Knowledge, attitude, and practice of primary care physicians about developmental dysplasia of the hip in a tertiary referral hospital in Riyadh, Saudi Arabia

INTRODUCTION

Developmental dysplasia of the hip (DDH) is a term that represents a broad spectrum of hip abnormalities such as acetabular dysplasia, subluxation, and true dislocation, which manifests as an unstable hip.^[1,2] Incidence of DDH has been reported in developed countries to be around 4–6 cases/1000 live births, although two regional studies reported incidence rates around 3.2~3.5/1000 live births.^[2,3] However, both studies were not conducted on a national level and their results cannot be extrapolated to represent the country. Another local study identified the most common risk factors for DDH in the region and showed that positive family history, parents’ consanguinity, breech delivery, and baby swaddling are the most common.^[4] Some other important risk factors that have been reported in the literature included genetic predisposition, oligohydramnios, breech presentation, female gender, and large birth weight and many other causes related to intra-uterine mechanical constraint.^[3-6]

Pathologic hips can be diagnosed early and treated accordingly without long-term sequelae through neonatal screening examination, risk factors assessment, and appropriate imaging modalities.^[2,7,8] The treatment aims to reduce the hip joint to avoid associated long-term morbidities, including muscle weakness, degenerative arthritis, chronic pain, and to maximize functional outcome.^[8] As such, early detection and proper management at the primary care center are key to prevent further complications of the disease.^[9] Active screening for DDH is not generally conducted and the literature provides little evidence of its efficacy.^[10-12] This led to a lack of this practice and a drop-in the knowledge regarding proper DDH practices in primary care centers, as shown by Uzel et al.^[13] Although their study has its regional limitations and cannot be applied to every population, it highlighted what the authors hypothesized regarding the possible misconceptions about proper DDH-related practice in primary care centers and the need for improvement in the knowledge, attitude and practice toward DDH management.^[13] Several other studies reported very low knowledge of DDH in more than 50% of healthcare workers, including physicians, nurses and medical students.^[14-17] Therefore, we conducted this study to determine the current knowledge, attitude and practice of management of DDH among primary care physicians (PCP) in Saudi Arabia. This will, in turn, provide insight to direct further research and educational efforts.

MATERIALS AND METHODS

RESULTS

A total of 65 participated in the survey, 34 (52.3%) males and 31 (47.7%) females. Thirty-two respondents (49.2%) were GPs and 33 (50.8%) were fellows and consultants. Thirty-six respondents (55.4%) received their education from Saudi universities, 8 (12.3%) from western countries, and 21 (32.3%) from other nearby Arab countries. In addition, 13 respondents (20.0%) had experience of 21 years and above in primary health care. Only six participants (9.2%) had formal training on DDH management. [Table 1] shows the detailed demographic profile of the 65 respondents.

DISCUSSION

The prevalence of DDH may not be that high, occurring in <1% of live births.^[2,3] However, despite the several screening guidelines that have been developed, there seems to be a deficiency in the knowledge, attitude, and practice of PCPs in the diagnosis, referral, and management of DDH patients. DDH is primarily a pediatric orthopedic problem, but early diagnosis and prevention are based on a multidisciplinary approach involving pediatric orthopedic surgeons, neonatologists, obstetricians, pediatricians, and PCPs.^[18] The problem of complex diagnosis, prevention, and treatment of DDH has been a center for discussion for many practitioners.

This study showed that 2 of 3 of our respondents have sufficient knowledge of DDH regardless of gender, age, job level, years of experience, or whether they had received their training locally or abroad. However, despite their knowledge of what DDH is about, there seemed to be a wide gap in translating knowledge of DDH to physicians’ practice of DDH management. One example is that 89.2% of the respondents believed that they needed to go for further training about DDH. This implies a need to translate their theoretical knowledge into practice that may be evidenced by persistent confusion on diagnosis, decision-making and management of DDH cases.^[19] One study showed that around 18.6% of physicians fail to recognize DDH as a treatable disease.^[13] In this study, we noticed that majority (at least >70%) of our respondents answered the knowledge questions correctly with regards to risk factors, particularly the presence of a family history of DDH, absence of total dislocation of the hip, presence of oligohydramnios, breech presentation, and the presence of hip clunk, abnormal skin fold, limping and limb-length discrepancy. Furthermore, many respondents fell short on the knowledge of the diagnostic imaging procedure that is ideal for diagnosing DDH at a varying age of the patients, such as the use of ultrasonography for younger aged patients and radiographs of the pelvis for older patients. Although there is insufficient evidence in using ultrasonography for younger patients aged 6–8-weeks-old, the presence of risk factors would warrant a dedicated screening to institute proper management, particularly among breech-delivered babies.^[19]

Another highlight of this study is the way the respondents refer cases of DDH. Nine of ten respondents refer a DDH case to a pediatric orthopedic surgeon when a radiograph or ultrasound is positive. However, only one in ten of these respondents will always examine the hip for DDH. This is because of the lack of universally agreed guidelines on what must be examined and at what age will constitute a developmental disease or an actual disease.^[20] One particular example is the Ortolani maneuver, which is one important clinical test for detecting hip dysplasia in newborns. In this study, 64.6% of the respondents reported the performance of Ortolani test at 3 months, whereas 35.4% said it is best to perform it beyond the age of 3 months to a year. It is known that in most of DDH cases, Barlow and Ortolani tests will not be positive after the age of 3 months in patients with DDH.^[21,22] In other instances, some of the Barlow-positive hips, resolve spontaneously and the mild DDH that occurs with this in newborns also resolve spontaneously.^[21,22]

Several clinical practice guidelines, including the American Academy of Pediatrics, the American Academy of Orthopedic Surgeons, the Pediatric Orthopedic Society of North America, recommended screening of all newborns by physical examination for DDH. However, there were controversial oppositions from the US Preventive Services Task Force (USPSTF) that routine screening for DDH may potentially cause avascular necrosis with frequent manipulation of the hip joint.^[23,24] However, several studies have reputed the USPSTF claim and advocated the early screening and diagnosis of DDH.^[25,26] Consequently, undiagnosed and uncorrected DDH during infancy were reported to be the main cause for the need of total hip arthroplasty when they grow up.^[27]

The wide variation in the responses pertaining to the practice, approachn and management of DDH in this study reflects discrepancies in the diagnostic opinions of our respondents.^[28] In turn, these differing opinions may be brought about by the absence of a standard care pathway for the management of DDH. About 68% of surgeons surveyed in North America do not endorse a standard care pathway for DDH.^[29] In India, even though only 30% of institutions follow an international standard care pathway, most physicians support their own implemented care pathway that is multidisciplinary, involving orthopedic surgeons and enhancing the skills of their local practitioners.^[30]

The present study had several limitations. Firstly, our results are limited to a small convenience sample of PCPs from a single institution primary care health centers in Riyadh and cannot be generalized to reflect the greater population of physicians involved in the screening and management of DDH. Another limitation is that this study included all PCPs, which made a major defect in the results. It could have been devoted to pediatric PCPs as adult PCPs do not see infants or children to look for DDH. The knowledge of DDH from other segments of the population may reflect a different scenario. However, we were able to deduce some important information regarding our respondents’ knowledge, attitudes, and practices that may give a bird’s eye view of the current situation. The small sample size also limited us to generate more concrete results.

CONCLUSION

Knowledge of DDH among our PCPs who are directly involved in the screening and management of DDH is sufficient. There is discordance between knowledge, attitude and practice. Despite their knowledge, our respondents fall short in the translation of their knowledge into practice.

RECOMMENDATIONS

The results of this study suggest and recommend a revisit on the knowledge, attitudes and practice of our PCPs, particularly those pediatric PCPs who are involved in the screening, diagnosis and management of patients with DDH. There is a need for continuing education on DDH, particularly on screening, management and referral. In addition, the formulation of a standard general protocol for screening and managing patients with DDH would be helpful to minimize confusion and discordance in the practices.