Interobserver agreement and clinical disparity between the Graf method and femoral head coverage measurement in developmental dysplasia of the hip screening

Chang, Wen-Chieh; Hsu, Kuei-Hsiang; Lo, I-Fang; Liao, Kai-Hao; Su, Yu‐Ping

doi:10.1097/md.0000000000026291

Cited by 7 publications

(12 citation statements)

References 27 publications

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“…The earlier the DDH is detected, the better the outcome, with less complications in early phase and less likely progress to total hip replacement in adolescence or young adulthood . However, the late detection rate and the need for operative treatment are not zero with universal ultrasonographic screening either, because ultrasonography does not detect all patients with clinical instability, and the reproducibility of ultrasonographic findings varies among examiners . For example, nationwide studies from Germany and Austria presented late detected and operated rates for DDH of 0.16 to 0.26 per 1000 neonates, whereas a Swedish study reported a rate of 0.12 per 1000 neonates in clinical screening .…”

Section: Discussionmentioning

confidence: 99%

“…93,94 However, the late detection rate and the need for operative treatment are not zero with universal ultrasonographic screening either, because ultrasonography does not detect all patients with clinical instability, and the reproducibility of ultrasonographic findings varies among examiners. 95,96 For example, nationwide studies from Germany and Austria presented late detected and operated rates for DDH of 0.16 to 0.26 per 1000 neonates, whereas a Swedish study reported a rate of 0.12 per 1000 neonates in clinical screening. 84,90,97 Therefore, the cost-effectiveness of universal ultrasonographic screening should be critically assessed.…”

Section: Incidence Per 1000 Neonates (95% Ci)mentioning

confidence: 99%

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Incidence of Neonatal Developmental Dysplasia of the Hip and Late Detection Rates Based on Screening Strategy

et al. 2022

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ImportanceUniversal ultrasonographic screening for developmental dysplasia of the hip (DDH) has gained increasing popularity despite the lack of benefit in terms of reducing the rates of late-detected cases (age ≥12 weeks) in randomized clinical trials.ObjectiveTo report the reported incidence of DDH in the English scientific literature and compare rates of late-detected cases in settings with different DDH screening strategies.Data SourcesPubMed, Scopus, and Web of Science databases were searched on November 25 and 27, 2021. No time filters were used in the search.Study SelectionAll observational studies reporting the incidence of early-detected or late-detected (age ≥12 weeks) DDH were included. Non-English reports were excluded if the abstract did not include enough information to be included for analysis.Data Extraction and SynthesisThe number of newborns screened and the detection rates were extracted. Meta-analysis calculated the pooled incidence of DDH per 1000 newborns with 95% CIs using a random- or fixed-effects model. This study is reported according to the PRISMA and MOOSE guidelines.Main Outcomes and MeasuresThe main outcome measures were early detection, early treatment, late detection, and operative treatment incidences.ResultsA total of 1899 studies were identified, 203 full texts were assessed, and 76 studies with 16 901 079 infants were included in final analyses. The early detection rate was 8.4 (95% CI, 4.8-14.8) infants with DDH per 1000 newborns with clinical screening, 4.4 (95% CI, 2.4-8.0) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 23.0 (95% CI, 15.7-33.4) infants with DDH per 1000 newborns with universal ultrasonographic screening. Rates for nonoperative treatment were 5.5 (95% CI, 2.1-14) treatments per 1000 newborns with clinical screening, 3.1 (95% CI, 2.0-4.8) treatments per 1000 newborns with selective ultrasonographic screening, and 9.8 (95% CI, 6.7-14.4) treatments per 1000 newborns with universal ultrasonographic screening. The incidence of late-detected DDH was 0.5 (95% CI, 0.2-1.5) infants with DDH per 1000 newborns with clinical screening, 0.6 (95% CI, 0.3-1.3) infants with DDH per 1000 newborns with selective ultrasonographic screening, and 0.2 (95% CI, 0.0-0.8) infants with DDH per 1000 newborns with universal ultrasonographic screening. The corresponding incidences of operative treatment were 0.2 (95% CI, 0.0-0.9) operations per 1000 newborns with clinical screening, 0.5 (95% CI, 0.4-0.7) operations per 1000 newborns with selective ultrasonographic screening, and 0.4 (95% CI, 0.2-0.7) operations per 1000 newborns with universal ultrasonographic screening.Conclusions and RelevanceThis meta-analysis found that early detection rates and nonoperative treatments were higher with universal screening. The late detection and operative treatment rates with universal screening were similar to those among selectively and clinically screened newborns. Based on these results, universal screening may cause initial overtreatment without reducing the rates of late detection and operative treatment.

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Section: Discussionmentioning

confidence: 99%

Section: Incidence Per 1000 Neonates (95% Ci)mentioning

confidence: 99%

Incidence of Neonatal Developmental Dysplasia of the Hip and Late Detection Rates Based on Screening Strategy

et al. 2022

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“…Of 378 unique articles identified, 9 studies satisfied the prespecified inclusion criteria (Figure 2). The included studies (Table 1) were conducted between 1992 and 2021 and reported data on 50 579 hips in 27 175 infants. Information was available for both hips in 85.9% of infants.…”

Section: Resultsmentioning

confidence: 99%

“…All studies had low applicability concerns across all domains. Six studies had an unclear risk of bias in the reference standard domain because the results may have been interpreted with knowledge of the examination findings …”

Section: Resultsmentioning

confidence: 99%

Does This Infant Have a Dislocated Hip?

Singh,

Wade,

Metcalfe

et al. 2024

JAMA

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ImportanceDelayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life, and premature osteoarthritis.ObjectiveTo evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants.Data SourcesSystematic search of CINAHL, Embase, MEDLINE, and the Cochrane Library from the inception of each database until October 31, 2023.Study SelectionThe 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 SynthesisThe 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 MeasuresSensitivity, specificity, and likelihood ratios (LRs) of identifying a dislocated hip were calculated.ResultsAmong 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 RelevanceIn 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.

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“…Although the α angle, β angle, and FHC are the most common parameters in the clinical assessment of hip development in infants under 6 months of age, their accuracy and reliability remain controversial ( 5 , 6 ). Possible reasons may include inconsistent measurement methods or inherent differences in the degree of hip development.…”

Section: Introductionmentioning

confidence: 99%

Morphological Development of the Hip in Normal Infants Under Six Months of Age by the Graf Ultrasound Method

Liu

et al. 2022

Front. Pediatr.

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ObjectiveThis large-sample observational study aims to analyze the morphological development of the hip joint in Chinese normal infants under 6 months of age by the Graf ultrasound method.MethodsThe clinical and ultrasound data of infants who underwent early screening for developmental dysplasia of the hip (DDH) in the authors' clinic from January 2011 to December 2019 were analyzed retrospectively. The standard Graf method was used to measure the hip joint α angle, β angle and femoral head coverage (FHC). The infants with Graf type I or IIa hips were included in this study. All infants were grouped by age. FHC, α and β angles were compared among different study groups.ResultsA total of 3,067 infants (6,134 hips) were included in the study. There were 1,164 males and 1,903 females with an average age of 77 days (1–180 days). The mean α angle was 62.4 ± 3.6° on the left and 63.2 ± 3.5° on the right (P < 0.001). The mean β angle was 55.6 ± 4.5° on the left and 54.8 ± 4.5° on the right (P < 0.001). The average FHC was 54.2 ± 4.6% and 54.8 ± 4.2%, accordingly (P < 0.001). The α angle and FHC of females was significantly smaller than that of males (P < 0.001). While the left β angle in females was slightly larger than males (P = 0.014), there were no significant differences in the right β angle between the two sexes (P = 0.150). During the first 3 postnatal months, the α angle and FHC increased while β angle decreased with age. However, the α and β angles and FHC were stable at a relatively constant level from the 4 to the 6th postnatal month.ConclusionsThe normal infant hip reveals progressive maturation during the first 3 months after birth, and then enters a plateau period during the 4 to 6th month. The development of hip joint in females and of the left side slightly lags behind that in males and of the right side, which is consistent with the observation that DDH is more common in females and on the left hips.

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Interobserver agreement and clinical disparity between the Graf method and femoral head coverage measurement in developmental dysplasia of the hip screening

Cited by 7 publications

References 27 publications

Incidence of Neonatal Developmental Dysplasia of the Hip and Late Detection Rates Based on Screening Strategy

Incidence of Neonatal Developmental Dysplasia of the Hip and Late Detection Rates Based on Screening Strategy

Does This Infant Have a Dislocated Hip?

Morphological Development of the Hip in Normal Infants Under Six Months of Age by the Graf Ultrasound Method

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