DDH_tab

Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made. (Formerly, these situations were captured under a "C Recommendation".) This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade. For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Preventive Health Care, 2001 update: Screening and Management of Developmental Dysplasia of the Hip in Newborns

Prepared by Hema Patel, with the Canadian Task Force on Preventive Health Care

These recommendations were finalized by the Task Force in February 1999.

MANEUVER EFFECTIVENESS LEVEL OF EVIDENCE <REF> RECOMMENDATION

Screening:

Infants at Normal Risk

Repeated serial clinical examination by trained examiners (Ortolani and Barlow tests in younger infants and surveillance for limitation in abduction, leg length discrepancy in older infants)
Serial clinical examinations decrease the operative rate from 1–2 per 1000 infants to 0.2–0.7 per 1000, with a concomitant increase in the abduction splinting rate, to
4–19 per 1000
Level III<19,23,25–27,29–35>

Fair evidence to include serial clinical examination of the hips by a trained clinician in the periodic health examination (PHE) of all infants until they are walking independently (grade B)

Rates of late DDH or operative intervention did not differ between infants undergoing ultrasound screening and those undergoing clinical examination Level II-1⁶

Ultrasound screening (static or dynamic method) General ultrasound screening programs significantly increase the rates of intervention (splint therapy), repeat evaluations and false-positive diagnoses, without a decrease in the rates of late DDH or operative intervention Level II-1⁶ and level III^{8,9,13,15,22,24,38–45} Fair evidence to exclude general ultrasound screening for DDH from the PHE of infants (grade D)

Infants at High Risk

Selective screening in high-risk infants (breech birth, clinical evidence of joint instability, family history of DDH) Because most infants with DDH have no risk factors, selective screening is ineffective in reducing the operative rate Level II-1⁶ and level III^32,41,67 Fair evidence to exclude selective screening for DDH from the PHE of high-risk infants (grade D)

Radiographic examination of hips and pelvis in infants aged 3–5 mo There is no consensus on the radiographic definition of DDH, and the clinical correlation to functional outcomes is lacking. Low sensitivity and poor interrater reliability have been reported Level III<2,21,36> Fair evidence to exclude routine radiographic screening for DDH from the PHE of high-risk infants (grade D)

Treatment:

Abduction therapy (Pavlik harness or other abduction devices) The true effectiveness of abduction therapy is unknown. Studies have been confounded by the naturally high spontaneous resolution rate of DDH in infants Insufficient evidence to evaluate the effectiveness of abduction therapy (grade C)

Early splint therapy is not always effective. At least 20% of infants requiring operative intervention had splint therapy started shortly after birth Level III<27,33,34,42,62>

Abduction splinting is associated with a variety of adverse events, including avascular necrosis of the hip (in 1%–4% of treated infants) Level III<39,42,60,61>

Timing of abduction therapy (early intervention) Given the high rate of spontaneous resolution of DDH, the optimal timing of early intervention is not immediately after birth Level I<11> and level III<18,39>
Good evidence to support a supervised period of observation for newborns with clinically detected DDH (grade A)
Insufficient evidence to determine the optimal duration of observation (grade C)

MANEUVER	EFFECTIVENESS	LEVEL OF EVIDENCE <REF>	RECOMMENDATION
Screening:
Infants at Normal Risk
Repeated serial clinical examination by trained examiners (Ortolani and Barlow tests in younger infants and surveillance for limitation in abduction, leg length discrepancy in older infants)	Serial clinical examinations decrease the operative rate from 1–2 per 1000 infants to 0.2–0.7 per 1000, with a concomitant increase in the abduction splinting rate, to 4–19 per 1000	Level III<19,23,25–27,29–35>	Fair evidence to include serial clinical examination of the hips by a trained clinician in the periodic health examination (PHE) of all infants until they are walking independently (grade B)
	Rates of late DDH or operative intervention did not differ between infants undergoing ultrasound screening and those undergoing clinical examination	Level II-1⁶
Ultrasound screening (static or dynamic method)	General ultrasound screening programs significantly increase the rates of intervention (splint therapy), repeat evaluations and false-positive diagnoses, without a decrease in the rates of late DDH or operative intervention	Level II-1⁶ and level III^{8,9,13,15,22,24,38–45}	Fair evidence to exclude general ultrasound screening for DDH from the PHE of infants (grade D)
Infants at High Risk
Selective screening in high-risk infants (breech birth, clinical evidence of joint instability, family history of DDH)	Because most infants with DDH have no risk factors, selective screening is ineffective in reducing the operative rate	Level II-1⁶ and level III^32,41,67	Fair evidence to exclude selective screening for DDH from the PHE of high-risk infants (grade D)
Radiographic examination of hips and pelvis in infants aged 3–5 mo	There is no consensus on the radiographic definition of DDH, and the clinical correlation to functional outcomes is lacking. Low sensitivity and poor interrater reliability have been reported	Level III<2,21,36>	Fair evidence to exclude routine radiographic screening for DDH from the PHE of high-risk infants (grade D)
Treatment:
Abduction therapy (Pavlik harness or other abduction devices)	The true effectiveness of abduction therapy is unknown. Studies have been confounded by the naturally high spontaneous resolution rate of DDH in infants		Insufficient evidence to evaluate the effectiveness of abduction therapy (grade C)
	Early splint therapy is not always effective. At least 20% of infants requiring operative intervention had splint therapy started shortly after birth	Level III<27,33,34,42,62>
	Abduction splinting is associated with a variety of adverse events, including avascular necrosis of the hip (in 1%–4% of treated infants)	Level III<39,42,60,61>
Timing of abduction therapy (early intervention)	Given the high rate of spontaneous resolution of DDH, the optimal timing of early intervention is not immediately after birth	Level I<11> and level III<18,39>	Good evidence to support a supervised period of observation for newborns with clinically detected DDH (grade A) Insufficient evidence to determine the optimal duration of observation (grade C)