The Journal of Bone and Joint Surgery (American). 2009;91:1705-1719.
doi:10.2106/JBJS.H.00122
© 2009 The Journal of Bone and Joint Surgery, Inc.
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To Screen or Not to Screen? A Decision Analysis of the Utility of Screening for Developmental Dysplasia of the Hip

Susan T. Mahan, MD, MPH1, Jeffrey N. Katz, MD, MSc2 and Young-Jo Kim, MD, PhD1

1 Department of Orthopaedic Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115. E-mail address for S.T. Mahan: susan.mahan{at}childrens.harvard.edu
2 Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, 75 Francis Street, PBB-3, Boston, MA 02115

Investigation performed at Children's Hospital Boston, Boston, Massachusetts

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institutes of Health (#K24 AR02123 and #P60 AR47782), the Orthopaedic Research and Education Foundation, and Siemens Medical Solutions. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: The United States Preventive Services Task Force recently determined that they could not recommend any screening strategies for developmental dysplasia of the hip. Disparate findings in the literature and treatment-related problems have led to confusion about whether or not to screen for this disorder. The purpose of the present study was to determine, with use of expected-value decision analysis, which of the following three strategies leads to the best chance of having a non-arthritic hip by the age of sixty years: (1) no screening for developmental dysplasia of the hip, (2) universal screening of newborns with both physical examination and ultrasonography, or (3) universal screening with physical examination but only selective use of ultrasonography for neonates considered to be at high risk.

Methods: Developmental dysplasia of the hip, avascular necrosis, and the treatment algorithm were carefully defined. The outcome was determined as the probability of any neonate having a non-arthritic hip through the age of sixty years. A decision tree was then built with decision nodes as described above, and chance node probabilities were determined from a thorough review of the literature. Foldback analysis and sensitivity analyses were performed.

Results: The expected value of a favorable hip outcome was 0.9590 for the strategy of screening all neonates with physical examination and selective use of ultrasonography, 0.9586 for screening all neonates with physical examination and ultrasonography, and 0.9578 for no screening. A lower expected value implies a greater risk for the development of osteoarthritis as a result of developmental dysplasia of the hip or avascular necrosis; thus, the optimum strategy was selective screening. This model was robust to sensitivity analysis, except when the rate of missed dysplasia rose as high as 4/1000 or the rate of treated hip subluxation/dislocation was the same; then, the optimum strategy was to screen all neonates with both physical examination and ultrasonography.

Conclusions: Our decision analytic model indicated that the optimum strategy, associated with the highest probability of having a non-arthritic hip at the age of sixty years, was to screen all neonates for hip dysplasia with a physical examination and to use ultrasonography selectively for infants who are at high risk. Additional data on the costs and cost-effectiveness of these screening policies are needed to guide policy recommendations.

Level of Evidence: Economic and decision analysis Level II. See Instructions to Authors for a complete description of levels of evidence.


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R. M. Schwend
What Is the Optimal Strategy To Screen for Hip Dysplasia?
AAP Grand Rounds, October 1, 2009; 22(4): 37 - 37.
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