Screening for developmental dysplasia of the hip: from theory to practice. Collaborative Group DDH Project

Integrative Analysis of MicroRNA and mRNA Sequencing Data Identifies Novel Candidate Genes and Pathways for Developmental Dysplasia of Hip

OBJECTIVE

Our aim is to explore the candidate pathogenesis genes and pathways of developmental dysplasia of hip (DDH).

DESIGN

Proliferating primary chondrocytes from hip cartilage were used for total RNA extraction including 5 DDH patients and 5 neck of femur fracture (NOF) subjects. Genome-wide mRNA and microRNA (miRNA) were then sequenced on the Illumina platform (HiSeq2500). Limma package was used for difference analysis of mRNA expression profiles. edgeR was used for difference analysis of miRNA expression profiles. miRanda was used to predict miRNA-target genes. The overlapped DDH associated genes identified by mRNA and miRNA integrative analysis were further compared with the differently expressed genes in hip osteoarthritis (OA) cartilage.

RESULTS

Differential expression analysis identified 1,833 differently expressed mRNA and 186 differently expressed miRNA for DDH. Integrative analysis of mRNA and miRNA expression profiles identified 175 overlapped candidate genes (differentially expressed genes, DEGs) for DDH, such as VWA1, TMEM119, and SCUBE3. Further gene ontology enrichment analysis detected 111 candidate terms for DDH, such as skeletal system morphogenesis (P = 4.92 × 10^-5) and skeletal system development (P = 8.85 × 10^-5). Pathway enrichment analysis identified 14 candidate pathways for DDH, such as Hedgehog signaling pathway (P = 4.29 × 10^-5) and Wnt signaling pathway (P = 4.42 × 10^-2). Among the identified DDH associated candidate genes, we also found some genes were detected in hip OA including EFNA1 and VWA1.

CONCLUSIONS

We identified multiple novel candidate genes and pathways for DDH, providing novel clues for understanding the molecular mechanism of DDH.

Traditional Mongolian swaddling and developmental dysplasia of the hip: a randomized controlled trial

BACKGROUND

Mongolian traditional swaddling of infants, where arms and legs are extended with a tight wrapping and hips are in adduction position, may lead to abnormal maturation and formation of the hip joint; and is a contributing factor for developmental dysplasia of the hip (DDH). This hypothesis was tested in this randomized controlled trial.

METHODS

Eighty newborns with one or two hips at risk of worsening to DDH (Graf Type 2a; physiologically immature hips) at birth were randomized into 2 groups at a tertiary hospital in Ulaanbaatar. The "swaddling" group (n = 40) was swaddled in the common traditional Mongolian method for a month while the "non-swaddling" group (n = 40) was instructed not to swaddle at all. All enrollees were followed up on monthly basis by hip ultrasound and treated with an abduction-flexion splint if necessary. The groups were compared on the rate of Graf's "non-Type 1" hips at follow-up controls as the primary outcome. Secondary outcomes were rate of DDH and time to discharge (Graf Type 1; healthy hips). In addition, correlation between the primary outcome and swaddling length in days and frequency of swaddling in hours per day were calculated.

RESULTS

Recruitment continued from September 2019 to March 2020 and follow-up data were completed in June 2020. We collected final outcome data in all 80 enrollees. Percentages of cases with non-Type 1 hip at any follow-up examination were 7.5% (3/40) in the non-swaddling group and 40% (16/40) in the swaddling group (p = 0.001). There was no DDH case in the non-swaddling group while there were 8 cases of DDH in the swaddling group. The mean time to discharge was 5.1 ± 0.3 weeks in the non-swaddling group and 8.4 ± 0.89 weeks in the swaddling group (p = 0.001). There is a correlation between the primary outcome and the swaddling frequency in hours per day (r = 0.81) and swaddling length in days (r = 0.43).

CONCLUSIONS

Mongolian traditional swaddling where legs are extended and hips are in extension and adduction position increases the risk for DDH.

TRIAL REGISTRATION

Retrospectively registered, ISRCTN11228572 .

Developmental dysplasia of the hip and associated risk factors in Saudi children: A retrospective study

BACKGROUND

Studies investigating the association between developmental dysplasia of the hip (DDH) and risk factors in Saudi Arabia are rare.

OBJECTIVE

Investigate the association between DDH and several risk factors among Saudi children.

METHODS

The medical records of 82 children born in or admitted to King Abdul Aziz Medical City in Riyadh, Saudi Arabia with clinical suspicion of hip dislocation (HD) were included. The association between DDH and the following risk factors was investigated: age < 3 y, female-gender, twinning, first-born child, C-section, breech presentation, prematurity, positive family history and presence of associated abnormalities.

RESULTS

HD was confirmed in 73 (89%) children (Positive HD) and excluded in 9 (11%) children (Negative HD). Eleven (13.4%) children were excluded from the positive cases as it was confirmed that they have paralytic hip dislocation not DDH. DDH was confirmed in 62 children (75.6%). The Chi square test (χ2) and odds ratios (OR) revealed that the positive family history, female-gender, age < 3 years, and presence of associated abnormalities had significant associations with the presence of DDH with P values and OR equal 0.00 (16.4), 0.002 (3.1), 0.005 (2.6), and 0.04 (1.9) respectively. Breech presentation, twinning, first-born children, prematurity, and C-section were not associated with DDH with P values and OR equal 0.93 (1.1), 0.46 (0.4), 0.11 (0.4), 0.08 (0.3), and 0.002 (0.3) respectively.

CONCLUSIONS

Positive family history, female-gender, age < 3 years, and presence of associated abnormalities had approximately 16, 3, 2.5, and 2 times increased risk for DDH.

Ultrasound Characteristics of Clinically Dislocated But Reducible Hips With DDH

BACKGROUND

Although ultrasound (US) is frequently used in diagnosis and management of infantile developmental dysplasia of the hip, precise ultrasonographic parameters of what constitutes a dislocation, subluxation etc remain poorly defined. The purpose of this study was (1) to describe the ultrasonographic characteristics of a large cohort of clinically dislocated but reducible hips and (2) to begin to develop ultrasonographic definitions for what constitutes a hip dislocation.

METHODS

A retrospective review of prospectively collected data from an international multicenter study group on developmental dysplasia of the hip was conducted on all patients under 6 months of age with hip(s) that were dislocated at rest but reducible based on initial physical examination (ie, Ortolani positive). Femoral head coverage (FHC), alpha angle (α), and beta angle (β) were measured on pretreatment US by the individual treating surgeon, and were recorded directly into the database.

RESULTS

Based on 325 Ortolani positive hips, the median FHC on presentation was 10% with an interquartile range of 0% to 23%. A total of 126 of the 327 hips (39%) demonstrated 0% FHC. The 90th percentile was found to be at 33% FHC. Of 264 hips with sufficient α data, the median α was 43 degrees with an interquartile range from 37 to 49 degrees. The 90th percentile for α was at 54 degrees. A total of 164 hips had documented β with a median of 66 degrees and an interquartile range of 57 to 79 degrees; the 90th percentile was at 94 degrees.

CONCLUSIONS

Analysis of a large cohort of patients with dislocated but reducible hips reveals a median percent FHC of 10%, a median α of 43 degrees, and a median β of 66 degrees on initial US. Using a threshold at the 90th percentile, a sensible ultrasonographic definition of a dislocated hip seems to be FHC≤33%, implying that FHC between 34% and 50% may be reasonably termed a subluxation. Although these findings are consistent with previous, smaller reports, further prospective research is necessary to validate these thresholds.

LEVEL OF EVIDENCE

Level IV-diagnostic study.

Hip Mobilization at Preterm Age May Accelerate Developmental Dysplasia Recovery

PURPOSE

Few studies have described mobilization approaches in developmental dysplasia of the hip (DDH). The present study describes the hip mobilization of a preterm infant (born at 33 6/7 weeks of gestational age) diagnosed with DDH.

DESIGN AND METHODS

During the 43-day hospital stay, the infant was seen twice a week (ten sessions, 20 minutes each). All sessions included hip approximation maneuvers, with the hip positioned in abduction, lateral rotation and flexion, and lower limbs passive mobilization, which were taught to the mother. Early intervention with auditory, tactile, visual, and vestibular stimulations was also performed. The infant was assessed with hip ultrasound before and after treatment.

RESULTS

At 34 2/7 weeks of gestational age, she was classified as Graf IIa (left: alpha: 55°, beta: 68°; right: alpha: 59°, beta: 64°). At 40 5/7 weeks, she was classified as Graf I for left (alpha: 67°; beta: 42°) and right (alpha: 66°; beta: 42°) hips.

PRACTICAL IMPLICATIONS

The intervention seemed to accelerate the acquisition of stability of dysplasic hips in a preterm infant. The outcome supports further investigation of hip approximation maneuvers as part of early stimulation in preterm infants with DDH during hospital stay.

The 'clicky hip': to refer or not to refer?

Aims

The significance of the 'clicky hip' in neonatal and infant examination remains controversial with recent conflicting papers reigniting the debate. We aimed to quantify rates of developmental dysplasia of the hip (DDH) in babies referred with 'clicky hips' to our dedicated DDH clinic.

Patients and Methods

A three-year prospective cohort study was undertaken between 2014 and 2016 assessing the diagnosis and treatment outcomes of all children referred specifically with 'clicky hips' as the primary reason for referral to our dedicated DDH clinic. Depending on their age, they were all imaged with either ultrasound scan or radiographs.

Results

There were 69 'clicky hip' referrals over the three-year period. This represented 26.9% of the total 257 referrals received in that time. The mean age at presentation was 13.6 weeks (1 to 84). A total of 19 children (28%) referred as 'clicky hips' were noted to have hip abnormalities on ultrasound scan, including 15 with Graf Type II hips (7 bilateral), one Graf Type III hip, and three Graf Type IV hips. Of these, ten children were treated with a Pavlik harness, with two requiring subsequent closed reduction in theatre; one child was treated primarily with a closed reduction and adductor tenotomy. In total, 11 (15.9%) of the 69 'clicky hip' referrals required intervention with either harness or surgery.

Conclusion

Our study provides further evidence that the 'clicky hip' referral can represent an underlying diagnosis of DDH and should, in our opinion, always lead to further clinical and radiological assessment. In the absence of universal ultrasound screening, we would encourage individual units to carefully assess their own outcomes and protocols for 'clicky hip' referrals and tailor ongoing service provision to local populations and local referral practices. Cite this article: Bone Joint J 2018;100-B:1249-52.

Treatment of Graf Type IIa Hip Dysplasia: A Cut-off Value for Decision Making

Background:

The rate of spontaneous normalization in type IIa hips is reported to be high, whereas dysplsia persists or worsens in 5%-10% of cases.

Aims:

To evaluate the natural course of type IIa hips using Graf’s own perspective of physiological immaturity and maturational deficit.

Study Design:

A single center, retrospective cohort study.

Methods:

This was an institutional review board-approved retrospective review of all patients diagnosed with type IIa hip dysplasia at a single institution from 2012 to 2014. All patients included in the study had hip ultrasonography at about 6 weeks and 3 months of age. To assess reliability in α and β angles, ultrasonography measurements were carried out on the same image individually by all observers. The α and β angles were used as the main outcome measurements to evaluate hip maturation at the last follow-up. A receiver operating characteristics curve was drawn at the 3 month ultrasonography to evaluate the cut-off values for α and β angles for persistent dysplasia.

Results:

Sixty-four patients and 88 affected hips (63% unilateral and 37% bilateral) were included. The mean age at diagnosis was 6.4±2.7 weeks. Fifty-four hips were type IIa(+) (physiologically immature) and 34 hips were type IIa(-) (maturational deficit) at the initial ultrasonography evaluation. Improvement to type I was seen in 52 type IIa(+) and 17 type IIa(-) hips. Receiver operating characteristic analyses showed that patients do well if the α angle was >55° (area under the curve: 0.86; p<0.001 for the left hip and area under the curve: 0.72; p=0.008 for the right hip).

Conclusion:

The cut-off α angle value of 55° on initial ultrasonography should be considered to prevent future dysplasia. An α angle <55° on the initial ultrasonography was an independent predictor of worsening sonographic findings.

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.

Developmental dysplasia of hip screening using ortolani and barlow testing on breech delivered neonates

ABSTRACT

INTRODUCTION

We conducted this study to compare the specificity and sensitivity of the Ortolani and Barlow tests performed by dedicated examiners, and to ascertain the incidence of developmental dysplasia of the hip (DDH) in breech babies.

METHODS

A dedicated examiner underwent specific training and testing by a paediatric orthopaedic surgeon. Routine examiners were medical officers who had basic training in medical school and were briefly trained by their superiors. The dedicated examiner examined 170 babies. Thirty babies including 5 babies with positive tests (according to the dedicated examiner) were examined by a blinded routine examiner. RESULTS of Ortolani and Barlow tests on 30 babies were compared with ultrasound examination by blinded radiologist.

RESULTS

Five babies had positive Ortolani and Barlow tests. The routine examiner did not detect positive Ortolani and Barlow tests.

CONCLUSION

The incidence of positive Ortolani and Barlow tests among breech babies was 2.8%. Result of Ortolani and Barlow tests by dedicated hip screener were better than results performed by routine examiner.

KEY WORDS

Ortolani and Barlow, Dedicated Examiner, Routine Examiner, Breech, Ultrasound.

The costs of late detection of developmental dysplasia of the hip

PURPOSE

Debate currently exists regarding the economic viability for screening for developmental dysplasia of the hip in infants.

METHODS

A prospective study of infant hip dysplasia over the period of 1998-2008 (36,960 live births) was performed to determine treatment complexity and associated costs of disease detection and hospital treatment, related to the age at presentation and treatment modality. The involved screening programme utilised universal clinical screening of all infants and selective ultrasound screening of at-risk infants.

RESULTS

One hundred and seventy-nine infants (4.8/1,000) presented with hip dysplasia. Thirty-four infants presented late (> 3 months of age) and required closed or open reduction. One hundred and forty-five infants presented at < 3 months of age, 14 of whom failed early Pavlik harness treatment. A detailed cost analysis revealed: 131 early presenters with successful management in a Pavlik harness at a cost of £601/child; 34 late presenters who required surgery (36 hips, 19 closed/17 open reductions, one revision procedure) at a cost of £4,352/child; and 14 early presenters with failed management in a Pavlik harness requiring more protracted surgery (18 hips, four closed/14 open reductions, seven revision procedures) at a cost of £7,052/child.

CONCLUSIONS

Late detection causes increased treatment complexity and a sevenfold increase in the short-term costs of treatment, compared to early detection and successful management in a Pavlik harness.

DISCUSSION

Improved strategies are needed for the 10 % of early presenting infants who fail Pavlik harness treatment and require the most complex and costly interventions.

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

BACKGROUND

Developmental dysplasia of the hip (DDH) is the most common neonatal musculoskeletal condition. In 2008, the NHS Newborn and Infant Physical Examination committee added selective 'at risk' screening to the existing universal neonatal and general practitioner clinical hip screening guidelines.

OBJECTIVE

Assessment of breech and family history risk factors in DDH.

DESIGN

A 15 year prospective, observational, longitudinal cohort study.

METHOD

Breech presentation and evidence of a strong family history for DDH were the 'risk factors' studied. All infants referred were clinically and sonographically screened by one consultant paediatric orthopaedic surgeon.

RESULTS

From a cohort of 64 670 live births, 2984 neonates/infants, 46.1 (95% CI 44.6 to 47.8) per 1000 live births, were referred and sonographically screened with these risk factors alone. 1360 were male, of which four were identified as having 'pathological' DDH (an incidence of 0.003 (95% CI 0.001 to 0.008)). 1624 were female, of which 45 were identified as having 'pathological' DDH (an incidence of 0.028 (95% CI 0.021 to 0.037)). This difference in incidence of 0.025 (95% CI 0.016 to 0.033) was statistically significant (p<0.001). From those who were clinically stable and screened with either or both of the two risk factors, four individuals were diagnosed with irreducible hip dislocation (0.06 (95% CI 0.024 to 0.159) per 1000 live births). All were females.

CONCLUSIONS

This study questions the current UK screening policy for DDH in clinically stable males referred with risk factors, and may influence future DDH screening programme policy.

Breech preterm infants are at risk of developmental dysplasia of the hip

AIM

There is uncertainty about the risk of developmental dysplasia of the hip (DDH) in breech preterm infants and therefore uncertainty about the benefits of using ultrasound screening in this population. The aim of this study was to determine if preterm infants born in the breech position are at risk of DDH.

METHODS

A retrospective audit of preterm and term infants born in the breech position was performed to determine the incidence of DDH. Group 1 included breech preterm infants (<37 weeks gestational age) born between 2004 and 2008. Group 2 included breech term infants (≥37 weeks gestational age) born between 2005 and 2007. Infants were screened with clinical examination and ultrasound of the hip and were classified into two outcome groups: positive or negative for DDH.

RESULTS

Three out of 129 (2.3%) preterm infants screened had DDH. For term infants, 3 out of 163 (1.8%) infants screened had DDH. The odds ratio for DDH in breech preterm infants compared with breech term infants was 1.27 (95% confidence interval 0.25 to 6.40).

CONCLUSION

Preterm infants born in the breech position appear to have a similar incidence of DDH to term infants and thus require similar screening guidelines.

Using the Graf method of ultrasound examination to classify hip dysplasia in neonates

Developmental dysplasia of the hip (DDH) is one of the most common congenital orthopedic anomalies. Ultrasound examination employing the Graf method is used to diagnose DDH. We conducted a retrospective cross-sectional study of 222 neonatal patients (140 females and 82 males) submitted to ultrasound examination of the right and left hips between January of 2009 and May of 2011. The mean age was 5.0 days. The patients were grouped by laterality, mean alpha (α) and beta (β) angles (in degrees), and hip type (as determined by the Graf classification). The data collected were statistically correlated. Mean α angle values were higher in males than in females, as well as being higher for right hips than for left hips (p < 0.001). In contrast, mean β angle values were lower in males than in females, as well as being lower for right hips than for left hips (p < 0.001). Type Ia hips (i.e., mature hips) predominated in both genders and on both sides, having been found in 82.32% of the examinations of males and in 71.09% of those of females. The right hip was classified as type Ia in 78.38% of the examinations, and the left hip was classified as type Ia in 72.07%. Type IIa hips (i.e., immature hips) were found in 12.8% of the examinations of males and in 20% of those of females. The right hip was classified as type IIa in 13.96% of the examinations, and the left hip was classified as type IIa in 20.72%. The remaining hip types were less common. We emphasize the importance of ultrasound as a standard method of screening for DDH.

The epidemiology and demographics of hip dysplasia

The etiology of developmental dysplasia of the hip (DDH) is unknown. There are many insights, however, from epidemiologic/demographic information. A systematic medical literature review regarding DDH was performed. There is a predominance of left-sided (64.0%) and unilateral disease (63.4%). The incidence per 1000 live births ranges from 0.06 in Africans in Africa to 76.1 in Native Americans. There is significant variability in incidence within each racial group by geographic location. The incidence of clinical neonatal hip instability at birth ranges from 0.4 in Africans to 61.7 in Polish Caucasians. Predictors of DDH are breech presentation, positive family history, and gender (female). Children born premature, with low birth weights, or to multifetal pregnancies are somewhat protected from DDH. Certain HLA A, B, and D types demonstrate an increase in DDH. Chromosome 17q21 is strongly associated with DDH. Ligamentous laxity and abnormalities in collagen metabolism, estrogen metabolism, and pregnancy-associated pelvic instability are well-described associations with DDH. Many studies demonstrate an increase of DDH in the winter, both in the northern and southern hemispheres. Swaddling is strongly associated with DDH. Amniocentesis, premature labor, and massive radiation exposure may increase the risk of DDH. Associated conditions are congenital muscular torticollis and congenital foot deformities. The opposite hip is frequently abnormal when using rigorous radiographic assessments. The role of acetabular dysplasia and adult hip osteoarthritis is complex. Archeological studies demonstrate that the epidemiology of DDH may be changing.

Screening programmes for developmental dysplasia of the hip in newborn infants

BACKGROUND

Uncorrected developmental dysplasia of the hip (DDH) is associated with long term morbidity such as gait abnormalities, chronic pain and degenerative arthritis.

OBJECTIVES

To determine the effect of different screening programmes for DDH on the incidence of late presentation of congenital hip dislocation.

SEARCH STRATEGY

Searches were performed in CENTRAL (The Cochrane Library), MEDLINE and EMBASE (January 2011) supplemented by searches of clinical trial registries, conference proceedings, cross references and contacting expert informants.

SELECTION CRITERIA

Randomised, quasi-randomised or cluster trials comparing the effectiveness of screening programmes for DDH.

DATA COLLECTION AND ANALYSIS

Three independent review authors assessed study eligibility and quality, and extracted data.

MAIN RESULTS

No study examined the effect of screening (clinical and/or ultrasound) and early treatment versus not screening and later treatment.One study reported universal ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery but was associated with a significant increase in treatment.One study reported targeted ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery, with no significant difference in rate of treatment.Meta-analysis of two studies found universal ultrasound compared to targeted ultrasound did not result in a significant reduction in late diagnosed DDH or surgery. There was heterogeneity between studies reporting the effect on treatment rate.Meta-analysis of two studies found delayed ultrasound and targeted splinting compared to immediate splinting of infants with unstable (but not dislocated) hips resulted in no significant difference in the rate of late diagnosed DDH. Both studies reported a significant reduction in treatment with use of delayed ultrasound and targeted splinting.One study reported delayed ultrasound and targeted splinting compared to immediate splinting of infants with mild hip dysplasia on ultrasound resulted in no significant difference in late diagnosed DDH but a significant reduction in treatment. No infants in either group received surgery.

AUTHORS' CONCLUSIONS

There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery.

Follow-up sonographic results for Graf type 2A hips: association with risk factors for developmental dysplasia of the hip and instability

OBJECTIVES

The purpose of the study was to evaluate the association of sonographic worsening in type 2a hips with risk factors of developmental dysplasia of the hip, stability of the hip, and initial sonographic findings.

METHODS

Among infants who were referred for hip sonography between 2007 and 2009, 3450 were included in this study. Sonographic examinations were performed by combining the static Graf technique and the dynamic Harcke technique. The rate of sonographic worsening in type 2a hips and the relationship between sonographic worsening and risk factors for developmental dysplasia, instability of the hip, lateralization (right or left) of immaturity, and the presence of unilateral and bilateral immature hips were evaluated.

RESULTS

Type 2a hips were observed in 529 infants (15.3%; 780 hips [11.3%]). Of these, in 36 cases (6.8%; 44 hips [5.6%]), the sonographic results worsened. Twenty-five of these 36 cases (32 of 44 hips) were diagnosed as type 2 b; in others, the dysplasia worsened, and 6 cases (7 hips) were classified as type 2 c, 3 cases (3 hips) as type D, and 2 cases (2 hips) as type 3. Instability, unilateral type 2a hips, and associated central nervous system anomalies were found to be independent predictors of sonographic worsening in type 2a hips.

CONCLUSIONS

Type 2a hips may worsen sonographically at a rate of 5.6%; hence, sonographic follow-up is needed. Instability, central nervous system anomalies, and unilateral type 2a hips were found to be independent predictors of sonographic worsening. Our study shows that cases with these risk factors should be followed more carefully.

Diagnostic accuracy of static graf technique of ultrasound evaluation of infant hips for developmental dysplasia

INTRODUCTION

Ultrasound examination of infant hips is a widely used and accepted tool for the diagnosis and monitoring of developmental dysplasia of the hip. Its use and timing is still a focus of debate and its diagnostic accuracy has not been fully investigated.

METHOD

We have compared the ultrasound findings by the Graf technique with radiographic appearance (acetabular index) at 6 months of age.

RESULT

The negative predictive value of Ultrasound for DDH was 98% and was unaffected by the timing of the examination. The specificity and accuracy of the examination increased with age and was highest at 3 months of age.

CONCLUSION

Ultrasound examination of the infant hip by the static Graf technique is a safe and effective screening tool for the evaluation of DDH.

Immediate treatment versus sonographic surveillance for mild hip dysplasia in newborns

OBJECTIVE

We conducted a blinded, randomized, controlled trial to examine whether mildly dysplastic but stable or instable hips would benefit from early treatment, as compared with watchful waiting.

PATIENTS AND METHODS

A total of 128 newborns with mild hip dysplasia (sonographic inclination angle [alpha angle] of 43 degrees -49 degrees ) and stable or instable but not dislocatable hips were randomly assigned to receive either 6 weeks of abduction treatment (immediate-treatment group) or follow-up alone (active-sonographic-surveillance group). The main outcome measurement was the acetabular inclination angle, measured by radiograph, at 1 year of age.

RESULTS

Both groups included 64 newborns, and there was no loss to follow-up. With the exception of a small but statistically significant excess of girls in the active-sonographic-surveillance group, there were no statistically significant differences in baseline characteristics between the 2 groups. The mean inclination angle at 12 months was 24.2 degrees for both groups (difference: 0.1 [95% confidence interval (CI): -0.8 to 0.9]), and all children had improved and were without treatment. The mean alpha angle was 59.7 degrees in the treatment group and 57.1 degrees in the active-surveillance group for a difference of 2.6 degrees evaluated after 1.5 and 3 months (95% CI: 1.8 to 3.4; P < .001). At 1.5 months of age, the hips had improved in all treated children but not in 5 children under active surveillance (P = .06). Among the sonographic-surveillance group, 47% received treatment after the initial surveillance period of 1.5 months.

CONCLUSIONS

Active-sonographic-surveillance halved the number of children requiring treatment, did not increase the duration of treatment, and yielded similar results at 1-year follow-up. Given a reported prevalence of 1.3% for mildly dysplastic but stable hips, a strategy of active surveillance would reduce the overall treatment rate by 0.6%. Our results may have important implications for families as well as for health care costs.

Ultrasound in developmental dysplasia of the hip: A screening study in Sardinian newborns

INTRODUCTION

Developmental dysplasia of the hip (DDH) is the most frequent inborn deformity of the locomotor apparatus. Ultrasound screening is frequently used to identify DDH in view of the brevity of the preclinical period during which diagnosis is possible. Appropriate therapeutic intervention during this period can positively affects the evolution of the disorder.

METHODS

An unselected population of 1158 Sardinian neonates underwent ultrasound examinations of both hips, and findings were classified according to the method described by Graf. Patients were assessed by means of retrospective analysis to reveal cases of congenital dislocation of the hip joint. All cases were classified and treatment outcomes determined.

RESULTS

A total of 145 hips requiring treatment were observed in 122 children. Hip dysplasia and/or dislocation were diagnosed between the ages of 14 days and 3 months. One month after diagnosis ultrasound findings were normal in 94% of the infants with at least one hip classified as type 2a. The remaining 6% were classified as types 2b, 2c, D, and 3. All were treated with abduction splints, and normal hip development was observed after one or two months of treatment. Type 4 hips were referred to an orthopedic surgeon for specialist treatment.

CONCLUSIONS

When performed by skilled operators, ultrasonographic techniques are of considerable value in prescribing treatment for DDH. The satisfactory prognosis associated with early treatment of severe congenital dislocation of the hip joint underlines the advisability of scheduling routine hip screening programs to ensure early diagnosis and effective treatment of the disorder.

Differential diagnosis of torticollis: a case report

PURPOSE

This case report describes a method of differential diagnosis for torticollis in a 4-month-old male infant who also had hydrocephalus.

SUMMARY OF KEY POINTS

The infant presented to physical therapy (PT) with a "classic torticollis posture." Differential diagnosis was completed to determine the cause of the signs and the appropriate intervention. PT consisted of positioning, strengthening, stretching, and neuromuscular facilitation techniques to assist the infant to develop gross motor skills and a midline head position. A home exercise program was incorporated into the family's routines.

STATEMENT OF CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

After 6 months of PT, the infant demonstrated considerable gains in cervical range of motion but continued to exhibit gross motor delay and difficulty in maintaining the head in midline. Intervention for infants with torticollis should address corrective positioning to facilitate symmetry during positioning and handling. Differential diagnosis is critical in establishing the appropriate plan of care.

Neonatal incidence of hip dysplasia: ten years of experience

The advantages of sonographic examination are well known, but its main disadvantage is that it might lead to overdiagnosis, which might cause overtreatment. Variations in the incidence of developmental dysplasia of the hip are well known. We ascertained the incidence of neonatal sonographic developmental dysplasia of the hip without considering the development of those joints during followup. All 45,497 neonates (90,994 hips) born in our institute between January 1992 and December 2001 were examined clinically and sonographically during the first 48 hours of life. Sonography was performed according to Graf's method, which considers mild hip sonographic abnormalities as Type IIa. We evaluated the different severity type incidence pattern and its influence on the total incidence during and between the investigated years. According to our study, sonographic Type IIa has major effects on the incidence of overall developmental dysplasia of the hip with a correlation coefficient of 0.95, whereas more severe sonographic abnormalities show relatively stable incidence patterns.

LEVEL OF EVIDENCE

Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Developmental dysplasia of the hip

In its severest form, developmental dysplasia of the hip is one of the most common congenital malformations. The pathophysiology and natural history of the range of morphological and clinical disorders that constitute developmental dysplasia of the hip are poorly understood. Neonatal screening programmes, based on clinical screening examinations, have been established for more than 40 years but their effectiveness remains controversial. Whereas systematic sonographic imaging of newborn and young infants has afforded insights into normal and abnormal hip development in early life, we do not clearly understand the longer-term outcomes of developmental hip dysplasia, its contribution to premature degenerative hip disorders in adult life, and the benefits and harms of newborn screening. High quality studies of the adult outcomes of developmental hip dysplasia and the childhood origins of early degenerative hip disease are needed, as are randomised trials to assess the effectiveness and safety of neonatal screening and early treatment.

Ultrasound in the diagnosis of developmental dysplasia of the hip in newborns. The European approach. A review of methods, accuracy and clinical validity

Based on soft evidence that ultrasound screening tends to reduce the rate of late developmental dysplasia of the hip (DDH) and the need for surgical interventions, different screening strategies including universal or selective ultrasound screening have been established in several European countries and centres during the last decade. We performed an extensive search for articles on ultrasound diagnosis of developmental dysplasia of the hip over the last 26 years. A few studies reported an adequate repeatability for the static [Graf, Morin, modified Morin (Terjesen)] and for the combined static/dynamic methods [modified Graf (Rosendahl)], while no such reports were found for the dynamic (Harcke) ultrasound techniques. The effect of newborn ultrasound screening on late DDH have been addressed in two randomised trials (RCTs), both concluding that both selective and universal ultrasound screening tend to reduce the prevalence of subluxed or dislocated DDH, thus without reaching statistical significance. Finally, several observational studies have shown that morphologically normal hips tend to remain normal with or without a co-existing instability, and 97% of sonographically immature hips tend to normalise spontaneously within 3 months. Two studies report on a similar pattern for mildly dysplastic, but stable hips. From the data available we suggest that selective ultrasound screening is worthwhile in areas with a high prevalence of late cases, given a well-organised, high-quality service can be provided.

Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force

BACKGROUND

Developmental dysplasia of the hip (DDH) represents a spectrum of anatomic abnormalities that can result in permanent disability.

OBJECTIVE

We sought to gather and synthesize the published evidence regarding screening for DDH by primary care providers.

METHODS

We performed a systematic review of the literature by using a best-evidence approach as used by the US Preventive Services Task Force. The review focused on screening relevant to primary care in infants from birth to 6 months of age and on interventions used in infants before 1 year of age.

RESULTS

The literature on screening and interventions for DDH suffers from significant methodologic shortcomings. No published trials directly link screening to improved functional outcomes. Clinical examination and ultrasound identify somewhat different groups of newborns who are at risk for DDH. A significant proportion of hip abnormalities identified through clinical examination or ultrasound in the newborn period will spontaneously resolve. Very few studies examine the functional outcomes of patients who have undergone therapy for DDH. Because of the high rate and unpredictable nature of spontaneous resolution of DDH and the absence of rigorous comparative studies, the effectiveness of interventions is not known. All surgical and nonsurgical interventions have been associated with avascular necrosis of the femoral head, the most common and most severe harm associated with all treatments of DDH.

CONCLUSIONS

Screening with clinical examination or ultrasound can identify newborns at increased risk for DDH, but because of the high rate of spontaneous resolution of neonatal hip instability and dysplasia and the lack of evidence of the effectiveness of intervention on functional outcomes, the net benefits of screening are not clear.

Screening for developmental dysplasia of the hip: results of a 7-year follow-up study

BACKGROUND

Screening for developmental dysplasia of the hip (DDH) is widely recommended for all infants to prevent disability from late diagnosis of dislocation of the hip. The present study evaluates the results of screening for developmental dislocation of hip in a clinic in Turkey over the course of 7 years.

METHODS

Hospital records of 5798 infants who were examined regularly until walking age at Gazi University well child clinics between January 1995 and December 2001 were reviewed. Infants with known risk factors for DDH such as breech presentation, family history of DDH or swaddling, and of infants with physical examination findings suggestive of DDH, were referred to orthopedic surgeons for diagnosis. Based on this final diagnosis, sensitivity, specificity, positive and negative predictive values of risk factors and physical examination findings were calculated.

RESULTS

Of the 5798 infants, risk factors were detected in the medical history of 111 infants, and in 14 infants a musculoskeletal deformity was detected. In 606 infants the physical examination findings were suggestive of DDH. Ten patients were subsequently diagnosed with DDH. The sensitivity, specificity, positive predictive value and negative predictive values of having a risk factor for DDH in history were 10.0%, 98.1%, 0.9%, 99.8%, and having abnormal hip examination findings were 100.0%, 88.9%, 1.6% and 100.0%, respectively.

CONCLUSIONS

A careful history and physical examination is the cornerstone of DDH screening. Serial hip examinations performed during health examination visits provide an opportunity to identify DDH cases. The sensitivity of risk factors in history and physical examination findings together is high enough to be accepted as a screening tool.

Paediatric hip--ultrasound screening for developmental dysplasia of the hip: a review

This paper will try to deal with the following questions: Which is the correct screening model for the developmental dysplasia of the hip (DDH)? What is the clinical significance of "sonographic" DDH? Can overtreatment produced by ultrasound (US) screening cause a waste of resources and eventually morbidity? We reviewed the literature since January, 1996 through December, 2000. To compare our experience with the literature, we analysed the results of the US examinations of the hip performed in our Institute. Over 4 years of US screening 11326 infants (22652 hips), aged 3 days to 4 months, were examined consecutively. Sonographic hip findings were abnormal in 531 infants (4.7%). The screening showed 381 subjects (3.36% of the population) with a type IIa hip (bilateral or unilateral); 65% of these infants were normal at follow up and only 35% worsened. On the whole we treated 282 infants (2.5%). No open reduction was performed. Avascular necrosis appeared in 2/282 treated cases (1.06%). We support the routine generalised US screening of neonatal hips. The excess of doubtful cases and, consequently, of the extra referrals may be limited, and the overtreatment decreased to the lowest rates reported by optimisation of everyone's approach.

Developmental dysplasia of the hip: a new approach to incidence

OBJECTIVE

The controversy over the incidence of developmental dysplasia of the hip (DDH) stems mainly from an ambiguity of criteria for defining a genuinely pathologic neonatal hip. In this study, we evaluate an algorithm we devised for the treatment of DDH, for its ability to identify those neonatal hips which, if left untreated, would develop any kind of dysplasia and, therefore, are to be included in the determination of DDH incidence.

METHODS

Clinical and ultrasonographic examinations for DDH were performed on 18 060 consecutive neonatal hips at 1 to 3 days of life. Newborns with skeletal deformities, neurologic/muscular disorders, and neural tube defects were excluded. Hips that featured any type of sonographic pathology were reexamined at 2 or 6 weeks, depending on the severity of the findings. Only hips in which the initial pathology was not improved or had deteriorated were treated; all others were examined periodically until the age of 12 months.

RESULTS

Sonographic screening of 18 060 hips detected 1001 instances of deviation from normal, indicating a sonographic DDH incidence of 55.1 per 1000. However, only 90 hips remained abnormal and required treatment, indicating a true DDH incidence of 5 per 1000 hips. All the others evolved into normal hips, and no additional instances of DDH were found on follow-up throughout the 12 months.

CONCLUSIONS

The implementation of our protocol enables us to distinguish two categories of neonatal hip pathology: one that eventually develops into a normal hip (essentially sonographic DDH); and another that will deteriorate into a hip with some kind of dysplasia, including full dislocation (true DDH). This approach seems to allow for a better-founded definition of DDH, for an appropriate determination of its incidence, for decision-making regarding treatment, and for assessment of the cost-effectiveness of screening programs for the early detection of DDH.