Shipman and colleagues can be congratulated for their comprehensive
review of the literature on screening for Developmental Dysplasia of the
Hip (DDH). There are indeed many issues about screening for DDH we should
know more about. At least one paper, however, seems to have escaped their
attention.
Active surveillance data covering about 750 000 births annually over
a five year period have shown that operative procedures for DDH are quite
low in a population with an ongoing ultrasound screening program: 0.26/100
000 live births (1). These figures are much lower than previously
established rates for operative procedures for DDH in the same population
prior to the introduction of the ultrasound screening program: 1/100 000
(2). Additionally these rates are much lower than in other populations
with clinical screening only: 0.46, 0.78 and 1.03 / 100 000 live births in
Australia, UK and Ireland respectively (3-5).
This low rate could neither be explained by under ascertainment since
it was based on active surveillance with capture recapture correction for
underreporting nor by a too narrow case definition: As in other
publications the case definition was wide including closed reductions,
open reductions and osteotomy (1).
The ultrasound screening program in Germany, however, did not prevent
all operative procedures for DDH. There were still 0.26 operative
procedures per 100 000 live births (1) despite a widely accepted and
implemented ultrasound screening program. About half these cases were in
children with early ultrasound diagnosis and therapy within the first 10
weeks suggesting that operative procedures might not be completely
prevented by early diagnosis and treatment of DDH. The remaining cases
regarded were related to delayed screening, potentially spuriously normal
ultrasound findings or unscreened children.
These prospective data from a population with about 750 000 births
per year does provide evidence for a substantial reduction in the rate of
operative procedures for DDH by an ultrasound screening program. The rate
of operative procedures for DDH was an accepted benchmark for the
assessment of ultrasound screening programs in the systematic review.
Why was this paper ignored while others with an identical
methodological approach were included in the review (3-5)?
References:
1. von-Kries R, Ihme N, Oberle D, Lorani A, Stark R, Altenhofen L, et
al. Effect of ultrasound screening on the rate of first operative
procedures for developmental hip dysplasia in Germany. Lancet
2003;362(9399):1883-7.
2. Katthagen B.-D. MH, Becker D. Häufigkeit und stationärer
Behandlungsbeginn kindlicher Hüftgelenksluxationen in der BR Deuschland.
Z. Orthop. 1988;126:475 - 483.
3. Chan A, Cundy PJ, Foster BK, Keane RJ, Byron-Scott R. Late
diagnosis of congenital dislocation of the hip and presence of a screening
programme: South Australian population-based study. Lancet
1999;354(9189):1514-7.
4. Godward S, Dezateux C. Surgery for congenital dislocation of the
hip in the UK as a measure of outcome of screening. Lancet 1998;351:1149-
1152.
5. Maxwell SL, Ruiz AL, Lappin KJ, Cosgrove AP. Clinical screening
for developmental dysplasia of the hip in Northern Ireland. Bmj
2002;324(7344):1031-3.
Conflict of Interest:
None declared
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