Diagnostik und Therapie der Säuglingshüfte – sind sich die deutschsprachigen Kinderorthopäden einig?

Abstract

Ultrasound examination of the neonatal hip has been an integral part of the German programme for the "early detection of disease in childhood" since 01.01.1996. The aim of this study is to determine if any consensus exists among German-speaking paediatric orthopaedic specialists concerning diagnosis and treatment of the neonatal hip 15 years after legal implementation of hip ultrasound screening by the Graf technique. A questionnaire was sent to all members of the German speaking Association of Paediatric Orthopaedic Surgeons (Vereinigung für Kinderorthopädie - VKO). The query included questions concerning education and field of activity of the member as well as information on the diagnostics of neonatal hip with regard to examiner, technical equipment, and type of screening. In addition, four cases were presented with clinical history, clinical findings, and rateable Graf sonogram (case 1: 3 days old ♀, type D; case 2: 2 days old ♀, type IV; case 3: 4 weeks old ♀, type II a; case 4: 4 months old ♀, type III a) and a treatment recommendation was requested for each case. 78 of 179 contactable VKO members participated in this survey. 75.6 % of the participants are specialists with additional qualification in paediatric orthopaedic surgery. 68 % of the participants work in a hospital. As stated by 61.5 % of the participants the ultrasound examination of the neonatal hip is primarily done by orthopaedic surgeons. One participant stated that the examination is performed primarily by medical-technical assistants. The majority of participants use a 7.5-MHz linear transducer for ultrasound examination, a positioning device according to Graf and a foot switch as technical equipment. State-of-the-art equipment as recommended by Graf including in addition to the above mentioned an upright image display and a transducer guiding arm system is available to only 21.8 % of the participating VKO members. 23 of 50 participants stated that a general screening is performed at their institution where all newborns get an ultrasound examination within the first week of life regardless of medical history and clinical findings. Therapeutic recommendations for the first case (type D hip) were in 15.4 % wait and check by some colleagues, supplemented by double diapering. 56.4 % would use a flexion-abduction splint and 26.9 % would perform reduction with consecutive retention. To treat case 2 (type IV hip) 3.8 % of participants suggest a flexion-abduction splint and 88.5 % reduction and retention. Concerning the type of reduction the participants do not agree. Pavlik harness as well as closed reduction under anaesthesia or without anaesthesia is recommended. In case 3 (type II a hip) 67.9 % of the colleagues suggest to wait and check, some with supplementary double diapering. 25.6 % suggest a flexion-abduction splint. One colleague would prescribe a Pavlik harness. In case 4 (type III a hip) 14.1 % of the participants suggest a flexion-abduction splint, 80.8 % reduction and retention as described before with disagreement concerning the preferred type of reduction. On combining the therapeutic suggestions for all four cases, 66 % of the participants recommend a type of treatment that is concordant with Graf's guidelines. Despite the existence of clear recommendations the German-speaking paediatric orthopaedic surgeons are quite discordant concerning diagnostics and treatment of the neonatal hip. Uncertainty particularly concerning the evaluation of sonograms of physiologically immature and dysplastic-unstable hips bears the risk of overtreatment as well as of delayed diagnosis of hip dysplasia.