Home publikacje Screening ultrasound of the Infant Hip
1).Screening ultrasound of the Infant Hip PDF Drukuj Email

1): Orthopade. 2008 Jun;37(6):541-549. Links
[Hip ultrasound screening in Germany : Results and comparison with other screening procedures.]
[Article in German]
Ihme N, Altenhofen L, von Kries R, Niethard FU.
Abteilung Orthopädie und Unfallchirurgie, Schwerpunkt Orthopädie, Universitätsklinikum, Pauwelsstraße 30, 52074, Aachen, Deutschland, Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć. Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć. .
General ultrasound screening programmes to determine DDH are still a matter of discussion due to a lack of evidence. To facilitate further discussions this review gives an overview of the international data and literature concerning the different screening policies taking into account the results of the German evaluation study from 1997 to 2002.General ultrasound screening programmes are established in Germany and Austria. The analysis of the German screening showed 535 cases of DDH with first operative procedure (age 10 weeks to 5 years) that were treated as inpatients: 66% underwent a closed reduction, 11% an open reduction and 23% an osteotomy of the acetabulum/femur. The number of children who had no ultrasound of the hip before diagnosis decreased from 22% in the first year to 8% in the last. The first ultrasound examination was without pathological findings in 12% of the cases.Capture-recapture estimates suggested that 52% of cases were reported, so that the incidence for first operation due to DDH was 0.26 per 1,000 live births in 1997. This is much lower than in other countries and 4/5 less than the time before screening with ultrasound in Germany. At most 42% of the cases might be preventable by an improvement of the screening programme, but at least 51% would not be prevented. The German ultrasound screening programme has proved to be effective. Improvement of economic efficiency is still possible. Therefore, the German programme with different screening times can be recommended.

The southern Bavarianpopulation analysed for the capture-recapture estimateconsisted of 7•5% of all livebirths in Germany (yearlylivebirth rate in southern Bavaria of 60 000 comparedwith an average yearly livebirth rate in Germany of780 000) and 7•1% of the cases observed.Other important results were that 19% of children whowere screened within the recommended timeframe hadnormal findings despite being actual cases, with no
evidence of geographical clustering of those cases with anormal ultrasound.

Initially, 7% of children had a recommendation for treatment.20 By 2000,this percentage was reduced to 5%. High indications fortreatment in relation to ultrasound screening (3•1%)havebeen reported,21 whereas rates for defined treatment(Pavlik Harness) have been noted to be as low as 0•24 %.22Unfortunately, there are no data for conservativetreatment rates for developmental hip dysplasia (eg,splinting) in Germany. In a Swedish municipality, clinicalscreening resulted in treatment rates of 0•6–3•5%. 23 If allrecommendations for treatment were followed by
splinting or other invasive treatments, the rate ofovertreatment would be unacceptably high.24 This issue of
potential overtreatment and side-effects of treatmentshould be addressed.


2)Orthopa¨de (1997) 26: 25–32 Ó Springer-Verlag 1997Hip screening in AustriaF. Grill and D.Mu¨ ller
The role of hip sonography in neonatalhip screening is still a controversialmatter. This paper reportsthe results of the Austrian ultrasound
hip screening program, inwhich all Austrian babies undergohip sonography twice: at the birthclinic during the 1st week of life
and at an age of 12–16 weeks. Datafrom all public health insurancecompanies since 1985 and all ICDdata about children hospitalized
because of CDH in Austria werecollected and analyzed. The rate ofsonographically pathological hipswas 6.57% (1994). The treatment
rate before introduction of hipsonography was 13.16% (1985).The rate of open reduction wentdown to 0.24 per 1000 newborns,
including a high number of unscreenedchildren born abroad andalso children with teratological dislocationof the hip
. Hip sonography
screening proved to be effective indetecting true instability of the hipjoint as well as dysplasia. The optimaltime for sonographic screening
does not seem to be immediatelyafter birth when only “high risk”hips (clinical instability, positivefamily history, breech delivery)
should undergo hip sonography,but at an age between 4 and6 weeks when the hip has alreadyshown its true nature. Since one
sonographic scan appears to be sufficientfor screening, a further reductionof costs could be accomplished.Disability owing to DDH
can be avoided in a number ofcases, and costs for conservativeand surgical treatment as well asfor later endoprostheses and early
retirement can be economized.Key wordsHip ultrasound – Neonatal screening– Austrian data analysis

3) Acta Orthop Traumatol Turc. 2007;41 Suppl 1:6-13. Links
[The use of ultrasonography in developmental dysplasia of the hip]
[Article in Turkish]
Graf R.
Allgemeines und Orthopädisches Landeskrankenhaus Stolzalpe Stolzalpe, 8852 Stolzalpe, Austria. reinhard.graf@lkh-stolzalpe.at Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
Approach to hip sonography in Europe differs considerably from that in the USA, with different examination techniques and, therefore, discrepant results. The method used in Austria, Switzerland, Germany, and other countries is strictly standardized, reproducable, and out of the experience and skill of the examiner. Open reductions have been reduced to 0.13/1000 newborn babies in Austria, and to 0.26/1000 in Germany. This is the lowest rate which ever has been reported in the world. Costs for screening and treatment are three times lower than in the presonography era. These improvements result from training given by authorized teachers, implementation of ultrasonography screening program within the first six weeks of life, and planning treatment according to the sonography types.

4) Experiences in diagnosis and treatment of hip dislocation and dysplasia in populations screened by the ultrasound method of Graf
G. Kohlera, A. K. Hellb
a Klinik fur Orthopadie und Traumatologie des Bewegungsapparates des Kantonsspitals Frauenfeld,Frauenfeld
b Kinderorthopadie des Universitatskinderspital beider Basel (UKBB), Basel
The Graf ultrasound hip screening procedure[3, 4] was introduced in Switzerland in the early
. Today, approximately 80% of all neonatesin German-speaking Switzerland are screened accordingto this method [6, 9]. The screening rateis clearly lower in the French-speaking areas. The
Graf hip screening procedure, which is performedfor the first time when the infant is 6–8 weeks old,
aims at the early identification of hip dysplasia andhip dislocation in order to administer adequate
treatment according to the degree of severity (forstable dysplastic hips: abduction splinting; for unstablehips: closed reduction, hip-leg plaster cast;for dislocated hips: overhead extension, closed reduction,hip-leg plaster cast) [2, 10]. Reports in theliterature have confirmed that more rapid healingwith less invasive treatment methods is achieved iftreatment can commence as early as possible [5, 11,14]. Despite all efforts cases repeatedly occur inwhich there has been delayed or missed diagnosisof hip dysplasia and dislocation (IV congenitaldisorders 183) or which have required furtherpaediatric-orthopaedic treatment despite timelysonographic investigation. The causes behind thisphenomenon are analysed in this study, which wasinitiated by the Swiss Group of Paediatric OrthopaedicSurgeons (SGPO).Ultrasound investigation of the hip accordingto Graf is performed, whenever possible, as a routinescreening test for hip dysplasia and dislocationin neonates. However, in spite of screening, hipdysplasia and/or dislocation is identified in a numberof children after the third month of life only.The present study presents an analysis of reasonsand causes. Between August 1999 and July 2001children aged between six months and five yearswere documented, in whom the diagnosis of hipdysplasia or dislocation was made, despite normalultrasound findings at primary investigation andwho required non operative or operative treatmentby a specialist surgeon working in Switzerland inpaediatric orthopaedics. The study included 26children (17 girls / 9 boys). Hip dysplasia and/ordislocation was diagnosed between the age of 6days and 41 months. Twelve children had to be excludedfrom the sample (n = 26), four were infantswho had basic neurological disorders or multiple
anomalies and there were eight children fromabroad whose original documentation could not be
obtained.Analysis of the remaining 14 children showedthat 43% were misdiagnosed (n = 6) and a treatmenterror occurred in 36% (n = 5) of cases. Onechild presented with a teratogenic hip dislocation.
In two other infants with normal primary ultrasoundfindings, hip dysplasia was identified radiographicallyonce the child started to walk.Delayed diagnosis can be the result of technical
errors or misinterpretation
. The six patientsmeeting the criteria of misinterpretation can be expressed
as a rate of 0.04% of all births.
However,even if the disorder is correctly diagnosed, its identification
and treatment may be inadequate or failto produce the desired results. This was the case
for five of the children, that is, for a rate of 0.03%of births.
Key words: missed hip dysplasia; hip dislocation;
ultrasound; delay

5) BMJ 2005;330;1413; originally published online 1 Jun 2005;
Nerys F Woolacott, Milo A Puhan, Johann Steurer and Jos Kleijnen

Ultrasonography in screening forewborns: systematic reviewevelopmental dysplasia of the hip inAbstract
Objective To assess the accuracy and effectiveness of thescreening of all newborn infants for developmental dysplasia of
the hip (DDH) using ultrasound imaging, as is standard practicein some European countries but not in the United Kingdom,
the United States, or Scandinavia.Design Systematic review.Data sources Twenty three medical, economic, and grey
literature databases (to March 2004), with no limitations ofdesign or language; some references were provided by experts.
Selection of studies Only diagnostic accuracy studies andcomparative studies condcted in an unselected newborn
population were eligible for the review. Two reviewersindependently selected the studies and performed the quality
assessment.Results The review identified one diagnostic accuracy study,and this was of limited quality. In this study the reference
standard was treatment up to age of 8 months or an abnormalultrasound finding at age 8 months. Ultrasound screening had a
sensitivity of 88.5% (95% confidence interval 84.1% to 92.1%),specificity of 96.7% (96.4% to 97.4%), a positive predictive value
of 61.6% and a negative predictive value of 99.4%. Ten studiesevaluated the impact of ultrasound in screening, but these too
had various methodological weaknesses, limiting the reliabilityof their findings. Compared with clinical screening, general
ultrasound screening in newborns may increase overallreatment rates, but ultrasound screening seems to be
associated with shorter and less intrusive treatment.
Conclusions Clear evidence is lacking either for or against
general ultrasound screening of newborn infants for DDH.Studies that investigate the natural course of the disorder, the
optimal treatment for DDH, and the best strategy forultrasound screening are needed.

However, a systematic review of English languageobservational studies reported that 20% to 100% of infants who
had had abduction therapy eventually required surgery.10Recently published surveillance data collected over five years in
Germany showed that although the incidence of first operativeprocedures for DDH was low (at 0.26 per 1000 live births), 55%
of children having a first operative procedure had been detectedby the early ultrasound screening programme31; these children
therefore represent a degree of failure of the available conservativetreatment. This experience is reflected in that reported in a
UK study, which found that all children with abnormal hipradiographs at age 2 years had started treatment before the age
of 8 weeks and that overall 12% of all children treated withabduction splinting before the age of 8 weeks subsequently
required surgery.11 These data would suggest some publicationbias in observational studies of ultrasound screening in which
the reported success rates of treatment are much higher.32Our review has been unable to provide information on the
adverse effects of general ultrasound screening—either of thetreatment or of the screening programme as a whole. Of the 10
studies we identified, none properly assessed adverse events. Thisis an important omission as avascular necrosis has been reported
in 1-4% of all treated infants.10 Pressure sores, epiphysitis, femoralnerve palsy, inferior dislocation of the hip, and medial instability
of the knee joint have also been reported,10 and potentialpsychological problems must be considered.33 34
Our review has confirmed the conclusions

6) org20 Pickering Street, Needham, MA 02492-3157The Journal of Bone and Joint SurgeryCOPYRIGHT © 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED2472
Economic Evaluation ofltrasonography in the Diagnosisnd Management of Developmental
Hip Dysplasia in the United Kingdom and Ireland

Investigation performed at Department of Public Health, Health Economics Research Center,
University of Oxford, Headington, Oxford, United Kingdom
Background: Clinical neonatal hip screening is performed to identify hip instability and the increased risk of later hip
subluxation and dislocation. However, there is minimal information regarding the costs of such screening to parents
and health services. The aim of this study was to assess these costs in association with the use of ultrasonography
for the diagnosis and management of neonatal hip instability.
Methods: We conducted a prospective economic analysis in conjunction with a randomized clinical trial (the Hip
Trial), for which 629 patients were recruited from thirty-three centers in the United Kingdom and Ireland to be randomized
to undergo either ultrasonographic hip examination (314 patients) or clinical assessment alone (315 patients).
Information on clinical outcomes was obtained from hospital records and records from the Hip Trial. Resource information
was obtained from hospital records and from repeated periodic cross-sectional surveys of the families. Typical
unit costs were applied to resource information to obtain a cost per patient, and the mean costs in the two study
groups were calculated and compared.
Results: The average overall health-service cost per patient (and standard deviation) was $1298 ± $2168 in the ultrasonography
group and $1488 ± $2912 in the group that underwent clinical assessment alone, a net difference of
–$190 (95% confidence interval, –$630 to $250). Families in which the infant was examined with ultrasonography
had significantly lower costs associated with splinting: $92 compared with $118 in the group that underwent clinical
assessment alone, a mean difference of –$26 (95% confidence interval, –$46 to –$6). Costs associated with surgery
and total costs to the family were also slightly, but not significantly, lower in the ultrasonography group.
Conclusions: Our results suggest that use of ultrasonography in the management of neonates with clinical hip instability
is unlikely to impose an increased cost burden and may reduce costs to health services and families.

Level of Evidence: Economic and decision analysis, Level I. See Instructions to Authors for a complete description
of levels of evidence.

7) doi:10.1016/S0929-8266(01)00145-8
Copyright © 2001 Elsevier Science Ireland Ltd. All rights reserved. Review article Paediatric hip—ultrasound screening for developmental dysplasia of the hip: a review Paolo Toma , , Maura Valle, Umberto Rossi and Giorgio Marré BrunenghiRadiology/Orthopaedy II. G. Gaslini Institute, Largo Gaslini 5, I-16148 Genova, Italy Available online 19 September 2001.

This paper will try to deal with the following questions: Which is the correct screening model for the developmental dysplasia of the hip (DDH)? What is the clinical significance of ‘sonographic’ DDH? Can overtreatment produced by ultrasound (US) screening cause a waste of resources and eventually morbidity? We reviewed the literature since January, 1996 through December, 2000. To compare our experience with the literature, we analysed the results of the US examinations of the hip performed in our Institute. Over 4 years of US screening 11 326 infants (22 652 hips), aged 3 days to 4 months, were examined consecutively. Sonographic hip findings were abnormal in 531 infants (4.7%). The screening showed 381 subjects (3.36% of the population) with a type IIa hip (bilateral or unilateral); 65% of these infants were normal at follow up and only 35% worsened. On the whole we treated 282 infants (2.5%). No open reduction was performed. Avascular necrosis appeared in 2/282 treated cases (1.06%). We support the routine generalised US screening of neonatal hips. The excess of doubtful cases and, consequently, of the extra referrals may be limited, and the overtreatment decreased to the lowest rates reported by optimisation of everyone's approach.

8): Tidsskr Nor Laegeforen. 2005 Aug 11;125(15):1998-2001. Links
[Ultrasound screening for hip dysplasia in newborns and treatment with Frejka pillow]
[Article in Norwegian]
Blom HC, Heldaas O, Manoharan P, Andersen BD, Soia L.
hchrbl@online.no Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
BACKGROUND: The prevailing strategy concerning ultrasound screening for DDH in newborns in Norway does not intercept all who should be treated. In recent years typical rates for hospital treatment of late hip dislocations in newborn have been 15-20 cases. By universal ultrasound examination, 10-20 % of the newborns present with "physiological immature" hips. By this we mean hips with subnormal ultrasound values that will normalise in the course of the neonatal period. An agreed basis of defined and standardised criteria in order to diagnose and treat physiological immature hips is required. We hope tat this study will contribute to the final solution to these questions. MATERIAL AND METHODS: Over the period 1 February 1998 through 2002 we had 2466 alive newborns at our hospital. 26 were directly transferred to another hospital, 130 were left out because of limited skills or inadequate training in ultrasound among temporary staff. The hips have been graduated morphologically in accordance with Graf's alpha angle. All newborns have been investigated by ultrasound and clinical examination with Ortolani/Barlow test 1-3 day after birth. Those with diagnosed dysplasia (alpha < 50 masculine) and those with positive clinic and physiological immature hip were immediately treated with Frejka pillow. Those with negative clinic and physiological immature hip were revaluated after 4 weeks by ultrasound, and those still immature were given Frejka pillow. Duration of pillow treatment was 4 months, followed by further clinically and radiological surveillance. All infants given the pillow treatment were clinically examined 2-3 months after they were able to walk without support, and again 1-5 years later radiologically. RESULTS: Of the newborn, 31 (1.3%) had a positive Ortolani/Barlow test. Among them, 7 had dysplasia, 20 immature hip; 4 were normal. Among the 2275 infants with normal clinic, 9 had dysplasia and 232 (10.9%) had at least one physiological immature hip. After 4 weeks, 26 still had immature hip by ultrasound evaluation. A total of 62 infants (2.7%) were treated with Frejka pillow. At the "walk alone" control and the radiological control 1-5 years later, there were no pathological findings, specially no sign of aseptic necrosis. In the total material we had 2 girls with late subluxations, detected at the age of 8 and 10 months. Both had normal clinic with an ultrasound immature hip at birth. They should have been followed up, but were missed, for uncertain reasons. Both attained normal hips after treatment. CONCLUSION: Our study of universal ultrasound screening for DDH of the hips in newborns shows that 1 % of the infants born with normal hips clinically still have physiological immature hips at the age of 4 weeks. Taking those into account as potentially dysplastic, it gives an overall treatment rate of 2.7%. Today, the only possible way to intercept those physiological immature hips that will not normalise is by universal ultrasound examination. For these children, early treatment with Frejka pillow is effective, without any risk of iatrogenic injury.


9): Srp Arh Celok Lek. 2007 Jul-Aug;135(7-8):428-39. Links
[Diagnostic and prognostic values of standard and dynamic ultrasound in early detection and treatment of developmental hip deformity]
[Article in Serbian]
Pajić M, Vukasinović Z.
INTRODUCTION: A clinical examination of a newborn infant is indispensable, but certainly insufficient for a diagnosis of developmental deformity of the hip (DDH) to be made. The use of the ultrasound in the diagnostics of DDH, beside the visualization and making the respective clinical findings objective, made possible verification (still without a distinction of the tissues) of the two basic categories of the primary condition of a newborn baby hips. OBJECTIVE: The purpose of this study was to find out the optimal methodological procedure for the early detection of DDH in newborn infants and sucklings. METHOD: During 2002 and 2003, at the Neonatal Department of the Clinic for Gynaecology and Obstetrics, Novi Sad, as well as at the Institute for Orthopaedic Surgery "Banjica" Belgrade, there were 4016 newborn infants examined, i.e. 8032 hips clinically and by ultrasound. The standard Graf's methodological procedure was applied completely, supplemented by the dynamic examination by pushing back and streching femora along, that is by the techniques of Couture and Harcke. RESULTS: In order to categorize the condition of the hip of a newborn infant, the sonographic classification of R. Graaf, Th. Harcke and D. Pajidćwas used. The ultrasound analysis demonstrated a frequency of the sonotype lI in 552 (13.08%) of the newborn infants, the sonotype lI in 2934 (73.00%), the sonotype iII+ in 481 (11.97%) and the pathological cases with sonotypes IlIg+42 (1.04%), lIl 17 (0.42%), IlII 15 (0.37%) and IV5 (0.12%). The total number of unstable critical, discentering and discentered cases of DDH was 79 (1.95%). The incidence of DDH was three times more frequent in girls, mostly bilateral; when unilateral, it was more frequent in the left one.T he results of the early treatment were uniformly excellent, but in two cases there was established osteochondritis of the first degree (Pavlik's harness 1, Von Rosen's splint 1). CONCLUSION: iIt as been proven that the clinical examination was inevitable, but insufficient for diagnosis of DDH.T he standard sonographic examination should be supplemented by provocative dynamic diagnostic procedures in all immature, at risk and discentering hips. By doing so, it is possible to differentiate prognostically the hips evolving to a spontaneous normalization from those striving to a progredient decentralization. For a sonographic diagnosis, the first three weeks are essential, but for therapy, the crucial is the sixth week.

10: Bratisl Lek Listy. 2007;108(6):251-4. Links
Developmental dysplasia of the hip. Prevention and real incidence.
Kokavec M, Bialik V.
University Department of Paediatric Orthopaedics, Comenius University, Childrens Hospital, Bratislava, Slovakia. kokavecm@hotmail.com Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
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).

11: Acta Paediatr. 2002;91(8):926-9. Links
Neonatal hip instability: results and experiences from ten years of screening with the anterior-dynamic ultrasound method.
Andersson JE.
Department of Paediatrics, Blekingesjukhuset, Karlskrona, Sweden. john.andersson@blf.net Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
AIM: To record the results and experiences from a 10-y screening period with the anterior-dynamic ultrasound method for detecting neonatal hip instability. METHODS: An ultrasonographic improvement of the Palmén/Barlow test was used. The screening programme included 22,047 newborns. Decisions about treatment were made solely on the ultrasound result. RESULTS: It was found that 175 infants (7.9/1000) had at least one unstable hip--dislocated or dislocatable. Dislocated hips were found in 1.1/1000. Dislocatable hips were found in 6.8/1000 but only 1.1/1000 needed treatment. The total frequency of treatment was 2.2/1000. All cases but one were diagnosed before discharge from the maternity ward. The rate of surgery was 0.1/1000 newborns. Girls were more affected than boys, by a ratio of 3:1. Among the affected hips 64.4% were a left hip. CONCLUSION: Neonatal hip instability is always present at birth and can be diagnosed immediately after birth. We have no indications that instability can appear at a later stage. The anterior-dynamic ultrasound screening programme is an efficient tool to diagnose neonatal hip instability and to decide when to begin treatment.

12: Swiss Med Wkly. 2003 Sep 6;133(35-36):484-7. Links
Experiences in diagnosis and treatment of hip dislocation and dysplasia in populations screened by the ultrasound method of Graf.
Kohler G, Hell AK.

Klinik für Orthopäde und Traumatologie des Bewegungsapparates des Kantonsspitals Frauenfeld. gregor.kohler@stgaug.ch Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
Ultrasound investigation of the hip according to Graf is performed, whenever possible, as a routine screening test for hip dysplasia and dislocation in neonates. However, in spite of screening, hip dysplasia and/or dislocation is identified in a number of children after the third month of life only. The present study presents an analysis of reasons and causes. Between August 1999 and July 2001 children aged between six months and five years were documented, in whom the diagnosis of hip dysplasia or dislocation was made, despite normal ultrasound findings at primary investigation and who required non operative or operative treatment by a specialist surgeon working in Switzerland in paediatric orthopaedics. The study included 26 children (17 girls / 9 boys). Hip dysplasia and/or dislocation was diagnosed between the age of 6 days and 41 months. Twelve children had to be excluded from the sample (n = 26), four were infants who had basic neurological disorders or multiple anomalies and there were eight children from abroad whose original documentation could not be obtained. Analysis of the remaining 14 children showed that 43% were misdiagnosed (n = 6) and a treatment error occurred in 36% (n = 5) of cases. One child presented with a teratogenic hip dislocation. In two other infants with normal primary ultrasound findings, hip dysplasia was identified radiographically once the child started to walk. Delayed diagnosis can be the result of technical errors or misinterpretation. The six patients meeting the criteria of misinterpretation can be expressed as a rate of 0.04% of all births. However, even if the disorder is correctly diagnosed, its identification and treatment may be inadequate or fail to produce the desired results. This was the case for five of the children, that is, for a rate of 0.03% of births.

More recent specialist literature considers screeningf neonates as early as possible to be ideal [1–3,7, 11, 12].

13.Our three-year experience with an ultrasonographic hip screeningp rogram conducted in infants at 3 to 4 weeks of age
Üç-dört haftal›k bebeklerde yürütülen ultrasonografik kalçataramas› program›nda üç y›ll›k deneyimimiz
Nusret KOSE,1 Hakan OMEROGLU,2 Bulent OZYURT,3 Nevbahar AKCAR,4Abdurrahman OZCELIK,5 Ulukan INAN,1 Sinan SEBER1
Eskiflehir Osmangazi University Faculty of Medicine, 1Department of Orthopaedics and Traumatology, 4Department of Radiology;
2Ufuk University Faculty of Medicine, Department of Orthopaedics and Traumatology; 3Eskiflehir State Hospital, Clinics of Orthopaedics
and Traumatology; 5Private Eskiflehir Anadolu Hospital, Clinics of Orthopaedics and TraumatologyObjectives: The aim of this study was to evaluate the resultsof a newborn ultrasonographic hip screening program conductedat 3-4 weeks of life, and to assess its utility and feasibility
in Turkey.Methods: During a three-year period, parents of 1440 newbornsere interviewed within 48 hours following birth to be
informed in detail about developmental dysplasia of the hipDDH) and its risk factors. They were asked to bring their
infants for clinical and ultrasonographic examinations of theips 3 to 4 weeks after birth.results: A total of 975 infants (67.7%;
488 girls, 487 boys;mean age 26 days; range 17 to 34 days) were available on theday of screening. According to the Graf’s classification, 1664
hips (85.3%) were considered type I. Immediate treatment wasinitiated for 22 hips (1.2%) which were considered type IIc, D,
or IIIa. All but one hip were found to be type I after eight weeksof treatment. Among type IIa hips with a complete follow-up,
12% required treatment. In total, 45 hips (2.3%) of 35 infants(3.6%) were treated preferably with a Pavlik harness. Of these,
10 infants (28.6%) had at least one risk factor for DDH, themost common being a positive family history (n=7, 20%). Of 45
treated hips, 12 hips (26.7%) exhibited positive clinical findings,the most common being asymmetry of the thigh/inguinal folds.
C o nclusion: Ultrasonographic hip screening program conductedat the age of 3 to 4 weeks is effective for early diagnosis and
successful treatment of DDH. However, nearly one-thirds of theinfants were not available at the appointed date, despite transmission
of detailed inf rmation to the parents just after birth.Key words: Hip dislocation, congenital/therapy/ultrasonography;
infant, newborn; neonatal screening; risk factors


14)British Society for Children's Orthopaedic Surgery
Glasgow, Scotland: June 2007
President: Professor N. M. P. Clarke

P. Nunag; R. Duncan; and N. Wilson
The Royal Hospital for Sick Children, Glasgow
Aim: To assess the efficacy of selective ultrasound screening for DDH, with and without an orthopaedic examination.
Method: From 2002 our secondary DDH screening program was changed. Newborns with risk factors were referred directly for hip ultrasound. The orthopaedic surgeon was not involved if ultrasound was normal. An audit for 1997–2001 found an average annual incidence of 0.57(29 cases). The audit was extended to 2005 by identifying late DDH cases presenting from 2002 onwards, using the same criteria.
Results: Ninety-six cases were identified. After excluding children born outside Glasgow 36 cases were left for audit. The yearly incidence per 1000 live-births is shown below. The average incidence for 2002–2005 was 0.95. No significant difference between the two periods was found (p= 0.3).
Average age at diagnosis was 14.9 months. Two had risk factors but had not been screened. Thirty-one hips were dislocated, two were subluxed and one had borderline dysplasia that resolved. Twenty needed open reduction. Sixteen of 22 patients over 1 year at treatment required open reduction compared to 5 of 13 treated age 1 year or less (p = 0.046). Ten had femoral osteotomy, five a pelvic osteotomy, and five both femoral and pelvic osteotomy. There was one postoperative infection.
Conclusion: Direct ultrasound screening of infants with risk factors without concomitant assessment by an orthopaedic surgeon has not significantly altered the incidence of late DDH.
Correspondence should be addressed to: Mr J. B. Hunter, BSCOS, c/o BOA, The Royal College of Surgeons, 35–43 Lincoln’s Inn Fields, London WC2A 3PE.

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