An Examination of Screening Practices for Developmental Dysplasia of the Hip Across Sri Lankan Medical Specialties.
Abstract
Purpose:
Sri Lanka does not have a formal care pathway that clinicians use to assess for developmental dysplasia of the hip (DDH), which may lead to later diagnosis, more invasive treatments, and long-term adverse health outcomes. With the goal of developing a care pathway for DDH in Sri Lanka, we first surveyed relevant medical specialities regarding their experience with DDH screening, diagnosis, and treatment to understand current care practices and to identify knowledge gaps that may be addressed.
Method:
A panel composed of four members affiliated with three Sri Lankan organizations worked with our team of researchers to inform development of three specialty-specific surveys. Specialty surveys were distributed to the members of the Sri Lankan Orthopaedic Association (SLOA), The Sri Lankan College of Radiologists (SLCR) and The Sri Lankan College of Pediatricians (SLCP). Responses were recorded for six weeks.
Results:
In total, 88 responses were recorded; 24 Radiologists, 27 Orthopaedic Surgeons and 37 Pediatricians/Neonatologists.
Across specialties, birth to three months of age was the most prevalent age group for DDH presentation. Pediatricians/neonatologists and orthopaedic surgeons agreed that risk factors for DDH screening should include breech presentation, family history and history of clinical hip instability. Additionally, 31% of orthopaedic surgeons and 36% of pediatricians reported that incorrect hip swaddling should be considered a risk factor when screening. However, 54% of pediatricians/neonatologists reported that they were unaware of healthy hip swaddling practices, indicating an opportunity to increase awareness about swaddling and hip dysplasia. Regarding imaging, 92% of radiologists indicated preference for Graf classification for ultrasound (US) assessment, and 63% used Tonnis classification for X-rays. There may be some concerns with reliability of ultrasound (US) reporting, with, 54% of pediatricians/neonatologists and 44% of orthopaedic surgeons rating US imaging as reliable.
Thirty-eight percent of orthopaedic surgeons reported that primary care physicians are not ordering images appropriately, with respondents evenly split on if images were ordered too frequently or insufficiently. Fifty-six percent of orthopaedic surgeons and 43% of pediatricians reported awareness of American Academy of Orthopaedics Surgeons (AAOS) clinical practice guidelines for screening and non-operative management of DDH.
Conclusion:
We identified potential areas to improve screening and diagnosis, such as providing guidance on how to connect appropriate referrals. Our findings indicate that reliability of imaging interpretation warrants further investigation and improvement. Swaddling practices may also be considered as a risk factor when screening for DDH. The results from these subspecialty surveys helped inform the materials necessary to conduct a modified Delphi process to reach consensus on a list of DDH screening statements specific to the local context and needs in Sri Lanka. Care pathway development must be mindful of healthcare structure, resource availability, and strive to increase awareness of best care practices among healthcare practitioners.