Surgery For Developmental Dysplasia Of The Hip Research Articles

Does epinephrine use reduce perioperative blood loss during pelvic and femoral osteotomy with open reduction of the patients with developmental dysplasia of the hip?

In this study, we aimed to investigate whether the use of epinephrine solution-impregnated gauzes and irrigation fluid with epinephrine could reduce perioperative blood loss during the combined surgical treatment of developmental dysplasia of the hip (DDH) patients. Between January 2018 and June 2023, a total of 68 pediatric patients (8 males, 60 females; mean age: 32.4±13.2 months; range, 18 to 98 months) who underwent combined surgery for DDH were retrospectively analyzed. The patients were divided into two groups as those who used topical epinephrine in the surgical sites during combined surgical treatment (n=34) and those who did not (n=34). Demographic and clinical characteristics and pre-, intra-, and postoperative data were recorded. To avoid transfusion complications, blood transfusion was performed in only symptomatic patients in the postoperative period. Age, sex, weight, and surgical duration were similar between the two groups (p>0.05). No statistically significant difference was found between the groups in terms of preoperative hemoglobin and hematocrit levels (p>0.05) There were statistically significantly differences between the groups in terms of postoperative hemoglobin and hematocrit levels, perioperative amount of blood loss, and postoperative length of hospital stay (p<0.001). No significant difference was found between the groups in terms of intraoperative hemodynamic parameters (p>0.05). The differences in perioperative and estimated intraoperative blood loss amounts and length of hospital stay were statistically significant between the groups (p<0.001). There was a significant relationship between the groups in terms of perioperative and estimated intraoperative blood loss, and transfusion of blood products (p<0.01). Blood transfusion was administered to five patients in the no epinephrine group. No local complications were observed in any group; however, one patient had transfusion-related fever and one patient had allergic skin lesions in the no epinephrine group. The intraoperative topical use of epinephrine irrigation solution and epinephrine solution-impregnated gauze dressings is effective and safe in reducing blood loss in DDH patients.

Proximal Femoral Growth Alterations Can Be Seen Prior to Treatment of Developmental Dysplasia of the Hip: A Multicenter Cohort Study

Background: Avascular necrosis (AVN), better considered proximal femoral growth disturbance (PFGD), following treatment for developmental dysplasia of the hip (DDH) remains poorly defined. In addition to limited reliability, it has been our experience that some radiographic features attributed to AVN/PFGD may be present prior to surgery. The purpose of this study was to determine the baseline prevalence of radiographic features suggestive of PFGD in a diverse cohort of patients with surgically treated DDH.Methods: The prospectively collected database for an international multicenter study group was retrospectively queried for patients who underwent surgery for DDH with minimum 1-year radiographic and clinical follow-up. Preoperative radiographs were evaluated for findings typically used to define PFGD at follow-up. Development of actual AVN/PFGD was determined by consensus review of follow-up radiographs by three experts separate from this study. These experts (KM, CP, WS) were specifically selected by the study group to evaluate all patients in the database for development of AVN/PFGD. This occurred prior to the conception of this study.Results: 145 patients were evaluated, with median preoperative age of 16.8 months (IQR:10.7-25.60). The proportion of patients with initial International Hip Dysplasia Institute (IHDI) grades of 2, 3, or 4 was 18%, 32%, and 50%, respectively. Prior to surgery, 20 hips (14%) had a heterogenous or “fragmented” epiphysis. Eight of the 145 epiphyses (6%) were significantly ellipsoid in shape. Depending on the definition, between 5-10% of hips had a wider neck at baseline compared to the contralateral, normal hip. At final follow-up, 42% of the hips were determined to have PFGD based on consensus review. Of all the patients that were considered to have PFGD at follow-up, 59% of patients had one feature of PFGD at baseline, and 20% had two or more.Conclusions: The current study suggests that several factors used to define the development of PFGD following DDH surgery may be present prior to surgical intervention. Our data demonstrates that 20% of the patients who develop AVN have at least two markers of PFGD, per Salter criteria, prior to receiving any treatment. This suggests that some of these hips may not be morphologically “normal” at baseline and adds to the mounting body of evidence about the limitations of the Salter classification for AVN.Level of Evidence: Level 2 - Prospective cohort study Key Concepts•Avascular necrosis classification systems in infantile DDH historically have had limited reliability and can be better thought of as proximal femoral growth disturbance (PFGD).•Our study demonstrated that approximately 20% of the patients who were found to have postoperative PFGD/AVN actually had signs of proximal femoral growth disturbance prior to surgery.•These findings suggests that some hips undergoing surgery for DDH may not be morphologically “normal” at baseline and add to the mounting body of evidence about the limitations of the Salter classification for AVN.

Does the use of i-FACTOR bone graft affect bone healing in those undergoing periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH)? A retrospective study.

The aims of this study were to compare, in patients with and without the use of i-FACTOR bone graft during periacetabular osteotomy (PAO) surgery for developmental dysplasia of the hip (DDH), (i) bone healing at six-weeks post-operatively (ii) rate of complications. This was a retrospective review of case records. Participants were people aged 15-50 years undergoing rectus-sparing minimally invasive PAO surgery for DDH. Group 1: patients with i-FACTOR, Group 2: No i-FACTOR. The primary outcome was the rate of bone healing on radiographs at 6 weeks. The likelihood of bone healing was compared using logistic regression with Generalised Estimating Equations (GEE) and expressed as odds ratios (95% confidence intervals (CIs; P < 0.05)). The occurrence of complications was extracted from surgical records. The i-FACTOR group had 3-times greater odds of partial/full union than those without [adjusted odds ratio (95% CIs, P-value)]: [3.265 (1.032 to 10.330, P = 0.044)]. The i-FACTOR group had 89% partial/full union at 6-weeks, compared to 69% of the non-i-FACTOR group. Half of the patients had leaking of bone graft in the i-FACTOR group versus 10% in the non-i-FACTOR group, 26% of the i-FACTOR group and 12% of the non-i-FACTOR group had neuropraxia of the lateral femoral cutaneous nerve (LFCN). Complication rates were low, and similar between groups. However, the rate of LFCN neuropraxia and bone graft leakage was higher in the i-FACTOR. These findings should be confirmed in a future prospective randomised clinical trial and include outcomes such as pain and quality of life.

274 The Accuracy of Clinical Coding of Developmental Dysplasia of The Hip (DDH) Operations

Abstract Aim: To assess the accuracy of clinical coding of developmental dysplasia of the hip (DDH) operations Method 106 children underwent surgery for DDH at our turst from 1997 to 2018. Our coding department was sent a list of patients and operation dates and asked to tabulate data on what each operation had been coded as. We compared what each operation was coded as with the procedure actually performed (as per operation notes, clinic letters and intra-operative fluoroscopy images). Results Of the 106 patients included in our study, 128 operations were performed. 36 out of 128 (28%) of operations were coded incorrectly. The commonest error was that closed reduction was missed from coding (n = 13). Seven patients did not have their femoral osteotomy coded. Seven patients had a closed reduction incorrectly labelled as an open reduction. Four patients had pelvic osteotomies that were not coded. Two patients had open reductions that were not coded. Conclusions We have shown that an unacceptably high number of DDH operations are being coded for incorrectly. This has clear cost implications for the trust. This study questions the use of retrospective coding data in audit and research and suggests inaccuracy when considering the surgical outcomes of developmental dysplasia of the hip.

Investigation of sensory nerve endings in pulvinar, ligamentum teres, and hip joint capsule: A prospective immunohistochemical study of 36 cases with developmental hip dysplasia.

The aim of this study was to immunohistochemically identify and characterize the presence of sensory nerve endings (SNEs) in pulvinar, ligamentum teres (LT), and hip joint capsule (HJC) of children with developmental dysplasia of the hip (DDH). Pulvinar, LT, and HJC specimens were obtained from 38 hips of 36 children (31 girls, five boys; mean age=49 months; age range=18-132 months) during open reduction surgery for DDH. All specimens underwent subsequent routine tissue processing (formalin fixation and paraffin embedding). To determine tissue morphology, haematoxylin and eosin staining was used. SNEs were analyzed immunohistochemically using a mouse monoclonal antibody against S-100 Beta Protein based on the classification of Freeman and Wyke including four types of SNEs including mechanoreceptors: type I Ruffini corpuscles, type II Pacini corpuscles, type III Golgi organs, and type IVa unmyelinated free nerve endings (FNEs). Additionally, children were sorted into three groups based on their age at the time of surgery: Group 1 (age <3 years; 19 hips of 18), Group 2 (age: 3-5 years; 10 hips of 10 children), and Group 3 (age >5 years; 9 hips of 8 children). Although no Type I, II, or III SNEs were identified in any specimen, type IVa mechanoreceptor (FNEs) was immunohistochemically characterized in 13 (34%) pulvinar, 19 (50%) LT, and 16 (42%) HJC specimens. The total density of FNEs was 3.31±5.70)/50 mm2 (range 0-21) in pulvinar specimens, 3.18 ± 5.92)/50 mm2 (range 0-24) in HJC specimens, and 4.51±6.61/50 mm2 (range 0-22) in LT specimens. Furthermore, the operated side, gender, and the number of FNEs in specimens did not differ significantly among the age groups (p>0.05 for all), and the number of FNEs was not significantly correlated with age, gender, or the operated side (p>0.05 for all). Evidence from this study revealed that pulvinar, LT, and HJC include only FNEs, which play a role in pain sensation, among mechanoreceptors. Surgical excision of these tissues may not cause a significant loss of sensory function in the hip joint of children with DDH. Level II, Therapeutic Study.

Evaluation of Dislocation Risk Factors With Total Hip Arthroplasty in Developmental Hip Dysplasia Patients: A Multivariate Analysis

BackgroundThis study aimed to investigate the risk factors for dislocation in patients diagnosed with developmental dysplasia of the hip (DDH) who underwent total hip arthroplasty. MethodsWe retrospectively reviewed 40 patients who developed dislocation and compared them with 400 patients in the control group without hip instability. Patients-, surgery-, and implant-related factors were investigated. Risk factors were evaluated using multivariate logistic regression. ResultsThe mean follow-up period was 32.3 months. The mean time to dislocation was 4.4 months. There were 7 men (17.5%) and 33 women (82.5%) in the dislocation group and 83 men (20.7%) and 317 women (79.3%) in the control group (P = .627). Diabetes mellitus (DM; P = .032) and history of previous hip surgery for DDH were associated with dislocation (P < .001). The subtrochanteric shortening osteotomy (P = .001), acetabular inclination (P = .037), acetabular anteversion (P < .001), femoral head size (P < .001), and postoperative infection (P = .003) were associated with dislocation. Major predictors of hip dislocation after total hip arthroplasty in patients with DDH were previous hip surgery (odds ratio [OR], 6.76; 95% confidence interval [CI], 1.86-24.6; P = .004), high hip center (OR, 2.90; 95% CI, 1.31-6.38; P = .008), DM (OR, 2.68; 95% CI, 1.06-6.80; P = .037), and acetabular inclination (OR, 2.62; 95% CI, 1.09-6.26; P = .03). ConclusionPatients with DM and previous hip surgery should be informed about increased dislocation rates. Using a larger head diameter and restoration of the true hip rotation center are essential to prevent hip dislocation in these patients. Furthermore, accurate positioning of the acetabular inclination and anteversion are also important.

Revision of Failed Open Reduction of Developmental Dysplasia of the Hip.

BackgroundThe most common causes of re-dislocation after open reduction are inadequate exposure and failure to release the obstructing soft tissues inside and around the hip.MethodsThis clinical study included 33 consecutive children (34 hips) who underwent a revision surgery after failed open reduction of developmental dysplasia of the hip (DDH).ResultsAccording to the McKay clinical criteria, the results were good in 28 cases (82.4%), fair in 4 cases (11.8%), and poor in 2 cases with re-dislocation (5.9%). Radiological results according to the modified Severin criteria were as follows: 28 hips (82.4%) were identified as category 2 (good), 4 hips (11.8%) category 4 (fair), and 2 hips (5.9%) category 5 (poor).ConclusionsRevision surgery for DDH is demanding and the long-term consequences are usually serious, but stable, concentric reduction should be obtained either at the first or second open reduction by addressing the causes of failure. Failed acetabulum remodeling and technical errors with inadequate soft-tissue release were the most common causes of failure in the primary operation. Based on the results, the outcome of revision surgery after failed open reduction for DDH was good.

Universal or selective ultrasound screening for developmental dysplasia of the hip? A discussion of the key issues.

PurposeTo summarize recent developments and provide recommendations as to whether universal or selective programmes are advisable.MethodsA literature review was performed and preference given to studies with higher levels of evidence. All programmes reviewed included clinical screening.ResultsRecent studies underline the need for high quality screening programmes to promote the early detection of developmental dysplasia of the hip (DDH). A small number of cases may be missed clinically but with universal ultrasound screening programmes the late presentation rates appear to be virtually zero. Contemporary studies show treatment rates with universal screening programmes which are now lower than those with selective ultrasound. There is little agreement over the criteria used for selective programmes. Alternative outcome measures, such as the first operation rate or the percentage undergoing major (open) surgery are both lowest with universal ultrasound screening programmes. Furthermore, a significant reduction in the rate of surgery for DDH later in life was seen after the introduction of universal ultrasound screening, whereas the defined criteria for selective screening may not detect the majority of patients who require late surgery. Abduction bracing with modern orthoses is associated with a zero rate of avascular necrosis (AVN), whereas closed reduction techniques have an overall risk of 10%.ConclusionOn clinical grounds, if future studies confirm that hip abduction in flexible orthoses is not associated with AVN, it may be time for a paradigm shift of screening for DDH towards a universal ultrasound protocol. The costs associated both with each type of screening programme and with the management of late presenting cases are also important but may be secondary to clinical benefit.

An improved method for measuring hip abduction in spica after surgical reduction for developmental dysplasia of the hip.

PurposeExcessive in-spica abduction is a risk factor for oste-onecrosis after surgical reduction for developmental dysplasia of the hip (DDH). The traditional method for radiographically measuring hip abduction using axial imaging does not reflect the true angle, which usually lies in an oblique plane. The purpose of this study was to describe a novel method for measuring true hip position using advanced imaging.MethodsA trigonometric model was derived to define hip position based upon the femoral axis angular deviation from midline as measured on axial and coronal sequences of MRI studies. In-spica MRIs of 28 hips having undergone surgery for DDH were reviewed. On two separate occasions, the same three raters measured the femoral axis deviation from mid-line on axial and coronal imaging. Abduction was estimated using the traditional method of measurement and our novel method. Intra- and inter-rater reliability were assessed.ResultsThe methods yielded different estimates (p < 0.001). Inter- and intra-rater reliability were excellent for both methods (inter-rater ICC > 0.922, intra-rater ICC > 0.919). The traditional method is accurate at 90° of flexion, but it increasingly overestimates abduction as hip flexion decreases. All cases where hip flexion was ≤ 40° exhibited ≥ 10° of error.ConclusionsDecreasing hip flexion in spica modifies the perceived angle of abduction as measured using axial imaging. This inaccuracy can be overcome through assessment of orthogonal views using our new approach, which is accurate and reliable. It should be considered for future research investigating the effects of in-spica hip position on outcomes of DDH treatment.

Clinical and Radiographic Predictors for Worsened Clinical Outcomes After Hip Arthroscopic Labral Preservation and Capsular Closure in Developmental Dysplasia of the Hip

Background: Patients with developmental dysplasia of the hip (DDH) have a greater risk of acetabular labral tearing and joint instability, which predispose them to developing osteoarthritis. The arthroscopic management of DDH, however, remains controversial. Hypothesis: Specific clinical characteristics and radiographic parameters correlate with and predict a worsened clinical outcome after hip arthroscopic surgery for DDH. Study Design: Case control study; Level of evidence, 3. Methods: Of patients with DDH who underwent an arthroscopic procedure between March 2009 and June 2011, there were 28 hips in 28 patients (6 male and 22 female) that met the inclusion criteria. The mean patient age was 28.4 years. Clinical and radiographic follow-up evaluations up to a minimum of 2 years after surgery were performed for all patients. Failure of the procedure was defined as conversion to subsequent surgery or having a Tönnis osteoarthritis grade of 2 and modified Harris Hip Score (mHHS) that remained <85, and success was defined as patients who did not need subsequent surgery and had an mHHS >85. Univariate analysis and Cox hazard proportional analysis were performed on the 2 subpopulations. Results: There were 9 patients in the failure group (including 3 hips with T nnis grade 2) and 19 patients in the success group. In 22 of 28 patients, the mean mHHS significantly improved from 61.6 ± 18.8 (range, 12.0-85.0) preoperatively to 94.3 ± 7.0 (range, 73.7-100.0) at final follow-up, and the mean Non-Arthritic Hip Score (NAHS) improved from 56.2 ± 13.9 (range, 35.0-81.3) preoperatively to 92.7 ± 9.5 (range, 65.0-100.0) at final follow-up (P < .001, Wilcoxon signed-rank test). Univariate analysis showed that a broken Shenton line was significantly more prevalent in the failure group compared with the success group (8/9 [89%] vs 3/19 [16%] patients, respectively; P < .001). High-grade cartilage delamination (Multicenter Arthroscopy of the Hip Outcomes Research Network [MAHORN] grades 3-5) was significantly higher in the failure group than in the success group (8/9 [89%] vs 3/19 [16%] patients, respectively; P < .001). The median femoral neck-shaft (FNS) angle in the failure group was significantly higher than that in the success group (139° vs 134°, respectively; P = .01). Further, Cox hazard proportional analysis of the failure group showed that the predictors for a poor clinical outcome were the presence of a broken Shenton line, FNS angle >140°, center-edge (CE) angle <19°, body mass index (BMI) >23 kg/m2, acetabular cartilage damage (MAHORN grades 3-5), and cartilage damage of the femoral head (International Cartilage Repair Society grades 2-4). The most important predictors for a poor clinical outcome at the time of surgery were a broken Shenton line and an FNS angle >140°. Conclusion: Patients with a broken Shenton line, FNS angle >140°, CE angle <19°, or BMI >23 kg/m2 at the time of surgery are not good candidates for the arthroscopic management of DDH.

Etiology of the bifid (double) femoral head, with prior history of developmental dysplasia of the hip

Our patient presented with a double femoral head, that is, two separate heads with individual epiphyses, but a single contiguous metaphysis. Two similar cases had been described in the literature. The only common feature in these three cases is that they had open reduction for Developmental Dysplasia of the Hip (DDH) through an anterior approach. No other pathology was detected in these patients. A rabbit model was created in which the cartilaginous anlage of the rabbit femoral head was surgically split. After 2-4 weeks a bifid femoral head developed, mimicking that described in the literature. We suggest that inadvertent damage to the femoral head during surgery for DDH may in fact lead to the development of a bifid femoral head. Prior history of DDH should be considered when the isolated bifid femoral head is identified.

Evaluation of Experienced Surgeons’ Decisions Regarding the Need for Secondary Surgery in Developmental Dysplasia of the Hip

We aimed to evaluate experienced surgeons' decisions regarding the need for secondary surgery in developmental dysplasia of the hip (DDH) at 5 to 7 years of age. We selected 21 hips from 17 patients who had mid-term and skeletally mature radiographs and who had neither had complications nor secondary surgery until skeletal maturity after having an initial soft tissue surgery for DDH before the age of 18 months. Twenty experienced orthopaedic surgeons evaluated the mid-term follow-up radiographs of these hips in terms of their need for secondary surgery. On the basis of management grading of the observers at mid-term follow-up, the risk of unnecessary surgical management was 12% in hips that would eventually be normal at skeletal maturity. The risk of not performing needed surgery was 40% in hips that would eventually become dysplastic at skeletal maturity. Experience of the surgeons in terms of years had no significant effect on the management decisions. The center-edge angle, the acetabular index angle (AIA), percentage of femoral head coverage, Shenton line, and the acetabular angle of Sharp were the 5 most commonly used radiographic parameters at mid-term follow-up to assess whether a secondary surgery would be needed. Center-edge angle, AIA, femoral head coverage, and Shenton line correlated, whereas the acetabular angle did not significantly correlate with surgeons' quantitative management decisions on the basis of mid-term radiographs. Experienced surgeons are more likely to opt for nonoperative management in hips that show no ischemic changes or instability at 5 to 7 years of age even in the presence of slightly abnormal radiographic measurements. AIA is considered the best radiographic parameter for making decisions regarding the need for secondary surgery in DDH at 5 to 7 years of age. Level II prognostic study.

MRI after operative reduction with femoral osteotomy in developmental dysplasia of the hip

The use of MRI scanning has been described after open reduction of the hip in developmental dysplasia of the hip (DDH) to check hip position, but has not previously been reported after open reduction with femoral osteotomy and the use of metalwork. We report a prospective study to determine whether MRI scanning can be used to confirm satisfactory reduction of the hip following surgery for DDH, even in the presence of metalwork in the proximal femur. MRI scans were performed in 12 consecutive children, and all gave diagnostic information indicating satisfactory reduction. Sedation was not required and the mean scanning time was 3 min 45 s. Satisfactory images, the lack of need for sedation, comparable time and cost to CT scanning and most importantly the lack of exposure of the child to ionizing radiation make MRI a most appealing method for imaging. We therefore recommend it as the investigation of choice in this patient group.

Incidence of Surgery in Developmental Dysplasia of the Hip in Taiwan

Early detection and treatment for developmental dysplasia of the hip (DDH) by screening in nursery has been recommended for several decades. With the recent survey of high prevalence of surgery for DDH in Taiwan, it has raised issues of the effectiveness of baby hip screening. National Health Insurance covers 97% of the 22 million population in Taiwan. From the databank, we retrieved children who were admitted from birth to 5 years of age, with the diagnosis of DDH (International Classification of Disease version 9 [ICD-9] code 754.3x) or had had one of the treatments for DDH (ICD-9 code 77.39, 79.75, 79.85, 88.32) between 1997 and 2004. There were 1229 children undergoing surgeries for DDH in this study. A total of 1097 of them were female (89%). The mean age at the first surgery was 1.7 years. Major operation, open reduction with or without osteotomy, accounted for 85% of the cases. The number of children who were born between 1997 and 1999 and who had surgery for DDH were 160, 129 and 134, respectively. Incidences of surgery for DDH among these 3 cohort years were 0.49, 0.48 and 0.47 per thousand live births, respectively. The incidence of DDH in Taiwan was reported as 1.2 per thousand, so 40% of the DDH children underwent surgery. However, with 87% of surgeries occurring after walking age, it is reasonable to postulate that the screening program was not performed accurately or universally. The rate of major procedures in surgical cases of DDH is a better indicator for the effectiveness of mass screening.

Differences in risk factors between early and late diagnosed developmental dysplasia of the hip

Background: Developmental dysplasia of the hip (DDH) is common, affecting 7.3 per 1000 births in South Australia. Clinical screening programmes exist to identify the condition early to gain the maximum...

Splintage in Developmental Dysplasia of the Hip: How Low Can We Go?

The indications for using abduction splints in developmental dysplasia of the hip (DDH) are not clearly defined. In this study, the authors prospectively evaluated 797 babies born between 1996 and 1998 as part of a limited targeted ultrasound screening program. In the first group (1996-97), babies with clinical hip instability at first scan were placed in a Pavlik harness. In the second group (1998), only babies who had persistent instability at 2 weeks were splinted. Children with persistent major dysplasia at 9 weeks were splinted in both groups. The splintage rate was 1.6/1,000 live births in the first group and 0.8/1,000 live births in the second group. The rate of surgery for DDH did not increase despite a significant decrease in the number of babies being splinted. This study demonstrates that a splintage rate as low as 1.3/1,000 live births (average rate for 1996-98) can be achieved without adversely affecting the outcomes following treatment of DDH.

Cost-effectiveness of Alternative Screening Strategies for Developmental Dysplasia of the Hip

To compare the cost-effectiveness of adding either a general or a selective ultrasound screening program to the routine clinical examination for developmental dysplasia of the hip (DDH) with use of the data from a large, randomized study of 11,925 newborns. Our previous study comparing the clinical outcomes of three strategies for screening infants for DDH suggested (but results were not statistically significant) that general ultrasound screening resulted in fewer children requiring hospitalization and surgery for DDH than did a strategy based on ultrasound screening of the 11.8% of infants considered to be at increased risk of DDH or one with no ultrasound screening. General ultrasound screening led to early splinting of 3.4% of the newborns compared with 2.0% for the selectively screened group and 1.8% for the group not receiving ultrasound screening. Using these data, we decided on sequences and intervals of diagnostic and therapeutic actions considered to be sufficient for each regimen. We applied estimates of the costs of screening, treatment of DDH discovered early and late, and follow-up examinations to arrive at total program costs for each strategy. Total program costs were similar for each of the three screening strategies (costs varied by < 5%). However, treatment of late cases accounted for only 22% of total costs in the group undergoing general screening vs 65% in the two latter groups. The cost estimates were sensitive to several variables. Application of the data to a hypothetical ultrasound program in which all girls and only boys at increased risk for DDH underwent an ultrasound examination showed substantially reduced total program costs. Application of costs from other centers to our data regarding frequency of clinical outcomes may yield different comparative program costs. If the findings of our clinical study can be generalized to other centers, a strategy of screening all girls and boys with risk factors for DDH may be the most cost-effective approach.