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.

Tübingen hip flexion splint more successful than Pavlik harness for decentred hips after the age of three months.

AIMS: The objective of this study was to evaluate the clinical and radiological outcomes of patients younger than six months of age with developmental dysplasia of the hip (DDH) managed by either a Pavlik harness or Tübingen hip flexion splint. METHODS: Records of 251 consecutive infants with a mean age of 89 days (SD 47), diagnosed with DDH between January 2015 and December 2018, were retrospectively reviewed. Inclusion criteria for patients with DDH were: younger than 180 days at the time of diagnosis; ultrasound Graf classification of IIc or greater; treatment by Pavlik harness or Tübingen splint; and no prior treatment history. All patients underwent hip ultrasound every seven days during the first three weeks of treatment and subsequently every three to four weeks until completion of treatment. If no signs of improvement were found after three weeks, the Pavlik harness or Tübingen splint was discontinued. Statistical analysis was performed. RESULTS: The study included 251 patients with Graf grades IIc to IV in 18 males and 233 females with DDH. Mean follow-up time was 22 months (SD 10). A total of 116 hips were graded as Graf IIc (39.1%), nine as grade D (3.0%), 100 as grade III (33.7%), and 72 as grade IV (24.2%). There were 109 patients (128 hips) in the Pavlik group and 142 patients (169 hips) in the Tübingen group (p = 0.227). The Tübingen group showed a 69.8% success rate in Graf III and Graf IV hips while the success rate was significantly lower in the Pavlik group, 53.9% (p = 0.033). For infants older than three months of age, the Tübingen group showed a 71.4% success rate, and the Pavlik group a 54.4% success rate (p = 0.047). CONCLUSION: The Tübingen splint should be the preferred treatment option for children older than three months, and for those with severe forms of DDH such as Graf grade III and IV, who are younger than six months at time of diagnosis. The Tübingen hip flexion splint is a valid alternative to the Pavlik harness for older infants and those with more severe DDH. Cite this article: Bone Joint J 2021;103-B(5):991-998.

Novel 3D printed integral customized acetabular prosthesis for anatomical rotation center restoration in hip arthroplasty for developmental dysplasia of the hip crowe type III: A Case Report.

RATIONALE: Exact restoration of the rotation center in total hip arthroplasty (THA) is technically challenging in patients with end-stage osteoarthritis due to developmental dysplasia of the hip (DDH), especially in the Crowe type II and III procedures. The technical difficulty is attributable to the complex acetabular changes. In this study, a novel 3-dimensional (3D) printed integral customized acetabular prosthesis for anatomical rotation restoration in THA for DDH Crowe type III was developed using patient-specific Computer-aided design and additive manufacturing (AM) methods. PATIENT CONCERNS: A 69-year-old female patient had developed left hip joint pain and restricted movement for 40 years; the symptoms had increased in the past 5 months. Pain, limited motion of the left hip joint, and lower limb length discrepancy were noted during physical examination. DIAGNOSIS: The patient was diagnosed with left hip end-stage osteoarthritis secondary to DDH (Crowe type III). INTERVENTION: A 3D printed acetabulum model was manufactured and a simulated operation was performed to improve the accuracy of reconstruction of the rotation center and bone defect. A 3D printed titanium alloy integral customized acetabular prosthesis was designed according to the result of simulated operation. The integral customized prothesis was implanted subsequently via the posterolateral approach. Radiography of the pelvis and Harris score assessment were performed during the perioperative period as well as at the 6- and 12-month follow-up. OUTCOMES: The 3D printed integral customized acetabular prosthesis matched precisely with the reamed acetabulum. The rotation center was restored and the bone defect was exactly reconstructed. There were no signs of prosthetic loosening at the 12-month follow-up. The Harris score gradually improved during the follow-up period. LESSONS: Satisfactory results of hip rotation restoration and bone defect reconstruction could be achieved by using 3D printed integral customized acetabular prosthesis, which provides a promising way to reconstruct the acetabulum in patients with DDH anatomically and rapidly for THA.

Total hip arthroplasty for high-riding hips: A retrospective analysis of 79 cases and proposal of a new classification.

PURPOSE: Total hip arthroplasty (THA) for high-riding hips is a complex procedure and the requirement for subtrochanteric osteotomy (STO) is an important decision that needs to be taken preoperatively. STO renders this complex surgery even more complicated and there are no guidelines to determine the STO requirement. In this study, the outcomes of THA for patients with high-riding hips were evaluated and a practical classification system is proposed to predict any osteotomy requirement. METHODS: A retrospective evaluation was made of 79 hips of 76 patients who underwent THA for high-riding hip dysplasia. The amount of shortening in patients with STO and in patients without STO was compared. All patients were evaluated in respect of Harris hip score, operating time, erythrocyte suspension need, and actual limb length discrepancy. Preoperative radiographs were classified into four types according to the ratio of the distance between the lesser trochanter and the ischial tuberosity with pelvic height (LT-IT/P) to grade the degree of dislocation. RESULTS: The mean follow-up was 30 ± 6.54 months. STO was applied to 47 (60%) hips and not to 32 (40%). There was no statistically significant difference between the groups in respect of the functional scores. STO prolonged the operating time and increased the need for blood transfusion (p = 0.026, p < 0.001, respectively). When the LT-IT/P index was <0.19 (type 1), no additional surgical approach was required for reduction, at 0.19-0.29 (type 2), the head can be safely reduced with additional reduction methods, and when >0.3 (type 3), a shortening osteotomy will most likely be required. The rate of complications is increased if LT-IT/P is >0.4 (type 4). CONCLUSION: STO adjunct to THA increases the rate of complications. This practical classification system may guide the surgeon in the decision of whether an STO should be added to the procedure or not. LEVEL OF EVIDENCE: Level III, clinical trial.

Neonatal hip ultrasound: tangent to lateral roof angle correlates better with stability than alpha angle according to Graf or percentage femoral head coverage.

The aim of this study was to determine the relationship of tangent to the lateral roof angle (TLRA), Graf's alpha angle and percentage femoral head cover (PHC) and to observed stability, and to establish intraobserver and interobserver errors for measurement of alpha angle and TLRA. In total, 2235 babies referred to the hip review clinic over a period of 8 years. Intraobserver and interobserver errors were calculated from readings of 383 hip images by an experienced paediatric radiologist and a trainee. Taking TLRA <70° as abnormal resulted in sensitivity for unstable right hips of 88% compared with 77% for alpha angle <60° (P = 0.002) and 81% for PHC <60% (P = 0.028) and specificity of TLRA 89%, alpha angle 90% (P = 0.07) and PHC 83% (P < 0.001). Corresponding figures for left hips are sensitivity of TLRA 99%, alpha angle 91% (P < 0.001) and PHC 96% (P = 0.013), and specificity TLRA 86%, alpha angle 83% (P = 0.001) and PHC 67% (P < 0.001). Mean intraobserver errors for alpha angle were 1.85° and 1.81° for consultant and trainee compared to 2.54 and 2.55 for TLRA. Mean interobserver errors were 2.22 for alpha angle and 3.42 for TLRA. TLRA, a new parameter, correlated better with observed stability with significant improvement in sensitivity in both hips and specificity in left hips compared with Graf's alpha angle, and significantly improved sensitivity and specificity in both hips compared with percentage femoral head cover.

Interpreting neonatal hip sonography: intraobserver and interobserver variability.

The purpose of this study is to state the reliability of neonatal hip ultrasound interpretation, defining the intra and interoperator variability in the evaluation of the scans. We considered a sample of 2071 scans (coming from 798 patients who attended the screening programme for hip dysplasia), which were interpreted by the operator who obtained and read the images at the screening time and then by a different operator who saw the images for the first time. Both the intra and interoperator variability of α and ß angles' values resulted statistically not significative (intraclass correlation coefficient > 0.8) and determining a class shift (according to the Graf's classification) in a nonstatistically significative number of cases (agreement percentage >91% and Cohen's κ >0.8). Hip sonography can reliably detect hip dysplasia and the intra and interoperator variability in the interpretation of the exam is NS when the examination is correctly executed.

Deep Convolutional Neural Network-Based Automatic Classification of Neonatal Hip Ultrasound Images: A Novel Data Augmentation Approach with Speckle Noise Reduction.

Neonatal hip ultrasound imaging has been widely used for a few decades in the diagnosis of developmental dysplasia of the hip (DDH). Graf's method of hip ultrasonography is still the most reproducible because of its classification system; yet, the reproducibility is questionable as a result of the high dependency on the skills of the sonographer and the evaluator. A computer-aided diagnosis system may help evaluators increase their precision in the diagnosis of DDH using Graf's method. This study describes a fully automatic computer-aided diagnosis system for the classification of hip ultrasound images captured in Graf's standard plane based on convolutional neural networks (CNNs). Automatically segmented image patches containing all of the necessary anatomical structures were given to the proposed CNN system to extract discriminative features and classify the recorded hips. For ease of evaluation, the data set was divided into three groups: normal, mild dysplasia and severe dysplasia. This study proposes a different approach to data augmentation using speckle noise reduction with an optimized Bayesian non-local mean filter. Data augmentation with this filter increased the accuracy of the proposed CNN system from 92.29% to 97.70%. This new approach for automatic classification of DDH, classifies dysplastic neonatal hips with a high accuracy rate and might help evaluators to increase their evaluation success.

Exploration of femoral head coverage in screening developmental dysplasia of the hip in infants.

PURPOSE: To investigate the relationship of femoral head coverage (FHC) with Graf's classification for diagnosis of developmental dysplasia of the hip (DDH) and its role in evaluating hip stability. METHODS: A total of 4222 hips were screened ultrasonographically with Graf's and Harcke's methods. The stability of hips was analyzed using the difference between FHCs at neutral and flexion positions (FHC-D). RESULTS: (1) For the non-dislocated hips, the mean value of FHC at the neutral position was 59.4%, which was significantly greater than 55.0% of FHC at the flexion position (p < 0.001). (2) FHC at the neutral position corresponding to Graf I, IIa/b, IIc, D, III, and IV was 63.0 ± 4.7%, 57.0 ± 5.2%, 49.5 ± 5.5%, 37.7 ± 3.7%, 30.2 ± 12.7%, and 7.4 ± 11.9%, respectively, and that at the flexion position was 59.0 ± 4.4%, 50.7 ± 9.4%, 35.2 ± 5.2%, 30.8 ± 1.3%, 23.4 ± 10.7%, and 4.7 ± 9.9%, respectively, showing a statistically significant difference between the two positions. (3) The AUC of FHC-D in evaluating the stability of hips was 0.972. When the threshold was 8.5%, the sensitivity, specificity, and accuracy of FHC-D in detecting hip instability were 89.0%, 93.0%, and 93.9%, respectively. CONCLUSIONS: FHC can be used as a reference indicator for DDH classification. FHC at different positions corresponds to different reference values, and FHC-D can be used as a quantitative indicator for assessment of hip stability.

Reduction of the dislocated hips with the Tübingen hip flexion splint in infants.

PURPOSE: Early detection and conservative treatment are essential for a successful outcome in developmental dysplasia of the hip (DDH). The aim of this study was to evaluate the efficacy of Tübingen hip flexion splint treatment on dislocated hips of type D, 3, and 4 according to the Graf classification. METHODS: A total of 104 dislocated hips in 92 patients were treated with Tübingen splints. Splint treatment was applied to patients with dislocated hips as diagnosed under ultrasonographic evaluation. After four to six weeks of treatment, the hips were re-evaluated according to the Graf classification under ultrasonography. The success of Tübingen splinting was determined as follows: hips initially diagnosed as Graf type 3 and 4 were upgraded to type 2c, 2b, or 1 after treatment, and hips initially diagnosed as Graf type D were upgraded to type 2b or 1 after treatment. RESULTS: The mean age at treatment initiation was 11.91 ± 5.16 (range, 4-32) weeks. There were no statistically significant relationships between success rates and sex, bilateral hip involvement, or initial physical examination findings (p > 0.05). The age at the start of treatment was found to be statistically significant in terms of the success of the splint (p = 0.03). CONCLUSIONS: For successful treatment with Tübingen splints, the cut-off point of starting initial treatment was defined as the 15th week, with sensitivity of 84.62% and specificity of 62.50%. The success rate was 75% with a successful outcome in 78 hips. In view of these results, Graf type D, 3, and 4 dislocated hips can be successfully treated with Tübingen splints.

Total hip arthroplasty with a monoblock conical stem and subtrochanteric transverse shortening osteotomy in Crowe type IV dysplastic hips.

PURPOSE: This series assessed the clinical and radiographic outcomes of total hip arthroplasty (THA) with femoral shortening osteotomy for the management of patients with Crowe type IV hip dysplasia. METHODS: Only patients with Crowe type IV hip dysplasia who underwent primary THA combined with a subtrochanteric transverse osteotomy with an uncemented monoblock conical stem were included. The clinical and radiographic evaluations were performed before and immediately after surgery, and at last follow-up. The hip function was assessed with the Harris Hip Score (HHS). RESULTS: Seventy-four patients (102 hips) with a mean age of 53.9 (range, 20-83) were evaluated at an average follow-up of 11.3 years (range, 5-25). Stem revision occurred in two (1.9%) cases, with a survivorship of 95.9% (95%IC, 91.9-99.9%) at ten years. The average HHS increased from 44 (range, 15-78) pre-operatively to 90.3 (range, 62-100) at last follow-up (p < 0.001). Osteotomy site non-union and early dislocation were observed in 3.9 and 3.8%, respectively. No cases of nerve palsy were reported. CONCLUSIONS: THA with a monoblock conical stem associated with subtrochanteric transverse osteotomy provides good long-term survival, clinical and radiographic results. It may be considered an effective management of patients with Crowe IV hip dysplasia.

Coronal plane alignment of the lower limbs in patients with unilateral developmental hip dislocation.

PURPOSE: We aimed to identify the coronal plane alignment of lower limbs in patients with unilateral developmental hip dislocation (UDHD) and observe the difference between Hartofilakidis type II and III. PATIENTS AND METHODS: The radiographic data of 76 patients who met the inclusion criteria were retrospectively reviewed, including the hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), anatomical lateral distal femoral angle (aLDFA), mechanical proximal tibial angle (MPTA), and lateral distal tibial angle (LDTA). RESULTS: The valgus alignment on ipsilateral side was most frequently seen in both Hartofilakidis type II (51.3%) and type III groups (67.6%), whereas for the contralateral side, the neutral alignment in type II group (69.2%) and varus alignment in type III group (51.4%) were most commonly observed. Both the mLDFA and aLDFA of the ipsilateral side were significantly smaller than the contralateral side. CONCLUSIONS: UDHD patients may present with lower limb malalignment on both sides. The ipsilateral valgus alignment is the most common deformity. On the contralateral side, Hartofilakidis type III patients may be more prone to be varus than type II patients. The lower limb malalignment and deformity of the ipsilateral distal femur should be considered during surgery involving hip, knee, or femur.

Shortening subtrochanteric osteotomy and cup placement at true acetabulum in total hip arthroplasty of Crowe III-IV developmental dysplasia: results of midterm follow-up.

INTRODUCTION: The anatomic abnormalities in developmental dysplasia of hip (DDH) often make total hip replacement (THR) inevitable at a younger age. However, there is no universal gold standard technique of THR for high dislocated dysplastic hips. MATERIALS AND METHODS: Here we present the outcomes of midterm follow-up after THR in patients diagnosed with DDH Crowe type III and IV hospitalized in a tertiary center in Iran for whom placement of a cup in true acetabulum and selective transverse subtrochanteric osteotomy was performed. Pre- and postoperative Harris Hip Score, leg length discrepancy and postoperative complications were evaluated. RESULTS: A total of 48 patients with DDH Crowe type III and IV (uni- or bilateral which made 52 hips) were studied. Mean age of patients was 41 years with minimum follow-up ranging from 12 months to 3 years. Mean Harris Hip Score significantly improved from 41.70 preoperatively to 88.1 at last follow-up postoperatively. Leg length discrepancy of less than 2 cm was observed which was well tolerated using shoe lifts. Regarding postoperative complications, two patients had transient peroneal nerve palsy in early postoperative period which recovered within 2 months. No other major complication was encountered. CONCLUSION: THR in patients with DDH (Crowe III and IV) with a cup positioned in true acetabulum and transverse subtrochanteric osteotomy is a safe successful procedure.

A New Radiographic Classification System for Developmental Hip Dysplasia is Reliable and Predictive of Successful Closed Reduction and Late Pelvic Osteotomy.

BACKGROUND: The Tonnis radiographic classification of developmental dysplasia of the hip (DDH) has been used as a prognostic indicator for patients with walking-age DDH. The International Hip Dysplasia Institute (IHDI) classification, a new radiographic classification system, has been proposed to be more reliable by its creators. We sought to validate its reliability using independent observers, to compare it to the Tonnis method, and to assess its prognostic significance in a large cohort of patients. METHODS: A consecutive series of walking-age DDH patients were examined radiographically and classified by the Tonnis and IHDI schemes by 3 independent observers. Interobserver agreement was determined using the Kappa method. Clinical data were collected on patients with regard to success of closed reduction, need for later pelvic osteotomy, and presence of subsequent radiographic avascular necrosis (AVN). The prognostic value of the Tonnis and IHDI classifications to predict these clinical outcomes was determined. RESULTS: A total of 287 hips were available for analysis of the classification schemes. In total, 235 hips underwent attempted closed reduction and were eligible for analysis of successful closed reduction, and 131 hips had >4-year follow-up and were utilized for analysis of late pelvic osteotomy and AVN. Both classifications showed excellent interobserver reliability and in general, there was nonstatistically significant better reliability for the IHDI versus the Tonnis classification. In multivariate analysis, both IHDI and Tonnis classifications were found to be predictive of successful closed reduction and need for late pelvic osteotomy. Both methods showed trends toward being predictive of AVN rate, without statistical significance. CONCLUSIONS: The IHDI classification is subjectively more facile to use and has excellent interrelater agreement for classifying the radiographic severity of DDH. It is also reliable in predicting success of closed reduction and need for late pelvic osteotomy. SIGNIFICANCE: practitioners and researchers should consider the IHDI classification as a useful classification scheme and prognosticator when considering treatment options for late-presenting DDH. SIGNIFICANCE: Practitioners and researchers should consider the IHDI classification as a useful classification scheme and prognosticator when considering treatment options for late-presenting DDH. LEVEL OF EVIDENCE: Level III.

Equalisation of leg lengths in total hip arthroplasty for patients with Crowe type-IV developmental dysplasia of the hip: classification and management.

AIMS: There is no consensus about the best method of achieving equal leg lengths at total hip arthroplasty (THA) in patients with Crowe type-IV developmental dysplasia of the hip (DDH). We reviewed our experience of a consecutive series of patients who underwent THA for this indication. PATIENTS AND METHODS: We retrospectively reviewed 78 patients (86 THAs) with Crowe type-IV DDH, including 64 women and 14 men, with a minimum follow-up of two years. The mean age at the time of surgery was 52.2 years (34 to 82). We subdivided Crowe type-IV DDH into two major types according to the number of dislocated hips, and further categorised them into three groups according to the occurrence of pelvic obliquity or spinal curvature. Leg length discrepancy (LLD) and functional scores were analysed. RESULTS: Type-I included 53 patients with unilateral dislocation, in which 25 (category A) had no pelvic obliquity or spinal deformity, 19 (category B) had pelvic obliquity with a compensated spinal curvature and nine (category C) had pelvic obliquity and decompensated spinal degenerative changes. Type-II included 25 patients with one dislocated and one dysplastic hip, in which there were eight of category A, 15 of category B and two of category C. Pre-operatively, there were significant differences between the anatomical and functional LLD in type-IB (p = 0.005) and -IC (p < 0.001), but not in type-IA, -IIA or -IIB. Post-operatively, bony LLD increased significantly in types-IB, -IC and -IIB, whereas functional LLD decreased significantly in each type except for IIA. The mean functional LLD decreased from 30.7 mm (standard deviation (sd) 18.5) pre-operatively to 6.2 mm (sd 4.4) post-operatively and the mean anatomical LLD improved from 35.8 mm (sd 19.7) pre-operatively to 12.4 mm (sd 8.3) post-operatively. CONCLUSION: Pelvic and spinal changes are common in patients with Crowe type-IV DDH and need to be taken into consideration when planning THA, in order to obtain equal leg lengths post-operatively. The principal subdivisions of Crowe type-IV DDH which we describe proved effective in achieving equal leg lengths and satisfactory outcomes. Cite this article: Bone Joint J 2017;99-B:872-9.

Subtrochanteric femoral shortening osteotomy combined with cementless total hip replacement for Crowe type IV developmental dysplasia: a retrospective study.

BACKGROUND: Total hip replacement for high dislocation of the hip presents some difficulties, considering patients' young ages, the abnormal hip anatomy and the high rate of complications. In this study, we present our experience in terms of clinical and radiological results in the treatment of Crowe type IV hips with subtrochanteric femoral shortening osteotomy and cementless total hip replacement. MATERIALS AND METHODS: We retrospectively reviewed 15 patients with Crowe type IV hip dysplasia (two bilateral cases for a total of 17 hips) treated with cementless total hip replacement associated with shortening subtrochanteric osteotomies (nine transversal and eight Z-shape osteotomies) between March 2000 to February 2006. The mean follow-up was 88 months (range 63-133). Harris hip score, leg length discrepancy, neurological status, union status of the osteotomy and the component stability were the criteria of the evaluation. All complications were noted. RESULTS: The mean HHS improved from 38.3 (range 32-52) to 85.6 (range 69-90). The mean preoperative leg length discrepancy was of 45 mm (range 38-70) and reduced to a mean of 12 mm (range 9-1.6) postoperatively. All osteotomies resulted healed at an average of 12.3 weeks (range 10-15). No cases of delayed union or nonunion were detected. Two patients (11%) showed early symptoms of sciatic nerve palsy which resolved uneventfully in 6 months. There was no migrations and none of the implants required revision. CONCLUSIONS: Cementless THA with shortening subtrochanteric osteotomy is an effective method in the treatment of patients with Crowe type IV development dysplasia of the hip. LEVEL OF EVIDENCE: IV.

Total hip arthroplasty for patients with Crowe type IV developmental dysplasia of the hip: Ten years results.

BACKGROUND AND OBJECTIVES: The aim of this study was to determine the rate of union, functional results and complications in patients with Crowe IV developmental dysplasia of the hip (DDH) who underwent cementless total hip arthroplasty (THA) with S-ROM prostheses and subtrochanteric transverse shortening osteotomy. METHODS: Forty-five patients (52 hips) operated between January 2005 and May 2008, with a mean age of 40.6 years at surgery were followed. The mean follow-up period was 9.8 years. Clinical outcomes, radiographic outcomes and complications were evaluated. RESULTS: Osteotomy union occurred in 52 of 52 femurs (100%). Mean Harris hip score improved from 33.7 ± 4.7 preoperatively to 81.2 ± 6.3, 90.8 ± 5.3 and 89.8 ± 7.1 at 1, 5 and 10 years postoperatively. Two patients had temporary sciatic nerve paralysis postoperatively, and 2 patients experienced early postoperative dislocation. Two patients complained about mild longer limb length than the non-operated limb at the last follow-up. Three hips showed osteolysis in Gruen zone 1, and 1 hip showed osteolysis in zone 1 and 7. No implants were revised, and no signs of component loosening and migration were observed at the last follow-up visit. CONCLUSIONS: S-ROM stem combined with transverse subtrochanteric shortening osteotomy in THA for patients with Crowe type IV DDH has good clinical results with small risk of complications.

Pavlik harness treatment for pathological developmental dysplasia of the hip: meeting the standard?

In the UK, the Pavlik harness is generally the accepted treatment technique for the treatment of neonatal and infant pathological developmental dysplasia of the hip. In 2013, the success rate of the Pavlik harness became an outcome measure from the British Society of Children's Orthopaedic Surgery for appraisal and revalidation with the GMC for paediatric orthopaedic surgery. The standard set requires an 80% success rate, with less than 20% requiring surgery. This study evaluated the outcomes of Pavlik harness treatment in neonates/infants with 'pathological hips' diagnosed by ultrasound imaging in a district general hospital setting. In a 10-year prospective observational longitudinal cohort study, modified Graf type III and IV hips (excluding those presenting with irreducible hip dislocation) were classified as pathological and splinted. A total of 2826 neonates/infants underwent ultrasound assessment in the paediatric orthopaedic 'screening clinic'. Neonates and infants were referred as 'at-risk' or as clinically unstable by the Paediatric Department and by general practitioners. Thirty-one Graf type III and 95 Graf type IV hips were identified and treated with a Pavlik harness. One Graf type III (30/31=success rate 96.8%) and three clinically unstable Graf type IV hips progressed to irreducible hip dislocations (92/95=96.8%). The success rate of the Pavlik harness in Graf type III and IV dysplasia was 96.8%, with 3.2% requiring surgery because of progression of the condition, confirming acceptable results for this technique in a district general hospital setting.

Retrospective observational study comparing the international hip dysplasia institute classification with the Tonnis classification of developmental dysplasia of the hip.

The Tonnis radiographic classification of developmental dysplasia of the hip (DDH) has been widely used. The International Hip Dysplasia Institute (IHDI) classification, a new classification system recently developed by the IHDI, is beginning to be applied to evaluate DDH with the absence of an ossification center. This study aimed to validate its reliability in evaluating DDH with an ossification center and compared the 2 classifications in evaluating all DDH hips. In addition, the prediction values of the 2 classifications on clinical management selection were compared.In total, the pelvic radiographs of 212 DDH patients (318 hips) between the ages of 6 and 48 months admitted to Shanghai Children's Medical Center between 2007 and 2014 were assessed by 3 observers retrospectively using the 2 classifications. Intraobserver and interobserver agreements were evaluated using the kappa method. We also assessed the correlation of the 2 radiographic classifications in terms of treatment selection.In total, 216 hips received closed reduction, 61 hips received open reduction, and 41 hips received pelvic osteotomy. Both classifications showed excellent intraobserver and interobserver reliability. However, the IHDI demonstrated more interobserver reliability, especially for evaluating DDH without an ossification center. Both classifications were found to be relevant in detecting the DDH treatment type (P < 0.01). The Tonnis classification was also relevant, especially for evaluating DDH with an ossification center.The IHDI classification exhibited good practicability in classifying the radiographic severity of DDH compared to the Tonnis classification, particularly in hips without an ossification center. Like the Tonnis classification, the IHDI classification can predict treatment plans. Therefore, the IHDI classification seems to be the upgraded version of the Tonnis classification.

Three Patterns of Acetabular Deficiency Are Common in Young Adult Patients With Acetabular Dysplasia.

BACKGROUND: Detailed recognition of the three-dimensional (3-D) deformity in acetabular dysplasia is important to help guide correction at the time of reorientation during periacetabular osteotomy (PAO). Common plain radiographic parameters of acetabular dysplasia are limited in their ability to characterize acetabular deficiency precisely. The 3-D characterization of such deficiencies with low-dose CT may allow for more precise characterization. QUESTIONS/PURPOSES: The purposes of this study were (1) to determine the variability in 3-D acetabular deficiency in acetabular dysplasia; (2) to define subtypes of acetabular dysplasia based on 3-D morphology; (3) to determine the correlation of plain radiographic parameters with 3-D morphology; and (4) to determine the association of acetabular dysplasia subtype with patient clinical characteristics including sex, range of motion, and femoral version. METHODS: Using our hip preservation database, we identified 153 hips (148 patients) that underwent PAO from October 2013 to July 2015. Among those, we noted 103 hips in 100 patients with acetabular dysplasia (lateral center-edge angle < 20°) and who had a Tönnis grade of 0 or 1. Eighty-six patients (86%) underwent preoperative low-dose pelvic CT scans at our institution as part of the preoperative planning for PAO. It is currently our standard to obtain preoperative low-dose pelvic CT scans (0.75-1.25 mSv, equivalent to three to five AP pelvis radiographs) on all patients before undergoing PAO unless a prior CT scan was performed at an outside institution. Hips with a history of a neuromuscular disorder, prior trauma, prior surgery, radiographic evidence of joint degeneration, ischemic necrosis, or Perthes-like deformities were excluded. Fifty hips in 50 patients met inclusion criteria and had CT scans available for review. These low-dose CT scans of 50 patients with symptomatic acetabular dysplasia undergoing evaluation for surgical planning of PAO were then retrospectively studied. CT scans were analyzed quantitatively for acetabular coverage, relative to established normative data for acetabular coverage, as well as measurement of femoral version. The cohort included 45 females and five males with a mean age of 26 years (range, 13-49 years). RESULTS: Lateral acetabular deficiency was present in all patients, whereas anterior deficiency and posterior deficiency were variable. Three patterns of acetabular deficiency were common: anterosuperior deficiency (15 of 50 [30%]), global deficiency (18 of 50 [36%]), and posterosuperior deficiency (17 of 50 [34%]). The presence of a crossover sign or posterior wall sign was poorly predictive of the dysplasia subtype. With the numbers available, males appeared more likely to have a posterosuperior deficiency pattern (four of five [80%]) compared with females (13 of 45 [29%], p = 0.040). Hip internal rotation in flexion was significantly greater in anterosuperior deficiency (23° versus 18°, p = 0.05), whereas external rotation in flexion was significantly greater in posterosuperior deficiency (43° versus 34°, p = 0.018). Acetabular deficiency pattern did not correlate with femoral version, which was variable across all subtypes. CONCLUSIONS: Three patterns of acetabular deficiency commonly occur among young adult patients with mild, moderate, and severe acetabular dysplasia. These patterns include anterosuperior, global, and posterosuperior deficiency and are variably observed independent of femoral version. Recognition of these distinct morphologic subtypes is important for diagnostic and surgical treatment considerations in patients with acetabular dysplasia to optimize acetabular correction and avoid femoroacetabular impingement.