Hip Sonography for Developmental Dysplasia of the Hip: The Graf Method
Keywords:
: Developmental Dysplasia of the Hip (DDH), Graf method, hip ultrasonography, preventive screeningAbstract
Developmental Dysplasia of the Hip (DDH) is one of the most common musculoskeletal disorders for children. Multiple risk factors as female sex, positive family history, breech positioning in utero are blamed for the presentation of this entity. The hip joint of the infant is affected and more specifically, the acetabulum remains shallow and the femoral head grows in a wrong position. Until 1980 the diagnosis was based on clinical examination (Barlow and Ortolani maneuvers) and radiological imaging. The diagnosis was not certain and many cases remained undiagnosed until childhood or adolescence. In 1980 Prof. Reinhard Graf presented his ultrasonographic method for the examination of the infant hip joint. This method evaluates the bony and cartilaginous coverage of the femoral head by the acetabulum in the infantile joint by measuring α-angle and β-angle. Using and valuating these measurements the hip joint is later on classified by Graf classification (Types I-IV) and each type corresponds to a specific treatment option. Graf method is the most used ultrasonographic examination in many European countries and has contributed to the reduction of neglected DDH cases and decreased the number of complex pelvic operations that children with dysplastic hips should undergo to be cured.
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References
1. Paton RW, Hossain S, Eccles K (2002) Eight-year prospective targeted ultrasound screening program for instability and at-risk hip joints in developmental dysplasia of the hip. J Pediatr Orthop 22:338–341
2. Graf R. Hip sonography: background; technique and common mistakes; results; debate and politics; challenges. Hip Int. 2017 May 12;27(3):215-219. doi: 10.5301/hipint.5000514. Epub 2017 May 8. PMID: 28497455.
3. Ponseti IV. Morphology of the acetabulum in congenital dislocation of the hip. Gross, histological and roentgenographic studies. J Bone Joint Surg Am. 1978;60: 586–99
4. Guille JT, Pizzutillo PD, MacEwen GD. Development dysplasia of the hip from birth to six months. J Am Acad Orthop Surg. 2000;8:232–42.
5. Wynne-Davies R. Acetabular dysplasia and familial joint laxity: Two etiological factors in congenital dislocation of the hip. A review of 589 patients and their families. J Bone Joint Surg Br. 1970;52:704–16.
6. Massie WK. Congenital dislocation of the hip; its causes and effects. Clin Orthop. 1956;8:103–21.
7. Wylock P. The life and times of Guillaume Dupuytren, 1777–1835. Brussels, Belgium: Brussels University Press; 2010.
8. Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic combound treatment. Arch Orthop Trauma Surg. 1980;97(2):117–33
9. R Graf, The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment, Arch Orthop Trauma Surg.1980;97(2):117-33
10. von Kries R, Ihme N, Oberle D, et al. Effect of ultrasound screening on the rate of first operative procedures for developmental hip dysplasia in Germany. Lancet. 2003;362(9399):1883-1887
11. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical practice guideline: Early detection of developmental dysplasia of the hip. Committee on quality improvement, subcommittee on developmental dysplasia of the hip. American academy of pediatrics. Pediatrics. 2000;105(4 Pt 1):896–905.
12. Paulozzi LJ, Lary JM. Laterality patterns in infants with external birth defects. Teratology. 1999;60:265–71.
13. Hadlow V. Neonatal screening for congenital dislocation of the hip. A prospective 21-year survey. J Bone Joint Surg Br. 1988;70:740–3
14. Lowry CA, Donoghue VB, O’Herlihy C, Murphy JF. Elective Caesarean section is associated with a reduction in developmental dysplasia of the hip in term breech infants. J Bone Joint Surg Br. 2005;87:984–5
15. Houston CS, Buhr RH. Swaddling of Indian infants in northern Saskatchewan. Musk-ox. 1988;36:5–14
16. Woolf CM, Koehn JH, Coleman SS. Congenital hip disease in Utah: The influence of genetic and nongenetic factors. Am J Hum Genet. 1968;20(5):430–9.
17. Czeizel A, Szentpétery J, Tusnády G, Vizkelety T. Two family studies on congenital dislocation of the hip after early orthopaedic screening Hungary. J Med Genet. 1975;12(2):125–30
18. Andren L, Borglin NE. A disorder of oestrogen metabolism as a causal factor of congenital dislocation of the hip. Acta Orthop Scand. 1960;30:169–71
19. Abd el-Kader Shaheen M. Mehad: The Saudi tradition of infant wrapping as a possible aetiological factor in congenital dislocation of the hip. J R Coll Surg Edinb. 1989;34(2):85–7
20. Czeizel A, Szentpétery J, Kellermann M. Incidence of congenital dislocation of the hip in Hungary. Br J Prev Soc Med. 1974;28(4):265–7
21. Wynne-Davies R. A family study of neonatal and late-diagnosis congenital dislocation of the hip. J Med Genet. 1970;7(4):315–33
22. Torisu T, Fujikawa Y, Yano H, Masumi S. Association of HLA-DR and HLA-DQ antigens with congenital dislocation and dysplastic osteoarthritis of the hip joints in Japanese people. Arthritis Rheum. 1993;36(6):815–8.
23. Ishikawa N. The relationship between neonatal developmental dysplasia of the hip and maternal hyperthyroidism. J Pediatr Orthop. 2008;28(4):432–4
24. Stevenson RE, Huntley CC. Congenital malformations in offspring of phenylketonuric mothers. Pediatrics. 1967;40(1):33–45
25. Record RG, Edwards JH. Environmental influences related to the aetiology of congenital dislocation of the hip. Br J Prev Soc Med. 1958;12(1):8–22
26. Li Y, Guo Y, Li M, Zhou Q, Liu Y, Chen W, Li J, Canavese F, Xu H. Acetabular index is the best predictor of late residual acetabular dysplasia after closed reduction in developmental dysplasia of the hip. Int Orthop. 2018;42(3):631–40
27. Stanisavljevic S. Congenital hip pathology in the newborn. Baltimore, MD: Williams and Wilkins; 1964
28. Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia. J Pediatr Orthop. 1984;4(6):735–40
29. Leveuf J. Primary congenital subluxation of the hip. J Bone Joint Surg Am. 1947;29(1):149–62
30. Chen J, Zhang WB, He JZ, Zhang R, Cao YQ, Liu X. Developmental dysplasia of the hip: A special pathology. Chin J Traumatol. 2018;21(4):238–42
31. Liu R, Wen X, Tong Z, Wang K, Wang C. Changes of gluteus medius muscle in the adult patients with unilateral developmental dysplasia of the hip. BMC Musculoskelet Disord. 2012;13:101
32. Spyridon Sioutis, Stylianos Kolovos, Maria-Eleni Papakonstantinou, Lampros Reppas, Dimitrios Koulalis & Andreas F. Mavrogenis, Developmental Dysplasia of the Hip: A Review, Journal of Long-Term Effects of Medical Implants, 32(3):39–56 (2022)
33. Harsanyi S, Zamborsky R, Krajciova L, Kokavec M, Danisovic L. Developmental dysplasia of the hip: A review of etiopathogenesis, risk factors, and genetic aspects. Medicina. 2020;56(4):153
34. Ortolani M. Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop Relat Res. 1976;(119):6–10
35. Kotlarsky P, Haber R, Bialik V, Eidelman M. Developmental dysplasia of the hip: What has changed in the last 20 years? World J Orthop. 2015;6(11):886–901
36. Kamath SU, Bennet GC. Does developmental dysplasia of the hip cause a delay in walking? J Pediatr Orthop. 2004;24(3):265.
37. Shorter D, Hong T, Osborn DA. Cochrane Review: Screening programmes for developmental dysplasia of the hip in newborn infants. Evid Based Child Health. 2013;8(1):11–54
38. Terjesen T. Ultrasound as the primary imaging method in the diagnosis of hip dysplasia in children aged < 2 years. J Pediatr Orthop B. 1996;5(2):123–8.
39. Dunn PM. The anatomy and pathology of congenital dislocation of the hip. Clin Orthop Relat Res. 1976;(119):23–7
40. Lewis CL, Laudicina NM, Khuu A, Loverro KL. The human pelvis: Variation in structure and function during gait. Anat Rec. 2017;300(4):633–42
41. Spaans AJ, Beek FJA, Uiterwaal CSPM, Pruijs JEH, Sakkers RJ. Correlation between ultrasonic and radiographic imaging of developmental dysplasia of the hip. J Child Orthop. 2019;13(2):155–60
42. Grissom L, Harcke HT, Thacker M. Imaging in the surgical management of developmental dislocation of the hip. Clin Orthop Relat Res. 2008;466(4):791–801
43. S Suzuki, G Awaya, S Wakita, M Maekawa, T Ikeda, Diagnosis by ultrasound of congenital dislocation of the hip joint, Clin Orthop Relat Res. 1987 Apr;(217):171-8
44. Graf R., Hip ultrasonography. Basic principles and current aspects., Orthopade. 1997 Jan;26(1):14-24
45. Müller W, Lercher K, DeVaney TT, Giner F, Graf R., Technical errors in the application of Graf’s hip sonography method, Ultraschall Med. 2001 Feb;22(1):48-54
46. Graf R, Tschauner C, Steindl M., Does the IIa hip need treatment? Results of a longitudinal study of sonographically controlled hips of infants less than 3 months of age, Monatsschr Kinderheilkd. 1987 Dec;135(12):832-7
47. Graf R., Classification of hip joint dysplasia by means of sonography., Arch Orthop Trauma Surg. 1984;102(4):248-55
48. Reinhard Graf, Hip sonography: background; technique and common mistakes; results; debate and politics; challenges, Hip Int 2017; 27 (3): 215-219
49. Garcia T, Hornof WJ, Insana MF. On the ultrasonic properties of tendon. Ultrasound Med Biol. 2003;29:1787–1797
50. Schams M, Labruyère R, Zuse A, Walensi M. Diagnosing developmental dysplasia of the hip using the Graf ultrasound method: risk and protective factor analysis in 11,820 universally screened newborns. Eur J Pediatr. 2017 Sep;176(9):1193-1200. doi: 10.1007/s00431-017-2959-z. Epub 2017 Jul 17. PMID: 28717864
51. Graf R, Graf reference standard, a “standard sector”, in ultrasound examination of anatomic preparations of infant acetabuli, Z Orthop Ihre Grenzgeb. 2001 Sep-Oct;139(5):463-4
52. Graf R. Sonographie der Säuglingshüfte und therapeutische Konsequenzen. Ein Kompendium. Thieme 2010
53. Kassenärztliche Bundesvereinigung. Ultraschallvereinbarung gemäss § 135 Absatz 2.SGBV. Berlin 2012
54. H T Harcke , L E Grissom, Performing dynamic sonography of the infant hip, AJR Am J Roentgenol. 1990 Oct;155(4):837-44
55. Arti H, Mehdinasab SA, Arti S (2013) Comparing results of clinical versus ultrasonographic examination in developmental dysplasia of hip. J Res Med Sci 18:1051–1055
56. Dogruel H, Atalar H, Yavuz OY, Sayli U (2008) Clinical examination versus ultrasonography in detecting developmental dysplasia of the hip. Int Orthop 32:415–419
57. Tschauner C, Fürntrath F, Saba Y, Berghold A, Radl R (2011) Developmental dysplasia of the hip: impact of sonographic newborn hip screening on the outcome of early treated decentered hip joints-a single center retrospective comparative cohort study based on Graf’s method of hip ultrasonography. J Child Orthop 5:415–424
58. Clegg J, Bache CE, Raut VV (1999) Financial justification for routine ultrasound screening of the neonatal hip. J Bone Joint Surg Br 81:852–857
59. Pillai A, Joseph J, McAuley A, Bramley D. Diagnostic accuracy of static graf technique of ultrasound evaluation of infant hips for developmental dysplasia. Arch Orthop Trauma Surg. 2011 Jan;131(1):53-8
60. Shirai Y, Wakabayashi K, Wada I, Goto H, Ueki Y, Tsuchiya A, Tsuboi Y, Ha M, Otsuka T. Reproducibility of acquiring ultrasonographic infant hip images by the Graf method after an infant hip ultrasound training course. J Med Ultrason (2001). 2018 Oct;45(4):583-589
2. Graf R. Hip sonography: background; technique and common mistakes; results; debate and politics; challenges. Hip Int. 2017 May 12;27(3):215-219. doi: 10.5301/hipint.5000514. Epub 2017 May 8. PMID: 28497455.
3. Ponseti IV. Morphology of the acetabulum in congenital dislocation of the hip. Gross, histological and roentgenographic studies. J Bone Joint Surg Am. 1978;60: 586–99
4. Guille JT, Pizzutillo PD, MacEwen GD. Development dysplasia of the hip from birth to six months. J Am Acad Orthop Surg. 2000;8:232–42.
5. Wynne-Davies R. Acetabular dysplasia and familial joint laxity: Two etiological factors in congenital dislocation of the hip. A review of 589 patients and their families. J Bone Joint Surg Br. 1970;52:704–16.
6. Massie WK. Congenital dislocation of the hip; its causes and effects. Clin Orthop. 1956;8:103–21.
7. Wylock P. The life and times of Guillaume Dupuytren, 1777–1835. Brussels, Belgium: Brussels University Press; 2010.
8. Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic combound treatment. Arch Orthop Trauma Surg. 1980;97(2):117–33
9. R Graf, The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment, Arch Orthop Trauma Surg.1980;97(2):117-33
10. von Kries R, Ihme N, Oberle D, et al. Effect of ultrasound screening on the rate of first operative procedures for developmental hip dysplasia in Germany. Lancet. 2003;362(9399):1883-1887
11. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical practice guideline: Early detection of developmental dysplasia of the hip. Committee on quality improvement, subcommittee on developmental dysplasia of the hip. American academy of pediatrics. Pediatrics. 2000;105(4 Pt 1):896–905.
12. Paulozzi LJ, Lary JM. Laterality patterns in infants with external birth defects. Teratology. 1999;60:265–71.
13. Hadlow V. Neonatal screening for congenital dislocation of the hip. A prospective 21-year survey. J Bone Joint Surg Br. 1988;70:740–3
14. Lowry CA, Donoghue VB, O’Herlihy C, Murphy JF. Elective Caesarean section is associated with a reduction in developmental dysplasia of the hip in term breech infants. J Bone Joint Surg Br. 2005;87:984–5
15. Houston CS, Buhr RH. Swaddling of Indian infants in northern Saskatchewan. Musk-ox. 1988;36:5–14
16. Woolf CM, Koehn JH, Coleman SS. Congenital hip disease in Utah: The influence of genetic and nongenetic factors. Am J Hum Genet. 1968;20(5):430–9.
17. Czeizel A, Szentpétery J, Tusnády G, Vizkelety T. Two family studies on congenital dislocation of the hip after early orthopaedic screening Hungary. J Med Genet. 1975;12(2):125–30
18. Andren L, Borglin NE. A disorder of oestrogen metabolism as a causal factor of congenital dislocation of the hip. Acta Orthop Scand. 1960;30:169–71
19. Abd el-Kader Shaheen M. Mehad: The Saudi tradition of infant wrapping as a possible aetiological factor in congenital dislocation of the hip. J R Coll Surg Edinb. 1989;34(2):85–7
20. Czeizel A, Szentpétery J, Kellermann M. Incidence of congenital dislocation of the hip in Hungary. Br J Prev Soc Med. 1974;28(4):265–7
21. Wynne-Davies R. A family study of neonatal and late-diagnosis congenital dislocation of the hip. J Med Genet. 1970;7(4):315–33
22. Torisu T, Fujikawa Y, Yano H, Masumi S. Association of HLA-DR and HLA-DQ antigens with congenital dislocation and dysplastic osteoarthritis of the hip joints in Japanese people. Arthritis Rheum. 1993;36(6):815–8.
23. Ishikawa N. The relationship between neonatal developmental dysplasia of the hip and maternal hyperthyroidism. J Pediatr Orthop. 2008;28(4):432–4
24. Stevenson RE, Huntley CC. Congenital malformations in offspring of phenylketonuric mothers. Pediatrics. 1967;40(1):33–45
25. Record RG, Edwards JH. Environmental influences related to the aetiology of congenital dislocation of the hip. Br J Prev Soc Med. 1958;12(1):8–22
26. Li Y, Guo Y, Li M, Zhou Q, Liu Y, Chen W, Li J, Canavese F, Xu H. Acetabular index is the best predictor of late residual acetabular dysplasia after closed reduction in developmental dysplasia of the hip. Int Orthop. 2018;42(3):631–40
27. Stanisavljevic S. Congenital hip pathology in the newborn. Baltimore, MD: Williams and Wilkins; 1964
28. Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia. J Pediatr Orthop. 1984;4(6):735–40
29. Leveuf J. Primary congenital subluxation of the hip. J Bone Joint Surg Am. 1947;29(1):149–62
30. Chen J, Zhang WB, He JZ, Zhang R, Cao YQ, Liu X. Developmental dysplasia of the hip: A special pathology. Chin J Traumatol. 2018;21(4):238–42
31. Liu R, Wen X, Tong Z, Wang K, Wang C. Changes of gluteus medius muscle in the adult patients with unilateral developmental dysplasia of the hip. BMC Musculoskelet Disord. 2012;13:101
32. Spyridon Sioutis, Stylianos Kolovos, Maria-Eleni Papakonstantinou, Lampros Reppas, Dimitrios Koulalis & Andreas F. Mavrogenis, Developmental Dysplasia of the Hip: A Review, Journal of Long-Term Effects of Medical Implants, 32(3):39–56 (2022)
33. Harsanyi S, Zamborsky R, Krajciova L, Kokavec M, Danisovic L. Developmental dysplasia of the hip: A review of etiopathogenesis, risk factors, and genetic aspects. Medicina. 2020;56(4):153
34. Ortolani M. Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop Relat Res. 1976;(119):6–10
35. Kotlarsky P, Haber R, Bialik V, Eidelman M. Developmental dysplasia of the hip: What has changed in the last 20 years? World J Orthop. 2015;6(11):886–901
36. Kamath SU, Bennet GC. Does developmental dysplasia of the hip cause a delay in walking? J Pediatr Orthop. 2004;24(3):265.
37. Shorter D, Hong T, Osborn DA. Cochrane Review: Screening programmes for developmental dysplasia of the hip in newborn infants. Evid Based Child Health. 2013;8(1):11–54
38. Terjesen T. Ultrasound as the primary imaging method in the diagnosis of hip dysplasia in children aged < 2 years. J Pediatr Orthop B. 1996;5(2):123–8.
39. Dunn PM. The anatomy and pathology of congenital dislocation of the hip. Clin Orthop Relat Res. 1976;(119):23–7
40. Lewis CL, Laudicina NM, Khuu A, Loverro KL. The human pelvis: Variation in structure and function during gait. Anat Rec. 2017;300(4):633–42
41. Spaans AJ, Beek FJA, Uiterwaal CSPM, Pruijs JEH, Sakkers RJ. Correlation between ultrasonic and radiographic imaging of developmental dysplasia of the hip. J Child Orthop. 2019;13(2):155–60
42. Grissom L, Harcke HT, Thacker M. Imaging in the surgical management of developmental dislocation of the hip. Clin Orthop Relat Res. 2008;466(4):791–801
43. S Suzuki, G Awaya, S Wakita, M Maekawa, T Ikeda, Diagnosis by ultrasound of congenital dislocation of the hip joint, Clin Orthop Relat Res. 1987 Apr;(217):171-8
44. Graf R., Hip ultrasonography. Basic principles and current aspects., Orthopade. 1997 Jan;26(1):14-24
45. Müller W, Lercher K, DeVaney TT, Giner F, Graf R., Technical errors in the application of Graf’s hip sonography method, Ultraschall Med. 2001 Feb;22(1):48-54
46. Graf R, Tschauner C, Steindl M., Does the IIa hip need treatment? Results of a longitudinal study of sonographically controlled hips of infants less than 3 months of age, Monatsschr Kinderheilkd. 1987 Dec;135(12):832-7
47. Graf R., Classification of hip joint dysplasia by means of sonography., Arch Orthop Trauma Surg. 1984;102(4):248-55
48. Reinhard Graf, Hip sonography: background; technique and common mistakes; results; debate and politics; challenges, Hip Int 2017; 27 (3): 215-219
49. Garcia T, Hornof WJ, Insana MF. On the ultrasonic properties of tendon. Ultrasound Med Biol. 2003;29:1787–1797
50. Schams M, Labruyère R, Zuse A, Walensi M. Diagnosing developmental dysplasia of the hip using the Graf ultrasound method: risk and protective factor analysis in 11,820 universally screened newborns. Eur J Pediatr. 2017 Sep;176(9):1193-1200. doi: 10.1007/s00431-017-2959-z. Epub 2017 Jul 17. PMID: 28717864
51. Graf R, Graf reference standard, a “standard sector”, in ultrasound examination of anatomic preparations of infant acetabuli, Z Orthop Ihre Grenzgeb. 2001 Sep-Oct;139(5):463-4
52. Graf R. Sonographie der Säuglingshüfte und therapeutische Konsequenzen. Ein Kompendium. Thieme 2010
53. Kassenärztliche Bundesvereinigung. Ultraschallvereinbarung gemäss § 135 Absatz 2.SGBV. Berlin 2012
54. H T Harcke , L E Grissom, Performing dynamic sonography of the infant hip, AJR Am J Roentgenol. 1990 Oct;155(4):837-44
55. Arti H, Mehdinasab SA, Arti S (2013) Comparing results of clinical versus ultrasonographic examination in developmental dysplasia of hip. J Res Med Sci 18:1051–1055
56. Dogruel H, Atalar H, Yavuz OY, Sayli U (2008) Clinical examination versus ultrasonography in detecting developmental dysplasia of the hip. Int Orthop 32:415–419
57. Tschauner C, Fürntrath F, Saba Y, Berghold A, Radl R (2011) Developmental dysplasia of the hip: impact of sonographic newborn hip screening on the outcome of early treated decentered hip joints-a single center retrospective comparative cohort study based on Graf’s method of hip ultrasonography. J Child Orthop 5:415–424
58. Clegg J, Bache CE, Raut VV (1999) Financial justification for routine ultrasound screening of the neonatal hip. J Bone Joint Surg Br 81:852–857
59. Pillai A, Joseph J, McAuley A, Bramley D. Diagnostic accuracy of static graf technique of ultrasound evaluation of infant hips for developmental dysplasia. Arch Orthop Trauma Surg. 2011 Jan;131(1):53-8
60. Shirai Y, Wakabayashi K, Wada I, Goto H, Ueki Y, Tsuchiya A, Tsuboi Y, Ha M, Otsuka T. Reproducibility of acquiring ultrasonographic infant hip images by the Graf method after an infant hip ultrasound training course. J Med Ultrason (2001). 2018 Oct;45(4):583-589
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