Follow-up Value of Hip Medial Ultrasound in Infants and Children With Developmental Dysplasia of the Hip Treated With Reduction and Spica Casting.

OBJECTIVE: Closed or open reduction and spica casting are common treatments for children aged 6 to 18 months, as well as infants aged 0 to 6 months whose harness treatment for developmental dysplasia of the hip (DDH) was unsuccessful. The study aimed to quantify the distance between the femoral head and the acetabulum after closed or open reduction and evaluate the dynamic docking progression of the femoral head using serial hip medical ultrasound. METHODS: We retrospectively reviewed the medical records and hip medial ultrasound images of a consecutive series of patients with DDH who underwent spica casting after reduction and compared images obtained immediately after reduction and at follow-up. The first cast (stage I) was maintained for 2 to 3 months and scheduled for outpatient repeat ultrasound in 4 to 8 weeks. Then the second cast was placed (stage II), lasting for another 2 to 3 months. The triradiate cartilage-femoral head distance (TFD) was measured in the acetabulum coronal mid-sectional plane. The Wilcoxon signed-rank test was used to compare the TFD values. RESULTS: This study included 49 patients. All patients underwent hip medial ultrasound 0 to 3 days after stage I (time 1) and 4 to 8 weeks (time 2) postoperatively, with 24 patients reviewed again 0 to 7 days after stage II. The TFD values in time 1 and time 2 were 6.0 (5.0, 9.0) mm and 5.0 (3.6, 7.0) mm, respectively. There was a statistically significant difference between times 1 and 2 regarding TFD values in 49 close-reduction hips (6.0 vs 5.0 mm, P < 0.001). Similar findings were also observed in 13 open-reduction hips (6.0 vs 5.0 mm, P = 0.023). CONCLUSIONS: Hip medial ultrasonography during the period of cast immobilization after reduction in children with DDH can objectively and quantitatively show the dynamic change of the distance between the femoral head and the acetabulum, and can be used to assess reduction of the hip and progression of femoral head docking. LEVEL OF EVIDENCE: Level II-prognostic study.

An Eastern Europe and Middle East multinational expert Delphi consensus study on the prevention, diagnosis, and treatment of developmental dysplasia of the hip before walking age.

PURPOSE: The incidence of developmental dysplasia of the hip (DDH) is higher in Eastern Europeans and Middle Easterners. This study aimed to establish consensus among experts in this geographical area on the management of DDH before walking age. METHODS: Fourteen experienced orthopedic surgeons agreed to participate in a four-round online consensus panel by the Delphi method. The questionnaire included 31 statements concerning the prevention, diagnosis, and treatment of DDH before walking age. RESULTS: Consensus was established for 26 (84%) of 31 statements. Hip ultrasonography is the proper diagnostic tool under six months in DDH; universal newborn hip screening between three and six weeks is necessary; positive family history, breech presentation, female gender, and postnatal swaddling are the most important risk factors; Ortolani, Barlow tests, and limitation of abduction are the most important clinical findings; Pavlik harness is the first bracing preference; some Graf type IIa hips and all Graf type IIb and worse hips need abduction bracing treatment; the uppermost age limit for closed and open reductions is 12 months and 12-24 months, respectively; anatomic reduction is essential in closed and open reductions, postoperative MRI or CT is not always indicated; anterior approach open reduction is better than medial approach open reduction; forceful reduction and extreme positioning of the hips (> 60° hip abduction) are the two significant risk factors for osteonecrosis of the femoral head. CONCLUSION: The findings of the present study may be useful for clinicians because a practical reference, based on the opinions of the multinational expert panel, but may not be applicable to all settings is provided.

Developmental Dysplasia of the Hip - Part 1 / Displasia do desenvolvimento do quadril - Parte 1

Abstract Developmental dysplasia of the hip (DDH) is a condition characterized by changes in joint formation within the last months of intrauterine life or the first months after birth. Developmental dysplasia of the hip presentation ranges from femoroacetabular instability to several stages of dysplasia up to complete dislocation. Early diagnosis is essential for successful treatment. Clinical screening, including appropriate maneuvers, is critical in newborns and subsequent examinations during the growth of the child. Infants with suspected DDH must undergo an ultrasound screening, especially those with a breech presentation at delivery or a family history of the condition. A hip ultrasound within the first months, followed by pelvic radiograph at 4 or 6 months, determines the diagnosis and helps follow-up. Treatment consists of concentric reduction and hip maintenance and stabilization with joint remodeling. The initial choices are flexion/abduction orthoses; older children may require a spica cast after closed reduction, with or without tenotomy. An open reduction also can be indicated. After 18 months, the choices include pelvic osteotomies with capsuloplasty and, eventually, acetabular and femoral osteotomies. The follow-up of treated children must continue throughout their growth due to the potential risk of late dysplasia.

Resumo O termo displasia do desenvolvimento quadril (DDQ) refere-se à condição na qual a articulação sofre alterações na sua formação durante os últimos meses da vida intrauterina ou nos primeiros meses após o nascimento. No espectro de apresentação, varia desde a instabilidade femuroacetabular, passando por estádios de displasia até a completa luxação. O diagnóstico precoce é fundamental para o sucesso do tratamento. A triagem através do exame clínico incluindo manobras apropriadas é imprescindível nos recém-nascidos e nas avaliações subsequentes durante o crescimento da criança. O rastreamento ultrassonográfico é indicado nos bebês sob suspeita clínica e muito mais recomendável naqueles que tiveram apresentação pélvica para o parto ou que tenham antecedentes familiares. A ultrassonografia do quadril nos primeiros meses seguida da radiografia da bacia após o 4° ou 6° mês de vida são os exames que determinam o diagnóstico e auxiliam o seguimento. O tratamento está baseado na obtenção de uma redução concêntrica e na manutenção e estabilização do quadril, propiciando a remodelação articular. Inicialmente, as órteses de flexão/abdução são a escolha; em crianças maiores pode ser necessário o uso de gesso após redução incruenta com ou sem tenotomia; redução aberta pode ser indicada e após os 18 meses as osteotomias pélvicas associadas a capsuloplastia e eventuais osteotomias acetabular e femoral. Crianças tratadas devem ser acompanhadas durante todo o seu crescimento pelo eventual risco de displasias tardias.

Clinical and sonographic improvement of developmental dysplasia of the hip: analysis of 948 patients.

BACKGROUND: Developmental dysplasia of the hip is a common condition, which varies in severity. Abduction treatment is widely used to correct the development of the hips, but mild forms of DDH can also recover spontaneously. The purpose of this study was to evaluate factors affecting the rate of improvement of developmental dysplasia of the hip, and evaluate any risk factors slowing the process. MATERIAL AND METHODS: The study population consisted of patients diagnosed with DDH in Tampere University hospital in the years 1998-2018. Data were retrospectively collected, and associations between clinical variables and rate of improvement were analyzed. Alpha angles were assessed monthly, and associations between risk factors and improvement of alpha angles were studied. A total of 948 patients were included in the analysis. RESULTS: More severe first status of the hips was associated with faster improvement in dynamic ultrasound compared to milder DDH in univariate design in first 3 months of age; in the multivariable design, Ortolani positivity was conversely associated with lower alpha angles in 1-month follow-up. Immediate abduction treatment was associated with faster recovery rate compared to delayed abduction or watchful waiting. Female sex and positive family history were associated with slower rate of improvement and lower alpha angles. In multivariable design, female sex, positive family history and treatment strategy remained statistically significant as initiation time of the treatment explained the first found association of clinical hip status and the recovery rate after 2 months of age. CONCLUSION: Female sex and positive family history might be independent risk factors for slower recovery in DDH before 6 months of age. These children might need special attention in their follow-up plans and abduction treatment.

Active monitoring versus immediate abduction as treatment of stable developmental dysplasia of the hip: a systematic review of the literature.

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.

Incidence of Neonatal Developmental Dysplasia of the Hip and Late Detection Rates Based on Screening Strategy: A Systematic Review and Meta-analysis.

Importance: Universal ultrasonographic screening for developmental dysplasia of the hip (DDH) has gained increasing popularity despite the lack of benefit in terms of reducing the rates of late-detected cases (age ≥12 weeks) in randomized clinical trials. Objective: To report the reported incidence of DDH in the English scientific literature and compare rates of late-detected cases in settings with different DDH screening strategies. Data Sources: PubMed, Scopus, and Web of Science databases were searched on November 25 and 27, 2021. No time filters were used in the search. Study Selection: All observational studies reporting the incidence of early-detected or late-detected (age ≥12 weeks) DDH were included. Non-English reports were excluded if the abstract did not include enough information to be included for analysis. Data Extraction and Synthesis: The number of newborns screened and the detection rates were extracted. Meta-analysis calculated the pooled incidence of DDH per 1000 newborns with 95% CIs using a random- or fixed-effects model. This study is reported according to the PRISMA and MOOSE guidelines. Main Outcomes and Measures: The main outcome measures were early detection, early treatment, late detection, and operative treatment incidences. Results: A total of 1899 studies were identified, 203 full texts were assessed, and 76 studies with 16 901 079 infants were included in final analyses. The early detection rate was 8.4 (95% CI, 4.8-14.8) infants with DDH per 1000 newborns with clinical screening, 4.4 (95% CI, 2.4-8.0) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 23.0 (95% CI, 15.7-33.4) infants with DDH per 1000 newborns with universal ultrasonographic screening. Rates for nonoperative treatment were 5.5 (95% CI, 2.1-14) treatments per 1000 newborns with clinical screening, 3.1 (95% CI, 2.0-4.8) treatments per 1000 newborns with selective ultrasonographic screening, and 9.8 (95% CI, 6.7-14.4) treatments per 1000 newborns with universal ultrasonographic screening. The incidence of late-detected DDH was 0.5 (95% CI, 0.2-1.5) infants with DDH per 1000 newborns with clinical screening, 0.6 (95% CI, 0.3-1.3) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 0.2 (95% CI, 0.0-0.8) infants with DDH per 1000 newborns with universal ultrasonographic screening. The corresponding incidences of operative treatment were 0.2 (95% CI, 0.0-0.9) operations per 1000 newborns with clinical screening, 0.5 (95% CI, 0.4-0.7) operations per 1000 newborns with selective ultrasonographic screening, and 0.4 (95% CI, 0.2-0.7) operations per 1000 newborns with universal ultrasonographic screening. Conclusions and Relevance: This meta-analysis found that early detection rates and nonoperative treatments were higher with universal screening. The late detection and operative treatment rates with universal screening were similar to those among selectively and clinically screened newborns. Based on these results, universal screening may cause initial overtreatment without reducing the rates of late detection and operative treatment.

A Global Survey of Patient and Caregiver Experiences Throughout Care for Developmental Dysplasia of the Hip.

BACKGROUND: Diagnosis and treatment for developmental dysplasia of the hip (DDH) varies greatly depending on condition severity, age at diagnosis, and professional opinion. Little is known about patient experiences across the globe. We aimed to characterize global patient and caregiver experiences during DDH care and to highlight patient-identified priorities. METHODS: We developed a cross-sectional survey in collaboration with 7 DDH outreach organizations. DDH patients and/or their caregivers (above 18 y old) were invited to complete an international online survey about their experiences. Participants were recruited through web media of all collaborating organizations. Data collection took place over 3 months. Descriptive statistics were used to analyze quantitative results. Qualitative content analysis was used to categorize open-ended responses. RESULTS: A total of 739 participants completed the survey, representing 638 (86.3%) parents/guardians of DDH patients, and 101 (13.7%) patients. Three hundred eighty-six (52.2%) participants received diagnosis by 3 months of age; mean age of diagnosis was 15.96 months (90% confidence interval=12.04, 19.91). Of 211 participants with family history of DDH, 68 (32.3%) did not receive DDH screening. Of 187 patients born breech, 82 (43.9%) did not receive DDH screening. In total, 36/94 (38.3%) participants with both family history and breech birth did not receive DDH screening. Most participants reported treatment (696/730, 95.3%), including bracing (n=461) surgery (n=364), and/or closed reduction (n=141). A total of 144 patients reported >1 surgery; 82 reported >3 surgeries. Participants reported a range of 1 to 400 visits to health care professionals for DDH care across 1 to 66 years. Lack of information and resources on treatment practicalities and timelines, along with emotional burden of diagnosis, were greatest challenges reported. CONCLUSION: Results demonstrate that DDH diagnosis and treatment can pose significant burden on patients and caregivers. Reliable public information is needed to support those affected. Global educational efforts are needed to raise awareness of DDH risk factors, signs, and symptoms among care providers, to increase awareness and improve identification, screening, and monitoring of at-risk children.

Displasia del desarrollo de la cadera: tamizaje y manejo en el lactante / Developmental dysplasia of the hip: screening and management in the infant

La displasia del desarrollo de la cadera comprende un conjunto de anormalidades que afectan la articulación coxofemoral: la displasia, subluxación y luxación de la cadera. El concepto de "displasia" describe anormalidades en la estructura femoral, acetabular o ambas. Corresponde a la patología ortopédica más frecuente del recién nacido y lactante, lo que genera mucha preocupación e intranquilidad entre los padres, en los primeros controles sanos de sus hijos. Es una patología en la que un diagnóstico oportuno y precoz son la clave para poder realizar un tratamiento efectivo, obteniendo como resultado una cadera clínica y radiológicamente normal al finalizar el desarrollo esquelético. Para esto es fundamental conocer la patología e ir activamente en su búsqueda. Actualmente existe mucha discusión sobre la manera de pesquisar esta patología. En Chile, se realiza tamizaje universal con imagen -radiografía de pelvis- a todos los niños a los 3 meses de edad. El objetivo de la siguiente revisión, es traer a la práctica clínica actual de todos aquellos profesionales que se enfrentan en distintos escenarios a esta patología: médicos de atención primaria, enfermeras, médicos en etapas de destinación y formación en distintas regiones del país, pediatras y ortopedistas, aquellas características y signos de sospecha propios de esta enfermedad y detallar las herramientas para un correcto diagnóstico y oportuno tratamiento.

Developmental dysplasia of the hip (DDH) comprises a set of abnormalities that affect the hip joint: hip dysplasia, subluxation, and dislocation. It is the most frequent orthopedic pathology of the newborn and infant, and it generates great concern among parents during the first health check-ups of their children. It is a condition in which a timely and early diagnosis is key to be able to carry out an effective treatment, obtaining as a result of a clinically and radiologically normal hip at the end of skeletal development. For this, it is essential to know this orthopedic condition and actively search for it. Currently, there is much discussion about how to screen DDH. In Chile, universal screening with imaging - pelvic radiography - is performed on all children at 3 months of age. The objective of the following review is to bring to the current clinical practice of all those professionals who face this pathology in different scenarios: primary care physicians, nurses, physicians in training stages in different regions of the country, pediatricians and orthopedic surgeons, signs of suspicion typical of the disease and detail the assessment tools for a correct diagnosis and timely treatment.

Morphological variants to predict outcome of avascular necrosis in developmental dysplasia of the hip.

AIMS: The most important complication of treatment of developmental dysplasia of the hip (DDH) is avascular necrosis (AVN) of the femoral head, which can result in proximal femoral growth disturbances leading to pain, dysfunction, and eventually to early onset osteoarthritis. In this study, we aimed to identify morphological variants in hip joint development that are predictive of a poor outcome. METHODS: We retrospectively reviewed all patients who developed AVN after DDH treatment, either by closed and/or open reduction, at a single institution between 1984 and 2007 with a minimal follow-up of eight years. Standard pelvis radiographs obtained at ages one, two, three, five, and eight years, and at latest follow-up were retrieved. The Bucholz-Ogden classification was used to determine the type of AVN on all radiographs. Poor outcome was defined by Severin classification grade 3 or above on the latest follow-up radiographs and/or the need for secondary surgery. With statistical shape modelling, we identified the different shape variants of the hip at each age. Logistic regression analysis was used to associate the different modes or shape variants with poor outcome. RESULTS: In all, 135 patients with AVN were identified, with a minimum of eight years of follow-up. Mean age at time of surgery was 7.0 months (SD 0.45), and mean follow-up was 13.3 years (SD 3.7). Overall, 46% had AVN type 1 while 54% type 2 or higher. More than half of the patients (52.6%) had a poor outcome. We found 11 shape variants that were significantly associated with a poor outcome. These shape variants were predominantly linked to AVN type 2 or higher. CONCLUSION: Specific morphological characteristics on pelvis radiographs of AVN hips were predictive for poor outcome, at a very young age. There was an overall stronger association to Bucholz-Ogden types 2-3-4 with the exception of two modes at age two and five years, linked to AVN type 1. Cite this article: Bone Joint J 2021;103-B(5):999-1004.

Timing of Repeat Ultrasound Examination in Treatment of Stable Developmental Dysplasia of the Hip.

BACKGROUND: Worldwide a wide variation exists in duration of Pavlik harness treatment for infants up to 6 months with stable developmental dysplasia of the hip (DDH). The purpose of this study was to evaluate whether shortening the time to first routine follow-up ultrasound after initiation of Pavlik harness treatment would reduce treatment duration and whether this influenced radiologic outcome at 1 year of age. Furthermore, predictors of higher acetabular index (AI) at 1 year of age were investigated. METHODS: A retrospective study was conducted in infants with stable DDH (Graf IIb and IIc) diagnosed and treated between 2015 and 2017. Two groups were identified: first routine follow-up ultrasound at 12 weeks after Pavlik harness initiation (group I) and first routine follow-up ultrasound at 6 weeks after Pavlik harness initiation (group II). In both groups, treatment was continued until repeat ultrasound measurements (every 6 wk) showed a normalized hip. Radiologic outcome at 1 year of age was defined as residual dysplasia measured on an anteroposterior hip radiograph according to the Tönnis table. RESULTS: A total of 222 infants were included. The median time of Pavlik harness treatment was 12 weeks (interquartile range, 11.9 to 12.3) in group I compared with 6.1 weeks (interquartile range, 6.0 to 7.5) in group II (P<0.001). Residual dysplasia at 1 year of age was detected in 20 infants (16.8%) in group I compared with 11 infants (10.7%) in group II (P=0.189). The multivariable prediction model showed that positive family history and lower baseline alpha angle correlate with a higher AI at 1 year of age. CONCLUSIONS: First routine follow-up ultrasound can be safely brought forward from 12 to 6 weeks after Pavlik harness initiation. Furthermore, infants with a positive family history for DDH and an initial low alpha angle are at higher risk to have a higher AI at 1 year of age. LEVEL OF EVIDENCE: Level III-retrospective study.

Consistency of Indices Obtained via Hip Medial Ultrasound and Magnetic Resonance Imaging in Reduction and Spica Cast Treatment for Developmental Dysplasia of the Hip.

Children younger than 18 mo with developmental dysplasia of the hip (DDH) were treated with reduction and spica cast. X-Ray, computed tomography or magnetic resonance imaging (MRI) was used to evaluate reduction effectiveness. This study explored the hip medial ultrasonography method and anatomic structure sonograms. Twenty-eight children with DDH were enrolled. A total of 51 hips (24 left hips /27 right hips) were measured, including 30 affected hips and 21 normal hips. Various indices, including femoral head diameter (DIA), triradiate cartilage-femoral distance (TFD), acetabular-femoral distance (AFD) and ilium-femoral distance (IFD), were measured in the acetabular median coronal plane of ultrasound and the median coronal plane of MRI. The intra-group correlation coefficients for DIA, TFD, AFD and IFD were 0.968 (95% confidence interval: 0.917-0.985), 0.959 (0.929-0 976), 0.923 (0.869-0.955) and 0.950 (0914-0.971), respectively. Hip medial ultrasound and MRI exhibited good consistency. It is feasible to use hip medial ultrasound to evaluate the reduction of DDH in infants and children after spica cast.

Team Approach: Developmental Dysplasia of the Hip.

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of hip disorders, including neonatal instability, acetabular dysplasia, hip subluxation, and frank dislocation of the hip. It is a common disorder, with a reported incidence of between 0.1% and >10% of live births. Coordinated, interdisciplinary care is important to achieving successful outcomes. This starts with accurate assessment of risk factors in the prenatal period, thorough clinical examination by the primary care provider at all well-child visits, and early referral to a pediatric orthopaedic surgeon for prompt diagnosis and treatment. Early diagnosis and prompt treatment is critical for an excellent outcome. Ongoing, open communication between clinicians is essential for the effective coordination of care. Treatment options vary depending on the age of presentation. A Pavlik harness (dynamic hip abduction orthosis) is used for children up to 6 months of age. A more rigid abduction orthosis may be used if treatment with a Pavlik harness is unsuccessful, with a closed reduction and spica cast being the next step if needed for children up to 18 months of age. Finally, open reduction with possible concomitant femoral and/or pelvic osteotomies is the surgical option in an older child, when necessary. In general, the later the child is diagnosed with and treated for DDH, the greater the risk of a nonoptimal outcome. Depending on the severity of the condition, children with DDH may need to be followed closely until skeletal maturity so as not to miss the diagnosis of asymptomatic residual hip dysplasia, which can predispose patients to early hip arthritis.

Closed Reduction in Developmental Dysplasia of the Hip in Patients Older than One Year.

INTRODUCTION: Besides an effective screening method for developmental dysplasia of the hip, there is certain number of children in whom the condition has been overseen or they have never been screened and the parents have noticed the odd walking pattern in their toddler. Treatment of such patients is controversial. One of the recommended treatment methods because of the short-term hospitalization, but often considered unsuccessful is closed reduction of the hip followed by cast immobilization. HYPOTHESIS: Closed hip reduction in late diagnosed developmental dysplasia of the hip gives good results. AIM: Our aim in this retrospective study was evaluation of the success of the treatment with closed reduction of hip dislocation in children older than 12 months. PATIENTS AND METHODS: In the study, we included 20 patients treated at our clinic from June 2004 to May 2017. Of these 20 patients, 8 had bilateral involvement, 12 had unilateral, in a total of 28 hips. In all patients we noted preoperatively the range of movement, the presence of limp, any limb inequality, and hip pain. We used clinical and radiological parameters for evaluation. Clinically, we examined the range of movement, limb inequality as well as limb function and we classified it according to the modified McKay's criteria. Same examinations were done at 1, 3, and 5 years after closed reduction. RESULTS: At the last follow-up examination, using McKey's criteria for clinical evaluation we rated the hips in two patients (7%) as grade III, i.e. fair grade, 10 hips (36%) were grade II - rated good, and 16 hips (57%) were evaluated as grade I. In four hips, there were signs of avascular necrosis of the hip, while in one patient the avascular necrosis developed after the closed reduction. Radiographic assessment (Figs 3, 4) using Severin's scoring system showed no hips with types V and VI, type IV was observed in 7%, type III in 21%, type II in 29%, while most of the hips (12, 43%) were type I. CONCLUSION: We concluded that the procedure was justified. An advantage of this method is that it is inexpensive; it entails no direct operative changes of the bone structures and gives good results.

Significance of Asymmetry of Groin and Thigh Skin Creases in Developmental Dysplasia of the Hip Revisited: Results of a Comparative Study.

BACKGROUND: No high level of scientific evidence exists about the use of asymmetry of skin creases (ASC) on the groin and thigh regions in diagnosing developmental dysplasia of the hip. The aim of this comparative study was to revisit whether or not ASC was a significant clinical finding in developmental dysplasia of the hip. METHODS: This was retrospective analysis of a prospectively collected data. Control group was composed of 1000 consecutive healthy infants (mean age, 46.7 d) whose both hips were considered Graf type I (normal). Study group (SG) was composed of 246 consecutive patients (mean age, 96.5 d) whose treatments by abduction bracing were initiated due to unilateral or bilateral Graf type IIa(-) and worse hips. RESULTS: SG included 178 patients with bilateral or unilateral dysplastic hips [Graf type IIa(-), IIb, IIc] and 68 patients with at least 1 decentered hip (Graf type D, III, IV). ASC was seen in 63 of 101 patients (63%) having positive clinical finding(s). The rates of both ASC alone (P<0.001; odds ratio, 3.46) and ASC total (ASC with and without additional findings) (P<0.0001; odds ratio, 7.48) were significantly higher in SG than in control group. ASC was the only clinical finding in 31 patients and 24 of these 31 patients (77%) had unilateral or bilateral dysplastic hips. Sensitivity and specificity of ASC alone were 12.60% and 96.00%, respectively. ASC was accompanied by other clinical findings (mostly Galeazzi sign and limitation of abduction) in 32 patients and 23 of these 32 patients (72%) had at least 1 decentered hip. Sensitivity and specificity of ASC total were 25.61% and 95.60%, respectively. CONCLUSIONS: ASC is a significant finding, as there is considerable increased risk of having dysplastic or decentered hips in infants having such a finding alone or associated with other findings. ASC alone is more commonly seen in patients with dysplastic hip(s) whereas ASC is mostly accompanied with other clinical finding(s) in patients with decentered hip(s). This study shows that, ASC can be introduced as a risk factor in selected newborn hip screening programs. LEVEL OF EVIDENCE: Level II-diagnostic study.

Evaluation of primary care 6- to 8-week hip check for diagnosis of developmental dysplasia of the hip: a 15-year observational cohort study.

BACKGROUND: The current 6- to 8-week Newborn and Infant Physical Examination (NIPE) clinical assessment is a current standard hip-screening test in the community (England) to detect developmental dysplasia of the hip (DDH). AIM: To assess the value of the primary care 6- to 8-week clinical hip examination for the diagnosis of DDH. DESIGN AND SETTING: A single-centre 15-year observational cohort study at a district general hospital between 1 January 1996 and 31 December 2010. METHOD: Those referred by the GP or community practitioner with suspected instability or abnormality of the hip joint (DDH), were clinically and sonographically examined in a specialist hip-screening clinic. Modified Graf Type III and IV, and radiological irreducible hip dislocation were considered to be 'pathological' hips. Screening failures were defined as those who had not been identified by this primary care screening assessment (but had irreducible hip dislocation). Secondary univariate and multivariable analyses were performed to determine which clinical findings are predictive of instability. RESULTS: Over the study period, there were 70 071 infants who underwent the 6- to 8-week clinical hip assessment. In the specialist hip-screening clinic, six (from the 170 referred) were diagnosed with pathological DDH. The sensitivity, specificity, positive predictive value, and negative predictive value for the 6- to 8-week clinical hip assessment were 16.7%, 99.8%, 3.5%, and 100.0%, respectively. A multivariable model showed a positive Ortolani manoeuvre to be the sole independent predictor of instability at 6 to 8 weeks. CONCLUSION: This 15-year study highlights the limitations of a hip check at 6 to 8 weeks. These findings support the reassessment of the national guidelines for this aspect of the NIPE DDH screening programme.

Discrepancy between ultrasonographic and radiographic findings in patients treated for developmental dysplasia of the hip; hip maturation on ultrasonography may not be consistent with radiographic hip maturation.

Currently, hip sonography is used for early diagnosis and for monitoring developmental dysplasia of the hip (DDH) treatment in many countries. An early pioneer of ultrasonography for early diagnosis of DDH was Graf. Based on the Graf approach, hip ultrasonography is more sensitive and specific than radiography for the diagnosis of DDH, because of its capability to show cartilaginous structures of the hip joint. The aim of this study was to compare radiographic and ultrasonographic findings in patients treated for DDH. This study included 88 infants (98hips) treated for DDH. Radiography was simultaneously used for treatment and follow-up evaluation in addition to ultrasonography after six months of age. A retrospective evaluation was made of the ultrasonographs and radiographs of these infants. Of the total 98 hips, 28 were normal both ultrasonographically and radiographically, and a pathologic hip was demonstrated in 32 hips both sonographically and radiographically. Hip ultrasonography showed abnormal development in 32 hips, while radiography showed abnormal development in 70 hips. In 38 hips, the findings were normal according to ultrasonography but pathological according to radiography. There were no hips that were normal radiographically but pathological sonographically. When radiography is accepted as the standard imaging method in our study patients, the sensitivity and specificity of hip ultrasonography were determined as 45.7% [95% confidence interval (CI): 41.5-45.7] and 100% (95% CI: 89.4-100), respectively. These findings suggest that hip maturation apparent on ultrasonography may not be consistent with radiographic hip development in infants treated for DDH.

Transgluteal ultrasonography in spica cast in postreduction assessment of developmental dysplasia of the hip.

PURPOSE: The position of the femoral head in spica cast after the reduction of developmental dysplasia of the hip (DDH) should be examined and followed up closely and regularly. The study aimed to use the transgluteal ultrasonography approach for this purpose and compare its accuracy with the results of CT scan, which is the most commonly used modality. METHODS: Twenty-three patients with an average age of 20-21 months were examined for 1 year after the reduction of DDH, both closed and open. Ultrasonography and CT scan were performed on the patients on the same day, and the results were interpreted by different radiologists. Transgluteal ultrasonography in spica cast was performed while the legs were abducted, internally rotated, and flexed. A blanket was placed under the patient to elevate the cast. RESULTS: Thirty cases of proper reduction (81%) and 7 cases of dislocated hip (19%) were reported in transgluteal ultrasonography, and 29 cases of proper reduction (78%) and 8 cases of dislocated hip (22%) were reported in the CT scan. The rate of agreement between the results of ultrasonography and CT scan was 91%. CONCLUSION: Transgluteal ultrasonography can be used as an excellent modality to examine the position of the femoral head in relation to the posterior rim of the acetabulum in spica cast. The position of the femoral head can be viewed properly needless of perineal opening in the cast. Thus, transgluteal ultrasonography can replace the CT scan to assess the position of the femoral head. Sonography does not expose patients to radiation and does not require sedation.