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DC C2006.5 VR

DC C2006.5 VR

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Published by: Perez Angarita Carlos Andres on Jun 07, 2012
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Acta Orthopaedica 
2006; 77 (2): 257–261 257
6 weeks with the von Rosen splint is sufficient for treatment of neonatal hip instability
Henrik Lauge-Pedersen
1
, Johan Gustafsson
2
and Gunnar Hägglund
1
Departments of
1
Orthopedics,
2
Radiology, Lund University Hospital, Lund, SwedenCorrespondence H L-P: Henrik.Lauge-Pedersen@ort.lu.seSubmitted 04-10-18. Accepted 05-09-25
Copyright© Taylor & Francis 2006. ISSN 1745–3674. Printed in Sweden – all rights reserved. DOI 10.1080/17453670610045993
BackgroundThere is no concensus on the optimal treat-ment time for unstable hips in the newborn. We analyzedthe efficiency of a treatment program that has been usedfor 10 years at our hospital, in which all unstable hips(subluxatable, Barlow-positive and Ortolani-positive)are treated with the von Rosen splint for 6 weeks.Patients and methodsBetween 1988 and 1997, 32,171children were born alive at the hospital. During thisperiod 247 children had a clinically unstable hip diag-nosed. 223 of the 247 children underwent a radiographicfollow-up after 5–15 years.Results1 patient with bilateral instability and treatedwith a splint for 6 weeks showed a dislocated left hip atthe radiographic examination at 8 months, which is partof the screening program, and needed operative treat-ment. 1 patient did not follow the treatment programand showed a dislocated hip at the age of 3. Another 4patients required more treatment than the 6 weeks withthe splint.We found no dysplastic hips at the radiographicfollow-up. There was no late dysplasia and there were nolate dislocations in children born in Lund between 1988and 1997 who were diagnosed at other Swedish centersthat treat developmental dysplasia of the hip (DDH).InterpretationWe conclude that the present screen-ing and 6-week treatment in a von Rosen splint preventalmost all cases of late dysplasia and late dislocation of the hip.
It is generally accepted that early treatment of Neo-natal Instability of the Hip (NIH) prevents disloca-tion (Palmen 1984). There are, however, variationsin the screening procedure, the splinting technique,the duration of splinting, and the follow-up routines(Emneus 1966, Fredensborg 1976, Palmen 1984,Sahlstrand et al. 1985, Krikler and Dwyer 1992).We analyzed the efficiency of a treatment programthat has been used for 10 years in Lund, Sweden,in which subluxatable (unstable, but not dislocat-able) and Barlow-positive and/or Ortolani-positivehips are treated with the von Rosen splint (Figure1) for 6 weeks. With this program, we reduced thetreatment time in the von Rosen splint from 12 to6 weeks and sonography was introduced as a diag-nostic tool for NIH. 
Patients and methods
During the 10-year period 1988–1997, 32,171children were born alive at the University Hospitalin Lund. The pediatricians routinely examined allhips during the first days of life, and those hipsthat were judged to be unstable were referred for
Figure 1. The von Rosen splint.
   A  c   t  a   O  r   t   h  o  p   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   1   6   8 .   1   7   6 .   5 .   1   3   6   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .
 
258
Acta Orthopaedica 
2006; 77 (2): 257–261
a second examination in the orthopedic depart-ment by two senior orthopedic surgeons. Duringthis period, 247 children (68 boys and 179 girls)had an unstable hip diagnosed. In doubtful casessonography was performed, but in cases withclear clinical instability, treatment was startedwith a von Rosen splint. The NIH was left-sidedin 137 children, right-sided in 41, and bilateralin 68. In 1 child the side of instability could notbe determined from the patient’s medical record.4 children with teratological dislocations wereexcluded from this analysis. All 247 children weretreated with the von Rosen splint for 6 weeks,after which the hips were re-examined clinicallyand with sonography using an anterior dynamictechnique (Harcke et al. 1984, Dahlström et al.1986, Harcke and Grissom 1990, Harcke 1992).If the displacement of the femoral head exceededone quarter of its diameter, measured by sonogra-phy, the hip was diagnosed as being unstable. If the hips were stable, treatment was discontinued.If the hips were unstable, treatment was extendedfor 3 weeks more. 2 weeks after completion of thetreatment, a repeat examination with sonographywas performed. At 8 months, a final clinical andradiographic examination was done. Radiographswere taken in the anteroposterior direction with thelegs straight. The radiographs were analyzed withregard to the presence of dislocation, acetabulardysplasia, and development of the femoral head(Table 1). Furthermore, 223 children (90%) com-pleted a radiographic follow-up after 5–15 years atwhich time acetabular index (Hilgenreiner 1925),CE-angle (Wiberg 1939) and the spherical index(Fredensborg 1976) were determined. The per-centage migration (Reimers 1980) was calculatedin cases with borderline acetabular index or bor-derline CE-angles. An acetabular index of < 20ºwas considered normal (Tönnis 1976) and a spher-ical index of > 35 was considered to be normal(Fredensborg 1976). We used the Severin (1941)definition concerning the CE-angles; for patientsaged 6–13 years, >19º is normal and 15–19º isuncertain. We measured CE-angles and sphericalindex in 275 primary unstable hips (241 patientswith 306 unstable hips minus 24 patients with 31unstable hips) and in 159 normal hips. Acetabularindex was measured in 206 hips (and the resultsfrom patients who received additional treatmentand hips with ossification of the triradiate cartilagehave been excluded).All treatment failures were also evaluated clini-cally. All other centers in Sweden that treat DDHwere contacted and asked whether any late dis-location or dysplastic hip had been diagnosed inpatients born in Lund between 1988 and 1997.
Statistics
Differences in paired measurements were testedusing paired t-test. If the data distribution wasasymmetric, the p-value from the t-test was com-pared with the p-value obtained from the corre-sponding non-parametric test: Wilcoxon signed-rank test.
Results
Of the 247 children with NIH, 244 had stable hipsafter both 6 and 8 weeks, as judged clinically andby sonography. 1 patient with unstable hip at 6weeks had extended treatment for 3 weeks in a von
Table 1. Treatment program for neonatal hip instability
Time of examination and finding TreatmentNeonatal hip instability at birth Splinting for 6 weeks6 weeks Examination with ultrasoundstable Splinting discontinuedunstable Splinting extended 3 weeks, then repeat examination2 weeks after completion of splinting Examination with ultrasoundstable No further ultrasound examinationsunstable Splinting extended 3 weeks, then repeat examination8 months of age Examination with radiographynormal No further follow-up examinationsdysplasia Further radiographic follow-up and/or abduction splint until normalization
   A  c   t  a   O  r   t   h  o  p   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   1   6   8 .   1   7   6 .   5 .   1   3   6   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .
 
Acta Orthopaedica 
2006; 77 (2): 257–261 259
Rosen splint. 1 hip had not stabilized with splintingand was operated on with adductor-psoas tenotomyand hip spica for 8 weeks, followed by an abduc-tion splint for another 3 months. The hip developednormally. 1 girl with left-sided unstable hip did notshow up for examination at 8 weeks and 8 months,and the parents had terminated the treatment withthe von Rosen splint themselves. She was referredto our orthopedic clinic at the age of 3 years withleg length discrepancy. Radiographs revealed a dis-located hip. She was operated on with open reduc-tion and Chiari osteotomy. After operation, the hipdeveloped satisfactorily and at the latest examina-tion at the age of 8, the patient had no leg lengthdiscrepancy and walked without any limp.Of the 244 children with stable hips, 241 showedno dysplasia at the radiographic examination at8 months. 2 hips showed minor dysplasia withacetabular indexes of 34º at 8 months and weretreated with an abduction splint for 3 months.The radiographic follow-up examination showednormal hips. 1 girl with bilateral instability, andtreated with von Rosen for 6 weeks, revealed adislocated left hip at the radiographic examinationat 8 months. She was operated on with adductor-psoas tenotomy and closed reduction, and the hipdeveloped normally (Figure 2). Thus, altogether 6children required additional treatment (Table 2).217 children (275 originally unstable hips)had no dysplasia at the radiographic follow-upat 5–15 years. Of the remaining 24 children (31unstable hips), 19 would not participate at the lateradiographic follow-up and 5 patients were livingabroad. These 24 patients all had normal radio-graphs at the 8-month radiographic control.At the 5–15 year radiographic follow-up, themean CE-angle was 30° (15–44) in the 275 pri-mary unstable hips and 29° (19–45) in the 159normal hips. The mean acetabular index was 14°(5–27) in 206 unstable hips and 14° (4–23) in 111normal hips. The mean spherical index was 48%(37–52) for the 275 unstable hips and 48% (36–50)for the normal hips (Table 3). We found 9 hips withborderline acetabular index and 9 hips with border-line CE-angles (Table 4). The radiographs were re-evaluated. All had normal Reimers indexes below20% and were not regarded as dysplastic. We foundno hips with spherical index below 35.
Figure 2. Patient no. 1 at 8 months. Left hip dislocated.Patient no. 1 at 9 years of age. Left hip normal.
Table 2. Treatment failures
Patient Sex Side Ultrasound 1 Ultrasound 2 Radiography at Treatmentno. (6 weeks) (8 weeks) 8 months/5–15 years1 Girl Bilateral Stable Stable Dislocation/Normal Tenotomy2 Girl Left Stable Stable Minor dysplasia/Normal Camp splinting 3 months3 Boy Bilateral Stable Stable Minor dysplasia/Normal Camp splinting 3 months4 Girl Left Unstable Unstable Normal/Normal Tenotomy5 Girl Bilateral Unstable Stable Normal/Normal 9 weeks of von Rosen splinting6 Girl Left Stable ?
a
?
a
 /Acetabular dysplasia Chiari osteotomy 
a
The patient did not come for follow-up at 8 weeks or at 8 months.
   A  c   t  a   O  r   t   h  o  p   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   1   6   8 .   1   7   6 .   5 .   1   3   6   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .

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