Research Article

Comparison of the efficacy of native radiography and computed tomography in the evaluation of the closed reduction in developmental dysplasia of the hip

Milena Bogojevska Doksevska^‡§, Zoran Bozinovski^‡§, Daniela Georgieva^‡§, Roza Dzoleva Tolevska^‡§, Marta Foteva^§‡, Nenad Atanasov^‡§, Vilijam Velkovski^‡§, Ilir Shabani^‡§, Milan Samardziski^‡§

‡ University Clinic for Orthopedic Diseases, Skopje, Republic of North Macedonia

§ Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, Republic of North Macedonia

Corresponding author: Milena Bogojevska Doksevska ( milena.bogojevska@gmail.com )

This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation: Doksevska MB, Bozinovski Z, Georgieva D, Tolevska RD, Foteva M, Atanasov N, Velkovski V, Shabani I, Samardziski M (2026) Comparison of the efficacy of native radiography and computed tomography in the evaluation of the closed reduction in developmental dysplasia of the hip. Folia Medica 68(3): e182430. https://doi.org/10.3897/folmed.68.e182430

Abstract

Introduction: Developmental dysplasia of the hip (DDH) is a common orthopedic disorder in infants, and accurately assessing the success of reduction is critical for achieving positive outcomes. While native radiography has traditionally been the standard postoperative imaging modality, its diagnostic limitations have prompted consideration of computed tomography (CT) as an alternative.

Aim: The goal was to compare the diagnostic efficacy of native radiography and CT in evaluating the success of closed reduction in DDH.

Materials and methods: A total of 50 patients (100 hips) who underwent closed reduction for DDH were divided into two groups: 25 evaluated by postoperative CT and 25 by native anteroposterior pelvic radiography. The adequacy of reduction was assessed using standardized radiological parameters.

Results: Statistical analyses included comparisons of sensitivity, specificity, and overall accuracy between the two techniques. CT achieved perfect diagnostic performance (100% sensitivity, specificity, and accuracy), while radiography showed lower sensitivity (28.6%), specificity (86.0%), and accuracy (77.6%). The difference between the methods was statistically significant (p<0.001).

This study demonstrates that computed tomography is clinically superior to native radiography for postoperative evaluation after closed reduction in DDH, offering significantly higher diagnostic accuracy and reliability, especially when radiographs are equivocal, while justifying the selective or exclusive use of low-dose CT protocols despite radiation concerns.

Conclusion: Incorporating low-dose CT protocols can enhance diagnostic confidence while minimizing radiation exposure, ensuring better long-term clinical outcomes.

Keywords

closed reduction, computed tomography, developmental dysplasia of the hip, diagnostic accuracy, native radiography

Introduction

Developmental dysplasia of the hip (DDH) remains one of the most significant musculoskeletal disorders of infancy and early childhood, with potential long-term sequelae including joint incongruity, early osteoarthritis, and compromised hip function.^[1] Successful management hinges upon timely and accurate reduction of the femoral head into the acetabulum, often by closed reduction under general anesthesia and subsequent immobilization in a spica cast.^[2] The radiographic confirmation of a stable, concentric reduction is critical for optimal outcomes: residual subluxation or non-reduction predisposes to persistent dysplasia, increased risk of avascular necrosis (AVN), and the need for salvage procedures.^[1]

Historically, the primary imaging modality for post-reduction assessment has been native anteroposterior (AP) pelvic radiography (Fig. 1). Radiographs offer broad availability, low cost, and a relatively low radiation dose; however, they are inherently limited in infants and young children by incomplete ossification of the femoral head and proximal femur, by the presence of spica cast material, and by superimposition of cartilaginous structures.^[3]

Figure 1.

Native anteroposterior pelvic radiography (post-reduction). Note the abundant artifacts at the level of the hips.

Conversely, cross-sectional techniques, particularly CT, offer superior delineation of bony and cartilaginous anatomy, allow assessment of femoral head position in three dimensions, and are increasingly used to evaluate hip reduction adequacy in DDH (Fig. 2).^[4]

Figure 2.

Postoperative computed tomography after closed reduction.

Despite these advantages, CT is not without drawbacks: radiation exposure, the potential need for sedation in young children, and logistical constraints may limit its routine use.^[5] Moreover, the relative merits of radiography versus CT for the evaluation of closed reduction in DDH have not been definitively established in large comparative studies. While some authors suggest that CT provides a more accurate assessment of femoral head positioning and acetabular morphology after reduction, others question whether it adds prognostic value over plain films.^[6]

Aim

Given the pivotal role of imaging in guiding clinical decision-making and the potential implications of residual hip incongruity, this study aims to compare native radiography and CT in the assessment of closed reduction in DDH. Specifically, we evaluate their relative accuracy, reliability, and clinical utility in confirming reduction and, by extension, guiding subsequent management. The findings may inform imaging protocols and algorithmic pathways in the immediate post-reduction period for children with DDH.

Material and methods

Study design

This study is a clinical, observational investigation conducted at the Clinic for Orthopedic Surgery from 2016 to 2024. Patients were selected based on predefined inclusion and exclusion criteria. All participants underwent closed reduction of the hip under general anesthesia at the Clinic. Postoperative imaging, radiography or CT, was performed on the same day or within 24 hours of the intervention at the Institute of Radiology. Parents or legal guardians of all participants provided written informed consent after being thoroughly informed about the study’s purpose, procedures, and potential risks. The study protocol adhered to the principles of the Declaration of Helsinki and local ethical standards.

Patient selection

A total of 50 patients who underwent closed reduction for developmental dysplasia of the hip (DDH) were included.

Inclusion criteria were as follows:

Children from the neonatal period up to four years of age.
Clinically, sonographically, and/or radiographically confirmed DDH, including hip dislocation or subluxation.
Sonographic classification of Graf type III or IV hips.
Closed reduction performed as the primary treatment modality.
Signed informed consent obtained from parents or legal guardians.

Exclusion criteria included:

Associated conditions such as neuromuscular disorders or teratologic dislocations secondary to genetic syndromes or arthrogryposis.
Previous surgical intervention on the affected hip.
Incomplete clinical or imaging documentation.

Previous treatment with an orthosis (Pavlik harness, Hilgenreiner, or Tübingen brace) was not considered an exclusion criterion.

Study groups and imaging protocol

Of the 50 patients, 25 underwent postoperative CT imaging using a narrow-window protocol to evaluate reduction success, preferably with lead shielding applied to the genital region. Selection of patients for CT evaluation was operator-dependent, influenced by the surgeon’s experience, familiarity with imaging modalities, and ethical considerations.

The control group consisted of the remaining 25 patients, who underwent postoperative evaluation with native anteroposterior (AP) pelvic radiography, preferably with lead shielding. This method was also chosen in response to operator preferences.

The minimum follow-up period for all participants was one year post-intervention. Patients who did not attend follow-up visits within this timeframe were excluded from the final analysis. Follow-up evaluations were scheduled every three months and included clinical and ultrasonographic assessment of the hip. Control radiographs were obtained every six months for both groups under standard protective protocols.

Clinical procedure

A national general DDH screening program exists in North Macedonia, encompassing clinical and ultrasonographic evaluation of all newborns and infants. For patients with abnormal findings, a standardized diagnostic and monitoring form is initiated to track clinical, ultrasonographic, and radiographic parameters throughout follow-up.

Most infants with DDH achieve favorable outcomes using orthotic management (Pavlik harness, Tübingen, or Hilgenreiner brace). However, approximately ten to fifteen patients annually with Graf type III or IV hips require closed reduction.

Parents or guardians were informed verbally and in writing about the procedure, including the need for ionizing radiation for evaluation, and consented to the use of anonymized clinical and imaging data (US, CT, and radiographs) for research purposes.

Closed reduction was performed under general anesthesia in an operating room, without surgical incision. The patient was positioned on a specialized orthopedic table, and reduction was achieved through gentle abduction, elevation, and flexion of the femur. After the Ortolani reduction sign was obtained, hip stability was assessed by determining the range of adduction and extension at which dislocation reoccurred. The range within which reduction remained stable was defined as the “safe zone according to Ramsey.” Excessive abduction and flexion were avoided to minimize the risk of avascular necrosis (AVN) of the femoral head.

Intraoperative radiographic evaluation confirmed femoral head position. In some cases, adductor tenotomy was required, performed percutaneously using a tenotome or scalpel No. 15. When a stable position was achieved, a hip spica cast was applied, extending from the umbilicus to the ankles, regardless of unilateral or bilateral involvement. Following recovery from anesthesia and stabilization of the cast, postoperative imaging was performed—CT in the study group or radiography in the control group. Preoperative traction was occasionally applied based on the surgeon’s preference.

Imaging technique

Computed tomography imaging with a narrow window was performed in patients immobilized in a hip spica cast. Owing to the immobilization and short duration of the scan, additional sedation was not required.

The CT protocol, standardized in collaboration with radiologic technologists, was as follows:

The patient is positioned supine in the craniocaudal direction, with the head oriented superiorly.
The abducted lower limbs are positioned at the widest section of the scanner entry.
Lead shielding should be applied over the genital area.
Radiation exposure is minimized by limiting the scanning field to the level of the triradiate cartilage.
The scan range extends bilaterally to the level of the subtrochanteric line.
Axial sections are obtained with a slice thickness of 10 mm (1 cm).

Evaluation parameters and variables

To assess the quality of closed reduction, several radiological parameters were evaluated on the obtained CT or radiographic images (Fig. 3). These indicators provided objective measures for determining the adequacy and concentricity of the femoral head position within the acetabulum.

Figure 3.

Parameters for evaluation: (a) contact between the femoral head and the triradiate cartilage of the acetabulum indicating lateral/posterior displacement (right-no contact, left-there is contact); (b) shallow and dysplastic acetabular morphology (more dysplastic on the right side); (c) widened joint space (normal on the left); (d) disrupted modified Shenton’s line (right disrupted, left intact); (e) posterior femoral neck line not entering the acetabulum (positive on the right, negative on the left).

The following parameters were analyzed:

Contact between the femoral head and the triradiate cartilage of the acetabulum, to identify potential lateral or posterior displacement.
Acetabular morphology, specifically evaluating for shallow or dysplastic acetabula.
Joint space width, with emphasis on detecting abnormal widening suggestive of suboptimal congruence.
Integrity of the modified Shenton’s line, used to assess the continuity of the femoral neck–acetabular relationship.
Posterior contour of the femoral neck, noting whether it failed to enter or align properly within the acetabular cavity.

Control group

The control (non-exposed) group consisted of patients who underwent closed reduction of the hip but were evaluated postoperatively using the conventional standard protocol—native anteroposterior (AP) pelvic radiography performed through the plaster immobilization. This imaging approach represents the current standard practice for assessing the adequacy of reduction.^[7]

Parameters routinely analyzed in the control or comparative group included the contact between the superior margin of the femoral neck and the acetabular cavity or triradiate cartilage, as well as the continuity and integrity of Shenton–Menard’s line, when visualized. These radiographic indicators served as primary criteria for confirming concentric reduction and assessing the quality of hip alignment following the procedure.

Results

A total of 50 patients treated with closed reduction for developmental dysplasia of the hip (DDH) by thirteen orthopedic surgeons were included in the study. Among them, 42 (84%) were female and 8 (16%) male. Of the 100 hips evaluated, 70 were dislocated. Seventeen patients presented with left-sided dislocation, thirteen with right-sided, and another twenty with bilateral involvement. The median age at the start of treatment was 9 months (range: 2–25 months). Preoperative skin traction was applied in 10 patients for periods ranging from 1 to 21 days, and adductor tenotomy was performed in 4 patients.

Group characteristics

In the CT group (n=25; 31 dislocated and 19 unaffected hips), five parameters were measured to evaluate the postoperative reduction. In the radiography group (n=25; 39 dislocated and 11 unaffected hips), two standard parameters were analyzed whenever visualized.

Due to ethical considerations regarding ionizing radiation exposure in pediatric patients, it was not feasible to perform both imaging methods (radiography and CT) on the same subjects. Therefore, two separate but comparable groups of patients were analyzed. The groups were matched by age, sex, and disease characteristics to minimize potential bias and ensure comparability between the diagnostic methods.

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics (version 29.0; IBM Corp., Armonk, NY, USA) and Microsoft Excel (Microsoft Corp., Redmond, WA, USA) and it included five variables in the CT group and two in the radiography group. Categorical variables, including modality of imaging (CT vs. radiography) and diagnostic accuracy (correct vs incorrect evaluation), were summarized as frequencies and percentages.

Post-reduction findings

On the initial post-reduction CT scan, persistent dislocation of the femoral head was identified in 4 of 31 (9.7%) dislocated hips. Two of these patients underwent repeat closed reduction with adductor tenotomy, while one required open reduction. No false positive or negative cases were established.

In the radiography group, 5 of 39 (12.8%) hips were found intraoperatively to have suboptimal hip stability despite apparently satisfactory reduction. Only one case (two hips) of persistent dislocation was detected on postoperative radiography by the most experienced surgeon, while in three cases (three hips), artifacts and poor visualization masked persistent dislocation, which was subsequently confirmed on follow-up CT.^[17] Among these, two patients underwent repeat reduction with adductor tenotomy, two required open reduction, and one underwent open reduction combined with femoral osteotomy. Five hips were equivocal; if there was persistent dislocation, follow-up CT showed that the hip was reduced properly.

Computed tomography demonstrated complete diagnostic accuracy in evaluating closed reduction outcomes in developmental dysplasia of the hip (DDH). All successfully reduced and unreduced hips were correctly classified, yielding a sensitivity, specificity, and accuracy of 100%. In contrast, native radiography displayed significantly lower sensitivity (28.6%), while specificity and overall accuracy remained moderately high (86.0% and 77.6%, respectively) (Table 1).

Table 1.

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Diagnostic validity of computed tomography (CT) and native radiography in evaluating closed reduction outcomes in developmental dysplasia of the hip (per-hip analysis)

Parameter	CT (%)	Radiography (%)	Fisher’s exact test (p-value)	Odds Ratio (95% CI)
Sensitivity	100.0	28.6	<0.001	∞ (4.5–∞)*
Specificity	100.0	86.0	0.0134	∞ (2.8–∞)*
Accuracy	100.0	77.6	<0.001	∞ (5.0–∞)*

Fisher’s exact test confirmed statistically significant differences between CT and radiography for all diagnostic parameters (p<0.05). The odds ratios approached infinity, reflecting the absence of false positive or false negative findings in the CT group. These results highlight the superior diagnostic reliability of CT in verifying the adequacy of closed reduction compared with conventional radiography (Fig. 4).

Figure 4.

CT demonstrated perfect sensitivity, specificity, and accuracy (100%), while radiography yielded markedly lower values (28.6%, 86.0%, and 77.6%, respectively). Bars represent proportions for each diagnostic parameter (dark blue = sensitivity, medium blue = specificity, light blue = accuracy). Fisher’s exact test indicated statistically significant differences for all parameters (p<0.05), with odds ratios approaching infinity due to the absence of false classifications in the CT group.

Computed tomography achieved 100% diagnostic accuracy, with all 50 hips correctly classified and no false results, whereas radiography correctly identified 39 of 50 hips (78%), with 11 misclassifications. A chi-square test demonstrated a statistically significant difference between the two modalities (χ²=12.62, p=0.0004). The calculated phi coefficient (φ=0.36) indicated a moderate-to-strong association between imaging modality and diagnostic correctness (Fig. 5). These findings confirm the superior diagnostic reliability of CT, highlighting its precision in identifying adequate reductions compared with conventional radiography.

Figure 5.

Comparison of correct versus incorrect classifications between computed tomography (CT) and native radiography in evaluating closed reduction outcomes in developmental dysplasia of the hip (DDH).

Discussion

The findings of this study underscore the clinical superiority of CT over native radiography in the postoperative assessment of closed reduction in DDH. The perfect diagnostic performance of CT demonstrates its ability to precisely determine femoral head positioning and detect subtle subluxations that are often missed on radiographs, particularly in the presence of plaster cast artifacts or immature ossification centers.^[2-5,8-16]

Although native radiography remains widely used due to its lower radiation exposure, accessibility, and cost-effectiveness, its limited sensitivity poses a substantial risk of false reassurance, potentially delaying the identification and management of persistent dislocation or residual dysplasia. This aligns with prior research advocating the selective use of low-dose CT protocols for postoperative evaluation, balancing diagnostic accuracy with radiation safety.

The statistically significant difference in diagnostic validity between the two modalities supports the routine incorporation of CT imaging in cases where radiographic assessment is equivocal or inconclusive. The absence of false classifications in CT not only reinforces its reliability but also demonstrates its potential to reduce the rate of late complications, including avascular necrosis and the need for secondary reconstructive surgery. The chi-square analysis reinforces the superiority of CT as a post-reduction imaging modality for DDH. The perfect classification performance observed with CT and the medium-to-large effect size reflect not only statistical significance but also strong clinical relevance. Radiography’s higher rate of misclassification can be attributed to limited visualization through plaster casts and immature bony structures, which reduce sensitivity to subtle malpositioning. The sensitivity and specificity of the CT-based assessment, as measured in our study, are higher than the values reported for the radiography-based assessment in the control cohort (native radiography); however, due to differences in populations and reference standards, a direct head-to-head comparison cannot be made.

One limitation of this study is the use of two independent patient groups rather than paired imaging within the same subjects. This approach was chosen intentionally to avoid unnecessary additional radiation exposure in children, in accordance with the ALARA (As Low As Reasonably Achievable) principle of radiological protection. The two groups were carefully selected to be similar in age and clinical presentation to maintain comparability.

From a clinical standpoint, these findings suggest that radiographic evaluation alone may provide false reassurance regarding reduction adequacy, potentially delaying the identification of persistent dislocation or leading to residual dysplasia. The robust significance (p<0.001) supports routine or selective use of CT, particularly in ambiguous or borderline reductions, to ensure concentric femoral head positioning.

Conclusion

Computed tomography demonstrates superior diagnostic accuracy compared with native radiography for confirming successful closed reduction in developmental dysplasia of the hip. Based on its ability to provide a definitive and reproducible assessment of femoral head position, low-dose CT should be regarded as the reference imaging modality for post-reduction evaluation whenever available.

In an algorithmic perspective, native radiography may serve as an initial screening tool. However, reliance on radiography alone carries a substantial risk of misclassification. Incorporation of low-dose CT into structured post-reduction imaging pathways, either as a confirmatory modality or as a primary assessment tool in centers with ready access, allows early identification of inadequate reduction, supports timely corrective intervention, and promotes standardized, evidence-based care. When applied within optimized low-dose protocols aligning with ALARA principles, this algorithmic approach enhances diagnostic confidence while adhering to radiation-protection principles, with the potential to improve long-term clinical outcomes in children with developmental dysplasia of the hip.^[18]

References

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Additional information

Ethical statement

The authors declared that no clinical trials were used in the present study.
The authors declared that no experiments on humans or human tissues were performed for the present study.
The authors declared that they obtained written informed consent for publishing this study and any accompanying images from the parents or legal guardians of all participants. They ensured that all parties were thoroughly informed about the study’s purpose, procedures, and potential risks.
This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee for Human Trials at the Medical Faculty, Ss. Cyril and Methodius University, Skopje, North Macedonia (ref. No. 03-5505/7 of 28.10.2024).
The authors declared that no experiments on animals were performed for the present study.
The authors declared that no commercially available immortalized human and animal cell lines were used in the present study.

Conflict of interest

The authors have declared that no competing interests exist.

Artificial Intelligence (AI) use

Artificial intelligence assistance (ChatGPT, OpenAI, GPT-5 model) was used exclusively for language refinement, grammar correction, and formatting suggestions during manuscript preparation. The authors verified all content for accuracy and scientific validity. No part of the data analysis, interpretation, or conclusions was generated by AI. The authors take full responsibility for the integrity and originality of the manuscript.

Funding

No funding was reported.

Author contributions

All authors have contributed equally.

Author ORCIDs

Milena Bogojevska Doksevska https://orcid.org/0000-0003-0885-0491

Data availability

All of the data that support the findings of this study are available in the main text.