Developmental dysplasia of the hip

Can Pre-operative MRI Predict the Need for Salter's Osteotomy in DDH Children Undergoing Open Reduction?

Introduction

MRI having the multiplanar capability is a good choice for pre-operative planning in developmental dysplasia of hip (DDH). Although few previous studies utilised MRI to quantify dysplasia, predict outcomes, and the procedure required, there are no defined pre-operative conclusive criteria on when to do Salter's osteotomy?

Material and Methods

A prospective cohort study was conducted in unilateral idiopathic DDH cases those who underwent an open reduction in the age group of one to four years. Pre- and post-operative MRI was done to assess various acetabular and femoral parameters. Intra-operatively, osteotomy was planned. Based on stability assessment given by Zadeh et al Clinical follow-up assessment was done at three- and six-month post-op. Functional assessment using Modified McKay's criteria was done at six months follow-up.

Results

Out of 15 cases, seven children underwent only open reduction (OR), whereas eight underwent OR with Salter's osteotomy. Based on pre-op acetabular index and anteversion, Salter's osteotomy should be done in 14 out of 15 cases, but intra-operative stability test precluded Salter's in 6 cases. Post-operative anterior sectoral angle and femoral head coverage percentage were better in OR with Salter's group than OR-only group, but not statistically significant. Functional assessment at final follow-up showed all OR with Salter's group cases were Grade I, whereas in OR-only group, 4 were Grade I and 3 were Grade II.

Conclusion

Three-dimensional dynamic assessment using intra-operative stability test predicts the best possible interrelation between the articular surface of the femoral head and acetabulum and the need for osteotomy rather than preoperative MRI.

Articular cartilage degeneration and aberrant osteocyte perilacunar/canalicular remodeling in subchondral bone of patients with developmental dysplasia of the hip

BACKGROUND

Developmental dysplasia of the hip (DDH) is a congenital musculoskeletal disease that impairs the hip joint and exacerbates hip osteoarthritis. This study aims to investigate the alterations of osteocytic characteristics including apoptosis, lacuna-canalicular network, and perilacunar/canalicular remodeling (PLR) activity in subchondral bone from DDH patients, and potential relationship of these alterations between the cartilage degeneration and DDH progression.

METHODS

The femoral head specimens were acquired from 16 patients with hip fractures who received total hip arthroplasty operation, 24 patients with primary hip OA and 25 patients with DDH. The femoral head were scanned by a micro-computed tomography and the volume of interest was used for a micro-finite element analysis. Histological and immunohistochemical staining was used to observe chondrocytes in cartilage and osteocytes in subchondral bone. Terminal deoxynucleotidyl transferase dUTP nick end labeling staining was used to investigate the apoptotic osteocytes in subchondral bone. Ploton silver staining was used to visualize lacunocanalicular network and picrosirius red staining was to visualize collagen fiber orientation in subchondral bone.

RESULTS

The DDH group showed the highest apoptosis rate of osteocytes and increased PLR activity among the three groups. The micro-finite-element analysis revealed that DDH group had deteriorative microstructural and biomechanical properties of subchondral bone. The histological and immunohistochemical analyses showed that the cartilage degeneration in DDH group was the most severe. Linear regression analysis revealed a significant correlation between osteocytic activity in subchondral bone and cartilage degeneration in DDH.

CONCLUSIONS

Our findings indicate that the abnormal osteocyte activity in subchondral bone might contribute to the deterioration of subchondral bone structure, which accelerates cartilage degeneration and DDH progression. Targeting subchondral bone remodeling could offer a promising therapeutic strategy for DDH.

The Role of Contrast-enhanced Ultrasound in the Femoral Head Perfusion Evaluation: A Pilot Study

OBJECTIVES

We explored the value of contrast-enhanced ultrasound (CEUS) in evaluating femoral head (FH) perfusion, guiding interventions and follow-up for infants with developmental dysplasia of the hip (DDH) and septic arthritis of the hip (SAH). The aim was to provide robust evidence for clinical assessment.

METHODS

Ten infants, including 7 with DDH and 3 with SAH, were prospectively enrolled, with their bilateral hips alternately scanned during the CEUS exams. Twenty hips were classified into the case group (n = 11) and the control group (n = 9). Pre- and post-interventional studies were performed in DDH infants requiring interventions. FH perfusion was assessed by the perfusion area ratio (PAR) and quadrant location of microbubble-defect regions.

RESULTS

In the case group, 25 CEUS studies were conducted, including 11 baseline, 7 follow-up and 7 post-intervention studies. The PAR significantly decreased in the case group (49.79% vs. 100.00%, p < 0.05). The microbubble-defect regions averagely affected 2 quadrants, primarily quadrat No. 3 (30%) and No. 4 (32%). Seven hip abduction angle adjustments were made based on pre-interventional studies, resulting in a significant increase in PAR in post-interventional studies (37.63% vs. 60.24%, p < 0.05). PAR increased in follow-up studies compared to baseline values (45.61% vs. 76.07%, p < 0.05). The inter- and intra-observer reproducibility of PAR measurements were excellent (intraclass correlation coefficient, both 0.97).

CONCLUSION

CEUS proves to be a promising technique for quantitatively detecting FH perfusion in DDH and SAH infants with high reproducibility. It is valuable for baseline, intra-intervention and follow-up studies, aiming in clinical conditions and therapeutic effect evaluation.

Molecular mechanisms and genetic factors contributing to the developmental dysplasia of the hip

The most prevalent hip disease in neonates is developmental dysplasia of the hip (DDH). A timely and accurate diagnosis is required to provide the most effective treatment for pediatric patients with DDH. Heredity and gene variation have been the subject of increased attention and research worldwide as one of the factors contributing to the pathogenesis of DDH. Genome-wide association studies (GWAS), genome-wide linkage analyses (GWLA), and exome sequencing (ES) have identified variants in numerous genes and single-nucleotide polymorphisms (SNPs) as being associated with susceptibility to DDH in sporadic and DDH family patients. Furthermore, the DDH phenotype can be observed in animal models that exhibit susceptibility genes or loci, including variants in CX3CR1, KANSL1, and GDF5. The dentification of noncoding RNAs and de novo gene variants in patients with DDH-related syndrome has enhanced our understanding of the genes implicated in DDH. This article reviews the most recent molecular mechanisms and genetic factors that contribute to DDH.

Using an Innovative Model to Improve Performance of the Infant Hip Examination

OBJECTIVES

Determine if a new teaching bundle targeting developmental dysplasia of the hip screening improved interns' examination skills across multiple pediatric residency programs.

METHODS

This multicenter prospective cohort study included interns across 6 pediatric residency sites within the Academic Pediatric Association's Better Outcomes through Research for Newborns Network in 2022. Participants underwent a baseline hip examination assessment on models using a checklist derived from textbook descriptions of Galeazzi, Ortolani, and Barlow maneuvers before receiving a teaching bundle. Repeat testing occurred after instruction. Data were analyzed using t-test for continuous and χ2 test for categorical variables. Semistructured focus groups provided qualitative feedback regarding the teaching bundle.

RESULTS

We enrolled 117 of 155 interns across 6 sites (76%) for participation in the teaching bundle. Only 2% of participants (n = 2) identified a positive Galeazzi sign at baseline, whereas 88% (n = 103, P < .001) did so on the postinstructional assessment. Although 27% of participants (n = 32) correctly identified a positive Barlow sign at baseline, 69% (n = 81, P < .001) did so on the postinstructional assessment. The ability to correctly detect a positive Ortolani sign increased from 22% (n = 26) to 92% (n = 108, P < .001). Fifteen interns participated in the semistructured focus groups, with resultant themes reinforcing the limited experience of the infant hip examination before this intervention and the positive impact of the teaching bundle.

CONCLUSIONS

Most participants in this study did not have strong infant hip examination skills at entry into residency. A standardized teaching bundle significantly improved skills in examination technique and identifying abnormalities.

Treatment of bilateral developmental dysplasia of the hip joint with an improved technique: A case report

BACKGROUND

Developmental dysplasia of the hip (DDH) is a common osteoarticular deformity in pediatric orthopedics. A patient with bilateral DDH was diagnosed and treated using our improved technique "(powerful overturning acetabuloplasty)" combined with femoral rotational shortening osteotomy.

CASE SUMMARY

A 4-year-old girl who was diagnosed with bilateral DDH could not stand normally, and sought surgical treatment to solve the problem of double hip extension and standing. As this child had high dislocation of the hip joint and the acetabular index was high, we changed the traditional acetabuloplasty to "powerful turnover acetabuloplasty" combined with femoral rotation shortening osteotomy. During the short-term postoperative follow-up (1, 3, 6, 9, 12, and 15 months), the child had no discomfort in her lower limbs. After the braces and internal fixation plates were removed, formal rehabilitation training was actively carried out.

CONCLUSION

Our "powerful overturning acetabuloplasty" combined with femoral rotational shortening osteotomy is feasible in the treatment of DDH in children. This technology may be widely used in the clinic.

Effects of different pelvic osteotomy surgeries on acetabular center and pelvic morphology

OBJECTIVE

To compare the effects of Salter pelvic osteotomy, Pemberton pelvic osteotomy, and triple pelvic osteotomy on the center of acetabulum and pelvic morphology in children with hip joint disease.

METHODS

The data of children treated with Salter pelvic osteotomy (2 males and 14 females with an average age of 2.49 years), Pemberton pelvic osteotomy (4 males and 11 females with an average age of 6.11 years), and triple pelvic osteotomy(4 males and 8 females with an average age of 9.59 years) between January 2011 and December 2020 were collected. After discharge, the outpatient review was followed up for at least 1 year. All patients underwent anterior-posterior pelvic X-ray scanning before surgery, three months after surgery in the first year and every six months after the first year. The following X-ray features were analyzed: bilateral pelvic height (PH), iliac crest inclination (ICI), a horizontal distance of the acetabulum center (HD), and vertical distance of the acetabulum center (VD).

RESULTS

The mean follow-up time was 16.9 ± 4.9 months in the Salter group, 20.7 ± 5.1 months in the Pemberton group, and 18.0 ± 5.4 months in the triple group (all P > 0.05). No significant differences between PH, HD, and VD of both sides on the preoperative AP pelvic x-ray were found. However, at the last follow-up, PH, HD,VD, and ICI increased in the Salter group (all P < 0.05), PH and VD increased in the Pemberton group (all P < 0.05), and VD decreased in the Triple group (P < 0.05).

CONCLUSION

Salter pelvic osteotomy may cause pelvic height to increase and the center of acetabulum to move outward and downward. In contrast, Pemberton pelvic osteotomy may cause pelvic height to increase and the center of acetabulum to move downward. Triple pelvic osteotomy only causes the center of acetabulum to move downward.

Three-Dimensional CT and 3D MRI of Hip- Important Aids to Hip Preservation Surgery

Common hip internal derangements include femoroacetabular impingement (FAI), developmental dysplasia of hip (DDH) dysplasia, and avascular necrosis (AVN) of the femoral head. These are initially screened by radiographs. For preoperative planning of hip preservation, 3-dimensional (3D) CT is commonly performed to assess bony anatomy and its alterations. Magnetic resonance imaging (MRI) is used to evaluate labrum, hyaline cartilage, tendons, synovium, and loose bodies, and provides vital information for surgical decision-making. However, conventional 2D MRI techniques are limited by lack of isotropic multiplanar reconstructions and partial volume artifacts. With advancements in hardware and software, novel isotropic 3D MR Proton Density images are acquired with acceptable acquisition times leading to improved visualization of soft tissue and osseous structures for various hip conditions. Three-Dimensional MRI allows multiplanar non-gap reconstructions along the structures of interest. It results in detection of small, otherwise inconspicuous labral tears without the need for MR arthrogram, which can be subsequently measured. In addition, radial reconstructions of the femoral head can be performed from original 3D volume MR imaging and CT imaging without the need for individual different plane acquisitions. Three-Dimensional MRI thus impacts surgical decision-making for the important common hip derangement conditions. For example, femoral head hyaline cartilage loss may make hip preservation difficult or impossible. In this review, we discuss the advantages and technical details of 3D CT and MRI and their significant role in aiding hip preservation surgery for common hip conditions. The conditions discussed in this article include FAI, DDH, AVN, synovial disorders, cartilaginous tumors, and hip fractures.

Preterm birth does not increase the risk of developmental dysplasia of the Hip: a systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review was to appraise the literature on the association between preterm birth and developmental dysplasia of the hip (DDH).

METHODS

Medline, Embase, Scopus, and Web of Science databases were queried for all studies pertaining to DDH and preterm birth. Data were imported and analyzed in Revman5 and Comprehensive Meta-Analysis (CMA) for pooled prevalence estimation.

RESULTS

Fifteen studies were included in the final analysis. There were 759 newborns diagnosed with DDH in these studies. DDH was diagnosed in 2.0% [95%CI:1.1-3.5%] of the premature newborns. Pooled incidence rate of DDH was not statistically different between those groups (2.5%[0.9%-6.8%] vs. 0.7%[0.2%-2.5%] vs. 1.7%[0.6%-5.3%];Q = 2.363,p = 0.307).

CONCLUSIONS

In this systematic review and meta-analysis, we did not find preterm birth to be a significant risk factor for DDH. Data suggests that female sex and breech presentation are associated with DDH in preterm infants, but the data is scarce in the literature.

Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle?

Sex differences have been reported for diseases of the musculoskeletal system (MSK) as well as the risk for injuries to tissues of the MSK system. For females, some of these occur prior to the onset of puberty, following the onset of puberty, and following the onset of menopause. Therefore, they can occur across the lifespan. While some conditions are related to immune dysfunction, others are associated with specific tissues of the MSK more directly. Based on this life spectrum of sex differences in both risk for injury and onset of diseases, a role for sex hormones in the initiation and progression of this risk is somewhat variable. Sex hormone receptor expression and functioning can also vary with life events such as the menstrual cycle in females, with different tissues being affected. Furthermore, some sex hormone receptors can affect gene expression independent of sex hormones and some transitional events such as puberty are accompanied by epigenetic alterations that can further lead to sex differences in MSK gene regulation. Some of the sex differences in injury risk and the post-menopausal disease risk may be "imprinted" in the genomes of females and males during development and sex hormones and their consequences only modulators of such risks later in life as the sex hormone milieu changes. The purpose of this review is to discuss some of the relevant conditions associated with sex differences in risks for loss of MSK tissue integrity across the lifespan, and further discuss several of the implications of their variable relationship with sex hormones, their receptors and life events.

Congenital hip dysplasia: The importance of early screening and treatment

Congenital Hip Dysplasia (CHD) is characterized by a hip joint dislocation between the femoral head and the acetabulum, with a multifactorial etiology. This disorder can be an isolated condition or the manifestation of a syndromic condition, and it has been estimated with higher rates than registered, with a predominance in female sex and left side; risk factors are now defined. In Italy, the incidence rate is 3-4%, with significant regional differences: higher in Lombardy and lower in Sicily. Because clinical examination alone is insufficient to diagnose CHD, it is supplemented with ultrasonography and X-ray if necessary. Surveillance, static or dynamic splints, or osteotomies are the only treatment options. The goal of this study was to evaluate our experience in terms of management and conservative treatment of all newborns from January 2018 to May 2022: female sex and left hip were major involved, risk factors were not significant in our case, but results from early diagnosis and treatments, in terms of better outcome, were interesting. After a strict 6-month follow-up period, 89.13% of the patients were classified as grade Ia or Ib according to the Graf classification system. Finally, we emphasize the importance of early universal screening and subsequent diagnosis to allow for early treatment of the disorder, at an age when conservative treatments can yield good results.

Clinical and Radiological Outcomes of Revision Total Hip Arthroplasty for Patients with Prior Hartofilakidis Type C Hip Dysplasia

OBJECTIVE

To investigate the clinical and radiological results of revision total hip arthroplasty (THA) for patients with previously diagnosed Hartofilakidis type C hip dysplasia, which is technically challenging and lacks literature.

METHODS

We enrolled 20 patients with previously diagnosed Hartofilakidis type C hip dysplasia who underwent revision THA between November 2008 and July 2015 at our hospital. Patients were followed up for an average of 87 months. Data pertaining to the Harris hip score (HHS), modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), general satisfaction, and the level of satisfaction related to 16 hip functions or issues experienced after revision THA were collected. The vertical and horizontal center of rotation (COR) of the hips were measured bilaterally based on preoperative and postoperative anteroposterior radiographs. Categorical variables were analyzed by the chi-square test. Continuous variables were analyzed using the student's t test or non-parametric Wilcoxon Rank Sum test.

RESULTS

There were significant postoperative improvements in the HHS (47.4 ± 31.6 vs 70.1 ± 39.0), modified WOMAC (48.5 ± 27.9 vs 75.7 ± 36.8), and the vertical (45.7 ± 33.7 mm vs 21.6 ± 21.8 mm) and horizontal (41.8 ± 17.0 mm vs 31.4 ± 14.7 mm) offset of the COR after revision THA (P < 0.05). Fifteen (75.0%) patients were satisfied with the procedure. The satisfaction rate for each of the 16 items ranged from 45% to 100%. The top three dissatisfactory items were squatting, getting into/out of cars, and leg-length discrepancy. Postoperatively, dissatisfied patients had a significantly higher visual analogue scale pain score and lower WOMAC pain, HHS pain, WOMAC total, and HHS total scores, a lower satisfaction rate for pain relief, and a higher vertical COR.

CONCLUSION

There is a high rate (25%) of dissatisfaction with the outcome after revision THA for patients with prior Hartofilakidis type C hip dysplasia. The most likely reasons for dissatisfaction were inadequate pain relief and a higher vertical COR measured on radiography.

Outcome Prognostic Factors in MRI during Spica Cast Therapy Treating Developmental Hip Dysplasia with Midterm Follow-Up

Closed reduction followed by spica casting is a conservative treatment for developmental dysplasia of the hip (DDH). Magnetic resonance imaging (MRI) can verify proper closed reduction of the dysplastic hip. Our aim was to find prognostic factors in the first MRI to predict the possible outcome of the initial treatment success by means of ultrasound monitoring according to Graf and the further development of the hip dysplasia or risk of recurrence in the radiological follow-up examinations. A total of 48 patients (96 hips) with DDH on at least one side, and who were treated with closed reduction and spica cast were included in this retrospective cohort study. Treatment began at a mean age of 9.9 weeks. The children were followed for 47.4 months on average. We performed closed reduction and spica casting under general balanced anaesthesia. This was directly followed by MRI to control the position/reduction of the femoral head without anaesthesia. The following parameters were measured in the MRI: hip abduction angle, coronal, anterior and posterior bony axial acetabular angles and pelvic width. A Graf alpha angle of at least 60° was considered successful. In the radiological follow-up controls, we evaluated for residual dysplasia or recurrence. In our cohort, we only found the abduction angle to be an influencing factor for improvement of the DDH. No other prognostic factors in MRI measurements, such as gender, age at time of the first spica cast, or treatment involving overhead extension were found to be predictive of mid-term outcomes. This may, however, be due to the relatively small number of treatment failures.

Evaluating the association between pulmonary abnormalities and complications following pediatric hip dysplasia surgery

PURPOSE

Developmental dysplasia of the hip (DDH) encompasses a wide range of abnormal hip development and is a common condition in the pediatric population. Congenital pulmonary abnormalities are typically mild in the pediatric population but can be associated with severe comorbid conditions. The purpose of this study was to analyze the effect of structural pulmonary/airway abnormalities on the incidence of postoperative complications following surgical management of DDH.

METHODS

From 2012 to 2019, the National Surgical Quality Improvement Program-Pediatric database was utilized to identify pediatric patients undergoing surgical treatment for hip dysplasia. Patients were stratified into two groups: patients with a structural pulmonary/airway abnormality and patients without a pulmonary abnormality. Patient demographics, comorbidities, and postoperative complications were compared between the two cohorts with the use of various statistical analyses, including bivariate and multivariate analyses.

RESULTS

Of the 10,853 patients who underwent surgical treatment for hip dysplasia, 10,157 patients (93.6%) did not have a structural pulmonary/airway abnormality whereas 696 (6.4%) had an airway abnormality. Following adjustment on multivariate analysis, patients with a structural pulmonary abnormality had an increased risk of cardiac arrest requiring cardiopulmonary resuscitation (OR 2.342; p = 0.045).

CONCLUSION

The results indicated that patients with a structural pulmonary abnormality had an increased risk of cardiac arrest requiring cardiopulmonary resuscitation compared to those without a pulmonary abnormality. Ensuring appropriate preoperative evaluation with a multidisciplinary team and close monitoring postoperatively is important to prevent the risk of severe outcomes in this vulnerable patient population.

Point-of-Care Ultrasound Reduces Visit Time and Cost of Care for Infants with Developmental Dysplasia of the Hip

BACKGROUND

Healthcare institutions and policymakers are searching for system-wide approaches to reduce costs while maintaining quality and improving patient outcomes. In most healthcare systems infants referred for the detecting or treating developmental dysplasia of the hip (DDH) are sent to a radiology department for sonographic evaluation. The total duration of visit and cost of visit are essential variables in any healthcare setting and affect both efficiency and "the bottom line". By having the treating clinician perform point-of-care ultrasound (POCUS) for the detection and follow-up of patients with DDH, we hypothesize that there would be a significant reduction in the time spent on the visit and the cost incurred without compromising quality or patient satisfaction. To our knowledge, no prior study has examined the effect of incorporating POCUS on the duration and cost of the visit in patients with DDH.

PURPOSE

To determine if there was a difference in the duration of the visit for patients with DDH when POCUS was performed compared to when traditional "formal" sonography was performed. To determine if there was a difference in the cost of the visit for patients with DDH when POCUS was performed compared to when traditional "formal" sonography was performed.

METHODS

Data for visits to a specialized outpatient office were collected over two years at a single-specialty orthopedic hospital, comparing the duration and cost of the visit between patient encounters for infants who had "formal" sonograms performed in the radiology suite to infants who underwent POCUS of the hip. In all, we included 532 patient encounters, 326 patients had POCUS performed, and 206 had a "formal" ultrasonographic evaluation performed. Of these, 140 were new evaluations and 392 were follow-up evaluations for treatment. Of the 140 new patients, 80 were in the POCUS group, and 60 were in the "formal" US group. Of the 392 follow-ups, 246 were in the POCUS group, and 146 were in the "formal" US group.

RESULTS

The mean duration of the encounter for the POCUS group was 42 min (range 16-75 min), and for the "formal" US group, it was 92 min (range 36-163 min). This difference was statistically significant (p = 0.002). The mean cost of the encounter for the POCUS group was $121.13, and for the "formal" US group, it was $339.38. This difference was statistically significant (p = 0.002).

CONCLUSION

Ultimately, our study demonstrated a statistically significant reduction in the duration and cost of a patient encounter for infants with DDH when they undergo POCUS rather than "formal" sonographic evaluation.