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Developmental dysplasia of the hip: Treatment and outcome

Developmental dysplasia of the hip: Treatment and outcome
Author:
Scott B Rosenfeld, MD
Section Editor:
William A Phillips, MD
Deputy Editor:
Diane Blake, MD
Literature review current through: Jan 2024.
This topic last updated: Sep 01, 2023.

INTRODUCTION — Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the development of the hip in infants and young children. It encompasses abnormal development of the acetabulum and proximal femur and mechanical instability of the hip joint (table 1). (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Terminology'.)

Treatment of DDH is initiated with referral to a pediatric orthopedic surgeon or other orthopedic surgeon who is familiar with the diagnosis and treatment of DDH. The treatment and outcome of DDH in otherwise healthy children will be reviewed here. The epidemiology, pathogenesis, natural history, clinical features, and diagnosis are discussed separately. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis" and "Developmental dysplasia of the hip: Clinical features and diagnosis".)

TERMINOLOGY — Specific terms describing the position, stability, and shape of the hip in infants and children with DDH are defined below:

Dislocation – There is a complete loss of contact between the femoral head and the acetabulum.

Subluxation – The femoral head is partially outside of the acetabulum, but remains in contact.

Dislocatable – The femoral head is reduced (ie, within the acetabulum) at rest but can dislocate in other positions or with examination maneuvers. This is a hip with instability.

Subluxatable/subluxable – The femoral head is reduced at rest but can be partially dislocated or subluxated with examination maneuvers. This is a hip with mild instability or laxity.

Reducible – The hip is dislocated at rest but the femoral head can be positioned into the acetabulum with manipulation (generally flexion and abduction).

Dysplasia – Abnormality of the shape of the hip joint (usually shallowness of the acetabulum, involving the superior and anterior margins).

OVERVIEW — The information provided in this topic review is intended to provide an overview of the orthopedic management of DDH in healthy children to enable the primary care provider to educate and support families, and to help the primary care provider to coordinate care, provide timely referrals, and ensure appropriate orthopedic follow-up. The management of teratologic hip dysplasia, which occurs in association with various syndromes (eg, Ehlers-Danlos syndrome, Down syndrome, arthrogryposis), and neuromuscular hip dysplasia, which occurs when there is weakness and/or spasticity in some or all of the hip muscle groups (eg, in spina bifida or cerebral palsy) differ from the management of DDH in healthy infants and is not discussed in this topic.

Natural history of untreated DDH — The natural history of untreated DDH depends upon the age of the patient and the severity of DDH [1-4].

Newborns often have physiologic laxity of the hip and immaturity of the acetabulum during the first few weeks of life. Most hip instability in newborns stabilizes soon after birth, as physiologic laxity decreases and the femoral head and acetabulum grow. In observational studies, there is a high rate of resolution of neonatal hip instability without intervention [5-10]. In a cohort of 11,989 infants, 60 percent of hips that demonstrated instability on physical examination at birth stabilized in the first week of life, and nearly 90 percent stabilized by 2 months and were functionally and radiographically normal at 12 months [5].

A dislocated hip may function well for many years [4]. However, over time, there may be gradual progression of functional disability, pain, and accelerated osteoarthritis. The risk of these complications is not well defined but may be associated with the development of a false acetabulum [2,3,11].

The natural history of untreated dysplasia in a reduced or subluxated hip is variable. In infants and young children, radiographic abnormalities may improve with time because the acetabulum still has excellent remodeling potential [11-14]. However, after school age, the likelihood of spontaneous improvement is low. Patients with persistent dysplasia without dislocation may develop activity-related hip pain or osteoarthritis in adolescence or young adulthood. Pain may start soon after skeletal maturity, or, in females, during the first or second pregnancy or at menopause. Patients 40 to 60 years old who present with hip osteoarthritis are often found to have mild dysplasia as a contributing cause [1-4]. (See "Epidemiology and risk factors for osteoarthritis", section on 'Anatomic factors'.)

Indications for referral — Indications for referral to an orthopedic surgeon who is experienced in the diagnosis and treatment of DDH are summarized below. They are discussed in greater detail separately. (See "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Approach to diagnosis and referral'.)

Infants (of any age) with dislocation or instability (ie, positive Ortolani test) or limited/asymmetric abduction of the hip on examination

Serial follow-up examination for infants ≥4 weeks with a positive Barlow test (ie, a dislocatable or subluxatable hip (table 1)) to ensure the development of hip stability; serial examination also may be performed by the primary care clinician according to local practice and preference

Infants two to four weeks of age with inconclusive examination (eg, joint clicks or thigh asymmetry without evidence of instability); alternatively, the primary care provider may obtain ultrasonography of the hip at six to eight weeks of age or continue to follow clinically [15] (see "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Suboptimal or inconclusive examination')

Infants <1 year of age with apparent shortening of the femur (ie, positive Galeazzi sign (figure 1) also called the Allis or Perkins sign ), positive Klisic test (figure 2), or marked asymmetry of leg creases (see "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Examination')

Infants with evidence of DDH (including stable hips with acetabular dysplasia/underdevelopment) on ultrasonography (figure 3A-B) or plain radiographs (eg, lateral and superior positioning of the ossified portion of the femoral head, increased acetabular index, delayed appearance of the femoral ossific nucleus, or asymmetric size of femoral ossific nuclei) (see "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Diagnostic imaging')

Children older than one year who have clinical findings suggestive of DDH (table 2)

Caregiver or clinician concern

Goal of treatment — The goal of treatment of DDH is to obtain and maintain concentric reduction (ie, alignment of the geometric centers of the femoral head and the acetabulum) of the hip. In the young child, concentric reduction provides an optimal environment for the development of the femoral head and acetabulum. In the older child, who has completed development of the hip joint, concentric reduction helps to prevent or postpone development of osteoarthritis of the hip [16,17]. (See "Epidemiology and risk factors for osteoarthritis", section on 'Anatomic factors'.)

The optimal environment for development of the femoral head and acetabulum is one in which the cartilaginous surface of the femoral head is in contact with the cartilaginous floor of the acetabulum. Both the femoral head and the acetabulum have the capacity for growth and reshaping, which can result in gradual resolution of dysplasia over time (months to years) if concentric reduction is maintained [12,18]. Acetabular remodeling has been estimated to continue up until age 11 years [19-21], with maximal acetabular remodeling 4 to 6 years after reduction of the dislocated hip (image 1) [22].

Concentric reduction is the goal no matter when DDH is diagnosed. However, the therapies necessary to achieve concentric reduction vary depending upon the age at presentation or diagnosis, stability, and severity [23,24].

AGE 0 TO 4 WEEKS — Hip instability or risk factors for DDH, such as breech positioning, often are identified in the newborn period and first month of life. Hip dislocation is rare in infants younger than four weeks, but laxity (mild instability) and/or a shallow acetabulum (dysplasia) (table 1) are common. Whether these findings in newborn infants should be considered signs of pathology or normal immature development is controversial [6,25]. The management of infants younger than four weeks of age depends upon the clinical findings and risk factors.

Laxity — Given that mild instability/laxity in infants younger than four weeks usually improves spontaneously, it is important to avoid over-diagnosis and overtreatment of DDH in this age group [5,26,27]. If mild instability/laxity is found in the newborn nursery, repeat examination after four weeks of age is suggested. (See 'Age 4 weeks to 6 months' below.)

Dislocation or instability — Although not an emergency, prompt referral (within a few weeks) to an orthopedic surgeon who is experienced in the diagnosis and treatment of DDH is indicated if the hip is dislocated or dislocatable (at any age), or if laxity persists beyond four weeks of age.

For infants with a hip that is in the socket but unstable, waiting until at least four weeks of age allows time for spontaneous resolution of neonatal instability and does not jeopardize treatment success [28]. In a retrospective review of 176 children treated with Pavlik harness for hip instability at ≤6 months of age, outcomes were similar whether treatment was initiated before or after 30 days of age [29]. (See 'Age 4 weeks to 6 months' below.)

If the orthopedic surgeon's examination is normal, but the infant has risk factors for DDH (eg, breech presentation regardless of sex or positive family history), ultrasonography after two weeks of age may be warranted [15]. (See "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Normal examination and risk factors'.)

Abnormal ultrasonography — If the infant's hips are stable on examination but the infant has undergone hip ultrasonography and abnormalities were identified (figure 3A-B), we generally suggest observation with repeat ultrasonography at six weeks of age [10,30,31].

AGE 4 WEEKS TO 6 MONTHS

Mild instability — In the absence of high-quality evidence or consensus, the orthopedic management of infants with mild instability/laxity that persists beyond two weeks of age is determined on a case-by-case basis.

For infants who continue to have a reduced hip with mild instability/laxity beyond two weeks of age, we suggest re-examination and ultrasonography at six weeks of age [5,32]. However, some orthopedic surgeons may begin treatment with a Pavlik harness. (See 'Pavlik harness' below.)

Dislocation or persistent instability

Abduction devices — We recommend treatment with an abduction splint (eg, Pavlik harness, von Rosen splint, Tübingen splint) for infants younger than six months with hip dislocation or persistently dislocatable or subluxatable hips. These types of DDH are unlikely to resolve without treatment and may result in functional disability, pain, and accelerated osteoarthritis. (See 'Natural history of untreated DDH' above.)

The choice of abduction splint varies regionally. The Pavlik harness is the most thoroughly studied and most commonly used abduction splint worldwide [24], although the von Rosen splint and Tübingen splint also appear to be safe and effective [33-37]. The Pavlik harness is the only abduction splint that will be discussed in this topic. The Frejka pillow is another type of abduction device used in the treatment of DDH, but it has been associated with an increased rate of avascular necrosis [38-43].

We recommend not using double- or triple-diapering for the treatment of DDH. Double- or triple-diapering was recommended in the past, but it is not effective and has the potential to be harmful. It may promote hip extension, which is an unfavorable position for normal hip development [23]. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Embryology and pathogenesis'.)

Pavlik harness — The Pavlik harness is a dynamic splint that prevents hip extension and limits adduction (which can lead to dislocation), but permits flexion and abduction (figure 4). This positioning promotes normal development of a dysplastic hip and stabilization of a subluxated hip and usually leads to gradual reduction of a dislocated hip, even if it is not reducible on physical examination [44].

Indications – We suggest treatment with a Pavlik harness rather than other abduction splints for infants younger than six months with hip dislocation or persistently dislocatable or subluxatable hips. The Pavlik harness is the most thoroughly studied and most commonly used abduction splint.

Contraindications – Contraindications to the use of the Pavlik harness include muscle imbalance (spina bifida), severe stiffness (arthrogryposis), excessive laxity (Ehlers-Danlos syndrome), age older than 10 months, and a family situation in which consistent and careful use cannot be guaranteed [23,45]. DDH in infants with contraindications to the use of a Pavlik harness may be treated with observation or closed or open reduction.

Application and instructions – The Pavlik harness is typically fit with hip flexion of 100° and adduction limited to within three fingerbreadths of the midline (ie, the knees should be separated by six fingerbreadths when brought to the midline). Abduction is not forced but encouraged via gravity. In the setting of rapid infant growth, weekly or biweekly adjustments are necessary to maintain the ideal position. Caregivers are cautioned regarding hyperflexion and hyperabduction of the hips, which may cause femoral nerve palsy and osteonecrosis, respectively [46]. Ultrasonography is used to monitor treatment.

We generally suggest that the harness be worn for 23 hours per day (ie, except during bathing) for the first six weeks or until the hip is stabilized [47]. Once the hip is stabilized, the harness is used during sleep for the next six weeks.

Duration of treatment – The duration of treatment varies depending upon age, severity, and response. Two to three months of treatment is usually necessary for patients who demonstrate improvement with the Pavlik harness. A combination of clinical examination demonstrating a stable hip and ultrasonography demonstrating improved acetabular development are used to determine when treatment can be discontinued [10,48]. Limited evidence from an observational study suggests that radiographic results at age one year are similar whether Pavlik harness therapy is weaned or abruptly discontinued [49].

Treatment with the Pavlik harness should be discontinued after three weeks if a dislocated hip has not reduced [50,51]. After failure of reduction with a Pavlik harness, a rigid abduction orthosis (ie, brace that holds the hip[s] in abduction, but unlike the Pavlik harness is not flexible (figure 5)) may be used to gain reduction. In a single institution case series, 13 of 15 hips that failed treatment in a Pavlik harness were successfully reduced with a rigid abduction orthosis [52]. Reduction under anesthesia is usually required if reduction with a rigid abduction orthosis is unsuccessful [24]. (See 'Age 6 to 18 months or failure of abduction splint' below.)

Effectiveness – In observational studies, dislocatable or subluxatable hips improve in approximately 95 percent of cases when treated with the Pavlik harness [53-57]. The success rate for complete dislocation is approximately 85 percent (with success defined as achievement and maintenance of hip reduction) [50,54,58].

For children older than four weeks, the age at initiation of Pavlik harness treatment is an important predictor of outcome [58,59]. Earlier treatment is associated with greater success, although the optimal threshold has not been defined. In a multicenter prospective study that included only infants with dislocated hips, the overall success rate was 79 percent. Success rates were higher when treatment was initiated at ≤7 weeks (approximately 85 versus 66 percent). Factors associated with failure included developing femoral nerve palsy during brace treatment, an initially irreducible hip, a right hip dislocation, and a Graf type IV hip (figure 3A) [58]. In a retrospective study of children with the spectrum of DDH, success rates were higher when treatment was initiated at <4 months (76 to 94 percent versus 37 to 57 percent) [59].

Early failure of Pavlik harness treatment is more likely when there is low percentage coverage (<20 percent) of the femoral head, a high dislocation (ie, one in which the femoral head has migrated superiorly), or irreducible dislocation on physical examination [46,57,58,60-63].

Complications – Complications of Pavlik harness therapy include osteonecrosis of the femoral head, residual dysplasia, femoral nerve palsy, and skin breakdown. To avoid complications, Pavlik harness treatment should be instituted by an orthopedic surgeon who is experienced in the evaluation and treatment of DDH. Although Pavlik harness treatment is usually safe, complications may occur.

Osteonecrosis – The most serious complication is osteonecrosis (avascular necrosis) of the femoral head, which can result in permanent damage to the femoral head and acetabulum. The reported incidence of osteonecrosis varies widely (from 0 to 16 percent), depending upon the age and severity at initiation of treatment and the duration of follow-up; in most case series, the reported incidence is between 0 and 5 percent [54,57,58,64,65]. Proper fit and wear of the harness decrease the risk of osteonecrosis [24].

Residual dysplasia – Residual dysplasia is uncommon, occurring in approximately 3 percent of treated patients [54]. Follow-up radiographs are performed to monitor acetabular development. Most patients show gradual correction by age 18 months [12,18,24,54]. If dysplasia persists past three to four years of age, surgical treatment is commonly recommended. (See 'Long-term follow-up' below and 'Residual or late-presenting acetabular dysplasia' below.)

Femoral nerve palsy – Femoral nerve palsy (weakness of the quadriceps muscle with inability to extend the knee and decreased or unobtainable knee-jerk reflex) is another important complication [66]. In a retrospective review of 1218 patients who were treated with a Pavlik harness for DDH, femoral nerve palsy occurred in 2.5 percent, almost always within the first week of treatment [67]. Femoral nerve palsy resolved in all patients, usually within 14 days. Compared with patients who did not develop femoral nerve palsy, those who did were older at diagnosis (56 versus 22 days), heavier (4.8 versus 3.7 kg), and had more severe disease (ie, reducible or fixed dislocation versus laxity or dysplasia).

Skin breakdown – Skin breakdown may affect adherence to Pavlik harness therapy [68,69]. In a prospective study of 160 parents of children undergoing treatment with a Pavlik harness, dermatitis in the groin or popliteal fossa was reported by 12.5 percent of parents, dermatitis of the shoulder by 9.4 percent, and dermatitis of the leg by 8.8 percent [69]. Suggestions for preventing skin breakdown include keeping the skin as clean and dry as possible; avoiding lotions, powders, and creams under the harness; and changing diapers frequently or using leak-proof diapers [70].

Other complications – Other complications may include brachial plexus palsy, knee subluxation, inferior dislocation, and Pavlik disease (flattening of the posterior acetabulum caused by excessive hip abduction and flexion) [71-74]. The frequency of these complications is not known.

Dysplasia without dislocation — The management of infants younger than six months with dysplasia without dislocation is determined on a case-by-case basis. Decisions generally are made by the orthopedic surgeon in conjunction with the child's caregivers after discussion of the risks and benefits of therapy versus observation.

We suggest treatment with the Pavlik harness if isolated acetabular dysplasia (Graf type IIa or worse) (figure 3A-B) persists beyond six weeks of age [64]. However, other centers may have different thresholds for intervention in infants with dysplasia without dislocation. (See "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Ultrasonography'.)

We monitor treatment with ultrasonography every four to six weeks until the ultrasonographic measurements become normal, at which point use of the Pavlik harness is weaned over six weeks. Follow-up radiographs are obtained at six months of age and regularly until skeletal maturity. (See 'Pavlik harness' above and 'Long-term follow-up' below.)

Data supporting treatment over observation are limited. On the one hand, there is some evidence that dysplasia resolves over time without treatment, suggesting that few patients are likely to benefit from treatment [14,75]. On the other hand, treatment with abduction splinting has few risks but a large potential benefit for the small number of infants in whom dysplasia would persist or worsen without treatment and who would possibly require surgical intervention. In a prospective study in which 780 Graf type IIa hips were followed ultrasonographically, worsening occurred in 5.6 percent [76].

AGE 6 TO 18 MONTHS OR FAILURE OF ABDUCTION SPLINT

Dislocation — Closed or open reduction performed in the operating room under anesthesia usually is necessary for children with DDH who are older than six months at the time of diagnosis or initiation of therapy and infants who fail treatment with abduction splinting [24]. In children older than six months, the rate of successful reduction with Pavlik harness treatment is less than 50 percent, and there is a higher risk of osteonecrosis (avascular necrosis) of the femoral head [45].

Timing of reduction — Orthopedic specialists at most centers, including the author's, recommend treatment of the dislocated hip soon after the diagnosis is made. The age of the child and development of the hip joint at the time of treatment affect outcome. In observational studies, the earlier the hip is reduced, the more likely the success of closed reduction; the older the patient, the more likely the need for open reduction and possible femoral and pelvic osteotomies [77-79].

The practice of early reduction is supported by an observational study in which reduction before ossification of the capital femoral epiphysis was associated with decreased rate of subsequent reconstructive surgery (eg, varus rotational osteotomy, pelvic osteotomy) compared with reduction after ossification (22 versus 44 percent) [77].

The presence or absence of ossification of the capital femoral epiphysis at the time of reduction has been thought to affect the risk of osteonecrosis [80,81]. However, a 2017 systematic review and meta-analysis of 21 observational studies (only three of which were prospective), including 1655 patients, did not find an association between ossification of the capital femoral epiphysis and the risk of osteonecrosis (of any grade) or of more severe osteonecrosis [82].

Closed reduction — The goal of closed reduction is to place the femoral head into the acetabulum and to maintain it in this position with a spica cast. Closed reduction involves gentle manipulation of the hip to achieve reduction. Closed reduction is performed under general anesthesia using intraoperative arthrography and fluoroscopic imaging to guide positioning. Release of tight adductors may be necessary to increase hip abduction and facilitate positioning. Wide abduction should be avoided to decrease the risk of osteonecrosis.

It is important that reduction is achieved with gentle manipulation. Forced reduction and reduction requiring a high degree of abduction are likely to result in complications or poor outcomes (eg, redislocation, osteonecrosis). If it is not possible to reduce the hip with gentle manipulation (with or without release of adductors), closed reduction is abandoned and open reduction is performed. (See 'Open reduction' below.)

Once concentric reduction is confirmed, a spica cast is applied to maintain the position. After a successful closed reduction, the spica cast should hold the hips in 100° of flexion and 40 to 50° of abduction (ie, the "human position"). Three-dimensional imaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), is usually obtained immediately postoperatively to confirm reduction. Specially formatted "spica MRI" facilitates a shorter time for image acquisition without need for sedation [83,84]. Contrast enhancement may provide additional information about femoral epiphyseal perfusion [85].

Casting is typically continued for three to four months after closed reduction. Cast changes and repeat hip arthrography may be performed at six-week intervals as clinically necessary. Following treatment in the spica cast, some centers transition to a rigid abduction orthosis for 6 to 12 weeks.

The outcomes of closed reduction vary depending upon severity and other clinical factors [86-89]. Complications of closed reduction include redislocation, osteonecrosis, and skin breakdown.

Open reduction — The goal of open reduction is to place the femoral head into the acetabulum and to maintain it in this position with a spica cast. Open reduction is typically performed after an unsuccessful attempt at closed reduction or primarily in patients who are older than 18 months.

Open reduction can be performed through a medial or an anterior incision. The hip capsule is opened to remove the obstacles to reduction, including medial capsular constriction, inverted labrum, neolimbus, pulvinar, hypertrophied ligamentum teres and transverse acetabular ligament, and tight iliopsoas tendon (figure 6). Capsulorrhaphy may be performed to remove redundant capsule, tighten the remaining capsule, and improve stability. Additional procedures, such as femoral or pelvic osteotomies and adductor tenotomy, may be required to increase hip stability.

After open reduction, a spica cast is placed with the hips held in approximately 30° of flexion and 30° of abduction to avoid postoperative flexion contractures [90]. Postoperative three-dimensional imaging (eg, CT, MRI) is typically obtained to confirm reduction.

Casting typically is continued for six weeks to three months after open reduction. Cast changes may be performed at six-week intervals as clinically necessary. We generally remove the cast six weeks after open reduction and begin night-time abduction splinting with a rigid abduction orthosis, which is continued for six weeks.

The outcomes of open reduction vary depending upon severity and other clinical factors. In long-term follow-up of patients from one institution (1955 to 1995), approximately 50 percent of patients required additional surgery for dysplasia [78]. In another study of 149 children (average age at surgery of 23 months), approximately 25 percent of patients required additional surgery for dysplasia and 13 percent developed avascular necrosis [91]. Need for additional surgery and development of avascular necrosis were not statistically different between children ≥12 months versus those <12 months.

Complications of open reduction include redislocation, osteonecrosis, infection, scar, and stiffness.

Dysplasia without dislocation — There is little evidence to guide the management of children older than six months with dysplasia without dislocation. The author usually uses a part-time or full-time abduction orthosis, such as a rhino abduction brace or a spica cast. This allows improved positioning of the femoral head within the acetabulum to promote acetabular development during a time when there is good potential for acetabular remodeling.

Support for abduction bracing is provided by a retrospective study from a single institution comparing part-time bracing (during naps and at night) with observation in 70 hips (48 patients) with residual acetabular dysplasia (acetabular index ≥30°) at six months of age [92]. Part-time bracing was associated with greater improvement in acetabular index at 12 months of age (5.3 versus 1.1°). A subsequent prospective study in which compliance was monitored with a thermal sensor confirmed the benefits of part-time bracing [93]. After approximately six months with an average daily duration of bracing of approximately 12 hours (range 1.3 to 21.7), the mean improvement in acetabular index was 4.8° (from 33.3 to 28.5°) [93].

Treatment with a part-time or full-time abduction orthosis is reasonable up to the age of three or four years. If by that age there is still evidence of acetabular dysplasia, the orthopedic surgeon may recommend continued observation with serial radiographs every 6 to 12 months or proceed with pelvic osteotomy to correct dysplasia. The duration of observation of acetabular dysplasia and the age at which an osteotomy may be recommended varies from center to center.

AGE ≥18 MONTHS

Dislocation — For children ≥18 months of age with hip dislocation, the risks and benefits of reduction are weighed against the natural history of untreated hip dislocation. The major risks of surgery in children ≥18 months of age include osteonecrosis and proximal femoral growth disturbance, residual dysplasia, and the need for additional surgeries. Benefits of successful surgery include correction of leg length discrepancy and prevention or postponement of development of osteoarthritis of the hip. (See 'Goal of treatment' above and 'Natural history of untreated DDH' above.)

The earlier the reduction is performed, the more time there is for acetabular growth and remodeling and the more likely the benefits of surgery will outweigh the risks. Reduction of unilateral dislocation generally is undertaken until 9 or 10 years of age and reduction of bilateral dislocations until approximately 8 years of age [94]. After age 9 or 10 years (for unilateral dislocations) or 8 years (for bilateral dislocations), surgical outcomes are likely to be less satisfactory than the untreated natural history. Older patients with dislocations often have already developed femoral head deformities, which decrease the likelihood of achieving a concentric reduction. In addition, the rate of osteonecrosis after open reduction in older patients is much higher than that in younger patients [4,95]. (See 'Natural history of untreated DDH' above.)

After ≥18 months of age, closed reduction of a dislocated hip is less likely to be successful, and open reduction is usually required. Concomitant procedures (eg, adductor tenotomy, iliopsoas release, capsulorrhaphy, femoral shortening and derotational osteotomy, acetabular osteotomy) also are more likely to be necessary [90,96-98].

Although the risk of poor outcome (eg, failure of reduction, residual dysplasia, osteonecrosis, proximal femoral growth disturbance) is increased when reduction is performed in older compared with younger children, many patients achieve satisfactory outcomes, particularly when femoral shortening osteotomy is performed concomitant with reduction [97,99,100]. As an example, in a retrospective series, among 22 hips in children with bilateral dislocation who underwent open reduction at ≥3 years of age, the outcome in 16 was excellent or good (using a clinical and radiographic scoring system); however, 4 patients had leg length discrepancy of approximately 1.5 cm and 12 developed osteonecrosis [100]. Among 29 hips in children with unilateral dislocation, the outcome was excellent or good in 29, but 18 developed osteonecrosis.

Residual or late-presenting acetabular dysplasia — Among children older than five years with residual or late-presenting acetabular dysplasia, surgery is usually necessary to achieve concentric reduction to reduce the risk of osteoarthritis. Acetabular remodeling after age five years is unlikely to achieve concentric reduction.

Treatment usually involves acetabular osteotomy with or without femoral osteotomy. The type of acetabular osteotomy depends upon the severity of acetabular dysplasia and whether the triradiate cartilage remains open.

LONG-TERM FOLLOW-UP — Recurrent or residual DDH may occur after successful treatment, and the likelihood increases with age at the time of treatment [30,101]. Children treated for hip dysplasia should have regular radiographs until they are skeletally mature to ensure that the hip is developing normally and to look for late complications or sequelae (eg, recurrent or residual dysplasia, osteonecrosis, osteoarthritis). The frequency of long-term follow-up varies depending upon the preference of the treating orthopedic surgeon.

OUTCOME — The long-term outcome of treated DDH depends upon the severity of dysplasia, the age of diagnosis and treatment, and whether a concentrically reduced hip joint was obtained. It is generally accepted that the earlier the patient is treated, the greater the likelihood of a good outcome, highlighting the importance of early diagnosis [77-79,102]. (See "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Clinical features'.)

Approximately 90 percent of neonatal hips with instability or mild dysplasia resolve spontaneously with normal functional and radiographic outcomes [5]. (See 'Natural history of untreated DDH' above.)

When DDH is diagnosed before six months of age, treatment with a Pavlik harness achieves and maintains hip reduction in approximately 95 percent of patients [24,53-56]. Long-term follow-up is important to monitor for residual dysplasia, which may occur in up to 20 percent of patients after successful treatment of DDH [1]. Once the hip has stabilized and the patient is recovered from any surgical procedures, annual or biennial follow-up is recommended until skeletal maturity. (See 'Pavlik harness' above and 'Long-term follow-up' above.)

Residual dysplasia, either following treatment or undiagnosed, may progress to osteoarthritis. In a population-based study of 2.2 million children (1967 to 2004), there was a 2.6-fold increase (95% CI 1.4-4.8) in total hip replacements in young adults who had been diagnosed with neonatal hip instability compared with those without neonatal hip instability; however, the absolute risk of total hip replacement was low (approximately 1 in 1750 in children with neonatal hip instability and 1 in 5000 for children without a neonatal hip instability) [103]. The majority of young adults who underwent hip replacement that was attributed to dysplasia was not known to have neonatal hip instability.

Total hip replacement is common among patients diagnosed with DDH at ≥18 months of age. In a long-term follow-up study, approximately 40 percent of patients who underwent either closed reduction or open reduction with pelvic osteotomy for DDH had total hip replacement within 40 to 45 years after the initial procedure [104].

MANAGEMENT OF FAMILY MEMBERS — Family history of DDH is a well-known risk factor for DDH. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Family history'.)

First- and second-degree relatives of children who require treatment for DDH also may be at increased risk of occult acetabular dysplasia. Consultation with an orthopedic surgeon and radiographs may be warranted if these relatives develop hip pain. In an observational study, 120 family members (first- or second-degree relatives) from 19 families in which one member underwent treatment for DDH with bracing or surgery were evaluated with physical examination and radiographs [105]. Among the 86 subjects without a known history of DDH, 27 percent had occult acetabular dysplasia; 60 percent of these were younger than 30 years. These findings support the genetic contribution to DDH.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Developmental dysplasia of the hip".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)

Basics topic (see "Patient education: Developmental dysplasia of the hip (The Basics)")

SUMMARY AND RECOMMENDATIONS

Terminology – Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the development of the hip in infants and young children. It encompasses abnormal development of the acetabulum and proximal femur and mechanical instability of the hip joint (table 1). (See 'Introduction' above.)

Natural history – The natural history of untreated DDH depends upon the age of the patient and the severity of DDH. Most hip instability in newborns stabilizes soon after birth. Over time, untreated dislocation and untreated dysplasia without dislocation may be associated with functional disability, pain, and early osteoarthritis. (See 'Natural history of untreated DDH' above.)

Goal of treatment – The goal of treatment of DDH is to obtain and maintain concentric reduction of the hip to provide an optimal environment for the development of the femoral head and acetabulum and reduce the risk of early osteoarthritis. (See 'Goal of treatment' above.)

Management

Age 0 to 6 months

-We recommend treatment with an abduction splint for infants younger than six months with hip dislocation or persistently dislocatable or subluxatable hips (Grade 1B). The Pavlik harness is the most thoroughly studied and most commonly used abduction splint. (See 'Dislocation or persistent instability' above.)

-We suggest treatment with a Pavlik harness for infants younger than six months who have acetabular dysplasia without dislocation (Graf type IIa or worse) (figure 3A-B) that persists beyond six weeks of age (Grade 2C). (See 'Dysplasia without dislocation' above.)

Age ≥6 months – Reduction under anesthesia (closed or open) is usually necessary for children who are older than six months of age at the time of diagnosis or initiation of therapy. (See 'Age 6 to 18 months or failure of abduction splint' above and 'Age ≥18 months' above.)

Long-term follow-up – Children who have been treated for DDH should be monitored with regular hip radiographs until they are skeletally mature to evaluate hip development and complications or sequelae. The frequency of long-term follow-up varies depending upon the treating orthopedic surgeon. (See 'Long-term follow-up' above.)

Outcome – The long-term outcome of treated DDH depends upon the age at diagnosis, the severity of dysplasia, and the success of treatment. Treatment with Pavlik harness achieves and maintains hip reduction in approximately 95 percent of infants with DDH who are treated during the first six months of life. (See 'Outcome' above.)

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Topic 6293 Version 29.0

References

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