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Natural progression of hip dysplasia in newborns: a reflectionof hip ultrasonographic screenings in newborn nurseriesHui-Wen Chen a,d , Chia-Hsieh Chang e , Suei-Tsau Tsai a , Wen-Jiunn Liub ,Ceferino Chua b , Yu-Ying Chenc and Ken N. Kuof

Hip screening is recommended for early detectionof hip dysplasia; however, the strategy and efficacy werequestioned. We performed ultrasonography to objectivelyobserve the hip development in a group of infantsand raise reflections on the efficacy of newbornultrasonographic hip screening. A total of 1333 newborns(705 male and 628 female) received hip ultrasonographyin the first week after birth. Clinical hip instability wasdetected by the Ortolani test. Hip dysplasia was definedby ultrasonography. A second survey of 90 babies wasperformed 1 month later on the babies with clinical hipinstability or ultrasonographic Graf’s type IIa, I Ic, D, III,and IV hips. All the hip ultrasonographies were performedby the same investigator. Clinical instability was detectedin 13 hips of 10 babies. Manual tests helped to detectunstable hips that had worse ultrasonographicmeasurements than those stable hips. Five Graf’s type IIchips and four type III hips were detected from the 2666hips. At the age of 1 month, eight of the nine Graf’s type IIcor III hips attained physiological status without treatment.A strong trend of spontaneous resolution in clinical hip

instability and ultrasonographic dysplasia was observedin the newborns. The results did not support immediatetreatment on the basis of newborn manual or ultrasoundhip screening. We recommend manual testing in thenewborn nursery to detect the hips at risk of dysplasia andultrasonography after the first month after birth to confirm thediagnosis and judge the management. J Pediatr Orthop B19:418–423 c 2010 Wolters Kluwer Health | LippincottWilliams & Wilkins.

Journal of Pediatric Orthopaedics B 2010, 19:418–423

Keywords: developmental dysplasia of the hip, neonatal screening,ultrasonography

Departments of a Pediatrics, b Orthopedics, c Child Rehabilitation Center, TaiwanAdventist Hospital, d Department of Pediatrics, Buddhist Tzu Chi GeneralHospital, Taipei, e Department of Pediatric Orthopedics, Chang Gung MemorialHospital, Chang Gung University,Taoyuan and fCenter for Health Policy Researchand Development, National Health Research Institute, Miaoli, Taiwan

Correspondence to Ken N. Kuo, MD, Center for Health Policy R&D, NationalHealth Research Institute, 35 Keyan Road, Zhunan Town, Miaoli County 35053,TaiwanTel: + 886 37 246166 x36300; fax: + 886 37 586261;e-mail: [email protected]

IntroductionDevelopmental dysplasia of the hip (DDH) is the mostcommon musculoskeletal disorder in infants. DDH is acorrectable deformation and early splinting restores thenormal hip anatomy in more than 90% of the patients [1–3].For early detection and treatment, hip screening by manual tests has been the standard in newborn nurseriesand baby clinics. Despite excellent results from newbornhip screening, as shown in some studies [4–7], incidencesof late diagnosed DDH continue to occur [8–10].

Since the first application of ultrasound to visualize infanthips in the early 1980s [11,12], it has became an estab-lished method to detect hip dysplasia and monitor thecourse of treatment [13,14]. The use of ultrasound inhip screening was reported to decrease the rate of latediagnosed DDH [15–17]. However, the strategy of ultra-sound screening, universal or selective, is still debatable[18–21]. The optimal timing of ultrasound examinationin newborn nurseries or before 3 months of age is alsocontroversial [22,23].

On account of the local folk custom in Taiwan whereinthe mother and baby were expected to stay home for1 month after birth, most of the babies with clinicalinstability of the hip or abnormal hip ultrasound, which is

detected in a newborn nursery, had no treatment in thefirst month after birth. This offered an opportunity toobserve the natural outcome of neonatal hip instability and ultrasonographic dysplasia. The aim of this observa-tional study is to offer evidence from a group of accidentally untreated patients and raise reflections on the efficacy of newborn hip screening.

Patients and methodsFrom April 2006 to December 2007, all women who gavebirth in the authors’ hospital were informed of hipultrasonographic study. Procedures and possible problemswere explained by one of the authors. Participation in thestudy was voluntary. The medical records of babies whoreceived hip ultrasonography in the first week after birthwere reviewed. The study was approved by the hospital’sinstitutional review board.

The newborns were placed in a supine position withoutsedation. The stability of the hip joints was evaluatedmanually by the Ortolani test [24]. For the ultrasono-graphic study, the hips of the newborns were examinedin slight flexion and neutral in axial rotation andabduction-adduction. A linear-array ultrasound transducerwas applied horizontally at the lateral aspect of the hip.

418 Original article

1060-152X c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/B PB.0b013e328339ecff



The proximal femur and straight line of the ilium wereidentified to determine the plane crossing the mid-portion of the acetabulum.

Graf’s a and b angles [11,12] were measured. Thea angle, an indicator of acetabular development by measuring the bony roof, is defined as the angle between

the iliac line and the line from the bony edge of theacetabulum superior laterally to the lowest point of theilium inferior medially. The b angle, an indicator of hipdisplacement by measuring the cartilaginous roof, isdefined as the angle between the iliac line and the linefrom the bony edge of the acetabulum to the labrumlaterally.

All hip ultrasonographies were performed by one pedia-trician who was trained to perform musculoskeletal ultra-sonographic evaluation. We randomly chose 20 successivenewborns to test the reliability of ultrasonographicmeasurement. The measurement of the a and b angleshad a good test–retest reliability (intraclass correlationcoefficient, 0.785 and 0.800, respectively).

Babies with clinical hip instability or ultrasonographicdysplasia (Graf type IIc, D, III, or IV) were referred toorthopedic surgeons for further management after beingdischarged from the nursery. A second hip ultrasonogra-phy was performed 4–6 weeks after birth for the abovebabies and babies with Graf’s IIa hips by the sameinvestigator. Babies with persistent hip pathology on thesecond ultrasonography were referred to orthopedicsurgeons again. Pelvis radiography was performed at theage of 4 months to confirm the hip condition.

The a and b angles were compared between the new-borns grouped by sex, birth body weight, gestational age,birth order, and breech. The ultrasonographic findings inthe hips with a positive Ortolani test were compared withthat in the hips with a negative Ortolani test. Indepen-dent t -test was used for continuous variables. Categoricalvariables (Graf’s type) were put into a table and analyzedwith Fisher’s exact test because of the small numbers ineach cell.

Results

Between April 2006 and December 2007, 1333 consecu-tive newborns (705 male and 628 female) received hipultrasonography in the first week after birth. The meangestational age was 38.3 weeks (range 33–42 weeks), and103 babies were premature (gestational age < 37 weeks).Birth body weight was 3090g on an average (range 1700–4320g) and 93 babies were born with a weight less than2500 g. Of the 1333 babies, 105 (7.9%) had breechpresentation and 830 (62.3%) were first births. Hip inst-ability, tested by the Ortolani and Barlow tests, was foundin 10 babies (bilateral hip instability in three babies andunilateral hip instability in seven babies). No irreducibledislocation of the hip was detected.

Ultrasonography was performed on both hips of the 1333babies. The mean a angle in the 2666 hips was 64.7 1

(range 38–78 1, standard deviation 3.7), and the meanb angle was 45.5 1 (range 23–87 1, standard deviation 6.8). According to Graf’s classification, three babies had fourtype III hips (bilateral in one baby and unilateral in twobabies), four babies had five type IIc hips (bilateral in onebaby and unilateral in three babies), and the other 82babies had 122 type IIa hips (bilateral in 40 babies andunilateral type IIa plus type I in 42 babies). A total of seven babies had nine hips with ultrasonographic dys-plasia (five type IIc and four type III).

The mean values of the a and b angles in newbornsgrouped by sex, birth body weight, gestational age, birthorder, and breech presentation are listed in Table 1. Sex isa significant factor that influences both the acetabulardevelopment and the position of the femoral head. Lowbirth body weight (<2500g) and prematurity (< 37 weeks)

were associated with a low b angle (Table 1).Ten babies had a positive Ortolani test in 13 hips. The 13unstable hips were three type III, three type IIc, six typeIIa, and one type I. The data of the 10 babies and theresults one month after ultrasonography are listed inTable 2. On an average, the mean a angle was 53.7 1 andthe mean b angle was 64.8 1. The data were significantly different from the mean a angle of 66.2 1 and the meanb angle of 44.0 1 in the other 1323 babies without hipinstability ( P < 0.001). Ultrasonographic dysplasia (typeIIc and beyond) was detected in six of the 20 hips (30%)of the 10 babies with a positive Ortolani test and in three

of the 2646 hips (0.1%) in babies with a negative Ortolanitest. The rate to detect a dysplastic hip by ultrasound wassignificantly greater in the babies with a positive Ortolanitest ( P < 0.001). (Fig. 1)

Table 1 Mean data of a and b angles according to charactersof newborns

a angle b angle

Number of newborns (%) Mean P value Mean P value

SexMale 705 (53) 65.5 < 0.001 44.1 < 0.001

Female 628 (47) 63.8 47.2Birth body weightZ 2500 g 1240 (93) 64.7 0.672 45.8 < 0.001 a

< 2500 g 93 (7) 64.8 42.6Gestational age

Z 37 weeks 1230 (92) 64.7 0.660 45.8 < 0.001 b

< 37 weeks 103 (8) 64.6 43.5Birth order

First 830 (63) 64.7 0.581 45.4 0.342Others 503 (37) 64.7 45.7

BreechPositive 105 (8) 64.2 0.055 45.3 0.545Negative 1228 (92) 64.7 45.6

a Correlation between birth body weight and b angle was significant (Pearson’sr = 0.102, P < 0.001).b Correlation between gestational age and b angle was significant (Pearson’sr = 0.137, P < 0.001).

Natural progression of hip dysplasia in newborns Chen et al. 419



Management after newborn hip ultrasonographyThirteen babies with clinical hip instability or Graf’s typeIIc, III hips were referred to orthopedic clinics afterdischarge from the newborn nursery. However, most of them stayed home in the first month of after birthbecause of the local folk custom. Two of the 13 babieswere brought to orthopedic clinic and had harnesstreatment in the first month after birth. Both of themhad unilateral type IIa hips. Another baby initially hadbilateral type IIc hips and improved to one type IIa hipand one type I hip 1 month later. Clinical instability was absent. This baby received harness treatment at theage of 3 months because of unilateral hip dysplasia shownon the pelvis radiograph. Of the 1333 babies, threeunderwent harness treatment; the rate of treatmentwas 0.23%.

The second survey We arranged for 90 babies to return for a second survey,including 10 babies with clinical instability and 80 babieswith ultrasound findings (type IIa and beyond) after thefirst month after birth. Two babies with a unilateralOrtolani-positive hip underwent harness therapy by orthopedic doctors and did not come back for the secondultrasound. Twelve babies with type IIa hips missed thesecond survey. There were 76 babies, eight babies forclinical instability and 68 babies for ultrasound findings,who came back to undergo ultrasound survey. They didnot have any treatment in the first month of life (Fig. 1).

The Ortolani test was negative in all babies at age of 1month. In the average 4.2 weeks between the twoultrasonographic studies, the mean a angle of the 76babies improved from 55.6 to 64.8 1 and the b angleimproved from 58.4 to 41.3 1. There were nine hips withultrasonographic dysplasia at birth. The four type III hipsat birth became two type I hips and two type IIa hips at1 month of age. (Fig. 2) Of the five type IIc hips, fourimproved to type I and IIa hips, whereas one remained atype IIc hip. The baby with a persistent type IIc hip wasreferred to the orthopedic clinic again. No treatment wasrecommended by orthopedic doctor because the hip wasstable on manual testing. Pelvis radiography was negativeat follow-up 3 months later.

In the 82 babies with 122 type IIa hips at birth, fivebabies had unstable (Ortolani test positive) type IIa hipsand the other 77 babies had stable type IIa hips. Two of the five babies with unstable IIa hips received harnesstreatment. The other three babies had a second survey

Table 2 The Graf’s classification of the 20 hips in the 10 babieswho had at least one unstable hip. Two babies received harness

therapy and the other eight babies had stable hips spontaneously1 month later

At birth At 1 month old

Babies Unstable hips Stable hips Unstable hips Stable hips

1 III I — I/I2 III/III — — IIa/I3 IIc IIa — IIc/I4 IIc IIa — I/I5 IIc/I — — I/I6 IIa/IIa — — I/I7 IIa I — IIa/I8 IIa I — I/I9 IIa IIa Harness

10 IIa I Harness

Fig. 1

1333 babies

(a) Ortolani ( + )10 babies

III 3 hips; IIc 3 hipsIIa 9 hips; I 5 hips

III 1 hip; IIc 2 hipsIIa 115 hipsI 2528 hips

III:0; IIc:0, IIa:5, I:131

No hip problem checkedat 19 months old

1 baby had harnessat 3 months old

8 babies(III:3; IIc:3; IIa:7; I:3)

second survey

2 babies (2 IIa. 21)had harness in the

first month

(b) 68 babies(III:1; IIc:2; IIa:100:

I:33)

1243 babies(bilateral type I

hips)

(c) 12 babies(15 IIa, 9 I)

Miss second survey

III:0; IIc:1, I Ia:2, I:13

Ortolani (− )1323 babies

A diagram showing the outcome of the 1333 babies. Babies with clinical instability (cell a) and babies with clinical stable but ultrasonographic type II,III and IV hips (cells b and c) were arranged to have the second survey. Twelve babies missed the second survey (cell c).

420 Journal of Pediatric Orthopaedics B 2010, Vol 19 No 5



and their hips became stable type I hips. In the 77 babieswith stable IIa hips, 65 babies with 100 type II hips hada second survey. The 100 stable IIa hips improved to 97type I hips (97%) and to three type IIa hips 1 month later.The other 12 babies who missed the second survey werefollowed at a mean age of 19 months (range 9–29months). There was no hip problem noted.

Discussion A strong trend of spontaneous resolution of newbornultrasonographic dysplasia was observed in this study.The high rate of spontaneous resolution in this study

was not the result of overdiagnosis. The data of the2666 ultrasonographies were continuous variables anddistributed in a bell-shaped curve. (Fig. 3) Using thedefinition of a dysplastic hip, by an a angle less than 50 1,we only screened nine dysplastic hips from a total of 2666hips (0.3%). It is reasonable to pay special attention tosuch cases, and harness therapy was recommended inGraf’s type IIc and type III hips [12]. However, all butone of the hips recovered to physiological status 1 monthlater without treatment. The study results did notsupport immediate treatment on the basis of newbornultrasound hip screening.

Fig. 2

A female baby with bilateral Graf’s type III hips and a positive Ortolani test. (a) Right hip ultrasonography at birth showed thea angle of 42 1 and theb angle of 81 1. (b) Left hipa angle was 41 1 and the b angle was 77 1. (c) Ultrasonography 1 month later showed right hip a angle of 53 1 and b angleof 491 without treatment. (d) Left hip a angle was 62 1 and b angle was 41 1.




Neonatal hip screening, either by manual test or by ultrasound might detect a dynamic physical status in thefirst few days after birth. Evidences from Barlow’s originalstudy showed that 60% of Barlow-positive hips becamestable after the first week and 88% of these unstable hipsbecame stable in the first 2 months after birth withouttreatment [25]. In this study, we defined neonatal hipinstability by the Ortolani test, a strict test dependingon the relocation of a dislocated hip. It is the reasonwhy only 10 of the 1333 newborns (0.75%) had neonatalhip instability. Nevertheless, the eight babies who stayedhome for 1 month resolved to have stable hips spon-taneously. In a systemic review of literature using the bestevidence approach by Shipman et al. [26], the high rate of spontaneous resolution of neonatal hip instability anddysplasia was emphasized and the net benefit of hipscreening was challenged.

There were several prospective studies to compare theresults of general ultrasound screening and selectiveultrasound [18–21]. The case number in this study wastoo small to make any contribution to this debatableissue. This study is to question the immediate treatmentapproach when DDH is detected in the first week afterbirth. As the treatment for DDH at birth is not an urgentrequirement, the reason to support newborn ultrasoundscreening is questionable.

We support manual screening in a newborn nursery because the simple manual tests helped to detectunstable hips that had worse ultrasonographic measure-ments than the stable hips. Similar findings that showedthat ultrasonography in hips with clinical instability had ahigher positive rate were reported before [22,27,28]. Hip

ultrasonography could be deferred after the first monthafter birth to confirm the diagnosis and judge the furthermanagement, when the physical status became settledand harness could still treat the hip problem.

However, one should be cautious of type III and IV hipsas they may have a worse course, in spite of our small

number of cases that showed good progression in the ob-servation follow-up. In a country that can offer universalultrasound hip screening, it is more specific to performthe first ultrasonography after the first month after birth.

A limitation of this study is that we did not follow all theGraf’s type I hips at birth. There could be very few casesof DDH that developed later in life and showed a stableand mature hip at birth. Another limitation of this study is that the ultrasound hip screening in the authors’hospital is not universal. The distribution of sex, birthorder, type of birth, and Ortolani test results in this study group are not representative of the Taiwanese population.

The hip ultrasonography in this study differed fromGraf’s technique in which babies were put in a lateralposition during the examination. There could be a debateas to whether the measured a and b angles in this study were consistent with Graf’s normal values. However, as allthe ultrasonographies including the second survey wereperformed by one investigator, the trend of improvementin ultrasonographic measurements should be consistentand reliable.

The study results do not support immediate treatmenton the basis of newborn hip screening because of the

strong trend of spontaneous resolution of newborn hipinstability and ultrasonographic dysplasia. We recommendmanual testing in the newborn nursery to detect the hipsat risk of instability and dysplasia, and ultrasonography after the first month after birth to confirm the diagnosisand judge the management.

AcknowledgementThe authors have no financial relationships relevant tothis article to disclose.

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Fig. 3

400

300

200

N u m

b e r o

f h i p

s

100

040 50 60

Alpha angle70

Distribution of the a angle of the 2666 hips. The vertical line indicated49 1 and the cases left to the line (ultrasonographic dysplasia) were only0.3%.

422 Journal of Pediatric Orthopaedics B 2010, Vol 19 No 5



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