Performance, treatment pathways, and effects of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom

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.

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.

Neonatal hip ultrasound: tangent to lateral roof angle correlates better with stability than alpha angle according to Graf or percentage femoral head coverage

The aim of this study was to determine the relationship of tangent to the lateral roof angle (TLRA), Graf's alpha angle and percentage femoral head cover (PHC) and to observed stability, and to establish intraobserver and interobserver errors for measurement of alpha angle and TLRA. In total, 2235 babies referred to the hip review clinic over a period of 8  years. Intraobserver and interobserver errors were calculated from readings of 383 hip images by an experienced paediatric radiologist and a trainee. Taking TLRA <70° as abnormal resulted in sensitivity for unstable right hips of 88% compared with 77% for alpha angle <60° (P  =  0.002) and 81% for PHC <60% (P  =  0.028) and specificity of TLRA 89%, alpha angle 90% (P  =  0.07) and PHC 83% (P  <  0.001). Corresponding figures for left hips are sensitivity of TLRA 99%, alpha angle 91% (P  <  0.001) and PHC 96% (P  =  0.013), and specificity TLRA 86%, alpha angle 83% (P  =  0.001) and PHC 67% (P  <  0.001). Mean intraobserver errors for alpha angle were 1.85° and 1.81° for consultant and trainee compared to 2.54 and 2.55 for TLRA. Mean interobserver errors were 2.22 for alpha angle and 3.42 for TLRA. TLRA, a new parameter, correlated better with observed stability with significant improvement in sensitivity in both hips and specificity in left hips compared with Graf's alpha angle, and significantly improved sensitivity and specificity in both hips compared with percentage femoral head cover.

DNA hypermethylation of GDF5 in developmental dysplasia of the hip (DDH)

INTRODUCTION & OBJECTIVE

Developmental Dysplasia of the Hip (DDH) is one of the most common congenital skeletal anomalies. Body of evidence suggests that genetic variations in GDF5 are associated with susceptibility to DDH. DDH is a multifactorial disease and its etiology has not been entirely determined. Epigenetic changes such as DNA methylation could be linked to DDH. In this scheme, we hypothesized that changes in GDF5 DNA methylation could predispose a susceptible individual to DDH.

METHODS

This study consisted of 45 DDH patients and 45 controls with healthy femoral neck cartilage, who underwent hemi-, or total arthroplasty for the femoral neck fracture. A cartilage sample of 1 cm in diameter and 1 mm in the thickness was obtained for DNA extraction. DNA was extracted and DNA methylation of GDF5 was evaluated by metabisulfite method.

RESULTS

Methylation analysis showed that the promoter of GDF5 in cartilage samples from DDH patients was hypermethylated in comparison to healthy controls (p = .001).

CONCLUSION

Our study showed that the methylation status of the GDF5 in patients with DDH is dysregulated. This dysregulation indicates that adjustment in the methylation might modify the expression of this gene. Since this gene plays an essential role in cartilage and bone development, thus reducing its expression can contribute to the pathogenesis of DDH. Further studies are needed to elucidate the role of GDF5 in this disease.

Values for bony acetabular roof angle and percentage femoral head cover in a selective ultrasound neonatal hip-screening programme: effect of age, sex and side

Published maturation curves for bony acetabular roof or α angle (AA) and percentage femoral head cover (FHC) with age are sparse. We aimed to determine typical values for AA and FHC in 2236 infants referred to a selective ultrasound screening programme. There was increase in the values of first measurement of AA and FHC related to the logarithm of age. Males had greater values than females (P<0.001) and right hips had greater values than left (P<0.001) for both measurements. Significant side differences have not been reported previously. Treatment decisions should be made on the basis of sex, side and age-specific data.

Congenital Dislocation or Developmental Dysplasia of the newborn hip?

The role of universal primary ultrasound screening for detection of developmental dysplasia of the hip of the newborn remains controversial in Britain. Two infants in whom ultrasonography was reported to show no evidence of developmental dysplasia in the newborn period, but who later presented with acetabular dysplasia and subluxation requiring surgery, are presented.

Bilateral One-half Spica Cast After Open Reduction and Pelvic Osteotomy in the Developmental Dislocation of the Hip

Background:

The prevalence of DDH ranges from 1 per1000 to 3.4 per 100 live- births. One- and-one-half hip spica cast is the conventional technique of immobilization after the open reduction with or without osteotomy.

Objectives:

In this study, we evaluated the preference of bilateral one-half spica cast over the one-and-one-half spica cast.

Materials and Methods:

Eight hips in five patients with developmental dislocation of the hip have undergone open reduction. Salter osteotomy, Pemberton osteotomy and femoral shortening were done on two, two and six hips, respectively. Bilateral one-half spica cast with trochanteric molding was applied for all of the hips.

Results:

The patients’ age ranged from 1.5 to 7 years old. The only complications consisted of two osteonecrosis of the head and one superficial infection. No dislocation, graft displacement, nonunion and device failure was occurred.

Conclusions:

Bilateral one-half spica cast is sufficient after the open reduction with or without osteotomy in DDH patients and we can substitute the bilateral one-half spica cast above the knee cast for the conventional one and one-half spica cast.

Selective ultrasound screening for developmental hip dysplasia: effect on management and late detected cases. A prospective survey during 1991-2006

BACKGROUND

Early treatment is considered essential for developmental dysplasia of the hip (DDH), but the choice of screening strategy is debated.

OBJECTIVE

We evaluated the effect of a selective ultrasound (US) screening programme.

MATERIALS AND METHODS

All infants born in a defined region during 1991-2006 with increased risk of developmental dysplasia of the hip, i.e. clinical hip instability, breech presentation, congenital foot deformities or a family history of DDH, underwent US screening at age 1-3 days. Severe sonographic dysplasia and dislocatable/dislocated hips were treated with abduction splints. Mild dysplasia and pathological instability, i.e. not dislocatable/dislocated hips were followed clinically and sonographically until spontaneous resolution, or until treatment became necessary. The minimum observation period was 5.5 years.

RESULTS

Of 81,564 newborns, 11,539 (14.1%) were identified as at-risk, of whom 11,190 (58% girls) were included for further analyses. Of the 81,564 infants, 2,433 (3.0%) received early treatment; 1,882 (2.3%) from birth and 551 (0.7%) after 6 weeks or more of clinical and sonographic surveillance. An additional 2,700 (3.3%) normalised spontaneously after watchful waiting from birth. Twenty-six infants (0.32 per 1,000, 92% girls, two from the risk group) presented with late subluxated/dislocated hips (after 1 month of age). An additional 126 (1.5 per 1,000, 83% girls, one from the risk group) were treated after isolated late residual dysplasia. Thirty-one children (0.38 per 1,000) had surgical treatment before age 5 years. Avascular necrosis was diagnosed in seven of all children treated (0.27%), four after early and three after late treatment.

CONCLUSION

The first 16 years of a standardised selective US screening programme for developmental dysplasia of the hip resulted in acceptable rates of early treatment and US follow-ups and low rates of late subluxated/dislocated hips compared to similar studies.

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.

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.

Screening for developmental dysplasia of the hip in Hong Kong

PURPOSE

To review records of children referred to our hospital for developmental dysplasia of the hip (DDH) and evaluate the effectiveness of hip screening in Hong Kong.

METHODS

Records of children suspected of DDH and referred to our hospital between 1 January 2005 and 31 March 2010 were reviewed. The diagnosis was based on static and dynamic ultrasonography of the hips and/or radiographic features of hip subluxation, dislocation, and pelvic dysplasia. The age of the children at presentation was recorded. Late diagnoses were those presenting after the age of 6 months. Late presentations were those presenting after the walking age.

RESULTS

Of 213 referred children, 33 were diagnosed to have DDH. Their mean age at presentation was 90.8 (range, 9-559) days. The female-to-male ratio was 2.9:1, and the mean follow-up duration was 25.1 (range, 4.2-50.3) months. 30 of the DDH infants were diagnosed before the age of 6 months, one at 8 months, and 2 were late presenters. Hence, the failure rate of the hip screening was 0.09 per 1000 live births. The remaining 180 were confirmed to be normal and followed up until the walking age. The point prevalence of DDH on Hong Kong Island was 0.87/1000 live births.

CONCLUSION

In light of the low point prevalence of DDH in Hong Kong born children, the protocol of universal clinical assessment and selective ultrasonographic screening of suspected cases is justified.

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.

Single-stage open reduction, Salter innominate osteotomy, and proximal femoral osteotomy for the management of developmental dysplasia of the hip in children between the ages of 2 and 4 years

The management of neglected developmental dysplasia of the hip in walking children has always been a challenge to orthopedic surgeons. The aim of this study was to access the early clinical and radiographic results of surgical treatment of such cases using one-stage open reduction, Salter innominate osteotomy, and proximal femoral osteotomy. Seventy-one surgeries were performed in 55 patients. Favorable clinical and radiographic outcomes were comparable to other studies. We concluded that this single-stage surgery is a technically demanding, but satisfactory procedure in the management of neglected developmental dysplasia of the hip patients, and when performed adequately in indicated patients in specialized centers, it is expected to give good short-term results.

Screening for developmental dysplasia of the hip: current practices in Ireland

OBJECTIVE

To ascertain the current approach to screen for developmental dysplasia of the hip in the Republic of Ireland.

METHODS

Two-pronged prospective and retrospective study. (1) Postal questionnaire to consultant paediatricians responsible for the routine neonatal care of infants in the Irish Republic in June 2006. (2) Retrospective database review to identify infants undergoing radiological follow-up and their outcome.

RESULTS

All maternity units surveyed responded. Most units (84%) were dependent on radiographs at 4-6 months for imaging hips, only two units primarily used ultrasound (10.5%). We estimate that neonatal hip examination is performed by an experienced examiner in less than 30% of routine newborn examinations. On retrospective analysis, 94% of radiographs performed were normal.

CONCLUSIONS

The most effective interventions, selective ultrasound and examination by an experienced clinician are not widely practiced. There is a need for the development of national guidelines based on available resources.

[When is the optimal time for hip ultrasound screening?]

The perfect time for hip screening is when every pathologically deformed hip can be diagnosed by sonography and after spontaneous resolution of immature, dysplastic hips. In addition, the beginning of therapy should be early enough to provide the best possible outcome concerning the anatomically correct healing of the patient's hip. Even though every child should be screened by sonography in the first few days of life, a reasonable way could be ultrasound screening in the first week for clinically unstable hips or newborns with risk factors such as breech position combined with ultrasound screening of every newborn between the fourth and sixth week.

[Hip ultrasound screening in Germany. Results and comparison with other screening procedures]

General ultrasound screening programmes to determine DDH are still a matter of discussion due to a lack of evidence. To facilitate further discussions this review gives an overview of the international data and literature concerning the different screening policies taking into account the results of the German evaluation study from 1997 to 2002. General ultrasound screening programmes are established in Germany and Austria. The analysis of the German screening showed 535 cases of DDH with first operative procedure (age 10 weeks to 5 years) that were treated as inpatients: 66% underwent a closed reduction, 11% an open reduction and 23% an osteotomy of the acetabulum/femur. The number of children who had no ultrasound of the hip before diagnosis decreased from 22% in the first year to 8% in the last. The first ultrasound examination was without pathological findings in 12% of the cases. Capture-recapture estimates suggested that 52% of cases were reported, so that the incidence for first operation due to DDH was 0.26 per 1,000 live births in 1997. This is much lower than in other countries and 4/5 less than the time before screening with ultrasound in Germany. At most 42% of the cases might be preventable by an improvement of the screening programme, but at least 51% would not be prevented. The German ultrasound screening programme has proved to be effective. Improvement of economic efficiency is still possible. Therefore, the German programme with different screening times can be recommended.

Associated risk factors in children who had late presentation of developmental dysplasia of the hip

PURPOSE

The purpose of this study was to assess the role of clinical examination, associated risk factors and plain radiograph of the pelvis in children who had late presentation of DDH.

METHODS

We report on a 7-year prospective study, in children who had late presentation of developmental dysplasia of the hip (DDH). For this purpose, 740 hips in 370 referred children, age range 3-7 months (mean 3.44 months) were clinically and radiologically assessed, and the associated risk factors recorded.

RESULTS

Female sex, first born, positive family history and breech presentation were confirmed as risk factors for DDH. Significant findings were an increased risk for vaginal delivery over caesarean section for breech presentation (P = 0.002). There was an increased risk for caesarean section in the absence of breech presentation. Multiple births and preterm births had a reduced risk. For breech presentation, the risk of DDH was estimated to be at least 1.6% for girls and 3.4% for boys; a combination of factors increased the risk. Limitation of abduction (43.2%) and asymmetry of the groin skin folds (72.7%) were found to be the two most common clinical findings associated with DDH. Bilateral acetabular dysplasia is more common than unilateral dysplasia. Foot deformities were rarely encountered in children with acetabular dysplasia.

CONCLUSIONS

The percentage of first-born babies who had DDH is lower than reported in the literature (34%), but still shows significant risk. We did find that bilateral acetabular dysplasia is more common than unilateral dysplasia. Torticollis and foot deformities are rarely found to be associated with DDH. All these findings needs further evaluation in children who had surgical treatment for DDH, to see if they are different from dysplastic groups. Limitation of abduction is an important clinical finding, but is not always associated with DDH. Asymmetry of the skin folds in the groin were found to be an important clinical finding associated with DDH for all age groups. As clinical examination depends on many factors, and most DDH cases are of the dysplastic type, it is mandatory to depend on further diagnostic tools for confirmation of DDH.

Developmental dysplasia of the hip

In its severest form, developmental dysplasia of the hip is one of the most common congenital malformations. The pathophysiology and natural history of the range of morphological and clinical disorders that constitute developmental dysplasia of the hip are poorly understood. Neonatal screening programmes, based on clinical screening examinations, have been established for more than 40 years but their effectiveness remains controversial. Whereas systematic sonographic imaging of newborn and young infants has afforded insights into normal and abnormal hip development in early life, we do not clearly understand the longer-term outcomes of developmental hip dysplasia, its contribution to premature degenerative hip disorders in adult life, and the benefits and harms of newborn screening. High quality studies of the adult outcomes of developmental hip dysplasia and the childhood origins of early degenerative hip disease are needed, as are randomised trials to assess the effectiveness and safety of neonatal screening and early treatment.

The lack of evidence of the effect of selective ultrasound screening on the incidence of late developmental dysplasia of the hip in the Greater Glasgow Region

The aim of our study was to establish whether the use of ultrasound to screen babies with risk factors has reduced the number of children presenting late with developmental dysplasia of the hip. Screening based on selection by risk factors was introduced in 1997. The average annual incidence from 1992 to 1996 was 0.84 and from 1997 to 2001 was 0.57 per 1000 live births. This decline in incidence of late developmental dysplasia of the hip was not significant (P=0.088). Sixty-four children (82%) had nothing that could be perceived as a risk factor for the condition. Our study presents population-based findings and it is clear that selective screening is not working in our region. It is unlikely that there will be one solution that could be applied throughout the United Kingdom given the diversity in the access to healthcare facilities. Clear leadership and accountability are required if we are to make any progress towards abolishing this condition that causes a significant morbidity in young adults.

Differences in risk factors between early and late diagnosed developmental dysplasia of the hip

BACKGROUND

Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in South Australia. Clinical screening programmes exist to identify the condition early to gain the maximum benefit from early treatment. Although these screening programmes are effective, there are still cases that are missed. Previous research has highlighted key risk factors in the development of DDH.

OBJECTIVE

To compare the risk factors of cases of DDH identified late with those that were diagnosed early.

METHODS

A total of 1281 children with DDH born in 1988-1996 were identified from the South Australian Birth Defects Register. Hospital records of those who had surgery for DDH within 5 years of life were examined for diagnosis details. Twenty seven (2.1%) had been diagnosed at or after 3 months of age and were considered the late DDH cases (a prevalence of 0.15 per 1000 live births). Various factors were compared with early diagnosed DDH cases.

RESULTS

Female sex, vertex presentation, normal delivery, rural birth, and discharge from hospital less than 4 days after birth all significantly increased the risk of late diagnosis of DDH.

CONCLUSIONS

The results show differences in the risk factors for early and late diagnosed DDH. Some known risk factors for DDH are in fact protective for late diagnosis. These results highlight the need for broad newborn population screening and continued vigilance and training in screening programmes.

Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force

BACKGROUND

Developmental dysplasia of the hip (DDH) represents a spectrum of anatomic abnormalities that can result in permanent disability.

OBJECTIVE

We sought to gather and synthesize the published evidence regarding screening for DDH by primary care providers.

METHODS

We performed a systematic review of the literature by using a best-evidence approach as used by the US Preventive Services Task Force. The review focused on screening relevant to primary care in infants from birth to 6 months of age and on interventions used in infants before 1 year of age.

RESULTS

The literature on screening and interventions for DDH suffers from significant methodologic shortcomings. No published trials directly link screening to improved functional outcomes. Clinical examination and ultrasound identify somewhat different groups of newborns who are at risk for DDH. A significant proportion of hip abnormalities identified through clinical examination or ultrasound in the newborn period will spontaneously resolve. Very few studies examine the functional outcomes of patients who have undergone therapy for DDH. Because of the high rate and unpredictable nature of spontaneous resolution of DDH and the absence of rigorous comparative studies, the effectiveness of interventions is not known. All surgical and nonsurgical interventions have been associated with avascular necrosis of the femoral head, the most common and most severe harm associated with all treatments of DDH.

CONCLUSIONS

Screening with clinical examination or ultrasound can identify newborns at increased risk for DDH, but because of the high rate of spontaneous resolution of neonatal hip instability and dysplasia and the lack of evidence of the effectiveness of intervention on functional outcomes, the net benefits of screening are not clear.

Developmental dysplasia of the hip: definition, recognition, and prevention of late sequelae

When a child presents with a dislocated hip after the walking age, parents are upset, pediatricians are distraught, and lawsuits often follow. The prevention of late presentation is a goal that all practitioners should strive for. However, at this time, using current diagnostic techniques, the late presentation of DDH can be minimized but not eliminated. The AAP Subcommittee on DDH has estimated that approximately 15% of DDH at birth is not detectible, even by experienced examiners or ultrasonographers. In addition to preventing the late presentation of a developmentally dislocated hip, the prevention of premature degenerative arthritis of the hip secondary to developmental subluxation and acetabular dysplasia is equally, if not more, important in terms or morbidity and cost. It is hoped that the identification and treatment of babies with DDH at birth will have the added benefit of decreasing the incidence of degenerative arthritis of the hip in adults. As the key to early detection remains repeated, careful examination of the infant in the first year of life, it is imperative for practitioners to become as skilled as possible in performing the exam. Unfortunately, medical school curricula and pediatric and family practice residency programs often are deficient in teaching the neonatal hip examination. Strategies for clinicians to improve their examination technique include asking a pediatric orthopedic surgeon to demonstrate the examination in their nursery or attending one of the AAP courses on DDH. Starting a formal DDH screening program in the nursery is another option, using few screeners to maximize their experience. Nurse practitioners, physician's assistants, and physiotherapists could be used in addition to physicians. Having a child present with a developmentally dislocated hip after the walking age is not malpractice if the child has had repeated careful examinations. It is important to document the examinations in writing, rather than placing a check mark next to "musculoskeletal" or "hips" on standard, pre-printed exam forms. The best documentation is a handwritten note that states "the hips are stable and there is wide symmetrical abduction" at every well-child visit. At this time, careful, repeated physical exam supplemented by ultrasonography or X-rays for babies with risk factors is our best strategy to minimize the late presentation of DDH.

Ultrasonography in screening for developmental dysplasia of the hip in newborns: systematic review

OBJECTIVE

To assess the accuracy and effectiveness of the screening of all newborn infants for developmental dysplasia of the hip (DDH) using ultrasound imaging, as is standard practice in some European countries but not in the United Kingdom, the United States, or Scandinavia.

DESIGN

Systematic review.

DATA SOURCES

Twenty three medical, economic, and grey literature databases (to March 2004), with no limitations of design or language; some references were provided by experts.

SELECTION OF STUDIES

Only diagnostic accuracy studies and comparative studies conducted in an unselected newborn population were eligible for the review. Two reviewers independently selected the studies and performed the quality assessment.

RESULTS

The review identified one diagnostic accuracy study, and this was of limited quality. In this study the reference standard was treatment up to age of 8 months or an abnormal ultrasound finding at age 8 months. Ultrasound screening had a sensitivity of 88.5% (95% confidence interval 84.1% to 92.1%), specificity of 96.7% (96.4% to 97.4%), a positive predictive value of 61.6% and a negative predictive value of 99.4%. Ten studies evaluated the impact of ultrasound in screening, but these too had various methodological weaknesses, limiting the reliability of their findings. Compared with clinical screening, general ultrasound screening in newborns may increase overall treatment rates, but ultrasound screening seems to be associated with shorter and less intrusive treatment.

CONCLUSIONS

Clear evidence is lacking either for or against general ultrasound screening of newborn infants for DDH. Studies that investigate the natural course of the disorder, the optimal treatment for DDH, and the best strategy for ultrasound screening are needed.

Efficiency of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom

AIMS

To assess, using a decision model, the efficiency of ultrasound based and clinical screening strategies for developmental dysplasia of the hip.

METHODS

The additional cost per additional favourable outcome was compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; addition of static and dynamic ultrasound examination of the hips of all infants (universal ultrasound) or restricted to infants with defined risk factors (selective ultrasound); "no screening" (that is, clinical diagnosis only).

RESULTS

Ultrasound based screening strategies are predicted to be more effective but more costly than clinical screening or no screening. Estimated total costs per 100,000 live births are approximately pound 4 million for universal ultrasound, pound 3 million for selective ultrasound, pound 1 million for clinical screening alone, and pound 0.4 million for no screening. The relative efficiency of selective ultrasound and clinical screening is poorly differentiated, and depends on how infants are selected for ultrasound as well as the expertise of clinical screening examiners. If training costs less than pound 20 per child screened, clinical screening alone would be more efficient than selective ultrasound. Relative to no screening, each of the 16 additional favourable outcomes achieved as a result of selective ultrasound costs approximately pound 0.2 million, while each of the five favourable outcomes achieved through universal ultrasound screening, over and above selective ultrasound, costs approximately pound 0.3 million.

CONCLUSIONS

Policy choice depends on values attached to the different outcomes, willingness to pay to achieve these and total budget.