Is limitation of hip abduction a useful clinical sign in the diagnosis of developmental dysplasia of the hip?

Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review

Importance

Delayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life, and premature osteoarthritis.

Objective

To evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants.

Data Sources

Systematic search of CINAHL, Embase, MEDLINE, and the Cochrane Library from the inception of each database until October 31, 2023.

Study Selection

The 9 included studies reported the diagnostic accuracy of the clinical examination (index test) in infants aged 3 months or younger and a diagnostic hip ultrasound (reference test). The Graf method of ultrasound assessment was used to classify hip abnormalities.

Data Extraction and Synthesis

The Rational Clinical Examination scale was used to assign levels of evidence and the Quality Assessment of Diagnostic Accuracy Studies tool was used to assess bias. Data were extracted using the individual hip as the unit of analysis; the data were pooled when the clinical examinations were evaluated by 3 or more of the included studies.

Main Outcomes and Measures

Sensitivity, specificity, and likelihood ratios (LRs) of identifying a dislocated hip were calculated.

Results

Among infants screened with a clinical examination and a diagnostic ultrasound in 5 studies, the prevalence of a dislocated hip (n = 37 859 hips) was 0.94% (95% CI, 0.28%-2.0%). There were 8 studies (n = 44 827 hips) that evaluated use of the Barlow maneuver and the Ortolani maneuver (dislocate and relocate an unstable hip); the maneuvers had a sensitivity of 46% (95% CI, 26%-67%), a specificity of 99.1% (95% CI, 97.9%-99.6%), a positive LR of 52 (95% CI, 21-127), and a negative LR of 0.55 (95% CI, 0.37-0.82). There were 3 studies (n = 22 472 hips) that evaluated limited hip abduction and had a sensitivity of 13% (95% CI, 3.3%-37%), a specificity of 97% (95% CI, 87%-99%), a positive LR of 3.6 (95% CI, 0.72-18), and a negative LR of 0.91 (95% CI, 0.76-1.1). One study (n = 13 096 hips) evaluated a clicking sound and had a sensitivity of 13% (95% CI, 6.4%-21%), a specificity of 92% (95% CI, 92%-93%), a positive LR of 1.6 (95% CI, 0.91-2.8), and a negative LR of 0.95 (95% CI, 0.88-1.0).

Conclusions and Relevance

In studies in which all infant hips were screened for developmental dysplasia of the hip, the prevalence of a dislocated hip was 0.94%. A positive LR for the Barlow and Ortolani maneuvers was the finding most associated with an increased likelihood of a dislocated hip. Limited hip abduction or a clicking sound had no clear diagnostic utility.

Validation of parameters recommended for secondary screening for developmental dysplasia of the hip in Japan

BACKGROUND

Based on the Japanese Pediatric Orthopaedic Association's guidelines, secondary screening and imaging including ultrasonography and radiography, are recommended in infants with limited hip abduction (<70°) or in those with multiple risk factors including the following: asymmetrical skin creases, a family history of developmental dysplasia of the hip, female sex, and pelvic position at delivery. However, there is still little information regarding the usefulness of this guideline. The objective of this study was to investigate the association between the risk factors and developmental dysplasia of the hip diagnosed using ultrasound and radiography.

METHODS

A total of 356 infants (67 boys and 289 girls) underwent secondary ultrasonographic and radiological screening for developmental dysplasia of the hip in our hospital. Risk factors were documented from their medical records. The recommended item score, which we defined as an integrated value of the recommended item, was calculated for each patient. The limitation of hip abduction alone was a criterion for secondary screening; therefore, we defined the scores as follows: the limitation of hip abduction scored 2 points and other recommended scores were assigned 1 point. If the recommended item score was 2 points or more, we classified the infants as high-risk.

RESULTS

A total of 280 of 356 infants were included in the high-risk group, which showed a higher ratio of cases with abnormal imaging findings than the low-risk group. According to the multivariate logistic regression analyses among the recommended items, being female, skin asymmetry, and limb limitation were identified as independent risk factors for imaging abnormality and the need for Pavlik harness treatment.

CONCLUSIONS

The recommended items for secondary screening based on the Japanese Pediatric Orthopaedic Association's guidelines could be useful for screening infants in need of treatment.

Multivariate analysis of the predictive value of asymmetric skin creases in diagnosis of decentralized developmental dysplasia of the hip

The aim of this study was to investigate the relationship of developmental dysplasia of the hip (DDH) with asymmetrical skin crease (ASC) in the inguinal, gluteal and thigh regions and to determine which ASC has the most predictive value for the diagnosis of hip dislocation in infants. This study was planned as a prospective, observational study and conducted between 1 October 2020 and 1 June 2021. Asymmetric distribution of skin creases was evaluated separately in three regions (inguinal, gluteal and thigh). Then, hip ultrasonography (USG) was performed and the Graf method was used to classify the cases as 'centralized' [Graf types I, IIa (-), IIb and IIc] and 'decentralized' (Graf types IId, III and IV). The relationship between the groups was evaluated using univariate and then multivariate analyses. A total of 241 patients were included in the study. The number of patients with ASC was 49 (21%). While 36 of these 49 patients had centralized hips, 13 had decentralized hips ( P  < 0.001). Sixty-five percent (13/20) of 20 infants with decentralized hips had ASC in at least one of the inguinal, gluteal or thigh regions. The presence of ASC in the inguinal ( P  < 0.001) and gluteal ( P  < 0.014) regions increased the risk of the decentralized hip in the child, whereas the presence of ASC in the isolated thigh region did not increase the risk of the dislocated hip ( P  = 0.534). Inguinal ASC and gluteal ASC are reliable findings in DDH screening, but the relationship of isolated thigh ASC with DDH could not be demonstrated statistically. Level of Evidence: Level II - diagnostic study.

Estimated effect of secondary screening for hip dislocation

OBJECTIVES

To quantify the effect of secondary screening for hip dislocations.

DESIGN

Retrospective analysis of hospital files from participants in a prospectively collected nationwide registry.

SETTING

Child healthcare centres and orthopaedic departments in Sweden.

PARTICIPANTS

Of 126 children with hip dislocation diagnosed later than 14 days age in the 2000-2009 birth cohort, 101 had complete data and were included in the study.

INTERVENTIONS

The entire birth cohort was subject to clinical screening for hip instability at 6-8 weeks, 6 months and 10-12 months age. Children diagnosed through this screening were compared with children presenting due to symptoms, which was used as a surrogate variable representing a situation without secondary screening.

MAIN OUTCOME MEASURES

Age at diagnosis and disease severity of late presenting hip dislocations.

RESULTS

Children diagnosed through secondary screening were 11 months younger (median: 47 weeks) compared with those presenting with symptoms (p<0.001). Children diagnosed through secondary screening had 11% risk of having a high (severe) dislocation, compared with 38% for those diagnosed due to symptoms; absolute risk reduction 27% (95% CI: 9.7% to 45%), relative risk 0.28 (95% CI: 0.11 to 0.70). Children presenting due to symptoms had OR 5.1 (95% CI: 1.7 to 15) of having a high dislocation, and OR 11 (95% CI: 4.1 to 31) of presenting at age 1 year or older, compared with the secondary screening group. The secondary screening was able to identify half of the children (55%, 95% CI: 45% to 66%) not diagnosed through primary screening.

CONCLUSIONS

Secondary screening at child healthcare centres may have substantially lowered the age at diagnosis in half of all children with late presenting hip dislocation not diagnosed through primary screening, with the risk of having a high dislocation decreased almost to one-quarter in such cases.

The diagnosis and management of common childhood orthopedic disorders: An update

Musculoskeletal illness represents a significant portion of office visits to primary and urgent care clinicians. Despite this, little emphasis is placed on learning pediatric orthopaedics during medical school or residency. The focus of this paper is to provide a systematic approach to this general musculoskeletal physical exam and to assist in the recognition of what conditions are normal development and what conditions require observation, workup and referral to an experienced pediatric orthopaedist.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Developmental dysplasia of the hip: update of management

The term ‘developmental dysplasia of the hip’ (DDH) includes a wide spectrum of hip alterations: neonatal instability; acetabular dysplasia; hip subluxation; and true dislocation of the hip.

DDH alters hip biomechanics, overloading the articular cartilage and leading to early osteoarthritis. DDH is the main cause of total hip replacement in young people (about 21% to 29%).

Development of the acetabular cavity is determined by the presence of a concentrically reduced femoral head. Hip subluxation or dislocation in a child will cause an inadequate development of the acetabulum during the remaining growth.

Clinical screening (instability manoeuvres) should be done universally as a part of the physical examination of the newborn. After two or three months of life, limited hip abduction is the most important clinical sign.

Selective ultrasound screening should be performed in any child with abnormal physical examination or in those with high-risk factors (breech presentation and positive family history). Universal ultrasound screening has not demonstrated its utility in diminishing the incidence of late dysplasia.

Almost 90% of patients with mild hip instability at birth are resolved spontaneously within the first eight weeks and 96% of pathologic changes observed in echography are resolved spontaneously within the first six weeks of life. However, an Ortolani-positive hip requires immediate treatment.

When the hip is dislocated or subluxated, a concentric and stable reduction without forceful abduction needs to be obtained by closed or open means. Pavlik harness is usually the first line of treatment under the age of six months.

Hip arthrogram is useful for guiding the decision of performing a closed or open reduction when needed.

Acetabular dysplasia improves in the majority due to the stimulus provoked by hip reduction. The best parameter to predict persistent acetabular dysplasia at maturity is the evolution of the acetabular index.

Pelvic or femoral osteotomies should be performed when residual acetabular dysplasia is present or in older children when a spontaneous correction after hip reduction is not expected.

Avascular necrosis is the most serious complication and is related to: an excessive abduction of the hip; a force closed reduction when obstacles for reduction are present; a maintained dislocated hip within the harness or spica cast; and a surgical open reduction.

Cite this article: EFORT Open Rev 2019;4:548-556. DOI: 10.1302/2058-5241.4.180019

Risk Factor Assessment and a Ten-Year Experience of DDH Screening in a Well-Child Population

Aim

Risk based screening for developmental dysplasia of the hip (DDH) with ultrasound is common. However, risk factors vary from one country to the other since data are insufficient to give clear recommendations. We aimed to evaluate the risk factors for developmental dysplasia of the hip (DDH).

Methods

In this retrospective case-control study, the health records of all children, who were followed up between 2004 and 2014 at a well-child unit, were investigated for the diagnosis of DDH in Turkey. Of 9758 children, 57 children were found to have abnormal ultrasonographic findings (according to Graf classification) and these constituted the case group. As the control group, healthy 228 children who matched the case children in birth months were selected. Two groups were compared for the risk factors.

Results

A total of 19516 hips of 9758 children were examined for DDH. 97 hips of 57 children were found to have abnormal ultrasonographic findings. When the two groups were compared, breech presentation, multiple pregnancy, and torticollis were identified as risk factors. The female sex was also found to have a significantly high prevalence among the children in the case group. Limited hip abduction, positive Ortolani, and Barlow signs were important clinical findings in the case group.

Conclusion

According to our findings, breech presentation, female sex, torticollis, and multiple pregnancy were found to be the risk factors of this disorder. Infants with these risk factors should be investigated carefully for DDH.

Do the risk factors for developmental dysplasia of the hip differ according to gender? A look from another perspective

AIM

The aim of the present study was to examine if there were gender differences in risk factors in 4415 infants who were evaluated through a physical examination and hip ultrasonography (USG).

METHODS

Physical examination of the hip and hip USG were performed on 4415 infants by the same paediatric orthopaedics specialist. Barlow and Ortolani tests were performed together with the evaluation for the limitation of abduction. Ultrasonographic hip examination was performed according to the Graf technique. The birth records of all the infants were examined, and anamneses (genetic disease, maternal age, delivery type, swaddling, multiple pregnancies, duration of gestation period, gravida, birthweight, breech presentation, oligohydramnios and family history) were obtained from the families. Any accompanying musculoskeletal (torticollis, pes equinovarus, congenital knee dislocation) abnormality was recorded.

RESULTS

Pathological hip was determined in 149 (3.37%) of 4415 infants. In males, gestational week, family history, breech presentation, swaddling, congenital knee dislocation and limited abduction were observed to be significant for the presence of developmental dysplasia of the hip (DDH). In females, significant factors for the presence of DDH were determined to include birthweight, gestational week, breech presentation, multiple pregnancy, accompanying oligohydramnios, torticollis, pes equinovarus and limited abduction.

CONCLUSION

Risk factors for DDH can differ according to gender.

Developmental Dysplasia of the Hip

Pediatricians are often the first to identify developmental dysplasia of the hip (DDH) and direct subsequent appropriate treatment. The general treatment principle of DDH is to obtain and maintain a concentric reduction of the femoral head in the acetabulum. Achieving this goal can range from less-invasive bracing treatments to more-invasive surgical treatment depending on the age and complexity of the dysplasia. In this review, we summarize the current trends and treatment principles in the diagnosis and treatment of DDH.

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

Aims

The aim of this prospective cohort study was to evaluate the effectiveness of the neonatal hip instability screening programme.

Patients and Methods

The study involved a four-year observational assessment of a neonatal hip screening programme. All newborns were examined using the Barlow or Ortolani manoeuvre within 72 hours of birth; those with positive findings were referred to a ‘one-stop’ screening clinic for clinical and sonographic assessment of the hip. The results were compared with previous published studies from this unit.

Results

A total of 124 newborns with a positive Barlow or Ortolani manoeuvre, clunk positive, or ‘unstable’ were referred. Five were found to have clinical instability of the hip. Sonographically, 92 newborns had Graf Type I hips, 12 had Graf Type II hips, and 20 had Graf Type IV hips. The positive predictive value (PPV) of clinical screening was 4.0% and the PPV of sonography was 16.1%. This has led to an increased rate of surgery for DDH.

Conclusion

Compared with previously published ten-year and 15-year studies, there has been a marked deterioration in the PPV in those referred with potential instability of the hip. There appears to be a paradox, with rising referrals and a decreasing PPV combined with an increasing rate of surgery in newborns with developmental dysplasia of the hip. Cite this article: Bone Joint J 2018;100-B:806–10.

The positive predictive value of asymmetrical skin creases in the diagnosis of pathological developmental dysplasia of the hip

Aims

The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH).

Patients and Methods

Between 1 January 1996 and 31 December 2016, all patients referred to our unit from primary or secondary care with risk factors for DDH were assessed in a "one stop" clinic. All had clinical and sonographic assessment by the senior author (RWP) with the results being recorded prospectively. The inclusion criteria for this study were babies and children referred with asymmetrical skin creases. Those with a neurological cause of DDH were excluded. The positive predictive value (PPV) for pathological DDH was calculated.

Results

A total of 105 patients met the inclusion criteria. There were 71 girls and 34 boys. Only two were found to have pathological DDH. Both also had unilateral limited abduction of the hip in flexion and a positive Galeazzi sign with apparent leg-length discrepancy. Thus, if the specialist examination of a patient with asymmetrical skin creases was normal, the PPV for DDH was 0%.

Conclusion

Isolated asymmetrical skin creases are an unreliable clinical sign in the diagnosis of pathological DDH. Greater emphasis should be placed on the presence of additional clinical signs to guide radiological screening in babies and children. Cite this article: Bone Joint J 2018;100-B:675-9.

Developmental dysplasia of the hip: an update on diagnosis and management from birth to 6 months

PURPOSE OF REVIEW

Our understanding of the epidemiology, diagnosis, and management of developmental dysplasia of the hip (DDH) is evolving. This review focuses on the most up-to-date literature on DDH in patients from birth to six months of age.

RECENT FINDINGS

Well known risk factors for DDH include family history, female sex, and breech positioning. Recent evidence suggests higher birth weight is a risk, whereas prematurity may be protective. Screening includes physical examination of all infant hips and imaging when abnormal findings or risk factors are present. Treatment in the first six months consists of a harness, with 70-95% success. Failure risk factors include femoral nerve palsy, static bracing, irreducible hips, initiation after seven weeks of age, right hip dislocation, Graf-IV hips, and male sex. Rigid bracing may be trialed if reduction with a harness fails and closed reduction is indicated after failed bracing. If the hip is still irreducible, nonconcentric, or unstable, open reduction may be required following closed reduction. Evidence does not support delaying hip reduction until the ossific nucleus is present.

SUMMARY

DDH affects 1-7% of infants. All infants should be examined and selective screening with imaging should be performed for abnormal physical exams or risk factors. Early treatment is associated with optimal outcomes.

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.

Screening in Developmental Dysplasia of the Hip (DDH)

Screening for Developmental Dysplasia of the Hip (DDH) is a controversial subject. Screening may be by universal neonatal clinical examination (Ortolani or Barlow manoeuvres) with the addition of sonographic imaging of the hip (selective 'at risk' hips or universal screening in the neonate). In the UK, the NIPE guidelines recommend universal neonatal clinical assessment of the hip joints, a General Practitioner 6-8 week clinical 'hip check' and assessment clinically with sonographic imaging at 4-6 weeks for certain 'at risk' hips for pathological DDH. The effectiveness and difficulties arising from the UK current screening policy (clinical and sonographic) are highlighted. The purpose of the review was to assess the risk factors and efficacy of diagnostic methods in DDH, based on longitudinal cohort studies of 10 years or more.

CONCLUSION

Hip screening in DDH does not meet most of the World Health Organisation's criteria for an effective screening programme and should only be considered as surveillance due to its low sensitivity and positive predictive value (PPV). There is a significant risk of over diagnosis and over treatment. There is no International consensus on screening in DDH. Pathological DDH is mainly a female condition and 'at risk'/General Practitioner screening identifies few pathological cases in male subjects. The General Practitioner 6-8 week 'hip check' has a very low PPV for pathological DDH and is of doubtful value in screening and diagnosis. Unilateral limitation of hip abduction is a time dependent and useful clinical sign in the diagnosis of pathological DDH. The majority of the previously considered 'at risk' factors are not true risk factors with little or no association with pathological DDH.

Utilization of ultrasonography to detect developmental dysplasia of the hip: when reality turns selective screening into universal use

Background

Developmental dysplasia of the hip (DDH) occurs in 3–5 of 1000 live births and is associated with known risk factors. In most countries, formal practice for early detection of DDH entails the combination of risk factor identification and physical examination of the hip, while the golden standard diagnostic instrument is hip ultrasonography (US). This practice is commonly referred to as selective screening. Infants with positive US findings are treated with a Pavlik harness, a dynamic abduction splint.

The objective of our study was to evaluate hip US utilization patterns in Maccabi Healthcare Services (MHS), a large health plan.

Methods

Study population: All MHS members, born between June 2011 and October 2014, who underwent at least one US before the age of 15 months. Study variables: Practice specialty and number of enrolled infants. Positive US result was defined as referral to an abduction splint. Cost was based on Ministry of Health price list. Chi square and correlation coefficients were employed in the statistical analysis.

Results

Of the 115,918 infants born during the study period, 67,491 underwent at least one hip US. Of these, 60.6% were female, mean age at performance: 2.2 months. Of those who underwent US, 625 (0.93%) were treated with a Pavlik harness: 0.24% of the male infants and 1.60% of the female infants (p < 0.001). Analysis of physician practice characteristics revealed that referral to US was significantly higher among pediatricians as compared with general practitioners (60% and 35%, respectively). Practice volume had no influence on referral rate. Direct medical costs of the 107 hip US examinations performed that led to detection of one positive case (treated by Pavlik): US$10,000.

Conclusions

Current pattern of hip US utilization for early detection of DDH resembles universal screening more closely than selective screening. This can inform policy decisions as to whether a stricter selective screening or a formal move to universal screening is appropriate in Israel.

Retrospective Multicenter Analysis of the Accuracy of Clinical Examination by Community Physicians in Diagnosing Developmental Dysplasia of the Hip

OBJECTIVES

To determine among general practitioners (GPs) the most common clinical findings that raised concern for developmental dysplasia of the hip (DDH) and necessitated an orthopedic outpatient referral. In addition, we assessed the sensitivity and specificity of the most common of these clinical findings.

STUDY DESIGN

We performed a multicenter retrospective review of all referrals by GPs to local orthopedic outpatient departments for DDH over a 12-month period. All patients had undergone pelvic radiographs, and the acetabular index (AI) was measured. The AI was used as a reference test to assess the accuracy of the clinical examination in diagnosing DDH. Sensitivity and specificity of each clinical sign was calculated.

RESULTS

Twenty-six of 174 (14.9%) referred patients were diagnosed with DDH, defined as an AI score > 30. The most common indication for referral, per the GP letter was asymmetrical skin folds (97 patients, 45.8%), followed by hip click (42 patients, 19.8%), and limb shortening (34 patients, 16%). Sensitivities and specificities, respectively, among findings were asymmetric skin folds 46.2% (95% CI 26.6%-66.6%) and 42.6% (95% CI 34.5%-51.0%), hip click 23.1% (95% CI 9.0%-43.6%) and 75.7% (95% CI 67.9%-82.3%), limb shortening 30.8% (95% CI 14.3%-51.8%) and 82.4% (75.3%-88.2%), and reduced abduction 19.2% (95% CI 6.6%-39.4%) and 91.9% (95% CI 86.3%-95.7%). Using logistic regression analysis, no clinical sign was found to be a statistically significant indicator of an abnormal AI.

CONCLUSIONS

Clinical examination by GPs does not reliably detect radiographically-defined DDH. None of the clinical findings by the GP showed an acceptable level of sensitivity. Absence of reduced abduction and limb shortening are relevant negatives given the high level of specificity of these signs.

Developmental dysplasia of the hip: What has changed in the last 20 years?

Developmental dysplasia of the hip (DDH) describes the spectrum of structural abnormalities that involve the growing hip. Early diagnosis and treatment is critical to provide the best possible functional outcome. Persistence of hip dysplasia into adolescence and adulthood may result in abnormal gait, decreased strength and increased rate of degenerative hip and knee joint disease. Despite efforts to recognize and treat all cases of DDH soon after birth, diagnosis is delayed in some children, and outcomes deteriorate with increasing delay of presentation. Different screening programs for DDH were implicated. The suspicion is raised based on a physical examination soon after birth. Radiography and ultrasonography are used to confirm the diagnosis. The role of other imaging modalities, such as magnetic resonance imaging, is still undetermined; however, extensive research is underway on this subject. Treatment depends on the age of the patient and the reducibility of the hip joint. At an early age and up to 6 mo, the main treatment is an abduction brace like the Pavlik harness. If this fails, closed reduction and spica casting is usually done. After the age of 18 mo, treatment usually consists of open reduction and hip reconstruction surgery. Various treatment protocols have been proposed. We summarize the current practice for detection and treatment of DDH, emphasizing updates in screening and treatment during the last two decades.

What's new in pediatric orthopaedics

This past year has seen an increase in the quality of studies in pediatric orthopaedics, and the completion of BrAIST demonstrated that high-level studies of important questions can be addressed in pediatric orthopaedics. The current commitment of improving quality of care for children promises a healthy future for pediatric orthopaedics.