Introducing universal ultrasound screening for developmental dysplasia of the hip doubled the treatment rate

Screening of Developmental Dysplasia of the Hip in Europe: A Systematic Review

BACKGROUND

Developmental dysplasia of the hip (DDH) is a prevalent orthopaedic disorder in children, and screening methods vary across regions due to local health policies. The purpose of this review is to systematise the different ultrasound screening strategies for detecting DDH in newborns in Europe.

METHODS

Eligible studies from the PubMed, Embase, and Scopus databases, published between 1 January 2018 and 18 March 2023, were included. The inclusion criteria specified a European origin, a focus on newborn human patients, and information on ultrasound for DDH detection.

RESULTS

In total, 45 studies were included, covering 18 countries. Among them, six nations (Austria, Bosnia and Herzegovina, Poland, Slovenia, the Czech Republic, and Germany) perform universal ultrasound screening. The timing of the first ultrasound varies, with Austria and the Czech Republic within the 1st week, Bosnia and Herzegovina on the day of birth, Poland between 1 and 12 weeks, and Germany before the 6th week. The Graf method is the most popular ultrasound technique used.

CONCLUSIONS

There is no consensus on the optimal DDH detection approach in Europe. Varied screening methods stem from epidemiological, cultural, and economic differences among countries.

Costs of abduction treatment in developmental dysplasia of the hip. Analysis of 900 patients

BACKGROUND

Developmental dysplasia of the hip (DDH) is a disorder of hip development that leads to dysplasia, subluxation, or total hip dislocation. Early detection of DDH is important, and early initiation of abduction treatment is key to successful correction of the hip joint. However, mild forms of DDH, including hip instability without complete dislocation, have good spontaneous healing potential, and a watchful waiting strategy in mild DDH has been found to be safe. In this study, we aimed to evaluate the cost differences between different treatment strategies for DDH.

MATERIAL AND METHODS

Data were collected retrospectively from the medical records of all children diagnosed with diagnosis and treatment of DDH in Tampere University hospital between 1998 and 2018. In total, 948 patients were included in the study. Patients who underwent casting or operative treatment (n = 48) were excluded from the analysis. All Ortolani positive children were subjected to early abduction treatment. Children with Ortolani negative DDH were subjected to either watchful waiting or early abduction treatment, based on the clinicians' decision. The regression model estimates for the number of clinical visits with and without ultrasound examination were assessed together with cost reports from Tampere University Hospital for the calculation of savings per patient in spontaneous recovery.

RESULTS

Alpha angles at one month of age (p < 0.001) and treatment method (p < 0.001) affected the number of clinical visits and ultrasound examinations during the treatment follow-up. A low alpha angle predicted closer follow-up, and children with spontaneous recovery had lower numbers of clinical visits and ultrasound examinations than children in abduction treatment. Spontaneous recovery was found to result in approximately 375€/patient savings compared to successful abduction treatment.

CONCLUSION

With correct patient selection, a watchful waiting strategy is cost-effective in treating mild developmental dysplasia of the hip, considering the high percentage of spontaneous recovery.

Progress in screening strategies for neonatal developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) is the most common congenital disease of the musculoskeletal system in newborns and encompasses a disease spectrum ranging from a stable hip with a mildly dysplastic acetabulum to complete hip dislocation. Systematic screening for infant DDH has been performed for several decades all over the world and has contributed greatly to the early detection, diagnosis and treatment of DDH. However, some cases of delayed diagnosis still occur among the screened population, or conversely, overdiagnosis or overtreatment occasionally occurs. Furthermore, screening strategies for DDH are still controversial. The aim of our study was to analyze the current literature on DDH screening, paying particular attention to DDH screening strategies and their effectiveness. We searched the DDH screening literature from 1958 to 2021 in MEDLINE and other databases using PubMed. In this study, we reviewed the history of DDH screening and the progress of screening strategies and discussed the controversies regarding clinical and ultrasound screening methods with particular emphasis on the current opinions. Given the existing scientific evidence and changes in newborn DDH screening practices, universal ultrasound screening seems to be the best option for preventing late-detected cases and can be recommended as a favorable prevention strategy.

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.

Screening of Newborns and Infants for Developmental Dysplasia of the Hip: A Systematic Review

BACKGROUND

Developmental dysplasia of hip (DDH) is a common disorder of childhood and has a good prognosis when treated at an early age. In spite of being a significant concern, many children with DDH are not picked early and present late at walking age. In our country, it is presumed to be due to absence of a national policy for screening of DDH. Screening programmes including the combination of clinical and radiological methods in different ways have been suggested. However, the exact method of screening is controversial.

PURPOSE

To analyze effectiveness and cost-effectiveness of various screening methods for DDH.

STUDY DESIGN

Systematic review.

METHODS

This review was conducted in accordance with PRISMA guidelines. Medline database was explored for original case series and randomized clinical trials. Inclusion criteria were English language, screening for DDH in neonates, sample size more than 500, and studies with minimum duration of one year.

RESULTS

Thirty-four studies were selected to write the manuscript. This included 23 studies looking for effectiveness of a screening programme and 11 studies comparing various outcomes of different screening strategies. A trend favoring universal ultrasound screening was observed.

CONCLUSION

The literature supports universal ultrasound screening and has proved its cost-effectiveness. However, considering the logistic and financial challenges in our country, immediate implementation of universal ultrasound screening seems impractical. In the absence of any current guidelines for screening for DDH in India, we suggest professional organizations involved in the care of children and public health policy-makers to come together to develop national screening guidelines for DDH.

Early detection of developmental dysplasia of hip by ultrasound

OBJECTIVE

To assess the effectiveness of early universal ultrasound (US) screening of developmental dysplasia of the hip (DDH).

STUDY DESIGN

A prospective study of universal hip screening of all mature neonates was conducted from 2012 to 2013, at the Department of Obstetrics and Gynaecology, University of Szeged; 1636 newborns (3272 hips) had clinical examinations and hip ultrasound by the Graf method within the1st 3 days of life. Prevalence of DDH, risk factors, sensitivity and specificity of clinical examinations were evaluated.

RESULTS

At the 1st US, 70 of the examined 3272 hips (2.14%) were found to be positive. According to Graf categories, the following distribution was observed: type II C, 21 hips (30.0%); D, 24 hips (34.28%); III, 24 hips (34.28%); IV, 1 hip (1.44%). Regarding the risk factors, female gender, breech presentation and positive family history proved to be significant. Interestingly, 28 (50.90%) of the 55 newborns with DDH had neither positive physical signs nor any risk factors, except being female. The physical examination was calculated for sensitivity (20.0%) and specificity (98.34%).

CONCLUSIONS

In our 1-year period study, 50.9% of the newborns with DDH had neither any positive physical signs nor any risk factors, except being a female. In contrast, early universal US screening of the hip facilitated to diagnose all cases with hip dysplasia. Hip sonography is an effective mode of prevention in orthopaedics, however further studies are needed to compare the rates of operative procedures in selective versus universal screening models.

Pulvinar and pubic cartilage measurements to refine universal ultrasound screening for developmental dysplasia of the hip: Data from 1896 infant hips

PURPOSE

Screening modalities for Developmental Dysplasia of the Hip (DDH) and indications for treatment of mild forms remain controversial. Ultrasound (US) measurement of the pubofemoral distance (PFD > 6 mm, composed of the pubic cartilage and the pulvinar) can avoid late diagnoses of DDH. A thick pubic cartilage may nevertheless lead to false positives. The purpose of this study was to establish standard measurements of pubic cartilage and pulvinar, through universal US screening, to lower false positive results and thus any overtreatment.

METHODS

This is a single-center observational prospective study conducted from December 2016 to January 2018, on infants who underwent universal US screening for DDH. The only inclusion criterion was an adjusted age between 4 and 12 weeks when US was realized. PFD measurement was made using the Couture and Tréguier method. In addition, thicknesses of pubic cartilage and pulvinar were measured on the same US section, in millimeters.

RESULTS

Nine hundred and forty-eight patients, representing 1896 hips, were included. The average value of pubic cartilage thickness was 1.25 mm ± 0.58 mm, with an upper threshold of 2.39 mm (+1.96σ). The average value of pulvinar thickness was 2.67 mm ± 0.78 mm, with an upper threshold of 4.20 mm (+1.96σ). We found high inter-observer reproducibility in pubic cartilage measurements.

CONCLUSION

Systematic measurements of pubic cartilage and pulvinar may refine therapeutic decision by identifying false positives. Patients with increased PFD due to a thick pubic cartilage >2,39 mm, without an associated pulvinar enlargement (<4,20 mm), could be therefore only monitored and not overtreated.

Developmental dysplasia of the hip

Developmental dysplasia of the hip encompasses a range of hip abnormalities in which the femoral head and acetabulum fail to develop and articulate anatomically. Developmental dysplasia of the hip is a clinically important condition, with a prevalence of 1-2/1000 in unscreened populations and 5-30/1000 in clinically screened populations. The pathology is incongruence between the femoral head and the acetabulum, which can be caused by an abnormally shaped femoral head, acetabulum, or both. This results in a spectrum of different hip abnormalities. The precise aetiology behind developmental dysplasia of the hip is unclear, but there are a number of established risk factors. In the UK, universal clinical examination of newborns and 6-8-week-old babies is performed under the national UK newborn screening programme for developmental dysplasia of the hip (part of the Newborn and Infant Physical Examination). The physical examination of the newborn hip involves initial inspection of the infant for any of the clinical features of developmental dysplasia of the hip, followed by hip stability tests (Barlow's and Ortolani's tests). Hip ultrasound is the gold standard diagnostic and monitoring tool for developmental dysplasia of the hip in newborns and infants under 6 months of age, or until ossification of the femoral head. Some mild cases of developmental dysplasia of the hip (and the immature hip) resolve without requiring intervention; however, there are a number of treatments, both non-operative and operative, that may be used at various stages of this condition.

Developmental Dysplasia of the Hip

Pediatricians are often the first to identify developmental dysplasia of the hip (DDH) and direct subsequent appropriate treatment. The general treatment principle of DDH is to obtain and maintain a concentric reduction of the femoral head in the acetabulum. Achieving this goal can range from less-invasive bracing treatments to more-invasive surgical treatment depending on the age and complexity of the dysplasia. In this review, we summarize the current trends and treatment principles in the diagnosis and treatment of DDH.