Ortolani Test Research Articles

Computed tomographic evaluation of growth-related changes in the hip joints of young dogs

To evaluate changes in canine hip joint characteristics during growth via computed tomography (CT) and compare CT features of hip joints with and without laxity in young dogs placed in 2 imaging positions. 21 dogs (42 hip joints). From 2 to 12 months after birth, CT examinations of the acetabulum of each hip joint in simulated normal standing and simulated weight-bearing positions were performed monthly for all dogs. Acetabular angle, dorsal acetabular rim angle (DARA), and femoral head diameter (FHd) were analyzed as skeletal variables; the lateral center edge angle (LCEA), dorsolateral subluxation (DLS) score, and center distance (CD) index were analyzed as joint laxity variables. At 12 months, all dogs underwent the Ortolani test to as-sess hip joint laxity. Hip joint laxity was detected in 5 dogs (10 joints) at 12 months of age; from 2 months, the acetabular angle and FHd increased and DARA decreased significantly until 5 months and the LCEA and DLS score increased significantly until 6 months. In nonlax hip joints in both positions, the CD index decreased significantly until 4 months of age and be-came stable thereafter. In lax hip joints, the CD index increased from 4 through 12 months; between 8 and 12 months, these changes were significantly greater in the weight-bearing position than in the standing position. Results suggest that CT-detected abnormalities in the DARA and CD index during body weight loading might be useful indicators of hip dysplasia in 2- to 6-month-old dogs.

Assessment of the hip reduction angle for predicting osteoarthritis of the hip in the Labrador Retriever

Hip palpation has been used to provide semiquantitative information regarding passive joint laxity and susceptibility to hip dysplasia. The purpose of this study was to: (1) evaluate the intra- and inter-examiner repeatability of the hip reduction angle measured at 4 months of age by three examiners using manual goniometry and an electromagnetic tracking system; (2) compare the hip reduction angle measured with manual goniometry to the hip reduction angle measured with the electromagnetic tracking system; and (3) evaluate the hip reduction angle, distraction index and Ortolani manoeuvre at 4 months of age as predictors of the development of hip osteoarthritis at 12 months of age in 11 Labrador Retriever dogs. Intra- and inter-examiner repeatability was demonstrated for both the manual and electromagnetic goniometric measurement of the hip reduction angle (coefficient of variation < 4.3% and < 6.1%; and P = 0.163 and P = 0.836 respectively). The hip reduction angle measured by manual goniometry was moderately correlated to the hip reduction angle measured by the electromagnetic tracking system (r = 0.603, P < 0.0000). The hip reduction angle measured by manual and electromagnetic goniometry was a poor predictor of osteoarthritis at 12 months of age (r = 0.231, P < 0.062, and r = 0.321, P < 0.01). The distraction index was moderately correlated with the development of osteoarthritis by 12 months of age (r = 0.493, P < 0.0000). The Ortolani sign was sensitive (100%) but not specific (41%) for the development of osteoarthritis at 12 months of age. The hip reduction angle did not further quantify the Ortolani manoeuvre as a predictor of osteoarthritis in Labrador Retrievers.

In this issue

In this issue

Early diagnosis and treatment of DDH:a sonographic approach

This study reviews the data regarding clinical and ultrasound (US) examinations, collected during an 11-year period, in a DDH dedicated outpatient clinic. The material was analysed in order to verify the importance of US hip examination and Ortolani's test for early DDH diagnosis, to select dysplastic, unstable hips, to identify the role of the labrum in DDH, and to analyse the treatment strategy. Of the 21709 newborns (43418 hips) examined with US and Ortolani's manoeuvre for DDH diagnosis, 431 patients (356 F; 75 M; average age 42+/-33 days) had 574 unstable, dysplastic hips (1.32%). The hips identified according to Graf's classification were: 298 type D, 252 type IIIa, 4 type IIIb, 20 type IV. In 73.09% of the patients, no risk factors were identified; 18.56% had positive family history for DDH, 5.57% had breech presentation, 2.78% had both risk factors. Only 10.63% had a positive Ortolani's test. The diagnosis was made in 21.5% of cases by the 2nd week of life, in 52.9% between the 2nd-8th week, and in 25.5% after the 8th week. Unstable dislocated hips were treated, after reduction with or without sedation, by applying a cast; dysplastic hips were treated using a Gekeler splint. No open reductions or reconstruction surgery were needed. The labrum was always positioned on top of the femoral head, never inverted, and it was not an obstacle to closed reduction. Neither the Ortolani's sign, nor the risk factors are sure signs for the early diagnosis of DDH and its instability. Only US examination permits an early diagnosis of dysplasia and instability of the hip.

Early Diagnosis and Treatment of DDH: A Sonographic Approach

This study reviews the data regarding clinical and ultrasound (US) examinations, collected during an 11-year period, in a DDH dedicated outpatient clinic. The material was analysed in order to verify the importance of US hip examination and Ortolani's test for early DDH diagnosis, to select dysplastic, unstable hips, to identify the role of the labrum in DDH, and to analyse the treatment strategy Of the 21709 newborns (43418 hips) examined with US and Ortolani's manoeuvre for DDH diagnosis, 431 patients (356 F; 75 M; average age 42 ± 33 days) had 574 unstable, dysplastic hips (1.32%). The hips identified according to Grafs classification were: 298 type D, 252 type IIIa, 4 type IIIb, 20 type IV. In 73.09% of the patients, no risk factors were identified; 18.56% had positive family history for DDH, 5.57% had breech presentation, 2.78% had both risk factors. Only 10.63% had a positive Ortolani's test. The diagnosis was made in 21.5% of cases by the 2nd week of life, in 52.9% between the 2nd-8th week, and in 25.5% after the 8th week. Unstable dislocated hips were treated, after reduction with or without sedation, by applying a cast; dysplastic hips were treated using a Gekeler splint. No open reductions or reconstruction surgery were needed. The labrum was always positioned on top of the femoral head, never inverted, and it was not an obstacle to closed reduction. Neither the Ortolani's sign, nor the risk factors are sure signs for the early diagnosis of DDH and its instability. Only US examination permits an early diagnosis of dysplasia and instability of the hip.

A Reappraisal of the Ortolani Examination in Children With Developmental Dysplasia of the Hip

The Ortolani maneuver is currently accepted as an accurate test to detect developmental dislocation of the hip. However, the clinical sign does not always correlate with the findings seen on ultrasound. The ultrasound-documented position of the femoral head was correlated with the result of the clinical Ortolani examination to better understand the value and validity of the Ortolani test. Two populations were compared: hips with a positive Ortolani sign and hips with a negative Ortolani sign but with an ultrasound-documented dislocated hip. In the Ortolani-positive group, there were 45 patients (53 affected hips), and in the Ortolani-negative group, there were 24 patients (25 dislocated hips). Position of the femoral head at rest, side of involvement, and sex showed no significant difference between the Ortolani-positive and -negative groups. Mean age of patients in the Ortolani-positive group was less (mean, 28 days) and was statistically different (P < 0.05) from those in the Ortolani-negative group (mean, 91 days). In conclusion, dislocated hips that show similar femoral head movement can produce an Ortolani-positive examination in a younger patient and an Ortolani-negative examination in an older patient. The classic clinical method described by Ortolani for detecting hip dislocation in which the thigh of the affected hip is abducted and the femoral head was thought to be reducing into the acetabulum can be erroneous. All Ortolani-positive hips were abnormal, as the sensation characteristic of a positive Ortolani examination may be felt without full reduction and, in some cases, with no reduction, as documented by ultrasound.

Plastazote abduction orthosis in the management of neonatal hip instability.

Since 1987, 113 consecutive newborns with either Ortolani-positive or provocative-positive hip examinations in the newborn nursery have been treated with a Plastazote hip abduction orthosis when diagnosed and followed to determine if the method was safe, effective, and easy to use. Ortolani-positive hips often had bilateral abnormalities in the hip examination, were frequently associated with breech position, and were anatomically more dysplastic than those hips that were unstable by provocative testing. No patient developed ischemic necrosis during follow-up. Only two had additional treatment of their unstable hips. The rest had excellent results. Parents and caregivers found the device easy to use. The orthosis is recommended as the primary method for managing newborns with clinical instability to either the provocative or Ortolani test as being safe, effective, and easy to use across all skill levels.

Performance, treatment pathways, and effects of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom

Aims: To compare, using a decision model, performance, treatment pathways and effects of different newborn screening strategies for developmental hip dysplasia with no screening. Methods: Detection rate, radiological absence of...

Efficiency of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom

Aims: To assess, using a decision model, the efficiency of ultrasound based and clinical screening strategies for developmental dysplasia of the hip. Methods: The additional cost per additional favourable outcome...

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.

Unilateral limitation of abduction of the hip. A valuable clinical sign for DDH?

Between 1992 and 1997, we undertook a prospective, targeted clinical and ultrasonographic hip screening programme to assess the relationship between ultrasonographic abnormalities of the hip and clinical limitation of hip abduction. A total of 5.9% (2 of 34) of neonatal dislocatable hips and 87.5% (7 of 8) of 'late' dislocated hips seen after the age of six months, presented with unilateral limitation of hip abduction. All major (Graf type III) and 44.5% of minor (Graf type II) dysplastic hips presented with this sign. Statistically, bilateral limitation of hip abduction was not a useful clinical indicator of underlying hip abnormality because of its poor sensitivity, but unilateral limitation of abduction of the hip was a highly specific (90%) and reasonably sensitive sign (70%). It was more sensitive than the neonatal Ortolani manoeuvre, which has been considered to be the method of choice. It was, however, not sensitive enough to be of value as a routine screening test in developmental dysplasia of the hip. We consider unilateral limitation of hip abduction to be an important clinical sign and its presence in an infant over the age of three to four months makes further investigation essential.

Unilateral limitation of abduction of the hip

Between 1992 and 1997, we undertook a prospective, targeted clinical and ultrasonographic hip screening programme to assess the relationship between ultrasonographic abnormalities of the hip and clinical limitation of hip abduction. A total of 5.9% (2 of 34) of neonatal dislocatable hips and 87.5% (7 of 8) of ‘late’ dislocated hips seen after the age of six months, presented with unilateral limitation of hip abduction. All major (Graf type III) and 44.5% of minor (Graf type II) dysplastic hips presented with this sign. Statistically, bilateral limitation of hip abduction was not a useful clinical indicator of underlying hip abnormality because of its poor sensitivity, but unilateral limitation of abduction of the hip was a highly specific (90%) and reasonably sensitive sign (70%). It was more sensitive than the neonatal Ortolani manoeuvre, which has been considered to be the method of choice. It was, however, not sensitive enough to be of value as a routine screening test in developmental dysplasia of the hip. We consider unilateral limitation of hip abduction to be an important clinical sign and its presence in an infant over the age of three to four months makes further investigation essential.

The effect of triple pelvic osteotomy on the articular contact area of the hip joint in dysplastic dogs: an in vitro experimental study.

To investigate the effect of triple pelvic osteotomy (TPO) on articular contact area and acetabular coverage of dysplastic hip joints in dogs. Articular contact area and femoral head coverage by the acetabulum were computed in vitro in normal and dysplastic canine hips. The effect of TPO on articular contact and coverage was then analyzed in the dysplastic hips. Sample Population-Five normal and six dysplastic canine cadaver specimens. Contact area and coverage of loaded hips were computed using serial computed tomography scan images before and after TPO. Three angles of acetabular ventroversion (AVV) were studied (20 degrees, 30 degrees, and 40 degrees). Using a custom-designed hinge plate, angles of spontaneous hip reduction in dysplastic hips were compared with previously recorded angles of reduction determined by the Ortolani test. Contact area significantly increased from 0 degrees to 30 degrees of AVV, then remained virtually unchanged. Coverage significantly increased from 0 degrees to 20 degrees of AVV. Both contact and coverage of normal hips were similar, yet significantly smaller than those of dysplastic hips once reduction had occurred. The experimental angles of reduction were significantly smaller and poorly correlated with the angles of reduction determined by the Ortolani test. Although coverage continued to increase with AVV, the actual joint contact area did not significantly vary after relocation of the femoral head. This study suggests that increasing AVV beyond 20 degrees does not significantly improve the beneficial effects of TPO and therefore should be carefully weighed against increased risks of postoperative complications associated with large angles of AVV.

Ultrasonography screening for developmental dysplasia of the hip joint

The use of ultrasonography as a complement to clinical examination will increase the reliability of the evaluation of unstable hips in newborn infants. In particular, the number of false-positive Ortolani and Barlow tests will decrease. However, the interpretation of the ultrasonogram in newborn infants has a steep learning curve with considerable risk of a high number of false-positive hips being diagnosed. Therefore, universal screening for developmental dysplasia of the hip by ultrasonography cannot yet be recommended from a cost-benefit point of view.

Ultrasonography of clinically unstable hips: A prospective study of 143 neonates at birth and early follow-up

We evaluated the ability of ultrasonography to reduce the treatment rate of hips with clinical instability or uncertain findings at birth. Among 9,514 live births during the period 1988-1990, unstable hips were detected in 143 neonates by the Ortolani and Barlow tests, whereas the physical examination was inconclusive in 59 cases. These 202 neonates were also examined by ultrasound and instability was confirmed in 108 neonates who were treated with the Frejka pillow. The mean femoral head coverage (FHC) was 37%, indicating slight subluxation in the majority of unstable hips. The remaining 94 infants had normal ultrasonographic findings and were not treated. Their mean FHC was 53% and all these hips developed normally, except in 2 girls, who were treated with an abduction splint from age 4-5 months because subluxation developed. We conclude that ultrasound improved the reliability of the neonatal hip evaluation, thus markedly reducing the number of treated infants. Sonography also reduced the use of radiography during followup.

Ultrasonographic evaluation of breech presentation as a risk factor for hip dysplasia

In order to gain more information of breech position as a risk factor for congenital hip dysplasia or dislocation, the hips of 408 newborns delivered in the breech position were examined by ultrasound. Clinical examination was performed by both experienced paediatricians and orthopaedic surgeons. The infants were re-examined by ultrasound at 2-3 months of age. Twenty-five newborns (6.1%) had neonatal hip instability. Breech presentation as a risk factor was confirmed, with first borns, breech position with extended knees, and high birthweight as special high-risk groups. Ultrasound showed subluxation in most of the unstable hips. The main benefit of using ultrasound was that direct visualization permitted more reliable evaluation, especially when the clinical findings were uncertain. Normal ultrasound findings in false positive and uncertain Ortolani tests reduced the frequency of unnecessary treatment. Because ultrasound was used in follow-up, the need of radiography was reduced. There were no late-detected cases of hip dysplasia or dislocation, indicating that routine follow-up is not necessary in breech infants with normal hips at birth, provided that the neonatal screening is optimal.

ERRATUM

In the article by Aronsson et al entitled "Developmental Dysplasia of the Hip" that appears in the August issue of Pediatrics (1994;94:201-208), page 203, part of the legend in Figure 1 is incorrect. It should read as follows: Drawings demonstrating the technique for performing the Ortolani and Barlow maneuvers. The Ortolani sign is obtained by gently abducting the leg and a palpable "clunk" is felt as the femoral head slides over the posterior rim of the acetabulum into the socket. This is called the sign of entry. The Barlow provocative test is obtained by adducting the hip and pushing gently on the knee and a palpable "clunk" is felt as the femoral head slides over the posterior rim of the acetabulum and out of the socket. This is called the sign of exit.

A New Stress Test for the Diagnosis of Hip Dysplasia: A Preliminary Study on a Manikin

Early detection of hip dysplasia remains elusive due to lack of a safe and objective diagnostic screening test. A new hip stress test sequence for improving the diagnosis of hip dysplasia is proposed: firstly the Barlow manoeuvre is performed, followed by an instrumented hip stiffness test and lastly the Ortolani test. Both the Barlow and the Ortolani tests consist of manual manipulative examinations which produce characteristic vibration in abnormal hips. The clinical examiner detects this vibration using finger-tip sensation. To verify this three-phase technique, the test was performed on a commercially available patient simulator. The force applied to the hip joint was measured using a force plate, and the hip laxity measured with an instrumented linkage. Significant differences in hip stiffness were found between dislocated and reduced hips. Further clinical testing will allow the theory to be finally verified and the technique to be refined.

Neonatal Hip Instability in Saudi Arabia: Results And Cost Effectiveness

The benefits of screening hips at birth for congenital dislocation have been repeatedly confirmed but doubts have been raised about the need for splinting all positive cases. Experience from an ongoing screening program, now in operation for over 11 years, is presented particularly with reference to cost benefit of screening and early surgical intervention. Of 30,651 live born babies screened for congenital dislocation of the hip (CDH) employing Barlow and Ortolani maneuvers, 132 were found to be positive, giving an incidence of two to six per 1000 liver births, averaging 4.3/1000 for the period. The implications of epidemiologic and clinical observations and of management have been discussed. The cost of screening and of surgical management of cases that would not have stabilized without intervention. Cost effectiveness of a screening program for CDH was observed from this 11 year study, fully justifying a sustained program apart from the human misery an overlooked diagnosis may cause.

Congenital hip dislocation: the importance of early detection and comprehensive treatment.

Hip dislocation is the musculoskeletal condition most commonly missed during neonatal examinations. Failure to diagnose the condition can lead to long-term disability and is a common target in pediatric legal suits concerning damage to the musculoskeletal system. Early neonatal assessment for hip dislocation includes an examination using the Barlow and Ortolani tests. Later examinations include assessment of gluteal folds, knee height and the degree of hip abduction. The preferred treatment is use of the Pavlik harness, an outpatient treatment regime that provides effective reduction in 90 percent of the cases. The harness uses flexion and free abduction to direct the femoral head into the acetabulum; it uses time, gravity and motion to position the hip in a reduced position. The harness requires three to six months of continuous wear for the hip to become radiographically stable. Health care providers are instrumental in diagnosing congenital hip dislocation and teaching families how to promote the infant's physical and psychosocial well-being. If this condition is not detected until after the infant is 6 weeks old, or the harness is ineffective after three weeks, skin traction, closed reduction and spica-cast application may be needed. Open reduction and recasting are also options. In rare cases, total hip replacement is necessary in later life.