Perinatal risk factors for developmental dysplasia of the hip

AIMS—To identify perinatal risk factors for developmental dysplasia of the hip (DDH) and define the risk for each factor.METHODS—In this case control study, using logistic regression analysis, all 1127 cases of isolated DDH live born in South Australia in 1986-93 and notified to the South Australian Birth Defects Register were included; controls comprised 150 130 live births in South Australia during the same period without any notified congenital abnormalities.RESULTS—Breech presentation, oligohydramnios, female sex and primiparity were confirmed as risk factors for DDH. Significant findings were an increased risk for vaginal delivery over caesarean section for breech presentation (as well as an increased risk for emergency section over elective section), high birthweight (?4000 g), postmaturity and older maternal age; multiple births and preterm births had a reduced risk. There was no increased risk for caesarean section in the absence of breech presentation. For breech presentation, the risk of DDH was estimated to be at least 2.7% for girls and 0.8% for boys; a combination of factors increased the risk.CONCLUSIONS—It is suggested that the risk factors identified be used as indications for repeat screening at 6 weeks of age and whenever possible in infancy. Other indications are family history and associated abnormalities.     

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。     

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.     

Treatment of developmental dysplasia of the hip before walking: results of closed reduction and immobilization in hip spica cast

We retrospectively evaluated 200 hips of 129 patients with the diagnosis of developmental dysplasia of the hip treated with closed reduction and hip spica cast. There were 153 female and 47 male hips in the group. The mean age of the patients at the time of the reduction were six (range. 2-13) months and mean follow-up was 51 (range: 16-240) months. All the patients were treated with closed reduction and were immobilized in hip spica cast. The mean time of immobilization in the cast was 102 (range: 45-190) days. Avascular necrosis was observed in 15% of the hips. Clinical and radiological end results of the patients were evaluated with modified McKay criteria and Severin classification. Eighty-two percent of the patients had satisfactory results according to modified McKay criteria and 76% of the patients according to Severin classification. The most important parameters affecting the end result were pre-reduction location of the hip, pre-operative acetabular index values and avascular necrosis. Based on the results of this study, treatment of developmental hip dysplasia with closed reduction and hip spica cast is a relatively safe and effective method.     

Auditing hip ultrasound screening of infants at increased risk of developmental dysplasia of the hip.

BACKGROUND: Clinical examination, while useful, has been shown to be insufficient as the sole screening method in infants. Ultrasound examination at 8 weeks in high risk infants is an integral part of the screening process in some units. AIMS: To show the efficiency of hip sonography in detection of developmental dysplasia of the hips in those without clinically dislocated hips. METHODS: All infants born at the National Maternity Hospital between January 1994 and December 2001 were included. All those with clinically dislocated hips were treated by a Pavlik harness and referred for follow up to a paediatric orthopaedic surgeon. An 8 week hip ultrasound scan was performed for those infants with stable hips on examination but who met the following criteria: (1) a first degree relative with congenital dislocation of hips; (2) breech presentation at birth; and (3) a persistent "click" at birth in an otherwise stable hip. RESULTS: During the period of study a total of 52 893 infants were born in the National Maternity Hospital. Based on the criteria above, 5485 hip ultrasound scans were performed. Of those scanned, 18 (0.33%) were found to have dislocated hips and 153 (2.78%) to have dysplasic hips. The 18 infants with dislocation were treated with Pavlik harness; the remaining 153 were followed up by serial ultrasound examinations but did not require active intervention. CONCLUSIONS: Among the population of infants at increased risk of developmental dysplasia of the hip, the hip screening programme identified 18 cases among 5485 infants; a rate of 3.2 per 1000. Hip sonography is therefore worthwhile.     

Value of limited hip abduction in developmental dysplasia of the hip

BACKGROUND: Developmental dysplasia of the hip (DDH) continues to be missed by routine physical examination in up to 50% of cases. Ultrasound (US) supplementation is the best method of screening for DDH, but the resources required should not be underestimated. Limited abduction of the hip (LHA) in an infant triggers suspicion, and often an urge to treat, in most orthopaedic surgeons and pediatricians alike. This study aimed to document the value of unilateral LHA in the diagnosis and decision making of DDH, and the correlation between LHA and US. METHODS: In total, 464 infants referred from the pediatrics clinic with LHA, aged between 30 and 120 days, were included in the study. RESULTS: Physical examination revealed LHA in 186 (41%) infants, 26 of which were unilateral and 160 were bilateral. US examination showed that 13 (8.1%) patients in the bilateral LHA group and 18 (69.2) patients in the unilateral LHA group, had DDH (total number 31, 7%). CONCLUSION: Unilateral limitation of hip abduction was found to be a sensitive sign for developmental hip dysplasia, but US could be defined once again as the best golden standard before initiating treatment.     

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.     

Ultrasonography and developmental dysplasia of the infant hip

Hip sonography has been developed, refined, and critiqued for over 18 years. It is now widely accepted as a highly sensitive and useful technique for both the diagnosis and management of developmental dysplasia of the infant hip. Controversy continues surrounding the issue of when and how often hip sonography should be performed. Currently, clinical screening of newborns is the standard of care in the United States, with sonography employed selectively based on clinical findings. Universal ultrasound screening has been used in some countries and is under consideration by many investigators, using a variety of algorithms. This review will focus on recent reports dealing with issues of screening for developmental dysplasia of the infant hip and also will highlight techniques suggested for use in the treatment of development dysplasia of the infant hip.     

Ultrasound screening for developmental dysplasia of the hip

BACKGROUND: Clinical examination of newborns has been shown to be inadequate for the early detection of developmental dysplasia of the hip (DDH). It is debatable whether US examination is a valid alternative. OBJECTIVE: To contribute further knowledge to the natural history of DDH; to examine the distribution of hip morphology as classified by Graf according to sex and risk factors in an unselected Italian population; to propose a temporal pattern of US screening of all newborns to detect DDH. MATERIALS AND METHODS: All newborns (n=8,896) sequentially delivered in the Maternal and Child Health Hospital of Milan underwent US examination in the first week of life and, when findings were within normal limits, in the third month of life. Subjects categorised at birth as Graf type 2a with alpha angle between 50 degrees and 52 degrees, underwent a further US examination at the end of the first month of life. Subjects with ambiguous findings at the 3-month examination were re-examined at the end of the fourth month of life. All infants with abnormal hips abandoned the screening process and underwent treatment. RESULTS. Overall, 56 cases of DDH were identified: 34 in the first week of life examination, 10 at 1 month; 10 at 3 months and 2 at 4 months. CONCLUSIONS. A two-step US screening of newborns is recommended: at the end of the first month and within the fourth month of life.     

Diagnosis and management of developmental hip dysplasia

Congenital dislocation of the hip represents a spectrum of disease from transient neonatal hip instability to established dislocation. Established risk factors include breech presentation and a positive family history. Emphasis should be placed on early diagnosis and treatment to minimize the need for surgical intervention. Clinical assessment has limited accuracy which further diminishes soon after birth. Ultrasound based screening is more sensitive, but controversy remains as to which method to use and its effect on outcome. When initiated early, treatment using a simple abduction device such as a Pavlik harness has an excellent success rate. Resistant cases and late presentations usually require surgical management, which are largely age dependent. We discuss the condition, detail the screening protocol in our institution and outline the surgical options in this article.     

Ultrasonography screening for developmental dysplasia of the hip joint

The use of ultrasonography as a complement to clinical examination will increase the reliability of the evaluation of unstable hips in newborn infants. In particular, the number of false-positive Ortolani and Barlow tests will decrease. However, the interpretation of the ultrasonogram in newborn infants has a steep learning curve with considerable risk of a high number of false-positive hips being diagnosed. Therefore, universal screening for developmental dysplasia of the hip by ultrasonography cannot yet be recommended from a cost-benefit point of view.     

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.     

Ultrasound for screening developmental dysplasia of the hip: a European perspective

PURPOSE OF REVIEW: For the past 20 years, sonography of the hip has become the imaging procedure of choice to diagnose hip maturation disorders in German-speaking countries. In Austria, hip sonography is a mandatory and essential feature of preventive public health measures; the "Mutter-Kind-Pass" has been the official medical identity card for mother and child since 1992 in Austria. This review summarizes the most recent literature dealing with ultrasound screening for developmental dysplasia of the hip in Europe. RECENT FINDINGS: This article focuses on the results in recent articles about sonography screening of the hip joint in the first year of life. SUMMARY: The continued development and refinement of the method, which is now standardized in German-speaking countries and hence can be taught in uniformly structured courses, has made sonography of the infant hip a gold standard for screening for developmental dysplasia of the hip in these countries.