Diagnostic Accuracy of Ultrasonography Method of Graf in the Detection of Developmental Dysplasia of the Hip: A Meta-Analysis and Systematic Review

Document Type : SYSTEMATIC REVIEW

Authors

1 Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran

3 Department of Radiology, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Background: The present study aimed to perform a meta-analysis on the performance of Graf’s ultrasonography
method in the detection of developmental dysplasia of the hip (DDH).
Methods: A query was conducted on electronic bibliographic databases until the end of October 2020. The inclusion
criteria entailed: 1. the use of Graf method in less than 12 weeks of age, 2. the use of follow-up as reference test, and 3.
provision of crude data. Pooled diagnostic performance measures were calculated. Quality Assessment of Diagnostic
Accuracy Studies-2 (QUADAS-2) checklist was utilized to assess the quality of the included studies. The hierarchical
summary receiver-operating characteristic (HROC) curves were also drawn.
Results: Six articles (including seven populations, 11,012 patients) were considered eligible. The pooled sensitivity
and specificity were obtained at 93% (95% CI: 0.57-0.99) and 97% (95% CI:0.86-0.99), respectively (area under curve=
0.99). The pooled positive and negative likelihood ratio, as well as diagnostic odds ratio, was reported as 28.4, 0.07,
and 396, respectively.
Conclusion: As evidenced by the obtained results, Graf’s method is a useful ultrasonography technique with acceptable
accuracy for screening DDH in neonates. However, there are uncertainties about the best population and age for
screening. Furthermore, more attention should be paid to the proper training of this method to reduce the number of
operator errors.
Level of evidence: I

Keywords


1. Wilf–Miron R, Kuint J, Peled R, Cohen A, Porath
A. Utilization of ultrasonography to detect
developmental dysplasia of the hip: when reality
turns selective screening into universal use. BMC
pediatrics. 2017;17(1):136.
2. Vafaee AR, Baghdadi T, Baghdadi A, Jamnani RK. DDH
epidemiology revisited: do we need new strategies?
Archives of Bone and Joint Surgery. 2017;5(6):440.
3. Westacott DJ, Butler D, Shears E, Cooke SJ, Gaffey A.
Universal versus selective ultrasound screening for
developmental dysplasia of the hip: a single-centre
retrospective cohort study. Journal of Pediatric
Orthopaedics B. 2018;27(5):387-90.
4. Zargarbashi RH, Bonaki HN, Zadegan SA, Baghdadi
T, Nabian MH, Shirazi MR. Comparison of pediatric
and general orthopedic surgeons’ approaches in
management of developmental dysplasia of the hip
and flexible flatfoot: the road to clinical consensus.
Archives of Bone and Joint Surgery. 2017;5(1):46.
5. De Pellegrin M, Moharamzadeh D, Fraschini G. Early
diagnosis and treatment of DDH: a sonographic
approach. Hip International. 2007;17(5_suppl):15-21.
6. Hansson G, Jacobsen S. Ultrasonography screening
for developmental dysplasia of the hip joint. Acta
Pædiatrica. 1997;86(9):913-5.
7. Alamdaran SA, Kazemi S, Parsa A, Moghadam MH,
Feyzi A, Mardani R. Assessment of diagnostic value
of single view dynamic technique in diagnosis of
developmental dysplasia of hip: a comparison with
static and dynamic ultrasond techniques. Archives of
Bone and Joint Surgery. 2016;4(4):371.
8. Thaler M, Biedermann R, Lair J, Krismer M, Landauer
F. Cost-effectiveness of universal ultrasound screening
compared with clinical examination alone in the
diagnosis and treatment of neonatal hip dysplasia in
Austria. The Journal of bone and joint surgery British
volume. 2011;93(8):1126-30.
9. Graf R. The diagnosis of congenital hip-joint
dislocation by the ultrasonic Combound treatment. 
Archives of orthopaedic and traumatic surgery.
1980;97(2):117-33.
10. Woolacott NF, Puhan MA, Steurer J, Kleijnen J.
Ultrasonography in screening for developmental
dysplasia of the hip in newborns: systematic review.
bmj. 2005;330(7505):1413.
11. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati
A, Petticrew M, et al. Preferred reporting items for
systematic review and meta-analysis protocols
(PRISMA-P) 2015 statement. Systematic reviews.
2015;4(1):1.
12. Harbord RM, Whiting P. Metandi: meta-analysis
of diagnostic accuracy using hierarchical logistic
regression. The Stata Journal. 2009;9(2):211-29.
13. Kim KW, Lee J, Choi SH, Huh J, Park SH. Systematic
review and meta-analysis of studies evaluating
diagnostic test accuracy: a practical review for clinical
researchers-part I. General guidance and tips. Korean
journal of radiology. 2015;16(6):1175-87.
14. Deeks JJ, Macaskill P, Irwig L. The performance of
tests of publication bias and other sample size effects
in systematic reviews of diagnostic test accuracy
was assessed. Journal of clinical epidemiology.
2005;58(9):882-93.
15. Doebler P, Holling H. Meta-analysis of diagnostic
accuracy with mada. R Packag. 2015;1:15.
16. Dwamena B, Sylvester R, Carlos R. midas: Metaanalysis
of diagnostic accuracy studies. Available
at:)(Accessed on February 8, 2017) http://fmwww
bc edu/repec/bocode/m/midas pdf View in Article.
2009.
17. Gokharman FD, Aydin S, Fatihoglu E, Ergun E, Kosar
PN. Optimizing the time for developmental dysplasia
of the hip screening: earlier or later? Ultrasound
Quarterly. 2019;35(2):130-5.
18. Pillai A, Joseph J, McAuley A, Bramley D. Diagnostic
accuracy of static graf technique of ultrasound
evaluation of infant hips for developmental dysplasia.
Archives of orthopaedic and trauma surgery. 2011; 
131(1):53-8.
19. Rosendahl K, Markestad T, Lie R. Developmental
dysplasia of the hip. A population‐based comparison
of ultrasound and clinical findings. Acta Paediatrica.
1996;85(1):64-9.
20. Tan SHS, Wu CH, Wong KL, Hui JH. Correlations
between ultrasonographic and subsequent radiographic
findings of developmental dysplasia of the
hips. Ultrasonography. 2020;39(1):43.
21. Roovers E, Boere-Boonekamp MM, Castelein R,
Zielhuis G, Kerkhoff T. Effectiveness of ultrasound
screening for developmental dysplasia of the hip.
Archives of Disease in Childhood-Fetal and Neonatal
Edition. 2005;90(1):F25-F30.
22. Kishore Kumar R, Shah P, AN R, Rajan R. Diagnosing
Developmental Dysplasia of Hip in Newborns
Using Clinical Screen and Ultrasound of Hips—An
Indian Experience. Journal of tropical pediatrics.
2016;62(3):241-5.
23. Lee J, Kim KW, Choi SH, Huh J, Park SH. Systematic
review and meta-analysis of studies evaluating
diagnostic test accuracy: a practical review for
clinical researchers-part II. Statistical methods of
meta-analysis. Korean journal of radiology. 2015;
16(6):1188-96.
24. McGrath TA, Alabousi M, Skidmore B, Korevaar DA,
Bossuyt PM, Moher D, et al. Recommendations for
reporting of systematic reviews and meta-analyses
of diagnostic test accuracy: a systematic review.
Systematic reviews. 2017;6(1):194.
25. Roposch A, Moreau NM, Uleryk E, Doria AS.
Developmental dysplasia of the hip: quality of
reporting of diagnostic accuracy for US. Radiology.
2006;241(3):854-60.
26. Pedrotti L, Crivellari I, Degrate A, De Rosa F, Ruggiero
F, Mosconi M. Interpreting neonatal hip sonography:
intraobserver and interobserver variability. Journal of
Pediatric Orthopaedics B. 2020;29(3):214-8.
27. Clegg J, Bache C, Raut V. Financial justification for
routine ultrasound screening of the neonatal hip. The
Journal of Bone and Joint Surgery British volume.
1999;81(5):852-7.
28. Holen K, Tegnander A, Bredland T, Johansen O, Saether
O, Eik-Nes S, et al. Universal or selective screening of
the neonatal hip using ultrasound? A prospective,
randomised trial of 15 529 newborn infants. The
Journal of bone and joint surgery British volume.
2002;84(6):886-90.
29. Buonsenso D, Curatola A, Lazzareschi I, Panza G,
Morello R, Marrocco R, et al. Developmental dysplasia
of the hip: real world data from a retrospective
analysis to evaluate the effectiveness of universal
screening. Journal of ultrasound. 2020.
30. Laborie LB, Markestad TJ, Davidsen H, Brurås KR,
Aukland SM, Bjørlykke JA, et al. Selective ultrasound
screening for developmental hip dysplasia: effect on
management and late detected cases. A prospective
survey during 1991–2006. Pediatric radiology. 2014;
44(4):410-24.
31. Rosendahl K, Markestad T, Lie RT. Ultrasound
screening for developmental dysplasia of the hip in the
neonate: the effect on treatment rate and prevalence
of late cases. Pediatrics. 1994;94(1):47-52.
32. Gulati V, Eseonu K, Sayani J, Ismail N, Uzoigwe C,
Choudhury MZ, et al. Developmental dysplasia of
the hip in the newborn: A systematic review. World
journal of orthopedics. 2013;4(2):32.
33. Ortiz-Neira CL, Paolucci EO, Donnon T. A meta-analysis
of common risk factors associated with the diagnosis
of developmental dysplasia of the hip in newborns.
European journal of radiology. 2012;81(3):e344-e51.
34. Quader N, Schaeffer EK, Hodgson AJ, Abugharbieh R,
Mulpuri K. A systematic review and meta-analysis on
the reproducibility of ultrasound-based metrics for
assessing developmental dysplasia of the hip. Journal
of Pediatric Orthopaedics. 2018;38(6):e305-e11.
35. Mostofi E, Chahal B, Zonoobi D, Hareendranathan
A, Roshandeh KP, Dulai SK, et al. Reliability of
2D and 3D ultrasound for infant hip dysplasia in
the hands of novice users. European Radiology.
2019;29(3):1489-95.