Screening for developmental dysplasia of the hip: Results of a 7-year follow-up study

BACKGROUND: Screening for developmental dysplasia of the hip (DDH) is widely recommended for all infants to prevent disability from late diagnosis of dislocation of the hip. The present study evaluates the results of screening for developmental dislocation of hip in a clinic in Turkey over the course of 7 years. METHODS: Hospital records of 5798 infants who were examined regularly until walking age at Gazi University well child clinics between January 1995 and December 2001 were reviewed. Infants with known risk factors for DDH such as breech presentation, family history of DDH or swaddling, and of infants with physical examination findings suggestive of DDH, were referred to orthopedic surgeons for diagnosis. Based on this final diagnosis, sensitivity, specificity, positive and negative predictive values of risk factors and physical examination findings were calculated. RESULTS: Of the 5798 infants, risk factors were detected in the medical history of 111 infants, and in 14 infants a musculoskeletal deformity was detected. In 606 infants the physical examination findings were suggestive of DDH. Ten patients were subsequently diagnosed with DDH. The sensitivity, specificity, positive predictive value and negative predictive values of having a risk factor for DDH in history were 10.0%, 98.1%, 0.9%, 99.8%, and having abnormal hip examination findings were 100.0%, 88.9%, 1.6% and 100.0%, respectively. CONCLUSIONS: A careful history and physical examination is the cornerstone of DDH screening. Serial hip examinations performed during health examination visits provide an opportunity to identify DDH cases. The sensitivity of risk factors in history and physical examination findings together is high enough to be accepted as a screening tool.     

Screening for hip abnormality in the neonate

Clinical screening policies for the detection of hip instability or dysplasia of the hip vary internationally. There is general agreement in the Western world that at birth all hip joints should be clinically assessed by the Ortolani and Barlow tests. Currently, there is no consistency regarding who should undertake the examination, the results being worse when inexperienced personnel are used. These clinical tests have poor sensitivity and should be regarded as surveillance, not screening methods. Since the 1980s ultrasonographic assessment of the hip has become a valuable diagnostic tool. However there is continuing controversy on whether this imaging method should be used universally or selectively for 'at risk' and clinically unstable hip joints. Universal ultrasonographic evaluation may result in over-treatment and selective screening may be no better than the best clinical screening programs in reducing the incidence of 'late' irreducible dislocation of the hip. It is generally accepted that all clinically unstable hips should be imaged by ultrasound by static and dynamic methods in order to confirm the diagnosis and to monitor treatment.     

Value of limited hip abduction in developmental dysplasia of the hip

BACKGROUND: Developmental dysplasia of the hip (DDH) continues to be missed by routine physical examination in up to 50% of cases. Ultrasound (US) supplementation is the best method of screening for DDH, but the resources required should not be underestimated. Limited abduction of the hip (LHA) in an infant triggers suspicion, and often an urge to treat, in most orthopaedic surgeons and pediatricians alike. This study aimed to document the value of unilateral LHA in the diagnosis and decision making of DDH, and the correlation between LHA and US. METHODS: In total, 464 infants referred from the pediatrics clinic with LHA, aged between 30 and 120 days, were included in the study. RESULTS: Physical examination revealed LHA in 186 (41%) infants, 26 of which were unilateral and 160 were bilateral. US examination showed that 13 (8.1%) patients in the bilateral LHA group and 18 (69.2) patients in the unilateral LHA group, had DDH (total number 31, 7%). CONCLUSION: Unilateral limitation of hip abduction was found to be a sensitive sign for developmental hip dysplasia, but US could be defined once again as the best golden standard before initiating treatment.     

新生儿髋关节筛查资料分析

目的 探讨超声及临床髋关节检查在新生儿发育性髋关节发育不良（DDH）早期筛查中的意义.方法 采用前瞻性的方法,分两阶段对我院2011年8月1日至2013年3月29日出生的新生儿分别进行髋关节临床检查和超声检查,并对筛查结果进行分析.第一阶段为2011年8月1日至2013年1月29日,筛查出生3 ～ 10天的新生儿,了解我院新生儿DDH的患病率、DDH发生的高危因素,以及髋关节超声筛查和临床物理检查两者之间的吻合度等.第二阶段为2013年1月30日至2013年3月29日,对初诊与复诊的一致性及灵敏度和特异度进行调查.结果 第一阶段共筛查5193例新生儿,临床髋关节检查阳性616例（11.86％）,超声检查阳性556例（10.71％）.男、女超声阳性率分别为6.41％和15.78％.臀位及羊水量少的新生儿超声检查阳性率分别为10.55％和13.00％.男、女左、右髋超声分度比较和男、女左髋、右髋、双髋超声检查比较显示,女婴、臀位、羊水量少、右髋发生DDH的风险高,差异有统计学意义（P＜0.05）.第二阶段共筛选出符合超声初查和复查双条件的新生儿108例,初诊与复诊结果差异无统计学意义（P＞0.05）.ROC曲线下面积为0.675（95％ CI：0.183～1.000）.阳性预测值5.88％,阴性预测值98.90％.灵敏度及特异度的95％可信区间分别为50.00％ （95％ CI：1.26％ ～ 98.70％）,84.90％（95％ CI：76.60％ ～91.10％）.结论 超声进行新生儿髋关节DDH检查排除性诊断的意义大.运用髋关节临床及超声检查筛查新生儿DDH简便、安全,可早期发现可疑及异常病例,有利于门诊随访和早期干预.     

Developmental dysplasia of the hip: Risk markers, clinical screening and outcome

Background: Early detection, diagnosis and treatment of developmental dysplasia/dislocation of hip (DDH) are essential in preventing further disability and quality of life impairment in children. DDH risk markers and association between the age of clinical screening and outcome, were evaluated.
Methods: Clinical screening at ages birth, 6 and 13 weeks was performed in 8145 infants by pediatricians. Infants suspected for DDH were referred to the community hospital clinic for clinical evaluation by a pediatric orthopedic surgeon, imaging procedures and follow up. Demographic and perinatal characteristics of the children with suspected ( n = 77) and diagnosed DDH ( n = 51) were compared to matched controls ( n = 154).
Results: The rate of suspected DDH was 0.95% and that of diagnosed DDH was 0.63%. Female gender, firstborn child and breech presentation were significantly more frequent among cases versus controls (odds ratio [OR]: 4.3, 2.7, and 6 respectively; P < 0.05). The highest positive predictive value (95.5%) in physical evaluation was any evidence of a dislocatable hip. The proportion of DDH among infants referred from the newborn department was significantly higher (OR, 4.4). DDH diagnosis after 6 weeks of age was associated with a higher likelihood of subsequent surgery and motor disability. Untoward outcome was significantly associated with increasing age of referral both at ages of 6 and 13 weeks ( P < 0.05).
Conclusions: Children with DDH have certain specific demographic and perinatal risk markers. Clinical screening targeted towards early diagnosis may lessen the need for surgical intervention and the risk of disability or motor handicap.     

The ultrasonographic image of the infant hip affected by developmental dysplasia with a positive Ortolani's sign

Instability of the hip may be assessed by the Ortolani and Barlow tests, which are the keystone of clinical screening for developmental dysplasia of the hip (DDH). However, Ortolani's sign implies that there is strong evidence of a severe form of DDH with a completely dislocated, but still reducible, femoral head. Barlow's test addresses several different forms of "instability" of the hip that are quite difficult to describe and in 80% of cases disappear during growth. For this reason, Ortolani's sign in a baby should be considered an indication for emergency treatment to reduce and stabilise the hip while it is still reducible. The increasingly widespread use of US of the hip in newborns and infants has enabled clinicians to observe the hip from the first day of life and to establish both the static and dynamic relationships of the femoral head and acetabulum. The purpose of this paper is to describe the US pattern and relative classification of the hip affected by Ortolani's sign and examined by Graf's method, and to confirm through US that Ortolani's sign should be considered a totally reliable specific test for the identification of dislocation of the infant hip.     

Ultrasonography screening for developmental dysplasia of the hip joint

The use of ultrasonography as a complement to clinical examination will increase the reliability of the evaluation of unstable hips in newborn infants. In particular, the number of false-positive Ortolani and Barlow tests will decrease. However, the interpretation of the ultrasonogram in newborn infants has a steep learning curve with considerable risk of a high number of false-positive hips being diagnosed. Therefore, universal screening for developmental dysplasia of the hip by ultrasonography cannot yet be recommended from a cost-benefit point of view.     

The diagnosis and management of congenital dislocation of the hip

Congenital dislocation of the hip (CDH) or developmental dysplasia of the hip (DDH) is a common condition that encompasses a spectrum of pathology affecting the neonatal hip. Clinical signs of instability may be difficult to detect at birth using the Barlow Ortolani test. A clear imperative is to make an early diagnosis since delay after 3 months is synonymous with the necessity for surgery and also leads to a compromised prognosis. There is considerable controversy about clinical screening for DDH or ultrasound screening, either comprehensive or selective. Risk factors – such as breech presentation, oligohydramnios and talipes – are well known and there is some evidence that selective screening for these babies with ultrasound may assist diagnosis. The incidence of neonatal hip instability is around 15–20 per 1000 live births but that of established dislocation 1–2 per 1000 live births in unscreened cohorts. The usual early treatment is with the Pavlik harness but after 3 months, surgery – either an open or closed reduction – is necessary and in some surgically untreated children, secondary procedures such as pelvic osteotomy are necessary.     

Riesgo de displasia del desarrollo de la cadera en pacientes sometidos a versión cefálica externa

Introduction

Developmental dysplasia of the hip (DDH) refers to the spectrum of abnormalities of maturation and development of the hip. Breech presentation is associated with DDH. This risk factor can be modified by external cephalic version (ECV). The aim of this study is to evaluate the incidence of DDH in patients who successfully underwent ECV, as well as to evaluate need for these children (breech for a period during gestation) to be included in the DDH screening protocol.

婴幼儿发育性髋关节发育不良早期筛查和治疗

目的探讨开展婴幼儿发育性髋关节发育不良(DDH)的早期筛查和治疗的意义。方法选取2010年4月-2011年10月在本院进行婴幼儿体检时发现以大腿皮纹不对称为主要临床表现的18个月以下婴幼儿1 429例(男684例,女745例)进行严格的分组后,采用影像学检查方法对病例资料进行分析;同时对筛查检出的异常病例积极进行早期个体化干预治疗。结果初诊0～6个月婴儿检出的髋关节异常率为2.4%,对异常病例积极应用pavlik吊带保守治疗平均4个月后,治愈率达98.1%;初诊6～12个月婴儿检出的髋关节异常率为5.9%,早期应用个体化的治疗方法进行保守治疗,治愈率为64.7%;初诊年龄12～18个月的婴儿检出的髋关节异常率为52.9%,应用个体化方案保守治疗后,髋关节复位效果不满意,需要进一步行手术治疗。结论开展婴幼儿DDH早期筛查,并对DDH患儿进行早期个体化干预治疗具有重要的意义。     

Developmental dysplasia of the hip. A population-based comparison of ultrasound and clinical findings

Clinical and ultrasound findings were compared in 3613 newborns examined for developmental dysplasia of the hip (DDH) within 48 hours of delivery. Clinical and sonographic hip stability was described as stable, borderline unstable, dislocatable or dislocated, and the morphology on ultrasound as normal, immature or dysplastic. Persistent clinical or sonographic dislocatability or dislocation. major dysplasia or minor dysplasia combined with an unstable femoral head were indications for early treatment. A total of 123 (3.4%) infants were subjected to early treatment. of which 55 (45%) fulfilled the criteria for treatment on both clinical and ultrasound examinations, 52 (42%) were treated on the basis of ultrasound findings alone, and 16 (13%) on the basis of clinical findings alone. Thirty percent of the infants with clinically dislocated or dislocatable hips were judged to have stable or just borderline unstable hips on the first clinical examination. Of 486 (13.5%) infants with sonographically immature or minor dysplastic but stable hips, 472 (97%) normalized spontaneously, while treatment was initiated in 14 (3%) of them at 1-3 months of age because of lack of sonographic improvement. Only one infant presented with late DDH during an observation period of 3 years. Accepting sonographic dysplasia as a criterion for early splinting may result in a treatment rate which is almost twice the rate based on clinical criteria, but late dislocation may be virtually eliminated.     

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.     

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

Aims: To compare, using a decision model, performance, treatment pathways and effects of different newborn screening strategies for developmental hip dysplasia with no screening. Methods: Detection rate, radiological absence of subluxation at skeletal maturity and avascular necrosis of the femoral head, as favourable and unfavourable treatment outcomes respectively, were compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; the 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: Universal or selective ultrasound detects more more affected children (76% and 60% respectively) than clinical screening alone (35%), results in a higher proportion of affected children with favourable treatment outcomes (92% and 88% respectively) than clinical screening alone (78%) or no screening (75%), and the highest proportion of these achieved without recourse to surgery (64% and 79% respectively) compared with clinical screening alone (18%). However, ultrasound based strategies are also associated with the highest number of unfavourable treatment outcomes arising in unaffected children treated following a false positive screening result. The detection rate of clinical screening alone becomes similar to that reported for universal ultrasound when based on studies using experienced examiners (80%) rather than junior medical staff (35%). Conclusion: From the largely observational data available, ultrasound based screening strategies appear to be most sensitive and effective but are associated with the greatest risk of potential adverse iatrogenic effects arising in unaffected children.     

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

AIMS: To compare, using a decision model, performance, treatment pathways and effects of different newborn screening strategies for developmental hip dysplasia with no screening. METHODS: Detection rate, radiological absence of subluxation at skeletal maturity and avascular necrosis of the femoral head, as favourable and unfavourable treatment outcomes respectively, were compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; the 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: Universal or selective ultrasound detects more more affected children (76% and 60% respectively) than clinical screening alone (35%), results in a higher proportion of affected children with favourable treatment outcomes (92% and 88% respectively) than clinical screening alone (78%) or no screening (75%), and the highest proportion of these achieved without recourse to surgery (64% and 79% respectively) compared with clinical screening alone (18%). However, ultrasound based strategies are also associated with the highest number of unfavourable treatment outcomes arising in unaffected children treated following a false positive screening result. The detection rate of clinical screening alone becomes similar to that reported for universal ultrasound when based on studies using experienced examiners (80%) rather than junior medical staff (35%). CONCLUSION: From the largely observational data available, ultrasound based screening strategies appear to be most sensitive and effective but are associated with the greatest risk of potential adverse iatrogenic effects arising in unaffected children.     

Developmental dysplasia of the hip in South Australia in 1991: Prevalence and risk factors

To determine the prevalence of developmental dysplasia of the hip (DDH) in South Australia (SA) in 1991, the proportion of cases detected in the neonatal period and the perinatal risk factors for DDH.

Methodology:

Cases of DDH born in SA in 1991 were identified from multiple sources and their clinical data linked to perinatal data provided by midwives; five controls per case were obtained randomly from SA livebirths without congenital abnormalities and adjusted odds ratios (OR) for potential risk factors obtained by logistic regression analysis. South Australia perinatal data were also used to estimate numbers of births with perinatal risk factors for targeted screening.

Results:

Two hundred and six cases of isolated DDH were identified, giving a prevalence of 10.5 per 1000 births. Of these, 173 (84%) had been detected in the neonatal period. The perinatal risk factors for DDH were identified as breech presentation (OR 9.65), female babies (OR 4.04), first births (OR 1.91) and maternal age of 25 years or more (OR 1.53). Screening breech and firstborn female babies (23% of births) would yield approximately 51% of cases of DDH.

Conclusions:

Isolated DDH had a prevalence of 10.5 per 1000 births and 84% of cases had been detected in the neonatal period in SA. Repeated screening during infancy of 'at risk' groups of babies is recommended.     

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 £4 million for universal ultrasound, £3 million for selective ultrasound, £1 million for clinical screening alone, and £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 £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 £0.2 million, while each of the five favourable outcomes achieved through universal ultrasound screening, over and above selective ultrasound, costs approximately £0.3 million. Conclusions: Policy choice depends on values attached to the different outcomes, willingness to pay to achieve these and total budget.     

Early detection of hip dysplasia in the neonatal period

Several risk factors are associated with an increased incidence of congenital hip dysplasia. Since the introduction of hip sonography the understanding of correlation between risk factors and US have been studied to decrease the prevalence of the deformity. Regression analysis and chi-square test were used to study the incidence of factors associated with congenital hip dysplasia. Positive family history, breech presentation, positive Ortolani manoeuvre, abduction deficit, asymmetric skin folds, feet or neuromuscular abnormities were compared to ultrasound examination. No significant correlation was found with any of the studied risk factors. Mild congenital hip dysplasia can be diagnosed only by ultrasound. It was found that 1.7% of congenital hip dysplasia are clinically asymptomatic and cannot be recognized without ultrasonographic screening.     

Neonatal hip instability: results and experiences from ten years of screening with the anterior-dynamic ultrasound method

AIM: To record the results and experiences from a 10-y screening period with the anterior-dynamic ultrasound method for detecting neonatal hip instability. METHODS: An ultrasonographic improvement of the Palmén/Barlow test was used. The screening programme included 22,047 newborns. Decisions about treatment were made solely on the ultrasound result. RESULTS: It was found that 175 infants (7.9/1000) had at least one unstable hip--dislocated or dislocatable. Dislocated hips were found in 1.1/1000. Dislocatable hips were found in 6.8/1000 but only 1.1/1000 needed treatment. The total frequency of treatment was 2.2/1000. All cases but one were diagnosed before discharge from the maternity ward. The rate of surgery was 0.1/1000 newborns. Girls were more affected than boys, by a ratio of 3:1. Among the affected hips 64.4% were a left hip. CONCLUSION: Neonatal hip instability is always present at birth and can be diagnosed immediately after birth. We have no indications that instability can appear at a later stage. The anterior-dynamic ultrasound screening programme is an efficient tool to diagnose neonatal hip instability and to decide when to begin treatment.     

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.     

Effectiveness of ultrasound screening for developmental dysplasia of the hip

OBJECTIVE: To determine the effectiveness of ultrasound screening for developmental dysplasia of the hip (DDH) after the neonatal period. DESIGN: Prospective cohort study. SETTING: Child health care centres. PARTICIPANTS: Infants attending the child health care centres. INTERVENTIONS: The intervention group (n = 5170) was screened by ultrasound at 1, 2, and 3 months of age. The control group (n = 2066) was screened by routine physical examination as part of the programme for child health surveillance at the child health care centres (CHC screening). For evaluation of the screening, the children in both the intervention and control group received an ultrasound examination after 6 months of age to detect any abnormality that might have been missed by the screening. RESULTS: The sensitivity of the ultrasound screening was 88.5%, and the referral rate 7.6%. As a result of the ultrasound screening, 4.6% of the children were treated. The sensitivity of the CHC screening was 76.4%, with a referral rate of 19.2%. The treatment rate was 2.7%. Of the treated children in the ultrasound screening group, 67% were referred before the age of 13 weeks, whereas in the CHC screening group only 29% were referred before this age. CONCLUSIONS: This study shows that ultrasound screening detects more children with DDH than CHC screening and that more of them are detected at an earlier age. To accomplish this, even fewer children have to be referred. However, even general ultrasound screening seems not to eradicate late cases of DDH. The higher treatment rate in the population screened by ultrasound may be a result of overtreatment.