The evaluation of ultrasonographic hip measurement differences among physicians according to the Graf method in newborns

Ultrasonographic measurements between physicians in the newborn



Hip, Ultrasonography, Newborn


Background/Aim: Hip ultrasonography (USG) is the most important diagnostic method in developmental hip dysplasia in newborns. However, a disadvantage of the ultrasonography method is that there can be measurement differences among doctors measuring the same hip. We aimed to investigate the causes and solutions of this situation. We further strived to measure the hip ultrasonography performed by different physicians using the Graf method and comparing the obtained values.

Methods: Hip USGs of newborns admitted to Malatya Turgut Ozal University Faculty of Medicine Hospital between Jan. 8, 2020 and Jan. 5,.2021 were measured and classified using the Graf method. The study type is consistent with retrospective cohort studies. Newborns aged 0-22 weeks without any additional pathology were included in the study. A radiologist and two orthopedists measured and interpreted the images separately in accordance with the Graf method. The first hip measurements (R1) were made by the radiologist (R) with the USG device, and they were classified according to alpha and beta angles; two printouts were made. The first orthopedic specialist (OS1) and the second orthopedic specialist (OS2) made their measurements with printouts. Subsequently, the results from the physicians were compared.

Results: A statistically significant difference was found between R1-OS2 (P < 0.001) and OS1-OS2 (P < 0.001) in terms of the Graf classifications. No statistically significant difference was found between R1 and OS1 in terms of the Graf classification (P = 0.562). A statistically significant difference was found between R1-OS2 (P < 0.001) and OS1-OS2 (P = 0.048) angles (alpha and beta) measurements. While R1 and OS1 measurements were compatible with each other, OS2 measurements were found to be inconsistent.

Conclusion: We think that there may be differences in angle measurements and the Graf classification among physicians who perform hip ultrasonography in newborns, and the most important way to correct this is through regular participation of physicians in subject-specific trainings.


Download data is not yet available.


Ellen de OG, Miguel A, Juliana Pp, Claudio S. The epidemıology of developmental dysplasıa of the hip in males. Acta Ortop Bras. 2020;28:26–30. DOI:

Kutlu A, Memik R, Mutlu M. Congenital dislocation of the hip and its relation to swadding in Turkey. J Pediatr Orthop. 1992;12:80-2. DOI:

Falliner A, Schwinzer D, Hahne H-J, Hedderich J, Hassenpflug J. Comparing Ultrasound Measurements of Neonatal Hips Using the Methods of Graf and Terjesen. JBJS. 2006;88:104–6. DOI:

Sadık B, Bartu S. Gelişimsel Kalça Displazisi Gelişimsel Kalça Displazisi. Güncel Pediatri. 2005;3:18-21.

Keller MS, Nijs EL. The role of radiographs and US in developmental dysplasia of the hip: how good are they? Pediatr Radiol. 2009;39:211–5. DOI:

Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment. Arch Orthop Trauma Surg. 1980;97:117–33. DOI:

Grissom L, Harcke HT, Thacker M. Imaging in the surgical management of developmental dislocation of the hip. Clin Orthop Relat Res. 2008;466:791–01.

Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia. J Pediatr Orthop 1984;4:735–40. DOI:

Graf R. New possibilities for the diagnosis of congenital hip joint dislocation by ultrasonography. J Pediatr Orthop. 1983;3:354–9. DOI:

Bar-On E, Meyer S, Harari G, Porat S. Ultrasonography of the hip in developmental hip dysplasia. J Bone Joint Surg Br. 1998;80:319–22.

Zieger M. Ultrasound of the infant hip. Part 2. Validity of the method. Pediatr Radiol. 1986; 16:488–92. DOI:

Alpar, R, Spor, Sağlık ve Eğitim Bilimlerinde Örneklerle Uygulamalı İstatistik ve Geçerlik-Güvenirlik. Ankara: Detay; 2020. Pp. 147.

Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86:420–8. DOI:

Rankin G, Stokes M . Reliability of assessment tools in rehabilitation: an illustration of appropriate statistical analyses. Clinical Rehabilitation. 1988;12:187-99. DOI:

Thomas JR, Nelson JK, Silverman J. Research methods in physical activity. Champaign: Human Kinetics; 2005. pp. 66-7.

Kropmans, TJB, Dijkstra PU, Stegenga B, Stewart R, De Bont, LGM. Smallest detectable difference in outcome variables related to painful restriction of the temporomandibular joint. J Dent Res.1999;78:784-9. DOI:

Coppieters M, Stappaerts K, Janssens K, Jull G. Reliability of detecting ’onset of pain’ and ’submaximal pain’ during neural provocation testing of the upper quadrant. Physiother Res Int. 2002;7:146-56. DOI:

Joseph P Weir. Quantıfyıng Test-Retest Relıabılıty Usıng The Intraclass Correlatıon Coeffıcıent And The Sem. J Strength Cond Res. 2005;19:231–40. DOI:

Köse N, Ömeroğlu H, Dağlar B. Gelişimsel Kalça Displazisi Ulusal Erken Tanı ve Tedavi Programı. 2010;2-19.

Hoaglund FT, Steinbach LS. Primary osteoarthritis of the hip: etiology and epidemiology. J Am Acad Orthop Surg. 2001;9:320–7. DOI:

Furnes O, Lie SA, Espehaug B, Vollset SE, Engesaeter LB, Havelin LI. Hip disease and the prognosis of total hip replacements. A review of 53,698 primary total hip replacements reported to the Norwegian Arthroplasty Register 1987–99. J Bone Joint Surg Br. 2001;83:579–86. DOI:

Macnicol MF. Results of a 25-year screening programme for neonatal hip instability. J Bone Joint Surg Br. 1990;72:1057–60. DOI:

Jones D. An assessment of the value of examination of the hip in the newborn. J Bone Joint Surg Br. 1977;59:318–22. DOI:

Grissom L, Harcke HT, Thacker M. Imaging in the surgical management of developmental dislocation of the hip. Clin Orthop Relat Res. 2008;466:791–801. DOI:

Thallinger C, Pospischill R, Ganger R, Radler C, Krall C, Grill F. Long-term results of a nationwide general ultrasound screening system for developmental disorders of the hip: the austrian hip screening program. J Child Orthop. 2014;8:3–10. DOI:

Riccabona M, Schweintzger G, Grill F, Graf R, Graf R. Screening for developmental hip dysplasia (DDH)-clinically or sonographically? Comments to the current discussion and proposals. Pediatr Radiol. 2013;43:637–40. DOI:

Simon EA, Saur F, Buerge M, Glaab R, Roos M, Kohler G. Inter-observer agreement of ultrasonographic measurement of alpha and beta angles and the final type classification based on the graf method. Swiss Med Wkly. 2004;134:671–7. DOI:

Dias JJ, Thomas IH, Lamont AC, Mody BS, Thompson JR. The reliability of ultrasonographic assessment of neonatal hips. J Bone Joint Surg Br. 1993;75:479–82. DOI:

Graf R. Hip sonography: background; technique and common mistakes; results; debate and politics; challenges. Hip Int. 2017;27:215–9. DOI:

Graf R, Mohajer M, Plattner F. Hip sonography update. Quality-management, catastrophes - tips and tricks. Med Ultrason. 2013;15:299–3. DOI:

Bar-On E, Meyer S, Harari G, Porat S. Ultrasonography of the hip in developmental hip dysplasia. J Bone Joint Surg Br. 1998;80:323-5. DOI:

Roovers EA, Boere-Boonekamp M, Geertsma T, Zielhuis G, Kerkhof A. Ultrasonic screening for developmental dysplasia of the hip in infants. Reproducibility of assessments made by radiographers. J Bone Joint Surg. 2003;85:726–30. DOI:

Omeroğlu H, Biçimoğlu A, Koparal S, Seber S. Assessment of variations in the measurement of hip ultrasonography by the graf method in developmental dysplasia of the hip. J Pediatr Orthop B. 2001;10:89–95. DOI:

Roposch A, Graf R, Wright JG. Determining the reliability of the graf classification for hip dysplasia. Clin Orthop Relat Res. 2006;447:119–24. DOI:

Ozgun K, Ozgur K, Ahmet SS, Mehmet MO, Hasan HM. Is it difficult to obtain inter-observer agreement in the measurement of the beta angle in ultrasound evaluation of the paediatric hip. J Orthop Surg Res. 2019; 17;14:221. DOI:

Melzer Ch. Röntgenbild-Sonographie-Anatomie, Orthopädische Klinik Giessen, Angeborene Hüftdysplasie und -luxation vom Neugeborenen bis zum Erwachsenen. 1993 Nov; Symposium Zürich Universität-Irchel. 1993.p. 69-77.

Niethard FU, Roesler H. Die Genauigkeit von Längen- und Winkelmessungen im Röntgenbild und Sonogramm des kindlichen Hüftgelenkes. Z Orthop. 1987;125:170–6. DOI:

Graf R. Die anatomischen Strukturen der Sauglingshüfte und ihre sonographische Darstellung. Morphol Med.1982;2:29–38.

Luisella P, Ilaria C, Alessandro D, Federica D, Francesca R, Mario M. Interpreting Neonatal Hip Sonography: Intraobserver and Interobserver Variability. J Pediatr Orthop B. 2020;29:214–8. DOI:

Rosendahl K, Aslaksen A, Lie RT, Markestad T. Reliability of ultrasound in the early diagnosis of developmental dysplasia of the hip. Pediatr Radiol. 1995;25:219-24. DOI:






Research Article

How to Cite

Altunkılıç T, Arı B, Yetiş M, Kılıçaslan N, İnceoğlu F. The evaluation of ultrasonographic hip measurement differences among physicians according to the Graf method in newborns: Ultrasonographic measurements between physicians in the newborn. J Surg Med [Internet]. 2022 Nov. 8 [cited 2023 Feb. 6];6(11):893-8. Available from: