AAOS approves diagnostic criteria for management of DDH in infants up to six months of age
The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors approved new Appropriate Use Criteria (AUC) for Management of Developmental Dysplasia of the Hip (DDH) in Infants up to Six Months of Age. In babies and children with developmental dislocation (dysplasia) of the hip, the hip "ball and socket" joint is not formed normally and may easily be dislocated. This AUC is also the first to provide an online diagnostic tool for management of DDH customized for both generalists and referring physicians and orthopaedic specialists to better detect and determine appropriate treatments for the nonoperative management of DDH.
The AUCs provide clinicians with algorithms on how to optimally treat an orthopaedic injury or condition, including hypothetical scenarios and possible treatments, ranked for appropriateness based on the latest research and clinical expertise and experience. The new AUC supports the Clinical Practice Guideline, "Management of Detection and Nonoperative Management of Pediatric DDH in Infants Up to Six Months of Age." The two most significant recommendations of this CPG, both of which are moderate in strength with supporting evidence, offer the following guidance:
- Evidence does not support universal ultrasound screening of newborn infants.
- Evidence supports performing an imaging study before six months of age in infants with one or more of the following risk factors: breech presentation, family history, or history of clinical instability.
The AUC was amended to support a stronger recommendation than the original CPG states, as breech presentation is felt to be a particularly strong risk factor for DDH, even in the face of a normal physical exam. The AUC recommends a screening ultrasound at six-weeks-old and a single anteroposterior (AP), or front-to-back, pelvis X-ray at six months.
"Because DDH encompasses so many specialties and subspecialties, this AUC provides a forum that can help a physician or orthopaedist determine who should be screened by identifying risk factors often associated with DDH," said Antonia F. Chen, MD, MBA, AUC section leader, AAOS Committee on Evidence-Based Quality and Value. "Pediatricians are often on the first line of evaluating these patients, and now they can be more aware of the risk factors to determine the next best course of action for their patients."
The AUC was developed with the participation of several medical disciplines including the AAOS, American Academy of Pediatrics (AAP), Pediatric Orthopaedic Society of North America (POSNA), Society of Diagnostic Medical Sonography (SDMS), American College of Radiology (ACR), Society for Pediatric Radiology (SPR) and American Institute for Ultrasound in Medicine (AIUM).
"In an era where clinicians tend to over-screen patients, this can often lead to over diagnosis and over treatment," explains Dr. Chen. "The good news is that we are starting to swing the pendulum the other way, and the idea behind this AUC is meant to turn the tide a little to understand that screening is not necessary for every child. But, we also want parents to understand that if your child was born breech, there's a family history, or a history of clinical instability, then it's worthwhile to bring it up to your pediatrician or orthopaedic surgeon to discuss potentials for screening and follow-up. As with all AUCs, just because the guidelines give suggestions and recommendations, they are not hardline facts that must be followed. Every patient and clinical scenario should be evaluated on an individual basis."
The AUCs and CPG are available through AAOS OrthoGuidelines website and free mobile app.