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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.  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
4.  Arthroscopic labral repair concomitantly performed with curved periacetabular osteotomy 
A 23-year-old female presented with pain in the left hip. Radiological examination showed developmental dysplasia of the hip (DDH) combined with acetabular retroversion and posterior wall deficiency. Findings in the physical examination were coincident with femoroacetabular impingement. At surgery, we performed curved periacetabular osteotomy concomitant with arthroscopic labral repair and osteochondroplasty, simultaneously addressing dysplastic acetabulum and femoroacetabular impingement. The final follow-up examination at 18 months showed satisfactory outcome with the D’Aubigne and Postel hip score of 17/18. In addition to accurate diagnosis, the arthroscopic procedure for associated intra- and peri-articular problems seems to help improve the surgical outcome of periacetabular osteotomy performed for patients with DDH.
Level of evidence IV.
doi:10.1007/s00167-013-2362-x
PMCID: PMC3956971  PMID: 23338661
Hip; Arthroscopy; Osteotomy
5.  Exclusion of COL2A1 and VDR as Developmental Dysplasia of the Hip Genes 
Developmental dysplasia of the hip (DDH) is a spectrum of disorders affecting the proximal femur and/or acetabulum leading to an abnormal formation of the hip. Genetic factors are involved in the etiology of DDH. Early recognition of DDH affords the best results from treatment and a better knowledge of the genetics of DDH could enhance early diagnosis. Variants in the Type II collagen (COL2A1) and vitamin D receptor (VDR) genes have been associated with patients with osteoarthritis of the hip secondary to DDH, suggesting these genes could contribute to DDH. To see whether there was linkage between the COL2A1/VDR locus and nonsyndromic DDH, we conducted a linkage study on 11 families with multiple cases of DDH. We demonstrated no evidence of linkage between the COL2A1/VDR locus and nonsyndromic DDH (LOD score < −2), suggesting, although variants in these genes could play a role in osteoarthritis in patients with DDH, they do not contribute to nonsyndromic DDH. The search for causal gene variants should proceed with other candidates.
doi:10.1007/s11999-008-0120-z
PMCID: PMC2504671  PMID: 18288556
6.  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
7.  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
8.  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
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.  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
12.  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
13.  Femoral Head Deformity after Open Reduction by Ludloff’s Medial Approach 
Ludloff’s medial approach has been described as a simple procedure for open reduction of developmental dysplasia of the hip (DDH) requiring minimal dissection and tissue disruption. Many patients undergo subsequent reconstruction of the acetabulum after skeletal maturity for residual dysplasia. Femoral head deformity reportedly influences the long-term outcome of these osteotomies. The literature suggests this deformity may be related to the patient’s age at the time of a medial approach. We therefore asked whether femoral head deformity (roundness index, femoral head enlargement) at skeletal maturity correlates with patient age at surgery. We assessed the radiographs of 40 patients (42 hips). Their mean age at surgery was 14.3 months (range, 6–31 months); the minimum followup was 10 years (mean, 15.8 years; range, 10–27 years). The mean roundness index at skeletal maturity correlated with increased age at the time of the operation (mean index, 58.3; range, 47–79) while enlargement did not. Using a medial approach for correction of DDH in older patients increases the risk of femoral head deformity at skeletal maturity.
Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0266-8
PMCID: PMC2584288  PMID: 18584265
14.  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
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 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
17.  The Presence of an Ossific Nucleus Does Not Protect Against Osteonecrosis After Treatment of Developmental Dysplasia of the Hip 
Background
Osteonecrosis (ON) is a major complication after treatment of developmental dysplasia of the hip (DDH). Several studies have explored the absence of the femoral head ossific nucleus at the time of hip reduction as a risk factor for the development of ON, but findings have been inconsistent.
Questions/purposes
We therefore determined the incidence of ON in children who underwent reduction of a dislocated hip in the presence or absence of the ossific nucleus.
Patients and Methods
We retrospectively reviewed the radiographs of 105 hips in 89 patients treated for DDH at the age of 18 months or younger. Radiographs were graded for the presence of the ossific nucleus at the time of hip reduction and for the presence of ON, as graded by the Bucholz and Ogden classification, for patients at a mean age of 10 years. We used log-binomial regression to estimate if the presence of the ossific nucleus was associated with a lower incidence of ON.
Results
We identified ON in 37 of the 105 hips (35%). The incidence of ON at 10 years was 40% in the absence of the ossific nucleus and 32% in the presence of the ossific nucleus (adjusted relative risk, 0.86; 95% confidence interval, 0.36–1.81). When only radiographic changes of Grade II and greater were considered ON, the risk was still not increased (relative risk, 1.26; 95% confidence interval, 0.62–2.56).
Conclusion
Patients with an ossific nucleus at the time of hip reduction showed a slight tendency toward better outcomes. The ossific nucleus did not protect for ON.
Level of Evidence
Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-011-1801-6
PMCID: PMC3171532  PMID: 21312075
18.  Standardized Diagnostic Criteria for Developmental Dysplasia of the Hip in Early Infancy 
Background
Clinicians use various criteria to diagnose developmental dysplasia of the hip (DDH) in early infancy, but the importance of these various criteria for a definite diagnosis is controversial. The lack of uniform, widely agreed-on diagnostic criteria for DDH in patients in this age group may result in a delay in diagnosis of some patients.
Questions/Purposes
Our purpose was to establish a consensus among pediatric orthopaedic surgeons worldwide regarding the most relevant criteria for diagnosis of DDH in infants younger than 9 weeks.
Material and Methods
We identified 212 potential criteria relevant for diagnosing DDH in infants by surveying 467 professionals. We used the Delphi technique to reach a consensus regarding the most important criteria. We then sent the survey to 261 orthopaedic surgeons from 34 countries.
Results
The response rate was 75%. Thirty-seven items were identified by surgeons as most relevant to diagnose DDH in patients in this age group. Of these, 10 of 37 (27%) related to patient characteristics and history, 13 of 37 (35%) to clinical examination, 11 of 37 (30%) to ultrasound, and three of 37 (8%) to radiography. A Cronbach alpha of 0.9 for both iterations suggested consensus among the panelists.
Conclusion
We established a consensus regarding the most relevant criteria for the diagnosis of DDH in early infancy and established their relative importance on an international basis. The highest ranked clinical criteria included the Ortolani/Barlow test, asymmetry in abduction of 20° or greater, breech presentation, leg-length discrepancy, and first-degree relative treated for DDH.
Level of Evidence
Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-011-2066-9
PMCID: PMC3210254  PMID: 21952742
19.  Re-dislocation following open reduction for developmental dysplasia of the hip 
International Orthopaedics  2005;29(3):191-194.
We have reviewed 17 patients (18 hips) who required repeat open reduction for recurrent or persistent dislocation after a previous attempt at open reduction for developmental dysplasia of the hip (DDH). The mean follow-up was 5.5 (3–15) years. At the review, five patients were limping and had limited hip motion but no pain. Six hips were classified as Severin class III or more, and avascular necrosis was evident in 11. We suggest that technical failure is usually the cause for re-dislocation in unilateral cases, as we discovered at repeat open reduction in five of six patients with unilateral dislocation. The biological behaviour of bilateral dislocations may in someway be different since in nine of 11 patients with bilateral dislocations, no obvious cause could be attributed. The outcome is usually poor.
doi:10.1007/s00264-005-0654-6
PMCID: PMC3456882  PMID: 15815903
20.  Developmental dysplasia of the hip in the newborn: A systematic review 
World Journal of Orthopedics  2013;4(2):32-41.
Developmental dysplasia of the hip (DDH) denotes a wide spectrum of conditions ranging from subtle acetabular dysplasia to irreducible hip dislocations. Clinical diagnostic tests complement ultrasound imaging in allowing diagnosis, classification and monitoring of this condition. Classification systems relate to the alpha and beta angles in addition to the dynamic coverage index (DCI). Screening programmes for DDH show considerable geographic variation; certain risk factors have been identified which necessitate ultrasound assessment of the newborn. The treatment of DDH has undergone significant evolution, but the current gold standard is still the Pavlik harness. Duration of Pavlik harness treatment has been reported to range from 3 to 9.3 mo. The beta angle, DCI and the superior/lateral femoral head displacement can be assessed via ultrasound to estimate the likelihood of success. Success rates of between 7% and 99% have been reported when using the harness to treat DDH. Avascular necrosis remains the most devastating complication of harness usage with a reported rate of between 0% and 28%. Alternative non-surgical treatment methods used for DDH include devices proposed by LeDamany, Frejka, Lorenz and Ortolani. The Rosen splint and Wagner stocking have also been used for DDH treatment. Surgical treatment for DDH comprises open reduction alongside a combination of femoral or pelvic osteotomies. Femoral osteotomies are carried out in cases of excessive anteversion or valgus deformity of the femoral neck. The two principal pelvic osteotomies most commonly performed are the Salter osteotomy and Pemberton acetabuloplasty. Serious surgical complications include epiphyseal damage, sciatic nerve damage and femoral neck fracture.
doi:10.5312/wjo.v4.i2.32
PMCID: PMC3631949  PMID: 23610749
Developmental dysplasia of the hip; Congenital; Pavlik harness; Ultrasound screening; Pelvic osteotomy
21.  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
22.  Radiographic Evaluation of the Hip has Limited Reliability 
Radiographic evaluation provides essential information regarding the diagnosis and treatment of musculoskeletal disorders. We evaluated the ability of hip specialists to reliably identify important radiographic features and to make a diagnosis based on plain radiographs alone. Five hip specialists and one fellow performed a blinded radiographic review of 25 control hips, 25 hips with developmental dysplasia (DDH), and 27 with femoroacetabular impingement (FAI). On two separate occasions, readers assessed acetabular version, inclination and depth, position of the femoral head center, head sphericity, head-neck offset, Tönnis grade, and joint congruency. Observers made a diagnosis categorizing each hip as normal, dysplastic, FAI, or combined DDH and FAI (features of both). Reliability was determined using Cohen’s kappa coefficient. Intraobserver values were highest for acetabular inclination (κ = 0.72) and determination of femoral head center position (κ = 0.77). Interobserver reliability values were highest for acetabular inclination (κ = 0.61) and Tönnis osteoarthritis grade (κ = 0.59). All other measurements, including diagnosis, had kappa values less than 0.55. We concluded many of the standard radiographic parameters used to diagnose DDH and/or FAI are not reproducible. Accordingly, a more clear set of definitions and measurements must be developed to allow for more reliable diagnosis of early hip disease.
Level of Evidence: Level III, diagnostic study. See the guidelines for authors for a complete description of the levels of evidence.
doi:10.1007/s11999-008-0626-4
PMCID: PMC2635468  PMID: 19048356
23.  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
24.  Cumulative Hip Contact Stress Predicts Osteoarthritis in DDH 
Hip stresses are generally believed to influence whether a hip develops osteoarthritis (OA); similarly, various osteotomies have been proposed to reduce contact stresses and the risk of OA. We asked whether elevated hip contact stress predicted osteoarthritis in initially asymptomatic human hips. We identified 58 nonoperatively treated nonsubluxated hips with developmental dysplasia (DDH) without symptoms at skeletal maturity; the control group included 48 adult hips without hip disease. The minimum followup was 20 years (mean, 29 years; range, 20–41 years). Peak contact stress was computed with the HIPSTRESS method using anteroposterior pelvic radiographs at skeletal maturity. The cumulative contact stress was determined by multiplying the peak contact stress by age at followup. We compared WOMAC scores and radiographic indices of OA. Dysplastic hips had higher mean peak contact and higher mean cumulative contact stress than normal hips. Mean WOMAC scores and percentage of asymptomatic hips in the study group (mean age 51 years) were similar to those in the control group (mean age 68 years). After adjusting for gender and age, the cumulative contact stress, Wiberg center-edge angle, body mass index, but not the peak contact stress, independently predicted the final WOMAC score in dysplastic hips but not in normal hips. Cumulative contact stress predicted early hip OA better than the Wiberg center-edge angle.
Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0145-3
PMCID: PMC2504672  PMID: 18288549
25.  Femoral Morphologic Differences in Subtypes of High Developmental Dislocation of the Hip 
Background
Previous studies show the shape of the femur in developmental dislocation of the hip (DDH) becomes more abnormal with increasing subluxation. Two kinds of high dislocations associated with DDH have been observed in clinical practice, one with (Type C1) and one without (Type C2) a false acetabulum. The presence or absence of a false acetabulum in high dislocated hips is associated with different loading patterns and could influence the development and shape of the proximal femur.
Questions/purposes
We therefore determined whether (1) the proximal femoral shape and dimension in Type C1 and Type C2 hips differ from each other, and (2) the femur dislocated with the same height in Types C1 and C2 hips.
Patients and Methods
We examined the following variables on 54 proximal femurs from 54 patients with high DDH (28 Type C1 hips and 26 Type C2 hips) on AP and lateral radiographs; the ML widths of the cortical and medullary canals, height of the femoral head, height of dislocation, and height of the greater trochanter. Reproducibility of the measurements was tested by two researchers with high interobserver and intraobserver agreement.
Results
The proximal femur in Type C2 hips was narrower and stovepipe shaped, with a smaller flare index (2.7 ± 0.6), compared with Type C1 hips (3.5 ± 1.2). The proximal femur migrated an average of 18 mm more superiorly in Type C2 than in Type C1 hips.
Conclusions
Our data confirm distinctions in the shape of the proximal femur in the presence and absence of a false acetabulum.
Clinical Relevance
Owing to the abnormal shapes, special implants of different geometries or modular stems may be needed for reconstruction Type C2 high dislocations.
doi:10.1007/s11999-010-1386-5
PMCID: PMC2974896  PMID: 20480403

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