Congenital Hip Dysplasia

Disease/Disorder

Definition

Congenital dysplasia of the hip, now more commonly recognized as developmental dysplasia of the hip (DDH), refers to a spectrum of pathologies that result from abnormal hip development secondary to insufficient acetabular coverage of the femoral head.¹ Presentation may vary from mild acetabular dysplasia with a stable hip to subluxation and dislocation of the joint. The diagnosis is often associated with a progressive course.^1,2

Currently, developmental dysplasia of the hip is the preferred term for this disease spectrum as not all cases are recognized or present at birth; rather, many patients are diagnosed in childhood during periods of growth and development.¹

Etiology

The etiology of congenital dysplasia of the hip is estimated to be multifactorial in origin, including one or more hormonal, mechanical, or genetic factors.^1,2,3,4

• Proposed hormonal involvement
  • Imbalance of estrogen and progesterone
  • Higher levels of progesterone related to higher rates of dislocation.
  • Gender -related factors: female patients at higher risk²
• Mechanically, periods of high growth or stimulation can result in development of DDH.¹
  • Demonstrated both in utero and childhood development
  • If persistent subluxation or dislocation:
    • femoral head flattens
    • femoral anteversion
    • Acetabulum becomes shallow and dysplastic.
  • Increased laxity of the hip capsule
    • Hip instability
    • Disrupted smooth articulation at the interface of the femoral head and the acetabulum
    •  increased likelihood of subluxation or dislocation
• Genetic involvement:
  • multiple genes associated
  • Includes CX3CR1,PAPPA2, COL2A1, HOXD9, GDF-5, and TGFB1.^2,4

Epidemiology including risk factors and primary prevention

The incidence of DDH/CDH varies with age, race, and symptomology. Prevalence is 1-1.5% of infants. Incidence varies between sexes, with males and females having an incident rate of 5 versus 13 out of 1,000 respectively. In infancy, hip instability is relatively common; however, in cases of mild instability, 90% of children will improve within 8 weeks after birth.^2,3

Major risk factors are as follows⁵

• Gestational positioning
  • Most significant risk factor: breech positioning in the third trimester.
  • Other physical limitations include large for gestation age, oligohydramnios, and twin pregnancies
• Post-maturity at birth.
• Genetics and familial predispositions⁶
  • Female sex: females are four times as likely to develop this disease.
  • First degree relatives are 12 times more likely to acquire DDH/CDH
• Post-birth positioning
  • Adducted and extended positions when swaddled
• Musculoskeletal deformities secondary to a crowding phenomenon in the womb associated with DDH
  • Metatarsus adductus in 4%⁸ of cases
  •  Torticollis in about 8% of cases.^6,9

Patho-anatomy/physiology

To understand the pathogenesis of this disease process, it is important to understand the anatomy of the hip. In a nondysplastic hip joint, the femoral head is situated inside the acetabulum. Optimal function depends intimately on a smooth, concentric reduction between the acetabulum and the femoral head with movement aiding in hip development. The joint is supported by the capsule, teres ligament, and transverse acetabular ligament with the labrum being the cartilage cushioning the bony surfaces.¹

When the femoral head and acetabulum are not approximated appropriately, the acetabulum will flatten over time, leading to dysplasia and instability at the hip joint. This instability can lead to subluxation or dislocation at the hip which can further worsen the dysplastic changes.

The success of a functional hip joint relies on the close approximation of the femoral head and acetabulum; therefore, treatment goals are to achieve stable reduction between the femoral head and acetabulum and thus promote normal development⁵

Key factors that influence pathoanatomy include:

• Disruption of femoral head and acetabulum relationship
• Fatty tissues in the depths of the hip, preventing reduction and stability
•  Hypertrophy of the ligamentum teres, preventing reduction.
• Thickened transverse acetabular ligament, narrowing the opening of the acetabulum
• Shortened iliopsoas tendon across the anterior hip
  •  creates an hourglass shape to the hip capsule
  •  limits access of the femoral head to the acetabulum.
• Infoldings and thickening of labrum secondary to increased pressure on acetabular rim and labrum

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Congenital hip dysplasia, or developmental dysplasia of the hip, refers to a spectrum of pathology, with four distinct clinical patterns noted. These presentations include varying degrees of hip instability to include^1,2,3,5

• Acetabular dysplasia: a shallow hip socket which leads to increased pressure on the rim of the hip socket
• Hip subluxation: a presentation where the femoral head is not appropriately sitting in the acetabulum
• Hip dislocation: the femoral head is fully displaced from the acetabulum

Symptom presentation and symptom load also varies by age and development.

• Neonates: DDH will be asymptomatic and requires screening by specific clinical maneuvers (Ortolani test and Barlow test, as subsequently described in the Physical Examination section) and/or imaging.^5,7,8
• Infants: After 2 to 3 months, soft tissues tighten and specific physical findings include limited hip abduction, thigh shortening (Galeazzi or Allis sign), and asymmetry of gluteal or thigh folds.
• Ambulatory children: Often present after a leg-length discrepancy, limp, or waddling gait is noticed. These children will have a positive Trendelenburg sign, with a shortened femur on the affected side.
• DDH is more commonly seen in the left hip (60%) but can often be found to be present bilaterally.⁹

Specific secondary or associated conditions and complications

Associated conditions and complications of DDH include avascular necrosis of the femoral head, persistent dislocation, residual subluxation, progressive acetabular dysplasia, persistent limp, premature degenerative arthritis of the hip, leg length discrepancy, lumbar lordosis, knee pain, scoliosis, and degenerative changes of the spine. Patients with progressed dysplastic changes have higher rates of total hip arthroplasty and earlier onset of arthritis.^{5,9, 10,11}

If in utero hip dislocation occurs and the hips are not reducible on neonatal examination, chromosomal or neuromuscular conditions should be considered in the differential diagnosis. These conditions include myelomeningocele, arthrogryposis, and Ehlers-Danlos syndrome.^5,9

Essentials of Assessment

History

A thorough review of the listed risk factors (i.e., positive family history, female sex, breech positioning, conditions leading to a tighter intrauterine space) should help guide the examiner’s suspicion for DDH when screening.

Physical examination

Hip examination is recommended to be performed on all infants during routine clinical examinations. Hip instability in the neonate is classically screened via the Galeazzi, Barlow, and Ortolani tests, with the infant in a supine position¹²:

Galeazzi (Allis) sign, which screens for shortening of the thigh as an indication of hip dysplasia

• With the infant supine, the examiner flexes the hips and knees, looking for asymmetry in the height of the knees.
• this test is positive if one knee (when flexed) is lower than the other.

Barlow test, click of exit maneuver, which screens for dislocation of a non-displaced hip.¹²

• The examiner adducts the flexed hip and gently pushes the thigh posteriorly to try and dislocate the femoral head.
• The test is positive if the hip is felt to slide out of the acetabulum.

Ortolani test, click of entry maneuver, which screens for dislocation by trying to reduce a dislocated femoral head.¹²

• Grasping the child’s thigh between the thumb and index finger, the examiner lifts the greater trochanter with the 4th and 5th fingers while simultaneously abducting the hip.
• The test is positive when the femoral head slips into the hip socket with a fine clunk that should be palpable but not audible.

The Barlow and Ortolani tests are now frequently done in conjunction and with the assistance of ultrasound guidance. Ultrasound is utilized to ensure that bilateral dislocations are not missed during the execution of these tests as bilateral dislocations may feel symmetric dislocation and reduction.¹²

Note that clicks audible during Barlow and Ortolani maneuvers are usually benign and result from soft tissues snapping over bony prominences. An estimated 1/100 newborns have evidence of some hip instability with a positive Ortolani or Barlow sign; however, a true dislocation is reported to be 1-15/1000 births.

After 2 to 3 months of age, the soft tissues around the hip tighten, so the Barlow and Ortolani tests become less reliable. In infants at this stage of development, the examiner must consider other physical findings as follows.

• Galeazzi (Allis) sign
• Asymmetry of the gluteal or thigh folds.
• Limited hip abduction, especially if asymmetric (more difficult to detect if DDH is bilateral).
• Limb length discrepancies¹³
  • A direct measurement of the ‘true’ limb length can be obtained from anterior superior iliac spine to the medial malleoli.

A walking child may present with abnormal gait signs, including any of the following¹³

• Limp.
• Waddling gait.
• Hyperlordosis.
• Positive Trendelenburg sign.
• Asymmetry of pelvic alignment, as viewed from the frontal plane (use pelvic brim, anterior superior iliac spine, posterior superior iliac spine, and/or greater trochanters as landmarks).

Functional assessment

Manual serial hip examinations are recommended until a child ambulates. Once a child begins to ambulate, age-appropriate gait evaluation is imperative to assess for alterations to normal gait patterns. Ambulating children may experience pain with walking, a waddling gait, or limp. Likewise, range of motion testing assesses for asymmetries in motion or evidence of impingement symptoms. As children age into adolescence, early arthritic symptoms, including impingement, pain or limitations with internal rotation and hip adduction can present.^1,10,11,13

Imaging

Ultrasound is the diagnostic modality of choice, especially in infants from birth to six months of age because it is superior to radiographs in evaluating cartilaginous structures of the femoral joint. After approximately six months, the cartilaginous structures of the hip are ossifying, resulting in ultrasound being less effective than other imaging modalities.

• Ultrasound visualization limits exposure to radiation, contrast, or the need for sedation.^1,2
• Placing the transducer on the greater trochanter allows visualization of the ilium, bony acetabulum, labrum, and femoral epiphysis, allowing visual confirmation of femoral head displacement, as well as pathologic malformation of bony and cartilaginous structures.²
• A dynamic technique, which assesses stability of the femoral head in the acetabulum as well as the static anatomy, is preferred.
• False-positives can occur in the early newborn period, because the acetabulum is immature and the joint has some temporary laxity (0-4 weeks of age).
• The Graf method of classification was developed in 1980 with severity ratings from type I (normal hip) to type IV (dislocated hip). A good quick reference for this classification is found at: http://radiopaedia.org/articles/graf-method-for-ultrasound-classification-of-developmental-dysplasia-of-the-hip
• Some centers utilize ultrasonography in patients with a positive Ortolani sign and its used progressively to monitor subluxation or dislocated hip being treated in a Pavlik harness

Radiographs (anteroposterior [AP] view) are recommended after femoral head ossification (4-6 months) occurs.^2,14

• Lateral femoral head migration is measured by the intersection of the Hilgenreiner line (horizontal through the triradiate cartilage) and the Perkins line (vertical from the lateral acetabulum).
• The AP view is interpreted via the acetabular index (AI), which measures the slope of the ossified acetabular roof. AI >30 degrees is abnormal.
• A broken Shenton line (a curved line drawn from the medial femoral neck to the lower border of the superior pubic ramus) is indicative of hip subluxation or dislocation.

Computed tomographyis often utilized to evaluate the hip reduction. CT also is helpful in assessing bone quality and dysplastic changes that can assist in appropriate surgical intervention technique.^1,14

Magnetic resonance imaging does not expose children and adolescents to radiation and is helpful in assessing labral or soft tissue abnormalities around the hip. It can also be utilized to evaluate or predict avascular necrosis of the femoral head.^1,14

Hip arthrogram is primarily done in the operating room by an orthopedic surgeon to evaluate the joint during and/or after closed reduction of the hip.¹

Rehabilitation Management and Treatments

Available or current treatment guidelines

Clinical practice guidelines on early detection and management have been published by the American Academy of Pediatrics in 2016.¹⁵ This report includes a clinical algorithm for screening and recommended actions based on age and presence of risk factors.

• Newborns to 6 months
  • Orthosis and Pavlik harness utilized in subluxation or reducible dislocation
• 6 to 18 months of age
  • Reducible hip can undergo closed reduction
  • Non-reducible hip is treated with surgical intervention for open reduction
• Greater than 18 months
  • Surgical intervention with open reduction
  • Risk factors or symptoms determine whether femoral or pelvic osteotomy is warranted

At different disease stages

Newborn infants are routinely evaluated within several days of birth by their primary care physicians. At these initial visits, performing thorough history, physical exam and standard screening tests is imperative for assessing infants for hip defect. Ortolani and Barlow tests should be performed in conjunction, and, if there is concern for abnormal or positive results, referral to an orthopedist is recommended. Likewise, ultrasound guidance with dynamic testing can be utilized for further evaluation.¹² With negative testing, it is still important to provide routine screenings as the child grows and continues to develop in case of latent onset of dysplastic changes.

Triple diapering is a common practice in newborns, which lacks clinical evidence for effectiveness in treatment and may delay appropriate referral to orthopedics when clearly dislocated.

Patients <1 year old with negative Ortolani sign

• Traction for 3-6 weeks with imaging
• Possible closed reduction with dynamic arthrogram
  • Less than 6mm gap after reduction: successful procedure
    • Spica cast for 2-3 months
  • Greater than 6mm gap after reduction: unsuccessful intervention
    • Open reduction of hip

Patients <1 with positive Ortolani sign

• < 6 months of age: Pavlik Harness
  • Adjusted every two weeks to follow a baby’s growth
    • If not adjusted correctly, can worsen hip pathology
  • Once stability of the hip is noted, weaning from the harness should be over a 3-4 week period
• > 6 months of age: Hip abduction orthoses
• Improvements in ultrasound or physical exam noted within 3-4 weeks of harness use.
• If no improvement in stability, refer to orthopedist

Pavlik harness has 95% rate of treatment in Ortolani-positive hips and 85% rate of treatment in reduction of subluxed or dislocated hip. Complications of using the Pavlik harness are usually iatrogenic with prolonged excessive hip flexion, induction of a femoral nerve compression neuropathy resolves with removal of harness and compression, and cartilaginous femoral head and proximal femoral physeal pate damage from forced abduction with failure of reduction in a complete dislocation. Other devices like von Rosen splint and Frejka pillow are used but the Pavlik harness continues to be the most commonly used device in treatment of DDH.

<18 months of age with persistent dislocated hip: Closed reduction of the hip

• Performed by orthopedic surgery
• Followed by hip spica casting for a total of 3-4 months
  • Casts changed every 6 weeks to follow growth of the child
• With Spica casting, special arrangements may be needed for transport including special car seat, such as Hippo Car Seat, for safety

>6 months  to < 2 years with failed closed reduction: open reduction of the hip

• Performed by orthopedic surgery
• Open reduction with or without femoral shortening osteotomy
  • shortening osteotomies more common in children older than 2 years

Internal reduction, which refers to bony fixation with hardware placement, is required when the Pavlik harness and/or closed reduction is ineffective. This most commonly occurs after the child is 18 months of age. Other Surgical interventions when more conservative options fail include percutaneous adductor tenotomy, psoas tenotomy, femoral osteotomy, and pericapsular osteotomy.^{16,17, 18,19}

Failure to adequately achieve reduction in the older child may lead to more chronic medical issues requiring continued treatment. Pain, osteoarthritis, and gait deviations may occur if the hip is not properly reduced. Development of acetabular dysplasia requires acetabular or femoral osteotomies to increase the coverage of femoral head acting on the acetabular side. While savage osteotomies remain controversial in unstable hips, reorientation osteotomies increase lateral and anterior coverage of the femoral head. Regardless, acetabuloplasties provide a higher degree of correction compared to reorientation osteotomies.¹⁸ Long-term complications can arise, such as a need for earlier total hip arthroplasty in the young adult period.^19,20 Postsurgical rehabilitation should include a physical therapy program focusing on stretching of tight hip and leg muscles, positioning, weight bearing, and appropriate orthoses.¹⁷

Coordination of care

Once DDH is identified, it is important that the care team works together for the best functional outcomes for the patient. A consultation with an orthopedic surgeon is required. Pediatric physiatrists, when involved with patients with DDH, can play a role in pain management and improving functional outcomes through orthotics and therapy. With this in mind, pediatric rehabilitation physicians may be asked to provide advice on positioning and splinting. Because undiagnosed or mismanaged DDH may lead to undesired consequences, communication between the primary care provider, orthopedist, and pediatric physiatrist is essential. Patients and orthotists need communication regarding who is the primary physician managing the orthotic. If pediatric physical therapists are involved in helping the family use the hip positioning devices, it is important the therapists provide feedback to the physician directing the treatment program.²¹

Patient & family education

Patient and family education is imperative in all health care settings. DDH is a progressive disease that can lead to complications with gait, pain, limb length discrepancy, and range of motion, all of which can hinder quality of life in children, adolescents, and even into adulthood. It is crucial that parents understand the importance of screening measures in their children. Likewise, it is necessary to ensure that parents are informed of possible warning signs that something could be impacting their child’s development. These signs can present as difficulty walking, ambulating with a limp, or experiencing pain with walking. DDH diagnoses can be missed due to progressive course, but, when appropriately screened and monitored, can be treated.

Cutting Edge/Emerging and Unique Concepts and Practice

Issues Related to Care of Hip Dysplasia with Conservative Treatment vs Surgical Options

If conservative treatment with reduction and splinting fails, surgical management is recommended to prevent worsening progression of disease and address current complications. Open reduction has been a selected surgical option occurring more frequently in those presenting with progressed disease or delayed diagnosis of dysplasia. Reasons for delayed presentation have been associated in patients who were not appropriately screened as an infant or who had limited healthcare access as they developed, resulting in lack of physical exam or US methods.

In those requiring a surgical approach, the use of hip arthroscopy is common in the management of femoroacetabular impingement and labral tears; however, there is heterogeneity in management approach to doing a hip arthroscopy in patients with hip dysplasia secondary to variable outcomes.^18,19.20

Comparing results of early vs delayed surgery for those with hip dysplasia, those with delayed surgery were found to have complications including decreased range of motion and a limping gait secondary to hip pathology resulting in an abnormal gait cycle.¹⁹

Modern imaging models have assisted with better surgical technique and outcomes. The use of CT imaging to create 3D models of the pelvis and bony structures allows better pre-operative assessment of the dysplastic changes and relative positioning of the femoral head and acetabulum. This can be useful for better surgical planning in patients, especially if dysplastic changes are severe enough to warrant a total hip arthroplasty. Unfortunately, total hp arthroplasty, or total hip replacement, tends to be a more difficult procedure with overall worse mechanical outcomes compared to primary osteoarthritis-derived pathology.¹

Gaps in the Evidence-Based Knowledge

More research is currently being performed to address the confusion regarding screening, diagnosis, and management of CDH/DDH. Better understanding of symptom classification, disease staging, and best next steps in management continue to be studied. Likewise, improvements in screening guidelines for hip instability need further exploration as current practices tends to focus on screening newborn infants despite DDH presenting at multiple stages in childhood.^22,23

There is significant medical literature evidence that though patients with dysplastic hips improve after hip arthroscopy, the re-operation rate is increased. The total hip arthroplasty rate is also increased compared to the general hip arthroscopy population and is associated with more significant mechanical dysfunction postoperatively. There is no significant evidence that early vs delayed surgery results in higher incidence of recurrent surgeries.^19,22

References

1. Bakarman, K., Alsiddiky, A. M., Zamzam, M., Alzain, K. O., Alhuzaimi, F. S., Rafiq, Z.,  Alhuzaimi, F. S. A. S. (2023). Developmental Dysplasia of the Hip (DDH): Etiology, Diagnosis, and Management. Cureus, 15(8).
2. Nandhagopal T, De Cicco FL. Developmental Dysplasia of the Hip. [Updated 2022 Oct 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563157/
3. Harsanyi S, Zamborsky R, Krajciova L, Kokavec M, Danisovic L. Developmental Dysplasia of the Hip: A Review of Etiopathogenesis, Risk Factors, and Genetic Aspects. Medicina. 2020; 56(4):153. https://doi.org/10.3390/medicina56040153
4. Agostiniani, R., Atti, G., Bonforte, S. et al. Recommendations for early diagnosis of Developmental Dysplasia of the Hip (DDH): working group intersociety consensus document. Ital J Pediatr 46, 150 (2020). https://doi.org/10.1186/s13052-020-00908-2
5. Yang, S., Zusman, N., Lieberman, E., et. al. Developmental Dysplasia of the Hip. Pediatrics. 2019;143(1): e20181147
6. Zamborsky R, Kokavec M, Harsanyi S, Attia D, Danisovic L. Developmental Dysplasia of Hip: Perspectives in Genetic Screening. Med Sci (Basel). 2019 Apr 11;7(4):59. doi: 10.3390/medsci7040059. PMID: 30979092; PMCID: PMC6524033.
7. Vaquero-Picado A, González-Morán G, Garay EG, Moraleda L. Developmental dysplasia of the hip: update of management. EFORT Open Rev. 2019 Sep 17;4(9):548-556. doi: 10.1302/2058-5241.4.180019. PMID: 31598333; PMCID: PMC6771078.
8. Gambling TS, Long A. Psycho-social impact of developmental dysplasia of the hip and of differential access to early diagnosis and treatment: A narrative study of young adults. SAGE Open Med. 2019 Mar 18;7:2050312119836010. doi: 10.1177/2050312119836010. PMID: 30911387; PMCID: PMC6423670.
9. Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip  American Academy of Pediatrics. Pediatrics. 2000;105(4 Pt 1):896–905.
10. Pavone V, de Cristo C, Vescio A, Lucenti L, Sapienza M, Sessa G, Pavone P, Testa G. Dynamic and Static Splinting for Treatment of Developmental Dysplasia of the Hip: A Systematic Review. Children. 2021; 8(2):104. https://doi.org/10.3390/children8020104
11. Katz JN, Arant KR, Loeser RF. Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. JAMA. 2021 Feb 9;325(6):568-578. doi: 10.1001/jama.2020.22171. PMID: 33560326; PMCID: PMC8225295.
12. Cuccurullo, Sara J. Physical Medicine and Rehabilitation Board Review. Fourth Edition. Demos Medical. 2020. 743-744
13. Merchant RM, Tolk JJ, Ayub AA, Eastwood DM, Hashemi-Nejad A. The Importance of Monitoring and Factors That May Influence Leg Length Difference in Developmental Dysplasia of the Hip. Children (Basel). 2022 Dec 12;9(12):1945. doi: 10.3390/children9121945. PMID: 36553388; PMCID: PMC9776676.
14. Aydıngöz, Ü., Yıldız, A.E. (2022). An Overview of Diagnostic Imaging Modalities for DDH. In: O’Beirne, J., Chlapoutakis, K. (eds) Developmental Dysplasia of the Hip. Springer, Cham. https://doi.org/10.1007/978-3-030-94956-3_5
15. Shaw BA, Segal LS, AAP SECTION ON ORTHOPAEDICS. Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. Pediatrics. 2016;138(6):e20163107
16. Merckaert S, Zambelli PY. Treatment perspective after failed open reduction of congenital hip dislocation. A systematic review. Front Pediatr. 2023 Aug 9;11:1146332. doi: 10.3389/fped.2023.1146332. PMID: 37622079; PMCID: PMC10445129.
17. Papachristou GC, Pappa E, Chytas D, Masouros PT, Nikolaou VS. Total Hip Replacement in Developmental Hip Dysplasia: A Narrative Review. Cureus. 2021 Apr 29;13(4):e14763. doi: 10.7759/cureus.14763. PMID: 34094728; PMCID: PMC8168999.
18. O’Brien MJM, Jacobsen JS, Semciw AI, Mechlenburg I, Tønning LU, Stewart CJW, Heerey J, Kemp JL. Physical impairments in Adults with Developmental Dysplasia of the Hip (DDH) undergoing Periacetabular osteotomy (PAO): A Systematic Review and Meta-Analysis. Int J Sports Phys Ther. 2022 Oct 1;17(6):988-1001. doi: 10.26603/001c.38166. PMID: 36237653; PMCID: PMC9528691.
19. Alnamshan MK., Jawadi AH., Alshoaibi YA., et. al. Outcome of delayed surgery in developmental hip dysplasia in a teritiary care setting. Egyptian J of Hos Med. 2018; 73(4): 6446-6451
20. Willemsen, K., Doelman CJ., Sam ASY., et. al. Long-term outcomes of the hip shelf arthroplasty in adolescents and adults with residual hip dysplasia: a systematic review. Acta Orthopaedica. 2020; 91 (4): 383-389. DOI: 10.1080/17453674.2020.1747210.
21. Keelan R. Enseki, Nancy J. Bloom, Marcie Harris-Hayes, et al. Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision. Journal of Orthopaedic & Sports Physical Therapy 2023 53:7.
22. Lee, WC., Gera, SK., Mahadev A. Developmental dysplasia of the hip: why are we still operating on them? A plea for institutional newborn clinical screening. Singapore Med J. 2019; 60(3): 150-153. DOI 10.11622.2018064
23. Schaeffer EK, Study Group I, Mulpuri K. Developmental dysplasia of the hip: addressing evidence gaps with a multicentre prospective international study. Med J Aust. 2018 May 7;208(8):359-364. doi: 10.5694/mja18.00154. PMID: 29716513.

Original Version of the Topic

Frank S. Pidcock, MD, Andrew H. Gordon, MD, PhD. Congenital hip dysplasia. 1/9/2013

Previous Revision(s) of the Topic

Matthew McLaughlin, MD. Congenital hip dysplasia. 8/19/2016

Matthew McLaughlin, MD, Denesh Ratnasingam, MD. Congenital Hip Dysplasia. 12/22/2020

Author Disclosure

Cristina Marie Sanders, DO
Nothing to Disclose

Olivia Tincher, DO
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Tanner Ashcraft, MS IV
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Rajashree Srinivasan, MBBS
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