DDH_abs

Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made. (Formerly, these situations were captured under a "C Recommendation".) This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade. For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Preventive Health Care, 2001 update: Screening and Management of Developmental Dysplasia of the Hip in Newborns

Prepared by Hema Patel, with the Canadian Task Force on Preventive Health Care

These recommendations were finalized by the Task Force in February 1999.

Objective

To review the effectiveness of, and make practice recommendations for, serial clinical examination and ultrasound screening for developmental dysplasia of the hip (DDH) in newborns. The effectiveness of selective screening of high-risk infants with hip and pelvic radiographs and treatment with abduction therapy are also examined.

Burden of Suffering

Most developed countries report an incidence of 1.5 to 20 cases of DDH per 1000 births, the variation due in part to differences in diagnostic method and timing of evaluation. The long-term morbidity of DDH is unclear, but complications observed in case series include leg length discrepancy, gait abnormalities, chronic pain and osteoarthritis. Some adults may have little or no functional disability; those with bilateral dislocations or a well-developed “false acetabulum” may have good clinical function.

More than 60% of infants with DDH have no identifiable risk factors. Infants with the following features have been considered to be at high risk for DDH, although these risk factors have not been validated: first-degree relative with DDH, breech delivery or clinical evidence of joint instability. Also, females are more predisposed than males to DDH. Less widely accepted risk factors include persistent “click” on clinical examination, congenital postural or foot deformities, and fetal growth retardation. Certain ethnic and geographic populations have also been identified as being at high risk for DDH (e.g., Aboriginal Canadians).

Options

Screening options: serial clinical examination, ultrasound screening, radiographic evaluation.

Treatment options: abduction therapy.

Outcomes

Outcomes included rates of operative intervention, abduction splinting, delayed diagnosis of DDH (beyond 3–6 months), treatment complications and false diagnostic labelling. Long-term functional outcomes were considered important.

Evidence

MEDLINE was searched for relevant English-language articles published from 1966 to November 2000 using the key words “screening,” “hip,” “dislocation,” “dysplasia,” “congenital” and “ultrasound.” Comparative and descriptive studies and key reviews were retrieved, and their bibliographies were manually searched for further studies.

Recommendations were graded as:

A Good evidence to support the recommendation that the condition be specifically considered in a PHE.

B Fair evidence to support the recommendation that the condition be specifically considered in a PHE.

C Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.

D Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

E Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

Quality of evidence was rated according to 5 levels:

I Evidence from at least 1 properly randomized controlled trial (RCT).

II-1 Evidence from well-designed controlled trials without randomization.

II-2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.

II-3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.

III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Values

The 13-member Task Force of experts in family medicine, geriatric medicine, paediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon during 2 meetings (October 1998 and January 1999). Consensus was reached on final recommendations.

Benefits, Harms, and Costs

Because most infants will have spontaneous resolution of nonteratologic DDH, early identification and intervention results in unnecessary labelling of newborns as having the problem and unnecessary treatment. Ultrasound screening is a highly sensitive but poorly specific measure of clinically relevant DDH. Abduction splinting is associated with a variety of problems, and its effectiveness in treating DDH is not clearly known. At least 20% of infants requiring operative intervention have had splint therapy. The harms of labelling, repetitive investigations, unnecessary splinting and resource consumption associated with screening are substantial.

Recommendations

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

There is fair evidence to include serial clinical examination of the hips by a trained clinician in the periodic health examination of all infants until they are walking independently [B, II-1, III].
There is fair evidence to exclude general ultrasound screening for DDH from the periodic health examination of infants [D, II-1, III].
There is fair evidence to exclude selective screening for DDH from the periodic health examination of high-risk infants [D, II-1, III].
There is fair evidence to exclude routine radiographic screening for DDH from the periodic health examination of high-risk infants [D, III].
There is insufficient evidence to evaluate the effectiveness of abduction therapy [C, III], but good evidence to support a period of close observation for newborns with clinically detected DDH [A, I]. However, there is insufficient evidence to determine the optimal duration of observation [C, III].

Validation

The members of the Canadian Task Force on Preventive Health Care reviewed the findings of this analysis through an iterative process. The task force sent the final review and recommendations to two selected external expert reviewers, and their feedback was incorporated. It was then peer-reviewed as part of the journal publication process.

Selected References

Source Document:

Patel H. with the Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ 2001; 164(12):1681-90.

A	Good evidence to support the recommendation that the condition be specifically considered in a PHE.
B	Fair evidence to support the recommendation that the condition be specifically considered in a PHE.
C	Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D	Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.
E	Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

I	Evidence from at least 1 properly randomized controlled trial (RCT).
II-1	Evidence from well-designed controlled trials without randomization.
II-2	Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3	Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III	Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.