Ultrasound screening of hips at risk for CDH. Failure to reduce the incidence of late cases

Abstract

Of 4,617 babies born in Coventry in 1986, a total of 448 (9.7%) had either clinical abnormality of the hip or at risk factors for CDH. All were examined by ultrasound, but only 17 required treatment (3.7 per 1,000); in five of these no clinical abnormality had been detected. An additional 81 babies had ultrasound abnormalities but did not require treatment, despite the fact that ultrasound at first showed major hip displacement in 17 of them. Three late cases of CDH have presented among the babies born in 1986, but not examined by ultrasound. This incidence of late CDH is unchanged compared with the previous nine years, although ultrasound had detected covert displacement in a number of hips.

Financial justification for routine ultrasound screening of the neonatal hip

“…15,16 While there have been a number of reports of high rates of detection, 17,18 we have previously calculated our rate of failure to be 50% using clinical examination alone. 6 This matches other studies 16,19 including that of Palmén 19 who reviewed 98 000 live births in Sweden in 1976. In this series, which is one of the largest published, the rate of failure decreased to 15% by seven months which was then too late to initiate treatment in a Pavlik harness.…”

“…Only 40% of infants with a clinically detectable abnormality of the hip have 'at-risk' signs. 6,20 A prerequisite for any screening programme is that it be highly sensitive, with low false-negatives. In Coventry we have had no cases of late-presenting DDH since the introduction of routine screening.…”

“…The adoption of these methods to identify all infants with abnormality of the hips has not been universally successful, and has failed to eliminate late presentations of subluxation and dislocation for a number of infants who present with an established abnormality. [4][5][6] Such late presentation frequently results in the need for major operations 7 which often have an unsatisfactory long-term outcome with the development of early degenerative changes in the hip and functional morbidity. The pioneering work in ultrasound examination of Graf 8 in Austria and Harcke et al 9 in the USA has revolutionised our understanding of the process of the disease and allowed the identification and early treatment of instability of the hip.…”

Screening for Developmental Dysplasia of the Hip: A Systematic Literature Review for the US Preventive Services Task Force

“…Studies of the impact of screening programs on the frequency of late diagnosis have had mixed results. [16][17][18]21,25,[40][41][42][43][44][45][46][47][48][49][50][51][52] Most of these studies report the experience of a screening program in a defined geographic or hospital service area over many years. The comparisons are ecological, and these studies have the same methodologic problems as those that examined the effect of screening on rates of surgical treatment (discussed above in "Key Question 1").…”

Imaging in the Surgical Management of Developmental Dislocation of the Hip

“…Although there are continuing controversies regarding what type of scan to perform, when to perform the scan, and which infants should have a scan, DDH is being diagnosed at an earlier age, leading to more successful and less invasive treatment [12,15]. However, there continue to be ''missed'' or late cases, even in countries that have instituted screening programs for all infants [4]. Some infants miss the initial screening examination; some infants who at first appear to have normal hips later develop acetabular dysplasia.…”