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1.  Diagnosis and treatment of developmental dysplasia of the hip in the Netherlands: national questionnaire of paediatric orthopaedic surgeons on current practice in children less than 1 year old 
Purpose
There is no consensus in the literature regarding the diagnosis and treatment of developmental dysplasia of the hip (DDH). We designed a national questionnaire to assess the various opinions and current practice of paediatric orthopaedic surgeons in the Netherlands regarding the diagnosis and treatment of DDH in children less than 1 year old.
Methods
The questionnaire was sent to all members of the Dutch Paediatric Orthopaedic Society (DPOS). It discusses different methods and criteria used in the diagnosis of DDH, the use of different therapies and the use of different imaging techniques to evaluate the result of treatment.
Results
With 38 responders, the overall response rate to the survey was 67%. Most surgeons use clinical, radiographic and/or ultrasound examination for the diagnosis. The starting point of treatment is usually on the mild part of the DDH spectrum. The Pavlik harness is most popular in the treatment of dislocated hips, whereas in dysplastic hips, most surgeons use a rigid splint. The duration of treatment has a wide range and evaluation of the effect of treatment is predominantly done by radiography.
Conclusions
The diagnosis and treatment of DDH in the Netherlands has as much diversity as the literature has recommendations about this subject. The lack of consensus on many aspects of DDH diagnosis and treatment should form the basis for a discussion among Dutch paediatric orthopaedic surgeons. Using the available evidence, it should be possible to formulate a more uniform protocol for the diagnosis and treatment of DDH.
doi:10.1007/s11832-011-0355-1
PMCID: PMC3145893  PMID: 21949542
Developmental dysplasia of the hip; Current practice; Diagnosis; Treatment
2.  Diagnosis and treatment of developmental dysplasia of the hip in the Netherlands: national questionnaire of paediatric orthopaedic surgeons on current practice in children less than 1 year old 
Purpose
There is no consensus in the literature regarding the diagnosis and treatment of developmental dysplasia of the hip (DDH). We designed a national questionnaire to assess the various opinions and current practice of paediatric orthopaedic surgeons in the Netherlands regarding the diagnosis and treatment of DDH in children less than 1 year old.
Methods
The questionnaire was sent to all members of the Dutch Paediatric Orthopaedic Society (DPOS). It discusses different methods and criteria used in the diagnosis of DDH, the use of different therapies and the use of different imaging techniques to evaluate the result of treatment.
Results
With 38 responders, the overall response rate to the survey was 67%. Most surgeons use clinical, radiographic and/or ultrasound examination for the diagnosis. The starting point of treatment is usually on the mild part of the DDH spectrum. The Pavlik harness is most popular in the treatment of dislocated hips, whereas in dysplastic hips, most surgeons use a rigid splint. The duration of treatment has a wide range and evaluation of the effect of treatment is predominantly done by radiography.
Conclusions
The diagnosis and treatment of DDH in the Netherlands has as much diversity as the literature has recommendations about this subject. The lack of consensus on many aspects of DDH diagnosis and treatment should form the basis for a discussion among Dutch paediatric orthopaedic surgeons. Using the available evidence, it should be possible to formulate a more uniform protocol for the diagnosis and treatment of DDH.
doi:10.1007/s11832-011-0355-1
PMCID: PMC3145893  PMID: 21949542
Developmental dysplasia of the hip; Current practice; Diagnosis; Treatment
3.  MR-based Parameters as a Supplement to Radiographs in Managing Developmental Hip Dysplasia 
Clinics in Orthopedic Surgery  2011;3(3):202-210.
Background
Some dysplastic hips with favorable radiographic parameters fail to develop normally, suggesting that we should consider cartilaginous or soft tissue structures for further information regarding the condition of the hip. The purpose of this study was to provide a clear definition of concentric reduction in developmental dysplasia of the hip (DDH) based on magnetic resonance imaging (MRI), and to determine how radiographic and MR-based parameters could be used together to treat dysplastic hips.
Methods
We studied range of motion (ROM)-MRI of 25 patients with unilateral hip dysplasia (mean age at the time of MR imaging, 44.1 months). Each ROM-MRI consisted of a set of bilateral hip scans in the following positions: neutral; abduction; abduction- internal rotation; abduction-internal rotation-flexion; and adduction. Before MR scanning, the 25 patients received the following primary treatments: closed reduction (n = 15; at a mean age of 14.5 months); and open reduction (n = 10; at a mean age of 10.0 months). The following new parameters appear to be useful in treating DDH: 1) the labral angle, the angle the labrum makes with the acetabulum; 2) the uncorrected labral deformity (ULD), the "residual deformity" (deflection of the labrum) when the affected labrum is freed from pressure in abduction; and 3) the zone of compressive force (ZCF), the region of the acetabulum through which the body weight acts on the femoral head.
Results
A concentrically-reduced hip is one in which the labrum points downward in the neutral position, at the same angle as that of the normal side; and in which the ZCF is zone 3, the inner acetabular zone as defined herein. The ULD and the ZCF may be determined precisely as we have done, or the physician may simply observe the changes in the orientation of the labrum and compare the changes qualitatively to the unaffected side, and likewise for the medial joint space.
Conclusions
Detailed analysis of the labrum as permitted by ROM-MRI, together with acetabular index and other parameters measured from radiographs, provides important information for physicians treating childhood hip dysplasia.
doi:10.4055/cios.2011.3.3.202
PMCID: PMC3162200  PMID: 21909467
Developmental hip dysplasia; Dysplastic hip; Magnetic resonance imaging; Concentric reduction; Labrum
4.  Screening and treatment in developmental dysplasia of the hip—where do we go from here? 
International Orthopaedics  2011;35(9):1359-1367.
Purpose
Developmental dysplasia of the hip (DDH) is a leading cause of disability in childhood and early adult life. Clinical and sonographic screening programmes have been used to facilitate early detection but the effectiveness of both screening strategies is unproven. This article discusses the role for screening in DDH and provides an evidence-based review for early management of cases detected by such screening programmes.
Methods
We performed a literature review using the key words ‘hip dysplasia,’ ‘screening,’ ‘ultrasound,’ and ‘treatment.’
Results
The screening method of choice and its effectiveness in DDH still needs to be established although it seems essential that screening tests are performed by trained and competent examiners. There is no level 1 evidence to advise on the role of abduction splinting in DDH although clinicians feel strongly that hip instability does improve with such a treatment regime. The definition of what constitutes a pathological dysplasia and when this requires treatment is also poorly understood.
Conclusion
Further research needs to establish whether early splintage of clinically stable but sonographically dysplastic hips affects future risk of late-presenting dysplasia/dislocation and osteoarthritis. There is a need for high quality studies in the future if these questions are to be answered.
doi:10.1007/s00264-011-1257-z
PMCID: PMC3167447  PMID: 21553044
5.  Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns 
Objective
To review the effectiveness of, and make practice recommendations for, serial clinical examination and ultrasound screening for developmental dysplasia of the hip (DDH) in newborns. The effectiveness of selective screening of high-risk infants with hip and pelvic radiographs and treatment with abduction therapy are also examined.
Options
Screening: serial clinical examination, ultrasound screening, radiographic evaluation. Treatment: abduction therapy.
Outcomes
Rates of operative intervention, abduction splinting, delayed diagnosis of DDH (beyond 3–6 months), treatment complications and false diagnostic labelling. Long-term functional outcomes were considered important.
Evidence
MEDLINE was searched for relevant English-language articles published from 1966 to November 2000 using the key words “screening,” “hip,” “dislocation,” “dysplasia,” “congenital” and “ultrasound.” Comparative and descriptive studies and key reviews were retrieved, and their bibliographies were manually searched for further studies.
Benefits, harms and costs
Because most infants will have spontaneous resolution of nonteratologic DDH, early identification and intervention results in unnecessary labelling of newborns as having the problem and unnecessary treatment. Ultrasound screening is a highly sensitive but poorly specific measure of clinically relevant DDH. Abduction splinting is associated with a variety of problems, and its effectiveness in treating DDH is not clearly known. At least 20% of infants requiring operative intervention have had splint therapy. The harms of labelling, repetitive investigations, unnecessary splinting and resource consumption associated with screening are substantial.
Values
The strength of evidence was evaluated using the evidence-based methods of the Canadian Task Force on Preventive Health Care.
Recommendations
· There is fair evidence to include serial clinical examination of the hips by a trained clinician in the periodic health examination of all infants until they are walking independently (level II-1 and III evidence; grade B recommendation). · There is fair evidence to exclude general ultrasound screening for DDH from the periodic health examination of infants (level II-1 and III evidence; grade D recommendation). · There is fair evidence to exclude selective screening for DDH from the periodic health examination of high-risk infants (level II-1 and III evidence; grade D recommendation). · There is fair evidence to exclude routine radiographic screening for DDH from the periodic health examination of high-risk infants (level III evidence; grade D recommendation). · There is insufficient evidence to evaluate the effectiveness of abduction therapy (level III evidence; grade C recommendation), but good evidence to support a period of close observation for newborns with clinically detected DDH (level I evidence; grade A recommendation). However, there is insufficient evidence to determine the optimal duration of observation (level III evidence; grade C recommendation).
Validation
The members of the Canadian Task Force on Preventive Health Care reviewed the findings of this analysis through an iterative process. The task force sent the final review and recommendations to selected external expert reviewers, and their feedback was incorporated in the final draft of the manuscript.
Sponsors
The Canadian Task Force on Preventive Health Care is funded through a partnership between the Provincial and Territorial Ministries of Health and Health Canada.
PMCID: PMC81153  PMID: 11450209
6.  Etiology of Congenital Dislocation of the Hip 
Dr. Carl E. Badgley was born in 1893, the son of a Presbyterian minister [2]. He received his medical degree at the University of Michigan in 1919, and became interested in orthopaedic surgery owing to Drs. Hugh Cabot and LeRoy Abbott. He was appointed as an instructor of surgery in 1920 and was appointed professor and head of the Section of Orthopaedic Surgery in 1932, an appointment he retained until 1963 when he retired.
Dr. Badgley, devoted to his home state, was active in organizing institutions and organizations within Michigan. These included the Rackham Arthritis Research Unit within the hospital devoted exclusively to arthritis research and the Michigan Crippled Children Commission. He was active in the Board of Control of Intercollegiate Athletics. As President of the AAOS in 1942, he faced challenges organizing the 1943 meeting owing to the war years and many parts of the social program, particularly for the spouses, were eliminated [3]. (Travel was limited in part due to rationing of gas and a reduction in some public transportation since the war effort had priority on petroleum products.) Of the 235 members and 461 guests attending the 11th Annual Meeting in 1943, 203 of the men were in the military service. Nonetheless, during his year of Presidency of the AAOS, Instructional Course Lectures (13 courses) were introduced at the 1942 annual meeting (at a cost of $1.00 per course) and were an immediate success [3]. They were first published the following year (1943) by J.W. Edwards Co., of Ann Arbor, Michigan (who continued to publish the ICL through 1958), under the editorship of a future AAOS President, Dr. Tommy Thomson.
The article we reproduce here details the two major theories of congenital dislocation of the hip: “a primary germinal fault…(and)…a defect of development of environmental origin” [1]. As a true scientist, he commented, “The most commonly accepted theory of developmental abnormality is a primary failure of proper formation of the acetabulum, particularly a germinal failure of development of the posterior superior buttress of the ilium…It is difficult to see how an observer, unless influenced by the weight of pre-existing statements and concepts, can authoritatively state a hypothesis as an accepted fact. The author denies dogmatically, for example, that there is scientific evidence of a primary genetic developmental fault of the posterior superior portion of the acetabulum. He does not refute the existence of such a lesion, but contends that no satisfactory evidence has been submitted that this lesion is the primary developmental fault.” How often do we make our judgments based on the “weight of preexisting statements,” rather than compelling observations and data? Also as a true scientist, his thorough review leads to and ends with a hypothesis: “Congenital dislocation and congenital dysplasia of the hip may be regarded as the result of faulty development, due to environmental factors extrinsic to the hip joint. An inherited fault in the timing of development may produce these extrinsic changes… Heredity can play an important part in altering the growth and time factors.” Despite astonishing technical advances, we have the same working hypothesis today and DDH may indeed be related to the timing of genetically controlled events in conjunction with external factors; the details of the genetic factors are being explored with tools not available to Dr. Badgley, but we seem no closer to the larger answer.Carl E. Badgley, MD is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.
References
Badgley CE. Etiology of congenital dislocation of the hip. J Bone Joint Surg Am. 1949;31:341–356.Carl E. Badgley, M.D. 1893–1973. J Bone Joint Surg Am. 1973;55:1112–1113.Heck CV. Fifty Years of Progress: In Recognition of the 50th Anniversary of the American Academy of Orthopaedic Surgeons. Chicago, IL: American Academy of Orthopaedic Surgeons; 1983.
doi:10.1007/s11999-007-0020-7
PMCID: PMC2505289  PMID: 18196378
7.  Screening for hip dysplasia in congenital muscular torticollis: is physical exam enough? 
Purpose
An association between congenital muscular torticollis (CMT) and developmental dysplasia of the hip (DDH) has been established in the literature; however, whether the screening of patients with CMT for DDH requires hip imaging remains controversial. The purpose of this study is to determine (1) the coexistence rate of DDH requiring treatment in individuals with CMT and (2) if physical exam alone is sufficient screening.
Methods
A single-center retrospective chart review was performed among 97 consecutive patients between 1/1/2003 and 9/1/2012 with CMT who had hip imaging performed.
Results
12 % (12/97) of patients with CMT had DDH, all requiring treatment. 75 % (9/12) of the patients with DDH had an abnormal clinical exam. Of the three patients with DDH and a normal clinical exam, two patients were presenting for a second opinion after being treated for DDH prior to evaluation. 90 % (9/10) of patients with DDH at the time of presentation had an abnormal hip exam. All 12 patients with hip dysplasia were referred for DDH or DDH with CMT. There were no patients who were referred for CMT alone that had DDH.
Conclusions
In the care of a patient with CMT, it is important that the clinician remains vigilant about screening for DDH. An ultrasound or radiograph of the hips should be strongly considered as part of the evaluation of a child with CMT.
Level of evidence: IV.
doi:10.1007/s11832-014-0572-5
PMCID: PMC3965766  PMID: 24578172
Congenital muscular torticollis; Developmental dysplasia of the hip; Screening
8.  Associated risk factors in children who had late presentation of developmental dysplasia of the hip 
Purpose
The purpose of this study was to assess the role of clinical examination, associated risk factors and plain radiograph of the pelvis in children who had late presentation of DDH.
Methods
We report on a 7-year prospective study, in children who had late presentation of developmental dysplasia of the hip (DDH). For this purpose, 740 hips in 370 referred children, age range 3–7 months (mean 3.44 months) were clinically and radiologically assessed, and the associated risk factors recorded.
Results
Female sex, first born, positive family history and breech presentation were confirmed as risk factors for DDH. Significant findings were an increased risk for vaginal delivery over caesarean section for breech presentation (P = 0.002). There was an increased risk for caesarean section in the absence of breech presentation. Multiple births and preterm births had a reduced risk. For breech presentation, the risk of DDH was estimated to be at least 1.6% for girls and 3.4% for boys; a combination of factors increased the risk. Limitation of abduction (43.2%) and asymmetry of the groin skin folds (72.7%) were found to be the two most common clinical findings associated with DDH. Bilateral acetabular dysplasia is more common than unilateral dysplasia. Foot deformities were rarely encountered in children with acetabular dysplasia.
Conclusions
The percentage of first-born babies who had DDH is lower than reported in the literature (34%), but still shows significant risk. We did find that bilateral acetabular dysplasia is more common than unilateral dysplasia. Torticollis and foot deformities are rarely found to be associated with DDH. All these findings needs further evaluation in children who had surgical treatment for DDH, to see if they are different from dysplastic groups. Limitation of abduction is an important clinical finding, but is not always associated with DDH. Asymmetry of the skin folds in the groin were found to be an important clinical finding associated with DDH for all age groups. As clinical examination depends on many factors, and most DDH cases are of the dysplastic type, it is mandatory to depend on further diagnostic tools for confirmation of DDH.
doi:10.1007/s11832-007-0041-5
PMCID: PMC2656728  PMID: 19308496
DDH; Risk factors; Female child; First-born; Skin folds
9.  Pelvic Morphology Differs in Rotation and Obliquity Between Developmental Dysplasia of the Hip and Retroversion 
Background
Developmental dysplasia of the hip (DDH) and acetabular retroversion represent distinct acetabular pathomorphologies. Both are associated with alterations in pelvic morphology. In cases where direct radiographic assessment of the acetabulum is difficult or impossible or in mixed cases of DDH and retroversion, additional indirect pelvimetric parameters would help identify the major underlying structural abnormality.
Questions/Purposes
We asked: How does DDH and retroversion differ with respect to rotation and coronal obliquity as measured by the pelvic width index, anterior inferior iliac spine (AIIS) sign, ilioischial angle, and obturator index? And what is the predictive value of each variable in detecting acetabular retroversion?
Methods
We reviewed AP pelvis radiographs for 51 dysplastic and 51 retroverted hips. Dysplasia was diagnosed based on a lateral center-edge angle of less than 20° and an acetabular index of greater than 14°. Retroversion was diagnosed based on a lateral center-edge angle of greater than 25° and concomitant presence of the crossover/ischial spine/posterior wall signs. We calculated sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve for each variable used to diagnose acetabular retroversion.
Results
We found a lower pelvic width index, higher prevalence of the AIIS sign, higher ilioischial angle, and lower obturator index in acetabular retroversion. The entire innominate bone is internally rotated in DDH and externally rotated in retroversion. The areas under the ROC curve were 0.969 (pelvic width index), 0.776 (AIIS sign), 0.971 (ilioischial angle), and 0.925 (obturator index).
Conclusions
Pelvic morphology is associated with acetabular pathomorphology. Our measurements, except the AIIS sign, are indirect indicators of acetabular retroversion. The data suggest they can be used when the acetabular rim is not clearly visible and retroversion is not obvious.
Level of Evidence
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2473-6
PMCID: PMC3492631  PMID: 22798136
10.  Diagnosis of Developmental Dislocation of the Hip by Sonospectrography 
Because not all infants can be screened for DDH by experts, early diagnosis of developmental dysplasia of the hip (DDH) by primary health care professionals is important. We developed a broadband electroacoustic sound transmission-detection (sonospectrography) system and explored its utility in 22 patients (average age, 5.9 years; range, 0.3–14 years) with unilateral DDH in this preliminary study. Distinct from ultrasonography, the sonospectrography system functions by sound transmission and recording through tissues to differentiate between normal and abnormal hips. All hips were examined at four different hip and knee positions. The normal hip served as the control. The sonospectrography system was able to detect unilateral DDH. Dysplastic hips had lower sound transmission values when compared to normal hips in all patients and all four positions; however, the highest (X = 88.8 ± 30.2 Hz) and lowest (X = 8.3 ± 5.4 Hz) sound transmission mean values were obtained at different positions in the normal hips and those with DDH. Sound transmission values of dysplastic hips were always lower than that of normal hips when the hip and knee was flexed during measurements. Sound transmission values decreased with age. The sonospectrography system may offer a new noninvasive method in the diagnosis of unilateral DDH but requires further study of sensitivity and specificity of detecting dysplastic hips without subluxation in newborn infants.
Level of Evidence: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0163-1
PMCID: PMC2504664  PMID: 18274713
11.  The Gothic Arch: A Reliable Measurement for Developmental Dysplasia of the Hip 
Background
The “Gothic Arch” is a radio-graphic finding on AP pelvis x-rays postulated to be predictive of hip osteoarthritis.
Purpose
The purpose of this study was to determine the reliability of measurement of the Gothic Arch in patients with no known hip pathology and patients with unilateral developmental dysplasia of the hip (DDH).
Patients and Methods
After obtaining IRB approval, nine skeletally mature patients (18 hips) with no known hip pathology were selected to serve as the control group. The AP pelvis x-rays at skeletal maturity of eight patients (16 hips) with unilateral DDH treated with closed reduction and casting comprised the comparison group. A digitizing program was designed to measure the Gothic Arch based on landmarks identified by the user. Two pediatric orthopaedic surgeons and two orthopaedic residents completed the program on two separate occasions. Intra-and interobserver reliability were determined using intraclass cor-relation coefficients (ICC) for continuous variables.
Results
Both the unilateral DDH group and the control group demonstrated excellent inter- and intraobserver reliability (ICC >0.70) for base, height, area, and orientation of the Gothic Arch, but poor reliability (ICC <0.40) for medial and lateral sharpness.
Conclusion
The Gothic Arch can be reliably measured on AP pelvis x-rays of patients with normal and dysplastic hips.
Level of Evidence
III, Diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3748863  PMID: 24027453
12.  Dysplasia of the hip in adolescent patients successfully treated for developmental dysplasia of the hip 
Background
The purpose of this study was to analyze whether hips treated for developmental dysplasia of the hip (DDH) during infancy, which were clinically and radiologically fully normalized by walking age, may become dysplastic again during later growth.
Materials and methods
A total of 150 patients were randomly selected out of a collective of 386 patients treated for DDH at the Department of Orthopaedics at the University of Zurich between 1993 and 2004. Treatment was started at birth and continued for 6 months. All patients had clinically and radiographically normal hips by walking age. The patients did not suffer from other diseases, in particular, neurological or neuromuscular diseases.
Results
We detected four female subjects among the 150 patients who had been successfully treated for DDH, who had developed dysplastic hips in early adolescence, necessitating acetabular surgery.
Conclusion
The successful treatment of DDH in infancy does not ensure normal hip development; therefore, follow up into maturity may be recommended.
Level of evidence
Level IV.
doi:10.1007/s11832-011-0356-0
PMCID: PMC3234894  PMID: 22852032
Developmental dysplasia of the hip; Congenital dysplasia of the hip; Pavlik harness
13.  Hip joint pain in children with cerebral palsy and developmental dysplasia of the hip: why are the differences so huge? 
Backgrounds
Non-traumatic hip dislocation in children is most often observed in the course of developmental dysplasia of the hip (DDH) and infantile cerebral palsy. The risk of pain sensations from dislocated hip joint differentiates the discussed groups of patients. Will every painless hip joint in children with cerebral palsy painful in the future?
Methods
Material included 34 samples of joint capsule and 34 femoral head ligaments, collected during open hip joint reduction from 19 children with CP, GMFCS level V and from 15 children with DDH and unilateral hip dislocation. All the children were surgically treated.
The density of nociceptive fibres was compared between the children with CP and DDH, using S-100 and substance P monoclonal antibodies.
Results
More frequent positive immunohistochemical reaction to S-100 protein concerned structures of the femoral head ligaments in children with CP and cartilage losses on the femoral head, when compared to the same structures in children with DDH (p = 0.010). More frequent were found positive immunohistochemical reactions for S-100 protein in the joint capsules of children with cartilage losses (p = 0.031) and pain ailments vs. the children with DDH (p = 0.027). More frequent positive reaction to substance P concerned in femoral head ligaments in CP children and cartilage lesions (p = 0.002) or with pain ailments (p = 0.001) vs. the DDH children.
Conclusions
Surgical treatment of hip joint dislocation should be regarded as a prophylactics of pain sensations, induced by tissue sensitisation, inflammatory process development or articular cartilage defects.
doi:10.1186/1471-2474-15-96
PMCID: PMC4004466  PMID: 24656137
Dislocated hip joint; Pain; Cerebral palsy; Developmental dysplasia of the hip
14.  The Epidemiology and Demographics of Hip Dysplasia 
ISRN Orthopedics  2011;2011:238607.
The etiology of developmental dysplasia of the hip (DDH) is unknown. There are many insights, however, from epidemiologic/demographic information. A systematic medical literature review regarding DDH was performed. There is a predominance of left-sided (64.0%) and unilateral disease (63.4%). The incidence per 1000 live births ranges from 0.06 in Africans in Africa to 76.1 in Native Americans. There is significant variability in incidence within each racial group by geographic location. The incidence of clinical neonatal hip instability at birth ranges from 0.4 in Africans to 61.7 in Polish Caucasians. Predictors of DDH are breech presentation, positive family history, and gender (female). Children born premature, with low birth weights, or to multifetal pregnancies are somewhat protected from DDH. Certain HLA A, B, and D types demonstrate an increase in DDH. Chromosome 17q21 is strongly associated with DDH. Ligamentous laxity and abnormalities in collagen metabolism, estrogen metabolism, and pregnancy-associated pelvic instability are well-described associations with DDH. Many studies demonstrate an increase of DDH in the winter, both in the northern and southern hemispheres. Swaddling is strongly associated with DDH. Amniocentesis, premature labor, and massive radiation exposure may increase the risk of DDH. Associated conditions are congenital muscular torticollis and congenital foot deformities. The opposite hip is frequently abnormal when using rigorous radiographic assessments. The role of acetabular dysplasia and adult hip osteoarthritis is complex. Archeological studies demonstrate that the epidemiology of DDH may be changing.
doi:10.5402/2011/238607
PMCID: PMC4063216  PMID: 24977057
15.  Outcome in Unilateral or Bilateral DDH Treated with One-stage Combined Procedure 
The surgical treatment of patients with neglected developmental dysplasia of the hip (DDH) has been the subject of controversy. We asked if age affected outcome in patients with neglected DDH with unilateral or bilateral dislocation who underwent one-stage combined procedures. We retrospectively reviewed the results of 40 patients (51 hips) treated with a one-stage combined procedure consisting of open reduction, pelvic osteotomy, and femoral shortening. The average age at the time of surgery was 5.4 years for Group I (bilateral dislocation, 22 hips) and 6.7 years for Group II (unilateral dislocation, 29 hips). Mean followup was 5.4 years for Group I and 6.7 years for Group II. According to the modified score system of Trevor et al, 13 hips rated excellent, three were good, and six were fair in Group I; the ratings were 14, nine, and six hips respectively in Group II. Four patients had a limb-length discrepancy of approximately 1.5 cm in Group I. Twelve hips in Group I and 18 hips in Group II had osteonecrosis of varying severity. Our data suggest the outcomes of the children who were 5.5 years or younger in Group I and 8 years or younger in Group II were better.
Level of Evidence: Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0162-2
PMCID: PMC2504680  PMID: 18297368
16.  The techniques of soft tissue release and true socket reconstruction in total hip arthroplasty for patients with severe developmental dysplasia of the hip 
International Orthopaedics  2012;36(9):1795-1801.
Purpose
Total hip arthroplasty (THA) is an effective procedure for developmental dysplasia of the hip (DDH); however, it is sometimes difficult to complete for severe cases because of femoral head dislocation, dysplasia of the acetabulum and the femur, disparity in limb length, soft tissue contraction, and muscular atrophy. We aimed at exploring the efficiency of the techniques of release and balance of soft tissues and reconstruction of true socket THA for patients with severe DDH.
Methods
From January 2000 to January 2009, 46 adult patients with severe DDH (50 hips) were included in this study. According to the classification system, there were 26 type III and 24 type IV. Among them there were 32 women and 14 men, aged from 38 to 77 years. THA was performed via a lateral approach. All acetabular sockets were reconstructed at the original anatomical location following a meticulous technique of soft tissue release and balance around the hip to restore limb length, to strengthen the abductor and improve its function.
Results
All patients had restoration of limb length (range, 2.5–5.5 cm; 30 limbs of more than 4 cm) without injury to the sciatic nerve. One postoperative dislocation occurred due to slight enlargement of the angle of abduction of the acetabulum. The follow-up ranged from 2.2 to 11.5 years (median 6.4 years) in 46 patients, and the Harris score increased from 40.2 preoperatively to 86.5 (P = 0.027). All hips were pain free with good function at the latest follow-up.
Conclusion
The meticulous techniques of soft tissue release and balance can be recommended to ensure anatomical reconstruction of the true acetabular socket and to improve abductor function during arthroplasty for DDH.
doi:10.1007/s00264-012-1622-6
PMCID: PMC3427426  PMID: 22820830
17.  A Replication Study for the Association of rs726252 in PAPPA2 with Developmental Dysplasia of the Hip in Chinese Han Population 
BioMed Research International  2014;2014:979520.
Developmental dysplasia of the hip (DDH) is a common developmental hip disorder, which ranges from mild acetabulum malformation to irreducible hip dislocation. A previous study suggested a significant association of pregnancy-associated plasma protein-A2 (PAPPA2) with DDH susceptibility in Chinese Han population. But with the consideration of the sample size, the association was still debatable. To confirm the association of the reported single nucleotide polymorphism (SNP) in PAPPA2, rs726252 with DDH, we conducted a case-control study in a larger number of subjects. We genotyped rs726252 in 697 DDH subjects and 707 control subjects by TaqMan assay. The association between this SNP and DDH was evaluated statistically. No significant difference was found in any comparison of genotype distribution nor allele frequency between cases and controls. Our replication study indicated that the association between rs726252 and DDH in Chinese Han population was debatable. The association between PAPPA2 and DDH should be evaluated by additional studies.
doi:10.1155/2014/979520
PMCID: PMC3930137  PMID: 24672801
18.  Natural History of Type III Growth Disturbance After Treatment of Developmental Dislocation of the Hip 
Background
Type III growth disturbance (T3GD) following reduction for developmental dysplasia of the hip (DDH) is a relatively rare, but potentially devastating complication. This study evaluated the long-term outcomes of patients treated for DDH who developed a T3GD hip compared to those who didn't, with an emphasis on possible risk factors.
Methods
A case-control design was used. All radiographs of a consecutive set of patients with DDH were evaluated. Twenty-two patients (29 hips) developed T3GD. The control group consisted of 57 patients (72 hips) without any sign of growth disturbance. Variables examined included age at reduction, type of reduction and serial radiographic parameters reflecting pre- and post-reduction status. Average age at final follow up was 26 years in the T3GD group and 34 years in the control group.
Results
Evidence of T3GD was first noticed radiographically at 11 months after reduction and healing of the epiphysis occurred an average of 8.5 months later. Univariate analysis demonstrated no increased risk of T3GD related to age at presentation, presence or absence of the ossific nucleus, type of reduction, initial acetabular index or Smith’s centering ratios. However, the Tönnis grade was significantly associated with an increased risk of T3GD. Tönnis grade 4 hips (high-degree dislocations) had 3.43 times greater risk of developing T3GD compared to those with lower dislocations. At maturity, 90% of the T3GD hips were classified as Severin III/IV, compared to 35% of the controls. At last follow-up, 7 of the 29 T3GD hips (32%) had undergone total hip replacement at an average age of 39 years (range 19 to 57 years).
Conclusions
T3GD remains the most severe and devastating complication after treatment of DDH in children. In most cases, poor acetabular development and flattening of the femoral head lead to early degenerative changes in the hip joint. The risk increases in high-degree dislocations, independent of the treatment performed.
PMCID: PMC2603346  PMID: 19223945
19.  Posteromedial Limited Surgery in Developmental Dysplasia of the Hip 
We questioned whether our modified soft tissue surgical procedure can provide acceptable results with lower complication rates in developmental dysplasia of the hip (DDH). We retrospectively reviewed 143 patients (185 hips) with a mean age of 11.6 months at operation and a minimum followup of 5 years (mean, 7.5 years; range, 5–13 years). We used a posteromedial approach and sectioned the adductor longus and iliopsoas tendons. If we achieved an arthrographically documented anatomic reduction we closed the incisions; if not, we made an arthrotomy to obtain an anatomic reduction through the same incision at the same session. A hip score indicating an acceptable outcome was obtained in 168 hips (90.8%). We identified osteonecrosis of the femoral head (ON) in 36 (19.5%) hips and redislocation in four (2.2%). Both the ossific nucleus and physis were affected in 10 of the 36 hips with ON. We performed secondary operations in 12 hips (6.5%). Hips of the infants after walking age and hips with higher preoperative dislocation grades, acetabular indices, and ON were more prone to having lower hip scores. Based on the data, we believe routine arthrotomy is not needed during posteromedial surgery in DDH and this modified procedure was safe and effective.
Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0127-5
PMCID: PMC2504676  PMID: 18288554
20.  Cemented Total Hip Arthroplasty With Subtrochanteric Osteotomy in Dysplastic Hips 
Background
Total hip arthroplasty (THA) in the presence of developmental dysplasia of the hip (DDH) can be technically challenging. Restoring the anatomic center of hip rotation may require femoral osteotomy. Techniques using cementless components are widely reported but less is known about using cemented components that may be more appropriate with osteopenic bone.
Questions/purposes
We therefore determined the rate of union, complications, and early functional score in a series of patients with DDH who underwent cemented THA and simultaneous subtrochanteric osteotomy.
Methods
We retrospectively reviewed 28 patients (35 hips) who underwent a cemented THA for DDH at a mean age of 47.3 years. Two patients (two hips) died within 12 months of surgery of unrelated conditions. The clinical notes and radiographs were reviewed with a minimum followup of 2 years (mean, 5.6 years; range, 2–14 years). Complications were noted. SF-12 and Oxford hip scores (OHS) were recorded for 18 patients preoperatively and after 6 and 12 months.
Results
Union occurred in 32 of 33 femora (97%); one patient had an infected nonunion. The overall revision rate was 20% (9% femoral revision rate). There were three dislocations, two of which had further surgery. Two patients had a transient neuropraxia. The mean SF-12 physical component score increased from 32 to 52 and mean SF-12 mental component score increased from 48 to 51. The mean OHS decreased from 40 to 27.
Conclusion
Combined subtrochanteric osteotomy and cemented THA is technically demanding with a higher complication rate than routine THA. The rate of union, complications, implant survival, and early OHS were comparable to those for similar techniques using cementless components.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1367-8
PMCID: PMC2974863  PMID: 20461484
21.  Pelvic Deformity Influences Acetabular Version and Coverage in Hip Dysplasia 
Background
Although a wide variety of acetabular deformities in developmental dysplasia of the hip (DDH) have been reported, the morphologic features of the entire pelvis in DDH are not well characterized and their correlation with acetabular deformity is unknown.
Questions/purposes
We determined whether there was a rotational deformity of the entire innominate bone, and if so, whether it related to acetabular version and coverage.
Patients and Methods
We examined the morphologic features of the pelvis using CT for 50 patients with DDH (82 hips). Forty normal hips were used as controls. The innominate rotation angle was determined at three levels in the axial plane. The acetabular sector angle served as an indicator of acetabular coverage of the femoral head. We evaluated the association between innominate rotation angles and acetabular version and coverage.
Results
We observed greater internal rotation of the innominate bone in patients with DDH than in the control subjects. Internal rotation of the innominate bone was associated with increased acetabular anteversion angle and acetabular inclination angle. In hips with acetabular retroversion (nine of 82 hips; 11.0 %), the entire innominate bone was externally rotated, compared with hips with acetabular anteversion. Internal rotation of the innominate bone also was associated with decreased anterior and superior acetabular coverage.
Conclusion
Our observations suggest structural abnormalities exist throughout the pelvis in DDH, and the morphologic abnormalities of the acetabulum are not caused solely by local dysplasia around the hip, but are influenced by the morphologic features of the entire pelvis.
Level of Evidence
Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1746-1
PMCID: PMC3094603  PMID: 21203874
22.  Three dimensional-CT evaluation of femoral neck anteversion, acetabular anteversion and combined anteversion in unilateral DDH in an early walking age group 
International Orthopaedics  2011;36(1):119-124.
Purpose
At present, the indications for femoral derotational osteotomy remain controversial due to the inconsistent findings in femoral neck anteversion in developmental dysplasia of the hip (DDH). Moreover, combined anteversion is not assessed in unilateral DDH using three dimensional-CT. Therefore, the purposes of our study were to observe whether the femoral neck anteversion (FA), acetabular anteversion (AA) and combined anteversion (CA) on the dislocated hips were universally presented in unilateral DDH according to the classification system of Tönnis.
Methods
Sixty-two patients with unilateral dislocation of hip were involved in the study, including 54 females and eight males with a mean age of 21.63 months (range, 18–48 months). The FA, AA and CA were measured and compared between the dislocated hips and the unaffected hips.
Results
Although no significant difference was observed in FA between the dislocated hips and the unaffected hips (P = 0.067, 0.132, respectively) in Tönnis II and III type, FA was obviously increased on the dislocated hips compared with the unaffected hips in Tönnis IV type. Increased AA on the dislocated hips was a universal finding in Tönnis II, III and IV types. Meanwhile, a wide safe range of CA from 24° to 62° was demonstrated on the unaffected hips.
Conclusion
Femoral derotational osteotomy seems not to be necessary in Tönnis II and III types in unilateral DDH. Femoral derotational osteotomy should be considered in DDH, especially in Tönnis IV type, if the CA is still above 62° and the hip joints present instability in operation after abnormal acetabular anteversion, acetabular index and acetabular coverage of the femoral head are recovered to normal range through pelvic osteotomy.
doi:10.1007/s00264-011-1337-0
PMCID: PMC3251674  PMID: 21858684
23.  Developmental Dysplasia of the Hip and Occult Neurologic Disorders 
Developmental dysplasia of the hip (DDH) is a neonatal condition with various causes. Neuromuscular dysplasia of the hip (NDH) is a sequel of neuromuscular disease, and generally presents later in childhood than DDH. Some evidence, however, supports a concept of a neuromuscular etiology of DDH: (1) a high prevalence of spinal dysraphism in DDH; and (2) abnormal sensory evoked potentials in 31% of DDH patients. To explore this suggestion we ascertained the presence of neuromuscular disease within a cohort of DDH patients, and asked whether the neuromuscular condition is the initial etiology of the dysplasia or a coincidental finding. We retrospectively reviewed patients presenting with DDH. Only those with an initial diagnosis of DDH and a subsequent diagnosis of a neuromuscular condition were assessed. Fifteen of 560 patients fulfilled the criteria, however the presence of true DDH within this group was minimal, as several cases emerged as early presenting NDH. We therefore believe it unlikely DDH has a substantial neurological etiology.
Level of Evidence: Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0118-6
PMCID: PMC2504646  PMID: 18231844
24.  Use of ultrasonography in developmental dysplasia of the hip 
Purpose
Ultrasonography has been used as a diagnostic tool in developmental dysplasia of the hip (DDH) during early infancy since the early 1980s. The aim of this review article is to summarise the technique, benefits and shortcomings of four infantile hip ultrasonography methods, focusing mainly on the Graf method, and to assess the effectiveness of ultrasonographic newborn hip screening programmes.
Methods
Several infantile hip ultrasonography methods have been defined to assess the relationship between the femoral head and acetabulum. The Graf, Harcke, Terjesen and Suzuki methods are the universally known ones. The Graf method is composed of a quantitative classification system, while the Harcke and Suzuki methods have qualitative definitions and the Terjesen method contains both quantitative and qualitative descriptions.
Results
Although the results of several studies assessing the sensitivity and consistency of the ultrasonography methods have still not proven a clear dominance of one of these techniques, the primary advantage of the Graf method is that it has a standardised examination technique, as well as a very well defined numeric hip typing system. The importance of newborn hip screening has been universally accepted, but there is still no strong evidence regarding the superiority of either universal (screening of all newborns) or selective (screening of high-risk newborns) ultrasonographic newborn hip screening programmes.
Conclusions
An effective ultrasonographic method should include simple, precise, quantitative and consistent definitions for a proper examination and diagnosis. Both universal and selective ultrasonographic newborn hip screening programmes have significantly decreased the rate of late detected DDH and lessened the need for surgical treatment.
doi:10.1007/s11832-014-0561-8
PMCID: PMC3965765  PMID: 24510434
Ultrasonography; Developmental dysplasia of the hip; Newborn hip screening
25.  Early articular cartilage degeneration in a developmental dislocation of the hip model results from activation of β-catenin 
Developmental dislocation or dysplasia of the hip (DDH) is one of the most common deformities in children. Osteoarthritis (OA) is the most frequent long-term complication. The molecular mechanism of early articular cartilage degeneration in DDH is still unclear. It is well known that β-catenin plays a crucial role in articular cartilage degeneration. The objective of this study was to verify the relationship between β-catenin and DDH cartilage degeneration. We used a DDH model that was established by modification of swaddling position in newborn Wistar rats. The hips were isolated from the DDH model rats and untreated control group at the age of 2, 4, 6 and 8 weeks. β-Catenin gene and protein were investigated by quantitative (q)RT-PCR and immunohistochemistry. Collagen X and matrix metalloproteinase (MMP)-13, markers of early cartilage degeneration, were assessed by qRT-PCR. Primary chondrocytes were cultured from cartilage of two groups at the age of 8 weeks. Expression of β-catenin, collagen X and MMP-13 was detected. Continued high expression of β-catenin was observed in cartilage from DDH model rats. mRNA and protein expression of β-catenin was significantly increased in primary chondrocytes of the DDH model compared with the control group. Collagen X and MMP-13 expression was higher in the cartilage and chondrocytes from DDH model rats than the control group. Our findings suggest that early cartilage degeneration in DDH may result from activation of β-catenin signaling.
PMCID: PMC4014217  PMID: 24817933
β-catenin; hip dysplasia; cartilage degeneration; osteoarthritis

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