Screening of selected risk factors in developmental dysplasia of the hip: an observational study

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.

Analysis of the results of hip ultrasonography in 48 666 infants and efficacy studies of conservative treatment

PURPOSE

This study aimed to investigate the detection rate of developmental dysplasia of the hip (DDH) by ultrasound. To obtain the distribution characteristics of the different types (I-IV) and the role of ultrasound in the evaluation of infants with DDH (type IIc and above) receiving conservative treatment.

METHODS

A retrospective analysis was performed. The chi-square test was used for comparisons between count-data groups. Two-sided tests were used for all analyses. The results of ultrasound follow-up after conservative treatment are described.

RESULTS

Among the 48 666 infants examined, the detection rates were as follows: type I, 95.42%; IIa, 3.18%; IIb, 0.91%; IIc, 0.22%; D, 0.01%; III, 0.14%; and IV, 0.12%. There were 4456 hips with IIa and above, more left (54.65%) than right (45.35%) hips, and more females (82.60%) than males (17.40%). The detection rate of type IIa and above was 4.58%, and that of type IIb and above was 1.40%. After the treatment, the α value increased, and β value decreased. The cure rate of the less-than-42-days group was higher than that of the other groups.

CONCLUSION

The ultrasound detection rate of DDH is high. DDH was more likely to occur on the left side and in females. It is recommended that the infants should be treated within 42 days.

The cost effectiveness of potential risk factors for developmental dysplasia of the hip within a national screening programme

Aims

Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities.

Methods

A five-year prospective registry study investigating every live birth in the study’s catchment area (n = 27,731), all of whom underwent screening for risk factors and examination at the newborn and six- to eight-week neonatal examination and review. DDH was diagnosed using ultrasonography and the Graf classification system, defined as grade IIb or above or rapidly regressing IIa disease (≥4^o at four weeks follow-up). Multivariate odds ratios were calculated to establish significant association, and risk differences were calculated to provide quantifiable risk increase with DDH, positive predictive value was used as a measure of predictive efficacy. The cost-effectiveness of using these risk factors to predict DDH was evaluated using NHS tariffs (January 2021).

Results

The prevalence of DDH that required treatment within our population was 5/1,000 live births. The rate of missed presentation of DDH was 0.43/1000 live births. Breech position, family history, oligohydramnios, and foot deformities demonstrated significant association with DDH (p < 0.0001). The presence of breech presentation increased the risk of DDH by 1.69% (95% confidence interval (CI) 0.93% to 2.45%), family history by 3.57% (95% CI 2.06% to 5.09%), foot deformities by 8.95% (95% CI 4.81% to 13.1%), and oligohydramnios nby 11.6% (95 % CI 3.0% to 19.0%). Primary risk factors family history and breech presentation demonstrated an estimated cost-per-case detection of £6,276 and £11,409, respectively. Oligohydramnios and foot deformities demonstrated a cost-per-case detected less than the cost of primary risk factors of £2,260 and £2,670, respectively.

Conclusion

The inclusion of secondary risk factors within a national screening programme was clinically successful as they were more cost and resource-efficient predictors of DDH than primary risk factors, suggesting they should be considered in the national guidance.

Cite this article: Bone Jt Open 2023;4(4):234–240.

Establishment of pediatric developmental dysplasia of the hip biobank: Shanghai children's hospital experience

Developmental dysplasia of the hip (DDH) is a debilitating condition that affects 1–7% of newborns. Children with DDH, not treated early and effectively, will easily lead to disability. A better understanding of the biology of DDH is critical to the development of prognostic biomarkers and novel therapies. The purpose of this study was to establish a biobank of DDH genetic resources, to facilitate clinical and basic scientific research. The biological specimen and clinical data of DDH were collected in Shanghai Children’s Hospital from 2014 to 2021. The collection of blood samples was performed at definitive diagnosis and review, tissue specimens were performed at definitive surgery. The clinical data was collected at the whole stage of DDH patients at diagnosis, treatment and follow-up. A total of 528 patients with DDH were enrolled in this study, 90 were men and 438 were women, with the mean age of 4.67 years. The numbers of tissue and blood specimens reached 2172 and 1490, respectively. The quality test results showed that the DNA concentration decreased slightly with the extension of storage time, but the DNA purity did not change. Meanwhile, the extension of storage time slightly affected the stability of protein of tissue samples but did not affect the expression of the housekeeping gene. The DDH biobank built has the potential of monitoring disease pathogenesis and progress, which could provide specimens to the researchers improving the biological understanding and provide guidance of clinical treatment of this disease to clinicians.

Positive predictive values in clinical screening for developmental dysplasia of the hip

AIM

To establish the positive predictive value (PPV) of clinical hip examinations performed by referrers in the Danish screening programme for Developmental Dysplasia of the Hip (DDH) utilising three definitions of true positive DDH diagnosis.

METHODS

We retrospectively identified 290 children (169 female) referred during a 4-year period to the orthopaedic outpatient clinic at our institution with a positive clinical hip examination. Positive predictive value was calculated for clinical hip examinations across three definitions of a true positive clinical hip examination for all referrers and subgroups consisting of general practitioners, midwives and paediatricians. The PPV for clinical hip examinations was calculated for paediatric orthopaedic surgeons using one of the three definitions.

RESULTS

Positive predictive value of clinical hip examinations for all referrers were 5.4%, 3.6% and 1.8% with the definition of a true positive DDH diagnosis defined as clinical instability found by orthopaedic surgeon, ultrasound classification ≥Graf IIc or both definitions combined, respectively. Positive predictive value of clinical hip examinations performed by orthopaedic surgeons was 33.3% with a true positive clinical examination defined as an ultrasound classification ≥Graf IIc.

CONCLUSION

We conclude that the positive predictive value of clinical hip examinations made by referrers in the Danish screening programme for DDH is low.

Screening of Newborns and Infants for Developmental Dysplasia of the Hip: A Systematic Review

BACKGROUND

Developmental dysplasia of hip (DDH) is a common disorder of childhood and has a good prognosis when treated at an early age. In spite of being a significant concern, many children with DDH are not picked early and present late at walking age. In our country, it is presumed to be due to absence of a national policy for screening of DDH. Screening programmes including the combination of clinical and radiological methods in different ways have been suggested. However, the exact method of screening is controversial.

PURPOSE

To analyze effectiveness and cost-effectiveness of various screening methods for DDH.

STUDY DESIGN

Systematic review.

METHODS

This review was conducted in accordance with PRISMA guidelines. Medline database was explored for original case series and randomized clinical trials. Inclusion criteria were English language, screening for DDH in neonates, sample size more than 500, and studies with minimum duration of one year.

RESULTS

Thirty-four studies were selected to write the manuscript. This included 23 studies looking for effectiveness of a screening programme and 11 studies comparing various outcomes of different screening strategies. A trend favoring universal ultrasound screening was observed.

CONCLUSION

The literature supports universal ultrasound screening and has proved its cost-effectiveness. However, considering the logistic and financial challenges in our country, immediate implementation of universal ultrasound screening seems impractical. In the absence of any current guidelines for screening for DDH in India, we suggest professional organizations involved in the care of children and public health policy-makers to come together to develop national screening guidelines for DDH.

Is foot deformity associated with developmental dysplasia of the hip?

Aims

To assess if congenital foot deformity is a risk factor for developmental dysplasia of the hip (DDH).

Methods

Between 1996 and 2012, 60,844 children were born in Sør-Trøndelag county in Norway. In this cohort study, children with risk factors for DDH were examined using ultrasound. The risk factors evaluated were clinical hip instability, breech delivery, a family history of DDH, a foot deformity, and some syndromes. As the aim of the study was to examine the risk for DDH and foot deformity in the general population, children with syndromes were excluded. The information has been prospectively registered and retrospectively analyzed.

Results

Overall, 494 children (0.8%) had DDH, and 1,132 (1.9%) a foot deformity. Of the children with a foot deformity, 49 (4.3%) also demonstrated DDH. There was a statistically significant increased association between DDH and foot deformity (p < 0.001). The risk of DDH was highest for talipes calcaneovalgus (6.1%) and club foot (3.5%), whereas metatarsus adductus (1.5%) had a marginal increased risk of DDH.

Conclusion

Compared with the general population, children with a congenital foot deformity had a significantly increased risk for DDH and therefore we regard foot deformity as a true risk factor for DDH.

Cite this article: Bone Joint J 2020;102-B(11):1582–1586.

Oligohydramnios: should it be considered a risk factor for developmental dysplasia of the hip?

Breech, family history, first born and female sex are the main risk factors described for developmental dysplasia of the hip (DDH). Foot abnormalities and oligohydramnios have also been listed. Recent studies have discredited torticollis, multiple gestation pregnancy, mode of delivery and prematurity as risk factors. Definition of oligohydramnios in the literature is inconsistent. Our aim was to investigate the term oligohydramnios and evaluate whether it should be considered a risk factor for DDH. All live births in our institution between 2001 and 2014 were included. We identified all pregnancies classed as reduced amniotic fluid (AF) or oligohydramnios over that period. Data on DDH, breech presentation, female sex and positive family history were collected. The significance level was set to 5%. We identified 73 990 live births, 3408 pregnancies were classed as reduced AF or oligohydramnios. The incidence of DDH (Graf type IIb and higher) was 1: 1000 (75 babies, 18 bilateral). Oligohydramnios/reduced AF was found in 12 (16%) DDH babies. Breech presentation was found in 24 (32%), positive family history in 19 (25%) and female sex in 71 (94.7%). Oligohydramnios was found to be associated with a higher odds ratio (OR) for DDH [OR = 3.9, 95% confidence interval (CI): 2.1-7.3] as were breech presentation (OR = 10.6, 95% CI: 6.5-17.1) and female sex (OR = 19.1, 95% CI: 7-52.4). All examined risk factors showed statistical significance (P < 0.05). A regression analysis was performed to control for interactions and confounding factors and confirmed the findings. On the basis of our findings the diagnosis of reduced AF/oligohydramnios in consecutive antenatal sonographic scans should be regarded as an independent risk factor for DDH and be considered in any future studies regarding DDH. Level of evidence: Level IV: Case series.

Do the risk factors for developmental dysplasia of the hip differ according to gender? A look from another perspective

AIM

The aim of the present study was to examine if there were gender differences in risk factors in 4415 infants who were evaluated through a physical examination and hip ultrasonography (USG).

METHODS

Physical examination of the hip and hip USG were performed on 4415 infants by the same paediatric orthopaedics specialist. Barlow and Ortolani tests were performed together with the evaluation for the limitation of abduction. Ultrasonographic hip examination was performed according to the Graf technique. The birth records of all the infants were examined, and anamneses (genetic disease, maternal age, delivery type, swaddling, multiple pregnancies, duration of gestation period, gravida, birthweight, breech presentation, oligohydramnios and family history) were obtained from the families. Any accompanying musculoskeletal (torticollis, pes equinovarus, congenital knee dislocation) abnormality was recorded.

RESULTS

Pathological hip was determined in 149 (3.37%) of 4415 infants. In males, gestational week, family history, breech presentation, swaddling, congenital knee dislocation and limited abduction were observed to be significant for the presence of developmental dysplasia of the hip (DDH). In females, significant factors for the presence of DDH were determined to include birthweight, gestational week, breech presentation, multiple pregnancy, accompanying oligohydramnios, torticollis, pes equinovarus and limited abduction.

CONCLUSION

Risk factors for DDH can differ according to gender.

The positive predictive value of asymmetrical skin creases in the diagnosis of pathological developmental dysplasia of the hip

Aims

The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH).

Patients and Methods

Between 1 January 1996 and 31 December 2016, all patients referred to our unit from primary or secondary care with risk factors for DDH were assessed in a "one stop" clinic. All had clinical and sonographic assessment by the senior author (RWP) with the results being recorded prospectively. The inclusion criteria for this study were babies and children referred with asymmetrical skin creases. Those with a neurological cause of DDH were excluded. The positive predictive value (PPV) for pathological DDH was calculated.

Results

A total of 105 patients met the inclusion criteria. There were 71 girls and 34 boys. Only two were found to have pathological DDH. Both also had unilateral limited abduction of the hip in flexion and a positive Galeazzi sign with apparent leg-length discrepancy. Thus, if the specialist examination of a patient with asymmetrical skin creases was normal, the PPV for DDH was 0%.

Conclusion

Isolated asymmetrical skin creases are an unreliable clinical sign in the diagnosis of pathological DDH. Greater emphasis should be placed on the presence of additional clinical signs to guide radiological screening in babies and children. Cite this article: Bone Joint J 2018;100-B:675-9.

Late presentation of developmental dysplasia of the hip

Aims

Despite the presence of screening programmes, infants continue to present with late developmental dysplasia of the hip (DDH), the impact of which is significant. The aim of this study was to assess infants with late presenting dislocation of the hip despite universal clinical neonatal and selective ultrasound screening.

Patients and Methods

Between 01 January 1997 to 31 December 2011, a prospective, longitudinal study was undertaken of a cohort of 64 670 live births. Late presenting dislocation was defined as presentation after three months of age. Diagnosis was confirmed by ultrasound and plain radiography. Patient demographics, referral type, reason for referral, risk factors (breech presentation/strong family history) and clinical and radiological findings were recorded.

Results

There were 31 infants with an irreducible dislocation of the hip, an incidence of 0.48 (95% confidence interval (CI) 0.34 to 0.68) per 1000 live births. Of these, 18 (0.28 (95% CI 0.17 to 0.44) per 1000 live births; 58%) presented late. All infants had a documented normal newborn clinical examination and no abnormality reported in the six to eight week check. Of the 18 late presenting cases 72% (n = 13) had no risk factors: 16 were referred by GPs and two were late due to administrative issues (missed appointments). The mean time to diagnosis was 62.4 weeks (19 to 84).

Conclusion

Despite universal clinical neonatal and selective ultrasound screening, late cases of irreducible hip dislocation still occur. We recommend an update of the national screening programme for DDH, a review of training and education of healthcare professionals involved in the physical examination of neonates and infants, and the addition of a further assessment after the six to eight week check. Cite this article: Bone Joint J 2017;99-B:1250–5.

Screening in Developmental Dysplasia of the Hip (DDH)

Screening for Developmental Dysplasia of the Hip (DDH) is a controversial subject. Screening may be by universal neonatal clinical examination (Ortolani or Barlow manoeuvres) with the addition of sonographic imaging of the hip (selective 'at risk' hips or universal screening in the neonate). In the UK, the NIPE guidelines recommend universal neonatal clinical assessment of the hip joints, a General Practitioner 6-8 week clinical 'hip check' and assessment clinically with sonographic imaging at 4-6 weeks for certain 'at risk' hips for pathological DDH. The effectiveness and difficulties arising from the UK current screening policy (clinical and sonographic) are highlighted. The purpose of the review was to assess the risk factors and efficacy of diagnostic methods in DDH, based on longitudinal cohort studies of 10 years or more.

CONCLUSION

Hip screening in DDH does not meet most of the World Health Organisation's criteria for an effective screening programme and should only be considered as surveillance due to its low sensitivity and positive predictive value (PPV). There is a significant risk of over diagnosis and over treatment. There is no International consensus on screening in DDH. Pathological DDH is mainly a female condition and 'at risk'/General Practitioner screening identifies few pathological cases in male subjects. The General Practitioner 6-8 week 'hip check' has a very low PPV for pathological DDH and is of doubtful value in screening and diagnosis. Unilateral limitation of hip abduction is a time dependent and useful clinical sign in the diagnosis of pathological DDH. The majority of the previously considered 'at risk' factors are not true risk factors with little or no association with pathological DDH.

The association between gender and familial prevalence of hip dysplasia in Danish patients

BACKGROUND

The development of hip dysplasia is associated with several risk factors. 1 of these risk factors is gender, since 80% of patients with symptomatic hip dysplasia are females. Another risk factor for hip dysplasia is familial predisposition of hip dysplasia. Several studies indicate that the risk of hip dysplasia is increased with familial prevalence of hip dysplasia. However, little is known about the association between the familial prevalence and gender and the development of hip dysplasia.

PURPOSE

The aim of the study was to estimate the prevalence of hip dysplasia among relatives to Danish patients with hip dysplasia operated with periacetabular osteotomy (PAO), and the degree of relationship of affected family members. Furthermore, to assess the association between gender and family predisposition in the same group of patients.

METHOD

The study is a cross-sectional study, with a descriptive and an analytical part. The study population consists of 676 patients drawn from a clinical database of patients operated with PAO at Aarhus University hospital from 1998 to 2014. Information about gender, operated hip side and age was collected from the clinical PAO database, while information about familial prevalence was collected through questionnaires. The association between gender and familial prevalence of hip dysplasia was presented as the prevalence proportions ratio (PPR), tested by χ2 test. Stratification was conducted for the variables age and operated hip side, with the Mantel-Haenszels analytical method, and tested for statistical significance by χ2.

RESULTS

The familial prevalence of hip dysplasia in the study population was 30% (95% CI, 27%-34%), with 73% reporting affected first-degree relatives. Females have 32% increased risk of familial prevalence of hip dysplasia compared to males, but this difference in risk was not statistically significant (p = 0.10).

CONCLUSIONS

The study shows that females have 32% increased familial prevalence of hip dysplasia compared to males, but the increased prevalence was not statistically significant probably due to the low power of the study.

The most relevant diagnostic criteria for developmental dysplasia of the hip: a study of British specialists

Background

Developmental dysplasia of the hip (DDH) is the most common orthopaedic disorder in newborns. Despite this considerable variation in practice exists. The aim of this study was to determine the clinical relevance and a ranking order for the diagnostic criteria in DDH amongst paediatric orthopaedic surgeons practicing in the UK.

Method

One hundred members of the British Society of Children’s Orthopaedic Surgery (BSCOS) were asked to rate the importance of 37 criteria useful in the diagnosis of DDH in newborns, using a 10 cm visual analogue scale. We determined the consistency among specialists in rating the criteria with the intraclass correlation coefficient (ICC) and compared the results to a group of international peers.

Results

Ortolani/Barlow tests, asymmetry in abduction ≥20° and a first-degree relative treated for DDH ranked among the top ten. Participants demonstrated poor consistency in rating the 37 criteria (ICC 0.39; 95 % CI 0.29, 0.52), but for clinical examination criteria alone their consistency improved (ICC 0.52; 0.35, 0.75). The importance ratings of members of BSCOS and members of the European Paediatric Orthopaedic Society differed for 15/37 (41 %) criteria (p <0.05).

Conclusions

Members of BSCOS had a preference for criteria relating to clinical examination and ultrasound.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0867-4) contains supplementary material, which is available to authorized users.

Selective ultrasound screening is inadequate to identify patients who present with symptomatic adult acetabular dysplasia

PURPOSE

One goal of neonatal screening for developmental dysplasia of the hip (DDH) is the prevention of late surgery. However, the majority of patients with acetabular dysplasia at skeletal maturity are not diagnosed with DDH during infancy. Selective ultrasound screening may identify patients with neonatal hip instability, but may be ineffective for the prevention of dysplasia presenting in adulthood. The purpose of this study is to identify the prevalence of risk factors for DDH that would have warranted selective ultrasound screening in patients with symptomatic acetabular dysplasia after skeletal maturity.

METHODS

A prospective hip specialty center registry was used to identify 68 consecutive skeletally mature patients undergoing corrective osteotomy for symptomatic acetabular dysplasia. Risk factors for DDH evaluated in all patients included sex, family history of hip osteoarthritis or DDH, breech, method of delivery, previous hip treatments, and birth order. Radiographs [lateral center edge angle (CEA), anterior CEA, Tönnis grade, and Tönnis angle] were measured preoperatively.

RESULTS

Sixty-seven females and one male were identified. No patients were previously diagnosed with DDH or received treatment for their hips. The majority of patients (85.3 %) did not meet selective ultrasound screening guidelines following a stable neonatal hip exam and, therefore, would not have been screened in a selective screening program. Of the findings outside of screening guidelines, 98.5 % were females, 52.9 % were first born, and 36.8 % had a family history of hip osteoarthritis.

CONCLUSIONS

The majority (85.3 %) of patients with symptomatic acetabular dysplasia at skeletal maturity would not have met current recommendations for selective ultrasound screening in the USA had they been born today.