Prevalence of Developmental Dysplasia of the Hip in Neonates with Congenital Talipes Equinovarus: A Case-Control Study from Iran

Prevalence of Developmental Dysplasia of the Hip in Neonates with Congenital Talipes Equinovarus: A Case-Control Study from Iran | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence of Developmental Dysplasia of the Hip in Neonates with Congenital Talipes Equinovarus: A Case-Control Study from Iran Shahab Ilka, Mohammadreza Kashani, Farshad Zandrahimi, Ahmad Enhesari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6489921/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: This study investigates the relationship between congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip (DDH), two distinct pediatric musculoskeletal conditions with emerging evidence of association. Given the importance of early DDH detection to avert long-term issues like pain, reduced mobility, and osteoarthritis, the research examines ultrasound screening using the Graf classification. Although effective as a diagnostic tool, its routine use in neonates with CTEV continues to be debated, providing vital insights for diagnostics. Methods: This case-control study involved 150 neonates diagnosed with idiopathic congenital clubfoot and 155 healthy controls at Bahonar Hospital, Kerman, Iran, between 2016 and 2021. Participants underwent pelvic ultrasound assessment based on the Graf classification system to evaluate acetabular morphology. Alpha and beta angles were measured bilaterally, and subgroup analyses by sex were performed. Statistical analysis utilized SPSS version 26, with p < 0.05 considered significant. Results: The prevalence of DDH in neonates with CTEV was 13.3%, significantly higher than in controls (p < 0.001). Alpha angles less than 60° were exclusively observed in the CTEV group, occurring in 26% and 27.3% of right and left hips, respectively. Beta angles greater than 55° were more prevalent in controls (61.9% vs. 16.7% for right hips; 59.4% vs. 14.7% for left hips). Notably, males exhibited nearly double the DDH prevalence compared to females (18.8% vs. 9.3%). Conclusion: Our findings indicate a significant association between CTEV and DDH, emphasizing the need for targeted ultrasound screening in neonates with clubfoot. Future research should focus on elucidating the underlying mechanisms linking these conditions and refining screening protocols. Congenital talipes equinovarus Developmental dysplasia of the hip Ultrasound screening Graf classification Neonatal orthopedics Figures Figure 1 Introduction Developmental dysplasia of the hip (DDH) represents a spectrum of abnormalities affecting the hip joint, ranging from subtle acetabular dysplasia to complete dislocation of the femoral head [ 1 ]. This condition, if left untreated, can lead to significant long-term morbidity, including pain, limited mobility, and early-onset osteoarthritis [ 2 ]. Early detection and intervention are, therefore, paramount in mitigating these adverse outcomes [ 1 ]. Congenital talipes equinovarus (CTEV), commonly known as clubfoot, is another congenital musculoskeletal condition characterized by a complex deformity of the foot involving equinus at the ankle, varus at the heel, adduction of the forefoot, and cavus of the midfoot [ 3 ]. CTEV affects approximately 1 to 2 per 1,000 live births, making it a relatively common congenital anomaly [ 4 ]. While both DDH and CTEV are recognized as distinct entities, a potential association between them has been a subject of ongoing investigation and debate [ 5 ]. The reported prevalence of DDH in neonates with CTEV varies considerably, ranging from less than 1% to over 10% in different studies [ 6 ]. This variability underscores the complexity of the relationship and the influence of factors such as study design, population characteristics, and diagnostic methods. The rationale for considering CTEV as a risk factor for DDH stems from the hypothesis that shared etiological factors, such as intrauterine constraint or genetic predisposition, may contribute to the development of both conditions [ 5 ]. The presence of CTEV, therefore, might signal an increased likelihood of underlying hip instability or dysplasia [ 7 ]. Early detection of DDH is crucial for optimizing treatment outcomes [ 8 ]. Traditional clinical examination methods, such as the Barlow and Ortolani tests, have limited sensitivity, particularly in detecting subtle forms of dysplasia [ 9 ]. Consequently, ultrasound (US) screening has emerged as a valuable tool for early diagnosis, allowing for timely intervention with conservative measures like the Pavlik harness [ 10 ]. However, the routine use of US screening in all neonates with CTEV remains a contentious issue [ 11 ]. Proponents argue that the increased prevalence of DDH in this population justifies universal screening to ensure that no cases are missed [ 7 ]. Conversely, opponents emphasize the potential for overdiagnosis and overtreatment of physiologically immature hips that would spontaneously resolve, thereby increasing healthcare costs and parental anxiety without demonstrable benefit [ 12 ]. The debate surrounding routine US screening in neonates with CTEV for DDH is multifaceted. It involves weighing the potential benefits of early detection against the risks of overdiagnosis and overtreatment, considering the cost-effectiveness of screening programs, and acknowledging the limitations of current diagnostic tools. This study aims to further investigate the relationship between CTEV and DDH, providing additional evidence to inform clinical decision-making and refine screening strategies. By examining the prevalence of DDH in a cohort of neonates diagnosed with CTEV and exploring the role of early ultrasound screening, we hope to contribute to a more nuanced understanding of this complex clinical scenario and ultimately improve outcomes for affected infants. Methods and Materials This case-control study was conducted at Bahonar Hospital in Kerman, Iran, between 2016 and 2021, to evaluate the association between CTEV and DDH. The study population comprised 150 neonates diagnosed with idiopathic congenital clubfoot and 155 age-, sex-, and hospital-matched healthy controls. Infants with other congenital anomalies, genetic disorders, or incomplete medical records were excluded. Participants were recruited from the pediatric orthopedic clinic, with all clubfoot cases confirmed by a pediatric orthopedic surgeon. Demographic data, obstetric history (e.g., delivery type), and clinical evaluations, including hip range of motion and Barlow/Ortolani tests, were collected. Hip ultrasonography, performed by a certified radiologist, utilized the Graf classification system to assess acetabular morphology. Ultrasound parameters included alpha angles (acetabular bony roof inclination) and beta angles (cartilaginous roof inclination), with measurements repeated at three months of age. Ethical approval was granted by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.AH.REC.1400.188). Statistical analyses were conducted using Statistical Product and Service Solutions (SPSS; IBM SPSS Statistics for Windows, Armonk, NY) version 26. Descriptive statistics (mean ± SD for continuous variables; frequency percentages for categorical variables) and chi-square tests assessed associations, with p < 0.05 considered significant. Results A total of 305 neonates were enrolled, comprising 150 infants diagnosed with CTEV and 155 healthy controls. Demographic characteristics, laterality of CTEV, and ultrasound-derived alpha (α) and beta (β) angles were analyzed to evaluate the association between CTEV and DDH. The gender distribution in the CTEV group was 42.7% male (n = 64) and 57.3% female (n = 86), while the control group comprised 46.5% males (n = 72) and 53.5% females (n = 83) ( Table 1 ) . The difference in sex distribution between groups approached statistical significance (P = 0.0506). Among neonates with CTEV, unilateral involvement was predominant, with 39.3% (n = 59) presenting with right foot deformity, 34% (n = 51) with left foot involvement, and 26.7% (n = 40) exhibiting bilateral clubfoot (Table 1 ). Ultrasound evaluation using Graf criteria revealed significant disparities in α and β angles between the CTEV and control groups (Table 2 ). In the CTEV cohort, α angles < 60°—a key indicator of acetabular dysplasia—were exclusively observed, with 26% (n = 39) of neonates demonstrating α angle < 60° in the right hip (αR < 60°) and 27.3% (n = 41) in the left hip (αL < 60°; P 60° bilaterally. Table 1 Distribution of Gender Frequency and Location of Involvement of Infants with Congenital Foot Clubfoot and control group Variable CTEV Group Control Group P-value Number Percentage Number Percentage sex Boy 64 42.7 72 46.50 0.506 Girl 86 57.3 83 53.50 Place involved Both Legs 40 26.7 --- --- --- Left Foot 51 34 --- --- Right Foot 59 39.3 --- --- For β angles, which assess cartilaginous roof coverage, values > 55°—suggesting insufficient acetabular coverage—were significantly less frequent in the CTEV group compared to controls. Specifically, βR > 55° was observed in 16.7% (n = 25) of CTEV neonates versus 61.9% (n = 96) of controls (P 55° occurred in 14.7% (n = 22) of CTEV infants compared to 59.4% (n = 92) of controls (P < 0.001). These findings indicate that neonates with CTEV exhibit distinct acetabular morphology, characterized by lower α angles and reduced prevalence of elevated β angles. Subgroup analysis by sex within the CTEV group revealed notable differences in ultrasound parameters (Fig. 1 ). Females demonstrated a higher frequency of α angle abnormalities: 61.5% (n = 24) of αR < 60° and 61% (n = 25) of αL 55° and 59.1% (n = 13) of βL > 55° cases. Despite these sex-based disparities in angle distribution, the overall prevalence of DDH (defined by α 55°) was higher in males (18.8%, n = 12) than females (9.3%, n = 8) ( Table 3 ) . Table 2 Pelvic Ultrasound Angle for Diagnosis of DDH Using Graf Classification Criteria in Infants with Congenital Foot Clubfoot and Control Group Variable CTEV Group Control Group Number Percentage Number Percentage αR Angle > 60 111 74 155 100 < 60 39 26 0 0 βR Angle 55 25 16.7 96 61.9 αL Angle > 60 109 72.7 155 100 < 60 41 27.3 0 0 βL Angle 55 22 14.7 92 59.4 The alpha (α) angle measures acetabular bony coverage, while the beta (β) angle reflects cartilaginous coverage; * P-value = < 001.0. The composite prevalence of DDH in neonates with CTEV was 13.3% (n = 20), with no cases detected in the control group (P < 0.001) (Table 3 ). Stratified by sex, males with CTEV exhibited nearly double the prevalence of DDH (18.8%, n = 12) compared to females (9.3%, n = 8). Table 3 Prevalence of DDH based on Graf classification criteria in infants with congenital foot clubfoot and control group Variable CTEV Group Control Group Number Percentage Number Percentage Total pelvic dysplasia cases No 130 86.7 155 100 Yes 20 13.3 0 0 Pelvic dysplasia in boys No 52 81.3 72 100 Yes 12 18.8 0 0 Pelvic dysplasia in girls No 78 90.7 83 100 Yes 8 9.3 0 0 * P-value = < 001.0 Discussion The findings of this study underscore the complex relationship between CTEV and DDH. The observed prevalence of DDH in neonates with CTEV was 13.3%, significantly higher than that reported in the general population, which ranges from less than 1% to over 10% depending on the study [ 6 ]. This finding is consistent with earlier reports suggesting a potential association between these two conditions, although the exact nature of this relationship remains unclear [ 5 ]. Developmental dysplasia of the hip represents a spectrum of abnormalities affecting the hip joint, ranging from subtle acetabular dysplasia to complete dislocation of the femoral head[ 1 ]. If left untreated, DDH can lead to significant long-term morbidity, including pain, limited mobility, and early-onset osteoarthritis [ 2 ]. Early detection and intervention are therefore paramount in mitigating these adverse outcomes [ 1 ]. In our study, pelvic ultrasound criteria based on the Graf classification revealed distinct differences in acetabular morphology between infants with CTEV and healthy controls. Specifically, α angles less than 60° were exclusively observed in neonates with CTEV, occurring in 26% and 27.3% of cases for the right and left hips, respectively (P < 0.001). These findings align with previous observations by Canavese et al., who reported the presence of DDH in infants with unilateral and bilateral congenital clubfoot during treatment and recommended ultrasound screening in such cases [ 13 ]. In contrast, β angles greater than 55°, indicative of insufficient acetabular coverage were more prevalent in the control group, further emphasizing the unique acetabular characteristics of infants with CTEV. Perry et al. systematically examined the association between idiopathic CTEV and DDH, identifying hip dysplasia in 7 of 119 infants with CTEV (prevalence: 5.9%). Based on these findings, they advocated selective hip ultrasonography in this population [ 7 ]. However, other studies have reported lower prevalence rates, leading some authors to contest routine screening practices. For instance, Mahan et al. argued that despite widespread clinician concern, ultrasonographic evaluation for DDH in CTEV cases lacks sufficient justification [ 14 ]. Similarly, Westberry et al. identified only one case of hip dysplasia among 127 idiopathic clubfoot patients (prevalence: 0.8%), concluding against systematic pelvic radiography in this cohort [ 15 ]. The variability in reported prevalence underscores the complexity of the relationship between CTEV and DDH, likely influenced by factors such as study design, population characteristics, and diagnostic methods [ 6 ]. Our study contributes to this ongoing debate by demonstrating a higher prevalence of DDH in neonates with CTEV compared to previous reports, suggesting that targeted ultrasound screening may be warranted in this population. This approach could help mitigate the potential long-term complications associated with undiagnosed and untreated DDH, improving health outcomes for affected infants. Sex-based disparities in ultrasound parameters were also noted within the CTEV group, with females exhibiting a higher frequency of α angle abnormalities and males predominating in β angle deviations. Despite these differences, the overall prevalence of DDH was higher in male infants with CTEV (18.8%) than in females (9.3%), consistent with the higher incidence of CTEV in males (male-to-female ratio: 1.5:1 in this cohort) [ 3 , 16 , 17 ]. These findings align with previous studies highlighting gender as a risk factor for DDH, with a higher prevalence reported in female infants [ 18 ]. Rosendahl and colleagues demonstrated that the prevalence of DDH is 9.3% in male infants and 16.9% in female infants [ 16 ]. Interestingly, Borjian et al. reported that 74% of neonates with clubfoot are boys, with a boy-to-girl ratio of 2.8, reinforcing the notion that sex plays a significant role in the development of both conditions [ 19 ]. The rationale for considering CTEV as a risk factor for DDH stems from the hypothesis that shared etiological factors, such as intrauterine constraint or genetic predisposition, may contribute to the development of both conditions [ 5 ]. The presence of CTEV, therefore, might signal an increased likelihood of underlying hip instability or dysplasia [ 7 ]. Early detection of DDH is crucial for optimizing treatment outcomes, particularly given the limitations of traditional clinical examination methods like the Barlow and Ortolani tests, which have low sensitivity for detecting subtle forms of dysplasia [ 9 ]. Consequently, ultrasound screening has emerged as a valuable tool for early diagnosis, allowing for timely intervention with conservative measures like the Pavlik harness [ 10 ]. However, the routine use of US screening in all neonates with CTEV remains a contentious issue. Proponents argue that the increased prevalence of DDH in this population justifies universal screening to ensure that no cases are missed [ 20 , 21 ]. Conversely, opponents emphasize the potential for overdiagnosis and overtreatment of physiologically immature hips that would spontaneously resolve, thereby increasing healthcare costs and parental anxiety without demonstrable benefit [ 12 ]. Our findings suggest that while not all neonates with CTEV require screening, those exhibiting specific risk factors such as abnormal alpha angles or a family history of DDH may benefit from targeted evaluation. Subgroup analysis revealed notable differences in ultrasound parameters by sex, with females demonstrating a higher frequency of alpha angle abnormalities and males predominating in beta angle deviations. This observation aligns with previous reports highlighting the influence of sex on musculoskeletal development and the differential expression of certain genetic and environmental factors [ 18 ]. While laterality of CTEV (unilateral vs. bilateral presentation) was analyzed, no statistically significant association with DDH prevalence emerged. However, the limited sample size of bilateral cases (n = 40) precluded definitive conclusions regarding laterality-dependent risk stratification. The implications of these findings extend beyond individual patient care, informing broader public health strategies aimed at reducing the burden of DDH and its associated morbidities. By identifying high-risk populations and implementing evidence-based screening protocols, healthcare providers can improve early detection rates and enhance treatment efficacy[ 10 , 22 ]. Furthermore, understanding the underlying mechanisms linking CTEV and DDH may pave the way for novel therapeutic interventions targeting common etiological pathways[ 23 ]. In summary, the results of this study indicate a significant association between CTEV and DDH, characterized by distinct acetabular morphology and a higher prevalence of DDH in affected infants. While further research is needed to elucidate the precise nature of this relationship, our findings support the use of targeted ultrasound screening in neonates with CTEV, particularly those exhibiting specific risk factors. Such an approach balances the need for early detection with concerns about overdiagnosis and resource allocation, ultimately promoting optimal health outcomes for affected infants. Conclusion The present study demonstrates a high prevalence of pelvic dysplasia in neonates with congenital clubfoot, specifically 13.3% in our cohort. Moreover, the prevalence of pelvic dysplasia was notably higher in male infants with congenital clubfoot (18.8%) compared to female neonates (9.3%). Although simultaneous occurrences of hip and clubfoot dysplasia are rare, early diagnosis and treatment of DDH in these infants remain essential due to the potential for irreversible complications if untreated. Therefore, the hypothesis of a relationship between these two abnormalities supports the implementation of targeted ultrasound screening for diagnosing DDH in neonates with congenital clubfoot. Given the observed association, pelvic ultrasound screening should be considered for infants diagnosed with congenital clubfoot, particularly considering the higher prevalence of pelvic dysplasia noted in this study. Future research should aim to clarify the underlying mechanisms linking these conditions and validate the utility of targeted screening protocols. Such efforts will refine clinical guidelines and ensure optimal care for neonates at risk of DDH. Declarations Conflicts of interest The authors declare no conflicts of interest in relation to this research study. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors. Author Contribution A.I and M.K conceptualized and designed the study. Data curation and Data validation were done by A.I , M.K, F.Z and A.E. Data analysis was done by A.I , M.K and A.E. Writing the original draft was prepared by A.I and M.K. F. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Vaquero-Picado A, González-Morán G, Garay EG, Moraleda L (2019) Developmental dysplasia of the hip: update of management. EFORT Open Reviews 4:548–556. https://doi.org/10.1302/2058-5241.4.180019 Alhaddad A, Gronfula AG, Alsharif TH, et al An overview of developmental dysplasia of the hip and its management timing and approaches. Cureus 15:e45503. https://doi.org/10.7759/cureus.45503 Dobbs MB, Gurnett CA (2009) Update on clubfoot: Etiology and treatment. Clin Orthop Relat Res 467:1146–1153. https://doi.org/10.1007/s11999-009-0734-9 Smythe T, Kuper H, Macleod D, et al (2017) Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: A systematic review and meta-analysis. Trop Med Int Health 22:269–285. https://doi.org/10.1111/tmi.12833 Håberg Ø, Foss OA, Lian ØB, Holen KJ (2020) Is foot deformity associated with developmental dysplasia of the hip? Bone Joint J 102-B:1582–1586. https://doi.org/10.1302/0301-620X.102B11.BJJ-2020-0290.R3 Ibrahim T, Riaz M, Hegazy A (2015) The prevalence of developmental dysplasia of the hip in idiopathic clubfoot: a systematic review and meta-analysis. International Orthopaedics (SICOT) 39:1371–1378. https://doi.org/10.1007/s00264-015-2757-z Perry DC, Tawfiq SM, Roche A, et al (2010) The association between clubfoot and developmental dysplasia of the hip. J Bone Joint Surg Br 92:1586–1588. https://doi.org/10.1302/0301-620X.92B11.24719 St George J, Kulkarni V, Bellemore M, et al (2021) Importance of early diagnosis for developmental dysplasia of the hip: A 5-year radiological outcome study comparing the effect of early and late diagnosis. J Paediatr Child Health 57:41–45. https://doi.org/10.1111/jpc.15111 Singh A, Wade RG, Metcalfe D, Perry DC (2024) Does this infant have a dislocated hip?: The rational clinical examination systematic review. JAMA 331:1576–1585. https://doi.org/10.1001/jama.2024.2404 Gyurkovits Z, Sohár G, Baricsa A, et al (2021) Early detection of developmental dysplasia of hip by ultrasound. Hip Int 31:424–429. https://doi.org/10.1177/1120700019879687 McLaughlin D, De Salvo S, Brewerton K, et al (2024) Routine ultrasound screening for hip dysplasia in children with clubfoot is not supported. International Orthopaedics (SICOT) 48:1793–1797. https://doi.org/10.1007/s00264-024-06169-6 Kuitunen I, Uimonen MM, Haapanen M, et al (2022) Incidence of neonatal developmental dysplasia of the hip and late detection rates based on screening strategy: A systematic review and meta-analysis. JAMA Netw Open 5:e2227638. https://doi.org/10.1001/jamanetworkopen.2022.27638 Canavese F, Vargas-Barreto B, Kaelin A, De Coulon G (2011) Onset of developmental dysplasia of the hip during clubfoot treatment: report of two cases and review of patients with both deformities followed at a single institution. Journal of Pediatric Orthopaedics B 20:152–156. https://doi.org/10.1097/BPB.0b013e3283441030 Mahan ST, Yazdy MM, Kasser JR, Werler MM (2013) Is it worthwhile to routinely ultrasound screen children with idiopathic clubfoot for hip dysplasia? J Pediatr Orthop 33:847–851. https://doi.org/10.1097/BPO.0000000000000100 Westberry DE, Davids PLijj JR (2003) Clubfoot and developmental dysplasia of the hip: value of screening hip radiographs in children with clubfoot. 23:503–7 Rosendahl K, Markestad T, RJPr L (1996) Developmental dysplasia of the hip: prevalence based on ultrasound diagnosis. 26:635–9 Taleb H, Tabrizi A, Mandi A, et al (2020) Predictive factors for tenotomy in ponseti method for idiopathic clubfoot. Medical Journal of Tabriz University of Medical Sciences 42:433–9 Jawadi AJPT (2016) Clubfoot and congenital muscular torticollis prevalence in children diagnosed with developmental dysplasia of hip: review of 594 DDH patients. 6:2161–0665 Borjian AAH, Nasr Esfahani H, Masoudi F (2007) Investigation of the surgical treatment results in children with clubfoot, a sinning posteromedial and lateral approach in Alzahra hospital. Arak medical university journal 10:1–6 Graf R (2017) Hip Sonography: Background; Technique and Common Mistakes; Results; Debate and Politics; Challenges. HIP International 27:215–219. https://doi.org/10.5301/hipint.5000514 Graf R (1980) The diagnosis of congenital hip-joint dislocation by the ultrasonic combound treatment. Arch Orth Traum Surg 97:117–133. https://doi.org/10.1007/BF00450934 Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip (2000) Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip. Pediatrics 105:896–905. https://doi.org/10.1542/peds.105.4.896 Agostiniani R, Atti G, Bonforte S, et al (2020) Recommendations for early diagnosis of Developmental Dysplasia of the Hip (DDH): working group intersociety consensus document. Ital J Pediatr 46:150. https://doi.org/10.1186/s13052-020-00908-2 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6489921","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":452401165,"identity":"e15a22e7-c15d-494a-bb80-22035a90bcb5","order_by":0,"name":"Shahab Ilka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYDCCAwxsDIwNDAls7GwMDB+AAmzsRGthBtIzQFqYidXCANTCzAMSIaSF7/bxZw9+7rDL42NmS/xs82ubPB8zA+OHjzm4tUieyzE37D2TXAx02GHp3L7bhm3MDMySM7fh1mJwhodNgreNObGNmb1BOrfnNiNQCxszL14t7M8k/7bVg7Q0/7bsuW1PhBYGM2netsNALWzHpBl+3E4kqEXyDI+ZtGzbcZBf0ix7G24ntzEzNuP1Cx/IYW/bqvPk29uMb/z4c9t2fnvzwQ8f8WhBBYxtYLKBWPUg8IcUxaNgFIyCUTBSAAB6RUxzmhncHwAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Orthopedics, Kerman University of Medical Sciences, Kerman, Iran","correspondingAuthor":true,"prefix":"","firstName":"Shahab","middleName":"","lastName":"Ilka","suffix":""},{"id":452401166,"identity":"cd749ec5-0e31-4cda-80d1-06b25ed66994","order_by":1,"name":"Mohammadreza Kashani","email":"","orcid":"","institution":"Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Science, Kerman, Iran","correspondingAuthor":false,"prefix":"","firstName":"Mohammadreza","middleName":"","lastName":"Kashani","suffix":""},{"id":452401167,"identity":"a4fdcde1-7f43-4c07-bd55-9f4c486c9196","order_by":2,"name":"Farshad Zandrahimi","email":"","orcid":"","institution":"Department of Orthopedics, Kerman University of Medical Sciences, Kerman, Iran","correspondingAuthor":false,"prefix":"","firstName":"Farshad","middleName":"","lastName":"Zandrahimi","suffix":""},{"id":452401168,"identity":"434af028-23da-4c2d-9dc1-bd4a7a6e9332","order_by":3,"name":"Ahmad Enhesari","email":"","orcid":"","institution":"Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Science, Kerman, Iran","correspondingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"","lastName":"Enhesari","suffix":""}],"badges":[],"createdAt":"2025-04-20 14:53:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6489921/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6489921/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82560035,"identity":"a41d1d42-91aa-409b-a4fb-4a8d1f8b3bfd","added_by":"auto","created_at":"2025-05-13 01:30:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32952,"visible":true,"origin":"","legend":"\u003cp\u003esummarizes the distribution of α and β angles across groups, highlighting the pronounced differences in acetabular morphology. The graphical representation reinforces the higher frequency of α\u0026lt;60° in the CTEV group and β\u0026gt;55° in controls.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6489921/v1/a352be3bcde749f234709a6b.png"},{"id":83591888,"identity":"11c74293-45c6-4aef-841f-8f8d0d0e9caa","added_by":"auto","created_at":"2025-05-29 06:31:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":465518,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6489921/v1/2f81ff3e-e4ed-4bae-8b1f-ad4a51bf31dc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence of Developmental Dysplasia of the Hip in Neonates with Congenital Talipes Equinovarus: A Case-Control Study from Iran","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDevelopmental dysplasia of the hip (DDH) represents a spectrum of abnormalities affecting the hip joint, ranging from subtle acetabular dysplasia to complete dislocation of the femoral head [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This condition, if left untreated, can lead to significant long-term morbidity, including pain, limited mobility, and early-onset osteoarthritis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Early detection and intervention are, therefore, paramount in mitigating these adverse outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Congenital talipes equinovarus (CTEV), commonly known as clubfoot, is another congenital musculoskeletal condition characterized by a complex deformity of the foot involving equinus at the ankle, varus at the heel, adduction of the forefoot, and cavus of the midfoot [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. CTEV affects approximately 1 to 2 per 1,000 live births, making it a relatively common congenital anomaly [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile both DDH and CTEV are recognized as distinct entities, a potential association between them has been a subject of ongoing investigation and debate [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The reported prevalence of DDH in neonates with CTEV varies considerably, ranging from less than 1% to over 10% in different studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This variability underscores the complexity of the relationship and the influence of factors such as study design, population characteristics, and diagnostic methods. The rationale for considering CTEV as a risk factor for DDH stems from the hypothesis that shared etiological factors, such as intrauterine constraint or genetic predisposition, may contribute to the development of both conditions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The presence of CTEV, therefore, might signal an increased likelihood of underlying hip instability or dysplasia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly detection of DDH is crucial for optimizing treatment outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Traditional clinical examination methods, such as the Barlow and Ortolani tests, have limited sensitivity, particularly in detecting subtle forms of dysplasia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Consequently, ultrasound (US) screening has emerged as a valuable tool for early diagnosis, allowing for timely intervention with conservative measures like the Pavlik harness [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the routine use of US screening in all neonates with CTEV remains a contentious issue [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Proponents argue that the increased prevalence of DDH in this population justifies universal screening to ensure that no cases are missed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Conversely, opponents emphasize the potential for overdiagnosis and overtreatment of physiologically immature hips that would spontaneously resolve, thereby increasing healthcare costs and parental anxiety without demonstrable benefit [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe debate surrounding routine US screening in neonates with CTEV for DDH is multifaceted. It involves weighing the potential benefits of early detection against the risks of overdiagnosis and overtreatment, considering the cost-effectiveness of screening programs, and acknowledging the limitations of current diagnostic tools. This study aims to further investigate the relationship between CTEV and DDH, providing additional evidence to inform clinical decision-making and refine screening strategies. By examining the prevalence of DDH in a cohort of neonates diagnosed with CTEV and exploring the role of early ultrasound screening, we hope to contribute to a more nuanced understanding of this complex clinical scenario and ultimately improve outcomes for affected infants.\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cp\u003eThis case-control study was conducted at Bahonar Hospital in Kerman, Iran, between 2016 and 2021, to evaluate the association between CTEV and DDH. The study population comprised 150 neonates diagnosed with idiopathic congenital clubfoot and 155 age-, sex-, and hospital-matched healthy controls. Infants with other congenital anomalies, genetic disorders, or incomplete medical records were excluded.\u003c/p\u003e \u003cp\u003eParticipants were recruited from the pediatric orthopedic clinic, with all clubfoot cases confirmed by a pediatric orthopedic surgeon. Demographic data, obstetric history (e.g., delivery type), and clinical evaluations, including hip range of motion and Barlow/Ortolani tests, were collected. Hip ultrasonography, performed by a certified radiologist, utilized the Graf classification system to assess acetabular morphology. Ultrasound parameters included alpha angles (acetabular bony roof inclination) and beta angles (cartilaginous roof inclination), with measurements repeated at three months of age. Ethical approval was granted by the Ethics Committee of Kerman University of Medical Sciences (IR.KMU.AH.REC.1400.188).\u003c/p\u003e \u003cp\u003eStatistical analyses were conducted using Statistical Product and Service Solutions (SPSS; IBM SPSS Statistics for Windows, Armonk, NY) version 26. Descriptive statistics (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for continuous variables; frequency percentages for categorical variables) and chi-square tests assessed associations, with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 305 neonates were enrolled, comprising 150 infants diagnosed with CTEV and 155 healthy controls. Demographic characteristics, laterality of CTEV, and ultrasound-derived alpha (α) and beta (β) angles were analyzed to evaluate the association between CTEV and DDH.\u003c/p\u003e \u003cp\u003eThe gender distribution in the CTEV group was 42.7% male (n\u0026thinsp;=\u0026thinsp;64) and 57.3% female (n\u0026thinsp;=\u0026thinsp;86), while the control group comprised 46.5% males (n\u0026thinsp;=\u0026thinsp;72) and 53.5% females (n\u0026thinsp;=\u0026thinsp;83) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The difference in sex distribution between groups approached statistical significance (P\u0026thinsp;=\u0026thinsp;0.0506). Among neonates with CTEV, unilateral involvement was predominant, with 39.3% (n\u0026thinsp;=\u0026thinsp;59) presenting with right foot deformity, 34% (n\u0026thinsp;=\u0026thinsp;51) with left foot involvement, and 26.7% (n\u0026thinsp;=\u0026thinsp;40) exhibiting bilateral clubfoot (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUltrasound evaluation using Graf criteria revealed significant disparities in α and β angles between the CTEV and control groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the CTEV cohort, α angles\u0026thinsp;\u0026lt;\u0026thinsp;60\u0026deg;\u0026mdash;a key indicator of acetabular dysplasia\u0026mdash;were exclusively observed, with 26% (n\u0026thinsp;=\u0026thinsp;39) of neonates demonstrating α angle\u0026thinsp;\u0026lt;\u0026thinsp;60\u0026deg; in the right hip (αR\u0026thinsp;\u0026lt;\u0026thinsp;60\u0026deg;) and 27.3% (n\u0026thinsp;=\u0026thinsp;41) in the left hip (αL\u0026thinsp;\u0026lt;\u0026thinsp;60\u0026deg;; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both). In contrast, all controls exhibited α angles\u0026thinsp;\u0026gt;\u0026thinsp;60\u0026deg; bilaterally.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Gender Frequency and Location of Involvement of Infants with Congenital Foot Clubfoot and control group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCTEV Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003esex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGirl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlace involved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBoth Legs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft Foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight Foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor β angles, which assess cartilaginous roof coverage, values\u0026thinsp;\u0026gt;\u0026thinsp;55\u0026deg;\u0026mdash;suggesting insufficient acetabular coverage\u0026mdash;were significantly less frequent in the CTEV group compared to controls. Specifically, βR\u0026thinsp;\u0026gt;\u0026thinsp;55\u0026deg; was observed in 16.7% (n\u0026thinsp;=\u0026thinsp;25) of CTEV neonates versus 61.9% (n\u0026thinsp;=\u0026thinsp;96) of controls (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, βL\u0026thinsp;\u0026gt;\u0026thinsp;55\u0026deg; occurred in 14.7% (n\u0026thinsp;=\u0026thinsp;22) of CTEV infants compared to 59.4% (n\u0026thinsp;=\u0026thinsp;92) of controls (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings indicate that neonates with CTEV exhibit distinct acetabular morphology, characterized by lower α angles and reduced prevalence of elevated β angles.\u003c/p\u003e \u003cp\u003eSubgroup analysis by sex within the CTEV group revealed notable differences in ultrasound parameters (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Females demonstrated a higher frequency of α angle abnormalities: 61.5% (n\u0026thinsp;=\u0026thinsp;24) of αR\u0026thinsp;\u0026lt;\u0026thinsp;60\u0026deg; and 61% (n\u0026thinsp;=\u0026thinsp;25) of αL\u0026thinsp;\u0026lt;\u0026thinsp;60\u0026deg; cases occurred in females. Conversely, males predominated in β angle deviations, accounting for 56% (n\u0026thinsp;=\u0026thinsp;14) of βR\u0026thinsp;\u0026gt;\u0026thinsp;55\u0026deg; and 59.1% (n\u0026thinsp;=\u0026thinsp;13) of βL\u0026thinsp;\u0026gt;\u0026thinsp;55\u0026deg; cases. Despite these sex-based disparities in angle distribution, the overall prevalence of DDH (defined by α\u0026thinsp;\u0026lt;\u0026thinsp;60\u0026deg; and β\u0026thinsp;\u0026gt;\u0026thinsp;55\u0026deg;) was higher in males (18.8%, n\u0026thinsp;=\u0026thinsp;12) than females (9.3%, n\u0026thinsp;=\u0026thinsp;8) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePelvic Ultrasound Angle for Diagnosis of DDH Using Graf Classification Criteria in Infants with Congenital Foot Clubfoot and Control Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCTEV Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eαR Angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eβR Angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e61.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eαL Angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eβL Angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe alpha (α) angle measures acetabular bony coverage, while the beta (β) angle reflects cartilaginous coverage; * P-value\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;001.0.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe composite prevalence of DDH in neonates with CTEV was 13.3% (n\u0026thinsp;=\u0026thinsp;20), with no cases detected in the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Stratified by sex, males with CTEV exhibited nearly double the prevalence of DDH (18.8%, n\u0026thinsp;=\u0026thinsp;12) compared to females (9.3%, n\u0026thinsp;=\u0026thinsp;8).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of DDH based on Graf classification criteria in infants with congenital foot clubfoot and control group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCTEV Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal pelvic dysplasia cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePelvic dysplasia in boys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePelvic dysplasia in girls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* P-value\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;001.0\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study underscore the complex relationship between CTEV and DDH. The observed prevalence of DDH in neonates with CTEV was 13.3%, significantly higher than that reported in the general population, which ranges from less than 1% to over 10% depending on the study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This finding is consistent with earlier reports suggesting a potential association between these two conditions, although the exact nature of this relationship remains unclear [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDevelopmental dysplasia of the hip represents a spectrum of abnormalities affecting the hip joint, ranging from subtle acetabular dysplasia to complete dislocation of the femoral head[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. If left untreated, DDH can lead to significant long-term morbidity, including pain, limited mobility, and early-onset osteoarthritis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Early detection and intervention are therefore paramount in mitigating these adverse outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In our study, pelvic ultrasound criteria based on the Graf classification revealed distinct differences in acetabular morphology between infants with CTEV and healthy controls. Specifically, α angles less than 60\u0026deg; were exclusively observed in neonates with CTEV, occurring in 26% and 27.3% of cases for the right and left hips, respectively (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings align with previous observations by Canavese et al., who reported the presence of DDH in infants with unilateral and bilateral congenital clubfoot during treatment and recommended ultrasound screening in such cases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, β angles greater than 55\u0026deg;, indicative of insufficient acetabular coverage were more prevalent in the control group, further emphasizing the unique acetabular characteristics of infants with CTEV. Perry et al. systematically examined the association between idiopathic CTEV and DDH, identifying hip dysplasia in 7 of 119 infants with CTEV (prevalence: 5.9%). Based on these findings, they advocated selective hip ultrasonography in this population [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, other studies have reported lower prevalence rates, leading some authors to contest routine screening practices. For instance, Mahan et al. argued that despite widespread clinician concern, ultrasonographic evaluation for DDH in CTEV cases lacks sufficient justification [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Similarly, Westberry et al. identified only one case of hip dysplasia among 127 idiopathic clubfoot patients (prevalence: 0.8%), concluding against systematic pelvic radiography in this cohort [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe variability in reported prevalence underscores the complexity of the relationship between CTEV and DDH, likely influenced by factors such as study design, population characteristics, and diagnostic methods [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Our study contributes to this ongoing debate by demonstrating a higher prevalence of DDH in neonates with CTEV compared to previous reports, suggesting that targeted ultrasound screening may be warranted in this population. This approach could help mitigate the potential long-term complications associated with undiagnosed and untreated DDH, improving health outcomes for affected infants.\u003c/p\u003e \u003cp\u003eSex-based disparities in ultrasound parameters were also noted within the CTEV group, with females exhibiting a higher frequency of α angle abnormalities and males predominating in β angle deviations. Despite these differences, the overall prevalence of DDH was higher in male infants with CTEV (18.8%) than in females (9.3%), consistent with the higher incidence of CTEV in males (male-to-female ratio: 1.5:1 in this cohort) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These findings align with previous studies highlighting gender as a risk factor for DDH, with a higher prevalence reported in female infants [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Rosendahl and colleagues demonstrated that the prevalence of DDH is 9.3% in male infants and 16.9% in female infants [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Interestingly, Borjian et al. reported that 74% of neonates with clubfoot are boys, with a boy-to-girl ratio of 2.8, reinforcing the notion that sex plays a significant role in the development of both conditions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rationale for considering CTEV as a risk factor for DDH stems from the hypothesis that shared etiological factors, such as intrauterine constraint or genetic predisposition, may contribute to the development of both conditions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The presence of CTEV, therefore, might signal an increased likelihood of underlying hip instability or dysplasia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Early detection of DDH is crucial for optimizing treatment outcomes, particularly given the limitations of traditional clinical examination methods like the Barlow and Ortolani tests, which have low sensitivity for detecting subtle forms of dysplasia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Consequently, ultrasound screening has emerged as a valuable tool for early diagnosis, allowing for timely intervention with conservative measures like the Pavlik harness [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the routine use of US screening in all neonates with CTEV remains a contentious issue. Proponents argue that the increased prevalence of DDH in this population justifies universal screening to ensure that no cases are missed [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Conversely, opponents emphasize the potential for overdiagnosis and overtreatment of physiologically immature hips that would spontaneously resolve, thereby increasing healthcare costs and parental anxiety without demonstrable benefit [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our findings suggest that while not all neonates with CTEV require screening, those exhibiting specific risk factors such as abnormal alpha angles or a family history of DDH may benefit from targeted evaluation.\u003c/p\u003e \u003cp\u003eSubgroup analysis revealed notable differences in ultrasound parameters by sex, with females demonstrating a higher frequency of alpha angle abnormalities and males predominating in beta angle deviations. This observation aligns with previous reports highlighting the influence of sex on musculoskeletal development and the differential expression of certain genetic and environmental factors [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While laterality of CTEV (unilateral vs. bilateral presentation) was analyzed, no statistically significant association with DDH prevalence emerged. However, the limited sample size of bilateral cases (n\u0026thinsp;=\u0026thinsp;40) precluded definitive conclusions regarding laterality-dependent risk stratification.\u003c/p\u003e \u003cp\u003eThe implications of these findings extend beyond individual patient care, informing broader public health strategies aimed at reducing the burden of DDH and its associated morbidities. By identifying high-risk populations and implementing evidence-based screening protocols, healthcare providers can improve early detection rates and enhance treatment efficacy[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Furthermore, understanding the underlying mechanisms linking CTEV and DDH may pave the way for novel therapeutic interventions targeting common etiological pathways[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn summary, the results of this study indicate a significant association between CTEV and DDH, characterized by distinct acetabular morphology and a higher prevalence of DDH in affected infants. While further research is needed to elucidate the precise nature of this relationship, our findings support the use of targeted ultrasound screening in neonates with CTEV, particularly those exhibiting specific risk factors. Such an approach balances the need for early detection with concerns about overdiagnosis and resource allocation, ultimately promoting optimal health outcomes for affected infants.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study demonstrates a high prevalence of pelvic dysplasia in neonates with congenital clubfoot, specifically 13.3% in our cohort. Moreover, the prevalence of pelvic dysplasia was notably higher in male infants with congenital clubfoot (18.8%) compared to female neonates (9.3%). Although simultaneous occurrences of hip and clubfoot dysplasia are rare, early diagnosis and treatment of DDH in these infants remain essential due to the potential for irreversible complications if untreated. Therefore, the hypothesis of a relationship between these two abnormalities supports the implementation of targeted ultrasound screening for diagnosing DDH in neonates with congenital clubfoot.\u003c/p\u003e \u003cp\u003eGiven the observed association, pelvic ultrasound screening should be considered for infants diagnosed with congenital clubfoot, particularly considering the higher prevalence of pelvic dysplasia noted in this study. Future research should aim to clarify the underlying mechanisms linking these conditions and validate the utility of targeted screening protocols. Such efforts will refine clinical guidelines and ensure optimal care for neonates at risk of DDH.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflicts of interest\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflicts of interest in relation to this research study.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eA.I and M.K conceptualized and designed the study. Data curation and Data validation were done by A.I , M.K, F.Z and A.E. Data analysis was done by A.I , M.K and A.E. Writing the original draft was prepared by A.I and M.K. F. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVaquero-Picado A, Gonz\u0026aacute;lez-Mor\u0026aacute;n G, Garay EG, Moraleda L (2019) Developmental dysplasia of the hip: update of management. EFORT Open Reviews 4:548\u0026ndash;556. https://doi.org/10.1302/2058-5241.4.180019\u003c/li\u003e\n\u003cli\u003eAlhaddad A, Gronfula AG, Alsharif TH, et al An overview of developmental dysplasia of the hip and its management timing and approaches. Cureus 15:e45503. https://doi.org/10.7759/cureus.45503\u003c/li\u003e\n\u003cli\u003eDobbs MB, Gurnett CA (2009) Update on clubfoot: Etiology and treatment. Clin Orthop Relat Res 467:1146\u0026ndash;1153. https://doi.org/10.1007/s11999-009-0734-9\u003c/li\u003e\n\u003cli\u003eSmythe T, Kuper H, Macleod D, et al (2017) Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: A systematic review and meta-analysis. Trop Med Int Health 22:269\u0026ndash;285. https://doi.org/10.1111/tmi.12833\u003c/li\u003e\n\u003cli\u003eH\u0026aring;berg \u0026Oslash;, Foss OA, Lian \u0026Oslash;B, Holen KJ (2020) Is foot deformity associated with developmental dysplasia of the hip? Bone Joint J 102-B:1582\u0026ndash;1586. https://doi.org/10.1302/0301-620X.102B11.BJJ-2020-0290.R3\u003c/li\u003e\n\u003cli\u003eIbrahim T, Riaz M, Hegazy A (2015) The prevalence of developmental dysplasia of the hip in idiopathic clubfoot: a systematic review and meta-analysis. International Orthopaedics (SICOT) 39:1371\u0026ndash;1378. https://doi.org/10.1007/s00264-015-2757-z\u003c/li\u003e\n\u003cli\u003ePerry DC, Tawfiq SM, Roche A, et al (2010) The association between clubfoot and developmental dysplasia of the hip. J Bone Joint Surg Br 92:1586\u0026ndash;1588. https://doi.org/10.1302/0301-620X.92B11.24719\u003c/li\u003e\n\u003cli\u003eSt George J, Kulkarni V, Bellemore M, et al (2021) Importance of early diagnosis for developmental dysplasia of the hip: A 5-year radiological outcome study comparing the effect of early and late diagnosis. J Paediatr Child Health 57:41\u0026ndash;45. https://doi.org/10.1111/jpc.15111\u003c/li\u003e\n\u003cli\u003eSingh A, Wade RG, Metcalfe D, Perry DC (2024) Does this infant have a dislocated hip?: The rational clinical examination systematic review. JAMA 331:1576\u0026ndash;1585. https://doi.org/10.1001/jama.2024.2404\u003c/li\u003e\n\u003cli\u003eGyurkovits Z, Soh\u0026aacute;r G, Baricsa A, et al (2021) Early detection of developmental dysplasia of hip by ultrasound. Hip Int 31:424\u0026ndash;429. https://doi.org/10.1177/1120700019879687\u003c/li\u003e\n\u003cli\u003eMcLaughlin D, De Salvo S, Brewerton K, et al (2024) Routine ultrasound screening for hip dysplasia in children with clubfoot is not supported. International Orthopaedics (SICOT) 48:1793\u0026ndash;1797. https://doi.org/10.1007/s00264-024-06169-6\u003c/li\u003e\n\u003cli\u003eKuitunen I, Uimonen MM, Haapanen M, et al (2022) Incidence of neonatal developmental dysplasia of the hip and late detection rates based on screening strategy: A systematic review and meta-analysis. JAMA Netw Open 5:e2227638. https://doi.org/10.1001/jamanetworkopen.2022.27638\u003c/li\u003e\n\u003cli\u003eCanavese F, Vargas-Barreto B, Kaelin A, De Coulon G (2011) Onset of developmental dysplasia of the hip during clubfoot treatment: report of two cases and review of patients with both deformities followed at a single institution. Journal of Pediatric Orthopaedics B 20:152\u0026ndash;156. https://doi.org/10.1097/BPB.0b013e3283441030\u003c/li\u003e\n\u003cli\u003eMahan ST, Yazdy MM, Kasser JR, Werler MM (2013) Is it worthwhile to routinely ultrasound screen children with idiopathic clubfoot for hip dysplasia? J Pediatr Orthop 33:847\u0026ndash;851. https://doi.org/10.1097/BPO.0000000000000100\u003c/li\u003e\n\u003cli\u003eWestberry DE, Davids PLijj JR (2003) Clubfoot and developmental dysplasia of the hip: value of screening hip radiographs in children with clubfoot. 23:503\u0026ndash;7\u003c/li\u003e\n\u003cli\u003eRosendahl K, Markestad T, RJPr L (1996) Developmental dysplasia of the hip: prevalence based on ultrasound diagnosis. 26:635\u0026ndash;9\u003c/li\u003e\n\u003cli\u003eTaleb H, Tabrizi A, Mandi A, et al (2020) Predictive factors for tenotomy in ponseti method for idiopathic clubfoot. Medical Journal of Tabriz University of Medical Sciences 42:433\u0026ndash;9\u003c/li\u003e\n\u003cli\u003eJawadi AJPT (2016) Clubfoot and congenital muscular torticollis prevalence in children diagnosed with developmental dysplasia of hip: review of 594 DDH patients. 6:2161\u0026ndash;0665\u003c/li\u003e\n\u003cli\u003eBorjian AAH, Nasr Esfahani H, Masoudi F (2007) Investigation of the surgical treatment results in children with clubfoot, a sinning posteromedial and lateral approach in Alzahra hospital. Arak medical university journal 10:1\u0026ndash;6\u003c/li\u003e\n\u003cli\u003eGraf R (2017) Hip Sonography: Background; Technique and Common Mistakes; Results; Debate and Politics; Challenges. HIP International 27:215\u0026ndash;219. https://doi.org/10.5301/hipint.5000514\u003c/li\u003e\n\u003cli\u003eGraf R (1980) The diagnosis of congenital hip-joint dislocation by the ultrasonic combound treatment. Arch Orth Traum Surg 97:117\u0026ndash;133. https://doi.org/10.1007/BF00450934\u003c/li\u003e\n\u003cli\u003eCommittee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip (2000) Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip. Pediatrics 105:896\u0026ndash;905. https://doi.org/10.1542/peds.105.4.896\u003c/li\u003e\n\u003cli\u003eAgostiniani R, Atti G, Bonforte S, et al (2020) Recommendations for early diagnosis of Developmental Dysplasia of the Hip (DDH): working group intersociety consensus document. Ital J Pediatr 46:150. https://doi.org/10.1186/s13052-020-00908-2\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Congenital talipes equinovarus, Developmental dysplasia of the hip, Ultrasound screening, Graf classification, Neonatal orthopedics","lastPublishedDoi":"10.21203/rs.3.rs-6489921/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6489921/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e This study investigates the relationship between congenital talipes equinovarus (CTEV) and developmental dysplasia of the hip (DDH), two distinct pediatric musculoskeletal conditions with emerging evidence of association. Given the importance of early DDH detection to avert long-term issues like pain, reduced mobility, and osteoarthritis, the research examines ultrasound screening using the Graf classification. Although effective as a diagnostic tool, its routine use in neonates with CTEV continues to be debated, providing vital insights for diagnostics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis case-control study involved 150 neonates diagnosed with idiopathic congenital clubfoot and 155 healthy controls at Bahonar Hospital, Kerman, Iran, between 2016 and 2021. Participants underwent pelvic ultrasound assessment based on the Graf classification system to evaluate acetabular morphology. Alpha and beta angles were measured bilaterally, and subgroup analyses by sex were performed. Statistical analysis utilized SPSS version 26, with p \u0026lt; 0.05 considered significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The prevalence of DDH in neonates with CTEV was 13.3%, significantly higher than in controls (p \u0026lt; 0.001). Alpha angles less than 60° were exclusively observed in the CTEV group, occurring in 26% and 27.3% of right and left hips, respectively. Beta angles greater than 55° were more prevalent in controls (61.9% vs. 16.7% for right hips; 59.4% vs. 14.7% for left hips). Notably, males exhibited nearly double the DDH prevalence compared to females (18.8% vs. 9.3%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Our findings indicate a significant association between CTEV and DDH, emphasizing the need for targeted ultrasound screening in neonates with clubfoot. Future research should focus on elucidating the underlying mechanisms linking these conditions and refining screening protocols.\u003c/p\u003e","manuscriptTitle":"Prevalence of Developmental Dysplasia of the Hip in Neonates with Congenital Talipes Equinovarus: A Case-Control Study from Iran","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 01:30:44","doi":"10.21203/rs.3.rs-6489921/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e1b899ee-86e9-4dee-95fd-9d273c243938","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-29T06:23:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 01:30:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6489921","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6489921","identity":"rs-6489921","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}