Hip Ultrasounds: Where do We Go from Here?

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In this issue of The Journal, von Kries et al¹ have addressed one of the more controversial questions in the care of pediatric orthopedic patients. Many have attempted to balance the value of early detection of developmental dysplasia of the hip with the cost of screening and the direct and indirect costs of intervention. Some have questioned the improvement in outcomes from orthopedic interventions for children with developmental dysplasia of the hip. Absence of conclusive evidence that ultrasound screening of newborns is helpful does not translate to evidence of absence of any value for screening newborns for hip dysplasia.

Casting a net across Germany was an ambitious task and undoubtedly uncovered many inconvenient pieces of information. The authors clearly stated that their goal was “to assess the effect of ultrasound screening under real life conditions.” Operations for developmental dysplasia of the hip are not performed as frequently as many other procedures; thus, quantifying the effects of screening measures aimed at further decreasing the number of operations proved challenging.² By comparing the rates of ultrasound screening in children who underwent surgery and those who did not, the authors showed that the relative risk of surgery for developmental dyplasia of the hip—a rare event—is lower in children screened with hip ultrasound compared with those who were not screened.

There is no universal agreement on the best method for screening children for developmental dysplasia of the hip. In the 2000 American Academy of Pediatrics Committee on Quality Improvement’s clinical practice guideline,³ recommendations included an algorithm for each clinical scenario and focused on the importance of the physical examination, going so far as to state that “ultrasonography of all newborns is not recommended.” It was added that the evidence was fair and the consensus was strong. Reservations about ultrasound screening included availability, cost, technical inconsistencies, variability of studies, and risk of overtreatment. These are some of the “real life” concerns shared by the authors as well. However, the American Academy of Pediatrics group did recommend the selective use of ultrasonography in patients with suspicious examinations and those with risk factors.

On the other hand, the Canadian Task Force on Preventive Health Care went a step further, stating that selective ultrasonographic screening and routine radiographic screening in the high-risk infants are not warranted.⁴ Reasons for this pronouncement included a low rate of developmental dysplasia of the hip in high-risk infants, a high rate of spontaneous resolution of early ultrasonographically detected dysplasia, and the lack of evidence proving that interventions such as ultrasound screening actually reduced the need for operations in the future. Downsides of screening included the harm of labeling, repetitive investigations, unnecessary splinting, and substantial resource consumption.

A British group found that the rate of surgery did not differ between a group of children screened with clinical examination and ultrasound and a group assessed by clinical examination alone.⁵ Interestingly, the ultrasound group underwent splinting less frequently. An economic evaluation found no increase in the cost burden associated with the use of ultrasonography in the management of infants with clinical hip instability, and suggested that the ultrasonography group may even reduce the costs of health services to families.⁶

Shipman et al⁷ questioned the effectiveness of surgical and nonsurgical interventions for developmental dysplasia of the hip, noting gaps and shortcomings in the literature. Citing the known complication of avascular necrosis of the femoral head and the lack of evidence demonstrating clear benefits from the treatment, the reviewers did not find screening and early detection of developmental dysplasia of the hip to be helpful.

Rosendahl and Toma⁸ qualified their recommendation based on the European literature to state that selective ultrasound screening may be worthwhile in areas with a high prevalence of late cases, given the ability to provide a well-organized, high-quality service. Using a decision analysis model, Mahan et al⁹ concluded that screening all newborns with a physical examination and using ultrasonography selectively for infants at high risk would have the highest probability of having a nonarthritic hip at age 60 years.

Intuitively, the inherent value of screening children for a treatable condition seems quite obvious. Yet, as noted by many investigators, there is no agreement on the best method for screening infants for developmental dysplasia of the hip. Some have gone so far as to state that screening is not even helpful. This divergence in opinion is not unique to ultrasound screening and highlights the complexities of medical care. How difficult can it be to perform a hip ultrasound? Is it that difficult to interpret? Why can’t orthopedic surgeons and their teams provide superlative care after all that training? As is the case in many specialties, there are subspecialities, and this falls into a so-called “sub-subspecialty” category. Only large tertiary pediatric medical centers perform a high volume of hip ultrasound examination in the United States. Typically, only an orthopedic surgeon who has completed a pediatric orthopedic fellowship would even consider treating a child with developmental dysplasia of the hip, especially once the child is considered a surgical candidate. Even among pediatric orthopedic surgeons, experience and skill level in caring for children with hip dysplasia vary considerably, often influenced by the patient population. Certain conditions are treated more commonly at certain centers, sometimes due to geography and other times due to the availability of other high-volume specialization and expertise at that particular center.

Surgery for developmental dysplasia of the hip is performed less frequently today. This decrease is attributed to early detection. The possible reasons for early detection range from improvements in ultrasound technique, greater awareness of hip dysplasia among primary care providers, the threat of litigation for missing the diagnosis, and the greater public awareness of medical conditions. Orthopedic surgery residents and fellows do not have as many opportunities to participate in one of these cases compared with a generation ago. Perhaps screening would be worthwhile only if all children had access to specialized screening services, possibly aided by telemedicine consultations. For the few families of children who require surgery for developmental dysplasia of the hip, having access to selected medical centers skillfully treating a high volume of these children would be imperative.

The current study by von Kries et al takes a practical approach to estimating the relative risk of hip surgery for developmental dysplasia of the hip in children who were screened with ultrasound examinations and those who were not screened, and found that ultrasound screening decreases the need for surgery. The debate regarding the value of using ultrasound in the screening for developmental dysplasia of the hip will continue until outcomes measures for treatment are accurately collected and presented.

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References 

1. Von Kries R, Ihme N, Altenhofen L, Niethard U, Krauspe R, Ruckinger S. General ultrasound screening reduces the rate of first operative procedures for developmental dysplasia of the hip: A case-control study. J of Pediatr. 2012;160:271–275
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2. Von Kries R, Ihme N, Oberle D, Lorani A, Stark R, Altenhofen L, et al. Effect of ultrasound screening on the rate of first operative procedures for developmental hip dysplasia in Germany. Lancet. 2003;362:1883–1887
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8. Rosendahl K, Toma P. Ultrasound in the diagnosis of developmental dysplasia of the hip in newborns: the European approach. A review of methods, accuracy and clinical validity. Eur Radiol. 2007;17:1960–1967
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9. Mahan ST, Katz JN, Kim YJ. To screen or not to screen? A decision analysis of the utility of screening for developmental dysplasia of the hip. J Bone Joint Surg. 2009;91:1705–1719
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