Dr. Bob Underwood (Host): Welcome to MDCast by Tampa General Hospital, a go-to listening location for specialized physician-to-physician content and a valuable learning tool for world-class healthcare. I'm Dr. Bob Underwood. During this episode, we'll be discussing developmental dysplasia of the hip or DDH, including early recognition, which infants should undergo imaging, when referral is indicated, and current approaches to management.

To help us explore these topics, I'm joined by the Medical Director of Pediatric Orthopedic Surgery and a pediatric orthopedic surgeon at the USF Health Morsani College of Medicine, Dr. David Cearley. Dr. Cearley, welcome and thank you for joining us today.

Dr. David Cearley: Good morning. Glad to be here.

Host: So, what is developmental dysplasia of the hip or DDH? Why is it important for both parents and healthcare providers to recognize it early?

Dr. David Cearley: DDH or developmental dysplasia of the hip used to be known as congenital hip dysplasia, but they changed the name several years ago, because they realized that it encompassed a much more broad range of pathology. Really, what it refers to is any abnormal or inappropriate development of the hip, which includes both the femoral side and the pelvic side. So, it can range anything from subtle acetabular dysplasia or insufficiency to an unstable hip that has a tendency to subluxate or a frankly dislocated hip. So, it really encompasses all of that pathology.

Host: So, there's quite an array of abnormality.

Dr. David Cearley: Yes. And what makes it a little bit interesting is that if it's just the acetabular dysplasia, but there's no clinical instability, it's unrecognizable without imaging. So, the big question is should we be imaging all infants with this condition to look for this condition, or do we screen based on certain criteria? And in this country, we actually don't have a screening program. But the reason that this topic is important is that it traditionally has been sort of identified as the leading cause of hip arthritis, which often leads to total hip replacements in middle to elderly aged folks.

But more importantly, as our understanding of hip pathology has evolved, we actually realize that subtle unrecognized dysplasia can lead to early onset arthritis and a condition known as femoroacetabular impingement, or FAI, which is really common in young athletes and is a leading cause of disability, pain, and often leads to major reconstructive surgery in adolescence or early adulthood prior to the development of late-stage arthritis requiring hip replacement. So really, as our understanding of hip pathology has evolved, we realize the importance of treating dysplasia early during infancy with the hope of just trying to prevent these disabilities later on in life.

Host: Right. Now, so you made reference that we don't really have a screening process currently, but who should be screened for developmental dysplasia of the hip? And how do current guidelines really define what is that population

Dr. David Cearley: So fortunately, we do know what the risk factors are. And so, that does give clinicians a guidebook to lean towards screening or not screening a particular child. So, those risk factors are firstborn female, breach at presentation, and a family history. We often call them the four Fs. It's firstborn female, fetal positioning, and family history

And so, typically, it's not standardized by any means in this country. But typically, if there is more than one risk factor, it's a good indication to go ahead and screen that infant because the screening is cheap and efficient and harmless.

Host: And when we say screening, typically, we're talking about imaging, right? So, you said that on a physical examination, these may not be evident. So, we're talking ultrasound?

Dr. David Cearley: Correct. Yeah. So, every newborn gets a hip exam immediately after delivery. And that's the first step in screening. But if the hip feels normal, hip exam is benign, but there are those risk factors, then that child should be scheduled for an ultrasound.

Host: And how soon should you do that ultrasound?

Dr. David Cearley: So, the current recommendations are not to do it before four weeks of age, and no later than six.

Host: Okay. So, you're saying between four and six weeks of age is when the optimal time is for that ultrasound to be done?

Dr. David Cearley: Yeah. And the reason for that is the ultrasound, it's trying to delineate cartilaginous structures, soft tissue structures, and bony structures. And in that newborn period, the bony development is so insufficient that it can be really tricky for the ultrasound to be able to pick up the anatomy well enough to provide accurate measurements. About the only thing an ultrasound at that stage can do is tell if the hip is located or not. But that's something that you should hope be able to find on a physical exam.

Host: Sure. So, say we've got a concerning physical exam finding or an ultrasound that shows to be abnormal. How quickly does this baby need to be evaluated by you or another orthopedic surgeon?

Dr. David Cearley: Virtually immediately. I mean, generally, we say within one to two weeks.

Host: Okay. All right. So, you're saying get them in for that second evaluation by an orthopedist within two weeks.

Dr. David Cearley: Yes. The reason for that is that you want to start initiating treatment as soon as possible, as soon as you recognize there's a problem, because the treatment changes significantly based on the age of the patient.

Host: And what are the treatment options for DDH? And let's talk about after we say what are the options, how do they differentiate between late presenters and early presenters?

Dr. David Cearley: Yeah, that's the critical, issue. So in the newborn period, we typically use what's called a Pavlik harness. And really, it's just an apparatus with cotton straps and Velcro straps that kind of looks like a pair of overalls around the patient's chest and shoulders that connect to, like, boot straps that hold the hips in flexion and abduction. It allows the baby to move a little bit and the idea is that that dynamic movement helps that acetabulum deepen and develop. It also helps guide the hip into a reduced position. but it can only be worn in infants up to six months of age. And it cannot be worn, or should not be worn for more than four months. So, that's why if you get your ultrasound at, say, six weeks, if you see the patient two weeks later, you're already at two months of age. And so if you need to wear that harness for, say, three or four months, you're pushing the window already.

Host: What about late presenters? What are the treatment options there?

Dr. David Cearley: So, we would consider late presenter really anything after six months. So if you have somebody who's, say, six months to a year or early infancy, early walking period, you can put those children in what's called an abduction brace. It functions much the same way as a harness, but it can be sized up for bigger kids.

Host: What is the effectiveness of these treatments?

Dr. David Cearley: Well, so in the older children, a brace is only going to be effective for hips that are dysplastic but not dislocated. So if you have a dislocated hip in a child over six months of age, at that point, you're starting to think surgery, at least a closed reduction under anesthesia.

If it's just radiographic dysplasia over six months of age, then those are the children that you can brace. So, it really starts to get a little more complicated as they get older, because a hip that's dislocated in a six-week-old will often reduce with the harness. But a hip that's dislocated in a six-month-old is not going to do that because of the stiffening up of the soft tissues by that age, and those children will require an attempted reduction under a general anesthetic.

Host: Right. Right. So, what are some key take-home messages that you would like primary care clinicians to remember about this podcast and to be able to take action on?

Dr. David Cearley: So, one of the first things I would say is that to understand what an abnormal exam is and what would constitute an appropriate referral to an orthopedic surgeon. There's a common condition that's known as the hip click, which is present in a lot of infants. And it is a very common reason for referral to my practice.

But clicks are benign and generally are not an indication of any kind of pathology. Not exactly sure what does it, but there is a large ligament that's intra-articular in infants, and we think that the moving of the femoral head over this ligament is what causes that clicking. And so, a lot of pediatricians feel a click, and they think, "Oh my gosh, they've got dysplasia", and then they send an urgent referral to the orthopedic surgeon, and the parents are all concerned.

But it's really a hip that's unstable. So, I really would like the pediatricians to understand that it's the feeling of instability where the hip wants is able to be subluxated or dislocated, or a hip that's dislocated that clunks into the acetabulum upon reduction.

So, I would really encourage them to get with maybe a pediatric orthopedic surgeon at their facility or in their community and really see if they can't learn how to feel what is an abnormal hip exam. That's one thing I think that pediatricians should take home from this and go out and learn that.

Because then, unfortunately, you know, you only learn what you're taught. And if you don't see any dislocated hips during your pediatric residency or your family practice residency, you don't know. And so, if you're not sure what a abnormal hip exam is, I would encourage them to find a pediatric orthopedic surgeon in their community and see if they can get familiar with that. So, that's number one.

And then, number two is, like we talked about, is knowing which babies should get screened and when. Unfortunately, I've seen several, infants over that six months of age referred because the pediatrician remembered or realized they were breach. So, we probably should screen them. Well, at that point it's a little late, obviously, as we talked about. So, the treatment options are more limited. So really if you have any concerns from risk factors, get that ultrasound between four and six weeks and get that baby in to see someone like me right away.

So really, it's get familiar with what a abnormal hip exam is, understand when the screening should take place. And also I would like them to understand that just because a baby is breach for a period of time during the pregnancy, that doesn't really indicate a risk factor. It's really only the babies that were breach all the way to term and presentation So, those are what I would think three good take-home messages.

Host: Yes. Awesome, awesome. Is there anything else you'd like to add as we close?

Dr. David Cearley: I think we've covered a lot of it. I do think, though, that, one thing we didn't really get into is what are the options after they're really of walking age. And really, at that point, most of those kids are going to require an invasive procedure known as an open reduction, oftentimes even requiring bony work, such as an acetabular osteotomy or femoral osteotomy.

And those surgeries, in the right hands, are very effective. And it's been shown that if you can get the hip reduced and stable by the age of three, then those kids should be able to go on to have a pretty normal function and low risk factors for developing arthritis down the road.

So, it's not the end of the world if someone is found late, but it does obviously complicate things, and it puts them at a greater risk. Because once you start to get into the surgical treatment of this condition, the biggest risk factor is avascular necrosis, and that can be a devastating problem, even for a young infant. It doesn't seem to be as common, if at all. I've never really seen it when you get them reduced early with a harness. But once you get into that older age and you have to start doing surgical procedures, even if it's a closed reduction, then you're starting to introduce the risk of avascular necrosis.

So, it's not the end of the world if it's picked up late, but it really does make a huge difference if we can get those babies treated within the first couple of months of life.

Host: Yes, absolutely. Dr. Cearley, thank you for this very informative discussion.

Dr. David Cearley: well, thank you. I appreciate it. I hope that it provides some insight and maybe even the launching pad for providers to seek out more training and learn more about this topic.

Host: Thank you for listening to MD Cast by Tampa General Hospital, which is available on all major streaming services for free. To collect your CME, please click on the link in the description. For other CME opportunities, including live webinars, on-demand videos, and local events offered to you by Tampa General Hospital, please visit cme.tgh.org.