Screening the newborn for developmental dysplasia of the hip: now what do we do?

Why all newborn hip screening programs have same results-a mini review

All newborns are screened for developmental dysplasia of the hip (DDH), but countries have varying screening practices. The aim of this narrative mini review is to discuss the controversies of the screening and why it seems that all screening programs are likely to have same outcome. Different screening strategies are discussed alongside with other factors influencing DDH in this review. Universal ultrasound (US) has been praised as it finds more immature hips than clinical examination, but it has not been proven to reduce the rates of late-detected DDH or surgical management. Universal US screening increases initial treatment rates, while selective US and clinical screening have similar outcomes regarding late detection rates than universal US. This can be explained by the extrinsic factor affecting the development of the hip joint after birth and thus initial screening during the early weeks cannot find these cases.  Conclusion: It seems that DDH screening strategies have strengths and limitations without notable differences in the most severe outcomes (late-detected cases requiring operative treatment). Thus, it is important to acknowledge that the used screening policy is a combination of values and available resources rather than a decision based on clear evidence.

Acetabular index as an indicator of Pavlik harness success in grade I developmental dysplasia of the hip: A retrospective study

Purpose

Some articles have focused on the effectiveness of the Pavlik harness treatment for unstable and dislocated hips, yet data on monitoring its effectiveness with the acetabular index remains elusive. Therefore, this study aimed to assess Pavlik harness effectiveness in infants ≤6 months diagnosed with grade I developmental dysplasia of the hip using acetabular index improvement and identify the possible predictors of successful Pavlik harness treatment.

Methods

A retrospective review of infants with grade I acetabular dysplasia treated with a Pavlik harness and monitored with anteroposterior pelvis X-rays at presentation and follow-up. Successful treatment was defined as achieving an acetabular index <30°.

Results

A total of 231 infants with acetabular dysplasia were treated with a Pavlik harness. A successful outcome was achieved in 135 infants (58.4%). Younger age, lower initial acetabular index, and patients with unilateral developmental dysplasia of the hip were significant predictors of a successful outcome. An age of 4.5 months or older was found to be the threshold for an unsuccessful result following Pavlik harness treatment, with a sensitivity of 65.2% and specificity of 57.3%. An initial acetabular index of 35.5° was found to be the threshold for an unsuccessful result, with a sensitivity of 83.7% and specificity of 61.5%.

Conclusion

Pavlik Harness's success in correcting the acetabular index in acetabular dysplasia patients was related to unilateral cases, a younger age at presentation, and a lower initial acetabular index. The thresholds for unsuccessful treatment were an age of 4.5 months or greater and an acetabular index of 35.5° or higher.

Universal screening may reduce the incidence of late diagnosis of developmental dysplasia of the hip : a systematic review and meta-analysis

AIMS

We investigated the prevalence of late developmental dysplasia of the hip (DDH), abduction bracing treatment, and surgical procedures performed following the implementation of universal ultrasound screening versus selective ultrasound screening programmes.

METHODS

A systematic search of PubMed, Embase, The Cochrane Library, OrthoSearch, and Web of Science from the date of inception of each database until 27 March 2022 was performed. The primary outcome of interest was the prevalence of late detection of DDH, diagnosed after three months. Secondary outcomes of interest were the prevalence of abduction bracing treatment and surgical procedures performed in childhood for dysplasia. Only studies describing the primary outcome of interest were included.

RESULTS

A total of 31 studies were identified, of which 13 described universal screening and 20 described selective screening. Two studies described both. The prevalence of late DDH was 0.10 per 1,000 live births (95% confidence interval (CI) 0.00 to 0.39) in the universal screening group and 0.45 per 1,000 live births (95% CI 0.31 to 0.61) in the selective screening group. Abduction bracing treatment was performed on 55.54 per 1,000 live births (95% CI 24.46 to 98.15) in the universal screening group versus 0.48 per 1,000 live births (95% CI 0.07 to 1.13) in the selective screening group. Both the universal and selective screening groups had a similar prevalence of surgical procedures in childhood for dysplasia being performed (0.48 (95% CI 0.32 to 0.63) vs 0.49 (95% CI 0.31 to 0.71) per 1,000 live births, respectively).

CONCLUSION

Universal screening showed a trend towards lower prevalence of late DDH compared to selective screening. However, it was also associated with a significant increase in the prevalence of abduction bracing without a significant reduction in the prevalence of surgical procedures in childhood for dysplasia being performed. High-quality studies comparing both treatment methods are required, in addition to studies into the natural history of missed DDH.Cite this article: Bone Joint J 2023;105-B(2):198-208.

Screening for musculoskeletal system malformations and birth injuries in newborns: Results of a screening program in two hospitals in Shenzen, China

Importance

There are a variety of musculoskeletal malformations and injuries that can occur in newborns. These can be a significant cause of perinatal death or a reason for miscarriage and can lead to long‐term functional issues if not managed appropriately. There is no systematic and well‐established screening program for neonatal musculoskeletal malformations and injuries in China now.

Objective

To report the incidence and types of congenital musculoskeletal malformations in two hospitals in Shenzhen City, to explore and discuss the details of the screening procedure and improve future prevention and treatment.

Methods

From October 2013 to May 2014, 2564 one‐day‐old newborns were screened by a pediatric orthopedic physical examination, in combination with ultrasonography when required, and the incidence and variety of diseases were recorded statistically.

Results

Among 2564 screened newborns, the following musculoskeletal conditions were identified: congenital muscular torticollis (CMT) (seven cases, 0.27%), hip subluxation (four cases, 0.16%), hip dysplasia (47 cases, 1.83%), congenital talipes equinovarus (CTEV) (two cases, 0.08%), congenital talipes calcaneovalgus (15 cases, 0.58%), polydactyly (nine cases, 0.35%), syndactyly (one case, 0.04%), and spinal hemivertebra (one case, 0.04%). Additionally, there were five (0.19%) neonates with birth injuries.

Interpretation

It is feasible to carry out neonatal screening and identification of musculoskeletal malformations and birth injuries in China. This is helpful as timely detection and early intervention for many of these conditions can avoid permanent functional impairment in these children.

Epidemiology and costs of surgical treatment of developmental dysplasia of hip in the Brazilian Public Health System in a decade

Objective:

To describe and analyze the epidemiology and costs of surgical treatment of hip dysplasia in the Brazilian Public Health System.

Methods:

An ecological analytical study that evaluated a time series and the geographic distribution of surgical treatment of hip dysplasia in Brazil. Frequencies of cases, number of cases and associated factors were analyzed. Correlations, frequency maps and flow maps are presented and discussed.

Results:

During the study, 14,584 patients with dysplasia were admitted to hospitals according to Information Technology Department of the Public Health System. Patients underwent hospital treatment specific for dysplasia in 8,592 cases (at an average cost of R$ 2.225,50, total cost of R$ 19.124.086,25– updated values). In this group, mortality rate was 0.046% and mean hospitalization time was 4.41 days (standard deviation of 2,39 days). Age between 1 and 4 years (37.7%), female sex (64.5%) and white race (46%) were more frequent. Greater rates of specialists (R²=0.82; p<0.001), greater proportion of counties with high/very high human development index (R²=0.79; p<0.001), and higher per capita income (R²=0.68; p<0.001) correlated to greater rates of treatments undertaken per 1,000 live births (as per State of treatment). The factor most related to treatment rate per 1,000 live births (as per State of residence) was white race (R²=0.90; p<0.001). Southern states had higher treatment rates (as per State of residence, rate of 0.73/1,000), and Southeast states had greater absolute frequency of cases (46.7%) and greater flow of patients.

Conclusion:

The surgical treatment of hip dysplasia in Brazil occurs frequently, at relevant costs, and is distributed in a heterogenous and unequal fashion in the Public Health System. Southern states have a higher incidence of cases, and there is an association with racial and socioeconomic factors. There was no large variation in the incidence of cases over time.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Orthopaedic Surgeons in India

BACKGROUND

We evaluated screening, referral and treatment practices for developmental dysplasia of the hip (DDH) in India by surveying Orthopaedic surgeons who treat patients with DDH. The survey assessed the timing of DDH presentation, resource availability, and current state of screening and diagnosis, which would help in the development of a DDH care pathway for India.

METHODS

An online survey was distributed to Orthopaedic surgeons practicing in India via email and administered onsite to those attending the annual conference of the Pediatric Orthopaedic Society of India in 2019.

RESULTS

173 completed surveys were received from surgeons practicing in a predominantly urban setting. 68.8% of respondents had performed initial evaluations on children with DDH aged over 1 year in the past 12 months, and 49.1% had assessed children with DDH aged > 2 years on initial presentation. There was no consistent use of established guidelines, with only 30% of respondents stating that a care pathway was in place at their institution. However, 91.9% would support the implementation of a care pathway developed in India, to decrease the incidence of delayed diagnosis and facilitate earlier intervention. 85% of respondents had ready access to ultrasound scans and 95.4% had access to X-rays.

CONCLUSIONS

In India, there is still a large number of late-presenting cases of DDH, which could be improved with effective screening. The development of a care pathway for DDH in India is well-supported by Orthopaedic surgeons and may help decrease the incidence of late presenting cases; potentially improving outcomes, decreasing morbidity, and upskilling local practitioners.

Ultrasound Evaluation of Pediatric Orthopaedic Patients

Ultrasonography is a valuable tool that can be used in many capacities to evaluate and treat pediatric orthopaedic patient. It has the capability to depict bone, cartilaginous and soft-tissue structures, and provide dynamic information. This technique can be readily applied to a wide range of pediatric conditions, including developmental dysplasia of the hip, congenital limb deficiencies, fracture management, joint effusions, and many other musculoskeletal pathologies. There are many benefits of implementing ultrasonography as a regular tool. It is readily accessible at most centers, and information can be quickly obtained in a minimally invasive way, which limits the need for radiation exposure. Ultrasonography is a safe and reliable tool that pediatric orthopaedic surgeons can incorporate into the diagnosis and management of a broad spectrum of pathology.

Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatric Orthopaedic Surgeons in North America

BACKGROUND

Developmental dysplasia of the hip (DDH) is a common condition, affecting 1% to 2% of full-term infants. The American Academy of Orthopaedic Surgeons (AAOS) and American Academy of Pediatrics have published guidelines detailing best practices for DDH screening and treatment. The purpose of this survey was to determine DDH treatment practices of pediatric orthopaedic surgeons in North America.

METHODS

We queried orthopaedic surgeon members of the Pediatric Orthopaedic Society of North America (POSNA) about referral patterns, treatment practices, and use of DDH guidelines. The survey included demographics, clinical scenarios, referrals patterns, and ultrasound practices.

RESULTS

Of the 1392 members of POSNA, we received 432 total responses and included 353 in statistical analyses. Results show that 68% (233/342) of surgeons practice in an institution that does not endorse a standard care pathway for DDH. Of surgeons who personally use a DDH care pathway, the AAOS guidelines were most cited (143/353, 41%). The majority (94%, 316/337) of surgeons do not believe that universal ultrasound screening should be adopted in the United States. Responses regarding ultrasound screening for "high risk" infants as outlined by AAOS varied based on risk factor. Many (57%, 200/353) surgeons have performed initial evaluations for patients over 12 months of age. While 80% (260/327) of orthopaedic surgeons believe that primary care providers are referring patients appropriately, only 57% (183/323) believe that primary care providers are ordering imaging studies appropriately.

CONCLUSIONS

Results from this survey of POSNA membership indicate an opportunity to better distribute and implement DDH guidelines. In addition, the implementation of a care map with a focus on standard referral and imaging practices could improve the care of patients with DDH by: (1) reducing the total cost of care, (2) increasing the use of appropriate imaging, (3) increasing timely referral for DDH care, and (4) reducing the presentation rate of walking age DDH patients.

LEVEL OF EVIDENCE

The level of evidence rating for this survey-based study is level IV.

Optimizing the Time for Developmental Dysplasia of the Hip Screening: Earlier or Later?

INTRODUCTION

Developmental dysplasia of the hip (DDH) is still a common and important disorder of childhood, with a prevalence of 0.1 to 2/1000 children. Using ultrasonography (US) in screening of DDH reduces the rates of open reductions and complications. In the current study, we aim to detect the optimal time for US examination for detecting DDH to prevent unnecessary repeating US examinations and treatments.

METHODS

Children referred to US examination for a healthy child screening program, according to the health policy of our country, are included in the current prospective study. Both hips of each child were sonographically examined by the same radiologist using Graf's method at 4th, 8th, 12th weeks of life.

RESULTS

A total of 2020 hips of 1010 children were examined. Fourth-week US results can predict 12th-week results (right hip: sensitivity 100%, specificity 75.7%; left hip: sensitivity 100%, specificity 78.3%). Eighth-week US results can predict 12th-week results (right hip: sensitivity 100%, specificity 87.5%; left hip: sensitivity 100%, specificity 83.9%). In predicting 12th-week US results, 8th-week results are found to be more successful than 4th-week results.

CONCLUSIONS

Late diagnosis of DDH might cause serious public health problems. On the other hand, early US examinations can result in false-positive diagnosis. Unfortunately, there is still confusion about the optimal time for DDH screening with US, especially among radiologists who are not specialized in DDH sonography. A US scan performed at eighth week of life can predict any pathology presence safely and correctly.

Profile of Patients Diagnosed with Developmental Dysplasia of the Hip

Objective  To describe the profile of patients with developmental dysplasia of the hip (DDH) diagnosed by physical and ultrasound examination, with the implementation of a protocol for the treatment and follow-up of DDH.

Methods  A cross-sectional study with DDH patients born between January 2014 and December 2016, in the city of Pelotas, Southern Brazil. Ethnicity, gender, birth weight, fetal presentation, affected side of the hip, gestational age, maternal age and family history were considered. The data on the medical records were compared with the characteristics of the general population described on the Brazilian National Information System on Live Births (Sistema de Informação sobre Nascidos Vivos [SINASC]).

Results  A total of 33 DDH patients were identified, mostly female, with a four-fold higher probability of having the condition ( p  < 0.001); the left was the most affected side. No statistically significant association was found regarding the following factors: birth weight, gestational age, ethnicity, and maternal age. The newborns in breech presentation had a 15-fold higher probability of presenting DDH ( p  < 0.001). A total of 21 newborns required immediate treatment of the hips, since the ultrasound showed a Graf classification of IIb or higher, or the radiography showed dislocation in DDH patients older than 6 months of age.

Conclusion  Screening for DDH is essential in all newborns; physical examinations revealing alterations must be complemented with ultrasound imaging to avoid the delayed diagnosis of the condition.

Clinical significance of asymmetric skin folds in the medial thigh for the infantile screening of developmental dysplasia of the hip

BACKGROUND

The presence of asymmetric skin folds in the medial thigh (ASM) is often used as one of the screening items for developmental dysplasia of the hip (DDH). However, few studies have evaluated the clinical relevance of ASM in DDH.

METHODS

We reviewed the data of 584 infants aged 4-12 months who were referred to our institute because of suspicious findings in periodic infantile DDH screenings. The reasons for referral were classified into ASM, gluteal asymmetry, limb-length discrepancy, limitation of hip abduction, and click/clunk of the hip. A simple radiograph and hip examination including stability assessment were evaluated in all the infants by an experienced pediatric orthopedic surgeon.

RESULTS

Most of the referred infants presented with ASM only (78.4%, 458/584), but none of them were diagnosed with DDH. On the other hand, about 18.3% of infants referred for other reason(s) were diagnosed with DDH.

CONCLUSION

Although the presence of ASM was the most common reason for referral, it had little clinical significance as a screening item for DDH in the infants aged 4-12 months. Therefore, ASM alone is not a clinical indicator of DDH.

Evaluating and managing acetabular dysplasia in adolescents and young adults

Hip dysplasia is a developmental deformity in which abnormal acetabular or proximal femoral growth causes structural instability of the hip joint due to inadequate bony coverage of the acetabulum over the femoral head. Skeletally mature adolescents or young adults with underlying acetabular dysplasia may present with activity-related groin or lateral hip pain and a limp. This article reviews the current understanding of the disease and better treatment options for correcting acetabular dysplasia in symptomatic adolescents and young adults before secondary osteoarthritis develops.

Correlations between ultrasonographic and subsequent radiographic findings of developmental dysplasia of the hips

Purpose

The study aimed to investigate the utility of ultrasonographic (US) findings in predicting the subsequent radiographic parameters of developmental dysplasia of the hips.

Methods

In this 12-year retrospective cohort study, all new-born infants with a positive clinical examination or risk factors were included. They were scheduled for hip ultrasonography in the first 3 months, and subsequent radiographs at 1 year of life. The US images were evaluated using the Graf classification, Harcke’s dynamic screening method, and Terjesen’s femoral head coverage method. The radiographic images were evaluated using the acetabular index and femoral head position. The overall US or radiographic findings were considered abnormal if they were classified as abnormal for any of their respective parameters. The overall US and radiographic parameters were correlated.

Results

A total of 160 patients were included. The overall US and radiographic parameters showed no statistically significant difference (P=0.050). The sensitivity, specificity, and accuracy of the overall US parameters were 57.1%, 84.9%, and 81.3%, respectively. All three individual US parameters showed no statistically significant differences, with the overall radiographic findings and acetabular index (P>0.05). However, they showed a statistically significant difference, with the position of the femoral head (P<0.001), with the US parameters having an excellent negative predictive value of 100% for identifying an abnormal femoral head position.

Conclusion

The current study suggests that US findings evaluated in the first 3 months of life showed no statistically significant difference with radiographic findings evaluated at 1 year of life. The US parameters showed an excellent negative predictive value for abnormal femoral head position on radiographs.

Protein biomarkers in serum and urine for determining presence or absence of hip dysplasia in a canine model

This study compares serum and urine concentrations of relevant protein biomarkers among adult dogs with or without radiographic canine hip dysplasia (CHD). Adult (≥2 years of age), client-owned dogs (n = 74) radiographically categorized as having at least "good" hips (n = 49) or having "mild," "moderate," or "severe" hip dysplasia (n = 25) by the Orthopedic Foundation for Animals (OFA). Urine and serum samples were obtained from each dog at a single time-point and processed and analyzed for relevant protein biomarkers. Urinary concentrations of CTX-II (p < 0.001) and TIMP-1 (p = 0.002) were significantly lower in dogs with CHD compared to dogs with no CHD. ROC curve analyses were successful in establishing a panel of four biomarkers (urinary CTX-I and II, serum MMP-9, and serum PIICP) with high discriminatory capability for the presence or absence of hip dysplasia in adult dogs (AUC = 0.89). Urine and serum biomarkers can distinguish adult dogs with radiographic CHD from those with no CHD with a sensitivity of 0.95 and specificity of 0.77 using ROC analysis with AUC 0.89. Clinical Significance: This finding suggests that this simple, minimally invasive diagnostic technique has potential for discriminating dysplastic dogs from dogs with normal hips, with possible translational application to humans based on similar etiopathogenesis. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-5, 2019.

Operative Reduction for Developmental Dysplasia of the Hip: Epidemiology Over 16 Years

BACKGROUND

The burden of surgical treatment for infantile developmental dysplasia of the hip (DDH) is unknown. We aimed to investigate the epidemiology of operative DDH reductions in the United States and identify potential at-risk populations.

METHODS

The Healthcare Utilization Project Kids' Inpatient Database (1997 to 2012) were analyzed. International Classification of Diseases (ICD-9) codes identified inpatient hospitalizations for DDH reductions excluding neuromuscular cases. Hospital variables and patient demographics were captured. Weighted population-level counts were calculated to allow for national estimates.

RESULTS

An estimated 5525 (95% confidence interval, 4907.8-6142.2) operative reductions were performed. In total, 73.3% were open with a mean age at the reduction of 2.3 years (95% confidence interval, 2.1-2.5). In total, 70.0% were female and 42.3% were white. Regional distribution varied: 36.4% of reductions occurred in the West, 22.8% in the South, 21.9% in the Midwest, and 18.9% in the Northeast. Operative reductions decreased over time; open reductions decreased by 5.6% and closed by 53.4%. Mean age at treatment increased from 1.6 to 3.7 years (P<0.001). On multivariate analysis, age (P<0.001) and geographic location (P<0.05) were associated with open reduction. Patients in the West had increased odds of being Hispanic or Asian/Pacific Islander [odds ratio (OR), 4.9, P<0.001 and OR, 2.8; P=0.008]. In the South and Midwest, the highest income quartile was protective (OR, 0.4; P=0.001 and OR, 0.5; P=0.018).

CONCLUSIONS

The frequency of closed reductions decreased more over time compared with open reductions. However, the mean age of children undergoing reductions increased suggesting a possible delay in diagnosis. The data suggests that there is room for improvement in screening. Targeted research in identified populations may reduce the burden of surgical disease in infantile DDH.

LEVEL OF EVIDENCE

Level III.

Incorporating risk factors in the development of the screening programme for developmental dysplasia of the hips

In a 12-year cohort study, all newborns with suspected developmental dysplasia of the hips (DDHs) were scheduled for hip ultrasound at the sixth week of life. Female sex is the only isolated risk factor with a positive likelihood ratio predictive of DDH [1.26; 95% confidence interval (CI): 1.04-1.54]. In combination, the presence of two or more risk factors was predictive of DDH (positive likelihood ratio 1.10; 95% CI: 1.00-1.20). The sensitivity and specificity of two or more risk factors for the prediction of DDH were 93.6% (95% CI: 86.6-97.6) and 14.5% (95% CI: 8.70-22.2), respectively. The level of evidence for the cohort study is II.

Investigating the need for routine ultrasound screening to detect developmental dysplasia of the hip in infants born with breech presentation

Objectives

Breech presentation is a recognized risk factor for developmental dysplasia of the hip (DDH). Within North America, there is a lack of consensus on screening guidelines for DDH in infants with a negative physical examination of the hips. This study evaluates the need for ultrasound screening in all breech born infants to detect DDH and whether this is influenced by gender, gestational age and mode of delivery.

Methods

A retrospective chart review was conducted to identify breech born infants who underwent routine hip ultrasound to detect DDH between 2010 and 2015. Patients were grouped by physical exam and ultrasound findings and compared based on gender, gestational age and mode of delivery.

Results

Three hundred and eighteen patients were identified (191 female, 127 male; 26 preterm, 57 late preterm, 235 term; 263 caesarean section delivery, 55 vaginal delivery). Three hundred and eight patients had a negative physical exam of which 27 were diagnosed with DDH based on screening ultrasound with females predominant (P<0.05). 12.50% of females with a negative physical exam had DDH compared to 3.23% of males (P<0.05). There was no difference in the rate of DDH detected by screening ultrasound based on gestational age (P=0.94) or mode of delivery (P=0.59).

Conclusions

The diagnosis of DDH in breech born infants by screening ultrasound in those with a negative physical exam of the hips is more predominant in females, with no apparent association with gestational age or mode of delivery. Future analyses with larger sample sizes are needed before conclusions can be made on screening protocols.

Diagnosing developmental dysplasia of the hip using the Graf ultrasound method: risk and protective factor analysis in 11,820 universally screened newborns

The essential role of ultrasound examinations in diagnosis and treatment of developmental dysplasia of the hip (DDH) is widely accepted while the weighting and correlation of protective factors and perinatal risk for DDH still give rise to debate. Our aim was to investigate the impact of single and twofold combined risk and protective factors on the newborns' hip maturity, assessed with the Graf ultrasound method. Therefore, data sets of 11,820 universally screened newborns were analyzed. Univariate and logistic regression analyses were performed to correlate risk and protective factors with mature or immature but appropriate for age and pathologic hip types. Thereby, female gender (OR 4.07 (95% CI 3.01-5.51), p < 0.001), breech presentation (4.98 (3.71-6.71), p < 0.001), and positive family anamnesis (5.05 (3.49-7.31), p < 0.001) as well as the combination of female gender with high birth weight (3.51 (2.45-5.03), p < 0.001) could be identified as independent predictive risk factors. Only low birth weight (0.27 (0.11-0.66), p = 0.004) could be identified as a single protective factor, while no combination of protective factors was significant.

CONCLUSION

The significance and the informative value of risk and protective factor combinations, e.g., for selective ultrasound surveys, are limited. Early universal ultrasound screening using the Graf method is advised to timely detect hip immaturity and pathologies and to provide the optimal approach for mature or immature but appropriate for age and pathologic hips. What is Known: • Ultrasound screening is essential for diagnosis and treatment of DDH in time while the weighting and correlation of protective factors and perinatal risk and their role for the ultrasound screening protocol still give rise to debate. What is New: • The effects of single risk and protective factors for DDH do not cumulate or counteract, resulting in a limited value of a selective screening protocol based on risk and protective factors. • A universal screening protocol using the Graf ultrasound method is recommended.

Evaluation and Referral for Developmental Dysplasia of the Hip in Infants

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and accounts for 5% to 10% of all total hip replacements in the United States. Newborn and periodic screening have been practiced for decades, because DDH is clinically silent during the first year of life, can be treated more effectively if detected early, and can have severe consequences if left untreated. However, screening programs and techniques are not uniform, and there is little evidence-based literature to support current practice, leading to controversy. Recent literature shows that many mild forms of DDH resolve without treatment, and there is a lack of agreement on ultrasonographic diagnostic criteria for DDH as a disease versus developmental variations. The American Academy of Pediatrics has not published any policy statements on DDH since its 2000 clinical practice guideline and accompanying technical report. Developments since then include a controversial US Preventive Services Task Force "inconclusive" determination regarding usefulness of DDH screening, several prospective studies supporting observation over treatment of minor ultrasonographic hip variations, and a recent evidence-based clinical practice guideline from the American Academy of Orthopaedic Surgeons on the detection and management of DDH in infants 0 to 6 months of age. The purpose of this clinical report was to provide literature-based updated direction for the clinician in screening and referral for DDH, with the primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.

Incidence of Hip Dysplasia Associated With Bladder Exstrophy

BACKGROUND

Exstrophy of the bladder is a rare congenital defect seen in 2.15 children out of every 100,000 live births, with the most severe variant, cloacal exstrophy (CE), only occurring in 1 in 200,000. Developmental dysplasia of the hip (DDH) describes a spectrum of disease ranging from mild hip instability to frank dislocation. Underlying malformations, such as myelomeningocele and arthrogryposis, are often associated with the most severe variant of hip dysplasia, teratologic hip dislocation. The varying degrees of severity in DDH have been encountered in classic bladder exstrophy (CBE) patients, but the exact incidence is unknown. We sought to determine the incidence of DDH in CBE and CE patients.

METHODS

We performed a retrospective review of all children with CBE or CE presenting to a single pediatric center between 1994 and 2014. Each chart was reviewed for correct diagnosis of CBE or CE, patient age and demographics, associated medical conditions, pertinent surgeries performed, and the age at operation. Patient imaging was reviewed to determine whether bilateral hip imaging was available.

RESULTS

In a 20-year retrospective review, we identified 66 patients who were diagnosed with either CBE or CE and had available hip imaging (38 males and 28 females). Of these, 11 patients were found to have radiographic evidence of DDH, for an incidence of 16.7% (11/66). Five of these patients had CE, whereas 6 presented with CBE. The first radiographic evidence of DDH was noted at a mean age of 5.75 years (range, birth to 22 y).

CONCLUSIONS

We advocate the use of routine hip screening ultrasound in all infants born with either CBE or CE. Early identification of DDH in these patients may allow additional treatment options to coincide with frequently used osteotomy and orthopaedic interventions.

LEVEL OF EVIDENCE

Level III-retrospective study.

Effects of arthroscopic-assisted surgery on irreducible developmental dislocation of hip by mid-term follow-up: An observational study

The purpose of this study was to investigate the indications, surgical technique, and the clinical effects of arthroscopic-assisted treatment of irreducible developmental dislocation of the hip by mid-term follow-up. Arthroscopic-assisted surgeries were performed on 40 children (52 hips) between January 2005 and December 2009. Anterior and antero-superior greater trochanter portals were used in these treatments. Spica cast and abduction splint were applied for 3 months postoperatively. The follow-up was conducted on every 3 months postoperatively. During 12-month follow-up, a secondary treatment such as acetabuloplasty and/or femoral osteotomy (shortening, varus, and derotation) was applied if the acetabular angle was greater than 25°. The pelvic acetabular angle, Mckay and Severin score were evaluated every 6 months in all children. With 36 to 96 months (average 71 months) follow-up, 35 children (44 hips) were successfully followed up with complete case data while 5 children unsuccessfully. According to Tönnis classification, there were 5 grade 1 hips, 14 grade 2 hips, 14 grade 3 hips, 11 grade 4 hips, in which 3 children (4 hips) were failed in arthroscopic reduction and femoral head avascular necrosis occurred in 2 children (4 hips). According to Mckay standard, the good rate is 100%. According to Severin standard, the good rate is 84.1%. Arthroscopic assisted treatment is an effective way of reduction of the irreducible hip. Compared with the open reduction, arthroscopic treatment combined with acetabuloplasty and/or femoral osteotomy has advantages of less trauma and better function preservation.

Disparity between Clinical and Ultrasound Examinations in Neonatal Hip Screening

BACKGROUND

For early detection of developmental dysplasia of the hip (DDH), neonatal hip screening using clinical examination and/or ultrasound has been recommended. Although there have been many studies on the reliability of both screening techniques, there is still controversy in the screening strategies; clinical vs. selective or universal ultrasound screening. To determine the screening strategy, we assessed the agreement among the methods; clinical examination by an experienced pediatric orthopedic surgeon, sonographic morphology, and sonographic stability.

METHODS

From January 2004 to June 2009, a single experienced pediatric orthopedic surgeon performed clinical hip screenings for 2,686 infants in the neonatal unit and 43 infants who were referred due to impressions of hip dysplasia before 3 months of age. Among them, 156 clinically unstable or high-risk babies selectively received bilateral hip ultrasound examinations performed by the same surgeon using the modified Graf method. The results were analyzed statistically to detect any correlations between the clinical and sonographic findings.

RESULTS

Although a single experienced orthopedic surgeon conducted all examinations, we detected only a limited relationship between the results of clinical and ultrasound examinations. Ninety-three percent of the clinically subluxatable hips were normal or immature based on static ultrasound examination, and 74% of dislocating hips and 67% of limited abduction hips presented with the morphology below Graf IIa. A total of 80% of clinically subluxatable, 42% of dislocating and 67% of limited abduction hips appeared stable or exhibited minor instability on dynamic ultrasound examination. About 7% of clinically normal hips were abnormal upon ultrasound examination; 5% showed major instability and 3% showed dysplasia above Graf IIc. Clinical stability had small coefficients between ultrasound examinations; 0.39 for sonographic stability and 0.37 for sonographic morphology. Between sonographic stability and morphology, although 71% of hips with major instability showed normal or immature morphology according to static ultrasound examination, the coefficient was as high as 0.64.

CONCLUSIONS

Discrepancies between clinical and ultrasound examinations were present even if almost all of the exams were performed by a single experienced pediatric orthopedic surgeon. In relation to screening for DDH, it is recommended that both sonographic morphology and stability be checked in addition to clinical examination.

Imaging of Hip Pain: From Radiography to Cross-Sectional Imaging Techniques

Hip pain can have multiple causes, including intra-articular, juxta-articular, and referred pain, mainly from spine or sacroiliac joints. In this review, we discuss the causes of intra-articular hip pain from childhood to adulthood and the role of the appropriate imaging techniques according to clinical suspicion and age of the patient. Stress is put on the findings of radiographs, currently considered the first imaging technique, not only in older people with degenerative disease but also in young people without osteoarthritis. In this case plain radiography allows categorization of the hip as normal or dysplastic or with impingement signs, pincer, cam, or a combination of both.

[Incidence and duration of therapy of pathological hip findings in U2 and U3 examinations (SNiP study)]

INTRODUCTION AND OBJECTIVES

Determination of the efficacy of an early ultrasound examination followed by immediate treatment of hip joint dysplasia as well as measuring the therapeutic success in a population-based cohort study of neonates.

MATERIAL AND METHODS

The Survey of Neonates in Pomerania (SNiP) study included 4,093 neonates which represents 95.1 % of the total neonatal population. Of these children 2,534 (61.9 %) underwent ultrasound examination of the hip joint during the U2 stage (3-10 days after birth). The mean gestational age was 38.9 weeks. The sonographic classification was performed according to Graf.

RESULTS

Initially (U2 stage) 42 (1.66 %) children were reported to be in need of therapy (stage IIc or higher according to Graf). The analysis showed a significantly higher incidence in girls (32 girls vs. 10 boys, p < 0.023, χ(2) test) and in children who had a breech birth (116, 4.6 %). A genetic predisposition was ascertained in 180 (7.1 %) children. The children could be subdivided into two groups: 1) children who underwent hip joint ultrasound during both U2 and U3 and 2) children who were first screened at the U3 stage. Of the 49 out of 54 neonates where the ultrasound findings were positive at the U2 examination the hip joint was matured in 32 children at U3 (4-8 weeks), 11 children had to be treated for 8-12 weeks 5 children were treated for over 3 months and1 child needed surgical correction.

CONCLUSION

The early diagnosis of hip maturation disorders and joint dysplasia facilitates early implementation of effective treatment. At our clinic over 60 % of the infants underwent the U2 check up and, given a pathological finding, could undergo early treatment. It was possible to successfully treat 78 % of these children with a Tübingen hip flexion splint in just 4-8 weeks. In contrast, infants who were first examined at the U3 stage needed treatment for 4-12 months. In our opinion, early diagnosis at the age of 3-10 days should be carried out for all newborns.

Ultrasound quantification of acetabular rounding in hip dysplasia: reliability and correlation to treatment decisions in a retrospective study

Currently, acetabular rounding is only subjectively assessed on ultrasound for developmental dysplasia of the hip. We tested whether acetabular rounding can be quantified reliably and can distinguish between hips requiring and not requiring treatment. Consecutive infants (n = 90) suspected of having dysplasia of the hip, seen at a pediatric orthopedic clinic, were separated into four diagnostic categories (normal, borderline but resolved, treated by brace, treated surgically). Acetabular rounding was assessed by semi-quantitative grade (0 = nil, 1 = mild, 2 = moderate, 3 = severe) by three observers and by direct measurement of acetabular radius of curvature (AROC) by two observers. Inter-observer reliability of rounding grade was poor (κ = 0.30-0.37). AROC had an inter-observer intra-class correlation coefficient of 0.84 and coefficient of variation of 29%-34%. Mean AROC was significantly higher for hips requiring treatment than for those not requiring treatment (3.3 mm vs. 1.6 mm, p = 0.007). AROC reliably quantifies an observation currently being made subjectively by radiologists and surgeons, and may be useful as a supplementary ultrasound index of dysplasia of the hip in future prospective studies.

Evaluation and treatment of developmental hip dysplasia in the newborn and infant

Developmental dysplasia of the hip (DDH) encompasses a spectrum of physical and imaging findings. The child's hip will not develop normally if it remains unstable and anatomically abnormal by walking age. Therefore, careful physical examination of all infants to diagnosis and treat significant DDH is critical to provide the best possible functional outcome. Regardless of the practice setting, all health professionals who care for newborns and infants should be trained to evaluate the infant hip for instability and to provide appropriate and early conservative treatment or referral.

Screening for hip dysplasia in congenital muscular torticollis: is physical exam enough?

PURPOSE

An association between congenital muscular torticollis (CMT) and developmental dysplasia of the hip (DDH) has been established in the literature; however, whether the screening of patients with CMT for DDH requires hip imaging remains controversial. The purpose of this study is to determine (1) the coexistence rate of DDH requiring treatment in individuals with CMT and (2) if physical exam alone is sufficient screening.

METHODS

A single-center retrospective chart review was performed among 97 consecutive patients between 1/1/2003 and 9/1/2012 with CMT who had hip imaging performed.

RESULTS

12 % (12/97) of patients with CMT had DDH, all requiring treatment. 75 % (9/12) of the patients with DDH had an abnormal clinical exam. Of the three patients with DDH and a normal clinical exam, two patients were presenting for a second opinion after being treated for DDH prior to evaluation. 90 % (9/10) of patients with DDH at the time of presentation had an abnormal hip exam. All 12 patients with hip dysplasia were referred for DDH or DDH with CMT. There were no patients who were referred for CMT alone that had DDH.

CONCLUSIONS

In the care of a patient with CMT, it is important that the clinician remains vigilant about screening for DDH. An ultrasound or radiograph of the hips should be strongly considered as part of the evaluation of a child with CMT.

LEVEL OF EVIDENCE

IV.

Is it worthwhile to routinely ultrasound screen children with idiopathic clubfoot for hip dysplasia?

PURPOSE

Patients with idiopathic clubfoot are considered at increased risk for having developmental dysplasia of the hips (DDH). However, the studies showing this association have been relatively small. Many clinicians who treat idiopathic clubfoot routinely screen the hips of these patients with ultrasound or radiograph due to the concerns of increased risk of DDH. We evaluated a large clubfoot population to determine the risk of DDH and compare this to a population of children without clubfoot. We also evaluated if the clubfoot patients found to have DDH would have been discovered by standard DDH screening.

METHODS

We identified infants in 3 states (MA, NY, NC), who were reported to each state's birth defects registry as having a clubfoot. A second cohort of infants without clubfoot was also identified as a control group. Mothers of these children were contacted to be included in the study, and a computer-assisted telephone interview was administered by one of the study nurses, including questions about treatment of DDH. The child's median age at interview was 7 months. Mothers of clubfoot cases were also contacted for follow-up at mean age of 3.3 years.

RESULTS

Families of 677 patients with clubfoot and 2037 controls were interviewed. A total of 5/677 (0.74%) patients with clubfoot and 5/2037 (0.25%) controls reported having their infant treated with a brace or harness for hip problems (P=0.134). Of the patients with clubfoot, 2 of them did not need treatment for their DDH and 2 would have been discovered by standard hip screening. Follow-up study at 3.3 years of age found no serious late hip dysplasia.

CONCLUSIONS

Treatment of DDH was uncommon in all children; the higher proportion in infants with clubfoot was not statistically different than controls. Of the patients with clubfoot and DDH, standard hip screening would have been appropriate and others did not need treatment. These data suggest that routine hip ultrasound or radiographic screening of idiopathic clubfoot patients is not necessary unless indicated by the standard infant hip screening.

LEVEL OF EVIDENCE

Level 3 study.

[Dysplasia in the development of the hip]

Developmental dysplasia of the hip (DDH) causes anatomical changes that cause early coxarthrosis. Although risf factors have been determined, the aetiology and physiopathology remains exactly unknown. Neonatal screening with physical examination and ultrasound have been stablished in order to diagnose this disease early in life. A diagnosis in the first months of life is essential as it enables a normal hip to form and prevent the appearance of early coxarthrosis. Treatment principles are to be able to reduce the hip without provoking avascular necrosis of the femoral head, and to normalize the acetabular development. Knowledge of the orthopaedic and surgical options is essential in order to achieve success in the treatment.

Delayed diagnosis of developmental dislocation of the hip: the Western Australian experience

BACKGROUND

A delay in the diagnosis of developmental dislocation of the hip has many long-term consequences. This retrospective study was undertaken in order to establish an incidence of late-presenting developmental dislocation of the hip in Western Australia, and investigate possible causes for missed diagnoses.

METHOD

Data were collected retrospectively from 1 January to 31 December 2010. Theatre records were searched for operative descriptions including the words 'arthrogram hip', 'EUA hip', 'closed reduction hip', 'open reduction hip' and 'spica'. Medical records were checked to establish the demographic details and background history of cases identified. Delayed diagnosis of developmental dysplasia of the hip (DDH) was defined as a dislocated hip requiring operative reduction, diagnosed at age greater than 3 months.

RESULTS

Seventeen children with 21 dislocated hips were identified. Age at diagnosis ranged from 6 months to 5 years. Girls accounted for 88.2% (15/17) and the left hip was involved two-thirds of the time (14/21). Bilateral dislocations were found in four children.

CONCLUSION

This study has identified an incidence of late-presenting developmental hip dislocation of approximately three times the previously established rate. Possible reasons for this are explored. Additional retrospective audit is now underway, and changes are already in place to ensure that infants with DDH born in Western Australia are identified and treated as early as possible.

Prevention of hip dysplasia in children and adults

Klisic and Pajic summarized the history of early diagnosis and treatment of hip dysplasia when they wrote, Devising the preventive approach to developmental dysplasia of the hip (DDH) required much time.... Despite the 2400-year-old suggestion made by Hippocrates that children's hip dislocations are curable if treatment is started very early, the preventive approach was proposed by Roser only in 1879 [who] described early diagnosis in newborns and performed reduction by abduction... He also advocated early treatment by fixing babies' hips in abduction. However, surgeons did not readily accept these proposals, despite the good results shown by Froelich in 1906 and Le Damany in 1911. In 1927, Putti succeeded in interesting some orthopedic surgeons in the procedure by showing the results of early treatment. But the practical problem remained: ie, how to detect the DDH in patients at an early age. The turning point came in 1935 when pediatrician Ortolani introduced early detection of DDH by “early clinical search” shortly after a child's birth, instructing obstetricians, pediatricians, and midwives to perform the search. Rediscovering the diagnostic “segno della scatto,” ie, reducible displacement, he popularized the prophylactic approach to DDH by early detection and treatment. Fifteen years later, another pediatrician, Palmen, organized systematic screening in nurseries by pediatricians. Since Klisic and Pajic wrote this in 1993, the use of ultrasound, albeit still controversial in some ways, has influenced the treatment and prevention of DDH. Klisic's attempts to universally prevent the disease may still be able to be incorporated into further efforts at disease prevention through education and the systematic trials of hip abduction pillows or braces similar to his wide-diaper diapering technique. The goal of prevention is to eradicate a disease so that it does not present to the physician. For DDH, this goal may be tenable.

Strategies to improve nonoperative childhood management

Early diagnosis is of paramount importance to favorably alter the natural history of DDH. Most cases of dysplasia can be diagnosed by careful history taking and physical examination. Imaging modalities, such as ultrasonography, have increased our ability to detect subtleties not appreciated by means of physical examination or plain radiography. Although the evaluation of children with risk factors for DDH is important, most dysplasia occurs in girls who have no other risk factors. For all infants, a competent newborn physical examination using the Ortolani maneuver is the most useful procedure to detect hip instability. Early treatment of an unstable hip with a Pavlik harness or similarly effective orthosis is effective, safe, and strongly advised.

Developmental dysplasia of the hip: impact of sonographic newborn hip screening on the outcome of early treated decentered hip joints-a single center retrospective comparative cohort study based on Graf's method of hip ultrasonography

PURPOSE/BACKGROUND/INTRODUCTION: The aim of this study was to retrospectively evaluate the impact of neonatal sonographic hip screening using Graf's method for the management and outcome of orthopaedic treatment of decentered hip joints with developmental dysplasia of the hip (DDH), using three decades (1978-2007) of clinical information compiled in a medical database.

METHODS

Three representative cohorts of consecutive cases of decentered hip joints were selected according to different search criteria and inclusion and exclusion parameters: (1) cohort 1 (1978-1982; n = 80), without sonographic screening; (2) cohort 2.1 (1994-1996; n = 91), with nationwide established general sonographic screening according to the Graf-method; (3) cohort 2.2 (2003-2005; n = 91), with sonographic screening including referred cases for open reduction from non-screened populations. These three cohorts were compared for the following parameters: age at initial treatment, successful closed reduction, necessary overhead traction, necessary adductor-tenotomy, rate of open reduction, rate of avascular necrosis (AVN) and rate of secondary acetabuloplasty.

RESULTS

The age at initial treatment was reduced from 5.5 months in the first cohort to 2 months in the two subsequent two cohorts and the rate of successful closed reduction increased from 88.7 to 98.9 and 95.6%, respectively. There was a statistically significant improvement in six out of seven parameters with sonographic hip screening; only the rate of secondary acetabuloplasty did not improve significantly.

CONCLUSION

Compared to the era before the institution of a sonographic hip screening programme according to the Graf-method in Austria in 1992, ultrasound screening based-treatment of decentered hip joints has become safer, shorter and simpler: "safer" means lower rate of AVN, "shorter" means less treatment time due to earlier onset and "simpler" means that the devices are now less invasive and highly standardized.

The Shenton line in the diagnosis of acetabular dysplasia in the skeletally mature patient

BACKGROUND

Undetected developmental dysplasia of the hip can progress to hip instability, which can lead to the development of early osteoarthritis. The purpose of the present study was to determine the reliability and accuracy of the Shenton line in the diagnosis of acetabular dysplasia in the skeletally mature patient.

METHODS

Supine anteroposterior pelvic radiographs were obtained for a total of 128 hips in patients with a diagnosis of developmental dysplasia of the hip prior to pelvic osteotomy (sixty-four hips, including thirty-two left and thirty-two right hips) and normal patients (sixty-four hips, including thirty-two left and thirty-two right hips). Six orthopaedic surgeons determined if the Shenton line was broken or intact to determine interobserver reliability. Four observers reviewed the randomized radiographs again after four weeks to determine intraobserver reliability.

RESULTS

The mean intraclass kappa value was 0.90 (range, 0.79 to 0.97), indicating excellent agreement between each reviewer's primary and secondary reviews. The kappa estimate for interobserver reliability among all six reviewers was 0.80 (95% confidence interval, 0.75 to 0.84), indicating an excellent agreement. The determination of a normal or abnormal Shenton line had a mean sensitivity of 83.3% (range, 60.9% to 93.8%) and specificity of 98.4% (range, 92.2% to 100%).

CONCLUSIONS

The Shenton line is a reliable and accurate radiographic marker to detect superior femoral head subluxation indicative of acetabular dysplasia.

Diagnostic accuracy of static graf technique of ultrasound evaluation of infant hips for developmental dysplasia

INTRODUCTION

Ultrasound examination of infant hips is a widely used and accepted tool for the diagnosis and monitoring of developmental dysplasia of the hip. Its use and timing is still a focus of debate and its diagnostic accuracy has not been fully investigated.

METHOD

We have compared the ultrasound findings by the Graf technique with radiographic appearance (acetabular index) at 6 months of age.

RESULT

The negative predictive value of Ultrasound for DDH was 98% and was unaffected by the timing of the examination. The specificity and accuracy of the examination increased with age and was highest at 3 months of age.

CONCLUSION

Ultrasound examination of the infant hip by the static Graf technique is a safe and effective screening tool for the evaluation of DDH.

Late diagnosis of developmental dysplasia of the hip: an analysis of risk factors

A neonatal clinical screening program for developmental dysplasia of the hip (DDH) operates in South Australia to diagnose DDH as early as possible. However, some cases of DDH are diagnosed late (>3 months of age). The aims of this study were to identify the specific risk factors for late diagnosis by comparing early diagnosed DDH, late diagnosed DDH, and normal controls in the South Australian population. There were 1945 children with DDH born between 1988 and 2003, of which 67 cases were late diagnosis (3.4%). Maternal characteristics, pregnancy, and delivery details were analyzed, and compared with controls (early diagnosed DDH and the general population). There was a trimodal pattern of age at presentation with a gradual increase in the incidence of late diagnosed DDH over the time period in this study. Birthweight (<2500 g), birth in a rural setting, and early hospital discharge following delivery (<4 days) were significant risk factors for late diagnosed DDH. Breech presentation and delivery by caesarean section were protective for late diagnosed DDH. Risk factors for late diagnosed DDH relate to factors that influence the screening program. A rigorous population-based hip surveillance program is important for early diagnosis of DDH.

The diagnosis and management of common childhood orthopedic disorders

Musculoskeletal illness represents a significant portion of office visits to primary care physicians. Despite this, little emphasis is placed on learning pediatric orthopedics during medical school or residency. Many articles have been written on selected disorders, or approaches to common conditions, such as the limping child. Sometimes determining where to start and how to move toward a diagnosis prevents prompt evaluation, referral, and treatment. Based on the author's experience as a general pediatrician trained in, and exclusively practicing, nonoperative pediatric orthopedics, approaches to selected complaints related to the musculoskeletal system are presented. Emphasis is placed on conditions resulting in frequent consultation with pediatric orthopedists from pediatricians and other primary care practitioners, either in the office or over the phone. Important features that may not be familiar to the primary care physician are highlighted, including the identification of aspects that require further evaluation and indications for consultation. Guidance regarding in-office management is also provided.

The success of management with the Pavlik harness for developmental dysplasia of the hip using a United Kingdom screening programme and ultrasound-guided supervision

We present the results of treatment of developmental dysplasia of the hip in infancy with the Pavlik harness using a United Kingdom screening programme with ultrasound-guided supervision. Initially, 128 consecutive hips in 77 patients were reviewed over a 40-month period; 123 of these were finally included in the study. The mean age of the patients at the start of treatment was five weeks (1 to 12). All hips were examined clinically and monitored with ultrasound scanning. Failure of treatment was defined as an inability to maintain reduction with the harness. All hips diagnosed with dysplasia or subluxation but not dislocation were managed successfully in the harness. There were 43 dislocated hips, of which 39 were reducible, but six failed treatment in the harness. There were four dislocated but irreducible hips which all failed treatment in the harness. One hip appeared to be successfully treated in the harness but showed persistent radiological dysplasia at 12 and 24 months. Grade 1 avascular necrosis was identified radiologically in three patients at 12 months.

[Hip ultrasound screening in Germany. Results and comparison with other screening procedures]

General ultrasound screening programmes to determine DDH are still a matter of discussion due to a lack of evidence. To facilitate further discussions this review gives an overview of the international data and literature concerning the different screening policies taking into account the results of the German evaluation study from 1997 to 2002. General ultrasound screening programmes are established in Germany and Austria. The analysis of the German screening showed 535 cases of DDH with first operative procedure (age 10 weeks to 5 years) that were treated as inpatients: 66% underwent a closed reduction, 11% an open reduction and 23% an osteotomy of the acetabulum/femur. The number of children who had no ultrasound of the hip before diagnosis decreased from 22% in the first year to 8% in the last. The first ultrasound examination was without pathological findings in 12% of the cases. Capture-recapture estimates suggested that 52% of cases were reported, so that the incidence for first operation due to DDH was 0.26 per 1,000 live births in 1997. This is much lower than in other countries and 4/5 less than the time before screening with ultrasound in Germany. At most 42% of the cases might be preventable by an improvement of the screening programme, but at least 51% would not be prevented. The German ultrasound screening programme has proved to be effective. Improvement of economic efficiency is still possible. Therefore, the German programme with different screening times can be recommended.

Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States

In this article we discuss the medical diagnoses underlying the most common lawsuits involving pediatricians in the United States. Where applicable, specific and general risk-management techniques are noted as a means of increasing patient safety and reducing the risk of medical malpractice exposure.

Diagnosis of developmental dislocation of the hip by sonospectrography

Because not all infants can be screened for DDH by experts, early diagnosis of developmental dysplasia of the hip (DDH) by primary health care professionals is important. We developed a broadband electroacoustic sound transmission-detection (sonospectrography) system and explored its utility in 22 patients (average age, 5.9 years; range, 0.3-14 years) with unilateral DDH in this preliminary study. Distinct from ultrasonography, the sonospectrography system functions by sound transmission and recording through tissues to differentiate between normal and abnormal hips. All hips were examined at four different hip and knee positions. The normal hip served as the control. The sonospectrography system was able to detect unilateral DDH. Dysplastic hips had lower sound transmission values when compared to normal hips in all patients and all four positions; however, the highest (X = 88.8 +/- 30.2 Hz) and lowest (X = 8.3 +/- 5.4 Hz) sound transmission mean values were obtained at different positions in the normal hips and those with DDH. Sound transmission values of dysplastic hips were always lower than that of normal hips when the hip and knee was flexed during measurements. Sound transmission values decreased with age. The sonospectrography system may offer a new noninvasive method in the diagnosis of unilateral DDH but requires further study of sensitivity and specificity of detecting dysplastic hips without subluxation in newborn infants.

LEVEL OF EVIDENCE

Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.