Published online: 2020-07-28

Original Article

Is Prematurity a Protective Factor Against Developmental Dysplasia

of the Hip? A Retrospective Analysis of 660 Newborns
Ist die Frühgeburtlichkeit ein protektiver Faktor gegen die
Hüftdysplasie? Eine retrospektive Analyse an 660 Neugeborenen

Authors
Sebastian Koob1, Werner Garbe2, Rahel Bornemann1, Milena Maria Ploeger1, Sebastian Scheidt1, Martin Gathen1,
Richard Placzek1

Affiliations the first week after birth. Both hips of all infants were included
1 Clinic for Orthopaedics and Trauma Surgery, University in the study.
Hospital Bonn, Germany Results Surprisingly, the difference in alpha angles between
2 Neonatology, GFO-Kliniken Bonn Betriebsstätte St. Marien, the two groups was statistically extremely significant, favoring
Bonn, Germany the preterm infants. Moreover, we found a physiological curve

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of alpha angle development with a peak after the 31st week of
Key words
gestation. The incidence of pathological dysplasia was not sig-
graf ultrasound, hip development, congenital hip dysplasia,
nificantly different in the two groups.
hip ultrasound screening, developmental dysplasia of the hip
Conclusion Our results suggest that prematurity is not a pre-
received 26.11.2019 disposing factor for DDH, but rather is protective for hip
accepted 14.04.2020 development.

Bibliography Z US A M M E N FA SS U N G
DOI https://doi.org/10.1055/a-1161-8984 Ziel Die Inzidenz der kongenitalen Hüftdysplasie in Mittel-
Published online: 2020 europa beträgt bis zu 5,9 %. Die kongenitale Hüftluxation als
Ultraschall in Med schwerste Komplikation liegt zwischen 1,5 und 2,5 %. Zu den
© Georg Thieme Verlag KG, Stuttgart · New York akzeptierten Risikofaktoren der Hüftdysplasie werden die
ISSN 0172-4614 Beckenendlage, Mehrlingsgeburten, Fußdeformitäten und
familiäre Häufung gezählt. Das Ziel dieser retrospektiven
Correspondence
Datenerhebung ist die Untersuchung der Frühgeburtlichkeit
Dr. Sebastian Koob
als Risikofaktor für das Vorliegen einer Hüftdysplasie.
Clinic for Orthopaedics and Trauma Surgery, University
Material und Methode Daher wurden die Hüften von
Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
283 Neugeborenen, welche vor der 38. Schwangerschafts-
Tel.: ++ 49/1 51 58 23 35 47
woche oder früher, und jene von 377 Neugeborenen, welche
Sebastian.koob@ukbonn.de
nach der 37. Schwangerschaftswoche geboren wurden, mit
ABSTR AC T der Hüftultraschallmethode nach Graf et al. in der ersten
Woche postpartal untersucht.
Purpose In Middle Europe developmental dysplasia of the hip
Ergebnisse Überraschenderweise war der Unterschied der
(DDH) has an incidence of up to 5.9 %. The rate of congenital
Alpha-Winkel zwischen den beiden Gruppen äußerst signifi-
hip dislocation as the worst complication of a growth disorder
kant zugunsten der Frühgeborenen. Darüber hinaus konnten
of the hip is between 1.5 % and 2.5 %. Among known risk fac-
wir eine physiologische Entwicklungskurve mit einem Höchst-
tors of DDH are breech position, multiples, foot deformities
wert nach der 31. SSW darstellen. Die Inzidenz der Hüftdys-
and family history. The aim of this retrospective study was to
plasie war nicht statistisch signifikant unterschiedlich in bei-
investigate prematurity as a risk factor for developmental dys-
den Gruppen.
plasia of the hip (DDH).
Schlussfolgerung Unsere Daten deuten darauf hin, dass die
Materials and Methods The hips of 283 infants who were
Frühgeburtlichkeit kein Risikofaktur für die Hüftdysplasie
born before the 38th week of gestation or earlier, and those
darstellt, sondern wahrscheinlich protektiv auf die Hüftent-
of 377 infants who were born after the 37th week of gestation,
wicklung wirkt.
none of whom had other risk factors for DDH, were compared
using the ultrasound technique according to Graf et al., within

Koob S et al. Is Prematurity a… Ultraschall in Med

 Original Article
Introduction
In Middle Europe developmental dysplasia of the hip (DDH) has an
incidence of up to 5.9 % [1]. The rate of congenital hip dislocation
as the worst complication of a growth disorder of the hip is be-
tween 1.5 % and 2.5 % [2]. Clinically, early diagnosis of hip dyspla-
sia is essential for adequate therapy and prevention of later pain
symptoms and impairment of mobility. Since 1996, hip sonogra-
phy according to Graf et al. is a well-established screening pro-
gram for congenital hip dysplasia in Germany and in other Europe-
an countries [3]. Since implementation of the method, the rate of
surgical interventions in children and adolescents due to congeni-
tal hip dysplasia has decreased to one fifth of the previous number
of surgeries [4]. Among the known risk factors of DDH are breech
position, multiples, foot deformities and family history [5]. In pre-
mature children a pathological effect of the early extraction from
the mother’s womb is possible, since the fetus no longer remains
in its natural position. Preterm is defined as infants born alive
before 37 weeks of pregnancy are completed.
The aim of this study was to evaluate the incidence of develop-
mental hip dysplasia and growth retardation in premature chil-
dren in comparison to full-term children.
Patients and methods
A total of 283 premature children (prior to 38th gestational week)
born between February 2013 and December 2016 without any
other risk factors for DDH were included in this retrospective
study. A collective of 377 full-term infants from a second study
center close to the author’s institution served as the control
group (born 38th to 43rd gestational week). All included infants
received an ultrasound examination according to Graf by two cor-
respondingly trained doctors within the first week after birth
using a 7.5 MHz transducer and the respective positioning device.
Alpha angles and classification according to Graf et al. were re-
corded [3, 6]. A classification higher or equal to type “2b” accord-
ing to Graf et. al. was considered DDH in contrast to mature hips
and growth retardations (types “1a”, “1b” and “2a”).
The alpha angles were grouped according to their gestational
week (▶ Table 1).
Data were collected and analyzed retrospectively, anonymized
and in aggregate, thus no consent was obtained. Data were eval-
uated using GraphPad Prism statistical software (Version 8,
GraphPad Software, LLC) including Kruskal-Wallis test for analyz-
ing intergroup statistical differences and Tukey’s multiple com-
parisons test between each group. Odds and relative risks be-
tween groups were analyzed using two-sided Fisher’s exact test.
The study was approved by the local institutional review board
(University of Bonn Ethics Committee, Reg. No. 240/17).
Results
We were able to recruit 283 premature infants (156 males, 128 fe-
males) in our retrospective study. The mean gestational age was
34.96 ± 2.02 weeks (median: 35, min: 27 weeks). 4 premature
infants (1.40 %) were born prior to the 28 th gestational week
(“extremely preterm”, WHO classification), 16 (5.66 %) were born
prior to the 32nd gestational week (“very preterm”) and 263
(92.93 %) were born prior to the 37th week (“moderate to late pre-
term”). The number of premature und full-term infants per gesta-
tional week is listed in ▶ Table 1.
The control group included 377 full-term newborns (195 males,
216 females), who were born with a mean gestational age of
40.28 ± 1.13 weeks (median: 40 weeks).
The mean alpha angle of the hips (each side counted separate-
ly) within the full-term group (control) was 62.85 ± 3.32 (min:
49, max: 76, median: 63). The mean alpha angle in the preterm
group was 64.56 ± 5.02 (min: 42, max: 80, median: 64). The dif-
ference was extremely statistically significant (p < 0.0001, see
▶ Fig. 1). View ▶ Table 1 for the mean alpha angles according to
gestational week. Surprisingly, the alpha angles reach a peak
with completion of the 31 st week (67.06 ± 3.98) and slowly
decrease until the 42nd week (62.71 ± 4.19). The development of
alpha angles from week 27 to 42 is illustrated in ▶ Fig. 2.
Within the group of premature infants, we found a rate of
0.71 % (n = 4) of DDH (Graf type 2b or higher), while the full-term
Downloaded by: Karolinska Institutet. Copyrighted material.
infants showed a DDH rate of 0.27 % (n = 2). The difference was
not statistically significant (p = 0.41).
We found 7.47 % (n = 42) growth-retarded hips (type 2a) in the
premature group. The full-term group showed growth retardation
in 5.72 % (n = 43) of hips. The difference was not statistically
significant (p = 0.21). All premature und full-term infants with
growth retardation showed mature hips after 4 weeks of double
diapering as therapy.
Discussion
Contrary to our expectations, the premature infants in our collec-
tive do not show a statistically higher incidence of DDH than full-
term infants, and they do not show a statistically higher incidence
of growth retardation. Moreover, the preterm infants showed sig-
nificantly higher alpha angles than the full-term infants. Thus, ac-
cording to our data, prematurity does not serve as an indepen-
dent risk factor for DDH, which corresponds to the results of
Sezer et al. [7] who analyzed a smaller cohort of 421 infants and
Orak et al. [8]. A thorough review of the current literature did
not show other applicable retrospective or prospective studies,
suggesting that this field of investigation needs further research.
A closer look at the mean alpha angles according to gestational
week revealed a physiological curve of hip development, reaching
a peak of 67.06 ± 3.98 with completion of the 31 st gestational
week and going back to lower values until the 37th week, suggest-
ing that prematurity actually favors higher alpha angles. A possi-
ble explanation for this surprising data could be the spatial situa-
tion within the mother’s womb in the last weeks of gestation.
There could be a significant mismatch of the rapidly growing fetus
within the 34th and 40th week of gestation in relation to the mo-
ther’s womb which corresponds to other causes of spatial limita-
tion as risk factors for DDH, such as multiples, breech position,
and oligohydramnios.
In this context, prematurity can be discussed as a “protective”
factor for hip development. Accordingly, the authors state that
Koob S et al. Is Prematurity a… Ultraschall in Med
 Downloaded by: Karolinska Institutet. Copyrighted material.
62.71
4.182
(114)
42

57

49
76
27
62.56
(218)

2.69
109
41

53
71
18
62.71
3.137
(238)
119
40

52
74
22
63.32
3.627
(134)
39

67

57
76
19

3.574
63.6
(50)
38

25

56
72
16

▶ Fig. 1 Difference in alpha angles between full-term and preterm

62.64
3.758
(126)

babies.
37

63

55
75
20
63.86
4.865
(150)
36

75

45
73
28
64.76
4.923
(128)
35

64

52
75
23
66.79
5.763
(68)
34

34

49
80
31
▶ Table 1 Number of Newborns and Alpha-Angle data per Gestational Week.

66.64
4.835
(36)
33

18

59
77
18
9 (18)

67.06
3.977
32

60
74
14

▶ Fig. 2 Development of alpha angles according to gestational week.

27–31

66.23
6.133
(40)
20

48
76
28
there is a “physiological” curve of hip development that does not
peak right before the end of physiological time of birth, but rather
before then. The authors intend to extend the study in a prospec-
patients (number of hips inclu-

tive manner to enhance the power of its data and increase the
number of included cases.

maximum alpha angle

minimum alpha angle
gestational Week

standard deviation
mean alpha angle
Conflict of Interest
The authors declare that they have no conflict of interest.

range
ded)
Koob S et al. Is Prematurity a… Ultraschall in Med
 Original Article
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Koob S et al. Is Prematurity a… Ultraschall in Med