SonoHipAngles

Developmental Dysplasia of the Hip (DDH) encompasses a spectrum of conditions where the hip joint is improperly formed, ranging from a mild acetabular shallowness to full dislocation. Early detection of DDH is crucial for effective management and prevention of long-term complications such as pain, limited mobility, or early-onset osteoarthritis.

Ultrasonography, rather than X-ray, is the preferred method for diagnosing DDH in infants, especially under the age of 6 months. Ultrasound provides a non-invasive and radiation-free way to visualize the soft tissues, cartilage, and bones in real time. The Graf method is the most widely used technique, where two critical angles—alpha (α) and beta (β)—are measured to assess the development of the acetabulum and classify the hip's condition.

This application is designed to aid healthcare professionals—especially radiologists, orthopaedic surgeons—in evaluating DDH by calculating the alpha (α) and beta (β) angles quickly and from saved ultrasound images of the patient hip.
User can easily Annotate key anatomical landmarks required for angle measurement and the subtended lines for α and β are visually overlaid on the image simplifying the measurement process Display calculated α and β angles in real time on the ultrasound image as points are adjusted. Provide instant visual feedback by color-coding the angles:Alpha angle (α): red, Beta angle (β): yellow. Automatically also classify the hip joint based on the Graf method Type I,Type IIa/b,Type IIc,Type III, helping clinicians to have a quick glimpse and visualise the relationship between the angles real time.Healthcare professionals, particularly in busy departments, can save significant time by quickly loading ultrasound images and automating angle calculations, identify abnormal hips on the go . App can also be used as a training tool for medical students, residents, and junior clinicians, teaching them how to recognise key landmarks, make accurate measurements, and classify DDH using ultrasound images. By rapid visually displaying the measurements on the screen and generating easy-to-understand images, app helps clinicians explain the condition and its severity to parents.
This app is an essential tool for orthopedic surgeons, and radiologists involved in diagnosing DDH using ultrasonography. Its real-time measurements of alpha (α) and beta (β) angles, user-friendly interface, and reliable classification system streamline the diagnostic process, and improved overall workflow in clinical practice.

Positioning of the Reference Lines:

Line Placement three points of interest are commonly need to be indentified in the image for correct placement of lines according to Graf method in conventional method

1.Centre of labrum where the yellow line should pass,

2.Bony rim of acetabulum ,here the bony rim is angular this point is easily recognized.when rounded this point is defined as the point where the concavity of the bony acetabular roof changes into the convexity of the ilium

3.Triradiate cartilage where the undersurface of the medial border of the acetabulum where the iliac bone meets the triradiate cartilage.No need for Point Selection users can adjust the draggable points of 3 lines and select the preferred position without selecting three points with a double-tap on the image By aiming to adjust and to pass the first the line tangential to the Iliac Bone (blue), find then the Triradiate cartilage and the Bony rim of acetabulum(red), and the third the Labrum to(yellow).

Blue Line: This line -base line-is positioned along the vertical portion of the ilium tangential to the echo of the os ilium Place both draggable points of blue line over and blue line serves as a baseline and is the reference for the intersections with the other lines namely red yellow.

Red Line Place the two draggable points of red line aiming at crossing triradiate point and the intersection at bony rim of acetabulum. Red line is orming the acetabular roof, the sloping part of the hip joint. Alpha Angle (α): This is the angle formed between the red line (representing the acetabular roof) and the vertical baseline (blue line). It helps assess the development of the acetabulum. Normal values of the alpha angle are typically greater than 60°.

Red line representing the alpha angle (α) will be placed.

Yellow Line the cartilaginous roof line is drawn from the bony rim through the centreof the acetabular labrum. Beta Angle (β): This is the angle formed between the blue line (the ilium) and the yellow line. A normal beta angle is usually less than 55°.

Help how I can use it

1. Load an Ultrasound Image:

Action: Press the "Select Image" button on the main screen to load an ultrasound image from your device's photo library.
Consent Confirmation: A dialogue box will appear, asking for confirmation to load the image with the patient's consent. You must confirm before proceeding.
Why It’s Important: Loading an ultrasound image is the first step, as the app needs this visual input to measure the α (alpha) and β (beta) angles.

2. Select Hip Side & Enter Age:

Action: After the image is loaded, the app will prompt you to select which hip you are measuring: Left or Right.
Input Patient's Age: You will also be asked to enter the patient’s age in months. This information is crucial for classification, especially for Type IIa/b, which considers age when determining the diagnosis.
Why It’s Important: The side (left or right) influences how the lines and angles are displayed, and the patient's age plays a critical role in determining the classification.

3. Position Draggable Points:

Blue Line (Baseline):
- What to Do: Drag the blue point to position the vertical line along the ilium. This line acts as the reference or baseline.
- Why It’s Important: This line serves as the starting point for the other measurements and is essential for ensuring that the angles are correctly oriented.
Red Line (α Angle):
- What to Do: Drag two points to adjust the red line along the acetabular roof (the bony roof of the hip socket). One point should be near the triradiate cartilage, and the other should define the slope of the acetabular roof.
- Why It’s Important: The α angle helps assess the development of the acetabulum. Incorrect positioning here could result in inaccurate classifications.
Yellow Line (β Angle):
- What to Do: Place two draggable points along the cartilaginous roof. One point should align with the baseline, and the other defines the cartilaginous roof slope.
- Why It’s Important: The β angle is used to assess the state of the hip’s cartilaginous structures, essential for determining delayed ossification or dysplasia.

4. Adjust the Points:

Real-Time Feedback: As you drag and adjust the points on the image, the app continuously updates the measurements for the α and β angles in real time.
Fine-Tuning: Adjust the points to refine the lines. You can zoom in for precise positioning or pan around the image to adjust all points easily.
Why It’s Important: Accurate positioning of the points is essential for making a precise diagnosis. You can fine-tune the placement until the lines match the anatomical landmarks exactly.

5. View the Results:

Angle Display: The app calculates and displays the α (alpha) and β (beta) angles in real-time. These angles are color-coded for clarity:
- α (alpha) angle is shown in red.
- β (beta) angle is shown in yellow.
Classification: Based on the measured angles and the patient's age, the app automatically classifies the hip condition according to the Graf method:
- Type I: Normal hip development (α ≥ 60°, β ≤ 55°).
- Type IIa/b: Mild dysplasia (α = 50°–59°, β ≥ 55°).
- Type IIc: Borderline dysplasia (α = 43°–49°, β ≤ 77°).
- Type D: Severe dysplasia (α = 43°–49°, β > 77°).
- Type III: Dislocated hip (α < 43°, β > 77°).
Diagnosis and Feedback: The diagnosis is displayed alongside the measured angles, giving the clinician instant insight into the hip condition.
Why It’s Important: This feature streamlines diagnosis by eliminating the need for manual calculations and allows for real-time decision-making.

6. Zoom and Pan:

Action: Use pinch gestures to zoom in and out of the image for more precise positioning of the points. You can also drag to pan around the image for better visibility.
Why It’s Important: Zooming and panning make it easier to accurately place the draggable points on small or hard-to-see anatomical features, ensuring precise measurements.

7. Restart:

Action: Press the "New Image" button to start the process over. This will clear the current image and measurements, allowing you to load a new ultrasound image.
Why It’s Important: This feature is useful when analyzing multiple patients or when restarting the measurement process for a single patient.

Key Features Breakdown:

Real-Time Feedback:
- As you move the draggable points, the α and β angles are calculated instantly, providing visual feedback.
- The color-coded lines and angles (red for α, yellow for β) make it easy to distinguish between the two angles.
- Why It’s Important: Real-time feedback helps clinicians fine-tune the placement of points quickly and accurately.
Classification Based on Graf’s Method:
- Once the angles are calculated, the app automatically classifies the hip condition using Graf’s classification:
  - Type I (Normal).
  - Type IIa/b (Mild Dysplasia).
  - Type IIc (Borderline Dysplasia).
  - Type D (Severe Dysplasia).
  - Type III (Dislocated Hip).
- Why It’s Important: Automating this classification saves time and reduces the possibility of human error.
Training Tool:
- The app can also serve as a training tool for medical students, residents, and junior clinicians, teaching them how to:
  - Recognize key anatomical landmarks.
  - Accurately measure α and β angles.
  - Classify developmental dysplasia of the hip (DDH).
- Why It’s Important: It provides a practical learning environment for clinicians who are still mastering ultrasound evaluation for DDH.
Zoom and Pan:
- Pinch gestures allow the user to zoom in or out for more detailed placement of points.
- The image can also be panned for better access to specific parts of the hip joint.
- Why It’s Important: Allows for more precise point placement on anatomical structures that might be difficult to see.
Export & Reporting:
- Once the measurement and classification are complete, results can be exported for medical records or shared with colleagues for second opinions.
- Why It’s Important: It ensures that all data is documented and ready for further evaluation or telemedicine consultations.

Conclusion:

This app is an indispensable tool for orthopedic surgeons and radiologists. Its real-time angle calculations, user-friendly interface, and reliable Graf-based classification system allow for efficient, accurate, and reproducible assessments of developmental dysplasia of the hip (DDH). Whether used in everyday clinical practice or for educational purposes, the app simplifies the diagnosis and enhances the workflow for clinicians.

References

1.Hip sonography. Diagnosis and management of infant hip dysplasia.by Graf R.
Berlin: Springer; 2006.
2.Ultrasonographic Graf type IIa hip needs more consideration in newborn girlsby Hakan Ömeroğlu et al.J Child Orthop. 2013 Mar; 7(2): 95-98.
3.Observational studies on ultrasound screening for developmental dysplasia of the hip in newborns - a systematic review.by Puhan MA, Woolacott N, Kleijnen J, Steurer.
JUltraschall Med. 2003 Dec; 24(6):377-82.
4.Transinguinal sonographic determination of the position of the femoral head after reposition and follow-up in a spica cast (2010) Beek FJ, Nievelstein RJ, Pruijs HE, de Jong PA, Sakkers RJ. Pediatr Radiol 40(11):1794-9.

What the app has to offer compared to conventional measurement

Measuring the angles using draggable points and real-time feedback in an app is better than manually drawing lines on an X-ray for several reasons:

1. Precision and Accuracy:

Draggable Points allow for precise positioning, ensuring that the lines represent the exact anatomy and align with key landmarks, like the acetabular roof and ilium, with minimal errors.
Digital Calculations remove the risk of human error present in manually drawn lines. The angles are calculated accurately using mathematical algorithms, rather than relying on the user's estimation.

2. Real-time Updates:

With draggable points, the angles (α and β) are updated in real-time as you adjust the lines. This gives immediate feedback, allowing you to fine-tune the measurements without having to redraw or recalculate.
On X-rays, any change in the lines would require erasing and redrawing the lines, which is time-consuming and prone to further error.
Interactive Adjustment: The draggable points offer real-time feedback, meaning that moving one point will automatically recalculate the α and β angles and update the category (e.g., Type I or Type III/IV) based on predefined criteria.
Visual Clarity: The color-coded lines (red for α, yellow for β) ensure that the user can clearly see which line corresponds to which angle.

3. Consistency:

Software tools ensure consistent measurements every time, as the calculations are based on a standardized algorithm.
Manually drawing lines can vary from one user to another, even from one X-ray to another by the same user, leading to inconsistent results.

4. Speed and Efficiency:

Using draggable points in a digital interface speeds up the process of setting up the lines, adjusting, and getting results. You can adjust positions quickly, and the app calculates the angles instantly.
Manually drawing on X-rays is slower and less efficient, especially if you need to measure angles multiple times or for multiple patients.

5. Objective Measurements:

Digital tools remove the subjectivity inherent in manually placing and drawing lines on an X-ray. The software calculates the exact intersection points, slopes, and angles objectively.
Manual line drawing involves human judgment, which can introduce bias and reduce objectivity.

6. Automated Classification:

In the app, once the angles are measured, the software can automatically categorize the case (e.g., Type I, Type II) based on established criteria, saving time and ensuring accuracy.
With manual drawing, you would need to refer to a table or guidelines after drawing the lines, which increases the risk of misclassification.

7. Reproducibility:

Digital measurements can be easily reproduced by other clinicians, since the exact coordinates of the points can be saved or exported. This makes it easier to track patient progress over time or share with colleagues for second opinions.
Manually drawn lines on X-rays are difficult to reproduce exactly, making it harder to compare results over time or with other clinicians.

8. Data Export and Integration:

Digital systems allow you to export the angles, lines, and categories as data files for electronic medical records or further analysis.
On X-rays, you can’t easily export manual measurements or integrate them with electronic systems.

9. Enhanced Visualization:

Digital tools often provide visual enhancements like zoom, color-coded lines (red for α, yellow for β), and magnification for finer adjustments.
X-rays with drawn lines lack these enhancements, making it harder to precisely visualize small details, especially in complex cases.

10. No Need for Repeated X-rays:

With digital adjustments, there’s no need to take additional X-rays if a measurement seems off. You can just tweak the points and lines until the correct measurement is obtained.
In contrast, if there’s uncertainty or error in manual X-ray line drawing, it may result in taking more X-rays, which increases patient radiation exposure.

11. Scalability:

A digital system can easily handle a large volume of patients, as it allows for quick measurements and data management.
Manually drawing on X-rays can become cumbersome and impractical when dealing with a high patient load.

12. Patient Education and Communication:

With digital tools, you can easily show patients the results on a screen, explaining the condition and treatment options with clear visual aids.
On an X-ray, manually drawn lines are less visually clear, making it harder for patients to understand the measurements or the significance of the angles.

13. Data Storage and Accessibility:

Digital tools offer easy storage and retrieval of previous measurements, allowing you to track progress over time. You can easily access and compare results without physical space limitations.
Manual X-rays with drawn lines must be physically stored, take up space, and can degrade over time. Finding and comparing previous X-rays is less convenient.

In conclusion, using draggable points and real-time digital measurements is more precise, efficient, consistent, and scalable than manually drawing lines on X-rays. It reduces the chances of errors, improves reproducibility, and provides objective and immediate feedback, making it a superior method in clinical practice.

This app is an essential tool for pediatricians, orthopedic surgeons, and radiologists involved in diagnosing DDH using ultrasonography. Its real-time measurements of alpha (α) and beta (β) angles, user-friendly interface, and reliable classification system streamline the diagnostic process, and improved overall workflow in clinical practice

Disclaimer.

Regarding its plausibility app offers no diagnosis or treatment. App provide an early indication that further evaluation may be warranted by Speciality Doctor. Explicitly is announced that the apps are not for diagnosis. Clinical judgment and experience are required to properly use the software. App alone do not replace an M.D. or specialist. All information received from the App output must be reviewed before any attempted treatment. The software is not for primary image interpretation. Any influence to the operators in making decisions remains user own responsibility and experience. App does not dispense medical advice. Patient should seek a doctor’s advice in addition using the app and /or before making any medical decisions for themself. Never substitute or replace doctors advice or change treatment modalities based on any measured outcome. App indicated for assisting healthcare professionals for scientific and research reason. Clinical judgment and experience are required to properly use the app and further research and validation is pending in coming future.