Recommendation Statement
This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for developmental dysplasia of the hip.
This recommendation statement was first published in Pediatrics. Select for copyright and source information.
Summary of Recommendation
- The USPSTF concludes that evidence is insufficient to recommend routine
screening for developmental dysplasia of the hip in infants as a means to
prevent adverse outcomes.a
Rating: I Recommendation. Rationale: The pathophysiology and natural history of developmental dysplasia of the hip (DDH) are poorly understood. There is evidence that screening leads to earlier identification; however, 60% to 80% of the hips of newborns identified as abnormal or as suspicious for DDH by physical examination and >90% of those identified by ultrasound in the newborn period resolve spontaneously, requiring no intervention. There is poor evidence (poor quality studies) of the effectiveness of both surgical and non-surgical interventions; avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are treated for DDH. Thus, the USPSTF was unable to assess the balance of benefits and harms of screening for DDH but was concerned about the potential harms associated with treatment of infants identified by routine screening.
a Standard language associated with the grade
I recommendation is "The USPSTF concludes that the evidence is insufficient
to recommend for or against routinely providing {the service}." For
this specific recommendation, the USPSTF modified the language to indicate
the lack of evidence that screening for a condition with a poorly defined
natural history would improve health outcomes while there is evidence that
interventions cause known harms.
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Contents
Clinical Considerations
Discussion
Future Research
Recommendations of Other Groups
Members of the USPSTF
References
Clinical Considerations
- This
USPSTF screening recommendation applies only to infants who do not have obvious
hip dislocations or other abnormalities evident without screening. DDH represents
a spectrum of anatomic abnormalities in which the femoral head and the acetabulum
are aligned improperly or grow abnormally. DDH can lead to premature degenerative
joint disease, impaired walking, and pain. Risk factors for DDH include female
gender, family history of DDH, breech positioning, and in utero postural
deformities. However, the majority of cases of DDH have no
identifiable risk factors.
- Screening
tests for DDH have limited accuracy. The most common methods
of screening are serial physical examinations of the hip and lower extremities,
using the Barlow and Ortolani procedures, and ultrasonography. The
Barlow examination is performed by adducting a flexed hip with gentle posterior
force to identify a dislocatable hip. The Ortolani examination is performed
by abducting a flexed hip with gentle anterior force to relocate a dislocated
hip. Data assessing the relative value of limited hip abduction as a screening
tool are sparse and suggest the test is of little value in early
infancy and is of somewhat greater value as infants age.
- Treatments
for DDH include both nonsurgical and surgical options. Nonsurgical treatment
with abduction devices is used in early treatment and includes the commonly
prescribed Pavlik method. Surgical intervention is used when DDH is severe or diagnosed late or after an unsuccessful trial of non-surgical treatments. Evidence of the effectiveness of interventions is inconclusive because of a high rate of spontaneous resolution, absence of comparative studies of intervention versus nonintervention groups, and variations in surgical indications and protocols. Avascular necrosis of the hip is the most common and most severe potential harm of both surgical and nonsurgical interventions and can result in growth arrest of the hip and eventual joint destruction with significant disability.
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Discussion
DDH represents a spectrum of anatomical abnormalities in which the femoral head and the acetabulum are either in improper alignment or grow abnormally. Without the normal tight, concentric anatomic relationship between the femoral head and acetabulum, the hip joint may grow abnormally, resulting in permanent disability. The precise definition of DDH is controversial1,2 and includes a spectrum of hip abnormalities including dysplastic, subluxated, dislocatable, and dislocated hips. Long-term complications of DDH include premature degenerative joint disease, impaired walking, and chronic pain.3 The incidence of DDH in infants is influenced by a number of factors, including diagnostic criteria, female gender, genetics, race, and age.4 Reported incidence rates, varying between 1.5 and 20 per 1000 births,5 have increased dramatically since the advent of clinical and sonographic screening, possibly resulting from overdiagnosis. A minority (10%-27%) of all infants diagnosed with DDH in population-based studies have identified risk factors other than female gender.6-10 Between 1% and 10% of infants with risk factors have DDH.7-9
The USPSTF examined the evidence to determine the benefits and harms of
routine screening for DDH from birth through 6 months and for interventions
up to 12 months in otherwise normal infants. The USPSTF found no direct evidence
that screening for DDH leads to a reduced need for surgery or improved functional
outcomes. Therefore, the USPSTF examined the evidence for accuracy
of screening tools, efficacy of treatment, and harms of screening and treatment.
Several fair quality case-control and observational studies
found breech positioning, family history of DDH, and female gender to be
most consistently associated with the diagnosis of DDH. However,
the majority of cases of DDH have no identifiable risk factors.11 There
is evidence that screening leads to earlier identification; however, 60%
to 80% of abnormal hips of newborns identified by physical examination resolved
spontaneously by 2 to 8 weeks.3 Ninety percent of
the hips of newborns with mild dysplasia identified by ultrasound resolved
spontaneously between 6 weeks and 6 months. 12-20
The USPSTF found poor quality evidence regarding the accuracy of screening
tests because of variable definitions of a positive result, the lack of a
practical, confirmatory "gold standard" diagnostic test for DDH, and the
treatment of the majority of infants with a positive screening result. The
USPSTF found fair quality evidence that age may affect screening accuracy.
Limited hip abduction is a relatively insensitive and nonspecific marker
of DDH in early infancy but becomes more accurate after 3 to 6 months of
age and with more severely affected hips.4,5 A
prospective observational study in infants >3 months demonstrated that unilateral limited
hip abduction had a sensitivity of 69% and a specificity of 54% compared
with the reference standard of any ultrasound abnormality. In
this study, for subluxable and dislocatable hips, the sensitivity of limited
hip abduction was > 82%.21
The USPSTF found poor quality evidence
regarding the effectiveness of both surgical and non-surgical interventions.
Evidence of the effectiveness of interventions is of poor quality due to a
high rate of spontaneous resolution, limited study duration, significant
loss to followup, and variations in surgical indications and protocols. The
duration and specific approaches to preoperative and postoperative management
are highly variable, as are nonsurgical treatment protocols.
A variety of abduction devices are used to treat DDH, including the commonly
used Pavlik method and immobilization in a hip spica cast. Most
surgical procedures involve reduction of the femoral head into the acetabulum,
with or without additional procedures on the adductor tendons, the femur,
or the acetabulum. Few studies measure functional outcomes (e.g., amount of
pain, gait) because poor functional outcomes may not be manifested until
decades later. When functional outcomes are measured, the effect
of interventions is very difficult to quantify because of lack of a comparison
cohort, short followup, loss to followup, and unstandardized assessment
methods. A single long-term retrospective case series of 119 children with
DDH (with 152 treated hips), treated with surgery followed by an abduction
brace
at 1 to 96 months of age, used standardized scales to assess functional outcomes
(hip pain and gait). Followup visits at 15 to 53 years after
treatment found that 112 (75%) of 149 treated hips had good outcomes. However,
study limitations included study design, issues of confounding, and treatment
by a few surgeons.22 Because no experimental
or prospective cohort studies compare intervention with no intervention,
the net benefits and harms of interventions for DDH are unclear for all infants
and children.23
There is insufficient evidence on the harms of screening for DDH. Potential
harms from screening include examiner-induced hip pathology caused by vigorous
provocative testing, elevated risk for certain cancers from increased radiation
exposure from followup radiographic tests, parental psychosocial stress from the diagnosis
and therapy, and false positive results leading to unnecessary and potentially
harmful followup and intervention.24
There is poor-quality evidence on the harms of treatment. The most common
adverse effect from both surgical and nonsurgical interventions for DDH is
AVN. The rates described in the literature for this adverse effect vary greatly (0-60%)
for both surgical and nonsurgical interventions.25,26-44 The
reasons for this wide range of rates are most likely related to methodological
problems such as heterogeneous populations, a poorly standardized approach
to interventions, inconsistent followup protocols, variable loss to followup,
variable training among the treating physicians, and disparate health care
systems in which treatment and followup are undertaken. Additional harms
from abduction therapy that have been addressed in the literature are typically
mild and self-limited, and include rash, pressure sores, and femoral nerve palsy. The
potential harms of surgical intervention include those associated with general
anesthesia, intraoperative complications, and postoperative wound infections.
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Future Research
A more complete understanding of the natural
history of spontaneous resolution of hip instability and dysplasia is needed
before it will be possible to develop an
evidence-based strategy for screening and treating hip abnormalities. Given
the infrequent nature of DDH, multicenter studies of interventions that measure
functional outcomes (including long-term outcomes) in a standardized fashion
are needed. Studies designed to identify valid and reliable
radiological outcomes of DDH as proxy measures of functional outcomes are
also needed. Determining patient preferences and identifying
outcomes that are relevant to patients and families would be valuable. Similarly,
controlled studies that assess the effects of delaying treatment on outcomes
would allow physicians caring for children to better manage children with
DDH.
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Recommendations of Other Groups
Recommendations for screening for DDH can be obtained from the Canadian
Task Force on Preventive Care at http://www.ctfphc.org45 and
the American Academy of Pediatrics (AAP) at http://aappolicy.aappublications.org.46 The
Canadian Task Force recommends serial clinical examinations of the hips in
periodic health examinations of all infants until the age of 12 months and
a supervised period of observation for newborns with clinically detected
DDH. The Canadian Task Force does not recommend general ultrasound or radiographic
screening for high-risk infants. The AAP recommends serial clinical examinations
of the hips, hip imaging for female infants born in the breech position,
and optional hip imaging for boys born in the breech position or girls with
a positive family history of DDH.1,4 The
AAP does not recommend general ultrasound screening.
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Members of the Task Force
Members of the U.S. Preventive Services Task Force* are Ned Calonge, M.D., M.P.H., Chair, USPSTF (Chief Medical Officer and State Epidemiologist, Colorado Department of Public Health and Environment, Denver, CO); Janet D. Allan, Ph.D., R.N., CS, Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland, Baltimore, Baltimore, MD); Alfred O. Berg, M.D., M.P.H. (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Paul S. Frame, M.D. (Family Physician, Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Joxel Garcia, M.D., M.B.A. (Deputy Director, Pan American Health Organization, Washington, DC); Leon Gordis, M.D., M.P.H., Dr.P.H. (Professor, Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD); Kimberly D. Gregory, M.D., M.P.H. (Director, Women's Health Services Research and Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA); Russell Harris, M.D., M.P.H. (Professor of Medicine, Sheps Center for Health Services Research, University of North Carolina School of Medicine, Chapel Hill, NC); Mark S. Johnson, M.D., M.P.H. (Professor and Chair, Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Carol Loveland-Cherry, Ph.D., R.N. (Executive Associate Dean, Office of Academic Affairs, University of Michigan School of Nursing, Ann Arbor, MI); Virginia A. Moyer, M.D., M.P.H. (Professor, Department of Pediatrics, University of Texas Health Science Center, Houston, TX); Judith K. Ockene, Ph.D. (Professor of Medicine and Chief of Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA); Diana B. Petitti, M.D., M.P.H. (Senior Scientific Advisor for Health Policy and Medicine, Regional Administration, Kaiser Permanente Southern California, Pasadena CA); Albert L. Siu, M.D., M.S.P.H. (Professor and Chairman, Brookdale Department of Geriatrics and Adult Development, Mount Sinai Medical Center, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Executive Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); and Barbara P. Yawn, M.D., M.Sc. (Director of Research, Olmstead Research Center, Rochester, MN).
* Member of the USPSTF at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.
This statement summarizes the USPSTF recommendation on screening for developmental dysplasia of the hip. The complete information on which this statement is based, including evidence tables and references, is included in the systematic literature review47 and evidence synthesis48 on the topic, available on the USPSTF Web site (http://www.preventiveservices.ahrq.gov). The recommendation is also posted on the Web site of the National Guideline Clearinghouse™ (http://www.guideline.gov).
Recommendations made by the USPSTF are independent of the U.S. Government. They should not be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.
Corresponding Author: Ned Calonge, M.D., M.P.H., Chair, U.S. Preventive Services Task Force, c/o Program Director, USPSTF, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850; E-mail: info@ahrq.gov.
Copyright and Source Information
This document is in the public domain within the United States. For
information on reprinting, contact Randie Siegel, Director, Division of
Printing and Electronic Publishing, Agency for Healthcare Research and Quality,
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Requests for linking or to incorporate content in electronic resources
should be sent to: info@ahrq.gov.
Source: U.S. Preventive Services Task Force. Screening for developmental
dysplasia of the hip: recommendation statement. Pediatrics 2006;117:898-902.
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References
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AHRQ Publication No. 05(06)-0585-A
Current as of March 2006
Internet Citation:
U.S. Preventive Services Task Force. Screening for Developmental Dysplasia of the Hip: Recommendation Statement. AHRQ Publication No. 05(06)-0585-A, March 2006. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/uspstf06/hipdysp/hipdysrs.htm
540 Gaither Road Rockville, MD 20850