Watchful Waiting or Treatment for Developmental Dysplasia of the Hip?
Watchful Waiting or Treatment for Developmental Dysplasia of the Hip?
Karen Rosendahl, MD, PhD, is the lead author of the following study:
Rosendahl K, Dezateux C, Fosse KR, et al. Immediate treatment versus sonographic surveillance for mild hip dysplasia in newborns. Pediatrics. 2010;125:e9-e16.
This study was selected as the subject of this interview because of its high ranking in Medscape Best Evidence, which uses the McMaster Online Rating of Evidence System. Of a possible top score of 7, clinicians who used this system ranked this study as 6 for relevance and newsworthiness.
Abstract
Karen Rosendahl, MD, PhD, is a Consultant Pediatric Radiologist at Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom, and Professor at the Department of Surgical Sciences, University of Bergen, Norway. Dr. Rosendahl is an honorary fellow of the Norwegian College of Radiologists, which she chaired from 1999 to 2003. She co-chairs the Task Force Group on Developmental Dysplasia of the Hip, European Society of Pediatric Radiology (ESPR).
Dr. Rosendahl has a long-standing interest in hip dysplasia and musculoskeletal imaging, particularly in the areas of newborn hip screening and follow-up, clinical trials of different treatment strategies, and the impact of abduction treatment on future hip maturation and growth. She is the author or coauthor of more than 70 articles and book chapters in the field of hip dysplasia and pediatric imaging. Dr. Rosendahl is editor of the journal Acta Radiologica.
Developmental dysplasia of the hip (DDH) is the most common musculoskeletal condition encountered in newborns. The varying levels of severity of DDH range from hip instability with or without associated acetabular dysplasia to irreducible hip dislocation. Even with surgical intervention, DDH can lead to shortening of the affected leg and early osteoarthritis.
Conventional management of DDH includes clinical screening (Ortolani's and Barlow's maneuvers) followed by splinting the hips in abduction and surgery for infants whose dislocation does not resolve spontaneously with time. In recent years, ultrasound screening has been added to the evaluation of DDH, and some centers selectively screen infants at risk or screen all newborn infants for DDH using ultrasound.
Screening and early treatment of DDH are not universally practiced. In 2006, the United Stated Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes. Others have reached different conclusions. The evidence-based recommendation of Mahan and colleagues is to screen all newborns for DDH by physical examination and to use ultrasonography for infants at high risk for DDH. The American Academy of Pediatrics suggests an algorithm for evaluation and management of DDH that is driven by clinical examination.
Furthermore, the USPSTF found no evidence for the effectiveness of either surgical or nonsurgical interventions for DDH and expressed concern about the potential harms associated with treatment of infants identified by routine screening. These divergent opinions suggest that more evidence is needed to establish the need for screening and early intervention for infants with DDH.
In this best evidence study, Rosendahl and associates compared 2 approaches to the management of infants with mild hip dysplasia: active sonographic surveillance and early treatment. Results of this randomized, blinded prospective trial were reported in a recent issue of the journal Pediatrics. Of 128 newborns found to have mild DDH on initial screening, half received immediate treatment with a Frejka pillow splint. The remaining 64 infants were allocated to an active surveillance group and received no treatment until 6 weeks of age. All infants were evaluated with ultrasound at 6 weeks, at 3 and 6 months, and at 1 year. In the active surveillance group, abduction splinting was initiated for infants who were not improving after 6 weeks.
The researchers found that active sonographic surveillance of infants with stable, mildly dysplastic hips reduced the use of abduction splinting without increasing the risk for persistent or more severe dysplasia. Although early splinting was associated with more rapid and consistent improvement, active surveillance of infants who did not improve spontaneously did not increase the proportion of children with delayed acetabular ossification or persistent dysplasia at 1 year of age.
The investigators maintain that these results have important implications for families as well as for healthcare costs. Although universal treatment from birth of newborns with stable, mild hip dysplasia may result in faster normalization, surveillance for 6 weeks, with treatment reconsideration, does not result in more abnormal hips at 1 year of age.
Lead study author Karen Rosendahl MD, PhD, spoke with Laura Stokowski, RN, MS, of Medscape Pediatrics to discuss some of the implications of this study for Medscape's readers.
Medscape: In this study, you used ultrasound to screen newborns who had evidence of hip dysplasia on clinical examination or who had risk factors for hip dysplasia. What factors would place a baby at high risk for DDH?
Karen Rosendahl, MD, PhD: Newborns at high risk are those who have first-degree family members (siblings or parents) with hip dysplasia, congenital calcaneovalgus foot deformity, large birth weight for gestational age, and infants born in breech presentation. Babies who have spent time in the breech position, even if they turn prior to birth, are more likely to have DDH. Girls also have a much higher rate of DDH than boys.
Medscape: How is ultrasound used to define DDH and determine its severity? Does ultrasound replace clinical examination?
Dr. Rosendahl: There are 2 different schools as to method of defining hip dysplasia. Most European countries follow Graf's method or modifications of this, which uses a coronal standard plane to classify acetabular morphology (depth and shape of the acetabulum) and also takes hip stability into account. The other school of thought is the American school established by Theodore Harcke, who uses a dynamic method that focuses on hip stability without assessing hip morphology. We used a modified Graf technique and assessed morphology and stability separately in each hip.
In a dysplastic hip the acetabulum, particularly the anterior aspect, is shallow. With ultrasound we can assess the degree of "shallowness" as being mild, moderate, or severe based on measurement of an acetabular inclination angle (the alpha angle). Although most severely dysplastic hips are unstable, this is true for only 60% of mildly dysplastic hips, indicating a high association between hip morphology and stability.
Ultrasound can detect both acetabular dysplasia and hip instability, but clinical examination can only detect hip instability. This is unfortunate because some unstable hips are entirely normal morphologically and would normalize without treatment. On the other hand, a severely dysplastic hip can be stable and therefore impossible to detect on clinical examination alone. The low sensitivity, particularly when performed by less experienced physicians and in bilateral involvement, results in more late diagnosed cases, and limited specificity leads to potential overtreatment.
Having said that, both clinical and ultrasound examinations are highly operator-dependent, and as such, an expert clinical examination may be more accurate than an ultrasound performed by an inexperienced examiner, and vise versa.
Medscape: How does ultrasound tell you whether the hip dysplasia is resolving?
Dr. Rosendahl: Using a standard, reproducible coronal plane through the midacetabulum enables us to monitor acetabular maturation by following the alpha angle over time, from birth through 6 weeks, at 3 months, 4 and a half months, and up to around 6 months, when a pelvic x-ray provides better visualization of the hip joint. Most hips normalize or mature during the first 3 months, although some show delayed ossification and/or instability for at least a year or even longer. This combined information enables a more individualized treatment and follow-up approach.
Medscape: What does your study add to what is already known about DDH in the newborn?
Dr. Rosendahl: We knew from previous research that "watchful waiting" was probably appropriate for mild, stable hip dysplasia, but we didn't have long-term follow-up data to make sure that babies whose hips weren't treated immediately after birth didn't have worse dysplasia later on. Further, no previous study had shown that mildly dysplastic and potentially unstable, but not dislocatable hips, would normalize without treatment.
Medscape: Youalso notedthat treating babies helped their hip dysplasia normalize faster. Is this an important benefit? What is the significance of delaying the normalization of the hips?
Dr. Rosendahl: At present, the clinical significance of the accelerated acetabular maturation seen in those who received treatment from birth is unclear. But the fact that no differences were seen between the 2 groups at 6 and 12 months of age suggests that this finding is of little importance for later outcome.
Medscape: What is practice-changing about your study? What would you recommend to clinicians as a result of your findings?
Dr. Rosendahl: It would change the way we treat and follow newborns with mildly dysplastic and potentially unstable hips. According to Graf and his group in Austria, all newborns with mild acetabular dysplasia should be treated from birth, a policy resulting in high treatment rates of up to 5%-7%. We have shown that surveillance of these newborns and treatment reconsideration at 6 weeks does not result in more abnormal hips at 1 year of age.
From previous research we know that a thorough clinical hip examination is worthwhile to identify newborns with severe DDH. Those with normal clinical findings, including at-risk children, would benefit from an ultrasound examination within 5-6 weeks' time, with watchful waiting being an appropriate approach for infants showing mildly dysplastic and potentially unstable hips.
Medscape: Is this a change from current guidelines?
In the United Kingdom (UK) and parts of Europe, an additional ultrasound examination of newborns at risk, including those with positive clinical findings, has become common practice, despite the uncertain evidence base for doing so, and despite current guidelines that say otherwise. One reason for this is the numerous examples of improved outcomes from conscientiously applied programs implemented in different regions.
In the UK, the Standing Medical Advisory Committee (SMAC) states that all babies should be screened clinically within 24 hours of birth, prior to hospital discharge, at 6 weeks, between 6 and 9 months, and at walking age, and that clinicians are required to take responsibility for their assessments and audit the results of their local screening programs. The US Preventive Services Task Force did not recommend universal ultrasound screening in North America, although The American Academy of Pediatrics concluded otherwise. These different views obviously reflect the need for more long-term data to inform official practice.
Only 2 randomized controlled trials, including 1 from our group, have hitherto addressed the effect of neonatal ultrasound screening on treatment rates and the occurrence of late cases (diagnosed after 6-8 weeks of age). Both showed that universal ultrasound screening resulted in fewer late cases than selective screening, but without reaching statistical significance. In our study comparing clinical screening with clinical screening plus universal or targeted ultrasound, we also found higher rates of abduction splinting and follow-up because of borderline findings, but we had a lower proportion of late cases in the universal and selective ultrasound groups, although the differences were not statistically significant (P = .11, test for trend).
At present we are conducting a clinical and radiologic follow-up of half of the initial cohort of 12,000 newborns from 1988-1990, aimed at examining the long-term effect of different screening strategies as well as assessing the acetabular shape at skeletal maturity for different neonatal hip types. Further, we have performed a 6-year follow-up of the babies we just reported in January -- which is in the process of being published.
Medscape: You also conclude that your findings have "important implications for families as well as healthcare costs." Let's talk about families first. How does this research benefit them?
Dr. Rosendahl: Treatment for DDH with an abduction splint can be cumbersome for the baby, with constraints on mobility, as well as for the carers, with special needs for baby clothing, seating, etc. As such it may interfere with daily care and thus affect the relationship between the infant and parent or other carer.
Medscape: And cost? How cost-effective is the screening vs the alternatives?
Dr. Rosendahl: In a paper from 1995, based on the above-mentioned hip trial from 1988-1990, we showed that total program costs, including costs of screening, follow-up, and early and late treatment, may be similar for a universal, a selective, or a no ultrasound screening program. While most of the cost was related to the screening, follow-up of equivocal cases, and early treatment for infants subjected to universal ultrasound screening, the cost of treatment of late DDH may be dominant for infants subjected to just clinical screening.
Applying our data to a hypothetical ultrasound program, the most cost-effective strategy may be to subject all girls, but only boys with risk factors for DDH, to ultrasound screening in addition to routine clinical examination.
Medscape: Does ultrasound meet the criteria for a good screening test?
Dr. Rosendahl: In experienced hands and using an ultrasound technique that provides detailed information on both hip morphology and stability, ultrasound definitely meet the criteria for a good screening test -- eg, high sensitivity and specificity. However, more studies are needed to identify newborns who definitely are in need of treatment, and [to determine] when to instigate such treatment. These are some of the questions we hope to be able to answer.
Medscape: So would it be cheaper to just screen every baby for hip dysplasia after birth? Why aren't all babies screened for DDH?
Dr. Rosendahl: Although screening programs that do selective or universal ultrasound work perfectly well in some centers, the justification for a national program of screening has to be clarified. Initial experiences from Germany and Austria, where universal ultrasound screening was introduced in the 1990s, suggest that the rates of surgery have dropped; however, no robust evidence to support this has yet been published.
Medscape: You concentrated on babies with mild hip dysplasia. How would the approach differ for infants with severe hip dysplasia? What do we know about the natural history of more severe dysplasia?
Dr. Rosendahl: Little is known about the natural development of a shallow, unstable newborn hip, because such hips are treated from birth. Thus, long-term follow-up to skeletal maturity and beyond is needed to determine the outcomes of DDH and its treatment, as a hip that is radiologically poor may function well during childhood and adolescence but may become symptomatic as the individual grows older. The few reports of small selected case series that provide information about adult outcomes of treatment are unrepresentative of current approaches to early detection and management.
Medscape: Thank you for sharing your expertise and your research with us.
A Best Evidence Interview With Karen Rosendahl, MD, PhD
The Best Evidence Study
Karen Rosendahl, MD, PhD, is the lead author of the following study:
Rosendahl K, Dezateux C, Fosse KR, et al. Immediate treatment versus sonographic surveillance for mild hip dysplasia in newborns. Pediatrics. 2010;125:e9-e16.
This study was selected as the subject of this interview because of its high ranking in Medscape Best Evidence, which uses the McMaster Online Rating of Evidence System. Of a possible top score of 7, clinicians who used this system ranked this study as 6 for relevance and newsworthiness.
Abstract
About the Interviewee: Karen Rosendahl, MD, PhD
Karen Rosendahl, MD, PhD, is a Consultant Pediatric Radiologist at Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom, and Professor at the Department of Surgical Sciences, University of Bergen, Norway. Dr. Rosendahl is an honorary fellow of the Norwegian College of Radiologists, which she chaired from 1999 to 2003. She co-chairs the Task Force Group on Developmental Dysplasia of the Hip, European Society of Pediatric Radiology (ESPR).
Dr. Rosendahl has a long-standing interest in hip dysplasia and musculoskeletal imaging, particularly in the areas of newborn hip screening and follow-up, clinical trials of different treatment strategies, and the impact of abduction treatment on future hip maturation and growth. She is the author or coauthor of more than 70 articles and book chapters in the field of hip dysplasia and pediatric imaging. Dr. Rosendahl is editor of the journal Acta Radiologica.
Introduction to the Interview
Developmental dysplasia of the hip (DDH) is the most common musculoskeletal condition encountered in newborns. The varying levels of severity of DDH range from hip instability with or without associated acetabular dysplasia to irreducible hip dislocation. Even with surgical intervention, DDH can lead to shortening of the affected leg and early osteoarthritis.
Conventional management of DDH includes clinical screening (Ortolani's and Barlow's maneuvers) followed by splinting the hips in abduction and surgery for infants whose dislocation does not resolve spontaneously with time. In recent years, ultrasound screening has been added to the evaluation of DDH, and some centers selectively screen infants at risk or screen all newborn infants for DDH using ultrasound.
Screening and early treatment of DDH are not universally practiced. In 2006, the United Stated Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes. Others have reached different conclusions. The evidence-based recommendation of Mahan and colleagues is to screen all newborns for DDH by physical examination and to use ultrasonography for infants at high risk for DDH. The American Academy of Pediatrics suggests an algorithm for evaluation and management of DDH that is driven by clinical examination.
Furthermore, the USPSTF found no evidence for the effectiveness of either surgical or nonsurgical interventions for DDH and expressed concern about the potential harms associated with treatment of infants identified by routine screening. These divergent opinions suggest that more evidence is needed to establish the need for screening and early intervention for infants with DDH.
In this best evidence study, Rosendahl and associates compared 2 approaches to the management of infants with mild hip dysplasia: active sonographic surveillance and early treatment. Results of this randomized, blinded prospective trial were reported in a recent issue of the journal Pediatrics. Of 128 newborns found to have mild DDH on initial screening, half received immediate treatment with a Frejka pillow splint. The remaining 64 infants were allocated to an active surveillance group and received no treatment until 6 weeks of age. All infants were evaluated with ultrasound at 6 weeks, at 3 and 6 months, and at 1 year. In the active surveillance group, abduction splinting was initiated for infants who were not improving after 6 weeks.
The researchers found that active sonographic surveillance of infants with stable, mildly dysplastic hips reduced the use of abduction splinting without increasing the risk for persistent or more severe dysplasia. Although early splinting was associated with more rapid and consistent improvement, active surveillance of infants who did not improve spontaneously did not increase the proportion of children with delayed acetabular ossification or persistent dysplasia at 1 year of age.
The investigators maintain that these results have important implications for families as well as for healthcare costs. Although universal treatment from birth of newborns with stable, mild hip dysplasia may result in faster normalization, surveillance for 6 weeks, with treatment reconsideration, does not result in more abnormal hips at 1 year of age.
Lead study author Karen Rosendahl MD, PhD, spoke with Laura Stokowski, RN, MS, of Medscape Pediatrics to discuss some of the implications of this study for Medscape's readers.
The Interview
Medscape: In this study, you used ultrasound to screen newborns who had evidence of hip dysplasia on clinical examination or who had risk factors for hip dysplasia. What factors would place a baby at high risk for DDH?
Karen Rosendahl, MD, PhD: Newborns at high risk are those who have first-degree family members (siblings or parents) with hip dysplasia, congenital calcaneovalgus foot deformity, large birth weight for gestational age, and infants born in breech presentation. Babies who have spent time in the breech position, even if they turn prior to birth, are more likely to have DDH. Girls also have a much higher rate of DDH than boys.
Medscape: How is ultrasound used to define DDH and determine its severity? Does ultrasound replace clinical examination?
Dr. Rosendahl: There are 2 different schools as to method of defining hip dysplasia. Most European countries follow Graf's method or modifications of this, which uses a coronal standard plane to classify acetabular morphology (depth and shape of the acetabulum) and also takes hip stability into account. The other school of thought is the American school established by Theodore Harcke, who uses a dynamic method that focuses on hip stability without assessing hip morphology. We used a modified Graf technique and assessed morphology and stability separately in each hip.
In a dysplastic hip the acetabulum, particularly the anterior aspect, is shallow. With ultrasound we can assess the degree of "shallowness" as being mild, moderate, or severe based on measurement of an acetabular inclination angle (the alpha angle). Although most severely dysplastic hips are unstable, this is true for only 60% of mildly dysplastic hips, indicating a high association between hip morphology and stability.
Ultrasound can detect both acetabular dysplasia and hip instability, but clinical examination can only detect hip instability. This is unfortunate because some unstable hips are entirely normal morphologically and would normalize without treatment. On the other hand, a severely dysplastic hip can be stable and therefore impossible to detect on clinical examination alone. The low sensitivity, particularly when performed by less experienced physicians and in bilateral involvement, results in more late diagnosed cases, and limited specificity leads to potential overtreatment.
Having said that, both clinical and ultrasound examinations are highly operator-dependent, and as such, an expert clinical examination may be more accurate than an ultrasound performed by an inexperienced examiner, and vise versa.
Medscape: How does ultrasound tell you whether the hip dysplasia is resolving?
Dr. Rosendahl: Using a standard, reproducible coronal plane through the midacetabulum enables us to monitor acetabular maturation by following the alpha angle over time, from birth through 6 weeks, at 3 months, 4 and a half months, and up to around 6 months, when a pelvic x-ray provides better visualization of the hip joint. Most hips normalize or mature during the first 3 months, although some show delayed ossification and/or instability for at least a year or even longer. This combined information enables a more individualized treatment and follow-up approach.
Medscape: What does your study add to what is already known about DDH in the newborn?
Dr. Rosendahl: We knew from previous research that "watchful waiting" was probably appropriate for mild, stable hip dysplasia, but we didn't have long-term follow-up data to make sure that babies whose hips weren't treated immediately after birth didn't have worse dysplasia later on. Further, no previous study had shown that mildly dysplastic and potentially unstable, but not dislocatable hips, would normalize without treatment.
Medscape: Youalso notedthat treating babies helped their hip dysplasia normalize faster. Is this an important benefit? What is the significance of delaying the normalization of the hips?
Dr. Rosendahl: At present, the clinical significance of the accelerated acetabular maturation seen in those who received treatment from birth is unclear. But the fact that no differences were seen between the 2 groups at 6 and 12 months of age suggests that this finding is of little importance for later outcome.
Medscape: What is practice-changing about your study? What would you recommend to clinicians as a result of your findings?
Dr. Rosendahl: It would change the way we treat and follow newborns with mildly dysplastic and potentially unstable hips. According to Graf and his group in Austria, all newborns with mild acetabular dysplasia should be treated from birth, a policy resulting in high treatment rates of up to 5%-7%. We have shown that surveillance of these newborns and treatment reconsideration at 6 weeks does not result in more abnormal hips at 1 year of age.
From previous research we know that a thorough clinical hip examination is worthwhile to identify newborns with severe DDH. Those with normal clinical findings, including at-risk children, would benefit from an ultrasound examination within 5-6 weeks' time, with watchful waiting being an appropriate approach for infants showing mildly dysplastic and potentially unstable hips.
Medscape: Is this a change from current guidelines?
In the United Kingdom (UK) and parts of Europe, an additional ultrasound examination of newborns at risk, including those with positive clinical findings, has become common practice, despite the uncertain evidence base for doing so, and despite current guidelines that say otherwise. One reason for this is the numerous examples of improved outcomes from conscientiously applied programs implemented in different regions.
In the UK, the Standing Medical Advisory Committee (SMAC) states that all babies should be screened clinically within 24 hours of birth, prior to hospital discharge, at 6 weeks, between 6 and 9 months, and at walking age, and that clinicians are required to take responsibility for their assessments and audit the results of their local screening programs. The US Preventive Services Task Force did not recommend universal ultrasound screening in North America, although The American Academy of Pediatrics concluded otherwise. These different views obviously reflect the need for more long-term data to inform official practice.
Only 2 randomized controlled trials, including 1 from our group, have hitherto addressed the effect of neonatal ultrasound screening on treatment rates and the occurrence of late cases (diagnosed after 6-8 weeks of age). Both showed that universal ultrasound screening resulted in fewer late cases than selective screening, but without reaching statistical significance. In our study comparing clinical screening with clinical screening plus universal or targeted ultrasound, we also found higher rates of abduction splinting and follow-up because of borderline findings, but we had a lower proportion of late cases in the universal and selective ultrasound groups, although the differences were not statistically significant (P = .11, test for trend).
At present we are conducting a clinical and radiologic follow-up of half of the initial cohort of 12,000 newborns from 1988-1990, aimed at examining the long-term effect of different screening strategies as well as assessing the acetabular shape at skeletal maturity for different neonatal hip types. Further, we have performed a 6-year follow-up of the babies we just reported in January -- which is in the process of being published.
Medscape: You also conclude that your findings have "important implications for families as well as healthcare costs." Let's talk about families first. How does this research benefit them?
Dr. Rosendahl: Treatment for DDH with an abduction splint can be cumbersome for the baby, with constraints on mobility, as well as for the carers, with special needs for baby clothing, seating, etc. As such it may interfere with daily care and thus affect the relationship between the infant and parent or other carer.
Medscape: And cost? How cost-effective is the screening vs the alternatives?
Dr. Rosendahl: In a paper from 1995, based on the above-mentioned hip trial from 1988-1990, we showed that total program costs, including costs of screening, follow-up, and early and late treatment, may be similar for a universal, a selective, or a no ultrasound screening program. While most of the cost was related to the screening, follow-up of equivocal cases, and early treatment for infants subjected to universal ultrasound screening, the cost of treatment of late DDH may be dominant for infants subjected to just clinical screening.
Applying our data to a hypothetical ultrasound program, the most cost-effective strategy may be to subject all girls, but only boys with risk factors for DDH, to ultrasound screening in addition to routine clinical examination.
Medscape: Does ultrasound meet the criteria for a good screening test?
Dr. Rosendahl: In experienced hands and using an ultrasound technique that provides detailed information on both hip morphology and stability, ultrasound definitely meet the criteria for a good screening test -- eg, high sensitivity and specificity. However, more studies are needed to identify newborns who definitely are in need of treatment, and [to determine] when to instigate such treatment. These are some of the questions we hope to be able to answer.
Medscape: So would it be cheaper to just screen every baby for hip dysplasia after birth? Why aren't all babies screened for DDH?
Dr. Rosendahl: Although screening programs that do selective or universal ultrasound work perfectly well in some centers, the justification for a national program of screening has to be clarified. Initial experiences from Germany and Austria, where universal ultrasound screening was introduced in the 1990s, suggest that the rates of surgery have dropped; however, no robust evidence to support this has yet been published.
Medscape: You concentrated on babies with mild hip dysplasia. How would the approach differ for infants with severe hip dysplasia? What do we know about the natural history of more severe dysplasia?
Dr. Rosendahl: Little is known about the natural development of a shallow, unstable newborn hip, because such hips are treated from birth. Thus, long-term follow-up to skeletal maturity and beyond is needed to determine the outcomes of DDH and its treatment, as a hip that is radiologically poor may function well during childhood and adolescence but may become symptomatic as the individual grows older. The few reports of small selected case series that provide information about adult outcomes of treatment are unrepresentative of current approaches to early detection and management.
Medscape: Thank you for sharing your expertise and your research with us.
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