Neonatal screening and selective sonographic imaging in the diagnosis of developmental dysplasia of the hip

Risk factors for a false negative Ortolani and Barlow examination in developmental dysplasia of the hip

INTRODUCTION

Although universal screening by neonatal clinical examination with Ortolani and Barlow manoeuvres is widely adopted, its role as a sole screening tool is controversial due to its poor sensitivity and failure in identifying hip joints that eventually require surgical intervention.

HYPOTHESIS

This study aims to identify risk factors for a false negative Ortolani and Barlow examination in neonatal screening for DDH. The hypothesis is that risk factors for developmental dysplasia of the hips could similarly be risk factors for a false negative Ortolani and Barlow examination.

MATERIAL AND METHODS

In the 14-year retrospective cohort study, all newborn infants born in a single institution from 1st January 1999 to 31st December 2013 were screened clinically with the Ortolani/Barlow manoeuvre by a neonatologist. Infants with positive risk factors, despite a normal clinical examination, were then scheduled for bilateral hip ultrasound in the first three months of life and evaluated according to the Graf's method, Harcke's method of dynamic ultrasound screening and Terjesen's method of evaluation for femoral head coverage.

RESULTS

A total of 164 infants with normal Ortolani and Barlow examinations were scheduled for bilateral hip ultrasound due to the presence of risk factors. Amongst these, 32 (19.5%) infants were evaluated to have an abnormal hip on ultrasound. Breech position was the only statistically significant risk factor for a false negative Ortolani/Barlow examination (14/34, 41.2% vs. 18/112, 13.8%; p<0.001).

DISCUSSION

Sonographic hip examinations are recommended for all infants with breech presentation even if they have a normal Ortolani and Barlow examination.

LEVEL OF EVIDENCE

III; case-control study.

Who performs neonatal hip assessment: is there a cause for concern?

OBJECTIVE

The UK falls behind other European countries in the early detection of developmental dysplasia of the hip (DDH) and screening strategies differ for early detection. Clinical detection of DDH is challenging and recognised to be dependent on examiner experience. No studies exist assessing the number of personnel currently involved in such assessments.Our objective was to review the current screening procedure by studying a cohort of newborn babies in one teaching hospital and assess the number of health professionals involved in neonatal hip assessment and the number of examinations undertaken during one period by each individual.

METHODS

This was a retrospective observational study assessing all babies born consecutively over a 14-week period in 2020. Record of each initial baby check was obtained from BadgerNet. Follow-up data on ultrasound or orthopaedic outpatient referrals were obtained from clinical records.

RESULTS

1037 babies were examined by 65 individual examiners representing 9 different healthcare professional groups. The range of examinations conducted per examiner was 1-97 with a median of 5.5 examinations per person. 49% of individuals examined 5 or less babies across the 14 weeks, with 18% only performing 1 examination. Of the six babies (0.48%) treated for DDH, one was picked up on neonatal assessment.

CONCLUSION

In a system where so many examiners are involved in neonatal hip assessment, the experience is limited for most examiners. Currently high rates of late presentation of DDH are observed locally, which are in accordance with published national experience. The potential association merits further investigation.

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.

Pubofemoral distances correlate to acetabular morphology and sonological instability in screening for hip dysplasia

Aims

The present study seeks to investigate the correlation of pubofemoral distances (PFD) to α angles, and hip displaceability status, defined as femoral head coverage (FHC) or FHC during manual provocation of the newborn hip < 50%.

Methods

We retrospectively included all newborns referred for ultrasound screening at our institution based on primary risk factor, clinical, and PFD screening. α angles, PFD, FHC, and FHC at follow-up ultrasound for referred newborns were measured and compared using scatter plots, linear regression, paired t-test, and box-plots.

Results

We included 2,735 newborns, of whom 754 received a follow-up hip ultrasound within six weeks of age. After exclusion, 1,500 hips were included for analysis. Sex distribution was 372 male and 380 female, and the mean age at examination was 36.6 days (4 to 87). We found a negative linear correlation of PFD to α angles (p < 0.001), FHC (p < 0.001), and FHC during provocation (p < 0.001) with a 1 mm increase in PFD corresponding to a -2.1° (95% confidence interval (CI) -2.3 to -1.9) change in α angle and a -3.4% (95% CI -3.7 to -3.0) change in FHC and a -6.0% (-6.6 to -5.5) change in FHC during provocation. The PFD was significantly higher with increasing Graf types and in displaceable hips (p < 0.001).

Conclusion

PFD is strongly correlated to both α angles and hip displaceability, as measured by FHC and FHC during provocation, in ultrasound of newborn hips. The PFD increases as the hips become more dysplastic and/or displaceable.

Selective sonographic screening for developmental dysplasia of the hip - increasing trends in late diagnosis

There are concerns that selective sonographic screening for developmental dysplasia of the hip (DDH) may be suboptimal. Our aim was to test this hypothesis by identifying trends in presentation and surgical treatment in patients with DDH. This is a retrospective review of children born between 1997-2018 who were treated surgically for DDH at our sub- regional paediatric orthopaedic unit. Demographic data, risk factors, age of diagnosis and surgical treatments were analysed. Late diagnosis was defined as greater than 4 months. 103 children (14 male, 89 female) underwent surgery. 93 hips were operated for dislocation and 21 for dysplasia. 13 patients presented with bilateral hip dislocations. The median age at diagnosis was 10 months (95% CI: 4-15). 62/103 (60.2%) were diagnosed late (after 4 months) and the median age for diagnosis in this group was 18.5 months (95% CI: 16-20.5). Significantly more patients were referred late (p=0.0077). The presence of risk factors (breech presentation or family history) was associated with early diagnosis. Over the duration of our study the operation rate per 1000 live births gradually increased, and on Poisson regression analysis there was a statistically significant increasing trend towards late diagnosis in recent years (p=0.0237), which necessitated more aggressive surgical management. In the UK, the current selective sonographic screening programme for DDH has shown a deterioration over the years of this study and this questions its current effectiveness. It appears that the majority of irreducible hip dislocations are diagnosed late, with an increased need for surgical management.

Pubo-Femoral Distances Measured Reliably by Midwives in Hip Dysplasia Ultrasound

The pubo-femoral distance (PFD) has been suggested as an ultrasound screening tool for developmental dysplasia of the hip (DDH). The aim of this study was to examine if midwives undergoing minimal training could reliably perform pediatric hip ultrasound and PFD measurements. Eight recruited midwives performed two rounds of independent blinded PFD measurements on 15 static ultrasound images and participated in four supervised live-scanning sessions. The midwives were compared to a group of three experienced musculoskeletal radiologists. Reliability was evaluated using inter-rater correlation coefficients (ICC). Linear regression was used to quantify the learning curve of the midwives as a group. There was near complete intra- and inter-rater agreement (ICC > 0.89) on static ultrasound images across both rounds of rating for midwives and radiologists. The midwives performed a mean of 29 live hip scans (range 24−35). The mean difference between midwives and supervising radiologists was 0.36 mm, 95% CI (0.12−0.61) for the first session, which decreased to 0.20 mm, 95% CI (0.04−0.37) in the fourth session. ICC for PFD measurements increased from 0.59 mm, 95% CI (0.37−0.75) to 0.78 mm, 95% CI (0.66−0.86) with progression in sessions. We conclude that midwives reliably perform PFD measurements of pediatric hips with minimal training.

Application Value of Combined Diagnosis of Ultrasound, MRI, and X-Ray in Developmental Dysplasia of the Hip in Children

Objective

To explore the application value of the combined diagnosis of ultrasound, MRI, and X-ray in developmental dysplasia of the hip (DDH) in children.

Methods

Ninety children with suspected DDH admitted to our hospital from June 2017 to June 2020 were selected as the research objects to conduct a retrospective study. According to the age of the children, they were divided into a group with 0-6 months (group X), a group with 7-12 months (group Y), and a group older than 12 months (group Z), with 30 cases in each group. X-ray and high-frequency ultrasound were performed in all groups, and MRI examination was added to the children in groups Y and Z to compare the diagnostic value of the three imaging examinations in DDH children.

Results

No obvious differences in the general data and maternal risk factors were observed among the three groups (P < 0.05). The final comprehensive diagnostic results were taken as the gold standard, including 23 cases with acetabular dysplasia, 28 cases with subluxation of the femoral head, 31 cases with complete dislocation of the femoral head, and 8 non-DDH cases. The diagnostic accuracy of the three methods from high to low was MRI, high-frequency ultrasound, and X-ray, with obviously higher diagnostic accuracy of MRI than that of X-ray (P < 0.05). The ROC curves showed that the diagnostic efficacy from high to low was MRI + high-frequency ultrasound + X-ray, high-frequency ultrasound + X-ray, MRI, high-frequency ultrasound, and X-ray.

Conclusion

Ultrasound combined with X-ray has obvious advantages in the diagnosis of children at low months of age, while MRI has outstanding advantages in the diagnosis of children at high months of age. MRI combined with ultrasound and X-ray can significantly improve the diagnostic accuracy of DDH and provide objective data support for the clinical treatment of children.

Anterior hip ultrasound: A useful technique in developmental dysplasia of the hips

Introduction: Infant developmental dysplasia of the hips arises when there is an interruption to normal joint development, usually present at birth but may be a later development. It has a wide spectrum of severity with potentially disastrous long-term complications if left untreated. Incidence is highly variable, often being attributed to differences of opinion in definition and diagnosis; however, there is consensus that ultrasound be used in screening and management. Topic Description: The anterior hip ultrasound technique is underutilised but is of value due to the additional confidence it provides regarding joint stability. Discussion: The ability to relate the acquired ultrasound image to hip anatomy and a technical appreciation of the technique are crucial to successful use. The method is described and its use within previous literature briefly outlined. Using pictorial ultrasound imaging examples to demonstrate the technique, we aim to highlight the anterior approach as a useful addition to ultrasound assessment of infant developmental dysplasia of the hips. Conclusion: Knowledge and understanding of different techniques is essential for practitioners involved in the diagnosis and management of this multifaceted and vigorously debated condition.

Developmental dysplasia of the hip: Beyond the screening. Physical exam is our pending subject

INTRODUCTION

Developmental dysplasia of the hip is a common cause of disability among children. Early detection leads to better prognosis. There are some risk factors that increase the possibility of developing a dysplasia. But not every child with developmental dysplasia has them. This means that physical examination is still very useful to detect them. However, based on clinical findings, the amount of requested ultrasound seems higher than it would be necessary.

METHODS

Retrospective cohort study of infants born in a single tertiary care centre. Babies in which hip ultrasound was performed were included. During the period of study, patients with diagnosis of developmental hip dysplasia were also included, as well as the amount of ultrasounds requested during this period, and their efficiency.

RESULTS

Out of the 456 newborns included, 530 hip ultrasounds were performed. Just 3 of the total 12 dysplasias had risk factors. The others were diagnosed through clinical examination.

CONCLUSIONS

Screening protocols are useful to detect hip dysplasia but clinical examination is very important to detect those cases without risk factors. However, the number of tests is higher than expected according to the diagnosed dysplasias.

Self-reported knowledge of national guidelines for clinical screening for hip dysplasia: a web-based survey of midwives and GPs in Denmark

Background

The positive predictive value of clinical hip examinations performed by generalist health professionals in screening for developmental dysplasia of the hip (DDH) is low and declining.

Aim

To assess the self-reported recognition of nationally recommended clinical hip examinations in the screening programme for DDH in Denmark among midwives, GPs, and GPs in training.

Design & setting

A cross-sectional, web-based open survey study among Danish midwives, GPs, and GPs in training.

Method

Responders were asked to identify which of six written statements of clinical hip examinations were featured in the national Danish guidelines on DDH screening. Three statements were the official statements of the Ortolani, Galeazzi, and hip abduction examinations from the national guidelines, and three statements were false and constructed by the author group. Participants were asked to select up to six statements.

Results

A total of 178 (58 GPs, 97 midwives, and 23 GPs in training) responses were included. Overall, 89% of responders correctly identified the Ortolani manoeuvre and 92% correctly identified one of the constructed descriptions as being false. The remaining four descriptions had significantly lower correct answer percentages ranging from 41%–58%, with significantly lower correct answer percentages of midwives for three out of all six descriptions when compared with GPs.

Conclusion

The recognition of two out of three recommended clinical hip examinations in the Danish screening programme for DDH is low overall among current screeners. Efforts should be made to heighten the knowledge level by further education of screeners.

Positive predictive values in clinical screening for developmental dysplasia of the hip

AIM

To establish the positive predictive value (PPV) of clinical hip examinations performed by referrers in the Danish screening programme for Developmental Dysplasia of the Hip (DDH) utilising three definitions of true positive DDH diagnosis.

METHODS

We retrospectively identified 290 children (169 female) referred during a 4-year period to the orthopaedic outpatient clinic at our institution with a positive clinical hip examination. Positive predictive value was calculated for clinical hip examinations across three definitions of a true positive clinical hip examination for all referrers and subgroups consisting of general practitioners, midwives and paediatricians. The PPV for clinical hip examinations was calculated for paediatric orthopaedic surgeons using one of the three definitions.

RESULTS

Positive predictive value of clinical hip examinations for all referrers were 5.4%, 3.6% and 1.8% with the definition of a true positive DDH diagnosis defined as clinical instability found by orthopaedic surgeon, ultrasound classification ≥Graf IIc or both definitions combined, respectively. Positive predictive value of clinical hip examinations performed by orthopaedic surgeons was 33.3% with a true positive clinical examination defined as an ultrasound classification ≥Graf IIc.

CONCLUSION

We conclude that the positive predictive value of clinical hip examinations made by referrers in the Danish screening programme for DDH is low.

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.

[Develomental dysplasia of the hip: beyond the screening. Physical exam is our pending subject]

INTRODUCTION

Developmental dysplasia of the hip is a common cause of disability among children. Early detection leads to better prognosis. There are some risk factors that increase the possibility of developing a dysplasia. But not every child with developmental dysplasia has them. This means that physical examination is still very useful to detect them. However, based on clinical findings, the amount of requested ultrasound seems higher than it would be necessary.

METHODS

Retrospective cohort study of infants born in a single tertiary care centre. Babies in which hip ultrasound was performed were included. During the period of study, patients with diagnosis of developmental hip dysplasia were also included, as well as the amount of ultrasounds requested during this period, and their efficiency.

RESULTS

Out of the 456 new-borns included, 530 hip ultrasounds were performed. Just 3 of the total 12 dysplasias had risk factors. The others were diagnosed through clinical examination.

CONCLUSIONS

Screening protocols are useful to detect hip dysplasia but clinical examination is very important to detect those cases without risk factors. However, the number of tests is higher than expected according to the diagnosed dysplasias.

Evolution of concentricity after closed reduction in developmental dysplasia of the hip

AIMS

The goal of closed reduction (CR) in the treatment of developmental dysplasia of the hip (DDH) is to achieve and maintain concentricity of the femoral head in the acetabulum. However, concentric reduction is not immediately attainable in all hips and it remains controversial to what degree a non-concentric reduction is acceptable. This prospective study is aimed at investigating the dynamic evolution of the hip joint space after CR in DDH using MRI.

METHODS

A consecutive series of patients with DDH who underwent CR since March 2014 were studied. Once the safety and stability were deemed adequate intraoperatively, reduction was accepted regardless of concentricity. Concentricity was defined when the superior joint space (SJS) and medial joint space (MJS) were both less than 2 mm, based on MRI. A total of 30 children, six boys and 24 girls, involving 35 hips, were recruited for the study. The mean age at CR was 13.7 months (3.5 to 27.6) and the mean follow-up was 49.5 months (approximately four years) (37 to 60). The joint space was evaluated along with the interval between the inverted and everted limbus.

RESULTS

Only three hips (8.6%) were fully concentric immediately after CR. During follow-up, 24 hips (68.6%) and 27 hips (77.1%) became concentric at six months and one year, respectively. Immediate SJS after CR decreased from 3.51 mm to 0.79 mm at six months follow-up (p = 0.001). SJS in the inverted group decreased from 3.75 mm to 0.97 mm at six months follow-up. SJS or MJS in the everted group were less than those in the inverted group at each time of follow-up (p = 0.008, p = 0.002).

CONCLUSION

A stable, safe but non-concentric reduction achieved before the age of two years appears to improve over time with nearly 80% of hips becoming fully concentric by one year. Cite this article: Bone Joint J 2020;102-B(5):618-626.

The treatment of neonatal hip dysplasia with splints in the United Kingdom: time for consensus?

PURPOSE

To understand the variation in the management of hip dysplasia identified from the United Kingdom neonatal selective screening programme.

METHODS

Having been designed and tested by the research committee of the British Society for Children's Orthopaedic Surgery (BSCOS), a nationwide online survey was conducted of BSCOS members to ascertain their treatment strategies for neonatal hip dysplasia.

RESULTS

There were 111 responses (60% of members), which illustrated wide variation in care. In all, 91 (over 80%) of respondents treat more than ten cases per year, yet only 61 (55%) work to an agreed protocol. A total of 90 (81%) use the Graf classification and 103 (93%) use the Pavlik harness initially. Consensus is lacking in key areas including duration of harness use, hours per day, clothing and weaning. Importantly, notable differences of opinion even exist regarding which hip pathologies need treatment.

CONCLUSION

This study quantifies the wide variation in many key elements of the initial treatment of neonatal hip dysplasia in the United Kingdom. This variation appears unnecessary and unacceptable as the Getting It Right First Time programme seeks to standardize care pathways. The charitable sector has called for consensus to mitigate parental anxiety, and it has been suggested that this could allow better integration of hip dysplasia into national screening pathways. Standardized care benefits patients and represents the platform from which we can begin understanding effectiveness and optimizing outcomes.

LEVEL OF EVIDENCE

Level V.

Examining the effectiveness of examination at 6-8 weeks for developmental dysplasia: testing the safety net

OBJECTIVE

The 'GP check' at 6-8 weeks forms part of the selective surveillance system for developmental dysplasia of the hip (DDH) in the UK. It is imperative to pick up DDH within the first months of life to allow for non-invasive treatment and the avoidance of surgery. We aim to investigate the effectiveness of hip examination at 6-8 weeks.

METHODS

This is a longitudinal observational study including all infants born in our region in the 5 years following 2006. Early presentation was defined as diagnosis within 14 weeks of birth and late presentation after 14 weeks. Treatment records for early and late DDH as well as referrals for ultrasound (US) following examination at 6-8 weeks were analysed. Attendance of the examination at 6-8 weeks in those patients who went on to present with a late DDH was also analysed.

RESULTS

23 112 live births occurred during the study period. There were 141 confirmed cases of DDH. 400 referrals for US were received following examination at 6-8 weeks; 6 of these had a positive finding of DDH. 27 patients presented after 14 weeks and were classified as late presentations. 25 of these patients had attended examination at 6-8 weeks and no abnormality had been identified.

CONCLUSIONS

The sensitivity of examination at 6-8 weeks was only 19.4%, its specificity was 98% and it had a positive predictive value of 1.5%. For many years the check at 6-8 weeks has been thought of as a means to identify those children not identified as neonates; however, we found that four out of five children with DDH were not identified by the check at 6-8 weeks. Unfortunately, we conclude that the presumed safety net of the examination in its current form is not reliable.

Value of the 'clicky hip' in selective screening for developmental dysplasia of the hip

AIMS

The aim of this study was to review the value of accepting referrals for children with 'clicky hips' in a selective screening programme for hip dysplasia.

PATIENTS AND METHODS

A single-centre prospective database of all referrals to the hip clinic was examined to identify indication for referrals, diagnosis, and treatment. All patients referred received a standardized ultrasound scan and clinical examination by an orthopaedic consultant.

RESULTS

There were 5716 children referred to the orthopaedic hip clinic between 1 June 2014 and 26 September 2018. In all, 1754 children (30.1%) were referred due to 'clicky hip' with no additional risk factors or indications for ultrasound scan. A total of 123 children (7.1%) referred with 'clicky hip' and no additional risk factors or examination findings had an abnormal initial hip ultrasound, including 16 children (0.9%) with dysplastic hips. Of the 141 children who required treatment in a Pavlik harness during the study period, 23 (16%) had been referred with a 'clicky hip' and no additional risk factors or examination findings, including six children with Graf 3 or 4 hips.

CONCLUSION

There is significant value in reviewing children with an isolated 'clicky hip'. Many children who require treatment are referred to the orthopaedic service as 'clicky hip' with no additional risk factors. In a pragmatic pathway with a diverse population of clinicians performing baby checks, 'clicky hip' is an important indication for referral and should not be discarded. Cite this article: Bone Joint J 2019;101-B:635-638.