ULTRASOUND

AND

CONGENITAL THE HIP

DYNAMIC

DISLOCATION

OF

THE

IMPORTANCE

OF

ASSESSMENT

L.

B. ENGESAETER,

D. J. WILSON,

D. NAG,

M. K. D. BENSON

From

Nuffield

Orthopaedic

Centre,

Oxford

One-hundred newborn children at high risk of hip instability were prospectively assessed clinically and by ultrasound. The decision to treat was based only on the clinical examination. At the age of three months all the children were evaluated clinically and with an anteroposterior radiograph of the pelvis. None of the standard at three relation Early and diagnosis dysplasia ultrasound measurements of acetabular months. Dynamic assessment of stability with outcome. and of the treatment hip (CDH) of congenital are important remains radiographs diagnosis nor plain dislocation to ensure difficult: of the depth and femoral head cover

was the only

ultrasound

technique

correlated with the outcome that had a significant

the clinical protocol

assessment (Bradley,

alone, Wetherill

following and

a well-established 1987). Subse-

Benson

a successful outcome. Early neither clinical examination

quent
ultrasound ment.

analysis

allowed

us
should

to
have

judge

whether
our

early
treat-

evaluation

modified

pelvis are reliable indicators of dysplasia of the hip (Zieger and Schulz 1987). Ultrasound as a diagnostic aid was popularised by Graf(1980, 1981); many subsequent papers have claimed the usefulness of this technique for early diagnosis 1987). Because assessment, dependent picture. (Clarke there protocols upon We are is geometric concerned et al 1985 ; Clarke now confidence have of natural the analyses that 1986 ; Langer in been the ultrasound described, ultrasound of the

PATIENTS One-hundred investigated. childrens hip

AND

METHODS three months were referrals to a special referred with a clinical

infants aged under They were consecutive clinic. Each was

for treatment

abnormality, a history of breech history of congenital hip disease.

chromosomal excluded. Most disorders patients were referred

delivery, Patients
from

or a family with known

diseases were the maternity

history

or neuromuscular

maturing neonatal hip has not been established ultrasonically. Furthermore it is not clear whether accurate predictions ofoutcome can be made from early ultrasound examination. Since treatment carries risks ofhip damage,

unit of the John Radcliffe der being referred by

specialists. The babies

Hospital, Oxford, general practitioners

were born between

the remainor other

June 1987 and

care

must

be taken
have used

to ensure
ultrasound

that

unnecessary

therapy
prospectively

is

avoided. We

to examine

the hips
decision

of 100 babies
to observe

referred

with
these

possible
babies

CDH.
was made

The
on

April 1988. In this period 5 079 babies were born at the John Radcliffe Hospital and a total of 125 were referred to the hip clinic. The first 100 of these babies with complete clinical data, ultrasonic and radiographic measurements At the were included infants first in this study. attendance details of the

or to treat

pregnancy,
L. B. Engesaeter, MD, PhD, Honorary Registrar in Orthopaedics D. J. Wilson, MRCP, FRCR, Consultant Radiologist D. Nag, FRCR, Senior Registrar in Radiology M. K. D. Benson, FRCS, Consultant Orthopaedic Surgeon The Nuffield Orthopaedic Centre, Windmill Road, Headington, OX3 7LD, England Correspondence should be sent to Dr. D. J. Wilson Joint Surgery

labour,
were recorded.

family
On

history,
the basis

and
of the dislocated,

the

clinical clicking,
or irre-

findings

orthopaedic

examination
subluxatable,
Oxford

each hip was designated

dislocatable, reducibly

as normal,

1989 British 030l-620X/90/2025

Editorial Society of Bone and $2.00 JBoneJointSurg[Br] 1990; 72-B: 197-201.

ducibly dislocated (Bradley et al 1987). Children with irreducibly dislocated hips were not treated in early infancy. Those with reducibly dislocated hips were splinted with either von Rosen or Pavlic appliances.

Children

with

subluxatable

or dislocatable

hips

were
197

VOL.

72-B, No. 2, MARCH

1990

198

L. B. ENGESAETER,

D. J. wILsoN,

D. NAG,

M. K. D. BENSON

splinted only if they three weeks of age.

did

not

gain

clinical

stability

by

Ultrasonography was performed at the The technique used was based on the principles by Graf (1984, 1986). A Diasonics DRF-100

first visit. described realtime

sector
Ulis,

scanner
France).

was used
The

with

a 10 MHz
examination

transducer
was

(Les
per-

ultrasound

formed in the coronal plane with the transducer positioned on the lateral aspect ofthe flexed, slightly abducted
hip (Fig. resembles 1). This method an anteroposterior produces radiograph a sonogram of the right that hip

(Figs 2 to 5). Two images were recorded for each hip. For stability testing the hip was slightly adducted, exerting longitudinal pressure along the thigh (Barlows test). Movement of the femoral
classification

head
(1986)

of more

than
dysplasia

1 mm

away

from

the acetabulum
Grafs

indicated aspects

ultrasonic
of hip

instability.
is based

on morphological
and beta angles)

and angle

measurements

(alpha

consisted

of

four

(Fig. major

6). The original classification types which have since been

subdivided (Table I) (Langer 1987). To test reproducibility of the measurement all angles were remeasured by the same
measured

observer

at a later

date.

In addition

the

amount

of

the femoral

head covered on the sonograms,

by the bony acetabulum by the method described

was by

Fig.

Standard scanning position used for testing stability. Gentle pressure is exerted along the femur while it is beinglifted with the fingersofthe hand holding the thigh. The hand holding the probe is also used to stabilise the infants back.

Figure

sonogram. type lIlA).

IV).

A diagram of a normal sonogram. Figure 3 - A normal Figure 4 - Sonogram showing a shallow acetabulum (Graf Figure 5 - Sonogram showing a subluxated hip (Graf type

NORMAL
Fig. 2

Fig.

Fig.

Fig.

THE JOURNAL

OF BONE AND JOINT

SURGERY

UlTRASOUND

AND

CONGENITAL

DISLOCATION

OF

THE

HIP

199

reduction children,

and even

was those

repeated found

at

splint

removal.

All

to be clinically

reviewed
anteroposterior alignment, maturity

and

radiographed
radiographs

at
were

three
used

normal, months.
to assess

were Plain
the

centreing of the bony

of the femoral roof measured

head, and the as an acetabular

(Morin et al 1985). The babies were then outcome:

index

classified

in four

groups

by

Group 1. Normal hips on clinical examination (stable with full movement); pelvic radiograph showing normally centred hips with acetabular angles of 25#{176} or less. Group 2. Normal hips with
which

on clinical acetabular
had been

examination angles greater

splinted

; radiologithan
for

cally immature Group 3. Hips

Fig.
Diagram of sonogram with

25#{176}.
clinical

6 the lines drawn to measure

instability, but and radiologically

at three mature

months with

were clinically acetabular angles

normal of 25#{176}

or less.
Group because 4. Hips

Grafs

angles.

in which of correlation

further were
exact

treatment
or radiological

was necessary
dysplasia.

of clinical test smaller

instability

Coefficients
squared with

calculated

with

the chitables

or Fishers numbers.

test

for contingency

RESULTS There were 64 girls and 36 boys. Delivery had been induced in 29 and a Caesarean section done in 29. The presentation was by extended breech in 30 and by breech in eight. No correlation could be found between these variables and the the sequence ofthe final outcome. The length of labour, child in the family, or a family history

of CDH

were

unrelated

to outcome.
referred by paediatricians. of the referring physician. Table One or

Most babies were II shows the diagnosis two weeks usually paedic assessment.

elapsed between referral The high spontaneous

and orthoresolution of

a
Fig. 7

minor

instability

is reflected

in the finding

of more

stable

hips by the ofthis high

the (b) by

orthopaedic risk group

surgeon (Barlow of 100 babies were

1962). Fifteen splinted, 14 in

Diagrams of sonograms with lines drawn to measure (a) ratio of acetabular depth to femoral head size (A I /A2) and the ratio representing the amount of femoral head covered the labrum (Bl/B2).

von Rosen splints and one in a Pavlic harness. Thus the treatment incidence was about 3 per 1 000. The mean age for the first ultrasound examination
was 25 days (range 5 to 81). Tables results of the ultrasound measurements criteria (1984). The average difference urement of the bony acetabular
clinic examination and that

III

Morin,
and

Harcke
(1986) : two

and MacEwen
(Fig. lines were 7). The drawn

(1985)
amount

and Zieger,
of femoral

Hilpert
head base

and IV show the based on Grafs measat the

10#{176}).

Schulz

covered
as follows

by the labrum

was expressed of the aspect

at right

as a ratio
parallel

calculated other head.

line

to Grafs

between angle
at review

the original (alpha) made

was 2.3#{176} (s.d.

line, one through through the most

Distances and expressed were

the tip lateral

labrum of the
angles

and the femoral

to the base

The

difference

in the

cartilage

roof

measurements at a mean age

was of 98

measured as ratios.

greater,
The

with
pelvis

a mean
was

of3.6#{176} (s.d.
radiographed

16#{176}).

Follow-up

after

the with

initial mild

assessment

depended

on rewas hip

the clinical
monitored. assessed checked
VOL.

problem.
Those

Children

in splints
clinical ultrasonically. examination

were

regularly
were

instability

both clinically and weekly. Ultrasound

2,

Splintage confirmed

days (range 73 to 205). Table V shows the radiographic measurements. As a result ofthe clinical and radiographic evaluation 54 babies were discharged after hip normality was confirmed at three months (group 1); 30 had clinically

72-B, No.

MARCH

1990

200

L. B. ENGESAETER,

D. J. WILSON,

D. NAG, Table Type IA/B hA I.

M. K. D. BENSON of hip dysplasia

normal

hips,

but

bony

immaturity

on

radiographs

Classification
Description

indicated the need for further follow-up (group 2); 12 had been splinted for six to 12 weeks during the first three months, but then proved to have clinically and radiographically normal hips (group 3). Four had hips that needed further treatment at three months (group 4); in all four necessary. a further period in a Pavlic harness was judged

Mature Immature retarded Retarded months Critical

a deficient

hip hip (normal development ossification and older zone.

bony

finding up to age ofthree months); of the bony edge of the acetabulum of the cartilaginous edge in infants

indicating

IIB

aged

three

All hips

classified

as Graf

type

I had

a successful
there any

IIC

Delayed
acetabular

ossification
contour of the

of the cartilaginous

edge,

with

outcome, as did many oftypes was no statistically significant of the ultrasound measurements

II and III. correlation and the

However, between final

lID lilA

Decentring

hip ; lateralisation the cartilaginous

femoral

head

outcome. acetabular showed findings no at

Specifically, the Grafangles, Graftype, Morin depth measurements, and labrum cover ratios correlation with the radiographic and clinical

Eccentric hip; echo pattern

edge

is displaced

but normal

in

IIIB

Eccentric hip ; the cartilaginous echo pattern suggesting structural Eccentric hip ; the behind the femoral
cartilaginous

edge is compressed alteration edge is dislocated

with

an altered

three

months.

This

reflects
a poor testing clinical

the frequency
ultrasound correlated assessment that

of a satisfactory

IV

downwards

outcome despite namic ultrasound surgeons initial

classification. Dywith the orthopaedic for the left hip

head

(p < 0.01), but not with ofthe dynamic component for both hips showed compared with the cantly better outcome

ofthe right hip. The results ofthe ultrasound examination predictive value when
Table II. Assessment of physician and by orthopaedic Referring Right clinical surgeon stability by referring

a strong

outcome. Stable than unstable

hips had a signifihips (p < 0.00 1).

physician
Left 48

Orthopaedic

surgeon
Left 53

Right
72

DISCUSSION There has been increasing recognition that clinical examination alone, even in the hands of dedicated experts, will not detect all cases of hip instability at birth.

Normal

61

Click Subluxatable Dislocatable Dislocated

18 6 5 2

24 10 10 2

15 3 1

24 10 2 3

The
weeks

diagnosis
after

may
delivery. to

be even
increase

more
the

elusive
promised, accuracy

in the days
simply of diagnosis,

and
and

Ultrasound

non-invasively,

thereby reducing the number of babies treated and also the number that slip through the screening net (Berman and Klenerman 1986). Our study does not address the question of population screening, rather it concerns the value of ultrasound criteria in predicting the clinical outcome. group taken To this end we deliberately selected a high-risk should during be the and the overall in the context incidence of abnormality ofthe 5 079 children born

notable differences

that of

there 10%

was for the

fairly roof angle

wide and within

scatter, 16% one for

with the standard between

cartilaginous labrum angle being deviation of the mean. We did not find any significant

correlation

study period. Several techniques for analysing the hip by ultrasound have been evaluated. In our hands, only ultrasound dynamic stability testing assisted the clinical decision whether to treat or just observe a newborn with suspect hips. in our study postpartum Ifthe numbers in the various Graftypes (Table IV) are compared with thatofa normal

the Graftypes and outcome. Graf(l986) claims that hips oftype IIC or worse have such poor osseous development
(alpha
>

43#{176}) that

they

require

treatment

irrespective

of

age. This practice seems also to be that Langer (1987). If we had followed this would have been treated. However, that clinicalexamination, we found only

recommended by advice 80 infants on the basis of the needed groups 15 babies with eight

treatment.
Grafs (1986)classification system,

distribution (Langer 1987), it is clear that we achieved our aim of studying a group at high risk of hip instability. Langer reported 0.85% of hips with Graf-type IIC or worse in an unselected population ; we found 64% of the hips to be IIC or worse. Allowing for the total number of deliveries from which our patients were selected, the figures are much the same. The average difference between the Graf angles measured on review and those from the original observations was small. However, it is

of sonographic appearance, is complicated. other ways of assessing the hip by ultrasound

developed. The ratio femoral head covered in our study has been that expresses by the bony used by

Therefore, have been

the proportion of the acetabulum measured Morin et al (1985) and claim that this measure. The a significantly
JOINT SURGERY

Terjesen, Bredland and Berg (1988). They ratio is equally accurate and easier to unstable hips in our study did not have
THE JOURNAL OF BONE AND

ULTRASOUND

AND

CONGENITAL

DISLOCATION

OF THE

HIP

201

Table III.

Review

of ultrasound

evaluation Right side Left side

TableIV.
hips in Graf

Numberof
groups

Table
taken

V. Evaluation of at age three months

radiographs

Right
de

Left
de 7 7 26 9 8
Ossific

Right side Hip position Normal Doubtful Subluxated Acetabular Mean S.d. index 24.7 5.9 nucleus 24 76

Left
side

Inverted Yes
No Ossific

labrum 2
98 nucleus

3
97

IA lB

5 4 25 12 9 26 19 0

94 5 1

94
5

Yes
No

0
100

0
100

IIA IIC

Grafangle Alpha Beta

(mean) 44 77 44 78 lIlA D

24.3 5.7

29 14 0

Dynamic testing Stable Unstable Cover of femoral Acetabulum Labrum

Yes No

24 76

86 14 head Al :A2 (mean) Bl : B2 (mean) 0.36 0.63

89 11 0.36 0.64

IIIB IV

lower
findings

ratio
of

than

the stable
et

ones,
al (1988).

which
The

is contrary
ratio

to the labrum

hand.
2 mm

Ultrasound
of movement

highlights
are easily

minimal
detectable.

displacement

: 1 to

Terjesen

depicting

cover

of the

femoral

head

by the

cartilaginous

likewise We between

bears no relation to clinical outcome. could not show any significant the alpha angle on the initial ultrasound

correlation and the

Our study suggests that in early classification and Morins ratios do not the need for splintage. In our hands, the assessment dynamic of Saies,
This study

infancy Grafs reliably predict only ultrasound outcome with was the findings

which testing Foster

was

related ofthe and hip. Lequesne

to the This (1988).

clinical

acetabular index with the findings

Although

at three months, which of Morin et al (1985).

was a significant examination the right

is in accordance
between

concurs

there

correlation

supported

clinical and ultrasonic was not matched in

of the left hip this hip. A right-handed

The ultrasound
Rheumatism
Jean

equipment
Council

by a grant from the Oxford Health Authority. was in part purchased by the Arthritis and

for Research.

We thank

the research

secretary

observer
instability

may
of

be
the

less
hip

accurate
examined

in
by

detecting
the

minor

non-dominant

Glynn for her help in collecting the data and preparing the script. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Barlow
the

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L. Ultrasound screening for hip findings in 1001 neonates. Br MedJl986;

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VOL.

72-B,

No. 2, MARCH

1990