detailed journal club presentation on The reliability of ultrasonography in developmental dysplasia of the hip

1. SRI SIDDHARTHA MEDICAL OLLEGE,TUMKUR
DEPARTMENT OF ORTHOPAEDICS
TOPIC:
The Reliability of Ultrasonography in Developmental Dysplasia of the Hip
How reliable is it in different hands?
Moderator: Presenter:
Dr.J.K Reddy Dr.Jaipalsinh
Professor Jr. Resident M.S Ortho
Dept. of orthopaedics. Dept. of Orthopaedics.

2. INTRODUCTION
 Klisic(1989) introduced the term “ Developmental Dysplasia of Hip”( DDH)
 Subgrouped DDH into:
1. DDH ” at risk” – Family history, breech presentation, female child, oligohydramnios, associated deformities of
torticollis, talipes & genu recurvatum.
2. DDH – Hypoplastic with limited abduction
3. DDH – reducible displacement with jerk/ click on entry
4. DDH – reducible displacement with jerk/ click on exit
5. DDH – subluxation & limited abduction
6. DDH - Dislocation with limited abduction, femoral shortening & telescoping.

3. ASSOCIATED CONDITIONS
Torticollis (15% have DDH) Metatarsus Adductus (1.5-
10%have DDH)

4. NORMAL DEVELOPMENT
 Embryonic
 7th week - acetabulum and hip formed from same mesenchymal cells
 11th week - complete separation between the two
 Proximal femoral ossific nucleus - 4-7 months

5. NORMAL HIP
 Tight fit of head in acetabulum

6. PATHOANATOMY
 Ranges from mild dysplasia --> frank dislocation
 Bony changes
 Shallow acetabulum
 Typically on acetabular side
 Femoral anteversion
 Soft tissue changes
 Usually secondary to prolonged subluxation or dislocation
 Intraarticular
 Labrum
 Inverted + adherent to capsule (closed reduction with inverted labrum assoc with increased Avascular Necrosis)
 Ligamentum teres
 Hypertrophied + lengthened
 Pulvinar
 Fibrofatty tissue migrating into acetabulum

7. FATTY TISSUE (PULVINAR THICKENS)

8. TERES LIGAMENT (ELONGATED AND THICKENED)
DOCKING THE HEAD

9. subluxated dislocated
Labrum: Cartilaginous acetabular lip.
Neolimbus: a ridge of thickened articular cartilage

10. Hourglass shape of the capsule
by the iliopsoas tendon

11. Shortened of pelvifemoral
muscles
progressive

12. PATHOANATOMY
 Soft Tissue (Intraarticular)
 Transverse acetabular ligament
 Contracted
 Limbus
 Fibrous tissue formed from capsular tissue interposed between everted labrum and acetabular rim
 Extraarticular
 Tight adductors (adductor longus)
 Iliopsoas

13. Transverse ligament (hypertrophic)

14. Obstacles to reduction
 Extraarticular
 Tight iliopsoas and adductors
 Intraarticular
 Labrum
 Ligamentum teres
 Transverse acetabular ligament
 Pulvinar
 Redundant capsule (hourglass)
 +/- limbus

15. ETIOLOGY AND EPIDEMIOLOGY
 Multifactorial
 Genetics
 If a child has DDH, risk of another child having is 6%(1 in 17)
 If parent has DDH, risk of child having is 12% (1 in 8)
 If a parent & child have DDH, risk of subsequent child having is 36% (1 in 3)
 Syndromes
 Ehler’s Danlos
 Arthrogryposis
 Larsen’s syndrome
 Intrauterine environmental factors
 Positioning (breech presentation): 15%-50% of infants with DDH are born with breech intrauterine
position
 Neurologic Disorders
 Spina Bifida

16. DIAGNOSIS
Newborn screening
 Ortolani’s and Barlow’s maneuvers with a thorough history and physical
 Warm, quiet environment with removal of diaper
 Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity etc.)
 Baseline Neuro and Spine Exam

17. ORTOLANI’S MANEUVER
* After 3 months of age tests become negative

18. BARLOW’S MANEUVER

19. DIAGNOSIS
 Key physical findings
 Asymmetry
 Limb length- Galeazzi
 Abduction ROM
 Skin folds
 Limp
 Waddilng gait / hyperlordosis - bilateral involvement

20. CLINICAL PRESENTATION(THE NEONATE):
Barlow Ortolani
clunk

21. CLINICAL PRESENTATION (THE INFANT):
Limited Abduction Galeazzi Sign
Hips
90degrees

22. CLINICAL PRESENTATION(THE INFANT):
Asymmetric Folds

23. CLINICAL PRESENTATION (THE INFANT):
Klisic Test
recognize a bilateral dislocation.
Greater
trochanter
Anterior superior
iliac spine
Normal Dislocation

24. CLINICAL PRESENTATION (THE WALKING CHILD):

25. FEMORAL NECK ANTEVERSION

26. DIAGNOSIS
Some cases still missed
At risk groups should be further screened
Requires further imaging (e.g. US) if exam is “inconclusive” AND
 First degree relative + female
 Breech
 Positive provocative maneuver (Ortolani or Barlow)
Referral to Orthopaedist

27. IMAGING
X-rays
Femoral head ossification center
 4 -7 months
Ultrasound
Operator dependent
CT
MRI
Arthrograms
Open vs closed reduction

28. IMAGING
Ultrasound
 Introduced in 1978 for evaluation of DDH
 Operator dependent
 Useful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum,
documenting reducibility

29. IMAGING STUDIES(ULTRASOUND)

31. IMAGING STUDIES (ULTRASOUND)
 ‘inclination line' is the line along the margin of the cartilaginous acetabulum
 the 'acetabular roofline' along the bony roof.
BASELINE: line of ilium which intersects
the bony and the cartilaginous portions of
the acetabulum.
As the femoral head subluxates:
decreased ALPHA angle
increased BETA angle

32. IMAGING STUDIES (ULTRASOUND)
The Ultrasound ( before 3 mo. )
Abductor M.Ilium

33. IMAGING STUDIES (ULTRASOUND)
 The ultrasonographic investigation technique developed by Graf in 1980 is gaining wide acceptance as a
radiological evaluation method in patients with DDH.
 In Graf's method, DDH is classified into (four) main groups and nine subgroups based on the patient's
age and ultrasonographic measurements.

35. ULTRASOUND
Femoral head
Abductors
Ilium

36. ULTRASOUND
Femoral head
Abductors
Ilium

37. ULTRASOUND
Femoral head
Abductors
Ilium

38. ULTRASOUND
Femoral head
Abductors
Ilium

39. ULTRASOUND
Graf’s alpha
angle

40. ULTRASOUND
Graf’s alpha
angle
>60 = normal
*line w/ ilium
bisects head 50/50

44.  Ultrasonography has a highly important role in screening for DDH.
 the reliability of ultrasonographic assessment of the hips has been investigated in
many studies.
 Most of these studies involved ultrasonographic hip images taken by a single person but
measured and interpreted by various individuals.
 In clinical practice, the application and assessment of hip ultrasonography
are completed by a single person. This assessment determines the
followup of the patient. Thus, hip ultrasonography performed on the same
person by different individuals under the same conditions will yield a
more accurate assessment of the reliability of ultrasonographic assessment
of DDH. However, very few studies have been designed in this way.
 The aim of the present study was to investigate the inter-examiner
reliability of the results of hip ultrasonography, performed and assessed by
different clinicians for the diagnosis of DDH in the same hip.

45. MATERIALS AND METHODS
 Prospective study of 50 infants from 0 to 6 months of age who presented to the hospital from
September 2012 to December 2012 were included in the study.
 All infants were brought to the hospital for a healthy child followup examination, According to
the country's health policy.
 Babies with neuromuscular disorders, neural tube defects or any type of genetic anomalies were
excluded from the study.
 Both hips of each infant were sonographically assessed by four different clinicians (two
radiologists and two orthopedists) using the method described by Graf.
 All ultrasonography examinations were performed by using a 5-MHz linear transducer and the
same ultrasound device.
 In total, 100 hips of 50 infants were evaluated. Four ultrasonographic investigations of each hip
were performed for a total of 400 ultrasonographic investigations.
 The alpha and beta angles of the hip joints were recorded and the hips were typed according to
Graf's classification system.

46. RESULTS
 ages ranged from 1 to 179 days (mean: 64.36 ± 54.47 days).
 A highly statistically significant difference was found in the distribution of the alpha measurements
among the four clinicians.
Table 1: Average alpha and beta measurements (in degrees)
Investigator Mean ±SD
Alpha measurements Beta measurements
Orthopedist-1 67.38±6.24 53.85±8.86
Orthopedist-2 65.60±5.84 50.74±7.80
Radiologist-1 65.44±4.59 44.77±6.30
Radiologist-2 62.59±4.50 44.39+5.81
SD=Standard deviation

47.  The hips were divided into four subgroups according to Graf's classification system as follows:
Mature (tip la-lb), immature (tip 2a), minor dysplasia (tip 2b-2c-D), and major dysplasia (3a-3b-4)
 Investigation of the hip types according to this classification system revealed the following
 In total, 75 hips were evaluated as mature (la/lb) by all of the examiners. No hips were evaluated
as immature (Ha) or as having minor dysplasia (Ilb/IIc/D) by all of the examiners. In addition,
none of the examiners found any major dysplasia (Illa/IIIb/IV).
 There was a statistically significant difference in the hip typing among the four physicians
Table 2: Distribution of the types
Hip type n (%)
Orthopedist-1 Orthopedist-2 Radiologist-1 Radiologist-2
1 (normal)
lla (immature)
llb/llc/D (minor
dysplasia)
Illa/IIIb/IV (major
dysplasia)
94 (94)
4(4)
2(2)
0
89 (89)
10(10)
1(1)
0
96 (96)
4(4)
0
0
84 (84)
15(15)
1(1)
0

48. DISCUSSION
 Harcke and Kumar emphasized that the person who performs the ultrasonographic
examination can achieve the necessary basic skills and techniques after performing at least
100 ultrasonography procedures.
 Graf suggested that the method is tied to the established standards, with definite rules, and is
independent of repeatable experience and skill
 In the present study, each specialist had had experience with >500 hip ultrasonography
procedures
 Although various authors have reported that the performance of ultrasonography may vary
depending on the individual.very few studies have examined the reliability in this regard.
 Bar-On et a/. stated that the reliability and agreement were markedly low in ultrasonographic
examinations performed by two different people on 150 hips.

49. DISCUSSION
 Rosendahl et al reported low agreement in ultrasonography performed by two different people.
 Roovers et al reported an agreement rate of 94.8% in hip ultrasonography examinations performed
and assessed by two different examiners on 48 hips of 24 patients.
 Peterlein et al performed a similar study, in which ultrasonography was performed on each
newborn by three investigators with different levels of experience. Interestingly, they found no
statistically significant difference between investigators measurements even when the experience
levels were highly different from each other.
 In present study, statistically significant differences were found among the results of the four
investigators.
 An agreement rate of 3.6-44.5% was determined according to the alpha angle, 0.9-45.3%
according to the beta angle, and 19.1-42.6% according to the hip type.
 the differences in agreement among the investigators in present study seem to support the idea that
hip ultrasonography is dependent on the individual

50. DISCUSSION
 In previous studies, it was shown that the disagreement was higher for beta angle and
measurement in pathological hips. Our present study also had higher disagreement for beta angle.
 The limitations of study are relatively low number of pathological hips and sample size. However,
the strength is the performance of the ultrasonography evaluation of the same infant by four
different clinicians.
 Copuroglu et al also suggested that a major reason that made the difference between the observers
was to find the correct landmarks for measuring the angles on an ultrasonographic image. He
emphasized that the observer had problems to identify the anatomical structures or they did not
handle the correct definitions.
 ultrasonography images in present study were evaluated, it was seen that standard plain was
obtained for all images [Figure l a-d]. However, these images are not an exact replica of each
other. But. the most important reason of different results was the choice of the diverse reference
point when the alpha and beta angles were measured. A large number of self performed
examinations and training in potential mistakes may improve ultrasonographic measurements.

52. CONCLUSION
 Ultrasonography of normal hips has low inter-observer reliability. It should be kept in
mind that ultrasonographic evaluation in the followup and treatment of DDH may
vary, depending on the practitioner.

53. THANK YOU…