Aims. We investigated the prevalence of late developmental dysplasia of the hip (DDH), abduction bracing treatment, and surgical procedures performed following the implementation of universal ultrasound screening versus selective ultrasound screening programmes. Methods. A systematic search of PubMed, Embase, The Cochrane Library, OrthoSearch, and Web of Science from the date of inception of each database until 27 March 2022 was performed. The primary outcome of interest was the prevalence of late detection of DDH, diagnosed after three months. Secondary outcomes of interest were the prevalence of abduction bracing treatment and surgical procedures performed in childhood for dysplasia. Only studies describing the primary outcome of interest were included. Results. A total of 31 studies were identified, of which 13 described universal screening and 20 described selective screening. Two studies described both. The prevalence of late DDH was 0.10 per 1,000 live births (95% confidence interval (CI) 0.00 to 0.39) in the universal screening group and 0.45 per 1,000 live births (95% CI 0.31 to 0.61) in the selective screening group. Abduction bracing treatment was performed on 55.54 per 1,000 live births (95% CI 24.46 to 98.15) in the universal screening group versus 0.48 per 1,000 live births (95% CI 0.07 to 1.13) in the selective screening group. Both the universal and selective screening groups had a similar prevalence of surgical procedures in childhood for dysplasia being performed (0.48 (95% CI 0.32 to 0.63) vs 0.49 (95% CI 0.31 to 0.71) per 1,000 live births, respectively). Conclusion. Universal screening showed a trend towards lower prevalence of late DDH compared to selective screening. However, it was also associated with a significant increase in the prevalence of abduction bracing without a significant reduction in the prevalence of surgical procedures in childhood for dysplasia being performed. High-quality studies comparing both treatment methods are required, in addition to studies into the natural history of missed DDH. Cite this article: Bone Joint J 2023;105-B(2):198–208

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. Methods. A five-year prospective registry study investigating every live birth in the study’s catchment area (n = 27,731), all of whom underwent screening for risk factors and examination at the newborn and six- to eight-week neonatal examination and review. DDH was diagnosed using ultrasonography and the Graf classification system, defined as grade IIb or above or rapidly regressing IIa disease (≥4. o. at four weeks follow-up). Multivariate odds ratios were calculated to establish significant association, and risk differences were calculated to provide quantifiable risk increase with DDH, positive predictive value was used as a measure of predictive efficacy. The cost-effectiveness of using these risk factors to predict DDH was evaluated using NHS tariffs (January 2021). Results. The prevalence of DDH that required treatment within our population was 5/1,000 live births. The rate of missed presentation of DDH was 0.43/1000 live births. Breech position, family history, oligohydramnios, and foot deformities demonstrated significant association with DDH (p < 0.0001). The presence of breech presentation increased the risk of DDH by 1.69% (95% confidence interval (CI) 0.93% to 2.45%), family history by 3.57% (95% CI 2.06% to 5.09%), foot deformities by 8.95% (95% CI 4.81% to 13.1%), and oligohydramnios nby 11.6% (95 % CI 3.0% to 19.0%). Primary risk factors family history and breech presentation demonstrated an estimated cost-per-case detection of £6,276 and £11,409, respectively. Oligohydramnios and foot deformities demonstrated a cost-per-case detected less than the cost of primary risk factors of £2,260 and £2,670, respectively. Conclusion. The inclusion of secondary risk factors within a national screening programme was clinically successful as they were more cost and resource-efficient predictors of DDH than primary risk factors, suggesting they should be considered in the national guidance. Cite this article: Bone Jt Open 2023;4(4):234–240

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%. Methods. We retrospectively included all newborns referred for ultrasound screening at our institution based on primary risk factor, clinical, and PFD screening. α angles, PFD, FHC, and FHC at follow-up ultrasound for referred newborns were measured and compared using scatter plots, linear regression, paired t-test, and box-plots. Results. We included 2,735 newborns, of whom 754 received a follow-up hip ultrasound within six weeks of age. After exclusion, 1,500 hips were included for analysis. Sex distribution was 372 male and 380 female, and the mean age at examination was 36.6 days (4 to 87). We found a negative linear correlation of PFD to α angles (p < 0.001), FHC (p < 0.001), and FHC during provocation (p < 0.001) with a 1 mm increase in PFD corresponding to a -2.1° (95% confidence interval (CI) -2.3 to -1.9) change in α angle and a -3.4% (95% CI -3.7 to -3.0) change in FHC and a -6.0% (-6.6 to -5.5) change in FHC during provocation. The PFD was significantly higher with increasing Graf types and in displaceable hips (p < 0.001). Conclusion. PFD is strongly correlated to both α angles and hip displaceability, as measured by FHC and FHC during provocation, in ultrasound of newborn hips. The PFD increases as the hips become more dysplastic and/or displaceable. Cite this article: Bone Jt Open 2023;5(1):3–8

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. Methods. We conducted a systematic review and meta-analysis of the epidemiological literature from the last 25 years in the UK. Articles were selected from databases searches using MEDLINE, EMBASE, OVID, and Cochrane; 13 papers met the inclusion criteria. Results. The incidence of DDH within the UK over the last 25 years is 7.3/1,000 live births with females making up 86% of the DDH population (odds ratio 6.14 (95% confidence interval 3.3 to 11.5); p < 0.001). The incidence of DDH significantly increased following the change in the Newborn and Infant Physical Examination (NIPE) guidance from 6.5/1,000 to 9.4/1,000 live births (p < 0.001). The rate of late presentation also increased following the changes to the NIPE guidance, rising from 0.7/1,000 to 1.2/1,000 live births (p < 0.001). However, despite this increase in late-presenting cases, there was no change in the rates of surgical intervention (0.8/1,000 live births; p = 0.940). Conclusion. The literature demonstrates that the implementation of a selective screening programme increased the incidence of DDH diagnosis in the UK while subsequently increasing the rates of late presentation and failing in its goal of reducing the rates of surgical intervention for DDH. Cite this article: Bone Jt Open 2023;4(8):635–642

Developmental dysplasia of the hip (DDH) should be diagnosed as early as possible to optimise treatment. The current United Kingdom recommendations for the selective screening of DDH include a clinical examination at birth and at six weeks. In Northern Ireland babies continue to have an assessment by a health visitor at four months of age. As we continue to see late presentations of DDH, beyond one year of age, we hypothesised that a proportion had missed an opportunity for earlier diagnosis. We expect those who presented to our service with Tonnis grade III or IV hips and decreased abduction would have had clinical signs at their earlier assessments. We performed a retrospective review of all patients born in Northern Ireland between 2008 and 2010 who were diagnosed with DDH after their first birthday. There were 75 856 live births during the study period of whom 645 children were treated for DDH (8.5 per 1000). The minimum follow-up of our cohort from birth, to detect late presentation, was four years and six months. Of these, 32 children (33 hips) were diagnosed after their first birthday (0.42 per 1000). With optimum application of our selective screening programme 21 (65.6%) of these children had the potential for an earlier diagnosis, which would have reduced the incidence of late diagnosis to 0.14 per 1000. As we saw a peak in diagnosis between three and five months our findings support the continuation of the four month health visitor check. Our study adds further information to the debate regarding selective versus universal screening. . Cite this article: Bone Joint J 2015;97-B:1572–6

The aim was to compare the efficacy of selective ultrasound-screening (SUSS) for developmental dysplasia of the hip (DDH) to clinical screening alone, by comparing outcomes in a contemporary group with those from a 40 year old cohort. This was a retrospective cohort study. The department's DDH and surgical databases were used to identify all cases of DDH, and all cases of surgery for DDH during the study period (2009–13). Patients born outside our region, and teratologic cases were excluded from analysis. The Obstetric database provided the total number of live births over the five-year period. This data was used to calculate the incidence of late-diagnosis (age over 3 months) DDH and the rate of surgery for DDH in our region. These results were compared to those of a similar study from our institution published in 1977, after the introduction of universal clinical screening. Relative risk (RR) was calculated for the two groups, and analysed for statistical significance. The incidence of late-diagnosis DDH over the recent 5-year study period was 0.66/1000 live births, compared to 0.6/1000 in the control group. The RR for late-diagnosis DDH was not significantly different between the two groups (RR 1.14, 95% CI 0.6 to 2.2). The rate of surgery for DDH was 0.86/1000, compared to 0.9/1000 live births in the control group. The RR for surgery for DDH in the current study population compared to the historic control was 0.97, but this difference was not statistically significant (95% C.I. 0.57 to 1.68; p=0.92). Despite advances in screening for DDH over the last 40 years, neither the incidence of late diagnosis DDH, nor rates of surgery for DDH in our region have changed. Whilst previous studies have demonstrated that SUSS does not eliminate late-presenting DDH, this study suggests it confers no advantage over clinical screening alone

Aims. The aim of this prospective cohort study was to evaluate the effectiveness of the neonatal hip instability screening programme. Patients and Methods. The study involved a four-year observational assessment of a neonatal hip screening programme. All newborns were examined using the Barlow or Ortolani manoeuvre within 72 hours of birth; those with positive findings were referred to a ‘one-stop’ screening clinic for clinical and sonographic assessment of the hip. The results were compared with previous published studies from this unit. Results. A total of 124 newborns with a positive Barlow or Ortolani manoeuvre, clunk positive, or ‘unstable’ were referred. Five were found to have clinical instability of the hip. Sonographically, 92 newborns had Graf Type I hips, 12 had Graf Type II hips, and 20 had Graf Type IV hips. The positive predictive value (PPV) of clinical screening was 4.0% and the PPV of sonography was 16.1%. This has led to an increased rate of surgery for DDH. Conclusion. Compared with previously published ten-year and 15-year studies, there has been a marked deterioration in the PPV in those referred with potential instability of the hip. There appears to be a paradox, with rising referrals and a decreasing PPV combined with an increasing rate of surgery in newborns with developmental dysplasia of the hip. Cite this article: Bone Joint J 2018;100-B:806–10

Over a 15-year prospective period, 201 infants with a clinically unstable hip at neonatal screening were subsequently reviewed in a ‘one stop’ clinic where they were assessed clinically and sonographically. Their mean age was 1.62 weeks (95% confidence interval (CI) 1.35 to 1.89). Clinical neonatal hip screening revealed a sensitivity of 62% (mean, 62.6 95%CI 50.9 to 74.3), specificity of 99.8% (mean, 99.8, 95% CI 99.7 to 99.8) and positive predictive value (PPV) of 24% (mean, 26.2, 95% CI 19.3 to 33.0). Static and dynamic sonography for Graf type IV dysplastic hips had a 15-year sensitivity of 77% (mean, 75.8 95% CI 66.9 to 84.6), specificity of 99.8% (mean, 99.8, 95% CI 99.8 to 99.8) and a PPV of 49% (mean, 55.1, 95% CI 41.6 to 68.5). There were 36 infants with an irreducible dislocation of the hip (0.57 per 1000 live births), including six that failed to resolve with neonatal splintage. Most clinically unstable hips referred to a specialist clinic are female and stabilise spontaneously. Most irreducible dislocations are not identified from this neonatal instability group. There may be a small subgroup of females with instability of the hip which may be at risk of progression to irreducibility despite early treatment in a Pavlik harness. A controlled study is required to assess the value of neonatal clinical screening programmes. Cite this article: Bone Joint J 2015;97-B:265-9

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. Patients and Methods. A single-centre prospective database of all referrals to the hip clinic was examined to identify indication for referrals, diagnosis, and treatment. All patients referred received a standardized ultrasound scan and clinical examination by an orthopaedic consultant. Results. There were 5716 children referred to the orthopaedic hip clinic between 1 June 2014 and 26 September 2018. In all, 1754 children (30.1%) were referred due to ‘clicky hip’ with no additional risk factors or indications for ultrasound scan. A total of 123 children (7.1%) referred with ‘clicky hip’ and no additional risk factors or examination findings had an abnormal initial hip ultrasound, including 16 children (0.9%) with dysplastic hips. Of the 141 children who required treatment in a Pavlik harness during the study period, 23 (16%) had been referred with a ‘clicky hip’ and no additional risk factors or examination findings, including six children with Graf 3 or 4 hips. Conclusion. There is significant value in reviewing children with an isolated ‘clicky hip’. Many children who require treatment are referred to the orthopaedic service as ‘clicky hip’ with no additional risk factors. In a pragmatic pathway with a diverse population of clinicians performing baby checks, ‘clicky hip’ is an important indication for referral and should not be discarded. Cite this article: Bone Joint J 2019;101-B:635–638

Congenital Talipes Equinovarus (CTEV) is one of the most common congenital limb deformities. We reviewed the records of infants who had received treatment for structural CTEV between 1 January 2007 and 30 November 2012. This was cross-referenced with the prenatal scans of mothers over a corresponding period of time. We investigated the sensitivity, specificity, and positive and negative predictive values of the fetal anomaly scan for the detection of CTEV and explored whether the publication of Fetal Anomaly Screening Programme guidelines in 2010 affected the rate of detection. During the study period there were 95 532 prenatal scans and 34 373 live births at our hospital. A total of 37 fetuses with findings suggestive of CTEV were included in the study, of whom 30 were found to have structural CTEV at birth. The sensitivity of screening for CTEV was 71.4% and the positive predictive value was 81.1%. The negative predictive value and specificity were more than 99.5%. There was no significant difference between the rates of detection before and after publication of the guidelines (p = 0.5). We conclude that a prenatal fetal anomaly ultrasound screening diagnosis of CTEV has a good positive predictive value enabling prenatal counselling. The change in screening guidance has not affected the proportion of missed cases. This information will aid counselling parents about the effectiveness and accuracy of prenatal ultrasound in diagnosing CTEV. Cite this article: Bone Joint J 2014;96-B:984–8

Purpose. There is concern that the positive predictive value (PPV) of neonatal screening for instability may have deteriorated over recent years, this study aims to evaluate this. Method. This is a prospective observational longitudinal study from 2012 – 2016. Patients that were referred from paediatric neonatal screening with hip instability (Ortolani / Barlow positive, clunks) were identified and underwent ultrasound and clinical examination in the one stop hip clinic by the senior author. Referrals were taken from a range of screeners from paediatric doctors to midwives and advanced neonatal practitioners. Syndromic or neurological dislocated hips were excluded. The outcome measures were the presence of a subluxated / dislocated hip on ultrasound as per Graf and Harcke classification and a positive provocative manoeuvre on examination. This allowed a PPV to be evaluated for both ultrasound and clinical examination. Results. 139 neonates were referred for a suspected dislocated or dislocatable hip from paediatric screening services. These were seen at a mean 14.0 days (95% C I, 12.28 to 15.72). 20 patients had a Graf type 4 hip on ultrasound and 5 had a positive provocative test on examination. This represents an ultrasound PPV of 14.4% and clinical exam PPV of 3.6% . This has deteriorated from 15 year data from our unit (PPV 24% clinical, 49% sonographic). Our overall surgical rate for DDH has increased to 1.07 per 1000, and our overall rate of open reductions has increased to 0.7 per 1000. This is based upon figures from 2012 – 2014. Conclusion. The PPV of screening has decreased over the last 5 years. The concern is too many screeners who, with regards screening the paediatric hip, are poorly trained, inexperienced, not adequately supervised. We need to learn the lessons of Sweden and ensure better quality screening by limiting screening to a small number of experienced practitioners

The aim of this study was to evaluate whether universal (all neonates) or selective (neonates belonging to the risk groups) ultrasound screening of the hips should be recommended at birth. We carried out a prospective, randomised trial between 1988 and 1992, including all newborn infants at our hospital. A total of 15 529 infants was randomised to either clinical screening and ultrasound examination of all hips or clinical screening of all hips and ultrasound examination only of those at risk. The effect of the screening was assessed by the rate of late detection of congenital or developmental hip dysplasia in the two groups. During follow-up of between six and 11 years, only one late-detected hip dysplasia was seen in the universal group, compared with five in the subjective group, representing a rate of 0.13 and 0.65 per 1000, respectively. The difference in late detection between the two groups was not statistically significant (p = 0.22). When clinical screening is of high quality, as in our study, the effect of an additional ultrasound examination, measured as late-presenting hip dysplasia, is marginal. Under such circumstances, we consider that universal ultrasound screening is not necessary, but recommend selective ultrasound screening for neonates with abnormal or suspicious clinical findings and those with risk factors for hip dysplasia

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

Between May 1992 and April 1997, there were 20 452 births in the Blackburn District. In the same period 1107 infants with hip ‘at-risk’ factors were screened prospectively by ultrasound. We recorded the presence of dislocation and dysplasia detected under the age of six months using Graf’s alpha angle. Early dislocation was present in 36 hips (34 dislocatable and 2 irreducible). Of the 36 unstable hips, 30 (83%) were referred as being Ortolani-positive or unstable; 25 (69%) of these had at least one of the risk factors. Only 11 (31%) were identified from the ‘at-risk’ screening programme alone (0.54 per 1000 live births). Eight cases of ‘late’ dislocation presented after the age of six months (0.39 per 1000 live births). The overall rate of dislocation was 2.2 per 1000 live births. Only 31% of the dislocated hips belonged to a major ‘at-risk’ group. Statistical analysis confirmed that the risk factors had a relatively poor predictive value if used as a screening test for dislocation. In infants referred for doubtful clinical instability, one dislocation was detected for every 11 infants screened (95% confidence interval (CI) 8 to 17) whereas in infants referred because of the presence of any of the major ‘at-risk’ factors the rate was one in 75 (95% CI 42 to 149). Routine ultrasound screening of the ‘at-risk’ groups on their own is of little value in significantly reducing the rate of ‘late’ dislocation in DDH, but screening clinically unstable hips alone or associated with ‘at-risk’ factors has a high rate of detection

Since September 1964, neonates born in New Plymouth have undergone clinical examination for instability of the hip in a structured clinical screening programme. Of the 41 563 babies born during this period, 1639 were diagnosed as having unstable hips and 663 (1.6%) with persisting instability were splinted, five of which failed. Also, three unsplinted hips progressed to congenital dislocation, and there were four late-presenting (walking) cases, giving an overall failure rate of 0.29 per 1000 live births, with an incidence of late-walking congenital dislocation of the hip of 0.1 per 1000 live births. This study confirms that clinical screening for neonatal instability of the hip by experienced orthopaedic examiners significantly reduces the incidence of late-presenting (walking) congenital dislocation of the hip

Between 1978 and 1997 all newborns in the Austrian province of Tyrol were reviewed regarding hip dysplasia and related surgery. This involved a mean of 8257 births per year (7766 to 8858). Two observation periods were determined: 1978 to 1982 (clinical examination alone) and 1993 to 1997 (clinical examination and universal ultrasound screening). A retrospective analysis compared the number and cost of interventions due to hip dysplasia in three patient age groups: A, 0 to < 1.5 years; B, ≥ 1.5 to < 15 years; and C, ≥ 15 to < 35 years. In group A, there was a decrease in hip reductions from a mean of 25.2 (. sd. 2.8) to 7.0 (. sd. 1.4) cases per year. In group B, operative procedures decreased from a mean of 17.8 (. sd. 3.5) to 2.6 (. sd. 1.3) per year. There was a 75.9% decrease in the total number of interventions for groups A and B. An increase of €57 000 in the overall cost per year for the second period (1993 to 1997) was seen, mainly due to the screening programme. However, there was a marked reduction in costs of all surgical and non-surgical treatments for dysplastic hips from €410 000 (1978 to 1982) to €117 000 (1993 to 1997). We believe the small proportional increase in costs of the universal ultrasound screening programme is justifiable as it was associated with a reduction in the number of non-surgical and surgical interventions. We therefore recommend universal hip ultrasound screening for neonates

Purpose of study. Results clinically & statistically of a 10 year prospective observational longitudinal study of the effects of sonographic screening for ‘risk’ factors in DDH. Methods & Results. From 1997 to 2006 the project analysed the results of a sonographic screening programme for clinical instability & ‘risk factors’ in Blackburn (modified Graf system). ‘Risk factors’ included: breech presentation, strong family history, foot deformities & oligohydramnios. Statistically 95% confidence intervals, relative risk, sensitivity, specificity PPV & NPV were calculated. The outcome measure was irreducible dislocation of the hip joint. There was a birth population of 37,510, of which 2693 were ‘at risk’ & 132 clinically unstable. Three subsections:. 1. Clinically unstable hips (birth). 2 irreducible dislocations. 2. ‘At risk’. 6 irreducible dislocations. 3. Secondary referral (GP screening). 11 irreducible dislocations. The overall irreducible dislocation rate was 0.51 per 1000 live births. ‘Risk factors’: mGraf Type III/IV/ Irreducible:. CTCV:. 1: 13.8. RR = 26.5. Family history:. 1:18.5. RR = 23.3. Breech:. 1:35. RR = 14.8. Oligohydramnios. 1:99.5. TEV (postural). 1:202. CTEV (fixed). 0.0. Narrow 95% CI for Breech, CTCV & CTEV. Wide 95% CI for Family history, oligohydramnios & TEV (postural). 95% CI (RR) for Oligohydramnios & TEV not significant. RR for clinical hip instability was 983.6. Percentage female. 18/19 irreducible hips. 94.74%. 64/92 Type IV hips. 69.56%. 26/30 Type III hips. 86.66%. 34.15% of clinically unstable hip joints had a ‘risk factor’. Conclusion. Only 13 from 2693 ‘at risk’, had Type IV or Irreducible hips. Only 7 were treatable by splintage. Clinically & statistically screening for at ‘risk hips’ alone has a poor return. Female gender & clinical instability appear more important

We studied the reproducibility of ultrasonographic screening examination of the hip when read by diagnostic radiographers. In order to determine interobserver variability, 200 ultrasonograms were classified according to Graf’s method by five observers (four radiographers and one radiologist). The kappa values for interobserver variability indicated moderate agreement (kappa 0.47) for the exact Graf classification and substantial agreement (kappa 0.65) for the classification of normal (type I) versus abnormal (type IIa-IV). Agreement was significantly different for normal, immature and abnormal hips. Comparison of the findings in our interobserver study with existing information based on other examinations and treatment revealed that only a small number of infants with mildly dysplastic hips would have been typed as normal by some observers as a result of observer variability. In conclusion, the interobserver agreement on the ultrasound assessment of the hip was good enough for screening purposes. Observer variability did not result in any severe cases being missed

We have analysed the patterns of management of developmental dysplasia of the hip (DDH) in Coventry over a period of 20 years during which three different screening policies were used. From 1976 to the end of 1985 we relied on clinical examination alone. The mean surgical cost for the treatment of DDH during this period was £5110 per 1000 live births. This was reduced to £3811 after the introduction of ultrasound for infants with known risk factors. Since June 1989 we have routinely scanned all infants at birth with a mean surgical cost of £468 per 1000 live births. This reduction in cost is a result of the earlier detection of DDH with fewer children requiring surgery. In those who do, fewer and less invasive procedures are needed. The overall rate of treatment has not increased and regular review of patients managed in a Pavlik harness has allowed us to avoid the complication of avascular necrosis. When we add the cost of running the screening programme to the expense of treating the condition, the overall cost for the management of DDH is comparable for the different screening policies

The study was to ascertain if parents/carers could be effective screeners in the detection of infant hip dysplasia. Infants have been screened for developmental hip dysplasia (DDH) since the late 1960's. The recognition of the importance for early identification of the condition has been well documented. However, the changes to the national screening programme in 2008 have reduced the surveillance of DDH following the removal of the 8 month infant hip check, leaving only the 6–8 week hip check as standard. A self-check guide for DDH has been developed to enlist parents as screeners for the condition. The guide highlights common signs used to alert to the possibility of hip dysplasia or dislocation. The guide was disseminated by the Royal Berkshire Hospital NHS Trust between 2008 – 2013 within West Berkshire through the maternity services and Health Centres. The guide provided parents with information on classic signs associated with DDH which they were asked to check for. Of those infants referred to our specialist clinic as a result of parental screening, 73% were “abnormal” of these 33% went on to treatment with splintage. The mean age of these infants was 5.36 months. 20% of positive findings were in infants aged 7 month or over at the time seen. None went on to open surgery. These patients represented between 5 and 10% of our overall group of DDH positive patients. If left undiagnosed, they may have gone on to late presentation of hip dislocation requiring surgery as a child or undiagnosed acetabular dysplasia and possible surgical treatment in relatively early adult life. Therefore we concluded that given the right guidance parents/carers would be ideal screeners to assist in detecting possible later presenting DDH in their baby