Targeted Ultrasound Screening for Developmental Dysplasia of the Hip: Where Do We Stand?

AP X-ray of pelvis in a six-week old child

AP X-ray of pelvis in a six-week old child

Developmental dysplasia of the hip (DDH), seen in 2 of every 1000 infants, is present when there is an abnormal relationship between the femoral head and acetabulum, including dislocation, partial-dislocation, and instability. William Hennrikus, M.D., Penn State Hershey Bone and Joint Institute, says, “It’s widely understood that early detection of DDH is important because, if untreated, it can lead to gait anomalies, pain, and arthritis. All babies are universally screened for DDH at well-baby visits using a physical examination. Infants born in the breech position and those with a family history of DDH, however, are at increased risk and require regular examination and monitoring.” Since 2000, the American Academy of Pediatrics (AAP) has recommended targeted hip imaging via ultrasound at six weeks of age for female infants born in the breech position, along with optional hip imaging for boys born in the breech position or girls with a positive family history of DDH [1,2]. Hennrikus notes, “The AAP recommendation assumes that ultrasound is universally available. Our research shows that in Pennsylvania this isn’t the case.”

Responses to a survey conducted by Hennrikus and his colleagues at Penn State Hershey showed that only 67 percent of Pennsylvania members of the AAP have access to ultrasound. Among those without access to local ultrasound services, 86 percent sent their patients to other facilities up to 130 miles away, while 14 percent of pediatricians used radiographs to evaluate infants for possible hip dysplasia (Figure below). Survey results will be published in 2014. Hennrikus further questions the clinical value and cost effectiveness of the AAP targeted ultrasound recommendations, noting that “The AAP recommendation is not evidence based. It assumes that, [compared to regular monitoring and radiography], ultrasound improves early case detection and decreases late detection and risks of complications related to late treatment. Such benefits are needed to justify the roughly ten-fold higher cost of ultrasound compared to traditional monitoring by physical examination and X-ray. To my knowledge there is no clear evidence that demonstrates a benefit with targeted ultrasound studies as recommended by the AAP. ” Hennrikus’s views are in line with results from a 2013 systematic Cochrane review [3] showing that targeted ultrasound to infants at high risk of hip dysplasia did not significantly reduce the rate of late detected dysplasia or surgery, compared to physical examination alone.

Both Hennrikus and the review authors acknowledge, however, that the current evidence base is inadequate and, in order to conclusively determine which strategy is best, large, direct comparative studies are needed.

Until that time, physicians are likely to continue to rely on AAP recommendations and order targeted ultrasound studies for high-risk infants. To increase access to ultrasound services for DDH screening, collaboration of pediatric, orthopaedic, and radiologic organizations is recommended to strategically establish centers of excellence for standardized pediatric hip ultrasound studies in multiple locations in each state.

References
1. Clinical Practice Guidelines: Early Detection of developmental dysplasia of the hip: Committee on quality improvement: subcommittee on developmental dysplasia of the hip. (2000) Pediatrics 105: 896.
2. Lee J (2008) Developmental Dysplasia of the Hip: Universal or Selective Ultrasound Screening? Ann Acad Med Singapore 37(12 Suppl):101-3.
3. Shorter D, Hong T, Osborn DA. Cochrane Review: Screening programmes for developmental dysplasia of the hip in newborn infants. Evid Based Child Health. 2013 Jan;8(1):11-54.

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William Hennrikus, M.D.

William Hennrikus, M.D.

William Hennrikus, M.D.

  • Professor, orthopaedics and rehabilitation
  • Medical director, pediatric Bone and Joint Institute clinic
  • Surgeon, pediatric orthopaedics
  • Phone: 717-531-4826
  • Fellowship: Pediatric orthopaedics, Harvard Medical School, Boston, Massachusetts
  • Residency: Orthopaedic surgery, Balboa Naval Hospital, San Diego, California
  • Medical School: Georgetown University School of Medicine, Washington, DC

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Filed under Healthcare Practice, Musculoskeletal Sciences

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