Glenn E. Lipton
Haluk Altiok, M.D., H.Theodore Harcke, M.D., J.Richard Bowen, M.D.
Alfred I. duPont Institute
1600 Rockland Road
Wilmington, Delaware 19803
INTRODUCTION: In 1937, Ortolani described a clinical method for detecting hip dislocation, where he abducted the thigh of the affected hip and felt the femoral head reduce into the acetabulum. The Ortolani exam is currently accepted as an accurate method for assessment of hip dislocation in the newborn period and is the basis for clinical screening and diagnostic purpose. The reliability and validity of the Ortolani exam has been questioned. Hadlow, in 1988, stated that the Ortolani exam may not be positive in a grossly dislocated hip with poor acetabular development and capsular laxity. MacKenzie in 1981 stated that the movement of the femoral head into the acetabulum is not always demonstrable in the dislocated hip. The ultrasonographic hip examination has been shown to be effective method for examination in detecting congenital hip abnormalities. Studies by Graf, Marks, Terjesen, Boeree, Castelein, Berman, and Clarke confirm the reliability and show ultrasound is more sensitive in detecting pathological joints than the clinical examination. The purpose of this paper is to determine what degree of reduction the femoral head undergoes with respect to the acetabulum when the Ortolani exam is performed and to correlate these changes with the presence or absence of the clinical sign.
MATERIALS AND METHODS: The patient review encompassed four hundred infants referred with the diagnosis of congenital dislocation of the hip who were treated between 1988 and 1994. Two subgroups of infants were identified for analysis based upon clinical and sonographic findings. The group labeled as "Positive" included all patients with a positive Ortolani exam. The "Positive" group consisted of 45 patients of which 35 were girls and 10 were boys. The second group labeled as "Negative" included patients who had a negative Ortolani exam and a dislocated hip on ultrasonographic examination. The Negative group consisted of 24 patients of which 20 were girls and 4 were boys. All Ortolani exams were performed by fellowship trained attending pediatric orthopaedic surgeons as described by Ortolani, with the hip flexed 90 degrees. The dynamic hip ultrasound was performed by a pediatric radiologist utilizing the Harcke technique. In the Ortolani positive group abnormality occurred bilaterally in 8 patients and unilaterally in 37 patients, for a total of 53 clinically affected hips. In the Ortolani negative group dislocation occurred bilaterally in 1 patient and unilaterally in 23 patients, for a total of 25 affected hips. Each patient's hip sonograms were independently examined by a radiologist and two orthopaedic surgeons with agreement of femoral head position. The femoral head was recorded at two locations in the transverse flexion view when the flexed hips were adducted and again when abducted. The adducted location represents the hip prior to performing the Ortolani maneuver. The abducted location represents the hip after the reduction is attempted as in the Ortolani maneuver. The location of the femoral head in the acetabulum in adduction and abduction was categorized. We observed one of four possible positions of the femoral head: (1) well seated, (2) subluxated, (3) laterally, and (4) laterally and posteriorly dislocated. The change in femoral head position occurring during the adduction / abduction (Ortolani) maneuver was recorded according to the amount of reduction achieved. The patients were analyzed according to gender, side affected, and pattern of femoral head movement from adduction to abduction. These hips were subjected to the student's t-tests in order to evaluate whether a significant difference existed in hip types, side affected or age at exam.
RESULTS: The mean age at exam for all patients (both Positive and Negative groups) was 48 days. In the group with Ortolani Positive hips the mean age was 28 days. In the group with Ortolani Negative hips the mean age was 91.3 days. The Student's T-tests showed a statistically significant different age between the group with Ortolani Positive hips vs. the group with Ortolani Negative hips (p=0.001). From the ultrasound views of the adducted location (infants' femurs prior to Ortolani maneuver) we found in the Positive group, 20 hips at a posterior and laterally dislocated position, 25 hips at a laterally dislocated position, and 8 hips at a subluxated position. In the Negative group there were 8 hips at a posterior and laterally dislocated position and 17 hips at a laterally dislocated position. Fifty-three hips were able to reduce by moving from outside the acetabulum (posterior and laterally dislocated position or laterally dislocated position )into the acetabulum (subluxated position or located position). Thirty-eight of the reducing hips were from the Ortolani positive group(mean age 27 days) and fifteen were from the Ortolani negative group (mean age 49 days). Sixteen hips were found to be irreducible, remaining outside the acetabulum at posterior and laterally dislocated position or laterally dislocated position. Six of the hips which were irreducible and outside of the acetabulum were from the Ortolani positive group(mean age 34 days) and ten were from the Ortolani negative group (mean age 155 days). Finally, nine hips were irreducible and remained inside the acetabulum at subluxated position or located position. All nine irreducible hips which remained inside the acetabulum were from the Ortolani positive group.
Figure. Movement of the femoral head is illustrated with the number of positive and negative Ortolani hips which undergo each movement pattern. The position change from adduction to abduction is indicated by the solid arrow.
DISCUSSION: Dislocated hips that show similar femoral head movement can produce an Ortolani positive exam in a younger patient (28 days) and a negative exam in an older patient (91 days). All Ortolani positive hips were pathologic, however positive Ortolani test may be felt without full reduction, and in some cases with no reduction, as documented by ultrasound.
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