Search

Guidelines for children with Down syndrome (DS) suggest to perform an annual hip screening to enable early detection of developmental dysplasia of the hip (DDH). How to perform this screening is not described. Delayed detection can result in disabling osteoarthritis of the hip. Therefore, we determined the association between clinical history, physical, and radiological examination in diagnosing DDH in children with DS. Referral centers for children with DS were interviewed to explore variety of hip examination throughout the Netherlands. Clinical features of 96 outclinic children were retrospectively collected. Clinical history was taken, physical examination was performed, and X-ray of the hip was analyzed. All the referral centers performed physical examination and clinical history; however, 20% performed X-ray. Following physical examination according to Galeazzi test 26.9% and to limited abduction 10.8% of the outclinic-studied children were at risk for DDH. Radiological examination showed moderate or severe abnormal deviating migration rate of 14.6% resp. 11.5% in the right and left hip. However, no association between clinical history, physical examination, and radiological examination was found.Conclusion: Clinical history and physical examination are insufficient to timely detect DDH in children with Down syndrome. Thereby regular radiological examination of the hip is advised. What is Known: • Developmental dysplasia of the hip (DDH) in people with Down syndrome (DS) develops during childhood. • Guidelines for medical support of children with DS suggest an annual hip screening to enable early detection of hip damaging. How to perform this annual screening is not described. What is New: • This study shows no association between clinical history, physical and radiological examination of the hip. • We recommend regular radiological examination of the hip in children with DS in order to identify DDH early up to 16 years of age.

Aim: To study the cost-effectiveness of clinical screen with ultrasonography (USG) of hip for diagnosing developmental dysplasia of the hip (DDH) in newborns., Methods: Retrospective study (2006-14). Term newborns had (i) target scan at 6 weeks-family history of DDH or breech presentation-and (ii) early scan-abnormal clinical screen., Results: In all, 736 babies had USG scan. Five early scans (Graf's classification; three Type IIA, one Type IIC and one Type IIIB] and 15 target scans (Type IIA) were reported abnormal. All Type IIA DDH had subsequent 12 weeks' scans normal. Babies with Type IIIB and IIC had hip reduction surgery at 6 and 16 months of age, respectively. At cost 200 INR/scan, total 147 200 INR was incurred against two possible hip replacements prevented., Conclusion: Universal clinical screen with USG of hip can aid in early diagnosis of DDH in newborns. Large population-based studies from developing countries need to look in its cost-effectiveness., (© The Author [2016]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Uncorrected developmental dysplasia of the hip (DDH) is associated with long-term morbidity such as gait abnormalities, chronic pain and degenerative arthritis., Objectives: To determine the effect of different screening programmes for DDH on the incidence of late presentation of congenital hip dislocation., Search Methods: Searches were performed in CENTRAL (The Cochrane Library), MEDLINE and EMBASE (January 2011) supplemented by searches of clinical trial registries, conference proceedings, cross references and contacting expert informants., Selection Criteria: Randomised, quasi-randomised or cluster trials comparing the effectiveness of screening programmes for DDH., Data Collection and Analysis: Three independent review authors assessed study eligibility and quality, and extracted data., Main Results: No study examined the effect of screening (clinical and/or ultrasound) and early treatment versus not screening and later treatment. One study reported universal ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery but was associated with a significant increase in treatment. One study reported targeted ultrasound compared to clinical examination alone did not result in a significant reduction in late diagnosed DDH or surgery, with no significant difference in rate of treatment. Meta-analysis of two studies found universal ultrasound compared to targeted ultrasound did not result in a significant reduction in late diagnosed DDH or surgery. There was heterogeneity between studies reporting the effect on treatment rate. Meta-analysis of two studies found delayed ultrasound and targeted splinting compared to immediate splinting of infants with unstable (but not dislocated) hips resulted in no significant difference in the rate of late diagnosed DDH. Both studies reported a significant reduction in treatment with use of delayed ultrasound and targeted splinting. One study reported delayed ultrasound and targeted splinting compared to immediate splinting of infants with mild hip dysplasia on ultrasound resulted in no significant difference in late diagnosed DDH but a significant reduction in treatment. No infants in either group received surgery., Authors' Conclusions: There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery., Plain Language Summary: Screening methods for dislocated or improperly formed hips in newborn infants The hip joint is a ball and socket joint. Newborns may have hips that are not in their socket (dislocated) or hips that are improperly formed (dysplasia). Risk factors for hip dysplasia include a family history of a similar problem and female infants delivered in the breech position. The hips of most newborns will be examined clinically after birth and during infancy to determine whether they are stable, unstable or dislocated. Screening for hip dysplasia may prevent the need for late treatment, which is associated with long term hip deformity, gait disturbance and arthritis. However, early screening leads to increased treatment. Treatment may be complicated by damage to the hip due to impairment of the blood supply (avascular necrosis). This review found no studies that compared the benefits and costs of early screening versus not screening for hip problems. Studies that compared the addition of ultrasound to clinical examination reported that when ultrasound was performed on all infants, the rate of treatment increased with no significant difference in rate of late detected dysplasia or surgery. Targeted ultrasound to infants at high risk of hip dysplasia did not significantly increase the rate of treatment but also did not significantly reduce the rate of late detected dysplasia or surgery. It is not possible to give clear recommendations for hip screening of newborn infants from the available evidence. Where infants are clinically detected as having unstable but not dislocated hips, or are detected on ultrasound to have mild hip dysplasia, there is evidence that delaying treatment by two to eight weeks reduces the need for treatment without a significant increase in late diagnosed dysplasia or surgery., (Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

The operative management of DDH is technically challenging. To achieve excellent results, surgeons need to select the most appropriate operative treatment, minimize the risk of complications, and be aggressive in the management of serious complications, such as redislocation and AVN, when they occur. We have described specific steps and strategies to assist in each of these key steps., (Copyright © 2012 Elsevier Inc. All rights reserved.)

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., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Successful treatment of developmental displacement of the hip (DDH) depends on early diagnosis. Clinical screening of all newborns is a useful tool and should be encouraged in everyday practice, because DDH has a high prevalence and significant morbidity. Clinical exam is an important part of early diagnosis, but insufficient. Ultrasound exam is more sensitive in early diagnosis of DDH., Objective: Systematic struggle against DDH by means of early detection and treatment begins in neonatology units, and continues in primary healthcare centres., Methods: Methodology consists of personal history, clinical exam, ultrasonography and radiography. After these procedures, treatment is advised if necessary. Basically, DDH treatment is atraumatic involving abduction pillow, Von Rosen abduction device, Pavlik harnesses., Results: During 2007 and 2008, screening examination was performed in 769 boys (51.47%) and 725 girls (58.52%), born at the Medical Center "Veljko Vlahovic" in Vrbas. A total of 1,494 neonates or 2,988 hips were examined. Ultrasonographically, a normal type Ia was found in 406 hips (13.60%), intermediate type Ib in 2,014 hips (67.40%), immature type IIa+ in 374 hips (12.50%), unstable type IIg in 39 hips (1.30%), decentering IId in 52 hips (1.70%), and eccentric types III and IV in 35 hips (1.20%). Of 2988 examined hips, normal finding was detected in 2794 (93.50%) and pathological finding (DDH) was found in 194 (6.50%). Ultrasonographical findings were determined according to Graph classification., Conclusion: The frequency of DDH in the regions of Vrbas and Kula above 5% (6.50%) presents a social and medical problem in children of these locations. Eradication, early detection and treatment involve systematic examinations (clinical, sonographical and radiographical) in the first year of life. Treatment has to be initiated in a neonatal unit by atraumatic means. The team work including a gynaecologist, neonatologist and paediatric orthopaedic surgeon is crucial.

In a prospective study over 11 years we assessed the relationship between neonatal deformities of the foot and the presence of ultrasonographic developmental dysplasia of the hip (DDH). Between 1 January 1996 and 31 December 2006, 614 infants with deformities of the foot were referred for clinical and ultrasonographic evaluation. There were 436 cases of postural talipes equinovarus deformity (TEV), 60 of fixed congenital talipes equinovarus (CTEV), 93 of congenital talipes calcaneovalgus (CTCV) and 25 of metatarsus adductus. The overall risk of ultrasonographic dysplasia or instability was 1:27 in postural TEV, 1:8.6 in CTEV, 1:5.2 in CTCV and 1:25 in metatarsus adductus. The risk of type-IV instability of the hip or irreducible dislocation was 1:436 (0.2%) in postural TEV, 1:15.4 (6.5%) in CTCV and 1:25 (4%) in metatarsus adductus. There were no cases of hip instability (type IV) or of irreducible dislocation in the CTEV group. Routine screening for DDH in cases of postural TEV and CTEV is no longer advocated. The former is poorly defined, leading to the over-diagnosis of a possibly spurious condition. Ultrasonographic imaging and surveillance of hips in infants with CTCV and possibly those with metatarsus adductus should continue.

Aim: Ultrasound imaging has become an accepted tool for accurate diagnosis of developmental dysplasia of the hip (DDH) and for its management. The aim of the present study was to evaluate the results of the general neonatal hip screening program in Maribor between 1997 and 2005 in comparison with earlier reported results for our region, where this program was introduced in 1985., Patients and Methods: Of the total number of 17,846 newborns born in our maternity hospital, 17,393 were included in the study during the nine-year period. All hips were examined by ultrasonography within the first week of life. Data for 2.5% of newborns were not available. The incidence of sonographic hip types according to the Graf method was analyzed, together with the sex distribution, lateralization of hip pathology and treatment recommendations., Results: A total of 34,786 hips were evaluated sonographically: 84.9% of hips were mature at first examination (Graf types Ia and Ib), 14.1% were immature (Graf type IIa) and 1.1% were pathological (Graf types IIc or worse). In the group of pathological hips, girls were more frequently affected than boys (3.9:1) and the left hip was more frequently affected than the right (1.2:1). The incidence of hip types IIc or worse decreased sevenfold throughout the observation period, from 2.1 in 1997 to 0.3 in 2005. This distribution of hip types resulted in an average treatment rate of 18 newborns per 1000 live borns, down from 42 treated hips per 1000 newborns in 1997 to 6 hips per 1000 in 2005. During this nine-year period, only 19 children required surgical treatment for DDH before the age of three years., Conclusion: In our region, general ultrasound hip screening of newborns for DDH seems to be effective in reducing the overall treatment rate. The number of surgical procedures has remained stable during the past nine-year screening period and is lower than in the pre-ultrasound era.

Objective: The controversy over the incidence of developmental dysplasia of the hip (DDH) stems mainly from an ambiguity of criteria for defining a genuinely pathologic neonatal hip. The aim of this study was to identify those neonatal hips which, if left untreated, would develop any kind of dysplasia and, therefore, are to be included in the determination of DDH incidence., Methods: Clinical and ultrasonographic examinations for DDH were performed on 4356 neonatal hips. Newborns with skeletal deformities, neurologic/muscular disorders, and neural tube defects were excluded. Hips that featured any type of sonographic pathology were reexamined at 2 or 6 weeks, depending on the severity of the findings. Only hips in which the initial pathology was not improved or had deteriorated were treated; all others were examined periodically until the age of 12 months., Results: Sonographic screening of 4356 hips detected 301 instances of deviation from normal, indicating a sonographic DDH incidence of 69.5 per 1000. However, only 21 hips remained abnormal and required treatment, indicating a true DDH incidence of 4.8 per 1000 hips. All the others evolved into normal hips, and no additional instances of DDH were found on follow-up throughout the 12 months., Conclusions: These findings enables us to distinguish two categories of neonatal hip pathology: one that eventually develops into a normal hip (essentially sonographic DDH); and another that will deteriorate into a hip with some kind of dysplasia, including full dislocation (true DDH). This approach seems to allow for a better-founded definition of DDH, for an appropriate determination of its incidence, for decision-making regarding treatment, and for assessment of the cost-effectiveness of screening programs for the early detection of DDH (Tab. 2, Ref. 15).

The reported prevalence of established dislocation the hip in an unscreened population varies from 0.7 to 1.6 / 1000 children in European and American white populations. In clinically screened populations neonatal hip instability is reported to occur in 3 to 30 / 1000 newborns while established congenital dislocation has a prevalence of 0.1- 4/1000 of which 1/1000 is judged to be in need for surgery. Early diagnosis of DDH is essential for successful treatment and later prognosis of the disorder. Combined procedure including evaluation of both hip morphology and hip stability is currently recommended. Opinions differ about the need for universal versus selective sonographic screening for diagnosis of DDH. Currently selective screening of those infants with recognised risk factors and those with abnormal physical examination would be cost-effective and the only practicable method for most countries.

When a child presents with a dislocated hip after the walking age, parents are upset, pediatricians are distraught, and lawsuits often follow. The prevention of late presentation is a goal that all practitioners should strive for. However, at this time, using current diagnostic techniques, the late presentation of DDH can be minimized but not eliminated. The AAP Subcommittee on DDH has estimated that approximately 15% of DDH at birth is not detectible, even by experienced examiners or ultrasonographers. In addition to preventing the late presentation of a developmentally dislocated hip, the prevention of premature degenerative arthritis of the hip secondary to developmental subluxation and acetabular dysplasia is equally, if not more, important in terms or morbidity and cost. It is hoped that the identification and treatment of babies with DDH at birth will have the added benefit of decreasing the incidence of degenerative arthritis of the hip in adults. As the key to early detection remains repeated, careful examination of the infant in the first year of life, it is imperative for practitioners to become as skilled as possible in performing the exam. Unfortunately, medical school curricula and pediatric and family practice residency programs often are deficient in teaching the neonatal hip examination. Strategies for clinicians to improve their examination technique include asking a pediatric orthopedic surgeon to demonstrate the examination in their nursery or attending one of the AAP courses on DDH. Starting a formal DDH screening program in the nursery is another option, using few screeners to maximize their experience. Nurse practitioners, physician's assistants, and physiotherapists could be used in addition to physicians. Having a child present with a developmentally dislocated hip after the walking age is not malpractice if the child has had repeated careful examinations. It is important to document the examinations in writing, rather than placing a check mark next to "musculoskeletal" or "hips" on standard, pre-printed exam forms. The best documentation is a handwritten note that states "the hips are stable and there is wide symmetrical abduction" at every well-child visit. At this time, careful, repeated physical exam supplemented by ultrasonography or X-rays for babies with risk factors is our best strategy to minimize the late presentation of DDH.

Objectives: It is of special importance to educate families and health care providers, in particular midwives and nurses who are in close and frequent contact with families, for the prevention and early diagnosis of developmental dysplasia of the hip (DDH). A knowledge and attitude study was conducted concerning DDH among students of Nursing and Midwifery College of Kahramanmaraş Sütçü Imam University., Methods: A structured form was prepared consisting of 28 statements about medical and practical knowledge and traditional attitudes with regard to DDH and was administered to 232 voluntary students before and after an educational session of 60 minutes by a specialist in orthopedics. Prior to the study, the students of grade I and II had not received any theoretical or practical lectures about DDH, which were included in the curriculum of grades III and IV., Results: The knowledge of the students about risk factors and prevention strategies for DDH was of a moderate level. They were not sufficiently furnished with information about traditional attitudes and applications that predispose infants to DDH. The mean test scores before and after training were 51.52+/-13.90 and 87.86+/-5.90, respectively (p=0.000). Compared to grade III and IV students, grade I students performed significantly less in the former test (p=0.00); however, the scores of the latter test did not differ significantly between the grades (p>0.05)., Conclusion: The curriculum during the license education of midwives and nurses should include essential information on traditional attitudes. With sufficient knowledge and application skills, midwives and nurses may play an important role in the primary and secondary prevention of DDH in our country.

Despite the fact that ultrasound of children's hips is widely used for screening, late diagnosed cases of developmental dislocation of the hip are still a common problem in the orthopaedic practice. The aim of the study is to review final clinical and radiological outcomes of treatment of DDH with overhead traction and closed reduction after skeletal growth. Clinical records and radiograms of 107 hips (81 children) were retrospectively reviewed. All of them were treated according to the same program: overhead traction (about 2 weeks), followed by closed reduction, modified Lorenz cast (2 months) and finally cast in Lange position (3 months). Average age of children was 14.2 months at the beginning of treatment and 20.7 years at last visit. Good and very good results were found in 80% of cases according to final radiological assessment of Severin and in 91% according functional classification of Harris. Avascular necrosis of femoral head according to Bucholz-Ogden classification system was identified in one third of patients. Functional results are better than radiological, but deteriorated with time especially in hips with residual dysplasia and AVN due to development of early, secondary degenerative changes.

The authors analysed the status of screening and prevention of developmental dysplasia of the hip in the Slovak Republic on the basis of the European Pediatric Orthopaedic Society questionnaire. The questionnaire was sent to 31 heads of orthopaedic departments, with 23 (74%) responses. According to the responses received, in the Slovak Republic a neonatologist or orthopaedic surgeon, depending on availability, makes the first clinical examination of the hips up to the fifth day after delivery. Every instability, relative shortening of one of the lower limbs, or 'high-risk' baby is referred immediately to the orthopaedic surgeon. Sonographic examination up to 7 days after delivery is performed in six departments. In another 11 departments, two or more sonographic examinations are performed on each baby. Authors support the simple static ultrasound as an effective screening test for developmental dysplasia of the hip, that should be applied to the whole population and not simply to the at risk group.

Background: Hip dislocation in children with cerebral palsy has a well-documented history and morbidity., Objective: This paper presents a retrospective study of children with bilateral cerebral palsy who had various postural management and its effect on hip deformity. The most widely accepted theoretical model of hip subluxation/dislocation is that an imbalance in muscle length and strength around the hip leads to acetabular dysplasia and consequent hip subluxation. Maintenance of muscle length and strength and loadbearing is therefore a logical prevention. Research on normal infants' postures has provided biomechanical data to form the theoretical basis of 24 h postural management equipment., Methods: The notes and X-rays of 59 children with bilateral cerebral palsy from East and West Sussex and Oxfordshire were examined and measured to determine whether a relationship existed between postural management and the level of hip subluxation/dislocation. X-rays were measured using Reimers' hip migration percentage. Postural management support was divided into three groups for analysis. Category 1: use of a 24-h postural management approach using Chailey Adjustable Postural Support (CAPS) systems in lying, sitting and standing; category 2: two items of CAPS (either lying/sitting or sitting/standing supports); category 3: use of the CAPS seat only and/or any other postural supports. Hip status was recorded for analysis as both hips safe (under 33% migrated), or one/both hips subluxed., Results: Children using 'All CAPS' before hip subluxation maintained significantly more hip integrity than other groups (chi2 P < 0.05)., Conclusions: Postural management interventions have an important role in the prevention of hip dysplasia.

Objectives: To evaluate the role of the risk factors in the diagnosis of developmental hip dysplasia (DDH) by ultrasonographic screening., Methods: The hips of 327 newborns (151 females, 176 males) with identifiable risk factors including family history (n=20), congenital muscular torticollis (n=19), oligohydramniosis (n=2), breech presentation (n=51), multiple gestation (n=6), pes calcaneovalgus (n=74), clubfoot (n=152), and postural metatarsus adductus (n=3) were examined clinically on the first day of life and by ultrasonography within two weeks after birth. The hips were evaluated according to the Graf method., Results: Clinical examination of 239 newborns were normal. Of these, sonographic abnormalities were found in 15 newborns (6.3%). On the other hand, out of 88 newborns who were found clinically abnormal, ultrasonography findings were normal in 24 cases (27%). According to the Graf method, of 654 hips, 550 were type 1, 81 were type 2a, 15 were type 2c, five were type D, two were type 3a, and one was type 4. Treatment was required for only 19 infants (5.8%), four of whom had been found normal on clinical examination., Conclusion: Our data suggest that risk factors are important for early diagnosis of DDH, and that, due to detection of abnormal ultrasonography findings among newborns who had been found normal on clinical examination, screening of all newborns with ultrasonography seems to be essential regardless of the presence of any risk factors.

Background: Universal clinical screening for congenital dislocation of the hip to detect hip instability in neonates was introduced in the UK as a national policy in 1969, but its effectiveness is not known. We aimed to assess the extent to which surgery for congenital dislocation of the hip is the result of a failure of detection through screening or follows non-surgical treatment after detection by screening., Methods: We established a national orthopaedic surveillance scheme and used routine hospital data for inpatients for 20% of births in the UK (Scotland and the Northern and Wessex regions) to ascertain the number of children aged under 5 years per 1000 livebirths who had received at least one operative procedure for congenital dislocation of the hip from April, 1993, to April, 1994. Estimates of the incidence of operative procedures were adjusted for under-ascertainment by capture-recapture techniques., Findings: The ascertainment-adjusted incidence of a first operative procedure for congenital dislocation of the hip in the UK was 0.78 per 1000 livebirths (95% CI 0.72-0-84). Congenital dislocation of the hip had not been detected by routine screening in 222 (70%) of 318 children reported to the national orthopaedic surveillance scheme. In 112 (35%) children the diagnosis was made primarily as a result of parental concern. 67 (21%) children had previously received non-surgical treatment. In Scotland and the Northern and Wessex regions, 81 cases were notified to the national orthopaedic surveillance scheme, 62 cases were identified only through routine hospital data on inpatients, and an estimated 20 cases were not identified by either source, making a total of 163 cases. Thus, 81 (50%) of these 163 cases were identified by surveillance, 125 (77%) by routine data, and 143 (88%) by both sources., Interpretation: The incidence of a first operative procedure for congenital dislocation of the hip in the UK was similar to that reported before screening was introduced. In most children who received surgery, congenital dislocation of the hip was not detected by screening. Formal evaluation of current and alternative screening policies, including universal primary ultrasound imaging, is needed.

Purpose: This study aimed at investigating whether twin pregnancy is a risk factor for congenital dysplasia of the hip., Method: From 1987 until 1994 the hips of 3739 (1902 male, 1837 female) newborn were examined by ultrasound (screening) according to Graf's technique. We compared the results of twins and the other newborn (non-twins). The examinations were performed by 19 physicians. 73 (2%) of the newborn were twins (29 male, 44 female)., Results: In the group of 3666 non-twins we found the types of hip IIa (alpha < 55 degrees) to IV (Graf's classification) in 237 (6.5%) newborn: 136 (3.7%) right side/183 (5.0%) left side. Only 2 (2.7%) of the 73 twins showed these types of hip. We found 4% (149/3739) breech presentations at birth in the entire group. 3.9% (141/3666) in the group of non-twins and 11% (8/73) cases in the twin group. 5.2% (190/3666) of the non-twins and 2.7% (2/73) of the twins required a treatment with abduction orthosis or Pavlik harness., Conclusion: This report shows that the types of hip IIa (alpha < 55 degrees); IIc; D; IIa, IIb and IV according to Graf and a required treatment in twins was significantly not more frequent than in the other newborn (non-twins), although twins showed more often a breech presentation at birth. The different kind of breech position in twins (hips and knees in flexion, legs and feet parallel) and non-twins (hips in flexion, knees in extension) could be one reason for these results. Besides, non-twins assume their breech position earlier than twins with a consecutively longer period of time of mechanical stress on the hips.

The use of ultrasonography as a complement to clinical examination will increase the reliability of the evaluation of unstable hips in newborn infants. In particular, the number of false-positive Ortolani and Barlow tests will decrease. However, the interpretation of the ultrasonogram in newborn infants has a steep learning curve with considerable risk of a high number of false-positive hips being diagnosed. Therefore, universal screening for developmental dysplasia of the hip by ultrasonography cannot yet be recommended from a cost-benefit point of view.

The incidence of congenital dislocation of the hip (CDH) in Singapore and Malaysia has been reported as being lower than in the West. In our hospital, we have seen an increasing number of congenital hip dislocation as well as dysplastic hips. We undertook a prospective study from December 1989 to December 1994 of 20,000 live births. The neonates were all screened by a consultant neonatologist and the findings were confirmed by a consultant paediatric orthopaedic surgeon. All babies had plain X-rays at 3 months and an acetabular index (AI) of 30 degrees or more was considered dysplastic. All babies with positive signs were followed up for 1 year and again had radiographs taken at 1 year. Comparison of plain X-rays and ultrasound assessment in a subgroup of 130 neonates showed that 64% of patients with AI > 20 degrees had hip dysplasia by ultrasonographic (alpha angle < 60 degrees) The incidence of dysplastic hips was 16.8 per 1000 live births. The overall incidence of neonates with dislocated hips was 4.7 per 1000 live births. The Malays were most affected with an incidence of 5.4 per 1000 live births. The incidence of developmental dysplasia of the hip in Singapore is higher than previously reported, with the Malays having the highest incidence. A significant number of babies with clicking hips have radiological evidence of acetabular dysplasia (AI > 30 degrees). One-third of the babies' hips were still dysplastic at 1 year of age. A well-organised screening programme with experienced examiners has proved to be useful in making early and accurate clinical diagnosis.

Objective: To determine the prevalence of developmental dysplasia of the hip (DDH) in South Australia (SA) in 1991, the proportion of cases detected in the neonatal period and the perinatal risk factors for DDH., Methodology: Cases of DDH born in SA in 1991 were identified from multiple sources and their clinical data linked to perinatal data provided by midwives; five controls per case were obtained randomly from SA livebirths without congenital abnormalities and adjusted odds ratios (OR) for potential risk factors obtained by logistic regression analysis. South Australia perinatal data were also used to estimate numbers of births with perinatal risk factors for targeted screening., Results: Two hundred and six cases of isolated DDH were identified, giving a prevalence of 10.5 per 1000 births. Of these, 173 (84%) had been detected in the neonatal period. The perinatal risk factors for DDH were identified as breech presentation (OR 9.65), female babies (OR 4.04), first births (OR 1.91) and maternal age of 25 years or more (OR 1.53). Screening breech and firstborn female babies (23% of births) would yield approximately 51% of cases of DDH., Conclusions: Isolated DDH had a prevalence of 10.5 per 1000 births and 84% of cases had been detected in the neonatal period in SA. Repeated screening during infancy of "at risk' groups of babies is recommended.

Despite the introduction of clinical screening and early treatment of congenital dislocation of the hip (CDH), the prevalence of subluxated/luxated hips in later infancy is still reported to be as high as 1-3 per 1,000 infants. Using ultrasound, it is possible to evaluate both hip morphology and hip stability. Hip morphology is best evaluated using Graf's coronal section through the deepest part of the acetabulum. Classification of the hips into different categories can then be based on measuring the angle of inclination of the acetabulum (alpha-angle) or femoral had coverage. Hip stability can be assessed by a Barlow-equivalent provocation test during the ultrasound examination. In the Norwegian newborn population approximately 85% of the infants have morphologically normal hips (based on the alpha-angle) while 12% have immature and 3% dysplastic hips. About 80-90% of infants with dysplastic acetabula show only minor changes, and many of the hips may normalize without treatment. Several studies indicate that universal ultrasound screening might reduce the occurrence of late diagnosed congenital dislocation of the hip.

The role of hip sonography in neonatal hip screening is still a controversial matter. This paper reports the results of the Austrian ultrasound hip screening program, in which all Austrian babies undergo hip sonography twice: at the birth clinic during the 1st week of life and at an age of 12-16 weeks. Data from all public health insurance companies since 1985 and all ICD data about children hospitalized because of CDH in Austria were collected and analyzed. The rate of sonographically pathological hips was 6.57% (1994). The treatment rate before introduction of hip sonography was 13.16% (1985). The rate of open reduction went down to 0.24 per 1000 newborns, including a high number of unscreened children born abroad and also children with teratological dislocation of the hip. Hip sonography screening proved to be effective in detecting true instability of the hip joint as well as dysplasia. The optimal time for sonographic screening does not seem to be immediately after birth when only "high risk" hips (clinical instability, positive family history, breech delivery) should undergo hip sonography, but at an age between 4 and 6 weeks when the hip has already shown its true nature. Since one sonographic scan appears to be sufficient for screening, a further reduction of costs could be accomplished. Disability owing to DDH can be avoided in a number of cases, and costs for conservative and surgical treatment as well as for later endoprostheses and early retirement can be economized.

The effect of the introduction of a programme combining clinical hip screening supplemented by limited targeted ultrasound assessment on splintage for developmental dysplasia of the hip (DDH) was evaluated over a 3-year period. The use of ultrasound is of both diagnostic and therapeutic value as it allows monitoring of the effects of splintage and decreases the total treatment time required. In all, 82 dysplastic hips were identified in 65 infants and the period of splintage averaged 6.3 weeks (range 3-12 weeks). The overall splintage rate can also be reduced as hips with only minor dysplasia can be assessed by serial scans until resolution or progression occurs rather than automatic treatment of all abnormal hips and in this series the rate was 6 per 1000 (0.6%). The Wheaton-Pavlik harness is a dynamic light-weight splint which is user friendly, easy to apply and adjust, and with no major complications being encountered in this series. Unnecessary exposure to radiation was reduced as plain radiographs were not performed before ossification of the capital epiphysis; prolonged splintage was prevented and a weaning period from the brace was not used. All children remained under follow-up for 1 year after the hips were confirmed to be clinically and radiologically normal and there were no cases of late re-dislocation or subluxation. There were no cases of avascular necrosis and a markedly reduced need for diagnostic arthrograms, with only two being performed during the 3 years. This regimen has resulted in a low rate of late presenting DDH requiring surgery of 0.28/1000, as well as a low splintage rate of 6/1000 (0.6%). Most of the improvement in the results can be attributed to the more accurate evaluation of DDH by ultrasound, but the absence of avascular necrosis and other complications is likely to be due to the shorter period of time spent in a dynamic splint without the use of excessive abduction.

Objective: Screening for congenital dysplasia of the hips (CDH) of new-borns, mostly by Ortolani's of Barlow's tests, is widely performed, but nevertheless dysplasias are still discovered late. Ultrasonographic screening has been reported to reduce the number of these cases. The present investigation is intended to evaluate the cost-effectiveness of such as screening programme., Materials and Methods: The cost of performing ultrasound investigations at Haukeland Hospital and the treatment costs of late-discovered CDH were calculated on the basis of 26 cases of late-discovered CDH at Hagavik Orthopaedic Hospital. Figures for sensitivity and specificity were taken from the literature., Results: General ultrasonographic screening programmes for CDH will not be cost-effective because the population screened will be too large and the demands upon sensitivity too high. However, investigating babies at risk is probably cost-effective., Conclusion: A CDH screening programme requires high sensitivity and one should preferably aim at screening babies at risk. In Norway a centralisation to larger hospitals may therefore be necessary.

The effect of ultrasonographic screening and treatment with a Pavlik harness on the incidence of developmental dislocation of the hip has been studied retrospectively. Observations were made at three different consecutive periods; in the first, clinical screening was carried out, in the second, ultrasonography was added for children up to 3 months of age, and in the third ultrasonography was used within the first few days of birth. A significantly decreased dislocation rate was demonstrated in each group, suggesting that early ultrasonography was of value in the early detection of dislocation.

The continued diagnosis of cases of late developmental dysplasia of the hip reaffirms the failure of initial clinical neonatal screening programs. Even the identification of an "at risk" patient profile will not eliminate the late diagnoses, but referral of these patients will ensure that up to 50% of late diagnoses can be eliminated. The role of ultrasound as a screening diagnostic tool has not, at this time, been confirmed to eliminate late diagnoses. Its use, however, has led to an increased incidence of treatment with the recognition of the sonographic "immature hip." This, in turn, will increase the number of complications of treatment with iatrogenic avascular necrosis. Therefore, the ideal elimination of all late developmental dysplasia of the hip referrals remains the unattained goal.

In 1969 universal clinical screening for neonatal hip instability was formally adopted in the United Kingdom with the aim of detecting and treating children considered to be at high risk of congenital dislocation of the hip (CDH). However, clinical screening is associated with both false positive and false negative diagnoses and has never been evaluated in a randomised trial. The emergence of hip ultrasound provides renewed impetus to reconsider and formally evaluate screening for CDH. Ultrasound imaging of the newborn hip may be used as a screening test and to assess and manage infants with clinically detected hip instability. Universal primary ultrasound screening has been adopted in some European countries, but enthusiasm for this new technology has been tempered by the subsequent large increases in treatment and follow up. This paper reviews the existing evidence to support the different approaches to screening and describes the research agenda of the MRC working party on congenital dislocation of the hip. A randomised trial of screening is required to evaluate the policy options before ultrasound screening becomes widely adopted within the United Kingdom. The feasibility and acceptability of a trial need to be explored and key issues relating to trial design addressed.

In an experimental study, the sonographic speed in the hyaline cartilage of the hip of the newborn is measured. With 1549 m/s it lies in the intermediate range of the equipment's pre-set calculation basis. By comparing large groups the study shows that the accuracy of the measurements of the angle alpha is independent of the technology used in the production of the hip sonogram. On the other hand, the image scale has a clear influence. The image scale of 1:1 is inadequate for a reliable repeated cross-sectional presentation and for measurements. The study shows that there are no statistically demonstrable differences when measuring hip sonograms regardless of whether they have been produced using linear array or sector scanning. This is shown both by repeated presentation of the respective cross-section by one and the same researcher and by measurement of identical sonograms by different researchers.

Background: Congenital dislocation of the hip varies greatly in incidence among different regions. This work is aimed at comparing results of clinical investigation and ultrasonography of the hip in Languedoc-Roussillon and Brittany., Population and Methods: Two thousand eight hundred and twelve and 2,809 neonates admitted to Nîmes and Vannes hospitals respectively, were enrolled in a prospective study. Clinical examinations were made according to the protocol established by the "Groupe d' études en orthopédie pédiatrique". Ultrasound investigations were performed in every risk case., Results: No dislocation occurred in the 4946 neonates without risk factors. In the 675 neonates with risk factors, 213 ultrasonographic examinations were abnormal, more frequently in the Brittany group (P < 0.001); nine dislocations were observed. A familial history of hip dysplasia (P < 0.001) and the addition of two risk factors (P < 0.001) were more frequent in Brittany. One hundred and six cases required treatment, more frequently in Brittany (P < 0.001)., Conclusions: Some clinical risk factors and delayed ossification or hip dysplasia at ultrasound examination are significantly more frequent in Brittany. Clinical examination with selective ultrasonography is a reliable method, allowing early diagnosis and treatment of delayed dislocations.

Developmental dysplasia of the hip is a crippling disorder, causing early arthritis if left undetected. In Northern Ireland health visitors routinely screen infants' hips at specific intervals up to pre-school age. The screening tests used appear simple but involve a high degree of skill in order to identify abnormality. A video study of three health visitors found that their performance was poor, but a marked improvement was noted after a period of specialised training. Bernadette Trainor et al suggest that more initial training and post-qualification update sessions are necessary to support health visitors in this role.

Prevention of congenital hip dislocation is one of the main goals of pediatric activity. 839 newborn outpatients, with six months follow-up at least, were recruited at the Pediatric Clinic of the Catholic University of Rome, from January 1991 to December 1992. Every newborn baby was clinically examined for congenital hip dysplasia (CHD) at nursery and afterwards in the ambulatory. Hip sonography was performed, according to Graf's technique, in 504 babies (60%): 17 resulted pathological (3.3%), 30 borderline (6%) and 457 normal (90.7%). Ultrasonographic and clinical findings were compared. Clinical examinations at nursery and ambulatory have shown low sensitivity (21.3% and 34% respectively) in detecting dysplastic hips. Present experience confirms ultrasonography value in the diagnosis of CHD and the utility of its use in a general screening programme.

Objective: To investigate if those responsible for screening for neonatal hip instability are using acceptable manual hip stress tests as described by Ortolani and Barlow., Method: A video camera was used to record the technique of 35 personnel who were responsible for screening. They examined both a baby and a simulator. The study comprised five groups, classified by experience and practice: senior orthopaedic surgeons, senior paediatric staff, junior paediatric staff, nurses, community staff., Results: The seven authors together with six independent expert observers viewed the video and marked the performance with the aid of a specially designed proforma. Although there was some variation between these expert observers, the results showed differences in the scores obtained by the different groups of examiners over all aspects of the test procedure., Conclusion: Video recording for critical analysis and feedback is a useful technique in this situation. Overall, the results suggest that testing for neonatal hip instability was inadequate. A variety of hip stress manoeuvres were being performed. The ability of each subject to perform satisfactory tests seemed to depend on their experience and education. More "hands on" training and experience of testing might provide the necessary competency for screening.

Ultrasound imaging of the infant hip has gained wide acceptance, especially in diagnosis and therapy of infant hip dysplasias. Problems are the prognosis with regard to normal and pathological alpha-angle and treatment using cast, harness, or pillow. The well-known two-dimensional ultrasound techniques are not able to reproduce the correct relationship between femoral head and acetabulum. The use of the new three-dimensional technique is independent of the position of the infant hip. Although a special view into the acetabulum is possible, at present this method is not suitable for screening programs.

Early diagnosis of developmental dysplasia of the hip in newborns is essential if treatment is to be successful. Screening of newborns is appropriate because developmental dysplasia of the hip has a high prevalence [1] and significant morbidity [2, 3] and is treatable [4]. Screening by clinical examination alone has shortcomings [5], and the use of sonography for screening has been proposed [6]. The purpose of this article is to analyze the use of sonography in this regard.

Effective prevention of late dysplastic dislocation of the hip (DDH) has become a reality since reliable diagnosis has been possible at an early stage by means of the original sonographic method according to Graf. A correct sonographic diagnosis must be instantly followed by adequate, biomechanically rational, and consistent therapeutic management and long-term follow-up. The results of a strictly comparative follow-up study emphasize the enormous progress in the quality of therapeutic results gained when routine sonographic newborn hip "screening" is performed directly in the maternity wards: successful anatomical healing with conservative treatment is regularly obtained without femoral head necrosis, without surgery and without late DDH, and costs less when sonographic assessment is done within the first days of life. For this reason, the Austrian government has included sonographic neonatal hip screening in its general health prevention program-and also reimbursed the cost of this preventive procedure-since 1992.