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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics. Pediatrics. 2000; 105(4 Pt 1):896-905. Review/Other-Dx N/A DDH guideline from the American Academy of Pediatrics. N/A 4
2. Palmen K. Prevention of congenital dislocation of the hip. The Swedish experience of neonatal treatment of hip joint instability. Acta Orthop Scand Suppl. 1984;208:1-107. Review/Other-Dx N/A To review the Prevention of congenital dislocation of the hip. No results stated in abstract. 4
3. Kolb A, Schweiger N, Mailath-Pokorny M, et al. Low incidence of early developmental dysplasia of the hip in universal ultrasonographic screening of newborns: analysis and evaluation of risk factors. Int Orthop. 2016;40(1):123-127. Review/Other-Dx 2678 Newborns To evaluate the incidence and risk factors within the first neonatal weeks based on the results of the universal ultrasound hip screening program performed at a single tertiary care institution. Sonographic signs of developmental dysplasia of the hip were found in 0.24 % of the newborns. A significant negative influence of the risk factors birth weight, family history of dysplasia of the hip (DDH) and female gender on the a-angle was found. Early or pre-term delivery showed a protective potential for DDH. 4
4. Phelan N, Thoren J, Fox C, O'Daly BJ, O'Beirne J. Developmental dysplasia of the hip: incidence and treatment outcomes in the Southeast of Ireland. Ir J Med Sci. 2015;184(2):411-415. Review/Other-Dx 56 Children. To estimate the incidence and treatment outcomes of dysplasia of the hip (DDH) in the Southeast of Ireland. Fifty-six cases of developmental dysplasia of the hip (DDH) were diagnosed giving an incidence of 6.73 per 1,000 live births. 58.9% (n = 33) were referred to the clinic and began treatment early, while 41.1% (n = 23) presented late. The incidence of operative procedures was 1.08 per 1,000 live births. The incidence of those requiring surgery was higher in the late diagnosis group. 4
5. Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006; 117(3):e557-576. Review/Other-Dx N/A To gather and synthesize the published evidence regarding screening for DDH by primary care providers. Clinical examination and US identify somewhat different groups of newborns who are at risk for DDH. A significant proportion of hip abnormalities identified through clinical examination or US in the newborn period will spontaneously resolve. All surgical and nonsurgical interventions have been associated with avascular necrosis of the femoral head, the most common and most severe harm associated with all treatments of DDH. 4
6. Desteli EE, Piskin A, Gulman AB, Kaymaz F, Koksal B, Erdogan M. Estrogen receptors in hip joint capsule and ligamentum capitis femoris of babies with developmental dysplasia of the hip. Acta Orthop Traumatol Turc. 2013;47(3):158-161. Observational-Tx 15 Children. To detect the incidence of estrogen receptors in human hip joint capsule and ligamentum teres. Estrogen receptor (ER) staining rates were 1.6+/-0.2% for the ligamentum capitis femoris (LCF) and 1.3+/-0.2% for the hip joint capsule in the control groups, and 2.5+/-0.3% for the LCF and 2.0+/-0.3% for the hip joint capsule in the developmental dysphasia of the hip (DDH) groups. Estrogen receptor staining rates in the LCF and hip joint capsule control groups were significantly lower than that in the DDH groups (p<0.001). In both groups, ER rates were significantly lower in the hip joint capsule than in the LCF (p<0.01). 2
7. Mace J, Paton RW. Neonatal clinical screening of the hip in the diagnosis of developmental dysplasia of the hip: a 15-year prospective longitudinal observational study. Bone Joint J. 2015;97-B(2):265-269. Observational-Dx 201 Infant To assess the effectiveness of clinical neonatal screening using the primary outcome measure of clinically and sonographically confirmed dysplasia and instability of the hip. Their mean age was 1.62 weeks (95% confidence interval (CI) 1.35 to 1.89). Clinical neonatal hip screening revealed a sensitivity of 62% (mean, 62.6 95%CI 50.9 to 74.3), specificity of 99.8% (mean, 99.8, 95% CI 99.7 to 99.8) and positive predictive value (PPV) of 24% (mean, 26.2, 95% CI 19.3 to 33.0). Static and dynamic sonography for Graf type IV dysplastic hips had a 15-year sensitivity of 77% (mean, 75.8 95% CI 66.9 to 84.6), specificity of 99.8% (mean, 99.8, 95% CI 99.8 to 99.8) and a PPV of 49% (mean, 55.1, 95% CI 41.6 to 68.5). There were 36 infants with an irreducible dislocation of the hip (0.57 per 1000 live births), including six that failed to resolve with neonatal splintage. 3
8. de Hundt M, Vlemmix F, Bais JM, et al. Risk factors for developmental dysplasia of the hip: a meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2012;165(1):8-17. Meta-analysis 30 studies To systematically identify possible risk factors for developmental dysplasia of the hip in the general population and to quantify their associations by means of meta-analysis. No results stated in abstract. Good
9. Ortiz-Neira CL, Paolucci EO, Donnon T. A meta-analysis of common risk factors associated with the diagnosis of developmental dysplasia of the hip in newborns. Eur J Radiol. 2012;81(3):e344-351. Meta-analysis 236 studies To perform a meta-analysis on the five most common risk factors associated with developmental dysplasia of the hip (DDH) in patients less than 6 months of age. A secondary purpose was to calculate the prevalence of DDH and identify the methods (clinical exam, ultrasound, radiology) most commonly used to diagnosis DDH based on the studies included in this meta-analysis. Fixed effect and random effects models with 95% confidence intervals were calculated for each of the six risk factors. Reported relative risk ratio (RR) for each factor in newborns was: breech presentation 3.75 (95% CI: 2.25-6.24), females 2.54 (95% CI: 2.11-3.05), left hip side 1.54 (95% CI: 1.25-1.90), first born 1.44 (95% CI: 1.12-1.86), and family history 1.39 (95% CI: 1.23-1.57). A non-significant RR value of 1.22 (95% CI: 0.46-3.23) was found for mode of delivery. Good
10. Talbot CL, Paton RW. Screening of selected risk factors in developmental dysplasia of the hip: an observational study. Arch Dis Child. 2013;98(9):692-696. Observational-Dx 64 670 live births To assess the breech and family history risk factors in Developmental dysplasia of the hip (DDH). From a cohort of 64 670 live births, 2984 neonates/infants, 46.1 (95% CI 44.6 to 47.8) per 1000 live births, were referred and sonographically screened with these risk factors alone. 1360 were male, of which four were identified as having 'pathological' DDH (an incidence of 0.003 (95% CI 0.001 to 0.008)). 1624 were female, of which 45 were identified as having 'pathological' DDH (an incidence of 0.028 (95% CI 0.021 to 0.037)). This difference in incidence of 0.025 (95% CI 0.016 to 0.033) was statistically significant (p<0.001). From those who were clinically stable and screened with either or both of the two risk factors, four individuals were diagnosed with irreducible hip dislocation (0.06 (95% CI 0.024 to 0.159) per 1000 live births). All were females. 3
11. Shaw BA, Segal LS. Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. Pediatrics. 2016;138(6). Review/Other-Dx N/A To review the evaluation and referral for Developmental Dysplasia of the Hip in Infants. No results listed in abstract. 4
12. Barlow TG. Early Diagnosis and Treatment of Congenital Dislocation of the Hip. Proc R Soc Med. 1963;56:804-806. Review/Other-Dx N/A To review Early Diagnosis and Treatment of Congenital Dislocation of the Hip. No results stated in abstract. 4
13. Barr LV, Rehm A. Should all twins and multiple births undergo ultrasound examination for developmental dysplasia of the hip?: A retrospective study of 990 multiple births. Bone Joint J. 2013;95-B(1):132-134. Review/Other-Dx 26236 live births To investigate whether twins and multiple births have a higher incidence of Developmental dysplasia of the hip (DDH) than single births and determine if selective scanning should be introduced for these infants. Multiple births did not have a significantly higher incidence of DDH compared with single births (0.0030 vs 0.0023, p = 0.8939). Of the 990 multiple births, 267 had neonatal ultrasound scans and one case of DDH was diagnosed and treated successfully with a Pavlik harness. There were two late-presenting cases at eight and 14 months of age, neither of whom had risk factors for DDH and consequently had not had a neonatal scan. Whereas selective ultrasound scanning of multiple births would have led to earlier detection and treatment of the late-presenting cases, they did not have a significantly higher incidence of DDH compared with single births. 4
14. Orak MM, Onay T, Gumustas SA, Gursoy T, Muratli HH. Is prematurity a risk factor for developmental dysplasia of the hip? : a prospective study. Bone Joint J. 2015;97-B(5):716-720. Observational-Dx 221 pre-term infants; 246 term infants To investigate prematurity as a risk factor for developmental dysplasia of the hip (DDH). Ortolani's and Barlow's tests and restricted abduction were accepted as positive findings on examination. There was a statistically significant difference between pre- and full-term infants, according to the incidence of mature and immature hips (p < 0.001). The difference in the proportion of infants with an alpha angle < 60 degrees between the two groups was statistically significant (p < 0.001). The incidence of pathological dysplasia (alpha angle < 50 masculine) was not significantly different in the two groups (p = 1.000). The Barlow sign was present in two (0.5%) pre-term infants and in 14 (2.8%) full-term infants. 3
15. Quan T, Kent AL, Carlisle H. Breech preterm infants are at risk of developmental dysplasia of the hip. J Paediatr Child Health. 2013;49(8):658-663. Observational-Dx 256 breech preterm infants; 163 term infants To determine if preterm infants born in the breech position are at risk of developmental dysplasia of the hip (DDH). Three out of 129 (2.3%) preterm infants screened had DDH. For term infants, 3 out of 163 (1.8%) infants screened had DDH. The odds ratio for DDH in breech preterm infants compared with breech term infants was 1.27 (95% confidence interval 0.25 to 6.40). 3
16. Rosendahl K, Markestad T, Lie RT. Ultrasound screening for developmental dysplasia of the hip in the neonate: the effect on treatment rate and prevalence of late cases. Pediatrics. 1994; 94(1):47-52. Observational-Dx 11,925 infants To assess the effect of US screening on primary diagnosis, management and prevalence of late cases of DDH. Higher treatment rate: 3.4% US, vs 2% US high risk and 1.8% no US. For infants not subjected to treatment, US resulted in a higher follow-up rate (13%, 1.8% and 0%). Late DDH 0.3, 0.7 and 1.3 per 1,000 (P=.11). No support for generalized screening with US, clinical examiner is experienced. US may reassure and diminish the need for repeated clinical follow-up. US may have a marginal effect on late DDH. 1
17. Clarke NM, Clegg J, Al-Chalabi AN. Ultrasound screening of hips at risk for CDH. Failure to reduce the incidence of late cases. J Bone Joint Surg Br. 1989; 71(1):9-12. Review/Other-Dx 448 patients To evaluate the effect of US screening on infants at risk for CDH. 17 required treatment (3.7 per 1,000); no clinical abnormality was found in 5 of them. 81 babies had US abnormalities but did not require treatment, although US showed hip displacement in 17 of them. 4
18. Gardiner HM, Dunn PM. Controlled trial of immediate splinting versus ultrasonographic surveillance in congenitally dislocatable hips. Lancet. 1990; 336(8730):1553-1556. Observational-Dx 79 patients Possibility of delaying the treatment of dislocatable hips for 2 weeks to allow for spontaneous resolution. To elucidate the natural history of CDH, the clinical significance of the US morphological findings, and the value, reliability, and practicality of US in screening and diagnostic. The low specificity (70%) of US examination in the first week of life makes it an unsatisfactory primary method of screening at birth, but it is a most useful adjunct to the clinical screening and management of CDH. 3
19. Marks DS, Clegg J, al-Chalabi AN. Routine ultrasound screening for neonatal hip instability. Can it abolish late-presenting congenital dislocation of the hip? J Bone Joint Surg Br. 1994; 76(4):534-538. Review/Other-Dx 14,050 patients To determine whether routine US screening for neonatal hip instability can prevent late-presenting CDH. Routine US has detected cases which would have been presented late. 4
20. Mulpuri K, Song KM, Goldberg MJ, Sevarino K. Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age. J Am Acad Orthop Surg. 2015;23(3):202-205. Review/Other-Dx N/A To provide clinical practice guideline to help improve treatment and management based on the current evidence. No results stated in abstract. 4
21. Terjesen T, Holen KJ, Tegnander A. Hip abnormalities detected by ultrasound in clinically normal newborn infants. J Bone Joint Surg Br. 1996; 78(4):636-640. Review/Other-Dx 306 patients To follow progress of newborn infants in whom US examination showed abnormalities in hips. Newborn infants with abnormal and suspicious US findings who are normal on clinical examination do not need treatment from birth. 4
22. Mulpuri K, Schaeffer EK, Andrade J, et al. What Risk Factors and Characteristics Are Associated With Late-presenting Dislocations of the Hip in Infants? Clin Orthop Relat Res. 2016;474(5):1131-1137. Observational-Dx 392 patients To determine whether there were differences in (1) risk factors or (2) the nature of the dislocation (laterality and joint laxity) when comparing patients with early versus late presentation. A univariate/multivariate analysis was performed comparing key baseline demographics between early- and late-presenting patients. After controlling for relevant confounding variables, two variables were identified as risk factors for late-presenting DDH as compared with early-presenting: cephalic presentation at birth and swaddling history. Late-presenting patients were more likely to have had a cephalic presentation than early-presenting patients (88% [117 of 133] versus 65% [169 or 259]; odds ratio [OR], 5.366; 95% confidence interval [CI], 2.44-11.78; p < 0.001). Additionally, late-presenting patients were more likely to have had a history of swaddling (40% [53 of 133] versus 25% [64 of 259]; OR, 2.053; 95% CI, 1.22-3.45; p = 0.0016). No difference was seen for sex (p = 0.63), birth presentation (p = 0.088), birth weight (p = 0.90), maternal age (p = 0.39), maternal parity (p = 0.54), gestational age (p = 0.42), or family history (p = 0.11) between the two groups. Late presenters were more likely to present with an irreducible dislocation than early presenters (56% [82 of 147 hips] versus 19% [63 of 333 hips]; OR, 5.407; 95% CI, 3.532-8.275; p < 0.001) and were less likely to have a bilateral dislocation (11% [14 of 133] versus 28% [73 of 259]; OR, 0.300; 95% CI, 0.162-0.555; p = 0.002). 3
23. Eamsobhana P, Kamwong S, Sisuchinthara T, Jittivilai T, Keawpornsawan K. The Factor Causing Poor Results in Late Developmental Dysplasia of the Hip (DDH). J Med Assoc Thai. 2015;98 Suppl 8:S32-37. Observational-Dx 25 children To determine the factors that will predict poor results in walking-age children with Developmental Dysplasia of the Hip (DDH). Age > 28 months and > 30 months at the reduction is a factor resulting in poor results evaluated by Tonnis and Severin classification (p = 0.007), and (p = 0.008). Acetabular index (AI) and Center-edge angle (CE) at the time of index surgery are not statistical significant causing the poor results. Bilateral or unilateral of DDH are not statistical significant to cause poor results. 2
24. Price KR, Dove R, Hunter JB. Current screening recommendations for developmental dysplasia of the hip may lead to an increase in open reduction. Bone Joint J. 2013;95-B(6):846-850. Observational-Dx 455 infants To review the results from the past 15 years in terms of the consequences of later presentation on treatment requirements. Of children presenting before six weeks of age, 84% were treated successfully with abduction bracing, whereas 86% of children presenting after ten months eventually required open reduction surgery. This equates to a 12-fold increase in relative risk of requiring open reduction following late presentation. Increasing age at presentation was associated with an increase in the number of surgical procedures, which are inevitably more extensive and complex, with a consequent increased in cost per patient. 3
25. Wenger D, Duppe H, Tiderius CJ. Acetabular dysplasia at the age of 1 year in children with neonatal instability of the hip. Acta Orthop. 2013;84(5):483-488. Review/Other-Dx 243 infants To review the incidence of Acetabular dysplasia at the age of 1 year in children with neonatal instability of the hip. The incidence of neonatal instability of the hip (NIH) was 7 per 1,000 live births. The referral rate was 15 per 1,000. 82% of those treated were girls. The mean acetabular index was higher in dislocated hips (25.3, 95% CI: 24.6-26.0) than in neonatally stable hips (22.7, 95% CI: 22.3-23.2). Girls had a higher mean acetabular index than boys and left hips had a higher mean acetabular index than right hips, which is in accordance with previous findings. 4
26. Mahan ST, Katz JN, Kim YJ. To screen or not to screen? A decision analysis of the utility of screening for developmental dysplasia of the hip. J Bone Joint Surg Am. 2009; 91(7):1705-1719. Review/Other-Dx N/A To determine, with use of expected-value decision analysis, which newborn screening strategy leads to the best chance of having a non-arthritic hip by the age of 60 years (no screening, selective screening, or universal screening of neonates). The optimum strategy, associated with the highest probability of having a non-arthritic hip at the age of 60 years, was to screen all neonates for hip dysplasia with a physical examination and to use US selectively for infants who are at high-risk. Additional data on the costs and cost-effectiveness of these screening policies are needed to guide policy recommendations. 4
27. Novais EN, Hill MK, Carry PM, Heyn PC. Is Age or Surgical Approach Associated With Osteonecrosis in Patients With Developmental Dysplasia of the Hip? A Meta-analysis. Clin Orthop Relat Res. 2016;474(5):1166-1177. Meta-analysis 24 studies To evaluate the association between occurrence of osteonecrosis and (1) age at closed reduction; (2) age at open reduction; and (3) medial versus anterior operative approaches. Age at reduction (> 12 months versus </= 12 months) was not associated with osteonecrosis after closed reduction (OR, 1.1; 95% confidence interval [CI], 0.4-3.2; p = 0.9) or open reduction (OR, 1.1; 95% CI, 0.7-1.9; p = 0.66). The overall, adjusted incidence of osteonecrosis (>/= Grade II) was 8.0% (95% CI, 2.8%-20.6%) among patients treated with closed reduction at or before 12 months of age and 8.4% (95% CI, 3.0%-21.5%) among those treated after 12 months. Similarly, the odds of osteonecrosis after open reduction did not differ between patients treated after the age of 12 months compared with those treated at or before 12 months (OR, 1.1; 95% CI, 0.7-1.9; p = 0.7). The incidence of osteonecrosis (>/= Grade II) was 18.3% (95% CI, 11.7%-27.4%) among patients who had index open reduction at or before 12 months of age and 20.0% (95% CI, 13.1%-29.4%) among those who had index open reduction after 12 months of age. Among hips treated with open reductions, there was no difference in osteonecrosis after medial versus anterior approaches (18.7% medial versus 19.6% anterior; OR, 1.1; 95% CI, 0.5-2.2; p = 0.9). Good
28. Tibrewal S, Gulati V, Ramachandran M. The Pavlik method: a systematic review of current concepts. J Pediatr Orthop B. 2013;22(6):516-520. Review/Other-Dx 62 articles To evaluate treatment protocols, reported results and factors associated with successful outcomes. Our results have shown satisfactory clinical and radiological outcomes with the use of the harness at long-term follow-up. However, failures of harness use have been reported along with episodes of avascular necrosis. Ultrasound plays a key role in the early detection of such cases. Alternative methods of splintage have been described but larger comparative studies are required to change current practice. 4
29. Dorn U, Neumann D. Ultrasound for screening developmental dysplasia of the hip: a European perspective. Curr Opin Pediatr. 2005; 17(1):30-33. Review/Other-Dx N/A Review of literature dealing with US screening for DDH in Europe. US of the infant hip has become a gold standard for screening for DDH in European countries. 4
30. Holen KJ, Tegnander A, Bredland T, et al. Universal or selective screening of the neonatal hip using ultrasound? A prospective, randomised trial of 15,529 newborn infants. J Bone Joint Surg Br. 2002; 84(6):886-890. Experimental-Dx 15,529 infants Prospective study to evaluate whether universal (all neonates) or selective (neonates belonging to the risk groups) US screening of the hips should be recommended at birth. One late-detected hip dysplasia was seen in the universal group; 5 in the subjective group, representing a rate of 0.13 and 0.65 per 1,000, respectively. The difference in late detection between the two groups was not statistically significant (P=0.22). Recommend selective US screening for neonates with abnormal or suspicious clinical findings and those with risk factors for hip dysplasia. 1
31. Patel H. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ. 2001; 164(12):1669-1677. Review/Other-Dx N/A Review the effectiveness of, and make practice recommendations for, serial clinical examination and US screening for DDH in newborns. 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, to exclude general US screening for DDH from the periodic health examination of infants, to exclude selective screening for DDH from the periodic health examination of high-risk infants, to exclude routine radiographic screening for DDH from the periodic health examination of high-risk infants. Insufficient evidence to evaluate the effectiveness of abduction therapy but good evidence to support a period of close observation for newborns with clinically detected DDH. 4
32. Woolacott NF, Puhan MA, Steurer J, Kleijnen J. Ultrasonography in screening for developmental dysplasia of the hip in newborns: systematic review. BMJ. 2005; 330(7505):1413. Review/Other-Dx 23 databases To assess the accuracy and effectiveness of US screening of all newborn infants for DDH. US screening: sensitivity 88.5%; specificity 96.7%, positive predictive value 61.6%; negative predictive value 99.4%. Compared with clinical screening, general US screening in newborns may increase overall treatment rates. 4
33. Bracken J, Ditchfield M. Ultrasonography in developmental dysplasia of the hip: what have we learned? Pediatr Radiol. 2012;42(12):1418-1431. Review/Other-Dx N/A To review Ultrasonography in developmental dysplasia of the hip. No results stated in abstract. 4
34. Lowry CA, Donoghue VB, Murphy JF. Auditing hip ultrasound screening of infants at increased risk of developmental dysplasia of the hip. Arch Dis Child. 2005; 90(6):579-581. Review/Other-Dx 5,485 infants To determine the efficiency of hip US in detection of DDH in those without clinically dislocated hips. Among the population of infants at increased risk of DDH, the hip screening program identified 18 cases among 5,485 infants; a rate of 3.2 per 1,000. 4
35. Tonnis D, Storch K, Ulbrich H. Results of newborn screening for CDH with and without sonography and correlation of risk factors. J Pediatr Orthop. 1990; 10(2):145-152. Review/Other-Dx 1,310 patients examined by Ortolani’s and Barlow’s manual test, 2,587 patients evaluated by US To investigate the efficiency of US in the evaluation of DDH. Twice as many abduction pillows were ordered. A total of 6.54% treated patients. 52.25% of the sonographically pathological hips had no signs of instability, nor Ortolani or dislocation. 4
36. Choudry Q, Goyal R, Paton RW. Is limitation of hip abduction a useful clinical sign in the diagnosis of developmental dysplasia of the hip? Arch Dis Child. 2013;98(11):862-866. Observational-Dx 492 children To investigate the presence and severity of sonographically diagnosed developmental dysplasia of the hip (DDH) and the clinical abnormality of limitation of hip abduction (LHA) 492 children presented with LHA (55 unilateral LHA). The mean age of neonates/infants with either unilateral or bilateral LHA was significantly higher than those without (p<0.001). In the sonographic diagnosis of Graf Type III and IV dysplasias, unilateral LHA had a PPV of 40% compared with only 0.3% for bilateral LHA. The sensitivity of unilateral LHA increased to 78.3% and a PPV 54.7% after the age of 8 weeks for Graf Types III, IV and irreducible hip dislocation. 2
37. Elbourne D, Dezateux C, Arthur R, et al. Ultrasonography in the diagnosis and management of developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre randomised controlled trial. Lancet. 2002; 360(9350):2009-2017. Observational-Dx 629 patients To assess clinical effectiveness and net cost of US compared with clinical assessment alone, to provide guidance for management of infants with clinical hip instability. Use of US in infants with screen-detected clinical hip instability allows abduction splinting rates to be reduced, and is not associated with an increase in abnormal hip development, higher rates of surgical treatment by 2 years of age, or significantly higher health-service costs. 1
38. Peterlein CD, Fuchs-Winkelmann S, Schuttler KF, et al. Does probe frequency influence diagnostic accuracy in newborn hip ultrasound? Ultrasound Med Biol. 2012;38(7):1116-1120. Observational-Dx 206 consecutive newborns To give answers to the following questions: Can intraobserver variance between repeated measurements for a-angle or b-angle be reduced by use of a probe with higher resolution? Does the frequency of the probe influence reproducibility of the Graf classification? How are the results influenced by the level of investigator’s experience? Reproducibility of the Graf classification was not found to be influenced. In two of three investigators, we observed significant improvement concerning variation of the beta-angle with the 12 MHz probe. The use of high-resolution transmitters may improve diagnostic accuracy in ultrasonography of the newborn's hip. 2
39. Engesaeter LB, Wilson DJ, Nag D, Benson MK. Ultrasound and congenital dislocation of the hip. The importance of dynamic assessment. J Bone Joint Surg Br. 1990; 72(2):197-201. Observational-Dx 100 patients Prospective study to determine importance of US (dynamic assessment) in CDH. Test the reproducibility of the measurement of all US angles. The results of the dynamic component of the US examination for both hips show a strong predictive value. US dynamic stability testing assisted the clinical decision whether to treat or just observe a newborn with suspect hips. 3
40. Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment. Arch Orthop Trauma Surg. 1980; 97(2):117-133. Review/Other-Dx N/A To investigate the effectiveness of using US diagnostic devices to diagnose CHD. Major difficulties are small size of the object under examination and poor resolving power of ultrasonoscopes. The methods are good diagnostic tools. 4
41. Graf R. [The sonographic evaluation of hip dysplasia using convexity diagnosis]. Z Orthop Ihre Grenzgeb. 1983;121(6):693-702. Review/Other-Dx N/A To review the sonographic evaluation of hip dysplasia using convexity diagnosis. No results stated in abstarct. 4
42. American College of Radiology. ACR–AIUM–SPR–SRU Practice Parameter for the Performance of the Ultrasound Examination for Detection and Assessment of Developmental Dysplasia of the Hip. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/us-hip-dys.pdf. 2013. Review/Other-Dx N/A To provide Practice Parameter for the Performance of the Ultrasound Examination for Detection and Assessment of Developmental Dysplasia of the Hip. No results stated in abstract. 4
43. Terjesen T, Bredland T, Berg V. Ultrasound for hip assessment in the newborn. J Bone Joint Surg Br. 1989;71(5):767-773. Observational-Dx 1000 newborn To examine Ultrasound for hip assessment in the newborn. The mean Bony Rim Percentage (BRP) was 55.3% in girls and 57.2% in boys, a significant difference. Clinical instability occurred in 0.7% of the newborn babies, and all of the unstable hips had a BRP below the lower limit of normal. All infants with normal clinical findings and suspected abnormal hips based on ultrasound were followed up; in all but two the hips became normal spontaneously. 3
44. Roovers EA, Boere-Boonekamp MM, Mostert AK, Castelein RM, Zielhuis GA, Kerkhoff TH. The natural history of developmental dysplasia of the hip: sonographic findings in infants of 1-3 months of age. J Pediatr Orthop B. 2005; 14(5):325-330. Observational-Dx 5170 infants To examine US findings of DDH in infants. Of the normal hips at 1 month of age, 99.6% were still normal at 3 months of age. Of the immature type IIa/IIa+ and type IIa–, if untreated, 95.3% and 84.4% had become normal, respectively. Of the infants with type IIc, D and III/IV hips at the age of 1 month, 70%, 58.3% and 90.9% were treated, respectively. 4
45. Harcke HT, Grissom LE. Infant hip sonography: current concepts. Semin Ultrasound CT MR. 1994; 15(4):256-263. Review/Other-Dx N/A Description of the Dynamic Standard Minimum Sonographic Examination of the infant hip. Also reviews the classification and management of infant hip disorders. Whereas US is used increasingly to manage developmental dislocation and/or dysplasia of the hip, there is no agreement on the use of sonography for universal newborn screening. 4
46. Dias JJ, Thomas IH, Lamont AC, Mody BS, Thompson JR. The reliability of ultrasonographic assessment of neonatal hips. J Bone Joint Surg Br. 1993; 75(3):479-482. Observational-Dx 209 neonates To evaluate reliability of US assessment of neonatal hips. US of a neonatal hip is much better than radiography in defining the cartilaginous femoral head and acetabulum and can be repeated with no additional risks. 4
47. Jomha NM, McIvor J, Sterling G. Ultrasonography in developmental hip dysplasia. J Pediatr Orthop. 1995; 15(1):101-104. Observational-Dx 58 hips; 29 patients To document the repeatability and reliability of the measurements taken from the US. The interclass coefficient correlation were a=0.03, b=0.12, and the percent coverage = –0.02. The ability of examiners was important. The radiologist dealt with US very frequently, and was noted to be the most repeatable observer with an interclass coefficient correlation ranging between 0.82 and 0.89. Reliability among the 3 examiners was not consistent. If a cutoff of 55 degrees was implemented, then treatment would have changed 39 of 144 times within the examiners’ individual measurements. Even the most consistent examiner (the radiologist with an interclass coefficient correlation of 0.89) would have changed his treatment 8 of 48 times. Highly reliable examiners would alter their management decisions 17% of the time. 4
48. Rosendahl K, Aslaksen A, Lie RT, Markestad T. Reliability of ultrasound in the early diagnosis of developmental dysplasia of the hip. Pediatr Radiol. 1995; 25(3):219-224. Observational-Dx 3 groups of infants: 206, 74 and 78 To determine interobserver and intraobserver agreement in assessing hip morphology and stability by US. Interobserver: There was moderate agreement classifying hips subjectively into four morphologic categories (k=0.5) or objectively by recording Graf angle (k=0.3). Same observer (206 infants, k=0.7 and 0.8 for the two observers, respectively). There was a moderate interobserver agreement in determining hip stability (70 infants, k=0.4). Interobserver and intraobserver agreement in producing the scans is poorer than for reading. Stability and morphology may be evaluated differently by different examiners even when considerable effort is invested in standardizing procedures. 4
49. Tonnis D. Normal values of the hip joint for the evaluation of X-rays in children and adults. Clin Orthop Relat Res. 1976(119):39-47. Review/Other-Dx 2294 hips To review the Normal values of the hip joint for the evaluation of X-rays in children and adults. It is more important to look for the relationship between femoral head and acetabulum. A new measurement--the Hip Value is based on measurements of the Idelberg- Frank angle, the Wiberg angle and MZ-distance of decentralization. By statistical methods, normal and pathological joints can be separated as follows: in adult Hip Values, between 6 and 15 indicate a normal joint form; values between 16 and 21 indicate a slight deformation and values of 22 and above are indications of a severe deformation, in children in the normal range the Hip Value reaches 14; values of 15 and up are pathological. 4
50. Caffey J, Ames R, Silverman WA, Ryder CT, Hough G. Contradiction of the congenital dysplasia-predislocation hypothesis of congenital dislocation of the hip through a study of the normal variation in acetabular angles at successive periods in infancy. Pediatrics. 1956;17(5):632-641. Review/Other-Dx N/A To study the normal variation in acetabular angles at successive periods in infancy. No results stated in abstract. 4
51. Carbonell PG, de Puga DB, Vicente-Franqueira JR, Ortuno AL. Radiographic study of the acetabulum and proximal femur between 1 and 3 years of age. Surg Radiol Anat. 2009;31(7):483-487. Observational-Dx 224 x-rays in children To study the radiographic angles and the relationship between the acetabulum and the proximal femur. The acetabular index (AI) was 21.1 degrees (+/-3.8), 19.9 degrees (+/-3.5), and 16.1 degrees (+/-4.2) and epiphyseal angle (EA) was 75.8 degrees (+/-5.1), 75.9 degrees (+/-6.3), and 75.6 degrees (+/-4.7), at the ages of 1, 2, and 3 years, respectively. A significant difference was noted for AI between 2 and 3 years old (P = 0.003), but there was not significative EA decrease. No significant correlation was found between AI and EA among the different groups, nor overall (r = 0.03). Sex or side was not a significant factor for both angles. 3
52. Li Y, Xu H, Li J, et al. Early predictors of acetabular growth after closed reduction in late detected developmental dysplasia of the hip. J Pediatr Orthop B. 2015;24(1):35-39. Observational-Dx 86 patients To determine the association between the final AI and an earlier set of factors, including initial treatment age, sex, initial AI, initial center–edge (CE) angle, initial center–head distance discrepancy (CHDD), whether or not bilaterally involved, and avascular necrosis (AVN) of the femoral head. There was no difference in AI among the three groups before reduction (P=0.293). In groups A and C, the AI decreased significantly over time until 3 years after reduction and no differences were observed between the time points of 3 and 4 years. At 4 years after reduction, the AI of group C was significantly higher than that of groups A (P<0.001) and B (P=0.012). The overall AI improvement rate was 28.63%. The AI improvement rate of group A was significantly higher than that of group C (P=0.005). Pearson correlation analysis indicated no correlation between center-head distance discrepancy and the final AI (P=0.811). Linear regression suggested that age and initial AI correlated significantly with the final AI (R=0.617, F=15.031, P<0.001). Other factors, such as sex, center-edge angle of Wiberg, bilaterally involved, and avascular necrosis of the femoral head, showed no correlations with the final AI (P>0.05). According to the coefficients, initial AI (beta1=0.432, P<0.001) had greater effect than age (beta2=0.197, P=0.023) on the final AI. 2
53. Zamzam MM, Kremli MK, Khoshhal KI, et al. Acetabular cartilaginous angle: a new method for predicting acetabular development in developmental dysplasia of the hip in children between 2 and 18 months of age. J Pediatr Orthop. 2008;28(5):518-523. Observational-Dx 189 patients To find a simple, reliable, and reproducible measurement that can predict future acetabular development after successful closed reduction of developmental dysplasia of the hip (DDH). Multivariate analysis of 6 variables showed that the mean age and acetabular index at the time of closed reduction were significant to predict later acetabuloplasty, whereas acetabular cartilaginous angle (ACA) was highly significant. These 3 significant variables together had 96.58% correct prediction. The authors observed that some hips with high acetabular index developed satisfactorily, and other hips with small values required later acetabuloplasties. On the other hand, there was a clear cut value of ACA (20 degrees) under which almost all hips (99.5%) developed satisfactorily and another clear cut value of ACA (24 degrees) above which all hips (100%) needed acetabuloplasty. 2
54. Narayanan U, Mulpuri K, Sankar WN, Clarke NM, Hosalkar H, Price CT. Reliability of a New Radiographic Classification for Developmental Dysplasia of the Hip. J Pediatr Orthop. 2015;35(5):478-484. Observational-Dx 20 radiographs; 40 hips To compare the reliability of this new method with that of Tonnis, as the first step in establishing its validity and clinical utility. All 40 hips were classifiable by the International Hip Dysplasia Institute (IHDI) method by all raters. Ten of the 40 hips could not be classified by the Tonnis method because of the absence of the ossific nucleus on one or both sides. The ICC (95% confidence interval) for the IHDI method for all raters was 0.90 (0.83-0.95) and 0.95 (0.91-0.98) for the right and left hips, respectively. The corresponding ICCs for the Tonnis method were 0.63 (0.46-0.80) and 0.60 (0.43-0.78), respectively. There was no significant difference between the ICCs of the 6 experts and 2 trainees. 2
55. Boeree NR, Clarke NM. Ultrasound imaging and secondary screening for congenital dislocation of the hip. J Bone Joint Surg Br. 1994; 76(4):525-533. Review/Other-Dx 26,952 patients screened; 1,894 patients evaluated with US Prospective evaluation of a screening program for CDH which uses US to provide delayed selective screening to complement neonatal clinical screening. Treatment rate of 4.4 per 1,000. Of those referred with clinical instability, 35% did not require treatment. Dislocation or subluxation was detected in 17/643 infants referred only because they fell within one of three risk categories: breech presentation, foot deformity and family history. All 17 had normal clinical examinations. Six children presented with CDH after 12 weeks of age, giving a late presentation rate of 0.22 per 1,000 births. All had normal clinical examinations within 24 hours of birth and none was in a risk category. Surgery has been required in ten children, giving a surgical treatment rate of 0.37 per 1,000 births. 4
56. Garvey M, Donoghue VB, Gorman WA, O'Brien N, Murphy JF. Radiographic screening at four months of infants at risk for congenital hip dislocation. J Bone Joint Surg Br. 1992;74(5):704-707. Observational-Dx 13662 infants To report on a radiographic screening programme at four months of age for infants who were clinically normal at neonatal examination but were considered to be 'at risk' for congenital dislocation of the hip because of their family history, breech presentation, or a persistent click. Of these 46 had abnormal radiographs (six subluxations, 40 acetabular dysplasia). In 12 infants treatment resulted in a normal hip; 34 required no treatment but were followed up until their radiographs were normal and walking had begun. Of the 311 infants with normal radiographs, 256 (82%) were examined after 15 months of age; none had any detectable abnormality. 3
57. Gerscovich EO. A radiologist's guide to the imaging in the diagnosis and treatment of developmental dysplasia of the hip. I. General considerations, physical examination as applied to real-time sonography and radiography. Skeletal Radiol. 1997;26(7):386-397. Review/Other-Dx N/A To describe the disease, risk factors, statistics, the physical examination as applied to real-time sonography, and imaging (plain radiography, arthrography, computed tomography, and magnetic resonance imaging. No results stated in abstract. 4
58. Tudor A, Sestan B, Rakovac I, et al. The rational strategies for detecting developmental dysplasia of the hip at the age of 4-6 months old infants: a prospective study. Coll Antropol. 2007;31(2):475-481. Observational-Dx 1430 hips To provide radiographic assessment of every single ultrasonographic positive hip in infants aged from 4 to 6 months in order to see whether it affects infant splintage rate in treating developmental dysplasia of the hip (DDH). he sonographic DDH incidence was 51.75 per 1000 hips (51.75 per thousand). After X-ray examination of all 74 ultrasonographic positive hips, only 44 remained abnormal and required treatment indicating a true DDH incidence of 30.77 per 1000 hips (30.77 per thousand). The difference in incidence per ultrasonographic and X-ray positive hips is statistically significant p < 0.01 (t = 5,536). 3
59. Harcke HT, Grissom LE. Performing dynamic sonography of the infant hip. AJR Am J Roentgenol. 1990;155(4):837-844. Review/Other-Dx N/A To review the performing dynamic sonography of the infant hip. No results stated in abstract. 4
60. Roovers EA, Boere-Boonekamp MM, Castelein RM, Zielhuis GA, Kerkhoff TH. Effectiveness of ultrasound screening for developmental dysplasia of the hip. Arch Dis Child Fetal Neonatal Ed. 2005;90(1):F25-30. Observational-Dx 5170 participants To determine the effectiveness of ultrasound screening for developmental dysplasia of the hip (DDH) after the neonatal period. The sensitivity of the ultrasound screening was 88.5%, and the referral rate 7.6%. As a result of the ultrasound screening, 4.6% of the children were treated. The sensitivity of the child health care (CHC) screening was 76.4%, with a referral rate of 19.2%. The treatment rate was 2.7%. Of the treated children in the ultrasound screening group, 67% were referred before the age of 13 weeks, whereas in the CHC screening group only 29% were referred before this age. 3
61. Paton RW, Hinduja K, Thomas CD. The significance of at-risk factors in ultrasound surveillance of developmental dysplasia of the hip. A ten-year prospective study. J Bone Joint Surg Br 2005;87:1264-6. Observational-Dx 34723 infants To quantify the relationship between at-risk factors or neonatal instability and the presence of dislocation or Graf type-III dysplasia Instability of the hip was present in 77 patients, of whom only 24 (31.2%) had an associated risk factor. From the ‘at-risk’ groups, the overall risk of type-III dysplasia, instability and irreducibility was 1:15 when family history, 1:27 when breech delivery and 1:33 when foot deformity were considered as risk factors. Of those hips which were ultrasonographically stable, 88 had type-III dysplasia. 3
62. LeBa TB, Carmichael KD, Patton AG, Morris RP, Swischuk LE. Ultrasound for Infants at Risk for Developmental Dysplasia of the Hip. Orthopedics. 2015;38(8):e722-726. Observational-Dx 515 scans To assess whether ultrasound screening would increase in effectiveness if targeted toward infants with established risk factors for developmental dysplasia of the hip and normal findings on physical examination. Of the 530 cases that were reviewed, 217 had risk factors for developmental dysplasia of the hip and normal findings on physical examination. Mean age of the 217 selected patients was 6.9 weeks. Of the patients, 83% were female, 77% had breech presentation, 30% were firstborn children, 13% had intrauterine packaging abnormalities, and 3% had a family history of developmental dysplasia of the hip. Of the 217 infants, 44 had 1 risk factor, 121 had 2 risk factors, 46 had 3 risk factors, and 6 had 4 risk factors. Dynamic ultrasound evaluation showed instability in 17 patients, for a 7.8% incidence of developmental dysplasia of the hip. All 17 patients were treated with a Pavlik harness. The results suggested that selective ultrasound screening may be effective in infants with risk factors and normal findings on physical examination. Selective ultrasound screening changed treatment management in almost 8% of patients and clinical follow-up in 6.5%. 3
63. Ashby E, Roposch A. Diagnostic yield of sonography in infants with suspected hip dysplasia: diagnostic thinking efficiency and therapeutic efficiency. AJR Am J Roentgenol. 2015;204(1):177-181. Observational-Dx 66 hips To determine the impact of sonographic information on surgeons' diagnostic thinking and decision making in the management of infants with a possible diagnosis of developmental dysplasia of the hip (DDH). Sonography led to a change in diagnosis in 52% (34/66) of hips. The management plan changed in 32% (21/66) of hips. The mean gain in reported diagnostic confidence was 19.4% (95% CI, 17.3-21.5%), but it was 46.0% (95% CI, 30.5-60.8%) in cases where the management changed as a result of sonography (difference, 37.7%; p < 0.0001). The greatest yield of sonography was found in hips showing limited abduction. Sonography obviated further follow-up in 23% (15/66) of cases. 2
64. Boniforti FG, Fujii G, Angliss RD, Benson MK. The reliability of measurements of pelvic radiographs in infants. J Bone Joint Surg Br. 1997;79(4):570-575. Observational-Dx 60 anteroposterior pelvic radiographs To study the reliability of some common radiological measurements used for the diagnosis and follow-up of developmental dysplasia of the hip (DDH) in infants. There was a significant correlation between the presence of an acetabular notch on the radiograph and an increased error in measurement (p = 0.01). Yamamuro's measurement of lateral femoral displacement was more reliable than the Hilgenreiner distance. The errors of indicators of pelvic alignment showed a correlation with the age of the infant; the quotient of pelvic rotation was more reliable after seven months of age (p < 0.0001). The errors of the measurement of the symphysis os-ischium angle tended to increase with age and those of the measurement of the index of pelvic tilt decreased with skeletal maturation (p = 0.002). 3
65. Harcke HT, Lee MS, Sinning L, Clarke NM, Borns PF, MacEwen GD. Ossification center of the infant hip: sonographic and radiographic correlation. AJR Am J Roentgenol. 1986;147(2):317-321. Observational-Dx 150 cases To evaluate the ossification center of the infant's hip allowed identification of the ossific nucleus before it could be visualized radiographically. Acoustic shadowing causes the growing ossification center to appear curved and may make the medial acetabulum and triradiate cartilage difficult to identify. Sonographic hip evaluation usually ceases to be reliable in children over 1 year old. 3
66. Groarke PJ, McLoughlin L, Whitla L, Lennon P, Curtin W, Kelly PM. Retrospective Multicenter Analysis of the Accuracy of Clinical Examination by Community Physicians in Diagnosing Developmental Dysplasia of the Hip. J Pediatr. 2017;181:163-166 e161. Observational-Dx 174 patients To determine among general practitioners (GPs) the most common clinical findings that raised concern for developmental dysplasia of the hip (DDH) and necessitated an orthopedic outpatient referral. In addition, we assessed the sensitivity and specificity of the most common of these clinical findings. Twenty-six of 174 (14.9%) referred patients were diagnosed with DDH, defined as an AI score > 30. The most common indication for referral, per the GP letter was asymmetrical skin folds (97 patients, 45.8%), followed by hip click (42 patients, 19.8%), and limb shortening (34 patients, 16%). Sensitivities and specificities, respectively, among findings were asymmetric skin folds 46.2% (95% CI 26.6%-66.6%) and 42.6% (95% CI 34.5%-51.0%), hip click 23.1% (95% CI 9.0%-43.6%) and 75.7% (95% CI 67.9%-82.3%), limb shortening 30.8% (95% CI 14.3%-51.8%) and 82.4% (75.3%-88.2%), and reduced abduction 19.2% (95% CI 6.6%-39.4%) and 91.9% (95% CI 86.3%-95.7%). Using logistic regression analysis, no clinical sign was found to be a statistically significant indicator of an abnormal AI. 2
67. Andersson JE, Funnemark PO. Neonatal hip instability: screening with anterior-dynamic ultrasound method. J Pediatr Orthop. 1995; 15(3):322-324. Observational-Dx 4,430 patients To evaluate the effect of a screening program with an anterior dynamic US approach for hip dislocation. There were 5 dislocated and 1 dislocatable hips on 4 neonates; 59 dislocatable hips in 44 neonates (4 neonates received treatment). Radiographs were obtained at 18 weeks and decisions were made on the basis of US. The frequency of treatment for unstable hip joints was reduced to 0.18%, having been 1.7% without US screening. No cases of late-diagnosed dislocation were registered. The sensitivity of the pediatricians' clinical examination screening was low, only 24%. After intensive training over several years and improved clinical examination methods, our five technicians managed to increase the sensitivity to 53%. 3
68. Place MJ, Parkin DM, Fritton JM. Effectiveness of neonatal screening for congenital dislocation of the hip. Lancet. 1978; 2(8083):249-250. Review/Other-Dx N/A To examine effectiveness of neonatal screening for CDH. The effectiveness of neonatal hip testing in an urban area in which no previous special studies have been performed. Re-examination of all infants at 3-6 months is proposed to reduce the number of missed cases and so minimize late sequelae. The incidence of late diagnosed CDH is 0.78/1,000. 4
69. Poul J, Bajerova J, Sommernitz M, Straka M, Pokorny M, Wong FY. Early diagnosis of congenital dislocation of the hip. J Bone Joint Surg Br. 1992; 74(5):695-700. Observational-Dx 35,550 neonates Prospective 5 year duration to determine the effectiveness of clinical examination by orthopedic surgeon. Radiograph at 3 months of every patient with a stable hip. 775 hips were unstable or dislocated; 21 (0.6/1,000) hips missed early by clinical examination and 327 acetabular dysplasia (0.9%) found at 3 months by radiographs. Clinical evaluation by a skilled examiner is a valuable method of diagnosing DDH in neonates. 3
70. Cuomo AV, Fedorak GT, Moseley CF. A Practical Approach to Determining the Center of the Femoral Head in Subluxated and Dislocated Hips. J Pediatr Orthop. 2015;35(6):556-560. Observational-Dx 19 patients To determine the most accurate radiographic landmark to define the center of the immature femoral head in hip dysplasia, and, second, to quantitatively analyze the position of the ossific nucleus relative to the center of the femoral head. Nineteen patients of an average age of 35.5 months (range, 9 to 76 mo) yielded 22 dysplastic hips. Modified Mose circle was the most accurate technique. In subluxated hips, the center of the femoral physis was equally accurate. The ossific nucleus was the poorest estimation of the center of the femoral head. All of the ossific nuclei were located cephalad and lateral to the center of the femoral head as determined on arthrogram. 3
71. Sarkissian EJ, Sankar WN, Zhu X, Wu CH, Flynn JM. Radiographic Follow-up of DDH in Infants: Are X-rays Necessary After a Normalized Ultrasound? J Pediatr Orthop. 2015;35(6):551-555. Observational-Dx 115 infants To assess the importance of continued radiographic monitoring by contrasting the incidence of residual radiographic dysplasia to the risks of radiation exposure. We identified 115 infants with DDH who had achieved both normal ultrasonographic and clinical examinations at 3.1+/-1.1 months of age. At the age of 6.6+/-0.8 months, 17% of all infants demonstrated radiographic signs of acetabular dysplasia. Of infants left untreated (n=106), 33% had dysplasia on subsequent radiographs at 12.5+/-1.2 months of age. No significant differences were evident in either the 6- or 12-month rates of dysplasia between infants successfully treated with a Pavlik harness and infants normalizing without treatment but with a history of risk factors (P>0.05). The radiation effective dose was <0.01 mSv for the combined 6- and 12-month single-view anteroposterior radiographs of the pelvis. 3
72. Sibinski M, Adamczyk E, Higgs ZC, Synder M. Hip joint development in children with type IIb developmental dysplasia. Int Orthop. 2012;36(6):1243-1246. Observational-Dx 185 patients To analyse the results of treatment of sonographically diagnosed type IIb developmental hip dysplasia and to identify residual hip dysplasia using clinical and radiological assessment. According to the clinical classification of Mckay in Barrett's modification, all the type I and type IIb hips had very good results. No statistical differences were found between type I and IIb hips when comparing both measured radiological parameters and radiological results according to the Severin classification at latest follow-up. Using our criteria (two or more radiological parameters were outside of their normal range), 12 out of 49 type IIb hips demonstrated persistent dysplasia. Of the 12 hips, eight sonograms were normal at the end of treatment and four patients failed to normalise. No type I hips demonstrated two or more abnormal radiographic parameters at latest follow-up. 3
73. Omeroglu H, Kose N, Akceylan A. Success of Pavlik Harness Treatment Decreases in Patients >/= 4 Months and in Ultrasonographically Dislocated Hips in Developmental Dysplasia of the Hip. Clin Orthop Relat Res. 2016;474(5):1146-1152. Observational-Dx 130 children To present the following: (1) patient-related variables such as age, gender, and laterality; coexisting risk factors including family history, breech presentation, intrauterine packing, first-born girl, oligohydroamnios, and swaddling; and (2) the severity of hip dysplasia, defined by ultrasonography, are associated with differences in the success rate of Pavlik harness treatment in infants with DDH. Age was the only patient-related variable influencing the success rate of the treatment; the mean age of children in whom Pavlik harness treatment succeeded (97 +/- 38 days; 95% confidence interval [CI], 90-112) was lower than the age of those who failed (135 +/- 37 days; 95% CI, 123-147; p < 0.001). The highest success rate was obtained in children younger than age 3 months (37 of 40 [93%]) and the lowest one older than age 5 months (nine of 24 [37%]) (p < 0.001). The threshold age value related to an increased risk of failure was found to be 4 months and older, which had a sensitivity of 66% and a specificity of 77% (p < 0.001). A higher initial alpha angle was observed in the hips in which the treatment succeeded (53 degrees +/- 6 degrees ; 95% CI, 51 degrees -53 degrees ) than in those that failed (47 degrees +/- 7 degrees ; 95% CI, 45 degrees -50 degrees ; p < 0.001). The threshold alpha angle value related to an increased risk of treatment failure was 46 degrees and less, which had a sensitivity of 47% and a specificity of 86% (p < 0.001). Dislocated hips (Graf Type III and IV hips) had the lowest rate of treatment success (five of 19 [26%] and two of four [50%], respectively), whereas Graf Type IIa- hips had the highest (27 of 29 [93%]) (p < 0.001). 2
74. Lorente Molto FJ, Gregori AM, Casas LM, Perales VM. Three-year prospective study of developmental dysplasia of the hip at birth: should all dislocated or dislocatable hips be treated? J Pediatr Orthop. 2002;22(5):613-621. Observational-Dx 103 patients To present prospective study with the purpose of reducing the number of hips to be treated without the risk of developing a late hip dislocation or subluxation. When instability was still present after 2 weeks and a splint was applied (26.2%), there were no significant hip differences when compared with a control group of 50 patients (69 hips) who underwent treatment in the first days of life. 2
75. Suzuki S. Ultrasound and the Pavlik harness in CDH. J Bone Joint Surg Br. 1993;75(3):483-487. Observational-Dx 69 patients To establish strict ultrasonographic criteria for the use of the Pavlik harness. All 51 hips with type A displacement remained reduced. Of nine hips of type B, five were reduced, but the other four were not. None of the nine hips with type C dislocation became reduced with continued use of the harness. The Pavlik harness is indicated for type A and some type B dislocations, but the latter need daily ultrasound monitoring, with a change in method of treatment if type C displacement appears or if the hip is not reduced within one or two weeks. 3
76. Cashman JP, Round J, Taylor G, Clarke NM. The natural history of developmental dysplasia of the hip after early supervised treatment in the Pavlik harness. A prospective, longitudinal follow-up. J Bone Joint Surg Br. 2002;84(3):418-425. Observational-Dx 332 infants To determine the natural history of acetabular development after treatment in the harness, to ascertain the incidence of late dysplasia in those infants who were initially thought to have been successfully treated and to determine the minimum period necessary for effective radiological follow-up. Of those dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA <20 degrees) and 0.2% persistent severe late dysplasia (CEA <15 degrees). All could be identified by an abnormal CEA (<20 degrees) at five years of age, and many from the progression of the AI by 18 months. Dysplasia was considered to be sufficient to require innominate osteotomy in five (0.9%). Avascular necrosis was noted in 1% of hips treated in the harness. 1
77. Hedequist D, Kasser J, Emans J. Use of an abduction brace for developmental dysplasia of the hip after failure of Pavlik harness use. J Pediatr Orthop. 2003;23(2):175-177. Observational-Dx 15 patients To assess the use of an abduction brace as the next stage of treatment in hips that fail to stabilize in a Pavlik harness. There were no complications with regard to use of the abduction orthosis. At final follow-up of an average of 3 years and 7 months, no patient had undergone surgery and no patient had residual dysplasia or avascular necrosis of the hip. The two patients in whom both the Pavlik harness and abduction brace failed went on to successful closed reduction and spica cast application. 2
78. Malkawi H. Sonographic monitoring of the treatment of developmental disturbances of the hip by the Pavlik harness. J Pediatr Orthop B. 1998;7(2):144-149. Observational-Dx 547 patients To verify the efficacy of the Pavlik harness in the treatment of developmental disturbances of the hip (DDH) when reduction and stabilization of the hip and conclusion of the treatment are monitored by sonography. Sonographic reduction was achieved in 89.7% of the hips in 2 weeks, in 8.3% in 3 weeks, and in 2% in 4 weeks. Sonographic hip stabilization was achieved in 87.4% in 4 weeks, in 9.8% in 5 weeks, and in 2.9% in 6 weeks. Soft tissue landmarks (the cartilaginous roof angle and capsule) were used for assessment of reduction and stabilization, but for conclusion of the treatment, bony roof angle was used as well. Fulltime harness treatment averaged 2.7 months for the whole group (1.4 months for unstable hips, 2.3 months for dysplastic hips, and 3 months for dislocated hips). The harness was abandoned in five patients, four because of mother noncompliance and one because of abdominal surgery. Other serious complications, including avascular necrosis (AVN), did not occur in this study. 2
79. Ucar DH, Isiklar ZU, Kandemir U, Tumer Y. Treatment of developmental dysplasia of the hip with Pavlik harness: prospective study in Graf type IIc or more severe hips. J Pediatr Orthop B. 2004;13(2):70-74. Observational-Dx 18 patients; 22 hips To present the results of treatment with Pavlik harness and an abduction brace. Twenty-two hips of 18 patients with a mean age of 14.8+/-5.9 weeks (range, 6-26) when diagnosed were followed for an average of 24.2+/-10.8 months (range, 10-46). The hips were staged according to the classification of Graf with ultrasonography and Pavlik harness was instituted as the first line of treatment in all hips. If there was no improvement of ultrasonographic stage at the third week follow-up the harness treatment was discontinued. After the infant became too large for Pavlik harness an abduction brace was used. In all but one hip the treatment was successful (95.4%). In two hips type I avascular necrosis was noted. Of the dislocated hips 90% were reduced. 3
80. Hangen DH, Kasser JR, Emans JB, Millis MB. The Pavlik harness and developmental dysplasia of the hip: has ultrasound changed treatment patterns? J Pediatr Orthop. 1995;15(6):729-735. Observational-Dx 125 infants To compare Pavlik therapy for developmental dysplasia of the hip (DDH) without ultrasound monitoring (group A) to similar therapy with ultrasound monitoring (group B). The total number of radiographs was significantly decreased in group B. The duration of therapy was less in group B than in group A. Successfully treated hips had an average increase in alpha angle of 8.4 degrees per month. The average failure rate in hips resting in a dislocated position at the onset of Pavlik therapy was unchanged by Pavlik monitoring. 2
81. Lerman JA, Emans JB, Millis MB, Share J, Zurakowski D, Kasser JR. Early failure of Pavlik harness treatment for developmental hip dysplasia: clinical and ultrasound predictors. J Pediatr Orthop. 2001;21(3):348-353. Observational-Dx 93 patients To determine whether factors such as gender, patient age, presence of bilateral developmental dysplasia of the hip (DDH), initial clinical examination of stability, and findings on coronal ultrasound (US) images correlate with eventual failure of Pavlik harness treatment in the infant with DDH treated at our institution. Of 93 patients (137 hips), 17 (26 hips) failed Pavlik harness treatment. Univariate risk factors for failure included bilaterality, initial clinical exam, and initial ultrasound (US) percent coverage. Clinical exam and initial percent coverage were multivariate risk factors for failure. Among initially clinically dislocatable hips, a low initial US alpha angle correlated with an increased likelihood of failure. All (6/6) patients with an initially irreducible hip and an initial coverage of <20% by US eventually failed treatment. Gender, side of pathology, and age at diagnosis and initiation of treatment did not correlate with failure. Irreducibility by physical exam combined with US coverage of <20% identified a patient group that uniformly failed Pavlik harness treatment. These patients may be candidates for alternative bracing, traction, or closed or open reduction. 3
82. Ohmori T, Endo H, Mitani S, Minagawa H, Tetsunaga T, Ozaki T. Radiographic prediction of the results of long-term treatment with the Pavlik harness for developmental dislocation of the hip. Acta Med Okayama. 2009;63(3):123-128. Observational-Dx 217 hips of 192 patients To determine possible predictors for long-term results, various radiographic parameters were measured and statistically analyzed Severin's classification at the final follow-up was I or II in 71.9% and III or IV in 28.1% of the hips, respectively. Avascular necrosis of the femoral head (AVN) was seen in 10% of the hips. Stepwise multiple regression analysis was performed to retrospectively determine whether any radiographic factors were related to the final classification as Severin I/II or III/IV. Receiver operating characteristic (ROC) curves were drawn for these factors, and a Wiberg OE angle (Point O was the middle point of the proximal metaphyseal border of the femur) of 2 degrees on the 3-year radiographs was found to be the most useful screening value for judging the acetabular development of DDH cases after treatment with a Pavlik harness, with a sensitivity of 71% a specificity of 93%, and a likelihood ratio of 10.1. 2
83. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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