Screening Strategies for Hip Dysplasia: Long-term Outcome of a Randomized Controlled Trial

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Only 2 randomized controlled trials have addressed effects of ultrasound screening for developmental hip dysplasia. Both concluded that adding universal or selective ultrasound to routine clinical examination gave a nonsignificant reduction in rates of late presenting cases, but higher treatment rates. WHAT THIS STUDY ADDS:This maturity review assesses long-term outcome of one of these trials. Rates of radiographic findings indicating acetabular dysplasia and degenerative change were similar across the 3 screening groups in young adulthood. Increased treatment rates were not associated with avascular necrosis. abstract OBJECTIVE: Screening for hip dysplasia is controversial. A previous randomized controlled trial revealed that adding universal or selective ultrasound to routine clinical examination gave a nonsignificant reduction in rates of late presenting cases, but with higher treatment rates. This study assesses differences in outcome at skeletal maturity for the 3 newborn screening strategies in terms of radiographic markers of acetabular dysplasia and early degenerative change and avascular necrosis (AVN) secondary to neonatal treatment. METHODS:From the initial trial including 11 925 newborns, a populationbased sample of 3935 adolescents was invited for follow-up at age 18 to 20 years. A standardized weight-bearing anteroposterior view was obtained. The outcomes evaluated were the radiographic findings of dysplasia (center-edge angle, femoral head extrusion-index, acetabular depth-width ratio, Sharp' s angle, subjective evaluation of dysplasia) and degenerative change (joint-space width). Signs of AVN were documented. RESULTS:Of the 3935 subjects invited, 2038 (51.8%) attended the maturity review, of which 2011 (58.2% female patients) were included: 551, 665, and 795 subjects from the universal, selective, and clinical groups, respectively. Rates per group of positive radiographic findings associated with dysplasia or degenerative change varied depending on radiographic marker used. No statistically significant differences were detected between groups. No AVN was seen. CONCLUSIONS:Although both selective and universal ultrasound screenings gave a nonsignificant reduction in rates of late cases when compared with expert clinical programs, we were unable to demonstrate any additional reduction in the rates of radiographic findings associated with acetabular dysplasia or degenerative change at maturity. Increased treatment rates were not associated with AVN. Pediatrics 2013;132:492-501

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

“…However, it was reported that the majority of patients in the United States with symptomatic dysplasia of the acetabulum at skeletal maturity do not meet the criteria for selective ultrasound screening [61] . Recently, a large randomized controlled study comparing universal or selective ultrasound screening with well performed physical examination showed higher treatment rates, a slight reduction in late diagnosis of dysplasia which was not significant, and increased treatment rates which were not associated with AVN [62] . A Cochrane review of screening programs for DDH in newborns found that studies that compared the addition of ultrasonography to clinical examination reported that, when ultrasonography was performed on all infants, the rate of treatment increased with no significant change in the rate of late detected dysplasia or surgery.…”

Evaluation and Referral for Developmental Dysplasia of the Hip in Infants

“…37 The USPSTF also raised concerns about the psychological consequences or stresses with early diagnosis and intervention. Gardner et al 38 found that the use of hip ultrasonography allowed for reduction of treatment rates without adverse clinical or psychological outcomes.…”

“…33 Other studies have reported much lower rates of AVN. 36,37 One prospective study reported a zero prevalence of AVN by 6 years of age in mildly dysplastic hips treated with bracing. 30 However, abduction brace treatment is not innocuous.…”

Ultrasound Screening for Posterior Shoulder Dislocation in Infants with Persistent Brachial Plexus Birth Palsy

“…One characteristic physical examination finding is a lack of passive external rotation of the shoulder, but it is likely that physical examination alone will miss some dislocations. There is a strong precedent for targeted ultrasound screening of infants at risk for developmental hip dysplasia, making ultrasound a natural choice for screening for glenohumeral joint dysplasia in infants with BPBP 5,6 . The technique of shoulder ultrasound in BPBP has been well-described, but which infants with BPBP should undergo ultrasound screening is not yet understood 7 .…”