Developmental dysplasia of the hip: real world data from a retrospective analysis to evaluate the effectiveness of universal screening

Developmental Dysplasia of the Hip: Factors Related to the Diagnosis and Characteristics of Selective Screening for its Detection

Backgrounds

Breech presentation, family history, and physical examination are the most recognized risk factors for DDH, which form the basis of selective screening. However, this approach can lead to late diagnosis, invasive treatments, and complications. This study analyzes the effectiveness of selective screening and identifies additional factors related to DDH.

Methods

A retrospective case-control analytical study is designed, including children who are assessed through screening between 2012 and 2019. The variables examined include clinical and gestational characteristics, as well as examination findings. Descriptive analysis is conducted, followed by univariate analysis using Chi-squared, Fisher's exact, or Student's T tests. For multivariate analysis, the "all set" user command is employed. Sensitivity, specificity, and ROC curve are calculated, with a significance level set at p < 0.05. StataIC 16 and SAS System 9.4 are used.

Results

762 children are included in the study, of which 33 are diagnosis with DDH. A total of 8,191 models are developed to predict DDH. The best logistic regression model identified the following independent predictors of dysplasia: newborn weight (OR 1.2, 95% CI 1.1-1.4), female sex (OR 3.9; 95% CI 1.4-10.9), cephalic presentation (OR 17.8; 95% CI 2.3-137.3), primiparity (OR 2.6; 95% CI 1.1-5.7), and examination (OR 149.6; 95% CI 18-1121.4). This model correctly classifies 83.6% patients (ROC curve 0.86). In selective screening, examination is the only identified risk factor for DDH, yet its sensitivity does not exceed 10%.

Conclusions

This study proposed a total of 8191 models to predict DDH. The identified predictors include female sex, birth weight, cephalic presentation, and primiparity. While physical examination is the primary risk factor, it detects only decentred hips. The low sensitivity of selective screening raises questions about whether it remains the most appropriate method for identifying DDH in current practice.

ECAD study: Evaluating agreement degree among paediatricians in hip dysplasia assessment by the Graf ultrasound method

Developmental dysplasia of the hip (DDH) is the most common musculoskeletal anomaly of childhood. This study analyses paediatrician's concordance performing hip ultrasound according to Graf's method. An analytical cross-sectional study is designed. Patients' hips are evaluated by Graf's ultrasound method at 4-6 and 12-16 weeks of age. Demographic characteristics, pregnancy history, factors related to DDH, hip type, and α and β angles are collected. To assess the agreement degree of hip diagnosis and hip types Kappa index (I. kappa) is used. Intraclass correlation coefficient (ICC) evaluates the concordance of α and β angles. A p value < 0.05 is considered statistically significant. All results are represented with their 95% confidence interval (95% CI). Four hundred sixty-seven neonates are recruited and meet the inclusion criteria. A total of 3182 images were analysed. Agreement between paediatricians according to hip diagnosis and different types ranges from moderate to almost perfect I. kappa 0.6-1.0 (95% CI 0.5-0.7; 95% CI 1.0-1.0). α angle ICC for paediatricians is between 0.75 and 0.88 (95% CI 0.61-0.86; 95% CI 0.80-0.92). β angle value agreement degree among paediatricians at both visits is moderate. The Graf method is the most popular ultrasound technique for hip assessment. In our setting, paediatricians carry out children follow-up; therefore, they should perform universal screening. In this study agreement degree between paediatricians varies between substantial and almost perfect. Conclusion: The Graf ultrasound procedure performed by paediatricians is a reliable test and can be used for DDH screening. What is Known • Developmental dysplasia of the hip (DDH) is the most common congenital musculoskeletal anomaly of childhood. Early diagnosis and treatment improve DDH prognosis. Lack of detection can cause complications such as lameness, early osteoarthritis and need for hip replacement at an early age. What is New • Today, the best screening method is still subject of debate. But it seems that with selective screening many pathological hips go unnoticed. Universal screening implementation may be a challenge in some countries. But the question is if this could be carried out by paediatricians as part of healthy child follow-up.

Universal ultrasound screening and early treatment of developmental dysplasia of the hip: a critical review

Developmental dysplasia of the hip (DDH) is the most common musculoskeletal disease in infants, and delayed diagnosis can worsen the prognosis. Clinical evidence increasingly supports universal ultrasound (US) screening over selective US screening. The Graf method remains the most widely accepted US technique. Performing an US screening at one month of age seems appropriate as it allows for some hip maturity and early detection, thereby increasing the chances of a favorable outcome. This paper presents an approach to US findings based on the femoral head coverage method. Considering the long-term cost and psychosocial impact of missed DDH cases, universal ultrasound screening appears to be a cost-effective alternative.

Cost-effectiveness of screening for developmental dysplasia of the hip in Karachi, Pakistan using a universally applicable cost-effectiveness model

Introduction

Developmental dysplasia of the hip (DDH) is a congenital anomaly of the hip socket that can lead to lifelong disability and pain when left untreated. DDH is a good candidate for screening because of its high frequency in population, availability of treatment and the possibility of secondary prevention. Pakistan currently does not have any systematic or universal neonatal screening programme for DDH.

Methods

The cost-effectiveness model in this study uses one decision tree for each screening scenario: (1) the status quo, (2) universal screening by clinical examination, (3) universal screening by clinical examination with targeted ultrasound (US) screening, (4) and universal screening by US. Loss of disability-adjusted life-years (DALYs) is used as outcome variable.

Results

When left untreated DDH creates a loss of 3.4 DALYs per person. Clinical examination and targeted US averts most DALYs per dollar spent. Generalised US averts more DALYs overall but requires a greater financial investment per DALY averted.

Conclusions

Universal US screening reaches more children and can be considered the more equitable approach but requires 10 times the financial investment clinical examination and targeted US requires. The decision which option is most appropriate for Karachi, Pakistan depends on resource availability, geography, infrastructure, treatment capacity, health system values and societal factors in Pakistan.

The Risk of Developmental Dysplasia of the Hip in Premature Infants with Breech Presentation at Birth

OBJECTIVE

This article evaluates the risk (defined here as incidence per 1,000 infants) of developmental dysplasia of the hip (DDH) in premature infants undergoing hip ultrasound (HUS) for breech presentation only compared with other indications.

STUDY DESIGN

Retrospective study of infants born between January 1, 2009 and December 31, 2018 at <37 weeks' gestation with a HUS obtained in the first year of life, at Nationwide Children's Hospital, the only available facility for pediatric radiology and orthopaedic services in central Ohio. We calculated risk differences and odds ratios of DDH by the indication of HUS.

RESULTS

From 2,397 infants reviewed, 89% underwent HUS for breech presentation only. The local incidence of DDH for infants undergoing HUS for breech-only indication was 15 per 1,000 compared with 155 per 1,000 for infants undergoing HUS for other indications. The odds ratio of DDH diagnosis was 12.1 (95% confidence interval: 7.5, 19.6) for infants undergoing HUS for an indication other than breech presentation only relative to infants undergoing HUS for the indication of breech presentation only.

CONCLUSION

The risk of DDH diagnosis in premature infants undergoing HUS for breech presentation is much lower than those undergoing HUS for clinical concerns and other risk factors. Screening these infants with physical examination may be sufficient.

KEY POINTS

· Breech presentation is the most common indication for hip ultrasound in premature infants.. · The risk of DDH is lower in premature infants with breech presentation compared with premature infants with other clinical concerns.. · The risk of DDH is higher in infants born at 33 to 36 weeks of gestation compared with those born at an earlier gestation..

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.

Developmental dysplasia of the hip and ultrasound reading by pediatric orthopedic surgeons: a pilot study

Ultrasound is an imaging modality utilized for early detection and follow-up of developmental dysplasia of the hip (DDH) in infants. Traditionally, pediatric orthopedic surgeons have relied on radiologists to perform ultrasound examinations and interpret the imaging. Today, however, many orthopedic surgeons are performing and interpreting ultrasound themselves. The purpose of this paper was to evaluate the reliability of pediatric orthopedic surgeons in interpreting ultrasound imaging of infant hips. This was a prospective observational pilot study. After reading an instructional handout about the Graf method of hip ultrasonography, eight pediatric orthopedic surgeons measured 28 hip ultrasound images to determine the alpha angle and percent femoral head coverage. On the basis of cited intraclass correlation coefficient cutoff values, interrater reliability was found to be 'good' for percent femoral head coverage and 'fair' for alpha angle. These findings are equivalent to findings of similar studies using radiologists as examiners. Pediatric orthopedic surgeons can interpret ultrasound exams for diagnosing DDH.

How Ready are Pediatricians and Family Physicians in Saudi Arabia to Perform Clinical Screening of Developmental Dysplasia of the Hip?

Background

Developmental dysplasia of the hip (DDH) is one of the most common hip pathologies in pediatric age group and late diagnosis remains a major concern in Saudi Arabia.

Objective

The aim of this study is to examine the ability of Saudi Arabian pediatricians and family physicians to conduct clinical screening for (DDH) by estimating their clinical knowledge and skills and analyzing the gaps therein to determine whether there is potential to launch a national screening protocol for DDH in Saudi Arabia.

Methods

This is a multicenter cross-sectional study from three major regions in Saudi Arabia (Central, Eastern and Western provinces). The assessed aspects are risk factors, age of screening, incidence in Saudi Arabia, physical signs and diagnostic markers, and treatment, along with their 'clinical knowledge and skills' score.

Results

Half of the participants were pediatricians, while the rest were family physicians. More than a third of the participants were considered to have adequate knowledge, ie, above the mean score. Dimensions with the most significant knowledge gaps included the incidence of DDH in Saudi Arabia, adverse effects of swaddling, and the management of a high-risk infants presenting with a negative physical examination. Additionally, there were relatively low rates of awareness regarding positive risk factors as well as a generally poor ability to identify physical signs. Clinical knowledge and skill levels were significantly lower among family physicians.

Conclusion

Pediatricians and family physicians in Saudi Arabia still need further training to improve their clinical skills for DDH screening. The proper administration of training programs could eventually enable the gradual implementation of a national systematic screening program.

Risk factors for misdiagnosis in children with developmental dysplasia of the hip: a retrospective single centre study

OBJECTIVE

To investigate risk factors of misdiagnosis at the first visit of children with developmental dysplasia of the hip (DDH) who did not participate in hip ultrasound screening.

METHODS

A retrospective review was conducted on children with DDH admitted to a tertiary hospital in northwestern China between January 2010 and June 2021. We divided the patients into the diagnosis and misdiagnosis groups according to whether they were diagnosed at the first visit. The basic information, treatment process and medical information of the children were investigated. We made a line chart of the annual misdiagnosis rate to observe the trend in the annual misdiagnosis rate. Univariate and multivariate logistic regression analyses were used to identify significant risk factors for missed diagnosis.

RESULTS

A total of 351 patients met the inclusion criteria, including 256 (72.9%) patients in the diagnosis group and 95 (27.1%) patients in the misdiagnosis group. The line chart of the annual rate of misdiagnoses among children with DDH from 2010 to 2020 showed no significant change trend. Multiple logistic regression analysis showed that the paediatrics department (v the paediatric orthopaedics department: OR 0.21, p<0.001), the general orthopaedics department (v the paediatric orthopaedics department: OR 0.39, p=0.006) and the senior physician (v the junior physician: OR 2.47, p=0.006) on the misdiagnosis at the first visit of children were statistically significant.

CONCLUSION

Children with DDH without hip ultrasound screening are prone to be misdiagnosed at their first visit. The annual misdiagnosis rate has not been significantly reduced in recent years. The department and title of the physician are independent risk factors for misdiagnosis.

Preterm birth does not increase the risk of developmental dysplasia of the Hip: a systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review was to appraise the literature on the association between preterm birth and developmental dysplasia of the hip (DDH).

METHODS

Medline, Embase, Scopus, and Web of Science databases were queried for all studies pertaining to DDH and preterm birth. Data were imported and analyzed in Revman5 and Comprehensive Meta-Analysis (CMA) for pooled prevalence estimation.

RESULTS

Fifteen studies were included in the final analysis. There were 759 newborns diagnosed with DDH in these studies. DDH was diagnosed in 2.0% [95%CI:1.1-3.5%] of the premature newborns. Pooled incidence rate of DDH was not statistically different between those groups (2.5%[0.9%-6.8%] vs. 0.7%[0.2%-2.5%] vs. 1.7%[0.6%-5.3%];Q = 2.363,p = 0.307).

CONCLUSIONS

In this systematic review and meta-analysis, we did not find preterm birth to be a significant risk factor for DDH. Data suggests that female sex and breech presentation are associated with DDH in preterm infants, but the data is scarce in the literature.

The Use of Visual Analysis for Gait and Foot Posture in Children with Developmental Dysplasia of the Hip

BACKGROUND

Developmental dysplasia of the hip (DDH) is recognized as a leading cause of significant long-term complications, including inaccurate gait patterns, persistent pain, and early regressive joint disorder, and it can influence families functionally, socially, and psychologically.

METHODS

This study aimed to determine foot posture and gait analysis across patients with developmental hip dysplasia. We retrospectively reviewed participants referred to the pediatric rehabilitation department of KASCH from the orthopedic clinic between 2016 and 2022 (patients born 2016-2022) with DDH for conservative brace treatment.

RESULTS

The foot postural index for the right foot showed a mean of 5.89 (n = 203, SD 4.15) and the left food showed a mean of 5.94 (n = 203, SD 4.19). The gait analysis mean was 6.44 (n = 406, SD 3.84). The right lower limb mean was 6.41 (n = 203, SD 3.78), and the left lower limb mean was 6.47 (n = 203, SD 3.91). The correlation for general gait analysis was r = 0.93, presenting the very high impact of DDH on gait. Significant correlation results were found between the right (r = 0.97) and left (r = 0.25) lower limbs. Variation between the right and left lower limb p-values was 0.88 (p < 0.05). DDH affects the left lower limb more than the right during gait.

CONCLUSION

We conclude that there is a higher risk of developing foot pronation on the left side, which is altered by DDH. Gait analysis has shown that DDH affects the right lower limb more than the left. The results of the gait analysis showed gait deviation in the sagittal mid- and late stance phases.

Assessment for late developmental hip dysplasia in a cohort of infants with risk factors and normal hip ultrasound

Background

Developmental dysplasia of the hip (DDH) is a known orthopedic pathology of newborns that, if not diagnosed and treated, can lead to debilitating long-term consequences. Ultrasound has proven to be an effective method for the early diagnosis of this condition. Recently, reports of late DDH in populations at risk (breech presentation) and after negative ultrasound examination have emerged in the literature.

Aim

The objective of the study was to assess the possible appearance of late DDH in Italian children with risk factors but negative ultrasound screening.

Materials and methods

We selected patients with risk factors for DDH and a negative hip ultrasound from the medical records of children referred to the Hip Ultrasound Clinic (Rome, Italy) from January 2018 to November 2021. To identify possible cases of late DDH, from February 2022 to July 2022, all patients who met the inclusion criteria were submitted to orthopedic follow-up clinical evaluation. In the case of a pathological objective examination, radiography was performed.

Results

Fifty-five patients (52.7% female, 52.7% with breech presentation, and 41.8% with a positive family history) met the inclusion criteria. The median age of gait onset was 13 months. The median age of orthopedic follow-up examination was 45 months. Only three patients (5.5%) had a pathological examination, but no x-ray were pathological.

Conclusion

Our study has not documented cases of late DDH. Considering the small study population and the only clinical follow-up, further studies are needed to clarify the possible late development of this condition.

Impact of the coronavirus disease 2019 pandemic on ultrasound screening of developmental dysplasia of the hip and follow-up imaging: a report from southeastern Turkey

OBJECTIVE

To investigate the effect of coronavirus disease 2019 restrictions on ultrasound (US) screening of developmental dysplasia of the hip (DDH) in a children's hospital.

METHODS

The records of US screening of DDH were retrospectively evaluated in the pandemic period (April 2020 to July 2021) and the pre-pandemic period (January 2019 to February 2020). The monthly US number, sex, radiologist number, and age at the initial examination were recorded.

RESULTS

A total of 6107 US scans were performed during the pre-pandemic period, which significantly decreased to 3340 during the pandemic. The number of monthly US scans performed did not change between the pre-pandemic (142.7/month) and pandemic (128.2/month) periods. The number of delayed examinations in the total population did not significantly change between the two periods. However, the number of delayed examinations in patients with abnormal hips was significantly increased during the pandemic compared with that in the pre-pandemic period.

CONCLUSIONS

Coronavirus disease 2019 restrictions decreased the US screening rate of DDH by almost half, but the number of US scans performed by each radiologist was unchanged. The compliance with follow-up recommendations was reduced by half, which may lead to an increase in the incidence of delayed and untreated DDH cases.

Incidence of Neonatal Developmental Dysplasia of the Hip and Late Detection Rates Based on Screening Strategy: A Systematic Review and Meta-analysis

IMPORTANCE

Universal ultrasonographic screening for developmental dysplasia of the hip (DDH) has gained increasing popularity despite the lack of benefit in terms of reducing the rates of late-detected cases (age ≥12 weeks) in randomized clinical trials.

OBJECTIVE

To report the reported incidence of DDH in the English scientific literature and compare rates of late-detected cases in settings with different DDH screening strategies.

DATA SOURCES

PubMed, Scopus, and Web of Science databases were searched on November 25 and 27, 2021. No time filters were used in the search.

STUDY SELECTION

All observational studies reporting the incidence of early-detected or late-detected (age ≥12 weeks) DDH were included. Non-English reports were excluded if the abstract did not include enough information to be included for analysis.

DATA EXTRACTION AND SYNTHESIS

The number of newborns screened and the detection rates were extracted. Meta-analysis calculated the pooled incidence of DDH per 1000 newborns with 95% CIs using a random- or fixed-effects model. This study is reported according to the PRISMA and MOOSE guidelines.

MAIN OUTCOMES AND MEASURES

The main outcome measures were early detection, early treatment, late detection, and operative treatment incidences.

RESULTS

A total of 1899 studies were identified, 203 full texts were assessed, and 76 studies with 16 901 079 infants were included in final analyses. The early detection rate was 8.4 (95% CI, 4.8-14.8) infants with DDH per 1000 newborns with clinical screening, 4.4 (95% CI, 2.4-8.0) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 23.0 (95% CI, 15.7-33.4) infants with DDH per 1000 newborns with universal ultrasonographic screening. Rates for nonoperative treatment were 5.5 (95% CI, 2.1-14) treatments per 1000 newborns with clinical screening, 3.1 (95% CI, 2.0-4.8) treatments per 1000 newborns with selective ultrasonographic screening, and 9.8 (95% CI, 6.7-14.4) treatments per 1000 newborns with universal ultrasonographic screening. The incidence of late-detected DDH was 0.5 (95% CI, 0.2-1.5) infants with DDH per 1000 newborns with clinical screening, 0.6 (95% CI, 0.3-1.3) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 0.2 (95% CI, 0.0-0.8) infants with DDH per 1000 newborns with universal ultrasonographic screening. The corresponding incidences of operative treatment were 0.2 (95% CI, 0.0-0.9) operations per 1000 newborns with clinical screening, 0.5 (95% CI, 0.4-0.7) operations per 1000 newborns with selective ultrasonographic screening, and 0.4 (95% CI, 0.2-0.7) operations per 1000 newborns with universal ultrasonographic screening.

CONCLUSIONS AND RELEVANCE

This meta-analysis found that early detection rates and nonoperative treatments were higher with universal screening. The late detection and operative treatment rates with universal screening were similar to those among selectively and clinically screened newborns. Based on these results, universal screening may cause initial overtreatment without reducing the rates of late detection and operative treatment.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatricians

OBJECTIVE

To evaluate the decision making processes of pediatricians regarding diagnosis and management of developmental dysplasia of the hip (DDH) by conducting a survey of pediatricians in the United States.

STUDY DESIGN

An electronic survey was sent to multiple American Academy of Pediatrics state chapters and academic pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, guideline use, clinical scenarios, and referrals/imaging practices. The number of responses to each survey question and their relative frequencies were calculated.

RESULTS

We received 139 responses and included 126 in our analyses. Only 50% of the responding pediatricians (63 of 126) practiced in an institution that endorses a care pathway for DDH. Only 5.6% of the pediatricians (7 of 125) have referred patients at 12-18 months between diagnosis and management to a specialist for suspected DDH, and 9.5% (12 of 125) have referred patients between 6 and 9 months. Almost one-quarter of the pediatricians (23%; 29 of 126) cited "hip click" as an abnormality that would prompt them to refer a patient to a specialist, and 72.2% (91 of 126) indicated that family history of DDH warrants an ultrasound regardless of the physical examination findings. Moreover, 10.3% of the surveyed pediatricians (13 of 126) reported being only "somewhat" or "moderately" familiar with the Barlow and Ortolani maneuvers.

CONCLUSIONS

The results of this study indicate that there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatrician respondents who would not refer patients to a specialist or order imaging studies appropriately represents an opportunity for education. The implementation of a care map with standard referral and imaging practices could improve the care of patients with DDH.

Diagnostic Performance of Clinical Examination Versus Ultrasonography in the Detection of Developmental Dysplasia of Hip: A Systematic Review and Meta-Analysis

Background

Developmental dysplasia of the hip (DDH) is a spectrum of diseases involving the femoroacetabular joint. Due to the controversies over the value of different strategies used for DDH screening, this systematic review and meta-analysis aimed to assess the diagnostic performance of standard physical examination maneuvers on the diagnosis of DDH, compared to the Graf ultrasonography (US) method.

Methods

PubMed, Web of Science, and SCOPUS databases were searched until the end of October 2020. Studies that (i) used the Ortolani test, Barlow test, or limited hip abduction (LHA) test to assess the risk of DDH in physical examination, (ii)used the Graf US method to examine DDH in sonography, and (iii) provided adequate data to extract the diagnostic performance were included. Pooled sensitivity and specificity were calculated for clinical examinations.

Results

A total of 25 studies (72,079 patients in total) were considered eligible to enter the present study. The pooled data of the Ortolani-Barlow test demonstrated a sensitivity of 36% (95% CI:0.25-0.48) and specificity of 98% (95% CI:0.93-0.99). Calculated pooled sensitivity and specificity for the limited hip abduction exam were obtained at 45% (95% CI:0.24-0.69) and 78% (95% CI:0.62-0.88) respectively. A separate analysis of the studies using both exams revealed a sensitivity of 57% (95% CI:0.30-0.82) and a specificity of 95% (95% CI:0.68-0.99).

Conclusion

Based on the results, the investigated clinical examinations have high specificity but low sensitivity to detect the DDH; therefore, they have limited application as a screening test. If obliged to rely on clinical examinations for screening, the combination of Ortolani-Barlow and LHA tests can provide more sensitivity than either of these tests performed independently.

Can AI Automatically Assess Scan Quality of Hip Ultrasound?

Ultrasound images can reliably detect Developmental Dysplasia of the Hip (DDH) during early infancy. Accuracy of diagnosis depends on the scan quality, which is subjectively assessed by the sonographer during ultrasound examination. Such assessment is prone to errors and often results in poor-quality scans not being reported, risking misdiagnosis. In this paper, we propose an Artificial Intelligence (AI) technique for automatically determining scan quality. We trained a Convolutional Neural Network (CNN) to categorize 3D Ultrasound (3DUS) hip scans as ‘adequate’ or ‘inadequate’ for diagnosis. We evaluated the performance of this AI technique on two datasets—Dataset 1 (DS1) consisting of 2187 3DUS images in which each image was assessed by one reader for scan quality on a scale of 1 (lowest quality) to 5 (optimal quality) and Dataset 2 (DS2) consisting of 107 3DUS images evaluated semi-quantitatively by four readers using a 10-point scoring system. As a binary classifier (adequate/inadequate), the AI technique gave highly accurate predictions on both datasets (DS1 accuracy = 96% and DS2 accuracy = 91%) and showed high agreement with expert readings in terms of Intraclass Correlation Coefficient (ICC) and Cohen’s kappa coefficient (K). Using our AI-based approach as a screening tool during ultrasound scanning or postprocessing would ensure high scan quality and lead to more reliable ultrasound hip examination in infants.

Does the COVID-19 pandemic cause late diagnosis and delay in treatment in developmental dysplasia of hip patients?

BACKGROUND

The aim of the current study was to search the effect of COVID-19 restriction on developmental dysplasia of hip (DDH) screening.

MATERIAL AND METHODS

We retrospectively reviewed the patients who brought to DDH screening in April-May and June-July 2020 and compared with the same period of 2019. We recorded age, gender, DDH type and risk factors of the patients.

RESULTS

The number of patients taken for DDH screening was 430 and 400 in April-May 2019 and June-July 2019, respectively. In 2020, the number of patients taken for DDH screening was 159 and 776 in the same period, respectively. Thirteen patients were diagnosed with DDH older than 3 months age in June-July 2020. There were only two patients in same period in 2019. In 2020, 6 of 13 patients who applied to the hospital late for the routine US and had pathologic hips were not taken to orthopaedics or follow-up by their families.

CONCLUSION

In the era of COVID-19, the number of late diagnosis and lost follow-up for DDH are increased. To prevent future morbidities and reduce surgical interventions, special measures should be taken.

Developmental dysplasia of the hip and associated risk factors in Saudi children: A retrospective study

BACKGROUND

Studies investigating the association between developmental dysplasia of the hip (DDH) and risk factors in Saudi Arabia are rare.

OBJECTIVE

Investigate the association between DDH and several risk factors among Saudi children.

METHODS

The medical records of 82 children born in or admitted to King Abdul Aziz Medical City in Riyadh, Saudi Arabia with clinical suspicion of hip dislocation (HD) were included. The association between DDH and the following risk factors was investigated: age < 3 y, female-gender, twinning, first-born child, C-section, breech presentation, prematurity, positive family history and presence of associated abnormalities.

RESULTS

HD was confirmed in 73 (89%) children (Positive HD) and excluded in 9 (11%) children (Negative HD). Eleven (13.4%) children were excluded from the positive cases as it was confirmed that they have paralytic hip dislocation not DDH. DDH was confirmed in 62 children (75.6%). The Chi square test (χ2) and odds ratios (OR) revealed that the positive family history, female-gender, age < 3 years, and presence of associated abnormalities had significant associations with the presence of DDH with P values and OR equal 0.00 (16.4), 0.002 (3.1), 0.005 (2.6), and 0.04 (1.9) respectively. Breech presentation, twinning, first-born children, prematurity, and C-section were not associated with DDH with P values and OR equal 0.93 (1.1), 0.46 (0.4), 0.11 (0.4), 0.08 (0.3), and 0.002 (0.3) respectively.

CONCLUSIONS

Positive family history, female-gender, age < 3 years, and presence of associated abnormalities had approximately 16, 3, 2.5, and 2 times increased risk for DDH.

Diagnostic Accuracy of Ultrasonography Method of Graf in the detection of Developmental Dysplasia of the Hip: A Meta-Analysis and Systematic Review

Background

The present study aimed to perform a meta-analysis on the performance of Graf's ultrasonography method in the detection of developmental dysplasia of the hip (DDH).

Methods

A query was conducted on electronic bibliographic databases until the end of October 2020. The inclusion criteria entailed: 1. the use of Graf method in less than 12 weeks of age, 2. the use of follow-up as reference test, and 3. provision of crude data. Pooled diagnostic performance measures were calculated. Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) checklist was utilized to assess the quality of the included studies. The hierarchical summary receiver-operating characteristic (HROC) curves were also drawn.

Results

Six articles (including seven populations, 11,012 patients) were considered eligible. The pooled sensitivity and specificity were obtained at 93% (95% CI: 0.57-0.99) and 97% (95% CI:0.86-0.99), respectively (area under curve= 0.99). The pooled positive and negative likelihood ratio, as well as diagnostic odds ratio, was reported as 28.4, 0.07, and 396, respectively.

Conclusion

As evidenced by the obtained results, Graf's method is a useful ultrasonography technique with acceptable accuracy for screening DDH in neonates. However, there are uncertainties about the best population and age for screening. Furthermore, more attention should be paid to the proper training of this method to reduce the number of operator errors.

Impact of scan quality on AI assessment of hip dysplasia ultrasound

AIMS

Early diagnosis of developmental dysplasia of the hip (DDH) using ultrasound (US) is safe, effective and inexpensive, but requires high-quality scans. The effect of scan quality on diagnostic accuracy is not well understood, especially as artificial intelligence (AI) begins to automate such diagnosis. In this paper, we developed a 10-point scoring system for reporting DDH US scan quality, evaluated its inter-rater agreement and examined its effect on automated assessment by an AI system-MEDO-Hip.

METHODS

Scoring was based on iliac wing straightness and angulation; visibility of labrum, os ischium and femoral head; motion; and other artifacts. Four readers from novice to expert separately scored the quality of 107 scans with this 10-point scale and with holistic grading on a scale of 1-5. MEDO-Hip interpreted the same scans, providing a diagnostic category or identifying the scan as uninterpretable.

RESULTS

Inter-rater agreement for the 10-point scale was significantly higher than holistic scoring ICC 0.68 vs 0.93, p < 0.05. Inter-rater agreement on the categorisation of individual features, by Cohen's kappa, was highest for os ischium (0.67 ± 0.06), femoral head (0.65 ± 0.07) and iliac wing (0.49 ± 0.12) indices, and lower for the presence of labrum (0.21 ± 0.19). MEDO-Hip interpreted all images of a quality > 7 and flagged 13/107 as uninterpretable. These were low-quality images (3 ± 1.2 vs. 7 ± 1.8 in others, p < 0.05), with poor visualization of the os ischium and noticeable motion. AI accuracy in cases with quality scores <  = 7 was 57% vs. 89% on other cases, p < 0.01.

CONCLUSION

This study validates that our scoring system reliably characterises scan quality, and identifies cases likely to be misinterpreted by AI. This could lead to more accurate use of AI in DDH diagnosis by flagging low-quality scans likely to provide poor diagnosis up front.