key: cord-0946413-otvj7eix
authors: Mert Doğan, Güleç; Aslantürk, Okan
title: Does the COVID‐19 pandemic cause late diagnosis and delay in treatment in developmental dysplasia of hip patients?
date: 2021-07-05
journal: Int J Clin Pract
DOI: 10.1111/ijcp.14572
sha: 587c3d26a36c8130e318b2ca7a465949f0719b40
doc_id: 946413
cord_uid: otvj7eix

BACKGROUND: The aim of the current study was to search the effect of COVID‐19 restriction on developmental dysplasia of hip (DDH) screening. MATERIAL AND METHODS: We retrospectively reviewed the patients who brought to DDH screening in April‐May and June‐July 2020 and compared with the same period of 2019. We recorded age, gender, DDH type and risk factors of the patients. RESULTS: The number of patients taken for DDH screening was 430 and 400 in April‐May 2019 and June‐July 2019, respectively. In 2020, the number of patients taken for DDH screening was 159 and 776 in the same period, respectively. Thirteen patients were diagnosed with DDH older than 3 months age in June‐July 2020. There were only two patients in same period in 2019. In 2020, 6 of 13 patients who applied to the hospital late for the routine US and had pathologic hips were not taken to orthopaedics or follow‐up by their families. CONCLUSION: In the era of COVID‐19, the number of late diagnosis and lost follow‐up for DDH are increased. To prevent future morbidities and reduce surgical interventions, special measures should be taken.

We hypnotised that COVID-19 restrictions increased late administration of the patients for DDH screening and so increased the late diagnosis of DDH. In this study, we aimed to search the number of patients who did not apply to the hospital in the first 3 months of life to DDH examination in the period of restrictions in the COVID -19 pandemic. We also aimed to contribute to the guidelines for future pandemics by discussing the difficulties that may be in the late-onset treatment of children who do not have routine physical and neonatal hip US examination on time.

After the approval of the ethics committee in our hospital (No: 21-604), the records of patients who underwent neonatal hip US from 1 April to 31 May 2020, during the period of the pandemic restrictions and from 1 June to 31 July, when restrictions were reduced, were retrospectively reviewed. In addition, the records of patients who came to hip US 1 year ago within the same time period were retrospectively analysed and the US numbers from 2020 to 2019 were compared. The number of the children applying to the hip US for the first time when they were older than 3 months in 2020 and having pathology in US were detected and compared with the results of the corresponding patient group of 2019.

Detailed clinical information's of the babies were examined.

Gestational birth weeks, ages during US (in weeks), alpha and beta angle values and risk factors (positive family history, prematurity, first child, female gender, breech presentation, accompanying deformity, torticollis, metatarsus adductus, oligohydramnios and multiple pregnancy) were evaluated. Hip ultrasound examination was performed by one experienced paediatric radiologist. Each hip was classified according to Graf's classification. 9 

Totally 159 patients applied to our clinic for neonatal hip US in April and May 2020 during the pandemic restrictions ( In June and July 2019, neonatal hip US was performed on 400 (220 female, 180 male) patients and 53(13.25%) of these patients applied for the first time to US when they were older than >3 months (Table 1 ). Only two (3.7%) of those patients had pathologic hips and both of them were female. The pathology of these two patients were also type 2b pathological immature hip. Totally, six (1.5%) of the 400 patients had pathology in the US.

Only one of the 13 patients had a family history, while the other patients had no additional risk factors other than gender and none of them had pathologic findings for DDH during the physical examination.

Although there was an increase in the number of late diagnosis and pathological hips, there was no statistically significant difference (P = .813).

In 2020, 6 (46.1%) (5 patient with 2b, 1 patient with 2c) of 13 patients who applied to the hospital late for the routine US and had pathologic hips were not taken to orthopaedics or follow-up by their families. Pavlik bandage was applied to the remaining seven (53.8%) patients. It was observed that hips normalised in three (42.8%) of seven patients who were applied Pavlik bandage.

Two patients (%42.8) with persistent dysplasia were followed up with abduction orthosis, but it was observed that both were not taken to follow-up regularly in the later period. Closed reduction was applied to one patient with type 2c who did not improve for follow-up. The other patient's hip dysplasia continued in the follow-up, but she was not taken to control when the pandemic restrictions started.

Developmental dysplasia of the hip is an important problem in childhood, unfortunately, it is still common all over the world. The incidence varies greatly according to races and geographical regions.

Its prevalence is around 1.5%-2%. 10 There have been many studies investigating DDH in our country and the prevalence of the disease was obtained quite different. 11 Late diagnosis and inadequate treatment could result in increase in the failure of noninvasive treatments and the need for surgical interventions. 12 

Treatment Program significantly decreased late diagnosis of DDH. 12 In our study, we detected an increase in the number of late administrations for DDH examination and irregular follow-up in 2020 when compared with the same period of 2019.

Although the definition of pathological hip affects this ratio, in our study in which types 2b, 2c, 2d, 3 and 4 were considered pathological, the pathology prevalence detected in hip US was 2.3% in the COVID-19 pandemic. This rate was found to be 1.5% in June-July 2019. Rather than a single factor in the aetiology of DDH, several predisposing factors have been identified such as prenatal and post mechanical factors, maternal hormonal bond laxity, acetabular dysplasia, race characteristics, developmental factors, genetics and environmental factors. 13 Other identified risk factors were postural and structural foot deformities (metatarsus adductus, pes calcaneovalgus, pes equinovarus), torticollis, high birth weight, joint laxity, oligohydramnios, first baby and difficult birth history. 14 Girls have been found to be more affected than boys. 15 In our study, only female gender and family history were present among these risk fac- We also detected that patients with hip dysplasia were not taken to for treatment and regular follow-up in the COVID-19 era. In 2019, all patients were taken to regular controls by parents.

To best our knowledge, our study is the first study on this subject, and only one patient was reported in the literature. 18 But we believe that the number will increase as studies are carried out on this subject and that we will see this indirect effect of COVID 19.

The results of this study showed that if we do not continue to care for patients with the right precautions during pandemics, unfortunately, this will have bad consequences for public health. Moreover, the pandemic is still ongoing, and it is not clear how long it will last.

Some studies have shown that ultrasound can be a vector in the spread of infections. 19, 20 Therefore, some precautions should be taken during the US examination against a highly contagious infection such as COVID-19. US appointments should be planned properly to shorten the spent time of the patients in the hospital.

Patients should be taken to the examination room with only one parent, and there should not be any other patient or staff in the room.

Examination room, baby changing table and US probes should be cleaned every morning and just before every scan. Taking these precautions in US to reduce the spread of infection will relieve the society and will encourage the patients for hospital admissions if necessary.

Retrospective design and relatively small number of patients are major limitations of our study. Small sample size may be the cause of statistical insignificance. 

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The role of ultrasonography in the diagnosis of developmental dysplasia of the hip

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Can diagnostic ultrasound scanners be a potential vector of opportunistic bacterial infection?

The ultrasound unit and infection control -are we on the right track?

This is neither the first pandemic the world has faced nor will it be the last. That is why it's so important to create guidelines. Family health centres and paediatricians should warn the patients families about the diseases such as DDH during the pandemic period and ensure them to have a hip examination and US performed under appropriate conditions. Late diagnosis, inappropriate treatment and follow up may decrease the chance of conservative treatment and increase surgical intervention risk.

The authors declared no conflict of interest.

https://orcid.org/0000-0001-6167-3952