Explor Musculoskeletal Dis EMD Exploration of Musculoskeletal Diseases 2836-6468 Open Exploration Publishing 10.37349/emd.2024.00047 100747 Systematic Review A systematic review of DDH screening practices in the UK https://orcid.org/0000-0002-2191-0375 Birkett Nicholas Conceptualisation investigation writing—original draft preparation Writing—review & editing * https://orcid.org/0000-0002-5737-7998 Karam Edward Conceptualisation investigation Writing—review & editing https://orcid.org/0000-0003-2876-8225 Ferguson David Investigation Writing—review & editing Pinto Deepika Investigation Writing—review & editing Maizen Claudia Conceptualisation supervision Writing—review & editing Pérez-Ruiz Fernando Academic Editor Cruces University Hospital, Spain Department of Trauma and Orthopaedics, Royal London Hospital, E1 1BB London, UK *Correspondence: Nicholas Birkett, Department of Trauma and Orthopaedics, Royal London Hospital, E1 1BB London, UK. nbirkett@doctors.org.uk 2024 03 06 2024 2 3 181 188 14 12 2023 17 01 2024 © The Author(s) 2024. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Background:

The United Kingdom (UK) currently employs a selective screening system for developmental dysplasia of the hip (DDH). Despite this, late presentation rates remain high. The aim of this study was to systematically review the available literature to gain an understanding of screening practices throughout the UK.

 Methods:

A systematic review was conducted. Studies reporting DDH screening methods from the UK were included. The primary outcome measure was the method of ultrasound and clinical screening. Secondary outcomes were the treatment rate and late presentation rate. A narrative analysis was undertaken, as meta-analysis was felt to be inappropriate due to the differences between included studies.

 Results:

Nine studies were eligible and included. There was significant variability in practice, with a variety of ultrasound techniques being used and a variety of staff members performing clinical screening. Treatment rate ranged from 16.4/1,000 to 0.8/1,000. Late presentation rate ranged from 1.28/1,000 to 0.27/1,000.

 Discussion:

In spite of a national consensus statement, there is no standardised approach to clinical or ultrasound screening in the UK. A variety of different methods are used, which may explain the persistently high late presentation rate. A national system of quality control and a standardised screening process is recommended, with specialised training in the Graf method of ultrasound.

 DDH screening ultrasound clinical screening Introduction Rationale

Developmental dysplasia of the hip (DDH) is the most common orthopaedic disorder in newborns and is the leading cause of early-onset arthritis and total hip arthroplasty in young patients [1, 2]. Early detection and treatment of DDH can reduce the need for invasive surgical intervention and reduce long-term disability. Effective DDH screening is therefore essential to identify and treat cases as early as possible.

At present, the United Kingdom (UK) uses a selective screening model, with children with specific risk factors (breech presentation, multiple births, family history) or an abnormal clinical examination being invited for ultrasound screening. Clinical examination is performed at birth and repeated at 6–8 weeks in a primary care setting [3].

In 2022 the British Society for Children’s Orthopaedic Surgery (BSCOS) released a consensus statement regarding the management of DDH in the first three months of life [4]. They advocate for universal screening, but they also gave recommendations for selective screening within the current UK system. They recommend that the current risk factors be increased to include non congenital talipes equinovarus (CTEV) foot deformities and packaging disorders. They recommend that ultrasound should take place in a one-stop clinic, and that the Graf criteria of quality assurance should be adhered to. Those with clinical abnormalities on examination should have a scan within 2 weeks, and the examination itself should be performed by “expert” examiners with robust methods of quality assurance in place.

 Objectives

This paper aims to evaluate screening in the UK by performing a systematic review of the relevant literature. This will provide an overview of the screening methodologies used. It can then be evaluated whether UK practice reflects that of the BSCOS consensus statement.

 Materials and methods

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant systematic review was conducted to gain an overview of current screening practice in the UK [5]. The Embase and Medlin databases were searched, along with the Cochrane Library.

Eligibility criteria Study designs

Unpublished studies, guidelines, protocols, and editorials were not considered. Previous systematic reviews were also excluded. All other study designs were considered.

 Types of participants

Exclusion criteria included studies with either serious or critical risk of bias.

 Interventions

Interventions eligible for consideration were children who had undergone ultrasound screening for DDH in the UK. A full list of inclusion and exclusion criteria is detailed in Table 1.

Full inclusion and exclusion criteria

Selection criteria Inclusion criteria Exclusion criteria
Language English language Non-English studies
Study type All study designs Systematic reviews
Population Newborn populationHuman studiesUK based study Children older than newbornCadaveric or animal studiesNon-UK study
Intervention DDH screening Not relevant to screening
Date Studies after 2009 Studies prior to 2010
Quality Clearly reported methodology Serious or critical risk of bias
Availability Full text available Abstract only availableUnpublished studiesEditorials
Outcomes of interest

The primary outcome measures of interest were the methods of ultrasound and clinical screening used. Secondary outcomes were the treatment rate and late presentation rate. The search strategy is detailed in Figure 1.

PRISMA flow diagram illustrating literature search. n: number. RCTs: randomized controlled trials; ROBINS-I: risk of bias in non-randomized studies of interventions

 Search strategy

A systematic literature search was performed. The Embase, Medline, and PubMed databases, along with the Cochrane Library were searched. The search strategies and results are presented in Figure 1.

 Selection process

The resulting papers were then manually searched to determine whether they met the inclusion criteria (Table 1). This was performed independently by 2 authors (Nicholas Birkett and Edward Karam). In the case of only one author including a paper, it was included in the review nonetheless.

 Data collection process and synthesis methods

The methodologies and data extracted were reviewed. Meta-analysis was felt to be inappropriate due to the heterogeneity in both treatment modalities and outcome measurements. A narrative review was conducted to best answer the research question.

 Risk of bias assessment

The ROBINS-I critical appraisal tool was used to evaluate the included studies for risk of bias [6]. The studies were then categorised as either low, moderate, serious, or critical risk.

 Results Study selection

A total of 1,730 studies were identified from the literature search (Medline, Embase, PubMed, and Cochrane Library). Ninety one studies were selected for full-text review following assessment of their abstracts. Of these, 9 met the inclusion criteria and were deemed eligible for this review. The full results of the literature search are presented in Figure 1.

 Risk of bias in studies

The critical appraisal is summarised in Table 2, assessed using the ROBINS-I tool. The studies were all low or moderate risk.

Assessed risk of bias of included studies using the ROBINS-I tool

Study Type of bias Overall bias risk
Confounding Selection of participants Classification of intervention Deviations from intended interventions Missing data Measurement of outcomes Selection of reported results
Afaq et al. [7] Moderate Moderate Moderate Low Moderate Low Low Moderate
Broadhurst et al. [8] Low Low Low Low Low Low Low Low
Choudry et al. [9] Low Low Low Low Moderate Low Low Moderate
Clarke et al. [10] Low Low Moderate Low Low Moderate Low Moderate
Donnelly et al. [11] Low Low Low Low Low Low Low Low
McAllister et al. [12] Low Low Low Low Low Low Low Low
Talbot et al. [13] Low Low Moderate Low Low Low Low Low
Tyagi et al. [14] Low Moderate Low Low Low Low Low Moderate
Westacott et al. [15] Low Low Low Moderate Moderate Moderate Low Low
Findings

The included studies highlighted the variability in screening practice throughout the UK, with a variety of reported clinical and ultrasound screening methods. All papers reported on selective screening, except for Westacott et al. [15], whose study compared universal with selective screening.

Primary outcome—ultrasound and clinical screening method

The ultrasound screening method was reported in 7/9 (78%) of papers. Five studies used either the Graf technique or a modification of it. Other methods used were Harcke, Terjesen, and Clarke. Often, these methods were combined and modified.

There was significant variability in the healthcare professional performing the ultrasound screening. Four studies did not report who performed the ultrasound screening. Other papers reported screening being performed by orthopaedic consultants, radiologists, sonographers, and physiotherapists. It is unclear from the papers whether these staff members had specific training or not.

Clinical examination was performed by a wide variety of staff. Most commonly, the examination was performed by either midwives or junior doctors in paediatrics. Other studies reported examinations by orthopaedic surgeons, physiotherapists, paediatricians, and health visitors.

Risk factors that prompted screening generally conformed with the UK newborn and infant physical examination (NIPE) guidelines [3]. Westacott et al. [15] included packaging disorders and non-CTEV foot disorders as risk factors.

 Secondary outcomes

Treatment rates ranged from 16.4/1,000 to 0.8/1,000. The highest treatment rate was seen in the universal screening group in Westacott et al. [15], which is to be expected. Late presentation rates were poorly reported but ranged from 1.28/1,000 to 0.27/1,000. The definition of late presentation varied by study which made direct comparison difficult. It is worth noting that Westacott et al. [15] found 5 cases of delayed presentation in both their universal and selective screening groups, but all the cases in the universal group were due to administrative errors.

A summary of all the studies’ findings can be found in Table 3.

A summary of included studies and result

Study Number of patients US method Professional performing US Professional performing clinical exam Criteria for referral Treatment rate Late presentation rate
Afaq et al. [7] 200 Harcke method with Terjesen measurements Consultant radiologist or sonographer Junior doctor or midwife Family history, breech, syndromic children, spinal or foot deformities, abnormal examination Not reported Not reported
Broadhurst et al. [8] 3,635 Not reported Not reported Not reported Family history, breech presentation Not reported 1.28/1,000
Choudry et al. [9] 124 Graf & Harcke Orthopaedic consultant Variable—junior doctor/midwife/advanced nurse practitioner Family history, breech presentation, abnormal examination 0.8/1,000 0.78/1,000
Clarke et al. [10] 20,344 Clarke Not reported Paediatrician Family history, breech presentation, foot deformities, abnormal examination 7.2/1,000 0.34/1,000
Donnelly et al. [11] 75,856 Graf Not reported Health visitors Family history, breech presentation, abnormal examination 8.5/1,000 0.42/1,000
McAllister et al. [12] 896,594 Not reported Physiotherapist/Physician Physiotherapist/Physician Family history, breech presentation, moulding abnormality, abnormal examination Not reported Not reported
Talbot et al. [13] 2,984 Modified Harcke (dynamic) & modified Graf (static) Not reported Orthopaedic surgeon Family history, abnormal examination 16.4/1,000 Not reported
Tyagi et al. [14] 3,618 Graf Consultant radiologist/radiographer Maternity care professional Family history, breech, multiple pregnancies, CTEV, high bodyweight females, abnormal examination 3.31/1,000 0.27/1,000
Westacott et al. [15] (selective group) 18,053 Graf Radiographer or orthopaedic consultant Junior doctor or general practitioner Family history, breech presentation, multiple pregnancies, increased birth weight, non-CTEV foot deformities, packaging disorders 2.3/1,000 0.28/1,000
Westacott et al. [15] (universal group) 10,015 Graf Radiographer or orthopaedic consultant N/A—US screening alone N/A—universal 7.9/1,000 0.5/1,000

N/A: not applicable; US: ultrasound

 Discussion

The included studies highlight the variability in DDH screening practice throughout the UK. Criteria for screening appear relatively similar and in keeping with NIPE guidelines, but work is required to expand the indications to include foot deformities and packaging disorders as per the BSCOS consensus statement. Most variability was noticed in ultrasound methodology and in the seniority or experience of those carrying out clinical examinations. It is clear from many of the studies that the important task of clinical examination is often carried out by a relatively inexperienced member of the team.

The late presentation rate of DDH in the UK has been estimated at 1.2/1,000 [16]. Countries with universal screening have reported late presentation rates ranging from 0 to 0.16/1,000 [17, 18]. The introduction of selective screening in the UK did not have any effect on late presentation rates, highlighting inconsistency in practice [8]. If the current system of selective screening in the UK is to continue for the foreseeable future, consistency and quality control are required at all levels of the process, from the initial assessment of the newborn to the ultrasound screening itself.

One essential area for improvement is education and training in the Graf method of ultrasound. The method is recommended but is often implemented in a modified fashion. The Graf method is successful when performed with the correct technique and the strict reporting criteria are adhered to. Modifications of the Graf method invalidate its efficacy, therefore widespread training in how to properly apply the method is required.

In conclusion, despite a national consensus statement, the UK literature demonstrates significant variability in practice. Significant change is required at a national level to standardise screening processes, with a national level of quality control to ensure that the highest quality care is being delivered. Specific training in the Graf ultrasound method is recommended, to ensure it is delivered correctly without modification.

 Abbreviations BSCOS

British Society for Children’s Orthopaedic Surgery

 CTEV

congenital talipes equinovarus

 DDH

developmental dysplasia of the hip

 ROBINS-I

risk of bias in non-randomized studies of interventions

 Declarations Author contributions

NB: Conceptualisation, investigation, writing—original draft preparation, Writing—review & editing. EK: Conceptualisation, investigation, Writing—review & editing. DF and DP: Investigation, Writing—review & editing. CM: Conceptualisation, supervision, Writing—review & editing. All authors read and approved the submitted version.

 Conflicts of interest

The authors declare that they have no conflicts of interest.

 Ethical approval

Not Applicable.

 Consent to participate

Not Applicable.

 Consent to publication

Not Applicable.

 Availability of data and materials

All data is from studies referenced in the manuscript.

 Funding

Not Applicable.

 Copyright

© The Author(s) 2024.

 Engesæter IØ Lehmann T Laborie LB Lie SA Rosendahl K Engesæter LB Total hip replacement in young adults with hip dysplasia Acta Orthop 2011 82 149 54 10.3109/17453674.2011.56614621434808PMC3235283 Dezateux C Rosendahl K Developmental dysplasia of the hip Lancet 2007 369 1541 52 10.1016/S0140-6736(07)60710-717482986 Newborn and infant physical examination screening: standards [Internet] [Cited 2023 Dec 2]. Available from: https://www.gov.uk/government/publications/newborn-and-infant-physical-examination-screening-standards Regarding the management of developmental dysplasia of the hip (DDH) in the first three months of life [Internet] BSCOS; c2022 [cited 2023 Dec 8]. Available from: https://www.bscos.org.uk/consensus/consensus/DDH.php Moher D Liberati A Tetzlaff J Altman DG PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement Ann Intern Med 2009 151 264 9 10.7326/0003-4819-151-4-200908180-0013519622511 Sterne JA Hernán MA Reeves BC Savović J Berkman ND Viswanathan M et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions BMJ 2016 355 i4919 10.1136/bmj.i491927733354PMC5062054 Afaq AA Stokes S Fareed H Zadeh HG Watson M Ultrasound in the selective screening of developmental dysplasia of the hip Eur Rev Med Pharmacol Sci 2011 15 394 8 21608433 Broadhurst C Rhodes AML Harper P Perry DC Clarke NMP Aarvold A What is the incidence of late detection of developmental dysplasia of the hip in England? Bone Joint J 2019 101-B 281 7 10.1302/0301-620X.101B3.BJJ-2018-1331.R130813797 Choudry QA Paton RW Neonatal screening and selective sonographic imaging in the diagnosis of developmental dysplasia of the hip Bone Joint J 2018 100-B 806 10 10.1302/0301-620X.100B6.BJJ-2017-1389.R129855244 Clarke NM Reading IC Corbin C Taylor CC Bochmann T Twenty years experience of selective secondary ultrasound screening for congenital dislocation of the hip Arch Dis Child 2012 97 423 9 10.1136/archdischild-2011-30108522412044 Donnelly KJ Chan KW Cosgrove AP Delayed diagnosis of developmental dysplasia of the hip in Northern Ireland: can we do better? Bone Joint J 2015 97-B 1572 6 10.1302/0301-620X.97B11.3528626530663 McAllister DA Morling JR Fischbacher CM Reidy M Murray A Wood R Enhanced detection services for developmental dysplasia of the hip in Scottish children, 1997–2013 Arch Dis Child 2018 103 1021 6 10.1136/archdischild-2017-31435429436408PMC6225802 Talbot CL Paton RW Screening of selected risk factors in developmental dysplasia of the hip: an observational study Arch Dis Child 2013 98 692 6 10.1136/archdischild-2013-30364723852998 Tyagi R Zgoda MR Short R Targeted screening of hip dysplasia in newborns: experience at a district general hospital in Scotland Orthop Rev (Pavia) 2016 8 6640 10.4081/or.2016.664027761220PMC5066110 Westacott DJ Butler D Shears E Cooke SJ Gaffey A Universal versus selective ultrasound screening for developmental dysplasia of the hip: a single-centre retrospective cohort study J Pediatr Orthop B 2018 27 387 90 10.1097/BPB.000000000000050829578934 Poacher AT Hathaway I Crook DL Froud JLJ Scourfield L James C et al. The impact of the introduction of selective screening in the UK on the epidemiology, presentation, and treatment outcomes of developmental dysplasia of the hip Bone Jt Open 2023 4 635 42 10.1302/2633-1462.48.bjo-2022-0158.r137607720PMC10444535 Biedermann R Riccabona J Giesinger JM Brunner A Liebensteiner M Wansch J et al. Results of universal ultrasound screening for developmental dysplasia of the hip Bone Joint J 2018 100 1399 404 10.1302/0301-620X.100B10.BJJ-2017-1539.R230295526 Andersson JE Neonatal hip instability: results and experiences from ten years of screening with the anterior-dynamic ultrasound method Acta Paediatr 2002 91 926 9 10.1080/08035250276014865812222717