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. 2003 Sep;88(9):753–759. doi: 10.1136/adc.88.9.753

Performance, treatment pathways, and effects of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom

C Dezateux 1, J Brown 1, R Arthur 1, J Karnon 1, A Parnaby 1
PMCID: PMC1719641  PMID: 12937091

Abstract

Aims: To compare, using a decision model, performance, treatment pathways and effects of different newborn screening strategies for developmental hip dysplasia with no screening.

Methods: Detection rate, radiological absence of subluxation at skeletal maturity and avascular necrosis of the femoral head, as favourable and unfavourable treatment outcomes respectively, were compared for the following strategies: clinical screening alone using the Ortolani and Barlow tests; the addition of static and dynamic ultrasound examination of the hips of all infants (universal ultrasound) or restricted to infants with defined risk factors (selective ultrasound); "no screening" (that is, clinical diagnosis only).

Results: Universal or selective ultrasound detects more more affected children (76% and 60% respectively) than clinical screening alone (35%), results in a higher proportion of affected children with favourable treatment outcomes (92% and 88% respectively) than clinical screening alone (78%) or no screening (75%), and the highest proportion of these achieved without recourse to surgery (64% and 79% respectively) compared with clinical screening alone (18%). However, ultrasound based strategies are also associated with the highest number of unfavourable treatment outcomes arising in unaffected children treated following a false positive screening result. The detection rate of clinical screening alone becomes similar to that reported for universal ultrasound when based on studies using experienced examiners (80%) rather than junior medical staff (35%).

Conclusion: From the largely observational data available, ultrasound based screening strategies appear to be most sensitive and effective but are associated with the greatest risk of potential adverse iatrogenic effects arising in unaffected children.

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Figure 1.

Figure 1

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Decision tree depicting screening, treatment, and management pathways for each of the strategies. *Pathways for these strategies are similar to those depicted for clinical screening.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Altenhofen L., Allhoff P. G., Niethard F. U. Hüftsonographie-Screening im Rahmen der U3--Erste Erfahrungen. Z Orthop Ihre Grenzgeb. 1998 Nov-Dec;136(6):501–507. doi: 10.1055/s-2008-1045177. [DOI] [PubMed] [Google Scholar]
  2. Aronsson D. D., Goldberg M. J., Kling T. F., Jr, Roy D. R. Developmental dysplasia of the hip. Pediatrics. 1994 Aug;94(2 Pt 1):201–208. [PubMed] [Google Scholar]
  3. Boeree N. R., Clarke N. M. Ultrasound imaging and secondary screening for congenital dislocation of the hip. J Bone Joint Surg Br. 1994 Jul;76(4):525–533. [PubMed] [Google Scholar]
  4. Brown J., Dezateux C., Karnon J., Parnaby A., Arthur R. Efficiency of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom. Arch Dis Child. 2003 Sep;88(9):760–766. doi: 10.1136/adc.88.9.760. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Chan A., Cundy P. J., Foster B. K., Keane R. J., Byron-Scott R. Late diagnosis of congenital dislocation of the hip and presence of a screening programme: South Australian population-based study. Lancet. 1999 Oct 30;354(9189):1514–1517. doi: 10.1016/S0140-6736(98)12469-8. [DOI] [PubMed] [Google Scholar]
  6. Chan A., McCaul K. A., Cundy P. J., Haan E. A., Byron-Scott R. Perinatal risk factors for developmental dysplasia of the hip. Arch Dis Child Fetal Neonatal Ed. 1997 Mar;76(2):F94–100. doi: 10.1136/fn.76.2.f94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Clegg J., Bache C. E., Raut V. V. Financial justification for routine ultrasound screening of the neonatal hip. J Bone Joint Surg Br. 1999 Sep;81(5):852–857. doi: 10.1302/0301-620x.81b5.9746. [DOI] [PubMed] [Google Scholar]
  8. Davids J. R., Benson L. J., Mubarak S. J., McNeil N. Ultrasonography and developmental dysplasia of the hip: a cost-benefit analysis of three delivery systems. J Pediatr Orthop. 1995 May-Jun;15(3):325–329. doi: 10.1097/01241398-199505000-00013. [DOI] [PubMed] [Google Scholar]
  9. Deeks J. J. Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests. BMJ. 2001 Jul 21;323(7305):157–162. doi: 10.1136/bmj.323.7305.157. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Dezateux C., Godward S. A national survey of screening for congenital dislocation of the hip. Arch Dis Child. 1996 May;74(5):445–448. doi: 10.1136/adc.74.5.445. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Elbourne Diana, Dezateux Carol, Arthur Rosemary, Clarke N. M. P., Gray Alastair, King Andy, Quinn Anne, Gardner Frances, Russell Glynn, UK Collaborative Hip Trial Group Ultrasonography in the diagnosis and management of developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre randomised controlled trial. Lancet. 2002 Dec 21;360(9350):2009–2017. doi: 10.1016/s0140-6736(02)12024-1. [DOI] [PubMed] [Google Scholar]
  12. Feldman D. S. How to avoid missing congenital dislocation of the hip. Lancet. 1999 Oct 30;354(9189):1490–1491. doi: 10.1016/S0140-6736(99)00239-1. [DOI] [PubMed] [Google Scholar]
  13. Fiddian N. J., Gardiner J. C. Screening for congenital dislocation of the hip by physiotherapists. Results of a ten-year study. J Bone Joint Surg Br. 1994 May;76(3):458–459. [PubMed] [Google Scholar]
  14. Gardiner H. M., Dunn P. M. Controlled trial of immediate splinting versus ultrasonographic surveillance in congenitally dislocatable hips. Lancet. 1990 Dec 22;336(8730):1553–1556. doi: 10.1016/0140-6736(90)93318-j. [DOI] [PubMed] [Google Scholar]
  15. Geitung J. T., Rosendahl K., Sudmann E. Cost-effectiveness of ultrasonographic screening for congenital hip dysplasia in new-borns. Skeletal Radiol. 1996 Apr;25(3):251–254. doi: 10.1007/s002560050074. [DOI] [PubMed] [Google Scholar]
  16. Godward S., Dezateux C. 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. Lancet. 1998 Apr 18;351(9110):1149–1152. doi: 10.1016/s0140-6736(97)10466-4. [DOI] [PubMed] [Google Scholar]
  17. Gore D. R. Iatrogenic avascular necrosis of the hip in young children. A review of six cases. J Bone Joint Surg Am. 1974 Apr;56(3):493–502. [PubMed] [Google Scholar]
  18. Holen K. J., Tegnander A., Eik-Nes S. H., Terjesen T. The use of ultrasound in determining the initiation of treatment in instability of the hip in neonates. J Bone Joint Surg Br. 1999 Sep;81(5):846–851. doi: 10.1302/0301-620x.81b5.9502. [DOI] [PubMed] [Google Scholar]
  19. Jones D., Dezateux C. A., Danielsson L. G., Paton R. W., Clegg J. At the crossroads--neonatal detection of developmental dysplasia of the hip. J Bone Joint Surg Br. 2000 Mar;82(2):160–164. [PubMed] [Google Scholar]
  20. Kalamchi A., MacEwen G. D. Avascular necrosis following treatment of congenital dislocation of the hip. J Bone Joint Surg Am. 1980 Sep;62(6):876–888. [PubMed] [Google Scholar]
  21. Krikler S. J., Dwyer N. S. Comparison of results of two approaches to hip screening in infants. J Bone Joint Surg Br. 1992 Sep;74(5):701–703. doi: 10.1302/0301-620X.74B5.1527116. [DOI] [PubMed] [Google Scholar]
  22. Leck I. An epidemiological assessment of neonatal screening for dislocation of the hip. J R Coll Physicians Lond. 1986 Jan;20(1):56–62. [PMC free article] [PubMed] [Google Scholar]
  23. Lee T. W., Skelton R. E., Skene C. Routine neonatal examination: effectiveness of trainee paediatrician compared with advanced neonatal nurse practitioner. Arch Dis Child Fetal Neonatal Ed. 2001 Sep;85(2):F100–F104. doi: 10.1136/fn.85.2.F100. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Lehmann H. P., Hinton R., Morello P., Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics. 2000 Apr;105(4):E57–E57. doi: 10.1542/peds.105.4.e57. [DOI] [PubMed] [Google Scholar]
  25. Lennox I. A., McLauchlan J., Murali R. Failures of screening and management of congenital dislocation of the hip. J Bone Joint Surg Br. 1993 Jan;75(1):72–75. doi: 10.1302/0301-620X.75B1.8421040. [DOI] [PubMed] [Google Scholar]
  26. Lewis K., Jones D. A., Powell N. Ultrasound and neonatal hip screening: the five-year results of a prospective study in high-risk babies. J Pediatr Orthop. 1999 Nov-Dec;19(6):760–762. [PubMed] [Google Scholar]
  27. Limpaphayom M., Sa-Nguanngam B. A clinical trial on the use of a new hip splint and the spica cast for congenitally unstable or dislocated hips. J Med Assoc Thai. 1978 Dec;61(12):665–671. [PubMed] [Google Scholar]
  28. Macnicol M. F. Results of a 25-year screening programme for neonatal hip instability. J Bone Joint Surg Br. 1990 Nov;72(6):1057–1060. doi: 10.1302/0301-620X.72B6.2246288. [DOI] [PubMed] [Google Scholar]
  29. Marks D. S., Clegg J., al-Chalabi A. N. Routine ultrasound screening for neonatal hip instability. Can it abolish late-presenting congenital dislocation of the hip? J Bone Joint Surg Br. 1994 Jul;76(4):534–538. [PubMed] [Google Scholar]
  30. Maxwell S. L., Ruiz A. L., Lappin K. J., Cosgrove A. P. Clinical screening for developmental dysplasia of the hip in Northern Ireland. BMJ. 2002 Apr 27;324(7344):1031–1033. doi: 10.1136/bmj.324.7344.1031. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Patel H., Canadian Task Force on Preventive Health Care Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ. 2001 Jun 12;164(12):1669–1677. [PMC free article] [PubMed] [Google Scholar]
  32. Rosendahl K., Markestad T., Lie R. T. Congenital dislocation of the hip: a prospective study comparing ultrasound and clinical examination. Acta Paediatr. 1992 Feb;81(2):177–181. doi: 10.1111/j.1651-2227.1992.tb12198.x. [DOI] [PubMed] [Google Scholar]
  33. Rosendahl K., Markestad T., Lie R. T., Sudmann E., Geitung J. T. Cost-effectiveness of alternative screening strategies for developmental dysplasia of the hip. Arch Pediatr Adolesc Med. 1995 Jun;149(6):643–648. [PubMed] [Google Scholar]
  34. Rosendahl K., Markestad T., Lie R. T. Ultrasound screening for developmental dysplasia of the hip in the neonate: the effect on treatment rate and prevalence of late cases. Pediatrics. 1994 Jul;94(1):47–52. [PubMed] [Google Scholar]
  35. Royston G. Commentary: trials versus models in appraising screening programmes. BMJ. 1999 Feb 6;318(7180):360–361. [PubMed] [Google Scholar]
  36. Salter R. B., Kostuik J., Dallas S. Avascular necrosis of the femoral head as a complication of treatment for congenital dislocation of the hip in young children: a clinical and experimental investigation. Can J Surg. 1969 Jan;12(1):44–61. [PubMed] [Google Scholar]
  37. Somerville E. W. A long-term follow-up of congenital dislocation of the hip. J Bone Joint Surg Br. 1978 Feb;60(1):25–30. doi: 10.1302/0301-620X.60B1.627575. [DOI] [PubMed] [Google Scholar]
  38. Sucato D. J., Johnston C. E., 2nd, Birch J. G., Herring J. A., Mack P. Outcome of ultrasonographic hip abnormalities in clinically stable hips. J Pediatr Orthop. 1999 Nov-Dec;19(6):754–759. [PubMed] [Google Scholar]
  39. Wald N. J., Hackshaw A. K., Frost C. D. When can a risk factor be used as a worthwhile screening test? BMJ. 1999 Dec 11;319(7224):1562–1565. doi: 10.1136/bmj.319.7224.1562. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Wood M. K., Conboy V., Benson M. K. Does early treatment by abduction splintage improve the development of dysplastic but stable neonatal hips? J Pediatr Orthop. 2000 May-Jun;20(3):302–305. [PubMed] [Google Scholar]
  41. el-Shazly M., Trainor B., Kernohan W. G., Turner I., Haugh P. E., Johnston A. F., Mollan R. A. Reliability of the Barlow and Ortolani tests for neonatal hip instability. J Med Screen. 1994 Jul;1(3):165–168. doi: 10.1177/096914139400100306. [DOI] [PubMed] [Google Scholar]

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