What are the next steps in managing a 12-month-old patient with mild bilateral developmental hip dysplasia?

Management of Mild Bilateral Developmental Hip Dysplasia in a 12-Month-Old

This 12-month-old with mild bilateral DDH (acetabular angles 26-27 degrees) requires immediate referral to a pediatric orthopedic surgeon for evaluation and likely surgical intervention, as the age and severity preclude conservative bracing treatment. 1, 2

Immediate Next Steps

Urgent Orthopedic Referral

• Refer immediately to a pediatric orthopedic surgeon for definitive management planning, as treatment at 12 months typically requires more invasive approaches than simple bracing 1, 2
• The acetabular angles of 26-27 degrees indicate persistent dysplasia that will not resolve spontaneously at this age 3
• At 12 months, the child's ability to stand and bear weight, combined with progressive soft-tissue contractures, makes Pavlik harness treatment ineffective 4

Expected Treatment Approach

Closed vs. Open Reduction Decision:

• The orthopedic surgeon will likely perform examination under anesthesia with hip arthrogram to determine if closed reduction is feasible 3
• Closed reduction is successful in 91% of cases in infants up to one year of age, but success depends on achieving concentric reduction without obstacles 5, 3
• If closed reduction cannot achieve stable, concentric positioning, open reduction with possible pelvic or femoral osteotomy will be necessary 3

Surgical Timing Considerations:

• Treatment should not be delayed further, as outcomes deteriorate with increasing age at presentation 6
• After 18 months, open reduction and hip reconstruction surgery becomes the standard approach 6
• Untreated DDH leads to early degenerative joint disease, abnormal gait, and is the main cause of total hip replacement in young adults (21-29% of cases) 3

Pre-Operative Evaluation

Hematologic Screening

• Obtain complete blood count, platelet count, platelet function study, and von Willebrand screen before any surgical intervention 5
• Screen for easy bruising or bleeding history, as children with developmental conditions may have undiagnosed coagulopathies 5

Additional Imaging

• The orthopedic surgeon may order additional radiographic views or advanced imaging to plan surgical approach 1
• Hip arthrogram at time of examination under anesthesia will guide the decision between closed versus open reduction 3

Critical Monitoring Parameters

Avascular Necrosis Prevention

• Avascular necrosis (AVN) is the most serious complication and predictor of poor prognosis 7, 3
• AVN risk factors include: excessive hip abduction, forceful closed reduction when obstacles exist, maintained dislocation within harness/cast, and surgical open reduction 3
• The surgeon will carefully balance achieving stable reduction while avoiding excessive abduction positioning 3

Post-Treatment Follow-Up

• Serial radiographic monitoring will be required throughout childhood to assess acetabular development 1
• The acetabular index evolution is the best parameter to predict persistent dysplasia at skeletal maturity 3
• If residual acetabular dysplasia persists despite hip reduction, pelvic or femoral osteotomies may be needed later in childhood 3

Common Pitfalls to Avoid

• Do not delay referral hoping for spontaneous improvement - at 12 months with these acetabular angles, spontaneous resolution will not occur 1, 6
• Do not attempt Pavlik harness treatment at this age - it is contraindicated once the child is standing and bearing weight 4
• Do not underestimate the urgency - while not an emergency, prompt orthopedic evaluation within 2-4 weeks is appropriate to prevent further acetabular underdevelopment 5, 6

Parental Counseling Points

• Explain that early treatment at this age still offers excellent functional outcomes, but requires more intensive intervention than if detected earlier 2, 6
• Discuss that the goal is achieving and maintaining concentric reduction of the femoral head in the acetabulum to allow normal acetabular development 2, 3
• Inform parents that treatment will likely involve a period of immobilization in a spica cast (typically 3-6 months) followed by long-term radiographic monitoring 4, 3
• Address that without treatment, this condition leads to lifelong disability, early arthritis, and need for hip replacement in young adulthood 7, 3