Editorials
Ultrasonography in the Assessment of Developmental Dysplasia of the Hip
This article exemplifies the 2006 AAFP
Annual Clinical Focus on caring for children and adolescents
See related article on page 1310.
Up to 90 percent of hip dysplasia cases identified during the first six weeks of life resolve spontaneously.1 The effectiveness of universal screening for developmental dysplasia of the hip (DDH) in preventing long-term disability is unknown. One British study reported in 1998 that the rate of infants requiring operative hip procedures was the same before and after the implementation of universal DDH screening (0.66 to 0.85 per 1,000 children before implementation; 0.78 per 1,000 children after implementation).2
It is unlikely that a uniform recommendation supporting or discouraging universal screening for DDH will be made in the near future. Some experts suggest that technology is the answer because clinical examinations lead to many false-positive results, and imaging studies may be more objective. Radiography is not feasible because the hip is poorly ossified at birth. Therefore, ultrasonography has been suggested for use as a screening or diagnostic tool for DDH.3,4 In this issue of American Family Physician, Drs. Storer and Skaggs5 recommend the use of hip ultrasonography as a diagnostic tool to assess clinical improvement from noninvasive interventions such as the Pavlik harness.6
There are two types of newborn hip ultrasound assessment: dynamic and static. Dynamic ultrasonography evaluates the stability of the hip by measuring the movement of the acetabulum; static ultrasonography assesses anatomic hip abnormalities in fixed positions. Although some experts consider imaging to be more objective than clinical examinations, studies have shown that hip ultrasonography is operator-dependent, and that interpretation is subjective.7 For example, the Graf classification is used in most of the literature to differentiate among the spectrum of hip abnormalities, including dysplasia, stability, subluxation, and dislocation.8 When experienced and well-trained ultrasonographers examine a static assessment of a normal hip, they generally produce the same results (interoperator and intraoperator reliability is 98 percent).6 However, when abnormal static assessments are examined, agreement between a first and second interpretation of the same test by the same person is only moderate (kappa, a measure of agreement taking chance into account, is 0.41, with 1.0 being perfect agreement). When a second person interprets the same ultrasound results, agreement between the two assessments is only fair (kappa = 0.28).8,9 Grading of dynamic hip stability shows only moderate agreement between examiners (kappa = 0.42).10 Community-based hip ultrasonography is unlikely to reach even these levels of reliability or agreement because the operator likely will have less experience and training than operators who participate in clinical trials.
In addition to the problems in performing and interpreting hip ultrasonography, universal screening produces high rates of false-positive results, which lead to unnecessary and potentially harmful follow-up radiography and interventions (e.g., the Pavlik harness, which has a low but definite rate of avascular necrosis of the hip).11
Ultrasound screening could be limited to infants with risk factors for DDH (i.e., female, breech position at delivery, or a family history of DDH). However, only 10 to 27 percent of infants diagnosed with DDH in population-based studies have identified risk factors. Using female sex as a risk factor would require screening about 51 percent of all infants.12-15 Among infants with risk factors, only 1 to 10 percent have DDH, severely limiting the positive predictive value of screening based on the presence of risk factors.7,9,10
Hip ultrasonography has been studied as follow-up and diagnostic testing in specialty settings to which infants who failed Ortolani and Barlow examinations were referred.16 In specialty settings, hip ultrasonography decreased the number of children treated for DDH and decreased the number of hip-related hospitalizations and subspecialist office visits. However, it had no impact on the number of infants who eventually underwent hip surgery for DDH. This suggests that diagnostic testing with hip ultrasonography may be useful in subspecialty settings.
Hip ultrasonography does not appear to be a useful primary care addition to universal clinical examination screening for DDH. Because it does not improve the already high false-positive rate, routine hip ultrasonography seems to do little more than increase health care costs. However, it may be valuable as a diagnostic tool for subspecialists by limiting unnecessary interventions.
The Authors
BARBARA P. YAWN, M.D., M.SC., is director of research at the Olmsted Medical Center and adjunct professor of family medicine at the University of Minnesota Medical School, Rochester.
IRIS R. MABRY, M.D., M.P.H., is a pediatrician and medical officer at the Agency for Healthcare Research and Quality, Rockville, Md.
STEPHEN KO, M.D., M.A., is a preventive medicine resident at the State University of New York at Stony Brook School of Medicine.
Address correspondence to Barbara Yawn, M.D., M.Sc., 826 19th St. NE, Rochester, MN 55906-4247 (e-mail: yawnx002@umn.edu). Reprints are not available from the authors.
The opinions expressed in this editorial are those of the authors and do not represent the official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
REFERENCES
1. Shipman S, Helfand M, Nygren P, Bougatsos C. Screening for developmental dysplasia of the hip. Evidence synthesis number 42. Rockville, Md.: Agency for Healthcare Research and Quality, 2006. Accessed September 14, 2006, at: http://www.ahrq.gov/downloads/pub/prevent/pdfser/hipdyssyn.pdf.
2. Godward S, Dezateux C. Surgery for congenital dislocation of the hip in the UK as a measure of outcome of screening. MRC Working Party on Congenital Dislocation of the Hip. [Published correction appears in Lancet 1998 30;351:1664]. Lancet 1998;351:1149-52.
3. Andersson JE. Neonatal hip instability: results and experiences from ten years of screening with the anterior-dynamic ultrasound method. Acta Paediatr 2002;91:926-9.
4. Giannakopoulou C, Aligizakis A, Korakaki E, Velivasakis E, Hatzidaki E, Manoura A, et al. Neonatal screening for developmental dysplasia of the hip on the maternity wards in Crete, Greece. Correlation to risk factors. Clin Exp Obstet Gynecol 2002;29:148-52.
5. Storer SK, Skaggs, DL. Developmental dysplasia of the hip. Am Fam Physician 2006;74:1310-6.
6. Harding MG, Harcke HT, Bowen JR, Guille JT, Glutting J. Management of dislocated hips with Pavlik harness treatment and ultrasound monitoring. J Pediatr Orthop 1997;17:189-98.
7. Bar-On E, Meyer S, Harari G, Porat S. Ultrasonography of the hip in developmental hip dysplasia. J Bone Joint Surg Br 1998;80:321-4.
8. Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia. J Pediatr Orthop 1984;4:735-40.
9. Dias JJ, Thomas IH, Lamont AC, Mody BS, Thompson JR. The reliability of ultrasonographic assessment of neonatal hips. J Bone Joint Surg Br 1993;75:479-82.
10. Rosendahl K, Aslaksen A, Lie RT, Markestad T. Reliability of ultrasound in the early diagnosis of developmental dysplasia of the hip. Pediatr Radiol 1995;25:219-24.
11. Bialik V, Bialik GM, Wiener F. Prevention of overtreatment of neonatal hip dysplasia by the use of ultrasonography. J Pediatr Orthop B 1998;7:39-42.
12. Boere-Boonekamp MM, Kerkhoff TH, Schuil PB, Zielhuis GA. Early detection of developmental dysplasia of the hip in the Netherlands: the validity of a standardized assessment protocol in infants. Am J Public Health 1998;88:285-8.
13. Holen KJ, Tegnander A, Terjesen T, Johansen OJ, Eik-Nes SH. Ultrasonographic evaluation of breech presentation as a risk factor for hip dysplasia. Acta Paediatr 1996;85:225-9.
14. Jones DA. Importance of the clicking hip in screening for congenital dislocation of the hip. Lancet 1989;1:599-601.
15. Sahin F, Akturk A, Beyazova U, Cakir B, Boyunaga O, Tezcan S, et al. Screening for developmental dysplasia of the hip: results of a 7-year follow-up study. Pediatr Int 2004;46:162-6.
16. Elbourne D, Dezateux C, Arthur R, Clarke NM, Gray A, King A, et al. Ultrasonography in the diagnosis and management of developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre randomised controlled trial. Lancet 2002;360:2009-17.
See related article on page 1331.
Cardiovascular disease (CVD) is the leading cause of death among women and has claimed the lives of more women than men annually since 1984. A woman's risk of dying from CVD is one in 2.4; her risk of death from breast cancer is around one in 29.1 Despite the seeming ubiquity of the National Heart, Lung, and Blood Institute's red dress symbol, surveys continue to demonstrate a low awareness-particularly among minority groups-that CVD is the leading health risk for women.2
One cited barrier to initiating CVD risk-lowering behaviors is confusion in the media. Although media attention to heart disease in women raises awareness, the messaging can be overwhelming. There is clearly an opportunity in the clinical setting to educate women about CVD risk; however, the reason most often given by women for not speaking to their health care professionals about heart health is that the health care professional did not bring it up.2 In this issue of American Family Physician, Dr. Hayes discusses the American Heart Association's (AHA's) guidelines for assessment and treatment of CVD risk in women, including counseling on lifestyle interventions and management of risk factors.3 We propose that physicians speak to their female patients about the risks of CVD, focusing on two themes: (1) the need for emergency evaluation of any symptoms that suggest acute coronary syndrome (ACS); and (2) the concept of lifetime CVD risk reduction.
Key to the survival of patients with ACS is prompt recognition of symptoms and activation of the emergency response system. The difficulty is that many patients with ACS-men and women alike-do not experience "Hollywood" heart attack symptoms but something far less dramatic. Whereas chest discomfort is the most common symptom of ACS in both sexes, women are more likely than men to report atypical accompanying symptoms, such as dyspnea, nausea, and vomiting,4-6 that can blur the picture for the patient and possibly the physician. In addition to maintaining clinical vigilance, physicians need to be attentive to the instruction of staff (including receptionists with whom the patient is likely to have initial contact) in the emergent telephone and waiting-room triage of patients with symptoms-variable as they may be-that suggest ACS.
Physicians are ideally positioned to screen and educate female patients of all ages. The annual well-woman visit can serve as a venue to stress the importance of "knowing your numbers."7 Women are unlikely to focus on preventive strategies without being aware of their personal risk status, and surveys indicate that most women fail to personalize the risk of heart disease.2 Physicians should encourage every woman to know:
(1) Her lipid profile-not just low-density lipoprotein (LDL) cholesterol level, but also high-density lipoprotein (HDL) cholesterol and triglyceride levels. Low HDL cholesterol and high triglyceride levels are more potent risk factors for women than for men.
(2) Her blood pressure. At age 55, a normotensive adult has a 90 percent lifetime risk of developing hypertension8-a point worth stressing to middle-age or older women.
In addition, women who are at risk for diabetes should be encouraged to know their fasting glucose level. Diabetes confers a greater CVD risk for women than for men.
Although the Framingham 10-year coronary heart disease (CHD) risk score9 is central to evidence-based treatment decisions, it provides weak ammunition for impressing on a patient the importance of making lifestyle changes to improve her heart health. Age is the most powerful risk factor in the Framingham equation, and a woman younger than 55 years with a significant lifetime risk typically has a low risk in the short term. Consider the example of a 40-year-old nonsmoking woman with a total cholesterol level of 240 mg per dL (6.20 mmol per L), an LDL cholesterol level of 180 mg per dL (4.65 mmol per L), an HDL cholesterol of 32 mg per dL (0.85 mmol per L), and a blood pressure of 158/100 mm Hg. Most physicians would view her as a candidate for therapeutic lifestyle change and consider pharmacologic therapies to optimize her lipid profile and blood pressure. Yet, as calculated using the Framingham score, her 10-year risk of myocardial infarction or coronary death is only 1 percent.
Physicians need to impart a message to female patients that will help them view active optimization of their heart health as investing in long-term quality of life, in line with the AHA's "Go Red for Women" mission to help women live "stronger, longer" lives.10 There is emerging evidence that midlife CVD risk factors, particularly in combination, not only increase CVD risk but also may predict risk of overall unsuccessful aging (i.e., disease-related disability or poor mental and physical functioning), including dementia.11
We who are entrusted with women's primary care have the relationships, trust, and knowledge to make an impact on their lifelong health and wellness. Thoughtful, comprehensive guidance on their number one health risk should be the heart of what we do.
The Authors
DEBORAH S. PLATE, D.O., F.A.A.F.P., is clinical associate director in the Center for Family Medicine at Akron (Ohio) General Medical Center. She is acting director for the Family Medicine Clerkship and is associate professor of family medicine at the Northeastern Ohio Universities College of Medicine, Rootstown.
SUZANNE HUGHES, M.S.N., R.N., is director of clinical education for Whole Health Management, Inc., Cleveland, Ohio., and associate editor for Cardiosource, the online journal of the American College of Cardiology. At the time this article was written, she was patient education coordinator at the Center for Family Medicine at Akron General Medical Center.
Address correspondence to Deborah S. Plate, D.O., F.A.A.F.P., Akron General Center for Family Medicine, Akron General Medical Center, 400 Wabash Ave., Akron, OH 44307 (e-mail: dplate@agmc.org). Reprints are not available from the authors.
Author disclosure: Ms. Hughes receives consulting fees from Guidant Corporation, speaking honoraria from Pfizer Pharmaceuticals, and project honoraria from Kos Pharmaceuticals and Biosite, Inc.
REFERENCES
1. Wenger NK. You've come a long way, baby: cardiovascular health and disease in women: problems and prospects. Circulation 2004;109:558-60.
2. Mosca L, Mochari H, Christian A, Berra K, Taubert K, Mills T, et al. National study of women's awareness, preventive action, and barriers to cardiovascular health. Circulation 2006;113:525-34.
3. Hayes SN. Preventing cardiovascular disease in women. Am Fam Physician 2006;74:1331-40.
4. Goldberg R, Goff D, Cooper L, Luepker R, Zapka J, Bittner V, et al. Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT trial. Rapid Early Action for Coronary Treatment. Coron Artery Dis 2000;11:399-407.
5. Meischke H, Larsen MP, Eisenberg MS. Gender differences in reported symptoms for acute myocardial infarction: impact on prehospital delay time interval. Am J Emerg Med 1998;16:363-6.
6. Milner KA, Funk M, Richards S, Wilmes RM, Vaccarino V, Krumholz HM. Gender differences in symptom presentation associated with coronary heart disease. Am J Cardiol 1999;84:396-9.
7. American Heart Association. Know your numbers. Accessed September 26, 2006, at: http://www.goredforwomen.org/know_your_numbers/index.html.
8. Vasan RS, Beiser A, Seshadri S, Larson MG, Kannel WB, D'Agostino RB, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: the Framingham Heart Study. JAMA 2002;287: 1003-10.
9. National Cholesterol Education Program. Risk assessment tool for estimating 10-year risk of developing hard CHD. Accessed September 27, 2006 at: http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof.
10. American Heart Association. Go red for women. Accessed September 26, 2006, at: http://www.goredforwomen.org.
11. Whitmer RA, Sidney S, Selby J, Johnston SC, Yaffe K. Midlife cardiovascular risk factors and risk of dementia in late life. Neurology 2005;64:277-81.
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