International Orthopaedics

https://doi.org/10.1007/s00264-017-3726-5

ORIGINAL PAPER

Acetabular index is the best predictor of late residual acetabular

dysplasia after closed reduction in developmental dysplasia of
the hip
YiQiang Li 1 & YueMing Guo 2 & Ming Li 3 & QingHe Zhou 1 & Yuanzhong Liu 1 & WeiDong Chen 1 & JingChun Li 1 &
Federico Canavese 1,4 & HongWen Xu 1,5 & Multi-center Pediatric Orthopedic Study Group of China

Received: 14 August 2017 / Accepted: 10 December 2017

# SICOT aisbl 2017

Abstract
Purpose Our objective was to find the best predictor of late residual acetabular dysplasia in developmental dysplasia of the hip
(DDH) after closed reduction (CR) and discuss the indications for secondary surgery.
Methods We retrospectively reviewed the records of 89 patients with DDH (mean age 16.1 ± 4.6 months; 99 hips) who were
treated by CR. Hips were divided into three groups according to final outcomes: satisfactory, unsatisfactory and operation. The
changes in the acetabular index (AI), centre-edge angle of Wiberg (CEA), Reimer’s index (RI) and centre-head distance
discrepancy (CHDD) over time among groups were compared. The power of predictors for late residual acetabular dysplasia
of AI, CEA, RI and CHDD at different time points was analysed by logistic regression analysis. Receiver operating character-
istics (ROC) curve analysis was used to determine cutoff values and corresponding sensitivity, specificity and diagnostic
accuracy for these parameters.
Results Both AI and CEA improved in all groups of patients following CR. In the satisfactory group, AI progressively decreased until
seven to eight years, while CEA increased until nine to ten years (P < 0.05). In the unsatisfactory group, AI and CEA ceased to improve
three and two years after CR, respectively (P < 0.05). CEA and RI were significantly better in the satisfactory group compared with the
unsatisfactory group at all time points (P < 0.05). Following CR, both RI and CHDD remained stable over time in all groups. Final
outcome following CR could be predicted by AI, CEA and RI at all time points (P < 0.01). Cutoff values of AI, CEA and RI were
28.4°, 13.9° and 34.5%, respectively, at one year and 25°, 20° and 27%, respectively, at two to four years post-CR. A total of 80–88%
of hips had an unsatisfactory outcome if AI > 28.4° and >25 at one and two to four years following CR, respectively. However, if CEA
was less than or RI was larger than the cutoff values at each time point, only 40–60% of hips had an unsatisfactory outcome. Mean
sensitivity (0.889), specificity (0.933) and diagnostic accuracy (92.1%) of AI to predict an unsatisfactory outcome were significantly
better compared with CEA (0.731; 0.904; 78.2%) and RI (0.8; 0.655; 70.8%) (P < 0.05).
Conclusions Satisfactory and unsatisfactory hips show different patterns of acetabular development after reduction. AI, CEA and RI
are all predictors of final radiographic outcomes in DDH treated by CR, although AI showed the best results. AI continues to improve
until seven years after CR in hips with satisfactory outcomes, while it ceases to improve three to four years after CR in hips with
unsatisfactory outcomes. According to our results, surgery is indicated if AI >28° 1 year following CR or AI >25° two to four years
after CR. CEA and RI should be used as a secondary index to aid in the selection of patients requiring surgery.

Keywords Developmental dysplasia of the hip . Closed reduction . Acetabular index . Avascular necrosis of femoral head .
Predictor . Residual acetabular dysplasia

* HongWen Xu 3
Children’s Hospital of Chongqing Medical University,
gzorthopedics@qq.com Chongqing, China
4
1
Pediatric Surgery Department University Hospital Estaing, Clermont
GuangZhou Women and Children’s Medical Center, GuangZhou Ferrand, France
Medical University, GuangZhou, China 5
2
Department of pediatric orthopaedics, GuangZhou Women and
Foshan Hospital of TCM, Foshan, China Children’s Medical Center, 9th JinSui Road, GuangZhou 510623,
China

Introduction
Developmental dysplasia of the hip (DDH) is a congenital
defect of the skeleton, including acetabular dysplasia, sublux-
ation and complete dislocation of the femoral head [1, 2]. The
incidence of DDH per 1000 live births ranges from 0.06 in
Africans to 76.1 in Native Americans [3]. The aim of treat-
ment for DDH is to obtain a stable and concentric reduction of
the hip as early as possible. At present, closed reduction (CR)
and spica cast immobilisation under general anesthesia is the
gold standard of treatment for patients <18 months of age
[1–3].
However, residual acetabular dysplasia after CR is still a
major problem in clinical practice, as more than one third of
treated DDH patients have residual acetabular dysplasia [4, 5].
It is well known that persistent acetabular dysplasia may result
in abnormal gait, decreased strength and an increased rate of
secondary osteoarthritis into adulthood [4–6]. Because resid-
ual acetabular dysplasia is often asymptomatic, the decision to
perform secondary surgery usually relies on the radiographic
outcome. Recently, several radiographic parameters have been
investigated to detect the best predictive criteria of hip devel-
opment following CR and spica cast immobilisation; some
have been recommended to serve as guidelines for corrective
surgery. However, controversy remains as to when the second-
ary procedure should be performed in residual hip dysplasia.
The acetabular index (AI) and centre-edge angle of Wiberg
(CEA) are the most commonly used parameters [4, 7–9].
Additionally, centre-head distance discrepancy (CHDD) and
Reimer’s index (RI) have also been used by some investiga-
tors [6, 7, 10, 11]. Both RI and CHDD are measured on
anteroposterior (AP) pelvic radiographs. RI represents the per-
centage of the femoral head that is uncovered by the acetabu-
lum [10], while CHDD represents the difference in the centre-
head distance between the affected and normal sides [11].
In this study, we retrospectively reviewed hips treated by
CR in three hospitals with a follow-up time of at least
four years. The aim of this study was to determine the best
radiologic parameter among AI, CEA, CHDD and RI to pre-
dict radiographic outcome of DDH patients treated by CR
before 24 months of age and to discuss the indications for
secondary surgery.
Materials and methods
We retrospectively reviewed the records of 223 patients
<24 months of age diagnosed with DDH and treated by CR
between 2004 and 2013 in three institutions (Table 1).
We excluded patients with incomplete clinical and radio-
graphic data (56 patients; 25.1%), those who had cerebral
palsy (16 patients; 7.2%), myelomeningocele (2 patients;
0.9%), tethered cord syndrome (6 patients; 2.7%),
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arthrogryposis multiplex congenital (25 patients; 11.2%),
clubfoot (8 patients; 3.6%) or other neuromuscular conditions
(4 patients; 1.8%) and those who were redislocated after CR
and received open reduction (17 patients; 7.6%). Thus, 89
patients (39.9%) with 99 affected hips were included in the
study. There were 13 boys and 76 girls, with 79 unilateral and
ten bilateral dislocations. Average age at the time of treatment
was 16.1 ± 4.6 months (range, 6–24), with a mean follow-up
of 61.6 ± 17.7 months (range, 48–117). According to Tönnis
classification [12], 43 hips were graded as II (43.4%), 51 as III
(51.5%) and five as IV (5.1%). Initial Graf’s types could not
be evaluated because there is no universal screening. Patients
usually come to our clinic when they are >four to five months
of age, without any previous ultrasound examination and with
an ossific nucleus that is already visible on plain radiographs.
All patients received longitudinal or overhead traction prior
to CR for two to three weeks. CR was performed under gen-
eral anaesthesia. Adductor tenotomy was performed if the
adductor was considered to hinder reduction. Arthrography
was performed through an adductor longus muscle approach
using 1 cm3 of Iopromide as a contrast to evaluate hip position
and assist reduction. After CR, an abduction cast was applied
to maintain reduction for three months. The cast was changed
once—6six weeks after CR—and it was followed by an ab-
duction brace until a stable reduction was achieved. We ac-
knowledge that overhead extension is not the standard today
for all patients with Tönnis type II hips, in which abduction
braces are generally used. However, in this study, we included
patients from 2004 to 2013, when traction was systematically
used.
All patients were followed-up every three months during
the first year following CR and cast immobilisation.
Subsequent visits were organised every six months during
the second, third and fourth years following index treatment
and every two years thereafter. Anteroposterior (AP) pelvic
radiographs were performed at each visit. Figure 1 illustrates
the methods of measuring AI, CEA, RI and CHDD on plain
radiographs, as described previously by other investigators
[10, 11]. AI, CEA, RI and CHDD were measured on AP
pelvis radiographs using the Picture Archiving and
Communication System (PACS) by two observers (LYQ and
FC) who were blinded to the final Severin classification and
were not involved in the care of any patient at seven time
points: one, two, third, fourth, fifth to sixth, seventh to eigth
and ninth to tenth years after CR and cast immobilisation.
AVN of the femoral head was identified using the criteria
described by Salter et al. [13] and classified according to
Bucholz and Ogden’s method [14]. Type I was not considered
to be AVN. Two independent raters evaluated AVN. If they
could not come to an agreement on type, a discussion with at
least three other senior paediatric orthopaedic surgeons was
performed. Final radiographic outcomes were graded accord-
ing to criteria described by Severin [15]. Grades I and II were
International Orthopaedics (SICOT)

Table 1 Demographics of
patients in different hospitals GZWCMC FSHTCM CHCQMU F/χ2 P valuea

Hips (n) 59 19 21
Follow-up time(months) 63.9 ± 18.6 64.5 ± 19.7 57.7 ± 9.0 1.294 0.279
Age (months) 15.5 ± 3.9 18.4 ± 6.5 15.8 ± 3.6 2.984 0.055
Initial AI (°) 36.1 ± 5.0 34.6 ± 5.3 35.3 ± 3.5 0.833 0.438
Sex (female/male) 48/11 18/1 20/1 3.224 0.215
Side (left/right) 35/24 14/5 11/10 1.997 0.363
Presence of ossific nucleus (yes/no) 51/8 17/2 2/19 0.235 1.000
Tönnis grade
II (n) 26 8 9 4.820 0.267
III (n) 32 10 9
IV (n) 1 1 3
Avascular necrosis (AVN)
No (n) 50 16 19 0.467 0.850
Yes (n) 9 3 2

GZWCMC GuangZhou Women and Children’s Medical Center, FSHTCM Foshan Hospital of TCM, CHCQMU
Children’s Hospital of Chongqing Medical University
a
Patients treated at different institutions were comparable regarding follow-up time, age at reduction, initial AI,
sex, side, presence of ossific nucleus, Tönnis grade and incidence of AVN

considered to have a satisfactory outcome; grades III to VI Statistical analysis

were considered to have an unsatisfactory outcome.
According to final outcome, hips were divided into three
groups: (a) satisfactory (satisfactory radiographic outcome
without secondary surgery); (b) unsatisfactory (unsatisfactory
radiographic outcome without secondary surgery); (c) opera-
tion (late acetabular dysplasia treated surgically).
AI, CEA, RI and CHDD were measured at seven time points.
The results were analysed by two-way analysis of variance
(ANOVA) for repeated measures to investigate radiographic
changes over time. One-way ANOVA was used to evaluate
difference in AI, CEA, RI and CHDD values among groups.

Fig. 1 Radiographic
measurement: a acetabular index
(AI) and centre-edge angle
(CEA); b Reimer’s index (RI); c
centre-head distance discrepancy
(CHDD)
 International Orthopaedics (SICOT)

Table 2 Outcome according to

Severin’s classification Severin grade Satisfactory group Operation group Unsatisfactory group Total

I 53 11 0 64 (64.6%)
II 5 4 0 9 (9.2%)
III 0 0 22 22 (22.2%)
IV 0 0 4 4
Total 58 15 26 99

AI, CEA, RI and CHDD at one, two, three and four years after
CR were analysed to predict the final outcome. However,
because secondary surgery may significantly impact the out-
come, surgically treated hips (operation group) were excluded
when evaluating the power of prognostic factors for late resid-
ual dysplasia. Logistic regressions were performed to analyse
the association between final outcome and AI, CEA, RI and
CHDD at each time point. Receiver operating characteristics
(ROC) curve analysis was used to determine the cutoff values
and corresponding sensitivity, specificity and diagnostic accu-
racy for AI, CEA, RI and CHDD. All statistical analyses were
performed using the statistics package SPSS 13.0 (SPSS,
Chicago, IL, USA). The level of significance was set at
P < 0.05.
Results
Patient demographics are shown in Table 1. Patients treated at
different institutions were comparable regarding follow-up
time, age at reduction, initial AI, sex, side, presence of ossific
nucleus, Tönnis grade and incidence of AVN (P > 0.05)
(Table 1). Radiographic measurements showed good to excel-
lent interobserver reliability for AI [intraclass correlation

Table 3 Clinical and

radiographic characteristics of Satisfactory Unsatisfactory Operation F/χ2 P value
hips according to outcome
Hips (n) 58 26 15
Follow-up (months) 62.5 ± 17.9 57.2 ± 13.8 65.8 ± 22.2 1.303 0.277
Age (months) 16.2 ± 4.7 15.7 ± 4.9 16.6 ± 3.8 0.209 0.812
Initial AI (°) 34.6 ± 4.7 36.7 ± 4.4 37.1 ± 5.4 2.799 0.066
Sex (female/male) 49/8 22/4 14/1 0.839
Side
Left (n) 36 15 9 0.103 0.958
Right (n) 22 11 6
Ossific nucleus
No (n) 6 4 2 0.676 0.759
Yes (n) 52 22 13
Tönnis grade
II (n) 32 9 2 11.039 0.016
III (n) 23 15 13
IV (n) 3 2 0
Avascular necrosis (AVN)
No (n) 52 22 11 2.671 0.280
Yes (n) 6 4 4
AVN type
II (n) 3 4 1 0.202
III (n) 3 0 0 3.102
IV (n) 0 3 0
Final AI (°) 17.7 ± 3.4 27.4 ± 2.8 12.1 ± 4.8 106.194 <0.001
Final CEA (°) 26.5 ± 6.1 14.9 ± 6.0 29.3 ± 7.8 36.633 <0.001
Final RI (%) 18.9 ± 8.9 31.9 ± 6.3 10.7 ± 12.0 31.547 <0.001
Final CHDD (%) 5.6 ± 6.7 6.6 ± 6.7 5.6 ± 8.9 0.129 0.880

AI acetabular index, CEA centre-edge angle, RI Reimer’s index, CHDD centre-head distance discrepancy, AVN
avascular necrosis of the femoral epiphysis
International Orthopaedics (SICOT)
Fig. 2 In the satisfactory group, the acetabular index (AI) progressively
decreased until 7–8 years (15.8° ± 4.8°) following closed reduction (CR)
(P < 0.01). In the unsatisfactory group, the AI significantly decreased
until 3 years after CR (P < 0.05) and remained stable afterwards. In the
operation group, the AI significantly decreased 2 years after CR
(P < 0.05). AI of the satisfactory group was significantly lower than the
unsatisfactory group at all time points (P < 0.05)
coefficient (ICC) = 0.928], CEA (ICC = 0.903), RI (ICC =
0.827) and CHDD (ICC = 0.781), in agreement with previous-
ly published studies [16, 17]. Table 2 highlights overall results
according to Severin classification. Fifty-eight hips were
Fig. 3 In the satisfactory group, the centre-edge angle (CEA) progres-
sively increased until 9–10 years following closed reduction (CR)
(P < 0.05). In the unsatisfactory group, the CEA significantly increased
until 2 years after CR (P < 0.001). Comparable results were found in the
operation group. The CEA of the satisfactory group was significantly
larger than that of the unsatisfactory group at all time points (P < 0.05)
Fig. 4 The Reimer’s index (RI) remained stable in all groups from 1 year
after closed reduction (CR) to final follow-up (P > 0.05). The RI of sat-
isfactory group was significantly smaller than that of unsatisfactory group
at all time points (P < 0.05)
classified as satisfactory, 26 as unsatisfactory and the remain-
ing 15 as the operation group (Table 2).
Table 3 compares clinical and radiographic data according
to outcome, i.e. satisfactory, unsatisfactory or operation
(Table 3).
Groups were comparable regarding follow-up, age, gender,
side, initial AI, appearance of ossific nucleus and Tönnis
grade (P > 0.05). The total incidence of AVN was 14.1%;
there was no difference among groups (P = 0.280). No corre-
lation between the incidence of AVN and final outcome could
be identified (χ2 = 3.102, P = 0.202) (Table 3).
AI, CEA, RI and CHDD changes over time are shown in
Figs. 2, 3, 4, and 5, respectively. At final follow-up, significant
differences were observed among groups on AI, CEA and RI:
AI and RI in the unsatisfactory group were significantly larger
Fig. 5 The centre-head distance discrepancy (CHDD) remained stable in
all groups from 1 year after closed reduction (CR) to final follow-up
(P > 0.05). No difference between satisfactory and unsatisfactory groups
were identified (P > 0.05)
 International Orthopaedics (SICOT)

Table 4 Logistic regression analysis of prognostic factors for

unsatisfactory outcome

Coefficient SE χ2 P value OR 95% CI for

OR

Lower Upper

1-year post-CR
AI 0.471 0.109 18.733 <0.001 1.602 1.294 1.983
CEA −0.238 0.058 16.919 <0.001 0.788 0.704 0.883
RI 0.05 0.019 7.32 0.007 1.051 1.014 1.09
CHDD −0.021 0.051 0.178 0.673 0.979 0.886 1.081
2-years post-CR
AI 0.662 0.153 18.79 <0.001 1.939 1.437 2.616
CEA −0.195 0.05 14.981 <0.001 0.823 0.745 0.908
RI 0.066 0.022 8.74 0.003 1.068 1.023 1.116
CHDD −0.024 0.048 0.24 0.624 0.977 0.888 1.074
3-years post-CR Fig. 6 Receiver operating characteristics (ROC) curve for acetabular in-
AI 0.794 0.186 18.211 <0.001 2.212 1.536 3.186 dex (AI)
CEA −0.309 0.071 18.736 <0.001 0.734 0.638 0.844
RI 0.077 0.025 9.767 0.002 1.08 1.029 1.133 than those in the satisfactory and operation groups
CHDD −0.033 0.049 0.457 0.499 0.968 0.88 1.064 (P < 0.001); CEA in the unsatisfactory group was significantly
4-years post-CR smaller than in the satisfactory and operation groups
AI 0.693 0.234 8.747 0.003 1.999 1.263 3.164 (P < 0.001) (Table 3).
CEA −0.494 0.175 7.976 0.005 0.61 0.433 0.86 In the operation group, mean AI, CEA and RI were 26.9° ±
RI 0.083 0.034 5.994 0.014 1.086 1.017 1.161 3.6°, 17.5° ± 8.5° and 26% before secondary surgery, respec-
CHDD −0.045 0.082 0.295 0.587 0.956 0.814 1.123 tively. Surgery was performed at a mean of 40.7 ±
13.86 months (range, 29–84 months) after CR. Thirteen and
AI acetabular index, CEA centre-edge angle, RI Reimer’s index, CHDD two operations were performed four and five years after CR,
centre-head distance discrepancy,CR closed reduction, SE standard error,
OR odds ratio, CI confidence interval respectively. All radiographic parameters except for CHDD
significantly improved after secondary surgery (P < 0.05).

Table 5 Area under the curve

(AUC) and cutoff value of AI, Index Year(s) after reduction AUC SE P value Cutoff value 95% CI of AUC
CEA and RI at different time
points AI
1 0.905 0.035 <0.001 28.4° 0.837, 0.973
2 0.942 0.028 <0.001 25.3° 0.886, 0.997
3 0.951 0.023 <0.001 25.3° 0.906, 0.997
4 0.957 0.031 <0.001 24.7° 0.896, 1.000
CEA
1 0.845 0.048 <0.001 13.9° 0.752, 0.938
2 0.798 0.049 <0.001 21.5° 0.702, 0.894
3 0.863 0.044 <0.001 18.3° 0.777, 0.950
4 0.961 0.028 0.000 19.5° 0.906, 1.000
RI
1 0.702 0.062 0.004 34.5% 0.581, 0.821
2 0.722 0.057 0.001 26.5% 0.596, 0.825
3 0.756 0.055 <0.001 27.5% 0.641, 0.864
4 0.865 0.058 0.001 26% 0.752, 0.978

AI acetabular index, CEA centre-edge angle, RI Reimer’s index, CR closed reduction, SE standard error, OR odds
ratio, CI confidence interval
International Orthopaedics (SICOT)
Fig. 7 Receiver operating characteristics (ROC) curve for centre-edge
angle (CEA)
Final outcome could be predicted by AI, CEA and RI at all time
points after CR (P < 0.01). There was no correlation of final
outcome with CHDD at any time point (P > 0.05) (Table 4).
The analysis of ROC curves indicates that AI has better
reliability and goodness of fit than CEA and RI, because the
area under the curve (AUC) of AI (0.9–0.95) was significantly
higher compared with that of CEA (0.79–0.86) and RI (0.7–
0.75) (Table 5, Fig. 6, 7, and 8).
Mean sensitivity (0.889), specificity (0.933), diagnostic ac-
curacy (92.1%) and likelihood ratio (12.64) of AI to predict an
unsatisfactory outcome were significantly better compared
with CEA (0.731; 0.904; 78.2%; 7.78) and RI (0.8; 0.655;
70.8%; 1.85) (P < 0.05) (Table 6).
Overall, at one year after CR, >90% of hips had satisfactory
outcomes if AI <28° and CEA >14°. Similarly, at two to
four years after CR, >90% of hips had satisfactory outcomes
if AI <25° and CEA >20°. In contrast, 80–88% of hips had an
Fig. 8 Receiver operating characteristics (ROC) curve for Reimer’s index
(RI)
unsatisfactory outcome if AI >28° at one year after CR or AI
>25° at two to four years after CR. However, if CEA was less
than or RI was larger than the cutoff values at each time point,
only 40–60% of hips had an unsatisfactory outcome (Table 7).
Thus, AI is the best parameter to predict final outcome.
Discussion
This study showed that AI is the best predictor for late acetab-
ular dysplasia in patients undergoing CR for DDH and
showed a significant difference in the patterns of acetabular
development between the satisfactory and unsatisfactory
groups. Specifically, we found that AI ceases to improve three
to four years after CR in hips with unsatisfactory outcomes,
while it continues to improve for about seven years after CR in
hips with satisfactory outcomes.
Our results are consistent with those reported by Albinana
et al., Fu et al. and Li et al. [4, 10, 18]. Albinana et al. compared
the changes in AI over time for Severin I/II and III/IV hips and
found that the time for AI to cease improvement was between
four and five years after reduction in Severin III/IV and six years
in I/II hips [4]. Similarly, Fu et al. and Li et al. found that AI
ceased to improve three years after CR in the unsatisfactory
group [10, 18] and six to eight years after CR in the satisfactory
group [10].
Our study also indicates that AI, CEA and RI can predict
the final outcome but that CHDD cannot. Several studies have
investigated the relationship of these predictors with acetabu-
lar development following reduction in DDH patients. These
predictors in our and other studies are listed in Table 8 [4,
7–11, 19, 20], highlighting that our results for cutoff values
are different from previous studies. Previously, most investi-
gators used mean AI, CEA, or RI values as cutoffs to predict
an unsatisfactory outcome. However, in contrast, we used the
ROC curve to detect the accurate cutoff value to predict an
unsatisfactory outcome, as ROC curve analysis can provide
diagnostic accuracy and optimal cutoff value for the test [21].
Additionally, some investigators evaluated RI [22] and
CHDD [11] to predict the outcome of DDH treatment. Chen
et al. [19] reviewed 75 hips treated by CR or open reduction
(OR); they considered that the best predictor of success in a
unilateral case was CHDD at one year of follow-up and the
cutoff value was 6%. Similar results were reported by Kim
et al. [11]. However, both our research and that of Gotoh et al.
[8] indicated no relationship between CHDD and final outcome.
Fu et al. [10] used RI to predict final outcome in 36 patients (48
hips) with untreated residual subluxation after CR. They con-
cluded that a poor outcome should be expected when RI >38%
at the age of three to four years or when RI >33% with an
upwards sourcil at the age of four to five years [10]. Our results
showed comparable findings. Additionally, other parameters,
such as intra-operative-arthrogram-determined femoral head
 International Orthopaedics (SICOT)

Table 6 Sensitivity, specificity

and diagnostic accuracy of AI, Index Year(s) Cutoff Sensitivity Specificity False False Diagnostic Likelihood
CEA and RI to predict an after value + (%) − (%) accuracy ratio
unsatisfactory outcome at reduction (%)
different time points
AI
1 >28.4° 0.846 0.912 18.5 7.1 89.1 9.61
2 >25.3° 0.962 0.912 16.7 1.9 92.8 10.93
3 >25.3° 0.885 0.947 11.5 5.3 92.8 16.70
4 >24.7° 0.889 0.933 20.0 3.6 92.1 13.33
CEA
1 <13.9° 0.772 0.808 38.2 10.2 78.3 4.02
2 <21.5° 0.544 0.962 51.0 3.1 67.5 14.32
3 <18.3° 0.772 0.846 45.7 8.3 79.5 5.01
4 <19.5° .833 1.000 28.6 0 87.2 –
RI
1 >34.5% 0.667 0.661 54.3 17.8 66.3 1.97
2 >26.5% 0.800 0.544 56.5 13.9 67.5 1.75
3 >27.5% 0.731 0.684 15.2 48.6 69.9 2.31
4 >26% 1.000 0.733 47.1 0 79.5 1.36

Diagnostic accuracy = 100% × (true satisfactory + true unsatisfactory)/Total

AI acetabular index, CEA centre-edge angle, RI Reimer’s index, CR closed reduction, SE standard error, OR odds
ratio, CI confidence interval

coverage and centre-edge of acetabular limbus angle in the
arthrogram at 4 years of age were also used by some researchers
[9, 20].
Although AI, CEA and RI could predict final outcome, AI
appeared to be the best predictor of late residual dysplasia
following CR. In logistic regression analysis, the coefficient
and odds ratio of AI were larger than those of CEA and RI at
all time points. Similar results were observed for the AUC in
ROC curves. Additionally, based on cutoff values of ROC
curves, AI had better sensitivity, specificity and diagnostic
accuracy compared with CEA and RI in predicting an unsat-
isfactory outcome. In our series, if AI was larger than the
cutoff values at each time point, >80–88% of hips had unsat-
isfactory outcomes. However, if CEA was less than or RI was
larger than the cutoff values at each time point, only 40–60%
of hips had unsatisfactory outcomes.
According to our results, AI is the most simple and reliable
parameter to predict final outcome. Firstly, AI is easily mea-
sured when measuring CEA; the centre of the femoral head
must be precisely set by identifying it at the midpoint of the

Table 7 Relationship between final outcome and AI, CEA and RI at different time points

Group 1 year 2 years 3 years 4 years

SG USG Total SG USG Total SG USG Total SG USG Total

AI (°) <CV 53 4 57 53 1 54 55 3 58 27 1 28
> CV 5 22 27 5 25 30 3 23 26 2 8 10
χ2 47.53 59.91 58.27 –
P value <0.001 <0.001 <0.001 <0.001
CEA (°) < CV 13 21 34 26 25 51 13 22 35 5 9 14
> CV 45 5 50 32 1 33 45 4 49 25 0 25
χ2 25.37 19.83 28.58 –
P value <0.001 <0.001 <0.001 <0.001
RI (%) < CV 38 8 46 32 5 37 40 7 47 22 0 22
> CV 19 16 35 26 20 46 18 19 37 8 9 17
χ2 7.65 8.75 12.88 –
P value 0.007 0.004 <0.001 <0.001

AI acetabular index, CEA centre-edge angle, RI Reimer’s index, SG satisfactory group, USG unsatisfactory group, CV cutoff value
International Orthopaedics (SICOT)

Table 8 Predictive factors of an

unsatisfactory outcome after AI CEA CHDD RI
reduction in developmental
displaysia of the hip (DDH) re- Time Value Time Value Time Value Time Value
ported by different authors
This study 1 YAR >28° 1 <14° No – 1 YAR >34.5%
2–4 YAR >25° 2–4 <20° – – 2–4 YAR >27%
Albinana J [1] 2 YAR ≥35° – – – – –
Shin CH [18] 3 YAR >32° 3 <14° – – – –
Kitoh H [8] 4 YAR – 5 YAR – No – – –
Gotoh E [6] 5 years >26° 5 years <8° – – – –
Kim HT [7] No No – – 4–5 years ≥6% – –
Chen IH [3] – – – – 1 YAR ≥6% – –
Fu Z [5] – – – – – – 3–4 years >38%
4–5 years >33%
Satsuma S [15] – – 4 years <10°

Years years of age, AI acetabular index, CEA centre-edge angle,YAR year(s) after reduction, No no predictor,
CHDD centre-head distance discrepancy, RI Reimer’s index

epiphyseal growth plate [12]. In addition, CEA is validated in
patients aged ≥four years, although several studies reported
good interobserver reliability when CEA angle was assessed
in patients <four years of age [7, 10, 17]. Regardless, CEA
measurement remains a controversial parameter in very young
patients. Additionally, RI measurement depends on the ap-
pearance of an ossific nucleus of the femoral head; if the
ossific nucleus has not appeared or is very small, the measured
RI is unreliable. Secondly, compared with AI, changes in
CEA or RI over time are more unpredictable, and both are
influenced by the shape of the femoral head. AVN of the
femoral head will lead to residual deformities, including coxa
magna, coxa plana, coxa vara and a short broad femoral neck.
Thus, a significant proportion of hips with normal CEA or RI
early after reduction will likely develop an abnormal CEA or
RI at the final follow-up.
Based on our results, we consider that the decision to op-
erate on the acetabula after CR in DDH should be made de-
pending on AI, CEA and RI at different time points after
reduction. Pelvic osteotomy should be performed when AI
>28° at one year or >25° at two to four years after CR.
CEA < 14° and RI > 34.5% at one year after CR or CEA <
20° and RI > 27% at two to three years after reduction may be
used as the secondary index to help with patient selection.
Controversy remains about the indication for a secondary
operation after CR in DDH. Schwartz [23] suggested that an
acetabular operation should be performed at two years after
reduction if AI >25°. Tönnis [12] considered that an operation
should be performed if AI >2 standard deviations (SD) above
normal values. Shin et al. [9] considered that an AI > 32° and
CEA < 14° at the age of three years could serve as a guideline
for osteotomy. Tasnavites et al. [24] believed that a secondary
operation should not be undertaken until three years after
reduction and the value of AI >2, which agreed with the sug-
gestion of Tönnis. Vrdoljak et al. [25] considered that opera-
tive reconstruction of the acetabulum should not be done be-
fore the age of three years. Terjesen [6] proposed that children
with a migration percentage (MP) >33% and a CEA < 10° at
age eight to ten years should be evaluated for reconstructive
surgery. Overall, most investigators agree that corrective sur-
gery for residual acetabular dysplasia should be performed at
two to three years after reduction, when the age of the patient
is about three to four years. In fact, a value of AI >2 at three to
four years is ~25° [26, 27], which is similar to our results.
In conclusion, satisfactory and unsatisfactory hips show
different patterns of acetabular development after reduction.
AI, CEA and RI are all predictors of final radiographic out-
comes in DDH treated by CR, although AI showed the best
results. AI continues to improve until seven years after CR in
hips with satisfactory outcomes; in contrast, it ceases to im-
prove three to four years after CR in hips with unsatisfactory
outcomes. According to our results, surgery is indicated if AI
>28° 1 year following CR or >25° two to four years after CR.
CEA and RI should be used as a secondary index to aid in the
selection of patients requiring surgery.
Compliance with ethical standards
Conflict of interest and source of funding YiQiang Li, YueMing Guo,
and Ming Li contributed equally to this work. The authors declare that
they have no conflict interests. No benefits in any form have been re-
ceived or will be received from a commercial party related directly or
indirectly to the subject of this article.
Ethical approval All procedures were performed in studies involving
human participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964

Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed consent No patients were involved. This was a retrospective
study of patient data, and IRB approval was obtained (GZWCMC
2015020904).
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