Aims. To analyze whether the addition of risk-based criteria to clinical examination-based selective ultrasound screening would increase the rates of early detected cases of developmental dysplasia of the hip (DDH) and decrease the rate of late detected cases. Methods. A systematic review with meta-analysis was performed. The initial search was performed in the PubMed, Scopus, and Web of Science databases in November 2021. The following search terms were used: (hip) AND (ultrasound) AND (luxation or dysplasia) AND (newborn or neonate or congenital). Results. A total of 25 studies were included. In 19 studies, newborns were selected for ultrasound based on both risk factors and clinical examination. In six studies, newborns were selected for ultrasound based on only clinical examination. We did not find evidence indicating that there are differences in the incidence of early- and late-detected DDH, or in the incidence of nonoperatively treated DDH between the risk-based and clinical examination-based groups. The pooled incidence of operatively treated DDH was slightly lower in the risk-based group (0.5 (95% confidence interval (CI) 0.3 to 0.7)) compared with the clinical examination group (0.9 per 1,000 newborns, (95% CI 0.7 to 1.0)). Conclusion. The use of risk factors in conjunction with clinical examination in the selective ultrasound screening of DDH might lead to fewer operatively treated cases of DDH. However, more studies are needed before stronger conclusions can be drawn. Cite this article: Bone Joint J 2023;105-B(3):247–253

Background: Screening modalities in early detection of DDH remain controversial worldwide despite of universal accessibility to ultrasound and despite of encouraging preliminary results reported about the Austrian and German general ultrasound screening programs. The goal of our investigations was to provide a long time survey on effects following the introduction of the ultrasound exam in prevention of DDH and to proof its beneficial medical and economic effects as well as to analyze possible adverse effects, when utilized by a general screening. Method: Nationwide data about ultrasound screening exams, sonographic follow up exams, frequencies of functional abductive treatment measures as well as hospitalizations due to DDH were requested by different Austrian health care providers. Through a representative recall over a time frame ranging partially back to 1980 a surveillance analysis is provided. The medical effectiveness of the screening was mainly assessed by the annual appearance of early late cases, representing open reductions (O.R.) upon the first two years of life. Other variables as the disease related incidence of age matched annual hospitalizations and the disease prevalence measured by non age matched hospitalizations in relation to the year specific population were analyzed. A cost benefit analysis was performed by comparing the treatment and diagnostic costs in the year before program start (1991) to the last year of surveillance (2004). Results: Since 1980 the functional treatment rate has continuously been reduced from approximately 12 percent to 3.23 percent in 2004. Early late cases (O.R.) due to DDH have been also diminished to an international competitive rate of 0.13 per 1000 newborns, while other age specific early surgical interventions could be almost eradicated. Current additional investments of the program figure only 16.94 € per newborn and embody approximately 1370 € per detection of one affected newborn. Control exams are contributing to roughly 25% of the calculated costs. Interpretation: By founding a nationwide program Austria has introduced a medically efficient screening modality to reduce early late cases and to limit treatment of DDH exposed children to less invasive measures by early diagnosis. In contrary to suspicions of possible adverse effects of such screening, overtreatment has been abandoned while the functional treatment rate has sunken to an acceptable level. Costs saving effects have been already realized on the treatment side. Further savings shall be realized by limiting an unacceptable rate of control exams

Introduction: The quality of newborn hip screening is usually measured as the number of late detected cases of hip dysplasia. There is no consensus concernig the use of ultrasonography in hip joint screening in newborns. At our hospital the number of late detected cases was around 2/1000 births using clinical screening. In a prospective, randomised study we compared universal ultrasound screening and selective ultrasound screening. We reduced the number of late detected cases when using universal ultrasound screening to 0,13/1000, whereas the group with selective ultrasound screening had 0,65/1000, the difference was not significant. We have therefore continued selective ultrasound screening, and present the results concerning late detected cases in the 9-year period 1999–2007 with this screening model. Materials and Methods: Newborns in our county are now offered selective ultrasound hip joint screening, in addition to the stanard clinical screening. The ultrasound examinations are performed 1–3 days after birth. The following risk factors lead to ultrasound examination: positive or doubtful Ortolani or Barlow tests, breech position, family history of hip dysplasia, foot deformities, and some syndromes. In the 9-year period 1999–2007 a total of 34000 babies where born in our county, and 13% had risk factors for hips dysplasia and were examined by ultrasound. Our hospital is the only hospital dealing with lated detected cases in our county. Results: In the 9-year period the primary treatment rate using the Frejka pillow was 0,9/1000 births. In the same period there were 16 children treated for lated detected hip dysplasia. There were 14 girls and 2 boys, giving an incidence of late detected cases of 0,47/1000 births. There were no common characteristics among the children with late detected hip dysplasia. Discussion/Conclusions: It has been assumed that a good clinical hip joint screening in newborns should not give more than 0,5/1000 births of late detected cases. By using selective ultrasound screening we have achieved 0,47/1000 births of late detcted cases in our county. We therefore recommend selective ultrasound hip screening in newborns

Objective: The aim of this study was to show the effect of a universal (all neonates) ultrasound screening in newborns on the incidence of operative treatment of hip dysplasia. Materials: A retrospective study was performed and all newborns of the county Tyrol (Austria) between 1978 and 1998 (8257 births / year ((range: 7766 – 8858)) were reviewed regarding hip dysplasia and following hip surgeries. Between 1978 and 1983 clinical examination alone was performed to detect hip dysplasia. Between 1983 and 1988 an ultrasound screening programme according to Graf was initiated in our county. Between 1988 and 1998 ultrasound screening was performed in all newborns. Hence two observation periods were determined: 1978–1983 and 1993–1998. The time period between 1983 and 1993 was excluded to minimize bias and learning curve regarding the initiation of the ultrasound screening programme. A retrospective comparative analysis of the two observation periods regarding surgical treatment and costs caused by hip dysplasia was performed. During the observation period indication for surgery did not change, however new treatment techniques were introduced. Patients with neuromuscular and Perthes diseases were excluded. According to age dependent surgical procedures three patient samples were determined: Group A: 0–1.5 years, Group B: 1.5–15 years and Group C: 15–35 years. Results: Comparison of the two observation periods showed no influence on the number of interventions for dysplastic hips in group C (pelvic osteotomies and VDROs). In group A, a decrease of hip reductions was seen from 25.6±3.2 to 7.0± 1.4 cases per year. In group B, there was a decrease of operative procedures for dysplastic hips from 18.0±3.2 to 3.4±1.3 interventions per year. Since the introduction of universal hip ultrasound screening the decrease of the total number of interventions for all groups was 78.6%. Comparison of costs of the two observation periods showed an increase of all costs caused by DDH and CDH of 57.000 euro/ year for the time period between 1993 and 1998 which was mainly caused by the ultrasound screening programme. There was a significant reduction of costs regarding operative and non operative treatment for dysplastic hips from 410.000 euro (1978–1983) to 117.00 euro (1993–1998). Conclusion: Initially there were higher costs caused by the screening method, but on the other hand total number and costs for operative and nonoperative treatment of dysplastic hips were significantly reduced by the universal ultrasound screening programme. In our mind patient’s and family distress and pain related to interventions performed for CDH and DDH justify the slight increase of costs caused by the universal screening programme. We therefore recommend universal hip ultrasound screening for neonates

Introduction and purpose: There is a controversy about the value and usefulness of the ultrasound screening of hips as well as about what population should be screened. It seems clear that ultrasound is the best method for early screening of developmental dysplasia in infants. The purpose of this paper is to assess the results of the semi-universal ultrasound screening of hips in infants. Materials and methods: We evaluated the screening carried out of all girls and boys with risk factors delivered in our hospital (3/4 of those in the whole of Navarra) 1n 2001, 2002 and 2003. The number of newborns studied was 4144, 4199 and 4820 respectively. Ultrasounds were carried out when they were one month old. Diagnosed dysplasias accounted for between 6.19 and 6.27 per thousand newborns. Of all patients with diagnosed dysplasias, 4 girls (no boys) had to be operated on (adductor tenotomy and plaster cast). Results and conclusions: The majority of diagnosed and treated dysplasias were found in breech babies, babies with a family history of the disease and especially in cases where there was no other sign suggesting the disease (only eight of them had had a positive Ortolani-Barlow). The lack of cases of late dysplasia has prompted us to rely on this type of screening since it has helped us reduce the amount of surgical procedures

The use of targeted ultrasound screening for ‘at risk’ hips in order to reduce the rate of surgery in developmental dysplasia of the hip (DDH) are unproven. A prospective trial was undertaken in an attempt to clarify this matter. Over an 8-year period, there were 28,676 live births. Unstable and ‘at risk’ hips were routinely targeted for ultrasound examination. One thousand eight hundred and six infants were ultrasounded, 6.3% of the birth population. Twenty-five children (18 dislocations and 7 dysplasias) required surgical intervention (0.87 per 1000 births for DDH / 0.63 per 1000 births for dislocation). Targeted ultrasound screening does not reduce the overall rate of surgery compared with the best conventional clinical screening programmes. The development of a national targeted ultrasound screening programme for ‘at risk’ hips cannot be justified on a cost or result basis

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

Introduction: Ideally any screening system should use a simple reliable test with good intraobserver reproducibility. This is important in DDH as once there is an established abnormality surgical intervention is frequently required. The aim of early detection (within six weeks) is to increase the number of children that may be treated nonoperatively. We have evaluated the effectiveness of our selective screening program by determining the late presentation rate of DDH in our region. Methods: Between January 2001 and December 2003 we looked retrospectively at all patients presenting with DDH in our region. We recorded their age at scan and presentation, the Graf classification if recorded, their management, the presence of risk factors for DDH, referral source and presence of a positive clinical examination. All these were entered into a database and analyzed specifically with regard to patients presenting late. Results: In the period between January 2001 and June 2002 prior to selective ultrasound screening (Group 1) there were 9441 live births and 26 cases of DDH (incidence of 2.75). There were 11 late presenters with an incidence of 1.12 per 1000 per year. Between July 2002 and December 2003 (Group 2) there were 9428 live births and 20 cases of DDH (incidence of 2.12). There were 3 late presenters with an incidence of 0.3 per 1000 per year. Discussion: We have shown that a program of selective ultrasound screening in our region has decreased the number of children presenting late with DDH. It must be remembered however, that in the absence of any risk factors, clinical examination remains critical in identifying those with DDH in a selective screening program

Introduction: To measure the incidence of late presenting DDH following the introduction of selective ultrasound screening of neonatal hips with associated risk factors. Method: Retrospective cohort study of children with late diagnosed DDH in a defined population of Greater Glasgow Region. A hip ultrasound program was introduced in the year 1997 for secondary screening of children with risk factors for DDH. The departmental and theatre database was used to identify children with late diagnosed DDH. (Defined as diagnosed 3 months after birth) Demographic details, age at presentation, presence of risk factors (Breech presentation, family history, clicks, caesarian section) and details of treatment were recorded. The number of live births for each year was obtained from the General Registrar Office for Scotland. The incidence of late presenting DDH was calculated taking in to account the year of child’s birth. The incidence of late DDH was then compared between the period 1992 –1996 and 1997– 2001. Results: 78 children were identified, of which 49 babies were between 1992 – 96 and 29 between 1997 –01. The average age at diagnosis was 17 months (Median 15 months, range 5 –84 months). The average annual incidence from 1992 –6 was 0.84 per 1000 live births and from 1997 – 2001 was 0.57 per 1000 live births. This decrease in incidence of late DDH was not significant at 5% level (chi squared p = 0.088). 64 children (82%) with late diagnosed DDH had no factors that could be perceived as risk factors for the condition. Discussion: Targeted ultrasound screening of babies with risk factors appears to have reduced the average incidence of late DDH from 0.84 to 0.57 per 1000 live births. However this reduction in incidence is not statistically significant. The vast majority of late presenters (82%) do not have risk factors. It remains unclear whether universal ultrasound screening program, practiced in some parts of United Kingdom is a cost effective alternative to eliminate the incidence of late presenting DDH

Early detection and management of developmental dysplasia of the hip (DDH) yields simpler and more effective the treatment. Diagnosis by ultrasound has changed the clinical view of the disease. However, the need and the way of ultrasound screening is still controversial. Diagnosis by ultrasound has shown that morphological abnormalities may not be associated with clinical signs. In Hungary all newborns are screened clinically within the first and also the third week of life, and controlled at the age of four month. Clinical examination is performed by an Ortopaedic specialist. Ultrasound screening is first performed for children with clinical signs and for children at risk at three weeks of age. Radiological examination, when necessary, is first performed at the age of four month. In the five year timeline (2001–2005) that was re-evaluated 7339 children presented 9706 times for screening for DDH at the University of Szeged (Hungary) Department of Orthopaedics. Out of these cases 6991 (95.2%) children were found to be healthy and 348 (4.8%) were diagnosed for DDH. Children with dysplasia presented 896 times for treatment and follow-up. Patient compliance in the DDH group was average 2.5 visits, while for the healthy group it was only average 1.2 visits. Because of clinical signs or risk factors 1569 (21%) children had ultrasound examination, all-together 2169 times. 84% of the initial ultrasound examination showed Graf stage Ia hip. Out of the diagnosed 348 DDH cases 31 patients (Graf IIa-IIc) were administered with Pavlik harness, and 314 (Graf Ib-IIa) were treated with splinting. Remaining 3 cases were diagnosed late, where no ultrasound examination was performed. In the DDH cases 832 ultrsonographic examination was performed during the treatment (average 2.4 examination/case). Radiographic control of all treated children excluded avascular necrosis in all cases. For this population 14 first operative procedure was needed so far. In our experience clinical screening and selective ultrasound examination is effective in the screening and early detection of developmental dyspalsia of the hip. In our practice, we promptly treated all patients with detected morphological changes as a deficiency in hip development. This way selective screening has helped us in the management of developmental dyspalsia of the hip. Hopefully, with the selective indication the number of false positive cases was reduced, while the „silent” clinical instabilities were given a chance for better long term development

Aim. The aim of this study is to assess the effectiveness of clinic based ultrasound screening by Orthopaedic surgeon for early diagnosis and treatment of developmental dysplasia of hip (DDH) in one stop clinic. Methods. This prospective study included 395 infants (185 male and 210 female) (5.2% of study population) who were referred for screening on the basis of abnormal findings or the presence of risk factors for DDH. Average age was 12.5 weeks (1 day to 15 months). All infants were assessed for risk factors of DDH. Clinical examinations were performed by the senior author followed by ultrasonography of both of the infant's hips, using the Graf's technique. Alpha and beta angles were calculated and hips were classified according to Graf's classification system. Results. Out of 790 hips examined 670 (84.8%) were labelled as normal. 120 (15.1%) hips in 84 patients were diagnosed as dysplastic or dislocated. Clinical examination only detected 39 patients out of 84, sensitivity of 46%. Average age of diagnosis was 12 weeks (3days-11 months). 79 patients were successfully treated with pavlic harness, 2 required traction and 3 were referred for surgical treatment. There were 14 cases of late diagnosis during one year period (> 4 months of age) (1.8/1000). Conclusion. Selective ultrasound screening is effective in early diagnosis of DDH and significantly reduces the duration of non operative treatment as well as the need for surgical intervention but does not completely eliminate late diagnosis of DDH. We find the concept of one stop DDH clinic highly effective and recommend that ultrasound training should be a part of orthopaedic curriculum

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

The use of targeted ultrasound screening for ‘at risk’ hips in order to reduce the rate of surgery in developmental dysplasia of the hip (DDH) is unproven. A prospective trial was undertaken in an attempt to clarify this matter. Over an 8-year period, there were 28, 676 live births. Unstable and ‘at risk’ hips were routinely targeted for ultrasound examination. One thousand eight hundred and six infants were ultrasounded, 6. 3% of the birth population. Twenty-six children (19 dislocations and 7 dysplasia) required surgical intervention (0. 91 per 1000 births for DDH/0. 66 per 1000 births for dislocation). Targeted ultrasound screening does not reduce the overall rate of surgery compared with the best conventional clinical screening programmes. The development of a national targeted ultrasound screening programme for ‘at risk’ hips cannot be justified on a cost or result basis

We have undertaken routine ultrasound screening for neonatal hip instability in Coventry since June 1989. Of the 14,050 babies scanned during the first three years, 847 (6%) had ultrasound abnormalities. A grading system, based on the percentage of femoral head coverage, is presented. The proportion of abnormal hips decreased gradually so that by nine weeks, 90% had normal ultrasound appearances. Abnormality was more common in babies with a family history of CDH and in breech presentations. All babies with clinically abnormal hips had an abnormal first ultrasound examination. Five babies not diagnosed by clinical examination and with no risk factors had abnormal ultrasound appearances and were subsequently found to have clinically abnormal hips. Routine ultrasound screening has detected cases which would otherwise have presented late

Purpose. There are concerns of soft-tissue reactions such as metal hypersensitivity or pseudotumors for metal-on-metal (MoM) bearings in hip arthroplasty, however, such reactions around ceramic or polyethylene bearings are incompletely understood. The present study was conducted to examine the capabilities of ultrasound screening and to compare the prevalence of periarticular soft-tissue lesions among various types of bearings. Methods. Ultrasound examinations were conducted in 163 hips (153 patients) with arthroplasty after mean a follow-up of 8.1 years (range, 1–22 years). This included 39 MoM hip resurfacings (M-HR) including 30 Birmingham hip resurfacings (BHR) and 9 ADEPT resurfacings; 36 MoM total hip arthroplasties (M-THA) with a large femoral head including 26 BHR and 10 ADEPT bearings; 21 ceramic-on-ceramic THAs (C-THA) of Biolox forte alumina bearings; 24 THAs with a conventional polyethylene liner (cPE-THA) including 19 Lubeck and 5 Omnifit systems; and 43 THAs with a highly cross-linked polyethylene liner (hxPE-THA) including 28 Crossfire and 15 Longevity liners. All procedures were performed in the lateral position through the posterior approach without trochanteric osteotomy. The M-HR group had a significantly higher frequency of male patients than the C-THA, cPE-THA, and hxPE-THA groups, and the patients in the M-HR group were younger than those in the other four groups. Ultrasound images were acquired as a still picture and in video format as the hip moved in flexion and rotation, and 4 qualitative classifications for periarticular soft-tissue reactions were determined as normal pattern, joint-expansion pattern (marked hypoechoic space between the anterior capsule and the anterior surface of the femoral component), cystic pattern (irregularly shaped hypoechoic lesions), and mass pattern (a large mass extending anterior to the femoral component). Magnetic resonance imaging (MRI) was subsequently performed in 45 hips with high-frequency encoding bandwidths. For the reliability of ultrasound screening, positive predictive value, negative predictive value, and the accuracy of the presence of abnormal patterns on ultrasound were calculated using the abnormal lesions on MRI as a reference. Results. Among the 45 hips that underwent MRI, periarticular abnormal lesions were detected in 26 hips (58%). Using MRI findings as reference, positive predictive value, negative predictive value, and the accuracy of ultrasound examination for the detection of soft-tissue lesions were 83%, 71%, and 78%, respectively. Abnormal ultrasound lesions with joint expansion, cystic, or mass patterns were most frequently observed in the cPE-THA group (50%), followed by the M-THA (25%), hxPE-THA (23%), M-HR (18%), and C-THA groups (14%). Compared to the hxPE-THA group, the frequency of abnormal patterns did not differ significantly in the two MoM groups. A mass pattern was detected in 3 hips of the M-THA group and 1 hip of the C-THA group (Figure 1). Abnormal ultrasound lesions were significantly associated with the presence of symptoms. Conclusion: Various soft-tissue reactions could be observed other than those for MoM bearings, and pseudotumors may not be a specific feature of MoM bearings. Ultrasound examination may be a suitable screening tool for further large prospective investigations of soft-tissue reactions around various types of bearings

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

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

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

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

The incidence of DDH Varies depending on genetic and ethnic varieties but in Ireland on an average in 3 per 1,000 live births. Current treatment is focused on early diagnosis and congruent reduction of the hip joint. With conservative measures, principally skilful use of the Pavlik harness, the majority of (85%) of dislocated or subluxated hips will be successfully treated. Late diagnosis impacts on the mode of treatment and on the subsequent outcome. An audit of annual incidence of DDH in North Eastern health board, in Ireland showed a dramatic increase in late diagnosis (> 4 month). There were 4668 live births in 2004 with 17 cases of DDH presenting between the ages of 4 – 36 months during this period. The mean age of presentation was 10 months. Two cases were bilateral. The male: female ratio was 4.6:1. Risk factor analysis showed, only 50% fell in to the high risk group, majority of them had positive family history. Three fourth of them were frank dislocations and all of them required operative intervention. As opposed to early presenters, only 10% needed operative intervention. 30% of the late presenters needed major osteotomies. We examined the reasons for this extreme high rate of late presenters and argue for the introduction of routine ultrasound screening in this region based on historical high incidence of DDH and the dramatic incidence of delayed diagnosis