Hip Screening Program Research Articles

The Diagnosis and Management of Neonatal Hip Instability

This article reports the results of a neonatal hip screening program comprising clinical screening and targeted ultrasound performed by orthopaedic surgeons. Over 7 years, from 1995 to 2001, there were 15,397 live births in the authors' region. Seven hundred thirty-three babies (4.8% of births) were referred for hip ultrasound: 80% for risk factors and 20% for instability. Eighty-three babies (5.4/1,000) were splinted in a Pavlik harness. Three of these subsequently required surgery (1.9/1,000). Ten patients (0.65/1000) presented with hip dislocation after 12 weeks of age, nine of whom required open or closed reduction (0.56/1,000). From 1978 to 1985, when neonatal pediatricians clinically screened all babies, 18 babies presented late from 13,707 births (1.3/1000). Since the introduction of orthopaedic screening and targeted ultrasound, there has been a significant reduction in late diagnosis in the authors' institution.

Evolution of late presenting developmental dysplasia of the hip and associated surgical procedures after 14 years of neonatal ultrasound screening

Between 1985 and 1998, 12 331 patients were included in the general neonatal ultrasound hip screening programme for developmental dysplasia of the hip (DDH). Patients who needed treatment (604) were compared with a second group of 73 unscreened children treated conservatively and surgically for DDH. The incidence of Graf sonographic hip types IIc to IV varied throughout the observation period. Femoral and pelvic osteotomies were almost entirely restricted to the unscreened group of patients. The six to ten per year recorded in the period 1985 to 1990 declined subsequently to three or less per year. The yearly admissions to hospital fell noticeably after six years of screening. Late presentations of DDH were reduced to three or less per year from 1990 to 1994, none between 1995 and 1998 and one or two per year from 2000. We conclude that general neonatal sonographic hip screening can reduce significantly surgical procedures, hospitalisation and late presentation of DDH.

Should major surgery be the only intervention analyzed when determining the efficacy or cost-effectiveness of a hip-screening program?

Should major surgery be the only intervention analyzed when determining the efficacy or cost-effectiveness of a hip-screening program?

Unilateral limitation of abduction of the hip. A valuable clinical sign for DDH?

Between 1992 and 1997, we undertook a prospective, targeted clinical and ultrasonographic hip screening programme to assess the relationship between ultrasonographic abnormalities of the hip and clinical limitation of hip abduction. A total of 5.9% (2 of 34) of neonatal dislocatable hips and 87.5% (7 of 8) of 'late' dislocated hips seen after the age of six months, presented with unilateral limitation of hip abduction. All major (Graf type III) and 44.5% of minor (Graf type II) dysplastic hips presented with this sign. Statistically, bilateral limitation of hip abduction was not a useful clinical indicator of underlying hip abnormality because of its poor sensitivity, but unilateral limitation of abduction of the hip was a highly specific (90%) and reasonably sensitive sign (70%). It was more sensitive than the neonatal Ortolani manoeuvre, which has been considered to be the method of choice. It was, however, not sensitive enough to be of value as a routine screening test in developmental dysplasia of the hip. We consider unilateral limitation of hip abduction to be an important clinical sign and its presence in an infant over the age of three to four months makes further investigation essential.

Unilateral limitation of abduction of the hip

Between 1992 and 1997, we undertook a prospective, targeted clinical and ultrasonographic hip screening programme to assess the relationship between ultrasonographic abnormalities of the hip and clinical limitation of hip abduction. A total of 5.9% (2 of 34) of neonatal dislocatable hips and 87.5% (7 of 8) of ‘late’ dislocated hips seen after the age of six months, presented with unilateral limitation of hip abduction. All major (Graf type III) and 44.5% of minor (Graf type II) dysplastic hips presented with this sign. Statistically, bilateral limitation of hip abduction was not a useful clinical indicator of underlying hip abnormality because of its poor sensitivity, but unilateral limitation of abduction of the hip was a highly specific (90%) and reasonably sensitive sign (70%). It was more sensitive than the neonatal Ortolani manoeuvre, which has been considered to be the method of choice. It was, however, not sensitive enough to be of value as a routine screening test in developmental dysplasia of the hip. We consider unilateral limitation of hip abduction to be an important clinical sign and its presence in an infant over the age of three to four months makes further investigation essential.

SCREENING FOR NEONATAL HIP INSTABILITY IN AN ASIAN POPULATION: AN EVALUATION OF THE FIRST 5 YEARS

Developmental dysplasia of the hip can result in significant morbidity both in childhood and later in adult life. Early diagnosis enables better results to be obtained with fewer complications, while delayed diagnosis can lead to prolonged treatment with less satisfactory outcome.A Neonatal Hip Screening program for DDH has been in place in the National University Hospital, Singapore since December 1989. Our program is run by consultant neonatologists and consultant paediatric orthopaedic surgeons. All neonates seen with DDH are followed up for a minimum of 1 year with ultrasonography and X-rays.Our results show an incidence of dislocated hips of 4.7 per 1000 live births. The incidence of neonates with acetabular dysplasia as defined by an Acetabular Index of > 30° is 16.8 per 1000 live births.The early diagnosis and treatment of hip dislocation is important for the development of a normal acetabulum. Neonatal Hip Screening programs have been shown to be effective in the early diagnosis, resulting in successful outcome of treatment and reduction of economic costs in the management of DDH.The finding of a significant incidence of DDH in our population and the successful management after early diagnosis in our study have vindicated the establishment of our hip screening program.

The congenital dislocation of the hip joint in ultrasound examination--frequency, diagnosis and treatment

A real congenital dislocation of the hip joint is very rare. Because of the severeness of the disease an immediate diagnosis and begin of treatment is required. Between 1984 and 1995 clinical and sonographic screening examinations at 4177 newborns were performed at our hospital. We analyzed our patients retrospectively and found out all cases of congenital dislocation of the hip joint. All these cases were classified and the results of treatment were determined. The clinical success of our strategy of treatment was described. Among the 4177 observed newborns 39 cases of congenital dislocation of the hip joint in 27 children were found. We diagnosed the hip type IIIa, IIIb and IV according to Graf in 28.2 and 9 cases respectively. After 12 month a complete healing rate of 95 percent was exhibited with the functional management strategy. Five percent of the affected joints showed a residual dysplasia. The rate of residual dysplasias was 2.5%. The good prognosis after our early treatment strategy severe congenital dislocation of the hip joint underlines the use of earliest therapy together with a hip screening program.

Ultrasound screening for congenital dislocation of the hip: a limited targeted programme.

Abnormal hips, arising from a clinical universal neonatal hip screening programme, were referred to a specialist paediatric orthopaedic surgeon for ultrasound (US) assessment. Two different methods of US screening were undertaken in consecutive years: (a) Clinically abnormal hips were assessed for dynamic stability without formal assessment of dysplasia; and (b) Morphologic and dynamic assessment was undertaken in clinically abnormal and "at risk" hips. US has been reported as an accurate method for initial diagnosis of instability of the hip joint. The incidence of late congenital dislocation of the hip (CDH) was not reduced by extending the US programme to include "at risk groups" and morphologic assessment of the hips. Morphologic assessment of the hip alone cannot be recommended as a secondary screening programme for the diagnosis of hip dislocation. However, it may be of value in evaluation of persistent dysplasia and its relationship with dislocation. Targeted screening programmes may reduce the rate of late CDH requiring operative procedures; further trials of US are necessary.

Results of hip ultrasonographic screening in Austria

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.

Congenital Hip Instability in Hospital Born Neonates in Abha

In a prospective screening of 2222 consecutive live hospital births over a ten-month period in Abha, there was an incidence of 3.6% for congenital hip instability by examination within 48 hours of delivery. This is a higher incidence than that reported from most parts of the world and is comparable to earlier Japanese figures. This suggests a regional variation in the incidence of his instability within the Kingdom of Saudi Arabia. Bilateral instability was found in 32% and there was a left lateral dominance. There was a significantly higher incidence in female babies, in the local Saudi population and in first degree relatives of affected babies. Hip instability was noted in 8% of breech deliveries. No association was demonstrable with maternal age, birth order, size of the baby or gestation. Our findings are compared with other published data from Saudi Arabia and the West. The need for continued appropriate neonatal screening for early diagnosis of congenital hip instability is emphasized.

Economic Evaluation of Neonatal Screening for Congenital Dislocation of the Hip

A study was undertaken to determine the cost benefit of neonatal screening for dislocatable and subluxable hips. As a follow-up to retrospective and prospective studies that established the safety and efficacy of early treatment to the newborn, this study discusses the direct and significant economic benefit of a neonatal hip screening program to the participating institutions. British Columbia's Grace and Children's Hospitals experienced an economic benefit of $15,143.71 (Canadian) per 1,000 infants screened.

Efficacy of neonatal hip examination.

An examination of the ongoing neonatal hip screening program at the Vancouver General and Grace Hospitals in Vancouver, British Columbia, over a 9 1/2 year period revealed that of the 32,480 newborns examined, 321 (9.8 per 1,000 live births) had unstable hips. Treated immediately with abduction splintage, five of these children came to percutaneous adductor tenotomy and hip spica casts. There was one false-negative screening, and there were five children with unidentified acetabular dysplasia who presented within the first year of life. No child came to open reduction of the hip or innominate or femoral osteotomy. A standardized neonatal hip screening program would seem to significantly alter the natural history of the classic congenital dislocation of the hip but also seems unable to effectively screen out acetabular dysplasia.