The incidence of neonatal developmental dysplasia of the hip in Arar, Saudi Arabia

Abstract

AimIn this study, it was aimedto investigate the incidence and risk factors of neonatal hip joint Developmental Dysplasia in Arar City.MethodsHospital records of all newborns in both Arar Central Hospital and Prince Abdulaziz bin Musaad Hospital in Arar city from January 2013 to the end of December 2013 were reviewed with their follow-up files till December 2015. Records include a detailed history, careful physical examination, results of the laboratory and radiological investigations.ResultsThe records of 2582 newborns were reviewed. The incidence of DDH was estimated to be 6.19/1000 live births. Ten cases (62.5 %) were females with estimated male to female ratio equal to 1:2.6. Spontaneous vaginal delivery occurred in 11 cases (68.75%), a caesarean section in 5 cases (31.25%). Limping and waddling gait was the most common finding in 10 cases (62.5%). DDH was significantly associated with primiparity, low birth weight, prematurity and positive family history of DDH (p-values=0.0009, 0.014, 0.038, and 0.0006 respectively).ConclusionScreening of DDH in Arar City of Northern Border province of Saudi Arabia was estimated to be 6.19/ 1000 live births. Awareness programs, routine examination of the neonatal hip joint with the hip ultrasound and pelvis plain x-ray in babies with risk factors for DDH are strongly recommended.

Keywords

Introduction

Developmental dysplasia of the hip (DDH) is a common neonatal abnormality which was formerly named as congenital dislocation of the hip.¹ Till now, the definition of DDH is indefinite and obscure in literature with much more conflict about its incidence within the different studied populations.^2-3 It includes a group of hip disorders as hip instability, dysplasia, subluxation, or dislocation. The term also encompasses an array of radiographic abnormalities that reflect the inadequate formation of the acetabulum. The etiology of DDH is multifactorial. It is associated with family history and other hormonal and environmental factors.⁴
DDH occurs in 11.5 of 1,000 infants, with frank dislocations occurring in 1 to 1.5 of 1,000.^1-2 Before the 1980s, the incidence of DDH was estimated to range from zero to 40%.⁵ While after the introduction of the routine screening program in the 1980s, the reported incidence had increased up to 52%.^5-7 This wide variation in numbers was mainly due to indefinite definition and screening and diagnostic protocols.
Screening for DDH is a part of the newborn routine physical examination. DDH screening is mandatory for newborns with risk factors for developing DDH.⁸ The Ortolani and Barlow tests are the key for the screening of DDH among babies <3 months of age. Both tests mainly detect only the hip instability which necessitates further evaluation.⁹ The Galeazzi sign will be of higher importance in the older child examination for DDH.¹⁰ In doubtful cases, ultrasound is the imaging tool of choice in infants up to five months. It can visualize the hip abnormalities as the subluxated or dislocated femoral head, abnormal alpha angle, abnormal thickness of labrum, presence of pulvinar, or ossific centers asymmetry,¹¹ while pelvic X-rays are more useful in ages more than 5 months.¹²
Data regarding the prevalence and incidence of DDH in Saudi Arabia are still unclear. Hence this study was conducted to evaluate the incidence of DDH in Arar City, The capital of Northern Border principality, Saudi Arabia from January 2013 to the end of December 2013 in Arar Central Hospital and Prince Abdulaziz bin Musaad Hospital.

Materials and Methods

The current study design was approved by the Institutional Research Board (IRB) of King Fahd Medical City. Ethical issues and confidentiality were considered in all the steps of the research project.
The present study is a retrospective study ofhospital records from both Arar Central Hospital and Prince Abdulaziz bin Musaad Hospital (The only hospitals which have obstetricians with available delivery rooms service in Arar) for all newborn infants from January 2013 to the end of December 2013. The study includes their follow-up files till December 2015.
The complete history including prenatal, natal, and postnatal history details of the enrolled babies were collected at the Delivery room. A meticulous physical examination of the newborn was conducted. Then the laboratory and radiological investigations were requested accordingly.
Ultrasonography was requested for infants below 6 months of age with suggestive signs for DDH such as Ortolani, Barlow signs, or limited abduction of the hips; while X-ray was requested in cases aged above 6 months with suggestive clinical examination data for DDH. In addition, Ultrasonography was routinely requested for babies with suggestive risk factors for DDH during the first 2 months after birth regardless of their examination data. The risk factors considered in the study were a positive family history of DDH, multiparous mother, prenatal history of oligohydramnios or breech presentation. In addition, orthopedic anomalies and swaddling were considered as risk factors of DDH among the enrolled babies.
All data regarding the babies’ history, examination, and investigations were collected for further statistical analysis. Babies with findings suggestive for DDH were referred to an orthopedic surgeon for the final decision and management planes. All infants enrolled in the study were being followed until walking age to detect any case which might be undiagnosed with the early evaluation.Statistical AnalysisThe Chi-Square test was used to study the effect of different risk factors on the appearance of DDH among the studied population. Graph pad Prism 5 (GraphPad Software Inc., San Diego, CA) software was used to perform the statistical analysis. Significance was considered with p-value<0.05.

Results

Among 2582 newborns, only 16 cases were diagnosed as DDH with an estimated incidence rate of 6.19/1000 live births. The data of diagnosed cases regarding the affected side, gender, mother ages and parity, gestational ages, birth weight and type of delivery are shown in Table 1.
The male to female ratio among the diagnosed cases was 1:2.6. Bilateral DDH was found in 3 cases (18.75%), Unilateral cases were more common in the right hip joint.[in 7 cases (43.75%)] Eleven cases (68.75%) were delivered through normal vaginal delivery. After walking, limping was the most common finding in the diagnosed cases.[10 cases (62.5%)]
Statistical analysis showed a significant association between the development of DDH with primiparity, low birth weight, prematurity and positive family history of DDH (p-values=0.0009, 0.014, 0.038, and 0.0006 respectively) Table 2).

Discussion

The current study was conducted to study the incidence and risk factors of neonatal developmental dysplasia of the hip in Arar City among newborns delivered during 2013. The records of 2582 newborns were reviewed. Sixteen cases were diagnosed as DDH in 2013 with an estimated incidence of 6.19/1000 live births. Ten cases (62.5 %) were females and 6 cases (37.5) were males (M: F ratio - 1:2.6). Bilateral DDH was found in 3 cases (18.75%); unilateral cases were more common in the right hip joint.[in 7 cases (43.75%)] Eleven cases (68.75%) were delivered through normal vaginal delivery. Five cases (31.255) were weighted blow 2.5 kilograms while four (25%) cases were delivered before the 37th week of gestation. DDH was significantly associated with primiparity, low birth weight, prematurity and positive family history of DDH (p-values=0.0009, 0.014, 0.038, and 0.0006 respectively).
The current study has estimated the incidence of DDH to be 6.19/1000 live births. The incidence of DDH is highly variable in different publications. The racial factor was shown to have a role in this variation; for example, Native Americans and Laplanders have a higher frequency of DDH (nearly up to 50 cases per 1000 persons), while its frequency is very low among black populations and southern Chinese.^13-15
The current data revealed a significant association of DDH with a family history of previous cases of DDH, primiparity, low birth weight, and prematurity. Our data is in accordance with previously published data. Positive family history of DDH among parents was reported to increase the risk 10 times among their babies in comparison to the others.¹⁶ Chan et al. (1997)¹⁷ reported a significant association between DDH and prematurity, primiparity and low birth weight. However, our finding is in discordance with Sezer et al. (2013)¹⁸ who reported that prematurity had no effect on DDH. In addition, the current study showed that the gender, mode of delivery, the breech presentation showed no effect on the incidence of DDH, which is also not in line with the previously published data.^8,19-22 Also, DDH was more commonly reported in the left side,²³ which is different from our data which find more prevalence in the right side hip joints among the studied cases. This dscrepancy in the published data related to the risk factors of DDH is mainly due to the multifactorial etiology of the problem. Thus some factors can predominate more than the others in the different study populations.
The current data showed that risk factors for DDH are not the same in the different studiedpopulation which may be mainly due to the multifactorial origin of the problem. Also, the study highlights the importance of the routine screening programs in diagnosis of the cases of DDH among newborns as all cases were detected with the initial screening without newly diagnosed cases in the follow-up. This early diagnosis is expected to improve the early family counseling about the disease which can help for better management planning.

Conclusion

Screening of DDH in Arar City of Northern Border province of Saudi Arabia was estimated to be 6.19/ 1000 live births. Awareness programs, routine examination of the neonatal hip joint using hip ultrasound and pelvis plain x-ray after the age of 3 months in babies with risk factors for DDH are strongly recommended.

Declarations

References

1. Kokavec M, Makai F, Maresch P. Present status of screening and prevention of developmental dysplasia of the hip in the Slovak Republic. J Pediatr Orthop B. 2003;12:106-108.
   PubMed · Google Scholar
2. Lotito FM, Riccio R, Peluso M, Giustardi A. Ultrasound screening for neonatal dysplasia of the hip. Riv Ital Pediatr. 1990;16:657-661.
   PubMed · Google Scholar
3. Kowalczyk B, Felus J, Kwinta P. Developmental dysplasia of the hip: the problem in the diagnosis process in our own experience.[in Polish] Med Wieku Rozwoj. 2005;9:395-406.
   PubMed · Google Scholar
4. Gulati V, Eseonu K, Sayani J, et al. Developmental dysplasia of the hip in the newborn: a systematic review. World J Orthop. 2013;4(2):32. doi:10.5312/wjo.v4.i2.32
   Article · PubMed · Google Scholar
5. Edelstein J. Congenital dislocation of the hip in Bantu. J Bone Joint Surg Br. 1966;48:397.
   PubMed · Google Scholar
6. Szoke N, Kuhl L, Heinrichs J. Ultrasound examination in the diagnosis of congenital hip dysplasia of newborns. J Pediatr Orthop. 1988;8:12-16.
   PubMed · Google Scholar
7. Bialik V, Bialik GM, Blazer S, Sujov P, Wiener F, Berant M. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics. 1999;103:93-99. doi:10.1542/peds.103.1.93
   Article · PubMed · Google Scholar
8. Agarwal A, Gupta N. Risk factors and diagnosis of developmental dysplasia of hip in children. J Clin Orthop Trauma. 2012;3(1):10-14. doi:10.1016/j.jcot.2011.11.001
   Article · PubMed · Google Scholar
9. Woolacott NF, Puhan MA, Steurer J, Kleijnen J. Ultrasonography in screening for developmental dysplasia of the hip in newborns: systematic review. BMJ. 2005;330(7505):1413. doi:10.1136/bmj.38450.646088.e0
   Article · PubMed · Google Scholar
10. Storer SK, Skaggs DL. Developmental dysplasia of the hip. Am Fam Physician. 2006;74(8):1310-1316.
    PubMed · Google Scholar
11. Shorter D, Hong T, Osborn DA. Cochrane Review: screening programmes for developmental dysplasia of the hip in newborn infants. Evid Based Child Health. 2013;8(1):11-54. doi:10.1002/ebch.1891
    Article · PubMed · Google Scholar
12. Roovers EA, Boere-Boonekamp MM, Castelein RM, Zielhuis GA, Kerkhoff TH. Effectiveness of ultrasound screening for developmental dysplasia of the hip. Arch Dis Child Fetal Neonatal Ed. 2005;90(1):F25-F30. doi:10.1136/adc.2003.029496
    Article · PubMed · Google Scholar
13. Tian FD, Zhao DW, Wang W, et al. Prevalence of developmental dysplasia of the hip in Chinese adults: a cross-sectional survey. Chin Med J (Engl). 2017;130(11):1261. doi:10.4103/0366-6999.206357
    Article · PubMed · Google Scholar
14. Lee CB, Mata-Fink A, Millis MB, Kim YJ. Demographic differences in adolescent-diagnosed and adult-diagnosed acetabular dysplasia compared with infantile developmental dysplasia of the hip. J Pediatr Orthop B. 2013;33(2):107-111. doi:10.1097/bpo.0b013e3182745456
    Article · PubMed · Google Scholar
15. Loder RT, Shafer C. The demographics of developmental hip dysplasia in the Midwestern United States: Indiana. J Child Orthop. 2015;9(1):93-98. doi:10.1007/s11832-015-0636-1
    Article · PubMed · Google Scholar
16. Bjerkreim I, Arseth PH. Congenital dislocation of the hip in Norway: late diagnosis CDH in the years 1970 to 1974. Acta Paediatr Scand. 1978;67(3):329-332. doi:10.1111/j.1651-2227.1978.tb16329.x
    Article · PubMed · Google Scholar
17. Chan A, McCaul KA, Cundy PJ, Haan EA, Byron-Scott R. Perinatal risk factors for developmental dysplasia of the hip. Arch Dis Child Fetal Neonatal Ed. 1997;76(2):F94-F100. doi:10.1136/fn.76.2.f94
    Article · PubMed · Google Scholar
18. Sezer C, Unlu S, Demirkale I, Altay M, Kapicioglu S, Bozkurt M. Prevalence of developmental dysplasia of the hip in preterm infants with maternal risk factors. J Child Orthop. 2013;7(4):257-261. doi:10.1007/s11832-013-0498-3
    Article · PubMed · Google Scholar
19. Carter CO, Wilkinson JA. Genetic and environmental factors in the etiology of congenital dislocation of the hip. Clin Orthop Relat Res. 1964;33:119-128. doi:10.1097/00003086-196400330-00010
    Article · PubMed · Google Scholar
20. Salter RB. Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Can Med Assoc J. 1968;98(20):933-945.
    PubMed · Google Scholar
21. Wilkinson JA. A post-natal survey for congenital displacement of the hip. J Bone Joint Surg Br. 1972;54(1):40-49. doi:10.1302/0301-620x.54b1.40
    Article · PubMed · Google Scholar
22. Panagiotopoulou N, Bitar K, Hart WJ. The association between mode of delivery and developmental dysplasia of the hip in breech infants: a systematic review of 9 cohort studies. Acta Orthop Belg. 2012;78(6):697.
    PubMed · Google Scholar
23. Kutlu A, Memik R, Mutlu M, Kutlu R, Arslan A. Congenital dislocation of the hip and its relation to swaddling used in Turkey. J Pediatr Orthop. 1992;12(5):598-602. doi:10.1097/01241398-199209000-00006
    Article · PubMed · Google Scholar

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