Unsatisfactory results of early treatment of infants with unstable hips at birth

Among 19,864 infants born in Trondheim between 1 May 1969 and 31 December 1974 instability of the hip joint was diagnosed in 378 (19.03 per thousand live-born). All infants were treated with Frejka cushion splint, usually for 3 months. In spite of this early treatment, 31 infants (8.2 per cent) developed subsequent signs of CDH. In 20 children the diagnosis of CDH was based solely on radiological criteria, while 11 children also displayed clinical abnormalities, most often restricted abduction of the hip joint. The prenatal and perinatal condition of the 31 children, with persistent signs of CDH in spite of early treatment, was compared with that of the 347 children who showed no obvious signs of CDH. The former group of patients had a relatively high frequency of hip abnormalities in their families, and an increased frequency of breech presentation at birth, concomitant foot deformities and instability of the hip joint also on the eight day after birth. It is suggested that infants with unsatisfactory results from the early treatment of unstable hips constitute a separate clinical entity and an especially severe form of CDH.     

Unsattsfa Ctory Results of Early Treatment of Infants with Unstable Hips at Birth

Among 19,864 infants born in Trondheim between 1 May 1969 and 31 December 1974 instability of the hip joint was diagnosed in 378 (19.03 per thousand live-born). All infants were treated with a Frejka cushion splint, usually for 3 months. In spite of this early treatment, 31 infants (8.2 per cent) developed subsequent signs of CDH. In 20 children the diagnosis of CDH was based solely on radiological criteria, while 11 children also displayed clinical abnormalities, mast often restricted abduction of the hip joint. The prenatal and perinatal condition of the 31 children, with persistent signs of CDH in spite of early treatment, was compared with that of the 347 children who showed no obvious signs of CDH. The former group of patients had a relatively high frequency of hip abnormalities in their families, and an increased frequency of breech presentation at birth, concomitant foot deformities and instability of the hip joint also on the eighth day after birth. It is suggested that infants with unsatisfactory results from the early treatment of unstable hips constitute a separate clinical entity and an especially severe form of CDH.     

Ultrasound screening for congenital dysplasia of the hip in newborns: its value

Three hundred seven newborns were examined clinically and by ultrasound for congenital dysplasia of the hip (CDH). The purpose of the study was to determine the prevalence of sonographic abnormalities and to discover if sonography could be helpful in detecting cases of CDH that would be missed by clinical diagnosis alone. Eighty-two hips (13.4%) had ultrasound abnormalities despite a normal clinical examination. Of these, three developed definite hip dysplasia. The remaining 79 hips became clinically and sonographically normal within 12 weeks. Ultrasound visualized and recorded the dislocation-reposition maneuver of three other hips that were clinically dislocatable at birth. Dislocation occurred in a craniodorsal direction.     

Recent advances in the prevention, early diagnosis, and treatment of congenital dislocation of the hip in Japan

Results of animal experiments and then of clinical study of newborn infants suggested that the main mechanical factor causing hip dislocation is prolonged tension on the hamstrings and iliopsoas and that each of these muscles has a synergistic effect in the production of hip dislocation during the perinatal period. It was, therefore, presumed that the high incidence of congenital dislocation of the hip (CDH) in Japan might be due mainly to the Japanese tradition of forcibly maintaining the legs of infants in an extended position with a "swathing diaper." The incidence of CDH in Japanese infants prior to 1965 was as high as 1.1%-3.5%. In an attempt to reduce the incidence of CDH, examination of newborns was performed on a national scale. However, early screening methods for hip abnormalities were not adequately reliable in Japan to allow identification of conditions that would later become CDH. In 1975 a national campaign to avoid prolonged extension of the hips and knees of infants during the early postnatal period was initiated. As a result, there has been a remarkable reduction in the incidence of CDH in infants, to less than 0.2%.     

Correlation of fetal posture and congenital dislocation of the hip

A statistical study was carried out on the incidence of CDH associated with mechanical factors in the uterus, including congenital genu recurvatum. There were 72 cases of CDH among 6559 infants (1.1 per cent). The incidence of CDH was 0.7 per cent in cephalic presentation, 2 per cent in footling presentation and 20 per cent in single-breech presentation. In another series, CDH was found in six of seven infants with congenital genu recurvatum. These findings suggest that a fetal posture with the hip flexed and the knee extended predisposes to the development of CDH.     

Graf法超声诊断婴幼儿髋关节发育不良和脱位

目的 探讨Ｇｒａｆ方法在婴儿髋关节发育不良（ＤＤＨ）和脱位检查中的应用。方法 采用Ｇｒａｆ方法对２２５８婴幼儿（４５１６髋）进行检查及评估分析。结果 Ⅰ型髋占７８．９９％〉Ⅱ型髋占２０．５６％,Ⅲ型和Ⅳ髋占０．４５％。结论 该项检查和评估方法可以在婴儿生后３个月内对髋关节进行准确的定性、定量评估,是较有效的临床筛查手段,有利于ＤＤＨ的早期治疗及随访。     

Prevention of congenital dislocation of the hip in the newborn

Routine examination and early treatment of any instability in the hips of newborns has recently been called into question after a period of universal agreement. The hips of 49,937 neonates were prospectively studied by a general hip screening. Every unstable hip--449 in 317 children--was immediately treated with a Von Rosen splint for a 3-month-period. Overall, satisfactory reduction of the incidence of established congenital dislocation of the hip (CDH) was achieved. Risk factors leading to unstable hips (sex, first birth, and breech birth) and the development of CDH (time of stabilization) were considered.     

Hip ultrasound screening within the scope of U3--initial experiences

OBJECTIVE: After introduction of hip sonographic screening in Germany in the year 1996 we are interested in its organisational features and the results on a national level. It has to be scrutinized in how far the medical consequences are oriented and in accordance with the national guideline of hip sonographic screening. METHODS: Our study includes all 191.000 documentation sheets of hip sonographic screening in the year of 1996 in Germany. RESULTS: In the year 1996 pediatricians were responsible of 70% of all hip sonographic screening which were performed on the 36. day (median). About 80% of the examined infants showed alpha-angles > 56 Grad, about 1.7% only reached < 51 Grad. 27% of all cases were recommended a second sonographic examination and 7.7% should get a therapy. For 73% of all examined infants the consequences were compatible with the national guidelines for hip sonography screening. Orthopaedists more often showed deviations than other professional groups. CONSEQUENCES: There is the case for a more binding consensus regarding the adequate consequences in the cases of sonographic alpha-ankles between 51 to 56 degrees. In the light of an unexpected high proportion of infants with therapy recommendations there is to establish an informational feedback which covers results from the monitoring of the hip sonographic screening as well as results from the national outcome study.     

Congenital hip dysplasia: problems in the diagnosis and management in the first year of life

Eighty-two infants less than 1 year of age who presented with a diagnosis of congenital hip dysplasia have been reviewed. Forty-one infants had a diagnosis of congenital dislocation of the hip (CDH), of which 14 were bilateral cases. Forty-one infants had a diagnosis of acetabular dysplasia, of which none was bilateral. The incidence of breech malposition was higher in the CDH group (34%) than in the acetabular dysplasia group (15%). The metaphyseal edge angle, which accurately discriminates between these two groups, is described. There was evidence of abnormal radiographic development in those children with acetabular dysplasia who were not treated by abduction splintage.     

Congenital Diaphragmatic Hernia: Advances in Prenatal Therapy

Congenital diaphragmatic hernia (CDH) is one of the most common causes of neonatal morbidity and mortality. The clinical spectrum of CDH ranges from minimally affected infants who do well with modern neonatal care to severely affected infants who die despite all interventions. Two decades of research have led to advances in the prenatal diagnosis of CDH and have better defined the natural history of CDH. Fetuses with CDH now can be stratified into "low" and "high" risk groups based on sonographic parameters. "Low risk" fetuses have an excellent chance of survival with postnatal therapy. Prenatal intervention is reserved for "high risk" fetuses. Ongoing research is focused on improving both prenatal and postnatal treatment of these severely affected infants.     

A sonographic study of perinatal hip development: from 34 weeks of gestation to 6 weeks of age

A sonographic study of perinatal hip development was performed by consecutive measurement of Graf's alpha and beta angles in fetal and newborn hips. The study group consisted of infants with sonographically normal hip findings at birth. Forty fetuses were examined by fetal hip sonography at 34, 36 and 38 weeks of gestation. Postnatally, hip sonography was performed in the first and sixth week of age. Maturation curves of the bony (alpha-angle) and cartilaginous (beta-angle) acetabular roof from 34 weeks of gestation to 6 weeks of age were established. Prenatally, the mean alpha-angles were above the level that corresponds to a mature hip joint. A significantly higher value of the mean alpha-angles was found after birth. The mean beta-angles of the fetuses did not differ from those of the newborns. Our results revealed that the fetal hip joint is sonographically mature at 34 weeks of gestation. Further progression of hip development occurs around term.     

Sonography in congenital dislocation of the hip

A new technique for ultrasonic examination of the hip joint was evaluated in neonatals and infants. An anterior approach was used with the sound sector centered over the femoral head and parallel to the femoral neck. The ultrasonograms corresponded to lateral radiographs of the joint with the leg in Lorenz' first position. It was possible to evaluate the size and depth of the acetabulum and the size and position of the femoral head. The projection also permitted a dynamic examination for determination of hip instability. Thus, the technique provided a method for an objective diagnosis in congenital dislocation of the hip (CDH). In 216 hips, the results of clinical evaluation for CDH were correlated with the degree of instability demonstrated by ultrasound. The comparison showed the clinical diagnosis to be highly inaccurate.     

Ossification of femoral head: normal sonographic standards

The aim of the study was to establish normal reference standards for the appearance of the femoral head ossification center according to age, sex, and gestational age. Sonographic examination of the hip was performed in 1,800 healthy Indian and Israeli infants (900 each) aged 2 to 24 weeks. There were an equal number of boys and girls. The ossification center was noted at 2 weeks of life in the Israeli infants and at 8 weeks in the Indian infants. However, from 10 to 16 weeks, it was noted in 81% or more of the Indian infants but only 22% to 74% of the Israeli ones. In both groups, between 20 and 24 weeks of age, it was noted in more than 90% of the infants. An association was found between gestational age at birth and chronologic age of appearance of the femoral head ossification center, but only among the Israeli infants. There were no differences between genders. Knowledge of the normal sonographic appearance of the femoral head ossification center by age and ethnicity will help clinicians in the diagnosis of hip disorders.     

Congenital dislocation of the hip in the American black

Between 1977 and 1982, 19 cases of congenital dislocation of the hip (CDH) were encountered in black infants. Six of these cases were associated with other anomalies (atypical CDH); 13 were typical CDH. The incidence of complete CDH in the white population studied is 1.5/1000; in the black population studied it is 0.46/1000. The increased incidence in comparison to previous studies may possibly reflect genetic heterogeneity in the control population relative to the African black.     

Current and future strategy in the treatment of congenital diaphragmatic hernia

The severity of congenital diaphragmatic hernia (CDH) depends on the degree of lung hypoplasia. It is still difficult to rescue the most severely affected infants with cardiopulmonary insufficiency immediately after birth. However, the recent treatment strategy has improved the outcome of CDH. High-frequency ventilation (HFV) and gentle ventilation have been reported to be effective in the treatment of CDH by minimizing the barotrauma of the hypoplastic lung. Various vasodilators such as nitric oxide and prostaglandin-E1 have been found to be improve the pulmonary hypertension due to hypoplastic lung. On the other hand, the indications for extracorporeal membrane oxygenation (ECMO), which used to be the most powerful life support for severe CDH, have become limited. In our institute, antenatally diagnosed CDH infants with inadequate oxygenation despite maximum respiratory support immediately after birth are excluded from ECMO candidates because of fatal lung hypoplasia. Recently, it has been reported that temporary tracheal occlusion can accelerate fetal lung growth and improve the outcome of severe CDH. Percutaneous fetal endoluminal tracheal occlusion is expected to become an effective and minimally invasive treatment for fatal lung hypoplasia due to CDH.     

Congenital dislocation of the hip and its relation to swaddling used in Turkey.

A screening program was initiated and performed at five hospitals in Konya, Turkey from 1988 to 1990. Four thousand one hundred seventy-three infants aged 3-24 months were examined. With this study, we hoped to determine the incidence of and contributing factors to the etiology of congenital dislocation of the hip (CDH) in the central region of Turkey. The overall CDH incidence was 1.34%. CDH occurred about three times more often among girls than boys (40 girls vs. 16 boys). No infant with CDH had been delivered by Cesarean section or breech presentation. No teratologic CDH was detected. The relationship between CDH and swaddling (bundled in extension and adduction) was statistically significant.     

Congenital dislocation of the hip in Finland: An epidemiologic analysis of 1035 cases

The incidence of congenital dislocation of the hip (CDH) and some birth characteristics of the population in Uusimaa county in southern Finland were investigated during the years 1966 through 1975. A total of 1035 babies with CDH was born during the time under review. This was 0.68 per cent of liveborns in the area. In 920 babies, the diagnosis was made during the first month of life, corresponding to 0.61 per cent of liveborns and 89 per cent of all children with CDH. The annual variation was great. The monthly variation of CDH in girls was significant, with a peak in June-July, differing from other investigations. Contrary to results of several other studies, the birth weight of the affected babies was normal. The sex distribution, number of first-born babies, side of the dislocation and associated calcaneovalgus foot were in accordance with findings in most other investigations.     

Sonography in congenital dislocation of the hip

A new technique for ultrasonic examination of the hip joint was evaluated in neonatals and infants. An anterior approach was used with the sound sector centered over the femoral head and parallel to the femoral neck. The ultrasonograms corresponded to lateral radiographs of the joint with the leg in Lorenz' first position. It was possible to evaluate the size and depth of the acetabulum and the size and position of the femoral head. The projection also permitted a dynamic examination for determination of hip instability. Thus, the technique provided a method for an objective diagnosis in congenital dislocation of the hip (CDH). In 216 hips, the results of clinical evaluation for CDH were correlated with the degree of instability demonstrated by ultrasound. The comparison showed the clinical diagnosis to be highly inaccurate.     

Sonography in congenital dislocation of the hip

A new technique for ultrasonic examination of the hip joint was evaluated in neonatals and infants. An anterior approach was used with the sound sector centered over the femoral head and parallel to the femoral neck. The ultrasonograms corresponded to lateral radiographs of the joint with the leg in Lorenz' first position. It was possible to evaluate the size and depth of the acetabulum and the size and position of the femoral head. The projection also permitted a dynamic examination for determination of hip instability. Thus, the technique provided a method for an objective diagnosis in congenital dislocation of the hip (CDH). In 216 hips, the results of clinical evaluation for CDH were correlated with the degree of instability demonstrated by ultrasound. The comparison showed the clinical diagnosis to be highly inaccurate.     

Clinical and sonographic study of the infant hip. A prospective study

In 1985 a clinical and sonographic study in 693 children was done. The instability and the limitation of the abduction of the hip joint proved to be the most important clinical signs. The weight of the newborn and the time of birth had no influence on the hip configuration. The importance of the sonographic and clinical examination was demonstrated in the follow up. In the ultrasonic examination qualitative signs rather than quantitative measurements were preferred in routine diagnosis.