Les auteurs ont analysé les dossiers de 353 enfants pris en charge à la clinique chirurgicale infantile de Rouen pour luxation congénitale de la hanche après l'âge de 3 mois au cours d'une période de 31 ans (1968-1998) afin d'observer l'évolution du diagnostic de cette pathologie en fonction des progrès de son dépistage précoce. L'étude des 70 derniers dossiers traitée de façon prospective permet de mettre en valeur les causes des échecs de la prise en charge précoce, afin d'en tirer les leçons utiles à la communication des meilleurs moyens d'améliorer le rendement de ce dépistage.

Jusqu'en 1981 (époque de la structuration de la prise en charge précoce de la maladie luxante de la hanche au CHU en collaboration avec les principales maternités de la région), 21,5 cas en moyenne étaient traités tous les ans pour une luxation de diagnostic tardif. Depuis 1982, ce chiffre semble stabilisé à 6,5 cas par an. En outre, l'âge de prise en charge a beaucoup diminué puisque le chiffre moyen des enfants âgés de plus de 1 an lors du diagnostic est passé de 11 par an jusqu'en 1981 à 2 par an à partir de 1982.

Les causes des échecs de la prise en charge précoce sont dominées par l'absence de diagnostic clinique néonatal (80 % des cas). Les échecs en rapport avec une interprétation erronée de l'imagerie demandée devant une hanche cliniquement instable sont rares (4 % des cas). En revanche, des traitements inadaptés, mal compris, mal expliqués ou mal suivis ont abouti à des échecs de prise en charge initiale (16 % des cas).

Primary management of developmental dislocation of the hip involves a series of events (clinical screening and detection, choice and interpretation of imaging studies, indication and proper execution of treatment). Each event has an important effect on outcome and failure may result from inadequate attention to any one. We analyzed the causes of failure observed over 31 years experience in our region.

We analyzed the files of children hospitalized in the Rouen Infantile Surgery Department from 1968 to 1998 for management of congenital dislocation of the hip diagnosed late (> 3 months) or for revision after inappropriate treatment. We identified 353 files. This series was retrospective from 1968 to 1985 (283 cases) and prospective from 1986 to 1998 (70 cases).

Up through 1981, failed detection of developmental dislocation of the hip was identified in 10 to 27 children per year (mean 21.5). Since 1982, this rate has varied from 1 to 10 (mean 6.5). The number of children treated before the age of one year was 10.5 per year up through 1981 then 4.5 per year after 1982. The number of children treated after the age of one year was 11 per year through 1981 then 2 per year after 1982. Since 1986, treatment was undertaken for failure of primary management in 57 children after clinical diagnosis, in 3 children after radiological and ultrasonographic diagnosis, and in 11 children during the course of treatment. Standard x-ray studies systematically obtained at four months corrected the diagnosis in 24 children. The diagnosis was corrected after repeating the examination in 14 children before the age of one year. Correct diagnosis was established after the age of one year in 18 children.

Although our University Department was the only referral center for pediatric surgery in our region during this period, these figures cannot be compared with the annual birth rate in the region (24000 births/year) because the number of infants managed in other centers is unknown. Nevertheless, organizing regular follow-up by a pediatric orthopedic surgeon of all infants screened positive in the maternity ward enabled a 70 % reduction in the number of failures since 1982. Systematic clinical screening, repeated regularly during the first year of life, has reduced the mean age of diagnosis. Neither ultrasonography nor radiography has replaced physical examination. Care must also be taken to avoid over reliance on ultrasound findings which do not correspond to clinical findings. Amongst the children treated late, 14 % had undergone an inappropriate treatment for dislocation correctly identified during the neonatal period. Referring all children screened positive to a pediatric orthopedic surgeon should help reduce this rate.