Timely radiographic detection of developmental dysplasia of the hip in family medicine residents. Educative intervention.

BACKGROUND: Developmental dysplasia of the hip (DDH) is a complex clinical entity that is usually underdiagnosed, if not detected and managed early, will turn the affected individual into a disabled being, with negative social, economic and emotional effects. OBJECTIVE: To determine the capacity for the timely radiographic detection of DDH before and after an educational intervention. METHOD: An educational intervention is carried out in family medicine resident, where they are given training on detection in DDH radiographic projections. Pre- and post-training evaluation is carried out. Statistical analysis is performed using Student's t and χ2, taking p ≤ 0.05 as significant. RESULTS: 94 residents participated. In the pre-intervention evaluation, 87.2% had no knowledge of the early detection protocol (p = 0.525). It was observed that 98.9% incorrectly drew the Perkins line (p = 0.427), 96.8% the Hilgenreiner line (p = 0.177) and 87.2% did not consider the data of bilateral dysplasia (p = 0.956). After the educational intervention, 87.2% correctly drew the Perkins line (p = 0.926), 97.8% the Hilgenreiner line (p = 0.325) and 78.7% if they considered the data of bilateral dysplasia (p = 0.826). CONCLUSIONS: After this training, 80% of family medicine residents were able to detect DDH in a timely manner.

ANTECEDENTES: La displasia del desarrollo de la cadera (DDC) constituye una entidad clínica compleja que suele ser infradiagnosticada que, de no ser precozmente detectadas y manejadas, convertirán al individuo afectado en un ser discapacitado, con efecto negativo social, económico y emocional. OBJETIVO: Determinar la capacidad para la detección radiográfica oportuna de la DDC antes y después de una intervención educativa en médicos residentes de medicina familiar. MÉTODO: Se realizó una intervención educativa en residentes de medicina familiar, en la que se les dio capacitación sobre detección de DDC en proyecciones radiográficas. Se realizó una evaluación previa y posterior a la capacitación. El análisis estadístico se realizó mediante pruebas t de Student y χ2, tomando como significativo un valor de p ≤ 0.05. RESULTADOS: Participaron 94 residentes. El 87.2% dijeron no conocer el protocolo radiológico de detección. En la evaluación preintervención, el 87.2% no tenían conocimiento del protocolo (p = 0.525). Se observó que el 98.9% trazaron de manera incorrecta la línea de Perkins (p = 0.427), el 96.8% la línea de Hilgenreiner (p = 0.177) y el 87.2% no consideraron los datos de displasia bilateral (p = 0.956). Posterior a la intervención educativa, el 87.2% trazaron de manera correcta la línea de Perkins (p = 0.926), el 97.8% la línea de Hilgenreiner (p = 0.325) y el 78.7% sí consideró los datos de displasia bilateral (p = 0.826). CONCLUSIONES: Tras la capacitación, el 80% de los médicos residentes de medicina familiar fueron capaces de detectar oportunamente la DDC.

Analysis of the epidemiological profile of congenital hip deformities, 2011-2021.

OBJECTIVE: This study aimed to identify the relevance of hospitalizations for congenital hip deformities in Bahia. METHODS: This is a retrospective epidemiological study in public databases. Descriptors in health sciences: "congenital hip dysplasia", "congenital hip dislocation", and "congenital dislocation hip". This is qualitative-quantitative research with the analysis of secondary data and cross-sectional typologies in the databases of the Ministry of Health - Health Information (TABNET), made available by the Department of Informatics of the Unified Health System (DATASUS). RESULTS: Bahia was the third Brazilian state with the highest number of hospitalizations, registering 1481 cases. The municipalities in Bahia with the highest prevalence were Itanhém, Salvador, and Barreiras, with 912, 445, and 20 cases, respectively. CONCLUSIONS: The elevated number of congenital hip deformities reflects a public health problem, requiring investments in public policies.

[Application of the Graf method for diagnosis and early detection of hip dysplasia]. / Aplicación del método de Graf para el diagnóstico y tratamiento oportuno de displasia de cadera.

INTRODUCTION: Developmental hip dysplasia (DHD) is the most common disorder affecting pediatric hip; screening all neonates clinically, and using ultrasonography selectively for those babies who are at high risk is a widespread recommendation. our goal is to evaluate the impact that USG diagnosis and early treatment of DHD has had on the child population of our unit. MATERIAL AND METHODS: Retrospective, descriptive and cross-sectional study. Records of those children from one to six months of age, with a diagnosis of DHD, without distinction of sex, subjected to ultrasonographic tracking in the period from January 2018 to December 2019 were reviewed. A follow-up of six months was carried out in all patients, from the moment of diagnosis and the start of treatment with harness, weekly visits for relocation, as well as ultrasonographic revision every four weeks to monitor the treatment. RESULTS: 19 cases were reported from the left side (47.5%), 10 cases from the right side (25%) and 11 bilateral cases (27.5%). The main associated risk factors were: product of the first pregnancy, family history of DHD, pelvic presentation, female sex. The results were favorable with a continuous use of harness of 23 hours observing a satisfactory evolution in 99.2% of the patients. CONCLUSION: With the results obtained we can analyze the considerable success rate of the hip clinic of our hospital with the realization of the ultrasound, we find a lower incidence of patients with pain, limitation of function, as well as satisfactory gait patterns.

INTRODUCCIÓN: La displasia del desarrollo de cadera (DDC) es el trastorno más común que afecta la cadera pediátrica; hacer tamizaje a todos los neonatos en forma clínica y utilizar ultrasonografía en forma selectiva para aquellos bebés que se encuentran con alto riesgo es una recomendación muy difundida. Nuestro objetivo es evaluar el impacto que ha tenido el diagnóstico por ultrasonografía (USG) y tratamiento temprano de la DDC en la población infantil de nuestra unidad. MATERIAL Y MÉTODOS: Estudio retrospectivo, descriptivo y transversal. Se revisaron expedientes de aquellos niños de uno a seis meses de edad, con diagnóstico de DDC, sin distinción de sexo, sometidos a rastreo ultrasonográfico en el período de Enero de 2018 a Diciembre de 2019. Se realizó un seguimiento de seis meses en todos los pacientes, a partir del momento del diagnóstico y del inicio de tratamiento con arnés, visitas semanales para recolocación, así como realización de rastreos ultrasonográficos cada cuatro semanas para monitorización del tratamiento. RESULTADOS: Se reportaron 19 casos del lado izquierdo (47.5%), 10 casos del lado derecho (25%) y 11 casos bilaterales (27.5%). Los principales factores de riesgo asociados fueron: producto de la primera gesta, antecedentes familiares de DDC, presentación pélvica, sexo femenino. Los resultados fueron favorables con un uso continuo de arnés de 23 horas, se observó una evolución satisfactoria en 99.2% de los pacientes. CONCLUSIÓN: Con los resultados obtenidos podemos analizar la tasa de éxito considerable de la clínica de cadera de nuestro hospital con la realización del ultrasonido, encontramos una menor incidencia de pacientes con dolor, limitación de la función, así como patrones de marcha satisfactorios.

Ultrasound techniques for the detection of developmental dysplasia of the hip: a systematic review and meta-analysis.

BACKGROUND: Developmental dysplasia of the hip (DDH) encompasses a broad spectrum of hip pathologies, including femoral or acetabular dysplasia, hip instability, or both. According to the medical literature, ultrasonography is the most reliable diagnostic method for DDH. Several techniques for the assessment of hips in newborns and infants, using ultrasonography, have been described. OBJECTIVE: To compare the accuracy of the Graf technique and other diagnostic techniques for DDH. DESIGN AND SETTING: A systematic review of studies that analyzed ultrasound techniques for the diagnosis of DDH within an evidence-based health program of a federal university in São Paulo (SP), Brazil. METHODS: A systematic search of relevant literature was conducted in the PubMed, EMBASE, Cochrane Library, CINAHL, and LILACS databases for articles published up to May 5, 2020, relating to studies evaluating the diagnostic accuracy of different ultrasound techniques for diagnosing DDH. The QUADAS 2 tool was used for methodological quality evaluation. RESULTS: All hips were analyzed using the Graf method as a reference standard. The Morin technique had the highest rate of sensitivity, at 81.12-89.47%. The Suzuki and Stress tests showed 100% specificity. The Harcke technique showed a sensibility of 18.21% and specificity of 99.32%. CONCLUSION: All the techniques demonstrated at least one rate (sensibility and specificity) lower than 90.00% when compared to the Graf method. The Morin technique, as evaluated in this systematic review, is recommended after the Graf method because it has the highest sensitivity, especially with the three-pattern classification of 89.47%. REGISTRATION NUMBER: Identifier: CRD42020189686 at the International Prospective Register of Systematic Reviews (identifier: CRD42020189686).

Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatricians.

OBJECTIVE: To evaluate the decision making processes of pediatricians regarding diagnosis and management of developmental dysplasia of the hip (DDH) by conducting a survey of pediatricians in the United States. STUDY DESIGN: An electronic survey was sent to multiple American Academy of Pediatrics state chapters and academic pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, guideline use, clinical scenarios, and referrals/imaging practices. The number of responses to each survey question and their relative frequencies were calculated. RESULTS: We received 139 responses and included 126 in our analyses. Only 50% of the responding pediatricians (63 of 126) practiced in an institution that endorses a care pathway for DDH. Only 5.6% of the pediatricians (7 of 125) have referred patients at 12-18 months between diagnosis and management to a specialist for suspected DDH, and 9.5% (12 of 125) have referred patients between 6 and 9 months. Almost one-quarter of the pediatricians (23%; 29 of 126) cited "hip click" as an abnormality that would prompt them to refer a patient to a specialist, and 72.2% (91 of 126) indicated that family history of DDH warrants an ultrasound regardless of the physical examination findings. Moreover, 10.3% of the surveyed pediatricians (13 of 126) reported being only "somewhat" or "moderately" familiar with the Barlow and Ortolani maneuvers. CONCLUSIONS: The results of this study indicate that there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatrician respondents who would not refer patients to a specialist or order imaging studies appropriately represents an opportunity for education. The implementation of a care map with standard referral and imaging practices could improve the care of patients with DDH.

[Age of initiation of treatment for hip dysplasia with Pavlik harness and residual dysplasia]. / Edad de inicio del tratamiento de la displasia de caderas con correas de Pavlik y displasia residual.

The successful treatment of hip dysplasia consists of achieving a concentric reduction and avoiding residual dysplasia. One of the essential factors is early diagnosis and treatment. OBJECTIVE: Evaluate the relationship between the age at initiation of hip dysplasia treatment and the presence of residual dysplasia at one year of age. PATIENTS AND METHOD: Prognostic retrospective study. Patients with hip dysplasia treated with Pavlik harness in a tertiary healthcare center were selected. Residual dyspla sia was defined as an acetabular index greater than 28 degrees at one year of age. An association of residual dysplasia with the age at treatment initiation, bilaterality, and acetabular index more than 36 degrees was determined. The T-Student, Chi-Square, and Youden index tests were used. A p- value < 0.05 was considered significant. The STATA v.16 software was used. RESULTS: 153 patients (262 hips) were included, 84.3% (129) were females, and 71.2% (109) presented bilateral dysplasia. Fifty-nine hips (22.52%) presented residual dysplasia, finding a significant association with the age at treatment initiation (p = 0.03), bilateral dysplasia (p < 0.01), and acetabular index greater than 36 degrees (p = 0.01). Starting treatment after 4.5 months increases the risk of residual dysplasia by 2.5 times (95% CI 1.25-5.03). CONCLUSION: An increase in residual dysplasia was observed at the start of treatment after 4.5 months. It is relevant to consider this result in local clinical guidelines to achieve a successful diagnosis and treatment.

Measurement of Pubofemoral Distance in the Diagnosis of Developmental Dysplasia of the Hip: Sensitivity and Specificity.

OBJECTIVES: To evaluate the accuracy of measurement of the pubofemoral distance (PFD) for the diagnosis of developmental dysplasia of the hip (DDH), using the Graf method as the reference standard. METHODS: This was a prospective diagnostic accuracy study evaluating 1980 hips in at-risk neonates. The PFD measurement and the Graf method were performed at the same opportunity, with the hips in the same position (slightly flexed, adducted, and medially rotated). RESULTS: In our sample, the prevalence of DDH, defined as Graf type IIb or higher, was 15.6%. The mean PFD for dysplastic hips was 3.5 mm (median, 3.3 mm), whereas it was 3.0 mm (median, 2.9 mm) for nondysplastic hips. In both groups, there was a significant overlap between the PFD measurements and the Graf classifications. The PFD cutoff with the largest area under the receiver operating characteristic curve was 3.0 mm, which was found to have a sensitivity and specificity of 63.6 and 62.2%, respectively, with positive and negative predictive values of 31.2 and 71.4%, respectively, for the diagnosis of DDH. CONCLUSION: Measurement of the PFD shows good overall accuracy for the diagnosis of DDH. However, given its low-positive predictive value, it should not be considered to be a replacement for the Graf method.

Is There a Benefit to Weaning Pavlik Harness Treatment in Infantile DDH?

BACKGROUND: Following successful treatment of developmental hip dysplasia with a Pavlik harness, controversy exists over the benefit of continued harness use for an additional "weaning" period beyond ultrasonographic normalization versus simply terminating treatment. Although practitioners are often dogmatic in their beliefs, there is little literature to support the superiority of 1 protocol over the other. The purpose of this study was to compare the radiographic outcomes of 2 cohorts of infants with developmental hip dysplasia treated with Pavlik harness, 1 with a weaning protocol and 1 without. METHODS: This was a comparative review of patients with dislocated/reducible hips and stable dysplasia from 2 centers. All patients had pretreatment ultrasounds, and all started harness treatment before 3 months of age. On the basis of power analysis, a sufficient cohort of hips were matched based on clinical examination, age at initiation, initial α angle, and initial percent femoral head coverage. Patients from institution W (weaned) were weaned following ultrasonographic normalization, whereas those from institution NW (not weaned) immediately ceased treatment. The primary outcome was the acetabular index at 1 year of age. RESULTS: In total, 16 dislocated/reducible and 16 stable dysplastic hips were matched at each center (64 total hips in 53 patients). Initial α angle and initial femoral head coverage were not different between cohorts for either stable dysplasia (P=0.59, 0.81) or dislocated/reducible hips (P=0.67, 0.70), respectively. As expected, weaned hips were treated for significantly longer in both the stable dysplasia (1540.4 vs. 1066.3 h, P<0.01), and dislocated/reducible cohorts (1596.6 vs. 1362.5 h, P=0.01). Despite this, we found no significant difference in the acetabular index at 1 year in either cohort (22.8 vs. 23.1 degrees, P=0.84 for stable dysplasia; 23.9 vs. 24.8 degrees, P=0.32 for Ortolani positive). CONCLUSIONS: Despite greater total harness time, infants treated with additional Pavlik weaning did not demonstrate significantly different radiographic results at 1 year of age compared with those who were not weaned. However, differences in follow-up protocols between centers support the need for a more rigorous randomized controlled trial. LEVEL OF EVIDENCE: Level III.

Periacetabular osteotomy with concomitant hip arthroscopy: A case series with 24 months minimum follow-up.

PURPOSE: To describe patient-reported outcomes, radiological results, and revision to total hip replacement in patients with hip dysplasia that underwent periacetabular osteotomy as isolated treatment or concomitant with hip arthroscopy. METHODS: Case series study. Between 2014 and 2017, patients were included if they complained of hip pain and had a lateral center-edge angle ≤ of 20°. Exclusion criteria included an in-maturate skeleton, age of 40 or older, previous hip surgery, concomitant connective tissue related disease, and Tönnis osteoarthritis grade ≥ 1. All patients were studied before surgery with an anteroposterior pelvis radiograph, false-profile radiograph, and magnetic resonance imaging. Magnetic resonance imaging was used to assess intraarticular lesions, and if a labral or chondral injury was found, concomitant hip arthroscopy was performed. The non-parametric median test for paired data was used to compare radiological measures (anterior and lateral center-edge angle, Tönnis angle, and extrusion index) after and before surgery. Survival analysis was performed using revision to total hip arthroplasty as a failure. Kaplan Meier curve was estimated. The data were processed using Stata. RESULTS: A total of 15 consecutive patients were included; 14 (93%) were female patients. The median follow-up was 3.5 years (range, 2 to 8 years). The median age was 20 (range 13 to 32). Lateral center-edge angle, Tönnis angle, and extrusion index correction achieved statistical significance. Seven patients (47%) underwent concomitant hip arthroscopy; three of them (47%) were bilateral (10 hips). The labrum was repaired in six cases (60%). Three patients (15%) required revision with hip arthroplasty, and no hip arthroscopy-related complications are reported in this series. CONCLUSION: To perform a hip arthroscopy concomitant with periacetabular osteotomy did not affect the acetabular correction. Nowadays, due to a lack of conclusive evidence, a case by case decision seems more appropriate to design a comprehensive treatment.

OBJETIVO: Describir los resultados funcionales, radiológicos y la tasa revisión a artroplastia total de cadera en una cohorte de pacientes con displasia de cadera que requirió osteotomía periacetabular como tratamiento aislado o concomitante con artroscopia de cadera. MÉTODO: Estudio de series de casos. Fueron incluidos pacientes intervenidos quirúrgicamente entre 2014 y 2017. Los criterios de inclusión fueron dolor en la cadera y un ángulo lateral de centro borde ≤ 20°. Los criterios de exclusión fueron esqueleto maduro, edad de 40 años o más, cirugía previa de cadera, enfermedad concomitante relacionada con el tejido conectivo y coxartrosis grado ≥ 1 de Tönnis. Todos los pacientes fueron estudiados antes de la cirugía con una radiografía anteroposterior de pelvis, radiografía de falso perfil y resonancia magnética. En caso de pesquisar una lesión intrarticular en resonancia magnética se realizó una artroscopia concomitante a osteotomía periacetabular. La prueba mediana no paramétrica para datos no pareados se utilizó para comparar medidas radiológicas (ángulo del borde central anterior y lateral, ángulo de Tönnis e índice de extrusión) antes y después de la cirugía. El análisis de sobrevida se realizó utilizando la revisión de la artroplastia total de cadera como fracaso. Se estimó la curva de Kaplan Meier. Los datos se procesaron con Stata. RESULTADOS: Fueron incluidos un total de 15 pacientes consecutivos; Siete pacientes (47%) se sometieron a artroscopia de cadera concomitante, tres de ellos (47%) fueron bilaterales (10 caderas). La mediana de seguimiento fue de 3.5 años (rango, 2 a 8 años). La mediana de edad fue de 20 (rango 13 a 32). El ángulo de cobertura lateral preoperatorio era de 12° (rango, -29° a 19°) y posterior a la cirugía fue de 25° (rango, 8° a 34°), logrando una mediana de corrección de 16° (rango, 7° a 53°). El labrum fue reparado en seis casos (60%). Tres pacientes (15%) requirieron revisión con artroplastia de cadera, y no se informan complicaciones relacionadas con la artroscopia en esta serie. CONCLUSIÓN: Realizar una artroscopia concomitante con osteotomía periacetabular no afectó la corrección acetabular, ni el resultado clínico. Hoy en día, debido a la falta de evidencia concluyente, el realizar una artroscopía es una decisión que debe ser tomada caso a caso para un tratamiento integral.

Periacetabular osteotomy with concomitant hip arthroscopy: a case series with 24 months minimum follow-up

PURPOSE To describe patient-reported outcomes, radiological results, and revision to total hip replacement in patients with hip dysplasia that underwent periacetabular osteotomy as isolated treatment or concomitant with hip arthroscopy. METHODS Case series study. Between 2014 and 2017, patients were included if they complained of hip pain and had a lateral center-edge angle ≤ of 20°. Exclusion criteria included an in-maturate skeleton, age of 40 or older, previous hip surgery, concomitant connective tissue related disease, and Tönnis osteoarthritis grade ≥ 1. All patients were studied before surgery with an anteroposterior pelvis radiograph, false-profile radiograph, and magnetic resonance imaging. Magnetic resonance imaging was used to assess intraarticular lesions, and if a labral or chondral injury was found, concomitant hip arthroscopy was performed. The non-parametric median test for paired data was used to compare radiological measures (anterior and lateral center-edge angle, Tönnis angle, and extrusion index) after and before surgery. Survival analysis was performed using revision to total hip arthroplasty as a failure. Kaplan Meier curve was estimated. The data were processed using Stata. RESULTS A total of 15 consecutive patients were included; 14 (93%) were female patients. The median follow-up was 3.5 years (range, 2 to 8 years). The median age was 20 (range 13 to 32). Lateral center-edge angle, Tönnis angle, and extrusion index correction achieved statistical significance. Seven patients (47%) underwent concomitant hip arthroscopy; three of them (47%) were bilateral (10 hips). The labrum was repaired in six cases (60%). Three patients (15%) required revision with hip arthroplasty, and no hip arthroscopy-related complications are reported in this series. CONCLUSION To perform a hip arthroscopy concomitant with periacetabular osteotomy did not affect the acetabular correction. Nowadays, due to a lack of conclusive evidence, a case by case decision seems more appropriate to design a comprehensive treatment.

Single-incision Extraperiosteal Triple Innominate Osteotomy: Outcomes of an Updated Technique.

BACKGROUND: Since its original description, the triple pelvic osteotomy has undergone several modifications and refinements most often utilizing 3 or 2 incisions. Recently, a single-incision extraperiosteal technique has been described; however, little data exist on the outcomes of this procedure. METHODS: All patients undergoing single-incision triple osteotomy from 2 centers were retrospectively reviewed. Demographic data, underlying diagnosis, and preoperative radiographic data were recorded. Intraoperative details including estimated blood loss and type of postoperative immobilization were noted. Over the follow-up period, complications were recorded as were radiographic outcomes including lateral center edge angle, acetabular index, migration percentage, continuity of Shenton's line, and time to union. RESULTS: Twenty-eight hips (in 24 patients) underwent surgery at a mean age of 9.3 years (range, 6.5 to 13.8 y). Diagnoses included Trisomy 21 (9), developmental dysplasia of the hip (5), Charcot-Marie-Tooth (3), and neuromuscular disease (9) among others. The mean estimated blood loss was 135 mL (±98 mL) and most patients were immobilized in an abduction brace or single-leg spica cast for an average of 7.6±2.2 weeks after surgery before weight-bearing was advanced. At a mean follow-up of 3.0±2.2 years, the lateral center edge angle improved from an average of 1±14 degrees preoperatively to 35±7 degrees, the acetabular index from 27±11 degrees to 2±5 degrees, and the migration percentage from 44%±21% to 3%±5%. Fourteen hips had frank instability before surgery and 20 had a break in Shenton's line >5 mm. At most recent follow-up, all but 1 hip was stable (93%) and all had restoration of Shenton's line (100%). Radiographic union occurred at a mean of 14 weeks (±11 wk). One patient developed an ischial nonunion that underwent further surgery, 1 had premature closure of the triradiate cartilage, and 1 patient with transverse myelitis developed Charcot arthropathy. There were no other complications in this series. CONCLUSIONS: In this dual-center retrospective series, the single-incision triple innominate osteotomy was extremely effective for improving acetabular coverage and stabilizing unstable hips in a variety of underlying diagnoses with an acceptably low rate of complications. LEVEL OF EVIDENCE: Level IV-case series.

The Direct Anterior Approach for Total Hip Arthroplasty for Severe Dysplasia (Crowe III and IV) Provides Satisfactory Medium to Long-Term Outcomes.

BACKGROUND: The direct anterior approach (DAA) is increasingly used for total hip arthroplasty (THA). Although the DAA can reduce pain, recovery time, and dislocations in nondysplastic hips, few studies report its results in patients with severe dysplasia. We aimed to evaluate outcomes of primary THA through the DAA with cup placement at the true acetabulum in hips with severe dysplasia. METHODS: We retrospectively evaluated 23 consecutive patients (29 hips) who underwent THA by DAA for osteoarthritis secondary to Crowe III-IV dysplasia. Surgical procedures were performed on a traction table, and the acetabular cup was placed in the true acetabulum. Patients were assessed clinically (complications, modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Hip Score) and radiographically (radiolucencies, subsidence, leg length discrepancies, cup inclination, and cup coverage) at a minimum of 2 years. RESULTS: One patient (2 hips) died with original implants (at 13 and 14 years), 3 patients (3 hips) were revised due to wear-induced loosening (at 14, 16, and 18 years), and there were no dislocations or infections. The remaining 19 patients (24 hips) were assessed at 8.4 ± 4.7 years (range 2-20); 2 patients (2 hips) had complications that required reoperation without implant removal. The modified Harris Hip Score improved from 32 ± 9 to 94 ± 7, Western Ontario and McMaster Universities Osteoarthritis Index from 46 ± 18 to 90 ± 7, and Oxford Hip Score was 56 ± 4. Patients were very satisfied (90%) or satisfied (10%). Limb length discrepancy was 2.5 ± 9.0 mm. CONCLUSION: THA through the DAA with cup placement at the true acetabulum provides satisfactory mid to long-term clinical and radiographic outcomes compared to other approaches for hips with severe dysplasia. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Ultrasound Characteristics of Clinically Dislocated But Reducible Hips With DDH.

BACKGROUND: Although ultrasound (US) is frequently used in diagnosis and management of infantile developmental dysplasia of the hip, precise ultrasonographic parameters of what constitutes a dislocation, subluxation etc remain poorly defined. The purpose of this study was (1) to describe the ultrasonographic characteristics of a large cohort of clinically dislocated but reducible hips and (2) to begin to develop ultrasonographic definitions for what constitutes a hip dislocation. METHODS: A retrospective review of prospectively collected data from an international multicenter study group on developmental dysplasia of the hip was conducted on all patients under 6 months of age with hip(s) that were dislocated at rest but reducible based on initial physical examination (ie, Ortolani positive). Femoral head coverage (FHC), alpha angle (α), and beta angle (ß) were measured on pretreatment US by the individual treating surgeon, and were recorded directly into the database. RESULTS: Based on 325 Ortolani positive hips, the median FHC on presentation was 10% with an interquartile range of 0% to 23%. A total of 126 of the 327 hips (39%) demonstrated 0% FHC. The 90th percentile was found to be at 33% FHC. Of 264 hips with sufficient α data, the median α was 43 degrees with an interquartile range from 37 to 49 degrees. The 90th percentile for α was at 54 degrees. A total of 164 hips had documented ß with a median of 66 degrees and an interquartile range of 57 to 79 degrees; the 90th percentile was at 94 degrees. CONCLUSIONS: Analysis of a large cohort of patients with dislocated but reducible hips reveals a median percent FHC of 10%, a median α of 43 degrees, and a median ß of 66 degrees on initial US. Using a threshold at the 90th percentile, a sensible ultrasonographic definition of a dislocated hip seems to be FHC≤33%, implying that FHC between 34% and 50% may be reasonably termed a subluxation. Although these findings are consistent with previous, smaller reports, further prospective research is necessary to validate these thresholds. LEVEL OF EVIDENCE: Level IV-diagnostic study.

Closed Reduction for Developmental Dysplasia of the Hip: Early-term Results From a Prospective, Multicenter Cohort.

BACKGROUND: Closed reduction (CR) is a common treatment for infantile developmental dysplasia of the hip. The purpose of this observational, prospective, multicenter study was to determine the early outcomes following CR. METHODS: Prospectively collected data from an international multicenter study group was analyzed for patients treated from 2010 to 2014. Baseline demographics, clinical exam, radiographic/ultrasonographic data, and history of previous orthotic treatment were assessed. At minimum 1-year follow-up, failure was defined as an IHDI grade 3 or 4 hip and/or need for open reduction. The incidence of avascular necrosis (AVN), residual dysplasia, and need for further surgery was assessed. RESULTS: A total of 78 patients undergoing CR for 87 hips were evaluated with a median age at initial reduction of 8 months (range, 1 to 20 mo). Of these, 8 hips (9%) were unable to be closed reduced initially. At most recent follow-up (median 22 mo; range, 12 to 36 mo), 72/79 initially successful CRs (91%) remained stable. The likelihood of failure was unaffected by initial clinical reducibility of the hip (P=0.434), age at initial CR (P=0.897), or previous treatment in brace (P=0.222). Excluding those hips that failed initial CR, 18/72 hips (25%) developed AVN, and the risk of osteonecrosis was unaffected by prereduction reducibility of the hip (P=0.586), age at CR (P=0.745), presence of an ossific nucleus (P=0.496), or previous treatment in brace (P=0.662). Mean acetabular index on most recent radiographs was 25 degrees (±6 degrees), and was also unaffected by any of the above variables. During the follow-up period, 8/72 successfully closed reduced hips (11%) underwent acetabular and/or femoral osteotomy for residual dysplasia. CONCLUSIONS: Following an initially successful CR, 9% of hips failed reduction and 25% developed radiographic AVN at early-term follow-up. History of femoral head reducibility, previous orthotic bracing, and age at CR did not correlate with success or chances of developing AVN. Further follow-up of this prospective, multicenter cohort will be necessary to establish definitive success and complication rates following CR for infantile developmental dysplasia of the hip. LEVEL OF EVIDENCE: Level II-prospective observational cohort.

Medición radiográfica del ángulo acetabular para el diagnóstico temprano de la displasia del desarrollo de la cadera / Radiographic measurement of the acetabular angle for early diagnosis of hip development dysplasia

Resumen: Antecedentes: Para evitar secuelas en la displasia del desarrollo de la cadera el tratamiento debe ser temprano; el ángulo acetabular corresponde a la inclinación del techo del acetábulo. Stanisavljevic indica que para medir adecuadamente el ángulo acetabular se deben colocar las caderas en abducción. Pregunta: ¿cuál es la magnitud de la diferencia de la medición radiográfica del ángulo acetabular entre las proyecciones anteroposterior de pelvis en posición neutra y con abducción de caderas? Métodos: Se tomaron 916 mediciones radiográficas comparando las de posición neutra contra las de abducción de caderas, de pacientes atendidos en consulta externa entre el 1 de Abril de 2010 y el 31 de Marzo de 2013. Resultados: Se realizaron pruebas t para medias de dos muestras emparejadas y se obtuvo una diferencia hipotética de las medias de 0.0000 y el coeficiente de correlación de Pearson para cadera derecha fue 0.74427531 y para la izquierda 0.73779866. Usando una Tabla propuesta de normalidad del ángulo acetabular según edad, se obtuvo el área bajo la curva en una distribución tgl457 = 0.650 con p = 0.516. El índice acetabular en posición neutra y con abducción de caderas es similar con alta significancia estadística, según el análisis de correlación de Pearson. Con base en la curva ROC, el índice acetabular en posición de rana tiene una alta sensibilidad y especificidad. Por tanto, la medición del índice acetabular en posición con abducción de caderas, tiene alta confiabilidad de lograr un diagnóstico correcto.

Abstract: Background: In order to avoid sequelae in the development dysplasia of the hip the treatment should be early; The acetabular angle corresponds to the inclination of the roof of the acetabulum. Stanisvljevic indicates that to properly measure the acetabular angle, the hips should be placed in abduction. Question: What is the magnitude of the difference in radiographic measurement of the acetabular angle between the anteroposterior projections of pelvis in neutral position and with abduction of hips? Methods: 916 radiographic measurements were taken by contrasting the neutral position against those of hip abduction, of patients in our clinic attended between April 1, 2010 and March 31, 2013. Results: T tests were performed for means of two matched samples and a hypothetical difference of the mean of 0.0000 was obtained and the Pearson correlation coefficient for right hip was 0.74427531 and for the left 0.73779866. Using a proposed Table of normality of the Acetabular angle according to age, the area was obtained under the curve in a distribution Tgl457 = 0.650 with P = 0.516. The index acetabular in neutral position and with abduction of hips is similar with high statistical significance, according to the analysis of correlation of Pearson. Based on the ROC curve, the acetabular index in frog position has a high sensitivity and specificity. Discussion: Therefore, the measurement of the acetabular index in position with hip abduction, has high reliability to achieve a correct diagnosis.

[Usefulness of the arthrogram in the decision therapy in children with developmental dysplasia of the hip from 3 months to 3 years of age]. / Utilidad de la artrografía en la decisión terapéutica en niños con displasia del desarrollo de cadera de tres meses a tres años de edad.

OBJECTIVE: To evaluate the utility of arthrography as a tool in therapeutic decision in developmental dysplasia of hip (DDH). MATERIAL AND METHODS: 19 children with true DDH with age between three months and three years, without previous surgical treatment, with Tonis II or III, and complete X-rays. For each case; therapeutic decision was registered for X-rays and arthrography by three independent observers, we took like standard, surgery in each patient necessary to obtain a concentric reduction and good acetabular coverage. RESULTS: 20 cases, 19 patients. 18 unilateral, 1 bilateral. They were 17 girls (89%) and 2 children (11%). Average Age: 1 year 3 months (4 months to 2 years 11 months). 11 Tonis II (55%) and 9 Tonis III (45%). The intraclass coefficient of correlation (ICC) in relation to the decision therapeutic radiographic was of 0.8933 and for the arthrography of 0.7205. And ICC of the decision therapeutic radiographic in connection with the standard was of 0.7933 and for the arthrography it was of 0.6219. We confirm that in our 20 cases, the utility of the arthrography (ICC 0.6219), is smaller to the X-rays (ICC 0.7933). The utility of the arthrography was bigger in the patients with Tonis II, and an age between nine months and two years.

OBJETIVO: Evaluar la utilidad de la artrografía como herramienta en la decisión terapéutica de pacientes con displasia del desarrollo de cadera (DDC). MATERIAL Y MÉTODOS: 19 niños con diagnóstico de DDC habitual de edad entre tres meses y tres años, sin antecedentes quirúrgicos, Tonis II o III y expediente radiográfico completo. Para cada caso se registró la decisión terapéutica radiográfica y artrográfica por tres observadores independientemente, en el análisis estadístico el estándar fue la cirugía realizada necesaria para lograr una reducción concéntrica y cobertura acetabular adecuada. RESULTADOS: 20 casos, 19 pacientes, de los cuales 18 fueron unilateral y uno bilateral. Fueron 17 niñas (89%) y dos niños (11%). Edad promedio: un año tres meses (de cuatro meses a dos años 11 meses), 11 Tonis II (55%) y nueve Tonis III (45%). El coeficiente de correlación intraclase (CCI) en relación con la decisión terapéutica radiográfica fue de 0.8933 y para la artrografía fue de 0.7205. El CCI de la decisión terapéutica radiográfica en relación con el estándar fue de 0.7933 y para la artrográfica fue de 0.6219. Se confirmó que en los 20 casos revisados la utilidad de la artrografía (CCI 0.6219) es menor que la de las radiografías (CCI 0.7933). La utilidad de la artrografía fue mayor en los pacientes con Tonis II con una edad entre nueve meses y dos años.

Utilidad de la artrografía en la decisión terapéutica en niños con displasia del desarrollo de cadera de tres meses a tres años de edad / Usefulness of the arthrogram in the decision therapy in children with developmental dysplasia of the hip from 3 months to 3 years of age

Resumen: Objetivo: Evaluar la utilidad de la artrografía como herramienta en la decisión terapéutica de pacientes con displasia del desarrollo de cadera (DDC). Material y métodos: 19 niños con diagnóstico de DDC habitual de edad entre tres meses y tres años, sin antecedentes quirúrgicos, Tonis II o III y expediente radiográfico completo. Para cada caso se registró la decisión terapéutica radiográfica y artrográfica por tres observadores independientemente, en el análisis estadístico el estándar fue la cirugía realizada necesaria para lograr una reducción concéntrica y cobertura acetabular adecuada. Resultados: 20 casos, 19 pacientes, de los cuales 18 fueron unilateral y uno bilateral. Fueron 17 niñas (89%) y dos niños (11%). Edad promedio: un año tres meses (de cuatro meses a dos años 11 meses), 11 Tonis II (55%) y nueve Tonis III (45%). El coeficiente de correlación intraclase (CCI) en relación con la decisión terapéutica radiográfica fue de 0.8933 y para la artrografía fue de 0.7205. El CCI de la decisión terapéutica radiográfica en relación con el estándar fue de 0.7933 y para la artrográfica fue de 0.6219. Se confirmó que en los 20 casos revisados la utilidad de la artrografía (CCI 0.6219) es menor que la de las radiografías (CCI 0.7933). La utilidad de la artrografía fue mayor en los pacientes con Tonis II con una edad entre nueve meses y dos años.

Abstract: Objective: To evaluate the utility of arthrography as a tool in therapeutic decision in developmental dysplasia of hip (DDH). Material and methods: 19 children with true DDH with age between three months and three years, without previous surgical treatment, with Tonis II or III, and complete X-rays. For each case; therapeutic decision was registered for X-rays and arthrography by three independent observers, we took like standard, surgery in each patient necessary to obtain a concentric reduction and good acetabular coverage. Results: 20 cases, 19 patients. 18 unilateral, 1 bilateral. They were 17 girls (89%) and 2 children (11%). Average Age: 1 year 3 months (4 months to 2 years 11 months). 11 Tonis II (55%) and 9 Tonis III (45%). The intraclass coefficient of correlation (ICC) in relation to the decision therapeutic radiographic was of 0.8933 and for the arthrography of 0.7205. And ICC of the decision therapeutic radiographic in connection with the standard was of 0.7933 and for the arthrography it was of 0.6219. We confirm that in our 20 cases, the utility of the arthrography (ICC 0.6219), is smaller to the X-rays (ICC 0.7933). The utility of the arthrography was bigger in the patients with Tonis II, and an age between nine months and two years.

Developmental dysplasia of the hip in female adult individual: Site Tres Cruces I, Salta, Argentina (Superior formative period, 400-1000 AD).

Developmental dysplasia of the hip (DDH) is a developmental defect that prevents normal articulation between the acetabulum and the femoral head. This is an unusual condition, with a prevalence of 1-2 per thousand, and with only two poorly described skeletons documented in South American paleopathological literature. In this work we report an individual with such a condition, from the archeological site Tres Cruces I (Quebrada del Toro, Salta, Argentina). Several radiocarbon dates and associated materials date it to the Superior Formative (400-1000 AD). The remains are of an adult female, who also has tabular oblique cranial modification. Through detection of abnormalities in the morphology of the femora and ossa coxae, a differential diagnosis was carried out. On the left hip joint the formation of a well-defined false acetabulum, without connection with the true one, was observed. The latter was shallow, triangular, with an irregular base. The left os coxae showed a wider greater sciatic notch angle. The right os coxae exhibited a false acetabulum connected with the true one. Both femora presented a small femoral head, flat and mushroom-shaped, with shortening of the neck. These features were more pronounced on the right-side elements. On the basis of the aforementioned, a presumptive diagnosis of bilateral developmental dysplasia of the hip with complete dislocation on both sides was established.

[Radiographic measurement of the acetabular angle for early diagnosis of hip development dysplasia]. / Medición radiográfica del ángulo acetabular para el diagnóstico temprano de la displasia del desarrollo de la cadera.

BACKGROUND: In order to avoid sequelae in the development dysplasia of the hip the treatment should be early; The acetabular angle corresponds to the inclination of the roof of the acetabulum. Stanisvljevic indicates that to properly measure the acetabular angle, the hips should be placed in abduction. Question: What is the magnitude of the difference in radiographic measurement of the acetabular angle between the anteroposterior projections of pelvis in neutral position and with abduction of hips? METHODS: 916 radiographic measurements were taken by contrasting the neutral position against those of hip abduction, of patients in our clinic attended between April 1, 2010 and March 31, 2013. RESULTS: T tests were performed for means of two matched samples and a hypothetical difference of the mean of 0.0000 was obtained and the Pearson correlation coefficient for right hip was 0.74427531 and for the left 0.73779866. Using a proposed table of normality of the Acetabular angle according to age, the area was obtained under the curve in a distribution Tgl457 = 0.650 with P = 0.516. The index acetabular in neutral position and with abduction of hips is similar with high statistical significance, according to the analysis of correlation of Pearson. Based on the ROC curve, the acetabular index in frog position has a high sensitivity and specificity. DISCUSSION: Therefore, the measurement of the acetabular index in position with hip abduction, has high reliability to achieve a correct diagnosis.

ANTECEDENTES: Para evitar secuelas en la displasia del desarrollo de la cadera el tratamiento debe ser temprano; el ángulo acetabular corresponde a la inclinación del techo del acetábulo. Stanisavljevic indica que para medir adecuadamente el ángulo acetabular se deben colocar las caderas en abducción. Pregunta: ¿cuál es la magnitud de la diferencia de la medición radiográfica del ángulo acetabular entre las proyecciones anteroposterior de pelvis en posición neutra y con abducción de caderas? MÉTODOS: Se tomaron 916 mediciones radiográficas comparando las de posición neutra contra las de abducción de caderas, de pacientes atendidos en consulta externa entre el 1 de Abril de 2010 y el 31 de Marzo de 2013. RESULTADOS: Se realizaron pruebas t para medias de dos muestras emparejadas y se obtuvo una diferencia hipotética de las medias de 0.0000 y el coeficiente de correlación de Pearson para cadera derecha fue 0.74427531 y para la izquierda 0.73779866. Usando una tabla propuesta de normalidad del ángulo acetabular según edad, se obtuvo el área bajo la curva en una distribución tgl457 = 0.650 con p = 0.516. El índice acetabular en posición neutra y con abducción de caderas es similar con alta significancia estadística, según el análisis de correlación de Pearson. Con base en la curva ROC, el índice acetabular en posición de rana tiene una alta sensibilidad y especificidad. Por tanto, la medición del índice acetabular en posición con abducción de caderas, tiene alta confiabilidad de lograr un diagnóstico correcto.

Pavlik Harness Disease Revisited: Does Prolonged Treatment of a Dislocated Hip in a Harness Adversely Affect the α Angle?

BACKGROUND: Current dogma contends that prolonged treatment of a dislocated hip in Pavlik harness beyond 3 weeks will cause "Pavlik harness disease." To our knowledge, however, no previous studies have documented objective morphologic changes to the acetabulum from continued treatment of a persistently dislocated hip. METHODS: We retrospectively reviewed a consecutive series of infants with developmental dysplasia of the hip, below 6 months old, who failed Pavlik treatment from a single, tertiary-care pediatric hospital and a multicenter, international study group. Inclusion criteria were dislocated hips confirmed by ultrasound (both initially and at Pavlik termination) and a minimum of 2 ultrasounds during harness treatment at least 3 weeks apart. As a global measure of acetabular morphology, α angle (AA) was compared between initial and final ultrasound. The final means of obtaining successful hip reduction was recorded from the medical records. RESULTS: Forty-nine hips in 38 patients were identified. Median age at Pavlik initiation was 4 weeks (range, 0 to 18 wk); median time in harness was 6 weeks (range, 3 to 14 wk). Surprisingly, a mean of 4 degrees improvement in AA (95% CI, 2-6 degrees; P=0.001) was observed between first and final ultrasound. We found no difference in AA change between those in harness 3 to 5 weeks and those with prolonged wear >5 weeks (P=0.817). There was no significant association between change in AA and time in harness (P=0.545), age at Pavlik initiation (P=0.199), clinical reducibility of the hip (P=0.202), or initial percent femoral head coverage (P=0.956). Following harness failure, 22/49 hips (45%) were successfully treated with rigid abduction bracing, 16 (33%) by closed reduction/spica casting, and 10 (20%) by open reduction; 1 hip (2%) spontaneously reduced and required no further treatment. CONCLUSIONS: On the basis of the lengths of harness treatment in our series, most hips did not exhibit negative changes in the acetabular AA in response to prolonged treatment of a dislocated hip in harness. Furthermore, 80% of hips failing Pavlik treatment were successfully reduced through closed means, indicating that subsequent treatment was not compromised. LEVEL OF EVIDENCE: Level IV-retrospective case series.