What is the management approach for Developmental Dysplasia of the Hip (DDH)?

Management of Developmental Dysplasia of the Hip (DDH)

The management of Developmental Dysplasia of the Hip (DDH) should follow an age-based approach, with early detection and treatment using Pavlik harness for infants under 6 months, closed reduction with spica casting for children 6-18 months, and surgical intervention for older children to prevent long-term complications. 1, 2

Diagnosis and Screening

Clinical Screening

• All infants should undergo clinical examination at every well-baby visit until 12 months of age 2
• Key clinical tests:
  • Barlow and Ortolani tests (most useful in infants <3 months)
  • Limited hip abduction (most important clinical sign after 3 months) 1
  • Asymmetry of thigh or gluteal folds
  • Leg length discrepancy (Galeazzi sign)

Imaging

• Age-specific imaging recommendations:

  Age	Recommended Imaging	Rationale
  0-4 weeks	Clinical examination only	Allows time for physiologic laxity to resolve 1
  4 weeks-4 months	Ultrasound	Visualizes cartilaginous structures, allows dynamic assessment 1
  >4 months	Pelvic radiography	Better visualization of ossified structures 1, 2

• Selective screening is recommended for infants with risk factors:

  • Female gender (2.5x risk)
  • Breech positioning (3.8x risk)
  • Positive family history (1.4x risk)
  • Left hip (more commonly affected) 2, 1

Treatment Algorithm

Infants 0-6 months

• First-line: Pavlik harness 1, 3

  • Most effective when applied before 6 weeks of age
  • Success rate: 70-95%
  • Typical treatment duration: 6-12 weeks
  • Monitoring: Ultrasound to confirm concentric reduction and assess treatment response

• If Pavlik harness fails:

  • Closed reduction and spica casting 3
  • Risk factors for harness failure include:
    • Femoral nerve palsy
    • Static bracing
    • Irreducible hips
    • Initiation after 7 weeks of age
    • Graf-IV hips
    • Male sex 3

Children 6-18 months

• First-line: Closed reduction with hip spica cast 4

  • Usually performed under general anesthesia
  • Pre-reduction traction may be used in some cases
  • Post-reduction imaging to confirm concentric reduction

• If closed reduction fails:

  • Open reduction may be required for:
    • Irreducible hips
    • Nonconcentric reduction
    • Unstable reduction 3

Children >18 months

• Surgical intervention is typically required 5
  • Open reduction
  • Often combined with femoral and/or pelvic osteotomy
  • Goals: achieve concentric reduction and improve acetabular coverage

Treatment Monitoring

• For infants in Pavlik harness: Ultrasound monitoring every 2-3 weeks 1
• For children in spica cast: Radiographs or MRI to confirm reduction
• Radiographs at or near conclusion of treatment to document bony acetabular development 1
• MRI is preferred over CT for post-surgical evaluation to:
  • Confirm concentric hip joint reduction
  • Identify soft-tissue barriers to reduction
  • Assess for complications 6

Complications and Pitfalls

• Avascular necrosis is the most serious complication of treatment 2

  • Predictor of poor prognosis
  • Can result from excessive abduction or forceful reduction

• Late diagnosis significantly worsens outcomes:

  • Increases need for complex treatment 2
  • Higher rates of surgical intervention 5
  • Greater risk of long-term complications 2

• Untreated DDH can lead to:

  • Premature osteoarthritis
  • Abnormal gait
  • Decreased strength
  • Up to one-third of total hip arthroplasties in patients <60 years 2, 5

Key Considerations

• The general treatment principle is to obtain and maintain a concentric reduction of the femoral head in the acetabulum 7
• Most borderline "abnormal" hips during the neonatal period represent physiologic immaturity, with 60-80% identified by physical examination and >90% identified by ultrasound spontaneously normalizing 2
• Hips with alpha angles between 50-59° (Graf type IIa) will likely normalize spontaneously without intervention in infants under 3 months 1
• Female infants have a higher risk of persistent abnormalities, with up to 15% of females with type IIa not resolving spontaneously 1

Early diagnosis and appropriate age-based treatment are critical for achieving the best possible functional outcomes and preventing long-term complications of DDH.