Aims. A clicky hip is a common referral for clinical and sonographic screening for developmental dysplasia of the hip (DDH). There is controversy regarding whether it represents a true risk factor for pathological DDH. Therefore a 20-year prospective, longitudinal, observational study was undertaken to assess the relationship between the presence of a neonatal clicky hip and pathological DDH. Patients and Methods. A total of 362 infants from 1997 to 2016 were referred with clicky hips to our ‘one-stop’ paediatric hip screening clinic. Hips were assessed clinically for instability and by ultrasound imaging using a simplified Graf/Harcke classification. Dislocated or dislocatable hips were classified as Graf Type IV hips. Results. The mean age at presentation was 13.8 weeks (12.8 to 14.7). In all 351 out of 362 children (97.0%) had Graf Type I hips (normal) that required no treatment. Nine children (2.5%) had Graf Type II hips but all resolved to Graf Type I hips on follow-up scans. One child (0.3%) had Graf Type III hip dysplasia and one child (0.3%) had an irreducible hip dislocation. The two pathological hips were associated with unilateral limited hip abduction. Mean referrals increased from 12.9 to 23.3 each year (p = 0.002) from the first decade of the study to the second, driven by increasing primary care referrals (5.5 versus 16.7 per year, p < 0.001). Conclusion. Most clicky hips required no treatment other than reassurance to parents. Clicky hips with a normal hip examination should be considered a variant of normal childhood and not a risk factor for DDH. However, an abnormal hip examination including unilateral limited hip abduction should prompt urgent further investigations. Cite this article: Bone Joint J 2017;99-B:1533–6

Purpose. This 20-year prospective longitudinal observational study aims to determine the incidence of pathological developmental dysplasia of the hip (DDH) in children referred with clicky hips and define the risk posed to inform neonatal hip screening programmes including the role of ultrasound. Method. 355 children from 1997 to 2016 were referred with clicky hips to our “one stop” paediatric hip clinic under the local neonatal hip screening programme. Hips were assessed clinically for instability and by ultrasound using a simplified Graf classification. Dislocated or dislocatable hips were classed as Graf type IV. Results. The mean age at presentation was 13.9 (1–56) weeks. 343 out of 355 (96.6%) were Graf type I which required no treatment. 9 (2.5%) were Graf type II but all converted to Graf type I on follow up scans. 2 (0.6%) had Graf type III dysplasia and 1 (0.3%) had irreducible dislocation but all three were associated with limited hip abduction or other hip pathology. Referrals increased from 12.9 to 22.6 per year (p=0.002) from first decade of the study to the second, driven by rising primary care referrals (5.5 vs. 16.5 per year p=0.00002). Conclusion. The study provided robust evidence that overwhelming majority of clicky hips required no treatment other than reassurance to parents. Clicky hips with normal hip examination should be considered a variant of normal childhood and not a risk factor for DDH. However clicky hips with limited hip abduction may represent a separate clinical entity at risk of hip pathology and therefore warrant further investigations

The aim was to assess the value of the GP 6–8 week hip examination. In a 15-year prospective observational longitudinal cohort study, every infant referred by the GP with suspected pathological developmental dysplasia of the hip (DDH) had their hip joints clinically and sonographically examined in a specialist hip screening clinic. Graf Type IV and dislocated hips were classified as pathological. Screening failures were defined as those who had not been identified by the 6–8 week check and presented with late instability. Secondary univariate and multivariable analysis was performed to determine which clinical findings are predictive of instability. 64,518 infants underwent the 6–8 week GP check. Of 176 referrals, 5 had pathological hips. 13 screening failures, presented between the ages of 17 and 80 weeks. The 6–8 week check has a sensitivity of 28% and a specificity of 99.7%. Univariate analysis revealed positive Ortolani tests and patients referred as ‘unstable hip’ to be significant predictors of hip pathology. Clicky hips, asymmetric skin creases, and leg length inequality were not predictive of pathological hips. A multivariable model showed a positive Ortolani test to be the sole independent predictor of instability at 6–8 weeks. This is the first attempt to test the validity of the 6–8 week GP clinical hip check. A low rate of hip pathology was identified. The high rate of false negatives raises questions about the value of screening at this age. At 6–8 weeks, clinical signs of hip instability are unreliable as hips become irreducible and stiff. Based on our findings, we recommend that at 6–8 weeks, referrals are only made if the Ortolani test is positive. We advocate the reintroduction of the 8-month check, including an assessment for limited hip abduction, which may improve the detection rate of those missed by initial screening

Background: Selective ultrasound screening of neonatal hips with risk factors has been undertaken in Lanarkshire from 2001. Referral reasons included family history, breech, clicky hip and instability. Patients are examined by an orthopaedic surgeon with a special interest and scanned by static Graf technique. Our experience with selective screening and its effect on late DDH is presented. Methods: All ultrasound screening data was collected prospectively and entered into a database. Late presenters were identified at the tertiary centre by case note and X ray review. Population data was obtained from the Scottish registry. Results: Between 2001–2005, there were 30,824 live-births. 405 babies (910 hips) were identified as being at risk. 5(1.2%) were identified as Graf III/IV. Three responded to splinting, 1 required closed reduction and 1 open reduction. 11 who had initially normal scans were noted to have abnormal acetabular index (> 30) at 6 months. 2 required open reduction, 1 closed reduction and the rest eventually normalised with follow up. True late presentation was identified (> 3 months) in 11 children. Mean age at diagnosis was 14.7m (4–29 mts). 7(64%) did not have any identifiable risk factors. 4 had risk factors, but had escaped screening. 8 underwent open and 3 closed reduction. 7 derotation osteotomies and 1 pelvic osteotomy were additionally performed. Discussion: The identifiable incidence of DDH in Lanarkshire is 0.87/1000. The incidence of true late presenting DDH in the same population was 0.35/1000. If all hips with risk factors had been successfully screened it would reduce to 0.22/1000. Selective screenings can minimise the incidence of late presenting DDH if rigorously implemented. Majority of late presenters do not have risk factors and are likely to escape detection with a selective screening programme. This suggests a different natural history in late presenting cases

Background: DDH represents a spectrum of anatomical abnormalities in which the femoral head and the acetabulum are either in improper alignment or grow abnormally. Although screening leads to earlier identification, 60–80% of abnormal hips of newborns identified by physical examination resolve spontaneously by 2–8 weeks and 90% of the hips of newborns with mild dysplasia identified by ultrasound resolve spontaneously between 6 weeks and 6 months. Aims: To assesses accuracy of ultrasound screening of neonatal hip by the static technique of Graf. We attempt to answer the question whether routine radiological follow up of these children are indicated. Methods: Since 2001, we have performed selective ultrasound screening of over 600 neonates (1200 hips). The reasons for referral included, breech presentation, clicky hip, unstable hip, dislocation, foot deformity and family history of DDH. Clinical examination, followed by serial ultrasound examinations at presentation, 6 weeks and 3 months of age were carried out. A radiological examination and measurement of the acetabular index was performed at 6 months of age. Hips were classified according to the 4 Graf types. We compared the ultrasound findings with the acetabular index (AI) for individual patients. Results: All children were followed up prospectively from presentation to discharge. For neonates without any family history of DDH and normal clinical examination (symmetrical skin creases, equal limb lengths, unrestricted abduction and no instability demonstrated on the Ortolani and Barlow manoeuvres) the ultrasound classification according to Graf co-related with the acetabular index on 6 month radiographs. 100% of hips with normal scan (Graf I) both at 6 weeks and at 3 months of age had a normal AI. Discussion: The static technique of Graf is an accurate and reliable method of assessment of neonatal hips. In children with normal clinical examination, and no family history of dysplasia, scan findings are a good predictor of the AI. Routine radiological follow up in such patients is not necessary

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.

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.

Aims

The significance of the ‘clicky hip’ in neonatal and infant examination remains controversial with recent conflicting papers reigniting the debate. We aimed to quantify rates of developmental dysplasia of the hip (DDH) in babies referred with ‘clicky hips’ to our dedicated DDH clinic.

Aims

The aim of this study was to review the value of accepting referrals for children with ‘clicky hips’ in a selective screening programme for hip dysplasia.

Aims

The aim of this prospective cohort study was to evaluate the effectiveness of the neonatal hip instability screening programme.

Of the 34 723 infants born between 1 June 1992 and 31 May 2002, the hips of 2578 with clinical instability or at-risk factors for developmental dysplasia of the hip were imaged by ultrasound.

Instability of the hip was present in 77 patients, of whom only 24 (31.2%) had an associated risk factor. From the ‘at-risk’ groups, the overall risk of type-III dysplasia, instability and irreducibility was 1:15 when family history, 1:27 when breech delivery and 1:33 when foot deformity were considered as risk factors. Of those hips which were ultrasonographically stable, 88 had type-III dysplasia.

A national programme of selective ultrasound screening of at-risk factors for the diagnosis of hip dislocation or instability alone cannot be recommended because of its low predictive value (1:88). However, the incidence of type-III dysplasia and hip dislocation or dislocatability in the groups with clinical instability, family history, breech position and possibly postural foot deformity as risk factors could justify a programme of selective ultrasound imaging.