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© 1996 The Journal of Bone and Joint Surgery, Inc. Clinical Screening for Congenital Dislocation of the Hip* , STARA ZAGORA, BULGARIAInvestigation performed at the Department of Orthopaedia, Higher Medical Institute, Stara Zagora
The hips of 20,417 newborns were examined within the first three days after birth and at the age of two to three months, from 1985 to 1990. One hundred and twenty-four children had abnormal findings in one or both hips and treatment was instituted. After an average duration of follow-up of six years (range, four to nine years), 122 (98 per cent) of the children had normally developed hip joints. One child had unilateral deformity of the femoral head due to ischemia, and another had bilateral anteversion as the only abnormal finding. A survey of the medical records of the only orthopaedic clinic in Stara Zagora that has a pediatric ward in which patients with hip problems are managed revealed no cases of congenital dislocation of the hip diagnosed after the age of three months in the infants born from 1985 to 1990. Clinical screening for congenital dislocation of the hip was effective in this group of patients, and a good result was noted in all but two patients who were treated for such a dislocation. Thus, a screening program is of value in the examination of all infants.
The ideal combination of factors that provides the most effective treatment for congenital dislocation of the hip is early diagnosis, atraumatic and concentric reduction, and maintenance of the reduction until normal development of the joint is obtained. Neonatal screening, developed by von Rosen29 in 1952, has been acknowledged universally1,6,9,17,23,25,26, with endorsement of the use of the so-called Ortolani sign22, first described by Le Damany15, as well as the Barlow test1 for the detection of dislocated and dislocatable hip joints. In many reports of neonatal screening, however, children who were judged to have stable hips later showed acetabular dysplasia or dislocation of the hip3,16,18,27. To solve this problem, a secondary screening procedure in early infancy2,3,17,19,20 has been suggested for the early detection of congenital dislocation of the hip. Reports of missed cases of congenital dislocation of the hip during neonatal screening3,16,18,27; the rising popularity of ultrasound10-12,14,21 and magnetic resonance imaging4,13; and, especially, the use of ultrasound as a screening method7,8 have seriously affected physicians' confidence in classic clinical screening methods and their importance in the diagnosis of congenital dislocation of the hip. The present study was undertaken to determine the results of a screening program for the early detection and treatment of congenital dislocation of the hip. The purpose was to reconfirm and reinforce confidence in clinical screening as a completely efficient method and to reassert the thesis that clinical screening of the hip joint should be an integral part of the examination of all infants.
There were 20,417 live births at the Stara Zagora Obstetric Clinic from January 1985 to December 1990. These 20,417 newborns were screened clinically for the early detection and treatment of congenital dislocation of the hip. One hundred and twenty-four children had abnormal findings in one or both hips. The clinical screening was conducted at two intervals: within the first three days after birth (primary neonatal screening) and at the age of two to three months (secondary screening). At the primary screening, all of the neonates were examined for instability of the hip joints with use of the Ortolani test15,22 to detect dislocated hips and with the Barlow test1 to detect dislocatable hips. I conducted the primary neonatal screening twice a week during my visits to the Department of Neonatology at the Stara Zagora Obstetric Clinic. Approximately 1000 infants were examined by another physician while I was on annual leave. At the secondary screening, clinical symptoms of limited or asymmetrical abduction of the hip joint and asymmetry of the skin folds were used as indicators of congenital dislocation or acetabular dysplasia. The secondary screening was performed by pediatricians working in the health centers for the care of infants in Stara Zagora. Radiographs of the hips were made for all of the two to three-month-old infants who had shown such clinical symptoms at either the neonatal or the secondary screening, and the infants were immediately seen by an orthopaedist. Each child had a special medical record, which included the range of motion of the hip joint and the time to clinical stabilization of the joints—that is, when the Ortolani sign had disappeared or whether it had persisted. Data from the radiographic examination were also recorded and included the acetabular index, the center-edge angle of Wiberg30, the migration percentage (the width of the lateral border of the proximal femoral metaphysis to the Ombrédanne-Perkins line divided by the width of the proximal femoral metaphysis from the lateral border to the medial beak of the femoral metaphysis), the neck-shaft angle, and the angle of anteversion as described by Rippstein24. The children who had a positive Ortolani or Barlow sign were managed with an abduction pillow and were re-examined every two weeks (Fig. 1). If the hip joints were clinically stable (if the Ortolani sign had disappeared) at the age of four weeks, use of the abduction pillow was continued until the age of two to three months. If the hip joints were clinically unstable (if the Ortolani sign had persisted) at this time, the child was managed for four to six weeks with a von Rosen abduction splint that had been modified by replacing the shoulder portion of the splint with straps similar to those used on a Pavlik harness. At the first radiographic examination, performed at the age of two to three months, the children in whom the acetabular index was more than 30 degrees and the migration percentage (the instability index of Reimers28) was more than 0 were then managed with a Pavlik harness. The children who had normal findings on the radiograph continued to be managed with an abduction device for an additional six to eight weeks. Treatment was discontinued when the acetabular index was less than 30 degrees and the migration percentage was 0.
A clinical and radiographic examination was performed after the children had started to walk, usually at the age of twelve to eighteen months. The range of motion at the hip joint as well as radiographic parameters, such as the acetabular index and the center-edge angle of Wiberg, were recorded.
The 100 girls and twenty-four boys were examined at an average age of six years, in December 1993 or January 1994. Thirty-nine (31 per cent) of the children were four years old, thirty-one (25 per cent) were five years old, forty-eight (39 per cent) were eight years old, and six (5 per cent) were nine years old. A retrospective analysis of the medical records of these 124 children showed that, for 119 (96 per cent), the dislocation of the hip was diagnosed at the primary neonatal screening and treatment was initiated during the first three days of life. Fifty-seven (48 per cent) of these 119 children had a positive Ortolani sign, and sixty-two (52 per cent) had a positive Barlow sign. The left hip was involved in sixty-one children; the right hip, in twenty-seven; and both hips, in thirty-one. For the remaining five children (4 per cent), the dislocation was diagnosed at the secondary screening and treatment was initiated at the age of two to three months. These five children had limited or asymmetrical abduction of the hip as well as asymmetrical skin folds. Two had not been examined at the neonatal screening as they had been taken to the intensive-care unit immediately after birth and were subsequently discharged without being examined. They were seen by an orthopaedic surgeon at the age of two months and were referred for treatment. Another child had had normal findings at the neonatal screening. The remaining two children had had abnormal findings at the neonatal screening but had not been brought for a check-up after discharge from the nursery. Four of these five children were managed successfully with a Pavlik harness. The fifth child was also managed with a Pavlik harness, but avascular necrosis of the femoral head developed. Eighty-six (72 per cent) of the 119 children for whom the diagnosis was made at the neonatal screening had clinical stabilization of the hip joints within the first four weeks of life and were managed with an abduction pillow only. Seven children (6 per cent) had persistent clinical instability of the hip joint at the age of four weeks and were then managed with the modified von Rosen abduction splint for four to six weeks. None of the children were treated successfully with the splint, and they were subsequently managed with a Pavlik harness. Twenty-six children (22 per cent) were managed with a Pavlik harness after the use of the abduction pillow. Of the thirty-one children who had clinical instability (a positive Ortolani or Barlow sign) bilaterally at the neonatal examination, seven were managed with an abduction pillow, a modified abduction splint, and a Pavlik harness. All seven had normal development of the hip joints. Of the other twenty-four children, fourteen were managed initially with an abduction pillow and then with a Pavlik harness and ten were managed with an abduction pillow and then with so-called abduction pants. There was normal development of the hip joints in all but one patient, who had increased anteversion of the proximal end of the femur bilaterally as the only abnormal finding. At the first radiographic examination, at the age of two or three months, 102 children (82 per cent) had an acetabular index of 18 to 25 degrees, a migration percentage of 0, and spherical and symmetrical ossific nuclei of the femoral head that were located deep in the acetabulum. Fifteen children (12 per cent) had acetabular dysplasia only—that is, an acetabular index of 32 to 38 degrees. The dysplasia was bilateral in three children (2 per cent) and unilateral in twelve (10 per cent). Seven children (6 per cent) had displacement of the hip joint, which was unilateral in three and bilateral in four. The acetabular index in these seven children ranged from 36 to 48 degrees, and the migration percentage ranged from 37 to 43 in four and from 69 to 100 in three. The complete treatment period lasted an average of three and a half months (range, three to seven months). At the second radiographic examination, all but one of the 124 children were seen to have normally developed hips. The girl who did not had had a positive Ortolani sign of the left hip at the neonatal screening. The parents objected to the treatment and it was discontinued. At the secondary screening at the age of three months, the girl was examined by a regional pediatrician and was found to have limited abduction, which was greater on the left side. Radiographs that were made at that time showed bilateral acetabular dysplasia and subluxation that was more severe on the left (Fig. 2-A). The acetabular index was 36 degrees on the left and 27 degrees on the right, and the migration percentage was 35 on the left and 26 on the right. A Pavlik harness was applied immediately and was used strictly and continuously until the age of six months and twenty-one days (Fig. 2-B). Treatment was discontinued when the acetabular index was 23 degrees on the left side and 21 degrees on the right side and the migration percentage was 0 bilaterally. Radiographs that were made at the age of eighteen months (Fig. 2-C) showed a hypoplastic ossific nucleus of the left femoral head, with an acetabular index of 20 degrees on that side and 19 degrees on the right side and a migration percentage of 0 bilaterally. When the child was six years old (Fig. 2-D), radiographs documented residual type-I ischemic necrosis5 of the left femoral head. The left acetabulum showed normal development, with an acetabular index of 19 degrees; the femoral head remained centered. The epiphyseal index of Eyre-Brook28 was twenty-nine on the left side, and the epiphyseal quotient, as measured with the method of Sjövall28, was 71 per cent, indicating a satisfactory recovery of the left capital femoral epiphysis. The center-edge angle of Wiberg was 25 degrees on the left side. The motion of both hips was normal.
At an average age of six years, 122 of the 124 children had normally developed hip joints (Figs. 3-A, 3-B, and 3-C). The average acetabular index was 17 degrees (range, 15 to 19 degrees), and the average center-edge angle of Wiberg was 29 degrees (range, 25 to 33 degrees). One of the remaining two children was the girl who was just described, and the other was a five-year-old boy in whom the only abnormal finding was increased anteversion of the proximal end of the femur bilaterally; motion of the hip was normal.
The purpose of this study was to confirm the value of clinical screening as an integral part of the over-all treatment of congenital dislocation of the hip, to evaluate the diagnostic value of the clinical tests used in a screening program for early diagnosis and treatment, and to evaluate the efficacy of the therapeutic devices used in the treatment program. The early and late results show that a well organized screening program with the use of clinical tests is highly efficient, especially if it is conducted strictly by a set team of qualified and experienced specialists. The good results in the present study are in full accord with those obtained by others with the use of screening procedures for congenital dislocation of the hip1,6,9,17,23,26,27,29. The therapeutic devices used in a program such as the one that I described are simple and easy to apply. They yield good results in the treatment of the various degrees of severity of clinical and radiographic manifestations of congenital dislocation of the hip and acetabular dysplasia. In the present series, the tendency was to apply the most suitable treatment devices, in part according to the age of the patient but predominantly according to the severity of the abnormality in the development of the hip joint. This is in accord with the opinions of other authors27 that the goal is to determine the appropriate treatment devices and not to use one device to solve problems of various degrees of severity. That is why the initial treatment was begun with the simplest abduction device possible, an abduction pillow. The modified von Rosen abduction splint has been used for children who have a clinically persisting Ortolani sign at the age of two to three weeks. Seven children in the present study had a persistent Ortolani sign at the age of four weeks (Figs. 3-A, 3-B, and 3-C), and they were treated with the von Rosen splint for four to six weeks. It provided better maintenance of the hips in a reduced position, and the daily care of these children was performed by their parents without difficulty. The splint was employed until the instability had resolved, as evidenced by the disappearance of the Ortolani sign, and its use was not associated with any complications. The Pavlik harness was used after the age of two to three months for patients who had radiographic evidence of dislocation of the hip or acetabular dysplasia. The only patient in the present study who had ischemia of the femoral head was managed with a Pavlik harness from the age of three months until the age of six months and twenty-one days (Figs. 2-A, 2-B, 2-C, through 2-D). In my opinion, ischemia of the femoral head is not related to the use of the therapeutic device itself but to the forced abduction of the hip joints if the device is applied incorrectly. A survey of the medical records of the only pediatric orthopaedic ward in Stara Zagora revealed that no new cases of congenital dislocation of the hip were diagnosed after the age of three months in the infants born from January 1985 to December 1990. Screening at two age-intervals—neonatal and early infancy—enables the complete evaluation of all children, and congenital dislocation of the hip can be diagnosed at an age when treatment is effective, single therapeutic devices can be used, and there are few complications. Thus, I believe that clinical screening should be an integral part of the examination of all newborns.
NOTE: The author is obliged to Professor Dr. Rosen Ivanov and Assistant Professor Petar Tivchen for their assistance in the organization of, and his training for, the screening program as well as for their advice concerning this paper.
*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. No funds were received in support of this study.
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