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3).Screening Clinical of the Infant Hip PDF Drukuj Email

Screening the newborn for developmental dysplasia of the hip: now what do we do?
Schwend RM, Schoenecker P, Richards BS, Flynn JM, Vitale M; Pediatric Orthopaedic Society of North America.
Section of Orthopaedics, Children's Mercy Hospital, Kansas City, MO, USA. 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.
Comment in:
• J Pediatr Orthop. 2007 Sep;27(6):605-6.
The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. Although evaluation of children with risk factors for DDH is important, most DDH occurs in infants who have no risk factors. For all infants, a competent newborn physical examination using the Ortolani maneuver is the most useful procedure to detect hip instability. Early treatment of an unstable hip with a Pavlik harness or similarly effective orthosis is effective, safe, and strongly advised. Despite having had normal newborn and infant hip examinations, there remains the possibility of a late-onset hip dislocation needing treatment in approximately 1 in 5000 infants.

No direct evidence that clinical screening for DDH, results in less surgery or better functional outcomes,althoug there was evidence that screening leads to earlier identification was found.

1)Developmental dysplasia of the hip Carol Dezateux, Karen Rosendahl
In its severest form, developmental dysplasia of the hip is one of the most common congenital malformations. The
pathophysiology and natural history of the range of morphological and clinical disorders that constitute developmental
dysplasia of the hip are poorly understood. Neonatal screening programmes, based on clinical screening examinations,
have been established for more than 40 years but their eff ectiveness remains controversial.
Whereas systematic
sonographic imaging of newborn and young infants has aff orded insights into normal and abnormal hip development
in early life, we do not clearly understand the longer-term outcomes of developmental hip dysplasia, its contribution
to premature degenerative hip disorders in adult life, and the benefi ts and harms of newborn screening. High quality
studies of the adult outcomes of developmental hip dysplasia and the childhood origins of early degenerative hip
disease are needed, as are randomised trials to assess the eff ectiveness and safety of neonatal screening and earlytreatment.

Lancet 2007; 369: 1541–52Centre of Epidemiology forChild Health, Institute of ChildHealth, London, UK(Prof C Dezateux FMedSci);
Section for Radiology,University of Bergen, Bergen,Norway; and Department ofImaging, Great Ormond StreetHospital for Children, London,
UK (Prof K Rosendahl PhD)Correspondence to:Prof Carol DezateuxMedical Research Council Centreof Epidemiology for Child Health,
Institute of Child Health,University College London,30 Guilford Street, LondonWC1N 1EH, UKc.dezateux@ich.ucl.ac.uk Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
Developmental dysplasia of the hip is an important cause of childhood disability. This disorder underlies up to 9%
of all primary hip replacements and up to 29% of thosein people aged 60 years and younger.In the past, without detection by screening,developmental dysplasia of the hip usually presented
clinically after walking age, and at least 50% of patientsstarted treatment by 5 years of age.121 The recognised
longer-term complications of untreated developmentaldysplasia of the hip include pain in the hip, knee, and
lower back; disturbances of gait; and degenerativechanges in the hip joint. However, the risk of such
complications is not well defi ned. Some reports suggestthat, without treatment, functional impairment due to
developmental dysplasia of the hip is common, and thatit increases with age but is not inevitable.42,121,122 When
followed up for an average of 50 years, 11–41% of thosewith untreated dislocation remained free of pain.42,121,122

2) Lancet. 1998 Apr 18;351 (9110):1149-52 9643684 (P,S,G,E,B) Cited:3
Surgery for congenital dislocation of the hip in the UK as a measure of outcome of screening. MRC Working Party on Congenital Dislocation of the Hip. Medical Research Council.
S Godward, C Dezateux
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

Findings The ascertainment-adjusted incidence of a firstoperative 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 tothe national orthopaedic surveillance scheme. In 112
(35%) children the diagnosis was made primarily as aresult of parental concern.

3) FAILURES OF SCREENING AND MANAGEMENT OF ONGENITAL DISLOCATION OF THE HIP
I. A. C. LENNOX, J. McLAUCHLAN, R. MURALI
From the Royal Aberdeen Children’s Hospital, Scotland
We report the screening of 67 093 infants for congenitaldislocation of the hip from 1980 to 1989 and comparethe results with those during the preceding two decades.More dislocations have been missed at neonatal examination during the last decade (0.13% of livebirths). Operative treatment was needed in 54 children(0.08% of live births) some of whom had been diagnosedat birth. We discuss the reasons for the failure ofneonatal screening.Boneloint Surg[Br] 1993;75-B:72-5.Received 11 May 1992; Accepted l2June 1992
Congenita ldislocation ofthe hip(CDH) is still potentiall ycrippling although Roser (1879), Le Damany (1912) andPutti (1927) showed that neonatal diagnosis and simplesplinting were successful as treatment. Ortolani described his test in 1937 and Barlow (1962) modified it for the dislocatable hip by applying posterolateral pressure. I twas thought that by screening every child at birth, usinga combination of these two tests, and splinting everyaffected child, the late results of congenital dislocationwould be eliminated.A regional service was started in Aberdeen in 1960,whereby every child born in the Grampian region ofScotland was screened at birth. Those thought to have evidence of CDH were referred to a special clinic for reexaminationand splinting if necessary. The result of this programme has, however, fallen short of the original expectations. Thirty years later, some children stillpresent for treatment long after the neonatal period,despite having been screened in a specialist clinic. Their prognosis may be worse than that before screening began,because the diagnosis is not suspected by doctors and health workers who believe that neonatal screening is fully effective

The value of any screening programme must be judged by its failures

 

 

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

________________________________________
ULTRASOUND SCREENING FOR DEVELOPMENTAL DYSPLASIA OF THE HIP WITHOUT ORTHOPAEDIC EXAMINATION: ITS EFFECT ON THE INCIDENCE OF LATE DIAGNOSED CASES.
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.


5) 1: Pediatrics. 2000 Apr;105(4):E57. Links
Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip.
Lehmann HP, Hinton R, Morello P, Santoli J.
Johns Hopkins University, Baltimore, Maryland, USA.
OBJECTIVE: To create a recommendation for pediatricians and other primary care providers about their role as screeners for detecting developmental dysplasia of the hip (DDH) in children. PATIENTS: Theoretical cohorts of newborns. METHOD: Model-based approach using decision analysis as the foundation. Components of the approach include the following: PERSPECTIVE: Primary care provider. OUTCOMES: DDH, avascular necrosis of the hip (AVN). OPTIONS: Newborn screening by pediatric examination; orthopaedic examination; ultrasonographic examination; orthopaedic or ultrasonographic examination by risk factors. Intercurrent health supervision-based screening. PREFERENCES: 0 for bad outcomes, 1 for best outcomes. MODEL: Influence diagram assessed by the Subcommittee and by the methodology team, with critical feedback from the Subcommittee. EVIDENCE SOURCES: Medline and EMBASE search of the research literature through June 1996. Hand search of sentinel journals from June 1996 through March 1997. Ancestor search of accepted articles. EVIDENCE QUALITY: Assessed on a custom subjective scale, based primarily on the fit of the evidence to the decision model. RESULTS: After discussion, explicit modeling, and critique, an influence diagram of 31 nodes was created. The computer-based and the hand literature searches found 534 articles, 101 of which were reviewed by 2 or more readers. Ancestor searches of these yielded a further 17 articles for evidence abstraction. Articles came from around the globe, although primarily Europe, British Isles, Scandinavia, and their descendants. There were 5 controlled trials, each with a sample size less than 40. The remainder were case series. Evidence was available for 17 of the desired 30 probabilities. Evidence quality ranged primarily between one third and two thirds of the maximum attainable score (median: 10-21; interquartile range: 8-14). Based on the raw evidence and Bayesian hierarchical meta-analyses, our estimate for the incidence of DDH revealed by physical examination performed by pediatricians is 8.6 per 1000; for orthopaedic screening, 11.5; for ultrasonography, 25. The odds ratio for DDH, given breech delivery, is 5.5; for female sex, 4.1; for positive family history, 1.7, although this last factor is not statistically significant. Postneonatal cases of DDH were divided into mid-term (younger than 6 months of age) and late-term (older than 6 months of age). Our estimates for the mid-term rate for screening by pediatricians is 0.34/1000 children screened; for orthopaedists, 0.1; and for ultrasonography, 0.28. Our estimates for late-term DDH rates are 0.21/1000 newborns screened by pediatricians; 0.08, by orthopaedists; and 0.2 for ultrasonography. The rates of AVN for children referred before 6 months of age is estimated at 2.5/1000 infants referred. For those referred after 6 months of age, our estimate is 109/1000 referred infants. The decision model (reduced, based on available evidence) suggests that orthopaedic screening is optimal, but because orthopaedists in the published studies and in practice would differ, the supply of orthopaedists is relatively limited, and the difference between orthopaedists and pediatricians is statistically insignificant, we conclude that pediatric screening is to be recommended. The place of ultrasonography in the screening process remains to be defined because there are too few data about postneonatal diagnosis by ultrasonographic screening to permit definitive recommendations. These data could be used by others to refine the conclusions based on costs, parental preferences, or physician style. Areas for research are well defined by our model-based approach.

6)Screening for Developmental Dysplasia of the Hip: recommendation Statement
US Preventive Services Task Force
The authors have indicated they have no relationships relevant to this article to disclose.
THE US PREVENTIVE Services Task Force (USPSTF) concludes that evidence is
insufficient to recommend routine screening for developmental dysplasia of
the hip (DDH) in infants as a means to prevent adverse outcomes (I recommendation).*
The pathophysiology and natural history of DDH are poorly understood. There
is evidence that screening leads to earlier identification; however, 60% to 80% of
the hips of newborns identified as abnormal or as suspicious for DDH by physical
examination and _90% of those identified by ultrasound in the newborn period
resolve spontaneously and require no intervention
. There is poor evidence (poorquality
studies) of the effectiveness of both surgical and nonsurgical interventions;
avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are
treated for DDH. Thus, the USPSTF was unable to assess the balance of benefits and
harms of screening for DDH but was concerned about the potential harms associated
with treatment of infants identified by routine screening.

7) 1: Pediatrics. 2000 Apr;105(4 Pt 1):896-905. Links
Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics.
[No authors listed]
Developmental dysplasia of the hip is the preferred term to describe the condition in which the femoral head has an abnormal relationship to the acetabulum. Developmental dysplasia of the hip includes frank dislocation (luxation), partial dislocation (subluxation), instability wherein the femoral head comes in and out of the socket, and an array of radiographic abnormalities that reflect inadequate formation of the acetabulum. Because many of these findings may not be present at birth, the term developmental more accurately reflects the biologic features than does the term congenital. The disorder is uncommon. The earlier a dislocated hip is detected, the simpler and more effective is the treatment. Despite newborn screening programs, dislocated hips continue to be diagnosed later in infancy and childhood,(1-11) in some instances delaying appropriate therapy and leading to a substantial number of malpractice claims. The objective of this guideline is to reduce the number of dislocated hips detected later in infancy and childhood. The target audience is the primary care provider. The target patient is the healthy newborn up to 18 months of age, excluding those with neur


8).J Pediatr Orthop. 2007 Sep;27(6):607-10.
Screening the newborn for developmental dysplasia of the hip: now what do we do?
Schwend RM, Schoenecker P, Richards BS, Flynn JM, Vitale M; Pediatric Orthopaedic Society of North America.
Section of Orthopaedics, Children's Mercy Hospital, Kansas City, MO, USA. rmschwend@cmh.edu Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
Comment in:
• J Pediatr Orthop. 2007 Sep;27(6):605-6.
The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. Although evaluation of children with risk factors for DDH is important, most DDH occurs in infants who have no risk factors. For all infants, a competent newborn physical examination using the Ortolani maneuver is the most useful procedure to detect hip instability. Early treatment of an unstable hip with a Pavlik harness or similarly effective orthosis is effective, safe, and strongly advised. Despite having had normal newborn and infant hip examinations, there remains the possibility of a late-onset hip dislocation needing treatment in approximately 1 in 5000 infants.

9).J Child Orthop. 2009 Nov 14. [Epub ahead of print]
Is ultrasound screening for DDH in babies born breech sufficient?
Imrie M, Scott V, Stearns P, Bastrom T, Mubarak SJ.
Department of Orthopedics, Lucile Packard Children's Hospital, Palo Alto, CA, USA.
PURPOSE: To review our incidence of developmental dysplasia of the hip (DDH) in breech infants referred for ultrasound screening and to determine if subsequent follow-up radiographs are necessary in these patients with normal clinical and ultrasound examinations. METHODS: A review of the clinical data and imaging studies of all children with the risk factor of breech presentation that were referred for orthopedic evaluation over a 5-year period was conducted. All patients were examined by a fellowship-trained pediatric orthopedic surgeon and all ultrasounds were done at approximately 6 weeks of age by an experienced ultrasonographer. Ultrasounds were evaluated using the dynamic method as described by Harcke. As per our protocol, all patients with normal screening ultrasounds were brought back for a final clinical examination and radiographic check at 4-6 months. Acetabular dysplasia was indicated by radiographic parameters-if there was severe blunting of the sourcil, abnormal acetabular index for age, or if there was significant asymmetry of acetabular indices side-to-side-in the setting of clinical parameters-if there was greater than 10 degrees difference in side-to-side abduction or symmetric abduction of less than 60 degrees . RESULTS: Three hundred patients with the risk factor of breech presentation were included. Thirty-four patients had clinically unstable hips; 266 had clinically stable hips and were screened by ultrasound. Sixty-four percent were female and 36% were male. Twenty-seven percent of these breech patients had abnormal screening ultrasounds and were subsequently treated. Of the remaining 73% with normal ultrasounds, who were returned per protocol at a mean of 5 months, 29% had evidence of dysplasia and underwent treatment. The diagnosis of dysplasia following a normal ultrasound was based on both radiographic and clinical parameters. Of the hips treated with a Pavlik harness, 62% had acetabular indices at least two standard deviations from the age-corrected average versus 26% of patients not treated. The average length of follow-up was 10 months. CONCLUSIONS: Retrospectively, we found that, at approximately 6 weeks of age, ultrasound screening of breech patients with clinically stable hips produces an incidence of DDH of 27%. In those patients with a normal ultrasound, 29%, at 4-6 months radiographic follow-up, were found to have dysplasia requiring treatment. This data supports breech as the most important risk factor for hip dysplasia and we, therefore, recommend careful and longitudinal evaluation of these patients with: a careful newborn physical examination, an ultrasound at age 6 weeks, and an anteroposterior (AP) pelvis and frog lateral radiograph at 6 months, as the risk of subsequent dysplasia is too high to discharge patients after a normal ultrasound.

 
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