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A.Duni, V.Ruci

Reliability of clinical tests in developmental dysplasia of the hip

University Hospital Center Mother Teresa, Department of Orthopedics and Trauma , Tirana, Albania



Abstract

Background: Diagnosis of DDH is still a challenge for the health system in our country. Screening should begin with clinical tests and their technique should be well known and performed not only by orthopedic surgeons but also other specialists like pediatricians, family physicians, obstetricians and nurses. Material and method: In 111 children (143 hips) already diagnosed and treated for x-ray confirmed DDH, we retrospectively analyzed if the Ortolani/Barlow and Limitation of Abduction tests had been reported to be positive in their clinical records in order to evaluate the reliability of those tests. We also compared the rate of positive results, when the orthopedic surgeon or other specialists performed each test. Results: Records of Ortolani/Barlow test showed that 34.9% of hips (50 out of 143) were reported as positive from the other specialists and 64.3% of them (84 from 143) when the Orthopedic surgeon was the examiner(p=0.014). No significant differences were observed when the Limitation of Abduction was analyzed. Both groups of examiners identified about 67% of the 143 affected hips. (92 hips from the other doctors versus 98 form the Orthopedic Surgeon, p=NS). Conclusion: Clinical tests resulted very useful for the early diagnosis of DDH. The limitation of Abduction test is more easily performed and simple than the Ortolani/Barlow maneuvers and should be used as the primarily screening tool from the specialists outside the orthopedic field.

Key words :

clinical tests, developmental dysplasia, hip



Introduction: Developmental Hip Dysplasia is still a challenging diagnosis for the specialists and healthcare systems especially in developing countries. The lack of nationwide strategies and precise protocols reflects on the high rate of late diagnosed cases. Clinical tests are essential part of any screening program. They should be performed routinely by any staff member dealing with a newborn in order to identify babies that will be followed and examined further with imaging examinations. Healthcare specialists like pediatricians, obstetricians, family doctors and nurses, should be familiar with the techniques of those simple but essential procedures. DDH is clearly an orthopedic disorder but any case has to be identified and referred to the Orthopedic Surgeon by other healthcare physicians, nurses or parents [1]. Training and update of the knowledge of those specialists should be an essential part of any screening strategy.

Material and method: The study extends over a period of nine years, from 1999 to 2007 and it is part of a new strategy applied experimentally in a single district of our county in order to lower the operability rate and the number of late presenting cases with DDH [2]. During this period a total number of 111 children with DDH were diagnosed from a number of 8490 live births. There were 22 males and 89 females and the left hip was affected in 53% of children (table1). All of the newborn babies were examined clinically, and the at risk babies and those with positive findings were referred to the orthopedic surgeon (main author) for reexamination, and eventual follow up. All of the treated cases had standard x-ray of the pelvis at the fourth month of age to confirm DDH.

Table 1.- Epidemiological data

1999-2007BirthsDDHMalesFemalesLeftBilateralRight
Number84901112289593220
Percentage 1.32080532918

We decided to evaluate the reliability of the clinical tests like the Ortolani/Barlow and limitation of abduction in the population of 111 children diagnosed and treated for x-ray confirmed DDH. We retrospectively analyzed if the above mentioned cases had been previously reported to be positive on those tests, checking their clinical records. The analysis has been carried out separately considering Ortolani and/or Barlow [3] like a single test, and limitation of abduction as another[4]. We also compared the rate of successful examination with each test depending on whether it was performed by the orthopedic surgeon or another specialist. The Chi-Square and Fisher-Student tests have been used for the statistical analysis.

Results: After the retrospective data collection and statistical analysis we found the following results: When the children were reported after clinical examinations performed by the different healthcare specialists like pediatricians, family doctors, obstetricians and general practitioners, the Ortolani/Barlow maneuver resulted 34.9% effective. 50 hips were reported as positive from the true number of 143 hips with certain DDH. The limitation of abduction test performed by the same specialists on the same population of children gave 64.3% good results. It successfully identified 92 out of 143 hips diagnosed later with DDH.

Table 2.- Results of clinical screening

Test →Ortolani/BarlowLimitation of abduction
Confirmed DDH (hips) →143143
Reported positiveOther Specialists5092
Orthopedic Surgeon8498
Significancep=0.014p=NS

As previously mentioned, we implemented a new program for the early detection of the DDH in a particular area of the country. It was our policy that, all of the children resulting positive from the clinical examination would have been reexamined by the Orthopedic Surgeon. So every child reported from other colleagues in this study was checked from the main author. The Ortolani/Barlow maneuvers reported 84 positive hips from the 143 affected or 58.7%, (p=0.01). When records about limitation of abduction were checked, 98 hips from 143 (68.5%) resulted to be identified as positive. (p=NS) See table no. 2 for detailed results.

Discussion: Interesting data resulted from this retrospective analysis. First of all clinical tests were a big help to the early detection of a lot of babies diagnosed and treated for DDH. The other colleagues correctly reported all those cases to us for final evaluation and treatment as modern protocols suggest. The clinical maneuvers of Ortolani and/or Barlow resulted to be at about 24% more sensitive when performed from the orthopedic surgeon and the difference in the rate of positive findings between the two groups of specialists was significant. The orthopedic surgeon reported 84 hips positive and the other specialists 50 hips from the 143 hips diagnosed with DDH (p<0.02).

Results were different when the Limitation of Abduction test was investigated. The differences between the two groups were really small (figure 1). The test identified nearly 67% of the hips with DDH in both cases. 98 hips were reported when the examiner was an Orthopedic Surgeon and 92 when the other doctors performed it. (p=NS).

Figure 1.- Results for each test performed by different specialists

Naturally the Ortolani and Barlow maneuvers are more complicated. They require special skills, being familiar them and in the best case, being also trained. Limitation of abduction test is, in our judgment, more simple, easy to perform and doesnt require special skills and/or experience [5]. It can be performed more easily from the staff members and sometimes even by qualified nurses helping to identify as much affected hips as possible. Other specialists and nurses can be of great help in the process of detecting clinically suspicious hips not only because they will have the very first contact with any newborn, but also they will follow those children during the normal check-up schedule through all the first year of life. Strict collaboration with those structures is a key element of all the protocols of early diagnosis of DDH.

Conclusion: Despite the huge advantages the imaging examinations offer to us, the simple clinical tests should be routinely used for the screening of DDH. They should be performed carefully, within the correct age groups and with the right techniques in order to be effective [6]. In our strategy all of the newborn children were clinically examined and only those resulting positive and the at risk group were further followed by imaging examination like ultrasound and X-ray at the fourth month of age when ultrasound wasnt available. The limitation of abduction test gave good results even in the hands of doctors outside the orthopedic specialty. Their help in the field of early diagnosis therefore, resulted essential. Every child with positive or equivocal findings should be referred to the orthopedic surgeon. Only to him belongs the responsibility for further evaluation and treatment. This scheme of screening is the most suitable for countries with limited resources in equipment and qualified staff.

References:

  1. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics. 2000;105:896905
  2. Duni A, Ruci V, Zenelaj A.: Developmental dysplasia of the hip in a developing country. Rebuilding the strategy for early diagnosis and management. Bulletin of the International Scientific Surgical Association. 2009;4(1):62-64
  3. Barlow, T. G.: Early diagnosis and treatment of congenital dislocation of the hip. J. Bone and Joint Surg.Am, 1962;44-B(2): 292-301
  4. Castelein RM, Korte J.: Limited hip abduction in the infant. J Pediatr Orthop. 2001;21:668670
  5. Bialik V, Fishman J, Katzir J, Zeltzer M.: Clinical assessment of hip instability in the newborn by an orthopedic surgeon and a pediatrician. J Pediatr Orthop. 1986;6:703705
  6. Jones DA. Neonatal hip stability and the Barlow test: a study in stillborn babies. J Bone Joint Surg Br. 1991;73:216218

Contact author: Artid Duni, MD

E-mail: aduni17@yahoo.com

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