Prediction of Late Dysplasia Based on Ultrasound and Plain X-Ray at 6 Months.

BACKGROUND: Developmental dysplasia of the hip represents a spectrum of deformity. Residual dysplasia at 2 years of age is associated with an increased risk for osteoarthritis and functional limitations. We compared the prognostic value of 6-month imaging modalities and aimed to identify optimal diagnostic metrics for the prediction of residual dysplasia. METHODS: After IRB approval, patients who underwent Pavlik treatment between 2009 and 2018 with 2-year follow-up were identified. Sonographs [ultrasound (US)] and radiographs (x-ray) were obtained at 6-month and 2-year-old visits. Dysplasia at 2 years was defined as an acetabular index (AI) >24 degrees. Receiver operating characteristic curves were constructed to quantitatively compare the prognostic ability of US and x-ray-based measures at 6 months. Youden's index [(YI) (values range from 0 (poor test) to 1 (perfect test)] was used to evaluate existing cutoffs at 6 months of age (normal measurements: alpha angle (AA) ≥60 degrees, femoral head coverage (FHC) ≥50%, and AI <30 degrees) relative to newly proposed limits. RESULTS: Fifty-nine patients were included, of which 28.8% of patients (95% CI: 17.3 to 40.4%) had acetabular dysplasia at 2 years. After adjusting for sex, AA [Area under the Curve (AUC): 80] and AI (AUC: 79) at 6 months of age were better tests than FHC (AUC: 0.77). Current diagnostic cutoffs for AA (YI: 0.08), AI (YI: 0.0), and FHC (YI: 0.06) at 6 months had poor ability to predict dysplasia at 2 years. A composite test of all measures based on proposed cutoffs (AA ≥73 degrees, FHC > 62% and AI ≤24 degrees) was a better predictor of dysplasia at 2 years (Youden's index (YI): 0.63) than any single metric. CONCLUSIONS: The rate of residual dysplasia remains concerning. The 6-month x-ray and US both play a role in the ongoing management of the developmental dysplasia of the hip. The prediction of dysplasia is maximized when all metrics are considered collectively. Existing parameters were not accurate; We recommend the following cutoffs: AA ≥73 degrees, FHC > 62%, and AI ≤24 degrees. These cutoffs must be validated. LEVEL OF EVIDENCE: Prognostic Level II.

Twelve-week standard of care protocol longer than median time to normalization among IIc hips treated with Pavlik harness.

Best treatment protocols for infants with developmental dysplasia of the hip (DDH) are poorly defined. This study estimates the time to normalization among Graf IIc hips undergoing Pavlik harness treatment. Following institutional review board approval, patients referred for DDH evaluation at a pediatric institution between 2009 and 2018 (n = 1424 hips/712 patients) were identified. We isolated all Graf IIc hips that underwent Pavlik harness treatment (n = 132 hips/n = 106 patients). Demographic and outcome measures were collected. Normalization was defined as alpha angle greater than or equal to 60° and femoral head coverage greater than or equal to 50%. Kaplan-Meier and Cox proportional hazards regression analyses modeled time to normalization and identified factors associated with earlier normalization. Median time to normalization was 7.0 weeks. At 12 weeks standard treatment, 85.8% [95% confidence interval (CI): 80.2-91.9%] had normalized. Greater femoral head coverage [hazard ratio (HR) per 1% increase: 1.03; 95% CI: 1.01-1.05; P = 0.0068] and hip stability at treatment initiation (HR unstable vs. stable: 0.64; 95% CI: 0.44-0.93; P = 0.0192) were associated with longer time to normalization. Some patients may not need 12 weeks of Pavlik bracing, particularly those with stable presentation who normalize before week 12. Shorter treatment lengths offer benefit without sacrificing long-term outcomes. Findings reinforce growing evidence that femoral head coverage should be a more significant consideration during diagnosis and instability is a concerning finding on examination.

Reliability of the Anterior Humeral Line Index Compared With the Gartland Classification for Posteriorly Hinged Supracondylar Humerus Fractures.

The Gartland classification of pediatric supracondylar humerus (SCH) fractures is commonly used but inconsistently defined regarding type 1 and type 2 (posteriorly hinged) SCH fractures. This study examined the reliability of the anterior humeral line (AHL) index compared with the Gartland classification. Fifty consecutive SCH fractures on anteroposterior and lateral elbow radiographs in pediatric patients (age range, 18 months to 15 years) were classified by 11 observers (9 attendings and 2 residents) according to the Gartland classification (types 1, 2, and 3) and the AHL index (AHL0, AHL passes anterior to the capitellum; AHL1, anterior one-third capitellum; and AHL2, middle one-third capitellum), with recommendations for treatment (cast immobilization vs surgery). Five attendings repeated the evaluation 4 to 6 weeks later. Interobserver and intraobserver reliability were scored using kappa statistics. Interobserver agreement for AHL with AHL1 and AHL2 combined (AHL1/2) was substantial (kappa=0.68) and moderate (kappa=0.55) when differentiating between AHL1 and AHL2. Anterior humeral line intraobserver reliability was almost perfect (kappa=0.83). Overall interobserver agreement on Gartland fracture type was fair (kappa=0.36), with type 2 fractures having the lowest (kappa=0.27), and with substantial (kappa=0.71) intraobserver reliability. For treatment, the interobserver agreement was fair (kappa=0.39), with substantial intraobserver reliability (kappa=0.72). Observers agreed more when using the AHL index than when using the Gartland classification. Observers differed on the degree of extension in posteriorly hinged SCH fractures that requires closed reduction. The AHL index is a more consistent method than the Gartland classification in differentiating posteriorly hinged SCH fractures and may be useful in guiding treatment. [Orthopedics. 2018; 41(4):e502-e505.].