The aim of this study was to ascertain the results and effectiveness of targeted screening of babies. All the newborn babies (30585 births from 1997 to 2002) in the geographical area served by our trust were assessed by the paediatricians (neonatologists) and general practitioners (GP). They were assessed for abnormal hip examination finding including clinical instability and risk factors for DDH. The risk factors were positive family history, abnormal lie or presentation other than vertex during pregnancy or at birth, oligohydramnios or other congenital abnormalities. On referral, they were assessed clinically and by ultrasound (US) scan in a special Hip screening clinic. The data were obtained prospectively. Over the period of these six years, 2742 babies were examined in the clinic. Many had more than one risk factor or abnormal hip examination finding (15.9% of babies with abnormal hips and 7.4% of babies with normal hips). Only five babies presented at or after 4 months of age (delayed presentation). They had been treated by the GP (1 patient), at a private hospital (1 patient) or were from outside our area (3 patients). All had abnormal hips on clinical examination. Of these, 3 were 3A or 3B Graf grade (US scan), 1 was 2B and another 2A+. Screening of babies with above risk factors has identified all patients with abnormal hips in our area, thus avoiding late presentation of DDH. Raising awareness of GPs and paediatricians about these factors should also reduce the number babies to be seen in the hip screening clinic to minimum yet safe levels

Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips. Materials/Methods: Of the 30585 births (over a 6 year period) in the population served by our hospital, 2742 babies (8.96percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive). Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans. Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and cost savings

Aim: We wanted to ascertain if clinical examination confers any additional benefit to secondary/targeted ultrasound screening of neonatal hips. Materials and Methods: Of the 30585 births (from 1997–2002) in the population served by our hospital, 2742 babies (8.96 percent) were referred to the Hip Screening Clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. Of these, 1862 hips were normal on clinical examination, 841 hips tense (clinical examination inconclusive). Results: 233 hips were identified as abnormal by the US scans (Graf method). 106 (45 percent) of these were normal on clinical examination. In 88 of the hips with abnormal US scans (38 percent), clinical examination could not be performed reliably as the babies were tense. None of the hips identified as abnormal on clinical examination were normal on US scans. Conclusion/Discussion: US scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist. This should lead to better utilisation of resources and cost savings

Since September 1964, neonates born in New Plymouth have undergone clinical examination for Neonatal Instability of the Hip (NIH) in a structured clinical screening programme. Forty one thousand, five hundred and sixty three babies were born during the period of this study, of which 1,638 were diagnosed as having unstable hips. Six hundred and thirty three with persisting instability were splinted (1.6%), with five hips failing splintage. In addition, three unsplinted hips progressed to CDH, and there were four late-presenting (walking) cases of CDH, giving an overall failure rate for the programme of 0.29 per 1000 live births, with a late-presenting (walking) CDH incidence of 0.1 per 1000 live births. This study confirms that clinical screening for NIH by experienced orthopaedic examiners significantly lowers the incidence of late-presenting (walking) CDH.

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.

The purpose of this study was to audit screening and treatment programmes for Developmental Dysplasia of the Hip (DDH) over a 12-year period from 1989 to 2000 with respect to late presentation and treatment rate and duration.

All babies born in Queen Mary Hospital are clinically screened for DDH by a consultant orthopaedic surgeon. Unstable hips are treated by Pavlik Harness and attend an ultrasound clinic run by an orthopaedic surgeon within 2 weeks. High-risk babies or those with suspected instability can also be referred for ultrasound. Serial ultrasound exams assisted with determining the duration of splintage. Radiographs are taken at 4 to 6 months. Late presenters were identified and analysed.

Over the 12-year period 13 cases of late presenting DDH were identified (0.6 per 1000). Half of these had not been screened. None had ultrasound screening. Our treatment rate was approximately 4 per 1000 live births.

Our screening programme can be improved by increased capture of patients for clinical screening. Ultrasound is a useful tool in managing neonatal hip instability allowing duration of splintage to be tailored to the individual and allows early detection of treatment failure.

Congenital Dislocation of the Hip (CDH) has been routinely screened for at birth using clinical tests since the early 60’s. In Edinburgh Macnicol (1) assessed the screening programme between 1962 to 1986. It particularly focussed on the change in incidence of late diagnosis when screening was undertaken by experienced staff in comparison to junior staff. The treatment of Orthopaedic conditions in children within the Edinburgh area was combined at the Royal Hospital for Sick Children in 1995. Therefore this paper aims to reassess the screening programme for CDH between 1995–1999 and compare it with the previously achieved results in the same population.

From 1 Jan 1995 to 31 Dec 1999 there were 34,597 live births at Edinburgh’s Maternity hospitals. An orthopaedic clinical assistant examined all infants within the first 24 hours with considerable experience in this field. In addition to the Ortolani and Barlow tests, skeletal and skin fold asymmetry, limitation of abduction and loss of the physiological flexion deformity present in the normal neonate were observed. FH, delivery and circumstances of the pregnancy were noted. Hips found to be clinically unstable were referred on to the CDH clinic where further assessment and ultrasound were performed in order to decide upon the further management of each child.

In 1995 there were 7179 live births, 2.93 of which were harnessed (incidence per 1000 births), 1.11 late diagnosis, (incidence per 1000 births) and 1.39 were operated upon (incidence per 1000 births).

In 1996 there were 7144 live births, 3.64 of which were harnessed (incidence per 1000 births), 1.40 late diagnosis, (incidence per 1000 births) and 1.82 were operated upon (incidence per 1000 births).

In 1997 there were 7065 live births, 2.12 of which were harnessed (incidence per 1000 births), 0.57 late diagnosis, (incidence per 1000 births) and 0.71 were operated upon (incidence per 1000 births).

In 1998 there were 6763 live births, 4.14 of which were harnessed (incidence per 1000 births), 0.59 late diagnosis, (incidence per 1000 births) and 0.30 were operated upon (incidence per 1000 births).

In 1999 there were 6446 live births, 6.12 of which were harnessed (incidence per 1000 births), 0.78 late diagnosis, (incidence per 1000 births) and 0.62 were operated upon (incidence per 1000 births).

Overall there were 34597 live births, 3.76 of which were harnessed (incidence pre 1000 births), 0.89 late diagnosis, (incidence per 1000 births) and 0.98 were operated upon (incidence per 1000 births).

The incidence of late diagnosis of CDH in Midlothian has increased from 0.5 per 1000 as reported by Macnicol between 1962–1986 to 0.89 per 1000 over the last 5 years. These results are clearly disappointing. Although Catford et al (2) has proposed that the incidence of CDH has been increasing this does not explain the size of the increase in late diagnosis seen. Further investigation is required in order to reduce this late presentation rate to that previously achieved.

Introduction: Infants referred under the Hip Screening Programme undergo both a clinical and ultrasonic assessment of hip stability. The majority are reviewed for repeat clinical assessment and X-ray of the hips before a diagnosis of DDH will be excluded. If we could safely rely on the ultrasound findings, then the number of children routinely reviewed with a hip radiograph could be reduced. As a result, many children would avoid the unnecessary and potentially harmful exposure to radiation. In addition, the burden on both the Orthopaedic Outpatients Department and the Radiology Department could be eased. Objective: The aim of the study was to assess the sensitivity of the ultrasound screening programme for DDH over a four year period. Study Design: A retrospective review of the 501 infants referred for hip screening between January 1997 and December 2000. Results: 28 patients were treated for DDH during the period of January 1997 to December 2000. Thirteen patients (46.4%) of those treated for DDH were referred via the Hip Screening Programme after their initial baby check by the paediatricians showed that they had a risk factor. The risk factors include Family History, Breech Deliver, and clinical instability. The remaining fifteen patients (53.6%) were referred via GP’s, Health Visitors and Paediatricians, following abnormal clinical findings ranging from ‘clicky hip’, abnormal skin creases, and decreased hip abduction at follow up baby checks. The average age of the infant in this group was 5.5 months. These 15 were diagnosed with X-ray only. All patients (501 patients) referred via the Hip screening programme underwent an ultrasound scan of both hips initially, and a pelvic X-ray 4–6 months after this. We identified 5 cases where the ultrasound had originally been interpreted as normal, yet the infant developed DDH as diagnosed by a later X–ray. Five infants (38.5%) of the thirteen diagnosed with DDH via the screening programme is unacceptable. These five infants could easily have been missed until they were a lot older, and subsequently their prognoses would have been worse. Three (20%) of the fifteen patients diagnosed with DDH which were not referred via the Hip Screening Programme had an identifiable risk factor at birth, yet were not sent for orthopaedic review and ultrasound examination via the Screening Programme. Conclusion: Normal ultrasound scan does not exclude a subsequent diagnosis of Developmental Dysplasia of the hip. X-ray is still considered the gold standard in assessing a child’s hips. Both the performance and interpretation of the hip ultrasound is skill with a steep learning curve and, for the meantime, will have to go hand in hand with pelvic X-rays in diagnosing DDH

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

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

Aims. To monitor the performance of services for developmental dysplasia of the hip (DDH) in Northern Ireland and identify potential improvements to enhance quality of service and plan for the future. Methods. This was a prospective observational study, involving all infants treated for DDH between 2011 and 2017. Children underwent clinical assessment and radiological investigation as per the regional surveillance policy. The regional radiology data was interrogated to quantify the use of ultrasound and ionizing radiation for this population. Results. Evidence-based changes were made to the Northern Ireland screening programme, including an increase in ultrasound scanning capacity and expansion of nurse-led screening clinics. The number of infant hip ultrasound scans increased from 4,788 in 2011, to approximately 7,000 in 2013 and subsequent years. The number of hip radiographs on infants of less than one year of age fell from 7,381 to 2,208 per year. There was a modest increase in the treatment rate from 10.9 to 14.3 per 1,000 live births but there was a significant reduction in the number of closed hip reductions. The incidence of infants diagnosed with DDH after one year of age was 0.30 per 1,000 live births over the entire period. Conclusion. Improving compliance with the regional infant hip screening protocols led to reduction in operative procedures and reduced the number of pelvic radiographs of infants. We conclude that performance monitoring of screening programmes for DDH is essential to provide a quality service. Cite this article: Bone Joint J 2020;102-B(4):495–500

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

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

Aims

Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app).

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%.

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.

Aim:. An assessment of the relationship between pathological Developmental Dysplasia of the Hip (DDH) and Congenital Talipes Equinovarus (CTEV). Introduction:. Traditional UK guidelines consider abnormalities of the foot to be a risk factor for DDH. 1,2. Currently, there is controversy whether congenital foot abnormalities are true risk factors for pathological DDH. 3,4. There is a relationship between CTCV and hip dysplasia though the relationship between CTEV and pathological DDH is less clear. 5. In a previous 11 year prospective longitudinal study no case of Graf Types III, IV or irreducible hip dislocation were associated with CTEV. 5. Subsequent correspondence and case histories have challenged this view. 6. Methods:. In order to clarify this issue, a 20-year prospective longitudinal observational study was undertaken. All cases of fixed CTEV (Harold & Walker types 1 to 3) referred to the sub-regional Paediatric Orthopaedic clinic at the Royal Blackburn Hospital were evaluated, the feet and hips clinically assessed (Ortolani & Barlow manoeuvres) and the hips ultra-sounded by the senior author (RWP). Modified Graf and Harcke hip ultrasound classification systems were employed. Graf Type III, IV and irreducible hip dislocation were considered pathological. Results:. The incidence of CTEV was 1.46 per 1000 live births (nationally quoted incidence of 1 to 2 per 1000 live births. 7. ). There was one case of Graf Type III dysplasia with no cases of clinical hip instability. Currently, the clinical significance of this type of dysplasia is uncertain. There were no cases of Graf Type IV dislocations or radiological irreducible hip dislocation. Conclusion:. Fixed CTEV should not be considered as a risk factor for pathological DDH and routine sonographic hip screening of CTEV should not be advocated. This is supportive evidence for the current English NIPE guidelines in which the only risk factors screened are family history and breech presentation. Level of evidence: II

Of the 30585 births (from 1997–2002) in the population served by our NHS trust, 2742 babies (8.96%) were referred to the hip screening clinic by the neonatologists and general practitioners. They were examined clinically and by US scans by the specialist consultants. The findings were documented prospectively. 233 hips were identified as abnormal by ultrasound scans (Graf). 45% (106) of these were normal on clinical examination. None of the hips identified as abnormal on clinical examination were normal on US scans. In 38% (88) clinical examination could not be reliably performed as the babies were tense. Of the 1862 hips which were clinically normal, 106 (5.69%) had abnormal ultrasound findings. Furthermore, of the 841 babies who were tense on clinical examination, 88 (10.46%) babies had abnormal ultra-sonographic findings. Ultrasound scanning of hips in at-risk babies by an experienced paediatric radiologist will identify all the abnormal hips. This will release the paediatric orthopaedic surgeon from routine clinical examination of all these babies. This time can be utilised for running other clinics. Babies found to have abnormal hips on US scanning may be seen by the orthopaedic surgeon for treatment and follow-up. Parents of babies with normal hip US scans may be reassured by a nurse practitioner or a paediatric physiotherapist

Introduction: Controversy continues over the value of routine ultrasound hip screening and the question of whether the outcome of hips with dysplasia detected by ultrasound can be improved with treatment. Graf describes a group of infants in whom ultrasound demonstrates a hip that is in joint and centred yet severely dysplastic. These are classified as Grade 2c and are important because, although they may be clinically stable on presentation, they are at risk of progressing to dislocation. Method: Cases were identified in which failure to recognize and/or treat Grade 2c hips lead to subluxation or dislocation of the joint. They were collected from centres where neonates had ultrasound examination of the hip as part of a selected screening program. Results: Eight cases from four UK centres, showing deterioration in untreated Grade 2c hips. All were identified on retrospective Graf grading. Five patients underwent open reduction. Discussion: The Graf method of hip ultrasound examination has not been widely accepted in the UK. Some authors believe that stable dysplastic hips will correct with growth and that treatment confers no specific advantage. However, an advantage of Graf’s method is that it can detect the centred, frequently ‘stable’ hip that will deteriorate in time; the Grade 2c hip. These cases illustrate the importance of recognising and appropriately managing this group of patients who will account for a proportion of late presenting cases of DDH

To determine whether reducing the splintage rate in DDH patients had any effect on the rate of surgical procedures for the treatment of DDH. . Since 1991, in the Blackburn region, there has been a limited target ultrasound screening programme for developmental dysplasia of the hip. The detailed records of the demographics, clinical and ultrasound findings, treatment and outcomes of all children screened by the senior author were reviewed. In 1996 and 1997 only those with persistent major dysplasia at 8 weeks and those with dislocatable hips were placed into Pavlik harnesses. In 1998 only those babies with persistent major dysplasia at 8 weeks of age, or persistent hip instability at 1–2 weeks were placed into Pavlik harnesses. The splintage rates, late dislocation rates (diagnosed after 6 mnths of age) and surgery rates were determined. During the study period 11164 babies were born in the region. 797 (7.1%) babies were seen by the senior author. Surgery in early irreducible hips is unavoidable. Surgery in late dislocators is only avoidable by changing from a selective ultrasound screening policy to performing ultrasound screening on every baby born. With a limited hip screening programme and clinical and ultrasound monitoring of patients, splintage rates can be minimised without increasing the rate of surgery for developmental dysplasia. No child who would have been splinted by the criteria used by other centres, and who wasn’t splinted in this series, required surgery