AAOS Appropriate Use Criteria: The Management of Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Intended for Use by Orthopaedic Specialists

Equity in the Developmental Dysplasia of the Hip (DDH) Diagnosis and Treatment: A Retrospective Cohort Study to Unravel the Effect of Area Deprivation and the Insurance Type

Background Timely diagnosis of developmental dysplasia of the hip (DDH) is crucial for implementing less invasive treatment. However, socioeconomic barriers may lead to late diagnoses. The Area Deprivation Index (ADI) is an indicator of the socioeconomic challenges experienced by patients and their families. The primary objective is to investigate if the age at which DDH is diagnosed and the treatment protocol are influenced by the ADI or the insurance type. Materials and methods Using International Classification of Diseases-Tenth Edition (ICD-10) codes, newly diagnosed DDH patients (age under 10 years) from 2020 to 2023 were retrospectively identified at our pediatric tertiary center. Patients were categorized into four groups based on ADI percentile: (1) 1-10th percentile, (2) 11-20th percentile, (3) 21-40th percentile, and (4) 41-100th percentile. They were also stratified by insurance type. Age at diagnosis and treatment protocol (non-operative vs. operative) were collected and compared between the different ADI groups and insurance groups. Operative treatment was defined as open reduction with or without femoral/pelvic osteotomy. Results A total of 327 patients satisfied the inclusion criteria and had available ADI scores for analysis. The average age at diagnosis was notably lower in ADI group 1 compared to all other ADI groups (p < 0.05) and considerably lower for patients with commercial insurance compared to those with public (p = 0.0002). The rate of surgical treatment was markedly lower in ADI group 1 compared to ADI groups 2 and 3 (both p < 0.05) and notably lower for those with commercial insurance compared to public (p = 0.0005). ADI groups 2-4 showed no significant differences in average age at diagnosis or surgical treatment rate. Conclusion The study demonstrates that socioeconomic factors affect the diagnosis and, consequently, the treatment course of DDH. Specifically, patients residing in areas with lower levels of deprivation tend to be diagnosed at a younger age and undergo surgical treatment less frequently.

Consistency of Indices Obtained via Hip Medial Ultrasound and Magnetic Resonance Imaging in Reduction and Spica Cast Treatment for Developmental Dysplasia of the Hip

Children younger than 18 mo with developmental dysplasia of the hip (DDH) were treated with reduction and spica cast. X-Ray, computed tomography or magnetic resonance imaging (MRI) was used to evaluate reduction effectiveness. This study explored the hip medial ultrasonography method and anatomic structure sonograms. Twenty-eight children with DDH were enrolled. A total of 51 hips (24 left hips /27 right hips) were measured, including 30 affected hips and 21 normal hips. Various indices, including femoral head diameter (DIA), triradiate cartilage-femoral distance (TFD), acetabular-femoral distance (AFD) and ilium-femoral distance (IFD), were measured in the acetabular median coronal plane of ultrasound and the median coronal plane of MRI. The intra-group correlation coefficients for DIA, TFD, AFD and IFD were 0.968 (95% confidence interval: 0.917-0.985), 0.959 (0.929-0 976), 0.923 (0.869-0.955) and 0.950 (0914-0.971), respectively. Hip medial ultrasound and MRI exhibited good consistency. It is feasible to use hip medial ultrasound to evaluate the reduction of DDH in infants and children after spica cast.

Expert-Based Consensus on the Principles of Pavlik Harness Management of Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) is the most common orthopaedic disorder in newborns. While the Pavlik harness is one of the most frequently used treatments for DDH, there is immense variability in treatment parameters reported in the literature and in clinical practice, leading to difficulties in standardizing teaching and comparing outcomes. In the absence of definitive quantitative evidence for the optimal Pavlik harness management strategy for DDH, we addressed this problem by obtaining international expert-based consensus on the subject.

METHODS

An initial list of items relevant to Pavlik harness treatment was derived by a review of the literature. Delphi methodology was used to guide serial rounds of surveying and obtaining feedback from content matter experts from the International Hip Dysplasia Institute (IHDI), which continued in the same manner until consensus based on standard statistical analysis was reached. This was followed by a corroboration of face validity to derive the final set of management principles.

RESULTS

Four rounds of structured surveying were required to reach consensus. Following 2 rounds of peer review, and from an initial list of 66 items in 8 categories, we were able to derive 2 simplified, yet comprehensive, print-friendly tables consisting of 28 items in 8 categories to assist clinicians in managing DDH with a Pavlik harness. The tables contain principles of treatment initiation, application and follow-up of the harness, complications, weaning, and end-of-treatment decision-making as well as specific criteria based on the severity of the DDH. Furthermore, highly contentious items were identified as important areas of future study.

CONCLUSIONS

We developed a comprehensive set of principles based on expert consensus to assist clinicians in the management of DDH using the Pavlik harness. This study also generated a list of the most controversial areas in the nonoperative management of DDH, which should be considered high priority for future study to further refine and optimize outcomes.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.