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Children's Orthopaedics: J. Myers, S. Hadlow, and T. Lynskey The effectiveness of a programme for neonatal hip screening over a period of 40 years: A FOLLOW-UP OF THE NEW PLYMOUTH EXPERIENCE J Bone Joint Surg Br 2009; 91-B: 245-248 [Abstract] [Full text] [PDF]

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Authors' reply

James Myers, S. Hadlow, T. Lynskey   (5 November 2009)

Authors' reply

James Myers, S. Hadlow, T. Lynskey   (5 November 2009)

Authors' reply

J Myers, S. Hadlow, T. Lynskey   (5 November 2009)

Screening for developmental dysplasia of the hip

Gad M. Bialik   (24 April 2009)

Methods for diagnosing avascular necrosis in developmental dysplasia of the hip

Junichi Nakamura, Makoto Kamegaya, Takashi Saisu, Wataru Koizumi, Kazuhisa Takahashi   (17 April 2009)

Importance of neonatal ultrasound hip screening

Ismet Gavrankapetanovic, Zoran Vukasinovic, orthopaedic surgeon, PhD, The Special Orthopedic-Surgery Hospital "Banjica" Belgrade, Serbia   (23 March 2009)

Authors' reply 5 November 2009
James Myers, Radiology Registrar Christchurch Hospital, Christchurch, New Zealand, S. Hadlow, T. Lynskey Send letter to journal: Re: Authors' reply james.myers{at}cdhb.govt.nz James Myers, et al.	Sir, We thank Drs Gavrankapetanovic and Vukasinovic for their comments in response to our paper, and we also agree with their sentiments. Our message is not that clinical screening is enough, but rather that a well-organised screening and treatment programme run by orthopaedic surgeons is beneficial. Other centres in our own country have general population programmes run largely in the community by a combination of practioners including general practioners, junior hospital doctors and midwives with varying experience in congenital dislocation of the hip (CDH). Even if a baby is born in a hospital, it is not likely to be assessed by an orthopaedic surgeon. It is the babies with abnormal examination findings and risk factors for CDH that are reviewed in orthopaedic clinics. We aim to show that a simple system, which is not overly time consuming, can have effective results. Of course the first step must to be to measure and compare the results of other centres. We did compare the results of von Kries et al,1 who reported their results of a general ultrasound screening programme in South Bavaria in Germany. Their surgical rate of 0.26 per 1000 is similar to our failure rate of 0.29 per 1000.2 We agree that unrecognised developmental dysplasia of the hip (DDH) may carry poor outcomes for individuals and society. However, at this stage we do not have the resources to conduct an ultrasound-based general population programme. We would be very interested in the number of Dr Gavrankapetanovic's patients with sonographic DDH who have gone on to require surgery in adulthood for developmental coxarthrosis. J. Myers, Radiology Registrar, S. Hadlow, T. Lynskey, Christchurch Hospital, Christchurch, New Zealand. 1. von Kries R, Ihme N, Oberle D, et al. Effect of ultrasound screening on the rate of first operative procedures for developmental hip dysplasia in Germany. Lancet 2003;362:1883-7. 2. Myers J, Hadlow S, Lynskey T. The effectiveness of a programme for neonatal hip screening over a period of 40 years: a follow-up of the New Plymouth experience. J Bone Joint Surg [Br] 2009;91-B:245-8.
Authors' reply 5 November 2009
James Myers, Radiology Registrar Christchurch Hospital, Christchurch, New Zealand, S. Hadlow, T. Lynskey Send letter to journal: Re: Authors' reply james.myers{at}cdhb.govt.nz James Myers, et al.	Sir, We thank Nakamura et al for their interest in our paper. Unfortunately we did not always record whether a neonate had subluxable or dislocatable hips in their early examinations, so we can not give an accurate rate of avascular necrosis (AVN) per complete congenital dislocation of the hip (CDH). We therefore apologise for the unfair comparison. However, all of the neonates with unstable hips were splinted within 10 days of birth, for eight weeks, thus none had their splints on after 10 weeks of age. We believe this was important in our low incidence of AVN. J. Myers, Radiology Registrar, S. Hadlow, T. Lynskey, Christchurch Hospital, Christchurch, New Zealand.
Authors' reply 5 November 2009
J Myers, Radiology Registrar Christchurch Hospital, Christchurch, New Zealand, S. Hadlow, T. Lynskey Send letter to journal: Re: Authors' reply james.myers{at}cdhb.govt.nz J Myers, et al.	Sir, We thank Dr Bialik for his interest in our paper, and we agree with his sentiments. We concentrated on congenital dislocation of the hip (CDH) because it is a far more readily definable condition. Although clinical screening tests involve examiner subjectivity, the natural outcome of CDH, a young limping child with a radiologically dislocated hip is a more objective event. It was pragmatic to screen neonates for hip instability, to treat them and then measure the failures to assess the benefit of our programme. Alternatively, using developmental dysplasia of the hip (DDH) would leave the end measure, failure of detection or treatment, subject to significant error in the data collection process. We agree that there are a number of people with developmental pathology in their hips which is clinically silent until adulthood when they develop early coxarthrosis. However, to be certain their arthrosis is due to a developmental anomaly is less easy. We surveyed orthopaedic surgeons and included ICD codes for pelvic osteotomy and total hip joint replacement in our data search in an endeavour to identify these patients. However, we found this is difficult to measure currently in our country. If a nationwide ultrasound screening programme is established and follow-up is completed into adulthood, we would be able to draw conclusions about the treatment of sonographically abnormal hips. J. Myers, Radiology Registrar, S. Hadlow, T. Lynskey, Christchurch Hospital, Christchurch, New Zealand.
Screening for developmental dysplasia of the hip 24 April 2009
Gad M. Bialik, Pediatric Orthopedic Surgeon Sheba Medical Center, Tel-Hashomer, Israel Send letter to journal: Re: Screening for developmental dysplasia of the hip gadvik{at}hotmail.com Gad M. Bialik	Sir, I read this paper with great interest. I appreciated very much the amount of work and enthusiasm involved, and the excellent results achieved over such a long period of time. However, the methods used in this article (based only on Barlow and Ortolani manoeuvres) seem inappropriate by today's standards. Those methods were correct at the beginning of this study, but not later than the early 80s. I would like to be enlightened on the following points: - the term congenital dislocation of the hip (CDH) used at the beginning of this study, was replaced by a more appropriate and broader term: developmental displacement (or dysplasia) of the hip (DDH).1 In the second paragraph of the introduction, the authors simplify this subject, ignoring the complexity of the incidence of DDH. As postulated by Bialik et al, the incidence of DDH is dependent on the definition of DDH, and on the method of the assessment.2 It is well known that Barlow found an early stabilisation rate of 58% for neonatal hip instability, but it must be mentioned that this rate was increased to nearly 90% at two months of age.3 This was recently proved by studies using sonography for assessment of neonatal hip pathology.2 Sonography, as a diagnostic tool and guideline for treatment of DDH, was introduced in the early 80s. The most widely used method today was introduced in 1983 by Graf.4 The main problem of the contribution of this article is in fact that only babies with unstable hips were assessed. Therefore the babies with clinically "silent" hip pathology or anatomically Type II, or worse, pathology according to Graf's classification, but clinically stable, were not included. Their pathology is initially not severe enough to be diagnosed clinically, and can be diagnosed only when developing early coxarthrosis (limping is not the only criterion for late diagnosis). Thus, the "walking CDH rates" (as named by the authors) are only the tip of the iceberg of the hidden hip pathology not identified by this study. I agree with the authors that the success (the high efficacy of this study) is for neonatal hip instability only, and not for DDH at all. Given the authors' lack of experience with screening and follow-up of treating DDH using sonography, it is difficult to comment. The treatment of DDH using Pavlik's method is well discussed in the literature, and basing opinions solely on one reference can lead to misleading conclusions. In my opinion, the references used in this article are mostly historical and would have been at the beginning of the study, but more recent publications should have been added. Of 27 references only four were published after the year 2000. I believe my comments can be valuable for continuing this highly important programme. G.M. Bialik, M.D., Sheba Medical Center, Tel-Hashomer, Israel. 1. Klisic PJ. Congenital dislocation of the hip--a misleading term: brief report. J Bone Joint Surg [Br] 1989;71-B:136. 2. Bialik V, Bialik GM, Blazer S, et al. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics 1999;103:93-9. 3. Barlow TG. Early diagnosis and treatment of congenital dislocation of the hip. J Bone Joint Surg [Br] 1962;44-B:292-301. 4. Graf R. New possibilities for the diagnosis of congenital hip joint dislocation by ultrasonography. J Pediatr Orthop 1983;3:354-8.
Methods for diagnosing avascular necrosis in developmental dysplasia of the hip 17 April 2009
Junichi Nakamura, Staff Surgeon Division of Orthopaedic Surgery, Chiba Children's Hospital, Japan, Makoto Kamegaya, Takashi Saisu, Wataru Koizumi, Kazuhisa Takahashi Send letter to journal: Re: Methods for diagnosing avascular necrosis in developmental dysplasia of the hip njonedr{at}yahoo.co.jp Junichi Nakamura, et al.	Sir, We read with great interest the recent article by Myers et al1 describing their long-term experience of neonatal hip screening. We agree that a clinical screening programme for hip instability is important. Avascular necrosis (AVN) is one of the most serious complications in the treatment of developmental dysplasia of the hip. It should be appreciated that the incidence of AVN was much lower in patients treated with the Von Rosen splint (only one hip out of 663 splinted hips) than in patients treated with the Pavlik harness (12.3%) in our study.2 However, it should be noted that their protocol included not only complete dislocations, but also instability of the hip (subluxation). The rate of AVN is thought to be lower in cases of subluxation than in cases of complete dislocation. Because we included complete dislocations only, it would be unfair to compare the rate of AVN between these two studies. Moreover, we would like to know the authors' method for diagnosing AVN. Although under Salter's criteria3 follow-up of one year or longer is needed, their follow-up period was not reported. We preferred to use the criteria of Kalamchi and MacEwen4 after skeletal maturity for accurate diagnosis of AVN, since we had some experience of hips showing coxa valga due to Kalamchi's type II AVN in patients older than ten years.2,5 We would appreciate it if the authors could show their long-term results for complete dislocation of the hip. J. Nakamura, Staff Surgeon, Division of Orthopaedic Surgery, M. Kamegaya, T. Saisu, W. Koizumi, K. Takahashi, Chiba Children's Hospital, Chiba, Japan. 1. Myers J, Hadlow S, Lynskey T. The effectiveness of a programme for neonatal hip screening over a period of 40 years: a follow-up of the New Plymouth experience. J Bone Joint Surg [Br] 2009;91-B:245-8. 2. Nakamura J, Kamegaya M, Saisu T, et al. Treatment for developmental dysplasia of the hip using the Pavlik harness: long-term results. J Bone Joint Surg [Br] 2007;89-B:230-5. 3. Salter RB, Kostuik J, Dallas S. Avascular necrosis of the femoral head as a complication of treatment for congenital dislocation of the hip in young children: a clinical and experimental investigation. Can J Surg 1969;12:44-61. 4. Kalamchi A, MacEwen GD. Avascular necrosis following treatment of congenital dislocation of the hip. J Bone Joint Surg [Am] 1980;62-A:876-88. 5. Koizumi W, Moriya H, Tsuchiya K, et al. Ludloff's medial approach for open reduction of congenital dislocation of the hip: A 20- year follow-up. J Bone Joint Surg [Br] 1996;78-B:924-9.
Importance of neonatal ultrasound hip screening 23 March 2009
Ismet Gavrankapetanovic, orthopaedic surgeon, PhD, University Professor Clinical Center University of Sarajevo, Clinic for Orthopaedics and Traumatology, Zoran Vukasinovic, orthopaedic surgeon, PhD, The Special Orthopedic-Surgery Hospital "Banjica" Belgrade, Serbia Send letter to journal: Re: Importance of neonatal ultrasound hip screening ismetcap{at}ortotrauma.com.ba Ismet Gavrankapetanovic, et al.	Sir, We read this paper with great interest. We are impressed with the number of newborns monitored, as well as with the period of follow-up. However, we think clinical screening of the newborn hip, even performed by the most experienced paediatricians or paediatric orthopaedic surgeons, is insufficient without ultrasound (US) screening. We think that in countries and regions with a high incidence of DDH it is essential that clinical examination using Ortolani and Barlow is followed by Graf technique US hip screening. The best way to evaluate neonatal hips is to combine clinical and ultrasound examinations.1 US hip screening of all newborns results in a lower rate of missed dislocations and surgical procedures, although the conservative treatment rate is higher.2 The explanation for this lies in the fact that 'silent' cases of dysplasia, cases not seen clinically or by X ray, can exclusively be diagnosed by US screening.3 An important thing that we would like to emphasise is that screening should be performed at four to six weeks of life. The greatest potential for maturation is in the first six weeks of life.4 Knowing the dynamic of hip development, most hips with abnormal US findings soon after birth develop normally with no treatment;5 with screening at this age we are minimising the number of overtreated babies and we still have time to start treatment. All doctors who are performing screening should be educated in US hip screening programmes in certificated courses according to the Graf technique in order to minimise false results. Hip ultrasound is practicable, reproducible, and can easily be taught.4 The surgical treatment, rate of complications, and the need for early arthroplasty have a much higher cost in developing countries with a high incidence of DDH. The number of surgical procedures, re-interventions, and implanted arthroplasties, especially in females with late presenting or unrecognised DDH, carries a high cost for society. Considering the above we do not think it is a good message that clinical examination is enough. The complexity of disease, as well as the number of patients and complications we are dealing with in the two biggest orthopaedic centres in the Balkans, obliges us to work together in this way and to promote our good experience with US hip screening according to Graf. I. Gavrankapetanovic, PhD, Orthopaedic Surgeon, University Professor, Clinical Center University Sarajevo, Clinic for Orthopaedics and Traumatology, Sarajevo, Bosnia-Herzegovina. Z. Vukasinovic, PhD, Orthopaedic Surgeon, University Professor, The Special Orthopedic-Surgery Hospital "Banjica", Belgrade, Serbia. 1. Abuamara S, Dacher JN, Gaucher S, et al. Hip dislocation. Organization of screening and follow-up. Arch Pediatr 1999;6:675-82. [French] 2. Grill F, Müller D. Results of hip ultrasonographic screening in Austria. Orthopade 1997;26:25-32. [German] 3. Graf R. The use of ultrasonography in developmental dysplasia of the hip. Acta Orthop Traumatol Turc 2007;41(Suppl 1):6-13. 4. Graf R. Hip Sonography: Diagnosis and Management of Infant Hip Dysplasia. Berlin: Springer, 2006:88. 5. Riad J, Cundy P, Gent RJ, et al. Longitudinal study of normal hip development by ultrasound. J Pediatr Orthop 2005;25:5-9.