Suggestions for Managing DDH in a Resource-Limited Environment During the COVID-19 Pandemic

Authors: International Hip Dysplasia Institute Pandemic Work Group: Pablo G. Castaneda MD (NYU Langone Medical Center), Charles T. Price, MD (Arnold Palmer Children’s Hospital, Orlando), Wudbhav N. Sankar MD (Children’s Hospital of Philadelphia), V. Salil Upasani, MD (UC San Diego, Rady Children’s Hospital), James R. Kasser MD (Harvard, Boston Children’s Hospital), Scott J. Mubarak MD (UC San Diego, Rady Children’s Hospital), Simon P. Kelley (U Toronto, Hospital for Sick Children)

Introduction: Management of DDH is age sensitive, and is neither an emergency, nor an elective process. Thus, these suggestions are intended to provide an opinion regarding DDH management if resources are limited, or when public and personal safety measures during the COVID-19 Pandemic limit capacity to conduct standard screening and treatment practices for hip dysplasia.

General Principles:

1. Management of DDH can often be postponed by several months without seriously compromising final results.
2. Patients should be treated conventionally if resources allow but future needs of the hospital system should be taken into consideration. Caution is recommended before beginning treatment that requires a series of hospital procedures.
3. Management of DDH is secondary to saving lives that are endangered by the COVID-19 Pandemic. The Centers for Disease Control and Prevention (CDC) has recommended that health care facilities and clinicians prioritize urgent and emergency visits and procedures now and for the coming several weeks. The CDC guidelines may be reviewed at the following website: https://www.ama-assn.org/delivering-care/public-health/helping-private-practices-navigate-non-essential-care-during-covid-19

Specific Circumstances

1. Newborn Diagnosis and Treatment (age 0 to 6 weeks)
2. When a DDH diagnosis is made in the newborn by a positive Barlow or Ortolani sign, treatment may be initiated with the Pavlik method without ultrasound if ultrasound resources are not available.
   1. Under optimum circumstances, the Pavlik harness should be applied initially by a trained healthcare provider. However, a validated educational video of proper Pavlik harness application is available on the website of the International Hip Dysplasia Institute as seen here: https://hipdysplasia.org/for-physicians/pavlik-harness-guide/
   1. Follow-up during treatment may be conducted by telemedicine or by a video from mobile hand-held devices. This can allow the clinician to evaluate harness fit and potential problems, so that adjustments can be made under direct guidance.
   1. Instead of ultrasound imaging at one- to two-week intervals, ultrasound imaging may be performed less frequently while in the harness.
3. 6 weeks to 6 months of age
   1. Treatment for clinically diagnosed dislocations in this age group is similar to treatment in the 0 to 6-week age group. Although there is some benefit from beginning treatment as soon as possible, the likelihood of successful non-surgical treatment depends more on severity of dislocation than on prompt initiation of treatment between six weeks and six months of age.(1, 2) Modest delays in treatment in this age group that are necessitated by resource limitations are unlikely to substantially compromise the final outcome.
   1. When an infant in this age group has risk factors and a normal clinical exam, or when the examination for hip instability is uncertain, imaging can be delayed until resources are available. A delay in diagnosis in this age group is unlikely to substantially alter management or change the final outcome of DDH treatment.  
4. Older than 6 months of age
   1. When resources are limited in this older age group, Pavlik harness treatment may be attempted in some circumstances. However, closed reduction with serial cast management, or surgical open reduction procedures can be postponed for several months without substantially compromising results prior to 18 months of age.
   1. In anticipation of increased need for hospital resources for management of COVID-19 patients, postponement of treatment in this age group until the pandemic is subsiding is consistent with CDC recommendations.

Additional resources: British National Health Services Guidelines for Screening during COVID 19 Pandemic: https://bscos.org.uk

1. Upasani V, Bomar JD, Matheney TH, Sankar WN, Mulpuri K, Price CT, Moseley CF, Kelley SP, Narayanan U, Clarke NM, Wedge JH, Castañeda P, Kasser JR, Foster BK, Herrera-Soto JA, Cundy PJ, Williams N, Mubarak SJ. Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure. J Bone Joint Surg Am. 2016;98(14):1215-21.

2. Ömeroğlu H. Treatment of developmental dysplasia of the hip with the Pavlik harness in children under six months of age: indications, results, and failures. J Child Orhop. 2018;12:308-16.