Congenital dislocation of the knee complicated with bilateral hip dislocation: a case report and literature review.

BACKGROUND: Congenital dislocation of the knee is characterised by excessive knee extension or dislocation and anterior subluxation of the proximal tibia, and this disease can occur independently or coexist with different systemic syndromes. Nevertheless, significant controversy surrounds treating this disease when combined with hip dislocation. This paper presents a case of a 4-month-old patient diagnosed with bilateral hip dislocation combined with this disease. The study discusses the pathophysiology, diagnosis, and treatment methods and reviews relevant literature. CASE PRESENTATION: We reported a case of a 4-month-old female infant with congenital dislocation of the right knee joint, which presented as flexion deformity since birth. Due to limitations in local medical conditions, she did not receive proper and effective diagnosis and treatment. Although the flexion deformity of her right knee joint partially improved without treatment, it did not fully recover to normal. When she was 4 months old, she came to our hospital for consultation, and we found that she also had congenital dislocation of both hip joints and atrial septal defect. We performed staged treatment for her, with the first stage involving surgical intervention and plaster orthosis for her congenital dislocation of the right knee joint, and the second stage involving closed reduction and plaster fixation orthosis for her congenital hip joint dislocation. Currently, the overall treatment outcome is satisfactory, and she is still under follow-up observation. CONCLUSIONS: Early initiation of treatment is generally advised, as nonsurgical methods prove satisfactory for mild cases. However, surgical intervention should be considered in cases with severe stiffness, unresponsive outcomes to conservative treatment, persistent deformities, or diagnoses and treatments occurring beyond the first month after birth.

Long-term Results of Developmental Hip Dysplasia Under Therapy With Pavlik Harness.

INTRODUCTION: The Pavlik harness is a commonly used treatment for developmental dysplasia of the hip (DDH) of types IIc or worse, based on the Graf classification. This study aimed to assess the long-term follow-up outcomes after treating DDH with the Pavlik harness. METHODS: Between 1995 and 2006, ultrasound screening was conducted on 7372 newborns within the first days of life. Among them, 203 dysplastic hips in 152 patients, whose sonograms were Graf type IIc or worse, were treated with Pavlik harness. Treatment was discontinued if the measurement indicated Graf type Ia/b. More than 20 years later (mean: 20.46 y), patients were invited for clinical evaluation (Oxford Hips Score, Schulthess Hip Score, Harris Hip Score) and radiologic examination (center-edge angle according to Wiberg and the Severis classification, the rate of roofing of the femoral head via the Reimers migration percentage, and the Sharp angle). RESULTS: Of the 152 patients, 60 (39.5%) participants with 80 (39.4%) affected hips (57.7% type IIc, 7.9% type D, and 15.6% type IIIa/b) were reexamined. The average follow-up duration was 20.5 years, with a maximum of 25.9 years. According to the Severin's classification, only 2 (3.77%) patients, each with one affected hip, showed slight residual dysplasia. The Reimer's migration percentage indicated an average of almost 90% canopy cover in the patient collective studied. No avascular necrosis was found, and the Sharp angle showed an average of almost 38 degrees. Only 4 participants with each one affected hip showed residual dysplasia according to the Sharp angle. The clinical results were quite satisfying, as none of the patients experienced hip pain that significantly limited their everyday activities or sports engagement, requiring medical attention before this study.Conclusions:Conservative therapy of DDH (Graf type IIc, D, III) with the Pavlik harness has demonstrated very good therapeutic success and a very low rate of residual dysplasia (2.81%). Both the radiologic and clinical outcomes were highly satisfactory. LEVEL OF EVIDENCE: Level IV.

What Are the Psychosocial Effects of Pavlik Harness Treatment? A Prospective Study on Perceived Impact on Families and Maternal-Infant Bonding.

BACKGROUND: The Pavlik harness (PH) is the most common treatment for infants with developmental dysplasia of the hip. Although success rates are high when used appropriately, brace treatment may impact family function and parental bonding. The purpose of this study was to prospectively determine how PH treatment affected these psychosocial variables. METHODS: This is a prospective, single-surgeon study at a tertiary-care, urban, academic children's hospital between November 2022 and March 2023. All patients newly treated with a Pavlik were eligible. Caregivers were administered the Postpartum Bonding Questionnaire and the Revised Impact on Family Scale (rIOFS) at the baseline visit and 2- and 6 weeks following treatment initiation. Demographic and treatment-specific information was collected through surveys and retrospective chart review. Descriptive statistics and bivariate analysis were used. RESULTS: A total of 55 caregiver-child dyads were included in the final analysis. Most patients were female (89%) and/or first-born (73%). Forty (73%) hips were diagnosed as having stable dysplasia. rIOFS scores steadily improved from baseline, through 2- and 6 weeks posttreatment initiation. Six-week rIOFS scores were significantly lower than both baseline ( P= 0.002) and 2 weeks ( P =0.018). Average parental bonding scores also improved steadily throughout treatment and did not surpass the threshold of clinical concern at any time. Neither full-time harness use (24 h/d vs. 23 h/d based upon clinical stability) nor age at treatment initiation had a statistically significant effect on parental bonding or family functioning (all P >0.05). Additional demographic variables such as birth order, parental history of anxiety/depression, and relative socioeconomic disadvantage also had no significant effect on psychosocial outcomes. CONCLUSION: PH treatment did not significantly impact maternal-fetal bonding or family dynamics. Relative to other pediatric diseases, PH treatment has an impact on family life greater than that of single-leg spica, but less than that of school-age children with chronic medical illnesses. As PH treatment is a widely used treatment for infantile developmental dysplasia of the hip, this study provides information that clinicians may use to more accurately counsel families and assuage parental concerns. LEVELS OF EVIDENCE: Level IV-prospective uncontrolled cohort study.

Reapplication of the Pavlik Harness for Treatment of Developmental Dysplasia of the Hip After Initial Pavlik Harness Failure.

OBJECTIVE: The Pavlik harness (PH) has been widely used as the standard treatment for infants with developmental dysplasia of the hip (DDH). When the initial application of the PH fails, alternative treatments, such as closed reduction, open reduction, and reapplication of the PH will be considered. Compared with other treatments, reapplication of the PH offers certain advantages, including simplicity and reduced physical, and psychological stress, on both infants and caregivers. This study aims to investigate the effectiveness of reapplying the PH in patients with DDH. METHODS: This study included patients with DDH (complete dislocation) who were treated by reapplication of PH between 1988 and 2012. Patients who were able to follow-up for more than 5 years were included. We examined the reduction rate and several factors to identify indicators associated with successful reduction during reapplication, including age, sex, side of hip dislocation, and the presence of the Ortolani sign. At the final follow-up, hip development was assessed using the Severin classification, whereas avascular necrosis (AVN) was evaluated using the Kalamchi classification and the Salter criteria. RESULTS: A total of 56 patients (48 females and 8 males) and 57 hips were included in this study. The mean age at first and second application of PH was 4.2 months old (range: 0.12 to 6.4), and 5.8 months old (3.0 to 11.4), respectively. The reduction rate was 49% (28 out of 57 hips). Among the successfully reduced hips, the AVN rate was 3.6% (1 out of 28 hips). The Severin classification revealed 27 hips in class I and 1 hip in class III. Statistical analysis indicated a significantly higher proportion of left hip involvement in the reduction group (85% vs 41%, χ 2 test, P < 0.001). Although not statistically significant, the rate of positive Ortolani sign tended to be higher in the reduction group (61% vs 38%, χ 2 test, P = 0.06). CONCLUSION: The reapplication method demonstrated a 49% reduction rate and a low AVN rate of 3.6% in our study. It is worth considering for patients who fail the initial PH treatment, particularly in cases of left-side dislocation and a positive Ortolani sign during the initial application.

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

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

Does Screening Ultrasound Timing in Developmental Dysplasia of the Hip Need to be Adjusted for Moderate Preterm and Near-term Infants: A Prospective Study.

INTRODUCTION: An initial screening ultrasound is essential for patients at higher risk of developmental dysplasia of the hip (DDH) due to breech presentation or a family history of DDH. The American Academy of Pediatrics recommends screening ultrasounds to be performed after 6 weeks of age to reduce the rate of false positives. However, there is limited evidence regarding whether these screening ultrasounds need to be adjusted for gestational age in prematurity. The purpose of this study was to evaluate the influence of moderate preterm and near-term births on screening hip ultrasounds for high-risk DDH populations. METHODS: We identified all prospectively enrolled patients in a single-center database referred for screening hip ultrasound for DDH. We included those hips referred for risk factors of DDH, including breech presentation, family history of DDH, or hip click, and excluded those with known dysplasia or referral for hip instability. Each ultrasound was measured by a pediatric radiologist to determine the alpha angle and femoral head coverage. Patients were classified as "premature" if born at <37 weeks gestation or "full term" if born at ≥37 weeks gestation. All patients underwent screening hip ultrasound between 5 and 8 weeks of age. Sonographic markers of dysplasia and the incidences of abnormal ultrasound and Pavlik harness treatment were compared between cohorts. Significance was set at P <0.05. RESULTS: A total of 244 hips in 122 patients were included, 58 hips in the premature cohort and 186 hips in the full-term cohort. The premature cohort had a significantly decreased gestational age compared with the full-term cohort (35.4 ± 1.1 vs 38.5 ± 1.1 wk, respectively, P < 0.001). However, there was no difference between premature and full-term cohorts in sex distribution (69% vs 75%, females, P = 0.39), unadjusted age at the time of ultrasound (6.6 ± 0.7 vs 6.8±0.7 wk, respectively, P = 0.07), or referral reason ( P = 0.14). On hip ultrasound, there was no difference between premature and full-term cohorts with respect to alpha angle (62.6 ± 3.3 vs 62.2 ± 5.3 degrees, P = 0.41), femoral head coverage (54.9 ± 6.3 vs 55.1 ± 10.6, P = 0.19), rate of abnormal ultrasound (18.3% vs 20.7%, respectively, P = 0.68), or the rate of Pavlik harness treatment (0% vs 5.3%, respectively, P = 0.12). DISCUSSION: There was no significant difference in alpha angle or femoral head coverage between premature and full-term patients at 5 to 8 weeks of unadjusted age. This preliminary data suggests that screening ultrasounds can be performed without adjusting for prematurity. LEVEL OF EVIDENCE: Level II, prognostic study.

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.

Prevalence of Acetabular Dysplasia at a Mean age of 18 Years After Treatment for Neonatal hip Instability.

BACKGROUND: The long-term radiological outcomes after the treatment of neonatal hip instability (NHI) in developmental dysplasia of the hip are unclear. Therefore, the prevalence of acetabular dysplasia at a mean age of 18 years after treatment was investigated. The relationship between acetabular dysplasia and hip discomfort has also been poorly established. Therefore, the differences in pain, hip-related quality of life (QOL), and hip impingement tests in hips with and without acetabular dysplasia were assessed. METHODS: All 127 patients treated for NHI from 1995 to 2001 at the study hospital and meeting the inclusion criteria were invited to participate in this population-based follow-up. Of these individuals, 88 (69.3%) participated. The lateral center-edge angle (LCEA), Sharp's angle (SA), and acetabular head index (AHI) were calculated for both hips from pelvic anterior-posterior radiographs. The Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire was completed for both hips separately; the total score, pain, and QOL subscores were calculated; and the impingement test was performed. RESULTS: The prevalence of acetabular dysplasia, defined as an LCEA <20°, was 3.4%. Only the mean AHI (81.1%, SD 5.3) differed (-5.08, 95% CI -5.77 to -4.38, P <0.001) from previously described gender-specific and side-specific means, whereas the mean LCEA and SA did not. The odds ratio for a positive hip impingement test was 2.8 (95% CI: 1.11-7.05, P = 0.029) for hips with an LCEA <25° compared to hips with LCEA ≥25°. The hips with an SA ≥45° had a mean of 7.8 points lower for the HAGOS pain subscore (95% CI: 4.2-11.4, P <0.001) and a mean of 6.1 points lower for the HAGOS QOL subscore (95% CI: 2.1-10.2, P = 0.003) compared with hips with an SA <45°. CONCLUSIONS: The prevalence of acetabular dysplasia was low after treatment for NHI. Acetabular dysplasia seems to be as common in the general population as for those treated for NHI based on the LCEA. Only an SA ≥45° resulted in slightly more pain and lower hip-related QOL.

Length of treatment and ultrasound timing in infants with developmental dysplasia of the hip.

PURPOSE: Developmental dysplasia of the hip (DDH) joint is a complex condition that may lead to severe problems. Ultrasound scan (USS) in the first four-to-six weeks of life is considered the gold-standard for diagnosis while the Pavlik harness (PH) is a widely utilized method as first-line treatment. The purpose of this study is to compare clinical outcomes of infants with DDH in relation to the timing and frequency of USS following application of the PH. METHODS: Retrospective data were collected over a 5-year period from February 2017 to February 2022. We included patients who underwent the first USS post-diagnosis and PH application in two, three, four and six weeks. Two-hundred-twenty-five patients were included and divided in four groups according to timing of the first follow-up: week-2, n = 13; week-3, n = 66; week-4, n = 95; and week-6, n = 51. For every patient Graf classification, treatment length and number of follow-ups were documented. RESULTS: Week-3 and week-4 groups displayed a statistically significant shorter treatment length compared to week-6 group (p value < 0.001), while also demonstrating a lower number of sonographic follow-ups per patient compared to both week-6 (p value < 0.001) and week-2 (p value = 0.002 vs week-3; p value < 0.001 vs week 4). Week-4 group presented the highest treatment completion (56%) on first visit post-diagnosis. Conservative treatment with PH failed in 1.8% (4/225) and displayed no significant difference among all subgroups. CONCLUSIONS: Differences in timing of first USS post-DDH diagnosis and initiation of treatment can lead to discrete outcomes with implications to the clinical outcome and cost effectiveness.

Causes of late-presenting developmental dislocation of the hip beyond 12 months of age: A pilot study.

Background & objectives: Developmental dysplasia of the hip (DDH), when detected early, can usually be managed effectively by simple methods. A delayed diagnosis often makes it a complex condition to treat. Late presentation of DDH is fairly common in developing countries, and there is scarcity of literature regarding the epidemiology and reason for late presentation. Through this study, we attempted to identify the reasons for late presentation of DDH in children more than 12 months of age. Methods: Fifty four children with typical DDH and frank dislocation of hip in whom treatment was delayed for 12 months or more were included. Parents were interviewed with a pre-structured questionnaire and data were collected for analysis with Microsoft Excel 2016 and SPSS version 26. Results: Diagnostic delay was the most common reason for late presentation and was observed in 52 children (96.2%). The mean age at diagnosis was 24.7 months. The mean age at treatment was 37.3 months with a mean delay of 12.5 months from diagnosis and 22.1 months from initial suspicion. Physician-related factors contributed 55.3 per cent, while family and social issues accounted for 44.7 per cent of overall reasons for diagnostic and treatment delays. Interpretation & conclusions: Late presentation of DDH in walking age is common. Physician- and family-related factors accounted for most of these cases. Failure or inadequate hip screening at birth by the attending physician is a common reason for late diagnosis. The family members were unaware about the disorder and developed suspicion once child started walking with an abnormal gait.

Known risk factors of the developmental dysplasia of the hip predicting more severe clinical presentation and failure of Pavlik harness treatment.

PURPOSE: Developmental dysplasia of the hip (DDH) varies from mild instability of the hip to subluxation or total dislocation of the joint. Well-known risk factors of DDH include pre-natal breech position, female sex, positive family history, hip side, primiparity and the mode of delivery. Aim of the present study was to further evaluate known risk-factors of DDH, find associations with more severe dysplasia (characterized with Ortolani positivity) and find risk factors of failure of the Pavlik harness treatment. MATERIAL AND METHODS: All children with the diagnosis of DDH treated in Tampere University hospital in the years 1998-2018 were retrospectively identified for the study and the data was collected from the medical records. Teratological dislocations (n = 3) were excluded from the analysis. Total of 945 patients were included. RESULTS: Breech presentation was strongly associated with Ortolani positivity (p < 0.001). Breech presentation was not associated with ending up for spica casting and/or operative treatment (p = 0.291) despite the association with Ortolani positivity. Ortolani positivity (p = 0.002), positive family history (p = 0.013) and girl sex (p = 0.029) were associated with ending up for spica casting and/or operative treatment. CONCLUSION: Breech presentation seems to increase the risk of Ortolani positive DDH. However, these infants are likely to recover with initially started Pavlik harness treatment, as it was not associated with elevated risk for undergoing more robust treatments. Positive family history and girl sex are associated with the most severe cases of developmental dysplasia of the hip, and it may predispose to the failure of the Pavlik harness treatment.

Active monitoring versus an abduction device for treatment of infants with centered dysplastic hips: study protocol for a randomized controlled trial (TReatment with Active Monitoring (TRAM)-Trial).

BACKGROUND: Developmental Dysplasia of the Hip (DDH) is one of the most common pediatric orthopedic disorders, affecting 1-3% of all newborns. The optimal treatment of centered DDH is currently under debate. This randomized controlled trial aims to study the (cost-)effectiveness of active monitoring versus abduction treatment for infants with centered DDH. METHODS: This is a multicenter, parallel-group, open-label, non-inferiority randomized controlled trial studying the (cost-)effectiveness of active monitoring versus abduction treatment for infants with centered DDH in fourteen hospitals in the Netherlands. In total, 800 infants with centered DDH (Graf IIa-/IIb/IIc), aged 10-16 weeks, will be randomly allocated to the active monitoring or abduction treatment group. Infants will be followed up until the age of 24 months. The primary outcome is the rate of normal hips, defined as an acetabular index lower than 25 degrees on an antero-posterior radiograph, at the age of 12 months. Secondary outcomes are the rate of normal hips at the age of 24 months, complications, time to hip normalization, the relation between baseline patient characteristics and the rate of normal hips, compliance, costs, cost-effectiveness, budget impact, health-related quality of life (HRQoL) of the infant, HRQoL of the parents/caregivers, and parent/caregiver satisfaction with the treatment protocol. DISCUSSION: The outcomes of this randomized controlled trial will contribute to improving current care-as-usual for infants with centered DDH. TRIAL REGISTRATION: Dutch Trial Register, NL9714, registered September 6, 2021. https://clinicaltrialregister.nl/en/trial/29596.

The Ortolani test has a high positive predictive value in clinical hip screening for developmental dysplasia of the hip.

AIM: Previous studies have not described separate positive predictive values for Ortolani and Barlow tests in clinical hip screening. We aimed to determine the positive predictive values at discharge following birth, in predicting dysplasia or instability in the subsequent hip ultrasound examinations. METHODS: We included all infants with suspected or diagnosed DDH at the study hospital from 2015 to 2017 in this retrospective study. Infants with positive Ortolani or Barlow test after birth were referred for a hip ultrasound, without treatment being started. The positive predictive value of the tests to predict Graf type ≥ IIC morphology, ≥5 mm displacement in a dynamic ultrasound, or either one or both findings at the hip ultrasound examination was calculated. RESULTS: There were 33 Ortolani-positive hips and 103 Barlow-positive hips in 105 referred infants (30% male) at the screening. They received ultrasound examination at mean 21.7 days of age (SD 4.8, range 11-35). The positive predictive value was 39-61% for the Ortolani test and 4%-16% for the Barlow test depending on the true positive definition. CONCLUSION: The Ortolani test, performed by a specialist at the maternity ward, has a high positive predictive value for developmental dysplasia of the hip.

Failure to achieve reduction on developmental dysplasia of hip: an ultrasound evaluation.

BACKGROUND: Ultrasound examination of the medial side of the hip joint has been rarely used to evaluate the status of developmental dysplasia of the hip (DDH) in Pavlik harness treatment according to the literature. PURPOSE: To analyze the effects of cartilaginous acetabulum, hip joint labrum, and acetabular tissue on the reduction of DDH. MATERIAL AND METHODS: A total of 50 cases (100 hips) were detected by the Graf method with a high-frequency linear transducer (L 5-12), and there were 59 dislocated hips and 41 non-dislocated hips. Patients were treated with a Pavlik harness. Ultrasound examination of the medial side of the hip joint was performed for follow-up. The hip joints were divided into three groups: the non-dislocated group; the reducible group; and the non-reducible group. RESULTS: The success rate of reduction was significantly higher when the acetabulum cartilage was located on the cephalic side (chi-square = 28.12, P < 0.001). The success rate was also significantly higher when the hip joint labrum was located on the cephalic side (chi-square = 17.21, P < 0.001). Type III and D had a higher success rate of reduction than type IV (P < 0.001). The pairwise comparison of the measurements of acetabular tissue between the non-dislocated group, the reducible group, and the non-reducible group showed statistical differences (P < 0.001). CONCLUSION: The present study confirmed that the location of acetabulum cartilage and hip joint labrum affected the outcome of treatment. The degree of dislocation and the amount of acetabular tissue were correlated with the success rate of treatment.

Is Hip Medial Ultrasound More Accurate Than Radiography for Determining the Status of Hip Reduction in Children Treated With a Spica Cast? A Retrospective Diagnostic Accuracy Study.

BACKGROUND: Developmental dysplasia of the hip (DDH) is the most common hip abnormality in children. Closed or open reduction and cast immobilization are the most commonly used treatments for patients aged 6 to 18 months with dislocation; they are also used in children younger than 6 months when brace treatment is not effective. During cast immobilization, surgeons need reliable and timely imaging methods to assess the status of hip reduction to ensure successful treatment and avoid complications. Several methods are used, but they have disadvantages. We developed and, in this study, evaluated a hip medial ultrasound method to evaluate the status of hip reduction in children treated with a spica cast. QUESTION/PURPOSE: Is hip medial ultrasound more accurate than radiography for determining the status of hip reduction in children treated with a spica cast? METHODS: Between November 2017 and December 2020, we treated 136 patients with closed or open reduction and spica casting for DDH in our department. These children were 3 to 18 months old at the time of surgical reduction and had a specific medical history, physical examination findings, or AP radiographic evidence of unilateral or bilateral DDH. None had a concomitant femoral/acetabular osteotomy procedure in these hips. All patients underwent hip medial ultrasound, AP radiography, and MRI under sedation within 2 to 7 days after open or closed reduction. The examination time was from the second day after reduction to enable the patient to recover from anesthesia. MRI was performed within 7 days after reduction because of a few long appointment times, and ultrasound and AP radiography were always performed 1 or 2 days before MRI. Based on that, 65% (88 of 136 [88 hips]) of patients were excluded due to the absence of MRI, ultrasound, or AP radiography; 3% (4 of 136 [4 hips]) of patients were excluded because of concurrent congenital spina bifida, Larson syndrome, or Prader-Willi syndrome; and 1% (1 of 136 [1 hip]) of patients were excluded because the patient underwent MRI before ultrasound. A total of 32% (43 of 136 [43 hips]) of patients were eligible for analysis in this cross-sectional diagnostic study, and these 43 patients underwent AP radiography, ultrasound, and MRI. In this retrospective study, the mean age at the time of surgery was 10 ± 4 months (male:female ratio 5:38; unilateral DDH: 34; bilateral DDH: 9). To ensure the independence of the results, the study was limited to one hip per patient (in patients with bilateral DDH, the right hip was evaluated). The reduction of 43 hips (left:right ratio 26:17; closed:open reduction ratio 30:13) was evaluated by MRI, hip medial ultrasound, and radiography. Children with spica casts were placed in the supine position, which is necessary to expose the perineum for ultrasound. We used a broad-spectrum, microconvex, and intracavitary probe. The acetabular medial wall was identified by the triradiate cartilage of the ischial tuberosity and the pubis superior, and the femoral head was identified by the femoral neck. Then, the acetabulum coronal midsectional plane was used to determine the positions of the femoral head and acetabulum and to measure the triradiate cartilage-femoral distance. MRI examinations were performed using a 1.5-T MRI system with an eight-channel body coil. Each reviewer evaluated each reduction independently. Additionally, to further assess the hip medial ultrasound method's reliability and reproducibility, we investigated the interobserver and intraobserver agreement in evaluating the reduction using hip medial ultrasound. Using ultrasound or radiography, the reviewers classified hips as reduced, uncertain status, or dislocated. MRI was considered the gold standard for assessing hip reduction, and the reviewers classified hips as reduced or dislocated by MRI. Patients with hips with an uncertain reduction status according to ultrasound or radiography were retained in the analysis. Thus, the test results of radiography and ultrasound were classified into three classifications (positive, negative, or uncertain) in the present study. The test was considered positive or negative when patients were assessed with dislocation or without dislocation, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasound and radiography were calculated and compared. We combined uncertain and positive into the positive classification to be conservative in the statistical choices. The specificity, sensitivity, PPV, and NPV were analyzed based on this premise. Furthermore, a subgroup analysis was conducted by sex. MRI evaluation revealed that 41 hips were reduced and two hips were dislocated. RESULTS: The sensitivity, specificity, PPV, and NPV of ultrasound were 100% (95% CI 16% to 100%), 95% (95% CI 84% to 99%), 50% (95% CI 7% to 93%), and 100% (95% CI 91% to 100%), respectively. The sensitivity, specificity, PPV, and NPV of radiography were 50% (95% CI 1% to 99%), 68% (95% CI 52% to 82%), 7% (95% CI 0% to 34%), and 97% (95% CI 82% to 100%), respectively. Ultrasound showed a higher specificity (95% versus 68%; p < 0.001) and PPV (50% versus 7%; p = 0.02) than radiography. The sensitivity, specificity, PPV, and NPV of ultrasound were 100% (95% CI 16% to 100%), 94% (95% CI 81% to 99%), 50% (95% CI 7% to 93%), and 100% (95% CI 90% to 100%), respectively, for female patients (with only five male patients, we could not perform these analyses in this group). The sensitivity, specificity, PPV, and NPV of radiography were 50% (95% CI 1% to 99%), 64% (95% CI 46% to 79%), 7% (95% CI 0% to 34%), and 96% (95% CI 79% to 100%), respectively, for female patients. The κ values for intra- and interobserver reliability both were 1.0. CONCLUSION: Hip medial ultrasound can directly visualize the femoral head and acetabulum. Hip medial ultrasound is more reliable than radiography as a preliminary evaluation method and does not involve irradiation. We recommend using hip medial ultrasound during outpatient follow-up visits for patients younger than 2 years treated with hip reduction and cast immobilization. LEVEL OF EVIDENCE: Level III, diagnostic study.

The Diagnosis of Developmental Dysplasia of the Hip From Hip Ultrasonography Images With Deep Learning Methods.

BACKGROUND: Hip ultrasonography is very important in the early diagnosis of developmental dysplasia of the hip. The application of deep learning-based medical image analysis to computer-aided diagnosis has the potential to provide decision-making support to clinicians and improve the accuracy and efficiency of various diagnostic and treatment processes. This has encouraged new research and development efforts in computer-aided diagnosis. The aim of this study was to evaluate hip sonograms using computer-assisted deep-learning methods. METHODS: The study included 376 sonograms evaluated as normal according to the Graf method, 541 images with dysplasia and 365 images with incorrect probe position. To classify the developmental hip dysplasia ultrasound images, transfer learning was applied with pretrained VGG-16, ResNet-101, MobileNetV2 and GoogLeNet networks. The performances of the networks were evaluated with the performance parameters of accuracy, sensitivity, specificity, precision, F1 score, and AUC (area under the ROC curve). RESULTS: The accuracy, sensitivity, specificity, precision, F1 score, and AUC results obtained by testing the VGG-16, ResNet-101, MobileNetV2, and GoogLeNet models showed performance >80%. With the pretrained VGG-19 model, 93%, 93.5%, 96.7%, 92.3%, 92.6%, and 0.99 accuracy, sensitivity, specificity, precision, F1 score, and AUC results were obtained, respectively. CONCLUSION: In this study, in addition to the ultrasonography images of dysplastic and healthy hips, images were also included of probe malpositioning, and these images were able to be successfully evaluated with deep learning methods. On the sonograms, which provided criteria appropriate for evaluation, successful differentiation could be made of healthy hips and dysplastic hips. LEVEL OF EVIDENCE: Level-IV; diagnostic studies.

Early Investigation and Bracing in DDH Impacts Maternal Wellbeing and Breastfeeding.

BACKGROUND: The outcomes of Pavlik Harness (PH) management for Developmental Dysplasia of the Hip (DDH) are equivalent regardless of the initiation timing, if it is within the first 6 weeks of life. A PH may be a physical barrier to breastfeeding, which is important for nutrition, immunity, and normal child development. The diagnosis of DDH and early management with a PH may also negatively affect the maternal psychosocial wellbeing and the infant-maternal relationship. The purpose of this study is to investigate the impact of the diagnosis of DDH and the management with a PH has on maternal wellbeing and maintenance of breastfeeding, compared with being screened for but not diagnosed with DDH. METHODS: A retrospective cohort of the mothers of infants who were diagnosed with DDH and treated with a PH brace was compared with the mothers of infants who were screened for DDH only. The Hip Worries Inventory and Edinburgh Postnatal Depression Scale were completed by the mothers in both groups. The PH group also completed an in-house questionnaire specific to PH and breastfeeding. RESULTS: Eighty completed surveys were included, 50 from the treatment group. The mean age of the PH initiation was 6.2 weeks. The modified Hip Worries Inventory score was higher in the treatment group, with a mean difference (MD) of 9.7 out of 50 (95% confidence interval, CI, 6.8, 12.5). The MD of the Edinburgh Postnatal Depression Scale was 2.0 out of 30 (CI -0.5, 4.5). Although there was no difference in the breastfeeding ease before and after the PH initiation (MD-0.2, CI-0.7, 0.2), 83% of mothers found breastfeeding more difficult with a PH and 11% of mothers stopped breastfeeding earlier than planned because of the PH. CONCLUSIONS: Mothers of infants with DDH worry more about their child's hips and the PH. Screening alone may contribute to maternal psychological dejection and negative thoughts. The presence of a PH makes breastfeeding more difficult. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

Caregiver Experiences Using Orthotic Treatment Options for Developmental Dysplasia of the Hip in Children.

BACKGROUND: Developmental dysplasia of the hip (DDH) is a common condition affecting 5 in 1000 newborns. The standard first line of treatment is the use of an orthotic, which has generally high success rates, but can pose substantial difficulties and put undue burden on caregivers. The general experience of caregivers using these orthotics has not been well documented on an orthotic-specific basis. The purpose of this study was to investigate caregiver experience using prescribed DDH orthotics to identify challenges, differences between treatment options, and areas of improvement. METHODS: A survey assessing treatment prescription, respondent demographics, and caregiver experience was distributed online to caregivers whose child/children were treated for DDH with an orthotic. Seven-point positively phrased Likert scale statements and open-ended questions were included to assess caregiver experience. The results were analyzed using summary statistics and orthotics with more than 30 responses were selected for more in-depth analysis. RESULTS: A total of 530 survey responses were collected with 63% (334/530) of respondents using a Pavlik harness, 45% (236/530) a Rhino brace, and 13% (67/530) a Denis Browne Bar. The overall weighted average score across all Likert Scale statements was positive for the Pavlik harness, Rhino brace, and Denis Browne Bar at 4.19 (95% CI, 3.83 to 4.54), 4.63 (95% CI, 4.27 to 4.99) and 4.91 (95% CI, 4.58 to 5.24), respectively. In the open-ended responses, all 3 orthotics were perceived as easy to use and not hindering child-caregiver bonding, but raised concerns of discomfort and skin irritation, as well as preventing the ability to cuddle their child the way they desired. The Pavlik harness respondents consistently brought up concerns regarding cleanability. CONCLUSIONS: The results show that the DDH orthotics analyzed are generally easy to use and perceived positively by caregivers, but have orthotic-specific challenges that should be a focus of future improvement work. CLINICAL RELEVANCE: This study evaluated opinions and attitudes of caregivers for children being treated with DDH orthotics, revealing experiences, concerns, and challenges associated with the use of commonly prescribed options.

Prediction of Late Dysplasia Based on Ultrasound and Plain X-Ray at 6 Months.

BACKGROUND: Developmental dysplasia of the hip represents a spectrum of deformity. Residual dysplasia at 2 years of age is associated with an increased risk for osteoarthritis and functional limitations. We compared the prognostic value of 6-month imaging modalities and aimed to identify optimal diagnostic metrics for the prediction of residual dysplasia. METHODS: After IRB approval, patients who underwent Pavlik treatment between 2009 and 2018 with 2-year follow-up were identified. Sonographs [ultrasound (US)] and radiographs (x-ray) were obtained at 6-month and 2-year-old visits. Dysplasia at 2 years was defined as an acetabular index (AI) >24 degrees. Receiver operating characteristic curves were constructed to quantitatively compare the prognostic ability of US and x-ray-based measures at 6 months. Youden's index [(YI) (values range from 0 (poor test) to 1 (perfect test)] was used to evaluate existing cutoffs at 6 months of age (normal measurements: alpha angle (AA) ≥60 degrees, femoral head coverage (FHC) ≥50%, and AI <30 degrees) relative to newly proposed limits. RESULTS: Fifty-nine patients were included, of which 28.8% of patients (95% CI: 17.3 to 40.4%) had acetabular dysplasia at 2 years. After adjusting for sex, AA [Area under the Curve (AUC): 80] and AI (AUC: 79) at 6 months of age were better tests than FHC (AUC: 0.77). Current diagnostic cutoffs for AA (YI: 0.08), AI (YI: 0.0), and FHC (YI: 0.06) at 6 months had poor ability to predict dysplasia at 2 years. A composite test of all measures based on proposed cutoffs (AA ≥73 degrees, FHC > 62% and AI ≤24 degrees) was a better predictor of dysplasia at 2 years (Youden's index (YI): 0.63) than any single metric. CONCLUSIONS: The rate of residual dysplasia remains concerning. The 6-month x-ray and US both play a role in the ongoing management of the developmental dysplasia of the hip. The prediction of dysplasia is maximized when all metrics are considered collectively. Existing parameters were not accurate; We recommend the following cutoffs: AA ≥73 degrees, FHC > 62%, and AI ≤24 degrees. These cutoffs must be validated. LEVEL OF EVIDENCE: Prognostic Level II.

Midterm Development of Ultrasound-unstable Hip Joints After Overhead Traction and Treatment With Tübingen Splint and Fettweis Plaster: A Radiologic Follow-up Analysis Over 5.5 Years.

PURPOSE: The aim of this study was to determine the success rate for treatment of ultrasound unstable hips (type D, III and IV) with Fettweis plaster in terms of a midterm follow-up from the very beginning in the neonatal period until the age of 4 to 8 years. METHODS: In total, 69 unstable hips, which were successfully treated with Fettweis plaster and after with a flexion-abduction splint, were included into the study. Hip delvelopment was followed by determining the acetabular index (ACI) on routine pelvic radiographs at the age of 12 to ≤24, 24 to ≤48 and 48 to ≤96 months and the center edge angle on the latter, and classifying both angles according to Tönnis. RESULTS: After initially successful treatment, the first radiograph at the age of 12 to ≤24 months showed 39.1% (n=27) hips with normal findings, 33.2% (n=23) hips with slightly dysplastic findings, and 27.5% (n=19) hips with severe dysplastic findings. Comparison between first and second radiograph showed improvement of the ACI in 9/69 hips and between the second and third time point in 20/69 hips. Overall, 20 hip joints showed deteriorations. Hereby, 16 deteriorations took place after the first radiograph and 4 after the second radiograph. Deteriorations were observed independently of the initial hip type (D, III, and IV). CONCLUSIONS: Midterm results indicate that radiologic controls should be provided to detect deteriorations after finishing treatment. ACI and center edge angle are helpful parameters in the assessment of hip joint development in the age range of 4 to 8 years. LEVEL OF EVIDENCE: Level III.