Breech Presentation in Twins as a Risk Factor for 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).

Risk factors of developmental dysplasia of the hip in infants: A meta-analysis based on cohort studies

INTRODUCTION

Developmental dysplasia of the hip (DDH) is a prevalent condition in children. Currently, the exact etiology of DDH remains uncertain. The objective of this study was to conduct a meta-analysis to investigate the risk factors associated with DDH in infants. The findings would provide a theoretical foundation for targeted early screening and diagnosis.

HYPOTHESIS

Several indicators, such as gender, intrauterine position, family history of DDH, gestational age, delivery mode, amniotic fluid levels, swaddling, parity, fetus number, combined musculoskeletal deformities, birth weight, and physical examination results, may serve as risk factors for DDH.

MATERIALS AND METHODS

Cohort studies investigating the risk factors of DDH in infants through logistic regression analysis were searched in the Wanfang, VIP citation, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc, Excerpta Medica Database (Embase), PubMed, and Cochrane Library databases up to May 2023. After extracting the data from eligible literature and assessing them using the Newcastle-Ottawa Scale (NOS), articles were selected based on pre-established inclusion and exclusion criteria.

RESULTS

A total of eleven literature reports covering 979,757 infants were included in this meta-analysis. The publication bias did not significantly influence the results. The incidence rate of DDH was 47.99‰ among infants with risk factors compared to 3.21‰ in the general population. Risk factors for DDH included being female (OR=6.97, 95% CI: 5.18-9.39, p<0.001), breech delivery (OR=4.14, 95% CI: 3.09-5.54, p<0.001), positive family history (OR=4.07, 95% CI: 2.20-7.52, p<0.001), cesarean section (OR=1.11, 95% CI: 1.01-1.21, p=0.032), oligohydramnios (OR=3.93, 95% CI: 1.29-12.01, p=0.016), swaddling (OR=6.74, 95% CI: 1.25-36.31, p=0.026), firstborn status (OR=1.84, 95% CI: 1.49-2.53, p<0.001), combined musculoskeletal malformations (OR=2.27, 95% CI: 1.58-3.27, p<0.001), and physical signs of DDH (OR=8.71, 95% CI: 2.44-31.07, p=0.001). Premature delivery (OR=0.91, 95% CI: 0.88-0.95, p<0.001) was a protective factor for DDH. The relationship between multiple pregnancies (OR=0.58, 95% CI: 0.33-1.02, p=0.060) and low birth weight (OR=0.62, 95% CI: 0.14-2.76, p=0.529) in relation to DDH remained uncertain.

DISCUSSION

This meta-analysis shows that female, breech delivery, positive family history, cesarean section, firstborn status, oligohydramnios, swaddling and combined musculoskeletal malformations are associated with DDH. Premature delivery appeared to be a protective factor against DDH. Nevertheless, the other factors need more research to reach more conclusive results.

LEVEL OF EVIDENCE

III; meta-analysis.

The risk of DDH between breech and cephalic-delivered neonates using Graf ultrasonography

PURPOSE

Developmental dysplasia of the hip (DDH) is one of the most common musculoskeletal disorder in infants. The most significant risk factors include female gender, breech presentation, left hip and family history. In this study, we utilized the Graf method at different time intervals to evaluate both breech-delivered and cephalic-born newborns. The objectives were to compare the incidence of DDH in cephalic and breech-delivered neonates and investigate whether the hip joints of neonates delivered in the breech position exhibit a distinct maturation pattern.

MATERIAL AND METHODS

We studied prospectively 618 hip joints (309 newborns). Each hip joint was examined with the Graf method in four time periods as follows: Phase #1 (0-1 weeks), Phase #2 (1-4 weeks), Phase #3 (4-7 weeks), and Phase #4 (7-10 weeks). The α and β angles for each hip joint were measured, and the hips were classified according to Graf classification. With our statistical analysis within the different phases, we were able to investigate potential variations in the maturation patterns between newborns delivered in the breech and cephalic delivery positions.

RESULTS

A significant difference (at the 5% level) was observed in Phase 1 between breech and cephalic-delivered neonates (35.6-8.6%). This difference tended to decrease in next phases (13.6-1% in Phase 2, 2.5-0% in Phase 3 and 1.7-0% in Phase 4). A significant difference (at the 5% level) for cephalic-delivered neonates was also observed between Phase 1 and Phase 4 (8.5-0%), but the percentages were low. Additionally, the breech-delivered had extreme difference in incidence of DDH from Phase 1 to Phase 4 (35.6-11.9%, 2.5%, and 1.7%, respectively).

CONCLUSION

It appears that there is an actual difference in the incidence of DDH between breech-delivered and cephalic-delivered neonates, although the difference may be less significant than previously considered. The majority of the breech-delivered neonates that were initially considered as pathological (Phase 1) are, in fact, healthy. This is ascertained in subsequent ultrasound examinations conducted in later phases (Phases 2-4), when the incidence of pathological cases decreases. This could be attributed to potential different maturation pattern between these groups.

Prevalence of Breech Presentation and Other Gestational/Delivery Characteristics Among Patients Born With Developmental Dysplasia of the Hip

Introduction Developmental dysplasia of the hip (DDH) is the most common congenital disability in newborns. The condition can range from a slight laxity in the hip joint to secondary femoral head injury, early osteoarthritis (OA), and mobility issues. There are several risk factors for DDH, including positive family history, female sex, breech presentation, and the presence of clubfoot. Early detection and treatment are crucial to avoid long-term hip dysplasia and arthritis, which can cause difficulty in walking and discomfort. Breech presentation, in particular, is a significant risk factor for DDH, with spontaneous vaginal birth increasing the risk of hip pathology and instability compared to elective Caesarean section. However, whether breech presentation continues to be a risk factor for DDH in preterm children is unknown. Objective and methods This study aimed to investigate the prevalence of breech presentation and other gestational/delivery characteristics among newborns diagnosed with DDH. This retrospective study was conducted at Abha Maternity and Children Hospital, Abha, Saudi Arabia, over a period of six months. Data were collected from medical records of DDH cases diagnosed between 2016 and 2023. Data analysis was performed using Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States) and IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States). Descriptive statistics and statistical tests were used to analyze the data. Results Most of the diagnosed children were female (86.7%), and bilateral hip dislocation (40%) was the most common presentation. X-ray was the most common diagnostic tool (48.3%), and operative management was the most common management strategy (73.3%). A positive family history of DDH was reported in more than one-third of cases. The study also analyzed the association between complications during pregnancy and various factors such as mode of delivery, presentation at delivery, gestational age at delivery, and associated maternal diseases. The difference in complication rates between women who delivered via C-section and those who delivered vaginally was insignificant (p = 0.14). Similarly, the difference in complication rates between women with breech and cephalic presentation was not statistically significant (p = 0.094). The difference in complication rates between women who delivered preterm, at term, or post-term was also not statistically significant (p = 0.578). Furthermore, the association between complications during pregnancy and pregnancy-associated maternal diseases was not statistically significant (p = 1.00). Conclusion DDH is a significant health issue in newborns, leading to long-term mobility problems and discomfort. Positive family history of DDH is a significant risk factor. Breech presentation was not significantly associated with DDH in preterm children, and no significant associations were found between complications during pregnancy and various factors. Early detection and treatment of DDH are crucial for preventing long-term complications. Family history should be considered an important risk factor, emphasizing the need for screening programs in families with a history of DDH.

Concentric Circles: A New Ultrasonographic Sign for the Diagnosis of Normal Infantile Hip Development

Ultrasound (US) of the infant hip is used to diagnose developmental dysplasia of the hip (DDH). We present a new sonographic sign that describes the periphery of the femoral head and the acetabulum as two concentric circles.During 2008−2019, 3650 infants were referred for diagnosis of DDH. All underwent a clinical and US examination. We recorded the femoral head as the inner circle, within a fixed external circle, which was identified as the acetabulum. We analysed the clinical signs and risk factors. The US sign of two concentric circles was normal in 3522 infants and was classified as normal hip development. The alpha angle was >60° in 3449 (95%) infants. For the remaining 73 (5%) infants, the alpha angle was 50−60° and underwent further follow-up examination until the alpha angle was normalised. In 128 babies (3.5%), we detected the disruption of the concentric circle sign; the femoral head was found outside the acetabulum, which appeared with an upward sloping roof and the alpha angle was <50°. These infants had DDH and received appropriate treatment. Infants with a concentric circle sign and normal alpha angle are normal, whereas those with a disrupted sign are considered as having DDH.

Geographical Distribution of Developmental Dysplasia of the Hip: A Brief Epidemiological Study of Iran

Background

Local epidemiological data are necessary to identify the disease hot spots and running screening programs. In this study, we evaluated the demographic characteristics of developmental dysplasia of the hip (DDH) in a tertiary referral hospital in Iran.

Methods

In a retrospective study, the medical profiles of 137 DDH children, who were referred to our university hospital between 2014 and 2020, were reviewed for characteristics such as gender, place of birth, age at the diagnosis, gestational age (term or preterm), twin or single birth, mother's age, pregnancy number, breech presentation, associated deformity, family history of DDH, et cetera.

Results

The study population included 24 (17.5%) boys and 113 (82.5%) girls with a mean age of 2.3 ± 2 years. In the majority of cases (54.2%), it was the firstborn. Twin delivery was seen in only 5 (4.1%) cases. The associated deformity was noticed in 17 (12.4%) patients. Clubfoot was the most commonly associated deformity that was seen in 6 of 17 (35.3%) patients. A family history of DDH was recorded in 12 (8.8%) patients. The breech presentation was recorded in 19 (13.9%) patients. The mean age of the mother at the delivery was 27.2 ± 6.1 years. Tehran, Lorestan, Kurdistan, and Khuzestan provinces had the most referrals.

Conclusion

DDH is associated with the female sex, positive family history, breech presentation at delivery, clubfoot deformity, and geographic district. These associations could be used for identifying the disease hot spots and running screening programs for earlier detection and better management of DDH.

Fluoride increases the susceptibility of developmental dysplasia of the hip via increasing capsular laxity triggered by cell apoptosis and oxidative stress in vivo and in vitro

The etiology of developmental dysplasia of the hip (DDH) is multifactorial, including breech presentation and hip capsular laxity. In particular, hip laxity is the main contributor to DDH by changing the ratio and distribution of collagens. Also, fluoride (F) affects collagens from various tissue besides bone and tooth. To investigate the association of DDH and excessive F intake, we conducted this research in lab on cell and animal model simultaneously. We established animal model of combination of DDH and F toxicity. The incidence of DDH in each group was calculated, and hip capsules were collected for testing histopathological and ultrastructural changes. The primary fibroblasts were further extracted from hip capsule and treated with F. The expression of collagen type I and III was both examined in vivo and in vitro, and the level of oxidative stress and apoptosis was also tested identically. We revealed that the incidence of DDH increased with F concentration. Furthermore, the oxidative stress and apoptosis levels of hip capsules and fibroblasts both increased after F exposure. Therefore, this study shows that excessive F intake increases susceptibility to DDH by altering hip capsular laxity in vivo and in vitro respectively. We believe that F might be a risk factor for DDH by increasing hip laxity induced by triggering fibroblast oxidative stress and apoptosis.