Clinical and sonographic improvement of developmental dysplasia of the hip: Analysis of 948 patients

doi:10.21203/rs.3.rs-2190810/v1

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Research Article

Clinical and sonographic improvement of developmental dysplasia of the hip: Analysis of 948 patients

https://doi.org/10.21203/rs.3.rs-2190810/v1

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Background

Developmental dysplasia of the hip is a common condition, which varies in severity. Abduction treatment is widely used to correct the development of the hips, but mild forms of DDH can also recover spontaneously. The purpose of this study was to evaluate factors affecting the rate of improvement of developmental dysplasia of the hip, and evaluate any risk factors slowing the process.

Material and methods

The study population consisted of patients diagnosed with DDH in Tampere University hospital in the years 1998–2018. Data was retrospectively collected and associations between clinical variables and rate of improvement was analyzed. Alpha angles were assessed monthly and associations between risk factors and improvement of alpha angles were studied. Total of 948 patients were included in the analysis.

Results

More sever first status of the hips was associated with faster improvement in dynamic ultrasound compared to milder DDH in univariate design in first 3 months of age, in the multivariable design Ortolani positivity was conversely associated with lower alpha angles in 1-month follow-up. Immediate abduction treatment was associated with faster recovery rate compared to delayed abduction or watchful waiting. Female sex and positive family history were associated with slower rate of improvement and lower alpha angles. In multivariable design, female sex, positive family history and treatment strategy remained statistically significant as initiation time of the treatment explained the first found association of clinical hip status and the recovery rate after 2 months of age.

Conclusion

Female sex and positive family history might be independent risk factors for slower recovery in DDH before six months of age. These children might need special attention in their follow-up plans and abduction treatment.

DDH

developmental dysplasia of the hip

ultrasound

ultrasonography

abduction splintage

Pavlik harness

Developmental dysplasia of the hip (DDH) includes a spectrum of abnormalities ranging from mild conditions such as laxity of the hip joint to more severe forms of the disease such as full luxation of the hip (1–3). Incidence of the condition is hard to evaluate since diagnostic criteria and screening methods vary around the world. For this reason, variation in incidence is present in previous studies. (4–7)

Normal development of the fetal hip is a complex process in which appropriate contact between acetabulum and femoral head is crucial. Development continues after birth as femur and acetabulum continue growing (8, 9). Known risk factors include female sex, pre-natal breech presentation, positive family history, left side, primiparity and clicking hips (10, 11). Risk factors are thought to be associated in 50–60% of the cases (10).

Diagnosis of DDH is primarily based on clinical findings in infant`s hips after birth. In physical examination, hip joint stability, limb length discrepancies and abduction deficits are assessed. Clinicians use Ortolani and Barlow tests to asses hip joint stability. Ortolani positive sign is detected, when during abduction and flexion of the hip joint femoral head returns to acetabulum making ‘clunk’ sound. Barlow positive hips are more stable, but can be dislocated in clinical evaluation with minor provocation. In the mildest clinical form of DDH hips are a little loose, but do not fully dislocate or subluxate even with provocation. After around 3 months of age Ortolani and Barlow tests lose their sensitivity and asymmetric hip abduction becomes the most relevant finding (2).

Ultrasound is used in the help of diagnostics and observation of the condition. As the ossification center of the femoral head begins to grow, ultrasound loses its value, thus at the age of four to six months radiographs are getting more useful to assess DDH (3, 12). Ultrasound assessment of DDH is based on Graf`s ultrasound classification (13, 14). Ultrasound features of the disease include lowered alpha angle, beta angle and/or insufficient bony coverage of the femoral head. Radiological maturity of the hip in Graf`s classification is age dependent. Ultrasound performed during Barlow maneuver tests dynamic stability of the hip. In infants with clinical instability, ultrasound may be performed in four to six weeks of age, and it may be used for further evaluation of the condition and as guidance for treatment plans (2, 3, 12). Universal ultrasound screening is not recommended, as it leads to overtreatment and is not useful in reducing incidence of late cases (12, 15, 16). Selective secondary radiographic screening in 6 weeks of age is used in children with known risk factors of DDH (12, 17).

Dysplastic changes in infant`s hips may resolve spontaneously; however conservative treatment has been efficient. Clinical practice guidelines recommend abduction splintage treatment for hips with Ortolani positive DDH (12). Pavlik harness, Von Rosen splint, Craig splint and Frejka pillow are alternative methods of splintage (18). Pavlik harness and Von Rosen splint are most used in splinting and limited evidence supports use of von Rosen splint over other the methods (12, 19, 20). However, treatment with Pavlik harness is the most widely used method in the world. With Barlow positive hips, it has been proven that waiting the onset of abduction treatment is safe, and gives room to spontaneous recovery of mild DDH (21). Abduction treatment in stable yet dysplastic hips has not been found effective, and in this situation, abnormalities detected in ultrasound can be observed (2, 12, 22–24). If hips do not improve with conservative treatment, operative treatment may be needed. Early detection and treatment are key factors in successful non-operative management of the disease.

The purpose of this study was to investigate the rate of improvement in DDH and evaluate risk factors affecting the rate. Evaluation of these risk factors helps to understand how improvement in children with DDH could be gained earlier and if there are groups of infants that need special attention in their treatment and/or follow-up plans.

Study population consisted of patients diagnosed with DDH according to World Health Organizations International Classification of Diseases and Health Related Problems 9th and 10th revisions (ICD-9 and ICD-10), codes 7543.0-7543.5 (ICD-9) and Q65.0-Q65.5 (ICD-10), treated in Tampere University hospital in the years 1998–2018. Data for the study was retrospectively collected from the patient records. Data regarding family history, newborn birth data, information about the mother regarding the pregnancy, breech presentation, mode of delivery, clinical and radiological status of the infant’s hips and information about the treatment and results of treatment were recorded and analyzed. Patients that only received operative treatment on Tampere University hospital but were initially and postoperatively treated in some other centers were excluded.

Improvement was assessed using parameters from sonographic follow-ups. Since the ultrasound is usually performed monthly, we divided the time of improvement in categories: 1 month, 2 months, 3 months, 4 months, 5 months and 6 months or more. Alpha angles 60 or over together with 50% or over bony coverage of femoral head and stability in dynamic ultrasound were considered normal.

Bivariate analysis of risk factors (clinical hip status, positive family history (defined as one or more first degree relative with DDH), gender, gestation age, primiparity, intra uterine breech presentation, bilaterality and birth weight) and the improvement was carried out in cross-tabulations separately with every month and Chi-square test was used to analyze statistical significance.

First clinical hip status was set by pediatric surgeon or pediatric surgery resident. Hips were ether Ortolani positive, Barlow positive, or Ortolani and Barlow negative, with possible minor laxity of the joint but no dislocation in provocation in otherwise normal hip.

Positive family history was defined as at least one first degree family member (parents or siblings) with the diagnosis of DDH.

In Tampere University Hospital, selective screening is used to patients with DDH suspicion. All the patient with the suspicion of DDH undergo clinical evaluation by pediatric surgeon or pediatric surgery resident within the first week of life, and ultrasound together with the clinical control in approximately 3–6 weeks of age. With completely dislocated hips (Ortolani positivity) abduction treatment is started at the first clinical evaluation. With mild DDH (subluxated, minor looseness in the clinical examination) it is up to Pediatric surgeon if the abduction treatment is started at the first clinical examination or if the child is taken to watchful waiting protocol. Second examination is at approximately 4 weeks of age together with the dynamic hip ultrasound. Pediatric hip ultrasound examination in our center includes assessment of alpha-angle (based on Graf method) and bony acetabulum coverage of femoral head (according to Terjesen method) as well as dynamic ultrasound evaluation of hip stability during manual axial compression of the femur whilst hip joint is in 90 degrees flexion and slight adduction and the child is lying on his/her side.

In Tampere University hospital watchful waiting is one treatment strategy in mild (Ortolani negative) DDH. The decision between the watchful waiting or abduction treatment is made by the pediatric surgeon (not the parents) case by case and is likely to be affected the anamnestic information on the known risk factors (such as DDH in first-degree relatives), in addition to the clinical status and ultrasound imaging. Watchful waiting strategy has been described before in mild DDH.(21, 25, 26) In ultrasound screening of these hips approximately at 4 weeks of age, if the hips are normal and stabile, watchful waiting is continued. With abnormal findings, abduction treatment is started. For that reason, we evaluated also associations between the treatment strategy (immediate abduction, delayed abduction after one month of observation and watchful waiting) and rate of improvement in bivariate analysis with Chi-square tests.

The concept of confounding factor was assessed in multivariable analysis carried out as an ordinal regression. The multivariable analysis was used solely as an additional analysis for previous analyses and separately in every month follow-ups. The statistical significance for all tests was set at p < 0.05. All analyses were carried out using SPSS version 27.

Total of 948 patients met the inclusion criteria and were included in the analysis. Of these 686 were girls and 262 boys. Breech presentation at the time of birth was evident in 312 patients. Ortolani positive DDH was diagnosed in 389 patients. Of these, 292 were unilateral and 97 bilateral. All together 226 patients had Barlow positive hip, and 303 patients had both Ortolani and Barlow negative hips. In 662 patient abduction treatment was performed with either Pavlik harness (n = 598) or Frejka pillow (n = 62). Late diagnosed (over three months of age) DDH was detected in 28 patients. All together 48 (5.1%) patients ended up receiving cast and/or operative treatment, which of 14 were late detected and 3 were teratological dislocations leaving 31 (3.3%) failing the initial treatment. Detailed patient demographics can be seen in Table 1.

Table 1

Patient demographics
Patient characteristics (n = 948)		n (%)
First clinical status of the hip	Ortolan positive: Unilateral Ortolan positive: Bilateral Barlow positive (Ortolani negative): Unilateral Barlow positive (Ortolani negative): bilateral Unstable, not dislocatable Information missing	292 (30.8%) 97 (10.2%) 180 (19.0%) 46 (4.9%) 303 (32.0%) 30 (3.2%)
Treatment	Immediate abduction treatment Delayed abduction treatment Operation and /or casting Observation (clinical/radiological follow-ups) Information missing	505 (53.3%) 157 (16.6%) 48 (5.1%) 266 (28.1%) 1 (0.1%)
Gender	Male Female	262 (27.6%) 686 (72.4%)
Presentation	Breech presentation Cephalic presentation Information missing	312 (32.9%) 628 (66.2%) 8 (0.8%)
Family history	Positive First-degree relative Negative Information missing	194 (20.5%) 138 (14.6%) 382 (40.3%) 372 (39.2%)
Parity	Nulliparous Primiparous Multiparous Information missing	202 (21.3%) 85 (9.0%) 36 (3.8%) 625 (65.9%)
Gestation age	Term Premature Postmature Information missing	848 (89.5%) 38 (4.0%) 44 (4.6%) 18 (1.9%)
Birth weight	Normal birth weight Low birth weight (< 2500g) Birth weight (> 4500g) Information missing	899 (94.8%) 21 (2.2%) 19 (2.0%) 9 (0.9%)

In 505 of the 662 patients that received abduction treatment, the treatment was initiated early, within the first week of life, after the first clinical examination by pediatric surgeon. In 157 patients, treatment was initiated later after an observation period (Ortolani negative hips). In 19 patients, abduction treatment was followed by operation/casting. Pavlik harness were used in 598 and Frejka pillow in 62 patients.

First clinical status of the hips was associated with higher alpha angles in 1st months follow-up, p = 0.002. Ortolani positive hips (27.2%) and Barlow positive hips (23.7%) had more rarely alpha angles 50–55 degrees than hips with only minor looseness (39.1%). And Ortolani positive (37.4%) and Barlow positive hips (39.6%) were more often normal in first months follow up compered to minor looseness (24.6%). On the other hand, Ortolani (14.0%) and Barlow (15.5%) positive hips had more often alpha angles under 50 degrees, compared to Ortolani and Barlow negative children (12.9%). After 2 months, difference in alpha angles was no more statistically significant between first clinical presentations, p = 0.120. There was no association in 2 months and 3 months follow-up, but after 6 months, Ortolani positive hips had more often immature alpha angles compared to Barlow positive and Ortolani and Barlow negative hips, p = 0.012.

Girl sex was associated with lower alpha angles in 1 months and 2 months follow-ups, p < 0.001. There was no statistically significant difference between sexes after 3 months follow-up (see the p-values in Tables 2–6).

Table 2

Risk factors and alpha angles in 1 months follow up
Risk factor(n)	p value	Alpha angle in 1 month control (degrees)		p value in multivariable design
		under 60	60 or over
First clinical status	0.002			0.041
Ortolan+ (342)		214 (62.6%)	128(37.4%)
Barlow+ (207)		125 (60.4%)	82(39.6%)
Minor looseness (256)		193 (75.4%)	63(24.6%)
Positive family history	0.597			0.299
Yes (123)		83 (67.5%)	40(32.5%)
No (393)		255 (64.9%)	138(35.1%)
Sex	< 0.001	0.007		0.009
Boy (228)		127 (55.7%)	101(44.3%)
Girl (591)		413 (69.9%)	178(30.1%)
Treatment method	< 0.001	< 0.001		< 0.001
IS (458)		271 (59.2%)	107(40.8%)
DS (149)		145 (97.3%)	4(2.7%)
WW (212)		124 (58.5%)	88(41.5%)
Breech presentation	< 0.001	0.002		0.123
no (577)		381 (70%)	163(30.0%)
yes (272)		158 (58.1%)	114(41.9%)
First born	0.610
no (101)		50 (49.5%)	51(50.5%)
yes (165)		87 (52.7%)	78(47.3%)
Birthweight	0.529
under 2500g (12)		9 (75.0%)	3(25%)
normal (781)		512 (65.6%)	269(34.4%)
over 4500g (19)		13 (68.4%)	6(31.6%)
Gestational age	0.490
preterm (28)		20 (71.4%)	8(28.6%)
37–42 weeks (737)		482 (65.4%)	255(31.6%)
over 42 weeks (41)		30 (73.2%)	11(26.8%)

Positive family history of first degree relative was associated with lower alpha angles in 1 months, 2 months, 3 months and 6 months follow-ups, see the results and p-values in Tables 3–6.

Table 3

*Risk factors and alpha angles in 2 months follow up*
Risk factor (n)	p value	Alpha angle in 2-month control (degrees)		p value in multivariable design
		Under 60	60 or over
First clinical status	0.280			0.220
Ortolan+ (271)		71 (26.2%)	200(73.8%)
Barlow+ (167)		41 (26.9%)	122(73.1%)
Minor looseness (227)		56 (24.7%)	171(75.3%)
Positive family history	0.028			0.016
Yes (102)		33 (32.4%)	69(67.6%)
No (332)		72 (21.7%)	260(78.3%)
Sex	< 0.001			0.006
Boy (228)		30 (15.4%)	165(84.6%)
Girl (591)		144 (29.8%)	339(70.2%)
Treatment method	< 0.001			< 0.001
IS (361)		88 (24.4%)	273(75.6%)
DS (168)		64 (43.0%)	85(57.0%)
WW (149)		22 (13.1%)	146(86.9%)
Breech presentation	0.015			0.070
no (577)		130 (28.4%)	327(71.6%)
yes (272)		43 (19.7%)	175(80.3%)
First born	0.580
Birthweight	0.201
Gestational age	0.201

Table 4

*Risk factors and alpha angles in 3 months follow up*
Risk factor (n)	p value	Alpha angle in 3-month control (degrees)		p value in multivariable design
		Under 60	60 or over
First clinical status	0.421			0.527
Ortolan+ (256)		25 (9.8%)	231(90.2%)
Barlow+ (165)		17 (10.3%)	142(89.7%)
Minor looseness (218)		15 (6.9%)	203(93.1%)
Positive family history	0.002			0.002
Yes (97)		16 (16.5%)	81(83.5%)
No (321)		21 (6.5%)	300(93.5%)
Sex	0.035			0.136
Boy (188)		10 (5.3%)	178(94.7%)
Girl (464)		49 (10.6%)	415(89.4%)
Treatment method	0.477			0.887
IS (346)		31 (9%)	315(91.0%)
DS (131)		15 (11.5%)	116(88.5%)
WW (175)		13 (7.4%)	162(92.6%)
Breech presentation	0.030			0.049
no (431)		46 (10.7%)	205(94.5%)
yes (214)		12 (5.5%)	385(89.3%)
First born	0.840
Birthweight	0.608
Gestational age	0.293

Table 5

*Risk factors and alpha angles in 6 months follow up*
Risk factor (n)	p value	Alpha angle in 6-month control (degrees)		p value in multivariable design
		Under 60	60 or over
First clinical status	0.003			0.171
Ortolan+ (319)		26 (8.2%)	293(91.8%)
Barlow+ (195)		7 (3.6%)	188(96.4%)
Minor looseness (242)		5 (2.1%)	237(97.9%)
Positive family history	0.344			0.302
Yes (115)		7 (6.1%)	108(93.9%)
No (375)		15 (4.0%)	360(96%)
Sex	0.070			0.093
Boy (222)		6 (2.7%)	216(97.3%)
Girl (550)		32 (5.8%)	518(94.2%)
Treatment method	0.186			0.454
IS (428)		27 (6.3%)	401(93.7%)
DS (150)		6 (4.0%)	144(96%)
WW (194)		5 (2.6%)	189(97.4%)
Breech presentation	0.047			0.384
no (506)		30 (5.9%)	476(94.1%)
yes (261)		7 (2.7%)	254(97.3%)
First born	0.357
Birthweight	0.569
Gestational age	0.597

Intra uterine breech presentation was associated with higher alpha angles in 1 month (p < 0.001) and 2 months (p = 0.003) follow ups, but after 3 months follow up, there was no statistically significant difference compared to those with cephalic presentation.

Treatment strategy was associated with faster recovery rate. Those with initially started abduction and those with only watchful waiting had higher alpha angles and normal alpha angles more often in 1 month compared to those with delayed start of abduction, p < 0.001. The same results were seen in 2 months follow-up (p < 0.001), but after three months there was no difference in correction rate of alpha angles (p = 0.560).

There was no association between correction rate of alpha angles and other studied risk factors (birthweight, first born birth and pregnancy duration), see the p-values in Tables 3–6.

In multivariable model all of the previously found associations remained statistically significant in 1 month follow-up, but it seemed that in first clinical status of the hips Ortolani positivity was associated with lower alpha angles, than Ortolani negative hips (p = 0.039), contrary to first found association in univariate model.

In multivariable model in 2-months follow-up, first clinical status of the hips was no more associated with recovery rate (p = 0.128), but other associations remained statistically significant. In 3-months follow-up, only positive family history (p = 0.001) and breech presentation (p = 0.042) were statistically significant, and after 6 months, there was no statistically significant associations with nether of the studied factors and recovery rate of alpha angles.

In this study immediate abduction treatment was associated with more rapid rate of improvement in children with developmental dysplasia of the hip in first three months of age. Ortolani positive and Barlow positive (Ortolani negative) clinical status of the hip in the first examination and intra uterine breech presentation were associated with more rapid rate of improvement, compared to Ortolani and Barlow negative status and cephalic presentation. Female sex and positive family history were associated with slower rate of improvement compared to male sex and those without family history of DDH. Other risk factors assessed did not reach statistical significance. In multivariable analysis immediate abduction treatment, sex, Ortolani positivity, positive family history and breech presentation remained statistically significant in 1 month follow-up, but nether of them were associated in 6 months follow-up.

It was clear that improvement in our data happened most effectively during the first three months. This is likely due to the fact, that after birth, acetabular and femoral head remodeling is most rapid during the first weeks of life (1). In our study clinical status of the hip was first associated with higher alpha angles in 1 month follow-up. It`s noted that positive Ortolani test indicates more severe form of DDH when comparing to Barlow positive or mildly loose hips (1–3). In our data, Ortolani positivity was associated with lower alpha angles in 1 month follow-up compared to Ortolani negative patients in multivariable design conversely in first found association in univariate design. This might be due to our data. In multivariable design, only 406 patients were included, because the family history data was incomplete. This might affect on our results. However, after 2 months of age, there was no more association between clinical hip status and recovery of alpha angles. It seems that it is not the clinical status of the hip that affects the recovery rate, rather it is the treatment method that accelerates the recovery rate. As Ortolani positivity in clinical examination according to guidelines results in immediate abduction treatment initiation, these patients are more likely to recover faster which can be clearly seen in our data. Delayed abduction treatment was associated with delayed improvement of alpha angles, which however does not indicate that delayed abduction treatment would be ineffective in treatment of DDH. Later initiated treatment inevitably leads to delayed improvement.

Clinical status of the hip and ultrasound appearance are not always congruent, and with ultrasound dysplasia can be detected also in hips clinically tested as normal (27, 28). However, ultrasound used in screening does not prevent late cases and is not associated with improved outcomes when comparing to programs based on clinical appearance of the hip (12, 15, 29, 30). Radiological classification at birth according to the Graf method has been associated with median age of normalization. Median age of normalization was linear with radiological grade of the hip (Type IIa – Type IV) as more severe forms of DDH gained recovery later (31). Result of the study are partly in contradiction to our study, which can be partly explained by the fact that treatment initiation indication and treatment method were different from ours. However, it might be that those with looser hips characterized with Ortolani positivity might still recover slower in first weeks of life as could be seen in our data in multivariable design in 1 month follow-up.

Ortolani negative patients with minor instability of the hips form a risk group for delayed recovery, because these patients are often observed in the beginning. Immediate Pavlik harness treatment in infants with Barlow positive hips is controversial because majority of the infants will improve without treatment, and it seems that it is safe to wait the initiation of the treatment (32, 33). Our results give new information as it seems that in mild DDH recovery might delay because of the watchful waiting period. Even if waiting is safe, it is mandatory to inform families of the possibility of more rapid recovery with the immediate abduction treatment.

Female sex is a known risk factor of DDH (10, 11). In our study female sex was associated with lower alpha angles compared to male sex (p < 0.001) in 1st and 2nd -months’ follow-up. Sex remained statistically significant in multivariable design. The associateion remained statistically significant in multivariable analysis. In previous studies, inconsistent with our finding, male gender has been associated with Pavlik harness treatment failure and slower rate of recovery (34–37). Our findings however indicate, that in addition of being a risk factor of DDH, female gender might also be a risk factor of slower recovery of DDH. Girls tend to have lower alpha angles to begin with and the recovery in the first three months is slower compared to boys.

Positive family history is a well-known risk factor of DDH (10, 11). We found that positive family history is associated with lower alpha angles throughout the recovery in six months. This finding remained statistically significant in multivariable design, however, after six months, the differentiation was not statistically significant. This finding gives new information of the effect of positive family history as a risk factor of DDH. Earlier we found, that positive family history could also predispose to failure of the Pavlik harness treatment (unpublished manuscript). These findings underline the importance of close follow up of these patients during the abduction treatment.

Intrauterine breech presentation was associated with faster recovery and higher alpha angles in first 3 months of age. Association was also statistically significant in multivariable design. This finding indicates that these children are to recover well with correct treatment and do not have a risk of delayed recovery. For other risk factors assessed in this study (parity, birth weight and gestation age) no statistical significance with the rate of improvement of alpha angles was found.

Our study has some limitations that should be addressed. The data was collected retrospectively, and the earliest cases dated back over 20 years. Although the sample size was substantial, data was not inclusive for all patients. Data of parity was missing for most of the patients and data of family history was also inadequate. Due to this factor, our results considering these risk factors might not be adequate. However, our findings still indicate that it is not the first clinical status of the hip that accelerates the rate of improvement in first weeks of life, rather it is the initially started treatment that accelerates it. We also found that female gender might predispose to delayed improvement and positive family history, despite the incomplete data, was associated with slower improvement and lower alpha angles in follow ups. In our center, ultrasound evaluation includes measurements of alpha angles (according to Graf’s criteria) and bony coverage of acetabulum (according to Terjesen method) as well as dynamic evaluation of hip stability during provocation. Our radiologists have not reported beta angles, and due to that we could not classify hips according to Graf’s criteria. However, normal hips were considered to have alpha angles over 60 degrees (at any age), which is comparable to Graf’s criteria. Despite of the differences to Graf’s ultrasound evaluation, our center had only 48 (5.1%) children needing casting or operation, which of 14 were late diagnosed cases and 3 were teratological dislocations leaving only 31 (3.3%) children failing the initial treatment in 20 years of time. Even though the concept of confounding factor was taken in account in multivariable analysis, the multivariable analysis itself was not perfectly fit for our data. In Tampere University hospital, where the study data originates, Pavlik harness is used for abduction treatment. Previously Frejka pillow was also used. Our results on treatment should be considered with precautions, keeping in mind that abduction treatment methods vary according to location.

Immediate abduction treatment rather than first clinical status of the hip resulted in accelerated rate of improvement of alpha angles in DDH. Female sex and positive family history were associated with slower rate of improvement and lower alpha angles in first three months of age, however after six months of age the differentiation could not be seen between any of the factors and recovery of alpha angles in multivariable analysis. Further clinical trials are needed to confirm these findings and analyze further the impact of spontaneous recovery potential of mild DDH to the benefits of early abduction treatment.

DDH

Developmental dysplasia of the hip

Ethical approvement

The study was carried out according to Finnish national and European Union legislation and guidelines. The Regional Ethics Committee of the Expert Responsibility area of Tampere University Hospital accepted the study. The need for patients’ written consent was deemed unnecessary by the Regional Ethics Committee of the Expert Responsibility area of Tampere University Hospital as we did not contact the families to conduct this retrospective study.

Consent for publication

Not applicable.

Availability of data and material

The datasets generated and/or analysed during the current study are not publicly available due to patient privacy and confidentiality but are available from the corresponding author on reasonable request.

Competing interests

Authors VL, KB, JVP, HL and AH declare that they have no conflict of interests.

Funding

This study has been funded by the Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital for AH.

Authors’ Contributions

Authors V.L. and K.B. wrote the main manuscript text and prepared the tables. Authors H.L., J.V-P., M.H. and A.H. reviewed the manuscript and helped with the writing. Authors V.L., K.B. and M.H. did the analysis of the data. Authors V.L. and K.B. collected the data from the medical records.

Acknowledgements

Our warm thanks to the institutional review board of the Tampere University hospital for enabling this research.

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Clinical and sonographic improvement of developmental dysplasia of the hip: Analysis of 948 patients

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