Developmental dysplasia of the hip: Epidemiology and pathogenesis
- Scott B Rosenfeld, MD
Scott B Rosenfeld, MD
- Assistant Professor of Pediatric Orthopaedic Surgery and Scoliosis
- Baylor College of Medicine
Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the development of the hip in infants and young children. It encompasses abnormal development of the acetabulum and proximal femur and mechanical instability of the hip joint.
Newborns often have physiologic laxity of the hip and immaturity of the acetabulum during the first few weeks of life. In most cases, the laxity resolves, and the acetabulum proceeds to develop normally. With assessment of risk factors, serial physical examination of the hips, and appropriate use of imaging, most children with pathologic hips can be correctly diagnosed and treated without long-term sequelae. (See "Developmental dysplasia of the hip: Treatment and outcome".)
Typical DDH, which generally occurs in otherwise healthy infants, will be the focus of this topic review. Hip dysplasia and instability also occur in association with other conditions. Teratologic hip dysplasia occurs in association with various syndromes (eg, Ehlers-Danlos, Down syndrome, arthrogryposis), and neuromuscular hip dysplasia occurs when there is weakness and/or spasticity in some or all of the hip muscle groups (eg, in spina bifida or cerebral palsy). The diagnosis and management of teratologic and neuromuscular hip dysplasia differ from the diagnosis and management of hip dysplasia in otherwise healthy infants.
The epidemiology and pathogenesis of DDH in otherwise healthy children will be reviewed here. The clinical features, diagnosis, treatment, and outcome are discussed separately. (See "Developmental dysplasia of the hip: Clinical features and diagnosis" and "Developmental dysplasia of the hip: Treatment and outcome".)
The terminology for developmental problems of the hip has changed over time. "Developmental dysplasia of the hip" (DDH) is the preferred term . "Developmental" is preferred to "congenital," since the condition is not always present or identifiable at birth and develops during early childhood [2,3]. "Dysplasia" is preferred to "dislocation" because it includes a broader spectrum of changes in the shape and position of the femoral head and acetabulum. "Congenital hip dislocation" is an outdated term that was used at a time when most children were diagnosed after they began walking and the dislocation was assumed to be congenital.
- American Academy of Orthopaedic Surgeons Advisory Statement. "CDH" should be "DDH". American Academy of Orthopaedic Surgeons, Park Ridge, IL, 1991.
- Garvey M, Donoghue VB, Gorman WA, et al. Radiographic screening at four months of infants at risk for congenital hip dislocation. J Bone Joint Surg Br 1992; 74:704.
- Ilfeld FW, Westin GW, Makin M. Missed or developmental dislocation of the hip. Clin Orthop Relat Res 1986; :276.
- Bialik V, Bialik GM, Blazer S, et al. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics 1999; 103:93.
- Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000; 105:E57.
- BARLOW TG. EARLY DIAGNOSIS AND TREATMENT OF CONGENITAL DISLOCATION OF THE HIP. Proc R Soc Med 1963; 56:804.
- von ROSEN . Diagnosis and treatment of congenital dislocation of the hip hoint in the new-born. J Bone Joint Surg Br 1962; 44-B:284.
- Marks DS, Clegg J, al-Chalabi AN. Routine ultrasound screening for neonatal hip instability. Can it abolish late-presenting congenital dislocation of the hip? J Bone Joint Surg Br 1994; 76:534.
- Coleman SS. Congenital dysplasia of the hip in the Navajo infant. Clin Orthop Relat Res 1968; 56:179.
- GETZ B. The hip joint in Lapps and its bearing on the problem of congenital dislocation. Acta Orthop Scand Suppl 1955; 18:1.
- Skirving AP, Scadden WJ. The African neonatal hip and its immunity from congenital dislocation. J Bone Joint Surg Br 1979; 61-B:339.
- Hoaglund FT, Kalamchi A, Poon R, et al. Congenital hip dislocation and dysplasia in Southern Chinese. Int Orthop 1981; 4:243.
- Dunn PM. Perinatal observations on the etiology of congenital dislocation of the hip. Clin Orthop Relat Res 1976; :11.
- Loder RT, Skopelja EN. The epidemiology and demographics of hip dysplasia. ISRN Orthop 2011; 2011:238607.
- Ortiz-Neira CL, Paolucci EO, Donnon T. A meta-analysis of common risk factors associated with the diagnosis of developmental dysplasia of the hip in newborns. Eur J Radiol 2012; 81:e344.
- Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics 2006; 117:e557.
- Screening for the detection of congenital dislocation of the hip. Arch Dis Child 1986; 61:921.
- Vogel I, Andersson JE, Uldbjerg N. Serum relaxin in the newborn is not a marker of neonatal hip instability. J Pediatr Orthop 1998; 18:535.
- Shaw BA, Segal LS, SECTION ON ORTHOPAEDICS. Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. Pediatrics 2016; 138.
- Chan A, McCaul KA, Cundy PJ, et al. Perinatal risk factors for developmental dysplasia of the hip. Arch Dis Child Fetal Neonatal Ed 1997; 76:F94.
- Lowry CA, Donoghue VB, O'Herlihy C, Murphy JF. Elective Caesarean section is associated with a reduction in developmental dysplasia of the hip in term breech infants. J Bone Joint Surg Br 2005; 87:984.
- Quan T, Kent AL, Carlisle H. Breech preterm infants are at risk of developmental dysplasia of the hip. J Paediatr Child Health 2013; 49:658.
- Lambeek AF, De Hundt M, Vlemmix F, et al. Risk of developmental dysplasia of the hip in breech presentation: the effect of successful external cephalic version. BJOG 2013; 120:607.
- Fox AE, Paton RW. The relationship between mode of delivery and developmental dysplasia of the hip in breech infants: a four-year prospective cohort study. J Bone Joint Surg Br 2010; 92:1695.
- Panagiotopoulou N, Bitar K, Hart WJ. The association between mode of delivery and developmental dysplasia of the hip in breech infants: a systematic review of 9 cohort studies. Acta Orthop Belg 2012; 78:697.
- Hoaglund FT, Healey JH. Osteoarthrosis and congenital dysplasia of the hip in family members of children who have congenital dysplasia of the hip. J Bone Joint Surg Am 1990; 72:1510.
- Stevenson DA, Mineau G, Kerber RA, et al. Familial predisposition to developmental dysplasia of the hip. J Pediatr Orthop 2009; 29:463.
- Wynne-Davies R. Acetabular dysplasia and familial joint laxity: two etiological factors in congenital dislocation of the hip. A review of 589 patients and their families. J Bone Joint Surg Br 1970; 52:704.
- Abd el-Kader Shaheen M. Mehad: the Saudi tradition of infant wrapping as a possible aetiological factor in congenital dislocation of the hip. J R Coll Surg Edinb 1989; 34:85.
- Kremli MK, Alshahid AH, Khoshhal KI, Zamzam MM. The pattern of developmental dysplasia of the hip. Saudi Med J 2003; 24:1118.
- Clarke NM. Swaddling and hip dysplasia: an orthopaedic perspective. Arch Dis Child 2014; 99:5.
- Wang E, Liu T, Li J, et al. Does swaddling influence developmental dysplasia of the hip?: An experimental study of the traditional straight-leg swaddling model in neonatal rats. J Bone Joint Surg Am 2012; 94:1071.
- Price CT, Schwend RM. Improper swaddling a risk factor for developmental dysplasia of the hip. AAP News 2011; 32:11. http://aapnews.aappublications.org/content/32/9/11.1.full (Accessed on September 12, 2011).
- Harcke HT, Karatas AF, Cummings S, Bowen JR. Sonographic Assessment of Hip Swaddling Techniques in Infants With and Without DDH. J Pediatr Orthop 2016; 36:232.
- American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age. Evidence-based clinical practice guideline. September 2014. http://www.aaos.org/research/guidelines/DDHGuidelineFINAL.pdf.
- Hummer CD, MacEwen GD. The coexistence of torticollis and congenital dysplasia of the hip. J Bone Joint Surg Am 1972; 54:1255.
- Tien YC, Su JY, Lin GT, Lin SY. Ultrasonographic study of the coexistence of muscular torticollis and dysplasia of the hip. J Pediatr Orthop 2001; 21:343.
- Walsh JJ, Morrissy RT. Torticollis and hip dislocation. J Pediatr Orthop 1998; 18:219.
- JACOBS JE. Metatarsus varus and hip dysplasia. Clin Orthop 1960; 16:203.
- Kumar SJ, MacEwen GD. The incidence of hip dysplasia with metatarsus adductus. Clin Orthop Relat Res 1982; :234.
- Westberry DE, Davids JR, Pugh LI. Clubfoot and developmental dysplasia of the hip: value of screening hip radiographs in children with clubfoot. J Pediatr Orthop 2003; 23:503.
- Perry DC, Tawfiq SM, Roche A, et al. The association between clubfoot and developmental dysplasia of the hip. J Bone Joint Surg Br 2010; 92:1586.
- Mahan ST, Yazdy MM, Kasser JR, Werler MM. Is it worthwhile to routinely ultrasound screen children with idiopathic clubfoot for hip dysplasia? J Pediatr Orthop 2013; 33:847.
- Paton RW, Choudry QA, Jugdey R, Hughes S. Is congenital talipes equinovarus a risk factor for pathological dysplasia of the hip? : a 21-year prospective, longitudinal observational study. Bone Joint J 2014; 96-B:1553.
- Rühmann O, Lazović D, Bouklas P, et al. Ultrasound examination of neonatal hip: correlation of twin pregnancy and congenital dysplasia. Twin Res 2000; 3:7.
- Bielski RJ, Gesell MW, Teng AL, et al. Orthopaedic implications of multiple gestation pregnancy with triplets. J Pediatr Orthop 2006; 26:129.
- Barr LV, Rehm A. Should all twins and multiple births undergo ultrasound examination for developmental dysplasia of the hip?: A retrospective study of 990 multiple births. Bone Joint J 2013; 95-B:132.
- Rális Z, McKibbin B. Changes in shape of the human hip joint during its development and their relation to its stability. J Bone Joint Surg Br 1973; 55:780.
- Ponseti IV. Growth and development of the acetabulum in the normal child. Anatomical, histological, and roentgenographic studies. J Bone Joint Surg Am 1978; 60:575.
- MASSIE WK, HOWORTH MB. Congenital dislocation of the hip. III. Pathogenesis. J Bone Joint Surg Am 1951; 33 A:190.
- Dunn PM. The anatomy and pathology of congenital dislocation of the hip. Clin Orthop Relat Res 1976; :23.