At the AAOS 2018 Annual Meeting in New Orleans, the AAOS Board of Directors approved the release of Appropriate Use Criteria covering Management of Developmental Dysplasia of the Hip (DDH) in Infants Up to 6 Months of Age.

Based on the Academy’s previously issued Clinical Practice Guideline (CPG) on DDH, this new AUC is noteworthy because it provides a customized version for orthopaedic surgeons as well as generalists/pediatricians.

The Academy’s AUCs are online tools that process patient characteristics and variables as entered by the physicians and use algorithms to indicate appropriate treatment paths, with the focus on those involving nonoperative management.

The physician panels developing the AUC created a separate tool for the generalist pediatricians and family physicians as they are most likely to be the first to evaluate infants for DDH.

“Pediatricians are often on the first line of evaluating these patients, and now they can be more aware of the risk factors to determine the best course of action for their patients,” said Antonia F. Chen, MD, MBA, AUC section leader, AAOS Committee on Evidence-Based Quality and Value.

The AUC incorporated two significant recommendations, both supported with evidence termed Moderate, of the underlying CPG:

• Evidence does not support universal ultrasound screening of newborn infants.
• Evidence supports performing an imaging study before 6 months of age in infants with one or more of the following risk factors: breech presentation, family history, or history of clinical instability.

Julie Balch Samora, MD, PhD, MPH, the moderator for the AUC writing and voting panels, explained that in developing the AUC, the group “had substantial discussions about when the orthopaedist sees the patient.” She elaborated, “The pediatrician typically manages the patient through the ultrasound, and if the ultrasound is normal, the child will never end up in an orthopaedist’s office. And yet, we might sometimes see babies that don’t need to go to a specialist. Sometimes the pediatrician manages from start to finish; sometimes an orthopaedic surgeon is involved but might not have needed to be. That’s why we wanted to capture both groups.”

Dr. Samora also noted, “The pathways are very regional because there are some places where there are no orthopaedic providers. The pediatrician or family doctor may be doing everything because there is no one to refer them to, and in large cities, everyone may be referred to the specialist. This is capturing everyone.”

A crucial risk factor
The AUC gives special weight to the variable of breech presentation even in the face of normal findings on physical examination (Fig. 1). For breech-birth patients, the AUC counsels a screening ultrasound at 6 weeks of age and a single anteroposterior radiograph at 6 months of age.

To underscore the point for the primary care physician, the online tool displays a green-box popup when breech presentation is entered.

“The pediatrician would be first in thinking about what the next steps are,” explained Dr. Samora. “That would include trying to understand the biggest risk factors and making sure everyone understood that some things weren’t well known. We identified the strongest risk factor by far to be breech presentation.” Other factors that indicate need for a radiograph at age 6 months include family history and improper swaddling.

Both Dr. Samora and Dr. Chen noted that, as with all AUCs and their underlying CPGs, this product aids the physician in determining the optimal course of treatment, or nontreatment, for each patient.

“These are suggestions and recommendations based on the best evidence, not hardline commands that must be followed,” Dr. Chen said. The panels developing the AUC included representatives from the American Academy of Pediatrics, the Pediatric Orthopaedic Society of North America, the Society of Diagnostic Medical Sonography, American College of Radiology, the Society for Pediatric Radiology, and the American Institute for Ultrasound in Medicine.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.