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Evidence review of universal ultrasound screening for developmental dysplasia of the hip (DDH) in infants in Ireland

Status: Published on

At the request of the National Screening Advisory Committee (NSAC), the Health Technology Assessment (HTA) Directorate within the Health Information and Quality Authority (HIQA) agreed to undertake an evidence review of universal screening for developmental dysplasia of the hip (DDH). The findings of this evidence review were presented to the NSAC to inform its recommendation to the Minister for Health.

Developmental dysplasia of the hip (DDH) is a congenital disorder impacting the musculoskeletal system. The condition manifests as abnormal development of the hip in infancy, with a wide range of severity. Early diagnosis of DDH may improve clinical outcomes and contribute to a decrease in hip osteoarthritis in young adults.

Clinical examination for DDH is commonly performed as part of the routine physical examination of newborns. However, some potential cases of DDH may be missed by clinical examination alone. Ultrasound may be used to screen for DDH in infancy and may allow for the detection of DDH cases that may have been missed with clinical examination alone, potentially reducing the rates of late-presenting DDH and associated complications. However, ultrasound screening can result in unnecessary treatment, as spontaneous correction of DDH is possible.

Ultrasound screening programmes for DDH can either be selective or universal. With selective screening, only infants with one or more risk factors (for example, family history or breech presentation) or clinical signs undergo ultrasound screening. In a universal screening programme, all infants undergo ultrasound. The optimal approach, whether it be selective or universal, remains unclear. In Ireland in 2017, the National Clinical Programme for Paediatrics and Neonatology and the DDH Subgroup of the National Child Health Review Steering Group recommended the implementation of a selective ultrasound screening programme for infants at risk of DDH.

This research was carried out in accordance with HIQA’s guidelines for the conduct of HTA. In summary:

  • The terms of reference for this evidence review were agreed between HIQA and the Chair of the NSAC, on behalf of the NSAC.
  • A multidisciplinary expert advisory group (EAG) was convened by HIQA comprising representation from the Department of Health, the Health Service Executive, the Irish Society of Chartered Physiotherapists, the Irish Institute of Radiography and Radiation Therapy, parent representatives (Cuidiú), and clinicians with specialist expertise in public health, neonatology, paediatrics, radiology, and orthopaedics.
  • A protocol for the work to be undertaken was reviewed by the HIQA EAG, and published on the HIQA website (link).
  • Potential diagnostic and treatment modalities, as well as the current Irish screening recommendations, were described.
  • The epidemiology of DDH in Ireland and internationally was described.
  • A brief review of the clinical effectiveness of universal ultrasound screening compared to selective ultrasound screening was carried out.
  • A draft report summarising the findings of this evidence review was produced and reviewed by the EAG. This was subsequently amended, where appropriate.
  • The final draft of the evidence review was submitted to the CEO of HIQA for approval. Following its approval, the final report was submitted to NSAC for consideration and published on the HIQA website.

  • Developmental dysplasia of the hip (DDH) is a congenital disease in which there is abnormal development of the hip in infancy. The severity can range from mild dysplasia to complete hip dislocation.

    • While many cases of mild hip instability identified in newborns resolve without treatment within the first six to eight weeks of life, persistent dysplasia and dislocation can lead to wear of the cartilage of the hip and osteoarthritis in young adults.
  • Some cases of DDH may be missed by clinical examination alone. Ultrasound screening can be used to support identification of a greater number of cases. However, it is unclear whether or not all cases identified would be clinically significant (that is, requiring intervention). The risk of unnecessary treatment in cases that would resolve without treatment may be reduced by training in Graf technique and classification.
    • Studies of universal ultrasound screening relative to selective ultrasound screening identified within this review were underpowered to detect potential harms. Therefore, there is insufficient evidence to assess the benefit-harm balance.
    • The optimal ultrasound screening programme, whether it be selective or universal, remains unclear.
  • Recommendations for a selective ultrasound screening programme for DDH in Ireland were published in 2017. As of November 2023, these recommendations are included as part of the diagnostic pathway for DDH, referred to as a targeted clinical diagnostics programme.
    • There is evidence to suggest that there may be variation in the implementation of the current recommendations for ultrasound screening in Ireland. Further understanding of current practice and barriers to uptake of the existing recommendations across Ireland would facilitate successful implementation of a formal screening programme.
  • Consideration could be given to implementing the current selective ultrasound screening recommendations as a formal screening programme with appropriate governance, end-to-end care, quality assurance and monitoring of outcomes.

Supporting Document