Elsevier

The Lancet

Volume 351, Issue 9110, 18 April 1998, Pages 1149-1152
The Lancet

Articles
Surgery for congenital dislocation of the hip in the UK as a measure of outcome of screening

https://doi.org/10.1016/S0140-6736(97)10466-4Get rights and content

Summary

Background

Universal clinical screening for congenital dislocation of the hip to detect hip instability in neonates was introduced in the UK as a national policy in 1969, but its effectiveness is not known. We aimed to assess the extent to which surgery for congenital dislocation of the hip is the result of a failure of detection through screening or follows non-surgical treatment after detection by screening.

Methods

We established a national orthopaedic surveillance scheme and used routine hospital data for inpatients for 20% of births in the UK (Scotland and the Northern and Wessex regions) to ascertain the number of children aged under 5 years per 1000 livebirths who had received at least one operative procedure for congenital dislocation of the hip from April, 1993, to April, 1994. Estimates of the incidence of operative procedures were adjusted for under-ascertainment by capture-recapture techniques.

Findings

The ascertainment-adjusted incidence of a first operative procedure for congenital dislocation of the hip in the UK was 0·78 per 1000 livebirths (95% Cl 0·72–0·84). Congenital dislocation of the hip had not been detected by routine screening in 222 (70%) of 318 children reported to the national orthopaedic surveillance scheme. In 112 (35%) children the diagnosis was made primarily as a result of parental concern. 67 (21%) children had previously received non-surgical treatment. In Scotland and the Northern and Wessex regions, 81 cases were notified to the national orthopaedic surveillance scheme, 62 cases were identified only through routine hospital data on inpatients, and an estimated 20 cases were not identified by either source, making a total of 163 cases. Thus, 81 (50%) of these 163 cases were identified by surveillance, 125 (77%) by routine data, and 143 (88%) by both sources.

Interpretation

The incidence of a first operative procedure for congenital dislocation of the hip in the UK was similar to that reported before screening was introduced. In most children who received surgery, congenital dislocation of the hip was not detected by screening. Formal evaluation of current and alternative screening policies, including universal primary ultrasound imaging, is needed.

Introduction

Congenital dislocation of the hip may lead to impaired hip function and premature degenerative joint disease.1 In 1969, universal clinical screening for congenital dislocation of the hip through the detection of neonatal hip instability was introduced in the UK.2 The Standing Medical Advisory Committee3 made recommendations in 1986 to screen three times during the first 6 weeks of life (within 24 h of birth, on discharge from hospital of birth, and at age 6 weeks). In addition, clinical examination for classic signs of dislocation and abnormal gait was advised until walking age. A national survey in 1994 confirmed that this remains current practice.4 Early detection of hip instability in infants allows the initial treatment to be non-surgical: a splint appliance is worn that keeps the hips abducted to encourage a stable and concentric reduction of the femoral head within the acetabulum. Without screening, clinical presentation of hip dislocation usually occurs after walking age and surgical treatment is required.

There are few available data on the prevalence of congenital dislocation of the hip in the UK before screening was introduced,5 but studies suggest it was about 1–2 per 1000 livebirths.6, 7, 8 Since clinical screening was introduced, some centres have reported a reduction in the number of children who need surgical treatment,9, 10, 11, 12 whereas others have reported no change,13, 14, 15 or even an increase.16, 17, 18 The effectiveness of screening is uncertain, reflecting lack of evidence from randomised trials.1 Despite recommendations to monitor the effectiveness of the programme, a national picture is lacking, partly because of the absence of agreed measures of outcome and routine data sources.19

Our national study was set up to estimate the number of children younger than 5 years who had at least one operative procedure for congenital dislocation of the hip, expressed per 1000 livebirths, and to assess the extent to which surgery was the result of a failure of detection through screening.

Section snippets

Methods

Routinely obtained data on hospital inpatients can be unreliable20 should be confirmed by inspection of the original medical records.21 Because such confirmation is not feasible on a national basis, an active reporting scheme was established among consultant orthopaedic surgeons who treat children in the UK in collaboration with the British Orthopaedic Association.22 This scheme was modelled on the British Paediatric Surveillance Unit of the Royal College of Paediatrics and Child Health.23 From

Incidence by active surveillance throughout the UK

Throughout the UK, surgeons returned 9123 (92%) of 9916 reporting cards and notified 564 cases through the national orthopaedic surveillance scheme. Further details were provided for 435 (77%) cases, 318 of which met the inclusion criteria.

We excluded 117 cases: the date of the first operative procedure fell outside the study period in 44 cases; surgeons notified 33 cases in error; 14 cases were notified twice; no operative procedure was undertaken in ten cases; six children had acquired or

Discussion

This is the first time since its introduction in 1969 that the screening programme for congenital dislocation of the hip has been evaluated on a national basis in the UK. We found that despite screening, the incidence of surgery was high and in most children congenital dislocation of the hip had not been detected by screening or surveillance before the age of 3 months

Although a high proportion of reporting cards were returned by the orthopaedic surgeons, suggesting good compliance with the

References (35)

  • TJ David et al.

    Reasons for late detection of hip dislocation in childhood

    Lancet

    (1983)
  • C Dezateux et al.

    Evaluating the national screening programme for congenital dislocation of the hip

    J Med Screen

    (1995)
  • Screening for the detection of congenital dislocation of the hip in infants

    (1969)
  • Screening for the detection of congenital dislocation of the hip

    (1986)
  • C Dezateux et al.

    A national survey of screening for congenital dislocation of the hip

    Arch Dis Child

    (1996)
  • EG Knox et al.

    Effectiveness of screening for congenital dislocation of the hip

    J Epidemiol Community Health

    (1987)
  • A Catterall

    The early diagnosis of congenital dislocation of the hip

    J Bone Joint Surg

    (1994)
  • GC Bennet

    Screening for congenital dislocation of the hip

    J Bone Joint Surg

    (1992)
  • I Leck

    An epidemiological assessment of neonatal screening for dislocation of the hip

    J Roy Coll Phys

    (1986)
  • D Yngve et al.

    Late diagnosis of hip dislocation in infants

    J Pediatr Orthop

    (1990)
  • SJ Tredwell

    Neonatal screening for hip joint instability

    Clin Orthop

    (1992)
  • PM Dunn et al.

    Congenital dislocation of the hip: early and late diagnosis and management compared

    Arch Dis Child

    (1985)
  • GP Mitchell

    Problems in the early diagnosis and management of congenital dislocation of the hip

    J Bone Joint Surg

    (1972)
  • MJ Place et al.

    Effectiveness of neonatal screening for congenital dislocation of the hip

    Lancet

    (1978)
  • S Rao et al.

    Congenital dislocation of the hip in the newborn: a postnatal study

    NZ Med J

    (1986)
  • IG MacKenzie et al.

    Problems encountered in the early diagnosis and management of congenital dislocation of the hip

    J Bone Joint Surg

    (1981)
  • J Sanfridson et al.

    Why is congenital dislocation of the hip still missed?

    Acta Orthop Scand

    (1991)
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