Is ultrasound screening for DDH in babies born breech sufficient?

Abstract

Purpose To review our incidence of developmental dysplasia of the hip (DDH) in breech infants referred for ultrasound screening and to determine if subsequent follow-up radiographs are necessary in these patients with normal clinical and ultrasound examinations. Methods A review of the clinical data and imaging studies of all children with the risk factor of breech presentation that were referred for orthopedic evaluation over a 5-year period was conducted. All patients were examined by a fellowship-trained pediatric orthopedic surgeon and all ultrasounds were done at approximately 6 weeks of age by an experienced ultrasonographer. Ultrasounds were evaluated using the dynamic method as described by Harcke. As per our protocol, all patients with normal screening ultrasounds were brought back for a final clinical examination and radiographic check at 4-6 months. Acetabular dysplasia was indicated by radiographic parameters-if there was severe blunting of the sourcil, abnormal acetabular index for age, or if there was significant asymmetry of acetabular indices side-to-side-in the setting of clinical parametersif there was greater than 10°difference in side-to-side abduction or symmetric abduction of less than 60°. Results Three hundred patients with the risk factor of breech presentation were included. Thirty-four patients had clinically unstable hips; 266 had clinically stable hips and were screened by ultrasound. Sixty-four percent were female and 36% were male. Twenty-seven percent of these breech patients had abnormal screening ultrasounds and were subsequently treated. Of the remaining 73% with normal ultrasounds, who were returned per protocol at a mean of 5 months, 29% had evidence of dysplasia and underwent treatment. The diagnosis of dysplasia following a normal ultrasound was based on both radiographic and clinical parameters. Of the hips treated with a Pavlik harness, 62% had acetabular indices at least two standard deviations from the age-corrected average versus 26% of patients not treated. The average length of follow-up was 10 months. Conclusions Retrospectively, we found that, at approximately 6 weeks of age, ultrasound screening of breech patients with clinically stable hips produces an incidence of DDH of 27%. In those patients with a normal ultrasound, 29%, at 4-6 months radiographic follow-up, were found to have dysplasia requiring treatment. This data supports breech as the most important risk factor for hip dysplasia and we, therefore, recommend careful and longitudinal evaluation of these patients with: a careful newborn physical examination, an ultrasound at age 6 weeks, and an anteroposterior (AP) pelvis and frog lateral radiograph at 6 months, as the risk of subsequent dysplasia is too high to discharge patients after a normal ultrasound.Keywords Developmental dysplasia of the hip Á Ultrasound Á Breech presentation Study conducted at Rady Children's Hospital,

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

“…The left side is more commonly involved, perhaps due to the left occiput anterior positioning of most non-breech newborns where the hip is adducted against the mother's spine with limited space for abduction [1,5] . The breech position is probably the most important single risk factor, whether delivered vaginally or by cesarean section [6,16,17] . Other risk factors include first born children, postural deformities, oligohydramnios and a positive family history [1,18] .…”

“…However, some studies raise doubt regarding the necessity of radiographic monitoring [165][166][167] , while others stress its significance [17,48,168] . The incidence of residual acetabular dysplasia after successful treatment with Pavlik harness cannot be disregarded [79,169,170] .…”

Značaj ultrazvučnog skrininga za dijagnostiku i liječenje razvojnog poremećaja kuka

“…Sličnu preporuku za uspješnost liječenja dali su i u Dječijoj klinici Palo Auto u Americi: fizikalni pregled, UZV pregled obavezan do šeste nedjelje, radiografija na šest mjeseci, praćenje kukova i nakon normalnog UZV nalaza do isključenja displazije radiografski po Tonnisu [18].…”

Developmental dysplasia of the hip

“…If results are not conclusive, a follow-up at 2 weeks of age is recommended, follow-up being continued till walking is established 8 . If the results are still equivocal at 2 weeks, an ultrasound scan is warranted at 3 to 4 weeks of life or an orthopaedic referral 9 . Babies with risk factors such as breech delivery, too, must have imaging 10 .…”

“…Babies with risk factors such as breech delivery, too, must have imaging 10 . The AAP recommendation is ultrasound scan when the baby is 6 weeks old or x-ray when the baby is over 4 months old During infancy, ultrasonography is the diagnostic procedure of choice as x-rays are of limited value till the femoral heads start to ossify when the baby is 4 to 6 months old 9 . Ultrasound scans allow visualization of the cartilaginous part of the acetabulum and femoral head 1 .…”