1. New international data on hip screening.
A journey through recent findings in ddh.
Carlo Bonifacini¹
Maurizio De Pellegrin²
IRCCS Ospedale Galeazzi, Milano
IRCCS Ospedale San Raffaele, Milano
ECPCP Symposium
Vienna 2017

2. The Cost of Hip Arthroplasties.
IN ITALY: about / Year
A 5% YEARLY INCREASE IN THE NUMBER OF IMPLANTS
Yearly expense: ONE BILLION AND 300 MILLIONS EURO (1% of the National Health Fund) +
OVER 500 MILLIONS EURO FOR REHABILITATION
30% of replacements in people younger then 60 years. (Furnes)

3. How is screening performed?
“Physical examination using the Ortolani and Barlow tests is the mainstay of screening for DDH”
Jiun Lee. Dec 2008 Annals Academy of Medicine
“High quality evidence does not support ultrasound either universally or selectively to screen for DDH”
Ultrasound should not be used outside a well-designed research setting.

4. Reported sensibility: 5-98%
Are classical clinical signs predictors of DDH?
Ortolani 1937
Reported sensibility: 5-98%
High specificity.
POOR PERFORMERS
(as well as: reduced abduction, limp, hip laxitu, external rotation)
Clinical examination by GPs does not detect radiographically-defined DDH.
Asymmetrical skin folds
Hip click
Leg length
discrepancy
Sens. 46,2%
Spec. 42,6%
PPV 12,4%
NPV 81,8%
Sens. 23,1%
Spec. 75,7%
PPV 14,3%
NPV 84,8%
Sens. 30,8%
Spec. 82,4%
PPV 23,5%
NPV 87,1%

5. Conclusion: improved early routine screening for DDH in Japan.
Is a screening based on clinical examination effective?
“Overall, 199 cases (15%) were diagnosed at >1 year of age, and these included 36 cases diagnosed very late, at >3 years of age.”
The majority of the 199 cases of late diagnosis had received earlier routine [CLINICAL] screening at <1 year of age.
Conclusion: improved early routine screening for DDH in Japan.
(2017)

6. Early or late diagnosis?
When congenital dislocation of the hip (CDH) is diagnosed only after walking age, management is greatly complicated.
The failure of screening is undeniable in the present series. The mean age at diagnosis triggered by family worries about limping is the proof of this.
[…] elements to be assessed that have been reported to impair screening quality, such as maternity stay of less than 4 days or falling in a period of reduced medical presence, such as holiday periods or public holidays .

7. Residual anormalities and early diagnosis
In conclusion, both cam deformity and acetabular dysplasia are strongly related to the development of hip OA.
EARLY DIAGNOSIS IS CRITICAL
FOR A SUCCESSFUL OUTCOME
DELAYS IN MANAGEMENT RESULT IN RESIDUAL ABNORMALITIES AND DEGENERATIVE ARTHRITIS LYNN T. STAHELI

8. BACKGROUND What is the role of an early treatment in severe ddh?
ACETABULAR DEVELOPMENT
α-ANGLE
ACETABULAR INDEX AI α
TYPE I
TYPE II
TYPE III
TYPE IV
QUANTITATIVE EVALUATION OF ACETABULAR MORPHOLOGY AND MATURATION
Author
Treatment start
Roovers et al.
5weeks
Hakan et al.
15 weeks
Smith
8 months
Danielsson
10 months
Lin
15 months
Albinana et al.
16 months
What is the role of an early treatment in severe ddh?
What is considered early?

9. PURPOSE MATERIALS 51 HIPS 93 TYPE III HIPS
EVALUATION OF AGE RELATED TREATMENT IN ACHIEVING ACETABULAR MATURATION IN PATIENTS WITH SEVERE DDH
MATERIALS
51 HIPS
CONTROL GROUP
(6 type-I, 27 type IIa, 3 type IIb, 15 type IIc)
93 TYPE III HIPS
144 HIPS α
21 LEFT SIDE
72 PATIENTS
(66 F, 6 M)
30 RIGHT SIDE
21 BOTH SIDES 9

10. METHODS BIRTH TREATMENT FOR A TOTAL OF 492 US EXAMINATIONS -FIRST US-
-TIME OF DIAGNOSIS-
-TREATMENT START-
-SECOND US-
-FIRST FOLLOW UP-
-THIRD US-
-SECOND FOLLOW UP-
FOR A TOTAL OF 492 US EXAMINATIONS
TREATMENT START
MIN = 1 day
MAX = 202 days
MEAN = 21 days
STD. DEV. = 25 days
MEAN = 48 days
AFTER DIAGNOSIS
MEAN = 112 days
AFTER DIAGNOSIS
~ 7 WEEKS
~ 16 WEEKS 10

11. ALPHA ANGLE GAIN AND FOLLOW UP LENGTH

12. ALPHA ANGLE GAIN AND FOLLOW UP LENGTH
BEST FIT
SLOPE
0,0030 ± 0,018
Y- INTERCEPT
24,78 ± 2,146
95% CONFIDENCE
-0,034 to 0,039
GOODNESS OF FIT
R SQUARE
0,0004
IS SLOPE SIGNIFICANTLY NON ZERO?
P VALUE
0,8664 F
0,028
PEARSON
0,0200
95% CONFIDENCE
-0,2111 to 0,2490
LONGER TREATMENT ≠ BETTER RESULTS
IT DOES NOT MEAN THAT THE TREATMENT LENGTH CAN BE REDUCED
SHORTEST FOLLOW UP WAS 84 DAYS (12 WEEKS ~ 3 MONTHS)
AFTER 3 MONTHS THERE IS FEW FURTHER IMPROVEMENT

13. MONOLATERAL vs BILATERAL DDH
FIRST US
p value = 0,104
t = 1,643
MD 1,5 ± 0,95
95% Conf ,33 to 3,4
THIRD US
p value = 0,726
t = 0,351
MD 0,5 ± 1,4
95% Conf ,24 to 3,2
NO SIGNIFICANT DIFFERENCE AT DIAGNOSIS
NO SIGNIFICANT DIFFERENCE AT FOLLOW UP

14. TYPE III HIPS AND GENDER
FIRST US
p value = 0,43
t = 0,79
MD 1,5 ± 1,9
95% Conf ,3 to 5,3
THIRD US
p value = 0,81
t = 0,24
MD -0,71 ± 2,97
95% Conf ,6 to 5,2
NO SIGNIFICANT DIFFERENCE AT DIAGNOSIS
NO SIGNIFICANT DIFFERENCE AT FOLLOW UP

15. ALPHA ANGLE VALUES -FIRST US- -THIRD US- 15
ARE MEANS SIGNIFICANTLY DIFFERENT ?
P VALUE
< 0,0001 t 18 MD
-16 ± 0,89
95% CI
-17 to -14
ARE MEANS SIGNIFICANTLY DIFFERENT ?
P VALUE
0,0023 t
3,115 MD
-3,3 ± 1,06
95% CI
-6,0 to -0,52 15

16. 3 GROUPS 72 PATIENTS (144 HIPS) AGE < 11 DAYS AGE AGE ≥ 42 DAYS
~ < 2 WEEKS
~4 WEEKS
> 6 WEEKS
MEAN FOLLOW UP
109 DAYS
MEAN FOLLOW UP
104 DAYS
MEAN FOLLOW UP
113 DAYS

17. 3 GROUPS –FIRST US- (DIAGNOSIS)
Type III
Control
Mean = 36,4°
Mean = 54,0°
StdDev = 4,4°
StdDev = 3,9°
Difference = 17,66 ± 1,3
P VALUE < 0,0001
Type III
Control
Mean = 37,2°
Mean = 50,3°
StdDev = 4,1°
StdDev = 6,9°
Difference = 13,01 ± 1,6
P VALUE < 0,0001
Type III
Control
Mean = 39,1°
Mean = 53,2°
StdDev = 5,6°
StdDev = 7,8°
Difference = 14,07 ± 1,9
P VALUE < 0,0001 17

18. 3 GROUPS –THIRD US- (FOLLOW UP)
Type III
Control
Mean = 65,6°
Mean = 66,1°
StdDev = 5,5°
StdDev = 4,1°
Difference = 0,52 ± 1,7
P VALUE = 0,76
Type III
Control
Mean = 61,5°
Mean = 62,8°
StdDev = 3,8°
StdDev = 3,0°
Difference = 1,3 ± 1,4
P VALUE = 0,35
Type III
Control
Mean = 58,7°
Mean = 66,2°
StdDev = 7,1°
StdDev = 5,8°
Difference = 7,5 ± 2,2
P VALUE = 0,0046

19. One Way Analysis of Variance
3 GROUPS –COMPARED-
One Way Analysis of Variance
P Value
< 0,0001 F
8,34
R Square
0,185
DUNNETT’S MULTIPLE COMPARISON TEST
Mean Diff q
Significant? P<0,05
95% CI of Difference
GROUP 1 vs OTHER
0,07°
0,05 NO
-3,1 to 3,3
GROUP 2 vs OTHER
4,0°
3,32
YES
1,1 to 6,9
GROUP 3 vs OTHER
6,0°
4,1
3,5 to 9,5 19

20. 3 GROUPS –COMPARED- MATURE HIPS (α > 60°) AT THIRD US α > 60°20

21. ALPHA ANGLE GAIN AND TIME OF DIAGNOSIS
A(151/25) & B(202/10) EXCLUDED FOR GRAPHICAL PURPOSES ONLY

22. ALPHA ANGLE GAIN AND TIME OF DIAGNOSIS
BEST FIT
SLOPE
-0,097 ± 0,02
Y- INTERCEPT
27,99 ± 0,98
95% CONFIDENCE Y- INTERCEPT
26,04 to 29,95
GOODNESS OF FIT
R SQUARE
0,222
IS SLOPE SIGNIFICANTLY NON ZERO?
P VALUE
< 0,0001 F
20,28
PEARSON
-0,4713
95% CONFIDENCE
-0,63 to -0,28
y = f(x) ~ 28 – 0,1x
~ 1° LOST EVERY 10 DAYS OF DELAYED TREATMENT

23. ACETABULAR MATURATION IN TYPE III HIPS

24. ACETABULAR MATURATION FUNCTION
α = f(t) = 33,34° + 31,66° * (1-e-t/9,348)
BEST FIT VALUES Y0
33,34°
Plateau
65,01° K
0,1070
Tau
9,348
Half-Time
6,480 Weeks
Span
31,66°
95% CI Y0
30,47° to 36,21°
Plateau
61,86° to 68,15° K
0,077 to 0,136
Tau
7,307 to 12,97
Half-Time
5,0 to 8,9 Weeks
Span
28,25° to 35,08°
GOODNESS OF FIT
R SQUARE
0,52
ACETABULAR MATURATION CURVE (NORMAL HIPS) BY MATTHIESSEN:
α = f(t) = 53,2° + 11,3° * (1-e-t/8,66)

25. BEFORE 2 WEEKS OF AGE AFTER 4-6 WEEKS OF AGE AFTER 6 WEEKS OF AGE
CONCLUSION 1
IF SEVERE DYSPLASTIC HIPS ARE TREATED.
BEFORE 2 WEEKS
OF AGE
THE ACETABULAR MATURATION EQUALS THAT OF NORMAL
(SLIGHTLY DYSPLASTIC) HIPS
AFTER 4-6 WEEKS
OF AGE
THE ACETABULAR MATURATION IS INFERIOR TO THAT OF NORMAL (SLIGHTLY DYSPLASTIC) HIPS
AFTER 6 WEEKS
OF AGE
MINIMAL MATURATION IS NOT CONSTANTLY REACHED AND RESULTS ARE LESS PREDICTABLE

26. To SCREEN or NOT to SCREEN?
CONCLUSION
Negative clinical examination does not exclude a dysplastic hip.
Residual dysplasia leads to premature osteoarthritis of the hip.
Late diagnosis leads to increase in surgical procedures and worse outcome (debated)
EARLY DIAGNOSIS
IS THE KEY!
(in severe DDH)
To SCREEN or NOT to SCREEN?
Overtreating vs Overlooking.