Osteoarthrosis and congenital dysplasia of the hip in family members of children who have congenital dysplasia of the hip

Four hundred and eight siblings, parents, and grandparents of seventy-eight children from the New England area who had congenital dysplasia of the hip were evaluated, by clinical examination and by measurements of the acetabulum on pelvic radiographs, for the signs and sequelae of congenital dysplasia of the hip. Six siblings and four mothers (representing seven of seventy-eight families) had been diagnosed with congenital dysplasia of the hip during childhood. The other ninety-one siblings were asymptomatic and had no radiographic evidence of dysplasia of the hip. In the adults in these families, acetabular coverage (as measured by the center-edge angle of Wiberg) was no different from that in the control subjects. There was no difference between the study group and the control subjects in the prevalence of osteoarthrosis of the hip or of osteoarthrosis that could be considered secondary to congenital dysplasia of the hip. The results indicate that children born to families that have a history of congenital dysplasia of the hip have a greater prevalence of this problem compared with the general population, but also that examinations of the hip in newborns are effective in detecting congenital dysplasia of the hip in such families. The greater prevalence of congenital disease of the hip among the siblings and mothers in these families is consistent with a multifactorial inheritance. The fact that acetabular development in the family members who did not have congenital dysplasia of the hip was no different from that in the control subjects suggests that acetabular dysplasia, rather than being an inherited abnormality, is secondary to subluxation or dislocation.     

Ultrasound in the diagnosis of congenital dysplasia and dislocation of the hip joints in children older than two years

To evaluate the use of ultrasound in the diagnosis to congenital dysplasia and dislocation of the hip (CDH) in children older than two years of age, 64 patients with normal hip joints and 47 patients with present or previous CDH were examined. Lateral and anterior ultrasound scanning was employed, and the coverage of the femoral head by the acetabular roof was assessed. The ultrasound measurements were compared with standard roentgenography, and a good accordance between the methods was found. A lateral projection of the femoral head in relation to the bony acetabular rim of more than 8 mm in children younger than ten years of age indicated subluxation and more than 15 mm at age two to four years indicated dislocation. Reliable images were obtained by ultrasound at any age between two and 18 years. Ultrasound is recommended as the primary imaging technique in the evaluation of hip joints, even in older children, and ultrasound should replace roentgenography in most of the follow-up examinations of children with previous CDH.     

The incidence of occult dysplasia of the contralateral hip in children with unilateral hip dysplasia

BACKGROUND: The purpose of this study is to determine the incidence of contralateral hip dysplasia in children with unilateral hip dysplasia. METHODS: We reviewed all patients with developmental dysplasia of the hip (DDH) who were evaluated at our institution until skeletal maturity (at least age 13 years). In the contralateral ("normal") hip, radiographic measurements of the acetabular angle >46 degrees, center edge angle <20 degrees, and migration index >20% were considered abnormal. RESULTS: Of the 43 patients in the study, 18 (42%) were diagnosed with bilateral hip dysplasia as an infant or toddler; 8 on the initial visit, and 10 after repeated evaluations. Twenty-five patients had no evidence of contralateral hip dysplasia, even on repeated examinations. Of this group, 10 of 25 (40%) had mild acetabular dysplasia at maturity (mean center edge angle, 31 degrees; acetabular angle, 43 degrees; and migration index, 14%). No child in this group was diagnosed with significant hip dysplasia at skeletal maturity that required treatment to date. DISCUSSION: The results of this study indicated that mild acetabular dysplasia occurs at maturity in the contralateral hip in up to 40% of patients diagnosed with unilateral DDH, even when the contralateral hip was carefully evaluated as a child. The significance of mild acetabular dysplasia is not well defined, but intermittent evaluation of the contralateral hip in children with DDH would seem prudent. LEVEL OF EVIDENCE: IV.     

The role of clinical examination and risk factors in the diagnosis of developmental dysplasia of the hip: a prospective study in 188 referred young infants

In this prospective study, the role of clinical examination and risk factors in the diagnosis of developmental dysplasia of the hip (DDH) was analysed. For this purpose, 376 hips of 188 referred infants with an average age of 3.7 months (range 0–8 months) were clinically and ultrasonographically (Graf method) examined. Infants who had at least one risk factor for DDH had a three times higher occurence rate of DDH than those who didn’t have any. Breech presentation and positive family history were the two most common risk factors associated with DDH. The rate of DDH was nearly 16 times higher in the hips with at least one abnormal clinical finding than in the ones without any. Ultrasonographically unstable hips (type IIc-unstable to type IV) were always detected during clinical examination. There was a risk of missing the diagnosis of hips with acetabular dysplasia alone. Limitation of abduction and asymmetry of the skin folds were the two most common clinical findings associated with DDH. Nearly two-thirds of the infants with at least one positive clinical finding and at least one risk factor had either an unilateral or bilateral dysplastic hip. It was concluded that a careful clinical examination was significantly more important than the coexisting risk factors in the detection of DDH. Received: 29 September 1999     

Radiographic screening at four months of infants at risk for congenital hip dislocation.

We report on a radiographic screening programme at four months of age for infants who were clinically normal at neonatal examination but were considered to be 'at risk' for congenital dislocation of the hip because of their family history, breech presentation, or a persistent click. From a total population of 13,662 live births over a two-year period, 357 (2.6%) infants at risk were identified. Of these 46 had abnormal radiographs (six subluxations, 40 acetabular dysplasia). In 12 infants treatment resulted in a normal hip; 34 required no treatment but were followed up until their radiographs were normal and walking had begun. Of the 311 infants with normal radiographs, 256 (82%) were examined after 15 months of age; none had any detectable abnormality. We suggest that radiography of the hip at four months is a valuable adjunct to neonatal screening for infants at increased risk of congenital dislocation of the hip.     

Ultrasonography in the diagnosis of congenital hip dysplasia in the newborn

A new technique for ultrasonic examination of the hip is aimed at identification of the acetabular cartilaginous ridge, called the "neolimbus" by Ortolani. The presence of this ridge is pathognomonic for congenital hip dysplasia in the newborn. Ultrasonography of 300 normal hips never showed the neolimbus, but it was present in 25 dysplastic hips. Ultrasound examination of the hips of newborn infants can therefore be combined with the Ortolani test in the very early diagnosis of hip dysplasia.     

Total hip arthroplasty with insertion of the acetabular component without cement in hips with total congenital dislocation or marked congenital dysplasia

BACKGROUND: End-stage osteoarthritis secondary to total congenital dislocation or severe congenital dysplasia of the hip (class B or C according to the system of Eftekhar or type 2 or 3 according to the system of Hartofilakidis et al.) in adults presents special problems with regard to reconstruction of the hip. The purpose of the present study was to assess the intermediate-term results associated with the use of a porous ingrowth acetabular component for the treatment of these difficult cases. METHODS: We performed a prospective study of a consecutive series of twenty-one patients (twenty-four hips) who had had a primary total hip arthroplasty with use of a hemispherical acetabular component that was inserted without cement and fixed with screws. No patient was lost to follow-up. Three patients (four hips) died, of causes unrelated to the total hip arthroplasty, before a minimum duration of follow-up of five years. None of these patients had had revision. Of the remaining eighteen patients (twenty hips), fifteen were women and three were men. Ten hips had total dislocation, and ten had severe dysplasia. RESULTS: After an average duration of follow-up of eighty-three months (range, sixty-four to 102 months), the average Harris hip score was 90 points (range, 68 to 97 points). No patient had revision, loosening, or migration of the acetabular component; pelvic osteolysis; or a continuous radiolucent line at the mesh-bone interface of the acetabular component. The average rate of polyethylene wear was 0.08 millimeter per year (range, zero to 0.21 millimeter per year). CONCLUSIONS: The porous ingrowth acetabular component that was used in the present study functioned well at the time of the intermediate-term follow-up of this group of patients who had marked congenital dysplasia or total dislocation of the hip. The use of this component decreased the need for structural acetabular grafts. This component appears to perform as well as larger components of this design that have been assessed after similar durations of follow-up.     

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.     

Bilateral femoral retroversion associated with acetabular dysplasia. A case report

Retroversion of the proximal femur is associated with a number of acquired conditions but is unusual in a congenital form. It is even more unusual to be associated with acetabular dysplasia. A 38-year-old woman with bilateral hip pain had roentgenographic evidence of acetabular dysplasia with valgus neck-shaft angles. Physical findings were consistent with femoral retroversion, and computed tomography demonstrated 28 degrees of retroversion on both sides. Symptomatic relief was obtained with bilateral varus internal rotation osteotomies of the proximal femur. To date, a case of retroverted femora associated with acetabular dysplasia seems not to have been reported in the literature.     

Incidence of hip dysplasia in idiopathic clubfoot

There is reported to be no increased risk for developmental dysplasia of the hip in children with idiopathic clubfoot. The purpose of this study was to determine the incidence of radiographic hip dysplasia in infants with idiopathic clubfoot. Fifty-one children with idiopathic clubfoot who underwent surgical release by a single surgeon had anterior-posterior pelvis radiographs obtained at 4 or more months of age to screen for developmental dysplasia of the hip. The acetabular index measured more than 28 degrees in eight children (16%). This study suggests an association between idiopathic clubfoot and developmental dysplasia of the hip.     

Is secondary radiological follow-up of infants with a family history of developmental dysplasia of the hip necessary?

The practice of regular radiological follow-up of infants with a positive family history of developmental dysplasia of the hip is based on the widespread belief that primary acetabular dysplasia is a genetic disorder which can occur in the absence of frank subluxation or dislocation. We reviewed all infants who were involved in our screening programme for developmental dysplasia of the hip, between November 2002 and January 2004, and who had a normal clinical and ultrasound examination of the hip at six to eight weeks of age, but who, because of a family history of developmental dysplasia of the hip, had undergone further radiography after an interval of 6 to 12 months. The radiographs of 89 infants were analysed for signs of late dysplasia of the hip and assessed independently by three observers to allow for variability of measurement. There were 11 infants (11%) lost to follow-up. All the patients had normal radiographs at the final follow-up and none required any intervention. We therefore question the need for routine radiological follow-up of infants with a positive family history of developmental dysplasia of the hip, but who are normal on clinical examination and assessment by ultrasound screening when six to eight weeks old.     

Magnetic resonance imaging in congenital dysplasia of the hip

This study was designed to determine the usefulness of magnetic resonance imaging (MRI) in managing congenital hip dysplasia and dislocation. We compared various hip parameters using bony and cartilaginous landmarks. MRI determined that the bony acetabular index (AI) accurately reflects the cartilaginous AI. Bony acetabular indices greater than 30 degrees indicated hip dysplasia, subluxation, or dislocation. MRI demonstrates qualitative information not available on plain films; however, it does not provide further quantitative data, so we do not recommend its routine use in the evaluation of congenital hip dysplasia. The true benefit of MRI may be its ability to identify a group of patients with bone dysplasia but normal cartilaginous growth potential.     

先天性髋脱位4种手术疗效的比较

目的　探讨 4种术式治疗先天性髋关节脱位 (CDH)疗效。方法　随访采用翻转造盖术2 4例 (30髋 )、插入造盖术 2 3例 (30髋 )、Salter截骨术 2 5例 (30髋 )和Chiari骨盆内移截骨术 2 4例 (2 7髋 )治疗CDH患者 96例 117髋。结果　平均随访时间 5年 10个月 ,疗效从临床功能和X线形态两方面评估 ,术后髋臼指数 (AI)的改善分别是 (2 0 2± 7 2 7)°、(2 1 9± 6 33)°、(15 0± 4 5 6 )°、(11 4±5 1)°,术后臼头指数 (AHI)分别是 (0 92± 0 2 4 )°、(1 0 0± 0 18)°、(0 80± 0 19)°、(0 82± 0 14 )° ;四种术式临床优良率分别是 90 %、86 7%、73 4 %和 6 6 6 % ,共发生再脱位 3例 ,关节僵硬 10例 ,股骨头坏死 7例。结论　临床疗效及对髋臼形态改善翻转、插入造盖术优于Salter截骨术和Chiari骨盆内移截骨术 ;翻转造盖术、插入造盖术安全有效是先天性髋关节脱位的首选术式。     

The management of primary acetabular dysplasia. Its association with habitual side-lying

Fifty-one infants with limited abduction of the hip and acetabular dysplasia were, between 1969 and 1975, treated with abduction-adduction exercises, administered by the parents; no abduction devices were used. In 1983 a follow-up examination was carried out on 41 of these patients. Although at birth these children had characteristics similar to patients with congenital dislocation of the hip, none of their hips dislocated. At birth acetabular measurements showed that half the children had severe dysplasia and the other half slight dysplasia; the difference between the affected and the healthy hips was significant. At follow-up the gait was normal in all the patients. Movements at the hips were symmetrical and within normal limits in all but one patient. The acetabular angle, the centre-edge angle, the shaft-neck angle, the hip ratio, and the size of the femoral head were the same on the previously affected side as on the normal side. Nineteen of the children followed up had preferred lying on one side and dysplasia of the upper hip had developed. The significance of the sleeping position on the development of acetabular dysplasia is discussed.     

Frejka pillow and Becker device for congenital dislocation of the hip: Prospective 6-year study of 104 late-diagnosed cases

During the period 1974-1986, 107 consecutive 1-9 month-old children with late-diagnosed congenital dislocation of the hip (CDH) were treated with a Frejka pillow primarily, followed by a Becker device. Treatment was initially successful in 96 cases with 2 not reduced, 4 failed stabilization, 4 persisting dysplasia, and 1 avascular necrosis. No correlation was found between age at the time of diagnosis or the severity of the dislocation and the duration or the result of treatment.

In those initially successful, 14 percent had slight dysplasia 6 months later. The last follow-up, at the mean age of 7 years, excluding the 11 children needing supplementary treatment, showed that 84 percent had normal hips on radiography, based on measurements of the acetabular angles and the center-edge angles. The clinical findings were normal.     

Operative treatment for type II avascular necrosis in developmental dysplasia of the hip

Lateral growth disturbance of the proximal femur may occur after treatment of developmental dysplasia of the hip, although usually it is not recognized until the child is older. This resultant dysplasia is also known as Kalamchi and MacEwen Type II avascular necrosis. The valgus configuration of the proximal femur and associated acetabular dysplasia may need operative reconstruction. Our purpose in doing this study was to assess the results of reconstruction in these patients. We reviewed 24 patients (30 hips) with Type II avascular necrosis who had acetabular and/or proximal femoral osteotomy after treatment for developmental dysplasia of the hip. The results were assessed according to the timing and type of operation and were graded using the Severin classification (I and II satisfactory and III and IV unsatisfactory). All patients were followed up past skeletal maturity. At a mean followup of 22 years, 15 of 24 patients (17 of 30 hips) had a satisfactory result. The patients with hips that were reconstructed after the diagnosis of Type II avascular necrosis had more satisfactory results than those operated on before the diagnosis of (70% versus 50%) avascular necrosis. Patients with 10 of the 13 hips that had acetabular and femoral reconstruction had a satisfactory result.     

Experimental study on the etiology of pathogenesis of acetabular dysplasia in congenital dislocation of the hip

In order to investigate the etiology of pathogenesis of congenital hip dislocation and acetabular dysplasia, experiments using fetuses of pregnant rabbits were conducted. The following findings were obtained. (1) Dislocation occurred in approximately 40% of total animals used. The earliest dislocation was seen 2 days after birth. (2) The hip dislocation could be relatively and easily generated by exogenous factors during the perinatal period, even without such primary cause, as hip joint dysplasia. The acetabular dysplasia could be generated secondarily to dislocation. (3) There was a difference in the cause of acetabular dysplasia between areas of the acetabulum with and without load. (4) The acetabular depth growth in the dislocated hip was more seriously impaired than the longitudinal and transverse diameters of the acetabular entrance. These results have indicated that endochondral ossification of the epiphyseal cartilage of the acetabulum in the dislocated hip was more markedly impaired than that of Y epiphyseal cartilage.     

非骨水泥臼杯加自体股骨头植骨全髋关节置换术治疗髋臼发育不良伴骨性关节炎

目的：评价非骨水泥臼杯加自体股骨头植骨的全髋关节置换术治疗髋臼发育不良继发骨性关节炎的结果。方法：回顾性分析20例(21髋)患者行全髋关节置换术治疗髋臼发育不良继发骨性关节炎。女性18例,男性2例,平均年龄50岁,采用非骨水泥臼杯加自体股骨头植骨螺钉固定重建髋臼侧。臼杯置于真性髋臼水平,所有病例由于髋臼缺损而需要行自体股骨头植骨。平均植骨块覆盖的臼杯比例为31％(10％～45％)。8髋植骨块覆盖小于25％,13髋位于25％-50％之间。平均随访时间4．7年(1．5—8年)。采用改良Harris评分对结果进行评估。术前及随访时进行摄片观察。结果所有植骨块均获得愈合。无植骨块塌陷和髋假体松动。改良Harris评分由术前平均46分增加到89分。术前除1例双髋发育不良外,下肢不等长均超过2cm,术后只有2例仍有双下肢不等长超过1cm。3髋的植骨块外侧非支撑臼杯部分出现轻微的骨吸收。3髋发现有BrookerⅠ度异位骨化,1髋Ⅱ度异位骨化。结论：使用非骨水泥臼杯加自体股骨头植骨重建髋臼侧的全髋关节置换术治疗髋发育不良继发骨性关节炎可获得良好结果。该方法在植骨块支撑臼杯不超过50％的情况下,髋臼固定可靠,可保留髋臼的骨量。     

Influence of the crowe rating on the outcome of total hip arthroplasty in congenital hip dysplasia

Few studies have examined the relationship between the severity of congenital dysplasia of the hip (CDH) and the clinical outcome of total hip arthroplasty. The authors have used a prospective design to study this question, using the Crowe grade to assess the severity of CDH. There were 71 patients with CDH operated on using the S-ROM total hip (Joint Medical Products, Stamford, CT); the control group was composed of 22 patients without CDH operated on using the same implant during the same period as the CDH patients. The patients with mild CDH did not have a different outcome from the patients without CDH with respect to Harris hip score or limp. The higher the Crowe grade, the more complications occurred. It was also found that the patients in whom the true acetabulum was not used had a significantly higher incidence of limp.     

A Long-Term Survivorship Comparison Between Cemented and Uncemented Cups With Shelf Grafts in Revision Total Hip Arthroplasty After Dysplasia

Long-term outcomes of cemented and uncemented cups were compared in patients with hip dysplasia who had undergone revision hip arthroplasty. Patients had uncontained superolateral acetabular defects reconstructed with a structural allograft. This retrospective study compared 18 cemented acetabular cups to 27 uncemented acetabular cups. Average follow-up was 216 months (range, 96-312). Nineteen acetabular cups (42%) failed due to loosening and were revised. The 10- and 20-year cup survival was 88% and 76% in the uncemented group and 67% and 36% in the cemented group. Log rank analysis showed this difference to be significant (P = .0077). Uncemented acetabular cups performed significantly better than cemented cups.