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

Incidence, Prevalence, Risk Factors, and Clinical Treatment for Children with Developmental Dysplasia of the Hip in Saudi Arabia. A Systematic Review

BACKGROUND

Developmental dysplasia of the hip (DDH) leads to pain, joint instability, and early degenerative joint disease. Incidence, prevalence, and management strategies of DDH have been well-documented in several countries, but not in Saudi Arabia.

OBJECTIVE

We synthesized the current evidence regarding incidence, prevalence, risk factors, and clinical treatment for children with DDH in Saudi Arabia.

METHODS

We searched 3 databases to locate studies. Studies that included children with DDH in Saudi Arabia; reported either incidence rate, prevalence, risk factors, and/or clinical practice; and were available in English or Arabic were included. We excluded reviews, case studies, or animal studies. Two independent authors reviewed potential studies and assessed study's quality.

RESULTS

Our search yielded 67 potential studies, of which 16 studies were included (total DDH sample = 3,127; age range = 2.5 to 86.4 months). Three studies reported incidence rates ranging from 3.1 to 4.9 per 1000 births, and 3 studies reported prevalence ranging from 6 to 78%. Nine studies reported that female sex, breech position, family history, and age less than 3 years were risk factors associated with DDH. Four studies reported that brace applications and closed reduction were conservative treatments, and 9 studies reported that open hip reduction, adductor tenotomy, and/or pelvic osteotomy were surgical approaches to treat DDH.

CONCLUSIONS

In Saudi Arabia, the Incidence and prevalence rates of DDH are 3.1 to 4.9 per 1,000 births, and 6-78%, respectively (differ from what has been reported in other countries), but the risk factors of DDH in Saudi Arabia appear to be similar in comparison to other countries (female, breech presentation, family history of DDH).

Screening of Developmental Dysplasia of the Hip in Europe: A Systematic Review

BACKGROUND

Developmental dysplasia of the hip (DDH) is a prevalent orthopaedic disorder in children, and screening methods vary across regions due to local health policies. The purpose of this review is to systematise the different ultrasound screening strategies for detecting DDH in newborns in Europe.

METHODS

Eligible studies from the PubMed, Embase, and Scopus databases, published between 1 January 2018 and 18 March 2023, were included. The inclusion criteria specified a European origin, a focus on newborn human patients, and information on ultrasound for DDH detection.

RESULTS

In total, 45 studies were included, covering 18 countries. Among them, six nations (Austria, Bosnia and Herzegovina, Poland, Slovenia, the Czech Republic, and Germany) perform universal ultrasound screening. The timing of the first ultrasound varies, with Austria and the Czech Republic within the 1st week, Bosnia and Herzegovina on the day of birth, Poland between 1 and 12 weeks, and Germany before the 6th week. The Graf method is the most popular ultrasound technique used.

CONCLUSIONS

There is no consensus on the optimal DDH detection approach in Europe. Varied screening methods stem from epidemiological, cultural, and economic differences among countries.

Multivariate analysis of the predictive value of asymmetric skin creases in diagnosis of decentralized developmental dysplasia of the hip

The aim of this study was to investigate the relationship of developmental dysplasia of the hip (DDH) with asymmetrical skin crease (ASC) in the inguinal, gluteal and thigh regions and to determine which ASC has the most predictive value for the diagnosis of hip dislocation in infants. This study was planned as a prospective, observational study and conducted between 1 October 2020 and 1 June 2021. Asymmetric distribution of skin creases was evaluated separately in three regions (inguinal, gluteal and thigh). Then, hip ultrasonography (USG) was performed and the Graf method was used to classify the cases as 'centralized' [Graf types I, IIa (-), IIb and IIc] and 'decentralized' (Graf types IId, III and IV). The relationship between the groups was evaluated using univariate and then multivariate analyses. A total of 241 patients were included in the study. The number of patients with ASC was 49 (21%). While 36 of these 49 patients had centralized hips, 13 had decentralized hips ( P  < 0.001). Sixty-five percent (13/20) of 20 infants with decentralized hips had ASC in at least one of the inguinal, gluteal or thigh regions. The presence of ASC in the inguinal ( P  < 0.001) and gluteal ( P  < 0.014) regions increased the risk of the decentralized hip in the child, whereas the presence of ASC in the isolated thigh region did not increase the risk of the dislocated hip ( P  = 0.534). Inguinal ASC and gluteal ASC are reliable findings in DDH screening, but the relationship of isolated thigh ASC with DDH could not be demonstrated statistically. Level of Evidence: Level II - diagnostic study.

Application Value of Combined Diagnosis of Ultrasound, MRI, and X-Ray in Developmental Dysplasia of the Hip in Children

Objective

To explore the application value of the combined diagnosis of ultrasound, MRI, and X-ray in developmental dysplasia of the hip (DDH) in children.

Methods

Ninety children with suspected DDH admitted to our hospital from June 2017 to June 2020 were selected as the research objects to conduct a retrospective study. According to the age of the children, they were divided into a group with 0-6 months (group X), a group with 7-12 months (group Y), and a group older than 12 months (group Z), with 30 cases in each group. X-ray and high-frequency ultrasound were performed in all groups, and MRI examination was added to the children in groups Y and Z to compare the diagnostic value of the three imaging examinations in DDH children.

Results

No obvious differences in the general data and maternal risk factors were observed among the three groups (P < 0.05). The final comprehensive diagnostic results were taken as the gold standard, including 23 cases with acetabular dysplasia, 28 cases with subluxation of the femoral head, 31 cases with complete dislocation of the femoral head, and 8 non-DDH cases. The diagnostic accuracy of the three methods from high to low was MRI, high-frequency ultrasound, and X-ray, with obviously higher diagnostic accuracy of MRI than that of X-ray (P < 0.05). The ROC curves showed that the diagnostic efficacy from high to low was MRI + high-frequency ultrasound + X-ray, high-frequency ultrasound + X-ray, MRI, high-frequency ultrasound, and X-ray.

Conclusion

Ultrasound combined with X-ray has obvious advantages in the diagnosis of children at low months of age, while MRI has outstanding advantages in the diagnosis of children at high months of age. MRI combined with ultrasound and X-ray can significantly improve the diagnostic accuracy of DDH and provide objective data support for the clinical treatment of children.

The diagnosis and management of common childhood orthopedic disorders: An update

Musculoskeletal illness represents a significant portion of office visits to primary and urgent care clinicians. Despite this, little emphasis is placed on learning pediatric orthopaedics during medical school or residency. The focus of this paper is to provide a systematic approach to this general musculoskeletal physical exam and to assist in the recognition of what conditions are normal development and what conditions require observation, workup and referral to an experienced pediatric orthopaedist.

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

BACKGROUND

No high level of scientific evidence exists about the use of asymmetry of skin creases (ASC) on the groin and thigh regions in diagnosing developmental dysplasia of the hip. The aim of this comparative study was to revisit whether or not ASC was a significant clinical finding in developmental dysplasia of the hip.

METHODS

This was retrospective analysis of a prospectively collected data. Control group was composed of 1000 consecutive healthy infants (mean age, 46.7 d) whose both hips were considered Graf type I (normal). Study group (SG) was composed of 246 consecutive patients (mean age, 96.5 d) whose treatments by abduction bracing were initiated due to unilateral or bilateral Graf type IIa(-) and worse hips.

RESULTS

SG included 178 patients with bilateral or unilateral dysplastic hips [Graf type IIa(-), IIb, IIc] and 68 patients with at least 1 decentered hip (Graf type D, III, IV). ASC was seen in 63 of 101 patients (63%) having positive clinical finding(s). The rates of both ASC alone (P<0.001; odds ratio, 3.46) and ASC total (ASC with and without additional findings) (P<0.0001; odds ratio, 7.48) were significantly higher in SG than in control group. ASC was the only clinical finding in 31 patients and 24 of these 31 patients (77%) had unilateral or bilateral dysplastic hips. Sensitivity and specificity of ASC alone were 12.60% and 96.00%, respectively. ASC was accompanied by other clinical findings (mostly Galeazzi sign and limitation of abduction) in 32 patients and 23 of these 32 patients (72%) had at least 1 decentered hip. Sensitivity and specificity of ASC total were 25.61% and 95.60%, respectively.

CONCLUSIONS

ASC is a significant finding, as there is considerable increased risk of having dysplastic or decentered hips in infants having such a finding alone or associated with other findings. ASC alone is more commonly seen in patients with dysplastic hip(s) whereas ASC is mostly accompanied with other clinical finding(s) in patients with decentered hip(s). This study shows that, ASC can be introduced as a risk factor in selected newborn hip screening programs.

LEVEL OF EVIDENCE

Level II-diagnostic study.

The treatment of neonatal hip dysplasia with splints in the United Kingdom: time for consensus?

PURPOSE

To understand the variation in the management of hip dysplasia identified from the United Kingdom neonatal selective screening programme.

METHODS

Having been designed and tested by the research committee of the British Society for Children's Orthopaedic Surgery (BSCOS), a nationwide online survey was conducted of BSCOS members to ascertain their treatment strategies for neonatal hip dysplasia.

RESULTS

There were 111 responses (60% of members), which illustrated wide variation in care. In all, 91 (over 80%) of respondents treat more than ten cases per year, yet only 61 (55%) work to an agreed protocol. A total of 90 (81%) use the Graf classification and 103 (93%) use the Pavlik harness initially. Consensus is lacking in key areas including duration of harness use, hours per day, clothing and weaning. Importantly, notable differences of opinion even exist regarding which hip pathologies need treatment.

CONCLUSION

This study quantifies the wide variation in many key elements of the initial treatment of neonatal hip dysplasia in the United Kingdom. This variation appears unnecessary and unacceptable as the Getting It Right First Time programme seeks to standardize care pathways. The charitable sector has called for consensus to mitigate parental anxiety, and it has been suggested that this could allow better integration of hip dysplasia into national screening pathways. Standardized care benefits patients and represents the platform from which we can begin understanding effectiveness and optimizing outcomes.

LEVEL OF EVIDENCE

Level V.

Should paediatricians initiate orthopaedic hip dysplasia referrals for infants with isolated asymmetric skin folds?

PURPOSE

Asymmetric skin folds (ASFs) have been linked to developmental dysplasia of the hip (DDH) in select studies, leading to their inclusion in paediatric practice guidelines regarding orthopaedic referral for hip evaluation. The purpose of this study was to investigate the utility of isolated ASFs as a screening tool for DDH in a series of patient referrals evaluated at a single institution.

METHODS

We performed a retrospective review of consecutive patients between 0 and 12 months of age referred to orthopaedic clinics for isolated ASFs. We recorded radiographic findings (acetabular inclination or alpha angle), diagnosis rendered and treatment administered.

RESULTS

A total of 66 patients were included (mean age 6.4 months; 2.47 to 10.76). All patients received pelvic radiographs or ultrasound. In all, 36 patients (55%) were considered normal by their treating physician and 25 (38%) were considered dysplastic and underwent brace treatment. One hip with an isolated ASF was found to have a dislocated hip on radiograph prior to their initial orthopaedic visit. None of the patients in this study have required surgery to date.

CONCLUSION

Using ASFs as a reason for referral led to increased diagnosis of mild dysplasia resulting in orthotic treatment. Thus, in our particular clinical environment, isolated ASFs can be an indicator of mild dysplasia and warrant further workup or referral. Because treatment philosophies regarding recognition and treatment of mild dysplasia vary amongst centres, the value of screening with ASFs likewise depends on the treating orthopaedic surgeon's threshold for treatment of mild dysplasia.

LEVEL OF EVIDENCE

Level IV- Retrospective.

Screening for Developmental Dysplasia of the Hip in Infants in Tibet Identifies Increased Prevalence Associated with Altitude

BACKGROUND Developmental dysplasia of the hip (DDH), also known as congenital hip dislocation or congenital hip dysplasia is usually diagnosed at birth. Studies on DDH at high-altitude are rare. Tibetans live mainly at altitudes above 3,500 m, and the prevalence of DDH in this population is not currently known. This cross-sectional epidemiological study aimed to identify the prevalence and associated risk factors for DDH in Tibet. MATERIAL AND METHODS Between 1st June 2015 and 30 June 2016, infants in Tibet aged between 0-6 months and from ten districts at different altitudes in Shigatse, Tibet were referred to our hospital for the assessment of DDH. All the infants underwent clinical evaluation for DDH and ultrasound testing using the Graf method. RESULTS There were 606 infants who met the study inclusion criteria, including 253 female infants and 353 male infants, of which 106 infants had DDH. The prevalence of DDH in Shigatse, Tibet was approximately 174.9/1000 infants (106/606). Altitude was strongly associated with increased risk of DDH in Tibet (r=0.82, P=0.004). CONCLUSIONS This is the first epidemiological study of DDH in the Tibetan population. The results showed that DDH is prevalent among native Tibetan people in Shigatse, and there was a significant correlation between altitude and the prevalence of DDH. Further studies are needed to investigate the mechanism of the association between altitude and the increased incidence of DDH in infants.

Value of the 'clicky hip' in selective screening for developmental dysplasia of the hip

AIMS

The aim of this study was to review the value of accepting referrals for children with 'clicky hips' in a selective screening programme for hip dysplasia.

PATIENTS AND METHODS

A single-centre prospective database of all referrals to the hip clinic was examined to identify indication for referrals, diagnosis, and treatment. All patients referred received a standardized ultrasound scan and clinical examination by an orthopaedic consultant.

RESULTS

There were 5716 children referred to the orthopaedic hip clinic between 1 June 2014 and 26 September 2018. In all, 1754 children (30.1%) were referred due to 'clicky hip' with no additional risk factors or indications for ultrasound scan. A total of 123 children (7.1%) referred with 'clicky hip' and no additional risk factors or examination findings had an abnormal initial hip ultrasound, including 16 children (0.9%) with dysplastic hips. Of the 141 children who required treatment in a Pavlik harness during the study period, 23 (16%) had been referred with a 'clicky hip' and no additional risk factors or examination findings, including six children with Graf 3 or 4 hips.

CONCLUSION

There is significant value in reviewing children with an isolated 'clicky hip'. Many children who require treatment are referred to the orthopaedic service as 'clicky hip' with no additional risk factors. In a pragmatic pathway with a diverse population of clinicians performing baby checks, 'clicky hip' is an important indication for referral and should not be discarded. Cite this article: Bone Joint J 2019;101-B:635-638.