Ultrasonography in the diagnosis and management of developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre randomised controlled trial

Incidence of risk factors in developmental dysplasia of the hip: a retrospective study on 18,954 cases

BACKGROUND

DDH is 1 of the most important causes of childhood disability. A diagnosis of instability can be made in the neonatal period via the Ortolani and Barlow manoeuvres. However, clinical examination, although highly specific, has poor sensitivity as compared to ultrasound. There is controversy between the necessity of universal screening for dysplasia of all newborns or selective screening reserved for those with clinical signs of instability or known risk factors of DDH.

AIM

To analyse the risk factors of congenital hip dysplasia in a consecutive case series of children referred for diagnosis and treatment of DDH.

MATERIALS AND METHODS

This was a cross-sectional study on infants consecutively examined between January 2000 and December 2019 at the Marino Ortolani Centre in Ferrara, Italy. The first 3 types on Graf's classification were considered physiological (1A, 1B, 2A+), while the last 6 pathological (2A-, 2B, 2C, 2D, 3, 4).

RESULTS

18,954 infants met the inclusion criteria and were therefore considered eligible for the study. Of these 18,954 infants, 56% (n = 10,629) were females and 44% (n = 8325) were males. According to Graf classification, 34.9% (n = 6621) were 1A, 52.7% (n = 9999) were 1B, 4.0% (n = 753) were 2A+, 2.5% (n = 478) were 2A-, 1.5% (n = 284) were 2B, 1% (n = 196) were 2C, 1.3% (n = 243) were 2D, 1% (n = 193) were 3 and 1.0% (n = 187) were 4. The most significant risk factor was the female gender (OR 5.36; 95% CI, 4.63-6.20) followed by a family history (OR 2.35; 95% CI, 2.08-2.65), then skeletal pathologies (OR 2.04; 95% CI, 1.21-3.42), oligohydramnios (OR 1.75; 95% CI, 1.44-2.13), and finally breech presentation (OR 1.42: 95% CI, 1.27-1.60).

CONCLUSIONS

Based on our data, family history, musculoskeletal disease, oligohydramnios and breech presentation are the main risk factors for DDH development, as is the female sex.

Analysis of the results of hip ultrasonography in 48 666 infants and efficacy studies of conservative treatment

PURPOSE

This study aimed to investigate the detection rate of developmental dysplasia of the hip (DDH) by ultrasound. To obtain the distribution characteristics of the different types (I-IV) and the role of ultrasound in the evaluation of infants with DDH (type IIc and above) receiving conservative treatment.

METHODS

A retrospective analysis was performed. The chi-square test was used for comparisons between count-data groups. Two-sided tests were used for all analyses. The results of ultrasound follow-up after conservative treatment are described.

RESULTS

Among the 48 666 infants examined, the detection rates were as follows: type I, 95.42%; IIa, 3.18%; IIb, 0.91%; IIc, 0.22%; D, 0.01%; III, 0.14%; and IV, 0.12%. There were 4456 hips with IIa and above, more left (54.65%) than right (45.35%) hips, and more females (82.60%) than males (17.40%). The detection rate of type IIa and above was 4.58%, and that of type IIb and above was 1.40%. After the treatment, the α value increased, and β value decreased. The cure rate of the less-than-42-days group was higher than that of the other groups.

CONCLUSION

The ultrasound detection rate of DDH is high. DDH was more likely to occur on the left side and in females. It is recommended that the infants should be treated within 42 days.

Universal screening may reduce the incidence of late diagnosis of developmental dysplasia of the hip : a systematic review and meta-analysis

AIMS

We investigated the prevalence of late developmental dysplasia of the hip (DDH), abduction bracing treatment, and surgical procedures performed following the implementation of universal ultrasound screening versus selective ultrasound screening programmes.

METHODS

A systematic search of PubMed, Embase, The Cochrane Library, OrthoSearch, and Web of Science from the date of inception of each database until 27 March 2022 was performed. The primary outcome of interest was the prevalence of late detection of DDH, diagnosed after three months. Secondary outcomes of interest were the prevalence of abduction bracing treatment and surgical procedures performed in childhood for dysplasia. Only studies describing the primary outcome of interest were included.

RESULTS

A total of 31 studies were identified, of which 13 described universal screening and 20 described selective screening. Two studies described both. The prevalence of late DDH was 0.10 per 1,000 live births (95% confidence interval (CI) 0.00 to 0.39) in the universal screening group and 0.45 per 1,000 live births (95% CI 0.31 to 0.61) in the selective screening group. Abduction bracing treatment was performed on 55.54 per 1,000 live births (95% CI 24.46 to 98.15) in the universal screening group versus 0.48 per 1,000 live births (95% CI 0.07 to 1.13) in the selective screening group. Both the universal and selective screening groups had a similar prevalence of surgical procedures in childhood for dysplasia being performed (0.48 (95% CI 0.32 to 0.63) vs 0.49 (95% CI 0.31 to 0.71) per 1,000 live births, respectively).

CONCLUSION

Universal screening showed a trend towards lower prevalence of late DDH compared to selective screening. However, it was also associated with a significant increase in the prevalence of abduction bracing without a significant reduction in the prevalence of surgical procedures in childhood for dysplasia being performed. High-quality studies comparing both treatment methods are required, in addition to studies into the natural history of missed DDH.Cite this article: Bone Joint J 2023;105-B(2):198-208.

Splinting for the non-operative management of developmental dysplasia of the hip (DDH) in children under six months of age

BACKGROUND

Developmental dysplasia of the hip (DDH) describes the abnormal development of a hip in childhood, ranging from complete dislocation of the hip joint to subtle immaturity of a hip that is enlocated and stable within the socket. DDH occurs in around 10 per 1000 live births, though only one per 1000 are completely dislocated. There is variation in treatment pathways for DDH, which differs between hospitals and even between clinicians within the same hospital. The variation is related to the severity of dysplasia that is believed to require treatment, and the techniques used to treat dysplasia.

OBJECTIVES

To determine the effectiveness of splinting and the optimal treatment strategy for the non-operative management of DDH in babies under six months of age.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, seven other electronic databases, and two trials registers up to November 2021. We also checked reference lists, contacted study authors, and handsearched relevant meetings abstracts.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including quasi-RCTs, as well as non-RCTs and cohort studies conducted after 1980 were included. Participants were babies with all severities of DDH who were under six months of age. Interventions included dynamic splints, static splints or double nappies (diapers), compared to no splinting or delayed splinting.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and performed risk of bias and GRADE assessments. The primary outcomes were: measurement of acetabular index at years one, two and five, as determined by radiographs (angle): the need for operative intervention to achieve reduction and to address dysplasia; and complications. We also investigated other outcomes highlighted by parents as important, including the bond between parent and child and the ability of mothers to breastfeed.

MAIN RESULTS

We included six RCTs or quasi-RCTs (576 babies). These were supported by 16 non-RCTs (8237 babies). Five studies had non-commercial funding, three studies stated 'no funding' and 14 studies did not state funding source. The RCTs were generally at unclear risk of bias, although we judged three RCTs to be at high risk of bias for incomplete outcome data. The non-RCTs were of moderate and critical risk of bias. We did not undertake meta-analysis due to methodological and clinical differences between studies; instead, we have summarised the results narratively. Dynamic splinting versus delayed or no splinting Four RCTs and nine non-RCTs compared immediate dynamic splinting and delayed dynamic splinting or no splinting. Of the RCTs, two considered stable hips and one considered unstable (dislocatable) hips and one jointly considered unstable and stable hips. No studies considered only dislocated hips. Two RCTs (265 babies, very low-certainty evidence) reported acetabular index at one year amongst stable or dislocatable hips. Both studies found there may be no evidence of a difference in splinting stable hips at first diagnosis compared to a strategy of active surveillance: one reported a mean difference (MD) of 0.10 (95% confidence interval (CI) -0.74 to 0.94), and the other an MD of 0.20 (95% CI -1.65 to 2.05). Two RCTs of stable hips (181 babies, very low-certainty evidence) reported there may be no evidence of a difference between groups for acetabular index at two years: one study reported an MD of -1.90 (95% CI -4.76 to 0.96), and another study reported an MD of -0.10 (95% CI -1.93 to 1.73), but did not take into account hips from the same child. No study reported data at five years. Four RCTs (434 babies, very low-certainty evidence) reported the need for surgical intervention. Three studies reported that no surgical interventions occurred. In the remaining study, two babies in the dynamic splinting group developed instability and were subsequently treated surgically. This study did not explicitly state if this treatment was to achieve concentric reduction or address residual dysplasia. Three RCTs (390 babies, very low-certainty evidence) reported no complications (avascular necrosis and femoral nerve palsy). Dynamic splinting versus static splinting One RCT and five non-RCTs compared dynamic versus static splinting. The RCT (118 hips) reported no occurrences of avascular necrosis (very low-certainty evidence) and did not report radiological outcomes or need for operative intervention. One quasi-RCT compared double nappies versus delayed or no splinting but reported no outcomes of interest. Other comparisons No RCTs compared static splinting versus delayed or no splinting or staged weaning versus immediate removal.

AUTHORS' CONCLUSIONS

There is a paucity of RCT evidence for splinting for the non-operative management of DDH: we included only six RCTs with 576 babies. Moreover, there was considerable heterogeneity between the studies, precluding meta-analysis. We judged the RCT evidence for all primary outcomes as being of very low certainty, meaning we are very uncertain about the true effects. Results from individual studies provide limited evidence of intervention effects on different severities of DDH. Amongst stable dysplastic hips, there was no evidence to suggest that treatment at any stage expedited the development of the acetabulum. For dislocatable hips, a delay in treatment onset to six weeks does not appear to result in any evidence of a difference in the development of the acetabulum at one year or increased risk of surgery. However, delayed splinting may reduce the number of babies requiring treatment with a harness. No RCTs compared static splinting with delayed or no splinting, staged weaning versus immediate removal or double nappies versus delayed or no splinting. There were few operative interventions or complications amongst the RCTs and the non-randomised studies. There's no apparent signal to indicate a higher frequency of either outcome in either intervention group. Given the frequency of this disease, and the fact that many countries undertake mandatory DDH screening, there is a clear need to develop an evidence-based pathway for treatment. Particular uncertainties requiring future research are the effectiveness of splinting amongst stable dysplastic hips, the optimal timing for the onset of splinting, the optimal type of splint to use and the need for 'weaning of splints'. Only once a robust pathway for treatment is established, can we properly assess the cost-effectiveness of screening interventions for DDH.

Incidence of Neonatal Developmental Dysplasia of the Hip and Late Detection Rates Based on Screening Strategy: A Systematic Review and Meta-analysis

IMPORTANCE

Universal ultrasonographic screening for developmental dysplasia of the hip (DDH) has gained increasing popularity despite the lack of benefit in terms of reducing the rates of late-detected cases (age ≥12 weeks) in randomized clinical trials.

OBJECTIVE

To report the reported incidence of DDH in the English scientific literature and compare rates of late-detected cases in settings with different DDH screening strategies.

DATA SOURCES

PubMed, Scopus, and Web of Science databases were searched on November 25 and 27, 2021. No time filters were used in the search.

STUDY SELECTION

All observational studies reporting the incidence of early-detected or late-detected (age ≥12 weeks) DDH were included. Non-English reports were excluded if the abstract did not include enough information to be included for analysis.

DATA EXTRACTION AND SYNTHESIS

The number of newborns screened and the detection rates were extracted. Meta-analysis calculated the pooled incidence of DDH per 1000 newborns with 95% CIs using a random- or fixed-effects model. This study is reported according to the PRISMA and MOOSE guidelines.

MAIN OUTCOMES AND MEASURES

The main outcome measures were early detection, early treatment, late detection, and operative treatment incidences.

RESULTS

A total of 1899 studies were identified, 203 full texts were assessed, and 76 studies with 16 901 079 infants were included in final analyses. The early detection rate was 8.4 (95% CI, 4.8-14.8) infants with DDH per 1000 newborns with clinical screening, 4.4 (95% CI, 2.4-8.0) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 23.0 (95% CI, 15.7-33.4) infants with DDH per 1000 newborns with universal ultrasonographic screening. Rates for nonoperative treatment were 5.5 (95% CI, 2.1-14) treatments per 1000 newborns with clinical screening, 3.1 (95% CI, 2.0-4.8) treatments per 1000 newborns with selective ultrasonographic screening, and 9.8 (95% CI, 6.7-14.4) treatments per 1000 newborns with universal ultrasonographic screening. The incidence of late-detected DDH was 0.5 (95% CI, 0.2-1.5) infants with DDH per 1000 newborns with clinical screening, 0.6 (95% CI, 0.3-1.3) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 0.2 (95% CI, 0.0-0.8) infants with DDH per 1000 newborns with universal ultrasonographic screening. The corresponding incidences of operative treatment were 0.2 (95% CI, 0.0-0.9) operations per 1000 newborns with clinical screening, 0.5 (95% CI, 0.4-0.7) operations per 1000 newborns with selective ultrasonographic screening, and 0.4 (95% CI, 0.2-0.7) operations per 1000 newborns with universal ultrasonographic screening.

CONCLUSIONS AND RELEVANCE

This meta-analysis found that early detection rates and nonoperative treatments were higher with universal screening. The late detection and operative treatment rates with universal screening were similar to those among selectively and clinically screened newborns. Based on these results, universal screening may cause initial overtreatment without reducing the rates of late detection and operative treatment.

Prevalence of Developmental Dysplasia of the Hip in a Maternity Hospital in São Paulo, Brazil

Objective  To evaluate the prevalence of developmental dysplasia of the hip (DDH), that is, hips classified as Graf type-IIc or higher, among a sample of the population of newborns aged from 0 to 3 days of life, and to correlate the findings with the main risk factors described in the literature. Methods  An observational, cross-sectional, prospective study on a sample of newborns at a Maternity Hospital School in the city of São Paulo, Brazil, to assess the prevalence of DDH diagnosed by the Graf method and verify its correlation with the risk factors. Results  A total of 678 newborns underwent hip ultrasound (1,356 hips). The prevalence of DDH was of 5.46%. The logistic regression analysis showed odds ratios (ORs) with statistical significance for the following parameters: white ethnicity (OR = 2.561; 95% confidence interval [95%CI]: 1.07 to 6.11); multiparity (OR = 3.50; 95%CI: 1.62 to 7.38), female gender (OR = 4.95; 95%CI: 1.86 to 13.13); and breech presentation (OR = 2.03; 95%CI: 1,01 to 4.11). Conclusion  The prevalence of DDH in the sample was of 5.45% using ultrasound as a diagnostic method. This result is different from that of studies that assessed prevalence exclusively through physical examination (Ortolani maneuver). The main risk factors associated with a higher risk of developing DDH were newborns of the female gender, with breech presentation, firstborns, and of white ethnicity.

Examining the Short-Term Natural History of Developmental Dysplasia of the Hip in Infancy: A Systematic Review

BACKGROUND

This study was an update on the AAOS clinical practice guideline's analysis of the natural history of developmental dysplasia of the hip (DDH). The objective was to delineate the natural history of clinical instability or radiologic abnormalities of the hip in infants by identifying the proportion of cases that resolved without treatment compared to cases that progressed and/or required treatment.

METHODS

We performed a literature search of PUBMED to identify studies which evaluated the natural history of DDH. We used the same search strategy as that utilized in the previous AAOS guidelines, updated to include articles published between September 2013 and May 2021. We assessed the quality of included articles using the Oxford Centre for Evidence-Based Medicine level of evidence and reported study demographics and outcomes using summary statistics.

RESULTS

Twenty-four articles met our eligibility criteria. Most included studies were retrospective (14/24), investigated either the incidence of DDH (8/24) or assessed screening programs (7/24). The most prevalent study population followed were Graf 2A hips (7/24). Most studies were low quality with level of evidence 3 (13/24) or 4 (7/24). Sample sizes ranged from 9 to 3251. Twenty studies reported the number of cases resolved over the follow-up period with a mean rate of 84.3% (95% confidence interval 76.1, 92.6).

CONCLUSION

We found most mild-to-moderate DDH can resolve without treatment in early infancy, especially in physiologically immature (Graf 2A) hips. More high-quality evidence is needed to properly assess the natural history of DDH as only one included study was a randomized trial.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00510-6.

Cost Analysis of Screening Programmes for Developmental Dysplasia of the Hip: A Systematic Review

AIMS

The aim of this study was to assess screening costs in developmental dysplasia of the hip (DDH), to provide any clarity on the cost-effectiveness of various hip screening programmes internationally.

METHODS

A PROSPERO-registered systematic review was performed by examining cost analysis studies of various DDH screening programmes, including those based around clinical examination, selective ultrasound and universal ultrasound. Costs were analysed using narrative synthesis.

RESULTS

There were 14 studies included in this review. Two studies found that clinical hip screening is advantageous over no screening at all, both in terms of overall cost and favourable outcomes. When considering selective ultrasound imaging versus clinical screening, two studies found it to be more expensive, one found it cheaper and three studies calculated the overall programme costs to be similar. With universal ultrasound, four studies calculated this to be cheaper than clinical or selective ultrasound screening due to a reduced late detection and surgery rate. However, a comparable number of studies concluded that the increased financial costs of universal ultrasound were greater than the reduction in surgical costs. No studies included any long-term data.

CONCLUSION

There is a dearth of information on DDH screening costs, with significant heterogeneity amongst the existing literature. Future research should include the cost analysis of long-term complications of DDH, including the social and psychological impact of early onset arthritis, as well as gender specific ultrasound screening programmes.

Unbiasing costs? An appraisal of economic assessment alongside randomized trials in neonatology

Economic evaluations performed alongside randomized controlled trials benefit from the protections against bias inherent in randomization. In this systematic review, we assessed the frequency and quality of economic assessments alongside randomized controlled trials of interventions in neonates published between 1990 and 2016. Over that period, 58 economic assessments were published, corresponding to approximately 2% of RCTs. We noted significant methodological limitations of these studies, including limitation of included costs to the health sector or payer rather than broader categories such as family or community expenditures (81%), short time horizon for cost measurement (less than one year in 60%), lack of reporting of uncertainty (26%), and infrequent analysis of costs and effects in a single metric (combined in 45%). Strategies for improving the quality and frequency of economic evaluations in neonatology are discussed, including selection of appropriate trials, funding, and peer review.

Study protocol for evaluation of aid to diagnosis for developmental dysplasia of the hip in general practice: controlled trial randomised by practice

INTRODUCTION

In the UK, a compulsory '6-week hip check' is performed in primary care for the detection of developmental dysplasia of the hip (DDH). However, missed diagnoses and infants incorrectly labelled with DDH remain a problem, potentially leading to adverse consequences for infants, their families and the National Health Service. National policy states that infants should be referred to hospital if the 6-week check suggests DDH, though there is no available tool to aid examination or offer guidelines for referral. We developed standardised diagnostic criteria for DDH, based on international Delphi consensus, and a 9-item checklist that has the potential to enable non-experts to diagnose DDH in a manner approaching that of experts.

METHODS AND ANALYSIS

We will conduct a controlled trial randomised by practice that will compare a diagnostic aid against standard care for the hip check. The primary objective is to determine whether an aid to the diagnosis of DDH reduces the number of clinically insignificant referrals from primary care to hospital and the number of late diagnosed DDH. The trial will include a qualitative process evaluation, an assessment of professional behavioural change and a full health economic evaluation. We will recruit 152 general practitioner practices in England. These will be randomised to conduct the hip checks with use of the study diagnostic aid and/or as per usual practice. The total number of infants seen during a 15-month recruitment period will be 110 per practice. Two years after the 6-week hip check, we will measure the number of referred infants that are (1) clinically insignificant for DDH and (2) those that constitute appropriate referrals.

ETHICS AND DISSEMINATION

This study has approval from the Health Research Authority (16/1/2020) and the Confidentiality Advisory Group (18/2/2020). Results will be published in peer-reviewed academic journals, disseminated to patient organisations and the media.

TRIAL REGISTRATION NUMBER

NCT04101903; Pre-results.

Implementation of a nationwide universal ultrasound screening programme for developmental dysplasia of the neonatal hip in Mongolia

PURPOSE

Mongolia is the first Asian country to launch universal ultrasound screening for newborns with developmental dysplasia of the hip (DDH). The aims of this study were to determine the coverage and treatment rate of this programme.

METHODS

Data from birth statistics and ultrasound hip screening from 29 hospitals were retrospectively reviewed (2010 to 2016, pre-nationwide phase; and 2017 to 2019, nationwide programme). DDH was diagnosed using the Graf-technique and treated according to 'ABCD', a modified Graf classification (Group A: Graf Type 1, mature; B: 2a, physiologically immature; C: 2c to 3, early DDH; D: 4, dislocated). Group B children were followed with monthly ultrasound. Group C and D children were treated with a flexion and abduction orthosis (Tübingen). Screeners used a web-based platform to upload images for quality surveillance.

RESULTS

Between 2017 and 2019, 230 079 live births were registered and 176 388 newborns screened. The nationwide screening coverage rate in newborns increased from 73.6% in 2017 to 82.1% in 2019. Group A (148 510 children, 84.2%) was discharged, while Group B (25 820, 14.6%) was followed. Among children in Group B, 284 cases worsened to Group C and were, therefore, treated with a Tübingen orthosis. The remaining 2058 (1.2%) of newborns with DDH were treated with a Tübingen orthosis, including 1999 newborns in Group C and 59 in Group D. Since 2017, a total of 142 860 (81.0%) hip sonograms were uploaded to the platform.

CONCLUSION

A simplified diagnostic and therapeutic framework for ultrasound DDH screening for newborns was successfully deployed in Mongolia, a developing country, providing high surveillance coverage and appropriate treatment.Level of evidence: IV.

A Comparison of Pavlik Harness Treatment Regimens for Dislocated But Reducible (Ortolani+) Hips in Infantile Developmental Dysplasia of the Hip

BACKGROUND

Variation exists in the Pavlik harness (PH) treatment regimen for infantile developmental dysplasia of the hip (DDH). The purpose of this study was to determine if the daily PH wear duration (23 vs. 24 h) and frequency of follow-up visits affect the clinical and radiographic outcomes of infants with dislocated but reducible (Ortolani+) hips.

METHODS

This study reviewed prospectively enrolled patients with DDH in a single center who presented at age <6 months with Ortolani+ hips and were treated with PH. Recommended daily PH wear duration (23 vs. 24 h) and the frequency of clinic visits in first 4 weeks after the initiation of PH treatment were analyzed. The clinical success (stable hip that did not require closed or open reduction or the use of an abduction orthosis) and radiographic success based on the acetabular index at 2-year follow-up were compared between different PH regimen groups.

RESULTS

Sixty-two patients (74 hips, 53 females) with Ortolani+ hips had a mean age of presentation of 23±28 days (range, 4 to 128 d) and mean follow-up of 33.2±18.4 months (range, 8 to 85 mo). Overall clinical success rate of PH for Ortolani+ hips was 93% (69/74 hips) and radiographic success rate at 2 years was 84% (48/57 hips). There was no difference in clinical or radiographic success rate between the 23- and 24-hour wear groups (P>0.99, 0.73) or between hips assessed almost weekly compared with once or twice during the first 4 weeks of PH treatment (P>0.99 for both).

CONCLUSIONS

The 23- versus 24-hour PH regimen and frequency of clinic visits in the first 4 weeks of PH treatment did not affect the clinical or radiographic success rate of Ortolani+ hips in infantile DDH. A strict weekly clinic visit and 24-hour PH regimen may not be necessary to obtain stable reduced hips in infants presenting <6 months of age with Ortolani+ hips.

LEVEL OF EVIDENCE

Level III-therapeutic.

Incidence of Late-Diagnosed Hip Dislocation After Universal Clinical Screening in Sweden

IMPORTANCE

Developmental dysplasia of the hip, including late-diagnosed hip dislocation, is the leading cause of hip arthroplasties in young adults. Early treatment is essential for a good prognosis. Before the institution of a national screening program, a minimum of 0.9 per 1000 Swedish children were affected.

OBJECTIVES

To evaluate the incidence of late-diagnosed hip dislocation among children who undergo clinical screening as neonates and to study antenatal and perinatal risk factors for late-diagnosed hip dislocation.

DESIGN, SETTING, AND PARTICIPANTS

This nested case-control study included children born in Sweden from January 1, 2000, through December 31, 2009. All maternity wards, maternal health units, and orthopedic departments in Sweden participated. Children with a late-diagnosed hip dislocation were matched by sex and birth year to randomly selected controls in a 1:10 ratio. Potential risk factors in pregnant women and newborns were recorded, and cases of hip dislocation were registered. Observation time ranged from 8 to 18 years, with the last data analysis in January 2019.

EXPOSURES

Clinical hip examinations neonatally and at 6 to 8 weeks, 6 months, and 10 to 12 months.

MAIN OUTCOMES AND MEASURES

Hip dislocation diagnosed more than 14 days after birth, age at diagnosis, and severity of dislocation.

RESULTS

Among 1 013 589 live births (521 728 [51.5%] boys), 126 children (0.12 [95% CI, 0.10-0.15] per 1000 live births) had a late-diagnosed hip dislocation at a median age of 31.4 weeks (interquartile range, 16.1-67.1 weeks; 95% CI, 27.4-44.1 weeks). The incidence of late-diagnosed hip dislocation was 9 times higher among girls (113 of 491 861; 0.23 [95% CI, 0.19-0.28] per 1000 live births) than among boys (13 of 521 728; 0.02 [95% CI, 0.01-0.04] per 1000 live births). Twenty-one children (0.02 per 1000 live births) had high (severe) dislocations. Breech delivery (adjusted odds ratio, 3.07; 95% CI, 1.34-7.02), short body length at birth (adjusted odds ratio, 0.86; 95% CI, 0.76-0.98, per additional 1 cm), and being large for gestational age (adjusted odds ratio, 3.59; 95% CI, 1.30-9.95) were independent risk factors. Maternal smoking at the first visit to the maternal health care center was less common among children with hip dislocation (adjusted odds ratio, 0.16; 95% CI, 0.04-0.70).

CONCLUSIONS AND RELEVANCE

Compared with historical data, the incidence of late-diagnosed hip dislocation in Swedish-born children appears to have decreased substantially since the screening program was initiated, as have the age at detection and disease severity. Similar screening programs should also be possible to institute in upper-middle- and lower-middle-income countries.

Imaging of developmental dysplasia of the hip: ultrasound, radiography and magnetic resonance imaging

Developmental dysplasia of the hip (DDH) describes a broad spectrum of developmental abnormalities of the hip joint that are traditionally diagnosed during infancy. Because the development of the hip joint is a dynamic process, optimal treatment depends not only on the severity of the dysplasia, but also on the age of the child. Various imaging modalities are routinely used to confirm suspected diagnosis, to assess severity, and to monitor treatment response. For infants younger than 4 months, screening hip ultrasound (US) is recommended only for those with risk factors, equivocal or positive exam findings, whereas for infants older than 4-6 months, pelvis radiography is preferred. Following surgical hip reduction, magnetic resonance (MR) imaging is preferred over computed tomography (CT) because MR can not only confirm concentric hip joint reduction, but also identify the presence of soft-tissue barriers to reduction and any unexpected postoperative complications. The routine use of contrast-enhanced MR remains controversial because of the relative paucity of well-powered and validated literature. The main objectives of this article are to review the normal and abnormal developmental anatomy of the hip joint, to discuss the rationale behind the current recommendations on the most appropriate selection of imaging modalities for screening and diagnosis, and to review routine and uncommon findings that can be identified on post-reduction MR, using an evidence-based approach. A basic understanding of the physiology and the pathophysiology can help ensure the selection of optimal imaging modality and reduce equivocal diagnoses that can lead to unnecessary treatment.

[Treatment recommendations for protracted hip immaturity in infants : Conservative approach versus open reduction]

The healthy upright posture is a result of a continuous maturation process of the locomotor system throughout skeletal growth rendering muscle strength and stability: The hip joint in its central position plays a key role for unimpaired and pain-free gait. Nonetheless, it is also regularly affected by delayed maturation, thus being of special interest for the disease screening procedures of every newborn child. Structured screening examinations in the first 3 postnatal months will ideally detect any dysplasia, therefore simple conservative interventions will usually accelerate the maturation process. Effective hip screening programs in Austria and Germany have reduced the necessity for open surgical hip reductions to a worldwide all-time low. Perinatal risk factor awareness in doctors and parents triggers an increased sensitivity to possible immature hip structures. Nevertheless, severe hip dysplasia in toddlers is regularly presented in pediatric orthopedic centers with or without hip dislocation, mostly due to the delay of or inefficiency of treatment options. This review deals with highly effective strategies for quick treatment and provides a balanced view on conservative and surgical methods.

How to use… Hip examination and ultrasound in newborns

Developmental dysplasia of the hip (DDH) ranges from a clinically detectable dislocation of the hip to radiologically diagnosed hip abnormalities. It is caused by both antenatal and postnatal factors. The Neonatal and Infant Physical Examination Screening Programme recommends that newborns should undergo a hip ultrasound (USS) when risk factor or clinical features suggestive of DDH are present. The aim of hip ultrasonography is to detect DDH early and prevent late complications through early treatment. Here, we discuss how to use hip examination and USS in newborns.

Utilization of ultrasonography to detect developmental dysplasia of the hip: when reality turns selective screening into universal use

Background

Developmental dysplasia of the hip (DDH) occurs in 3–5 of 1000 live births and is associated with known risk factors. In most countries, formal practice for early detection of DDH entails the combination of risk factor identification and physical examination of the hip, while the golden standard diagnostic instrument is hip ultrasonography (US). This practice is commonly referred to as selective screening. Infants with positive US findings are treated with a Pavlik harness, a dynamic abduction splint.

The objective of our study was to evaluate hip US utilization patterns in Maccabi Healthcare Services (MHS), a large health plan.

Methods

Study population: All MHS members, born between June 2011 and October 2014, who underwent at least one US before the age of 15 months. Study variables: Practice specialty and number of enrolled infants. Positive US result was defined as referral to an abduction splint. Cost was based on Ministry of Health price list. Chi square and correlation coefficients were employed in the statistical analysis.

Results

Of the 115,918 infants born during the study period, 67,491 underwent at least one hip US. Of these, 60.6% were female, mean age at performance: 2.2 months. Of those who underwent US, 625 (0.93%) were treated with a Pavlik harness: 0.24% of the male infants and 1.60% of the female infants (p < 0.001). Analysis of physician practice characteristics revealed that referral to US was significantly higher among pediatricians as compared with general practitioners (60% and 35%, respectively). Practice volume had no influence on referral rate. Direct medical costs of the 107 hip US examinations performed that led to detection of one positive case (treated by Pavlik): US$10,000.

Conclusions

Current pattern of hip US utilization for early detection of DDH resembles universal screening more closely than selective screening. This can inform policy decisions as to whether a stricter selective screening or a formal move to universal screening is appropriate in Israel.

Early dynamic ultrasound for neonatal hip instability: implications for rural Australia

BACKGROUND

Neonatal instability of the hip (NIH), where the femoral head can move away from the acetabulum, in the first weeks of life, is an important risk factor for developmental dysplasia of the hip (DDH). In rural areas in Australia, there is a recent trend to increased late diagnosis of DDH. Clinical screening of infant hips, a common practice in Australia, is experience dependent. Best practice early screening techniques are still debated with different techniques and timing used internationally. This systematic review examines early dynamic ultrasound (eDUS) screening for hip instability in the first 6 weeks after birth, and the early interventions informed by these findings and considers the findings for the context of rural Australia.

METHODS

The Cochrane Library, Medline, CINAHL and PEDro were searched for original research or systematic reviews, and clinical studies 1998 to 2015 involving dynamic ultrasound. Critical Appraisal Skills Programme tools were used to appraise the studies.

RESULT

Nineteen studies were included. Early Dynamic Ultrasound (DUS) is consistently described as a reliable assessment of NIH. Early DUS is recommended for risk factors including geographical areas of high prevalence. Approaches to early intervention of hips with excessive movement are somewhat discipline-related and include: primary prevention (advice), secondary prevention (abduction supports), and conservative management (removable splints).

CONCLUSIONS

In the context of increased prevalence of DDH in rural Australia, contemporary evidence suggests that introduction of early DUS could provide rural infants with more effective screening than clinical examination alone. Targeted early advice about posturing and simple removable supports to abduct infant hips could prevent some cases of DDH in rural Australia.

Evaluation and Referral for Developmental Dysplasia of the Hip in Infants

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and accounts for 5% to 10% of all total hip replacements in the United States. Newborn and periodic screening have been practiced for decades, because DDH is clinically silent during the first year of life, can be treated more effectively if detected early, and can have severe consequences if left untreated. However, screening programs and techniques are not uniform, and there is little evidence-based literature to support current practice, leading to controversy. Recent literature shows that many mild forms of DDH resolve without treatment, and there is a lack of agreement on ultrasonographic diagnostic criteria for DDH as a disease versus developmental variations. The American Academy of Pediatrics has not published any policy statements on DDH since its 2000 clinical practice guideline and accompanying technical report. Developments since then include a controversial US Preventive Services Task Force "inconclusive" determination regarding usefulness of DDH screening, several prospective studies supporting observation over treatment of minor ultrasonographic hip variations, and a recent evidence-based clinical practice guideline from the American Academy of Orthopaedic Surgeons on the detection and management of DDH in infants 0 to 6 months of age. The purpose of this clinical report was to provide literature-based updated direction for the clinician in screening and referral for DDH, with the primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.

Sonographic screening for developmental dysplasia of the hip in preterm breech infants: do current guidelines address the specific needs of premature infants?

OBJECTIVE

To assess the association between gestational age versus corrected age at the time of hip ultrasound with findings for developmental dysplasia of the hip (DDH) in preterm breech infants.

STUDY DESIGN

A retrospective medical chart review was conducted to examine hip ultrasounds of 318 premature breech infants for findings associated with DDH.

RESULTS

Positive findings for DDH occurred in 3/135 (2%) of infants <32 weeks gestational age and 17/183 (9%) of infants 32 to <37 weeks gestational age (odds ratio: 0.22, 95% CI: 0.04 to 0.79, P<0.015). No infants born <32 weeks gestational age had abnormal findings for DDH upon follow-up ultrasound. Infants <40 weeks corrected age at the time of hip ultrasound were more likely to have DDH findings compared with infants ⩾44 weeks corrected age (odds ratio: 7.83, 95% CI: 2.20 to 29.65, P<0.001).

CONCLUSION

Current hip ultrasonography policies that include screening of premature breech infants may need to be revised.

What Is the Impact of Center Variability in a Multicenter International Prospective Observational Study on Developmental Dysplasia of the Hip?

BACKGROUND

Little information exists concerning the variability of presentation and differences in treatment methods for developmental dysplasia of the hip (DDH) in children < 18 months. The inherent advantages of prospective multicenter studies are well documented, but data from different centers may differ in terms of important variables such as patient demographics, diagnoses, and treatment or management decisions. The purpose of this study was to determine whether there is a difference in baseline data among the nine centers in five countries affiliated with the International Hip Dysplasia Institute to establish the need to consider the center as a key variable in multicenter studies.

QUESTIONS/PURPOSES

(1) How do patient demographics differ across participating centers at presentation? (2) How do patient diagnoses (severity and laterality) differ across centers? (3) How do initial treatment approaches differ across participating centers?

METHODS

A multicenter prospective hip dysplasia study database was analyzed from 2010 to April 2015. Patients younger than 6 months of age at diagnosis were included if at least one hip was completely dislocated, whereas patients between 6 and 18 months of age at diagnosis were included with any form of DDH. Participating centers (academic, urban, tertiary care hospitals) span five countries across three continents. Baseline data (patient demographics, diagnosis, swaddling history, baseline International Hip Dysplasia Institute classification, and initial treatment) were compared among all nine centers. A total of 496 patients were enrolled with site enrolment ranging from 10 to 117. The proportion of eligible patients who were enrolled and followed at the nine participating centers was 98%. Patient enrollment rates were similar across all sites, and data collection/completeness for relevant variables at initial presentation was comparable.

RESULTS

In total, 83% of all patients were female (410 of 496), and the median age at presentation was 2.2 months (range, 0-18 months). Breech presentation occurred more often in younger (< 6 months) than in older (6-18 months at diagnosis) patients (30% [96 of 318] versus 9% [15 of 161]; odds ratio [OR], 4.2; 95% confidence interval [CI], 2.3-7.5; p < 0.001). The Australia site was underrepresented in breech presentation in comparison to the other centers (8% [five of 66] versus 23% [111 of 479]; OR, 0.3, 95% CI, 0.1-0.7; p = 0.034). The largest diagnostic category was < 6 months, dislocated reducible (51% [253 of 496 patients]); however, the Australia and Boston sites had more irreducible dislocations compared with the other sites (ORs, 2.1 and 1.9; 95% CIs, 1.2-3.6 and 1.1-3.4; p = 0.02 and 0.015, respectively). Bilaterality was seen less often in older compared with younger patients (8% [seven of 93] versus 26% [85 of 328]; p < 0.001). The most common diagnostic group was Grade 3 (by International Hip Dysplasia Institute classification), which included 58% (51 of 88) of all classified dislocated hips. Splintage was the primary initial treatment of choice at 80% (395 of 496), but was far more likely in younger compared with older patients (94% [309 of 328] versus 18% [17 of 93]; p < 0.001).

CONCLUSIONS

With the lack of strong prognostic indicators for DDH identified to date, the center is an important variable to include as a potential predictor of treatment success or failure.

What Risk Factors and Characteristics Are Associated With Late-presenting Dislocations of the Hip in Infants?

BACKGROUND

Most infants with developmental dysplasia of the hip (DDH) are diagnosed within the first 3 months of life. However, late-presenting DDH (defined as a diagnosis after 3 months of age) does occur and often results in more complex treatment and increased long-term complications. Specific risk factors involved in late-presenting DDH are poorly understood, and clearly defining an associated set of factors will aid in screening, detection, and prevention of this condition.

QUESTIONS/PURPOSES

Using a multicenter database of patients with DDH, we sought to determine whether there were differences in (1) risk factors or (2) the nature of the dislocation (laterality and joint laxity) when comparing patients with early versus late presentation.

METHODS

A retrospective review of prospectively collected data from a multicenter database of patients with dislocated hips was conducted from 2010 to 2014. Baseline demographics for fetal presentation (cephalic/breech), birth presentation (vaginal/cesarean), birth weight, maternal age, maternal parity, gestational age, family history, and swaddling history of patients were compared among nine different sites for patients who were enrolled at age younger than 3 months and those enrolled between 3 and 18 months of age. A total of 392 patients were enrolled at baseline between 0 and 18 months of age with at least one dislocated hip. Of that group, 259 patients were younger than 3 months of age and 133 were 3 to 18 months of age. The proportion of patients with DDH who were enrolled and followed at the nine participating centers was 98%.

RESULTS

A univariate/multivariate analysis was performed comparing key baseline demographics between early- and late-presenting patients. After controlling for relevant confounding variables, two variables were identified as risk factors for late-presenting DDH as compared with early-presenting: cephalic presentation at birth and swaddling history. Late-presenting patients were more likely to have had a cephalic presentation than early-presenting patients (88% [117 of 133] versus 65% [169 or 259]; odds ratio [OR], 5.366; 95% confidence interval [CI], 2.44-11.78; p < 0.001). Additionally, late-presenting patients were more likely to have had a history of swaddling (40% [53 of 133] versus 25% [64 of 259]; OR, 2.053; 95% CI, 1.22-3.45; p = 0.0016). No difference was seen for sex (p = 0.63), birth presentation (p = 0.088), birth weight (p = 0.90), maternal age (p = 0.39), maternal parity (p = 0.54), gestational age (p = 0.42), or family history (p = 0.11) between the two groups. Late presenters were more likely to present with an irreducible dislocation than early presenters (56% [82 of 147 hips] versus 19% [63 of 333 hips]; OR, 5.407; 95% CI, 3.532-8.275; p < 0.001) and were less likely to have a bilateral dislocation (11% [14 of 133] versus 28% [73 of 259]; OR, 0.300; 95% CI, 0.162-0.555; p = 0.002).

CONCLUSIONS

Those presenting with DDH after 3 months of age have fewer of the traditional risk factors for DDH (such as breech birth), which may explain the reason for a missed diagnosis at a younger age. In addition, swaddling history was more common in late-presenting infants. A high index of suspicion for DDH should be maintained for all infants, not just those with traditional risk factors for DDH. Further investigation is required to determine if swaddling is a risk factor for the development of hip dislocations in older infants. More rigorous examination into traditional screening methods should also be performed to determine whether current screening is sufficient and whether late-presenting dislocations are present early and missed or whether they develop over time.

LEVEL OF EVIDENCE

Level III, retrospective study.

Developmental dysplasia of the hip: What has changed in the last 20 years?

Developmental dysplasia of the hip (DDH) describes the spectrum of structural abnormalities that involve the growing hip. Early diagnosis and treatment is critical to provide the best possible functional outcome. Persistence of hip dysplasia into adolescence and adulthood may result in abnormal gait, decreased strength and increased rate of degenerative hip and knee joint disease. Despite efforts to recognize and treat all cases of DDH soon after birth, diagnosis is delayed in some children, and outcomes deteriorate with increasing delay of presentation. Different screening programs for DDH were implicated. The suspicion is raised based on a physical examination soon after birth. Radiography and ultrasonography are used to confirm the diagnosis. The role of other imaging modalities, such as magnetic resonance imaging, is still undetermined; however, extensive research is underway on this subject. Treatment depends on the age of the patient and the reducibility of the hip joint. At an early age and up to 6 mo, the main treatment is an abduction brace like the Pavlik harness. If this fails, closed reduction and spica casting is usually done. After the age of 18 mo, treatment usually consists of open reduction and hip reconstruction surgery. Various treatment protocols have been proposed. We summarize the current practice for detection and treatment of DDH, emphasizing updates in screening and treatment during the last two decades.

Evaluation and treatment of developmental hip dysplasia in the newborn and infant

Developmental dysplasia of the hip (DDH) encompasses a spectrum of physical and imaging findings. The child's hip will not develop normally if it remains unstable and anatomically abnormal by walking age. Therefore, careful physical examination of all infants to diagnosis and treat significant DDH is critical to provide the best possible functional outcome. Regardless of the practice setting, all health professionals who care for newborns and infants should be trained to evaluate the infant hip for instability and to provide appropriate and early conservative treatment or referral.

Treatment and prevention of hip dysplasia in infants and young children

The diagnosis and treatment of developmental dysplasia of the hip in the infant are uniform, with consensus that diagnostic ultrasound and Pavlik harness management are standard procedures. Sequential procedures for failed early treatment, residual dysplasia and late diagnosis are dependent on the age and the severity of the dysplasia. This paper reviews the treatment of developmental dysplasia of the hip from birth to subsequent follow-up procedures, with particular reference to some of the senior authors' research and the Southampton approach to the management of hip dysplasia.

Congenital dislocation of the hip: optimal screening strategies in 2014

A prospective multi-centre nationwide study of patients with congenital dislocation of the hip (CDH) diagnosed after 3 months of age was conducted with support from the French Society for Paediatric Orthopaedics (Société Française d'Orthopédie Pédiatrique [SoFOP]), French Organisation for Outpatient Paediatrics (Association Française de Pédiatrie Ambulatoire [AFPA]), and French-Speaking Society for Paediatric and Pre-Natal Imaging (Société Francophone d'Imagerie Pédiatrique et Prénatale [SFIPP]). The results showed inadequacies in clinical screening for CDH that were patent when assessed quantitatively and probably also present qualitatively. These findings indicate a need for a communication and educational campaign aimed at highlighting good clinical practice guidelines in the field of CDH screening. The usefulness of routine ultrasound screening has not been established. The findings from this study have been used by the authors and French National Health Authority (Haute Autorité de Santé [HAS]) to develop recommendations about CDH screening. There is an urgent need for a prospective randomised multi-centre nationwide study, which should involve primary-care physicians.

The costs of late detection of developmental dysplasia of the hip

PURPOSE

Debate currently exists regarding the economic viability for screening for developmental dysplasia of the hip in infants.

METHODS

A prospective study of infant hip dysplasia over the period of 1998-2008 (36,960 live births) was performed to determine treatment complexity and associated costs of disease detection and hospital treatment, related to the age at presentation and treatment modality. The involved screening programme utilised universal clinical screening of all infants and selective ultrasound screening of at-risk infants.

RESULTS

One hundred and seventy-nine infants (4.8/1,000) presented with hip dysplasia. Thirty-four infants presented late (> 3 months of age) and required closed or open reduction. One hundred and forty-five infants presented at < 3 months of age, 14 of whom failed early Pavlik harness treatment. A detailed cost analysis revealed: 131 early presenters with successful management in a Pavlik harness at a cost of £601/child; 34 late presenters who required surgery (36 hips, 19 closed/17 open reductions, one revision procedure) at a cost of £4,352/child; and 14 early presenters with failed management in a Pavlik harness requiring more protracted surgery (18 hips, four closed/14 open reductions, seven revision procedures) at a cost of £7,052/child.

CONCLUSIONS

Late detection causes increased treatment complexity and a sevenfold increase in the short-term costs of treatment, compared to early detection and successful management in a Pavlik harness.

DISCUSSION

Improved strategies are needed for the 10 % of early presenting infants who fail Pavlik harness treatment and require the most complex and costly interventions.

Evidence-based management of developmental dysplasia of the hip

Developmental Dysplasia of the Hip (DDH) refers to a spectrum of abnormalities involving the developing hip. These abnormalities range from mild instability to frank dislocation of the joint. It is important to treat the condition effectively in order to encourage the hip to develop normally and produce good long-term results. This article reviews the evidence related to the treatment of DDH. The quality of evidence for DDH management remains low, with little uniformity in terminology and most studies being retrospective in nature. Given this, it is not possible to recommend or reject most treatment modalities based on existing studies.

Acetabular dysplasia at the age of 1 year in children with neonatal instability of the hip

BACKGROUND AND PURPOSE

As much as one-third of all total hip arthroplasties in patients younger than 60 years may be a consequence of developmental dysplasia of the hip (DDH). Screening and early treatment of neonatal instability of the hip (NIH) reduces the incidence of DDH. We examined the radiographic outcome at 1 year in children undergoing early treatment for NIH.

SUBJECTS AND METHODS

All children born in Malmö undergo neonatal screening for NIH, and any child with suspicion of instability is referred to our clinic. We reviewed the 1-year radiographs for infants who were referred from April 2002 through December 2007. Measurements of the acetabular index at 1 year were compared between neonatally dislocated, unstable, and stable hips.

RESULTS

The incidence of NIH was 7 per 1,000 live births. The referral rate was 15 per 1,000. 82% of those treated were girls. The mean acetabular index was higher in dislocated hips (25.3, 95% CI: 24.6-26.0) than in neonatally stable hips (22.7, 95% CI: 22.3-23.2). Girls had a higher mean acetabular index than boys and left hips had a higher mean acetabular index than right hips, which is in accordance with previous findings.

INTERPRETATION

Even in children who are diagnosed and treated perinatally, radiographic differences in acetabular shape remain at 1 year. To determine whether this is of clinical importance, longer follow-up will be required.

Screening strategies for hip dysplasia: long-term outcome of a randomized controlled trial

OBJECTIVE

Screening for hip dysplasia is controversial. A previous randomized controlled trial revealed that adding universal or selective ultrasound to routine clinical examination gave a nonsignificant reduction in rates of late presenting cases, but with higher treatment rates. This study assesses differences in outcome at skeletal maturity for the 3 newborn screening strategies in terms of radiographic markers of acetabular dysplasia and early degenerative change and avascular necrosis (AVN) secondary to neonatal treatment.

METHODS

From the initial trial including 11 925 newborns, a population-based sample of 3935 adolescents was invited for follow-up at age 18 to 20 years. A standardized weight-bearing anteroposterior view was obtained. The outcomes evaluated were the radiographic findings of dysplasia (center-edge angle, femoral head extrusion-index, acetabular depth-width ratio, Sharp's angle, subjective evaluation of dysplasia) and degenerative change (joint-space width). Signs of AVN were documented.

RESULTS

Of the 3935 subjects invited, 2038 (51.8%) attended the maturity review, of which 2011 (58.2% female patients) were included: 551, 665, and 795 subjects from the universal, selective, and clinical groups, respectively. Rates per group of positive radiographic findings associated with dysplasia or degenerative change varied depending on radiographic marker used. No statistically significant differences were detected between groups. No AVN was seen.

CONCLUSIONS

Although both selective and universal ultrasound screenings gave a nonsignificant reduction in rates of late cases when compared with expert clinical programs, we were unable to demonstrate any additional reduction in the rates of radiographic findings associated with acetabular dysplasia or degenerative change at maturity. Increased treatment rates were not associated with AVN.

Current screening recommendations for developmental dysplasia of the hip may lead to an increase in open reduction

Most centres in the United Kingdom adopt a selective screening programme for developmental dysplasia of the hip (DDH) based on repeated clinical examination and selective ultrasound examination. The Newborn Infant Physical Examination protocol implemented in 2008 recommends a first examination at birth and then a second and final examination at six to ten weeks of age. Due to concerns over an increase in late presentations we performed a retrospective review of our 15-year results to establish if late presentation increases treatment requirements. Of children presenting before six weeks of age, 84% were treated successfully with abduction bracing, whereas 86% of children presenting after ten months eventually required open reduction surgery. This equates to a 12-fold increase in relative risk of requiring open reduction following late presentation. Increasing age at presentation was associated with an increase in the number of surgical procedures, which are inevitably more extensive and complex, with a consequent increased in cost per patient. The implementation of an opportunistic examination at three to five months could help to reduce the unintended consequences of the Newborn Infant Physical Examination programme.

Ultrasonography in developmental dysplasia of the hip: what have we learned?

Developmental dysplasia of the hip (DDH) is an important but poorly defined entity, the natural history of which is incompletely understood. The term encompasses a disease spectrum ranging from a stable hip with a mildly dysplastic acetabulum to complete hip dislocation. Much controversy surrounds the diagnosis, imaging and management of this condition. We present a review of the history of US imaging of DDH from the radiologist's perspective, summarising the most widely recognised US methods described to date. We discuss controversies in the approach to US examination, with particular emphasis on current opinions. The existing scientific evidence for and variations in the practice of US screening for DDH, including recommendations from the United States Preventive Services Task Force and the ESPR DDH Taskforce Group respectively, are discussed.

Developmental dysplasia of the hip: controversies and current concepts

Developmental dysplasia of the hip is an important but poorly understood disorder as evidenced by the vast amount of literature published to date on this topic. The precise definition of hip dysplasia is controversial and it encompasses a spectrum of abnormalities, rather than a single condition, which at one end overlap with normal hip maturation. We review the risk factors, clinical examination and radiological imaging of the hip in the infant and young child, the controversies of ultrasound screening for hip dysplasia and the current management, both operative and non-operative, of this condition according to patient age.

Does probe frequency influence diagnostic accuracy in newborn hip ultrasound?

Ultrasonography of the hip has gained wide acceptance as reliable method for diagnosing developmental hip dysplasia in infants. This blinded study was conducted to investigate the influence of two linear probes with different frequency on diagnostic accuracy and reproducibility. In 206 consecutive newborns, the bony roof angle (α-angle) and cartilage roof angle (β-angle) were assessed by three investigators according to Graf. The hips were measured twice both with a 7.5 MHz and a 12 MHz linear transducer (Sonoline G60S(®) ultrasound system; Siemens, Erlangen, Germany). Each investigator evaluated his sonograms 6 weeks later. Depending on the mean values for α-angle and β-angle, the hips were classified. Reproducibility of the Graf classification was not found to be influenced. In two of three investigators, we observed significant improvement concerning variation of the β-angle with the 12 MHz probe. The use of high-resolution transmitters may improve diagnostic accuracy in ultrasonography of the newborn's hip.

General ultrasound screening reduces the rate of first operative procedures for developmental dysplasia of the hip: a case-control study

OBJECTIVES

To assess the effectiveness of general ultrasound screening to prevent first operative procedures of the hip.

STUDY DESIGN

We conducted a case-control study in a population in which general ultrasound screening supplementing clinical screening is recommended and offered free of charge for all children. Participation in ultrasound screening before week 7 as recommended in Germany was the exposure of interest. Case ascertainment was based on active surveillance in orthopedic hospitals. The case definition was: first operative procedure for developmental dysplasia of the hip (closed reduction, open reduction, or osteotomy) in children >9 weeks old and <5 years old and born between 1996 and 2001. Control subjects from the same birth cohorts were recruited in telephone surveys.

RESULTS

Cases of first operative procedures for developmental dysplasia of the hip (n = 446) were compared with 1173 control subjects for ultrasound screening. Effectiveness of ultrasound screening to prevent first operative procedures for developmental dysplasia of the hip was estimated as 52% (95% CI, 32-67). Effectiveness did not vary substantially for closed and open reductions and osteotomy.

CONCLUSIONS

General ultrasound screening reduces the rate of operative procedures for developmental dysplasia of the hip; the impact on developmental dysplasia of the hip. Treatment rates and avascular necrosis need further assessment to balance the benefit against potential overtreatment and adverse effects.

Screening programmes for developmental dysplasia of the hip in newborn infants

BACKGROUND

Uncorrected developmental dysplasia of the hip (DDH) is associated with long term morbidity such as gait abnormalities, chronic pain and degenerative arthritis.

OBJECTIVES

To determine the effect of different screening programmes for DDH on the incidence of late presentation of congenital hip dislocation.

SEARCH STRATEGY

Searches were performed in CENTRAL (The Cochrane Library), MEDLINE and EMBASE (January 2011) supplemented by searches of clinical trial registries, conference proceedings, cross references and contacting expert informants.

SELECTION CRITERIA

Randomised, quasi-randomised or cluster trials comparing the effectiveness of screening programmes for DDH.

DATA COLLECTION AND ANALYSIS

Three independent review authors assessed study eligibility and quality, and extracted data.

MAIN RESULTS

No study examined the effect of screening (clinical and/or ultrasound) and early treatment versus not screening and later treatment.One study reported universal ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery but was associated with a significant increase in treatment.One study reported targeted ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery, with no significant difference in rate of treatment.Meta-analysis of two studies found universal ultrasound compared to targeted ultrasound did not result in a significant reduction in late diagnosed DDH or surgery. There was heterogeneity between studies reporting the effect on treatment rate.Meta-analysis of two studies found delayed ultrasound and targeted splinting compared to immediate splinting of infants with unstable (but not dislocated) hips resulted in no significant difference in the rate of late diagnosed DDH. Both studies reported a significant reduction in treatment with use of delayed ultrasound and targeted splinting.One study reported delayed ultrasound and targeted splinting compared to immediate splinting of infants with mild hip dysplasia on ultrasound resulted in no significant difference in late diagnosed DDH but a significant reduction in treatment. No infants in either group received surgery.

AUTHORS' CONCLUSIONS

There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery.

Cost-effectiveness of universal ultrasound screening compared with clinical examination alone in the diagnosis and treatment of neonatal hip dysplasia in Austria

Between 1978 and 1997 all newborns in the Austrian province of Tyrol were reviewed regarding hip dysplasia and related surgery. This involved a mean of 8257 births per year (7766 to 8858). Two observation periods were determined: 1978 to 1982 (clinical examination alone) and 1993 to 1997 (clinical examination and universal ultrasound screening). A retrospective analysis compared the number and cost of interventions due to hip dysplasia in three patient age groups: A, 0 to < 1.5 years; B, ≥ 1.5 to < 15 years; and C, ≥ 15 to < 35 years.

In group A, there was a decrease in hip reductions from a mean of 25.2 (sd 2.8) to 7.0 (sd 1.4) cases per year. In group B, operative procedures decreased from a mean of 17.8 (sd 3.5) to 2.6 (sd 1.3) per year. There was a 75.9% decrease in the total number of interventions for groups A and B.

An increase of €57 000 in the overall cost per year for the second period (1993 to 1997) was seen, mainly due to the screening programme. However, there was a marked reduction in costs of all surgical and non-surgical treatments for dysplastic hips from €410 000 (1978 to 1982) to €117 000 (1993 to 1997). We believe the small proportional increase in costs of the universal ultrasound screening programme is justifiable as it was associated with a reduction in the number of non-surgical and surgical interventions. We therefore recommend universal hip ultrasound screening for neonates.

The use of X-ray at 5 months in a selective screening programme for developmental dysplasia of the hip

BACKGROUND

The methods used for any screening programme for developmental dysplasia of the hip (DDH) can be controversial. This was an opportunistic audit of our selective ultrasound screening programme using an X-ray at 5 months to prevent inappropriate discharge due to the learning curve of ultrasound.

METHODS

Between 1990 and 2004 in Nottingham, UK, out of a total population of 108,500 births, approximately 11,500 neonates were screened using ultrasound. Any child with an ultrasound scan showing Graf α-angles greater than 60° (Graf Type I) with the hip in joint were discharged from the clinic. All of those discharged were subsequently X-rayed at 5 months in order to cover the learning curve of ultrasound. The X-rays were reviewed by a consultant radiologist and referred back to orthopaedics if there was lateralisation of the femoral head or an acetabular index above 30°.

RESULTS

Of approximately 11,000 X-rays performed, only 53 patients were referred back to orthopaedics, of which 47 had a complete data set. Of these 47 children, only 8 (17%) required intervention. On review of the original ultrasounds, Graf's α-angle did not seem to correlate well with the need for intervention, as all were Type I hips. The femoral head cover (FHC) appeared to be more predictive of the need for treatment. There have been no late presentations to our unit of DDH following a normal 5-month X-ray.

CONCLUSIONS

We now check the Graf α-angle, FHC and dynamic stability in the ultrasound assessment and only perform X-ray at 5 months if there was a low α-angle or low FHC. Since this change, there have been no late presentations of DDH from the population screened by ultrasound.

Diagnostic accuracy of static graf technique of ultrasound evaluation of infant hips for developmental dysplasia

INTRODUCTION

Ultrasound examination of infant hips is a widely used and accepted tool for the diagnosis and monitoring of developmental dysplasia of the hip. Its use and timing is still a focus of debate and its diagnostic accuracy has not been fully investigated.

METHOD

We have compared the ultrasound findings by the Graf technique with radiographic appearance (acetabular index) at 6 months of age.

RESULT

The negative predictive value of Ultrasound for DDH was 98% and was unaffected by the timing of the examination. The specificity and accuracy of the examination increased with age and was highest at 3 months of age.

CONCLUSION

Ultrasound examination of the infant hip by the static Graf technique is a safe and effective screening tool for the evaluation of DDH.