114 Original article
Hip arthrography in the assessment of children with
developmental dysplasia of the hip and Perthes’ disease
Rohit Kotnis, Veronique Spiteri, Christopher Little, Tim Theologis,
Andrew Wainwright and Michael K. Benson
In our unit, children with developmental dysplasia of
the hip or Perthes’ disease, for whom an operation is
considered, undergo examination under anaesthetic and a
hip arthrogram. This prospective study assessed whether
the arthrogram modified treatment and analysed the
reliability of its interpretation. All children undergoing a hip
c 2008
arthrogram for developmental dysplasia of the hip and
Perthes’ disease over a 12-month period were included.
Treatment plans before and after the arthrogram were
compared for each of the three children’s consultants. The
preoperative and arthrographic appearances were blindly
reviewed to monitor reproducibility. Twenty-one patients
with developmental dysplasia of the hip and 19 with
Perthes’ disease were included. The treatment plan
was modified in 12 of the 21 (57.1%) patients with
developmental dysplasia of the hip as a consequence of
Introduction
Developmental dysplasia of the hip (DDH) and Perthes’
disease are among the commoner orthopaedic conditions
treated in childhood. Abnormal development of the femoral
head and acetabulum, irrespective of cause, increases the
risk of early degenerative change in the hip joint [1]. This
risk is influenced by the age at presentation, the severity of
disease and the management. Children treated after 1 year
of age for DDH and 6 years for Perthes’ disease have a
poorer long-term outcome [2,3].
The goals of treatment for both conditions are to restore
spherical hip congruity and stability to minimize the risk
of premature degenerative hip disease [3].
It is important to identify children in whom hip devel-
opment is not progressing satisfactorily. Regular clinical
and radiographic review is necessary.
Cases in which clinical symptoms and signs or radiographs
cause concern, examination under anaesthetic (EUA) and
hip arthrography may help to develop a treatment plan.
A hip arthrogram may demonstrate head sphericity,
reducibility, stability and congruency. Abnormal patterns
of movement may be identified and the position of ‘best
fit’ determined [4].
Despite the potential advantages of an EUA and
arthrogram, their absolute need in the treatment for
DDH and Perthes’ disease remains controversial.
1060-152X
c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the arthrogram and six of the 19 patients (31.6%) with
Perthes’ disease. Intraobserver consultant agreement was
high but interobserver agreement was only moderate.
Static and dynamic arthrography helps decision-making in
patients with developmental dysplasia of the hip and
Perthes’ disease. J Pediatr Orthop B 17:114–119
Wolters Kluwer Health | Lippincott Williams & Wilkins.
Journal of Pediatric Orthopaedics B 2008, 17:114–119
Keywords: arthrogram, hip developmental dysplasia, Perthes’ disease
The Children’s Orthopaedic Service, Nuffield Orthopaedic Centre, Oxford, UK
Correspondence and requests for reprints to Mr Rohit Kotnis, c/o Mr Benson’s
Secretary, Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK
Tel/fax: + 44 1865 227624; e-mail: rkotnis@hotmail.com
The aim of this prospective study was to assess whether
hip arthrography was reliable and of value in planning
definitive treatment for children with DDH and Perthes’
disease.
Methods
Over the 12-month period July 2003–July 2004, children
over the age of 6 months undergoing EUA and hip
arthrography were entered into the study. The exclusion
criteria were those with skeletal dysplasia or abnormal
development secondary to infection, trauma and meta-
bolic and growth disorders.
In our unit, children with DDH and Perthes’ disease are
reviewed in a dedicated hip clinic. Symptoms that cause
concern include pain on weight bearing and a limp. Any
reduction in hip range of movements or a leg length
inequality of more than 1 cm is of concern. Cases in which
clinical and radiographic development is satisfactory, chil-
dren are reviewed at least every 6 months until skeletal
maturity. An anteroposterior plain radiograph of the pelvis is
obtained on each occasion. In DDH, our indications for
arthrography were occasionally clinical but more usually
failure of acetabular maturation with time following open or
closed reduction. For Perthes’ disease, the indications for
arthrography were failure for limp and discomfort to settle
with time, progressive loss of abduction in extension or loss
of adduction in flexion with radiological evidence of
increasing femoral head extrusion. When the child’s hip
causes concern based on clinical history, examination and

plain radiographs, an EUA and arthrogram is advised to help
formulate a definitive treatment plan. The arthrogram is
performed within 3 months. Following the decision to
perform an EUA and arthrogram, the child and parents
attend a preoperative assessment clinic. The range of
movement of the child’s hips is recorded and consent
obtained.
Technique
The procedure is performed under general anaesthesia in
the operating theatre using full sterile precautions.
An EUA and arthrogram are performed by the consultant
and team, and a note made of the hip range of movements
and stability. The child’s hips are abducted in flexion and a
22-gauge spinal needle inserted into the hip joint using an
inferomedial approach behind the tendon of adductor
longus guided by image intensification. We prefer this
approach because, if dye leaks from the hip, it does not
obscure the view. Physiological saline is flushed through
the needle to confirm joint placement: minimal resistance
and the aspiration of saline and/or joint fluid suggests
satisfactory placement. A few millilitres of Omnipaque 300
contrast (AmershamHealth, Oslo, Norway) diluted by 50%
physiological saline are injected and a successful arthrogram
confirmed with image intensification. Gentle movement of
the hip ensures an even spread of dye.
Images are taken in the following positions.
(1) Neutral anteroposterior.
(2) Full abduction in flexion.
(3) Full abduction in extension.
(4) Thirty degrees of flexion, internal rotation and
abduction (Salter position).
(5) False profile view of Le Quesne in flexion and
extension.
(6) Axial loading and traction (push–pull) views to assess
stability.
Examination under anaesthetic and arthrogram
interpretation
Following the arthrogram, a definitive treatment plan is
made. When the femoral head is aspherical, the ‘position
of best fit’ is recorded. If a surgical procedure is indicated
this is performed subsequently. The definitive surgical
procedure was performed at a mean of 3 months following
the arthrogram.
Study design
This study was divided into prospective and retrospective
parts.
Prospective study
(1) Before the arthrogram, the child’s consultant was
asked to formulate a prospective treatment plan for
each affected hip based on his clinical examina-
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Hip arthrogram for DDH and Perthes’ disease Kotnis et al. 115
tion and plain radiographic assessment. The options
included:
(a) continuing observation,
(b) a specific pelvic osteotomy,
(c) a specific femoral osteotomy, and
(d) a combined pelvic and femoral procedure.
(2) Following the arthrogram, the consultant formulated
a definitive treatment plan.
(3) This was compared with the pre-arthrogram plan. As
different numbers of patients were treated by each
consultant, the results were analysed for the group as
a whole.
Forty children underwent an EUA and hip arthrogram
over the study period. Twenty-one patients had DDH
and 19 patients had Perthes’ disease.
Retrospective study
To assess consultant reliability, the three children’s
consultants independently reviewed the 40 consecutive
patients who underwent EUA and hip arthrography for
DDH or Perthes’ disease before July 2003. Twenty-six
patients had DDH and 14 had Perthes’ disease. This
group of patients was intentionally different from those in
the prospective study.
(1) The consultants were independently given details
of the history and examination, shown the plain
radiographs and asked to decide what treatment each
would recommend on this basis alone.
(2) The arthrogram films were shown subsequently and a
second treatment plan formulated.
We compared the following data.
(a) The number of patients for whom all three
consultants agreed on a treatment plan using plain
radiographs alone.
(b) The number of patients for whom there was
agreement on treatment after the arthrogram films.
(c) For each consultant, the number of patients for
whom treatment was modified by the arthrogram.
(d) The second plan of the treating consultant with the
management undertaken.
Examples
Two patients in whom management was modified by the
arthrogram are illustrated below. Both patients were from
the prospective study.
Case 1
Figure 1a–h shows the plain radiographs and arthrogram
films of an 11-year-old girl with DDH of the left hip.
A previous Salter osteotomy with femoral shortening
had been performed when the child was 5 years old.
 116 Journal of Pediatric Orthopaedics B 2008, Vol 17 No 3

Fig. 1

Plain standing radiographs and arthrogram images of a patient with developmental dysplasia of the left hip (case 1). (a) Plain anteroposterior
radiograph demonstrating a shallow left acetabular roof by comparison with the right side. A previous healed Salter osteotomy is seen. Uncovering
and superolateral migration of the femoral head (loss of Shenton’s line) are demonstrated. A provisional plan for a Pemberton osteotomy alone was
made. After dye instillation: (b) the neutral anteroposterior radiograph shows an oval femoral head with mild subluxation (central dye pooling) and
uncovering. (c) The Salter view shows improved containment and congruency of the left hip. (d) In abduction and flexion (frog lateral), the femoral
head is spherical and reduction congruent. (e) The axial (push) view show only mild joint laxity and confirm reasonable joint congruity. The
cartilaginous roof is better than the plain films suggest (Shenton’s line is disrupted). (f) The traction (pull) view shows the head centres and Shenton’s
line is restored. There is incongruity in shape between the acetabular and femoral head, which could be improved by folding the roof down. (g) The
false profile view in hip extension shows imperfect anterior cover of the femoral head. (h) The postoperative radiograph demonstrates that Pemberton
and varus rotational femoral osteotomies have been performed. The left hip joint is now more congruent and the femoral head well covered.
Restoration of the left Shenton’s line is demonstrated.

Metalwork was subsequently removed. Despite surgery, Results

the plain radiograph taken 4 years later (Fig. 1a) showed
uncovering of the femoral head with coxa valga. The
arthrogram images (Fig. 1b–g) showed that the hip was
best contained in abduction and internal rotation. The
original plan was for a Pemberton osteotomy alone
although a Salter or triple osteotomy with or without a
femoral osteotomy was considered. The false profile view
(Fig. 1g) demonstrated poor anterior cover with incon-
gruity and a combined Pemberton and varus femoral
osteotomy realigned and reshaped the hip satisfactorily
and balanced the leg length discrepancy. Figure 1h shows
the postoperative radiograph.
Case 2
Figure 2a–e shows the radiographs of a 10-year-old
boy with Perthes’ disease. The provisional plan was to
‘observe’ only. The arthrogram, however, demonstrated
that the hip could not be contained and hinged with
abduction. The treatment plan was therefore modified
and a Staheli shelf procedure performed. The shelf was
inserted in such a way that the lateral acetabular growth
plate was not injured (Fig. 2e).
Analysis of results
The k test was used for statistical analysis of the results
for each consultant [5].
Prospective study
In the DDH group, the prospective treatment plan was
modified by the treating surgeon in 12 of the 21 (57.1%)
patients as a result of the arthrogram (Table 1). Six of the
19 patients (31.6%) with Perthes’ disease had their
treatment modified (Table 2).
In both groups, when it was felt likely that simple
observation was probable (10 patients), this was only
occasionally modified by the arthrogram (two patients).
Retrospective study
Table 3 shows the pre-arthrogram and post-arthrogram
plans that each consultant formulated for the patients in
the retrospective study.
(1) The three consultants agreed on a similar treatment
plan using plain radiographs alone for 20 of the 40
patients (DDH – 16/26; Perthes’ disease – 4/14).
(2) The three consultants agreed on a treatment plan
after the arthrogram films were shown in 28 of the 40
patients (DDH – 17/26, Perthes’ disease – 11/14).
(3) The number of times that each consultant modified
his treatment plan following the arthrogram is shown
in Table 4 with a k analysis in Table 5.

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 Hip arthrogram for DDH and Perthes’ disease Kotnis et al. 117

Fig. 2

Plain radiographs and arthrogram images of a patient with Perthes’ disease of the right hip (case 2). (a) Plain anteroposterior radiograph
demonstrating irregularity of the left femoral head and marked reduction in lateral pillar height. The femoral head appears well covered and it was
planned to simply observe the hip. (b) Neutral anteroposterior radiograph confirming the femoral head irregularity and incongruency of the hip joint.
The views taken in the Salter position (c) and with the leg in full abduction (d) demonstrate that the hip cannot be fully contained. Marked lateral point
loading with hinge abduction is noted. (e) The postoperative radiograph showing that a Staheli shelf procedure has been performed. The hip joint has
been stabilized.

Table 1 Prospective study of the number of patients with Table 2 Prospective study of the number of patients with Perthes’
developmental dysplasia of the hip in whom treatment was disease in whom treatment was modified by arthrogram
modified by arthrogram
Number of Pre-arthrogram Treatment Post-arthrogram plan
Number of Pre-arthrogram Treatment Post-arthrogram plan patients plan modified (number of patients)
patients plan modified (number of patients) (number of
(number of patients)
patients)
8 Observe 2 Observe (6), FO (1),
2 Observe 0 Observe (2) shelf procedure (1)
5 Femoral 3 FO (2), SO (1), observe (1), 5 Femoral 2 FO (3), observe (1), F + P (1)
osteotomy F + P (1) osteotomy
7 Salter osteotomy 5 SO (2), FO (2), PO (2), 3 Salter osteotomy 1 SO (2), F + P (1)
observe (1) 1 Pemberton 1 FO (1)
6 Pemberton 4 PO (2), SO (2), F + P (1), osteotomy
osteotomy observe (1) 1 Shelf procedure 0 Shelf procedure (1)
1 Shelf procedure 0 Shelf procedure (1) 1 Chiari osteotomy 0 Chiari osteotomy (1)
Total: 21 Total: 12 Total: 19 Total: 6

FO, femoral osteotomy; PO, Pemberton osteotomy; SO, Salter osteotomy; F + P, FO, femoral osteotomy; PO, Pemberton osteotomy; SO, Salter osteotomy; F + P,
femoral and pelvic osteotomy. femoral and pelvic osteotomy.

(4) When the treatment proposed for each patient after
the arthrogram films was compared with the defini-
tive treatment, the treating consultant made the
same decision in 31 of the 40 patients (Table 3).
correlates well with operative findings and is helpful in
management [9–12]. Drummond et al. [13], who found
arthrography reliable, concluded that the neutral and von
Rosen views helped to differentiate between a subluxated
hip and one with dysplasia and excess femoral anteversion.

Discussion In Perthes’ disease, Axer and Schiller [14] suggested that

Hip arthrography may help to demonstrate obstacles
to reduction and to plan subsequent treatment. The
cartilaginous shape of the femoral head and acetabulum
are demonstrated and hip movement and stability may be
dynamically assessed.
The role of arthrography in evaluating DDH and Perthes’
disease, however, is controversial. Some surgeons believe
arthrography to be unnecessary [1,6–8] while others find it
the primary role of arthrography was to assess femoral
head extrusion. Gallagher et al. [15], however, concluded
that for most patients, extrusion could be established
with plain radiographs alone. Moberg et al. [16] compared
the two and reported that in 33 of 76 patients,
arthrography demonstrated subluxation not identifiable
on plain radiographs. More recently, Bennett et al. [17]
evaluated the plain radiographs and arthrograms of 46
patients with Perthes’ disease. Only with arthrography

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 118 Journal of Pediatric Orthopaedics B 2008, Vol 17 No 3

Table 3 Results of the retrospective study

Pre-arthrogram plan Post-arthrogram plan

Patient Diagnosis C1 C2 C3 C1 C2 C3 Actual procedure

1 DDH P P O P O O P
2 DDH P P P P P P P
3 DDH C C C C C C C
4 DDH O O P O O P P
5 Perthes P P O P P P P
6 DDH P P P P P P P
7 DDH O P F+P P P P O
8 DDH P P P P P P P
9 Perthes P P P F P F F
10 DDH O O O F P P P
11 DDH O P P P O O O
12 DDH P P O P P P O
13 DDH P P P O P O O
14 Perthes O O O O O O O
15 DDH P F+P P F+P P F+P F+P
16 Perthes P O F P P P P
17 DDH P P F P O O O
18 Perthes P P F P P P P
19 Perthes P P P P P P P
20 DDH O O O O O O O
21 DDH C C C C C C C
22 DDH C C C C C C C
23 DDH P P F O O O F
24 DDH P P F+P P F+P F F
25 Perthes O P P P P P P
26 DDH O O O O O O O
27 Perthes O P O P P O O
28 DDH P O P P P P P
29 DDH Open Open Open Open Open Open Open
30 Perthes O P F P P P F
31 DDH C C C C C C C
32 Perthes F F O F F F F
33 DDH C C C Open Open Open Open
34 DDH O O O O O O O
35 Perthes P F F P F F P
36 DDH O O O O P P P
37 Perthes O O O O O O O
38 Perthes P F F+P F F F F
39 DDH O O O O O O O
40 Perthes O P F P P P P

C1–C3, consultant identification number; DDH, developmental dysplasia of the hip; O, to observe; C, closed reduction; open, open reduction; F, femoral osteotomy; P,
pelvic osteotomy; F + P, femoral and pelvic osteotomy. Entries in bold represent the consultant who performed the actual procedure. For example, patient 17 with DDH:
two of the three consultants agreed on a treatment plan pre-arthrogram. Two consultants changed their view as a consequence of the arthrogram and in the event, the
patient was simply observed.

Table 4 The number of times that each consultant modified his Table 5 Retrospective study: j analysis on the agreement of a
treatment plan following the arthrogram treatment plan for each consultant before and after the arthrogram
Consultant DDH (n = 26) Perthes’ disease (n = 14) Consultant Agreement on the Agreement k Value
same treatment expected by
1 7 (33.3%) 6 (31.5%) plan (%) chance (%)
2 9 (42.8%) 1 (5.2%)
3 11 (52.3%) 8 (42.1%) Before vs. after: 67.5 32.4 0.52
consultant 1
Before vs. after: 75 32.1 0.59
consultant 2
were the measurements of acetabular coverage, femoral Before vs. after: 52.5 24.5 0.37
subluxation and epiphyseal extrusion more consistent and consultant 3
reliable. The retrospective nature of this study precluded Agreement: k 0 = by chance, 0.2–0.4 = poor, 0.4–0.6 = strong, 0.6–0.8 = good,
the authors from drawing any conclusions on how arthro- 0.8–1.0 = excellent.
graphy influenced treatment. We have compared the
effect of plain radiographs with arthrography in planning
treatment for children with both Perthes’ disease and radiation dose of computerized tomography and its poor
DDH. quantification of cartilage and soft-tissue structures make
it of little value [20]. Resolution of the soft tissues is
Alternatives to hip arthrography include ultrasound that excellent with magnetic resonance imaging [21], but
is non-invasive and dynamic, but lacks definition and is young children may need an anaesthetic and only open
used primarily in screening for DDH [18,19]. The high scanners allow dynamic examination.

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In this study, we have compared whether each surgeon’s
decisions in managing patients with DDH and Perthes’
disease are consistent and whether they are modified by
arthrography.
In the prospective study, treatment was modified as a
consequence of arthrography in 57.1% (12 of 21) of patients
with DDH and 31.6% (six of 19) of those with Perthes’
disease (Tables 1 and 2). This number of modifications was
surprising. Although each consultant performed an arthro-
gram before definitive treatment, each believed it was
likely to modify treatment only slightly.
In the retrospective study, which did not take place until
the prospective study had concluded, we attempted to
assess the reproducibility of each surgeon’s treatment
plan. A different set of patients was chosen to minimize
any bias occurring from a consultant remembering a
specific patient.
When the consultants provisionally planned treatment
using plain radiographs only, they agreed in only 20 of the
40 (50%) patients (Table 3). When the arthrogram was
reviewed in addition, the treatment plan was more
consistent with agreement in 28 of the 40 (70%) patients.
Of interest, the interobserver agreement for the three
consultants increased only slightly for patients with DDH
[16 of 26 patients (61%) to 17 of 26 patients (65%)], but
a much larger increase was noted for patients with
Perthes’ disease [four of 14 patients (29%) to 11 of 14
patients (79%)]. The reason for this discrepancy between
the two conditions is unclear.
While the consultants agreed inconsistently on a treat-
ment plan both before and after arthrography, this was in
part the result of the variety of operative procedures
available. Consultants 1 and 2 showed strong agreement
(k = 0.52 and 0.59, respectively) and consultant 3 fair
agreement (k = 0.37). The plain radiograph therefore was
not sufficient in our practice to develop a definitive
treatment plan.
When blinded to their definitive treatment, the surgeons
were consistent in only 31 of the 40 patients they treated.
The k value of 0.69 indicates strong agreement but there
is concern that our reproducibility still lacks precision.
While both studies suggest that the arthrogram is
important in developing a definitive treatment plan for
both DDH and Perthes’ disease, there remains consider-
able consultant variability in planning treatment both
before and to a lesser extent after arthrography. This is
more remarkable in a children’s department in which the
consultants meet regularly for case discussion.
The advantages of one-stage definitive treatment include
a single pre-assessment attendance, hospital admission
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Hip arthrogram for DDH and Perthes’ disease Kotnis et al. 119
and anaesthetic. In our hospital, where operative time is
at a premium, arthrography and definitive surgery are
carried out in two stages. We recognize this is not ideal.
Continuing audit will address the inconsistencies demon-
strated by this study but the conclusion is drawn that
arthrography remains useful for planning definitive
treatment for children with DDH and Perthes’ disease
whose hips cause concern.
Acknowledgements
The authors wish to thank the Medical Illustration
Department at the Nuffield Orthopaedic Centre, Oxford
for the preparation of the figures and Nicola Alder from
the Centre for Statistics, Wolfson College, University of
Oxford for help with statistical analysis of results.
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