Hip dysplasia is the most common congenital defect of the locomotor system. Hip ultrasound should be done for every child up to 12 weeks of age. Defect detected early is easily curable. If missed, it may wear out the hip, and then an endoprosthesis will be required. One ultrasound is enough for most children. Doctors often recommend further visits. – I do not know how dishonest or ignorant it is, but it’s time to end it – says Dr. Jarosław Feluś, orthopedist, creator of the proprietary program, thanks to which 2000 children in Krakow hospitals were examined in a few months.
- In Poland, 4 percent of children are born with dysplasia. The defect detected early is easy to cure, and the child will avoid endoprosthesis in the future. That is why hip ultrasound in Poland is performed on all infants before they turn 12 weeks old
- – You only need to do an ultrasound scan once. And they are repeated many times, most often without medical indications and without any need – says Dr. Jarosław Feluś, an orthopedist who has been promoting early diagnosis of hip joints for years
- In Anglo-Saxon countries and Scandinavia, where the incidence of hip dysplasia is several or several dozen times lower than in other European countries, ultrasound is not performed in all children, but only in certain groups where the probability of hip dysplasia is higher
- In Poland, many doctors recommend multiple hip checks and repeat ultrasound. This exposes parents to stress, uncertainty about the child’s health and costs. And the truth is that 90 percent. children have perfectly healthy hips and one examination is enough to find out. If they are normal on the first ultrasound, the dysplasia will not appear later
Until the 80s, the diagnosis of hip dysplasia was based solely on a medical examination – it was believed that it was confirmed by some characteristic symptoms such as uneven skin folds on the thighs or reduced abduction in the hips (bending legs to the sides). The breakthrough was the development by the Austrian orthopedist Reinhold Graf of the principles of ultrasound examination of infants and the criteria for their unambiguous, almost mathematical assessment. This method is now recognized as the gold standard in diagnosing dysplasia around the world (so-called Graf Classification). It turned out that in many infants hip hypoplasia occurs despite the lack of clinical symptoms – without ultrasound diagnosis, it is impossible to diagnose it and start treatment.
Controls without medical indications
Implementation of these standards required educating and convincing pediatricians, midwives and often senior orthopedic surgeons that hip ultrasound is recommended for all newborn babies before the age of 12 weeks. In Krakow, this challenge was undertaken by a pediatric orthopedist, Dr. Jarosław Feluś, who created a proprietary pilot program for the prevention of the consequences of hip dysplasia, under which over 2000 children born in Krakow hospitals were examined over a period of several months. The program turned out to be a success, it was later included in the series of preventive health programs implemented by the city hall. It complements the Preluxation Outpatient Clinics, where, under the contract with the National Health Fund, also hip joints are diagnosed and treated in infants.
– In the last ten years, thanks to the extensive information campaign and popularization of hip ultrasound, it was possible to fundamentally change the awareness of pediatricians, midwives, neonatologists and other medical staff involved in the care of newborn babies – says Dr. Feluś. – Ultrasound examination, combined with a medical examination, has become a diagnostic standard for hip dysplasia. We have achieved success. Unfortunately, once we have come this long and important road, another unforeseen problem has arisen – the problem of overdiagnosis. Ultrasound examinations are repeated many times, most often without medical indications and without any need.
Why is this a problem? Well, 90 percent. children have perfectly healthy hips and one examination is enough to find out. If they are normal on the first ultrasound, the dysplasia will not appear later. It is a congenital defect resulting from an incorrect positioning during pregnancy, too little space inside the uterus or a genetic predisposition. Therefore, the patient cannot acquire it over time.
– Dysplasia is even more of an underdevelopment than a defect: the health of the hip, which was not fully developed during pregnancy – emphasizes the orthopedist. – Of course, there may be secondary dysplasia, but it is rare, it occurs in children with very severe neurological disease, with cerebral palsy and significantly increased muscle tone. It’s a completely different group. 90 percent children should complete their diagnostics on one, several-minute ultrasound examination. And period.
A waste of money
In 6-8 percent. of cases, the examination must indeed be repeated. When the first ultrasound shows minimally immature hips, proper care and inspection after 12 weeks of age is recommended to ensure the hips are mature. Dr. Feluś performed about a thousand of such repeated examinations and – as he claims – only saw twice that the hips did not mature spontaneously and required treatment, so this is a rather rare situation. The remaining 2-4 percent. Patients are children who evidently have dysplasia, they need to be treated and then regularly monitored (treatment consists of putting on a special felt pad or harness in such a way as to keep the patient’s legs bent and abducted from side to side, so-called “frog”).
– Doctors do the test, they order the control in a few months, the description says “gn”, which is the limit of the norm. There is no such thing in hip dysplasia! Abuse or lack of knowledge – notes Feluś and adds that although the ultrasound examination is not harmful, the amount of funds in the system is limited. – I test up to 300 children a month, so I often encounter this situation. Caring parents come as directed, you can’t blame them. Financial resources for their examination, however, could be allocated to another child, because the funds from the National Health Fund are not enough for all of them. The other parents pay over one hundred zlotys in private offices.
Record: child tested 11 times
We talked to the parents of children whose hips were first screened healthy, yet they were recommended another ultrasound:
“The doctor said that when he is 5-6 months old, we should show up for a check-up. We returned home with this information. Then we were vaccinated by the pediatrician and she also recommended another ultrasound. She didn’t explain why, and neither did I. I trusted blindly because my sister and friend also had such recommendations. If there is no deadline for the fund, the office proposes a private visit “
“After the first examination, the doctor recommended a check-up in six months. The second time we heard that there were no signs that the son was wrong. Then I panicked myself. The son is premature. I told the pediatrician about it – she decided that there was no need for another ultrasound, but since I have doubts, the decision is up to me. During this third visit, we learned that we had unnecessarily wasted our time, money and, most of all, our son’s nerves. I was oversensitive, lost, but also nobody put the matter straight “
«We heard that for this age, the daughter’s hips are fine, but it would be good to check them out. It was a trusted clinic. However, there was not enough space for the fund, so we went to the clinic the second time. There we found out that it was good the first time and this is confirmed by both the descriptions and the photo itself. If we went to the same clinic, maybe the daughter would be examined a third time ”.
The “record holder” in Dr. Feluś’s office was a child previously examined for dysplasia eleven times. Sometimes he could not stand it and told his parents that they were probably a victim of abuse. He later read unfavorable opinions about himself on the internet for questioning another doctor’s opinion.
The cost is small, but it is a fact
It is hardly surprising for parents – out of concern for the child, they follow the doctor’s recommendations, and often follow the path of research of their older siblings, when knowledge about the diagnosis of dysplasia was less. Anyway, even if the parent’s lamp came on and checked the information on the subject on the Internet, he could get lost anyway. One of the largest TV stations in Poland, in its section on health, states that “ultrasound of a child’s hips should be done three times, some experts suggest even four).”
– If the examination determines that the child has a mature hip, it does not require any further treatment: neither therapeutic nor diagnostic. The guidelines are clear and unchanged for years, echoed the orthopedist Dr. Bartłomiej Kowalczyk, deputy head of the Department of Children’s Orthopedics at the University Children’s Hospital in Krakow. – Such types of actions, which actually happen for the benefit of the patient, may result from ignorance, and good intentions to check the patient well, because the test is harmless. On the other hand, repeating the examination exposes the patient to financial losses, and although the cost is not high, it is all about the fact.
– In a decade, therefore, we have gone from the extreme to the extreme. From the situation when the awareness of proper hip diagnostics in infants was really low, through educational and promotional activities, the creation of the city program in Krakow, to the moment when we struggle with excessive, often unnecessarily duplicated diagnostics. This shows how much work is still ahead of us – sums up Dr. Feluś.