Universal Hip Screening in Babies Associated With Overtreatment

Universal ultrasonographic screening for developmental dysplasia of the hip (DDH) was associated with higher rates of early detection and nonoperative treatment, but similar rates of late detection and operative treatment, a large meta-analysis found.

Rates of early detection of DDH (before 12 weeks of age) varied significantly between universal and other types of screenings, as reported in JAMA Network Open.

• Clinical screening: 8.4 infants with DDH per 1,000 newborns (95% CI 4.8-14.8)
• Selective ultrasonographic screening based on risk or clinical findings: 4.4 per 1,000 (95% CI 2.4-8.0)
• Universal ultrasonographic screening: 23.0 infants per 1,000 (95% CI 15.7-33.4)

Accordingly, the incidence of early, nonoperative treatment (e.g., harness, splinting) differed by screening method:

• Clinical screening: 5.5 nonoperative treatments per 1,000 (95% CI 2.1-14)
• Selective ultrasonographic screening: 3.1 nonoperative treatments per 1,000 (95% 2.0-4.8)
• Universal ultrasonographic screening: 9.8 nonoperative treatments per 1,000 (95% CI 6.7-14.4)

Despite these findings, incidences of late detection (≥12 weeks of age) and operative treatment were similar among all three screening methods, according to Ilari Kuitunen, MD, PhD, of the University of Eastern Finland and Mikkeli Central Hospital, and colleagues.

Therefore, they said, the meta-analysis suggests that universal screening may cause initial overtreatment without reducing the rates of late detection and operative treatment.

"It is obvious that clinical screening will miss a small percentage of patients with DDH (e.g., bilateral or teratologic DDH) who could have been treated nonoperatively and will therefore undergo operative treatment at a later stage. The earlier the DDH is detected, the better the outcome, with less complications in early phase and less likely progress to total hip replacement in adolescence or young adulthood," they wrote.

"However, the late detection rate and the need for operative treatment are not zero with universal ultrasonographic screening either, because ultrasonography does not detect all patients with clinical instability, and the reproducibility of ultrasonographic findings varies among examiners," the authors cautioned.

DDH includes several newborn hip findings, including "clicky" hips, clinical instability, clinical reversible or irreversible dislocation, immature ultrasonographic findings, and potential dislocation on dynamic ultrasonographic examination. DDH tends to run in families and is more common in girls and firstborn children, according to the American Academy of Orthopaedic Surgeons.

Study authors noted that universal ultrasonographic screening for DDH is increasing in popularity, especially in Europe, despite the lack of reduction in late-detected cases and treatment. They pointed out that 97% of immature hips detected via ultrasonographic screening normalize during the first few months of life without any treatment.

"[G]iven the results of our analysis, universal ultrasonographic screening should be considered carefully and locally, based on the current screening effectiveness and resources," Kuitunen and colleagues urged.

Their meta-analysis included 76 studies with a sample size of 16,901,079 infants. Most studies were conducted in Europe (59%) or Asia (28%), limiting the generalizability of the results.

The investigators also acknowledged that the inclusion of only observational studies carried over the possibilities of bias and confounding to the meta-analysis. There was also a high heterogeneity among the studies analyzed due to differences in the number of study sites and participant selection criteria.

Finally, rates of dysplastic hips had to be estimated due to some studies only reporting pathologic hips.

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