N. Ihme

Effect of ultrasound screening on the rate of first operative procedures for developmental hip dysplasia in Germany

BACKGROUND Ultrasound screening for developmental hip dysplasia and early conservative treatment might prevent later hip operations. A national hip ultrasound-screening programme, undertaken during the first 6 weeks of life, was introduced across Germany in 1996 and was continued for 5 years. We assessed the rate of first operation on the hip during this programme. METHODS A national active surveillance programme of initial operations for developmental hip dysplasia was started in 1997 and continued for 5 years. Screening participation was assessed by a random digit dialing telephone survey. Cases were children aged between 10 weeks and 5 years at first operation, who had had no underlying disease leading to developmental hip dysplasia. Completeness of case ascertainment was validated with a capture-recapture study in a representative subsample. Calculated incidences were compared with previously established rates. FINDINGS About 90% of all children were screened. 147 cases in the first year, and between 81 and 105 for subsequent years were reported. Treatment included closed reductions 353 (66%), open reductions 61 (11%), and osteotomies 121 (23%). Developmental hip dysplasia was diagnosed by ultrasound before 6 weeks of age in 272 (55%) of cases, 64 (13%) were screened at the recommended time but had normal findings, 70 (14%) had delayed screening, and 89 (18%) were not screened. Capture-recapture estimates suggested that 52% of cases were reported. The corrected incidence for first operation was 0.26 per 1000 livebirths (95% CI 0.22-0.32). INTERPRETATION Ultrasound screening seems to prevent many, but not all, operations for developmental hip dysplasia. Rates of timely screening (ie, before 6 weeks of age) and training of doctors in ultrasound screening need to be improved.

Die konservative Therapie der angeborenen Hüftdysplasie und -luxation

ZusammenfassungDie Hüftdysplasie und -luxation gehören trotz Einführung des sonographischen Neugeborenenscreenings nach wie vor zu den häufigsten angeborenen Erkrankungen der Bewegungsorgane.Bei übermäßiger oder forcierter Therapie dieser Hüftgelenke besteht die Gefahr der Hüftkopfnekrose, bei nicht ausreichender Therapie können Restdysplasien resultieren, sodass im späteren Verlauf weitere Maßnahmen notwendig sind.Daher ist die differenzierte und stadienangepasste Behandlung der Hüftdysplasie, die erst nach Abschluss des Hüftwachstums beendet ist,Ziel aller therapeutischen Maßnahmen.Unabdingbare Voraussetzung ist jedoch eine korrekte und frühzeitige Diagnose.AbstractDespite general ultrasound screening of the newborn,congenital dysplasia and dislocation of the hip are still among the most common congenital skeletal diseases.A differentiated and stage-adjusted therapy must be the aim because inadequate therapy can lead to necrosis of the femoral head or a residual dysplasia that both require further treatment.Now as before a correct and early diagnosis is absolutely necessary for the treatment of dysplasia of the hip.A once treated hip should be observed until completion of growth.

Sonographisches Hüftscreening in Deutschland

General ultrasound screening programmes to determine DDH are still a matter of discussion due to a lack of evidence. To facilitate further discussions this review gives an overview of the international data and literature concerning the different screening policies taking into account the results of the German evaluation study from 1997 to 2002. General ultrasound screening programmes are established in Germany and Austria. The analysis of the German screening showed 535 cases of DDH with first operative procedure (age 10 weeks to 5 years) that were treated as inpatients: 66% underwent a closed reduction, 11% an open reduction and 23% an osteotomy of the acetabulum/femur. The number of children who had no ultrasound of the hip before diagnosis decreased from 22% in the first year to 8% in the last. The first ultrasound examination was without pathological findings in 12% of the cases. Capture-recapture estimates suggested that 52% of cases were reported, so that the incidence for first operation due to DDH was 0.26 per 1,000 live births in 1997. This is much lower than in other countries and 4/5 less than the time before screening with ultrasound in Germany. At most 42% of the cases might be preventable by an improvement of the screening programme, but at least 51% would not be prevented. The German ultrasound screening programme has proved to be effective. Improvement of economic efficiency is still possible. Therefore, the German programme with different screening times can be recommended.

Hüftdysplasie und -luxation

ZusammenfassungBei der angeborenen Hüftdysplasie und -luxation handelt es sich um eine der häufigsten angeborenen Erkrankungen des Bewegungsapparats. Durch moderne Methoden der Diagnostik, insbesondere der Hüftsonographie nach Graf, ist eine Frühdiagnostik möglich, die eine frühe, Erfolg versprechende Therapie gestattet. Die Röntgenbilddiagnose bei Laufbeginn, früher häufig die Regel, gehört heute zu den Ausnahmefällen. Sie wird notwendig, wenn aus verschiedenen Gründen eine Sonographie nicht oder fehlerhaft vorgenommen wurde. Fortschritte in der konservativen Behandlung ermöglichen auch bei vollständig luxierten Hüftgelenken in den meisten Fällen die vorsichtige, komplikationsarme Erlangung einer ausgereiften Hüftgelenksituation bis zum Beginn der Vertikalisierung. Ergänzt werden diese orthetischen Hilfen durch eine angepasste Physiotherapie auf neurophysiologischer Basis. Sind operative Maßnahmen angezeigt, bietet das Spektrum der Operationsmethoden die Möglichkeit, schonend eine akzeptable Situation zu erreichen, welche eine längerfristige schmerz- und hinkfreie Belastung erlaubt.AbstractCongenital luxation and dysplasia of the hip joint are among the most common congenital malformations of the skeletal system. Thanks to modern diagnostic methods, in particular ultrasound examinations, early detection is possible, offering the possibility for early and successful therapy. In the past, the diagnosis was made by radiograph when the patient became symptomatic at the time of verticalization. Nowadays this should be the exception and is found in cases with poor ultrasound evaluation. Progress in conservative management has made successful treatment of even completely dislocated joints possible. An anatomically correct hip joint can be obtained prior to verticalization with orthotics and physiotherapy. If an operation becomes necessary, the wide range of methods can lead to an acceptable situation permitting long-term pain- and limp-free ambulation.

Prävention und Früherkennung von Krankheiten

Praventive Herausforderungen waren eine der Ursachen fur die Entwicklung der Padiatrie als selbststandiges Fach, unabhangig von der Inneren Medizin, vor mehr als 100 Jahren. Aus heutiger Sicht unvorstellbar hohe Raten bei der Sauglingssterblichkeit waren ein wesentlicher Stimulus. Damals waren Probleme der Ernahrung und Infektionskrankheiten zentrale Herausforderungen in der Pravention. Verbesserung der Lebensverhaltnisse, Ernahrungsforschung mit dem Ziel der Verbesserung der Sauglingsernahrung und Erkenntnisse der Hygiene und Impfstoffentwicklung waren wesentlich fur die Fortschritte. Heute steht die Pravention vor neuen Herausforderungen.

Sonographisches Hüftscreening in Deutschland@@@Hip ultrasound screening in Germany: Ergebnisse und Vergleich mit anderen Screeningverfahren@@@Results and comparison with other screening procedures

General ultrasound screening programmes to determine DDH are still a matter of discussion due to a lack of evidence. To facilitate further discussions this review gives an overview of the international data and literature concerning the different screening policies taking into account the results of the German evaluation study from 1997 to 2002. General ultrasound screening programmes are established in Germany and Austria. The analysis of the German screening showed 535 cases of DDH with first operative procedure (age 10 weeks to 5 years) that were treated as inpatients: 66% underwent a closed reduction, 11% an open reduction and 23% an osteotomy of the acetabulum/femur. The number of children who had no ultrasound of the hip before diagnosis decreased from 22% in the first year to 8% in the last. The first ultrasound examination was without pathological findings in 12% of the cases. Capture-recapture estimates suggested that 52% of cases were reported, so that the incidence for first operation due to DDH was 0.26 per 1,000 live births in 1997. This is much lower than in other countries and 4/5 less than the time before screening with ultrasound in Germany. At most 42% of the cases might be preventable by an improvement of the screening programme, but at least 51% would not be prevented. The German ultrasound screening programme has proved to be effective. Improvement of economic efficiency is still possible. Therefore, the German programme with different screening times can be recommended.