Learning curves and training thresholds for paediatricians performing neonatal hip ultrasound using the Graf method...

Early detection of developmental dysplasia of the hip (DDH) is essential to prevent late presentation and long-term morbidity. Universal neonatal hip ultrasound screening using the Graf method improves early diagnosis. However, evidence-based training requirements for paediatricians remain unclear. This study aimed to determine the duration of training and the number of examinations required for paediatricians to achieve diagnostic competency in neonatal hip ultrasound. An analytical cross-sectional observational study was conducted. Fourteen paediatricians completed a standardized 40-h theoretical and practical training course and performed neonatal hip ultrasound examinations using the Graf method. A total of 467 newborns were screened between 4-6 and 12-16 weeks of age over a 10-month period. Images were compared with a blinded external expert reference standard. Diagnostic agreement was assessed using weighted κ statistics and learning curves and competency thresholds were evaluated using cumulative sum (CUSUM) analysis. A total of 3752 ultrasound images were obtained, of which 3182 (84.8%) met Graf standardization criteria. CUSUM analysis showed that diagnostic competency thresholds were reached after approximately 50 examinations, with performance consolidating between 50 and 100 examinations. Paediatricians completing around four months of supervised practice and at least 180 examinations achieved substantial interobserver agreement comparable to expert reviewers (weighted κ, 0.60-0.75). Diagnostic discrepancies occurred mainly during early training and involved borderline hip classifications (Graf IIa-IIc).

Paediatricians can achieve reliable diagnostic competency in neonatal hip ultrasound using the Graf method following structured training and adequate supervised clinical experience.

• Universal ultrasound screening using the Graf method improves early detection of developmental dysplasia of the hip (DDH). • Training requirements for paediatricians performing neonatal hip ultrasound remain poorly defined.

• This study defines learning curve thresholds for paediatricians performing neonatal hip ultrasound using the Graf method. • Competency was achieved after 50 examinations, with consolidated performance after 4 months of practice and180 examinations.