Team Approach: Developmental Dysplasia of the Hip

Developmental Dysplasia of the Hip: Factors Related to the Diagnosis and Characteristics of Selective Screening for its Detection

Backgrounds

Breech presentation, family history, and physical examination are the most recognized risk factors for DDH, which form the basis of selective screening. However, this approach can lead to late diagnosis, invasive treatments, and complications. This study analyzes the effectiveness of selective screening and identifies additional factors related to DDH.

Methods

A retrospective case-control analytical study is designed, including children who are assessed through screening between 2012 and 2019. The variables examined include clinical and gestational characteristics, as well as examination findings. Descriptive analysis is conducted, followed by univariate analysis using Chi-squared, Fisher's exact, or Student's T tests. For multivariate analysis, the "all set" user command is employed. Sensitivity, specificity, and ROC curve are calculated, with a significance level set at p < 0.05. StataIC 16 and SAS System 9.4 are used.

Results

762 children are included in the study, of which 33 are diagnosis with DDH. A total of 8,191 models are developed to predict DDH. The best logistic regression model identified the following independent predictors of dysplasia: newborn weight (OR 1.2, 95% CI 1.1-1.4), female sex (OR 3.9; 95% CI 1.4-10.9), cephalic presentation (OR 17.8; 95% CI 2.3-137.3), primiparity (OR 2.6; 95% CI 1.1-5.7), and examination (OR 149.6; 95% CI 18-1121.4). This model correctly classifies 83.6% patients (ROC curve 0.86). In selective screening, examination is the only identified risk factor for DDH, yet its sensitivity does not exceed 10%.

Conclusions

This study proposed a total of 8191 models to predict DDH. The identified predictors include female sex, birth weight, cephalic presentation, and primiparity. While physical examination is the primary risk factor, it detects only decentred hips. The low sensitivity of selective screening raises questions about whether it remains the most appropriate method for identifying DDH in current practice.

Weight Percentile Is Maintained During Spica Casting: A Retrospective Cohort Study of Patients Treated with Closed or Open Reduction for Developmental Dysplasia of the Hip

Background

Weight changes during spica casting previously have not been reported. The primary aim of this study was to determine weight percentile change from cast initiation to cast removal. Secondary aims were to assess weight percentile changes from initiation to mid-term follow-up visits after cast removal and to assess the mean weight change from cast initiation to cast removal.

Methods

Patients with developmental dysplasia of the hip (DDH) treated with closed or open reduction (± ​femoral/pelvic osteotomy) and spica cast were retrospectively reviewed from 2/2016-6/2023. Patients aged <4 years treated for ≥6 weeks in spica cast were included. Patients lacking weight measurements within the 4 weeks prior to cast initiation or within 2 weeks following cast removal were excluded. Demographics, weight, and weight percentiles at cast initiation, cast removal, and at follow-ups were collected. Mean weights and mean weight percentiles were compared across visits with dependent sample t-tests and one-way analysis of variance tests based on normality, with a significance threshold of P ​≤ ​.05.

Results

Thirty-six hips in 31 infants (median age: 10.4 [interquartile range {IQR}: 9, 16.3] months, 86% female) were included. The median duration of casting was 9.2 [IQR: 7.9, 12.6] weeks; 2 hips had midpoint cast change. The mean weight was 9.8 ​± ​2.3 ​kg at cast initiation and 10.1 ​± ​1.9 ​kg at final cast removal, with a mean change of 0.3 ​± ​0.4 ​kg (P ​= ​.527). Mean weight percentiles did not differ during or after treatment (range: 55-61st percentile, P ​= ​.974).

Conclusion

Weight percentiles were maintained during spica casting in the patients examined in this study, which should be reassuring to the family and treatment team; our study did not find that spica casting stunts weight gain. For surgeons who may consider maintaining the original spica cast throughout treatment, without cast change, a mean weight gain of 0.3 ​kg for a mean casting length of 9 weeks in infants of median age 10.4 months should be reassuring; many infants/toddlers may not require a cast change due to growth.

Key Concepts

(1)Spica casting does not appear to stunt weight gain.(2)The weight percentile did not change during spica casting following open or closed reduction for developmental dysplasia of the hip.(3)The mean weight gain during typical spica casting is 0.3 ​kg, which was not statistically significant.

Level of Evidence

III, retrospective cohort.

Gradual Reduction Using Overhead Traction for Late-Detected Developmental Dysplasia of the Hip: A Report of Three Cases Diagnosed Among Children Over Four Years Old

Optimal reduction methods for late-detected developmental dysplasia of the hip (DDH) remain debatable. Gradual reduction (GR) using traction is a safer and more reliable option for late-detected DDH than closed reduction or open reduction with or without preliminary traction. GR using overhead traction, one of the current GR methods, has been indicated for children of walking age up to four years of age, whereas the upper age limit of this method has not yet been determined. We present three cases of late-detected DDH whose hips were treated between four and six years of age with this method. Stable reduction without subsequent redislocation was technically accomplished for all patients, albeit the duration of horizontal traction became longer than usual. Clinically significant avascular necrosis (AVN) has developed in children aged ≥5 years, indicating the need for some modifications to the conventional protocol to prevent AVN.

Costs of abduction treatment in developmental dysplasia of the hip. Analysis of 900 patients

BACKGROUND

Developmental dysplasia of the hip (DDH) is a disorder of hip development that leads to dysplasia, subluxation, or total hip dislocation. Early detection of DDH is important, and early initiation of abduction treatment is key to successful correction of the hip joint. However, mild forms of DDH, including hip instability without complete dislocation, have good spontaneous healing potential, and a watchful waiting strategy in mild DDH has been found to be safe. In this study, we aimed to evaluate the cost differences between different treatment strategies for DDH.

MATERIAL AND METHODS

Data were collected retrospectively from the medical records of all children diagnosed with diagnosis and treatment of DDH in Tampere University hospital between 1998 and 2018. In total, 948 patients were included in the study. Patients who underwent casting or operative treatment (n = 48) were excluded from the analysis. All Ortolani positive children were subjected to early abduction treatment. Children with Ortolani negative DDH were subjected to either watchful waiting or early abduction treatment, based on the clinicians' decision. The regression model estimates for the number of clinical visits with and without ultrasound examination were assessed together with cost reports from Tampere University Hospital for the calculation of savings per patient in spontaneous recovery.

RESULTS

Alpha angles at one month of age (p < 0.001) and treatment method (p < 0.001) affected the number of clinical visits and ultrasound examinations during the treatment follow-up. A low alpha angle predicted closer follow-up, and children with spontaneous recovery had lower numbers of clinical visits and ultrasound examinations than children in abduction treatment. Spontaneous recovery was found to result in approximately 375€/patient savings compared to successful abduction treatment.

CONCLUSION

With correct patient selection, a watchful waiting strategy is cost-effective in treating mild developmental dysplasia of the hip, considering the high percentage of spontaneous recovery.

Clinical Examination Findings Can Accurately Diagnose Developmental Dysplasia of The Hip-A Large, Single-Center Cohort

BACKGROUND

Physical examination findings such as limited hip abduction (LHA), asymmetric skin creases (ASC), and a popping sensation in the hip facilitate the diagnosis of developmental dysplasia of the hip (DDH). Screening with a simple physical examination during the first weeks of infancy is important for early detection of the condition, and a wide range of medical professionals, including general practitioners, obstetricians, pediatricians, and orthopedic surgeons etc. are involved in this process. The aim of this study was to determine the correlation between easily recognizable physical examination findings such as LHA, thigh/groin ACSs, and Ortolani and Barlow tests with ultrasound findings for the diagnosis of DDH.

METHODS

This study included 968 patients undergoing routine hip ultrasonography between December 2012 and January 2015. All patients were examined by an experienced orthopedic surgeon who was not the physician who performed the ultrasound examination to exclude bias between physical examination findings and ultrasound findings. Asymmetric skin folds (thigh and groin), limited abduction, Barlow and Ortolani tests were recorded. The relationship between the physical examination findings, ultrasound findings, and developmental dysplasia was investigated.

RESULTS

Of the 968 patients, 523 were female (54%) and 445 were male. On ultrasonography examination, 117 patients were found to have DDH. The sensitivity, specificity and negative predictive values of patients who were found to have both LHA and thigh/groin ASCs in all three physical examinations were high (83.8%, 70.2%, and 96.9%, respectively) while positive predictive values were found to be low (27.8%).

CONCLUSION

Asymmetric skin creases on the thigh and groin and limited hip abduction, when evaluated together, have high sensitivity and specificity with additional high negative predictive values and could help during the initial screening process of DDH.

Assessment for late developmental hip dysplasia in a cohort of infants with risk factors and normal hip ultrasound

Background

Developmental dysplasia of the hip (DDH) is a known orthopedic pathology of newborns that, if not diagnosed and treated, can lead to debilitating long-term consequences. Ultrasound has proven to be an effective method for the early diagnosis of this condition. Recently, reports of late DDH in populations at risk (breech presentation) and after negative ultrasound examination have emerged in the literature.

Aim

The objective of the study was to assess the possible appearance of late DDH in Italian children with risk factors but negative ultrasound screening.

Materials and methods

We selected patients with risk factors for DDH and a negative hip ultrasound from the medical records of children referred to the Hip Ultrasound Clinic (Rome, Italy) from January 2018 to November 2021. To identify possible cases of late DDH, from February 2022 to July 2022, all patients who met the inclusion criteria were submitted to orthopedic follow-up clinical evaluation. In the case of a pathological objective examination, radiography was performed.

Results

Fifty-five patients (52.7% female, 52.7% with breech presentation, and 41.8% with a positive family history) met the inclusion criteria. The median age of gait onset was 13 months. The median age of orthopedic follow-up examination was 45 months. Only three patients (5.5%) had a pathological examination, but no x-ray were pathological.

Conclusion

Our study has not documented cases of late DDH. Considering the small study population and the only clinical follow-up, further studies are needed to clarify the possible late development of this condition.

Racial Disparities in Postoperative Outcomes Following Operative Management of Pediatric Developmental Dysplasia of the Hip

BACKGROUND

Developmental dysplasia of the hip in pediatric patients can be managed conservatively or operatively. Understanding patient risk factors is important to optimize outcomes following surgical treatment of developmental dysplasia of the hip. Racial disparities in procedural outcomes have been studied, however, there is scarce literature on an association between race and complications following pediatric orthopaedic surgery. Our study aimed to determine the association between pediatric patients' race and outcomes following operative management of hip dysplasia by investigating 30-day postoperative complications and length of hospital stay.

METHODS

The National Surgical Quality Improvement Program-Pediatric database was utilized from the years 2012 to 2019 to identify all pediatric patients undergoing surgical treatment for hip dysplasia. Patients were stratified into 2 groups: patients who were White and patients from underrepresented minority (URM) groups. URM groups included those who were Black or African American, Hispanic, Native American or Alaskan, and Native Hawaiian or Pacific Islander. Differences in patient demographics, comorbidities, and postoperative outcomes were compared between the 2 cohorts using bivariate and multivariate analyses.

RESULTS

Of the 9159 pediatric patients who underwent surgical treatment for hip dysplasia between 2012 and 2019, 6057 patients (66.1%) were White and 3102 (33.9%) were from URM groups. In the bivariate analysis, compared with White patients, patients from URM groups were more likely to experience deep wound dehiscence, pneumonia, unplanned reintubation, cardiac arrest, and extended length of hospital stay. Following multivariate analysis, patients from URM groups had an increased risk of unplanned reintubation (odds ratio: 3.583; P=0.018).

CONCLUSIONS

Understanding which patient factors impact surgical outcomes allows health care teams to be more aware of at-risk patient groups. Our study found that pediatric patients from URM groups who underwent surgery for correction of hip dysplasia had greater odds of unplanned reintubation when compared with patients who were White. Further research should investigate the relationship between multiple variables including race, low socioeconomic status, and language barriers on surgical outcomes following pediatric orthopaedic procedures.

LEVEL OF EVIDENCE

Level III-retrospective cohort analysis.