The association between clubfoot and developmental dysplasia of the hip

The association between idiopathic congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip is uncertain. We present an observational cohort study spanning 6.5 years of selective ultrasound screening of hips in clubfoot. From 119 babies with CTEV there were nine cases of hip dysplasia, in seven individuals. This suggests that 1 in 17 babies with CTEV will have underlying hip dysplasia. This study supports selective ultrasound screening of hips in infants with CTEV.     

Clubfoot and developmental dysplasia of the hip: value of screening hip radiographs in children with clubfoot

Clubfoot and hip dislocations are common conditions seen by pediatric orthopedists. In the evaluation of a child with clubfoot, most texts recommend a hip screening radiograph to rule out occult hip dysplasia. Between 1983 and 1998, 349 patients were treated for idiopathic clubfoot. Almost all feet required surgical correction. The average follow-up was 8.4 years. Of these patients, 127 had hip screening x-rays during their treatment of clubfoot. The remaining 222 patients were followed clinically for an average of 9.6 years. Of the 127 patients with hip screening x-rays, 1 was found to have hip dysplasia (0.8%). Of the 222 without hip screening x-rays, none developed signs or symptoms of hip pathology during their clinical follow-up period. The overall rate of hip dysplasia in the idiopathic clubfoot population in this series was less than 1.0%. Screening hip radiographs in the idiopathic clubfoot population are probably not warranted.     

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.     

Nonsurgical treatment of congenital dysplasia and dislocation of the hip

Despite general ultrasound screening of the newborn,congenital dysplasia and dislocation of the hip are still among the most common congenital skeletal diseases.A differentiated and stage-adjusted therapy must be the aim because inadequate therapy can lead to necrosis of the femoral head or a residual dysplasia that both require further treatment.Now as before a correct and early diagnosis is absolutely necessary for the treatment of dysplasia of the hip.A once treated hip should be observed until completion of growth.     

Universal or selective screening of the neonatal hip using ultrasound? A prospective,randomised trial of 15,529 newborn infants

The aim of this study was to evaluate whether universal (all neonates) or selective (neonates belonging to the risk groups) ultrasound screening of the hips should be recommended at birth. We carried out a prospective, randomised trial between 1988 and 1992, including all newborn infants at our hospital. A total of 15 529 infants was randomised to either clinical screening and ultrasound examination of all hips or clinical screening of all hips and ultrasound examination only of those at risk. The effect of the screening was assessed by the rate of late detection of congenital or developmental hip dysplasia in the two groups. During follow-up of between six and 11 years, only one late-detected hip dysplasia was seen in the universal group, compared with five in the subjective group, representing a rate of 0.13 and 0.65 per 1,000, respectively. The difference in late detection between the two groups was not statistically significant (p = 0.22). When clinical screening is of high quality, as in our study, the effect of an additional ultrasound examination, measured as late-presenting hip dysplasia, is marginal. Under such circumstances, we consider that universal ultrasound screening is not necessary, but recommend selective ultrasound screening for neonates with abnormal or suspicious clinical findings and those with risk factors for hip dysplasia.     

Developmental dysplasia of the hip (DDH): diagnosis and treatment

This article describes the definition, investigation, imaging and treatment of developmental dysplasia of the hip (DDH). There is controversy in what constitutes physiological or pathological DDH. The results of hip screening programmes are disappointing. DDH may be diagnosed by clinical, sonographic or radiological means. The clinical diagnosis is confirmed by sonographic imaging (in the first months of life). Late presenting pathological DDH (>6 months of age) is usually diagnosed by an X-ray(s) of the pelvis. The majority of pathological DDH cases are female and unilateral, with the left hip joint being involved more commonly. Dysplasia, subluxation and dislocation of the hip joint may be associated with the development of premature osteoarthrosis in adults. The majority of neonatal hip joint instabilities and sonographic hip dysplasia spontaneously resolve without treatment. Persistent hip joint instability is initially treated with bracing/splintage, the majority resolving without further additional treatment. Some early presenting probable irreducible hip dislocations can be treated by manipulation under anaesthetic, hip arthrography plus the application of a hip spica. If this procedure fails, if it is not technically possible or if the dislocation presents ‘late’, more invasive surgery with open reduction of the hip joint and reconstructive surgery to the pelvis or femur may be necessary.     

Gait in 5-year-old children with idiopathic clubfoot: A cohort study of 59 children,focusing on foot involvement and the contralateral foot

Background and purpose — Idiopathic clubfoot can be bilateral or unilateral; however, most studies of gait have assessed clubfoot cases as one uniform group. The contralateral foot in children with unilateral clubfoot has shown deviations in pedobarographic measurements, but it is seldom included in studies of gait. We evaluated gait in children with idiopathic clubfoot, concentrating on foot involvement.

Patients and methods — Three-dimensional gait analyses of 59 children, mean age 5.4 years, with bilateral (n = 30) or unilateral (n = 29) idiopathic clubfoot were stratified into groups of bilateral, unilateral, or contralateral feet. Age-matched controls (n = 28) were evaluated for comparison. Gait assessment included: (1) discrete kinematic and kinetic parameters, and (2) gait deviation index for kinematics (GDI) and kinetics (GDI-k).

Results — No differences in gait were found between bilateral and unilateral idiopathic clubfoot, but both groups deviated when compared to controls. Compared to control feet, contralateral feet showed no deviations in discrete gait parameters, but discrepancies were evident in relation to unilateral clubfoot, causing gait asymmetries in children with unilateral involvement. However, all groups deviated significantly from control feet according to GDI and GDI-k.

Interpretation — Bilateral and unilateral idiopathic clubfoot cases show the same persistent deviations in gait, mainly regarding reduced plantarflexion. Nevertheless, knowledge of foot involvement is important as children with unilateral clubfoot show gait asymmetries, which might give an impression of poorer deviations. The results of GDI/GDI-k indicate global gait adaptations of the contralateral foot, so the foot should preferably not be used as a reference for gait.     

Ultrasound and neonatal hip screening: the five-year results of a prospective study in high-risk babies

We present the 5-year results of an ongoing prospective study of static ultrasound scanning for developmental dysplasia of the hip (DDH) to enlarge on and update the findings after the first year of this screening programme. Between January 1988 and December 1992, there were 17,792 births, 2,683 of which had risk factors: 354 babies had abnormal scans. Screening failed in eight cases, two of which were preventable because they had risk factors but were not scanned; however, six cases came from the 85% of babies without risk factors. The incidence of late cases is therefore 0.45 per thousand births. These results indicate that static ultrasound scanning is effective in detecting abnormal hips, but if only the "at risk" group is screened in this way, then there will be an expected rate of late cases of approximately 0.34/1,000. We are concerned with the results of screening (i.e., detection) but not management. We conclude that simple static ultrasound is an effective screening test for DDH but that it should be applied to the whole population and not simply to the "at risk" group.     

False-positive sonographic hip examinations in newborns with congenital varus deformity of the proximal femur

In cases of congenital varus deformity of the proximal femur, the screening of hip dysplasia can lead to misinterpretations. The false-positive ultrasound result is caused by the superiorly displaced greater trochanter in hips with coxa vara, which narrows the scan window. In this paper three typical patients are presented to demonstrate that the use of additional non-standard views cannot exclude hip dysplasia in all cases. Hence, such patients with femoral abnormalities and doubtful sonographic findings should be further evaluated by arthrography or magnetic resonance imaging to rule out additional hip dysplasia.     

Late developmental dislocation of the hip after initial normal evaluation: a report of five cases

Developmental dysplasia of the hip (DDH) denotes a wide spectrum of pathologies ranging from hip instability to frank dislocation. The current understanding is that cases of late diagnosis were missed during the newborn period. However, there is some evidence that a number of hip subluxations or dislocations may have been clinically stable in the neonatal period, but dislocate late. We present 5 cases of otherwise healthy children with normal physical examinations and hip radiographs in the first 3 months of life who later developed hip dislocations. Four of the 5 cases required surgical open reduction. In light of these cases and others in the literature, normal neonatal screening for DDH does not assure that continued normal development of the hip joint will happen. Our study confirms the existence of another entity in the wide spectrum of DDH: the late hip dislocation. Therefore, hip evaluations should be continued beyond the neonatal period until the child begins to walk. Parents should be informed that hip dislocation can occur in a late form, and they should be encouraged to take their children for repeated evaluations even if the neonatal screening is normal.     

Management issues of congenital talipes equinovarus in the neonatal intensive care unit: A systematic review

BackgroundThe Ponseti method is the standard of care for managing idiopathic congenital talipes equinovarus (clubfoot) in the outpatient setting, but there are no clinical guidelines for inpatient treatment. Children in the neonatal intensive care unit (NICU) with clubfoot often delay treatment initiation due to medical reasons.MethodsWe systematically reviewed literature related to the treatment of clubfoot in the NICU, non-idiopathic clubfoot, and older infants, as well as barriers to care.ResultsIn a mixed NICU population of syndromic and idiopathic clubfoot, the Ponseti method has good functional outcomes with minimal interference with medical management. The Ponseti method has good functional outcomes with reduced need for extensive surgical procedures in non-idiopathic clubfoot and idiopathic clubfoot with delayed presentation (under one year of age).ConclusionsIt is possible to begin Ponseti treatment in the NICU without compromising medical management. It is not clear if this confers an advantage over waiting for outpatient casting.     

The natural history of hip abnormalities detected by ultrasound in clinically normal newborns: A 6-8 year radiographic follow-up study of 93 children

Ultrasound screening for hip dysplasia or dislocation has revealed a group of children with clinically normal hips, but with abnormal or suspicious ultrasound. During the 3-year period 1988-90, we found 170 children with this combination. We evaluated the natural history of these hips.

93 children were examined clinically and with standard radiography 6-8 years after birth. The center edge (CE) angle of Wiberg and migration percentage (MP) were measured on the radiographs.

87 children had not undergone any treatment, whereas treatment with an abduction orthosis had been initiated at approximately 4 months of age because of persisting dysplasia in 6 cases. All hips were radiographically normal at this follow-up. The mean CE value was 24 degrees (SD 6.5) and the mean MP was 13% (SD 5.2). 73 children had no complaints in their lower extremities, whereas 12 had in-toeing gait, 1 had outtoeing gait, 2 had hip or knee pain, and 5 had other complaints not relevant to hip dysplasia. We conclude that infants with sonographically abnormal or suspicious hips, but with normal clinical findings, do not need immediate treatment because spontaneous resolution occurs in most of them. Postponement of treatment in the few with persistent dysplasia does not seem to affect the outcome.     

The natural history of hip abnormalities detected by ultrasound in clinically normal newborns: a 6-8 year radiographic follow-up study of 93 children

Ultrasound screening for hip dysplasia or dislocation has revealed a group of children with clinically normal hips, but with abnormal or suspicious ultrasound. During the 3-year period 1988-90, we found 170 children with this combination. We evaluated the natural history of these hips. 93 children were examined clinically and with standard radiography 6-8 years after birth. The center edge (CE) angle of Wiberg and migration percentage (MP) were measured on the radiographs. 87 children had not undergone any treatment, whereas treatment with an abduction orthosis had been initiated at approximately 4 months of age because of persisting dysplasia in 6 cases. All hips were radiographically normal at this follow-up. The mean CE value was 24 degrees (SD 6.5) and the mean MP was 13% (SD 5.2). 73 children had no complaints in their lower extremities, whereas 12 had intoeing gait, 1 had outtoeing gait, 2 had hip or knee pain, and 5 had other complaints not relevant to hip dysplasia. We conclude that infants with sonographically abnormal or suspicious hips, but with normal clinical findings, do not need immediate treatment because spontaneous resolution occurs in most of them. Postponement of treatment in the few with persistent dysplasia does not seem to affect the outcome.     

Paediatric hip ultrasound: uncertainties in examination and choice of treatment

PurposeIn Germany, neonates undergo hip sonography examination using the Graf method during the routine U3 screening examination, performed by consultant physicians four to five weeks after birth, and are referred to specialized orthopaedic departments if there are any uncertainties. This study evaluated the quality of sonographic screening in the outpatient sector and the treatment requirements of referred children. MethodsWe performed a retrospective analysis of the patient data of 384 neonates collected in consultations performed between April 2016 and April 2019. ResultsIn total, 74% (n = 284) of neonates presented a hip type Ia/b. Treatment (abduction brace or Fettweis cast) was required in 32% (n = 122) of cases. The treatment duration was significantly correlated with age at first presentation (Pearson’s r = 0.678; p = 0.001). The treatment duration for patients aged > 200 days old at first presentation was twice as long as those aged 100 days at first presentation. Patients with public health insurance require referral by a consultant. Developmental dysplasia of the hip as referral diagnosis could not be confirmed in control examination in 64% (n = 132) of cases. Of the public health insured children, 97% (n = 200) were referred through a consultant paediatrician. ConclusionWe identified deficits in performing and interpreting the Graf method of ultrasound examination. A total of 64% of referred pathological hips turned out to be physiological configurations in our control examination. The future goal should be to increase anatomical knowledge of the newborn hip and ensure the correct use of Graf ultrasound method. Advanced training courses are recommended and necessary. Level of evidenceIV     

Role of ultrasound in the diagnosis and management of developmental dysplasia of the hip: an international perspective

Early diagnosis of developmental dysplasia of the hip is very important for proper treatment. Different ultrasound techniques have been used for early diagnosis of developmental dysplasia of the hip, but two of them are widely used in orthopedic practice: Graf's technique in Europe and Harcke's method in the United States. Our experience has led us to use an ultrasound technique that combines the two methods. Use of ultrasound has reduced the number of late-presenting cases, shortened treatment time, and decreased the number of surgical procedures of the hip joint in Poland.     

Outcome of ultrasonographic hip abnormalities in clinically stable hips

A retrospective review was performed of 192 newborn hips in 112 patients referred for hip evaluation. The average age at presentation was 12.7 days, with average radiographic follow-up of 15.9 months. Inclusion criteria for our study were a normal physical examination of the hip without evidence of instability and an ultrasound examination that was considered abnormal. Pavlik harness treatment was chosen at the discretion of the treating physician. At final follow-up, dysplasia was defined as greater than two standard deviations above the mean acetabular index (AI) for age. Group I consisted of 43 hips that had Pavlik treatment, and group II consisted of 149 hips that did not receive treatment. There was no difference in these two groups with respect to risk factors for dysplasia or the initial abnormalities seen on ultrasound evaluation, although patients in group I had less coverage of the femoral head during stress maneuvers. No hip in group I and two (1.3%) hips in group II were considered dysplastic (AI > 2 SD) at final radiographic follow-up (p > 0.10). There was no correlation between the severity of the ultrasound abnormality at birth and the subsequent presence of dysplasia (p > 0.10). The two hips considered dysplastic on radiograph were not being actively treated. When the hip examination of a newborn hip younger than 1 month is normal, a screening ultrasound does not appear to predict accurately subsequent hip dysplasia. In this specific setting, an initial screening ultrasound may be too sensitive and does not appear warranted.     

Natural history of ultrasound hip abnormalities in clinically normal newborns.

One hundred one clinically normal newborn hips showed varying degrees of sonographic hip dysplasia according to the classification of Graf. None were treated, and after +/- 6 months, radiographs showed that only four had definite dysplasia. Of these, three had had risk factors such as breech delivery or familial predisposition. Forty-three other clinically normal newborn hips showed ultrasonic instability, which spontaneously corrected. The severity of ultrasound dysplasia at birth was not related to ultimate development of the hip. Our results indicate that ultrasound should not be performed as a general screening procedure in clinically normal newborns.     

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.     

Initial results of the evaluation study of ultrasound hip screening in Germany

AIM OF STUDY: To assess the effectiveness of a universal sonographic screening of developmental dysplasia of the hip (DDH) established in Germany since 1996. METHODS: Currently a national survey is being performed in Germany to identify infants and young children who receive inpatient treatment for DDH. Between May, 1997 and October, 1997 monthly questionnaires were sent to all pediatric orthopaedic surgeons (active surveillance) and they were asked to report all inpatient cases between 10 weeks of age and 5 years with current closed or open reduction and/or osteotomies due to DDH. Information on time and results of previous ultrasound screening as well as treatment modalities was obtained in reported cases. RESULTS: 129 children (mean age at hospital admission 15.9 months, range 1.1 to 57.1 months) underwent closed reduction (n = 51), open reduction (n = 40) and osteotomies of the hip (n = 38) in the 6-month study period. Ultrasound screening has been performed too late and not at all in 45 children (35.1%). While in 18 cases (13.7%) no information could be obtained on screening results, the majority of children (n = 66, 51.2%) had completed DDH screening prior to the sixth week of life as recommended. Preliminary calculation of the unadjusted incidence of inpatient treatment for DDH in Germany was 0.33 per 1000 livebirths. CONCLUSION: DDH cases are still identified after introduction of an universal ultrasound hip screening in Germany. Continued evaluation must show, whether the incidence will decrease throughout the next few years.