Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants Up to Six Months of Age (2022)

There is moderate evidence to not do universal screening of all infants for DDH. Two moderate strength studies showed no statistical difference between universal and selective ultrasound screening of the infant hip for diagnosis of late presenting DDH (Holen 2002, Rosendahl 1994). Holen (2002) augmented clinical screening with either universal or selective (risk) ultrasound. The rate of late cases in Holen’s (2002) study was 0.13/1000 with universal ultrasound screening and 0.65/1000 with selective (risk) screening. The difference in late detection was not statistically significant. Rosendahl (1994) used three matched study groups: general ultrasound screening, risk factor screening and only clinical screening. Late cases identified by group were 0.3/1000, 0.7/1000 and 1.3/1000 respectively and these differences were not statistically significant.

Screening of all infants with ultrasound has the potential to lead to over-treatment. Rosendahl’s (1994) study found that general ultrasound screening resulted in a higher treatment rate (3.4%) than either selective ultrasound screening (2.0%) or clinical screening (1.8%). The higher rate with universal screening is statistically significant. Universal ultrasound screening requires considerable diagnostic and therapeutic effort and these studies which involve large numbers of newborns indicate that such a commitment of resources will not significantly impact the prevalence of late cases.

RISKS AND HARMS
There is a potential to miss a case of DDH in an infant with a normal clinical examination and no risk factors. This could lead to a late diagnosis with concerns for a potential of higher rate of treatment complications as a result of late diagnosis.

2022 UPDATE ADDITIONAL EVIDENCE
1. 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

2. Burnett, M., Rawlings, E. L., Reddan, T. An audit of referral time frames for ultrasound screening of developmental hip dysplasia in neonates with a normal antenatal clinical examination. Sonography 2018; 2: 61-66

3. Geertsema, D., Meinardi, J. E., Kempink, D. R. J., Fiocco, M., van de Sande, M. A. J. Screening program for neonates at risk for developmental dysplasia of the hip: comparing first radiographic evaluation at five months with the standard twelve week ultrasound. A prospective cross-sectional cohort study. Int Orthop 2019; 8: 1933-1938

4. 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

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

6. 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

7. Laborie, L. B., Engesaeter, IO, Lehmann, T. G., Eastwood, D. M., Engesaeter, L. B., Rosendahl, K. Screening strategies for hip dysplasia: long-term outcome of a randomized controlled trial. Pediatrics 2013; 3: 492-501

8. Laborie, L. B., Markestad, T. J., Davidsen, H., Bruras, K. R., Aukland, S. M., Bjorlykke, J. A., Reigstad, H., Indrekvam, K., Lehmann, T. G., Engesaeter, I. O., Engesaeter, 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

9. 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

10. 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

11. Tan, S. H. S., Wong, K. L., Lim, A. K. S., Hui, J. H. The earliest timing of ultrasound in screening for developmental dysplasia of the hips. Ultrasonography 2019; 4: 321-326

12. Westacott, D. J., Butler, D., Shears, E., Cooke, S. J., Gaffey, A. Universal versus selective ultrasound screening for developmental dysplasia of the hip: a single-centre retrospective cohort study. J Pediatr Orthop B 2018; 5: 387-390

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

If faced with an unstable hip examination, there is limited evidence to support the use of sequential ultrasound to aid in determining when to initiate brace treatment for infants up to 8 weeks of age. Fewer children may undergo brace treatment with no difference in the occurrence of late dysplasia. One moderate quality study (Elbourne 2002) met the inclusion criteria and compared infants with clinical hip instability who were evaluated with ultrasoniographic hip examination or clinical assessment alone. This study evaluated outcomes in a total of 629 infants across 33 centers (total patients in both evaluation groups). There was no statistically significant difference in outcomes for the need for surgical treatment for developmental hip dysplasia, but fewer children in the group which was assessed using ultrasonography required abduction splinting in the first 2 years than those in the group which received a clinical assessment alone. Initially this study was graded as high strength but was downgraded to moderate strength because the rate of splint treatment was not the primary outcome. Additionally, it is unclear that all subjects were normal infants with DDH and no confounding diagnoses.

In this study, infants with hips that had minor instability were not immediately treated. Experienced doctors performed the clinical examinations. Even though there is even distribution between the groups in terms of number of history of instability, subgroup analysis of dislocated versus dysplastic hip results were not available.

RISKS AND HARMS
There is a potential delay of necessary treatment.

2022 UPDATE ADDITIONAL EVIDENCE
1. Burnett, M., Rawlings, E. L., Reddan, T. An audit of referral time frames for ultrasound screening of developmental hip dysplasia in neonates with a normal antenatal clinical examination. Sonography 2018; 2: 61-66.

2. Lussier, E. C., Sun, Y. T., Chen, H. W., Chang, T. Y., Chang, C. H. Ultrasound screening for developmental dysplasia of the hip after 4 weeks increases exam accuracy and decreases follow-up visits. Pediatr Neonatol 2019; 3: 270-277

There is limited evidence that an AP pelvis radiograph is preferred to the use of ultrasound to assess for DDH in infants from 4-6 months of age. This evidence does not distinguish between children with normal or abnormal physical examinations or between children with and without risk factors for DDH. One moderate-strength study (Tudor 2007) investigated the radiographic assessment of every ultrasound positive hip in children four to six months of age. Seventy-four infants with ultrasound positive hips for acetabular dysplasia who met criteria for treatment received an AP pelvis radiograph. Of these 74 infants, 30 were found to have satisfactory acetabular indices and did not receive treatment.
Limitations of this study include the lack of long-term follow-up of the infants to determine if the radiographic assessment altered outcome and failed to address the optimal time of conversion from ultrasound to radiographic assessment in infants with DDH.

RISKS AND HARMS
Radiographs involve exposure to ionizing radiation.

2022 UPDATE ADDITIONAL EVIDENCE
1. Geertsema, D., Meinardi, J. E., Kempink, D. R. J., Fiocco, M., van de Sande, M. A. J. Screening program for neonates at risk for developmental dysplasia of the hip: comparing first radiographic evaluation at five months with the standard twelve week ultrasound. A prospective cross-sectional cohort study. Int Orthop 2019; 8: 1933-1938

If faced with a child who has a normal physical examination, there is limited evidence that performing subsequent hip physical examination screening of children up to 6 months of age will detect additional children with DDH. The reviewed literature does not include the screening of children up to walking age when other examination findings such as gait abnormalities may allow for detection of additional children with DDH. One low strength study (Myles 1990) presented evidence that repeated studies at three months were productive in identifying late diagnosed DDH. Another low strength study (Cooke 2011) noted that exams at eight months of age had a high rate of false positives, but no yield of true positives.

There is no literature to define the optimal frequency or duration of follow-up surveillance.

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

2022 UPDATE ADDITIONAL EVIDENCE
1. 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

2. 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.

For an infant with a normal physical examination and ultrasound abnormalities, there is limited evidence to support observation without treatment of that infant with serial ultrasound evaluation up to 6 weeks of age. One low-strength study (Wood 2000) evaluated a group of at-risk patients who were evaluated by ultrasound between two and six weeks of age with clinically stable hips showing ultrasonographic abnormalities that were randomized to treatment with Pavlik harness or observation. The two primary outcome measures were the acetabular coverage on ultrasound and acetabular index on radiograph. While acetabular coverage, measured ultrasonographically, improved in both groups, and was statistically better in the splinted group at the final three-month follow-up, there was no difference in acetabular index.

RISKS AND HARMS
The risk of implementing this recommendation is that necessary treatment could be delayed.

2022 UPDATE ADDITIONAL EVIDENCE
1. Burnett, M., Rawlings, E. L., Reddan, T. An audit of referral time frames for ultrasound screening of developmental hip dysplasia in neonates with a normal antenatal clinical examination. Sonography 2018; 2: 61-66

2. 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

3. Kim, H. K. W., Beckwith, T., De La Rocha, A., Zepeda, E., Jo, C. H., Sucato, D. Treatment Patterns and Outcomes of Stable Hips in Infants With Ultrasonic Dysplasia. J Am Acad Orthop Surg 2019; 2: 68-74

4. Laborie, L. B., Markestad, T. J., Davidsen, H., Brurås, 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

5. Larson, J. E., Patel, A. R., Weatherford, B., Janicki, J. A. Timing of Pavlik Harness Initiation: Can We Wait?. J Pediatr Orthop 2019; 7: 335-338

6. Tan, S. H. S., Wong, K. L., Lim, A. K. S., Hui, J. H. The earliest timing of ultrasound in screening for developmental dysplasia of the hips. Ultrasonography 2019; 4: 321-326

For infants with a positive hip instability exam, there is conflicting evidence about whether a period of observation or immediate brace treatment leads to a difference in later dysplasia or persistent hip instability leading to later brace treatment. One moderate strength and three low strength studies looked at radiographic differences between an early versus late brace treatment group (Gardiner, 1990, Gardiner, 1992, Molto, 2002, Paton, 2004, Wilkinson, 2002). None of these studies differentiate dislocated from dislocatable hips.

Gardiner (1992) found a significant difference in the radiographic appearance of the femoral capital epiphysis and delayed iliac indentation at 6 months for a no treatment group compared to a brace group. Twenty-nine percent of the non-treatment group had cross-over and were treated at two weeks. Limitations were not defining the femoral capital epiphyseal ossification subcategories and iliac indentation and not explaining the relevance of either.

Molto (2002) compared von Rosen splinting immediately after birth to splinting after two weeks. The outcome criterion was acetabular index. They noted a significant improvement in the acetabular index at 15 months in the immediate treatment group (76 patients) as compared to the 27 patients in the second group treated after two weeks.

Paton (2004) reported on 75 hips in 2 groups, including 37 patients (59 hips) in the early splint treatment group versus 11 patients (16 hips) in the late splint treatment group. Outcome measures included continued instability that required late splint treatment after six weeks, radiographic abnormality, AVN, or surgical intervention at walking age. Authors noted no significant differences when treatment started at less than one week in the early treatment group versus nine weeks on average in the delayed treatment group. This study included both dislocatable and dislocated hips with outcome measures not specifically correlated to the nature of the instability.

RISKS AND HARMS
The risks/harms of this recommendation are overtreatment and the potential complications and burden of care.

2022 UPDATE ADDITIONAL EVIDENCE
1. Bruras, K. R., Aukland, S. M., Markestad, T., Sera, F., Dezateux, C., Rosendahl, K. Newborns with sonographically dysplastic and potentially unstable hips: 6-Year follow-up of an RCT. Pediatrics 2011; 3: e661-e666.

2. Cook, K. A., Schmitt, M., Ingram, M., Larson, J. E., Burgess, J., Janicki, J. A. Pavlik Harness initiation on Barlow positive hips: Can we wait? J Orthop 2019; 5: 378-381.

3. Larson, J. E., Patel, A. R., Weatherford, B., Janicki, J. A. Timing of Pavlik Harness Initiation: Can We Wait?. J Pediatr Orthop 2019; 7: 335-338.

There are no high-quality comparative effectiveness studies between different types of braces for the treatment of DDH. Limited evidence suggests that rigid braces may have higher rates of resolution of hip dysplasia than non-rigid braces. Two low strength studies (Heikkila 1988, Wilkinson 2002) compared rigid bracing to soft bracing for initial treatment of unstable hips in infants. Heikkila (1988) compared the Frejka pillow with the von Rosen splint. There were 920 patients treated with Frejka pillow and 180 patients treated with von Rosen splint. Fifty-five of 920 from the Frejka pillow group had treatment failure, while 1 out of 180 from the von Rosen splint group failed treatment. These differences were significant. A limitation of this study is that it was a historical comparative study of two cohorts over two time periods. AVN rates were inadequately reported. The authors did not differentiate between dislocated and dislocatable hips.

Three splints were compared in the Wilkinson (2002) study: Craig, Pavlik, and von Rosen. Four of 28 in the Craig splint group, 13 of 43 in the Pavlik group, and 0 of 26 in the von Rosen group required further treatment in the form of plaster or operation.

This recommendation is based on the braces that were studied, but other similar fixed-position braces may or may not work as well as the braces mentioned in the evidence.

RISKS AND HARMS
Nineteen percent of the patients in the rigid brace group experienced skin irritation(Heikkila 1988). There is a potential risk of AVN with all bracing; the relative risk is unknown between rigid and soft bracing.

2022 UPDATE ADDITIONAL EVIDENCE
1. Azzoni, R., Cabitza, P. A comparative study on the effectiveness of two different devices in the management of developmental dysplasia of the hip in infants. Minerva pediatrica 2011; 5: 355-361

2. Ran, L., Chen, H., Pan, Y., Lin, Q., Canavese, F., Chen, S. Comparison between the Pavlik harness and the Tubingen hip flexion splint for the early treatment of developmental dysplasia of the hip. J Pediatr Orthop B 2019; 0:

3. Zidka, M., Dzupa, V. Pavlik harness and Frejka pillow: compliance affects results of outpatient treatment. Arch Orthop Trauma Surg 2019; 11: 1519-1524

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