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Background: Developmental dysplasia of the hip (DDH) is a common condition, affecting 1% to 2% of full-term infants. The American Academy of Orthopaedic Surgeons (AAOS) and American Academy of Pediatrics have published guidelines detailing best practices for DDH screening and treatment. The purpose of this survey was to determine DDH treatment practices of pediatric orthopaedic surgeons in North America., Methods: We queried orthopaedic surgeon members of the Pediatric Orthopaedic Society of North America (POSNA) about referral patterns, treatment practices, and use of DDH guidelines. The survey included demographics, clinical scenarios, referrals patterns, and ultrasound practices., Results: Of the 1392 members of POSNA, we received 432 total responses and included 353 in statistical analyses. Results show that 68% (233/342) of surgeons practice in an institution that does not endorse a standard care pathway for DDH. Of surgeons who personally use a DDH care pathway, the AAOS guidelines were most cited (143/353, 41%). The majority (94%, 316/337) of surgeons do not believe that universal ultrasound screening should be adopted in the United States. Responses regarding ultrasound screening for "high risk" infants as outlined by AAOS varied based on risk factor. Many (57%, 200/353) surgeons have performed initial evaluations for patients over 12 months of age. While 80% (260/327) of orthopaedic surgeons believe that primary care providers are referring patients appropriately, only 57% (183/323) believe that primary care providers are ordering imaging studies appropriately., Conclusions: Results from this survey of POSNA membership indicate an opportunity to better distribute and implement DDH guidelines. In addition, the implementation of a care map with a focus on standard referral and imaging practices could improve the care of patients with DDH by: (1) reducing the total cost of care, (2) increasing the use of appropriate imaging, (3) increasing timely referral for DDH care, and (4) reducing the presentation rate of walking age DDH patients., Level of Evidence: The level of evidence rating for this survey-based study is level IV.

The American Academy of Orthopaedic Surgeons has developed the Appropriate Use Criteria (AUC) for the Management of Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Intended for Use by Orthopaedic Specialists. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The Management of Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Intended for Use by Orthopaedic Specialists AUC clinical patient scenarios were derived from indications typical of patients presenting with developmental dysplasia of the hip in clinical practice. The 432 patient scenarios and three treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Next, a separate multidisciplinary, Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).

The American Academy of Orthopaedic Surgeons has developed the Appropriate Use Criteria (AUC) for 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. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. 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 AUC clinical patient scenarios were derived from indications typical of patients presenting with developmental dysplasia of the hip in clinical practice. The 24 patient scenarios and four treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Next, a separate multidisciplinary, Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).

Background: The burden of surgical treatment for infantile developmental dysplasia of the hip (DDH) is unknown. We aimed to investigate the epidemiology of operative DDH reductions in the United States and identify potential at-risk populations., Methods: The Healthcare Utilization Project Kids' Inpatient Database (1997 to 2012) were analyzed. International Classification of Diseases (ICD-9) codes identified inpatient hospitalizations for DDH reductions excluding neuromuscular cases. Hospital variables and patient demographics were captured. Weighted population-level counts were calculated to allow for national estimates., Results: An estimated 5525 (95% confidence interval, 4907.8-6142.2) operative reductions were performed. In total, 73.3% were open with a mean age at the reduction of 2.3 years (95% confidence interval, 2.1-2.5). In total, 70.0% were female and 42.3% were white. Regional distribution varied: 36.4% of reductions occurred in the West, 22.8% in the South, 21.9% in the Midwest, and 18.9% in the Northeast. Operative reductions decreased over time; open reductions decreased by 5.6% and closed by 53.4%. Mean age at treatment increased from 1.6 to 3.7 years (P<0.001). On multivariate analysis, age (P<0.001) and geographic location (P<0.05) were associated with open reduction. Patients in the West had increased odds of being Hispanic or Asian/Pacific Islander [odds ratio (OR), 4.9, P<0.001 and OR, 2.8; P=0.008]. In the South and Midwest, the highest income quartile was protective (OR, 0.4; P=0.001 and OR, 0.5; P=0.018)., Conclusions: The frequency of closed reductions decreased more over time compared with open reductions. However, the mean age of children undergoing reductions increased suggesting a possible delay in diagnosis. The data suggests that there is room for improvement in screening. Targeted research in identified populations may reduce the burden of surgical disease in infantile DDH., Level of Evidence: Level III.

Background: Recent literature has raised concern regarding the occurrence of late dysplasia after normal screening in breech babies. One paper states a late dysplasia incidence of 29%. This finding is in contrast with other published work, which suggests breech presentation is predictive of spontaneous stabilization of the unstable neonatal hip. We decided to identify the rate of late dysplasia after normal screening in our patient cohort and also to investigate the use of a prophylactic abduction diaper., Methods: During the study period of December 2012 to June 2014, breech babies referred to the screening program at our institution were identified. Ninety babies were prospectively enrolled into the study and randomized to either the observational arm or prophylactic treatment with the Healthy Hip Diaper (HALO, Minnetonka, MN). All babies had a normal initial clinical examination and ultrasound. Regular follow-up including clinical and ultrasound examination was undertaken culminating in pelvic x-rays performed at 13±1 months. A total of 63% of patients elected against their randomization to prophylactic treatment, 28% opted for prophylactic treatment against their randomization to observation only, meaning a total of 40% of babies proceeded against their initial randomization. In total, 75% of recruited babies completed follow-up. Dysplasia was defined as an acetabular index >2 SD from the mean sex, age, and side-specific values., Results: The overall rate of radiographic dysplasia at 13 months was 7.4%. The rate was 5% in those using a Healthy Hip Diaper and 8.3% in those under observation only. This was not a statistically significant difference. Two patients required operative intervention, one requiring capsulorraphy with acetabuloplasty, the other requiring an arthrogram. Overall compliance with the abduction diaper was low., Conclusions: We conclude that late radiographic dysplasia does occur after normal clinical and ultrasound screening in breech babies, although not to the same extent as recently published data. We cannot recommend prophylactic abduction devices for breech babies who have a normal hip ultrasound at 6 weeks of age. Consideration must be given to further clinical and radiographic follow-up for hip dysplasia when the risk factor of breech presentation is present., Level of Evidence: Level II-prospective comparative trial.

When a child presents with a dislocated hip after the walking age, parents are upset, pediatricians are distraught, and lawsuits often follow. The prevention of late presentation is a goal that all practitioners should strive for. However, at this time, using current diagnostic techniques, the late presentation of DDH can be minimized but not eliminated. The AAP Subcommittee on DDH has estimated that approximately 15% of DDH at birth is not detectible, even by experienced examiners or ultrasonographers. In addition to preventing the late presentation of a developmentally dislocated hip, the prevention of premature degenerative arthritis of the hip secondary to developmental subluxation and acetabular dysplasia is equally, if not more, important in terms or morbidity and cost. It is hoped that the identification and treatment of babies with DDH at birth will have the added benefit of decreasing the incidence of degenerative arthritis of the hip in adults. As the key to early detection remains repeated, careful examination of the infant in the first year of life, it is imperative for practitioners to become as skilled as possible in performing the exam. Unfortunately, medical school curricula and pediatric and family practice residency programs often are deficient in teaching the neonatal hip examination. Strategies for clinicians to improve their examination technique include asking a pediatric orthopedic surgeon to demonstrate the examination in their nursery or attending one of the AAP courses on DDH. Starting a formal DDH screening program in the nursery is another option, using few screeners to maximize their experience. Nurse practitioners, physician's assistants, and physiotherapists could be used in addition to physicians. Having a child present with a developmentally dislocated hip after the walking age is not malpractice if the child has had repeated careful examinations. It is important to document the examinations in writing, rather than placing a check mark next to "musculoskeletal" or "hips" on standard, pre-printed exam forms. The best documentation is a handwritten note that states "the hips are stable and there is wide symmetrical abduction" at every well-child visit. At this time, careful, repeated physical exam supplemented by ultrasonography or X-rays for babies with risk factors is our best strategy to minimize the late presentation of DDH.

Background: There are many examples of inadequate screening studies because of design faults and consent problems., Issues: Informed consent is the right of each person engaged in a clinical interaction, including service and research involvement in presymptomatic screening. Any screening approach must answer questions of efficacy, effectiveness, availability and efficiency. Accurate information, presented in clear language, must state a realistic assessment of the limitations, harms and benefits of the screening, including the consequences of false positive and false negative tests. There must be no coercive element in obtaining consent. Written and oral information should be presented. It is also important to recognize cultural differences between societies that emphasize individual autonomy and those in which autonomy derives from membership of a family, group or community, thus requiring different strategies to protect the vulnerable. Testing for genetic disorders presents additional challenges, partly due to the presence of relatively small numbers of affected individuals in the population, but also because of the complexity of counseling, confidentiality issues and the potential for social, insurance or employment discrimination., Conclusions: It is becoming increasingly difficult to present the data for many screening procedures in ways that can be understood by possible participants, and at the same time deal clearly with the costs to society and the efficacy and efficiency of the tests.