AAOS Appropriate Use Criteria: The Management of Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Intended for Use by Orthopaedic Specialists

Developmental dysplasia of the hip (DDH) is the most common pediatric hip condition and 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. Early detection and treatment of DDH is critical to reduce the need for complex surgical procedures and optimize long-term patient functional and quality of life outcomes.2 Consequently, screening programs involving clinical examination and/or ultrasonography are in place across many countries in an attempt to reduce the burden of late-diagnosed DDH. Much controversy and practice variability exist, however, in detection, diagnosis, and management of DDH, largely arising because of the lack of high-quality evidence available to guide practitioners. The spectral nature of the condition also adds to the complexity of diagnosis and management decision making and as such has 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) for Management of Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Intended for Use by Orthopaedic Specialists.3 These AUC were 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 Surgeon Clinical Practice Guideline on the Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age4 and collective expert opinion on topics for which randomized clinical trials were not available or of adequate quality. These criteria attempt to address the most common clinical scenarios facing appropriately trained orthopaedic specialists, with the intention of supplementing, not superseding, clinical expertise, experience, and patient preference in individual situations. The purpose of the following case studies is to present two clinical scenarios commonly faced by the orthopaedic specialist and present management and treatment options based on the AUC guidance tool available here. The indications and classifications for management of these cases are discussed in the DDH AUC summary for orthopaedic specialists. Case 1 A 6-week-old female infant was referred to the orthopaedic clinic after pediatrician noticed a dislocatable left hip at her well-baby routine examination. She has cephalic presentation at birth and no family history of DDH. Ultrasonography showed bilateral dysplastic hips (Figure 1), and physical examination confirmed a Barlow-positive (dislocatable) left hip. You are consulted for management of this patient: a 6-week-old female infant referred for a dislocatable hip with ultrasonography findings of bilateral dysplasia. An AP pelvis radiograph was not obtained because of the patient's age. Of the three management options to consider, one is deemed Appropriate, one is deemed May Be Appropriate, and one is deemed Rarely Appropriate (Table 1).Figure 1: Coronal flexion views of the right (A) and left (B) hips on the diagnostic ultrasonography examination performed at age 6 weeks.Table 1: Case 1 Management Options and Appropriateness RatingThe management option considered Appropriate by the DDH AUC Voting Panel is to instate treatment with an abduction orthosis of choice. 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.5 Agreement is considered to be achieved when three or fewer panelists rate the treatment outside the 3-point range containing the median. This level of agreement indicates that based on the current literature, this management approach can provide a good outcome, and the practitioner should feel comfortable proceeding in this manner after discussion with the patient family. The management option considered Rarely Appropriate in this case was to perform a surgical intervention (eg, closed reduction, arthrogram, open reduction). The median score for this management option was 1, with the panel reaching agreement. Given that the patient has a dislocatable or unstable hip, rather than a dislocated hip at rest, surgical treatment is likely to be excessive at this stage of her development, and it would therefore be rare to proceed with such a procedure. Repeating the clinical examination and ultrasonography/radiograph (age dependent) was deemed May Be Appropriate, with a median score of 5. Neither agreement nor disagreement was reached among the voting panel for this option. The scoring of this management option reflects the practice variability inherent among orthopaedic specialists because little high-quality evidence is available to suggest that abduction orthosis treatment of an unstable but not dislocated hip provides superior outcomes to continued clinical and radiologic monitoring. The risk of this choice is that it may delay treatment of a hip that remains persistently unstable; however, it may prevent unnecessary treatment of a hip that spontaneously stabilizes as the hip joint matures during early development. In this particular case, after confirmation of bilateral dysplastic hips and a dislocatable left hip by the orthopaedic surgeon, she was treated by Pavlik harness for a total of 17 weeks (ie, 3 weeks of full-time wear, 8 weeks of 23 hr/d wear, and 6 weeks of weaning with night-time wear). She was serially monitored with clinical and ultrasonography examinations throughout brace treatment, and an AP pelvis radiograph obtained at age 5 months showed stable hips and normal acetabular development (Figure 2). There is planned follow-up at age 1 year.Figure 2: AP pelvis radiograph, taken in the supine position at age 5 months.Case 2 A 9-day-old female infant is referred to an orthopaedic surgeon after a finding of hip instability on her newborn examination. Clinical examination showed that she had a dislocated reducible (Ortolani-positive) left hip and a stable right hip. Ultrasonography showed bilateral dysplastic hips with alpha angles of 45° and 49° and percent coverage of the femoral head of 20 and 50 for the left and right hips, respectively (Figure 3). You are consulted for management of this patient: a 9-day-old female infant referred for left hip reducible dislocation and bilateral dysplastic hips. Of the three management options to consider, one is deemed Appropriate, one is deemed May Be Appropriate, and one is deemed Rarely Appropriate (Table 2).Figure 3: Coronal flexion views of the right (A) and left (B) hips on the diagnostic ultrasonography examination performed at age 9 days.Table 2: Case 2 Management Options and Appropriateness RatingThe management option considered Appropriate by the DDH AUC Voting Panel is to instate treatment with an abduction orthosis of choice. The median score for this management option was 9, 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.5 This level of agreement indicates that based on the current literature, this management approach can provide a good outcome, and the practitioner should feel comfortable proceeding in this manner after discussion with the patient family. The management option considered Rarely Appropriate in this case was to perform a surgical intervention (eg, closed reduction, arthrogram, open reduction). The median score for this management option was 1, with the panel reaching agreement. Although the patient has a dislocated hip, the age of the infant combined with the reducibility of the dislocation makes abduction orthosis a preferred first-line management option before attempting any surgical treatment, and it would therefore be rare to proceed with such a procedure immediately. Repeating the clinical examination and ultrasonography/radiograph (age dependent) was deemed May Be Appropriate, with a median score of 4. Neither agreement nor disagreement was reached among the voting panel for this option. Practice variability exists among orthopaedic specialists with regard to this treatment option. In an infant as young as this patient, hip instability may resolve spontaneously as the hip joint matures and develops, although it is less likely to occur when the hip is dislocated at rest. In this particular case, after confirmation of bilateral dysplastic hips and a dislocated reducible left hip by the orthopaedic surgeon, she was treated by Pavlik harness full time for 6 weeks and then switched to a Rhino Cruiser for ease of parental care. Full-time Rhino Cruiser wear for 6 weeks was followed by 10 weeks of weaning with night-time wear. Brace wear was discontinued after normalization of both hips. She was serially monitored with clinical and ultrasonography examinations throughout brace treatment, and an AP pelvis radiograph obtained at age 9 months showed stable hips and normal acetabular development (Figure 4). There is planned follow-up at age 18 months.Figure 4: AP pelvis radiograph, taken in the supine position at age 9 months.Great practice variability exists among orthopaedic specialists on the treatment and management options of diagnosed DDH. Early diagnosis and treatment reduces complications and maximizes the potential for normal hip joint development throughout infancy and childhood. However, little strong comparative evidence exists to suggest the superiority of one treatment option over another.6 This has been particularly complicated by the severity spectrum of DDH. The challenge for the orthopaedic specialist is to balance the potential complications of bracing or surgical treatments with the benefits of early treatment to achieve and maintain a stable hip. The purpose of these AUC is to help guide the practitioner in their decision-making process for managing patients referred to them for DDH.

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