Developmental dysplasia of the hip in South Australia in 1991: Prevalence and risk factors

To determine the prevalence of developmental dysplasia of the hip (DDH) in South Australia (SA) in 1991, the proportion of cases detected in the neonatal period and the perinatal risk factors for DDH.

Methodology:

Cases of DDH born in SA in 1991 were identified from multiple sources and their clinical data linked to perinatal data provided by midwives; five controls per case were obtained randomly from SA livebirths without congenital abnormalities and adjusted odds ratios (OR) for potential risk factors obtained by logistic regression analysis. South Australia perinatal data were also used to estimate numbers of births with perinatal risk factors for targeted screening.

Results:

Two hundred and six cases of isolated DDH were identified, giving a prevalence of 10.5 per 1000 births. Of these, 173 (84%) had been detected in the neonatal period. The perinatal risk factors for DDH were identified as breech presentation (OR 9.65), female babies (OR 4.04), first births (OR 1.91) and maternal age of 25 years or more (OR 1.53). Screening breech and firstborn female babies (23% of births) would yield approximately 51% of cases of DDH.

Conclusions:

Isolated DDH had a prevalence of 10.5 per 1000 births and 84% of cases had been detected in the neonatal period in SA. Repeated screening during infancy of 'at risk' groups of babies is recommended.     

Ultrasonographic evaluation of breech presentation as a risk factor for hip dysplasia

In order to gain more information of breech position as a risk factor for congenital hip dysplasia or dislocation, the hips of 408 newborns delivered in the breech position were examined by ultrasound. Clinical examination was performed by both experienced paediatricians and orthopaedic surgeons. The infants were re-examined by ultrasound at 2–3 months of age. Twenty-five newborns (6.1%) had neonatal hip instability. Breech presentation as a risk factor was confirmed, with first borns, breech position with extended knees, and high birthweight as special high-risk groups. Ultrasound showed subluxation in most of the unstable hips. The main benefit of using ultrasound was that direct visualization permitted more reliable evaluation, especially when the clinical findings were uncertain. Normal ultrasound findings in false positive and uncertain Ortolani tests reduced the frequency of unnecessary treatment. Because ultrasound was used in follow-up, the need of radiography was reduced. There were no late-detected cases of hip dysplasia or dislocation, indicating that routine follow-up is not necessary in breech infants with normal hips at birth, provided that the neonatal screening is optimal.     

Developmental dysplasia of the hip: Risk markers, clinical screening and outcome

Background: Early detection, diagnosis and treatment of developmental dysplasia/dislocation of hip (DDH) are essential in preventing further disability and quality of life impairment in children. DDH risk markers and association between the age of clinical screening and outcome, were evaluated.
Methods: Clinical screening at ages birth, 6 and 13 weeks was performed in 8145 infants by pediatricians. Infants suspected for DDH were referred to the community hospital clinic for clinical evaluation by a pediatric orthopedic surgeon, imaging procedures and follow up. Demographic and perinatal characteristics of the children with suspected ( n = 77) and diagnosed DDH ( n = 51) were compared to matched controls ( n = 154).
Results: The rate of suspected DDH was 0.95% and that of diagnosed DDH was 0.63%. Female gender, firstborn child and breech presentation were significantly more frequent among cases versus controls (odds ratio [OR]: 4.3, 2.7, and 6 respectively; P < 0.05). The highest positive predictive value (95.5%) in physical evaluation was any evidence of a dislocatable hip. The proportion of DDH among infants referred from the newborn department was significantly higher (OR, 4.4). DDH diagnosis after 6 weeks of age was associated with a higher likelihood of subsequent surgery and motor disability. Untoward outcome was significantly associated with increasing age of referral both at ages of 6 and 13 weeks ( P < 0.05).
Conclusions: Children with DDH have certain specific demographic and perinatal risk markers. Clinical screening targeted towards early diagnosis may lessen the need for surgical intervention and the risk of disability or motor handicap.     

Hip Joint Instability in Breech Pregnancy

ABSTRACT. 222 consecutive fetuses found by ultrasound to be in breech presentation in the 33rd gestational week were followed with repeated examinations in weeks 35 and 38. Ninety-one of these fetuses persisted in breech presentation until delivery, while cephalic version occurred in 131. The frequency of hip joint instability was 21% in the breech delivered group and 1.5% in the vertex delivered group. The position of the fetal legs was established at each ultrasound examination. The intrauterine fetal attitude was classified as extended when the fetuses had extended knees and maximally flexed hips at all ultrasound examinations. This occurred in 30 breech delivered fetuses, 47% of which developed hip joint instability. Only 8% of the breech born infants with flexed legs in utero developed hip joint instability. It is concluded that instability of the hip joint is a consequence of the intrauterine attitude, rather than of the breech delivery per se.     

B超筛查疑似儿童髋关节脱位

目的探讨B超检查儿童髋关节脱位的功效和应用范围。方法2005年4月～2006年2月筛查疑似髋关节脱位儿童720例，予以出生史、家族史、其他畸形等危险因素评估，双侧髋关节B超检查。结果13个髋关节Ortolani和Barlow试验检查阳性，占0．9％。5例有家族史的儿童中1例出现髋关节异常。16例儿童至少有一侧异常髋关节超声表现，占2．2％。α角值在8周前后差异有统计学意义（t=5．438，P〈0．001）。结论选择性髋关节超声筛查是一种安全、有效的诊断方法，8周以后进行髋关节超声检查的准确率会增高，假阳性率也会逐步减小。     

发育性髋脱位髋臼指数与闭合复位后结果的相关性研究

目的 观察发育性髋脱位患儿闭合复位成功后的转归,探讨髋臼指数与预后间的关系,研究行走年龄段(Walking age)发育性髋脱位治疗方法的选择.方法 随诊在1997年1月至2006年12月10年间治疗的闭合复位患儿,纳入研究范围者需具备下列条件:闭合复位时年龄介于1岁至2岁之间;复位成功且经过三期共9个月石膏治疗;随诊时间在2年以上.共计72例患儿97髋,按年龄段分为A组(1岁至1岁半)和B组(1岁半至2岁), 再按髋臼指数40°为界分成两个亚组,如A1组(<40°),A2组(≥40°).进行两个亚组间最终结果的比较.结果 评价以影像学Severin分级为标准,评为Severin Ⅰ、Ⅱ级者则计入优良组,统计学分析采用卡方检验, P值设为0.05.结果 A1组优良率56%(14/25髋),有4髋小现股骨头坏死,6髋进行手术矫正残留的发育不良,A2组优良率24%(7/29髋), 8髋出现股骨头坏死,10髋进行手术,B1组优良率62%(13/21髋),5髋出现股骨头坏死,3髋进行手术, B2组优良率仅18%(4/22髋);2髋股骨头坏死,10髋已行手术.A1与A2组、B1与B2组间优良率差异均有统计学意义, 尤其D2组优良率极低.结论 行走年龄段(Walking age)患儿如髋臼指数大于40°, 闭合复位后优良率低,不提倡强行闭合复位、石膏制动的治疗方式.     

Differences in risk factors between early and late diagnosed developmental dysplasia of the hip

BACKGROUND: Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in South Australia. Clinical screening programmes exist to identify the condition early to gain the maximum benefit from early treatment. Although these screening programmes are effective, there are still cases that are missed. Previous research has highlighted key risk factors in the development of DDH. OBJECTIVE: To compare the risk factors of cases of DDH identified late with those that were diagnosed early. METHODS: A total of 1281 children with DDH born in 1988-1996 were identified from the South Australian Birth Defects Register. Hospital records of those who had surgery for DDH within 5 years of life were examined for diagnosis details. Twenty seven (2.1%) had been diagnosed at or after 3 months of age and were considered the late DDH cases (a prevalence of 0.15 per 1000 live births). Various factors were compared with early diagnosed DDH cases. RESULTS: Female sex, vertex presentation, normal delivery, rural birth, and discharge from hospital less than 4 days after birth all significantly increased the risk of late diagnosis of DDH. CONCLUSIONS: The results show differences in the risk factors for early and late diagnosed DDH. Some known risk factors for DDH are in fact protective for late diagnosis. These results highlight the need for broad newborn population screening and continued vigilance and training in screening programmes.     

发育性髋发育不良髋臼病理变化的实验研究

目的通过动物模型，探讨发育性髋发育不良髋臼的病理变化。方法21只新西兰兔，左膝关节伸直位管型石膏固定制作出髋臼发育不良或半脱位模型，右侧作为对照。按照石膏固定和模型出现的时间将实验动物分为A（4周）、B（6周）、C（8周）三组。测量X线片Sharp角及臼头指数，观察髋臼软骨的组织学变化，比较组间及组内各项指标是否存在显著性差异。结果A组出现髋臼发育不良6例，全脱位型1例；B组出现髋臼发育不良6例，全脱位型2例；C组6例全部为髋臼发育不良。结果比较显示，实验侧Sharp角均比对照侧增大（P〈0．01），A、B组实验侧臼头指数均比对照侧减小，差异有统计性意义（P〈0．05），但C组间无差异。随着固定时间的延长，各组间实验侧的Sharp角相比差异无统计学意义（P〉0．05）。组织学观察显示髋发育不良的髋臼软骨厚度明显变薄，软骨细胞排列紊乱，且有局灶性软骨细胞聚集或者退化的改变。而全脱位型的髋臼软骨则表现为厚度显著增加。结论发育性髋发育不良表现为一个渐进性的病理过程。体位因素影响髋臼的发育和病理改变，但这种影响具有个体差异，且可能仅作用于髋关节发育的某个阶段。     

三维超声在筛查新生儿发育性髋关节异常中的探索性应用

目的 探索三维高频超声髋关节检查技术在诊断新生儿发育性髋关节异常(DDH)中的应用价值.方法 2010年6月至2010年12月,采用PHILIPS IU22超声诊断仪,二维加三维高频线阵探头,对768例新生儿行髋关节超声筛查.新生儿7d内行超声波髋关节筛查,采用Graf法及股骨头覆盖率比值测量髋关节,并结合三维成像图评判髋关节发育情况.结果 本组受检新生儿768例(1 536髋),其中女婴398例,男婴370例,新生儿平均受检时间为出生后5.8d.正常的髋关节共1 412髋,占91.92％;髋关节不稳定共99髋,占6.45％;髋关节发育不良19髋、半脱位4髋、脱位2髋,共占1.63％.结论 Graf的髋关节额状面成像技术,可以对新生儿髋关节进行清晰的超声成像,并进行了定性、定量分析,诊断DDH,但标准图像的获得是测量和诊断的关键,它会受操作者的技术影响.三维超声成像技术,可观察髋关节空间结构,旋转X、Y、Z轴,更可从不同角度观察髋关节的发育情况,提供髋关节解剖形态和关节功能的信息,并能早期显示髋关节解剖结构,这点是传统X线片不能比拟的优势,图像更加直观,加上高频超声波检查的无放射性损害,重复性强,因此二维和三维超声二者相结合诊断发育性髋关节异常,更符合临床上治疗髋臼发育不良的时间越早越好的需求.     

髋发育不良数字声波技术的早期筛查价值

目的：开发一种非侵入性数字声波技术，反映髋关节的结构特征，用于新生儿髋发育不良的早期筛查，方法：应用包括有刺激系统、传导系统和带有双通道数字过滤程序数据分析系统的数字声波技术，测量分析了90例正常新生儿两侧髋关节声波信号相关性（CF）和声强差异（D），并初步对16例1－60岁月婴幼儿进行相应测量，并对正常组进行比较。结果：在160－315Hz范围，两侧髋关节声波信号相关性；正常组CF＞0．94，髋发育不良组中有6例CF＜0．8，声强差异；正常组D＜2dB；髋发育不良组均明显大于正常，差异有显著性意义（P＜0．001）。统计学处理还表明，以声强差异2dB为临界点，灵敏可以达到100％。结论：该声波技术提供了一个用数字客观评估髋关节声波信号的实用方法，可于新生儿髋发育不良的早期筛查。     

Screening for developmental dysplasia of the hip: Results of a 7-year follow-up study

BACKGROUND: Screening for developmental dysplasia of the hip (DDH) is widely recommended for all infants to prevent disability from late diagnosis of dislocation of the hip. The present study evaluates the results of screening for developmental dislocation of hip in a clinic in Turkey over the course of 7 years. METHODS: Hospital records of 5798 infants who were examined regularly until walking age at Gazi University well child clinics between January 1995 and December 2001 were reviewed. Infants with known risk factors for DDH such as breech presentation, family history of DDH or swaddling, and of infants with physical examination findings suggestive of DDH, were referred to orthopedic surgeons for diagnosis. Based on this final diagnosis, sensitivity, specificity, positive and negative predictive values of risk factors and physical examination findings were calculated. RESULTS: Of the 5798 infants, risk factors were detected in the medical history of 111 infants, and in 14 infants a musculoskeletal deformity was detected. In 606 infants the physical examination findings were suggestive of DDH. Ten patients were subsequently diagnosed with DDH. The sensitivity, specificity, positive predictive value and negative predictive values of having a risk factor for DDH in history were 10.0%, 98.1%, 0.9%, 99.8%, and having abnormal hip examination findings were 100.0%, 88.9%, 1.6% and 100.0%, respectively. CONCLUSIONS: A careful history and physical examination is the cornerstone of DDH screening. Serial hip examinations performed during health examination visits provide an opportunity to identify DDH cases. The sensitivity of risk factors in history and physical examination findings together is high enough to be accepted as a screening tool.     

Perinatal development of the rat hip joint with restrained fetal movement

ABSTRACT  We compared the structures of the femoral head (FH) of neonates between normal and operated legs with restrained fetal movement using an exo utero technique. At embryonic day (E) 16.5, one hind limb was sutured onto the embryonic membrane and the fetuses were allowed to develop exo utero until the term (E22.5). There was no significant difference in the largest diameter of the FH between the non-operated and operated side FH in the operated neonates and the FH of the non-operated neonates. By scanning electron microscopy, roughness and collagen fiber bundles, which were detected on the surface of the operated side FH at E18.5, disappeared at E22.5. However, the operated side FH was deformed and the surface cell arrangement was more irregular than that of the controls at E22.5 by light microscopy. These results suggest that the abnormality of cell arrangement caused by the restraint of fetal movement may induce the deformity and irregularity of the FH surface, although this operation may not disturb the basic cellular activities such as cell proliferation as well as the secretion of cartilage matrix and collagen fibers. To further investigate the recovery process in the operated newborns after releasing the restraint, we bred them artificially for a considerable period after birth. The operated side FH surface of the neonate bred for 45 hours was smoother than that at E22.5 and similar to that of the non-operated side FH. This result suggests that the proper movement of the extremities after birth may recover the deformity caused by restrained fetal joint movement     

发育性髋关节发育不良发病危险因素的研究进展

发育性髋关节发育不良(developmental dysplasia of the hip,DDH)是小儿骨科常见的下肢发育畸形,严重危害患者及其家长身心健康。影响DDH发病的因素可大致分为两部分,即遗传因素和环境因素。随着20世纪80年代高检出率髋关节超声的应用及国家二胎政策的开放,可预见未来一段时期内DDH患者数量将会增加。早诊断、早治疗是该病国内外公认的诊治原则,0~6月龄更是其治疗的黄金时期。但目前其发病的确切病因、发病机制尚不完全清楚,因此对婴儿进行早期筛查和及时干预,对早期诊治意义重大。笔者通过简要综述发育性髋关节发育不良发病危险因素的研究进展,以期为DDH早期筛查和诊断提供参考。     

Perinatal risk factors for early childhood onset type 1 diabetes in Austria – a population-based study (1989–2005)

Background:  To investigate the rapid increase in incidence of type 1 diabetes mellitus (T1DM) in children <5 yr in Austria.
Methods:  Data of children born between 1989 and 2005 (n = 444) from the T1DM children incidence registry were linked with birth certificates (n = 1 407 829).
Results:  Age of mother, level of education, birth weight, birth length, body mass index, and APGAR score at 10 min were not significant. Boys have about 25% higher risk than girls [hazard ratio = 0.75, 95% confidence interval (CI): 0.62–0.91]. The risk of developing diabetes increases over time significantly (1989–1991 vs. 2001–2005, hazard ratio = 2.86, 95% CI: 2.07–3.94). The linear effect of parity is borderline significant (p = 0.045), with lower risks for second and later born siblings. Marital status is significant [hazard ratio = 0.73, 95% CI: 0.57–0.90)]. Native-born children exhibit twice as high risk as non-native children (hazard ratio = 0.51, 95% CI: 0.37–0.71). Birth weight shows a positive but not significant effect on risk of T1DM.
Conclusions:  In this very young and rapidly increasing cohort of diabetic children <5 yr of age, no association with birth weight but with year of birth, gestational age, nationality and parity could be observed.     

发育性髋关节脱位闭合复位术后髋臼发育及其影响因素的研究

目的 研究发育性髋关节脱位(developmental dysplasia of the hip,DDH)闭合复位术后髋臼的发育以及影响因素.方法 回顾性分析2005年1月至2008年12月我院收治的并采用闭合复位加石膏固定且获得4年以上随访的DDH患儿62例(74髋).骨盆正位X线片上测量复位前、复位后6个月及1、2、3、4年的髋臼指数(acetabular index,AI),并记录股骨头坏死(avascular necrosis,AVN)的发生.根据年龄,所有患儿分为3组:A组(0～12个月,14例18髋)、B组(13～18个月,22例24髋)、C组(＞18个月,26例32髋).根据术后4年的AI值将所有患儿分成2组,正常组(29髋)和异常组(45髋).采用重复测量的方法分析闭合复位后髋臼发育随时间的变化情况;采用两独立样本的t检验和多重线性回归方法探讨年龄、性别、复位前AI、中心边缘角(center-edge angle of wiberg, CE)、股骨头中心头距离差(center-head distance discrepancy,CHDD)、单/双侧、AVN等因子与最终AI之间的关系.结果 复位前,各组AI无明显差别;复位后各组患儿AI均显著降低.术后4年时,A组AI值(21.9±4.4)°显著小于B组(24.2±3.4)°和C组(26.8±3.8)°,差异有统计学意义(P＜0.05);B组的AI值显著小于C组,差异有统计学意义(P＜0.05).所有患儿的AI平均改善率为28.6％,A组改善率34.6％±11.2％显著高于C组24.9％±9.7％,差异有统计学意义(P-0.005).多重线性回归分析提示复位前的年龄和AI和术后4年的AI值呈正相关(Re =0.617,F=15.031,P＜0.000 1),治疗前AI值(β1=0.432,P＜0.000 1)的回归系数大于年龄(β2=0.197,P=0.023).其它因素,如性别、单双侧受累、CE角、AVN等均与术后4年的AI无明显关系(P＞0.05).结论 DDH闭合复位后AI值均能获得显著的降低,并于术后3年趋于稳定.复位时的年龄和治疗前的AI值是影响闭合复位后髋臼发育的重要因素,复位时的年龄和AI与AI的改善率成负相关.     

Perinatal risk factors in neonatal infections

Perinatal risk factors were studied among 50 cases of neonatal septicemia and 200 matched normal neonates during one year period. The consanguinity among parents, birth order and sex of the baby did not increase the risk for developing septicemia. There was significant increase in the risk for septicemia when the duration of labour was more than 24 hours (P<0.01), time interval between rupture of membrane and delivery of baby was more than 12 hours (P < 0.001), liquor was meconium stained or foul smelling (P<0.001) and delivery was operative (P<0.01), The neonatal factors identified with risk for septicemia were preterm delivery (P<0.01), low birth weight (P<0.01), birth asphyxia (P < 0.001) assisted ventilation (P < 0.001) and intravenous alimentation (P<0.02). Identification of high risk pregnancies and appropriate management can minimize many of the above risk factors which in turn will reduce the occurrence of neonatal sepsis.     

Successful screening for neonatal hip instability in Australia

OBJECTIVE: Australian screening programmes for congenital dislocation of the hip (CDH) are characterized by lower neonatal hip instability (NHI) detection rates than more successful international programmes. Through creating a quality, accountable clinical screening programme for NHI detection, the present study aimed to establish the true incidence of NHI in Australian babies and to eliminate 'late diagnosed' CDH. METHODS: Doctors responsible for routine neonatal care were made accountable for NHI detection and examined 5166 consecutive live births in the first days of life between 1989 and 2000. Techniques for clinical NHI detection were taught, and doctors practised with teaching-mannequins. Paediatricians clinically determined true positive NHI cases and managed them for a 12-month period. Peer review of NHI detection rates was introduced to encourage accountability. Surveillance for 'late diagnosed' CDH occurred regularly through a variety of methods. RESULTS: One hundred babies with NHI were detected (19.4 per 1000): 77% were female; 26% were breech presentation, 25% had a family history of hip instability; and all received some form of splinting. Follow up for 85% of these babies at 12 months revealed no significant complications. Extensive searching has revealed no baby with 'late diagnosed' CDH from the study population in 12 years. One baby commenced treatment late (at 4 months) because of a failure of process following early NHI detection. CONCLUSIONS: The true incidence of NHI in Australia is > or =19 per 1000 births. Successful clinical CDH screening programmes using primary care doctors can be created and might eliminate 'late diagnosed' CDH.     

闭合复位治疗发育性髋关节脱位发生股骨头缺血坏死的相关因素分析

目的 研究闭合复位术治疗发育性髋脱位(DDH)的长期随访结果,评估导致股骨头缺血坏死(AVN)的相关因素.方法 对DDH闭合复位后81例(106髋)进行平均3.6年的随访,Kalamchi and MacEwen分级评定缺血坏死,总结临床记录和影像学资料,统计分析缺血坏死的相关因素.结果 106髋中39髋发生缺血坏死(36.8%).其中,股骨头骨化中心发育基本正常的59髋中,7髋发生缺血坏死(11.9%);骨化中心发育偏小的40髋中,27髋发生缺血坏死(67.5%);骨化中心延迟未出现的7髋中5髋发生缺血坏死(71.4%).脱位程度越高发生缺血坏死的风险越大(P＜0.05).其他因素:性别、复位年龄、石膏固定类型、内收肌合并髂腰肌切断与缺血坏死的发生均无显著统计学意义.结论 闭合复位治疗发育性髋脱位,股骨头骨化中心发育延迟和高脱位与股骨头缺血坏死的发生相关.