Developmental dysplasia of the hip (DDH) is the most common paediatric hip condition and is a major cause of hip replacement or osteoarthritis in young adults. Due to potential impact on quality of life, every child is checked at birth for unstable hips. Should instability be detected, or the infant has other DDH risk factors, they are referred for an ultrasound exam and orthopaedic surgeon consultation. Since the implementation of a DDH screening program at our institution, the Radiology Department has seen a dramatic increase in hip ultrasounds performed. While helping prevent the complications of missed DDH diagnoses, this program has placed strain on radiology resources, and often families must attend multiple appointments before receiving a diagnosis and beginning treatment. To mitigate this, we have implemented a pilot point-of-care DDH clinic, where an ultrasound technician performs hip ultrasound exams using a portable ultrasound in the orthopaedic clinic in conjunction with surgeon consultation. The aim of this clinic is to enable diagnosis and treatment in one appointment, reduce referral-to-treatment delays, wait times, and decrease costs and travel time for families while also alleviating strain on radiology resources. A point-of-care DDH test clinic was implemented in the Orthopaedic Department at our institution. Patients referred with suspected/confirmed DDH attended a single orthopaedic clinic appointment. An ultrasound technician was present to perform scans in conjunction with the orthopaedic surgeon's clinical assessment. Surveys were distributed at the end of the appointment to collect feedback on the family's satisfaction with the program, as well as other pertinent demographic information (i.e. occupation, geographic location, travel time to hospital). To date, 40 patients have attended the pilot clinic. Families spent an average 61.3 minutes (range 15–420 minutes) traveling to the hospital for an appointment (122.6 minutes round-trip). This program reduced the number of hospital visits for DDH screening from three (initial consultation, radiology, follow-up) to one per patient, saving an average 245.2 minutes of travel time to/from the hospital per family. Appointment time averaged 35.9 minutes and families rated their satisfaction with appointment length an average of 9.6/10 (35/40 families rated satisfaction 10/10, 1 = very unsatisfied, 10 = very satisfied). Additionally, 33/40 families were also asked to rate their satisfaction with check-in/check-out processes (average 9.4/10), ultrasound screening (average 9.9/10), and time with specialist (average 9.9/10). Satisfaction scores did not differ based on variables such as survey taker's gender, occupation, or geographic location. The pilot point-of-care ultrasound DDH clinic has considerably reduced the number of clinic visits and travel time for families, reduced aggregate clinic wait times, and has resulted in high family satisfaction. This specialized clinic may have potential to free up hospital staff time and resources, possibly decreasing wait times in other clinical areas, ultimately improving quality of care for patients and families across our institution

Aims

To establish cut-off values for lateral pubofemoral distance (PFD) measurements for detecting hip dysplasia in early (four days) and standard care (six weeks) screening for developmental dysplasia of the hip (DDH).

The aim was to determine reliability in treatment threshold based on USS angular measurements between observers involved in the DDH hip screening programme at the NOC and assess the effect of image orientation on the accuracy of these measurements. 3 independent observers measured alpha and beta angles on bilateral hips in 10 consecutive patients seen in the DDH hip screening clinic. All scans were performed by a single radiographer and observers used the same set of USS images for a given patient. Each observer measured alpha and beta angles a total of 4 times: conventional ultrasound image projection (with the ilium horizontal) (round 1), Graf's anatomical projection (round 2), and both techniques repeated 1 month later (round 3 and 4 respectively) to assess intra-observer reliability. To determine its effect on treatment threshold taking into account alpha and beta angles and patient's age, the consistency between observers' management recommendations was evaluated for each round. Possible outcomes were: 1) patient discharged, 2) no treatment needed yet, but follow-up required, 3) start treatment. Intra-observer reliability for conventional projection was moderate (Kappa 0.58), and improved for anatomical projection (Kappa 0.65). Inter-observer reliability, as a surrogate measure of consistency in management recommendations between observers, ranged from fair to moderate across the 4 rounds (Kappa 0.30 – 0.50). However, contrary to previous recommendations, reliability was better with conventional projection (Kappa 0.41 (95% CI 0.11–0.72)) compared to anatomical projection (Kappa 0.36 (95% CI −0.01–0.73)). The overall agreement in management recommendations, pooling all results across 4 rounds, was 51.3% (Kappa 0.39 (95%CI 0.15–0.63)). This audit supports the argument that anatomical image projection improves intra-observer consistency. However, as with all USS measurements, angular measurements were highly user dependent and treatment threshold based on USS may not be as consistent as anticipated

Aims

Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population.

A 15 year prospective, observational cohort study was undertaken to assess selective screening of DDH in males and females referred with risk factors only. Individuals born breech or with evidence of a strong family history for DDH were the ‘risk factors’ studied. All were clinically examined and sonographically screened by one Consultant Paediatric Orthopaedic surgeon. Irreducible hip dislocation rate was the primary outcome measure. From a cohort of 64670 live births, 2,984 neonates/infants, 46.1 per 1000 live births [95% CI 44.6 to 47.8 per 1000 live births] were referred and sonographically screened with ‘pure’ risk factors of breech presentation and/or family history, with clinical stability. 1360 were male, of which 4 were identified as having ‘pathological’ DDH; an incidence of 1 in 333 of those males referred [95 CI 0.001, 0.008]. 1624 were female, of which 45 were identified as having ‘pathological’ DDH; an incidence of 1 in 36 of those females referred [95% CI 0.021, 0.037]. There was a significant difference in the number of female individuals sonographically diagnosed as having ‘pathological’ DDH compared to males (p<0.001). Four individuals were diagnosed with irreducible hip dislocation, 0.06 per 1000 live births [95% CI 0.24, 0.159 per 1000 live births]. All were in females. Additionally, there were 2 female individuals; both with family history of DDH (1. st. cousin splinted and sister splinted, respectively) as a risk factor, referred late. Our study suggests that there is a significant difference between the incidence of female and male individuals diagnosed with ‘pathological’ DDH, in those referred purely with risk factors (breech and family history). These findings question the current screening policy for ultrasound examination of males with risk factors in the absence of clinical instability, and may influence future DDH screening programme policy. Level of evidence: II

Aims

Worldwide controversy exists on the optimal treatment of stable dysplastic hips. The most common treatment options are abduction brace treatment and active surveillance. The primary aim of this study was to assess the effect of active surveillance in stable hip dysplasia, by investigating the percentage of Graf IIb stable dysplastic hips that recover spontaneously without abduction brace treatment. The second aim was to identify prognostic factors for spontaneous recovery of stable dysplastic hips.

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

Aims

A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening.

Aims

Early detection of developmental dysplasia of the hip (DDH) is associated with improved outcomes of conservative treatment. Therefore, we aimed to evaluate a novel screening programme that included both the primary risk factors of breech presentation and family history, and the secondary risk factors of oligohydramnios and foot deformities.

Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme over the last 19 years. The following shows our result after a recent change in our screening programme protocol. All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic. However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatment. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS. No complications were noted. While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced. Yet, the need for a major surgical intervention has been all but eliminated

Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme for many years. The following shows our result after a recent hospital relocation and changes to the screening programme. All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic. However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatments. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Those with Graf III or higher at initial presentation, but spontaneous reduced without treatment were follow-up to one year. The acetabular index in these cases was normal. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS. While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced

Aims: The purpose of this study is the evaluation of the ultrasound screening process for DDH in a population of neonates from the prefecture of Chania, in Western Crete, an area with a history of excessively high incidence of DDH. Methods: Within the period between 1/7/99 and 1/7/01 (24 months) 1247 neonates (2494 hips) were examined clinically and ultrasonograþcally (transverse, oblique, dynamique views), all babies whose parents both descend from this area for generations. They were referred by a paediatrician for one or more of the following reasons: limited hip abduction (48%), hip laxity (6%), positive family DDH history (27%), musculoskeletal congenital abnormalities (11%), breech delivery (5.1%), paediatricianñs or parentsñ insecurity (18%).Results: We had the following þndings: signiþcant dysplasia-Graf III in 3.7%, milder dysplasia Ð Graf IIc, d in 7.2%, immature but satisfactory hips Ð Graf IIa, b in 19.3% and normal hips in 69.5% of the hips. Double diapers (sheets) were used in 43%, Frejka in 3% and Pavlik harness in 4.2% of the cases. In two cases the dysplasia persisted and we had to use a spica cast. Satisfactory results have been observed in all but one case. X-ray control was necessary in six children. Conclusion: Hip ultrasound, in experienced hands, is a safe, quick, well tolerated, non-inventory method for DDH screening, treatment and follow-up in neonates Ð babies in their þrst year of life

We have encountered radiological reports of ‘normal Graf α-angles’ when the femoral head was subluxed. We therefore developed a simple method to determine femoral/acetabular congruency known as the 50/50 method. We compare our method to the established Graf method. Two identical, randomly assorted sets of 100 ultra-sonograms were evaluated. All ultrasonograms were of patients under 3 months of age within our DDH screening program. The images were assessed to be either ‘normal’ or ‘abnormal’ by 6 FY1’s using each method after reading brief instructions. (Images were classified as normal or abnormal by consensus between an orthopaedic consultant and radiologist who also examined and preformed dynamic screening on each infant). The mean proportion of abnormal scans with agreement and normal scans with agreement was 0.52 (95% CI 0.39–0.69) and 0.92 (CI 0.87–0.96) respectively, indicating moderate agreement (kappa 0.41, CI 0.12–0.71) for inter-observer variability using the Graf method. On average the inter-observer variability using the 50/50 method for abnormal and normal scans with agreement was 0.60 (CI 0.35–0.84) and 0.92 (95% CI 0.85–0.99) respectively with moderate agreement (kappa 0.50, CI 0.20–0.80). Intra-observer variability between the Graf and 50/50 methods revealed moderate agreement (mean kappa 0.41, CI 0.17–0.66) with the average proportion of abnormal and normal scans with agreement of 0.50 (CI 0.32–0.69) and 0.91 (CI 0.83–0.98) correspondingly. The accuracy of each test was equal, ranging from 84% to 93%. The 50/50 method is straightforward to both use and teach. Moreover, it successfully serves as “red dot” system to flag up abnormal hips at clinic. The 50/50 method is at least as good as Graf with regard to accuracy, inter-observer and intra-observer variability. We recognise that dynamic screening remains the gold standard

Aims

The present study seeks to investigate the correlation of pubofemoral distances (PFD) to α angles, and hip displaceability status, defined as femoral head coverage (FHC) or FHC during manual provocation of the newborn hip < 50%.

Purpose of study: To assess whether a plane x-ray at five months is needed in a DDH screening program. Method: Between 1990 and 2004 we operated selective hip screening, including ultrasound. Hips screened as normal had an X-ray at 5 months, initially instituted to cover the ultrasound learning curve. These were reported by a consultant radiologist and referred if thought abnormal. For the purposes of this study the notes, scans and X-rays of all patients referred at 5 months were reviewed. Results: In Nottingham there were approximately 108,500 births between 1990 and 2004. Of these 11,425 were referred for ultrasound scan. 53 were referred to orthopaedics following the x-ray at 5 months. 47 of these had a complete data set. Of these 47 children, 30 (64%) were watched, 9 (19%) had arthrograms only, 5 (11%) had adductor tenotomy and application of a hip spica. One (2%) child had Pavlik harness treatment and 2 (4%) had a femoral osteotomy. Graf’s alpha angles and percentage cover were reviewed from the original ultrasounds, many of which were of poor quality. This demonstrated that there was less than 50% cover for 14/30 (47%) who were watched, for 6/9 (78%) who had arthrograms, for 1/1 (100%) treated by harness, for 4/5 (80%) treated with adductor tenotomy and hip spica and for 2/2 (100%) requiring surgery. Alpha angles less than 60 degrees did not predict the need for intervention. There were no late cases from the group that had X-rays classed as normal at 5 months. Conclusions: The importance of measuring head cover was established and is now routine in the hip instability clinic. It was clear that a large population had received unnecessary X-rays. X-rays are now only performed if US at 6 weeks reveals a low alpha angle or less than 50% cover

Introduction: Late diagnosed developmental dysplasia of the hip joint (DDH) is now a very rare case in an orthopaedic practice. It is mostly because of early ultrasound screenings of baby’s hips. Two ultrasound techniques are most popular and widely used in the world – the Graf’s technique in Europe and Harcke’s in the USA. The purpose of this study was to establish a value of Harcke’s technique which is not very popular in Europe. Material and Methods: During the last 10 years, 25 000 ultrasound hip examinations of newborns hips because of early DDH screening were performed in our Clinic. In every child both hips were examined using two techniques (Graf’s and Harcke’s). The mean age during the first hip ultrasound examination was 5 weeks (from 10 days to 8 weeks). The Siemens SL1 equipment with linear transducer of 7.5 MHz was used for examination. The position of the hip during examination followed all requirements indicated by Graf or Harcke. All ultrasound examination were performed and analyzed by two orthopaedic surgeons. Results: In this study the DDH was diagnosed in 5,6% of all examined hips. Most common type of dysplastic hip was type II according to Graf’s classification, or laxity with stress according to Harcke’s classification. The cases with decentration (subluxation or dislocation) were diagnosed in 2% of all dysplastic hips. In Graf’s technique there were some differences in measuring the beta or alfa angles between examiners, however, this did not influenced the type of hip dysplasia. Harcke’s method was easy to perform because the measuring of the angles was not necessary. The time which was required for examination of a child’s hips did not extend 2 minutes. Conclusions: Both methods are very useful in early diagnosis of DDH and could be used for general hip screening for newborn hips. Harcke’s method gives a better visualization of the hip in two planes and gives dynamic pictures

Aims

Studies of infant hip development to date have been limited by considering only the changes in appearance of a single ultrasound slice (Graf’s standard plane). We used 3D ultrasound (3DUS) to establish maturation curves of normal infant hip development, quantifying variation by age, sex, side, and anteroposterior location in the hip.