Developmental Dysplasia of the Hip: Care Practices of Pediatricians in North America

Background: Developmental Dysplasia of the Hip (DDH) is a common condition, affecting 1-2% of full-term infants. The American Academy of Pediatrics (AAP) and American Academy of Orthopaedic Surgeons (AAOS) have published guidelines detailing best practices for DDH screening and treatment. The purpose of this study was to evaluate DDH care practices by pediatricians in North America.

Methods: An electronic survey was sent to AAP state chapters and academic hospital pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, DDH guideline use, clinical scenarios, referral patterns, and ultrasound/imaging practices.

Results: We received 139 total responses and included 126 in statistical analyses. Results show that 50% (63/126) of pediatricians practice in an institution that endorses a standard care pathway for DDH. Most pediatricians (68%, 84/124) reported that they use AAP DDH guidelines in their practice, including in the absence of an institutionally endorsed pathway.

In total, 96% of respondents (120/125) endorsed Barlow and Ortolani maneuvers as appropriate screening tools for infants until 3 months of age. Additionally, 92% (113/123) of pediatricians do not believe that universal ultrasound screening should be adopted in the United States, consistent with AAP and AAOS guidelines. Responses regarding risk factors that would warrant Ultrasound screening regardless of physical exam findings varied based on risk factor. 94.4% (119/126) of respondents reported ordering ultrasounds to evaluate patients for DDH. Only 5.6% (7/125) of pediatricians have referred patients between 12-18 months to a specialist for suspected DDH, and 1.6% (2/125) have referred patients between 18-36 months.

23% of pediatricians (29/126) cited “hip click” as an abnormality that would prompt them to refer a patient to an orthopaedic specialist, which is not recommended by the AAP. Several surveyed pediatricians (10.3%, 13/126) are only “somewhat” or “moderately” familiar with Barlow and Ortolani maneuvers. 69% (87/126) of pediatricians would order an ultrasound for an infant <4 weeks of age with a positive Barlow, which is also not recommended.

Conclusion: This survey indicates that most pediatricians in North America do not see patients with walking-age DDH, unlike in much of the world in which late DDH presentation is common. Current clinical practices are appropriate for early identification of DDH before walking age, but there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatricians who would refer patients to a specialist or order imaging studies inappropriately represents an opportunity for education. The implementation of a care map with a focus on standard referral and imaging practices could improve the care of patients with DDH by reducing the total cost of care and increasing the use of appropriate imaging and pediatric orthopedic referral.