Secondary (Late) Developmental Dysplasia of the Hip with Displacement: From Case Studies to a Proposition for a Modified Diagnostic Path
Round 1
Reviewer 1 Report
Nice and comprehensive overview.
Some questions:
- Who performed the ultrasound examinations of the hip? the clinician or a pediatric radiologist?
- Was a radiologist involved in this paper?
- Are there better ultrasound images available? In our insitutiuon, ultrasound images are transfered to a PACS system, these images look like scanned hardcopy images.
- 3D images of a CT scan can be helpfull but diagnosis should be made on the source images.
Author Response
Reviewer 1
Nice and comprehensive overview.
Some questions:
- Who performed the ultrasound examinations of the hip? the clinician or a pediatric radiologist?
The ultrasound examinations were performed by a specialist general surgeon. In the study, we showed that an orthopedic specialist should be involved in the process of DDH diagnostics, because he is always vigilant, consisting in combining a physical examination with an additional examinations. Of course, we do not deny that the clinician or a pediatric radiologist can perform the examination, provided that the ultrasound examination is combined with a clinical examination (dynamic ultrasound) or the radiologist will refer the patient to an orthopedic specialist for final clinical verification.
- Was a radiologist involved in this paper?
The ultrasound documentation has been analyzed by an orthopedic specialist who is a specialist in hip ultrasound, certified by prof. R. Graf (Graf's method). He was appointed in the judicial investigation process professor of clinical radiology prof. Andrzej Urbanik and the best experts in ultrasound analysis in Poland.
- Are there better ultrasound images available? In our insitutiuon, ultrasound images are transfered to a PACS system, these images look like scanned hardcopy images.
As the data comes from paper court documents and not from the hospital IT system, the quality of the scans is not very good. However, due to the uniqueness of the material, it was decided to include it in this format of the manuscript.
We have included the above information in the manuscript in the methods section so that the reader is aware why the quality of the photos is not the best and what it comes from.
- 3D images of a CT scan can be helpfull but diagnosis should be made on the source images.
CT images from the very beginning of treatment of the patient were not taken as she was treated as a typical case. For this reason, advanced radiological techniques (high irradiation) are not used in screening. The attending physician in whom, in the final verdict, the malpractice did not apply the main diagnostic principle, which was an ultrasound examination with a physical examination, and missed the hip contracture. If he followed the principle that the priority is always a physical examination, then he would most likely enter the correct diagnostic path, extend the examination to a radiological examination and even a CT of the pelvis.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
The authors aimed to report, an example of secondary (late) developmental dysplasia of the hip (DDH). The peculiarity of the case presentation is distinguished by the fact that the course of DDH ended with total dislocation of the joint regarded as healthy at birth (from the point of view of its anatomical structure), even though in terms of function, it was a high-risk hip because bilateral postpartum contracture had been noted. Moreover they performed a brief literature review on the topic.
The study covers some issues that have been overlooked in other similar topics. The structure of the manuscript appears adequate and well divided in the sections. Moreover, the study is easy to follow, but few issues should be improved. Some of the comments that would improve the overall quality of the study are:
- Authors must pay attention to the technical terms acronyms they used in the text.
- English language needs to be revised.
- Conclusion Section: This paragraph required a general revision to eliminate redundant sentences and to add some "take-home message".
Author Response
Reviewer 2
The authors aimed to report, an example of secondary (late) developmental dysplasia of the hip (DDH). The peculiarity of the case presentation is distinguished by the fact that the course of DDH ended with total dislocation of the joint regarded as healthy at birth (from the point of view of its anatomical structure), even though in terms of function, it was a high-risk hip because bilateral postpartum contracture had been noted. Moreover they performed a brief literature review on the topic.
The study covers some issues that have been overlooked in other similar topics. The structure of the manuscript appears adequate and well divided in the sections. Moreover, the study is easy to follow, but few issues should be improved. Some of the comments that would improve the overall quality of the study are:
- Authors must pay attention to the technical terms acronyms they used in the text.
The manuscript uses mostly acronyms that have been removed, i.e.
- DDH: developmental dysplasia of the hip
- AAOS: American Academy of Orthopedic Surgeons
In one case concerning the example of genetic variation, namely the SNP, it was not explained, so we supplemented the manuscript with this explanation:
genetic variabilities headed by Single Nucleotide Polymorphisms (SNP)
In the second case, i.e. regarding CT, we have also included an explanation:
computed tomography (CT)
- English language needs to be revised.
The text was corrected as suggested. The changes are noted in the manuscript.
- Conclusion Section: This paragraph required a general revision to eliminate redundant sentences and to add some "take-home message".
As recommended, we added a paragraph containing the main message of our work as follow:
“The main message of the DDH case study is that physical examinations and additional examinations, such as diagnostic tests (USG, RTG, genetic), should be routinely performed in the screening procedure to identify both clinically and diagnostically mute cases.
Clarification of the diagnostic scheme could significantly affect the course of treatment of newborns, but also of older patients (late dysplasia). Doctors with knowledge of genetic variations which affect joint tissues, and possible scenarios for the development of pathological changes, could plan preventive procedures to mitigate the consequences of severe degenerative changes which are observed in the third and fourth decade of life [13] [33].”
Author Response File: Author Response.pdf
Reviewer 3 Report
The authors described a rare pediatric case of secondary (late) developmental dysplasia of the hip (DDH) with displacement. It is distinguished by the fact that the course of DDH ended with total dislocation of the joint regarded as healthy at birth. In this manuscript, there are some new points for more effective management of DDH cases and thus significantly reduce the cost of patient treatment. However, I have some concerns.
- As this report is a case report, the authors should summarise Introduction part and Conclusion. These sections were too long.
- It was too difficult for me to understand the Figures especially in ultrasonography findings. Please revise the figure legends to make it understandable.
- There are some typos (e.g. in Figure 1, a to A). Please carefully read your manuscript again.
- In general, I cannot understand the contents of this manuscript. Each section is too long. Extensive revise is needed because this article is "Case report".
Author Response
Reviewer 3
The authors described a rare pediatric case of secondary (late) developmental dysplasia of the hip (DDH) with displacement. It is distinguished by the fact that the course of DDH ended with total dislocation of the joint regarded as healthy at birth. In this manuscript, there are some new points for more effective management of DDH cases and thus significantly reduce the cost of patient treatment. However, I have some concerns.
- As this report is a case report, the authors should summarise Introduction part and Conclusion. These sections were too long.
As suggested, we have clarified and summarised both the introduction and the conclusions.
However, it was difficult for us to shorten these chapters because we touched on a rather complicated problem that requires a little more explanation than is usually used in this type of work.
Having experience in reviewing the literature in the field of hip disorders, we have often come across ambiguities, or even erroneous descriptions of the ethology of the defect, in significant titles of scientific publications. The described case is only a pretext to draw attention to the need for an improved diagnostic pathway in the treatment of hip developmental disorders.
- It was too difficult for me to understand the Figures especially in ultrasonography findings. Please revise the figure legends to make it understandable.
We made some minor changes to the captions of the figures as recommended.
We worked on data from court files. Consequently, the quality of the photos is not perfect. With detailed descriptions of the pictures, we tried to reflect the importance of this data, hence such a large amount of information. However, it seems to be necessary for understanding the problem, especially by orthopedic doctors.
- There are some typos (e.g. in Figure 1, a to A). Please carefully read your manuscript again.
Typos corrected as suggested.
- In general, I cannot understand the contents of this manuscript. Each section is too long. Extensive revise is needed because this article is "Case report".
As we wrote above, the case developed comes from court files. It concerns a complex issue that has not been unequivocally explained and structured to this day. For this reason, we undertook a literature review, and the presented case became a pretext to show shortcomings in the health system. We indicated them, suggesting a revision of the diagnostic and treatment processes of hip disorders.
Our line of thinking required the presentation of the problem of hip development disorders in a slightly more extensive form, hence both the introduction, discussion and conclusions are presented more broadly than usually in this type of paper.
Author Response File: Author Response.pdf
Round 2
Reviewer 3 Report
The authors revised the manuscript. However, there are still typos. Please reread and rewrite your manuscript.
