Evaluation of Infants with Risk Factors for DDH
Strong evidence supports performing an imaging study before 6 months of age in infants with one or more of the following risk factors: breech presentation, family history, or history of clinical instability.

Rationale

If the risk factors of family and/or breech presentation are present, there is moderate evidence to support selective ultrasound screening between 2-6 weeks of age for infants who otherwise have a normal clinical hip examination or an AP radiograph at 4 months of age. There were two studies of moderate strength that confirm significance for selective prospective screening by ultrasound in infants with history of possible clinical instability and/or risk factors: breech and family history to prevent late dislocations and need for surgery (Paton 2005, Paton 1999).

Of the 10 studies of low strength, the various risk factors included were: breech, family history, sex, combination of sex and breech, combination of sex and family history, hip click, first born, swaddling, and talipes.

Breech literature included six studies all of low study strength. The results of these studies were meta-analyzed and the meta-analysis overwhelmingly supported breech presentation as a risk factor for neonatal instability. The literature terminology on breech is: breech at birth, breech delivery, and breech position at the third trimester; there is no literature to substantiate a particular duration of breech positioning as a risk factor.

Family history included four articles of low strength all showing statistical significance for family history as a risk factor for DDH (Bache 2002, Baronciani 1997, Jones 1989, Rosendahl 1996). There was one study which showed no statistical significance (Akman 2007).

One study compared treatment for dislocatable hips (at age less than one week) with no treatment for stable hips with positive family history (Burger 1990). The outcome was residual dysplasia at five months and was noted to be significant for the no treatment category. The authors further treated these patients from the no treatment category at age five months and compared them with the original cohort of Barlow positive patients treated at age less than one week. This time around, the outcome parameter was residual dysplasia at two years and was again noted to be significant. Other outcome measures included AVN at two years, which was not significant, and treatment failure, which was noted to be significant. This study did not have a true comparative group for analysis. There was a combination of dislocated and dislocatable hips in the Barlow positive category, which confounds the analysis.
The literature definitions of family history of DDH range from unspecified hip disorders to hip dislocation and from first degree relative (parents and siblings), to any relative (even if distant or vague) with hip problems or DDH (all other articles). Three articles listed family history but did not specify the relationships or specific hip problems (Akman 2007, Baronciani 1997, Boo 1989).

One study compared ultrasound screening in infants who had risk factors alone with those who had “doubtful” clinical instability (Paton 1999). Rate of detection of dislocation as confirmed by ultrasound was 13/1000 (7 to 24) vs 87/ 1000 (57 to 126/1000) respectively.

There is no substantiation in the literature of the optimal age for imaging studies in these infants with risk factors (Burger 1990). One study performed hip radiographs at 4 months of age. Two studies performed ultrasound between 2-6 weeks of age (Khan 1992, Kian 1996).

Examination of other quoted risk factors was done. Evidence was not found to include foot abnormalities, gender, oligohydramnios, and torticollis as risk factors for DDH.

RISKS AND HARMS
There is a potential risk of over diagnosis and treatment.

2022 UPDATE ADDITIONAL EVIDENCE
1. Arti, H., Mehdinasab, S. A., Arti, S. Comparing results of clinical versus ultrasonographic examination in developmental dysplasia of hip. J Res Med Sci 2013; 12: 1051-5

2. Custovic S., Custovic K. The predictive value of the clinical sign of excessive hip abduction for developmental dysplasia of the HIP (DDH). Acta Medica Saliniana 2018; 1: 32-35

3. Custovic, S., Sadic, S., Vujadinovic, A., Hrustic, A., Jasarevic, M., Custovic, A., Krupic, F. The predictive value of the clinical sign of limited hip abduction for developmental dysplasia of the hip (DDH). Med Glas (Zenica) 2018; 2: 174-178

4. D'Alessandro, M., Dow, K. Investigating the need for routine ultrasound screening to detect developmental dysplasia of the hip in infants born with breech presentation. Paediatr Child Health 2019; 2: e88-e93.

5. Gokharman, F. D., Aydin, S., Fatihoglu, E., Ergun, E., Kosar, P. N. Optimizing the Time for Developmental Dysplasia of the Hip Screening: Earlier or Later?. Ultrasound Q 2019; 2: 130-135

6. Schams, M., Labruyere, R., Zuse, A., Walensi, M. Diagnosing developmental dysplasia of the hip using the Graf ultrasound method: risk and protective factor analysis in 11,820 universally screened newborns. Eur J Pediatr 2017; 9: 1193-1200

7. Ayanoglu, T., Ataoglu, M. B., Tokgoz, N., Ersoz, E., Atalar, H., Turlani S. Assessing the risk of asymptomatic dysplasia in parents of children with developmental hip dysplasia. Acta Orthop Traumatol Turc 2019; 5: 346-350

8. Davies, R., Talbot, C., Paton, R. Evaluation of primary care 6- to 8-week hip check for diagnosis of developmental dysplasia of the hip: a 15-year observational cohort study. Br J Gen Pract 2020; 693: e230-e235

9. Guler, O., Seker, A., Mutlu, S., Cerci, M. H., Komur, B., Mahirogullari, M. Results of a universal ultrasonographic hip screening program at a single institution. Acta Orthop Traumatol Turc 2016; 1: 42-8

10. Gyurkovits, Z., Sohar, G., Baricsa, A., Nemeth, G., Orvos, H., Dubs, B. Early detection of developmental dysplasia of hip by ultrasound. Hip Int 2019; 0: 1120700019879687

11. Kolb, A., Schweiger, N., Mailath-Pokorny, M., Kaider, A., Hobusch, G., Chiari, C., Windhager, R. Low incidence of early developmental dysplasia of the hip in universal ultrasonographic screening of newborns: analysis and evaluation of risk factors. Int Orthop 2016; 1: 123-7

12. Kyung, B. S., Lee, S. H., Jeong, W. K., Park, S. Y. Disparity between Clinical and Ultrasound Examinations in Neonatal Hip Screening. Clin Orthop Surg 2016; 2: 203-9

13. Laborie, L. B., Markestad, T. J., Davidsen, H., BrurÃ¥s, K. R., Aukland, S. M., Bjørlykke, J. A., Reigstad, H., Indrekvam, K., Lehmann, T. G., Engesæter, I. O., Engesæter, L. B., Rosendahl, K. Selective ultrasound screening for developmental hip dysplasia: Effect on management and late detected cases. A prospective survey during 1991-2006. Pediatr Radiol 2014; 4: 410-424

14. Munkhuu, B., Essig, S., Renchinnyam, E., Schmid, R., Wilhelm, C., Bohlius, J., Chuluunbaatar, B., Shonkhuuz, E., Baumann, T. Incidence and treatment of developmental hip dysplasia in Mongolia: a prospective cohort study. PLoS One 2013; 10: e79427

15. Olsen, S. F., Blom, H. C., Rosendahl, K. Introducing universal ultrasound screening for developmental dysplasia of the hip doubled the treatment rate. Acta Paediatr 2018; 2: 255-261