Elsevier

The Lancet

Volume 362, Issue 9399, 6 December 2003, Pages 1883-1887
The Lancet

Articles
Effect of ultrasound screening on the rate of first operative procedures for developmental hip dysplasia in Germany

https://doi.org/10.1016/S0140-6736(03)14957-4Get rights and content

Summary

Background

Ultrasound screening for developmental hip dysplasia and early conservative treatment might prevent later hip operations. A national hip ultrasound-screening programme, undertaken during the first 6 weeks of life, was introduced across Germany in 1996 and was continued for 5 years. We assessed the rate of first operation on the hip during this programme.

Methods

A national active surveillance programme of initial operations for developmental hip dysplasia was started in 1997 and continued for 5 years. Screening participation was assessed by a random digit dialling telephone survey. Cases were children aged between 10 weeks and 5 years at first operation, who had had no underlying disease leading to developmental hip dysplasia. Completeness of case ascertainment was validated with a capture-recapture study in a representative subsample. Calculated incidences were compared with previously established rates.

Findings

About 90% of all children were screened. 147 cases in the first year, and between 81 and 105 for subsequent years were reported. Treatment included closed reductions 353 (66%), open reductions 61 (11%), and osteotomies 121 (23%). Developmental hip dysplasia was diagnosed by ultrasound before 6 weeks of age in 272 (55%) of cases, 64 (13%) were screened at the recommended time but had normal findings, 70 (14%) had delayed screening, and 89 (18%) were not screened. Capture-recapture estimates suggested that 52% of cases were reported. The corrected incidence for first operation was 0·26 per 1000 livebirths (95% Cl 0·22–0·32).

Interpretation

Ultrasound screening seems to prevent many, but not all, operations for developmental hip dysplasia. Rates of timely screening (ie, before 6 weeks of age) and training of doctors in ultrasound screening need to be improved.

Introduction

Developmental hip dysplasia can lead to impaired hip function and premature degenerative joint disease because of higher than normal load and shearing forces.1 Diagnosis of this abnormality within the first weeks of life is essential for early abduction treatment, which aims to prevent a deleterious course, leading to hip disease.2, 3 Universal screening based on clinical signs has therefore been recommended for more than half a century.4

A report by Godward and Dezateux5 showed that the clinical screening programme for developmental hip dysplasia in the UK was not universally successful in preventing operative procedures related to the disease. The researchers challenged the present screening programme that is based on clinical signs and symptoms, and called for an assessment of alternative screening policies, including universal ultrasound imaging.5 Since the numbers of children with the disease who need an operation is small, randomised trials assessing the effectiveness of ultrasound screening on the rate of such procedures would need to assess large numbers of children to achieve significant results. Valid survey data might provide an alternative.

In Germany, a screening programme for developmental hip dysplasia that included universal static6 ultrasound imaging for all children was started in January, 1996.7 All children are screened clinically for the abnormality in the first week of life. Children with a family history, breech delivery, or suspicious findings after clinical examination are screened with ultrasound in the first week of life. Screening for all other children is scheduled at age 4–6 weeks—the latest at end of week 6.

Active surveillance for operations for this condition in children younger than 5 years was initiated in 1997 and maintained until 2002. The goal of this active surveillance was to establish whether the rates of first operation for developmental hip dysplasia were lower with a universal ultrasound screening programme compared with historical data in Germany8 and other countries,9, 10 where screening was based only on clinical signs and symptoms. A further goal was to see which, if any, operative procedures became necessary despite early diagnosis by the ultrasound screening programme.

Section snippets

Methods

Cases who had had operations were identified through active surveillance from May, 1997 to April, 2002, by use of the German paediatric surveillance unit (ESPED).11 Monthly postcards were sent to all heads of orthopaedic hospitals or departments caring for children younger than 5 years. They were to report the number of cases admitted for operative procedures in the previous month, or had the option of nothing to report. Reported cases were validated by a follow-up questionnaire for country of

Results

The proportion of children who were screened by ultra-sound increased from 83% in 1996 to 95% or above in most subsequent years (figure). Yearly, between 26% and 45% children had ultrasound screening for developmental hip dysplasia in the first week of life, with no trend over time.

The orthopaedic surgeons returned the cards on which cases were reported and follow-up questionnaires validating the cases in 1997–2002, at a rate that ranged from 89% to 98% (cards) and from 90 to 98%

Discussion

The adjusted rate of first operative procedures that we calculated—0·26 per 1000 livebirths—was considerably lower than that in other investigations,5, 9, 10 and much lower than previously estimated in Germany. In 1983, before ultrasound screening, Katthagen and colleagues8 reported 616 first operative procedures on children younger than 6 years (yearly birth rates in Germany 1977 to 1983 ranging between 590 000 and 620 000), accounting for a rate of about one per 1000 livebirths. Our finding

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