“Normal” Ultrasound May Not Rule Out DDH Later in Childhood

Some years ago, we moved away from calling hip dysplasia “congenital” and started using the term “developmental dysplasia of the hip” (DDH). Indeed, it is developmental. As a surgeon specializing in pediatric orthopaedics and hip preservation, I see not only infants when DDH is of potential concern but also young adults with more mature manifestations of hip dysplasia not previously diagnosed or treated.

Screening protocols have successfully helped in the early identification of DDH and dislocation, but what is the likelihood that infants with risk factors for dysplasia but normal ultrasound results will go on to experience DDH in childhood? And which risk factors are predictive?

In a recent report in JBJS Open Access, Humphry et al. provide new insight into these challenging questions. This study from the UK included 1,053 children from a cohort of 2,191 children who had been assessed as newborns and had at least 1 of 9 perinatal risk factors for DDH. All had undergone ultrasound at a mean of 8 weeks and were followed clinically.

The mean age of the children in the current study was 4.4 years (range, 2.0 to 6.6 years). Thirty-seven of the participants had been treated for DDH in the postnatal period, predominantly with a harness.

Assessing the acetabular index (AI) on pelvic radiographs, the authors found that:

  • 27 of the children had “severe” hip dysplasia (an AI of >2 standard deviations above age and sex reference values). Girls were more likely to have this outcome. Only 3 of the 27 received treatment for DDH in infancy.
  • 146 (13.9%) of the children had an AI of >20°, only 12 of whom had been treated during infancy; 92% had no prior diagnosis of DDH. On multivariate analysis, female sex and breech presentation at birth were significantly predictive of this “mild” dysplasia (breech presentation demonstrated a nearly twofold increased odds of an AI of >20° at ≥3 years of age), while first-born status had a protective effect.

The findings of this study lend support to radiographic monitoring later in childhood for patients with risk factors such as breech positioning at birth. While the exact algorithm of ultrasound and radiographic workup still needs to be elucidated, it appears that a “normal” ultrasound in infancy does not necessarily rule out the development of hip dysplasia in children with select risk factors.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

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