Mulpuri Kishore, Schaeffer Emily K, Andrade Janice, Sankar Wudbhav N, Williams Nicole, Matheney Travis H, Mubarak Scott J, Cundy Peter J, Price Charles T
Department of Orthopaedics, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada.
Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, BC, Canada.
Clin Orthop Relat Res. 2016 May;474(5):1131-7. doi: 10.1007/s11999-015-4668-0.
Most infants with developmental dysplasia of the hip (DDH) are diagnosed within the first 3 months of life. However, late-presenting DDH (defined as a diagnosis after 3 months of age) does occur and often results in more complex treatment and increased long-term complications. Specific risk factors involved in late-presenting DDH are poorly understood, and clearly defining an associated set of factors will aid in screening, detection, and prevention of this condition.
QUESTIONS/PURPOSES: Using a multicenter database of patients with DDH, we sought to determine whether there were differences in (1) risk factors or (2) the nature of the dislocation (laterality and joint laxity) when comparing patients with early versus late presentation.
A retrospective review of prospectively collected data from a multicenter database of patients with dislocated hips was conducted from 2010 to 2014. Baseline demographics for fetal presentation (cephalic/breech), birth presentation (vaginal/cesarean), birth weight, maternal age, maternal parity, gestational age, family history, and swaddling history of patients were compared among nine different sites for patients who were enrolled at age younger than 3 months and those enrolled between 3 and 18 months of age. A total of 392 patients were enrolled at baseline between 0 and 18 months of age with at least one dislocated hip. Of that group, 259 patients were younger than 3 months of age and 133 were 3 to 18 months of age. The proportion of patients with DDH who were enrolled and followed at the nine participating centers was 98%.
A univariate/multivariate analysis was performed comparing key baseline demographics between early- and late-presenting patients. After controlling for relevant confounding variables, two variables were identified as risk factors for late-presenting DDH as compared with early-presenting: cephalic presentation at birth and swaddling history. Late-presenting patients were more likely to have had a cephalic presentation than early-presenting patients (88% [117 of 133] versus 65% [169 or 259]; odds ratio [OR], 5.366; 95% confidence interval [CI], 2.44-11.78; p < 0.001). Additionally, late-presenting patients were more likely to have had a history of swaddling (40% [53 of 133] versus 25% [64 of 259]; OR, 2.053; 95% CI, 1.22-3.45; p = 0.0016). No difference was seen for sex (p = 0.63), birth presentation (p = 0.088), birth weight (p = 0.90), maternal age (p = 0.39), maternal parity (p = 0.54), gestational age (p = 0.42), or family history (p = 0.11) between the two groups. Late presenters were more likely to present with an irreducible dislocation than early presenters (56% [82 of 147 hips] versus 19% [63 of 333 hips]; OR, 5.407; 95% CI, 3.532-8.275; p < 0.001) and were less likely to have a bilateral dislocation (11% [14 of 133] versus 28% [73 of 259]; OR, 0.300; 95% CI, 0.162-0.555; p = 0.002).
Those presenting with DDH after 3 months of age have fewer of the traditional risk factors for DDH (such as breech birth), which may explain the reason for a missed diagnosis at a younger age. In addition, swaddling history was more common in late-presenting infants. A high index of suspicion for DDH should be maintained for all infants, not just those with traditional risk factors for DDH. Further investigation is required to determine if swaddling is a risk factor for the development of hip dislocations in older infants. More rigorous examination into traditional screening methods should also be performed to determine whether current screening is sufficient and whether late-presenting dislocations are present early and missed or whether they develop over time.
Level III, retrospective study.
大多数发育性髋关节发育不良（DDH）婴儿在出生后的前3个月内被诊断出来。然而，迟发性DDH（定义为3个月龄后诊断）确实会发生，并且通常会导致更复杂的治疗和增加长期并发症。迟发性DDH所涉及的具体风险因素了解甚少，明确一组相关因素将有助于筛查、检测和预防这种情况。
问题/目的：使用DDH患者的多中心数据库，我们试图确定在比较早发与迟发患者时，（1）风险因素或（2）脱位的性质（侧别和关节松弛度）是否存在差异。
对2010年至2014年从一个多中心脱位髋关节患者数据库中前瞻性收集的数据进行回顾性分析。比较了9个不同地点年龄小于3个月和3至18个月入组患者的胎儿先露（头位/臀位）、出生方式（阴道分娩/剖宫产）、出生体重、母亲年龄、母亲产次、孕周、家族史和襁褓包裹史等基线人口统计学数据。共有392例0至18个月龄的患者在基线时至少有一侧髋关节脱位入组。其中，259例患者年龄小于3个月，133例患者年龄为3至18个月。在9个参与中心入组并随访的DDH患者比例为98%。
对早发和迟发患者的关键基线人口统计学数据进行单因素/多因素分析。在控制了相关混杂变量后，与早发患者相比，有两个变量被确定为迟发性DDH的风险因素：出生时头位和襁褓包裹史。迟发患者出生时头位的可能性高于早发患者（88%[133例中的117例]对65%[259例中的169例]；比值比[OR]，5.366；95%置信区间[CI]，2.44 - 11.78；p < 0.001）。此外，迟发患者有襁褓包裹史的可能性更大（40%[133例中的53例]对25%[259例中的64例]；OR，2.053；95%CI，1.22 - 3.45；p = 0.0016）。两组在性别（p = 0.63）、出生方式（p = 0.088）、出生体重（p = 0.90）、母亲年龄（p = 0.39）、母亲产次（p = 0.54）、孕周（p = 0.42）或家族史（p = 0.11）方面没有差异。迟发患者比早发患者更易出现不可复位脱位（56%[147例髋关节中的82例]对19%[333例髋关节中的63例]；OR，5.407；95%CI，3.532 - 8.275；p < 0.001），且双侧脱位的可能性较小（11%[133例中的14例]对28%[259例中的73例]；OR，0.300；95%CI，0.162 - 0.555；p = 0.002）。
3个月龄后出现DDH的患者具有较少的传统DDH风险因素（如臀位产），这可能解释了在较年轻时漏诊的原因。此外，襁褓包裹史在迟发婴儿中更常见。对于所有婴儿，而不仅仅是那些具有传统DDH风险因素的婴儿，都应保持对DDH的高度怀疑指数。需要进一步研究以确定襁褓包裹是否是较大婴儿髋关节脱位发生的风险因素。还应更严格地检查传统筛查方法，以确定当前筛查是否足够，以及迟发性脱位是早期存在而漏诊还是随时间发展而来。
III级，回顾性研究。
