Elsevier

The Lancet

Volume 354, Issue 9189, 30 October 1999, Pages 1514-1517
The Lancet

Articles
Late diagnosis of congenital dislocation of the hip and presence of a screening programme: South Australian population-based study

https://doi.org/10.1016/S0140-6736(98)12469-8Get rights and content

Summary

Background

The Medical Research Council Working Party on Congenital Dislocation of the Hip have reported an ascertainment-adjusted incidence of a first operative procedure for congenital dislocation of the hip (CDH) of 0·78 per 1000 livebirths, which is similar to the incidence of CDH before the start of the UK screening programme. The report showed that CDH had not been detected by routine screening before age 3 months in 70% of children reported to the national orthopaedic surveillance scheme. This report raised concerns about the merit of screening at birth for CDH. We aimed to find out the incidence of an operative procedure for CDH in the first 5 years of life among children born in South Australia between 1988 and 1993, and the proportion of these patients that were detected at age 3 months or older.

Methods

The state's database for inpatient separations between January, 1988, and April, 1998 was searched. Case records were examined for the age and circumstances of diagnosis, and type of operative procedures. Prevalence rates of CDH were obtained from the South Australian Birth Defects Register, which receives notifications from a statutory perinatal data collection of birth defects detected at birth and subsequent voluntary notifications for children up to age 5 years.

Findings

Of the 55 children born in South Australia between 1988 and 1993 identified as having non-teratological CDH and operative procedures, only 22 (40%) had been diagnosed at age 3 months or older. 18 had an open reduction of the hip joint or osteotomy, or both, and the remainder had arthrograms, closed reductions, and/or tenotomy. The prevalence of non-teratological CDH in children was 7·74 per 1000 livebirths. The incidence of surgery for CDH in the first 5 years of life was 0·46 per 1000 livebirths (95% CI 0·34–0·59) and only 0·19 per 1000 livebirths (0·11–0·26) for those diagnosed late (age 3 months or older). These children diagnosed late represented 2·4% of all known cases of CDH.

Interpretation

Only 2·4% of known cases of CDH in children born in South Australia had been detected late and required surgery. These results show that a screening programme for CDH can be successful, contrary to the findings of the UK Medical Research Council Working Party.

Introduction

The study by the UK Working Party on Congenital Dislocation of the Hip- aroused considerable concern about the merit of screening for the condition at birth.1, 2, 3, 4 Godward and Dezateux1 showed that the ascertainmentadjusted incidence of a first operative procedure for congenital dislocation of the hip (CDH) within the first 5 years of life was 0·78 per 1000 livebirths, which was similar to the prevalence recorded in previous studies of the condition in the UK. They also found that CDH had not been detected by routine screening before 3 months of age in 70% of children reported to the national orthopaedic surveillance scheme. Suggestions were that the clinical screening programme introduced in the UK in 1969 had been ineffective in lowering the incidence of surgery for the condition, and that assessment of current and alternative screening policies is needed.1

In view of this concern, we audited the clinicalscreening programme for CDH in place in the State of South Australia. South Australia has an area of 984 377 km2, about four times the area of the UK. It has a population of 1·48 million, of whom about 73% live in the capital city, Adelaide. There are about 20 000 births every year. Screening for CDH was instituted as a state wide programme in 1964 after an earlier healthprofessional-education programme.5 The programme includes clinical screening for the condition at birth, before discharge from the hospital of birth, and again at about 6 weeks of age when the child is brought by the mother to see a paediatrician or general practitioner, or attends a well-baby clinic provided by the state's childhealth service (Child and Youth Health). Staff at these clinics throughout the state are trained to examine children for CDH at the first clinic visit at 1–4 weeks of age (when about 84% of children attend) and again at 6–8 months (when about 60% attend). Specific checks for gait aimed at detection of CDH are then repeated at 18 months and 2·5 years. Ultrasonographic scanning is not done routinely as part of the screening programme, but is used when there is doubt about the clinical diagnosis, and to confirm enlocation within 2 weeks of the start of treatment by splinting.

Orthopaedic surgeons in South Australia believe that late diagnosis of CDH is rare among children born in the state.5 A study of the prevalence and risk factors of the condition among liveborn children in 19916 noted that 60% of the patients had been detected within the first week of life, 84% within the first 4 weeks, and 97% within the first 12 weeks: these included all categories of CDH and children who only had acetabular dysplasia (shown by ultrasonography).

Our aim was to find out the incidence of operative procedures for CDH within the first 5 years of life among children born in South Australia between 1988 and 1993, the age at which CDH was detected in these patients, and the types of operative procedures undertaken.

Section snippets

Methods

South Australia has statutory perinatal data for births that occur in the state. These data include notifications of children who have birth defects detected before discharge from the hospital of birth. This database of children with birth defects held in the Pregnancy Outcome Unit of the Department of Human Services is complemented by voluntary notifications from health professionals of children who have birth defects detected after discharge from the hospital of birth and before age 5 years.

Results

Between January, 1988, and April, 1998 in South Australia, 85 children born between 1988 and 1993 were identified who had had any of the listed procedures for CDH. Of these, 16 were excluded because they were not born in South Australia: six were born in adjacent Australian states, of whom three were from country towns near the state border, and one had teratological CDH; and ten were born overseas. 14 other children born in South Australia were excluded because they had teratological CDH—eg,

Discussion

This study has shown that, with a prevalence of CDH of 7·74 per 1000 livebirths, the incidence of cases requiring operative procedures in the first 5 years of life among children born in South Australia between 1988 and 1993 was only 0·46 per 1000 livebirths. Of the 55 children who required operative procedures only 22 (40%) had been detected late, at age 3 months or older, yielding a rate of 0·19 per 1000 livebirths for this group. These children represented only 2·4% of all known CDH cases.

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