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Three Part Question

In a term baby [patient] is hip ultrasound [intervention] better than clinical examination [comparison] in preventing delayed diagnosis of developmental dysplasia of the hip [outcome].

Clinical Scenario

An SHO performing a baby check on the postnatal ward feels that one of the hips is “clicky”. There are no risk factors for developmental dysplasia of the hip (DDH). As the Registrar on call, you have to go and examine the baby. If the hips are stable and located on clinical examination, it is hospital policy for no further investigations or follow up. You wonder what the evidence is for performing hip ultrasound scans in all babies and whether or not a policy should be implemented locally to do this.

Search Strategy

A search was undertaken using the database Medline from 1996 to November Week 3 2008.
MeSH heading of physical examination. Then truncated keyword searches were undertaken as shown; (hip$ adj3 examin$), (ortolani or barlow test), (hip$ adj3 ultrasound$). The results of these were combined with AND, giving 115 hits. The Cochrane database was also searched and a protocol abstract found by McKechnie et al 2004, “Screening programmes for developmental dysplasia of the hip in newborn infants.” The reference lists of articles were also checked for further articles.

Search Outcome

Nine of 115 articles appeared to be useful but actually only two were going to be beneficial in answering the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Woolacot et al 2005	10 studies – 2 RCTs non blinded, 8 cohort studies neonates in non selected hip USS screening proramme	Systematic review	Overall treatment rate	2 RCTs and 5 other studies showed increased overall treatment rate	Unable to combine data on treatment rates as studies all varied 3 studies defined late diagnosis of DDH as after 1 month and 1 study defined it as 8 months
			Rate of late diagnosed DDH	Prevalence per 1000 1.4 (clinical screening & USS) 2.6 uss alone
Dogruel et al 2008	7,321 infants, single centre sept1997-2002, Examined D1 then USS at 4-6 weeks	Comparative study	DDH on USS	4.71%	Lost a lot to follow up scanned only 3,541 Excluded cases of unstable hips Risk factors -retrospectively
			Treatment	1.78%
			Clin exam v. hip USS	431 v 59 Sens 97% spec 13.68%
			Hip USS v. Clin exam	208 v 57

Comment(s)

The data available is currently inconclusive about the value of an unselected hip USS screening programme. There is no good quality blinded randomised control trial into the use of hip USS compared to clinical examination. The studies reviewed by the systematic review are large but non blinded randomised trials and the results cannot be compared due to the lack of homogeneity between the studies. The paper by Dogruel et al giving a sensitivity of 97% when comparing clinical examination to hip USS scanning reassures that DDH can be diagnosed clinically which supports current local practices, (going back to the original scenario).

Clinical Bottom Line

1. There is currently no evidence to support a non selective hip USS screening programme 2. Surgical treatment is decreased with a non selective hip USS screening Programme 3. There is debate as to whether DDH detected by USS is necessarily clinically relevant 4. The risks of over treatment with conservative measures are not widely documented

References

1. NF Woolacot, MA Puhan, J Steurer and J Kleijnen “Ultrasonography in screening for developmental dysplasia of the hip in newborns: systematic review.” BMJ 1 june 2005
2. Dogruel H. Atalar H. Yavuz OY. Sayli U Clinical examination versus ultrasonography in detecting developmental dysplasia of the hip. International orthopaedics 32(3):415-9, 2008 Jun.