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Keywords:

  • congenital hip dislocation;
  • mass screening;
  • systematic review;
  • ultrasonography;
  • congenital hip dislocation;
  • femur head necrosis;
  • neonatal screening;
  • ultrasonography

Abstract

  1. Top of page
  2. Abstract
  3. Commentary by A. R. Kemper
  4. Declaration of interest
  5. Response by authors
  6. Declaration of interest
  7. References

This is a commentary on a Cochrane review, published in this issue of EBCH, first published as: Shorter D, Hong T, Osborn DA. Screening programmes for developmental dysplasia of the hip in newborn infants. Cochrane Database of Systematic Reviews 2011, Issue 9 Art. No.: CD004595. DOI: 10.1002/14651858.CD004595.pub2. Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration


Commentary by A. R. Kemper

  1. Top of page
  2. Abstract
  3. Commentary by A. R. Kemper
  4. Declaration of interest
  5. Response by authors
  6. Declaration of interest
  7. References

Screening newborn infants for developmental dysplasia of the hip (DDH) by physical examination using the Barlow and Ortalani maneuvers is a common and well-accepted practice. However, ultrasound examination might improve detection. The review by Shorter, Hong and Osborn compares the pros and cons of different approaches to the detection and early management of DDH by evaluating relevant randomized and quasi-randomized trials1. Overall, five studies met the criteria and were included in the analysis.

None of the studies compared screening to no screening. This is not surprising. Screening, at least by physical examination, is deeply entrenched into paediatric care. Furthermore, in the US, missed cases of DDH are a common cause of malpractice claims2. However, understanding the value of DDH screening is important. Although early detection might improve outcome, many cases of early identified DDH resolve spontaneously and treatment may be associated with significant complications, including avascular necrosis of the femoral head. Treatment can also be stressful to families and unnecessary treatment is a waste of limited health-care resources.

In general, ultrasound screening, either universal or targeted, appears to be associated with increased case detection and treatment, but no difference in late diagnosis or the need for surgery. The lack of impact on meaningful outcomes suggests that without further compelling evidence, ultrasound screening is not worthwhile. Unfortunately, the evidence base regarding DDH screening is inadequate and subject to bias because of the relatively small number of infants studied in the trials. This is especially true for subpopulations at greater risk of developing DDH. For example, there is insufficient evidence to guide clinicians and parents regarding ultrasound screening for infants born in the breech position or who have a family history of DDH.

It seems likely that modification of how ultrasound is used could decrease unnecessary treatment. For example, the threshold for a positive screen could be altered or infants with a positive initial screen could receive repeat examination before treatment is initiated. Whether this would lead to better outcomes is uncertain. Shorter and colleagues estimate that a trial to evaluate the impact of screening on late-diagnosed DDH would require more than 100 000 infants, which is unlikely to ever be done. Observational cohort studies could help clarify the pros and cons of different approaches to screening but can also be significantly biased. In another systematic review, the US Preventive Services Task Force found that the available observational studies are of fair quality at best and do not resolve the uncertainty regarding DDH screening3.

As with many other areas of child health care, DDH screening is likely to remain within the purview of expert opinion, informed by groups like the American Academy of Pediatrics, and local practice. Parents should be aware of the uncertainty, ideally before screening but definitely in the event of a positive screen.

Response by authors

  1. Top of page
  2. Abstract
  3. Commentary by A. R. Kemper
  4. Declaration of interest
  5. Response by authors
  6. Declaration of interest
  7. References

We thank Dr Kemper for his thoughtful response to the Cochrane Review ‘Screening programmes for developmental dysplasia of the hip in newborn infants’1. Reported rates of late-diagnosed developmental dysplasia of the hip (DDH) vary from 1 to 13 per 10 0002. The single study in the review reporting the effect of clinical examination alone reported a rate of late-diagnosed DDH of 25 per 10 000. The addition of universal or targeted ultrasound screening did not result in a significant reduction in late diagnosed of DDH although given the low incidence the analysis is grossly underpowered to detect a difference. The most serious complication of treatment of DDH is avascular necrosis of the femoral head with rates reported in the range from 13.5 to 109 per 1000 infants who undergo treatment2. Avascular necrosis was not reliably reported by studies in the review with one study reporting 1 case in 138 treated infants (7 per 1000). Universal but not targeted ultrasound screening was associated with a significant increase in treatment of infants for hip abnormalities compared with clinical examination alone (3.4% vs. 2.0% vs. 1.8%). Surgical treatment for DDH was too uncommon in the included studies (0–0.5 per 1000) to determine whether there is a potential reduction in surgery from earlier ultrasound detection and abduction splinting. Without an extremely large trial it will remain unclear whether earlier diagnosis and treatment of ultrasound detected DDH will result in net health benefits at an acceptable cost.

The review also found some evidence that where infants are clinically detected as having unstable but not dislocated hips, or are detected on ultrasound to have mild hip dysplasia, delaying treatment by 2 to 8 weeks reduces the need for treatment without a significant increase in late-diagnosed dysplasia or surgery.

References

  1. Top of page
  2. Abstract
  3. Commentary by A. R. Kemper
  4. Declaration of interest
  5. Response by authors
  6. Declaration of interest
  7. References
  • 1
    Shorter D, Hong T, Osborn DA. Screening programmes for developmental dysplasia of the hip in newborn infants. Cochrane Database Syst Rev 2011; 9: CD004595. DOI 10.1002/14651858.CD004595.pub2.
  • 2
    McAbee GN, Donn SM, Mendelson RA, McDonnell WM, Gonzalez JL, Ake JK. Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States. Pediatrics 2008; 122: e1282e1286.
  • 3
    US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics 2006; 117: 898902.
  • 4
    Shorter D, Hong T, Osborn DA. Screening programmes for developmental dysplasia of the hip in newborn infants. Cochrane Database Syst Rev 2011; 9: CD004595.
  • 5
    Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics 2006; 117: e557e576.