Increase in late diagnosed developmental dysplasia of the hip in South Australia: risk factors, proposed solutions

Kathrin Studer, Nicole Williams, Georgia Antoniou, Catherine Gibson, Heather Scott, Wendy K Scheil, Bruce K Foster and Peter J Cundy
Med J Aust 2016; 204 (6): 240. || doi: 10.5694/mja15.01082


Objectives: To review evidence for the increased incidence of late diagnosed developmental dysplasia of the hip (DDH) in South Australia; to identify perinatal risk factors associated with late DDH in babies born between 2003 and 2009 in SA.

Design: Linkage study of data collected prospectively by the South Australian Birth Defects Register (SABDR) and the Pregnancy Outcome Statistics Unit (SA Department of Health), supplemented by medical records review.

Participants: All children born 2003–2009 in whom DDH was diagnosed between 3 months and 5 years of age and notified to the SABDR (data inclusion range, 2003–2014). Children with teratological hip dislocations and other major congenital abnormalities were excluded.

Main outcome measures: Uni- and multivariable analyses were performed to identify perinatal risk factors for late diagnosed DDH.

Results: The incidence of late diagnosed DDH in babies born 2003–2009 was 0.77 per 1000 live births, contrasting with the figure of 0.22 per 1000 live births during 1988–2003. Significant perinatal risk factors were birth in a rural hospital (v metropolitan public hospital: odds ratio [OR], 2.47; CI, 1.37–4.46; P = 0.003), and being the second child (v being the first-born: OR, 1.69; CI, 1.08–2.66; P = 0.023). Breech presentation was highly significant as a protective factor when compared with cephalic presentation (OR, 0.25; CI, 0.12–0.54; P < 0.001).

Conclusions: The incidence of late DDH has increased in SA despite an ongoing clinical screening program. Increased awareness, education, and avoidance of inappropriate lower limb swaddling are necessary to reverse this trend.

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  • Kathrin Studer1
  • Nicole Williams1,2
  • Georgia Antoniou1
  • Catherine Gibson3
  • Heather Scott3
  • Wendy K Scheil4
  • Bruce K Foster1,2
  • Peter J Cundy1,2

  • 1 Women's and Children's Hospital, Adelaide, SA
  • 2 University of Adelaide Centre for Orthopaedic and Trauma Research, Adelaide, SA
  • 3 South Australian Birth Defects Register, Women's and Children's Hospital, Adelaide, SA
  • 4 Pregnancy Outcomes Statistics Unit, SA Health, Adelaide, SA


The authors would like to thank the Bone Health Foundation and Big W for providing institutional research funding support.

Competing interests:

Nicole Williams, Bruce Foster and Peter Cundy are medical advisers to the International Hip Dysplasia Institute. Bruce Foster is the Healthy Hips Australia patron.

  • 1. Tschauner C, Furntrath F, Saba Y, et al. Developmental dysplasia of the hip: impact of sonographic newborn hip screening on the outcome of early treated decentered hip joints-a single center retrospective comparative cohort study based on Graf’s method of hip ultrasonography. J Child Orthop 2011; 5: 415-424.
  • 2. Thallinger C, Pospischill R, Ganger R, et al. Long-term results of a nationwide general ultrasound screening system for developmental disorders of the hip: the Austrian hip screening program. J Child Orthop 2014; 8: 3-10.
  • 3. Williams N, Foster BK, Cundy PJ. Is swaddling damaging our babies’ hips? Med J Aust 2012; 197: 272. <MJA full text>
  • 4. Azzopardi T, Van Essen P, Cundy PJ, et al. Late diagnosis of developmental dysplasia of the hip: an analysis of risk factors. J Pediatr Orthop B 2011; 20: 1-7.
  • 5. Birke O, Wallgren L, Bridge C, et al. Late open reduction and pelvic ± femoral osteotomy for increasing numbers of missed walking age DDH hip dislocation vs early treatment with Pavlik harness — evaluation at 5 years follow-up [unpublished presentation]. Australian Paediatric Orthopaedic Society annual scientific meeting, Noosa (Australia), 22 Sept 2012.
  • 6. Lisle R, Boekelaar M, Stannage K, Whitewood C. Delayed diagnosis of developmental dislocation of the hip: the Western Australian experience. ANZ J Surg 2012; 82: 612-615.
  • 7. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip; American Academy of Pediatrics. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics 2000; 105: 896-905.
  • 8. Wicart P, Bocquet A, Gelbert N, et al. Congenital dislocation of the hip: optimal screening strategies in 2014. Orthop Traumatol Surg Res 2014; 100(6 Suppl): S339-S347.
  • 9. Price KR, Dove R, Hunter JB. Current screening recommendations for developmental dysplasia of the hip may lead to an increase in open reduction. Bone Joint J 2013; 95-B: 846-850.
  • 10. Clarke NM. Swaddling and hip dysplasia: an orthopaedic perspective. Arch Dis Child 2014; 99: 5-6.
  • 11. Price CT. Swaddling and hip dysplasia: new observations. Commentary on an article by Enbo Wang, MD, PhD, 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: e92.
  • 12. Shorter D, Hong T, Osborn DA. Cochrane review: screening programmes for developmental dysplasia of the hip in newborn infants. Evid Based Child Health 2013; 8: 11-54.
  • 13. Lee CB, Mata-Fink A, Millis MB, Kim YJ. Demographic differences in adolescent-diagnosed and adult-diagnosed acetabular dysplasia compared with infantile developmental dysplasia of the hip. J Pediatr Orthop 2013; 33: 107-111.
  • 14. International Hip Dysplasia Institute. Hip-healthy swaddling [video]. (accessed Sept 2015).
  • 15. Hip Hip Hooray: raising awareness for hip dysplasia [website]. (accessed Sept 2015).
  • 16. Healthy Hips Australia [website]. (accessed Sept 2015).
  • 17. Raimann A, Baar A, Raimann R, Morcuende JA. Late developmental dislocation of the hip after initial normal evaluation: a report of five cases. J Pediatr Orthop 2007; 27: 32-36.
  • 18. Donnan L, The Royal Children’s Hospital Melbourne. Developmental dysplasia of the hip [website, video]. Melbourne: Department of Education and Early Childhood Development (Victoria), 2011. (accessed Sept 2015).
  • 19. Mahan ST, Kasser JR. Does swaddling influence developmental dysplasia of the hip? Pediatrics 2008; 121: 177-178.
  • 20. 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: 1071-1077.
  • 21. Yamamuro T, Ishida K. Recent advances in the prevention, early diagnosis, and treatment of congenital dislocation of the hip in Japan. Clin Orthop Relat Res 1984; (184): 34-40.
  • 22. Graham SM, Manara J, Chokotho L, Harrison WJ. Back-carrying infants to prevent developmental hip dysplasia and its sequelae: is a new public health initiative needed? J Pediatr Orthop 2015; 35: 57-61.
  • 23. Roposch A, Graf R, Wright JG. Determining the reliability of the Graf classification for hip dysplasia. Clin Orthop Relat Res 2006; 447: 119-124.
  • 24. Tegnander A, Holen KJ, Terjesen T. The natural history of hip abnormalities detected by ultrasound in clinically normal newborns: a 6–8 year radiographic follow-up study of 93 children. Acta Orthop Scand 1999; 70: 335-337.
  • 25. Imrie M, Scott V, Stearns P, et al. Is ultrasound screening for DDH in babies born breech sufficient? J Child Orthop 2010; 4: 3-8.


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access_time 04:18, 8 April 2016
Susan Lyndsay Charlton

The problem of late-diagnosis of DDH is increasing as reported by Katherine Studer, Nicole Williams et al in MJA 2016-04-07 and is stated to be impacted by birth in rural and regional South Australia compared with major tertiary hospitals in metropolitan areas.
In the Limestone Coast region of South Australia research has been carried out over the last four years into methods of assessment of infant hips with a view to providing better education about assessment and management of neonatal instability of the hip. One preliminary pilot study (Charlton 2012) offered early anterior dynamic ultrasound (ADUS) for hip screening to all infants born at a regional hospital. This study demonstrated ADUS was logistically feasible with high parent acceptance in a regional hospital
Following on from this study we have provided early ADUS to all babies with such risk factors as family history, breech delivery or abnormal clinical assessment. We have a cohort of 116 babies in this group since September 2013 and of that number, 22 warranted follow up ultrasound at 6 weeks. Four infants went on to splinting for insufficient femoral head cover on Graf ultrasound.
A further study is being conducted exploring whether ADUS has a place in educating and motivating parents to engage in preventative strategies such as loose swaddling and prone positioning of their baby.
A break down by postcode or region on the statistics in the published study would be of interest in possible variation in incidence of late diagnosis between regions in the light of these studies.

Competing Interests: No relevant disclosures

Mrs Susan Lyndsay Charlton
Flinders University Rural Clinical School

access_time 10:23, 13 April 2016
Nicole Williams

The authors thank Susan Charlton and her associates for their comment and commend her team for their well-respected and ongoing efforts to provide optimal care to babies with DDH in the Limestone Coast and promote healthy hip initiatives.
This study included data on South Australian births up to 2009, to allow a full 5 year follow-up to capture a late diagnosis. Any initiatives since then would not be reflected in this data.
To help with your ongoing efforts, we can provide the following information: of the 23 babies born in South Australian rural and regional hospitals with late DDH, 6 were from the Limestone Coast. The percentage of all cases of DDH born in Limestone Coast Hospitals from 2003-2009 with a late diagnosis was 22%, which is slightly above the figure for rural and regional births as a whole as presented in Box 3 in the article.
This study provides further evidence that selective ultrasound screening based on risk factors fails to prevent late diagnosed cases as many children will not have traditional risk factors. We continue to promote careful clinical examination in all babies and ask practitioners to be mindful that if performing ultrasound screening based on risk factors, this will fail to identify the cephalic presentation, second-born babies we found to be at risk of late diagnosis in this study.

Competing Interests: Study corresponding author

Dr Nicole Williams
Women's and Children's Hospital, North Adelaide

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