PEDIATRICS Vol. 119 No. 3 March 2007, pp. 652a-653 (doi:10.1542/peds.2006-2953)
LETTER TO THE EDITOR |
Screening for Developmental Dysplasia of the Hip
Perry L. Schoenecker, MDPresident, Pediatric Orthopaedic Society of North America
Department of Orthopaedic Surgery
Shriner's Hospital
St Louis, MO 63131-3597
John M. Flynn, MD
Chair, Advocacy Committee
Pediatric Orthopaedic Society of North America
Division of Orthopaedic Surgery
Children's Hospital of Philadelphia
Philadelphia, PA 19104-4399
To the Editor.—
Representing the Pediatric Orthopaedic Society of North America, we are writing in response to the special article by the US Preventive Services Task Force (USPSTF) "Screening for Developmental Dysplasia of the Hip: Recommendation Statement."1 We agree with the USPSTF that the available literature does not offer the highest level of evidence regarding screening and treatment. We also appreciate the difficulties in formulating recommendations for a disease with a severity spectrum that can range from severe teratologic dislocations to mild acetabular dysplasias. However, the authors of this recommendation statement reached their conclusion with flawed evidence synthesis (using "best data" rather than a model-driven method) and a misunderstanding of current practice, particularly as it relates to ultrasound use and the management of mild findings in newborns. Without developmental dysplasia of the hip (DDH) screening, our nation would have thousands more children each year with a preventable disability, a sharp rise in the surgical management of hip dysplasia, and a substantially higher liability risk for primary care providers.
In an ideal world, our literature would report several large, prospective, double-blind studies comparing treated and untreated infants, with follow-up for 70 years to document the full disability of a subluxated or dislocated hip. Such studies are both impractical and unethical. The authors of the American Academy of Pediatrics clinical practice guideline2 were wise enough to recognize this problem, and instead of relying on a data-driven method, used a model-driven method3 that combined the use of an expert panel, decision modeling, and evidence synthesis. In their flawed model, the USPSTF "was concerned about the potential harms associated with treatment of infants identified by routine screening." They based their concern on an avascular necrosis (AVN) rate as high as 60% in children who were treated for DDH. The USPSTF failed to recognize that the vast majority of AVN results from treating late-presenting DDH with closed or open reduction. Currently, as a result of infant screening, early detection, and use of the Pavlik harness, the risk of AVN is 
1% (1% in 546 cases4; 0% in 547 cases5). A sharply higher risk of AVN would be expected if screening were abandoned and DDH was missed in infants, because surgical open hip reduction would again become commonplace. Those of us caring for children from the underdeveloped world are all too familiar with this reality.
The USPSTF authors also suggest that if the screening process suggests an abnormality, yet none develops, the parents have had to incur unnecessary anxiety and concern over the future of their child. This is a fallacious reason against screening for DDH or any other health care issue in infancy in which early detection can lead to a simple, definitive treatment of a potentially pathologic condition.
We urge the USPSTF to gain a better understanding of current practice and risks before developing future recommendations. Under their "Clinical Considerations," the USPSTF reported that ultrasonography was one of the most common methods of screening. This is not true in America; instead, periodic physical examination (a harmless test) is our primary hip screening tool. Ultrasound is only used when there are very high risk factors (breech girls) or an abnormal physical examination. Those of us managing DDH are well aware that many early, mild findings spontaneously resolve in the first few months of life.6 Therefore, we only use the Pavlik harness for newborns with severe dysplasia or infants with persistent dysplasia. For the reasons outlined above, we urge primary care physicians to continue to follow the clinical practice guideline for early detection of DDH outlined by the American Academy of Pediatrics.2
REFERENCES
- US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement.
Pediatrics. 2006;117
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[Free Full Text] - American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Early detection of developmental dysplasia of the hip.
Pediatrics. 2000;105
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–905
[Abstract/Free Full Text] - Eddy DM. The confidence profile method: a Bayesian method for assessing health technologies.
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[Abstract/Free Full Text] - Cashman JP, Round J, Taylor G, Clarke NM. The natural history of developmental dysplasia of the hip after early supervised treatment in the Pavlik harness: a prospective, longitudinal follow-up. J Bone Joint Surg B. 2002;84 :418 –425[CrossRef][Medline]
- Malkawi H. Sonographic monitoring of the treatment of developmental disturbances of the hip by the Pavlik harness. J Pediatr Orthop B. 1998;7 :144 –149[Web of Science][Medline]
- Eidelman M, Katzman A, Frieman S, Peled E, Bialik V. Treatment of true developmental dysplasia of the hip using Pavlik's method. J Pediatr Orthop B. 2003;12 :253 –258[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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