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AAOS Clinical Practice Guideline Summary

Detection and Nonoperative


Management of Pediatric
Developmental Dysplasia of the
Hip in Infants up to Six Months
of Age

Abstract
Kishore Mulpuri, MMBS, MS Detection and Nonoperative Management of Pediatric
(Orth), MHSc (Epi) Developmental Dysplasia of the Hip in Infants up to Six Months of
Kit M. Song, MD, MHA Age: Evidence-Based Clinical Practice Guideline is based on
Michael J. Goldberg, MD a systematic review of the current scientific and clinical research.
This guideline has been endorsed by the Society of Diagnostic
Kaitlyn Sevarino
Medical Sonography, the Society for Pediatric Radiology, American
Academy of Pediatrics, and the Pediatric Orthopaedic Society of
North America. The purpose of this clinical practice guideline is to
help improve treatment and management based on the current
evidence. This guideline contains nine recommendations, including
both diagnosis and treatment. In addition, the work group highlighted
the need for better research in the early diagnosis and treatment of
developmental dysplasia of the hip.

The purpose of this clinical practice


Overview and Rationale guideline is to help improve treatment
and management based on the current
The American Academy of Orthopae-
dic Surgeons (AAOS), with input from evidence.
representatives from the American This guideline differs from the AAP
Academy of Pediatrics, American technical report guideline methodol-
Academy of Family Physicians, Society ogy as developed in 2000.2 The AAP
of Diagnostic Medical Sonography, technical report guideline was based
and Society for Pediatric Radiology, on an extensive literature review and
From the University of British Columbia,
recently published its clinical practice expert opinion. The current AAOS
Vancouver, British Columbia, Canada
(Dr. Mulpuri), Shriners Hospital for guideline (CPG), Detection and Non- evidence-based guideline utilized
Children, Los Angeles, CA (Dr. Song), operative Management of Pediatric a rigorous, standardized methodol-
Seattle Children’s Hospital, Seattle, WA ogy that led to nine recom-
(Dr. Goldberg), and the American
Developmental Dysplasia of the Hip
Academy of Orthopaedic Surgeons, in Infants up to Six Months of Age.1 mendations based on the quality of
Rosemont, IL (Kaitlyn Sevarino). This CPG was approved by the AAOS the evidence. Review articles, text-
J Am Acad Orthop Surg 2015;23: Board of Directors on September 5, books, animal studies, and retro-
202-205 2014, and has been officially endorsed spective articles without appropriate
by the American Academy of Pediat- controls were not used in this
http://dx.doi.org/10.5435/
JAAOS-D-15-00006 rics (AAP), Pediatric Orthopaedic guideline, in keeping with utilizing
Society of North America, Society of the best available evidence. Each
Copyright 2015 by the American
Academy of Orthopaedic Surgeons. Diagnostic Medical Sonography, and recommendation included an indi-
the Society for Pediatric Radiology. cation of the strength of the evidence,

202 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Kishore Mulpuri, MMBS, MS (Orth), MHSc (Epi), et al

a rationale, and a brief discussion of seven recommendations are of limited identifying the natural history of clini-
potential risks or harms. strength and focus on early inter- cally unstable or ultrasonographically
Both this guideline and the 2000 vention and management of children or radiographically abnormal hips
AAP technical report2 support con- with DDH. The limited strength rec- detected in infancy with natural self-
tinuing clinical screening of children ommendations reflect the ambiguity correction over time. The natural his-
for developmental dysplasia of the in the literature resulting from center tory of DDH has been difficult to
hip (DDH). The 2014 AAOS CPG variations in screening, diagnosing, clearly delineate because of inconsis-
has several important differences and treating children with DDH. tent terminology used throughout the
from the 2000 AAP guideline. First, Substantial work remains to be literature to describe hip abnormali-
the target population is shifted from done to strengthen the existing evi- ties. Specifically, recognized abnor-
all normal infants up to walking age dence supporting recommendations malities of the hip in newborns
to include only those up to 6 months for the early detection and manage- and infants have not been fully char-
of age. The two most significant ment of DDH. Of the 3,990 citations acterized and categorized either as
recommendations are of moderate found in the peer-reviewed literature progressive and pathologic or as self-
strength and serve to inform the on the topic of DDH, 42 articles resolving. The natural history of DDH
screening process for detection of (1.05%) met the rigorous inclusion appears to be dependent on both the
DDH. Universal ultrasonography criteria required to be included as evi- type and severity of the hip abnor-
screening of newborn infants is not dence related to recommendations in mality, with mild dysplasia often
recommended; however, performing the guideline, and 18 (0.45%) met resolving without any evident clinical
an imaging study before 6 months of inclusion criteria for an assessment of manifestation. The natural history
age in infants with significant risk the natural history for DDH in studies reviewed for development
factors is recommended. Risk factors infancy. A concerted and collaborative of this guideline indicated that most
deemed significant by this analysis are research effort among the orthopaedic DDH cases discovered by clinical
breech presentation, family history, surgeon community will be required to examination or imaging study in
and a history of clinical instability. In improve the evidence and strengthen newborns represent hip laxity and
comparison, the 2000 AAP guideline the recommendations made in this immaturity. Sixty percent to 80% of
included sex of the infant as a risk guideline in a future update. clinically identified abnormalities and
factor and did not include history During the development of this 90% of ultrasonographic abnormali-
of clinical instability. The remaining guideline, the work group prioritized ties spontaneously resolved without

Dr. Mulpuri or an immediate family member has received research or institutional support from DePuy and serves as a board member,
owner, officer, or committee member of the Canadian Orthopaedic Association, the International Hip Dysplasia Institute, and the Pediatric
Orthopaedic Society of North America. Dr. Song or an immediate family member serves as a board member, owner, officer, or committee
member of the American Academy of Orthopaedic Surgeons, the Pediatric Orthopaedic Society of North America, and the Scoliosis
Research Society. Dr. Goldberg or an immediate family member serves as a paid consultant to BioMarin and serves as a board member,
owner, officer, or committee member of the American Academy of Orthopaedic Surgeons. Neither Ms. Sevarino nor any immediate family
member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or
indirectly to the subject of this article.
This clinical practice guideline was approved by the American Academy of Orthopaedic Surgeons Board of Directors on September 5, 2014.
The complete document, Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six
Months of Age: Evidence-Based Clinical Practice Guideline, includes all tables, figures, and appendices, and is available at http://www.
aaos.org/guidelines.
Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age Work Group:
Kishore Mulpuri, MBBS, MS (Orth), MHSc (Epi) (Chair), Kit M. Song, MD, MHA (Vice-chair), Richard Henry Gross, MD, Gary B. Tebor, MD,
John P. Lubicky, MD, Elizabeth Ann Szalay, MD, Charlotte Henningsen, MS, Norman Yoshinobu Otsuka, MD, H. Theodore Harke, MD,
Bonnie Zehr, MD, FAAP, Andrew Spooner, MD, Doug Campos-Outcalt, MD, MPA, W. Timothy Brox, MD (Oversight Chair), David S.
Jevsevar, MD, MBA (Chair, Committee on Evidence Based Quality and Value, Guidelines Oversight Chair), Kevin G. Shea, MD (Guidelines
Oversight Section Leader), and Kevin Bozic, MD, MBA (Chair, Council on Research and Quality). Additional Contributing members: Stuart L.
Weinstein, MD (Pediatric Orthopaedic Society of North America), Lynn Fordham, MD (American College of Radiology), Neil D. Johnson,
MBBS (Society for Pediatric Radiology), Patricia Fontaine, MD (American Academy of Family Physicians), Matthew Barrett Dobbs, MD
(AAOS), Brian Coley, MD (American Institute of Ultrasound in Medicine), William L. Hennrikus, MD (AAOS), Harish S. Hosalkar, MD
(Pediatric Orthopaedic Society of North America), Harold Philip Lehmann, MD, PhD (American Academy of Pediatrics). Staff of the
American Academy of Orthopaedic Surgeons: William O. Shaffer, MD, Deborah S. Cummins, PhD, Jayson N. Murray, MS, Mukarram
Mohiuddin, MPH, Peter Shores, MPH, Anne Woznica, MLS, Yasseline Martinez, and Kaitlyn Sevarino. Former AAOS Staff: Leeaht Gross,
MPH.

March 2015, Vol 23, No 3 203

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Practice Guideline Summary: Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age

treatment in early infancy. Conse- preferences, and rights. For treat- Implication: Practitioners should
quently, these findings raise important ment procedures to provide benefit, generally follow a Moderate recom-
questions regarding treatment deci- mutual collaboration with shared mendation but remain alert to new
sions, including the potential to over- decision-making between the patient information and be sensitive to
treat hips that may self-correct, and her or his physician/allied patient preferences.
optimal treatment timing, and course healthcare provider is essential.
of treatment action. In contrast, severe A Strong recommendation means Imaging of the Unstable Hip
dysplasia can present clinically during that the quality of the supporting
infancy and adversely affect normal evidence is high. A Moderate recom- Limited evidence supports that the
hip growth and development, extend- mendation means that the benefits practitioner might obtain an ultra-
ing through childhood into adulthood. exceed the potential harm (or that sound in infants less than 6 weeks of
Interventions to ameliorate the natural the potential harm clearly exceeds age, with a positive instability exam-
history of DDH have depended upon the benefits in the case of a negative ination to guide the decision to initi-
the severity of dysplasia and on the recommendation), but the quality/ ate brace treatment.
age of diagnosis or presentation. applicability of the supporting evi- Strength of recommendation:
Bracing during infancy can be an dence is not as strong. A Consensus Limited.
extremely effective treatment option; recommendation means that expert Implication: Practitioners should
however, more drastic manipulative or opinion supports the guideline feel little constraint in following
surgical measures may be necessary as recommendation even though there is a recommendation labeled as Lim-
severity or age advances. The recom- no available empirical evidence ited, exercise clinical judgment, and
mendations in this CPG serve to pro- that meets the inclusion criteria of be alert for emerging evidence that
vide guidance to the practitioner on the guideline’s systematic review. A clarifies or helps to determine the
these specific issues. Limited recommendation means that balance between benefits and poten-
there is a lack of compelling evidence tial harm. Patient preference should
that has resulted in an unclear bal- have a substantial influencing role.
Recommendations ance between benefits and potential
harm. Imaging of the Infant Hip
This summary of recommendations Limited evidence supports the use of
of the AAOS Detection and Non- an AP pelvis radiograph instead of an
operative Management of Pediatric
Universal Ultrasound
Screening ultrasound to assess DDH in infants
Developmental Dysplasia of the Hip beginning at 4 months of age.
in Infants up to Six Months of Age Moderate evidence supports not Strength of recommendation:
contains a list of the evidence-based performing universal ultrasound Limited.
treatment recommendations for the screening of newborn infants. Implication: Practitioners should
practicing physician. Discussion of Strength of recommendation: feel little constraint in following
how each recommendation was Moderate. a recommendation labeled as Lim-
developed and the complete evidence Implication: Practitioners should ited, exercise clinical judgment, and
report are contained in the full generally follow a Moderate recom- be alert for emerging evidence that
guideline, available at www.aaos. mendation but remain alert to new clarifies or helps to determine the
org/guidelines. Readers are urged information and be sensitive to patient balance between benefits and poten-
to consult the full guideline for preferences. tial harm. Patient preference should
the comprehensive evaluation of have a substantial influencing role.
the available scientific studies. The
recommendations were established Evaluation of Infants with
using methods of evidence-based Risk Factors for DDH Surveillance after Normal
medicine that rigorously control for Moderate evidence supports per- Infant Hip Exam
bias, enhance transparency, and forming an imaging study before Limited evidence supports that
promote reproducibility. 6 months of age in infants with one or a practitioner re-examine infants
This summary of recommendations more of the following risk factors: previously screened as having a nor-
is not intended to stand alone. Med- breech presentation, family history, mal hip examination on subsequent
ical care should be based on evidence, or history of clinical instability. visits prior to 6 months of age.
a physician’s expert judgment, and Strength of recommendation: Strength of recommendation:
the patient’s circumstances, values, Moderate. Limited.

204 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Kishore Mulpuri, MMBS, MS (Orth), MHSc (Epi), et al

Implication: Practitioners should brace treatment for hips with a posi- Monitoring of Patients During
feel little constraint in following tive instability examination. Brace Treatment
a recommendation labeled as Lim- Strength of recommendation:
Limited evidence supports that the
ited, exercise clinical judgment, and Limited.
practitioner perform serial physical
be alert for emerging evidence that Implication: Practitioners should
examinations and periodic imaging
clarifies or helps to determine the feel little constraint in following
assessments (ultrasound or radio-
balance between benefits and poten- a recommendation labeled as Lim-
graph based on age) during manage-
tial harm. Patient preference should ited, exercise clinical judgment,
ment for unstable infant hips.
have a substantial influencing role. and be alert for emerging evidence
Strength of recommendation:
that clarifies or helps to determine
Limited.
the balance between benefits and
Stable Hip with Ultrasound Implication: Practitioners should
potential harm. Patient preference
Imaging Abnormalities feel little constraint in following
should have a substantial influenc-
a recommendation labeled as Lim-
Limited evidence supports observation ing role.
ited, exercise clinical judgment, and
without a brace for infants with a clin-
be alert for emerging evidence that
ically stable hip with morphologic
Type of Brace for the clarifies or helps to determine the
ultrasound imaging abnormalities.
Unstable Hip balance between benefits and poten-
Strength of recommendation:
tial harm. Patient preference should
Limited. Limited evidence supports use of the
have a substantial influencing role.
Implication: Practitioners should von Rosen splint over Pavlik, Craig,
feel little constraint in following or Frejka splints for initial treatment
a recommendation labeled as Lim- of an unstable hip.
References
ited, exercise clinical judgment, and Strength of recommendation:
be alert for emerging evidence that Limited. 1. American Academy of Orthopaedic
Implication: Practitioners should Surgeons: Detection and Nonoperative
clarifies or helps to determine the
Management of Pediatric Developmental
balance between benefits and poten- feel little constraint in following Dysplasia of the Hip in Infants up to Six
tial harm. Patient preference should a recommendation labeled as Lim- Months of Age. http://www.aaos.org/
research/guidelines/DDHGuidelineFINAL.
have a substantial influencing role. ited, exercise clinical judgment, and pdf. Accessed September 5, 2014.
be alert for emerging evidence that
2. American Academy of Pediatrics: Clinical
clarifies or helps to determine the practice guideline: Early detection of
Treatment of Clinical balance between benefits and developmental dysplasia of the hip.
Instability potential harm. Patient preference Committee on Quality Improvement,
Subcommittee on Developmental Dysplasia
Limited evidence supports either should have a substantial influenc- of the Hip. Pediatrics 2000;105(4 pt 1):
immediate or delayed (2 to 9 weeks) ing role. 896-905.

March 2015, Vol 23, No 3 205

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.