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.     

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.     

Screening of children with congenital dislocation of the hip joint on the maternity wards in Sweden

In Sweden screening for congenital dislocation of the hip joint (CDH) on the maternity wards was commenced in the 1950s. Of the estimated number of cases with CDH approximately 50% are diagnosed on the maternity wards and 80% during the first 6 months of life. Of the children "missed" at the primary screening on the maternity wards a substantial number have been premature babies treated at the intensive care unit postpartum. X-ray examination at the age of 1.5-3 months has been a helpful tool to reveal failure of early abduction treatment, which has been difficult to detect by clinical examination. Children with neonatal hip instability and a family history of CDH seem to represent a subgroup with an increased risk of failure of primary treatment and may need prolonged abduction treatment. The von Rosen splint has proved to be a reliable brace if used properly. If abduction treatment is commenced already during the first few days of life the risk for avascular necrosis is very low--1%.     

Congenital dislocation of the hip in Western Australia. A comparison of neonatally and postneonatally diagnosed cases

Speculation that neonatally diagnosed congenital dislocation of the hip (CDH) may have a different etiology from cases diagnosed in the postneonatal period has not been examined in Australia because insufficient data have been available. A population-based study of CDH in children up to the age of two years who were born in Western Australia (WA) in 1981, 1982, or 1983 is the subject of this report. Study material comprised cases of CDH from the WA Congenital Malformations Register and denominator data (all births in WA for 1981-1983) from the Health Department of WA. From this material, rates of CDH were calculated for each of the study variables of interest. The rate of CDH was low for babies born to aboriginal mothers, and it is postulated that this may have a cultural basis, possibly in infant carrying postures. Overall, the prevalence of CDH for 1981-1983 was 6.4 cases per 1000 births, with 4.2/1000 diagnosed in the neonatal period and 2.2/1000 in the postneonatal period. Epidemiologic differences were noted between infants diagnosed in the neonatal period and those diagnosed postneonatally; rates of neonatally diagnosed CDH were higher in first births, breech presentation, and postmature infants than were rates of postneonatally diagnosed cases. Bilateral dislocation was more common (45.3%) in neonatally diagnosed cases than in postneonatally diagnosed cases (23.3%). These findings tended to support the idea that the time of diagnosis may define two distinct entities in 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 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.     

Pitfalls of early diagnosis and treatment of congenital dislocation of the hip joint

The efficiency of the routines for early diagnosis and treatment of congenital dislocation of the hip joint (CDH) practiced in the 1960s in the city of G?teborg were reviewed. Between 1961 and 1970 there were 65,875 live births in G?teborg. Eighty-five percent of the estimated number of cases of CDH were diagnosed during the first month of life. Of the children "missed" at the primary screening on the maternity wards, 75% (15/20) were premature babies and/or had been delivered during weekends. In all, 475 newborn children were judged to have unstable hips (dislocated or dislocatable hips), corresponding to an incidence of 7.2 per thousand live births. In 19 children, abduction treatment with braces commenced during the first 10 days of life failed to prevent dislocation. Eighteen of these children were treated primarily with a Frejka pillow and one with a von Rosen splint. A history of CDH among relatives was obtained in 47% of these 19 children including four of five children who had developed pathological hips after supplementary treatment with a hip spica cast and/or surgery. Radiological examination at the age of 1-4 months was helpful in revealing failure of early abduction treatment to prevent dislocation, which in most cases was difficult to detect by clinical examination at this early age.     

带蹬吊带体系治疗先天性髋脱位

采用带蹬吊带体系治疗出生2月～3岁间婴幼儿先天性髋脱位（congenitaldislocationofthehip，CDH）418例，均获满意复位，并对其中的168例进行了2～11年远期随访。结果表明：近期复位率为100％，远期优良率为95％；患侧髋臼发育与健侧相比无显著性差异。从而证实该体系是治疗CDH的一种比较全面的方法，成功率高、远期效果好及并发症低。同时强调CDH必须早期诊断，及时治疗。     

Congenital dislocation of the hip. Observations on the early diagnosis and results of treatment with an abduction brace in infants two to nine months of age in Greece

In Greece, despite efforts toward early diagnosis of congenital dislocation of the hip (CDH) during the last 20 years, treatment of 75% of infants so diagnosed has not been begun until they are 2 to 9 months of age, with an average treatment onset age of 4.6 months. Five hundred eighty-seven infants (947 hips) two to nine months of age with typical CDH or subluxation were treated with a specially designed abduction brace. This brace, which has been in use for more than 22 years, proved simple and reliable. The follow-up period ranged from two to 20 years (average, 4.5 years). Excellent results were found in 862 hips (91.0%), good results in 44 hips (4.5%), fair results in 32 hips (3.5%), and poor results in nine hips (1.0%). Changes due to ischemic necrosis were noted in 6.8% of the hips, with severe changes present in 3.0%. The most recent results have improved as a result of greater attention to very gentle and gradual abduction of the hips before the application of the brace and the avoidance of extreme abduction positioning in the brace.     

A sonographic study of the morphology of the preterm neonatal hip

Preterm and low-birth-weight infants are reported to have an increased risk of late presentation of congenital dislocation of the hip (CDH). A sequential sonographic study of hip morphology was made of 82 live preterm infants. Eighty-two matched, term controls were scanned for comparison. The morphology of the hips was similar at birth. The increase in missed CDH cannot be explained in simple morphological terms. Abnormal birth sonograms resolved rapidly in the absence of clinical instability, casting doubt on the role of static sonographic appearances to predict the need for treatment in the immediate newborn period.     

Significance of inguinal folds for diagnosis of congenital dislocation of the hip in infants aged three to four months

We evaluated the usefulness of the appearance of asymmetrical inguinal folds in the frog leg position as a screening indicator for congenital dislocation of the hip (CDH) in the hope that we might be able to decrease the frequency of radiographic examinations of 3-4-month-old infants. Abnormal inguinal folds were observed in 499 (23.8%) of the 2,111 patients examined at the Asahikawa Health Center, and these 499 included all patients with complete dislocation or subluxation. Abnormal inguinal folds were also present in all 29 previously untreated patients with complete dislocation and in 11 with subluxation seen in our department. Because limited passive hip abduction is less sensitive than abnormal inguinal folds, we recommend inguinal fold assessment as a useful adjunct to other screening methods for CDH in 3-4-month-old infants.     

Pitfalls of early diagnosis and treatment of congenital dislocation of the hip joint

Summary The efficiency of the routines for early diagnosis and treatment of congenital dislocation of the hip joint (CDH) practiced in the 1960s in the city of Göteborg were reviewed. Between 1961 and 1970 there were 65 875 live births in Göteborg. Eighty-five percent of the estimated number of cases of CDH were diagnosed during the first month of life. Of the children missed at the primary screening on the maternity wards, 75% (15/20) were premature babies and/or had been delivered during weekends. In all, 475 newborn children were judged to have unstable hips (dislocated or dislocatable hips), corresponding to an incidence of 7.2 per thousand live births. In 19 children, abduction treatment with braces commenced during the first 10 days of life failed to prevent dislocation. Eighteen of these children were treated primarily with a Frejka pillow and one with a von Rosen splint. A history of CDH among relatives was obtained in 47% of these 19 children including four of five children who had developed pathological hips after supplementary treatment with a hip spica cast and/or surgery. Radiological examination at the age of 1–4 months was helpful in revealing failure of early abduction treatment to prevent dislocation, which in most cases was difficult to detect by clinical examination at this early age.     

Inguinal hernia in patients with congenital dislocation of the hip. A sign of general connective tissue disorder

During a 5-year period, all the children born in Malm?, Sweden, were examined for congenital dislocation of the hip (CDH) and for inguinal hernia. Girls with CDH had a hernia five times more frequently than other girls, and boys with CDH three times more frequently. The children with CDH sustained their hernia abnormally early in life. We suggest that relaxin, which stimulates collagenase, could alter the connective tissue and be of importance for the development of both CDH and the hernia.     

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.     

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.     

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.     

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.     

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.     

Closed reduction by two-phase skin traction and functional splinting in mitigated abduction for treatment of congenital dislocation of the hip

A method of a two-phase closed reduction using longitudinal skin traction followed by abduction was employed by the authors for treatment of children with congenital dislocation of the hip (CDH). Longitudinal traction was used for two to four weeks, depending on the child's age and the degree of dislocation. Traction in abduction required two weeks. Splinting after reduction was used with an intermediate abduction device, which allowed immediate hip function and motion without the risk of redislocation. The results of 1178 treated hips, with follow-up examinations in 809 cases, demonstrate the efficacy of this method even for completely dislocated hips. The procedure is nonaggressive, results in a low incidence of femoral head osteonecrosis (3.4%), and is suitable for children with CDH aged six weeks to about 2.5 years.     

Current trends in the treatment of congenital dislocation of the hip

The best results in CDH are after early diagnosis and treatment. More carefully taught examination techniques of the newborn are important. With the addition of ultrasound examination of the hip, the number of children with CDH diagnosed in the newborn period should increase. The Pavlik harness has had increased use in the child up to 6 months of age. It allows a simple reduction technique for approximately 90% of these children. If skillfully used, the risk of avascular necrosis can approach zero. The early gentle reduction will improve the results of treatment in avoiding avascular necrosis. Skin traction, the human position during the application of a cast, and femoral shortening at the time of open reduction in the child over 3 years of age also contribute to the decreased incidence of avascular necrosis. The early recognition of even the minor forms of subluxation and the treatment with proximal femoral or acetabular procedure is important. This program should increase the number of children reaching adulthood with a concentrically reduced painless hip.