Developmental
`
`Dysplasia
`
`of
`
`the Hip
`
`David
`
`D. Aronsson,
`
`MD*;
`
`Michael
`
`J. Goldberg,
`
`MDX;
`
`Thomas
`
`F. Kling,
`
`Jr. MD(cid:1);
`
`and
`
`Dennis
`
`R. Roy, MDII
`
`ABBREVIATIONS.
`developmental
`
`CDH,
`dysplasia
`
`congenital
`of
`the
`
`hip.
`
`dislocation
`
`of
`
`the
`
`hip;
`
`DDH,
`
`ABSTRACT.
`treatment
`versial.
`reasons
`plasia
`and
`
`Objective.
`congenital
`purpose
`changing
`hip
`(DDH)
`
`definition
`The
`and
`are
`hip
`of
`the
`dysplasia
`discuss
`to
`was
`study
`this
`to developmental
`acronym
`and
`to address
`its
`early
`
`early
`contro-
`the
`dys-
`detection
`
`of
`the
`
`designed
`was
`study
`definition,
`of
`the
`natural
`history,
`
`to pro-
`pathologic
`early
`
`de-
`
`describes
`dysplasia
`at birth
`neonatal
`develop
`dysplasia
`seen
`
`condi-
`the
`the
`hip.
`of
`(congenital)
`hip
`screening
`a dysplastic
`encompasses
`infants
`a
`
`or
`
`but
`to
`
`dysplasia
`been
`
`or
`
`of
`
`hip
`
`the
`synony-
`dis-
`
`it
`
`congenital
`used
`has
`and
`congenital
`dislocation
`in
`terminology
`of precision
`men-
`who
`physicians
`in which
`to the
`context
`mis-
`and
`is
`confusing
`A dislo-
`and
`juries.
`and
`the
`a diagnosis,
`Because
`at
`birth.
`physicians
`birth,
`examination
`normally.
`reports
`hip
`of
`the
`examination.’6
`dysplasia
`word
`time
`
`at
`
`was
`
`is
`
`This
`docu-
`have
`occurring
`
`or
`
`neonatal
`acronym
`should
`invokes
`the
`
`of
`
`is
`
`to
`
`to
`in
`
`a
`
`type
`
`in
`
`in
`
`acronym
`The
`(CDH)
`is
`confusing
`with
`congenital
`mously
`lack
`the
`hip.
`This
`of
`ease
`is
`understood
`by
`experienced
`tally
`define
`CDH
`according
`is
`used,
`this
`abbreviation
`leading
`patients,
`attorneys,
`is
`hip
`not
`cated
`a physical
`sign,
`congenital
`term
`means
`present
`CDH was
`be
`thought
`to
`present
`the
`were
`taught
`that
`if
`neonatal
`normal,
`the
`hip
`would
`develop
`clearly
`not
`the
`case
`several
`as
`mented
`dislocation
`dysplasia
`after
`a normal
`screening
`believe
`the
`developmental
`The
`hip
`(DDH)
`replace
`CDH.
`of
`opmental”
`the
`dimension
`that
`dislocation
`edging
`dysplasia
`or
`or
`after
`means
`before
`birth.
`Dysplasia
`development
`ity
`and
`encompasses
`of
`hip
`problems.
`trum
`By
`changing
`will
`the
`acronym
`DDH,
`no
`longer
`instances
`a
`disorder
`in
`when
`neither
`described
`congenital
`the
`spectrum
`understand
`of
`a knowledge
`in DDH,
`the
`joint
`is beneficial.
`
`of
`
`We
`the
`of
`“devel-
`acknowl-
`may
`occur
`abnormal-
`an
`a wide
`spec-
`CDH
`from
`characterize
`falsely
`the
`condition
`being
`nor
`dislocated.
`To
`problems
`included
`hip
`embryology
`of
`the
`
`hip
`
`Embryology
`
`METHODS
`
`of
`The
`for
`the
`of
`treatment.
`This multicenter
`Design.
`an updated
`assessment
`vide
`anatomy,
`prevalence,
`etiology,
`tection,
`and
`treatment
`of DDH.
`DDH
`accurately
`more
`Results.
`tion
`previously
`congenital
`termed
`The
`disorder
`not
`always
`present
`is
`and
`an
`infant
`may
`have
`a normal
`examination
`and
`subsequently
`dislocated
`hip.
`Developmental
`in
`problems
`the
`wide
`spectrum
`of
`hip
`and
`normal
`that
`understand
`children.
`Physicians
`should
`normal
`assure
`not
`does
`neonatal
`screening
`examination
`dys-
`developmental
`of
`hip
`development.
`The
`diagnosis
`Ortolani
`examination.
`The
`by
`plasia
`is made
`physical
`a sub-
`designed
`detect
`and
`Barlow
`maneuvers
`were
`neonatal
`hip
`luxatable,
`dislocatable,
`or dislocated
`the
`becomes
`abduction
`period.
`the
`older
`child,
`limited
`In
`depend-
`is
`variable
`more
`sign.
`The
`examination
`reliable
`growth.
`changes
`with
`ing
`of
`dysplasia
`and
`the
`on
`in
`con-
`a sensitive
`tool
`The
`is proving
`to be
`ultrasound
`infants
`from
`and
`firming
`diagnosis
`newborns
`the
`also
`valuable
`is
`to 4 months
`The
`ultrasound
`age.
`of
`birth
`that
`the
`dyspla-
`older
`of documenting
`infants
`terms
`in
`the
`ultrasound
`sia
`is
`responding
`to
`treatment.
`However,
`and,
`in
`some
`depends
`on
`experienced
`sonographer
`an
`may
`in overtreatment.
`cases,
`too
`sensitive,
`resulting
`be
`age,
`3
`to
`After
`4 months
`of
`an
`anteroposterior
`pelvis
`the
`radiograph
`can
`confirm
`diagnosis.
`a neonatal
`have
`newborns
`All
`should
`Conclusions.
`After
`screening,
`examination.
`screening
`physical
`hip
`health
`examination
`should
`be
`re-examined
`during
`hips
`at
`2 weeks,
`2 months,
`4 months,
`6 months,
`visits
`and
`1 year
`of
`age.
`If any
`question
`arises
`during
`months,
`visits
`or
`if
`there
`are
`associated
`factors,
`we
`these
`risk
`if
`recommend
`an
`ultrasound
`the
`infant
`is <4 months
`of
`pelvis
`age
`or an
`anteroposterior
`radiograph
`if >4 months
`of
`age.
`developmental
`dyspla-
`1994;94:201-208;
`Pediatrics
`sia
`of
`the
`hip,
`congenital
`dislocation
`of
`the
`hip,
`ultrasound
`for
`hip
`instability.
`
`the
`
`9
`
`the
`
`*Depaft(cid:1)ent
`College
`Medical
`IN;
`
`of Orthopaedics
`From
`of Medicine,
`Burlington,
`Vermont
`the
`Center,
`Boston,
`England
`MA;
`and
`the
`#{182}Children’s
`Hospital
`Indianapolis,
`Cincinnati,
`OH.
`of Orthopaedics,
`May
`publication
`20,
`Received
`for
`1993;
`requests
`to
`(D.D.A.)
`University
`Reprint
`Dept
`of Orthopaedics
`and
`Rehabilitation,
`05405-0084.
`(ISSN
`PEDIATRICS
`emy
`of Pediatrics.
`
`and
`
`Rehabilitation,
`flufts
`VF;
`§Riley
`Hospital
`Medical
`Center,
`
`of
`University
`University,
`New
`for Children,
`Department
`
`Jan
`accepted
`of Vermont
`Stafford
`
`25,
`1994.
`College
`Hall,
`
`of Medicine,
`Burlington,
`
`VT
`
`0031
`
`4005).
`
`Copyright
`
`111 1994
`
`by
`
`the American
`
`Acad-
`
`In
`
`the
`hip
`
`that
`
`are
`the
`
`Definitions
`
`includes
`DDH
`dislocated.
`or
`externally
`location.
`opment
`incomplete
`femoral
`plete
`Previous
`
`head
`displacement
`authors
`
`a
`
`malformed,
`unstable,
`hips
`hip
`of
`the
`inability
`is
`Instability
`applied
`force without
`a subluxation
`developing
`abnormality
`in
`any
`A malformation
`includes
`A subluxation
`acetabulum.
`of
`the
`femur
`and/or
`contact
`between
`some
`residual
`dislocation
`with
`and
`a
`dislocation
`indicates
`and
`acetabulum,
`femoral
`head
`from
`acetabulum.
`of
`the
`the
`have
`differentiated
`between
`teratologic
`
`the
`
`subluxated,
`an
`to
`resist
`dis-
`or
`devel-
`is
`
`an
`the
`com-
`
`and
`
`Downloaded from by guest on August 19, 2016Downloaded from by guest on August 19, 2016Downloaded from by guest on August 19, 2016
`
`
`
`
`PEDIATRICS
`
`Vol.
`
`94 No.
`
`2 August
`
`1994
`
`201
`
`embryo
`The
`joint
`begins
`between
`the
`occurs
`is usually
`opment
`located
`always
`pelvis.
`the
`from
`or
`perinatally,
`utero,
`position
`from the fetal
`after
`birth
`increases
`
`the
`
`early
`Hip
`
`the
`
`buds
`limb
`to
`develop
`acetabulum
`complete
`the
`in
`dysplasia
`subsequently
`of hip
`flexion
`susceptibility
`
`appear
`first
`8 weeks
`at
`head
`the
`and
`result,
`11 weeks.7
`by
`because
`embryologic
`may
`then
`or
`dislocation
`development.
`with
`of
`extension
`to
`one
`of
`dislocation.
`
`4 weeks
`at
`gestation
`femoral
`As
`stage
`
`a
`
`gestation.
`when
`a cleft
`and
`devel-
`the
`hip
`forms
`it
`occur
`Moving
`occurs
`
`is
`
`in
`
`as
`
`Petitioner Ex. 1065 Page 1
`
`

`
`dislocation
`utero
`
`typical
`in
`early
`chromosomal
`ical
`dislocation
`occur
`in
`utero,
`
`of
`
`the
`associated
`is
`and
`abnormalities
`occurs
`at
`birth,
`
`in
`or
`
`Pathologic
`
`Anatomy
`
`hip.8
`
`an
`after
`
`A teratologic
`with
`other
`neuromuscular
`and
`otherwise
`healthy
`birth.
`
`dislocation
`malformations
`disorders.
`infant
`
`occurs
`as
`such
`A typ-
`may
`
`and
`
`Etiology
`
`18th
`
`spectrum
`a wide
`includes
`on
`the
`is dependent
`period,
`the
`neonatal
`In
`spontaneously
`that
`the
`hip
`and
`reduce
`may
`dislocate
`the
`lower
`extremity.
`In
`and
`abduction
`that
`results
`flexion
`anterolateral
`orientation
`of
`and
`which
`runs
`across
`the
`out
`posteriorly
`with
`newborn.
`The
`everted
`and
`a few
`days,
`
`type,
`there
`
`utero
`in
`
`front
`hip
`labrum
`flattened.
`subsequent
`
`laxity
`newborn
`
`of
`
`the
`becomes
`within
`
`hip
`of
`grade,
`may
`dislocates
`with
`the
`hip
`hip
`the
`tightened
`a
`acetabulum.9
`the
`the
`hip,
`may
`of
`extension
`during
`(cartilaginous
`hip
`If
`the
`development
`
`hip
`
`space
`fibrofatty
`and
`further
`the
`
`and
`
`position
`
`diameter
`impossible.
`to the
`superior
`The
`tight
`hold
`difficult.
`
`the
`
`problems,
`and
`duration
`be
`sufficient
`and
`
`the
`
`is
`
`a
`
`re-
`kick-
`in
`ilio-
`The
`push
`kick-
`rim of
`spon-
`
`is
`
`the
`the
`is
`The
`
`it
`
`mus-
`head
`
`and
`
`that
`
`infants
`16% of
`with
`3% in
`the
`as
`is
`seen
`muscles
`
`with
`general
`in
`the
`and
`may
`able
`
`in
`
`Stanisavljevic”
`which
`the
`fetal
`the
`week,
`critical
`period
`limb
`rotates
`dislocates
`abnormally.
`femoral
`acetabulum
`form
`of DDH
`period
`second
`musculature
`lar
`development,
`The
`third
`period
`abnormal
`mechanical
`dramnios,
`may
`periods,
`hip
`the
`fourth
`critical
`Factors
`associated
`postnatal
`positioning,
`The maternal
`hormone
`laxity
`in
`the
`mother’s
`placenta
`into
`contribute
`fetus)
`and
`that
`the
`splinted
`in
`progesterone.
`of
`was
`procedure
`of hormonally
`extension
`that
`
`at
`
`head
`
`the
`
`are
`
`for
`
`risk
`the
`hip
`hip
`of
`
`there
`that
`dislocation:
`for
`4 weeks
`final
`develops
`joint
`at
`risk
`is
`elements
`the
`shallow,
`is
`trochanter
`type
`of
`
`with
`18th
`
`of
`
`reported
`is at
`hip
`(3)
`and
`the
`is after
`the
`medially,
`all
`this
`stage,
`The
`acetabulum
`and
`greater
`develops.
`This
`and
`correlates
`is during
`the
`If
`develops.
`there
`paralytic
`a
`is during
`forces,
`predispose
`may
`be
`period,
`with
`
`periods
`three
`12th
`the
`(1)
`gestation.
`of
`As
`the
`from
`the
`dislocation.
`develop
`joint
`the
`hip
`of
`distends,
`capsule
`the
`and
`small,
`remain
`is
`the most
`dislocation
`dislocation.
`a
`teratologic
`the
`when
`week
`of
`gestation
`neuromuscu-
`an
`abnormality
`is
`stage.
`at
`this
`dislocation
`may
`occur
`when
`gestation
`of
`the
`last
`4 weeks
`oligohy-
`position
`or
`such
`as
`a breech
`to DDH.
`In
`addition
`these
`three
`to
`at birth
`and
`then
`dislocate
`during
`normal
`postnatal
`period.4’2’4
`the
`laxity,
`DDH
`include
`ligamentous
`genetic
`factors,
`and
`environmental
`relaxin,
`which
`contributes
`to ligamen-
`pelvis
`during
`childbirth,
`passes
`freely
`and
`the
`newborn.
`Relaxin
`other
`mater-
`laxity
`to neonatal
`ligamentous
`(especially
`of DDH.
`may
`increase
`the
`risk
`Wilkinson’6
`would
`of
`hip
`a female
`rabbit
`dislocate
`if
`animal
`given
`extension
`and
`the
`was
`in male
`did
`This
`not
`occur
`rabbits
`performed.
`He
`concluded
`that
`there
`induced
`ligamentous
`laxity
`associated
`predisposes
`females
`to a higher
`incidence
`
`during
`week,
`The
`
`(2)
`first
`the
`hip
`
`pelvis.
`
`If
`
`the
`false
`a
`severe
`The
`hip
`
`pre-
`fac-
`
`the
`an
`
`when
`is
`
`a
`
`DDH
`Because
`anatomy
`pathologic
`of the
`dislocation.
`ligamentous
`duces.
`The
`ing
`movements
`of
`position
`psoas
`tendon
`tight
`iliopsoas,
`head
`the
`femoral
`ing
`or
`in swaddling
`the
`acetabulum)
`taneously
`reduces
`usually
`normal.
`subluxation
`a
`if
`In
`contrast,
`to
`develop.
`begin
`changes
`time
`on the posteromedial
`tened
`torsion)
`gradually
`ternal
`concentrically
`reduced,
`plastic.
`The
`capsule
`The
`hypertrophies.
`head
`is filled with
`base
`of
`the
`acetabulum
`femoral
`head
`moves
`pulled
`upward
`over
`iliopsoas
`tendon
`that
`anteriorly
`causing
`the
`constriction
`becomes
`head,
`nonoperative
`the
`muscles
`around
`shortened
`by
`becoming
`abduction
`des
`resist
`in
`the
`superior
`
`over
`then
`persists,
`dislocation
`or
`flat-
`becomes
`head
`The
`femoral
`surface
`and
`femoral
`(in-
`anteversion
`is not
`increases.
`Because
`the
`femoral
`head
`dys-
`the
`acetabulum
`becomes
`shallow
`and
`thickens
`and
`fibrocartilaginous
`labrum
`the
`between
`acetabulum
`femoral
`the
`and
`tissue
`(pulvinar)
`that
`in
`develops
`a thickened
`ligamentum
`As
`teres.
`inferior
`superolaterally,
`the
`capsule
`the
`lower
`part
`of
`acetabular
`socket.
`crosses
`the
`anterior
`capsule
`constricts
`hourglass
`deformity.
`Once
`the
`capsular
`narrower
`the
`the
`femoral
`of
`reduction
`fascia
`and
`The
`hip
`joint
`displacement
`and
`adductor
`the
`femoral
`making
`
`than
`becomes
`respond
`contracted.
`flexor
`muscles
`reduction
`
`Prevalence
`The
`prevalence
`parameters
`graphic
`that
`stei&#{176}reported
`The
`Bantu
`infants.
`only
`ies
`included
`dislocated,
`included
`I newborn
`that
`ported
`both
`When
`these
`hips.
`stable,
`and
`were
`58%
`that
`the
`emphasizes
`reporting
`in
`factor
`The
`the
`value
`of
`controversial.
`Barlow”
`the
`eliminate
`problem.
`were
`who
`tients
`negatively
`sia or dislocation.’6
`now
`It
`always
`detectable
`birth.
`children
`who
`had
`quently
`developed
`dislocated
`32 480
`and
`discovered
`newborns
`screening
`examinations
`and
`then
`contracture
`with
`radiographic
`age.
`of
`between
`2 and
`8 months
`36 who
`newborns
`and
`identified
`were
`examination
`and
`later
`10 children
`Walker’4
`reported
`on
`were
`obtained
`birth
`radiographs
`associated
`with
`they
`risk
`factors
`dysplasia
`on
`hips
`evidence
`were
`to
`clinical
`abnormalities
`studies
`dislocated.
`These
`examination,
`natal
`screening
`the
`importance
`This
`emphasizes
`examination
`visits
`during
`health
`6 months,
`9 months,
`and
`I year
`
`is
`
`varies
`greater
`not
`find
`did
`prevalence
`with
`
`hip
`
`slow
`document
`the
`
`hip
`of
`at
`of
`
`initially
`
`but
`had
`had
`
`at
`
`of
`
`geo-
`and
`racial
`to
`according
`of DDH
`Edel-
`blacks.
`than
`in whites
`and
`16 678 African
`among
`one
`case
`he
`as
`some
`stud-
`is controversial
`exact
`whereas
`others
`dislocated
`hips
`children
`re-
`hips.
`Barlow1’
`and
`unstable
`subluxated,
`or
`one
`instability
`of
`born
`with
`in
`67 was
`later
`were
`re-examined
`I week
`newborns
`study
`90%
`were
`This
`by
`2 months
`examination
`important
`of
`at
`the
`time
`age
`of DDH.
`prevalence
`the
`examination
`screening
`neonatal
`screening
`that
`widespread
`believed
`identified
`have
`investigators
`Other
`developed
`later
`screened
`then
`the
`disorder
`that
`seems
`clear
`reported
`In
`1971,
`Walker’2
`and
`normal
`examinations
`Bell’3
`and
`hips.
`Tredwell
`normal
`had
`five
`who
`to have
`an
`were
`found
`acetabular
`evidence
`a!4
`reported
`et
`Bialik
`neonatal
`had
`a normal
`DDH.
`found
`to
`have
`who
`had
`clinically
`one
`month
`at
`DDH.
`In all
`the
`radiographs
`appear,
`four
`that,
`despite
`may
`not
`sequential
`2 weeks,
`age.
`
`stable.
`is an
`
`remains
`would
`pa-
`dyspla-
`is
`not
`seven
`on
`subse-
`then
`evaluated
`neonatal
`adduction
`dysplasia
`on
`12 891
`screening
`Davies
`stable
`age
`one
`
`and
`at
`
`of
`cases,
`
`hips
`
`hips
`because
`or
`both
`although
`and
`subsequently
`neo-
`a negative
`develop
`normally.
`hip
`examinations
`2 months,
`4 months,
`
`of
`
`and
`tom.
`tous
`the
`through
`nal
`hormones
`in the
`female
`demonstrated
`knee
`was
`injection
`the
`same
`combination
`with
`knee
`of DDH.
`Seddon’7
`Muller
`presentation
`a breech
`had
`flexion
`Hip
`ulation.
`breech
`presentation
`to DDH.
`tribute
`DDH
`in
`duce
`however,
`sion,
`immobilizing
`which
`deformities
`and
`DDH.
`often
`as
`times
`involved
`side
`The
`left
`positioned
`were
`of
`newborns
`majority
`DDH.
`The
`In
`this
`of
`birth.
`the
`time
`at
`position
`put
`anterior
`spine
`and
`the mother’s
`against
`hip
`lies
`posteriorly
`disorder.
`incidence
`of
`a higher
`the
`left
`hip
`to
`muscular
`with
`congenital
`DDH
`is
`associated
`reported
`Iwahara
`and
`metatarsus
`adductus.
`had
`torticollis
`congenital
`muscular
`their
`patients
`with
`Jacobs2(cid:1)
`Hummer
`and MacEwen2#{176} found
`a 20% association.
`had
`that
`10%
`of
`newborns
`with
`metatarsus
`adductus
`subsequent
`studies
`reported
`a lower
`incidence.’#{176}”(cid:1)
`aP(cid:1)
`studied
`7356
`with
`metatarsus
`adductus
`unable
`to
`demonstrate
`association
`DDH.
`any
`There
`is evidence
`the
`in
`genetic
`factors
`a role
`their
`of DDH.
`Wynne-Davies’4
`studied
`589
`and
`family
`and
`reported
`the
`risk
`subsequent
`of
`a
`with
`as
`dislocation
`occurs
`is
`follows:
`parents
`affected,
`risk
`to subsequent
`affected
`2)
`one
`risk
`12% and
`3)
`one
`affected
`one
`affected
`36%.
`postnatal
`is a correlation
`There
`where
`newborns
`incidence
`is
`lower
`The
`attitude
`the
`hips
`in
`an
`the waist
`the mother
`hips
`position
`for most
`abduction.
`This
`is
`a stable
`duplicate
`this
`position.
`ment
`attempt
`to
`incidence
`high
`in American
`Indians
`who
`is
`borns
`a cradle
`board
`with
`hips
`swaddled
`adduction.
`Kutlu
`et
`aP’
`evaluated
`4173
`infants
`56,
`and
`55 of
`these
`had
`been
`swaddled
`in
`infancy
`45
`days.
`Green
`and
`Griffin26
`reported
`on
`18 infants
`in
`conjunction
`with
`an
`abduction
`contracture
`of
`hip.
`All
`patients
`responded
`abduction
`splinting
`
`limits
`
`of
`
`devices
`
`on
`
`is
`
`three
`
`the
`
`Ikeda’9
`
`have
`infants
`
`that
`
`to
`
`with
`play
`patients
`members
`1) healthy
`children
`6%;
`parent
`with
`
`in
`
`between
`India
`with
`
`the
`
`to
`
`reported
`compared
`knee
`extension
`hamstring
`Langenskiold’8
`immobilizing
`muscles
`not
`develop.
`is
`associated
`clubfoot,
`scoliosis,
`
`and
`the
`tightens
`and
`Michelsson
`by
`young
`rabbits
`when
`the
`hamstring
`the
`knee,
`DDH
`did
`intrauterine
`space,
`including
`torticollis,
`
`were
`
`DDH
`pop-
`frank
`con-
`pro-
`to
`exten-
`before
`
`were
`the
`knee
`sectioned
`Oligohydramnios,
`with
`mechanical
`plagiocephaly,
`
`the
`as
`the
`in
`position,
`may
`
`right
`left
`the
`predispose
`
`in
`occi-
`left
`
`torticollis
`15%
`that
`DDH
`
`and
`of
`and
`found
`but
`et
`were
`
`DDH
`Kollmer
`and
`
`etiology
`families,
`when
`one
`child
`parent,
`child,
`risk
`
`a
`
`positioning
`are
`
`and
`
`and
`
`for
`
`carried
`of
`flexion
`and
`most
`In
`contrast,
`position
`their
`in
`extension
`DDH
`found
`average
`an
`had
`who
`the
`contralateral
`of
`the
`
`DDH.
`astride
`and
`treat-
`the
`new-
`and
`in
`of
`
`DDH
`
`dys-
`
`202
`
`DEVELOPMENTAL
`
`DYSPLASIA
`
`Downloaded from
`OF THE
`HIP
`
`by guest on August 19, 2016
`
`Petitioner Ex. 1065 Page 2
`
`

`
`stretching
`
`of
`
`the
`
`abduction
`
`contracture
`
`of
`
`the
`
`BARLOW
`
`plastic
`contralateral
`investigators
`early
`Several
`to
`primary
`secondary
`demonstrated
`have
`dislocation
`the
`of
`reduced
`concentrically
`reversible
`dysplasia
`is
`the
`acetabulum
`to
`in
`contact
`be
`development.
`
`hip
`
`and
`hip.
`
`was
`reports
`cause
`being
`lar
`tween
`needs
`acetabular
`
`Natural
`
`History
`
`postulated
`acetabular
`that
`the
`is
`a
`in
`the
`restoring
`femoral
`the
`
`but
`
`by
`
`and
`with
`
`the
`that
`dysplasia.24’27
`acetabular
`dysplasia
`result
`of
`femoral
`acetabulum.(cid:1)”
`a normal
`head.’2’3’
`triradiate
`
`etiology
`
`of DDH
`Subsequent
`is not
`head
`acetabu-
`
`the
`not
`
`be-
`head
`normal
`
`the
`
`The
`cartilage
`
`The
`relationship
`femoral
`for
`
`as
`progressive
`McKinnon
`hips
`hips
`
`controversial
`remains
`develop
`resolve,
`dislocation.
`subluxatable
`subluxatable
`an
`increased
`involvement,
`that
`the
`as
`
`newborn
`sub-
`alM
`et
`The
`92.
`similar
`
`of
`
`associ-
`sub-
`disloca-
`
`hips
`
`of DDH
`history
`natural
`The
`spontaneously
`may
`instability
`complete
`or
`progress
`to
`luxation,
`and
`found
`149
`newborns
`15
`studied
`newborns
`with
`profile
`of
`the
`patient
`with
`dislocated
`with
`to
`those
`breech
`presentations,
`left-sided
`females,
`postural
`deformities.
`concluded
`ated
`luxatable
`arises
`from
`antecedents
`hip
`tion
`and
`is best
`managed
`and
`Cooperman
`et
`al3’
`dysplasia
`to determine
`average
`follow-up
`osteoarthritis.
`hips)
`who
`or
`dislocation.
`of
`subluxated
`trast
`to
`the
`dysplasia
`
`in
`was
`frequency
`and
`newborn
`They
`a frank
`the
`same
`early.
`treated
`if detected
`with
`(32
`hips)
`20
`studied
`disorder.
`of
`the
`natural
`the
`had
`severe
`30
`years,
`22
`reported
`on
`and Wasylenko(cid:1)
`by
`dysplasia,
`been
`affected
`only
`41% of dislocated
`hips
`received
`a good
`the
`patients
`with
`had
`more
`
`had
`
`of
`
`be
`
`Wedge
`previously
`At
`follow-up,
`and
`dysplastic
`dislocated
`group,
`tended
`to
`younger
`
`adults
`history
`(94%)
`
`and
`
`acetabular
`After
`or moderate
`54
`adults
`subluxation,
`hips
`and
`score.
`In
`subluxation
`pain.
`
`an
`
`(80
`
`42%
`con-
`and
`
`Fig.
`demonstrating
`1. Drawings
`maneuvers.
`and
`Ortolani
`leg
`and
`abducting
`gently
`over
`the
`slides
`head
`femoral
`is called
`the
`This
`the
`socket.
`by
`abducting
`test
`is
`obtained
`knee
`is
`“clunk”
`and
`a palpable
`the
`acetabulum
`the
`posterior
`rim of
`called
`the
`of
`exit.
`
`Barlow
`
`the
`
`sign
`
`rim
`
`entry.
`hip
`and
`as
`the
`and
`
`technique
`the
`Ortolani
`The
`palpable
`a
`posterior
`sign
`of
`the
`felt
`
`performing
`for
`is obtained
`sign
`is
`felt
`“clunk”
`acetabulum
`of
`the
`The
`Barlow
`provocative
`pushing
`gently
`on
`femoral
`head
`slides
`out
`of
`socket.
`
`the
`by
`the
`into
`
`as
`
`the
`over
`This
`
`is
`
`the
`
`History
`The
`
`held
`hips
`
`that
`
`if
`
`was
`is
`not
`
`examined
`both
`outdated
`detected
`are
`followed,
`
`at
`
`and
`
`are
`principles
`
`is
`
`thumb
`in
`
`trochanter
`greater
`the
`The
`leg
`thigh.
`dial
`90#{176}of hip
`flexion
`with
`the
`leg
`anteriorly.
`lifting
`as
`the
`femoral
`a clunk
`the
`acetabulum
`of
`rim
`This
`is
`the
`clunk
`1).
`(Fig
`the
`This
`called
`Ortolani.37
`with
`maneuver.
`relocates
`leg
`the
`then
`gently
`position,
`directed
`posteriorly
`pressure
`and
`a palpable
`clunk
`is
`slides
`over
`posterior
`the
`out
`the
`This
`of
`socket.
`by
`Barlow”
`liked
`who
`the
`test
`with
`Ortolani
`exit,
`sign
`of
`the
`hip
`Both
`tests
`designed
`femoral
`and
`the
`ity
`of
`tests
`is
`
`is
`this
`is
`
`as
`
`are
`head
`these
`
`noted
`rim of
`was
`clunk
`combine
`to
`(Fig
`test
`dislocates
`to detect
`acetabulum.
`dependent
`
`Umftsd
`
`AbducDon
`
`along
`the
`with
`neutral
`positioned
`abducted
`and
`is gently
`one
`With
`abduction
`the
`head
`slides
`over
`the
`and
`into
`described
`originally
`entry,
`as
`sign
`of
`Maintaining
`the
`while
`adducted
`on
`is
`placed
`femoral
`as
`the
`the
`acetabulum
`described
`originally
`provocative
`this
`I ). This
`is
`called
`this maneuver.
`with
`between
`motion
`reproducibil-
`The
`ligamentous
`
`the me-
`rotation
`while
`can
`feel
`posterior
`socket
`
`the
`
`by
`hip
`same
`gentle
`knee
`head
`and
`
`the
`
`the
`
`the
`
`or
`
`on
`
`previously
`dislocated
`all
`birth
`inaccurate.
`and
`dislocations
`the
`ability
`Asking
`history
`ily
`positioning,
`mended.
`the
`delivery
`Conditions
`tus,
`and
`DDH.
`The
`or
`that
`one
`when
`changing
`intoeing,
`or
`
`view,
`be
`would
`dislocations
`are
`There
`If several
`late.
`occur
`that
`can
`be
`DDH
`detect
`to
`potential
`about
`family
`the
`ligamentous
`of hip
`dislocation,
`environmental
`and
`genetic
`position,
`even
`A history
`of
`breech
`section,
`is
`an
`was
`cesarean
`including
`plagiocephaly,
`clubfeet,
`congenital
`muscular
`may
`mother
`may
`note
`in
`leg
`not
`come
`enough
`will
`diapers.
`In
`child,
`outtoeing
`
`newborn
`the
`diagnosable,
`that
`basic
`improved.
`risk
`
`factors
`laxity,
`
`and
`
`by
`
`torticollis
`a difference
`out
`far
`older
`secondary
`
`the
`be
`
`may
`
`the
`
`including
`pre
`and
`factors
`it was
`if
`important
`metatarsus
`be
`associated
`the
`length
`of
`(limited
`abduction)
`limp,
`toe-walking,
`a
`to DDH.
`
`a fam-
`postnatal
`is
`recom-
`transient
`or
`risk
`factor.
`adduc-
`with
`legs
`
`if
`
`RESULTS
`
`AND
`
`DISCUSSION
`
`period,
`The
`
`on
`
`the
`
`the
`
`are
`
`firm
`
`Physical
`In
`physical
`none
`patience
`on
`a
`adequate
`newborn.
`physician
`extremities.
`pearance,
`tion
`of
`findings.
`flexion
`should
`midline.
`The
`
`Examination
`diagnosis
`the
`neonatal
`physical
`signs
`examination.
`The
`examination
`pathognomonic.
`newborn
`must
`the
`and
`skill
`and
`impossible
`to
`is
`surface.
`It
`physical
`examination
`When
`performing
`looks
`for
`asymmetry
`Asymmetric
`thigh
`a prominent
`greater
`or
`abduction
`adduction
`supine
`In
`the
`position,
`hand
`and
`one
`stabilizing
`easily
`abduct
`to 75#{176}and
`
`by
`is made
`and
`change
`requires
`relaxed
`be
`perform
`crying,
`a
`examination
`between
`the
`folds,
`a
`trochanter,
`may
`with
`the
`adduct
`
`short
`
`an
`fussy
`the
`lower
`leg
`ap-
`limita-
`or
`significant
`hip
`in 90#{176}of
`the
`each
`hip
`pelvis,
`to 30#{176}past
`the
`
`be
`
`or
`tion
`maneuvers.
`examiner’s
`
`examiner
`subluxation
`With
`long
`
`attempts
`using
`newborn
`index
`
`the
`and
`
`to
`the
`
`reproduce
`Ortolani
`supine
`fingers
`
`the
`and
`tips
`placed
`
`disloca-
`Barlow
`of
`the
`over
`
`the
`
`are
`
`Fig.
`fant’s
`examiner
`tion
`is
`(DDH),
`
`2. A drawing
`left
`hip.
`The
`simultaneously
`often
`associated
`particularly
`
`limited
`demonstrating
`supine
`infant
`is
`placed
`both
`abducts
`with
`developmental
`infants
`over
`2 months
`
`hips.
`
`in
`
`Downloaded from
`
`by guest on August 19, 2016
`
`on
`
`abduction
`a firm
`Asymmetrical
`dysplasia
`of
`age.
`
`of
`table
`
`of
`
`in-
`this
`the
`and
`abduc-
`the
`hip
`
`ARTICLES
`
`203
`
`Petitioner Ex. 1065 Page 3
`
`

`
`which
`
`usually
`
`disappears
`
`by
`
`10 to
`
`12
`
`is performed
`to
`stabilize
`hand
`to
`illicit
`required
`important
`is
`It
`or Barlow
`may
`occur
`position.
`feeling
`temporal
`are
`exit
`infant,
`so
`
`of
`
`a
`
`(Fig
`
`the
`
`is
`positive
`femur),
`
`DDH
`the
`75
`
`at
`
`or
`
`a
`
`and
`
`or
`
`liga-
`and
`physical
`abduc-
`
`less
`is
`Ortolani
`best
`hip
`of
`identified
`Galleazzi’s
`and
`extra
`
`by
`
`is more
`be
`sym-
`typically
`3-
`
`laxity,
`capsular
`age.
`of
`weeks
`hip
`one
`examination
`physical
`The
`pelvis.
`the
`other
`the
`using
`time
`a
`an Ortolani
`of
`force
`The
`amount
`to
`distinguish
`is minimal.
`Barlow
`sign
`maneuver
`from
`an Ortolani
`the
`clunk
`of
`flexion
`with
`click,
`that
`high-pitched
`A subluxatable
`an
`abducted
`in
`extension
`telescoping
`of
`characterized
`by
`hip
`is
`Orto-
`head.
`The
`movement
`the
`of
`sliding
`negative
`because
`Barlow
`maneuvers
`and
`lani
`or
`entry.
`palpable
`clunk
`is no
`there
`there
`to
`12-month-old
`the
`3-
`In
`the
`laxity
`and
`capsular
`mentous
`The
`disappear.
`tests
`usually
`Barlow
`limitation
`group
`is
`in
`this
`age
`finding
`2). A unilateral
`dislocation
`tion
`abduction
`of
`hip,
`a
`limited
`(relative
`shortening
`of
`the
`sign
`to
`folds
`secondary
`shortening.
`thigh
`dislocation
`bilateral
`diagnosis
`of
`hip
`The
`as
`the
`limitation
`abduction
`may
`of
`difficult
`in
`Hip
`abduction
`bilateral
`is
`metric.
`to
`in
`to
`30
`to
`40#{176}although
`normal
`limited
`the
`be
`infant,
`it
`should
`80#{176}with
`to
`12-month-old
`to
`offers
`flexion.
`This
`test
`another
`clue
`hip
`in
`90#{176}of
`diagnosis
`of
`bilateral
`DDH.
`N#{233}laton’s
`the
`difficult
`line
`imaginary
`between
`the
`ischial
`tuber-
`line
`is
`an
`the
`anterosuperior
`iliac
`spine.
`The
`greater
`osity
`and
`in
`a
`dislocated
`lies
`cephalad
`to
`this
`hip
`trochanter
`the
`trochanter
`in a normal
`hip
`lies
`caudad.
`line
`while
`index
`of
`suspicion
`is
`required
`to
`detect
`bilat-
`A high
`eral
`DDH.
`physical
`is walking
`a child
`Once
`limp
`There
`is
`obvious.
`more
`side.
`on
`often
`toe-walk
`will
`lordosis,
`dislocated,
`increased
`are
`pattern
`buttocks,
`a waddling
`stand
`on
`When
`is
`asked
`opposite
`the
`leg,
`drops
`to
`side
`affected
`the
`trunk
`toward
`is
`positive
`test
`delenburg
`test).
`hip mechanically
`periorly
`dislocated
`decreasing
`their
`ductor
`muscles
`of
`hip
`dysplasia
`The
`diagnosis
`patient
`may
`note
`adolescent
`and
`limp
`walking
`examination
`be
`may
`be
`the
`particularly
`these
`of
`radiograph
`
`become
`signs
`the
`child
`and
`If both
`hips
`prominent
`are
`noted.
`the
`affected
`side
`and
`(positive
`because
`shortens
`strength.
`is more
`pain
`or
`intermittently.
`some
`normal
`or
`range
`extremes
`rotation.
`and
`internal
`anteroposterior
`
`the
`Tren-
`the
`su-
`the
`ab-
`
`difficult.
`discomfort
`
`The
`dis-
`of
`
`of
`
`the
`typical
`affected
`lumbar
`gait
`to
`
`a
`the
`
`the
`
`and
`patient
`pelvis
`the
`leans
`
`This
`
`The
`after
`physical
`comfort
`motion,
`If
`any
`pelvis
`
`may
`may
`at
`elicited
`abduction
`are
`present,
`recommended.
`
`is
`
`signs
`
`an
`
`pelvis
`
`neonatal
`may
`the
`
`Evaluation
`Radiographic
`The
`anteroposterior
`to interpret
`in
`the
`born
`radiograph
`of
`because
`much
`are
`head
`cartilaginous
`and
`femoral
`the
`head
`termine.
`positioning
`graph,
`technician
`dislocated
`hip
`producing
`
`In
`the
`
`radiograph
`period.”(cid:1)
`be misleading
`neonatal
`so
`the
`acetabulum
`the
`newborn
`may
`spontaneously
`normal
`
`difficult
`is
`new-
`A normal
`and
`deceptive
`and
`femoral
`between
`de-
`to
`radio-
`the
`reduce
`radiograph.
`
`a
`In
`
`pelvis
`relationship
`is
`difficult
`for
`
`a
`
`Perk(cid:1)(cid:1)s’
`
`Lk(cid:1)e
`
`Perkms’
`
`Line
`
`3. A, An
`Fig.
`infant
`with
`old
`shows
`graph
`cartilages.
`ate
`through
`the
`a
`forms
`line
`the medial
`and
`with
`a delay
`right
`displacement
`of
`acetabular
`
`index
`
`the
`
`line
`ossified
`
`of
`
`the
`
`of
`
`femoral
`“break”
`
`a
`
`8-month-
`an
`radiograph
`pelvis
`anteroposterior
`the
`radio-
`of
`B, The
`drawing
`right.
`DDH
`on
`the
`triradi-
`of
`top
`line
`connecting
`the
`Hilgenreiner’s
`is perpendicular
`to Hilgenreiner’s
`line
`Perkins’
`margin
`of
`acetabulum.
`lateral
`contour
`between
`the
`obturator
`continuous
`the
`femoral
`There
`is DDH
`neck.
`border
`appearance
`ossific
`nucleus,
`the
`the
`in
`proximal
`metaphysis,
`an
`the
`(40#{176}),and
`in Shenton’s
`line.
`
`of
`
`Shenton’s
`foramen
`the
`on
`lateral
`elevated
`
`addition,
`asymmetry
`difficult.
`From
`radiograph
`the
`hips.
`necting
`Perkins’39
`er’s
`line
`the
`roof
`proximal
`medial
`(Fig
`The
`sign
`
`3).
`
`that
`
`if
`
`the
`is
`
`newborn
`introduced
`
`is not
`that
`
`positioned
`makes
`
`properly,
`interpretation
`
`anteroposterior
`are
`used
`a horizontal
`triradiate
`
`is
`
`to
`
`pelvis
`positioned
`a properly
`evaluate
`parameters
`several
`line
`con-
`line
`Hilgenreiner’s
`cartilages.
`respective
`the
`the
`top
`of
`to Hilgenrein-
`perpendicular
`line
`is drawn
`ossified
`margin
`through
`the most
`lateral
`of
`the
`acetabulum.
`The medial
`margin
`femoral
`metaphysis
`should
`in the
`lie
`quadrant
`of
`the
`intersection
`these
`two
`
`of
`the
`of
`infero-
`lines
`
`of
`
`teardrop
`becomes
`
`shadow
`visible
`
`a
`is
`when
`
`normal
`the
`
`radiographic
`infant
`is 6 to
`
`12
`
`204
`
`DEVELOPMENTAL
`
`DYSPLASIA
`
`Downloaded from
`OF THE
`HIP
`
`by guest on August 19, 2016
`
`Petitioner Ex. 1065 Page 4
`
`

`
`of
`
`three
`to
`
`the
`line
`
`semi-
`
`of
`to
`
`short,
`
`notch.
`result
`re-
`a
`of
`
`a
`
`of
`
`of
`
`old.”#{176}It consists
`months
`line
`corresponding
`circular
`the
`acetabular
`fossa,
`the
`medial
`cortex
`curved
`line
`connecting
`to
`the
`semicylindrical
`Delay
`in
`the
`ossification
`from
`lack
`of
`stimulation
`duced
`femoral
`head
`delay
`in
`the
`appearance
`the
`femoral
`head,
`which
`3 and
`7 months
`age,
`Shenton’s
`a
`border
`of
`of
`border
`of
`continuous
`ation
`of
`rupted
`angle
`at
`beginning
`the
`acetabulum
`between
`the
`genreiner’s
`evaluating
`the
`newborn
`decreases
`ported
`clinically
`abnormal
`averaged
`with
`those
`to remember
`is helpful
`be misleading.
`by
`clinical
`ultrasound
`
`a lateral
`lines:
`cortical
`surface
`corresponding
`a medial
`a
`wall,
`and
`the
`pelvic
`lines
`corresponding
`these
`two
`the
`acetabular
`cortex
`of
`may
`teardrop
`of
`the
`a
`concentrically
`from
`DDH.
`Similarly,
`suggesting
`ossification
`center
`of
`the
`appears
`between
`normally
`DDH.
`also
`suggests
`the
`along
`line
`drawn
`the
`and
`the
`femur
`should
`and
`foramen
`superolateral
`there
`is
`head,
`Shenton’s
`acetabular
`index
`Hilgenreiner’s
`ossified
`extending
`the
`acetabular
`of
`acetabular
`The
`development
`acetabular
`the
`20#{176}by
`2 years
`to
`1155
`newborns
`and
`radiographically
`clinical
`examinations.
`29#{176}in
`the
`healthy
`abnormal
`clinical
`that
`a radiograph
`a normal-appearing
`The
`diagnosis
`examination
`examination.
`
`is
`
`line
`neck
`the
`obturator
`the
`contour.
`femoral
`The
`between
`the
`lateral
`and
`
`the
`(Fig
`formed
`
`3)41
`
`depth
`line.
`the
`
`on
`
`while
`
`If
`
`a
`
`medial
`superior
`form
`sublux-
`is
`inter-
`line
`the
`represents
`a line
`line
`and
`roof
`of
`of
`the
`intersection
`the
`Hil-
`and
`socket
`in
`helpful
`is
`In
`acetabulum.
`28#{176}and
`averages
`age.42
`Coleman43
`re-
`were
`examined
`both
`and
`found
`77 that
`had
`The
`acetabular
`index
`newborns
`and
`35#{176}in
`findings.
`important
`with
`findings
`may
`is made
`by
`
`margin
`to
`
`index
`the
`
`of
`index
`of
`
`who
`
`is
`It
`positive
`radiograph
`newborn
`be
`confirmed
`
`in
`
`the
`can
`
`and
`
`B
`
`‘,
`
`Beta
`angle
`‘\
`450
`
`Glenoid
`labrum
`
`Femoral
`head
`
`Triradiate
`cartilage
`
`Fig.
`infant
`drawn
`drawn
`is
`drawn
`alpha
`measures
`
`4. A, A coronal
`with
`DDH.
`parallel
`the
`along
`along
`
`ultrasound
`B, The
`drawing
`the
`lateral
`wall
`to
`roof
`the
`cartilaginous
`of
`the
`inferior
`edge
`measures
`56#{176}(Normal
`45#{176}(Normal
`<72#{176}).
`
`of
`
`the
`of
`of
`
`of
`
`the
`the
`
`hip
`right
`ultrasound
`ilium.
`acetabulum.
`bony
`the
`>55#{176})and
`
`in
`
`a 7-month-old
`shows
`a
`A second
`line
`A third
`acetabulum.
`the
`beta
`
`line
`is
`line
`The
`angle
`
`angle
`
`of
`eversion
`(Fig
`4)#{149}47The
`the
`alpha
`and
`accurately
`and
`may
`
`appear
`
`labrum
`the
`problem
`beta
`angles
`if
`the
`image
`more
`dysplastic
`
`and
`with
`
`sublux-
`the
`static
`difficult
`are
`is not
`pre-
`than
`
`it
`
`hip
`
`indicates
`>72#{176},it
`the
`hip
`ation
`of
`is
`that
`method
`to
`reproduce
`cise,
`the
`really
`is.
`The
`dynamic
`sualize
`the
`ultrasound
`ligamentous
`ical
`examination,
`the
`pendent
`on
`with
`performed
`supine
`itus
`and
`and
`transverse
`coronal
`image
`and
`posterior
`palm
`of
`the
`subluxation
`on
`the
`the
`first
`dislocates,
`Ortolani
`namic
`
`or
`
`consists
`
`real
`and
`Barlow
`The
`screen.
`or
`capsular
`the
`operator.
`the
`infant
`positions
`planes
`is obtained
`stress
`is
`hand
`(Barlow
`is noted
`(Fig.
`and
`4 mm
`on
`left
`days
`of
`life.(cid:1)
`few
`attempt
`at
`an
`maneuver).
`The
`method
`
`method
`time
`Ortolani
`technique
`laxity
`ultrasound
`The
`in
`and
`
`and
`
`with
`
`If
`reduction
`second
`similar
`
`of
`
`attempts
`maneuvers
`is
`dependent
`just
`like
`the
`examination
`dynamic
`technique
`both
`the
`lateral
`decub-
`imaging
`in
`the
`coronal
`and
`without
`stress.
`The
`with
`the
`hip
`flexed
`90#{176}
`with
`applied
`to
`the
`knee
`the
`and
`provocative
`test)
`any
`of
`5).
`Six mm
`subluxation
`the
`right
`is normal
`during
`the
`hip
`subluxates
`is performed
`stage
`of
`imaging
`
`to
`on
`
`vi-
`the
`on
`phys-
`is
`de-
`is
`
`to
`
`or
`(the
`dy-
`the
`
`the
`in
`
`Ultrasound
`In
`1980,
`trasound
`methods
`proposed
`method
`The
`in the
`flexion
`of
`the
`from
`the
`drawn
`from
`labrum.
`of
`the
`cartilage
`center
`between
`ilium
`The
`(Fig
`tabular
`angle,
`angle
`eral
`of
`
`of
`
`Graf
`study
`to
`currently
`by
`Graf,
`described
`as
`technique
`static
`decubitus
`lateral
`10#{176}of
`internal
`and
`is obtained
`and
`hip
`image.
`A vertical
`the
`lateral
`wall
`of
`ossified
`the
`roof
`of
`the
`along
`bony
`edge
`the
`lateral
`line
`drawn
`A third
`bony
`acetabulum
`at
`to
`the most
`the
`hip
`the
`line
`the
`line
`and
`limit
`of
`lower
`4)#{149}47Because
`coverage
`the
`greater
`is
`formed
`wall
`of
`the
`the
`cartilaginous
`
`developed
`the
`neonatal
`in use
`include
`and
`the
`by Harcke
`infant
`with
`is
`performed
`35#{176}of
`hip
`the
`position
`image
`A coronal
`rotation.
`are
`constructed
`lines
`three
`drawn
`parallel
`is
`line
`A second
`line
`ilium.
`the
`acetabulum
`cartilaginous
`the
`to
`of
`the
`acetabulum
`edge
`from
`the
`inferior
`roof
`of
`the
`triradiate
`on
`the
`ilium
`in
`angle
`is
`formed
`lateral
`wall
`of
`bony
`acetabulum.
`alpha
`angle
`is 55#{176}
`reflects
`bony
`ace-
`the
`smaller
`the
`head,
`dysplasia.
`The
`beta
`parallel
`to
`the
`lat-
`parallel
`to
`the
`roof
`If
`the
`angle
`
`the
`point
`alpha
`The
`the
`to
`the
`to
`the
`for
`angle
`
`distal
`joint.
`parallel
`parallel
`normal
`the
`alpha
`of
`the
`femoral
`the
`degree
`between
`the
`ilium
`the
`and
`acetabulum.
`
`the
`
`idea
`hip
`
`the
`dynamic
`et
`
`and
`
`ul-
`two
`
`adopting
`of
`joint.(cid:1)’45
`The
`static
`technique
`or
`real
`time
`
`al.(cid:1)
`
`the
`in
`
`to
`is
`
`the
`
`the
`
`of
`line
`line
`
`beta
`
`is
`
`is
`
`Downloaded from
`
`by guest on August 19, 2016
`
`ARTICLES
`
`205
`
`Petitioner Ex. 1065 Page 5
`
`(cid:1)
`

`
`hips
`
`a
`
`in
`
`and
`ultra-
`of
`the
`with
`ultrasound
`responding
`radiographs
`
`a
`
`is
`
`of
`
`are
`
`to
`late
`
`81
`
`In
`
`first
`in
`
`all
`of
`
`treated.
`were
`and
`had
`abnor-
`newborns
`visit.
`None
`on
`the
`cases
`fol-
`and
`the
`insta-
`resolution
`the
`ultra-
`compared
`1001
`newborns
`and
`sensitive
`diagnos-
`that
`the
`ultrasound
`sensitive
`in
`identifying
`
`examinations
`17
`cases,
`examinations
`treated
`was
`showed
`Klenerman53
`in
`findings
`a more
`to be
`document
`be
`too
`instability.
`on
`that
`
`with
`neonatal
`from
`screened
`preva-
`The
`hips.
`nor-
`in
`clinically
`after
`treated
`and
`were
`and
`had
`these,
`three
`of
`ultrasound
`should
`that
`screening
`procedure
`Gardiner
`al55
`reported
`et
`sonograms
`resolved
`rapidly
`ultrasound
`could
`predict
`the
`neonatal
`period.
`in
`longitudinal
`follow-up
`ligamentous
`laxity
`up
`with
`repeat
`a
`document
`resolution
`undergoing
`treatment
`followed
`up with
`that
`the
`hip
`number
`
`with
`
`infant
`be
`can
`to document
`and
`limit
`
`the
`
`clinical
`positive
`to
`these
`addition
`mal
`ultrasound
`of
`these
`newborns
`low-up
`ultrasounds
`and
`bility.
`Berman
`clinical
`sound
`and
`ultrasound
`found
`the
`tic
`tool.
`These
`studies
`is
`sensitive,
`it may
`but
`clinically
`insignificant
`Castelein
`et
`alM reported
`144
`were
`ultrasound
`ab