AAOS Appropriate Use Criteria: The Management of Developmental Dysplasia of the Hip in Infants up to 6 Months of Age: Intended for Use by General Pediatricians and Referring Physicians

Developmental dysplasia of the hip (DDH) is the most common pediatric hip condition, and it represents a spectrum of hip joint abnormalities, ranging in severity from mild dysplasia of a reduced and stable hip to an irreducibly dislocated hip at rest.1 This condition may be present at birth or develop during early infancy while the hip joint is immature. Screening for DDH has the potential to affect every child born, as clinical examination at birth for hip instability remains the universal benchmark for early detection and diagnosis. However, not all forms of DDH can be detected by clinical examination alone; therefore, ultrasonography examination is the imaging modality of choice in infants less than 6 months of age.2,3 There is a lack of consensus and little high-quality evidence on the ultimate utility of ultrasonography as a screening tool for DDH. Consequently, some countries, particularly Europe, have universal ultrasonography screening programs in conjunction with clinical examination for all infants4; whereas in North America, a selective screening approach based on the presence of DDH risk factors is often used.5 Early detection and management of DDH is critical to reduce the need for complex surgical procedures and to optimize long-term patient functional and quality-of-life outcomes. Much controversy and practice variability exist, however, in the detection, diagnosis, and management of DDH, largely arising because of the lack of high-quality evidence available to guide both the general and specialist practitioner. The spectral nature of the condition also adds to the complexity of diagnosis and management decision-making, which has consequently led to a distinct lack of standardized treatment protocols to provide optimal outcomes. The American Academy of Orthopaedic Surgeons created a set of appropriate use criteria (AUC)—The Management of Developmental Dysplasia of the Hip in Infants up to Six Months of Age—intended for use by general pediatricians and referring physicians.6 This AUC was created as an educational tool to guide qualified clinicians through a series of treatment decisions in an effort to improve the quality and efficiency of care for the heterogeneous patient population routinely seen in practice. They were developed based on best-available scientific evidence synthesized within the 2014 American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Detection and Nonsurgical Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age7 and collective expert opinion on topics for which randomized clinical trials were not available or not of adequate quality. These criteria attempt to address the most common clinical scenarios facing appropriately trained clinicians, with the intention of supplementing, not superseding, clinical expertise, experience, and patient preference in individual situations. The following case studies present two clinical scenarios commonly faced by the general pediatrician or referring physician and provide the management and treatment options based on the AUC guidance tool available here. The indications and classifications for the management of these cases are discussed in the DDH AUC summary for general pediatricians and referring physicians. Case 1 A 1-day-old female infant presents for her routine newborn examination. She is the first-born child, and her mother was diagnosed with and treated for DDH as an infant. Physical examination was normal, with no findings of hip instability or hip click. You are consulted for the treatment of this patient: a first-born female infant with a positive family history of DDH but with a normal physical examination. Four management options are available to consider. One of these options is considered Appropriate, one is identified as May Be Appropriate, and two are considered Rarely Appropriate (Table 1).Table 1: Case 1 Management Options and Appropriateness RatingThe management option considered Appropriate by the DDH AUC Voting Panel is to obtain an ultrasonography examination when the infant is at 4 to 6 weeks of age (or on presentation if the infant is older than 6 weeks). Consensus agreement exists for this option, indicating that, based on the current literature, this management approach can provide a good outcome and the practitioner should proceed in this manner after discussion with the patient family. The median score for this management option was 8, with the panel reaching agreement, as defined by The RAND/UCLA Appropriateness Method User's Manual for a panel of 11 to 13 voting members.8 Agreement is considered to be achieved when three or fewer panelists rate the treatment outside the three-point range containing the median. The following two management options were considered Rarely Appropriate: (1) continue routine well-baby exams only and (2) referral to specialist. Given an infant with the established risk factor of family history of DDH (more specifically in this case a first-degree relative in the mother), it would be rare to continue routine well-baby exams on this infant in the absence of ordering a screening ultrasonography once reaching the appropriate age. At this stage, referral to a specialist for a DDH risk factor alone would also be rare and would be more likely warranted pending results of the screening ultrasonography. The median score for these management options was 2 for continuing routine well-baby exams only and 3 for referral to specialist, with the panel reaching agreement for the first but not the second option. Continuing physical examinations and obtaining a single AP pelvis radiograph at 4 to 6 months of age was deemed May Be Appropriate, with a median score of 5. Among the voting panel, disagreement exists for this option, defined as when at least four members' ratings fall within the Appropriate range (7 to 9) and at least members' ratings fall within the Rarely Appropriate range (1 to 3). This management option may delay a potential DDH diagnosis in comparison to the infant receiving a screening ultrasonography at 4 to 6 weeks of age, thus providing the reason for its lower rating. However, accessibility and healthcare resource setting issues must also be considered. Ultrasonography screening for DDH requires technical expertise and resources that may not be readily available in many areas. Consequently, continued monitoring for hip instability, supplemented by obtaining a radiograph once the infant reaches 4 to 6 months of age, may provide an alternate means to detecting DDH before walking age. This option may be particularly relevant in underdeveloped or developing countries where ultrasonography typically is not available. In this particular case, the infant was referred for a screening ultrasonography, which she received at 6 weeks of age. The ultrasonography was found to be normal (Figure 1); however, she was still seen by an orthopaedic surgeon 3 weeks after the ultrasonography, with normal clinical examination findings at that assessment. At 4 months of age, she returned to the orthopaedic clinic for an AP pelvis radiograph and clinical assessment, both of which were normal (Figure 2). She has a planned follow-up for an additional pelvic radiograph at 1 year of age. Although potentially excessive follow-up, it is one of the case study author's (K.M.) current practice to follow infants with DDH risk factors and normal screening ultrasounds until 2 years of age. Evidence for the rates of dysplasia occurring in this patient population is lacking; however, one retrospective study has suggested a 29% incidence of dysplasia requiring treatment at 6 months of age after an initial normal ultrasonography at 6 weeks of age.9 Until additional definitive evidence is established, it may be prudent to follow these patients with pelvic radiographs at 6 months and 1 and 2 years of age to better understand the extent of follow-up required for infants presenting with DDH risk factors.10Figure 1: Coronal flexion views of the right (A) and left (B) hip on the screening ultrasonography examination done at 6 weeks of age.Figure 2: AP pelvis radiograph, taken in supine at 4 months of age.Case 2 A 1-day-old male infant presents for his routine newborn examination. His birth was a cephalic presentation, and he has no family history of DDH. Physical examination raises suspicion of bilateral hip instability. You are consulted for the treatment of this patient: a male infant without defined DDH risk factors of breech presentation or family history but with potential bilateral hip instability on newborn examination. Of the four management options to consider, two are deemed Appropriate and two are deemed Rarely Appropriate (Table 2).Table 2: Case 2 Management Options and Appropriateness RatingThe management options considered Appropriate by the voting panel include the following: (1) obtain ultrasonography at 4 to 6 weeks of age or on presentation if the infant is older than 6 weeks and (2) referral to specialist. The median score for each of these management options was 8, with the panel reaching agreement, as defined by The RAND/UCLA Appropriateness Method User's Manual for a panel of 11 to 13 voting members. In this case, the panel thought that the potential bilateral hip instability warranted both a screening ultrasonography scan at 4 to 6 weeks of age and a referral to an orthopaedic specialist for follow-up and additional clinical assessment to ensure hip dislocation or dislocations were not missed. Early detection is key to reducing the need for complex treatment and optimizing clinical and functional outcomes. The panel found the following two management options to be Rarely Appropriate for this case: (1) continue routine well-baby exams only and (2) continue physical examinations and obtain single AP pelvis radiograph at 4 to 6 months of age. The median score for each of these options was 3, with the panel reaching agreement on both. Considering the potential presence of hip instability in this patient, neither of these options would allow for timely detection and management of dislocated or unstable hips. Missed early diagnosis could lead to the need for more complex treatment options for this patient later on, including surgical reduction with the potential additional need for acetabular and/or femoral osteotomies and revision surgeries later in childhood. In this particular case, the infant was referred to an orthopaedic specialist and received an ultrasonography scan at 8 weeks of age (Figure 3). He was diagnosed with a dislocated left hip and a normal right hip and was subsequently treated by Pavlik Harness for a total of 11 weeks (4 weeks full time, 3 weeks 23 hr/d, and 4 weeks weaning) until the hip normalized. An AP pelvis radiograph obtained at 6 months of age showed normal hip development (Figure 4).Figure 3: Coronal flexion views of the right (A) and left (B) hip on the diagnostic ultrasonography examination done at 8 weeks of age.Much debate and controversy exist over how best to screen, diagnose, and manage DDH; however, there is consensus that early detection and treatment is critical to reducing complications and optimizing outcomes for the patients in the long term. Overzealous screening practices, however, may also lead to overtreatment and excessive unnecessary follow-ups and use of resources. The challenge for the general pediatrician or referring physician is to balance the potential harms and benefits of early screening and referral programs. This AUC helps guide the practitioner in their decision-making process for managing patients with the potential for DDH.

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