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

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)

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.

Reported sensibility: 5-98% 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. Asymmetrical skin folds Hip click Leg length discrepancy 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%

Conclusion: improved early routine screening for DDH in Japan. 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)

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 .

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

BACKGROUND What is the role of an early treatment in severe ddh? ACETABULAR DEVELOPMENT α-ANGLE ACETABULAR INDEX AI α TYPE I TYPE II TYPE III TYPE IV QUANTITATIVE EVALUATION OF ACETABULAR MORPHOLOGY AND MATURATION Author Treatment start Roovers et al. 5weeks Hakan et al. 15 weeks Smith 8 months Danielsson 10 months Lin 15 months Albinana et al. 16 months What is the role of an early treatment in severe ddh? What is considered early?

PURPOSE MATERIALS 51 HIPS 93 TYPE III HIPS 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 9

METHODS BIRTH TREATMENT FOR A TOTAL OF 492 US EXAMINATIONS -FIRST US- -TIME OF DIAGNOSIS- -TREATMENT START- -SECOND US- -FIRST FOLLOW UP- -THIRD US- -SECOND FOLLOW UP- FOR A TOTAL OF 492 US EXAMINATIONS TREATMENT START MIN = 1 day MAX = 202 days MEAN = 21 days STD. DEV. = 25 days MEAN = 48 days AFTER DIAGNOSIS MEAN = 112 days AFTER DIAGNOSIS ~ 7 WEEKS ~ 16 WEEKS 10

ALPHA ANGLE GAIN AND FOLLOW UP LENGTH

ALPHA ANGLE GAIN AND FOLLOW UP LENGTH BEST FIT SLOPE 0,0030 ± 0,018 Y- INTERCEPT 24,78 ± 2,146 95% CONFIDENCE -0,034 to 0,039 GOODNESS OF FIT R SQUARE 0,0004 IS SLOPE SIGNIFICANTLY NON ZERO? P VALUE 0,8664 F 0,028 PEARSON 0,0200 95% CONFIDENCE -0,2111 to 0,2490 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

MONOLATERAL vs BILATERAL DDH FIRST US p value = 0,104 t = 1,643 MD 1,5 ± 0,95 95% Conf. -0,33 to 3,4 THIRD US p value = 0,726 t = 0,351 MD 0,5 ± 1,4 95% Conf. -2,24 to 3,2 NO SIGNIFICANT DIFFERENCE AT DIAGNOSIS NO SIGNIFICANT DIFFERENCE AT FOLLOW UP

TYPE III HIPS AND GENDER FIRST US p value = 0,43 t = 0,79 MD 1,5 ± 1,9 95% Conf. -2,3 to 5,3 THIRD US p value = 0,81 t = 0,24 MD -0,71 ± 2,97 95% Conf. -6,6 to 5,2 NO SIGNIFICANT DIFFERENCE AT DIAGNOSIS NO SIGNIFICANT DIFFERENCE AT FOLLOW UP

ALPHA ANGLE VALUES -FIRST US- -THIRD US- 15 ARE MEANS SIGNIFICANTLY DIFFERENT ? P VALUE < 0,0001 t 18 MD -16 ± 0,89 95% CI -17 to -14 ARE MEANS SIGNIFICANTLY DIFFERENT ? P VALUE 0,0023 t 3,115 MD -3,3 ± 1,06 95% CI -6,0 to -0,52 15

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

3 GROUPS –FIRST US- (DIAGNOSIS) Type III Control Mean = 36,4° Mean = 54,0° StdDev = 4,4° StdDev = 3,9° Difference = 17,66 ± 1,3 P VALUE < 0,0001 Type III Control Mean = 37,2° Mean = 50,3° StdDev = 4,1° StdDev = 6,9° Difference = 13,01 ± 1,6 P VALUE < 0,0001 Type III Control Mean = 39,1° Mean = 53,2° StdDev = 5,6° StdDev = 7,8° Difference = 14,07 ± 1,9 P VALUE < 0,0001 17

3 GROUPS –THIRD US- (FOLLOW UP) Type III Control Mean = 65,6° Mean = 66,1° StdDev = 5,5° StdDev = 4,1° Difference = 0,52 ± 1,7 P VALUE = 0,76 Type III Control Mean = 61,5° Mean = 62,8° StdDev = 3,8° StdDev = 3,0° Difference = 1,3 ± 1,4 P VALUE = 0,35 Type III Control Mean = 58,7° Mean = 66,2° StdDev = 7,1° StdDev = 5,8° Difference = 7,5 ± 2,2 P VALUE = 0,0046

One Way Analysis of Variance 3 GROUPS –COMPARED- One Way Analysis of Variance P Value < 0,0001 F 8,34 R Square 0,185 DUNNETT’S MULTIPLE COMPARISON TEST Mean Diff q Significant? P<0,05 95% CI of Difference GROUP 1 vs OTHER 0,07° 0,05 NO -3,1 to 3,3 GROUP 2 vs OTHER 4,0° 3,32 YES 1,1 to 6,9 GROUP 3 vs OTHER 6,0° 4,1 3,5 to 9,5 19

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

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

ALPHA ANGLE GAIN AND TIME OF DIAGNOSIS BEST FIT SLOPE -0,097 ± 0,02 Y- INTERCEPT 27,99 ± 0,98 95% CONFIDENCE Y- INTERCEPT 26,04 to 29,95 GOODNESS OF FIT R SQUARE 0,222 IS SLOPE SIGNIFICANTLY NON ZERO? P VALUE < 0,0001 F 20,28 PEARSON -0,4713 95% CONFIDENCE -0,63 to -0,28 y = f(x) ~ 28 – 0,1x ~ 1° LOST EVERY 10 DAYS OF DELAYED TREATMENT

ACETABULAR MATURATION IN TYPE III HIPS

ACETABULAR MATURATION FUNCTION α = f(t) = 33,34° + 31,66° * (1-e-t/9,348) BEST FIT VALUES Y0 33,34° Plateau 65,01° K 0,1070 Tau 9,348 Half-Time 6,480 Weeks Span 31,66° 95% CI Y0 30,47° to 36,21° Plateau 61,86° to 68,15° K 0,077 to 0,136 Tau 7,307 to 12,97 Half-Time 5,0 to 8,9 Weeks Span 28,25° to 35,08° GOODNESS OF FIT R SQUARE 0,52 ACETABULAR MATURATION CURVE (NORMAL HIPS) BY MATTHIESSEN: α = f(t) = 53,2° + 11,3° * (1-e-t/8,66)

BEFORE 2 WEEKS OF AGE AFTER 4-6 WEEKS OF AGE AFTER 6 WEEKS OF AGE 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

To SCREEN or NOT to SCREEN? 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.