Universal or selective screening of the neonatal hip using ultrasound? A prospective, randomised trial of 15,529 newborn infants. Cost-effectiveness of alternative screening strategies for developmental dysplasia of the hip. Ultrasonography in the diagnosis and management of developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre randomised controlled trial. A randomized controlled trial in a hospital population of ultrasound measurement screening for the small for dates baby. Deep vein thrombosis in elderly Hong Kong Chinese with hip fractures detected with compression ultrasound and Doppler imaging: incidence and effect of low molecular weight heparin.
The aim of this study was to evaluate whether universal (all neonates) or selective (neonates belonging to the risk groups) ultrasound screening of the hips should be recommended at birth. We carried out a prospective, randomised trial between 1988 and 1992, including all newborn infants at our hospital. A total of 15 529 infants was randomised to either clinical screening and ultrasound examination of all hips or clinical screening of all hips and ultrasound examination only of those at risk. The effect of the screening was assessed by the rate of late detection of congenital or developmental hip dysplasia in the two groups. During follow-up of between six and 11 years, only one late-detected hip dysplasia was seen in the universal group, compared with five in the subjective group, representing a rate of 0.13 and 0.65 per 1,000, respectively. The difference in late detection between the two groups was not statistically significant (p = 0.22). When clinical screening is of high quality, as in our study, the effect of an additional ultrasound examination, measured as late-presenting hip dysplasia, is marginal. Under such circumstances, we consider that universal ultrasound screening is not necessary, but recommend selective ultrasound screening for neonates with abnormal or suspicious clinical findings and those with risk factors for hip dysplasia. To compare the cost-effectiveness of adding either a general or a selective ultrasound screening program to the routine clinical examination for developmental dysplasia of the hip (DDH) with use of the data from a large, randomized study of 11,925 newborns.
                Our previous study comparing the clinical outcomes of three strategies for screening infants for DDH suggested (but results were not statistically significant) that general ultrasound screening resulted in fewer children requiring hospitalization and surgery for DDH than did a strategy based on ultrasound screening of the 11.8% of infants considered to be at increased risk of DDH or one with no ultrasound screening. General ultrasound screening led to early splinting of 3.4% of the newborns compared with 2.0% for the selectively screened group and 1.8% for the group not receiving ultrasound screening. Using these data, we decided on sequences and intervals of diagnostic and therapeutic actions considered to be sufficient for each regimen. We applied estimates of the costs of screening, treatment of DDH discovered early and late, and follow-up examinations to arrive at total program costs for each strategy.
                Total program costs were similar for each of the three screening strategies (costs varied by < 5%). However, treatment of late cases accounted for only 22% of total costs in the group undergoing general screening vs 65% in the two latter groups. The cost estimates were sensitive to several variables. Application of the data to a hypothetical ultrasound program in which all girls and only boys at increased risk for DDH underwent an ultrasound examination showed substantially reduced total program costs.
                Application of costs from other centers to our data regarding frequency of clinical outcomes may yield different comparative program costs. If the findings of our clinical study can be generalized to other centers, a strategy of screening all girls and boys with risk factors for DDH may be the most cost-effective approach. Clinical screening aims to identify and treat neonatal hip instability associated with increased risk of hip displacement, but risks failures of diagnosis and treatment (abduction splinting), iatrogenic effects, and costs to parents and health services. Our objectives were to assess clinical effectiveness and net cost of ultrasonography compared with clinical assessment alone, to provide guidance for management of infants with clinical hip instability.
                Infants with clinical hip instability were recruited from 33 centres in UK and Ireland and randomised to either ultrasonographic hip examination (n=314) or clinical assessment alone (n=315). The primary outcome was appearance on hip radiographs by 2 years. Secondary outcomes included surgical treatment, abduction splinting, level of mobility, resource use, and costs. Analysis was by intention to treat.
                Protocol compliance was high, and radiographic information was available for 91% of children by 12-14 months and 85% by 2 years. By age 2 years, subluxation, dislocation, or acetabular dysplasia were identified by radiography on one or both hips of 21 children in each of the groups (relative risk 1.00; 95% CI 0.56-1.80). Fewer children in the ultrasonography group had abduction splinting in the first 2 years than did those in the no-ultrasonography group (0.78; 0.65-0.94; p=0.01). Surgical treatment was required by 21 infants in the ultrasonography group (6.7%) and 25 (7.9%) in the no-ultrasonography group (0.84; 0.48-1.47). One child from the ultrasonography group and four from the no-ultrasonography group were not walking by 2 years (0.25; 0.03-2.53; p=0.37). Infants in the ultrasonography group incurred significantly higher ultrasound costs over the first 2 years (pound 42 vs pound 23, mean difference pound 19, 95% CI 11-27); total hospital costs were lower for those infants, but the difference was not significant.
                The use of ultrasonography in infants with screen-detected clinical hip instability allows abduction splinting rates to be reduced, and is not associated with an increase in abnormal hip development, higher rates of surgical treatment by 2 years of age, or significantly higher health-service costs. Poor fetal growth is an important cause of perinatal mortality and morbidity. Based on the hypothesis that early diagnosis of fetal growth problems leads to more appropriate management and therefore, improved outcome, a randomized controlled trial of ultrasound measurement was performed on 1,528 women booked through a hospital antenatal clinic. This compared a number of perinatal outcomes between the group who had a routine 2-stage examination (early dating and 34-week scan) and a group who had only a dating scan and then additional scans as generated by their clinical situations. No significant differences could be found between the groups when these perinatal outcomes were considered. These results mirror previously published randomized controlled trials. Selection of women for third trimester ultrasound examination for suspected fetal growth problems should be based on careful clinical assessment and should not be routine. Seventy-eight patients of average age 78 years suffering from an unilateral non-pathological hip fracture underwent compression ultrasound and pulsed and colour Doppler examination of both legs. Twenty-three patients were randomly placed on low molecular weight heparin (LMWH). Twenty-nine (37%) suffered deep venous thrombosis (DVT). There was no statistically significant difference in the incidence of DVT between the control and LMWH groups, and the incidence of DVT in elderly Chinese patients after hip replacement for a hip fracture is similar to that in other studies in Caucasians. There were, however, some differences, namely the contiguous nature of the thrombi rather than focal segmental clots, and the absence of propagation or tail formation. Although the numbers are small, this could possibly represent a population difference. There was a significantly increased occurrence of DVTs on the operated side in both groups. Serial ultrasound examination supports evidence that DVTs occur in the 1st week postoperatively, but there were also a number of patients who developed DVTs in the 2nd week. There was no statistically significant difference in overall incidence of DVT between patients on prophylactic heparin and the control group. Patients on prophylactic heparin had no thigh DVTs in comparison to the control group. LMWH may thus be effective in preventing thigh DVTs and pulmonary emboli.
There is insufficient evidence to give clear recommendations for practice. There is inconsistent evidence that universal ultrasound results in a significant increase in treatment compared to the use of targeted ultrasound or clinical examination alone. Neither of the ultrasound strategies have been demonstrated to improve clinical outcomes including late diagnosed DDH and surgery. The studies are substantially underpowered to detect significant differences in the uncommon event of late detected DDH or surgery. For infants with unstable hips or mildly dysplastic hips, use of delayed ultrasound and targeted splinting reduces treatment without significantly increasing the rate of late diagnosed DDH or surgery.