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