P <0.001). CONCLUSIONS: The risk of RAD beyond walking age in children successfully treated with Pavlik harness is not negligible. However, we observed that a significant proportion of children with RAD at 2-year follow-up had spontaneously improved without any intervention. This data suggests that routine long-term radiologic follow-up of children treated with Pavlik harness is necessary, and surgical intervention to address RAD should be delayed until at least 4 years of age. LEVEL OF EVIDENCE: Level III-case-control study.

Intraoperative 3D Fluoroscopy During Open Reduction for DDH: An Effective Alternative to Postoperative CT/MRI.

BACKGROUND: Computed tomography CT or magnetic resonance imaging (MRI) has been the most used imaging modality to assess hip reduction in developmental dysplasia of the hip (DDH) after open reduction (OR). In 2015, intraoperative 3D fluoroscopy (3D) was introduced at our center as an alternative to CT/MRI. 3D offers the advantage that if hip reduction is insufficient, it can be addressed at the time of surgery. The purpose of this study was to assess the efficacy of 3D in comparison to CT/MRI. METHODS: This was a single-centre, retrospective comparative study of two consecutive cohorts: those with OR and 3D between 2015 and 2017 and those with OR and CT/MRI between 2012 and 2014. Time to imaging, re-imaging, length of stay (LOS), re-operation, and redislocation or subluxation after cast removal were evaluated. RESULTS: Forty-two patients (46 hips) had 3D, and 30 patients (32 hips) had CT/MRI. Significant differences were found between groups in time to imaging, cast changes, and LOS. All 3D was intraoperative (46 hips), and only 69% (22 hips) of CT/MRI was on the day of surgery ( P <0.01). In the 3D group, 1 hip (2%) had a cast change under the same anesthetic, and 4 hips (13%) from CT/MRI had cast changes in subsequent surgery ( P =0.03). The mean LOS in days for 3D was 1.72 and 2.20 for CT/MRI ( P =0.03). There were no statistically significant differences between groups in further imaging and subluxations or re-dislocations at cast removal. Two hips (4%) in the 3D group had MRI, but with no further intervention ( P =0.51), and at cast removal, there were 3 subluxations in each group ( P =0.69) and 1 redislocation in the 3D group ( P =1.00). CONCLUSIONS: Intraoperative 3D improved time to imaging, allowed for cast changes at surgery and had a shorter LOS. Moreover, there were no significant differences found in adverse outcomes between those who underwent 3D versus CT/MRI. 3D should thus be considered an effective alternative to CT/MRI for assessing hip reduction during OR for DDH. LEVEL OF EVIDENCE: Diagnostic Study, level II.

Proximal Femur Guided Growth: A Systematic Review.

Children with cerebral palsy (CP) and those with avascular necosis (AVN) after treatment of developmental hip dysplasia (DDH) are at risk of developing coxa valga. Proximal femur guided growth is a minimally invasive option to correct this deformity. A systematic review of articles that described treatment of coxa valga with proximal femur guided growth (PFGG) and reporting on primary radiographic outcomes, demographic variables, surgical variables and complications. One hundred and seventy-nine hips underwent PFGG (117 with CP and 62 with lateral overgrowth). Average age at surgery was 8.1 years; average follow-up was 52.5 months. Migration percentage improved from 11.2% (p < 0.0001). Neck-shaft angle improved by 11.9° (p < 0.0001). The most common complication was screw growth out of the physis (30% of cases). PFGG can correct coxa valga, improve radiographic parameters, and in children with CP prevent further subluxation. This technique modulates proximal femur growth, induces changes to the acetabulum and can correct valgus deformity. Evidence Level III. (Journal of Surgical Orthopaedic Advances 32(4):049-052, 2024).

2D/4D Finger Length Ratio in the Screening of Developmental Dysplasia of the Hip.

OBJECTIVE: To investigate whether there is a relationship between the 2nd finger and 4th finger length measurement ratios and developmental dysplasia of the Hip (DDH). STUDY DESIGN: Cross-sectional observational study. Place and Duration of the Study: Department of Orthopaedics and Traumatology, Meram Faculty of Medicine Hospital, Konya, Turkiye, from January 2020 to May 2023. METHODOLOGY: Infants were screened for DDH with Graff method for the ultrasounds of both hips. Lengths of the 2nd and 4th fingers of both hands were measured and recorded. Patients with additional risk factors for developmental dysplasia of the hip (breech birth, family history, oligohydramnios, swaddling) were excluded. RESULTS: Two hundred and fifty-six babies were screened including 55.1% (n = 141) girls and 44.9% (n = 115) boys. Their mean age was 2.51 ± 0.80 months. The average lengths were 31.73 ± 3.05 mm, for the left 2nd finger and 34.26 ± 3.48 mm for the left 4th finger. In the hip USG measurements, the mean alpha angles were 62.91 ± 3.12° for the right hip and, 63.20 ± 3.55° for the left hip. Eighteen (7%) of babies who underwent hip ultrasound (USG) had unilateral or bilateral DDH. Among these cases, 2.7% (n = 7) had right, 2.3% (n = 6) had left, and 2% (n = 5) had bilateral DDH. There was no statistically significant correlation between the ratios of right 2/4 finger lengths and the right alpha angle (rs = 0.051; p = 0.421). There was a statistically positive and statistically significant correlation between the ratios of left 2/4 finger lengths and the left alpha angle (rs = 0.154; p = 0.013). CONCLUSION: Only the left-hand finger ratio among the parameters in the model had a statistically significant effect on DDH. Therefore, the left hand 2D/4D finger length may be of value in screening for DDH. KEY WORDS: Developmental dysplasia of the hip, Second to fourth finger digit ratio, Ring finger, Digit ratios.

The usefulness of universal ultrasound before hospital discharge for early diagnosing hip dysplasia in Korean neonates with breech presentation in a single center: A retrospective study.

Developmental dysplasia of the hip (DDH) is a broad-spectrum disorder. Early diagnosis and treatment are important for improved prognosis and a lower risk of long-term complications. Selecting high-risk infants is important for the early diagnosis of DDH using ultrasonography; however, there are no standard international guidelines. This study aimed to identify the usefulness of universal ultrasound before hospital discharge in breech-born neonates and proposes selective ultrasound for high-risk patients. A retrospective chart review was conducted to identify breech-born neonates who underwent hip ultrasonography before discharge for the detection of DDH between 2019 and 2023. Patients were categorized into DDH and non-DDH groups according to the ultrasound results. We compared sex, gestational age, birth weight, first-born status, twin pregnancy, associated anomalies, presence of symptoms, physical examination results, and timing of the first hip ultrasound. The medical records of the mothers were reviewed to identify the amount of amniotic fluid and duration of breech presentation. This study included 102 patients, of whom 62 and 40 were assigned to the non-DDH and DDH groups, respectively. Congenital anomalies, positive symptoms, and positive physical examination results were significant risk factors. However, female sex, first-born status, and oligohydramnios were not statistically significant. The duration of breech presentation during pregnancy was not significant. Additionally, the risk of Pavlik harnesses was higher in patients who underwent a positive physical examination. Universal ultrasonography before discharge is not recommended for the early diagnosis of DDH in all breech-born neonates because of the high rate of overdiagnosis. We recommend that ultrasonography be performed in patients with congenital anomalies, except for foot problems, or in those with a positive physical examination conducted by trained specialists.

Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review.

Importance: Delayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life, and premature osteoarthritis. Objective: To evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants. Data Sources: Systematic search of CINAHL, Embase, MEDLINE, and the Cochrane Library from the inception of each database until October 31, 2023. Study Selection: The 9 included studies reported the diagnostic accuracy of the clinical examination (index test) in infants aged 3 months or younger and a diagnostic hip ultrasound (reference test). The Graf method of ultrasound assessment was used to classify hip abnormalities. Data Extraction and Synthesis: The Rational Clinical Examination scale was used to assign levels of evidence and the Quality Assessment of Diagnostic Accuracy Studies tool was used to assess bias. Data were extracted using the individual hip as the unit of analysis; the data were pooled when the clinical examinations were evaluated by 3 or more of the included studies. Main Outcomes and Measures: Sensitivity, specificity, and likelihood ratios (LRs) of identifying a dislocated hip were calculated. Results: Among infants screened with a clinical examination and a diagnostic ultrasound in 5 studies, the prevalence of a dislocated hip (n = 37 859 hips) was 0.94% (95% CI, 0.28%-2.0%). There were 8 studies (n = 44 827 hips) that evaluated use of the Barlow maneuver and the Ortolani maneuver (dislocate and relocate an unstable hip); the maneuvers had a sensitivity of 46% (95% CI, 26%-67%), a specificity of 99.1% (95% CI, 97.9%-99.6%), a positive LR of 52 (95% CI, 21-127), and a negative LR of 0.55 (95% CI, 0.37-0.82). There were 3 studies (n = 22 472 hips) that evaluated limited hip abduction and had a sensitivity of 13% (95% CI, 3.3%-37%), a specificity of 97% (95% CI, 87%-99%), a positive LR of 3.6 (95% CI, 0.72-18), and a negative LR of 0.91 (95% CI, 0.76-1.1). One study (n = 13 096 hips) evaluated a clicking sound and had a sensitivity of 13% (95% CI, 6.4%-21%), a specificity of 92% (95% CI, 92%-93%), a positive LR of 1.6 (95% CI, 0.91-2.8), and a negative LR of 0.95 (95% CI, 0.88-1.0). Conclusions and Relevance: In studies in which all infant hips were screened for developmental dysplasia of the hip, the prevalence of a dislocated hip was 0.94%. A positive LR for the Barlow and Ortolani maneuvers was the finding most associated with an increased likelihood of a dislocated hip. Limited hip abduction or a clicking sound had no clear diagnostic utility.

Routine ultrasound screening for hip dysplasia in children with clubfoot is not supported.

PURPOSE: Despite the existence of guidelines for screening for developmental dysplasia of the hip (DDH), there remains controversy regarding the need for routine ultrasound screening for DDH in patients with clubfoot due to an unclear correlation between the two conditions. The purpose of this study is to determine whether ultrasound screening for DDH in this population improved the diagnostic accuracy of DDH over standard assessment for patient risk factors and physical exam. METHODS: This is a retrospective cross-sectional review of infants diagnosed with idiopathic clubfoot who underwent hip ultrasounds to assess for DDH as identified by keyword search in an institutional radiological database at a tertiary care paediatric hospital. Patient demographics, risk factors for DDH, physical exam findings, and ultrasound results were recorded. RESULTS: Of the 120 patients who met the inclusion criteria between 2003 and 2018, 8 had hip dysplasia confirmed on ultrasound (6.7%). All these patients either had known risk factors for hip dysplasia or had an abnormal physical exam finding suggestive of hip instability or dislocation as performed by an orthopaedic surgeon on their initial consultation. CONCLUSION: A detailed history to determine risk factors and a thorough physical exam are adequate to determine the need for hip ultrasound in infants with idiopathic clubfoot. Routine ultrasound screening of all patients with clubfoot is likely unnecessary and may pose a significant burden on the health care system.

3D pre-operative planning and patient-specific guides for re-directional peri-acetabular osteotomy in children and adolescents.

Surgical procedures to correct hip dysplasia associated with subluxation or dislocation of the femoral head are complex. The 3D geometric abnormalities of the acetabulum and proximal femur vary across patients. We, therefore, suggest a patient-specific surgical treatment involving computer-assisted 3D planning of the peri-acetabular osteotomies, taking into account the femoral head position; 3D printing of patient-specific guides for the cuts, repositioning, and fixation; and intra-operative application of the simulated displacements with their fixation. LEVEL OF EVIDENCE: IV.

A 30-year follow-up study of rotational acetabular osteotomy for pre- and early-stage osteoarthritis secondary to dysplasia of the hip.

Aims: The objective of this study was to present the outcomes of rotational acetabular osteotomy (RAO) over a 30-year period for osteoarthritis (OA) secondary to dysplasia of the hip in pre- or early-stage OA. Methods: Between September 1987 and December 1994, we provided treatment to 47 patients (55 hips) with RAO for the management of pre- or early-stage OA due to developmental hip dysplasia. Of those, eight patients (11 hips) with pre-OA (follow-up rate 79%) and 27 patients (32 hips) with early-stage OA (follow-up rate 78%), totalling 35 patients (43 hips) (follow-up rate 78%), were available at a minimum of 28 years after surgery. Results: In the pre-OA group, the mean Merle d'Aubigné score improved significantly from 14.5 points (SD 0.7) preoperatively to 17.4 points at final follow-up (SD 1.2; p = 0.004) and in the early-stage group, the mean score did not improve significantly from 14.0 (SD 0.3) to 14.6 (SD 2.4; p = 0.280). Radiologically, the centre-edge angle, acetabular roof angle, and head lateralization index were significantly improved postoperatively in both groups. Radiological progression of OA was observed in two patients (two hips) in the pre-OA group and 17 patients (18 hips) in the early-stage group. Kaplan-Meier survival analysis, with radiological progression of OA as the primary outcome, projected a 30-year survival rate of 81.8% (95% confidence interval (CI) 0.59 to 1.00) for the pre-OA group and 42.2% (95% CI 0.244 to 0.600) for the early-stage group. In all cases, the overall survival rate stood at 51.5% (95% CI 0.365 to 0.674) over a 30-year period, and when the endpoint was conversion to total hip arthroplasty, the survival rate was 74.0% (95% CI 0.608 to 0.873). Conclusion: For younger patients with pre-OA, joint preservation of over 30 years can be expected after RAO.

Comparison of quality and interpretation of newborn ultrasound screening examinations for developmental dysplasia of the hip by basically trained nurses and junior physicians with no previous ultrasound experience.

BACKGROUND: We are obliged to give babies the chance to profit from a nationwide screening of developmental dysplasia of the hip in very rural areas of Mongolia, where trained physicians are scarce. This study aimed to compare the quality and interpretation of hip ultrasound screening examinations performed by nurses and junior physicians. METHODS: A group of 6 nurses and 6 junior physician volunteers with no previous ultrasound experience underwent Graf's standard training in hands-on practice. Newborns were examined before discharge from the hospital, according to the national guideline. Two standard documentation images of each hip were saved digitally. The groups were compared on the proportion of good quality of sonograms and correct interpretation. Two Swiss supervisors' agreed diagnosis according to Graf was considered the final reference for the study purposes. RESULTS: A total of 201 newborns (402 hips or 804 sonograms) were examined in the study, with a mean age of 1.3±0.8 days at examination. Junior physicians examined 100 newborns (200 hips or 400 sonograms), while nurses examined 101 newborns (202 hips or 404 sonograms). The study subjects of the two groups were well balanced for the distribution of baseline characteristics. The study observed no statistically significant difference in the quality of Graf's standard plane images between the providers. Eventually, 92.0% (92) of the physician group and 89.1% (90) of the nurse group were correctly diagnosed as "Group A" (Graf's Type 1 hip) or "Non-Group A" hips (p = 0.484). The most common errors among the groups were a missing lower limb, wrong measurement lines, and technical problems. CONCLUSION: Our study provides evidence that while there might be a trend of slightly more technical mistakes in the nurse group, the overall diagnosis accuracy is similar to junior physicians after receiving standard training in Graf's hip ultrasound method. However, after basic training, regular quality control is a must and all participants should receive refresher trainings. More specifically, nurses need training in the identification of anatomical structures.

Standardized In-harness Ultrasound Protocol Improves Success Rate of Brace Treatment for Dislocated Hips.

OBJECTIVE: Infant hip dislocations benefit from early detection and treatment for optimal outcomes. Prior studies have identified that there remains wide variability in the success rate of bracing between institutions. Although there are standardized methods to screen infants for hip dysplasia, there are no clear guidelines regarding how to image a child being treated for a hip dislocation with a Pavlik harness. As a result, there is substantial variability in how treatment success or failure is monitored between and within institutions. The goal of our study is to determine whether a standardized in-harness imaging protocol improves outcomes and the likelihood of successful treatment for dislocated hips being treated with the Pavlik harness. METHODS: All patients with hip dislocations and pretreatment ultrasound (US) were included from July 2018 to July 2022. A new institutional US protocol was implemented in July 2020, during which standardized in-harness imaging was obtained for patients with hip dislocations. Patients treated before the implementation of standardized in-harness imaging were categorized as nonstandardized and after implementation as a standardized group. Outcomes were compared between standardized and nonstandardized groups. P <0.05 determined the statistical significance. RESULTS: One hundred twenty-eight hips met the inclusion criteria (n = 97 patients). The mean age at diagnosis was 41.6 ± 23.4 days and was predominantly female (85.6%). There was no significant difference between the patients' demographics and baseline clinical characteristics between the standardized and nonstandardized groups. Pavlik harness success rate was significantly higher in the standardized group (85% vs 60%, P = 0.0024). Twenty-eight hips in the nonstandardized group remained dislocated and were indicated for surgical treatment, whereas only 8 hips remained dislocated in the standardized group and necessitated closed or open reduction. CONCLUSIONS: Standardization of in-harness imaging for patients undergoing treatment for developmental hip dislocations can significantly improve the Pavlik harness success rate. These findings emphasize the importance of obtaining images with the hip in flexion and abduction to prevent inadvertent stress during US evaluation for hips that have not yet stabilized, which may lead to premature cessation of the Pavlik harness. LEVEL OF EVIDENCE: Level III.

Application and evaluation of artificial intelligence 3D preoperative planning software in developmental dysplasia of the hip.

BACKGROUND: Accurate preoperative planning is crucial for successful total hip arthroplasty (THA) for developmental dysplasia of the hip (DDH). The aim of this study was to compare the accuracy of an artificial intelligence-assisted three-dimensional (3D) planning system (AIHIP) with two-dimensional templates in predicting acetabular cup size in THA for DDH. METHOD: This study retrospectively analyzed image data from 103 DDH patients who had THA between May 2019 and August 2023. AIHIP was used for 3D planning, and two-dimensional (2D) templates were used by two experienced surgeons. Accuracy was assessed by comparing predicted and actual cup sizes, and potential factors affecting accuracy were analyzed, including gender, side, BMI, and dysplasia classification. RESULTS: AIHIP had higher accuracy in predicting the acetabular cup size compared to the 2D template. Within ± 0 size, AIHIP's accuracy was 84.1%, while the 2D template's was 64.0% (p < 0.05). Within ± 1 size, AIHIP's accuracy was 95.1%, while the 2D template's was 81.1% (p < 0.05). Accuracy was unaffected by gender, side, or BMI but was by DDH classification. In subgroup analysis, AIHIP's mean absolute error (0.21 ± 0.54) was significantly lower than the 2D template's (0.62 ± 0.95) for Crowe II and Crowe III (p < 0.05). CONCLUSION: AIHIP is superior to 2D templates in predicting the acetabular cup size accurately for THA in DDH patients. AIHIP may be especially beneficial for Crowe II and III DDH patients, as 2D templates may not accurately predict cup size in these cases.

Surgical Treatment of Late Developmental Dysplasia of the Hip in Bladder Exstrophy: A Case Report.

CASE: We present a case of an 8-year-old boy with classical bladder exstrophy and a neglected right hip dislocation, exemplifying the risk of missed developmental dysplasia of the hip (DDH) in patients with exstrophy requiring careful orthopaedic oversight. CONCLUSIONS: When treating patients with bladder exstrophy, physicians and surgeons should be vigilant not to miss associated DDH. If this condition requires surgical treatment, preoperative planning with computed tomography scans is vital to uncovering the complexities arising from abnormal pelvic and acetabular anatomy and ensuring successful treatment outcomes.

The outcome of early screening and treatment of developmental dysplasia of the hip in infants and toddlers in the Northern Guizhou region.

This study is an observation of the early screening and treatment effect of infant developmental dysplasia of the hip (DDH) in an area in China. From January 2016 to December 2017, we selected infants and toddlers with high-risk factors for DDH, such as asymmetric gluteal folds, unequal length of lower limbs, and limited hip joint abduction, who visited the Department of Child Health Care and the Outpatient Clinic of Pediatric Orthopedics at the Affiliated Hospital of Zunyi Medical University. In total, 1485 cases were divided into age groups, examined using Graf ultrasound and X-ray, and the results were analyzed. Meanwhile, early interventions were actively adopted for cases with abnormalities during the screening. The detection rates of DDH were 24.0%, 2.8%, 9.3%, and 12.2% among those with 0 to 6 months, 7 to 12 months, 13 to 18 months, and 19 to 24 months of age, respectively. Early and individualized corrective conservative treatment was considered for children with abnormalities, and the cure rates were 87.0%, 65.7%, 41.0%, and 16.7% among those with 0 to 6 months, 7 to 12 months, 13 to 18 months, and 19 to 24 months of age, respectively. There was a statistically significant difference in the detection and cure rates of DDH in infants and toddlers of different ages (P < .01).

Neonatal Ultrasound and Radiographic Markers of Hip Dysplasia in Young Adults.

OBJECTIVES: To examine radiologic outcomes at skeletal maturity of sonographically normal, immature, mildly, and severely dysplastic newborn hips. METHODS: During 1988 to 1990, 11 925 newborns were enrolled in a randomized controlled trial examining screening strategies for developmental hip dysplasia. In total, 4469 were invited to clinical and radiologic follow-up 18 years later, of which 1735 had received neonatal ultrasound. Radiographic markers for dysplasia in left adult hips included the center-edge (CE) angle. RESULTS: At follow-up, 984 of 1735 (56.7%) with newborn ultrasound met, of which 966 (614 females) had valid radiographs and were thus included. For females, 34 (10.2%) and 1 (0.3%) of the 332 sonographically normal left neonatal hips were judged borderline (20°≤ CE <25°) or dysplastic (CE <20°) at skeletal maturity respectively. Corresponding numbers were 36 (19.7%) and 3 (1.6%) of the 183 immature, 12 (15.6%) and 2 (2.6%) of the 77 mildly dysplastic, and 3 (13.6%) and 3 (13.6%) of the 22 severely dysplastic neonatal left hips (P ≤ .001). In males, no associations were found. In females, adult joint hypermobility was associated with sonographic neonatal hip instability (P = .046), as well as with adult acetabular dysplasia (P = .024). CONCLUSIONS: Significant associations between neonatal hip phenotypes and adult dysplasia were revealed in females. This indicates the possibility of different mechanisms affecting the course of developmental dysplasia of the hip for females and males, prompting consideration of prolonged clinical and radiologic follow-up for females with dysplastic neonatal hips. Results in males are limited by low numbers of dysplastic hips. The significance of joint hypermobility warrants further investigation.