Rationale

The early diagnosis and treatment of DDH is widely accepted to improve long‐term radiographic and functional outcomes for the patient, while decreasing the need for more complex, operative treatment approaches and their potential complications. There is much controversy, however, as to which screening programs best optimize the balance between early detection and potential overdiagnosis or overtreatment. Clinical newborn examination for hip instability remains the universal minimum standard for DDH screening. However, the utility of additional ultrasound (US) imaging in DDH screening is an issue of continuing debate. Some centers or countries employ universal US screening in conjunction with newborn clinical examination, while others employ selective US screening based on the presence of defined DDH risk factors.¹

Clinical comment

DDH is a spectrum of hip joint abnormalities ranging in severity from mild dysplasia of a reduced and stable hip to an irreducible hip dislocation. The Barlow and Ortolani maneuvers are the standard clinical tests performed on newborns to detect the presence of a dislocated or dislocatable hip. However, these tests for clinical instability cannot detect the presence of stable acetabular dysplasia.¹ US is the primary imaging modality of choice to detect dysplasia in infants under 4–6 months of age, as bony ossification has not yet developed to the extent to allow plain radiographs to be useful. Some natural history studies have shown that up to 70% of cases of neonatal hip instability and 90% of cases of acetabular dysplasia resolve spontaneously as the hip joint matures in the developing infant.²

Available literature and quality of the evidence

• Level I: 1 systematic review/meta‐analysis.³
  
• Level II: 2 prospective studies.⁴,⁵
  
• Level III: 4 retrospective cohort studies.⁶–⁹

Findings

Shorter and colleagues sought to evaluate and compare screening programs for DDH in order to assess the effectiveness of clinical and US‐based screening procedures at preventing late presentation.³ With strict inclusion criteria of randomized, quasi‐randomized controlled trials (RCTs), and cluster randomized trials comparing different types of screening programs, only five studies were ultimately included for analysis. Meta‐analysis of two studies comparing clinical examination with universal US to clinical examination with targeted US in unselected infants revealed no significant difference in late‐diagnosed DDH between the two programs with a pooled relative risk (RR) ratio of 0.49 (95% confidence interval [CI]: 0.19–1.26). There was also no significant difference in surgery (pooled RR = 0.36; 0.04–3.48) or incidence of avascular necrosis or osteoarthritis (pooled RR = 0.33; 0.01–8.02). Meta‐analysis of two studies comparing treatment guided by US surveillance and treatment guided based on clinical assessment alone for infants with unstable hips likewise revealed no significant difference in late‐diagnosed DDH (RR = 1.05; 0.6–1.85). Given the small number of studies included and lack of power within individual studies to detect rare events, Shorter and colleagues concluded that neither US strategy proved more effective at improving clinical outcomes.

Laborie et al. performed a prospective survey of their center’s selective US screening program for all infants born in a 15‐year period with defined DDH risk factors of clinical hip instability, breech presentation, congenital foot deformities, or a family history.⁴ During the study period, 11 539/81 564 infants were identified as at‐risk infants, and subsequently received a US scan at 1–3 days of age. In total, 2433 infants received abduction treatment as a result of early screening (21.7% of at‐risk infants, 3.0% of entire cohort). Of the 152 infants diagnosed with late‐presenting DDH requiring treatment, only three (0.004%) were from the at‐risk group. The authors concluded that their screening program resulted in acceptable rates of early treatment and low rates of late‐detected DDH.

Choudry and Paton undertook a similar prospective assessment of their neonatal hip instability screening program.⁵ Rather than employ selective US screening for risk factors, this program only performed US scans on infants with positive clinical exam findings of hip instability. The primary goal was to assess the positive predictive value (PPV) of the initial screening – a positive Barlow or Ortolani maneuver performed by a nonexpert – compared with an expert in screening detecting clinical instability or sonographic dysplasia. During the study period, 124 newborns with findings of clinical instability were referred to the authors’ institution for clinical and sonographic screening from a birth cohort of 28 241. Overall, they reported a PPV of 4% for the Barlow/Ortolani tests (5/124 hips) and 16.1% for sonographic assessment (20 Graf type IV/124 hips). The authors concluded that referral volume for hip instability appeared to be increasing in conjunction with a decreasing PPV, and thus advocated for limiting DDH screening to a small group of experienced examiners.

Sahin et al. retrospectively reviewed hospital records of 5798 infants who were examined regularly until walking age at their institution over a seven‐year period.⁶ While 111 infants were found to have DDH risk factors, and 606 infants had physical examination findings suggestive of DDH, 10 infants were ultimately diagnosed with DDH. The authors concluded that the combined sensitivity of risk factors and physical exam findings is high enough to merit acceptance as a screening tool.

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