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New International Data on Hip Screening: Recent Findings in DDH

This article explores the latest research findings on hip screening for Developmental Dysplasia of the Hip (DDH), including the use of physical examination and ultrasound. It also discusses the importance of early diagnosis and treatment in achieving successful outcomes for DDH patients.

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New International Data on Hip Screening: Recent Findings in DDH

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  1. New international data on hip screening. A journey through recent findings in ddh. Carlo Bonifacini¹ Maurizio De Pellegrin² IRCCS Ospedale Galeazzi, Milano IRCCS Ospedale San Raffaele, Milano ECPCP Symposium Vienna 2017

  2. The Cost of Hip Arthroplasties. IN ITALY: about 100.000/ Year A 5% YEARLY INCREASE IN THE NUMBER OF IMPLANTS Yearly expense: ONE BILLION AND 300 MILLIONS EURO (1% of the National Health Fund) + OVER 500 MILLIONS EURO FOR REHABILITATION 30% of replacements in people younger then 60 years. (Furnes)

  3. How is screening performed? “Physical examination using the Ortolani and Barlow tests is the mainstay of screening for DDH” Jiun Lee. Dec 2008 Annals Academy of Medicine “High quality evidence does not support ultrasound either universally or selectively to screen for DDH” Ultrasound should not be used outside a well-designed research setting.

  4. Are classical clinical signs predictors of DDH? Ortolani 1937 Reported sensibility: 5-98% High specificity. POOR PERFORMERS (as well as: reduced abduction, limp, hip laxitu, external rotation) Clinical examination by GPs does not detect radiographically-defined DDH. Leg length discrepancy Asymmetrical skin folds Hip click Sens. 46,2% Spec. 42,6% PPV 12,4% NPV 81,8% Sens. 23,1% Spec. 75,7% PPV 14,3% NPV 84,8% Sens. 30,8% Spec. 82,4% PPV 23,5% NPV 87,1%

  5. Is a screening based on clinical examination effective? • “Overall, 199 cases (15%) were diagnosed at >1 year of age, and these included 36 cases diagnosed very late, at >3 years of age.” • The majority of the 199 cases of late diagnosis had received earlier routine [CLINICAL] screening at <1 year of age. Conclusion: improved early routine screening for DDH in Japan. (2017)

  6. Early or late diagnosis? When congenital dislocation of the hip (CDH) is diagnosed only after walking age, management is greatly complicated. The failure of screening is undeniable in the present series. The mean age at diagnosis triggered by family worries about limping is the proof of this. […] elements to be assessed that have been reported to impair screening quality, such as maternity stay of less than 4 days or falling in a period of reduced medical presence, such as holiday periods or public holidays .

  7. Residual anormalities and early diagnosis In conclusion, both cam deformity and acetabular dysplasia are strongly related to the development of hip OA. • EARLY DIAGNOSIS IS CRITICAL • FOR A SUCCESSFUL OUTCOME • DELAYS IN MANAGEMENT RESULT IN RESIDUAL ABNORMALITIES AND DEGENERATIVE ARTHRITIS LYNN T. STAHELI

  8. BACKGROUND ACETABULAR DEVELOPMENT α-ANGLE ACETABULAR INDEX AI α TYPE I TYPE II TYPE III TYPE IV QUANTITATIVE EVALUATION OF ACETABULAR MORPHOLOGY AND MATURATION • What is the role of an early treatment in severe ddh? • What is considered early?

  9. PURPOSE EVALUATION OF AGE RELATED TREATMENT IN ACHIEVING ACETABULAR MATURATION IN PATIENTS WITH SEVERE DDH MATERIALS 51 HIPS CONTROL GROUP (6 type-I, 27 type IIa, 3 type IIb, 15 type IIc) 93 TYPE III HIPS 144 HIPS α 21 LEFT SIDE 72 PATIENTS (66 F, 6 M) 30 RIGHT SIDE 21 BOTH SIDES

  10. METHODS BIRTH TREATMENT -FIRST US- -TIME OF DIAGNOSIS- -TREATMENT START- -SECOND US- -FIRST FOLLOW UP- -THIRD US- -SECOND FOLLOW UP- FOR A TOTAL OF 492 US EXAMINATIONS MEAN = 48 days AFTER DIAGNOSIS MEAN = 112 days AFTER DIAGNOSIS ~ 7 WEEKS ~ 16 WEEKS

  11. ALPHA ANGLE GAIN AND FOLLOW UP LENGTH

  12. ALPHA ANGLE GAIN AND FOLLOW UP LENGTH LONGER TREATMENT ≠ BETTER RESULTS IT DOES NOT MEAN THAT THE TREATMENT LENGTH CAN BE REDUCED SHORTEST FOLLOW UP WAS 84 DAYS (12 WEEKS ~ 3 MONTHS) AFTER 3 MONTHS THERE IS FEW FURTHER IMPROVEMENT

  13. MONOLATERAL vs BILATERAL DDH NO SIGNIFICANT DIFFERENCE AT DIAGNOSIS NO SIGNIFICANT DIFFERENCE AT FOLLOW UP

  14. TYPE III HIPS AND GENDER NO SIGNIFICANT DIFFERENCE AT DIAGNOSIS NO SIGNIFICANT DIFFERENCE AT FOLLOW UP

  15. ALPHA ANGLE VALUES -FIRST US- -THIRD US-

  16. 3 GROUPS 72 PATIENTS (144 HIPS) GROUP 1 GROUP 2 GROUP 3 AGE < 11 DAYS AGE 11 ≥ DAYS < 42 DAYS AGE ≥ 42 DAYS ~ < 2 WEEKS ~4 WEEKS > 6 WEEKS MEAN FOLLOW UP 109 DAYS MEAN FOLLOW UP 104 DAYS MEAN FOLLOW UP 113 DAYS

  17. 3 GROUPS –FIRST US- (DIAGNOSIS)

  18. 3 GROUPS –THIRD US- (FOLLOW UP)

  19. 3 GROUPS –COMPARED- DUNNETT’S MULTIPLE COMPARISON TEST

  20. 3 GROUPS –COMPARED- MATURE HIPS (α > 60°) AT THIRD US α > 60° GROUP 1 GROUP 2 GROUP 3

  21. ALPHA ANGLE GAIN AND TIME OF DIAGNOSIS A(151/25) & B(202/10) EXCLUDED FOR GRAPHICAL PURPOSES ONLY

  22. ALPHA ANGLE GAIN AND TIME OF DIAGNOSIS y = f(x) ~ 28 – 0,1x ~ 1° LOST EVERY 10 DAYS OF DELAYED TREATMENT

  23. ACETABULAR MATURATION IN TYPE III HIPS

  24. ACETABULAR MATURATION FUNCTION α = f(t) = 33,34° + 31,66° * (1-e-t/9,348) ACETABULAR MATURATION CURVE (NORMAL HIPS) BY MATTHIESSEN: α = f(t) = 53,2° + 11,3° * (1-e-t/8,66)

  25. CONCLUSION 1 IF SEVERE DYSPLASTIC HIPS ARE TREATED. BEFORE 2 WEEKS OF AGE THE ACETABULAR MATURATION EQUALS THAT OF NORMAL (SLIGHTLY DYSPLASTIC) HIPS AFTER 4-6 WEEKS OF AGE THE ACETABULAR MATURATION IS INFERIOR TO THAT OF NORMAL (SLIGHTLY DYSPLASTIC) HIPS AFTER 6 WEEKS OF AGE MINIMAL MATURATION IS NOT CONSTANTLY REACHED AND RESULTS ARE LESS PREDICTABLE

  26. CONCLUSION • Negative clinical examination does not exclude a dysplastic hip. • Residual dysplasia leads to premature osteoarthritis of the hip. • Late diagnosis leads to increase in surgical procedures and worse outcome (debated) EARLY DIAGNOSIS IS THE KEY! (in severe DDH) To SCREEN or NOT to SCREEN? Overtreating vs Overlooking.

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