Early detection and treatment of DDH, the most common orthopedic disorder in newborns, have major value, generally preventing the need for surgery and protecting joint health down the line. With a focus on infants, this presentation from pediatric orthopedic surgeon Sanjeev Sabharwal, MD, MPH, covers risk factors for the condition (including one surprising factor that's easily modified); which screening techniques are best for children of different ages; and application of bracing devices, such as the Pavlik harness. Sabharwal explains physical exam maneuvers and walks providers through using an app (developed by the AAOS) that helps with making appropriate decisions on testing and referrals.
Um, so my charge today is to talk a little bit about best practices for hip dysplasia. And I purposely, you know, didn't say recommendations for primary care cause I think end of the day, uh, uh, the data is such that we have to have, you know, some reflections and then assimilate knowledge and then see what's right for each individual patient, uh, that we encounter, uh, in the clinic or outpatient setting. Um, so I'm assuming the target audience here is primary care pediatrics, and for the most part, I'm gonna focus on Newborns and infants uh with hip dysplasia or children who need some screening and or surveillance for developmental dysplasia of the hip. And again, we're not gonna talk about stuff like uh hip pathology related to neuromuscular disorders such as cerebral palsy. Uh, Peres's disease, etc. etc. This is simply developmental dysplasia of the hip, uh, previously called congenital dysplasia of the hip. Uh, OK, I'm gonna start with a case. This was an 8 day old child who was referred to me. Um, by a pediatrician, um, because, uh, they found that, uh, the child had very limited hip abduction bilaterally. And, and I'm starting with this case because it's a success story. Not all of these are success stories. So, and it kind of breaks a couple of the screening rules, uh, in that, you know, she's only 8 days old, she's not 4 weeks, etc. uh, in terms of, you know, what the textbook is for. Um, getting the first screening ultrasound, and we can talk about it in the discussion section, um, but we got an ultrasound which shows, uh, essentially dislocated hips bilaterally. Um, but these were, uh, reducible or relocatable in the clinic, uh, so they were Odolani positive hips. Um, and this is a, uh, screenshot, uh, from the chart, uh, from our electronic medical record, you know, where we list all the risk factors or some of the risk factors. And so, yes, she was female but not breech, not first born, and she didn't have a positive family history in, um, in terms of prior hip dysplasia or hip pathology. Um, so she was treated in a pavvic harness, which is a dynamic brace, as you know, and we've got sequential images of the ultrasound. Uh, the one on the top is, you know, a few weeks out, maybe 4 weeks out, and then another couple of months later, and you can see the hips gradually reducing and settling down the Alpha angle is improving over time and it's nearly normalized. And this to the right is another snapshot of uh her electronic medical record, which shows that she was very uh compliant. The family was very compliant in using the Pavlik and then rhino is really uh one of the Fixed abduction orthosis which we used uh as she became slightly older and you know, the column in the middle where it says numbers recommended and numbers used based on, you know, their answering the question, how many hours did you use it, it was pretty um spot on. So I think the family was very compliant. And the images showed good progression. And as we discontinued the brace, you can see sequential X-rays over almost 4 years' time, you know, starting with the top left, you can see the hips. Although you can see the proximal femoral epiphysis at that young age, you know, the metaphysis is pointing towards um the acetabulum, and then these uh acephic nuclei, you know, appear somewhat asymmetrically, which is fine. And then if you look at the slope of the acetabulum, you can see if let's say you compare the top left to the bottom right, and you just look at the slope of the acetabulum. You can see that it's sort of come down and what's called the sour seal, uh, which is the eyebrow in French, uh, is not raised anymore, whereas it was raised on the top left. So this is really a success story. She did not need an operation. She just needed bracing and she was picked up at, you know, 8 days of age, um, thanks to a pediatrician who was astute. So, if you look at, you know, DDH, it's a catch-all term, and it's a spectrum, right? So it goes from very mild dysplasia, where the ball is in the socket, the hip is stable, but the morphology of the acetabulum is such that it's not deep enough. And then as you progress in terms of severity. You can see that the, you know, the acetabulum can get more steep, um, the hip can be unstable, um, it can be dislocatable, um, it can be dislocated and relocatable, meaning it's sitting out and then can be brought in, which is Ortolani positive. The one before that would be a barlow positive, and we'll go into that in a second, uh, where the hip is sitting in, uh, meaning the femoral head is sitting in the socket. And can be dislocated, that would be Barlow positive and dislocated, but reducible would be Ortolani positive. And then finally, where the hip is out and cannot be reduced, and that would be an irreducible dislocation. And really we see them all. Um, so just to, you know, briefly summarize how common is DDH. It is the most common orthopedic disorder in the newborn. If you look at, you know, all comers and what we see in the clinics, uh, when it comes to an orthopedic exam or orthopedic referrals uh in neonates, um. The There are estimates, and some of it is because we don't have universal screening, uh, in terms of imaging, uh, in North America, uh, so the, the estimates are somewhat unknown, um, but based on a bunch of studies, if you were to think of round numbers, I would say morphologically, uh, hip dysplasia is about 1 in 100, uh, hip dislocation is 1 in 1000. Um, and you know, this is an interesting figure. 5 to 7% of children in one study that got a hip ultrasound, um, in the first few weeks of life ended up getting treated, um, with some kind of a brace typically. Um, it is more common in females. 61 is the general number that's thrown around. It is um less common in African Americans. And due to intrauterine positioning, as you know, the left occiput anterior is the more common, uh, positioning, uh, in utero for the life of the child. Um, and so interestingly, the left sided DDH is more common and same way, you know, tibial torsion club foot, a lot of these lower extremity, uh, packaging problems are more common on the left and the right. Um, it can be bilateral in 20%. And other risk factors. So what I have. In bold are the ones that, you know, people talk about when they talk about algorithmic approach to screening, etc. etc. um, but then there are these other ones which also have, you know, a higher predisposition for hip dysplasia. So, you know, 3rd trimester breach, even if the child flips in the last few days is considered a risk factor. Family history and primarily, you know, uh first degree relatives, so parents and siblings, uh, improper swaddling, which I don't think many people think or talk about it, but that's been out there. Um, if the child has been swaddled with the leg straight and wrapped kind of snugly for several days to weeks, um, some people consider that as a risk factor. On exam, if there is limited hip abduction, uh, which is asymmetric or symmetric. And if there's a history of clinical instability, uh, that somebody else felt, uh, even if you don't feel it currently, I think that in itself is a risk factor. So you've got to You know, um, look at everything including their past exams. Uh, crowding phenomenon for obvious reasons such as lego hydramnias, multiple pregnancy, uh, well, uh, twins or triplets, etc. a large size baby, first born, as you can read, metatarsus ductus protoolis, and congenital hyperextension of the knee. Now, on the top right, you see a picture and that was a little bit of a news to me that it's not just breach, but it's like, what was the position when uh the baby was delivered or in the last trimester, you know, were the knees and hips flexed or were the knees hyperextended? So that the one on the right is a frank breech where the knees are extended and the hips are flexed. And I think that's the one that has that 20%. Uh, prevalence of uh DDH. Um, having said that, I think any breach positioning is still a risk factor for uh DDH and should be appropriately screened. And then, you know, in terms of carrying the child and swaddling, you could still have the parents swaddle the child but not with the legs uh sort of a deducted altogether but spread apart and there's, you know, a few videos out there on YouTube and different. Uh, websites which actually go over, um, you know, the correct technique, uh, what's called a hip safe swaddling technique, uh, and then same way when the parents are carrying a child, you know, that imposition where the legs are flexed and abducted at the hips is more hip friendly than if the legs are together. On physical exam, it's somewhat related to the age. Uh, in a younger child, first few days or weeks of gestation, um, you're gonna be able to, uh, sometimes feel hip instability with the Barlow and the Ortolani. And, you know, I know we talk about this a lot. There are some videos out there too, um, but a Barlow is done with the hip. Barlow is a provocative test. Meaning the hip is in and you flex the hip 90 degrees, 80 duct and then put a downward pressure and you want to see if the hip comes out. And if, if it is, then, you know, you'll get a palpable sensation or a clunk that the hip dislocated or subluxed. And to relocate, uh, and it's really, you know, they're not. Two separate tests. You kind of do it one following the other in the same sequence. So you kinda do the Barlow and then you abduct the hip and you see if it's out, um, then you push it back in. So that's where the abduction and a little pressure on the greater trochanter to relocate it. Um, another very um simple test is to look for asymmetry. With regards to hip abduction. Um, now, you can sometimes get fooled because sometimes, um, children are born and they have limited hip abduction, which improves over time and the hip is fine. Also, if there is bilateral hip dislocation, uh, which we see, you know, like we said, about 20% of the time, sometimes, um, there will be no legland difference, there'll be no asymmetry with regards to hip abduction. Yet the child has not one but both hips that are dysplastic and are dislocated. Um, asymmetric thigh creases is another sign that in the past people were like that has absolutely no relevance. Then there were a couple of studies from Southern California, uh, San Diego area that stated that sometimes that actually does help and leads to treatment in children with asymmetric hip creases, hip creases. So I think that's one of the problems when we talk about recommendations and surveillance and screening that you've got data that's somewhat conflicting sometimes. So, you know, you've got to use the best judgment uh for that particular case and your um clinical relevant situation. Uh, to sort of come up with, uh, what's right. And we'll go over some, you know, other ways algorithmically where you can, um, you know, figure out what the next steps are. Terminology can be confusing, you know, when we talk of age, this is important for all the guidelines. They're basing it on the corrected gestational age. So if a baby was born 5 weeks early, you've got to add those 5 weeks to the current chronologic age in terms of, you know, when to get the ultrasound, what numbers to look at, etc. etc. So I think that sometimes gets lost in terms of when, um, let's say someone's ordering a first hip ultrasound and we'll get into the age, so let's say it's gonna be 6 weeks of gestational age. So obviously, you add the 6 weeks to um a child's age if they were born several days or weeks early. This whole thing about click and clunk, I know some of it is semantics. Uh, it actually started, um, in the Italian literature when, um, you know, this was described as a clunk, um by I think Ortolani, uh, but for practical purposes. A clink, a click is not pathologic. It's either because there's a little fascia, a fascia ladder or something that sort of rubs as you move the leg, um, versus a clunk is more pat pathognomonic of hip instability. Now, we talked about Ortolani positive hip, which again is in that same spectrum. Uh, Odolani positive hip hip is more severe than a Barlow positive hip in the sense that Odolani, the hip is out and you're trying to relocate it, whereas in Barlow positive hip, the hip is sitting in the socket but can be dislocated. There is some confusion in terminology because, you know, Ortolani Barlow negative hips, you would think is only if the hip is normal and stable, uh, maybe not normal, normal, but not, um, the hip is in the socket. But if the hip is irreducible and dislocated, then that's also you're gonna have a negative ortolani and a Barlow test. So you just have to, you know, think about it. And sometimes it's better to just spell it out in the EMR as opposed to just write Ortolani Bardo if the hip is, uh, you think is dislocated and not reducible. Talked a little bit about the Galeaty sign which is looking for leg lengths, looking at the level of the knees when both hips are equally flexed, and then you look at the level of the knee. Now that again can have false positive and false negative. If The false positive would be that the hip is in the socket, but yet you have asymmetry with regards to the um knee heights, and that's partly, could be because of a short congenitally short femur, right? So if you have a short femur, you know, you'll have a positive galeatsy. You can have a false negative if both hips are out and equally out, then the Galleosy may be negative. We also, you know, come across measurement variability with any imaging, and that's not surprising, and that becomes more of an issue in hip dysplasia, especially now that, you know, patients and families can look at their own EMRs and radiology reports, and I think that sometimes becomes a problem because the radiologist may read a certain imaging study like an ultrasound. With certain specific numbers and the orthopedic surgeon or the pediatrician may look at it and have different numbers. So now, you know, for our radiologist, we actually have a little um line at the end which sort of is a disclaimer that basically says that there could be measurement variability. And I think that hopefully, you know, address some of these, uh, you know, frantic calls from family saying how come you guys don't agree on the numbers? I don't think I need to go, go into the details of how to read an ultrasound, but if you're interested, there's lots of good videos and uh pictures out there. There's a lot of good review articles. Um, but I'll tell you that uh we do like in orthopedics, we do measure some angles, uh, and you'll come across an alpha angle, a beta angle, percentage coverage, you know, is the ultrasound done with stress or without stress? And um there were sort of two, there was an evolution in this, right? So graph from Europe um uh started these morphological uh numbers and, you know, classified hips into 1 through 4 for ultrasound. And a normal alpha angle was 60 or greater. A normal beta angle was 55 degrees or less. And then Harkey from um uh from um the east coast from DuPont. Um, came up with a dynamic test to look at more the provocative test like doing a Barlow and an Orani maneuver, uh, with ultrasound imaging. So, and now we kinda use both. We use the hard numbers from graph, but we also look at hip instability based on provocative maneuvers if we do a hip ultrasound with stress. Um, You know, again, for the most part, um, the pelvic harness is applied, at least in North America, um, by the orthopedic surgeon, but it certainly can be applied um by the primary care specialist if they're comfortable with it. Um, again, there's a lot of resources in terms of how to apply it, how not to apply it, uh, and it's, it's honestly not that hard to do. Um, so that's Pavlik is a dynamic brace, meaning that the kid can kick their legs, um, the diapers can be changed without undoing the straps. Um, so it's sort of our go to, uh, for children who are younger than 6 months of age and have active knee extension and are not neuromuscular. Um, sometimes for special circumstances. In this younger age, we will use a fixed abduction orthosis and there's multiple types of those. Um, and then I just want to touch on this thing about double diapering, triple diapering. Um, so there's lots of literature out there that says triple diapers don't work. And while that's true, I must confess that there are times when I will do a variation of that triple diaper. And what I would do is, uh, and those will be patients who are too young or too mild for a harness. But I'm just waiting. So what I'll have the families do is have them put a regular diaper first and then take one or two clean diapers and roll them and then put it on top of the first diaper and then put another diaper, a third diaper, if you will, on top of that rolled diaper, which is in the perineum and all that does is it's a soft way of preventing the legs from coming together. And I feel like that's better than doing nothing. Well, yes, that's not a substitute for a real brace. I think it's a nice tweener while you and the family are waiting for the next ultrasound if you're not sure which way to go. And, and I think for the most part, families like that as opposed to saying we don't know, we're not gonna do anything, let's just do another ultrasound in next number of weeks, which is also fine, but I think in some circumstances. Um, it's not a bad way to go. There are some commercial products out there that kind of simulate this sort of, uh, triple diapering if you will, and I hid the name for obvious reasons, but, uh, you know, you could see it on that bottom right. X-rays again, um, I don't think uh we need the primary care physicians to independently just measure all the lines and angles, but just so that uh you're familiar with them, uh, an acetabular index of 30 or greater, I'm sorry, 30 or less at birth is good. And then we said 24 at 24, 24 degrees at 24 months. That's just a ballpark of the acetabular index, which is this line, um, which is the angle between these two lines, the horizontal line, uh, which connects the tri-radiate cartilage on the two sides, which is the Hilgen-reiner's line, and then this uh stipple red line which is along the edge of the acetabulum. Uh, and that ends at the Hilchoriers line, um, on the outside of the tri-radiate cartilage. So that angle is the Stabular index. And there are some more nuances to imaging classification, IHDI which is the International hip dysplasia, um. The Institute, um, has a classification, goes 1 through 4. we use that often and I think it's very reproducible, so this is just another way of quantifying where the proximal femur is in relationship to the acetate. So, you know, going to screening, you know, general principles are that a condition needs to be important and, you know, you've got to think of this in the context of hip dysplasia and in your mind you're like, OK, check or cross. So, OK, is this condition important? I think it is an important problem because There are a lot of studies in adult arthroplasty literature where they've said that a very sizable percentage of adult patients that need a hip replacement at an earlier age have evidence of hip dysplasia that was never treated or was treated. Um, so it's common, it's a problem if it's untreated. Uh, it is common. We talked about the prevalence. Um, does it have a readily available and acceptable treatment? And the answer is yes. You know, starting with early treatment with bracing, I think there is efficacy, it's not 100%, but certainly it's better than the natural history if done appropriately. Um, so I think that definitely you can alter the natural history by early diagnosis and early treatment. Um, moreover, Early treatment leads to better outcome with less aggressive treatment, i.e., you avoid an operation if you have to do an operation, it's a simpler operation, uh, less invasive, etc. etc. So I think it sort of meets all these criteria and then the test itself should be accurate, have a reasonable cost, and be acceptable to patient and society. And I think it gets a little muddied here, depends on the size of the population, the healthcare system, and um the prevalence uh in that uh part of the community or the country or the region. So I can tell you like universal um clinical exam for hip instability or hip dysplasia is, is still recommended. It it is recommended um in North America as well. Um, and that is up to age 2 years, meaning every time you do a well baby check or you're seeing the child in the newborn nursery, please examine the hips for instability. Um, but universal ultrasound screening is not recommended in North America, whereas it is in some of the smaller countries in Europe. Um, so I'm just gonna, um, some of these slides are gonna be busy, but I just want you to get an idea of what some of the other countries do in terms of guidelines for screening and surveillance, uh, for hip dysplasia. And it's not very different than what's recommended in North America, um, but there is some variation. So this is from Australia, uh, and again, screening means like the first time. You examine the child either radiographs or clinical or both? Sorry. And surveillance is then how do you, what do you do for follow-up? Uh, so I'm not gonna read the whole thing, but I think there's screening, there's surveillance, and then there is urgent referral to pediatric orthopedics. If the hip is unstable, if there's limited hip abduction, if you see legle difference, or there is abnormal ultrasound or X-ray. So it's pretty general, but I think it's pretty straightforward too. Uh, this gets busier, but this is closer to home. So this is, um, you know, this was a recent paper in Journal of Pediatrics where they asked a bunch of pediatric practices, you know, what they do in terms of their care pathways or hip dysplasia. And you could take a screenshot if you want, but um this is sort of, I'm not gonna run through every little bit of it because you've got something else coming up where we can do it together uh live uh in terms of, you know, what test to order, when for which patient, but I think this is a good one where, you know, it seems like Four-ish weeks, you know, gestational age seems to be a cutoff, that if the baby is under 4 weeks now, you know, the confusion comes, is it 4 weeks, is it 6 weeks? Honestly, we use 6 weeks or at least I use 6 weeks, uh, but, you know, 4 weeks is not the wrong answer by any stretch. It depends on the clinical situation. But if you want to minimize, you know, uh, overtreatment, I think 6 weeks is probably safer for the first ultrasound. Um, and so you could look at, you know, when to refer, when to get an ultrasound, and when to get an X-ray. Um, so usually, uh, and it'll come up in the upcoming slides, but we say an ultrasound around 8 to 6 weeks, gestational age, and a follow-up x-ray around 8 to 6 months. Um, so that's sort of, you know, if you just remember 6. Yeah, I think it's easy. 6 weeks for ultrasound, 6 months for x-rays. So this is the 3rd algorithm which again is from this International hip dysplasia Institute IHDI which looks at info and research from different parts of the world and that's why I think it's a little bit more generic in the sense that. They asked the question, do you have any trained staff that's accessible? Do you have ultrasound that's available? But I think if you just say yes to those two things, this is a pretty decent um algorithm, uh, for, you know, triaging and screening uh children with hip dysplasia. Um, and again, they use 4 weeks here. And then they use about more than 16 weeks, which is, you know, about 4 months uh to get an X-ray. So that, you know, 4 to 6 months is sort of the age that's recommended for the first X-ray, um, and the reason is that the osic nucleus of the proximal femur, you know, appears around that time, um, 3 to 6 months. Um, it's a little earlier in girls than boys, but that's sort of the, the rationale for those numbers. And then I'm just gonna jump now to what we know in the orthopedic side based on literature and professional societies. So AOS, which is the American Academy of Orthopedic Surgeons, has done a fair amount of work on establishing two things clinical practice guidelines and based on those guidelines, you know, appropriate, uh, use criteria, and we, we're gonna talk about both. So these CPGs were, um, you know, updated in 2022. So it's not that long ago. It's like, you know, three years or so, uh, ago, and they revised some of the recommendations. So I've just highlighted. What was available in the literature based on a very um sort of deep dive into the research, the quality of the research, how robust were the clinical studies, and I've only highlighted the ones that were moderate to strong strength for evidence-based recommendations. So just let's read through those 4 of those. So there is a fair amount of support, moderate support to um not perform universal ultrasound screening in newborn infants, and we talked about that. So that's relevant to North America, that you don't need to do an ultrasound screening for dysplasia for every child that's born. Given then um the second one is there's a strong evidence supporting performing imaging studies before 6 months in children or infants with one or more of the following risk factors, and they, they name the risk factors, and this, by the way, has the strongest strength of recommendation, the only one with 4 stars. So any one of these breach, positive family history, or a history of clinical instability. So, you know, you could sort of look at that and say, OK, this much is clear. And so maybe ask about those things every time you see a baby in a family, uh, in terms of dysplasia. That could be part of your intake form. Then the third one is there's moderate evidence supporting the practice to reexamine children that previously screened uh as normal on subsequent visits prior to 6 months. So this is important too, like the reason it changed from congenital dys dysplasia or congenital dislocation. To developmental dysplasia is that it's not always present at birth. It can happen over time in the first couple of years of life. So that's why I think to reexamine them at least till age 2 clinically is, is an appropriate thing to do. And the 4th 1 actually doesn't make too much sense to me because uh what they said based on two studies is that moderate evidence supporting von Rosen splint, which is this kind of a splint that honestly I've never used, um, is, um, is preferred over a pavlik and some other abduction braces. So that's the problem sometimes with Research studies that they'll look at one piece of it and that may or may not be always relevant in your setting. Uh, but be that as it may, I think this is what's the most strongly supported based on evidence. Um, OK, so now I'm gonna come to this resource, which again, I feel is a good one. So based on clinical practice guidelines and input from AAP and um which is American, is it American Academy or Association of Pediatricians, um, that I'm sure you're all familiar with and members of. And also from the radiology side, the professional societies, they sort of gave input and then there was general consensus meeting, um, and they came up with these appropriate use criteria for DDH and they have two separate ones, one for, uh, you know, primary care physicians, pediatricians, and another one for orthopedic surgeons, and they're available, uh, uh, openly, uh, at this website. And um I'll just give you a brief background on how it came about. So, You know, there are A lot of variability in terms of hip dysplasia, and the appropriateness is simply saying, is it appropriate to order a certain test or what to do with this child that I'm seeing if they have this, this, this X-ray finding or ultrasound finding, family history, risk factors, etc. So you can plug in those facts and it'll give you an answer. And the answer may come in three forms. Uh, it'll either be like it's an appropriate thing, it may be appropriate, or it's really appropriate. And all these are done in a very sort of structured way, uh, in terms of how they came up with these numbers. And then there's a score on the side which is 1 to 9, and you could see this is based on like a RAND UCLA appropriate use manual. So there's a lot of science behind that, uh, in terms of how they came up with these numbers and it looks something like this. So rather than just give you a screenshot, I wanna. Um, well, let's familiarize ourselves with this and then we'll go on a little live test drive. Uh, OK, so this is the appropriate rating. So you can put in the age, you can put in the risk factors, it's a toggle button, so you gotta commit to something. You can talk about physical findings. Um, this may have been the one for orthopedics, so, pardon me for that, but it's still the same kind of thing. Then what are the ultrasound findings? What are the hip X-ray findings? And then this is what, you know, it comes up with. You click a button and there's an app here too, so it'll tell you, so green is, you know, that's appropriate and there'll be a number on the site. So remember we said 789 is green. Um, you know, 123 is red and 456 is yellow, right? So definitely in this child, you know, uh, what's recommended is a repeat clinical exam. So let me actually escape this and um I'll go to So I just copy pasted the little um address, uh, the link um to this ortho guidelines, and this is where it lands me. Um, so what do you want to look at is this one. DDH management for general. Physicians, um. And then you say you've read it. Can you guys see the screen, Maria? Can you guys see this new screen? I'm assuming we can. OK. So this again is for generalists and referring physicians. So let's say we see a child who, I see your slides still. Oh, OK. So then I'll have to stop sharing and reshare. I'm sorry. OK, thank you. So let me stop sharing and then Let me reshare. OK, and Back to the meeting. OK. I'm gonna share again and Where is it? Oh, here it is. OK. Uh, can you see it now? Yes, I can see that. OK. So let me, let me just go back one more time. So I came here, um, I clicked on that address. It gave me these appropriate use criteria and then um there's a whole bunch of diagnosis for orthopods, but I think this is the one that's relevant for primary care physicians, pediatricians. So DDH management by generalists. So you click on that, you understand all that. And then, so it depends on what patient you have that you want to talk about. So let's say you're seeing a six week old, so you click this, let's say they have a risk factor, they're a frank breach, and they have a normal hip exam, OK? And then you submit it and it'll give you this listing of what to do and what may not be that. Uh, relevant or maybe what you shouldn't do, right? So, you gotta obtain an ultrasound, continue the physical exam. Referral to a specialist, I guess it depends on your practice and your comfort level, but certainly don't continue with a well baby exam, right? You can print it, you can put it in the chart, you can copy it, etc. etc. Um, let's do a different one. Let's say, OK, let me, let me go back, or I'll just do this. Oh, OK. So you have, uh, let's do an older kid. Um, this kid is, let's say 5 months. has no risk factors, but has a limited hip abduction. OK. So then what do you do for that one? That one, you should refer to a specialist. You can obtain an X-ray, right, to just confirm that the hip may be dislocated, uh, and you certainly don't want to continue with the physical exam, right? So again, I think this is a good um tool to have. It's available on your mobile uh devices as well. I've no You know, other uh conflict of interest, etc. but I but I feel like it it's a good uh thing for this audience. All right, let's go back to the slides. OK. Maria, I can see the lights now. Yes, see, I can see the slides. All right, good. OK, so I'm just gonna finish with a few cases just to kinda go over this point that early treatment helps and that the more uh you wait, and it's not like somebody's intentionally waiting, the later the presentation, um, the more complicated the treatment and not only that, the worse the outcome. OK, so let's look at 3 or 4 cases. This was a 7 month old uh family noted that they were having trouble when they were changing diapers. Um, you know, one side had limited abduction. We got an ultrasound, um, and you could argue, well, it's 7 months, why not just get an X-ray. Um, but yeah, I just wanted to see what the the ultrasound showed, um, and then here's the x-ray soon after, um, and so this was Um, an irreducible hip, you can see the right side or the, the patient's right side or left side, and the hip is up and out, um, the osci nucleus isn't there, so, um. We tried a close reduction with an arthrogram, but she did not have a very stable reduction. So under the same anesthesia, we actually proceeded with a limited open reduction through a medial approach and then a spica cast, and we often will get an advanced imaging in the cast to confirm that the hip is in. So that's the shot on your bottom right. Then you follow this patient, um, the hip stays in, but, um, the acetabulum is still dysplastic on the right. So she ended up a year later with a pelvic osteotomy, and then here is a more recent uh X-ray which shows a pretty normalized acetabulum and development of the proximal femur, but obviously this patient still needs follow up and, you know, she needed two separate trips to the operating room. Um, this is an interesting one, and kudos to the radiologist. This patient presented to the ED 8 month old, uh, with, uh, with vomiting, and, you know, uh, they sort of looked at the belly, they looked at the chest, but then an astute radiologist picked up that the left hip didn't seem right. Um, they talked to the pediatrician who then referred it to us, and sure enough, the left hip was Um, you know, um, dysplastic and dislocated, um, but interestingly, this patient had no other risk factors. Uh, you know, was a boy, not first born, not breech, etc. etc. So ended it with uh arthrogram, close reduction, spica cast, um, then getting an MR to confirm the relocation. And you know, sequential follow-up. And you can see um she's still a little dysplastic and then I think got better on the right, uh, maybe not all the way, but the left was more dysplastic, so needed again a second operation for a pelvic osteotomy, which we typically don't do till age 18 months or so. And then, um, which would be the youngest, and then you can see over time the, you know, the, the graft kind of incorporated, um, and then, you know, here she is 1 year or 3 years later. Um, this is another one. So now we are moving up in age of presentation. 17 months old, came from overseas, bilateral dislocated hips, just quote unquote walked funny. So here you need to do more than just a close reduction, more than just an open reduction. So we did a staged open reduction with pelvic osteotomy and graft, uh, and we staged the two sides because it's too much to do this big operation, both sides at the same time. And then here at the bottom right, you can see, uh, you know, once we're done with both procedures, a few months out and, you know, the acetabular uh morphology has been improved and the head uh is in the socket, but a lot more surgery. OK, this is sort of the last case and this I think is a humbling case of why we need to pick these children earlier so we avoid complications. This child again came from uh overseas and interestingly, um, he was treated in a body cast, according to the family, which probably is a spiCA cast with a close reduction that may not have succeeded. And then they were like, we don't trust the medical system here. When we come to the United States, we're gonna get it treated. But all these years they waited and 87 is kind of at the upper limit for, you know, relocating a hip, uh, that's dysplastic and it's just unilateral. But with, with, you know, with appropriate precautions and counseling, uh, we said let's do it. But now, Compared to the last case, we had to do everything we did in the last case, which is open reduction, pelvic osteotomy. Um, but also include femoral shortening to minimize the risk of sciatic nerve injury and osteonecrosis and growth problems related to the development of the proximal femoral epiphysis. But despite all those procedures and the shortening, if you look at the bottom right picture, you could see the femoral epiphysis is disappearing. Which is an early sign of osteonecrosis or growth issues related to vascularity of the proximal femur. Now, it may reossify, but it certainly doesn't look like it's gonna become a normal, uh, round femoral head. I don't think so. Uh, I hope so, but I don't think so. So the, the point is that, you know, earlier treatment would have probably improved the outcome. So I think this is sort of a take home um based on all this. Early diagnosis leads to not only early treatment opportunity, but less invasive. Like you may not even need to do an operation and, more importantly, a better outcome long term. And then you know the care pathways need to be modified based on local context, you know, that depends on the prevalence of DDH, what resources are available, you know, what population are we talking about, what's the health system like, what do they allow, what do they not allow easily, um, and at least for the for North America or the US. Um, universal clinical screening, meaning you ask the question, you examine the child, newborn up to age 2 years, and then do selective ultrasound screening based on the risk factors that we've outlined, uh, would be, you know, what it is, and then it gets a little bit muddy because you're like, well, they're not sure about the family history. It was the second cousin, etc. etc. So that's where, you know, it's a little bit gray zone. Um, but do be familiar with the risk factors, including inappropriate swaddling. And then, um, you know, take the opportunity to use clinical practice guidelines and um if you want, use these appropriate use criteria that are, you know, put out by the AOS and it's as it's, as I said, it's, it's, you can put it on your phone and you can just, while you're seeing a child or a family, you can plug in the facts and come up with, uh, you know, what you need to do next. And if all else fails, you know, please reach out to us. We have uh orthopedic hip clinic, uh, both sides of the bay, um, and, you know, it's not just DDH. We see sports injuries, uh, related to the hip. Uh, we do hip dysplasia, we doury, uh, we do skiffy and everything else. And then finally, you know, my other interest is in limb lengthening and deformity.
