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Is ultrasound screening for DDH in babies born breech sufficient?
Insights
Breech presentation is a significant risk factor for developmental dysplasia of the hip (DDH). Even with normal initial ultrasounds, follow-up radiographs are crucial for detecting DDH in these infants.
Area of Science:
- Pediatric Orthopedics
- Medical Imaging
- Developmental Pediatrics
Background:
- Developmental dysplasia of the hip (DDH) is a condition requiring early detection and intervention.
- Breech presentation is a known risk factor for DDH, necessitating specific screening protocols.
- Current screening guidelines for DDH in breech infants are continually evaluated for efficacy.
Purpose of the Study:
- To determine the incidence of DDH in breech infants identified via ultrasound screening.
- To assess the necessity of follow-up radiographs in breech infants with normal clinical and ultrasound examinations.
- To evaluate the effectiveness of current screening protocols for DDH in breech infants.
Main Methods:
- A 5-year retrospective review of clinical data and imaging studies for breech infants referred for orthopedic evaluation.
- Standardized ultrasound screening at approximately 6 weeks of age using the dynamic method.
- Protocol-based follow-up including clinical examination and radiographs at 4-6 months for infants with normal ultrasounds.
Main Results:
- Twenty-seven percent of breech infants with clinically stable hips showed abnormal screening ultrasounds.
- Among breech infants with initially normal ultrasounds, 29% were diagnosed with DDH upon radiographic follow-up at 4-6 months.
- Pavlik harness treatment was associated with higher acetabular indices compared to untreated cases.
Conclusions:
- Ultrasound screening of breech infants with clinically stable hips reveals a 27% incidence of DDH at 6 weeks.
- A significant proportion (29%) of breech infants with normal 6-week ultrasounds develop DDH requiring treatment by 6 months.
- Longitudinal evaluation including newborn exam, 6-week ultrasound, and 6-month radiographs is recommended for breech infants due to the high risk of subsequent DDH.
Purpose:
To review our incidence of developmental dysplasia of the hip (DDH) in breech infants referred for ultrasound screening and to determine if subsequent follow-up radiographs are necessary in these patients with normal clinical and ultrasound examinations.
Methods:
A review of the clinical data and imaging studies of all children with the risk factor of breech presentation that were referred for orthopedic evaluation over a 5-year period was conducted. All patients were examined by a fellowship-trained pediatric orthopedic surgeon and all ultrasounds were done at approximately 6 weeks of age by an experienced ultrasonographer. Ultrasounds were evaluated using the dynamic method as described by Harcke. As per our protocol, all patients with normal screening ultrasounds were brought back for a final clinical examination and radiographic check at 4-6 months. Acetabular dysplasia was indicated by radiographic parameters-if there was severe blunting of the sourcil, abnormal acetabular index for age, or if there was significant asymmetry of acetabular indices side-to-side-in the setting of clinical parameters-if there was greater than 10° difference in side-to-side abduction or symmetric abduction of less than 60°.
Results:
Three hundred patients with the risk factor of breech presentation were included. Thirty-four patients had clinically unstable hips; 266 had clinically stable hips and were screened by ultrasound. Sixty-four percent were female and 36% were male. Twenty-seven percent of these breech patients had abnormal screening ultrasounds and were subsequently treated. Of the remaining 73% with normal ultrasounds, who were returned per protocol at a mean of 5 months, 29% had evidence of dysplasia and underwent treatment. The diagnosis of dysplasia following a normal ultrasound was based on both radiographic and clinical parameters. Of the hips treated with a Pavlik harness, 62% had acetabular indices at least two standard deviations from the age-corrected average versus 26% of patients not treated. The average length of follow-up was 10 months.
Conclusions:
Retrospectively, we found that, at approximately 6 weeks of age, ultrasound screening of breech patients with clinically stable hips produces an incidence of DDH of 27%. In those patients with a normal ultrasound, 29%, at 4-6 months radiographic follow-up, were found to have dysplasia requiring treatment. This data supports breech as the most important risk factor for hip dysplasia and we, therefore, recommend careful and longitudinal evaluation of these patients with: a careful newborn physical examination, an ultrasound at age 6 weeks, and an anteroposterior (AP) pelvis and frog lateral radiograph at 6 months, as the risk of subsequent dysplasia is too high to discharge patients after a normal ultrasound.
