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

Six years of experience with the nationwide newborn ultrasonographic hip screening program in Turkey: a considerable change in the type of surgical interventions in developmental dysplasia of the hip

This study aims to assess whether or not the nationwide newborn ultrasonographic hip screening program has influenced the rate of different types of surgical interventions performed in developmental dysplasia of the hip (DDH) in children in Turkey. A retrospective analysis of the nationwide data obtained from the National Registry System between January 1, 2015, and December 31, 2020, was carried out. The rate of minor and major surgical interventions was calculated by dividing the total number of primary closed/open reductions with or without tenotomies and the total number of primary pelvic or periacetabular osteotomies with or without femoral osteotomies by the total number of live births in the country per year, respectively. The rates of primary minor surgical interventions were found to be 0.47/1000 in 2015, 0.71/1000 in 2016, 1.07/1000 in 2017, 1.00/1000 in 2018, 1.06/1000 in 2019, and 0.89/1000 in 2020. The rates of primary major surgical intervention were found to be 0.74/1000 in 2015, 0.40/1000 in 2016, 0.33/1000 in 2017, 0.31/1000 in 2018, 0.32/1000 in 2019, and 0.21/1000 in 2020. The introduction of the nationwide newborn hip screening program has significantly changed the surgical treatment modalities in children with DDH. A nearly twofold increase in the rate of primary closed/open reduction and hip spica casting and nearly three quarters decrease in the rate of primary bony procedures were observed within 6 years.

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.

Is Radiographic Imaging Necessary for Identifying Late Developmental Dysplasia of the Hip in Breech Infants with Normal Ultrasounds?

Purpose. The goal of our study was to investigate the prevalence of late DDH cases in breech infants who had a normal screening hip ultrasound and subsequent follow-up hip x-ray imaging. Methods. Infants with a history of intrauterine breech position, normal hip ultrasound within 3-months of birth, and follow-up hip x-rays within 2-years were included. Acetabular indices were measured on a supine AP pelvis radiograph. Results. Fifty-six patients had breech presentation at birth, a normal hip ultrasound, and returned for radiographic evaluation within 2 years. Of those, 11/112 (10%) of hips had late DDH based on their radiographic images at 1 standard deviation greater than normative values from age-adjusted controls. No infants showed hip dysplasia at 2 standard deviations greater than normative values from age-adjusted controls. Conclusions. Our results support previous studies that follow up should be considered for infants with breech presentation and normal hip ultrasounds near birth. Level of evidence. II.

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.

Understanding physician behaviour in the 6-8 weeks hip check in primary care: a qualitative study using the COM-B

OBJECTIVES

A compulsory hip check is performed on an infant at 6-8 weeks in primary care for the detection of developmental dysplasia of the hip (DDH). Missed diagnoses and infants incorrectly labelled with DDH remain an important problem. The nature of physician behaviour as a likely source of this problem has not been explored. The aims of this study were to make a behavioural diagnosis of general practitioners (GPs) who perform these hip checks, and identify potential behavioural change techniques that could make the hip checks more effective.

DESIGN

Qualitative study with in-depth semistructured interviews of 6-8 weeks checks. We used the Capability, Opportunity, Motivation and Behaviour model in making a behavioural diagnosis and elicited factors that can be linked to improving the assessment.

SETTING

Primary care.

PARTICIPANTS

17 GPs (15 female) who had between 5 and 34 years of work experience were interviewed.

RESULTS

Capability related to knowledge of evidence-based criteria and skill to identify DDH were important behavioural factors. Both physical (clinic time and space) and social (practice norms), opportunity were essential for optimal behaviour. Furthermore, motivation related to the importance of the 6-8 weeks check and confidence to perform the check and refer appropriately were identified in the behavioural diagnosis.

CONCLUSION

Aspects of capability, opportunity and motivation affect GPs' diagnosis and referral behaviours in relation to DDH. The findings from this work extend current knowledge and will inform the development of an intervention aimed at improving the diagnosis of DDH.

Importance of early diagnosis for developmental dysplasia of the hip: A 5-year radiological outcome study comparing the effect of early and late diagnosis

AIM

Australia utilises a selective ultrasound screening programme. The rate of late diagnosis of developmental dysplasia of the hip (DDH) in Australia is increasing. The aim of this study is to quantify the treatment required and compare the 5-year radiological outcomes between early and late diagnosis in children with DDH with frank dislocation.

METHODS

We performed a case-matched control study of children with frank DDH dislocations from 2000 to 2010 comparing three groups: children with an early diagnosis successfully treated in a Pavlik harness (SP), children with an early diagnosis who failed Pavlik harness treatment (FP) and children with a late diagnosis (LD). Minimum follow-up was 4 years.

RESULTS

A total of 115 hips were included. Patients in the LD group required significantly more open reductions (P < 0.001), acetabular osteotomies (P < 0.001) and femoral osteotomies (P < 0.001). LD was also associated with significantly higher rates of growth disturbance at 46.3%, compared to 20.6% in the FP group and 5% in the SP group (P < 0.001). Overall, there were excellent radiological outcomes in 58.5% of the LD group compared to 79.4% in the FP group and 100% in the SP group.

CONCLUSION

In Australia, high rates of LD in DDH persist in the context of selective ultrasound screening. While good radiological outcomes are achievable, a significantly greater level of surgical intervention is required and this is associated with significantly higher rates of growth disturbance. Optimisation of screening in Australia is vital.

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.

Recommendations for early diagnosis of Developmental Dysplasia of the Hip (DDH): working group intersociety consensus document

This consensus document has been prepared by a multidisciplinary group of experts (Paediatricians, Radiologists, Paediatric Orthopaedics) and it is mainly aimed at paediatricians, hospitals and primary care providers. We provide recommendations for the early diagnosis and treatment of Developmental Dysplasia of the Hip (DDH) and indications on its management.

Interpreting neonatal hip sonography: intraobserver and interobserver variability

The purpose of this study is to state the reliability of neonatal hip ultrasound interpretation, defining the intra and interoperator variability in the evaluation of the scans. We considered a sample of 2071 scans (coming from 798 patients who attended the screening programme for hip dysplasia), which were interpreted by the operator who obtained and read the images at the screening time and then by a different operator who saw the images for the first time. Both the intra and interoperator variability of α and β angles' values resulted statistically not significative (intraclass correlation coefficient > 0.8) and determining a class shift (according to the Graf's classification) in a nonstatistically significative number of cases (agreement percentage >91% and Cohen's κ >0.8). Hip sonography can reliably detect hip dysplasia and the intra and interoperator variability in the interpretation of the exam is NS when the examination is correctly executed.

Evaluation of primary care 6- to 8-week hip check for diagnosis of developmental dysplasia of the hip: a 15-year observational cohort study

BACKGROUND

The current 6- to 8-week Newborn and Infant Physical Examination (NIPE) clinical assessment is a current standard hip-screening test in the community (England) to detect developmental dysplasia of the hip (DDH).

AIM

To assess the value of the primary care 6- to 8-week clinical hip examination for the diagnosis of DDH.

DESIGN AND SETTING

A single-centre 15-year observational cohort study at a district general hospital between 1 January 1996 and 31 December 2010.

METHOD

Those referred by the GP or community practitioner with suspected instability or abnormality of the hip joint (DDH), were clinically and sonographically examined in a specialist hip-screening clinic. Modified Graf Type III and IV, and radiological irreducible hip dislocation were considered to be 'pathological' hips. Screening failures were defined as those who had not been identified by this primary care screening assessment (but had irreducible hip dislocation). Secondary univariate and multivariable analyses were performed to determine which clinical findings are predictive of instability.

RESULTS

Over the study period, there were 70 071 infants who underwent the 6- to 8-week clinical hip assessment. In the specialist hip-screening clinic, six (from the 170 referred) were diagnosed with pathological DDH. The sensitivity, specificity, positive predictive value, and negative predictive value for the 6- to 8-week clinical hip assessment were 16.7%, 99.8%, 3.5%, and 100.0%, respectively. A multivariable model showed a positive Ortolani manoeuvre to be the sole independent predictor of instability at 6 to 8 weeks.

CONCLUSION

This 15-year study highlights the limitations of a hip check at 6 to 8 weeks. These findings support the reassessment of the national guidelines for this aspect of the NIPE DDH screening programme.

Should paediatricians initiate orthopaedic hip dysplasia referrals for infants with isolated asymmetric skin folds?

PURPOSE

Asymmetric skin folds (ASFs) have been linked to developmental dysplasia of the hip (DDH) in select studies, leading to their inclusion in paediatric practice guidelines regarding orthopaedic referral for hip evaluation. The purpose of this study was to investigate the utility of isolated ASFs as a screening tool for DDH in a series of patient referrals evaluated at a single institution.

METHODS

We performed a retrospective review of consecutive patients between 0 and 12 months of age referred to orthopaedic clinics for isolated ASFs. We recorded radiographic findings (acetabular inclination or alpha angle), diagnosis rendered and treatment administered.

RESULTS

A total of 66 patients were included (mean age 6.4 months; 2.47 to 10.76). All patients received pelvic radiographs or ultrasound. In all, 36 patients (55%) were considered normal by their treating physician and 25 (38%) were considered dysplastic and underwent brace treatment. One hip with an isolated ASF was found to have a dislocated hip on radiograph prior to their initial orthopaedic visit. None of the patients in this study have required surgery to date.

CONCLUSION

Using ASFs as a reason for referral led to increased diagnosis of mild dysplasia resulting in orthotic treatment. Thus, in our particular clinical environment, isolated ASFs can be an indicator of mild dysplasia and warrant further workup or referral. Because treatment philosophies regarding recognition and treatment of mild dysplasia vary amongst centres, the value of screening with ASFs likewise depends on the treating orthopaedic surgeon's threshold for treatment of mild dysplasia.

LEVEL OF EVIDENCE

Level IV- Retrospective.

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.

Results of universal ultrasound screening for developmental dysplasia of the hip: a prospective follow-up of 28 092 consecutive infants

AIMS

The purpose of this study was to analyze the incidence of the different ultrasound phenotypes of developmental dysplasia of the hip (DDH), and to determine their subsequent course.

PATIENTS AND METHODS

A consecutive series of 28 092 neonates was screened and classified according to the Graf method as part of a nationwide surveillance programme, and then followed prospectively. Abnormal hips were followed until they became normal (Graf type I). Type IIb hips and higher grades were treated by abduction in a Tübinger orthosis until normal. Dislocated hips underwent closed or open reduction.

RESULTS

Overall, 90.2% of hips were normal at birth. Type IIa hips (8.9%) became normal at a median of six weeks (interquartile range (IQR) 6 to 9). Type IIc and IId hips (0.67%) became normal after ten weeks (IQR 7 to 13). There were 19 type lll and eight type lV hips at baseline. There were 24 closed reductions and one open reduction. No late presentations of DDH were detected within the first five years of life.

CONCLUSION

The incidence of DDH was eight per 1000 live births. The treatment rate was 1% (n = 273). The rate of first operations on the newborn hip was 0.86, and rate of open surgery was 0.04. The cumulative rate of open surgery was 0.07. The authors take the view that early identification and treatment in abduction of all dysplastic hips in early childhood reduces the rate of open reduction and secondary DDH-related surgery later in life. Cite this article: Bone Joint J 2018;100-B:1399-1404.

Universal versus selective ultrasound screening for developmental dysplasia of the hip: a single-centre retrospective cohort study

A total of 28 068 infants were studied to investigate whether universal ultrasound screening for developmental dysplasia of the hip results in fewer delayed presentations than selective screening, and whether the screening protocol affects subsequent treatment. The rate of delayed presentation was not lower with selective screening compared with universal screening but all cases of delayed presentation in this cohort were administrative errors. There were no sonographic errors (false-negatives). The treatment rate was significantly higher with universal screening but infants were treated earlier and were significantly less likely to require any surgical intervention. Those requiring surgery were less likely to require open reduction or pelvic osteotomy.

Universal or selective ultrasound screening for developmental dysplasia of the hip? A discussion of the key issues

PURPOSE

To summarize recent developments and provide recommendations as to whether universal or selective programmes are advisable.

METHODS

A literature review was performed and preference given to studies with higher levels of evidence. All programmes reviewed included clinical screening.

RESULTS

Recent studies underline the need for high quality screening programmes to promote the early detection of developmental dysplasia of the hip (DDH). A small number of cases may be missed clinically but with universal ultrasound screening programmes the late presentation rates appear to be virtually zero. Contemporary studies show treatment rates with universal screening programmes which are now lower than those with selective ultrasound. There is little agreement over the criteria used for selective programmes. Alternative outcome measures, such as the first operation rate or the percentage undergoing major (open) surgery are both lowest with universal ultrasound screening programmes. Furthermore, a significant reduction in the rate of surgery for DDH later in life was seen after the introduction of universal ultrasound screening, whereas the defined criteria for selective screening may not detect the majority of patients who require late surgery. Abduction bracing with modern orthoses is associated with a zero rate of avascular necrosis (AVN), whereas closed reduction techniques have an overall risk of 10%.

CONCLUSION

On clinical grounds, if future studies confirm that hip abduction in flexible orthoses is not associated with AVN, it may be time for a paradigm shift of screening for DDH towards a universal ultrasound protocol. The costs associated both with each type of screening programme and with the management of late presenting cases are also important but may be secondary to clinical benefit.

Outcomes following open reduction for late-presenting developmental dysplasia of the hip

PURPOSE

Patients with late-presenting developmental dysplasia of the hip (DDH) are more likely to require an open reduction. Since many developing countries do not have mandated screening, there continues to be a relatively high incidence of late-presenting DDH. We report the clinical and radiographic outcomes of open reduction in a series of patients who presented late.

PATIENTS AND METHODS

This was a retrospective review of 712 hips in 645 patients that underwent open reduction, alone or in combination with a pelvic osteotomy. In all, 91 hips had open reduction alone and 621 had open reduction and pelvic osteotomy. Femoral shortening was performed in 221 hips. The mean age at the time of surgery was 2.1 years (1 to 6.5) and the mean follow-up time was 9.3 years (6 to 14). We used the Children's Hospital Oakland Hip Evaluation Score (CHOHES) to determine functional outcomes and the Severin classification was used to evaluate radiographic outcomes. The rate of avascular necrosis (AVN) and the need for a reoperation were also recorded and analyzed.

RESULTS

In all 80% (570 hips) had good radiographic outcomes (Severin type I or II) and 87% had a CHOHES score of > 90 at final follow up. There was a 14% rate of AVN and only a 2% rate of redislocation. Better radiographic outcomes and lower reoperation rates were seen with patients who underwent both an open reduction and pelvic osteotomy. A trend was observed towards worse outcomes in older patients.

CONCLUSIONS

There was a high rate of good clinical and radiographic outcomes at a minimum six-year follow-up in patients with late-presenting DDH who underwent open reduction. Those who underwent open reduction in combination with a pelvic osteotomy had a higher rate of good radiographic outcomes and a lower rate of complications, particularly reoperation.

Clicky hip alone is not a true risk factor for developmental dysplasia of the hip

AIMS

A clicky hip is a common referral for clinical and sonographic screening for developmental dysplasia of the hip (DDH). There is controversy regarding whether it represents a true risk factor for pathological DDH. Therefore a 20-year prospective, longitudinal, observational study was undertaken to assess the relationship between the presence of a neonatal clicky hip and pathological DDH.

PATIENTS AND METHODS

A total of 362 infants from 1997 to 2016 were referred with clicky hips to our 'one-stop' paediatric hip screening clinic. Hips were assessed clinically for instability and by ultrasound imaging using a simplified Graf/Harcke classification. Dislocated or dislocatable hips were classified as Graf Type IV hips.

RESULTS

The mean age at presentation was 13.8 weeks (12.8 to 14.7). In all 351 out of 362 children (97.0%) had Graf Type I hips (normal) that required no treatment. Nine children (2.5%) had Graf Type II hips but all resolved to Graf Type I hips on follow-up scans. One child (0.3%) had Graf Type III hip dysplasia and one child (0.3%) had an irreducible hip dislocation. The two pathological hips were associated with unilateral limited hip abduction. Mean referrals increased from 12.9 to 23.3 each year (p = 0.002) from the first decade of the study to the second, driven by increasing primary care referrals (5.5 versus 16.7 per year, p < 0.001).

CONCLUSION

Most clicky hips required no treatment other than reassurance to parents. Clicky hips with a normal hip examination should be considered a variant of normal childhood and not a risk factor for DDH. However, an abnormal hip examination including unilateral limited hip abduction should prompt urgent further investigations. Cite this article: Bone Joint J 2017;99-B:1533-6.

Late presentation of developmental dysplasia of the hip

Aims

Despite the presence of screening programmes, infants continue to present with late developmental dysplasia of the hip (DDH), the impact of which is significant. The aim of this study was to assess infants with late presenting dislocation of the hip despite universal clinical neonatal and selective ultrasound screening.

Patients and Methods

Between 01 January 1997 to 31 December 2011, a prospective, longitudinal study was undertaken of a cohort of 64 670 live births. Late presenting dislocation was defined as presentation after three months of age. Diagnosis was confirmed by ultrasound and plain radiography. Patient demographics, referral type, reason for referral, risk factors (breech presentation/strong family history) and clinical and radiological findings were recorded.

Results

There were 31 infants with an irreducible dislocation of the hip, an incidence of 0.48 (95% confidence interval (CI) 0.34 to 0.68) per 1000 live births. Of these, 18 (0.28 (95% CI 0.17 to 0.44) per 1000 live births; 58%) presented late. All infants had a documented normal newborn clinical examination and no abnormality reported in the six to eight week check. Of the 18 late presenting cases 72% (n = 13) had no risk factors: 16 were referred by GPs and two were late due to administrative issues (missed appointments). The mean time to diagnosis was 62.4 weeks (19 to 84).

Conclusion

Despite universal clinical neonatal and selective ultrasound screening, late cases of irreducible hip dislocation still occur. We recommend an update of the national screening programme for DDH, a review of training and education of healthcare professionals involved in the physical examination of neonates and infants, and the addition of a further assessment after the six to eight week check. Cite this article: Bone Joint J 2017;99-B:1250–5.

The most relevant diagnostic criteria for developmental dysplasia of the hip: a study of British specialists

Background

Developmental dysplasia of the hip (DDH) is the most common orthopaedic disorder in newborns. Despite this considerable variation in practice exists. The aim of this study was to determine the clinical relevance and a ranking order for the diagnostic criteria in DDH amongst paediatric orthopaedic surgeons practicing in the UK.

Method

One hundred members of the British Society of Children’s Orthopaedic Surgery (BSCOS) were asked to rate the importance of 37 criteria useful in the diagnosis of DDH in newborns, using a 10 cm visual analogue scale. We determined the consistency among specialists in rating the criteria with the intraclass correlation coefficient (ICC) and compared the results to a group of international peers.

Results

Ortolani/Barlow tests, asymmetry in abduction ≥20° and a first-degree relative treated for DDH ranked among the top ten. Participants demonstrated poor consistency in rating the 37 criteria (ICC 0.39; 95 % CI 0.29, 0.52), but for clinical examination criteria alone their consistency improved (ICC 0.52; 0.35, 0.75). The importance ratings of members of BSCOS and members of the European Paediatric Orthopaedic Society differed for 15/37 (41 %) criteria (p <0.05).

Conclusions

Members of BSCOS had a preference for criteria relating to clinical examination and ultrasound.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0867-4) contains supplementary material, which is available to authorized users.

Delayed diagnosis of developmental dysplasia of the hip in Northern Ireland

Developmental dysplasia of the hip (DDH) should be diagnosed as early as possible to optimise treatment. The current United Kingdom recommendations for the selective screening of DDH include a clinical examination at birth and at six weeks. In Northern Ireland babies continue to have an assessment by a health visitor at four months of age. As we continue to see late presentations of DDH, beyond one year of age, we hypothesised that a proportion had missed an opportunity for earlier diagnosis. We expect those who presented to our service with Tonnis grade III or IV hips and decreased abduction would have had clinical signs at their earlier assessments.

We performed a retrospective review of all patients born in Northern Ireland between 2008 and 2010 who were diagnosed with DDH after their first birthday. There were 75 856 live births during the study period of whom 645 children were treated for DDH (8.5 per 1000). The minimum follow-up of our cohort from birth, to detect late presentation, was four years and six months. Of these, 32 children (33 hips) were diagnosed after their first birthday (0.42 per 1000).

With optimum application of our selective screening programme 21 (65.6%) of these children had the potential for an earlier diagnosis, which would have reduced the incidence of late diagnosis to 0.14 per 1000. As we saw a peak in diagnosis between three and five months our findings support the continuation of the four month health visitor check. Our study adds further information to the debate regarding selective versus universal screening.

Cite this article: Bone Joint J 2015;97-B:1572–6.

Selective ultrasound screening is inadequate to identify patients who present with symptomatic adult acetabular dysplasia

PURPOSE

One goal of neonatal screening for developmental dysplasia of the hip (DDH) is the prevention of late surgery. However, the majority of patients with acetabular dysplasia at skeletal maturity are not diagnosed with DDH during infancy. Selective ultrasound screening may identify patients with neonatal hip instability, but may be ineffective for the prevention of dysplasia presenting in adulthood. The purpose of this study is to identify the prevalence of risk factors for DDH that would have warranted selective ultrasound screening in patients with symptomatic acetabular dysplasia after skeletal maturity.

METHODS

A prospective hip specialty center registry was used to identify 68 consecutive skeletally mature patients undergoing corrective osteotomy for symptomatic acetabular dysplasia. Risk factors for DDH evaluated in all patients included sex, family history of hip osteoarthritis or DDH, breech, method of delivery, previous hip treatments, and birth order. Radiographs [lateral center edge angle (CEA), anterior CEA, Tönnis grade, and Tönnis angle] were measured preoperatively.

RESULTS

Sixty-seven females and one male were identified. No patients were previously diagnosed with DDH or received treatment for their hips. The majority of patients (85.3 %) did not meet selective ultrasound screening guidelines following a stable neonatal hip exam and, therefore, would not have been screened in a selective screening program. Of the findings outside of screening guidelines, 98.5 % were females, 52.9 % were first born, and 36.8 % had a family history of hip osteoarthritis.

CONCLUSIONS

The majority (85.3 %) of patients with symptomatic acetabular dysplasia at skeletal maturity would not have met current recommendations for selective ultrasound screening in the USA had they been born today.

Trends in the surgical management of hip dysplasia

Hip dysplasia is a spectrum of disease. There are established screening programmes for its detection in childhood, but there is also increasing interest in its presentation and surgical treatment at skeletal maturity. This study was aimed at establishing patterns of operative treatment for hip dysplasia in the UK using the hospital episode statistics database over an 11-year period. From a total of 12 100 operations during this interval, there has been no significant change in the level of intervention in the paediatric population. There has, however, been a four-fold rise in procedures in the adult population over the same timeframe.