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Developmental Dysplasia of the Hip - Infant

Developmental dysplasia of the hip (infant)
Objectives
  1. Define developmental dysplasia of the hip
  2. Describe the pathophysiology of hip instability in the neurologically normal newborn
  3. Discuss the terminology for describing the newborn hip examination
  4. Discuss management of the newborn with clinical instability of the hip
  5. Describe complications of treatment of developmental dysplasia of the hip
  6. Discuss the role of ultrasound in the diagnosis and treatment of developmental dysplasia in the newborn
  7. Discuss "risk factors" which are associated with increased incidence of DDH in the newborn

Discussion points
  1. Is newborn hip screening worthwhile? If so, who should do it?
  2. Should all unstable hips be treated in the newborn? If not how do you decide which ones to treat?

Discussion
Developmental dysplasia of the hip (DDH) is a complex topic with a voluminous literature. It can be difficult to develop an overall perspective, as there are so many studies with conflicting conclusions, creating difficulties in comprehension for any who do not have extensive experience with the topic. Principles for treating DDH have changed dramatically in the past century, even the name has changed. The dogma for one generation of orthopaedists can become the anathema of the next. The following brief description will attempt to correlate portions of the recent literature with general concepts; much must be omitted. For a more comprehensive review of the classic literature, standard pediatric orthopaedic texts must be consulted.

Exam of the newborn hip consists of a clinical test of stability, essentially reproducing the mechanism of traumatic dislocation of the hip (posterior pressure on the adducted hip) in a gentle manner and attempting to feel a reduction with abduction of unstable hips. The terminology used to describe the exam should reflect the findings -normal or dislocatable. Some include the category of subluxatable, to denote hips with excess mobility that cannot be palpably dislocated. The term click is useless, a recent study of hips designated as "clicking" established that this described an incidental finding in normal hips.

Screening programs have been used more in countries with more socialized systems of health care; their effectiveness is still debated more than 40 years since their introduction. Certainly, some of the effectiveness is examiner dependent; a recent American Academy of Pediatrics committee found that orthopaedists were somewhat more reliable examiners than pediatricians, but not to the point of significance. The UK Medical Research Council Working Party on Congenital Dislocation of the Hip could find no evidence of reduction of surgical treatment of DDH as a result of screening programs. Recent papers from Australia and Bulgaria concluded the opposite. A small rate of late dislocation, which eluded screening exams, is present in almost all series. All agree that early diagnosis and treatment are desirable.

The role of ultrasonography is another unsettled topic. There is no question about the ability of ultrasonography to depict the anatomy of the newborn hip; the question still remaining is the definition of a normal hip. Ultrasonography screening consistently identifies more abnormal hips in screening programs than clinical exam, and of course interpretation of findings by the ultrasonographer results in further clouding of a reliable standard. Routine ultrasonography for all newborns is simply too expensive, many attempts have been made to find subsets of newborns would benefit from screening ultrasonography, results of these studies area also not conclusive. Nontreatment of clinically normal, ultrasonographically abnormal hips does not appear to result in subsequent hip dysplasia in this population.

It has long been known that over half of all unstable hips detected in newborns will spontaneously stabilize; suggestions have thus been made to withhold treatment in the newborn and initiate treatment only if the hip does not spontaneously stabilize. Based on the work of Barlow, this should happen in 2 weeks, but Barlow felt the treatment was so difficult when the dislocation was established that early treatment was best. Thus, many studies recommend a few days or a week of observation, and then initiating treatment. There is evidence that ultrasonography can be quite helpful, and superior to radiography, in assessing hip position when treatment is initiated; it is also valuable in documenting response or lack of response to treatment. A number of splinting devices have been proposed for treatment of the newborn with DDH; all place the hip in an abducted position. The Pavlik harness is presently favored, proper application is felt to be safe and effective. It is somewhat more complicated than other splints. A small rate of avascular necrosis has been documented even for treatment of the newborn hip; accounting for the reluctance of some to treat all unstable newborn hips. Duration of treatment in abduction splinting is obviously arbitrary; we know some hips are inherently more unstable than others, but a cookbook solution of 6 weeks or 3 months is a common recommendation for duration of treatment.

Pathologic studies of the unstable hip in the newborn are very rare. Certainly, capsular laxity is contributory in many cases; acetabular dysplasia at birth could be the additional factor in some hips rendering them more unstable and less inclined to spontaneous stabilization.
Risk factors associated with increased rates of DDH are Caucasian or American Indian race, female, breech presentation, oligohydramnios, other positional deformations at birth, and torticollis.

References
  1. Anonymous. Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics. Pediatrics 2000; 105( 4 Pt 1): 896-905.
  2. Bar-On E, Meyer S, Harari G, Porat S. Ultrasonography of the hip in developmental hip dysplasia [see comments]. Journal of Bone & Joint Surgery -British Volume 1998; 80( 2): 321-4.
  3. Barlow TG. Early diagnosis and treatment of congenital dislocation of the hip. J Bone Joint Surg (Br) 1962; 44: 292.
  4. Bialik V, Bialik GM, Blazer S, Sujov P, Wiener F, Berant M. Developmental dysplasia of the hip: a new approach to incidence [see comments]. Pediatrics 1999; 103( 1): 93-9.
  5. Bond CD, Hennrikus WL, DellaMaggiore ED. Prospective evaluation of newborn soft-tissue hip "clicks" with ultrasound. Journal of Pediatric Orthopedics 1997; 17( 2): 199-201.
  6. Chan A, Cundy PJ, Foster BK, Keane RJ, Byron-Scott R. Late diagnosis of congenital dislocation of the hip and presence of a screening programme: South Australian population-based study [see comments]. Lancet 1999; 354( 9189): 1514-7.
  7. Darmonov AV, Zagora S. Clinical screening for congenital dislocation of the hip. Journal of Bone & Joint Surgery -American Volume 1996; 78( 3): 383-8.
  8. Godward S, Dezateux C. Surgery for congenital dislocation of the hip in the UK as a measure of outcome of screening. MRC Working Party on Congenital Dislocation of the Hip. Medical Research Council [published erratum appears in Lancet 1998 May 30;; 351( 9116): 1664] [see comments]. Lancet 1998; 351( 9110): 1149-52.
  9. Hangen DH, Kasser JR, Emans JB, Millis MB. The Pavlik harness and developmental dysplasia of the hip: has ultrasound changed treatment patterns? Journal of Pediatric Orthopedics 1995; 15( 6): 729-35.
  10. Holen KJ, Tegnander A, Eik-Nes SH, Terjesen T. The use of ultrasound in determining the initiation of treatment in instability of the hip in neonates [see comments]. Journal of Bone & Joint Surgery -British Volume 1999; 81( 5): 846-51.
  11. Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000; 105( 4): E57.
  12. Mostert AK, Tulp NJ, Castelein RM. Results of Pavlik harness treatment for neonatal hip dislocation as related to Graf's sonographic classification. Journal of Pediatric Orthopedics 2000; 20( 3): 306-10.
  13. Paton RW, Srinivasan MS, Shah B, Hollis S. Ultrasound screening for hips at risk in developmental dysplasia. Is it worth it? [see comments]. Journal of Bone & Joint Surgery -British Volume 1999; 81( 2): 255-8.
  14. Song KM, Lapinsky A. Determination of hip position in the Pavlik harness. Journal of Pediatric Orthopedics 2000; 20( 3): 317-9.
  15. Sucato DJ, Johnston CE, 2nd, Birch JG, Herring JA, Mack P. Outcome of ultrasonographic hip abnormalities in clinically stable hips. Journal of Pediatric Orthopedics 1999; 19( 6): 754-9.
  16. Taylor GR, Clarke NM. Monitoring the treatment of developmental dysplasia of the hip with the Pavlik harness. The role of ultrasound. Journal of Bone & Joint Surgery -British Volume 1997; 79( 5): 719-23.
  17. Tegnander A, Holen KJ, Terjesen T. The natural history of hip abnormalities detected by ultrasound in clinically normal newborns: a 6-8 year radiographic follow-up study of 93 children. Acta Orthopaedica Scandinavica 1999; 70( 4): 335-7.
  18. Weinstein SL. Developmental hip dyplasia and dislocation. In: Morrissy RT, Wenstein SL, editors. Pediatric Orthopaedics. Philadelphia: Lippincott-Raven; 1996. p. 903-50.
  19. Wientroub S, Grill F. Ultrasonography in developmental dysplasia of the hip. Journal of Bone & Joint Surgery -American Volume 2000; 82-A( 7): 1004-18.
  20. Williams PR, Jones DA, Bishay M. Avascular necrosis and the Aberdeen splint in developmental dysplasia of the hip. Journal of Bone & Joint Surgery -British Volume 1999; 81( 6): 1023-8.

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