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.

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.

Of 4,617 babies born in Coventry in 1986, a total of 448 (9.7%) had either clinical abnormality of the hip or at risk factors for CDH. All were examined by ultrasound, but only 17 required treatment (3.7 per 1,000); in five of these no clinical abnormality had been detected. An additional 81 babies had ultrasound abnormalities but did not require treatment, despite the fact that ultrasound at first showed major hip displacement in 17 of them. Three late cases of CDH have presented among the babies born in 1986, but not examined by ultrasound. This incidence of late CDH is unchanged compared with the previous nine years, although ultrasound had detected covert displacement in a number of hips.

Twenty-nine patients with thirty pseudarthroses after removal of infected total hip prostheses have been reviewed one to six years later. Six hips still had a discharging sinus. Complete removal of all cement was found to be essential for healing, and various points in the technique of its clearance have been made. In this respect radio-opaque cement was a great advantage, and lateral guttering of the femur was most effective. Compared with the situation before replacement considerable relief of pain was obtained in most patients but there was much less improvement in function.