Monitoring of Patients During Brace Treatment

If brace treatment is initiated, there is limited evidence that episodic serial physical and imaging reassessments during the treatment cycle can lead to changes or duration of the treatment plan. Two low strength studies (Cashman 2002, Swaroop 2009) report monitoring of brace treatment using physical exam, ultrasound, and radiography following the appearance of the ossific nucleus. Both studies identified failure of reduction or persistent dysplasia in patients undergoing brace treatment. These findings necessitated a change in treatment plan or duration. No parameters for optimal timing or frequency of imaging were established by research protocol.

RISKS AND HARMS
Radiographs involve exposure to ionizing radiation.

FUTURE RESEARCH
This clinical practice guideline is focused on early detection by the clinical and imaging screening of populations of infants and on the early management of DDH. The grades of recommendations for this clinical practice guideline range from limited to moderate strength. Of 3990 citations on the topic of DDH, 42 articles were ultimately included as evidence related to the recommendations in this guideline and 18 articles met our inclusion criteria for an assessment of the natural history for DDH in infancy. It has a large potential impact due to the size of populations to be screened and the functional limitations that can be created by late diagnosis and management of individuals with this condition.

We found significant gaps in the evidence that can be used to derive practice guidelines for the early diagnosis and management of DDH. There is considerable confusion related to the terminology and definitions that have been used in research related to DDH and about what defines a pathologic condition versus an expected developmental variation based upon the age and status of a child is needed. There are additional gaps in knowledge of the basic pathophysiology of DDH, understanding of the long-term impact of DDH upon the health status and well-being of affected individuals, the appropriateness of DDH for public health screening programs as they are practiced today, the optimal diagnostic tools to be used to detect the condition, and the relative efficacy and value of recommended interventions. Additional research is needed to create clarity in these areas. The large numbers of patients who need to be assessed and the severity of functional limitations that can be created by late diagnosis and management of individuals with this condition suggests that research inclusive of comparative effectiveness research design would be of great advantage.

Specifically, future research areas should attempt to:
• Establish clear, widely accepted, reproducible criteria and definitions for:

o Clinical terms that describe hip stability
o Radiographic and ultrasound criteria for dysplasia and dislocation based upon age.
o Historical and clinical risk factors to be assessed for all children that are related to DDH.
o What constitutes “standard” brace treatment of DDH
o What are outcomes criteria that define successful or failed treatment for DDH

• Establish universally accepted and reproducible ranges of normal values across ages for sonographic and/or radiographic hip measures or any future surrogates for normal hip development.
• Establish clear relationships between these surrogates for hip development and demonstrate long-term functional limitations that are correlated to surrogate values that fall outside of the normal ranges.
• Define the benefits and harms of late diagnosis of DDH
• Define the harms of early diagnosis and treatment of DDH
• Standardize follow-up times after bracing to improve objective testing of outcomes
Provide research design that is applicable to routine practice situations and allows for comparison of alternative methods of diagnosis and treatment.

2022 UPDATE ADDITIONAL EVIDENCE
1.Donma, M. M., Dogru, M., Demirkol, M., Ozcaglayan, O., Topcu, B., Ozcaglayan, T. I. K., Gonen, K. A., Nalbantoglu, B., Nalbantoglu, A., Dogru, R., Ulucan, H., Karakoyun, O., Erol, M. F., Guzelant, A. Y., Donma, O. What Is the Important Point Related to Follow-Up Sonographic Evaluation for the Developmental Dysplasia of the Hip? Journal of Child Science 2017; 1: e123-e126