Evaluation and Referral for Developmental Dysplasia of the Hip in Infants

Evaluation of Serum and Urine Biomarker Panels for Developmental Dysplasia of the Hip Prior to Onset of Secondary Osteoarthritis

OBJECTIVE

Evaluate serum and urine biomarker panels for their capabilities in discriminating between individuals (13- to 34-years-olds) with healthy hips versus those with developmental dysplasia of the hip (DDH) prior to diagnosis of secondary hip osteoarthritis (OA).

DESIGN

Urine and serum were collected from individuals (15-33 years old) with DDH, prior to and following diagnosis of hip OA, and from age-matched healthy-hip controls. Samples were analyzed for panels of protein biomarkers with potential for differentiation of hip status using receiver operator characteristic curve (area under curve [AUC]) assessments.

RESULTS

Multiple urine and serum biomarker panels effectively differentiated individuals with DDH from healthy-hip controls in a population at risk for developing secondary hip OA with the best performing panel demonstrating an AUC of 0.959. The panel comprised of two serum and two urinary biomarkers provided the highest combined values for sensitivity, 0.85, and specificity, 1.00, while a panel of four serum biomarkers provided the highest sensitivity, 0.93, while maintaining adequate specificity, 0.71.

CONCLUSION

Results of this study indicate that panels of protein biomarkers measured in urine and serum may be able to differentiate young adults with DDH from young adults with healthy hips. These data suggest the potential for clinical application of a routine diagnostic method for cost-effective and timely screening for DDH in at-risk populations. Further development and validation of these biomarker panels may result in highly sensitive and specific tools for early diagnosis, staging, and prognostication of DDH, as well as treatment decision making and monitoring capabilities.

LEVEL OF EVIDENCE

III.

Why all newborn hip screening programs have same results-a mini review

All newborns are screened for developmental dysplasia of the hip (DDH), but countries have varying screening practices. The aim of this narrative mini review is to discuss the controversies of the screening and why it seems that all screening programs are likely to have same outcome. Different screening strategies are discussed alongside with other factors influencing DDH in this review. Universal ultrasound (US) has been praised as it finds more immature hips than clinical examination, but it has not been proven to reduce the rates of late-detected DDH or surgical management. Universal US screening increases initial treatment rates, while selective US and clinical screening have similar outcomes regarding late detection rates than universal US. This can be explained by the extrinsic factor affecting the development of the hip joint after birth and thus initial screening during the early weeks cannot find these cases.  Conclusion: It seems that DDH screening strategies have strengths and limitations without notable differences in the most severe outcomes (late-detected cases requiring operative treatment). Thus, it is important to acknowledge that the used screening policy is a combination of values and available resources rather than a decision based on clear evidence.

Neonatal Assessment: Put Your Best Foot Forward

BACKGROUND

Assessment of the foot is an essential part of the newborn examination. Foot abnormalities range from an isolated deformity due to intrauterine positioning to a functional impairment due to a structural malformation. The purpose of this article is to review assessment, abnormal findings, and current treatment options of common foot deformities.

EVIDENCE ACQUISITION

A review of literature was conducted using keywords in PubMed, Google Scholar, and CINAHL databases from 2018 to 2023.

RESULTS

Although assessment techniques for the neonatal foot remain the same, recent nonsurgical treatment options are available for a variety of neonatal foot deformities. Early recognition allows for proper evaluation of foot deformities and corrective measures.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Neonatal providers equipped with knowledge of common foot problems can provide support and anticipatory guidance to families.

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.

Does Screening Ultrasound Timing in Developmental Dysplasia of the Hip Need to be Adjusted for Moderate Preterm and Near-term Infants: A Prospective Study

INTRODUCTION

An initial screening ultrasound is essential for patients at higher risk of developmental dysplasia of the hip (DDH) due to breech presentation or a family history of DDH. The American Academy of Pediatrics recommends screening ultrasounds to be performed after 6 weeks of age to reduce the rate of false positives. However, there is limited evidence regarding whether these screening ultrasounds need to be adjusted for gestational age in prematurity. The purpose of this study was to evaluate the influence of moderate preterm and near-term births on screening hip ultrasounds for high-risk DDH populations.

METHODS

We identified all prospectively enrolled patients in a single-center database referred for screening hip ultrasound for DDH. We included those hips referred for risk factors of DDH, including breech presentation, family history of DDH, or hip click, and excluded those with known dysplasia or referral for hip instability. Each ultrasound was measured by a pediatric radiologist to determine the alpha angle and femoral head coverage. Patients were classified as "premature" if born at <37 weeks gestation or "full term" if born at ≥37 weeks gestation. All patients underwent screening hip ultrasound between 5 and 8 weeks of age. Sonographic markers of dysplasia and the incidences of abnormal ultrasound and Pavlik harness treatment were compared between cohorts. Significance was set at P <0.05.

RESULTS

A total of 244 hips in 122 patients were included, 58 hips in the premature cohort and 186 hips in the full-term cohort. The premature cohort had a significantly decreased gestational age compared with the full-term cohort (35.4 ± 1.1 vs 38.5 ± 1.1 wk, respectively, P < 0.001). However, there was no difference between premature and full-term cohorts in sex distribution (69% vs 75%, females, P = 0.39), unadjusted age at the time of ultrasound (6.6 ± 0.7 vs 6.8±0.7 wk, respectively, P = 0.07), or referral reason ( P = 0.14). On hip ultrasound, there was no difference between premature and full-term cohorts with respect to alpha angle (62.6 ± 3.3 vs 62.2 ± 5.3 degrees, P = 0.41), femoral head coverage (54.9 ± 6.3 vs 55.1 ± 10.6, P = 0.19), rate of abnormal ultrasound (18.3% vs 20.7%, respectively, P = 0.68), or the rate of Pavlik harness treatment (0% vs 5.3%, respectively, P = 0.12).

DISCUSSION

There was no significant difference in alpha angle or femoral head coverage between premature and full-term patients at 5 to 8 weeks of unadjusted age. This preliminary data suggests that screening ultrasounds can be performed without adjusting for prematurity.

LEVEL OF EVIDENCE

Level II, prognostic study.

Developmental dysplasia of the hip and ultrasound reading by pediatric orthopedic surgeons: a pilot study

Ultrasound is an imaging modality utilized for early detection and follow-up of developmental dysplasia of the hip (DDH) in infants. Traditionally, pediatric orthopedic surgeons have relied on radiologists to perform ultrasound examinations and interpret the imaging. Today, however, many orthopedic surgeons are performing and interpreting ultrasound themselves. The purpose of this paper was to evaluate the reliability of pediatric orthopedic surgeons in interpreting ultrasound imaging of infant hips. This was a prospective observational pilot study. After reading an instructional handout about the Graf method of hip ultrasonography, eight pediatric orthopedic surgeons measured 28 hip ultrasound images to determine the alpha angle and percent femoral head coverage. On the basis of cited intraclass correlation coefficient cutoff values, interrater reliability was found to be 'good' for percent femoral head coverage and 'fair' for alpha angle. These findings are equivalent to findings of similar studies using radiologists as examiners. Pediatric orthopedic surgeons can interpret ultrasound exams for diagnosing DDH.

Risk factors for a false negative Ortolani and Barlow examination in developmental dysplasia of the hip

INTRODUCTION

Although universal screening by neonatal clinical examination with Ortolani and Barlow manoeuvres is widely adopted, its role as a sole screening tool is controversial due to its poor sensitivity and failure in identifying hip joints that eventually require surgical intervention.

HYPOTHESIS

This study aims to identify risk factors for a false negative Ortolani and Barlow examination in neonatal screening for DDH. The hypothesis is that risk factors for developmental dysplasia of the hips could similarly be risk factors for a false negative Ortolani and Barlow examination.

MATERIAL AND METHODS

In the 14-year retrospective cohort study, all newborn infants born in a single institution from 1st January 1999 to 31st December 2013 were screened clinically with the Ortolani/Barlow manoeuvre by a neonatologist. Infants with positive risk factors, despite a normal clinical examination, were then scheduled for bilateral hip ultrasound in the first three months of life and evaluated according to the Graf's method, Harcke's method of dynamic ultrasound screening and Terjesen's method of evaluation for femoral head coverage.

RESULTS

A total of 164 infants with normal Ortolani and Barlow examinations were scheduled for bilateral hip ultrasound due to the presence of risk factors. Amongst these, 32 (19.5%) infants were evaluated to have an abnormal hip on ultrasound. Breech position was the only statistically significant risk factor for a false negative Ortolani/Barlow examination (14/34, 41.2% vs. 18/112, 13.8%; p<0.001).

DISCUSSION

Sonographic hip examinations are recommended for all infants with breech presentation even if they have a normal Ortolani and Barlow examination.

LEVEL OF EVIDENCE

III; case-control study.

Environmental factors associated with incidence of developmental dysplasia of the hip: a systematic review and meta-analysis

BACKGROUND

Established associated factors for DDH include female sex, breech presentation, family history, congenital malformations, oligohydramnios, and maternal hyperthyroidism. However, evidence for environmental factors that may contribute to DDH is limited and inconsistent.

METHODS

A systematic review of medical literature was conducted to collect data on environmental factors, including latitude, longitude, average yearly precipitation, average yearly temperature, minimum monthly temperature, and maximum monthly temperature, from all institutions that published articles on DDH. Univariate linear regression analysis was used to examine the correlation between environmental factors and DDH incidence, while multiple regression analysis was conducted to identify significant associated factors for DDH incidence.

RESULTS

Data from a total of 93 unique manuscripts were analyzed, revealing a significant negative correlation between DDH incidence and temperature, including average yearly temperature (r = -0.27, p = 0.008), minimum monthly temperature (r = -0.28, p = 0.006), and maximum monthly temperature (r = -0.23, p = 0.029). Additionally, there was a significant positive correlation between DDH incidence and latitude (r = 0.27, p = 0.009), and a significant negative correlation between DDH incidence and average yearly precipitation (r = -0.29, p = 0.004). In the final multiple regression analysis, temperature, including average yearly temperature, minimum monthly temperature, and maximum monthly temperature, were identified as significant associated factors for DDH incidence.

CONCLUSION

The findings of this study suggest an association between cold weather and DDH incidence. Further research should explore the link between cold weather and DDH incidence, offering insights into potential interventions for cold climates.

Acetabular index as an indicator of Pavlik harness success in grade I developmental dysplasia of the hip: A retrospective study

Purpose

Some articles have focused on the effectiveness of the Pavlik harness treatment for unstable and dislocated hips, yet data on monitoring its effectiveness with the acetabular index remains elusive. Therefore, this study aimed to assess Pavlik harness effectiveness in infants ≤6 months diagnosed with grade I developmental dysplasia of the hip using acetabular index improvement and identify the possible predictors of successful Pavlik harness treatment.

Methods

A retrospective review of infants with grade I acetabular dysplasia treated with a Pavlik harness and monitored with anteroposterior pelvis X-rays at presentation and follow-up. Successful treatment was defined as achieving an acetabular index <30°.

Results

A total of 231 infants with acetabular dysplasia were treated with a Pavlik harness. A successful outcome was achieved in 135 infants (58.4%). Younger age, lower initial acetabular index, and patients with unilateral developmental dysplasia of the hip were significant predictors of a successful outcome. An age of 4.5 months or older was found to be the threshold for an unsuccessful result following Pavlik harness treatment, with a sensitivity of 65.2% and specificity of 57.3%. An initial acetabular index of 35.5° was found to be the threshold for an unsuccessful result, with a sensitivity of 83.7% and specificity of 61.5%.

Conclusion

Pavlik Harness's success in correcting the acetabular index in acetabular dysplasia patients was related to unilateral cases, a younger age at presentation, and a lower initial acetabular index. The thresholds for unsuccessful treatment were an age of 4.5 months or greater and an acetabular index of 35.5° or higher.

Avascular necrosis predictive factors after closed reduction in patients with developmental dysplasia of the hip

Background

Developmental dysplasia of the hip (DDH) is a common pediatric orthopedic condition. Closed reduction (CR) is the conservative treatment approach with high success rates for DDH. However, avascular necrosis (AVN) is a severe potential complication after this procedure. This study retrospectively assessed the potential risk factors for AVN occurrence after CR and Spica cast immobilization.

Materials and Methods

In a retrospective observational study, 71 patients (89 hips) with DDH aged 6-24 months old undergoing CR were enrolled. All patients were followed up for 3 years, and their demographic data, initial Tönnis grade, pre-reduction procedures, abduction angle in the Spica cast, and the AVN presence (based on Bucholz and Ogden classification [3rd-4th class]) were documented.

Results

Of 71 patients (89 hips) with a mean age of 12.5 ± 3.9 months, 13 patients (18 hips) developed AVN. The mean age of patients in the AVN and non-AVN groups was 14.3 ± 4.9 and 12.2 ± 3 months (P = 0.07); also, the mean abduction angle in patients with and without AVN was 51.86 ± 3.66 and 58.46 ± 3.91 (P < 0.001) in univariate analysis. The distribution of initial Tönnis grade, and previous conservative procedures, adductor tenotomies during the CR were comparable between the two groups (P > 0.05). We found age 12 months and 54° in abduction angle as the best cutoff values for differentiating AVN patients from non-AVN and the risk of experiencing AVN for patients older than 12 months was odds ratio (OR) =4.22 (P = 0.06) and patients with abduction angle greater than 54 was OR = 34.88 (P < 0.001).

Conclusion

In this study, older age at the time of intervention and larger abduction angle in the hip Spica cast were two predictors of experiencing AVN in DDH patients after undergoing CR treatment approach. Performing CR at a younger age and keeping the abduction angle lower than 54° in the hip Spica cast could help to have the best possible prognosis.

Level of Evidence

IV, retrospective, observational, cross-sectional study.

Neonatal Hip Loading in Developmental Dysplasia: Finite Element Simulation of Proximal Femur Growth and Treatment

Background

Abnormal prenatal hip joint loading can lead to compromised hip joint function. Early intervention is crucial for favorable outcomes.

Purpose

This study investigates the impact of treatment timing (initiation and duration) on cartilage growth and ossification in the proximal femur of infants with developmental dysplasia of the hip, a condition affecting newborns.

Methods

We used a mechanobiological model to simulate proximal femur growth during treatment durations of 3 months, 6 months, and a late-start treatment.

Results

The findings indicate that the timing of treatment initiation is crucial, while a longer treatment duration does not contribute to improved morphological development of the hip joint.

Conclusions

Mechanobiological models of growth can be used to develop treatments and therapies that correct loading conditions. Growing bone is particularly sensitive to loading conditions, and altered loading during growth can affect bone shape and functionality.

Neonatal clinical examination and selective ultrasound screening are not reliable for the early diagnosis of hip dysplasia: A retrospective cohort study

AIM

To compare the incidence, clinical features and timing of initial treatment of early- and later-presenting developmental dysplasia of the hip (DDH) in infancy in the context of a risk-based selective ultrasound screening programme.

METHODS

We conducted a retrospective observational study of infants born at a tertiary perinatal centre in Melbourne, Australia, between July 2016 and June 2020 and treated for DDH up to 18 months of age at a tertiary paediatric centre. The incidence of DDH was calculated for early- and later-presenting cases. Clinical features and ultrasound indications were analysed using multivariate logistic regression.

RESULTS

There were 192 infants with DDH requiring treatment, 100 (52%) of which were not detected by universal neonatal hip examination and selective ultrasound screening based on risk factors (overall incidence 6.3 per 1000 livebirths). The median age at which treatment was commenced was delayed by 8 weeks for the later-presenting group compared to those detected through screening (16.7 vs. 7.9 weeks, P < 0.001). Skin crease asymmetry was associated with later presentation (adjusted odds ratio (aOR) 44.03, 95% confidence interval (CI) 9.99-333), whilst breech presentation (aOR 0.08, 95% CI 0.02-0.26) and Barlow/Ortolani test positivity (aOR 0.06, 95% CI 0.01-0.25) were associated with early presentation. Only 39 (1.45%) infants receiving a screening ultrasound had DDH.

CONCLUSION

Approximately half of all infants with DDH were not detected by combining risk-based selective ultrasound screening with neonatal clinical findings, highlighting the failure of this screening method to reliably detect a significant proportion of dysplastic infant hips.

How Ready are Pediatricians and Family Physicians in Saudi Arabia to Perform Clinical Screening of Developmental Dysplasia of the Hip?

Background

Developmental dysplasia of the hip (DDH) is one of the most common hip pathologies in pediatric age group and late diagnosis remains a major concern in Saudi Arabia.

Objective

The aim of this study is to examine the ability of Saudi Arabian pediatricians and family physicians to conduct clinical screening for (DDH) by estimating their clinical knowledge and skills and analyzing the gaps therein to determine whether there is potential to launch a national screening protocol for DDH in Saudi Arabia.

Methods

This is a multicenter cross-sectional study from three major regions in Saudi Arabia (Central, Eastern and Western provinces). The assessed aspects are risk factors, age of screening, incidence in Saudi Arabia, physical signs and diagnostic markers, and treatment, along with their 'clinical knowledge and skills' score.

Results

Half of the participants were pediatricians, while the rest were family physicians. More than a third of the participants were considered to have adequate knowledge, ie, above the mean score. Dimensions with the most significant knowledge gaps included the incidence of DDH in Saudi Arabia, adverse effects of swaddling, and the management of a high-risk infants presenting with a negative physical examination. Additionally, there were relatively low rates of awareness regarding positive risk factors as well as a generally poor ability to identify physical signs. Clinical knowledge and skill levels were significantly lower among family physicians.

Conclusion

Pediatricians and family physicians in Saudi Arabia still need further training to improve their clinical skills for DDH screening. The proper administration of training programs could eventually enable the gradual implementation of a national systematic screening program.

Study on the efficacy of brace therapy for developmental dysplasia of the hip with Graf IIc and greater severity

To assess changes in the α and β angle with brace treatment in DDH classified as Type Graf IIc, D, III, and IV; to study the α angle threshold that can predict the treatment effect; to analyze the effective rate in different groups. A retrospective study was conducted on children from 2013 to 2018 with Graf type IIc and greater diagnosed with ultrasound (US). Brace therapy was applied to 356 patients, with 423 affected hips (Graf IIc: 202 hips; Graf D: 17 hips; Graf III: 118 hips; and Graf IV: 86 hips). For follow-up efficacy analyses using US, X-ray and clinical examination, based on the success of early treatment of the brace, the outcomes were divided into 'effective' and 'noneffective' groups. The statistical results showed that the α angle increased (P < 0.05) and the β angle decreased (P < 0.05). When α≥43°, the accuracy of success with early treatment was 95.95%. The overall effective rate of bracing treatment was 74.70%. Children with α ≥ 43° are recommended to receive brace therapy as soon as possible and demonstrate the best effects. The effective rate varies across different Graf types and the age at treatment initiation. Brace therapy is more effective for Graf IIc and D hips compared to Graf III and IV.

The Risk of Developmental Dysplasia of the Hip in Premature Infants with Breech Presentation at Birth

OBJECTIVE

 This article evaluates the risk (defined here as incidence per 1,000 infants) of developmental dysplasia of the hip (DDH) in premature infants undergoing hip ultrasound (HUS) for breech presentation only compared with other indications.

STUDY DESIGN

 Retrospective study of infants born between January 1, 2009 and December 31, 2018 at <37 weeks' gestation with a HUS obtained in the first year of life, at Nationwide Children's Hospital, the only available facility for pediatric radiology and orthopaedic services in central Ohio. We calculated risk differences and odds ratios of DDH by the indication of HUS.

RESULTS

 From 2,397 infants reviewed, 89% underwent HUS for breech presentation only. The local incidence of DDH for infants undergoing HUS for breech-only indication was 15 per 1,000 compared with 155 per 1,000 for infants undergoing HUS for other indications. The odds ratio of DDH diagnosis was 12.1 (95% confidence interval: 7.5, 19.6) for infants undergoing HUS for an indication other than breech presentation only relative to infants undergoing HUS for the indication of breech presentation only.

CONCLUSION

 The risk of DDH diagnosis in premature infants undergoing HUS for breech presentation is much lower than those undergoing HUS for clinical concerns and other risk factors. Screening these infants with physical examination may be sufficient.

KEY POINTS

· Breech presentation is the most common indication for hip ultrasound in premature infants.. · The risk of DDH is lower in premature infants with breech presentation compared with premature infants with other clinical concerns.. · The risk of DDH is higher in infants born at 33 to 36 weeks of gestation compared with those born at an earlier gestation..

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.

The Significance of Isolated Hip Click as a Sign of DDH: Implications on Referral Guidelines

BACKGROUND

The clinical significance of an isolated hip click remains unclear. The rates of developmental dysplasia of the hip (DDH) in those referred for hip click vary from 0% to 28%. The purpose of this study was to evaluate the rate of DDH in patients prospectively referred for isolated hip click.

METHODS

We prospectively enrolled patients referred to a single pediatric orthopaedic center with concern for DDH secondary to isolated hip click felt by the pediatrician on examination. Patients with known sonographic abnormalities or risk factors for DDH (breech presentation or positive family history) were excluded. Ultrasounds were obtained upon initial presentation and defined as abnormal if alpha angle <60 degrees and/or femoral head coverage (FHC) <50%. Mild dysplasia, analogous to Graf IIa physiological immaturity, was defined as alpha angle 50<α<60 and/or <50% FHC in a patient <3 months age. Severe dysplasia was defined as ≤33% FHC, which has been proposed to be sonographically consistent with a hip dislocation.

RESULTS

Two hundred fifty-five children were referred for isolated hip click. One hundred eighty-nine patients (74%) had normal ultrasound whereas 66 patients (26%) had sonographic abnormalities (mean age 6.5±6.2 wk at initial ultrasound). Fifty patients (19.6%) demonstrated physiological immaturity, 3 patients (1.2%) demonstrated moderate sonographic dysplasia, and 13 patients (5.1%) had sonographic findings consistent with severe dysplasia or dislocated hip. Hips with severe dysplasia were younger than the remaining population (2.8±2.4 wk vs. 6.6±6.2 wk, P <0.001) with no difference in sex distribution ( P =0.07) or first-born birth order ( P =0.36). For those with sonographic abnormality, 18 (27%) patients were treated with Pavlik harness, 1 (2%) was treated with abduction orthosis, and the remainder (71%) were observed for resolution of physiological immaturity.

CONCLUSIONS

Infants with isolated hip click identified by their pediatrician may have higher rates of dysplasia than previously reported. We recommend screening ultrasound and/or orthopaedic referral for all infants with isolated hip click.

LEVEL OF EVIDENCE

Level II-prospective prognostic study.

Risk factors for misdiagnosis in children with developmental dysplasia of the hip: a retrospective single centre study

OBJECTIVE

To investigate risk factors of misdiagnosis at the first visit of children with developmental dysplasia of the hip (DDH) who did not participate in hip ultrasound screening.

METHODS

A retrospective review was conducted on children with DDH admitted to a tertiary hospital in northwestern China between January 2010 and June 2021. We divided the patients into the diagnosis and misdiagnosis groups according to whether they were diagnosed at the first visit. The basic information, treatment process and medical information of the children were investigated. We made a line chart of the annual misdiagnosis rate to observe the trend in the annual misdiagnosis rate. Univariate and multivariate logistic regression analyses were used to identify significant risk factors for missed diagnosis.

RESULTS

A total of 351 patients met the inclusion criteria, including 256 (72.9%) patients in the diagnosis group and 95 (27.1%) patients in the misdiagnosis group. The line chart of the annual rate of misdiagnoses among children with DDH from 2010 to 2020 showed no significant change trend. Multiple logistic regression analysis showed that the paediatrics department (v the paediatric orthopaedics department: OR 0.21, p<0.001), the general orthopaedics department (v the paediatric orthopaedics department: OR 0.39, p=0.006) and the senior physician (v the junior physician: OR 2.47, p=0.006) on the misdiagnosis at the first visit of children were statistically significant.

CONCLUSION

Children with DDH without hip ultrasound screening are prone to be misdiagnosed at their first visit. The annual misdiagnosis rate has not been significantly reduced in recent years. The department and title of the physician are independent risk factors for misdiagnosis.

Investigation of Igf-1, Igf-Bp3 and Igf-Bp5 levels in umbilical cord blood of infants with developmental dysplasia of the hip

BACKGROUND

IGF-1 (insulin-like growth factor-1) is an important regulator of bone formation. Its deficiency has been associated with fetal growth disorders and hip dysplasia. The aim of this study was to evaluate whether IGF-1, IGF-BP3 (insulin like growth factorbinding protein 3), and IGF-BP5 levels in the umbilical cord blood can be predictive for early diagnosis of DDH.

METHODS

Umbilical cord blood samples were collected from 860 mothers with pregnancies at high risk for DDH between October 2020 and January 2021. Mothers at 37-42 weeks of gestation, with risk factors for DDH, who delivered healthy infants were included. Blood samples were collected during delivery. Each eligible infant was medically followed up and underwent a hip ultrasound in the postnatal 2nd or 3rd month. Infants diagnosed with DDH were matched with a healthy cohort in terms of sex, birth weight, maternal age, and gestational week, and the IGF-1, IGF-BP3 and IGF-BP5 levels were studied and compared.

RESULTS

Evaluation was made of 20 infants diagnosed with DDH and 60 healthy infants. Of the total 80 infants, 72.5% were female.The umbilical cord blood levels of IGF-1 and IGF-BP3 were similar in both groups. The IGF-BP5 values were significantly lower in the DDH patient group. Except for DDH diagnosis, the other categorical variables of the study did not appear to influence the levels of any of the IGFs.

DISCUSSION

Umbilical blood samples could potentially help diagnose DDH. The levels of IGF-BP5 were shown to be significantly lower in infants with DDH.

Telescoping Allograft Prosthetic Composite (APC) Reconstruction of the Femur Following Revision Arthroplasty for Neglected Developmental Dysplasia of the Hip (DDH)

Although uncommon, neglected developmental dysplasia of the hip (DDH) poses a technically demanding problem for treating surgeons. Due to the congenital malformation of the native hip joint and distortion of the surrounding soft tissue, addressing limb-length discrepancy is intricate. Despite detailed planning and meticulous soft tissue handling, complications can be difficult to avoid in these patients even under experienced hands. In this case report, we present a 73-year-old lady with neglected DDH who had undergone initial total hip arthroplasty and subsequent revision surgery that failed due to aseptic loosening. Due to limited length in the distal femur, we used a telescoping allograft prosthetic composite (APC) to provide adequate length to the native distal femur during revision with proximal femur fixation. This technique can help avoid the need for total femur replacement (TFR) surgery, which is more invasive and may require tibia replacement.

The Impact of Maternal Age and Educational Level on Developmental Dysplasia of the Hip Diagnosis and Screening: A Descriptive Comparative Study

Background

Early and proper screening for developmental dysplasia of the hip (DDH) is very critical to prevent catastrophic complication on the developing hip joint. Many factors (either maternal or child-related) that hinder timely DDH screening have been previously investigated.

Methods

A cross-sectional descriptive study design was adopted. 175 babies presented for DDH screening coming with their mothers were investigated. Maternal age, age group, and educational level were recorded. In addition, multiple child-related variables such as age of screening, gender, positive family history, preterm delivery, and mode of delivery were recorded as well. Analysis for association between delayed vs. early screening was made against the maternal and the child-related variables.

Results

A total number of 175 children with their mothers were investigated. The mean maternal age was 27.9 years, about one third of the mothers had a graduate level of education (36.3%), while 41.1% had high school education, and 22.3% had middle school education. On the other hand, 40.0% of the investigated babies were first born and two thirds of our sample babies were females (66.9%). Of the included babies, 100 (57.1%) were screened at the appropriate 4-month age, while 75 (42.9%) missed the 4-month screening. Chi-square analysis showed that delayed DDH screening was associated with a lower maternal educational level (P ≤ 0.001), younger maternal age (P ≤ 0.001), and first born baby (P ≤ 0.001). Positive family history was protective against delayed DDH screening (P = 0.032).

Conclusion

The lower maternal educational level, younger maternal age group, and first born babies are risk factors for delayed DDH screening.

Analysis of the results of hip ultrasonography in 48 666 infants and efficacy studies of conservative treatment

PURPOSE

This study aimed to investigate the detection rate of developmental dysplasia of the hip (DDH) by ultrasound. To obtain the distribution characteristics of the different types (I-IV) and the role of ultrasound in the evaluation of infants with DDH (type IIc and above) receiving conservative treatment.

METHODS

A retrospective analysis was performed. The chi-square test was used for comparisons between count-data groups. Two-sided tests were used for all analyses. The results of ultrasound follow-up after conservative treatment are described.

RESULTS

Among the 48 666 infants examined, the detection rates were as follows: type I, 95.42%; IIa, 3.18%; IIb, 0.91%; IIc, 0.22%; D, 0.01%; III, 0.14%; and IV, 0.12%. There were 4456 hips with IIa and above, more left (54.65%) than right (45.35%) hips, and more females (82.60%) than males (17.40%). The detection rate of type IIa and above was 4.58%, and that of type IIb and above was 1.40%. After the treatment, the α value increased, and β value decreased. The cure rate of the less-than-42-days group was higher than that of the other groups.

CONCLUSION

The ultrasound detection rate of DDH is high. DDH was more likely to occur on the left side and in females. It is recommended that the infants should be treated within 42 days.

A Novel Heterozygous Missense Variant in Parathyroid Hormone 1 is Related to the Occurrence of Developmental Dysplasia of the Hip

Introduction: Developmental dysplasia of the hip (DDH) is one of the most common diseases in the pediatric orthopedics, with an incidence of 1-5%. Genetic factors are the bases of the pathogenesis of DDH, but the pathogenic variants and pathogenesis of DDH are still unknown. There are no key accurate diagnostic or prognostic molecular markers for DDH. The purpose of our study was to screen for genetic variant associated with DDH and explore its pathogenesis. Materials and Methods: The genetic variation of DDH was tested by variant NGS-based exome analyses, verified by the Sanger sequencing. Results: A four-generation family in which DDH was present in three generations was recruited. A novel heterozygous missense variant c.629C>T (p.(Ala210Val)) in exon 7/8 of the parathyroid hormone 1 receptor (PTH1R) gene was identified through screening of two affected and one unaffected family members. The candidate variant was validated in all available family members with all three affected members being positive for the PTH1R variant. Conclusion: Our results are highly supportive of PTH1R as a novel candidate gene for DDH and demonstrated that the combination of pedigree information and next-generation sequencing is an effective method for identifying pathogenic variants associated with DDH.

Association between timing and duration of breech presentation during pregnancy and developmental dysplasia of the hip: A case-control study

This case-control study investigated the association between timing and duration of breech presentation in pregnancy and developmental dysplasia of the hip (DDH). Children with DDH aged 3 years or younger (n = 191) were compared with healthy controls (n = 209). Data on outcome, exposure and, covariates were collected using a parents' self-report online questionnaire. Term children with breech presentation at one or more check-ups after 30.0 weeks gestation had a twofold higher risk of developing DDH compared to children who had never presented in breech (OR 2.01; 95% CI [1.28, 3.15]). The strength of the association increased with duration of breech presentation (5-8 weeks: OR 2.65; 95% CI [1.36, 5.18]; 9-12 weeks: OR 3.63; 95% CI [1.82, 7.24]). Children who had presented in breech at least once in gestational period 37.0-birth had a 3.24 (95% CI [1.86, 5.65]) times higher risk of DDH, whereas the risk for children with breech presentation in gestational period 30.0-36.6 only was not increased. Also after adjusting for confounders, children who had presented in breech after gestational week 37.0-birth had a more than threefold higher risk of DDH (OR 3.33; 95% CI [1.81, 6.13]) compared to children who were never in breech or in gestational period 30.0-36.6 only.

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.

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

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

Clinical and sonographic improvement of developmental dysplasia of the hip: analysis of 948 patients

BACKGROUND

Developmental dysplasia of the hip is a common condition, which varies in severity. Abduction treatment is widely used to correct the development of the hips, but mild forms of DDH can also recover spontaneously. The purpose of this study was to evaluate factors affecting the rate of improvement of developmental dysplasia of the hip, and evaluate any risk factors slowing the process.

MATERIAL AND METHODS

The study population consisted of patients diagnosed with DDH in Tampere University hospital in the years 1998-2018. Data were retrospectively collected, and associations between clinical variables and rate of improvement were analyzed. Alpha angles were assessed monthly, and associations between risk factors and improvement of alpha angles were studied. A total of 948 patients were included in the analysis.

RESULTS

More severe first status of the hips was associated with faster improvement in dynamic ultrasound compared to milder DDH in univariate design in first 3 months of age; in the multivariable design, Ortolani positivity was conversely associated with lower alpha angles in 1-month follow-up. Immediate abduction treatment was associated with faster recovery rate compared to delayed abduction or watchful waiting. Female sex and positive family history were associated with slower rate of improvement and lower alpha angles. In multivariable design, female sex, positive family history and treatment strategy remained statistically significant as initiation time of the treatment explained the first found association of clinical hip status and the recovery rate after 2 months of age.

CONCLUSION

Female sex and positive family history might be independent risk factors for slower recovery in DDH before 6 months of age. These children might need special attention in their follow-up plans and abduction treatment.

Care of the Well Newborn

Care of the newborn infant is a critical skill for general pediatricians and other providers in the practice of pediatric medicine. Optimal care relies on a thorough understanding of risk factors that may be present during the pregnancy and delivery, as well as the ability to recognize and address unanticipated problems in the postnatal period. This article focuses on antenatal care of the newborn, issues that present in the immediate postdelivery period, and care of the newborn after discharge. It also includes updated information on current topics in pediatric practice, such as the importance of vaccination, parental hesitancy in accepting common medical interventions, and updated guidelines related to the coronavirus disease 2019 pandemic. At the conclusion of the article, the reader should have a general understanding of antenatal risk factors that could affect the transition from the intrauterine environment and have the knowledge to address common issues that arise in the care of newborn infants.

Surgical procedures in infants with early diagnoses of developmental dysplasia of the hip. A prospective 4-year follow-up study

Background

Dysplastic hips infants may normalize spontaneously without any intervention due to the natural growth. However, some infants need one or more surgical interventions to achieve stable and non-dysplastic hips. The purpose of this study is to determine the proportion of infants diagnosed with DDH before the age of 6 months undergoing surgical procedures of the hip(s) before the age of four years and to determine the number and types of surgical procedures in each infant.

Methods

A prospective and consecutive study of all infants aged 0-6 months diagnosed with dysplasia of the hips in the combined paediatric orthopaedic and radiologic examination in the Region of Southern Denmark 2013-2017. From medical records, we obtained information about all surgical procedures in the hips including open or closed reductions, arthrographies, tenotomies, and pelvic osteotomies before the age of 4 years.

Results

Overall, 281 infants with hip dysplasia were included. The median age at first examination was 48 days. In 254 (90%) of the infants, the hips resolved spontaneously, and 27 (10%) needed one or more surgical interventions. Overall, the 27 infants had 47 surgical intervention as 12 infants had more than one intervention. One infants had five surgical interventions. The most frequent surgical procedures were closed reduction and arthrography with or without adductor tenotomy (58%) and pelvic osteotomy (27%). Among infants with surgical interventions, 23 (8.2%) had unstable hips, and four (1.4%) had stable hips. All four infants with stable hips had an arthrography and none required a pelvic osteotomy.

Discussion

This study supports the propensity for spontaneous normalization early dysplasia of the hips in infants. Only a small proportion of the infants needed surgical interventions to achieve stable and non-dysplastic hips.

Ultrasound-guided lumbar plexus block versus transversus abdominis plane block for analgesia in children with hip dislocation: A double-blind, randomized trial

Lumbar plexus block is often used as analgesia for adult hip surgery, but it is rarely used in pediatric patients. This study aimed to compare the efficacy and feasibility of ultrasound-guided lumbar plexus block versus transversus abdominis plane block for postoperative analgesia in children with hip dislocation. Eighty children undergoing unilateral hip dislocation surgeries at our hospital from October 2019 to February 2021 were randomized to the lumbar plexus block group (group L) and transversus abdominis plane block group (group T). Compared with group L, the regional block time in group T was lower (8.0 ± 2.5 vs 11.5 ± 2.3 min, P < 0.05), and the ultrasound image definition was better (P < 0.05). There were no significant differences in mean blood pressure and heart rate within 24 h (all P > 0.05). Children’s Hospital of Eastern Ontario Pain Scale scores were lower in group L than in group T at 18–24 h only (all P < 0.05). The satisfying analgesia rate in group L was higher than in group T (87.5 vs 65%, P < 0.05). No regional block-related complications were found in both groups. Ultrasound-guided lumbar plexus block showed a longer postoperative analgesic effect in children with hip dislocation compared with transversus abdominis plane block.

Quantification of femoral position on radiographic acetabular coverage in children

An accurate assessment of the radiographic acetabular coverage is essential for clinical diagnosis or surgical decision-making in hip disorders. This study aimed to evaluate the effect of femoral position on acetabular coverage and to predict the actual acetabular coverage from nonstandard radiographs. A total of 21 children (34 hips) with normative acetabular coverage were screened in this retrospective study. The Mimics-based local-rotation fluoroscopy simulation method was used to tilt, incline, and rotate the femur in 4° increments within the range of femoral motion. The acetabular coverage, namely acetabular-head index (AHI) and center-edge angle (CEA), increased with femoral abduction but decreased with other motions. Compared to the femoral neutral position, no significant differences were identified in AHI with the rotation (range: 0°-16°) and in CEA with the tilt (range: -20°-4°), inclination (range: 0°-4°), or rotation (range: -8°-40°). The linear regression analysis showed that the CEA increased by about 0.20° for each 1° increase in femoral inclination and decreased by about 0.01°, 0.07°, 0.06°, or 0.07° for each 1° increase in internal rotation, external rotation, flexion, or extension, respectively. And a more significant change in AHI was observed. All femoral malpositions, especially the inclination, affected radiographic acetabular coverage in children. Therefore, each pelvic radiograph should assess potential femoral malpositioning before diagnosing hip disorders. This study will assist surgeons in predicting the acetabular coverage on nonstandard radiographs.

Late presenting developmental dysplasia of the hip after a normal hip ultrasound at 6 weeks of age: A report of two cases

Developmental hip dysplasia (DDH) is a paediatric condition in which the 'ball and socket' hip joint fails to form properly during infancy. The increased mechanical stress on the hip joint from DDH can contribute to the development of osteoarthritis during adulthood. Therefore, careful physical examination and imaging of all infants to diagnose DDH is critical to provide the best possible functional outcome. Ultrasonography (US) is a useful diagnostic test in providing a real-time evaluation and three-dimensional view of the hip in infants less than 4 months. In infants with a normal hip ultrasound, the risk of subsequent development of hip dysplasia at an older age and the need for further follow-up is assumed to be unnecessary. In the present study, we report 2 cases of late presenting DDH in infant girls born breech with a previous normal hip exam and normal hip ultrasound at 6 weeks of age.

Evaluation of CX3CR1 gene DNA methylation in developmental dysplasia of the hip (DDH)

INTRODUCTION AND OBJECTIVE

Developmental dysplasia of the hip (DDH) is a musculoskeletal disorder. Genetic and epigenetic changes in C-X3-C motif chemokine receptor 1 (CX3CR1) may lead to disturbance in chondrocyte development and change the labrum dimensions, which indirectly result in hip joint instability. Considering the important role of this gene in cell migration, cell adhesion and bone and cartilage development, we aimed to evaluate the CX3CR1 gene methylation in DDH pathogenesis.

METHODS

Our study comprised of forty-five DDH patients and forty-five healthy control subjects with healthy femoral neck cartilage. The healthy controls had total or hemiarthroplasty for the femoral neck fracture. Samples were collected from the femoral head (cartilage) of DDH patients and healthy controls. Genomic DNA was obtained from the samples, and DNA methylation of CX3CR1 gene was analyzed via metabisulfite method.

RESULTS

Methylation analysis reveals no significant differences in promoter of CX3CR1 gene in cartilage samples from DDH patients and healthy control subjects (P = 0.33).

CONCLUSION

Methylation status of CX3CR1 gene showed no significant difference between the patient and control groups. Our results indicate that DNA methylation may not modulate this gene in this disease and other epigenetic mechanisms such as non-coding RNAs and histone modifications could be implicated.

Developmental Dysplasia of the Hip Is Not Associated with Breech Presentation in Preterm Infants

OBJECTIVES

 The aim of the study is to (1) determine the incidence of developmental dysplasia of the hip (DDH) in preterm infants born prior to 35 completed weeks' gestation in a breech presentation, and (2) evaluate if the association between breech presentation and DDH in full-term infants holds for premature infants.

STUDY DESIGN

 This study design comprises retrospective review of infants born between January 1, 2008, and December 31, 2017, at <35 weeks' gestation and admitted to the NICU. Infants had hip ultrasounds at 4 to 6 weeks' corrected age if they were born in a breech presentation with a stable hip examination. We excluded infants born in a presentation other than breech or vertex, had no documentation of presentation at birth, or if they died within the first year.

RESULTS

 We included 1,533 infants. Preterm infants <35 weeks' gestation born in the breech versus vertex position had an incidence of DDH of 0.47% (2/428) and 0.36% (4/1,105), respectively. There was no significant difference in the incidence of DDH between infants born in the breech versus vertex position (Chi-square and Fisher's exact tests). The sensitivity, specificity, and positive and negative predictive values of breech presentation in detecting DDH were 33, 72, 0.47, and 99.6%, respectively.

CONCLUSION

 There is no association between breech presentation and DDH in preterm infants <35 weeks' gestation. Obtaining hip ultrasounds on preterm infants <35 weeks' gestation born in the breech presentation with a normal hip examination is not recommended.

KEY POINTS

· Breech position is a risk factor for DDH in term newborns.. · Preterm infants are often in the breech position until 37 weeks' gestation.. · This study shows that breech presentation is not a risk factor for DDH in preterm infants..

Developmental Dysplasia of the Hip: Guide for the Pediatric Primary Care Provider

Developmental dysplasia of the hip (DDH) is the most common congenital abnormality in newborns. Untreated DDH can cause significant impairments, including chronic hip pain, osteoarthritis, limb length discrepancy, altered gait, and joint contractures. Treatment outcomes are significantly worse with increasing delay in presentation, making early screening and detection critical. The purpose of this review is to provide a comprehensive guide for the pediatric primary care provider on the cause, diagnosis, and management of DDH. Screening practices, physical examination, imaging modalities, and treatment will be discussed. A missed hip dislocation in a walking-age child is a devastating but preventable event; pediatric primary care providers should have a high index of suspicion for DDH and promptly refer any patient with concerning findings to a pediatric orthopedic surgeon. [Pediatr Ann. 2022;51(9):e346-e352.].

The Effect of Traction before Closed Reduction in Patients with Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) with a dislocated hip can be treated with traction before closed reduction (CR). Currently, there is insufficient evidence supporting the use of preoperative traction treatment for a successful CR. The objective of this study was to determine the effect of preoperative traction on the success rate of primary CR in DDH patients with dislocated hips. A retrospective pair-matched study was performed in DDH patients with dislocated hips. Patients with preoperative traction treatment prior to primary CR were matched (based on age and the severity of DDH on the radiograph) to patients without preoperative traction treatment. The primary outcome was the presence or absence of maintained reduction after three weeks. A match was found for 37 hips, which resulted in the inclusion of 74 hips. No significant difference was found in the number of successful reductions after three weeks between the traction group and the control group (31 vs. 33 hips, p = 0.496). Traction treatment did not significantly improve the short-term or mid-term outcomes for closed reduction. Based on these results, we suggest that traction treatment should not be used as standard care for dislocated hips in DDH.

Impact of Multiple Factors on the Incidence of Developmental Dysplasia of the Hip: Risk Assessment Tool

Background and Objectives: Developmental dysplasia of the hip (DDH) is one of the most common musculoskeletal conditions in children. If not treated, it leads to disability, gait abnormalities, limb shortening, and chronic pain. Our study aims to determine the impact of multiple risk factors on the incidence of DDH and to develop an interactive risk assessment tool. Materials and Methods: We conducted a retrospective cohort study in the Outpatient Clinic for Children of the Medical University of Warsaw Hospital. The Graf classification system was used for universal ultrasonographic screening. In total, 3102 infants met the eligibility criteria. Results: The incidence of DDH in the study group was 4.45%. The incidence of DDH in the Warsaw population, Poland, during the study period was 3.73 to 5.17 (95% CI). According to the multivariate analysis, the risk factors for DDH were birth weight (OR = 2.17 (1.41−3.32)), week of delivery (OR = 1.18 (1.00−1.37)), female sex (OR = 8.16 (4.86−13.71)), breech presentation (OR = 5.92 (3.37−10.40)), physical signs of DDH (25.28 (8.77−72.83)) and positive family history in siblings (5.74 (2.68−12.31)). Our results support the recent hypothesis that preterm infants (<37 weeks) have a lower rate of DDH. Conclusions: A multivariate logistic regression predictive model was used to build the risk calculator. The DDH risk calculator will be evaluated in a prospective validation study.

Enhanced Child Care: Contrast Correction for Pediatric Hip Ultrasound Using Hyperanalytic Wavelets

(1) Background: The prevention of critical situations is a key ability in medicine. Hip ultrasound for neonates is a standard procedure to prevent later critical outcomes, such as hip dysplasia. Additionally, the SARS-CoV-2 pandemic has put worldwide stress upon healthcare units, resulting often in a lack of sufficient medical personnel. This work aims to develop solutions to ease and speed up the process of coming to a correct diagnosis. (2) Methods: Traditional medical procedures are envisaged, but they are enhanced to reduce diagnosing errors due to the movements of the neonates. Echographic noise filtering and contrast correction methods are implemented the Hyperanalytic Wavelet Transform, combined with an adaptive Soft Thresholding Filter. The algorithm is tailored to infants’ structure and is tested on real ultrasounds provided by the “Victor Babes” University of Medicine and Pharmacy. Denoising and contrast correction problems are targeted. (3) Results: In available clinical cases, the noise affecting the image was reduced and the contrast was enhanced. (4) Discussion: We noticed that a significant amount of noise can be added to the image, as the patients are neonates and can hardly avoid movements. (5) Conclusions: The algorithm is personalized with no fixed reference value. Any device easing the clinical procedures of physicians has a practical medical application.

A Survey of Parents' and Carers' Perceptions of Parenting a Child With Developmental Dysplasia of the Hip

PURPOSE

To explore parents' and carers' perceptions of parenting a child with developmental dysplasia of the hip (DDH).

METHODS

A retrospective analysis of a questionnaire of parents and carers of children with hip dysplasia. Data analysis was guided by qualitative content analysis.

RESULTS

There were 753 responses describing a range of parenting experiences. Three themes emerged: arduous parenting , detailed the parenting challenges, both practical and emotional posed by the management of DDH; insufficient understanding , described the social disconnection experienced by the respondents due to a lack of empathy from others; inconsistent guidance , encompassed respondents' reliance on health professionals for information and support, yet frustration at variability in the management of DDH.

CONCLUSIONS

Overall, having to care for a child with DDH has a negative effect on the practice of parenting. Health professionals can support parenting and provide consistent education to assist parents' understanding of the complex nature of DDH management. What this study adds to the evidence: Despite a good prognosis, the diagnosis of hip dysplasia has a negative effect on of parenting. Parents and carers of children with hip dysplasia rely on the support of health professionals but find the associated loss of parenting autonomy distressing.

Hip Morphology in Periacetabular Osteotomy (PAO) Patients Treated for Developmental Dysplasia of the Hip (DDH) as Infants Compared With Those Without Infant Treatment

BACKGROUND

A subset of patients successfully treated for developmental dysplasia of the hip (DDH) as infants have symptomatic acetabular dysplasia at skeletal maturity leading to periacetabular osteotomy (PAO). The purpose of this study was to compare femoral and acetabular morphology in PAO patients with late acetabular dysplasia after previous treatment for DDH with PAO patients who do not have a history of DDH treatment.

METHODS

A single surgeon's patients who underwent PAO between 2011 and 2021 were retrospectively reviewed. Patients previously treated for infantile DDH with a Pavlik harness, abduction brace, closed reduction and spica casting, or open reduction and spica casting were included. Patients with previous bony hip surgery were excluded. Preoperative radiographic measurements of each hip were recorded including lateral center edge angle, anterior center edge angle, and Femoro-Epiphyseal Acetabular Roof index. Computed tomography measurements included the coronal center edge angle, sagittal center edge angle, Tönnis angle, acetabular anteversion at 1, 2, and 3 o'clock, femoral neck-shaft angle, femoral version, and alpha angle. Control PAO cases without a history of DDH diagnosis or treatment were matched with the infantile DDH treatment group in a 2:1 ratio based on coronal center edge angle, age, and sex.

RESULTS

There were 21 hips in 18 patients previously treated for infantile DDH (13 patients Pavlik harness, 3 abduction brace, 1 closed reduction, and 1 open reduction). The control PAO cohort was 42 hips in 42 patients who did not have previous DDH treatment. There was no statistically significant difference in any of the recorded measurements between patients previously treated for DDH and those without previous treatment including femoral version (P=0.494), anteversion at 1 o'clock (P=0.820), anteversion at 2 o'clock (P=0.584), anteversion at 3 o'clock (P=0.137), neck-shaft angle (P=0.612), lateral center edge angle (P=0.433), Femoro-Epiphyseal Acetabular Roof index (P=0.144), and alpha angle (P=0.156).

CONCLUSIONS

Femoral and acetabular morphology is similar between PAO patients with persistent symptomatic acetabular dysplasia following DDH treatment and patients presenting after skeletal maturity with acetabular dysplasia and no previous history of DDH treatment.

LEVEL OF EVIDENCE

Level III-case-control, prognostic study.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatricians

OBJECTIVE

To evaluate the decision making processes of pediatricians regarding diagnosis and management of developmental dysplasia of the hip (DDH) by conducting a survey of pediatricians in the United States.

STUDY DESIGN

An electronic survey was sent to multiple American Academy of Pediatrics state chapters and academic pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, guideline use, clinical scenarios, and referrals/imaging practices. The number of responses to each survey question and their relative frequencies were calculated.

RESULTS

We received 139 responses and included 126 in our analyses. Only 50% of the responding pediatricians (63 of 126) practiced in an institution that endorses a care pathway for DDH. Only 5.6% of the pediatricians (7 of 125) have referred patients at 12-18 months between diagnosis and management to a specialist for suspected DDH, and 9.5% (12 of 125) have referred patients between 6 and 9 months. Almost one-quarter of the pediatricians (23%; 29 of 126) cited "hip click" as an abnormality that would prompt them to refer a patient to a specialist, and 72.2% (91 of 126) indicated that family history of DDH warrants an ultrasound regardless of the physical examination findings. Moreover, 10.3% of the surveyed pediatricians (13 of 126) reported being only "somewhat" or "moderately" familiar with the Barlow and Ortolani maneuvers.

CONCLUSIONS

The results of this study indicate that there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatrician respondents who would not refer patients to a specialist or order imaging studies appropriately represents an opportunity for education. The implementation of a care map with standard referral and imaging practices could improve the care of patients with DDH.

Secondary (Late) Developmental Dysplasia of the Hip with Displacement: From Case Studies to a Proposition for a Modified Diagnostic Path

(1) Background. This paper presents a case of hip joints that were initially described as either normal or physiologically immature in four successive ultrasound examinations using the static method by Graf; however, the final treatment of the patient involved multiple hip reconstruction surgeries. (2) Case presentation. The patient was born with an Apgar score of 10 and did not exhibit neurological diseases that could deform and lead to pathological dislocation of the right hip joint. The subsequent analysis of medical data revealed that the hip luxation was due to secondary (late) developmental dysplasia of the right hip. (3) Conclusion. The article emphasizes the importance of early diagnosis and treatment standards for developmental dysplasia of the hip (DDH). The development of uniform international medical guidelines for the diagnosis, treatment, and prevention of hip dysplasia, along with the unification of DDH-related terminology, would allow for more effective management of DDH cases and reduce the cost of patient treatment.

Measurement of Pubofemoral Distance in the Diagnosis of Developmental Dysplasia of the Hip: Sensitivity and Specificity

OBJECTIVES

To evaluate the accuracy of measurement of the pubofemoral distance (PFD) for the diagnosis of developmental dysplasia of the hip (DDH), using the Graf method as the reference standard.

METHODS

This was a prospective diagnostic accuracy study evaluating 1980 hips in at-risk neonates. The PFD measurement and the Graf method were performed at the same opportunity, with the hips in the same position (slightly flexed, adducted, and medially rotated).

RESULTS

In our sample, the prevalence of DDH, defined as Graf type IIb or higher, was 15.6%. The mean PFD for dysplastic hips was 3.5 mm (median, 3.3 mm), whereas it was 3.0 mm (median, 2.9 mm) for nondysplastic hips. In both groups, there was a significant overlap between the PFD measurements and the Graf classifications. The PFD cutoff with the largest area under the receiver operating characteristic curve was 3.0 mm, which was found to have a sensitivity and specificity of 63.6 and 62.2%, respectively, with positive and negative predictive values of 31.2 and 71.4%, respectively, for the diagnosis of DDH.

CONCLUSION

Measurement of the PFD shows good overall accuracy for the diagnosis of DDH. However, given its low-positive predictive value, it should not be considered to be a replacement for the Graf method.

Risk factors and screening timing for developmental dysplasia of the hip in preterm infants

BACKGROUND

The delayed diagnosis of developmental dysplasia of the hip (DDH) requires complex treatment and sometimes progresses to hip osteoarthritis.

PURPOSE

This study aimed to evaluate the risk factors and screening time for DDH in preterm infants.

METHODS

A total of 155 preterm infants with a gestational age <32 weeks screened for DDH with ultrasonography were enrolled in this retrospective chart review.

RESULTS

The incidence of DDH was 6.45% (10 of 155). Gestational age, birth weight, sex ratio, and breech presentation did not differ significantly between infants treated for DDH (n=10) and nontreated infants (n=145) (gestational age, 29.2±1.4 weeks vs. 29.6±2.0 weeks, P=0.583; birth weight, 1,240±237 g vs. 1,295±335 g, P=0.607; female sex, 7 of 10 (70.0%) vs. 77 of 145 (53.1%), P=0.346; and breech presentation, 5 of 10 (50.0%) vs. 43 of 145 (29.7%), P=0.286, respectively). Performing the first ultrasonography earlier than 38 weeks of postmenstrual age (PMA) increased the risk of an abnormal finding by 3.76 times compared to performing it at ≥38 weeks of PMA. These abnormal findings on ultrasonography resolved spontaneously. Breech presentation increased the risk of minor abnormal findings on the first ultrasonography by 3.11 times versus nonbreech presentation and resolved spontaneously. DDH in preterm infants did not occur predominantly on the left side or in infants born with breech presentation.

CONCLUSION

Performing ultrasonography screening earlier than 38 weeks of PMA caused unnecessary subsequent ultrasonography and overtreatment. Breech presentation was not a risk factor for DDH in preterm infants. However, breech presentation could increase the risk of minor abnormal findings at the 1st ultrasonography compared to nonbreech presentation, which resolved spontaneously. The etiology and risk factors for DDH in preterm infants are somewhat different from those for DDH in term infants.

Developmental Dysplasia of the Hip: Controversies in Management

PURPOSE OF REVIEW

Many aspects of developmental hip dysplasia (DDH) care and evaluation are still active areas of debate. Recent studies have provided more insight into these topics such as strategies for reducing osteonecrosis, assessing hip reduction after closed and open reduction, and the management of residual acetabular dysplasia.

RECENT FINDINGS

The presence of the ossific nucleus at the time of reduction does not alter the risk of osteonecrosis. The risk of osteonecrosis may be higher when hips are immobilized in excessive abduction. Limited sequence MRI may be the best choice for assessing hip reduction after closed and open reduction; however, new technologies are emerging such as 3D fluoroscopy and perfusion MRI. The treatment of residual acetabular dysplasia with bracing has been shown to be effective and the decision to perform a pelvic osteotomy is based on patient-specific factors. The spectrum of DDH treatment has evolved over the past several decades. Recent studies have provided insights into strategies for osteonecrosis prevention, hip evaluation during after reduction, and the management of residual acetabular dysplasia. However, there is ample room for additional and more rigorous studies guiding advanced imaging for assessing hip reduction such as 3D fluoroscopy and perfusion MRI, as well as the management of residual acetabular dysplasia.

Description of the ‘pronation manoeuvre’ for the diagnosis of developmental hip dysplasia

Introduction

Without a prompt diagnosis, developmental dysplasia of the hip (DDH) in infants can lead to severe sequelae. Current screening strategies emphasize the use of Ortolani and Barlow physical examination manoeuvres, yet they exhibit low sensitivity. The purpose of this study is to evaluate the performance of a new physical examination tool (the pronation manoeuvre) as a screening tool for DDH.

Methods

To evaluate the new manoeuvre, a cross-sectional and analytic study was performed with a nonprobabilistic sampling method. Patients with either a positive Ortolani or Barlow manoeuver were evaluated with the new manoeuvre and hip ultrasound. Controls were infants with negative Ortolani, Barlow and pronation manoeuvres and also had ultrasound performed.

Results

DDH was confirmed in 83 of 130 cases (64%) and 2 of 130 controls (2%). The new pronation manoeuvre had a sensitivity of 76% and a specificity of 94% as compared to the Ortolani and Barlow manoeuvres (sensitivity 31 to 32%, specificity 93 to 100%) (P&lt;0.05).

Conclusion

This new physical examination manoeuvre could serve as another clinical tool for the initial screening of DDH in newborns. Its promising results against traditional screening procedures might potentially impact diagnosis and prognosis for patients with DDH.

Outpatient Bryant's Overhead Traction Does Not Affect the Rate of Open Reduction or Avascular Necrosis in Developmental Dislocation of the Hip

BACKGROUND

The efficacy of preliminary traction to increase the likelihood of closed reduction and/or decrease the incidence of avascular necrosis in the management of developmental dysplasia of the hip (DDH) is controversial. We sought to document compliance with and effectiveness of Bryant's outpatient traction in patients with idiopathic DDH.

METHODS

Patients presenting between 6 and 24 months of age with idiopathic irreducible DDH were prospectively enrolled in the study. Prereduction outpatient traction was prescribed at participating surgeons' preference and parents' expressed willingness to comply with a traction protocol of at least 14 hours/day for 4 weeks. Traction hours were documented using a validated monitor; parents also reported average daily usage. Rate of successful closed reduction and evidence of capital epiphyseal growth disturbance 1 year' and 2 years' postreduction were documented.

RESULTS

Ninety-six patients with 115 affected hips were enrolled. Reliable recorded traction hours were obtained in 31 patients with 36 affected hips. Defining compliance as 14 hours/day average use, 14 of 31 patients (45.2%) were compliant, 2 (6.5%) admitted noncompliance, while 15 (48.2%) claimed to be compliant, but were not. Overall, 68/115 hips (59.0%) were closed reduced. Age at treatment was the only demographic characteristic associated with an increased incidence of closed reduction (11.7 vs. 14.6 mo, P<0.01). Successful closed reduction was achieved in 10/16 hips (62.5%) of compliant patients, 12/20 (60.0%) of noncompliant patients, and 43/72 (59.7%) of no-traction patients. Irregular ossific nucleus development was noted 1-year postindex reduction in 5/16 (31.3%) of complaint-patient hips and 25/92 (27.2%) of noncomplaint and no-traction hips. Distorted proximal femoral epiphysis was noted at 2 years postreduction in 2/15 hips (13.3%) of compliant patients and 15/52 hips (28.8%) in noncompliant and no-traction patients. None of these differences was statistically significant.

CONCLUSIONS

Parent-reported use of outpatient traction is unreliable. Four weeks of outpatient overhead Bryant's traction did not affect the rate of closed reduction or avascular necrosis in late-presenting DDH in this cohort.

LEVEL OF EVIDENCE

Level II-prospective cohort.

Establishment of pediatric developmental dysplasia of the hip biobank: Shanghai children's hospital experience

Developmental dysplasia of the hip (DDH) is a debilitating condition that affects 1–7% of newborns. Children with DDH, not treated early and effectively, will easily lead to disability. A better understanding of the biology of DDH is critical to the development of prognostic biomarkers and novel therapies. The purpose of this study was to establish a biobank of DDH genetic resources, to facilitate clinical and basic scientific research. The biological specimen and clinical data of DDH were collected in Shanghai Children’s Hospital from 2014 to 2021. The collection of blood samples was performed at definitive diagnosis and review, tissue specimens were performed at definitive surgery. The clinical data was collected at the whole stage of DDH patients at diagnosis, treatment and follow-up. A total of 528 patients with DDH were enrolled in this study, 90 were men and 438 were women, with the mean age of 4.67 years. The numbers of tissue and blood specimens reached 2172 and 1490, respectively. The quality test results showed that the DNA concentration decreased slightly with the extension of storage time, but the DNA purity did not change. Meanwhile, the extension of storage time slightly affected the stability of protein of tissue samples but did not affect the expression of the housekeeping gene. The DDH biobank built has the potential of monitoring disease pathogenesis and progress, which could provide specimens to the researchers improving the biological understanding and provide guidance of clinical treatment of this disease to clinicians.