DDH Consensus Steering Group

Current Position

Regarding The Management of Developmental Dysplasia of the Hip (DDH) in the First Three Months of Life

Delphi Method Approved Statements January 22

For the background behind the Delphi method used to reach this consensus please click here.

The general statements are outlined below:

BSCOS believe that surveillance for DDH is valuable, but recognise that the current model of clinical screening has low accuracy and alternative models should be sought. Nevertheless, at present we believe that the current system of screening using clinical examination at birth and a 6-8 week community examination should continue. The examination should be performed by a small group of ‘expert’ examiners in the maternity setting, and there should be methods of quality assurance in place for all professionals undertaking the examination. All surveillance systems must be linked to a children’s orthopaedic service.

BSCOS advocates for universal ultrasound screening. We believe a randomised clinical trial is necessary to compare universal ultrasound screening to the current screening pathway.

BSCOS believe that, in the context of selective USS screening / surveillance, children with an abnormal neonatal clinical examination must have an ultrasound scan within 2 weeks. In addition to the current ‘risk factors’ prompting an ultrasound scan, we believe that ‘non-CTEV foot deformities (i.e. metatarsus adductus / calcaneovalgus)’ and ‘packaging disorders’ should be included as risk factors.

Ultrasound scans should take place in a ‘one stop clinic’, such that treatment can be started at the time of the scan if required. There should be a system of quality assurance in place at both an individual and centre level to ensure the quality of the ultrasound assessment. The Graf criteria of standardised reporting should be employed (i.e. using the headings Age/ Useability/ Description/ Measurement/ Classification). To accurately measure Alpha angle, the minimum requirement of an acceptable coronal plane scan must include visualisation of a straight ilium, the acetabular labrum and the lower limb of the ilium (where the triradiate cartilage begins).

The CORE MINIMUM criteria to be assessed and documented on EVERY scan should include:

whether the hip is centred
the alpha angle (if the hip is centred)
sonographic dynamic test of stability

Numerous aspects did not reach consensus. There was no consensus on whether hips can wait until 4-6 weeks before an USS is undertaken, compared to the current national approach to scan those with clinical abnormalities at 2 weeks. No consensus was reached on whether ‘clicky hips’, first born females, high birth weight females (>4kg) or CTEV should be added as risk factors for DDH, thus prompting USS examination.

In undertaking the ultrasound, there was no consensus on whether a Graf cradle and probe holder should be mandatory, nor whether the core minimum criteria to be assessed and documented should include beta angle and description of femoral head coverage in terms of percentage. Regarding treatment, there was no consensus on whether a period of weaning from the harness / splint is required.