Graf Method Research Articles

ACR Appropriateness Criteria® on Developmental Dysplasia of the Hip—Child

Developmental dysplasia of the hip (DDH) affects 1.5 of every 1,000 caucasian Americans and less frequently affects African Americans. Developmental dysplasia of the hip comprises a spectrum of abnormalities, ranging from laxity of the joint and mild subluxation to fixed dislocation. Early diagnosis of DDH usually leads to low-risk treatment with a harness. Late diagnosis of DDH in children may lead to increased surgical intervention and complications. Late diagnosis of DDH in adults can result in debilitating end-stage degenerative hip joint disease. Screening decreases the incidence of late diagnosis of DDH. Clinical evaluation for DDH should be performed periodically at each well-baby visit until the age of 12 months. There is no consensus on imaging screening for DDH. Consideration for screening with ultrasound is balanced between the benefits of early detection of DDH and the increased treatment and cost factors. In addition, randomized trials evaluating primary ultrasound screening did not find significant decrease in late diagnosis of DDH. In the United States, hip ultrasound is selectively performed in infants with risk factors, such as family history of DDH, breech presentation, and inconclusive findings on physical examination. Ultrasound for DDH should be performed after 2 weeks of age because laxity is common after birth and often resolves itself. A pelvic radiograph can optimally be performed after the age of 4 months, when most infants will have ossification centers of the femoral heads.

Inter- und intraindividuelle Messabweichungen in der Säuglingshüftsonografie nach Graf

Inter- and intraobserver reliability and learning curve using Graf's ultrasonographic hip examination were assessed. 189 participants of the basic, advanced and final courses on hip ultrasound using the Graf method (DEGUM) were asked to answer a questionnaire and to measure 34 normal and pathological sonographic hip examinations. Measurement differences and the learning curve during the different courses were evaluated. There was a significant (p = 0.001) improvement of the average angle between the basic (6.74 degrees [+/- 1.46 degrees ]) and the advanced course (6.22 degrees [+/- 1.17 degrees ]). However, there were no better results in the final course and no additional improvement. Participants had higher variations when measuring the beta-angle than the alpha-angle. A significant improvement was seen if the participants performed a large number of hip ultrasounds between the courses. Higher measurement differences were seen in pathological hip ultrasounds and in ultrasonographic examinations of poorer quality. During the educational courses on hip ultrasound using the Graf method, a high intra- and interobserver variability was seen. These findings were most prominent in measurement of the beta-angle, in pathological hip ultrasounds and in ultrasonographic hip examinations of poorer quality. The best results were achieved by participants who had performed a large number of examinations between courses. For the improvement of ultrasonographic measurements, a large number of self-performed examinations and a training in potential mistakes seem to be of great importance.

Ultrasound Hip Evaluation in Achondroplasia

During the period from 1985 to 2006, 22 children (44 hips) affected by achondroplasia were ultrasonographically evaluated. The patients' age at examination ranged from 7 days to 29 months. The hip ultrasound (US) examination was performed, according to Graf's method, using a Siemens Sonoline sonogram with linear 5.0- and 7.5-MHz probes. In all the hips, the alpha angle was impossible to be measured because the medial margin of the ilium was not ultrasonographically detectable. The ultrasonographic findings included the following: configuration of the acetabular bony rim, configuration of the acetabular roof, echogenicity of the head and acetabular cartilage, bony coverage percentage of the femoral head according to Morin et al, beta angle according to Graf, dynamic hip instability, and presence of the proximal femoral ossific nucleus. All hips had a sharp acetabular bony rim, a horizontal acetabular roof, thickened acetabular cartilage, and normal echogenicity. The femoral head was well centered and deeply contained in the acetabular fossa. The mean coverage was 86.7% (range: 78%-90%) and showed progressively larger values with increasing age. The mean value of the beta angle was 20 degrees (range: 8 degrees-38 degrees). The value of the beta angle tended to decrease as age increased. No difference was observed between the right and the left hip in both measurements. All hips were stable. The ossific nucleus was present in 5 children. The characteristic findings in hip ultrasonography in children with achondroplasia can aid in its early diagnosis because ultrasound can anatomically detect the altered development of the achondroplastic acetabulum.

Ultrasonography studies of the fetal hip

Recent advances in ultrasound technology, especially high-resolution sonography, now permit visualisation of the fetal hip development. Since early diagnosis and treatment of congenital hip dislocation significantly influence the outcome of the disease, ultrasound screening of the newborn infants showed to be the most effective method. In our study assessment of the fetal hip has been performed on the prenatal level in order to provide basic knowledge on fetal hip development from 14th to 40th weeks of gestation. From the 20th week of gestation bony structures are clearly visible and allow the assessment of acetabular configuration. Soft tissue and chondral acetabular components are recognizable from the 21st week. For pre- and postnatal comparative measures Graf's method and standard documentation is used.

Anterior dynamic ultrasound and graf's examination in neonatal hip instability

Discrepancy between neonatal hip morphology and stability has been reported in the literature. Comparative ultrasound studies on this issue are limited. To compare neonatal hip instability, as assessed by dynamic ultrasound and clinical examination, with acetabular morphology, as assessed by Graf's method. 536 newborn infants with clinical signs of hip instability, ambiguous findings at clinical hip examination, or positive risk factors for DDH were investigated with two ultrasound methods, the Graf method and anterior dynamic ultrasound, at an average age of 12 days. The hips were allocated to three groups according to the Graf result: A, normal (type Ia and b); B, borderline or immature (type IIa); and C, pathologic (type IIc and worse). Graf examination was compared with two diagnostic tests for instability, namely clinical examination by senior pediatric orthopedists and anterior dynamic ultrasound. According to Graf's method, 77% of the hips were normal, 20% borderline/immature, and 3% pathologic. On clinical hip examination, 82% were stable, 14% unstable, and 4% dislocatable. The dynamic ultrasound outcome was 88% stable hips, 10% unstable, and 2% dislocatable. Of the hips considered unstable or dislocatable on dynamic ultrasound, 21% had normal (type I) and 66% immature acetabular morphology according to the Graf method. Of the hips that were stable on dynamic ultrasound, only one (0.1%) was dysplastic according to the Graf method. Graf's examination showed the smallest number of normal hips, but also the fewest pathologic hips, with many indeterminate results that needed follow-up. Acetabular morphology correlated better to stability as assessed by dynamic ultrasound than to the clinical examination results, with fair to moderate agreement. Graf's examination resulted in a large number of indeterminate results that needed follow-up, but when used as the sole criterion for deciding treatment did not lead to a higher treatment rate than when the decision was based on clinical hip examination.

Neonatal Incidence of Hip Dysplasia

The advantages of sonographic examination are well known, but its main disadvantage is that it might lead to overdiagnosis, which might cause overtreatment. Variations in the incidence of developmental dysplasia of the hip are well known. We ascertained the incidence of neonatal sonographic developmental dysplasia of the hip without considering the development of those joints during followup. All 45,497 neonates (90,994 hips) born in our institute between January 1992 and December 2001 were examined clinically and sonographically during the first 48 hours of life. Sonography was performed according to Graf's method, which considers mild hip sonographic abnormalities as Type IIa. We evaluated the different severity type incidence pattern and its influence on the total incidence during and between the investigated years. According to our study, sonographic Type IIa has major effects on the incidence of overall developmental dysplasia of the hip with a correlation coefficient of 0.95, whereas more severe sonographic abnormalities show relatively stable incidence patterns. Level I, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of Graf's Ultrasound Class III and IV Hips Using Pavlik's Method

When Pavlik introduced his method of treating congenital dislocation of the hip, he emphasized reducing the rate of osteonecrosis. Graf's method of sonographic evaluation afforded earlier accurate diagnosis and subsequent treatment of developmental dysplasia of the hip. To ascertain whether treatment duration, gender, age at diagnosis, clinical stability, and/or treatment onset correlate with the risk of osteonecrosis in Graf Type III or IV hips, we clinically and sonographically screened 18,067 neonates (36,134 hips) for developmental dysplasia of the hip over a 4-year period; 151 had Graf Type III or IV hips, and 78 of these were treated by us and had known outcomes. Of these 78 hips, 65 (0.18%) had Graf Type III and 13 (0.036%) had Graf Type IV hips. Sixteen of the 65 Type III hips (25%) reduced spontaneously. Using Pavlik's method, reduction was achieved in 46 of 65 (88.5%) Type III hips and eight of 13 Type IV hips. None of the hips treated exclusively by Pavlik's method developed osteonecrosis. Thus, the method achieves one of Pavlik's original goals of decreasing osteonecrosis incidence to close to zero. Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ultrasound screening for developmental dysplasia of the hip in the newborn: a population-based study in the Maribor region, 1997–2005

Ultrasound imaging has become an accepted tool for accurate diagnosis of developmental dysplasia of the hip (DDH) and for its management. The aim of the present study was to evaluate the results of the general neonatal hip screening program in Maribor between 1997 and 2005 in comparison with earlier reported results for our region, where this program was introduced in 1985. Of the total number of 17,846 newborns born in our maternity hospital, 17,393 were included in the study during the nine-year period. All hips were examined by ultrasonography within the first week of life. Data for 2.5% of newborns were not available. The incidence of sonographic hip types according to the Graf method was analyzed, together with the sex distribution, lateralization of hip pathology and treatment recommendations. A total of 34,786 hips were evaluated sonographically: 84.9% of hips were mature at first examination (Graf types Ia and Ib), 14.1% were immature (Graf type IIa) and 1.1% were pathological (Graf types IIc or worse). In the group of pathological hips, girls were more frequently affected than boys (3.9:1) and the left hip was more frequently affected than the right (1.2:1). The incidence of hip types IIc or worse decreased sevenfold throughout the observation period, from 2.1 in 1997 to 0.3 in 2005. This distribution of hip types resulted in an average treatment rate of 18 newborns per 1000 live borns, down from 42 treated hips per 1000 newborns in 1997 to 6 hips per 1000 in 2005. During this nine-year period, only 19 children required surgical treatment for DDH before the age of three years. In our region, general ultrasound hip screening of newborns for DDH seems to be effective in reducing the overall treatment rate. The number of surgical procedures has remained stable during the past nine-year screening period and is lower than in the pre-ultrasound era.

Avaliação ultra-sonográfica pelo método de Graf no quadril infantil

Ultrasonography of the hip performed by the Graf method is widely accepted as an important diagnostic and treatment tool for hip dysplasia. This study aims to examine the reliability and reproducibility of the interpretations of ultrasound scans by general orthopedists. Thirteen examiners evaluated five hip ultrasounds of the same normal child. The examiners measured alpha and beta angles according to Graf. Statistical analysis was performed by variance analysis (ANOVA) and agreement was calculated and expressed as the intraclass correlation coefficient (ICC). The alpha angle mean was 37.32 degrees (11.12) and the beta angle mean was 45.05 degrees (10.49). Error of the intra-observer was 17.65 for the alpha angle and 17.63 for the beta. Error of the inter-observer was 7.68 for the alpha angle and 17.21 for the beta. ICC intra-observer was 0.18 for the alpha angle and 0.29 for the beta. ICC inter-observer was -0.02 for the alpha angle and 0.3 for the beta. Ultrasound of the infantile hip using the Graf method is an important tool for the assessment of developmental dysplasia of the hip, however, it must be emphasized that preciseness of interpretation requires training and frequent use.

The natural history of developmental dysplasia of the hip: sonographic findings in infants of 1–3 months of age

The natural history of sonographic developmental dysplasia of the hip was determined in a population-based study in which 5170 infants were screened by ultrasound using Graf's method. Of the normal hips at the age of 1 month, 99.6% were still normal at the age of 3 months. Of the immature type IIa/IIa+ and type IIa- hips, if untreated, 95.3 and 84.4% had become normal, respectively. Of the infants with type IIc, D and III/IV hips at the age of 1 month 70, 58.3 and 90.9% were treated, respectively. This study shows that normal hips remain normal in nearly 100% of cases, but development to abnormality is possible. It shows also that most of the immature hips at the age of 1 month become normal without treatment. Although treatment seems to be indicated in the majority of sonographically abnormal hips, the occurrence of overtreatment could not be excluded in our study.

Is prematurity important in ultrasonographic hip typing?

The aim of this study was to determine whether prematurity is important with respect to hip typing and planning of treatment/follow-up in newborns assessed with the Graf's ultrasonography method. Between January 1998 and 2003, 1592 neonates; preterm (n=432) and term (n=1160), had their hips ultrasonographically evaluated with Graf typing. There were no statistical differences between the two groups with respect to the numbers of hips that required follow-up assessment, or treatment. The results suggest that prematurity is irrelevant and use of chronological age as opposed to corrected age for prematurity will further simplify diagnosis and planning of follow-up and treatment in the Graf system for neonatal hip assessment.

Assessment of the use of hip ultrasonography by Grafʼs method between 1 and 6 years of age

Ultrasonographic examinations of both hips of 133 children whose age ranged from 13 to 72 months were performed using the Graf's method. A standard plane which was mandatory prior to the hip typing could be obtained in 93, 91, 84, 79 and 66% of the sonograms for 13-24, 25-36, 37-48, 49-60 and 61-72 months age groups, respectively. The 61-72 months age group had the lowest percentage of valid sonograms and this difference was considered significant (P=0.001). It was concluded that plain radiography was still the gold standard imaging technique in developmental dysplasia of the hip, but hip ultrasonography by the Graf's method might be an alternative imaging technique in experienced hands for the evaluation of developmental dysplasia of the hip in children between 1 and 5 years of age.

乳児股関節検診における超音波検査の有用性

We performed ultrasonography screening for the hip joint in 145 infants between January 2003 and January 2004 at Nakajo-machi in Niigata Prefecture. This ultrasonographic study was conducted by Graf's method. The method could discriminate normal hip joints and was able to visualize 11 abnormal hip joints as well. All abnormal hip joints were dysplastic. This method is more useful than x-ray examination for infants, since the cartilaginous femoral head and the soft tissues around the hip could be clearly visualized. As a result, ultrasonography appears to be a useful screening method for congenital dislocation of the hip joint, without the hazard of radiation caused by x-rays.

Sonography of Hip Dysplasia

Early diagnosis of developmental dysplasia of the hip (DDH) is important to institute appropriate treatment and reduce the incidence of long-term complications. Risk factors for DDH include genetic, developmental, mechanical, and physiologic factors. Physical examination using Ortolani and Barlow maneuvers is standard for early detection. Plain film radiography is limited for the diagnosis of DDH even when applying several classic landmarks, lines, and measurements, due to the lack of visualization of the cartilaginous components of the infant's hip. Ultrasound arose as a tool for evaluation of the cartilaginous structures of the hip in the early 1980s. Graf's method of examination by ultrasound stresses morphology, whereas dynamic examination uses physical maneuvers to elicit laxity of the hip. The Pavlik harness is the mainstay of treatment of DDH in the young infant, and ultrasound examination in the harness is useful to monitor progress. Closed or open surgical reduction is reserved for unresponsive or advanced cases. Universal ultrasound screening of newborns is not deemed cost effective by most North American authors, although in Europe non-selective screening has been more widely used.

Inter-observer agreement of ultrasonographic measurement of alpha and beta angles and the final type classification based on the Graf method.

The aim of our study was to investigate the agreement of the assessment of hip ultrasonograms by different observers. In the period from June 3rd to December 9th 2002, four different (by experience and field) groups of observers rated all first time sonograms obtained in our hospital. The results in terms of angle and type classification were compared. 158 ultrasonographic images were evaluated. The inter-observer agreement for the classification "normal" (type I) versus "abnormal" (types IIa+ to IV) varied from 83% to 90% with kappa coefficients which indicated moderate (kappa 0.55) to substantial (kappa 0.71) inter-observer agreement. For one pair of observers, a better agreement could be demonstrated for the assessment of immature hips than for mature ones. The deviation for the a-angle was 0 to 16 degrees with a standard deviation of 3.15 degrees (95% CI 2.95, 3.37), and for the b-angle 0 to 26 degrees with a standard deviation of 6.1 degrees (95% CI 5.7, 6.5). The intra-class correlation coefficient was estimated to be 0.72 and 0.34 for the alpha and beta angles respectively. If the hip was immature there was no increase in the discrepancy in assessment between observers. The least agreement existed between the less experienced and the most experienced. It has not been possible to make a statement on the discrepancy with regard to initial signs of instability or decentralization of the hip joints because of the small number of hips of this type. Although the spread in measured a- and b-angles is large, the inter-observer agreement for the classification showed good results. No disagreement occurred in the diagnosis of normal vs. dysplastic hips, so no severe cases have been missed. The experience and training of the investigators seemed to play an important role with regard to variability and agreement. The agreement in the assessment of immature hips was better than that of mature hips. Therefore, ultrasound examination of infant hips would appear to be a trustworthy screening method.

Inter-observer agreement of ultrasonographic measurement of alpha and beta angles and the final type classification based on the Graf method.

The aim of our study was to investigate the agreement of the assessment of hip ultrasonograms by different observers. In the period from June 3rd to December 9th 2002, four different (by experience and field) groups of observers rated all first time sonograms obtained in our hospital. The results in terms of angle and type classification were compared. 158 ultrasonographic images were evaluated. The inter-observer agreement for the classification "normal" (type I) versus "abnormal" (types IIa+ to IV) varied from 83% to 90% with kappa coefficients which indicated moderate (kappa 0.55) to substantial (kappa 0.71) inter-observer agreement. For one pair of observers, a better agreement could be demonstrated for the assessment of immature hips than for mature ones. The deviation for the a-angle was 0 to 16 degrees with a standard deviation of 3.15 degrees (95% CI 2.95, 3.37), and for the b-angle 0 to 26 degrees with a standard deviation of 6.1 degrees (95% CI 5.7, 6.5). The intra-class correlation coefficient was estimated to be 0.72 and 0.34 for the alpha and beta angles respectively. If the hip was immature there was no increase in the discrepancy in assessment between observers. The least agreement existed between the less experienced and the most experienced. It has not been possible to make a statement on the discrepancy with regard to initial signs of instability or decentralization of the hip joints because of the small number of hips of this type. Although the spread in measured a- and b-angles is large, the inter-observer agreement for the classification showed good results. No disagreement occurred in the diagnosis of normal vs. dysplastic hips, so no severe cases have been missed. The experience and training of the investigators seemed to play an important role with regard to variability and agreement. The agreement in the assessment of immature hips was better than that of mature hips. Therefore, ultrasound examination of infant hips would appear to be a trustworthy screening method.

The value of ultrasound examination in the diagnosis and screening for congenital dislocation of the hip

In our study, the methods used for the diagnosis of congenital dislocation of the hip in the period of newborn and early infantile were investigated, compared with the other diagnostic methods of ultrasound technique, and the superiorities were discussed. The advantages and reliabilities that ultrasonography provide for the diagnosis of congenital dislocation of the hip were investigated. At first, 100 infants were examined clinically and pelvis anteroposterior radiograms were taken. Then, both hips were investigated under ultrasonography with Graf Method, the hips were measured for angle as to Graf method, and typed. As a result of investigation, in 200 hips of 100 cases, the proportion of type la, type Ib, and type Illa was found 91%. The rate of hips with dysplasia from type Ilb was found 9%. The hips evaluated pathologically were applied abduction splint treatment and followed

The ultrasonographic image of the infant hip affected by developmental dysplasia with a positive Ortolani's sign.

Instability of the hip may be assessed by the Ortolani and Barlow tests, which are the keystone of clinical screening for developmental dysplasia of the hip (DDH). However, Ortolani's sign implies that there is strong evidence of a severe form of DDH with a completely dislocated, but still reducible, femoral head. Barlow's test addresses several different forms of "instability" of the hip that are quite difficult to describe and in 80% of cases disappear during growth. For this reason, Ortolani's sign in a baby should be considered an indication for emergency treatment to reduce and stabilise the hip while it is still reducible. The increasingly widespread use of US of the hip in newborns and infants has enabled clinicians to observe the hip from the first day of life and to establish both the static and dynamic relationships of the femoral head and acetabulum. The purpose of this paper is to describe the US pattern and relative classification of the hip affected by Ortolani's sign and examined by Graf's method, and to confirm through US that Ortolani's sign should be considered a totally reliable specific test for the identification of dislocation of the infant hip.

Achilles tendon diseases and its management

Objectives: We evaluated the results of treatment in patients who were treated according to an algorithm established for developmental dysplasia of the hip (DDH) during the first 18 months of life. Methods: We developed an algorithm for DDH to be used in infants at 0 to 18 months of age. Patients who did not respond to, or who did not have the indication for, the use of Pavlik harness were treated according to our algorithm and evaluated prospectively. Thirty-three hips (24 patients; 21 girls, 3 boys; mean age 7.4 months; range 2.5 to 18 months) were followed-up for a mean of 42 months (range 15 to 90 months). Ultrasonographic evaluation was performed using the Graf method. Avascular necrosis was evaluated according to the Kalamchi and MacEwen classification, and radiological results according to the Severin classification. Results: The mean acetabular index angles before and after treatment were 37.3° (range 20 to 58°) and 21.8° (range 15° to 30°), respectively. According to the Kalamchi and MacEwen classification, six hips (18.2%) had type I, three hips (9.1%) had type II, and one hip (3%) had type III avascular necrosis. According to the Severin criteria, 21 hips were considered in group I, 10 in group II, and two hips in group III. Acetabular osteotomies were performed in four hips. All patients had full range of motion without any pain and limp. Conclusion: Successful clinical results obtained in the hips treated according to this algorithm for DDH may serve to justify its use as a standard algorithm in the treatment of infants at ages 0 to 18 months.

Assessment of Variations in the Measurement of Hip Ultrasonography by the Graf Method in Developmental Dysplasia of the Hip§

Summary: The purpose of this study was to assess the variations in the measurement of hip ultrasonography using the Graf method in developmental hip dysplasia. Twenty-two observers independently analyzed 20 hip ultrasonograms on two occasions. Intraobserver and interobserver agreement ratios on the exact Graf classification were 65% and 51%, respectively. Intraobserver and interobserver agreement ratios on the treatment method according to the hip type were 76% and 64%, respectively. Average intraobserver and interobserver differences were 4.0° and 5.1° for the alpha angle, and 5.9° and 10.1° for the beta angle, respectively. It was concluded that having a basic knowledge of the Graf method was the key point, and the observer's previous number of examinations had no effect on the results.