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1. Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics. Pediatrics. 2000; 105(4 Pt 1):896-905. Review/Other-Dx N/A DDH guideline from the American Academy of Pediatrics. N/A 4
2. Dezateux C, Rosendahl K. Developmental dysplasia of the hip. Lancet. 2007; 369(9572):1541-1552. Review/Other-Dx N/A To assess the problem of DDH in adults and newborns. Need for high quality studies of the adult outcomes of DDH and the childhood origins of early degenerative hip disease and randomized trials to assess the effectiveness and safety of neonatal screening and early treatment. 4
3. 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):e557-576. Review/Other-Dx N/A To gather and synthesize the published evidence regarding screening for DDH by primary care providers. Clinical examination and US identify somewhat different groups of newborns who are at risk for DDH. A significant proportion of hip abnormalities identified through clinical examination or US in the newborn period will spontaneously resolve. All surgical and nonsurgical interventions have been associated with avascular necrosis of the femoral head, the most common and most severe harm associated with all treatments of DDH. 4
4. Clarke NM, Clegg J, Al-Chalabi AN. Ultrasound screening of hips at risk for CDH. Failure to reduce the incidence of late cases. J Bone Joint Surg Br. 1989; 71(1):9-12. Review/Other-Dx 448 patients To evaluate the effect of US screening on infants at risk for CDH. 17 required treatment (3.7 per 1,000); no clinical abnormality was found in 5 of them. 81 babies had US abnormalities but did not require treatment, although US showed hip displacement in 17 of them. 4
5. Gardiner HM, Dunn PM. Controlled trial of immediate splinting versus ultrasonographic surveillance in congenitally dislocatable hips. Lancet. 1990; 336(8730):1553-1556. Observational-Dx 79 patients Possibility of delaying the treatment of dislocatable hips for 2 weeks to allow for spontaneous resolution. To elucidate the natural history of CDH, the clinical significance of the US morphological findings, and the value, reliability, and practicality of US in screening and diagnostic. The low specificity (70%) of US examination in the first week of life makes it an unsatisfactory primary method of screening at birth, but it is a most useful adjunct to the clinical screening and management of CDH. 3
6. Marks DS, Clegg J, al-Chalabi AN. Routine ultrasound screening for neonatal hip instability. Can it abolish late-presenting congenital dislocation of the hip? J Bone Joint Surg Br. 1994; 76(4):534-538. Review/Other-Dx 14,050 patients To determine whether routine US screening for neonatal hip instability can prevent late-presenting CDH. Routine US has detected cases which would have been presented late. 4
7. Terjesen T, Holen KJ, Tegnander A. Hip abnormalities detected by ultrasound in clinically normal newborn infants. J Bone Joint Surg Br. 1996; 78(4):636-640. Review/Other-Dx 306 patients To follow progress of newborn infants in whom US examination showed abnormalities in hips. Newborn infants with abnormal and suspicious US findings who are normal on clinical examination do not need treatment from birth. 4
8. Andersson JE, Funnemark PO. Neonatal hip instability: screening with anterior-dynamic ultrasound method. J Pediatr Orthop. 1995; 15(3):322-324. Observational-Dx 4,430 patients To evaluate the effect of a screening program with an anterior dynamic US approach for hip dislocation. There were 5 dislocated and 1 dislocatable hips on 4 neonates; 59 dislocatable hips in 44 neonates (4 neonates received treatment). Radiographs were obtained at 18 weeks and decisions were made on the basis of US. The frequency of treatment for unstable hip joints was reduced to 0.18%, having been 1.7% without US screening. No cases of late-diagnosed dislocation were registered. The sensitivity of the pediatricians' clinical examination screening was low, only 24%. After intensive training over several years and improved clinical examination methods, our five technicians managed to increase the sensitivity to 53%. 3
9. Place MJ, Parkin DM, Fritton JM. Effectiveness of neonatal screening for congenital dislocation of the hip. Lancet. 1978; 2(8083):249-250. Review/Other-Dx N/A To examine effectiveness of neonatal screening for CDH. The effectiveness of neonatal hip testing in an urban area in which no previous special studies have been performed. Re-examination of all infants at 3-6 months is proposed to reduce the number of missed cases and so minimize late sequelae. The incidence of late diagnosed CDH is 0.78/1,000. 4
10. Poul J, Bajerova J, Sommernitz M, Straka M, Pokorny M, Wong FY. Early diagnosis of congenital dislocation of the hip. J Bone Joint Surg Br. 1992; 74(5):695-700. Observational-Dx 35,550 neonates Prospective 5 year duration to determine the effectiveness of clinical examination by orthopedic surgeon. Radiograph at 3 months of every patient with a stable hip. 775 hips were unstable or dislocated; 21 (0.6/1,000) hips missed early by clinical examination and 327 acetabular dysplasia (0.9%) found at 3 months by radiographs. Clinical evaluation by a skilled examiner is a valuable method of diagnosing DDH in neonates. 3
11. Kay RM, Watts HG, Dorey FJ. Variability in the assessment of acetabular index. J Pediatr Orthop. 1997; 17(2):170-173. Observational-Dx 22 patients; 360 readings To assess the interobserver and intraobserver variability associated with the assessment of acetabular index. Variability was increased for the radiographs that were deemed poorly reproducible by the independent observer. Interobserver variability exceeded intraobserver variability. The results of this study cast doubt on the reliability of the acetabular index based on a single reading. 3
12. Spatz DK, Reiger M, Klaumann M, Miller F, Stanton RP, Lipton GE. Measurement of acetabular index intraobserver and interobserver variation. J Pediatr Orthop. 1997; 17(2):174-175. Observational-Dx 25 patients To evaluate the intraobserver and interobserver variation associated with the measurement of acetabular index. Interobserver measurements were found to vary ± 3.0 degrees, whereas the intraobserver variation was ± 3.6 degrees. This error reflects only measurement error and does not consider error introduced with different positioning of the pelvis. 3
13. ACR–AIUM Practice Guideline for the Performance of the Ultrasound Examination for Detection and Assessment of Developmental Dysplasia of the Hip. Accessed January 30, 2013. Review/Other-Dx N/A ACR Guideline for the performance of the US examination for detection and assessment of DDH. N/A 4
14. Engesaeter LB, Wilson DJ, Nag D, Benson MK. Ultrasound and congenital dislocation of the hip. The importance of dynamic assessment. J Bone Joint Surg Br. 1990; 72(2):197-201. Observational-Dx 100 patients Prospective study to determine importance of US (dynamic assessment) in CDH. Test the reproducibility of the measurement of all US angles. The results of the dynamic component of the US examination for both hips show a strong predictive value. US dynamic stability testing assisted the clinical decision whether to treat or just observe a newborn with suspect hips. 3
15. Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment. Arch Orthop Trauma Surg. 1980; 97(2):117-133. Review/Other-Dx N/A To investigate the effectiveness of using US diagnostic devices to diagnose CHD. Major difficulties are small size of the object under examination and poor resolving power of ultrasonoscopes. The methods are good diagnostic tools. 4
16. 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. Observational-Dx 209 neonates To evaluate reliability of US assessment of neonatal hips. US of a neonatal hip is much better than radiography in defining the cartilaginous femoral head and acetabulum and can be repeated with no additional risks. 4
17. Jomha NM, McIvor J, Sterling G. Ultrasonography in developmental hip dysplasia. J Pediatr Orthop. 1995; 15(1):101-104. Observational-Dx 58 hips; 29 patients To document the repeatability and reliability of the measurements taken from the US. The interclass coefficient correlation were a=0.03, b=0.12, and the percent coverage = –0.02. The ability of examiners was important. The radiologist dealt with US very frequently, and was noted to be the most repeatable observer with an interclass coefficient correlation ranging between 0.82 and 0.89. Reliability among the 3 examiners was not consistent. If a cutoff of 55 degrees was implemented, then treatment would have changed 39 of 144 times within the examiners’ individual measurements. Even the most consistent examiner (the radiologist with an interclass coefficient correlation of 0.89) would have changed his treatment 8 of 48 times. Highly reliable examiners would alter their management decisions 17% of the time. 4
18. 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. Observational-Dx 3 groups of infants: 206, 74 and 78 To determine interobserver and intraobserver agreement in assessing hip morphology and stability by US. Interobserver: There was moderate agreement classifying hips subjectively into four morphologic categories (k=0.5) or objectively by recording Graf angle (k=0.3). Same observer (206 infants, k=0.7 and 0.8 for the two observers, respectively). There was a moderate interobserver agreement in determining hip stability (70 infants, k=0.4). Interobserver and intraobserver agreement in producing the scans is poorer than for reading. Stability and morphology may be evaluated differently by different examiners even when considerable effort is invested in standardizing procedures. 4
19. Harcke HT, Grissom LE. Infant hip sonography: current concepts. Semin Ultrasound CT MR. 1994; 15(4):256-263. Review/Other-Dx N/A Description of the Dynamic Standard Minimum Sonographic Examination of the infant hip. Also reviews the classification and management of infant hip disorders. Whereas US is used increasingly to manage developmental dislocation and/or dysplasia of the hip, there is no agreement on the use of sonography for universal newborn screening. 4
20. Chin MS, Betz BW, Halanski MA. Comparison of hip reduction using magnetic resonance imaging or computed tomography in hip dysplasia. J Pediatr Orthop. 2011; 31(5):525-529. Observational-Dx 32 CT scans and 33 MRI scans in 39 patients To compare the use of CT vs MRI to evaluate hip reduction in patients with dysplasia of the hip. CT scanner time was 2.8 minutes, which was significantly less than the 8.9 minutes required for MRI (P=0.0001). Postoperative anesthesia was only required for 1 CT case. Average cost of CT examination was $788 and $1104 for MRI. Average radiation dose with CT examinations was 1 mSv. Of the postoperative nonsubluxated hips (n=30 for CT and n=37 for MRI), CT demonstrated a sensitivity of 100% and a specificity of 96%, whereas MRI exhibited a sensitivity of 100% and a specificity of 100%. Of the postoperative subluxated hips, 66.7% spontaneously reduced, 22.2% remained subluxated, and 11.1% redislocated. 3
21. Desai AA, Martus JE, Schoenecker J, Kan JH. Spica MRI after closed reduction for developmental dysplasia of the hip. Pediatr Radiol. 2011; 41(4):525-529. Review/Other-Dx N/A To discuss various post-reduction spica imaging techniques with emphasis on MRI of patients with DDH. Spica MRI is a fast and effective tool to assess morphology after closed reduction for DDH without the need for sedation. The multiplanar capabilities allow depiction of coronal and axial reduction of the hips. Due to MRI's inherent ability to delineate soft tissue structures, both intrinsic and extrinsic obstacles to failed reduction may be identified. 4
22. Jaramillo D, Villegas-Medina O, Laor T, Shapiro F, Millis MB. Gadolinium-enhanced MR imaging of pediatric patients after reduction of dysplastic hips: assessment of femoral head position, factors impeding reduction, and femoral head ischemia. AJR. 1998; 170(6):1633-1637. Observational-Dx 18 infants and young children with 23 dysplastic hips To describe gadolinium-enhanced MRI of position and vascular enhancement of the femoral head in pediatric patients who have undergone reduction of hip dislocation. MRI showed that all femoral heads were in their respective acetabula, but several structures interfered with concentric reduction. Obstacles to reduction included a pulvinar (n=16), infolding of the capsule (n=9), interposition of the labrum (n=2), and a hypertrophied ligamentum teres and transverse ligament (n=2). All 50 femoral heads showed enhancement: 35 normally, 10 homogeneously but less than on the contralateral femoral head or the ipsilateral greater trochanter, and 5 with areas of focally decreased enhancement. Hips that showed decreased enhancement had undergone greater degrees of abduction (r = .38, P<.01). 2
23. 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. Review/Other-Dx N/A To determine, with use of expected-value decision analysis, which newborn screening strategy leads to the best chance of having a non-arthritic hip by the age of 60 years (no screening, selective screening, or universal screening of neonates). The optimum strategy, associated with the highest probability of having a non-arthritic hip at the age of 60 years, was to screen all neonates for hip dysplasia with a physical examination and to use US selectively for infants who are at high-risk. Additional data on the costs and cost-effectiveness of these screening policies are needed to guide policy recommendations. 4
24. Dorn U, Neumann D. Ultrasound for screening developmental dysplasia of the hip: a European perspective. Curr Opin Pediatr. 2005; 17(1):30-33. Review/Other-Dx N/A Review of literature dealing with US screening for DDH in Europe. US of the infant hip has become a gold standard for screening for DDH in European countries. 4
25. 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. Experimental-Dx 15,529 infants Prospective study to evaluate whether universal (all neonates) or selective (neonates belonging to the risk groups) US screening of the hips should be recommended at birth. One late-detected hip dysplasia was seen in the universal group; 5 in the subjective group, representing a rate of 0.13 and 0.65 per 1,000, respectively. The difference in late detection between the two groups was not statistically significant (P=0.22). Recommend selective US screening for neonates with abnormal or suspicious clinical findings and those with risk factors for hip dysplasia. 1
26. Patel H. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ. 2001; 164(12):1669-1677. Review/Other-Dx N/A Review the effectiveness of, and make practice recommendations for, serial clinical examination and US screening for DDH in newborns. 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, to exclude general US screening for DDH from the periodic health examination of infants, to exclude selective screening for DDH from the periodic health examination of high-risk infants, to exclude routine radiographic screening for DDH from the periodic health examination of high-risk infants. Insufficient evidence to evaluate the effectiveness of abduction therapy but good evidence to support a period of close observation for newborns with clinically detected DDH. 4
27. 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. Observational-Dx 11,925 infants To assess the effect of US screening on primary diagnosis, management and prevalence of late cases of DDH. Higher treatment rate: 3.4% US, vs 2% US high risk and 1.8% no US. For infants not subjected to treatment, US resulted in a higher follow-up rate (13%, 1.8% and 0%). Late DDH 0.3, 0.7 and 1.3 per 1,000 (P=.11). No support for generalized screening with US, clinical examiner is experienced. US may reassure and diminish the need for repeated clinical follow-up. US may have a marginal effect on late DDH. 1
28. Woolacott NF, Puhan MA, Steurer J, Kleijnen J. Ultrasonography in screening for developmental dysplasia of the hip in newborns: systematic review. BMJ. 2005; 330(7505):1413. Review/Other-Dx 23 databases To assess the accuracy and effectiveness of US screening of all newborn infants for DDH. US screening: sensitivity 88.5%; specificity 96.7%, positive predictive value 61.6%; negative predictive value 99.4%. Compared with clinical screening, general US screening in newborns may increase overall treatment rates. 4
29. Lowry CA, Donoghue VB, Murphy JF. Auditing hip ultrasound screening of infants at increased risk of developmental dysplasia of the hip. Arch Dis Child. 2005; 90(6):579-581. Review/Other-Dx 5,485 infants To determine the efficiency of hip US in detection of DDH in those without clinically dislocated hips. Among the population of infants at increased risk of DDH, the hip screening program identified 18 cases among 5,485 infants; a rate of 3.2 per 1,000. 4
30. Tonnis D, Storch K, Ulbrich H. Results of newborn screening for CDH with and without sonography and correlation of risk factors. J Pediatr Orthop. 1990; 10(2):145-152. Review/Other-Dx 1,310 patients examined by Ortolani’s and Barlow’s manual test, 2,587 patients evaluated by US To investigate the efficiency of US in the evaluation of DDH. Twice as many abduction pillows were ordered. A total of 6.54% treated patients. 52.25% of the sonographically pathological hips had no signs of instability, nor Ortolani or dislocation. 4
31. Boeree NR, Clarke NM. Ultrasound imaging and secondary screening for congenital dislocation of the hip. J Bone Joint Surg Br. 1994; 76(4):525-533. Review/Other-Dx 26,952 patients screened; 1,894 patients evaluated with US Prospective evaluation of a screening program for CDH which uses US to provide delayed selective screening to complement neonatal clinical screening. Treatment rate of 4.4 per 1,000. Of those referred with clinical instability, 35% did not require treatment. Dislocation or subluxation was detected in 17/643 infants referred only because they fell within one of three risk categories: breech presentation, foot deformity and family history. All 17 had normal clinical examinations. Six children presented with CDH after 12 weeks of age, giving a late presentation rate of 0.22 per 1,000 births. All had normal clinical examinations within 24 hours of birth and none was in a risk category. Surgery has been required in ten children, giving a surgical treatment rate of 0.37 per 1,000 births. 4
32. Teanby DN, Paton RW. Ultrasound screening for congenital dislocation of the hip: a limited targeted programme. J Pediatr Orthop. 1997; 17(2):202-204. Review/Other-Dx 4000 patients To evaluate US of abnormal hips. The incidence of late CHD was not reduced by extending the US program to include “at risk groups” and morphologic assessment of the hips. 4
33. Roovers EA, Boere-Boonekamp MM, Mostert AK, Castelein RM, Zielhuis GA, Kerkhoff TH. The natural history of developmental dysplasia of the hip: sonographic findings in infants of 1-3 months of age. J Pediatr Orthop B. 2005; 14(5):325-330. Observational-Dx 5170 infants To examine US findings of DDH in infants. Of the normal hips at 1 month of age, 99.6% were still normal at 3 months of age. Of the immature type IIa/IIa+ and type IIa–, if untreated, 95.3% and 84.4% had become normal, respectively. Of the infants with type IIc, D and III/IV hips at the age of 1 month, 70%, 58.3% and 90.9% were treated, respectively. 4
34. Giannakopoulou C, Aligizakis A, Korakaki E, et al. Neonatal screening for developmental dysplasia of the hip on the maternity wards in Crete, Greece. correlation to risk factors. Clin Exp Obstet Gynecol. 2002; 29(2):148-152. Review/Other-Dx 6,140 newborns screened; 220 had US examination To evaluate the effects of US examination of newborns in early detection and management of DDH, and its correlation to known risk factors in Crete. DDH incidence was estimated to be 10.83 per 1,000. 32% of neonates whose clinical examination was normal, but who had US because of the presence of risk factors had pathological findings on the hip US. Medical and family histories and clinical examination play an important role in the diagnosis of hip instability. Selective US for all infants with risk factors, and those with clinical abnormality of the hip, is an adjunctive tool which aids early diagnosis and offers higher control in the results of treatment. 4
35. Riboni G, Bellini A, Serantoni S, Rognoni E, Bisanti L. Ultrasound screening for developmental dysplasia of the hip. Pediatr Radiol. 2003; 33(7):475-481. Observational-Dx 8,896 newborns screened with US; 56 DDH cases To examine the distribution of hip morphology as classified by Graf according to sex and risk factors in an unselected Italian population and propose a temporal pattern of US screening of all newborns to detect DDH. 56 cases of DDH were identified: 34 in the first week of life examination, 10 at 1 month; 10 at 3 months and 2 at 4 months. A two-step US screening of newborns is recommended: at the end of the first month and within the fourth month of life. 3
36. Elbourne D, Dezateux C, Arthur R, et al. Ultrasonography in the diagnosis and management of developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre randomised controlled trial. Lancet. 2002; 360(9350):2009-2017. Observational-Dx 629 patients To assess clinical effectiveness and net cost of US compared with clinical assessment alone, to provide guidance for management of infants with clinical hip instability. Use of US in infants with screen-detected clinical hip instability allows abduction splinting rates to be reduced, and is not associated with an increase in abnormal hip development, higher rates of surgical treatment by 2 years of age, or significantly higher health-service costs. 1
37. Gray A, Elbourne D, Dezateux C, King A, Quinn A, Gardner F. Economic evaluation of ultrasonography in the diagnosis and management of developmental hip dysplasia in the United Kingdom and Ireland. J Bone Joint Surg Am. 2005; 87(11):2472-2479. Review/Other-Dx 629 patients Prospective analysis to assess costs of clinical neonatal hip screening in association with US for the diagnosis and management of neonatal hip instability. The average overall health-service cost per patient (and standard deviation) was $1298 ± $2168 in the ultrasonography group and $1488 ± $2912 in the group that underwent clinical assessment alone, a net difference of -$190 (95% confidence interval, -$630 to $250). 4
38. Dunn PM, Evans RE, Thearle MJ, Griffiths HE, Witherow PJ. Congenital dislocation of the hip: early and late diagnosis and management compared. Arch Dis Child. 1985; 60(5):407-414. Review/Other-Dx 445 infants To determine the effectiveness and safety of neonatal screening and early treatment. Routine follow-up included clinical and radiological examination at 6, 12, 24, and 60 months. Altogether 90% completed the 12 month, 85% the 24 month, and 76% the 60 month checks. 5 infants (1.1%) required further orthopaedic treatment (adductor tenotomy and abduction splinting) but no major surgery was necessary, nor was avascular necrosis encountered. The radiological results were excellent. Every effort (1970-84) was also made to identify all cases of late CDH diagnosed after the neonatal period in infants born to women in Avon during the same decade (n=103,431). 91 cases were detected (0.88 per 1000 births), 10 in the university cohort (0.44 per 1000) and 81 in the non-university group (1.00 per 1000) (P<0.01). 4
39. Burger BJ, Burger JD, Bos CF, Obermann WR, Rozing PM, Vandenbroucke JP. Neonatal screening and staggered early treatment for congenital dislocation or dysplasia of the hip. Lancet. 1990; 336(8730):1549-1553. Observational-Dx 14,264 patients Prospective study to establish if neonatal screening and early treatment prevent dislocation, or dysplasia without dislocation. The possible complications of early treatment as well as the risk factors and the prevalence of a positive Barlow test and radiographically detected dysplasia. Dislocation was missed at screening in 0.02%. Dysplasia was seen at 5 months in 15% of Barlow-children with a family history and in 2%-3% of the reference group children. Test is efficient in the identification of dislocation but probably has no value for dysplasia. Of the babies in whom treatment was started immediately 17% had relapse dysplasia after withdrawal of therapy, 3% had avascular necrosis, and 78% were normal at 2 years. When treatment was started at 5 months we found no relapse dysplasia, only 1% avascular necrosis, and 53%-63% success at 2 years. In children with dislocatable hips we propose a wait-and-see treatment strategy, with early US or radiography at 5 months. 3
40. Gardiner HM, Duncan AW. Radiological assessment of the effects of splinting on early hip development: results from a randomised controlled trial of abduction splinting vs sonographic surveillance. Pediatr Radiol 1992; 22(3):159-162. Observational-Dx 76 patients Report on radiological data from newborns with dislocatable hips that were randomized either to immediate splinting or to US surveillance that examines the influence of early splinting on hip development. Epiphyseal maturation, iliac indentation and acetabular angle were assessed radiographically at 6 months, blind to the treatment group; hips with normal sonograms at birth had greater epiphyseal maturation and iliac indentation and smaller acetabular angle. While clinically unstable Graf type 1 and 2A hips were radiologically similar at 6 months, those splinted showed poorer epiphyseal maturation and iliac indentation compared with nonsplinted hips. 3