Skip to navigation bar Skip to breadcrumbs Skip to page content
clear place holder
Envelope icon E-mail Updates Teal square Text size:  a A A
You are heree: HomeRecommendations for Primary Care PracticePublished RecommendationsRecommendation SummaryFinal Recommendation Statement : Final Recommendation Statement

Final Recommendation Statement

Developmental Hip Dysplasia: Screening

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Recommendation Summary

Summary of Recommendation

PopulationRecommendationGrade
(What's This?)
Infants

The USPSTF concludes that evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomesa

I

a Standard language associated with the grade I recommendation is "The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing {the service}." For this specific recommendation, the USPSTF modified the language to indicate the lack of evidence that screening for a condition with a poorly defined natural history would improve health outcomes while there is evidence that interventions cause known harms

Preface

This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for developmental dysplasia of the hip.

Rationale

The pathophysiology and natural history of developmental dysplasia of the hip (DDH) are poorly understood. There is evidence that screening leads to earlier identification; however, 60% to 80% of the hips of newborns identified as abnormal or as suspicious for DDH by physical examination and >90% of those identified by ultrasound in the newborn period resolve spontaneously, requiring no intervention. There is poor evidence (poor quality studies) of the effectiveness of both surgical and non-surgical interventions; avascular necrosis of the hip (AVN) is reported in 0% to 60% of children who are treated for DDH. Thus, the USPSTF was unable to assess the balance of benefits and harms of screening for DDH but was concerned about the potential harms associated with treatment of infants identified by routine screening.

Clinical Considerations

  • This USPSTF screening recommendation applies only to infants who do not have obvious hip dislocations or other abnormalities evident without screening. DDH represents a spectrum of anatomic abnormalities in which the femoral head and the acetabulum are aligned improperly or grow abnormally. DDH can lead to premature degenerative joint disease, impaired walking, and pain. Risk factors for DDH include female gender, family history of DDH, breech positioning, and in utero postural deformities. However, the majority of cases of DDH have no identifiable risk factors.
  • Screening tests for DDH have limited accuracy. The most common methods of screening are serial physical examinations of the hip and lower extremities, using the Barlow and Ortolani procedures, and ultrasonography. The Barlow examination is performed by adducting a flexed hip with gentle posterior force to identify a dislocatable hip. The Ortolani examination is performed by abducting a flexed hip with gentle anterior force to relocate a dislocated hip. Data assessing the relative value of limited hip abduction as a screening tool are sparse and suggest the test is of little value in early infancy and is of somewhat greater value as infants age.
  • Treatments for DDH include both nonsurgical and surgical options. Nonsurgical treatment with abduction devices is used in early treatment and includes the commonly prescribed Pavlik method. Surgical intervention is used when DDH is severe or diagnosed late or after an unsuccessful trial of non-surgical treatments. Evidence of the effectiveness of interventions is inconclusive because of a high rate of spontaneous resolution, absence of comparative studies of intervention versus nonintervention groups, and variations in surgical indications and protocols. Avascular necrosis of the hip is the most common and most severe potential harm of both surgical and nonsurgical interventions and can result in growth arrest of the hip and eventual joint destruction with significant disability.

Discussion

DDH represents a spectrum of anatomical abnormalities in which the femoral head and the acetabulum are either in improper alignment or grow abnormally. Without the normal tight, concentric anatomic relationship between the femoral head and acetabulum, the hip joint may grow abnormally, resulting in permanent disability. The precise definition of DDH is controversial1, 2 and includes a spectrum of hip abnormalities including dysplastic, subluxated, dislocatable, and dislocated hips. Long-term complications of DDH include premature degenerative joint disease, impaired walking, and chronic pain.3 The incidence of DDH in infants is influenced by a number of factors, including diagnostic criteria, female gender, genetics, race, and age.4 Reported incidence rates, varying between 1.5 and 20 per 1000 births,5 have increased dramatically since the advent of clinical and sonographic screening, possibly resulting from overdiagnosis. A minority (10%-27%) of all infants diagnosed with DDH in population-based studies have identified risk factors other than female gender.6-10 Between 1% and 10% of infants with risk factors have DDH.7-9

The USPSTF examined the evidence to determine the benefits and harms of routine screening for DDH from birth through 6 months and for interventions up to 12 months in otherwise normal infants. The USPSTF found no direct evidence that screening for DDH leads to a reduced need for surgery or improved functional outcomes. Therefore, the USPSTF examined the evidence for accuracy of screening tools, efficacy of treatment, and harms of screening and treatment.

Several fair quality case-control and observational studies found breech positioning, family history of DDH, and female gender to be most consistently associated with the diagnosis of DDH. However, the majority of cases of DDH have no identifiable risk factors.11 There is evidence that screening leads to earlier identification; however, 60% to 80% of abnormal hips of newborns identified by physical examination resolved spontaneously by 2 to 8 weeks.3 Ninety percent of the hips of newborns with mild dysplasia identified by ultrasound resolved spontaneously between 6 weeks and 6 months. 12-20

The USPSTF found poor quality evidence regarding the accuracy of screening tests because of variable definitions of a positive result, the lack of a practical, confirmatory "gold standard" diagnostic test for DDH, and the treatment of the majority of infants with a positive screening result. The USPSTF found fair quality evidence that age may affect screening accuracy. Limited hip abduction is a relatively insensitive and nonspecific marker of DDH in early infancy but becomes more accurate after 3 to 6 months of age and with more severely affected hips.4, 5 A prospective observational study in infants >3 months demonstrated that unilateral limited hip abduction had a sensitivity of 69% and a specificity of 54% compared with the reference standard of any ultrasound abnormality. In this study, for subluxable and dislocatable hips, the sensitivity of limited hip abduction was > 82%.21

The USPSTF found poor quality evidence regarding the effectiveness of both surgical and non-surgical interventions. Evidence of the effectiveness of interventions is of poor quality due to a high rate of spontaneous resolution, limited study duration, significant loss to followup, and variations in surgical indications and protocols. The duration and specific approaches to preoperative and postoperative management are highly variable, as are nonsurgical treatment protocols.

A variety of abduction devices are used to treat DDH, including the commonly used Pavlik method and immobilization in a hip spica cast. Most surgical procedures involve reduction of the femoral head into the acetabulum, with or without additional procedures on the adductor tendons, the femur, or the acetabulum. Few studies measure functional outcomes (e.g., amount of pain, gait) because poor functional outcomes may not be manifested until decades later. When functional outcomes are measured, the effect of interventions is very difficult to quantify because of lack of a comparison cohort, short followup, loss to followup, and unstandardized assessment methods. A single long-term retrospective case series of 119 children with DDH (with 152 treated hips), treated with surgery followed by an abduction brace at 1 to 96 months of age, used standardized scales to assess functional outcomes (hip pain and gait). Followup visits at 15 to 53 years after treatment found that 112 (75%) of 149 treated hips had good outcomes. However, study limitations included study design, issues of confounding, and treatment by a few surgeons.22 Because no experimental or prospective cohort studies compare intervention with no intervention, the net benefits and harms of interventions for DDH are unclear for all infants and children.23

There is insufficient evidence on the harms of screening for DDH. Potential harms from screening include examiner-induced hip pathology caused by vigorous provocative testing, elevated risk for certain cancers from increased radiation exposure from followup radiographic tests, parental psychosocial stress from the diagnosis and therapy, and false positive results leading to unnecessary and potentially harmful followup and intervention.24

There is poor-quality evidence on the harms of treatment. The most common adverse effect from both surgical and nonsurgical interventions for DDH is AVN. The rates described in the literature for this adverse effect vary greatly (0-60%) for both surgical and nonsurgical interventions.25, 26-44 The reasons for this wide range of rates are most likely related to methodological problems such as heterogeneous populations, a poorly standardized approach to interventions, inconsistent followup protocols, variable loss to followup, variable training among the treating physicians, and disparate health care systems in which treatment and followup are undertaken. Additional harms from abduction therapy that have been addressed in the literature are typically mild and self-limited, and include rash, pressure sores, and femoral nerve palsy. The potential harms of surgical intervention include those associated with general anesthesia, intraoperative complications, and postoperative wound infections.

Future Research

A more complete understanding of the natural history of spontaneous resolution of hip instability and dysplasia is needed before it will be possible to develop an evidence-based strategy for screening and treating hip abnormalities. Given the infrequent nature of DDH, multicenter studies of interventions that measure functional outcomes (including long-term outcomes) in a standardized fashion are needed. Studies designed to identify valid and reliable radiological outcomes of DDH as proxy measures of functional outcomes are also needed. Determining patient preferences and identifying outcomes that are relevant to patients and families would be valuable. Similarly, controlled studies that assess the effects of delaying treatment on outcomes would allow physicians caring for children to better manage children with DDH.

Recommendations of Others

Recommendations for screening for DDH can be obtained from the Canadian Task Force on Preventive Care at http://www.ctfphc.org45 and the American Academy of Pediatrics (AAP) at http://aappolicy.aappublications.org.46 The Canadian Task Force recommends serial clinical examinations of the hips in periodic health examinations of all infants until the age of 12 months and a supervised period of observation for newborns with clinically detected DDH. The Canadian Task Force does not recommend general ultrasound or radiographic screening for high-risk infants. The AAP recommends serial clinical examinations of the hips, hip imaging for female infants born in the breech position, and optional hip imaging for boys born in the breech position or girls with a positive family history of DDH.1, 4 The AAP does not recommend general ultrasound screening.

Members of the U.S. Preventive Services Task Force

Members of the U.S. Preventive Services Task Force* are Ned Calonge, M.D., M.P.H., Chair, USPSTF (Chief Medical Officer and State Epidemiologist, Colorado Department of Public Health and Environment, Denver, CO); Janet D. Allan, Ph.D., R.N., CS, Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland, Baltimore, Baltimore, MD); Alfred O. Berg, M.D., M.P.H. (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Paul S. Frame, M.D. (Family Physician, Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Joxel Garcia, M.D., M.B.A. (Deputy Director, Pan American Health Organization, Washington, DC); Leon Gordis, M.D., M.P.H., Dr.P.H. (Professor, Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD); Kimberly D. Gregory, M.D., M.P.H. (Director, Women's Health Services Research and Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA); Russell Harris, M.D., M.P.H. (Professor of Medicine, Sheps Center for Health Services Research, University of North Carolina School of Medicine, Chapel Hill, NC); Mark S. Johnson, M.D., M.P.H. (Professor and Chair, Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Carol Loveland-Cherry, Ph.D., R.N. (Executive Associate Dean, Office of Academic Affairs, University of Michigan School of Nursing, Ann Arbor, MI); Virginia A. Moyer, M.D., M.P.H. (Professor, Department of Pediatrics, University of Texas Health Science Center, Houston, TX); Judith K. Ockene, Ph.D. (Professor of Medicine and Chief of Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA); Diana B. Petitti, M.D., M.P.H. (Senior Scientific Advisor for Health Policy and Medicine, Regional Administration, Kaiser Permanente Southern California, Pasadena CA); Albert L. Siu, M.D., M.S.P.H. (Professor and Chairman, Brookdale Department of Geriatrics and Adult Development, Mount Sinai Medical Center, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Executive Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); and Barbara P. Yawn, M.D., M.Sc. (Director of Research, Olmstead Research Center, Rochester, MN).


* Member of the USPSTF at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.uspreventiveservicestaskforce.org/about.htm.

Notes

This statement summarizes the USPSTF recommendation on screening for developmental dysplasia of the hip. The complete information on which this statement is based, including evidence tables and references, is included in the systematic literature review47 and evidence synthesis48 on the topic, available on the USPSTF Web site (http://www.uspreventiveservicestaskforce.org). The recommendation is also posted on the Web site of the National Guideline Clearinghouse™ (http://www.guideline.gov).

This document is in the public domain within the United States.

Requests for linking or to incorporate content in electronic resources should be sent via the USPSTF contact form.

Source: U.S. Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics 2006;117:898-902.

References:
  1. Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000;105(4):E57.
  2. Bialik V, Bialik GM, Blazer S, Sujov P, Wiener F, Berant M. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics 1999;103(1):93-9.
  3. Barlow T. Early diagnosis and treatment of congenital dislocation of the hip. J Bone and Joint Surgery 1962;44:292-301.
  4. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical practice guideline: early detection of developmental dysplasia of the hip. American Academy of Pediatrics. Pediatrics 2000;105(4 Pt 1):896-905.
  5. Patel H, Canadian Task Force on Preventive Health C. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ 2001;164(12):1669-77.
  6. Holen KJ, Tegnander A, Bredland T, Johansen OJ, Saether OD, Eik-Nes SH, et al. Universal or selective screening of the neonatal hip using ultrasound? A prospective, randomised trial of 15,529 newborn infants. J Bone & Joint Surgery—British Volume 2002;84(6):886-90.
  7. Sahin F, Akturk A, Beyazova U, Cakir B, Boyunaga O, Tezcan S, et al. Screening for developmental dysplasia of the hip: results of a 7-year follow-up study. Pediatrics International 2004;46(2):162-6.
  8. Jones DA. Importance of the clicking hip in screening for congenital dislocation of the hip. Lancet 1989;1(8638):599-601.
  9. Boere-Boonekamp MM, Kerkhoff TH, Schuil PB, Zielhuis GA. Early detection of developmental dysplasia of the hip in The Netherlands: the validity of a standardized assessment protocol in infants. AM J Public Health 1998;88(2):285-8.
  10. Tonnis D, Storch K, Ulbrich H. Results of newborn screening for CDH with and without sonography and correlation of risk factors. J  Pediatric Orthopedics 1990;10(2):145-52.
  11. Standing Medical Advisory Committee. Screening for the detection of congenital dislocation of the hip. Archives of Disease in Childhood 1986;61(9):921-6.
  12. Rosendahl K, Markestad T, Lie RT. Ultrasound screening for developmental dysplasia of the hip in the neonate: the effect on treatment rate and prevalence of late cases. Pediatrics 1994;94(1):47-52.
  13. Bache CE, Clegg J, Herron M. Risk factors for developmental dysplasia of the hip: ultrasonographic findings in the neonatal period. J Pediatric Orthopedics, Part B 2002;11(3):212-8.
  14. Sampath JS, Deakin S, Paton RW. Splintage in developmental dysplasia of the hip: how low can we go? J Pediatric Orthopedics 2003;23(3):352-5.
  15. Castelein RM, Sauter AJ, de Vlieger M, van Linge B. Natural history of ultrasound hip abnormalities in clinically normal newborns. J Pediatric Orthopedics 1992;12(4):423-7.
  16. Terjesen T. Ultrasound as the primary imaging method in the diagnosis of hip dysplasia in children aged < 2 years. J Pediatric Orthopaedics, Part B 1996;5(2):123-8.
  17. Wood MK, Conboy V, Benson MK. Does early treatment by abduction splintage improve the development of dysplastic but stable neonatal hips? J Pediatric Orthopedics 2000;20(3):302-5.
  18. Burger BJ, Burger JD, Bos CF, Obermann WR, Rozing PM, Vandenbroucke JP. Neonatal screening and staggered early treatment for congenital dislocation or dysplasia of the hip. Lancet 1990;336(8730):1549-53.
  19. Marks DS, Clegg J, al-Chalabi AN. Routine ultrasound screening for neonatal hip instability. Can it abolish late-presenting congenital dislocation of the hip? J Bone Joint Surg Br 1994;76(4):534-8.
  20. Puhan MA, Woolacott N, Kleijnen J, Steurer J. Observational studies on ultrasound screening for developmental dysplasia of the hip in newborns—a systematic review. Ultraschall in der Medizin 2003;24(6):377-82.
  21. Castelein RM, Korte J. Limited hip abduction in the infant. J Pediatric Orthopedics 2001;21(5):668-70.
  22. Malvitz TA, Weinstein SL. Closed reduction for congenital dysplasia of the hip. Functional and radiographic results after an average of thirty years. J Bone & Joint Surgery—American Volume 1994;76(12):1777-92.
  23. Dezateux C, Brown J, Arthur R, Karnon J, Parnaby A. Performance, treatment pathways, and effects of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom. Archives of Disease in Childhood 2003;88(9):753-9.
  24. Bialik V, Bialik GM, Wiener F. Prevention of overtreatment of neonatal hip dysplasia by the use of ultrasonography. J Pediatric Orthopedics, Part B 1998;7(1):39-42.
  25. Aksoy MC, Ozkoc G, Alanay A, Yazici M, Ozdemir N, Surat A. Treatment of developmental dysplasia of the hip before walking: results of closed reduction and immobilization in hip spica cast. Turkish J Pediatrics 2002;44(2):122-7.
  26. Cashman JP, Round J, Taylor G, Clarke NM. The natural history of developmental dysplasia of the hip after early supervised treatment in the Pavlik harness. A prospective, longitudinal followup. J Bone & Joint Surgery—British Volume 2002;84(3):418-25.
  27. Danielsson L. Late-diagnosed DDH: a prospective 11-year followup of 71 consecutive patients (75 hips). Acta Orthopaedica Scandinavica 2000;71(3):232-42.
  28. Eidelman M, Katzman A, Freiman S, Peled E, Bialik V. Treatment of true developmental dysplasia of the hip using Pavlik's method. J Pediatric Orthopaedics, Part B 2003;12(4):253-8.
  29. Konigsberg DE, Karol LA, Colby S, O'Brien S. Results of medial open reduction of the hip in infants with developmental dislocation of the hip. J Pediatric Orthopedics 2003;23(1):1-9.
  30. Tegnander A, Holen KJ, Anda S, Terjesen T. Good results after treatment with the Frejka pillow for hip dysplasia in newborns: a 3-year to 6-year followup study. J Pediatric Orthopedics, Part B 2001;10(3):173-9.
  31. Sosna A, Rejholec M. Ludloff's open reduction of the hip: long-term results. J Pediatric Orthopedics 1992;12(5):603-6.
  32. Tumer Y, Ward WT, Grudziak J. Medial open reduction in the treatment of developmental dislocation of the hip. J Pediatric Orthopedics 1997;17(2):176-80.
  33. Yamada N, Maeda S, Fujii G, Kita A, Funayama K, Kokubun S. Closed reduction of developmental dislocation of the hip by prolonged traction. J Bone & Joint Surgery—British Volume 2003;85(8):1173-7.
  34. Yoshitaka T, Mitani S, Aoki K, Miyake A, Inoue H. Long-term followup of congenital subluxation of the hip. J Pediatric Orthopedics 2001;21(4):474-80.
  35. Kruczynski J. Avascular necrosis of the proximal femur in developmental dislocation of the hip. Incidence, risk factors, sequelae and MR imaging for diagnosis and prognosis. Acta Orthopaedica Scandinavica. Supplementum 1996;268:1-48.
  36. Brougham DI, Broughton NS, Cole WG, Menelaus MB. Avascular necrosis following closed reduction of congenital dislocation of the hip. Review of influencing factors and long-term followup. J Bone & Joint Surgery—British Volume 1990;72(4):557-62.
  37. Buchanan JR, Greer RB, 3rd, Cotler JM. Management strategy for prevention of avascular necrosis during treatment of congenital dislocation of the hip. J Bone & Joint Surgery—American Volume 1981;63(1):140-6.
  38. Grill F, Bensahel H, Canadell J, Dungl P, Matasovic T, Vizkelety T. The Pavlik harness in the treatment of congenital dislocating hip: report on a multicenter study of the European Paediatric Orthopaedic Society. J Pediatric Orthopedics 1988;8(1):1-8.
  39. Lennox IA, McLauchlan J, Murali R. Failures of screening and management of congenital dislocation of the hip. J Bone & Joint Surgery—British Volume 1993;75(1):72-5.
  40. Pool RD, Foster BK, Paterson DC. Avascular necrosis in congenital hip dislocation. The significance of splintage. J Bone & Joint Surgery—British Volume 1986;68(3):427-30.
  41. Powell EN, Gerratana FJ, Gage JR. Open reduction for congenital hip dislocation: the risk of avascular necrosis with three different approaches. J Pediatric Orthopedics 1986;6(2):127-32.
  42. Suzuki S, Seto Y, Futami T, Kashiwagi N. Preliminary traction and the use of under-thigh pillows to prevent avascular necrosis of the femoral head in Pavlik harness treatment of developmental dysplasia of the hip. J Orthopedic Science 2000;5(6):540-5.
  43. Thomas IH, Dunin AJ, Cole WG, Menelaus MB. Avascular necrosis after open reduction for congenital dislocation of the hip: analysis of causative factors and natural history. J Pediatric Orthopedics 1989;9(5):525-31.
  44. Weiner DS. Avascular necrosis as a treatment complication in congenital dislocation of the hip in children under one year of age. Israel J Medical Sciences 1980;16(4):301-6.
  45. Canadian Task Force on Preventive Care. (2001). Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. Canadian Medical Association Journal 2001;164(12)1669-77.
  46. American Academy of Pediatrics (2000). Clinical practice guideline: early detection of developmental dysplasia of the hip. Retrieved on January 26, 2005 at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/4/896. 
  47. Shipman SA, Helfand M, Moyer V, Yawn B. Screening for developmental dysplasia of the hip: A systematic literature review for the United States Preventive Services Task Force. Pediatrics 2006;117:XXX.
  48. Shipman SA, Helfand M, Nygren P, Bougatsos C. Screening for developmental dysplasia of the hip: systematic evidence synthesis. Evidence Synthesis No. 42 (prepared by the Oregon Evidence-based Practice Center under Contract No. 290-02-0024.) Rockville, MD: Agency for Healthcare Research and Quality. March 2006. (Available on the AHRQ Web site at: http://www.uspreventiveservicestaskforce.org.)
Current as of: March 2006

Internet Citation: Final Recommendation Statement: Developmental Hip Dysplasia: Screening. U.S. Preventive Services Task Force. October 2014.
https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/developmental-hip-dysplasia-screening

USPSTF Program Office   5600 Fishers Lane, Mail Stop 06E53A, Rockville, MD 20857