Clin Orthop Surg.  2016 Jun;8(2):203-209. 10.4055/cios.2016.8.2.203.

Disparity between Clinical and Ultrasound Examinations in Neonatal Hip Screening

• Kyung BS
• Lee SH
• Jeong WK
• Park SY

• KMID: 2412347
• DOI: http://doi.org/10.4055/cios.2016.8.2.203

Abstract

BACKGROUND
For early detection of developmental dysplasia of the hip (DDH), neonatal hip screening using clinical examination and/or ultrasound has been recommended. Although there have been many studies on the reliability of both screening techniques, there is still controversy in the screening strategies; clinical vs. selective or universal ultrasound screening. To determine the screening strategy, we assessed the agreement among the methods; clinical examination by an experienced pediatric orthopedic surgeon, sonographic morphology, and sonographic stability.
METHODS
From January 2004 to June 2009, a single experienced pediatric orthopedic surgeon performed clinical hip screenings for 2,686 infants in the neonatal unit and 43 infants who were referred due to impressions of hip dysplasia before 3 months of age. Among them, 156 clinically unstable or high-risk babies selectively received bilateral hip ultrasound examinations performed by the same surgeon using the modified Graf method. The results were analyzed statistically to detect any correlations between the clinical and sonographic findings.
RESULTS
Although a single experienced orthopedic surgeon conducted all examinations, we detected only a limited relationship between the results of clinical and ultrasound examinations. Ninety-three percent of the clinically subluxatable hips were normal or immature based on static ultrasound examination, and 74% of dislocating hips and 67% of limited abduction hips presented with the morphology below Graf IIa. A total of 80% of clinically subluxatable, 42% of dislocating and 67% of limited abduction hips appeared stable or exhibited minor instability on dynamic ultrasound examination. About 7% of clinically normal hips were abnormal upon ultrasound examination; 5% showed major instability and 3% showed dysplasia above Graf IIc. Clinical stability had small coefficients between ultrasound examinations; 0.39 for sonographic stability and 0.37 for sonographic morphology. Between sonographic stability and morphology, although 71% of hips with major instability showed normal or immature morphology according to static ultrasound examination, the coefficient was as high as 0.64.
CONCLUSIONS
Discrepancies between clinical and ultrasound examinations were present even if almost all of the exams were performed by a single experienced pediatric orthopedic surgeon. In relation to screening for DDH, it is recommended that both sonographic morphology and stability be checked in addition to clinical examination.

Keyword

Developmental dysplasia of hip; Neonatal hip screening; Clinical examination; Ultrasound

MeSH Terms

Female
Hip/*diagnostic imaging
Hip Dislocation, Congenital/*diagnosis/*diagnostic imaging
Humans
Infant, Newborn
Male
*Neonatal Screening/methods/standards
Prospective Studies
*Ultrasonography

Reference

1. Holen KJ, Tegnander A, Bredland T, et al. Universal or selective screening of the neonatal hip using ultrasound? A prospective, randomised trial of 15,529 newborn infants. J Bone Joint Surg Br. 2002; 84(6):886–890.

2. Paton RW, Hossain S, Eccles K. Eight-year prospective targeted ultrasound screening program for instability and atrisk hip joints in developmental dysplasia of the hip. J Pediatr Orthop. 2002; 22(3):338–341.

3. Rosendahl K, Markestad T, Lie RT. Ultrasound screening for developmental dysplasia of the hip in the neonate: the effect on treatment rate and prevalence of late cases. Pediatrics. 1994; 94(1):47–52.

4. von Rosen S. Diagnosis and treatment of congenital dislocation of the hip hoint in the new-born. J Bone Joint Surg Br. 1962; 44(2):284–291.

5. Barlow TG. Early diagnosis and treatment of congenital dislocation of the hip. J Bone Joint Surg Br. 1962; 44(2):292–301.

6. Bernard AA, O'Hara JN, Bazin S, Humby B, Jarrett R, Dwyer NS. An improved screening system for the early detection of congenital dislocation of the hip. J Pediatr Orthop. 1987; 7(3):277–282.

7. Goss PW. Successful screening for neonatal hip instability in Australia. J Paediatr Child Health. 2002; 38(5):469–474.

8. Macnicol MF. Results of a 25-year screening programme for neonatal hip instability. J Bone Joint Surg Br. 1990; 72(6):1057–1060.

9. Lennox IA, McLauchlan J, Murali R. Failures of screening and management of congenital dislocation of the hip. J Bone Joint Surg Br. 1993; 75(1):72–75.

10. MacKenzie IG, Wilson JG. Problems encountered in the early diagnosis and management of congenital dislocation of the hip. J Bone Joint Surg Br. 1981; 63(1):38–42.

11. Krikler SJ, Dwyer NS. Comparison of results of two approaches to hip screening in infants. J Bone Joint Surg Br. 1992; 74(5):701–703.

12. Sanfridson J, Redlund-Johnell I, Uden A. Why is congenital dislocation of the hip still missed? Analysis of 96,891 infants screened in Malmo 1956-1987. Acta Orthop Scand. 1991; 62(2):87–91.

13. Palmen K. Prevention of congenital dislocation of the hip: the Swedish experience of neonatal treatment of hip joint instability. Acta Orthop Scand Suppl. 1984; 208:1–107.

14. Jones DA, Powell N. Ultrasound and neonatal hip screening: a prospective study of high risk babies. J Bone Joint Surg Br. 1990; 72(3):457–459.

15. Rosenberg N, Bialik V, Norman D, Blazer S. The importance of combined clinical and sonographic examination of instability of the neonatal hip. Int Orthop. 1998; 22(3):185–188.

16. 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 Am. 2009; 91(7):1705–1719.

17. Schwend RM, Schoenecker P, Richards BS, Flynn JM, Vitale M. Pediatric Orthopaedic Society of North America. Screening the newborn for developmental dysplasia of the hip: now what do we do? J Pediatr Orthop. 2007; 27(6):607–610.

18. Lee SH, Park SW, Lee KS, Byun YS, Ha KW, Lee BT. Selective ultrasonography and screening of neonatal hip. J Korean Orthop Assoc. 2000; 35(4):651–656.

19. Malkawi H, Asir B, Tadros F, Khasawneh Z. Sonographic image of the newborn hip with positive Ortolani's sign. Clin Orthop Relat Res. 1992; (279):138–143.

20. Rosendahl K, Markestad T, Lie RT. Congenital dislocation of the hip: a prospective study comparing ultrasound and clinical examination. Acta Paediatr. 1992; 81(2):177–181.

21. Laborie LB, Markestad TJ, Davidsen H, et al. Selective ultrasound screening for developmental hip dysplasia: effect on management and late detected cases. A prospective survey during 1991-2006. Pediatr Radiol. 2014; 44(4):410–424.

22. Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia. J Pediatr Orthop. 1984; 4(6):735–740.

23. Rosendahl K, Markestad T, Lie RT. Developmental dysplasia of the hip: a population-based comparison of ultrasound and clinical findings. Acta Paediatr. 1996; 85(1):64–69.

24. Rosendahl K, Markestad T, Lie RT. Ultrasound in the early diagnosis of congenital dislocation of the hip: the significance of hip stability versus acetabular morphology. Pediatr Radiol. 1992; 22(6):430–433.

25. Rosendahl K, Markestad T, Lie RT. Developmental dysplasia of the hip: prevalence based on ultrasound diagnosis. Pediatr Radiol. 1996; 26(9):635–639.

26. Dias JJ, Thomas IH, Lamont AC, Mody BS, Thompson JR. The reliability of ultrasonographic assessment of neonatal hips. J Bone Joint Surg Br. 1993; 75(3):479–482.

27. Rosendahl K, Aslaksen A, Lie RT, Markestad T. Reliability of ultrasound in the early diagnosis of developmental dysplasia of the hip. Pediatr Radiol. 1995; 25(3):219–224.

28. Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006; 117(3):e557–e576.

29. Omeroglu H, Bicimoglu A, Koparal S, Seber S. Assessment of variations in the measurement of hip ultrasonography by the Graf method in developmental dysplasia of the hip. J Pediatr Orthop B. 2001; 10(2):89–95.

30. Ashby E, Roposch A. Diagnostic yield of sonography in infants with suspected hip dysplasia: diagnostic thinking efficiency and therapeutic efficiency. AJR Am J Roentgenol. 2015; 204(1):177–181.

31. Lewis K, Jones DA, Powell N. Ultrasound and neonatal hip screening: the five-year results of a prospective study in high-risk babies. J Pediatr Orthop. 1999; 19(6):760–762.

32. Marks DS, Clegg J, al-Chalabi AN. Routine ultrasound screening for neonatal hip instability: can it abolish latepresenting congenital dislocation of the hip? J Bone Joint Surg Br. 1994; 76(4):534–538.

33. Gwynne Jones DP, Dunbar JD, Theis JC. Late presenting dislocation of sonographically stable hips. J Pediatr Orthop B. 2006; 15(4):257–261.