Children’s Hospital of Philadelphia (CHOP) is proud to offer a dedicated Hip Disorders Program that specializes in diagnosing and treating all pediatric hip disorders. One of the most common disorders is developmental dysplasia of the hip (DDH) – also known as infant hip dysplasia – which occurs once in every 1,000 births.
Wudbhav N. Sankar, MD, a nationally recognized leader in pediatric hip disorders, recently sat down to discuss which factors increase a child’s risk of infant hip dysplasia, how best to diagnose the disorder, bracing options, when surgery is needed and how CHOP can collaborate with pediatricians on care. Dr. Sankar heads up CHOP’s Hip Disorder Program and is Director of the Young Adult Hip Preservation Program.
Question: How is DDH screened in the U.S.?
Answer: Neither the U.S. Preventive Services Task Force nor the American Academy of Pediatrics (AAP) recommend universal ultrasound screening for hip dysplasia for all babies. Instead, the recommendation is for physicians to perform careful clinical exams with selective ultrasound screening.
What this means is that at every well-child visit for the first year – including in the newborn nursery – the hips should be felt by the pediatrician and assessed to determine:
- Whether the hip is dislocatable, i.e., sliding out (Barlow test)
- Whether the hip is dislocated but clunks back in with abduction (Ortolani test)
Essentially, both tests assess the stability of the hip. But this is a flawed assessment because if the hip is not moving in and out of the joint (because it is irreducible), it is not going to be felt by the pediatrician. It’s important to note that a physical exam is not going to catch everything – even experienced hip surgeons can miss DDH. I published a paper a few years ago looking at 500 hips (known to be dislocated, based on ultrasound) from 10 centers around the world. Hip experts missed 13% of these dislocations based solely on the physical exam.
Our recommendation at CHOP is to perform physical exams on all babies. If instability is found or suspected, or if there are risk factors in the patient’s history (i.e., the child has parents or siblings with hip dysplasia), we recommend an ultrasound – regardless of what the physical exam shows.
Q: Are breech babies more at risk for hip dysplasia?
A: Babies born in the breech position or who were breech for a significant portion of the pregnancy should be screened for hip dysplasia. That’s because the forces put on the hips in utero in breech kids are different than those in cephalic presentation – and that increases the stress on their hip and increases the risk of hip dysplasia.
Q: When should you send a patient for an ultrasound?
A: The classic reasons to send a patient suspected of having infant hip dysplasia for an ultrasound include:
- An abnormal exam
- An abnormal assessment from the Barlow or Ortolani test
- A feeling of instability in the hip
- A family history of hip dysplasia
- Any history of breech positioning in utero
There are other reasons a pediatrician may request a hip ultrasound, such as:
- Asymmetric thigh creases – or asymmetry in the baby fat in the legs. While most asymmetries in the buttocks and thigh creases have little to do with hip dysplasia (there are several studies on this topic), there is a slight increase of mild hip dysplasia caught in patients sent for ultrasound based on this indication.
- Hip clicks. There is one study that suggests there is a higher incidence of hip dysplasia in patients who have hip clicks. A little click or pop or noise when the hip moves is usually benign, but probably does warrant an ultrasound to be sure.
Q: Is there any new screening information for 2025?
A: One newer piece of DDH screening information that often catches pediatricians a little off guard is what to do with breech kids after the first ultrasound. There are two studies out – one CHOP published and one out of San Diego – showing a 10-30% risk of shallowness in the hip of babies who were breech. While not the most severe forms of hip dysplasia, these mild forms of dysplasia were found in older babies, even after a normal ultrasound at birth.
So, our recommendation is to get a follow-up X-ray at 6 months of age even if the baby has a normal ultrasound at 6 weeks old. Local pediatricians have caught on to our practice and I see this happening all the time now. While it’s not a published recommendation from the AAP, it is a trend now in most orthopedic communities.
Q: What bracing options are available for DDH at CHOP?
A: The Pavlik harness is the most widely used non-surgical treatment for infants with DDH in this country, but doesn’t always work. At CHOP, we have been very successful at taking care of patients who have failed the Pavlik harness. Our goal is to rescue the hip before it must go to surgery. We use three primary alternate braces:
- Ilfeld brace (dynamic Ilfeld hip abduction splint), which we’ve published quite a few papers on. Some other institutions use it, but very infrequently. I’ve found it to be a very useful second-line tool because it’s adjustable and you can ultrasound the patient in it to confirm the hip structure is in the correct position.
- Tubingen splint (Tubingen hip flexion and abduction orthosis), which is a commonly used brace in Germany.
- Rhino or “bucket” brace (hip abduction brace), which is a plastic brace that most orthopedic specialists are familiar with, but don’t use as widely as the Pavlik harness.
Q: How is bracing for DDH different at CHOP?
A: We offer a wider range of devices than most centers and can avoid surgery in a significant number of patients. While it’s not totally unique to use such a wide variety of braces, it’s certainly less common. Another one of the unique things about our practice is that we offer ultrasound in our clinics. So, in real-time, we fine-tune brace adjustments under ultrasound – which increases our success rate. Our non-operative approach is varied, experienced and flexible.
Q: What are CHOP’s surgical patient volumes for DDH?
A: CHOP is arguably the busiest program in the United States for DDH. Hundreds of babies are referred to us each year and we treat patients from every region of the U.S. While bracing is successful in more than 75 percent of these patients, sometimes it’s simply not enough. In these cases, we offer surgical treatment to place the femoral head more deeply into the acetabulum or to repair the angle of the hip socket. One in every 1,000 babies with DDH will require surgical correction. We used to do 5-6 open reductions for dislocated hips a year. Now we perform 45-50 of these surgeries every year.
Q: What drives CHOP’s surgical outcomes?
A: We now have very high surgical volumes for DDH, and that increase in volume drives better results for our patients. Another driving factor behind our success is that we have a dedicated hip dysplasia nurse, Meg Morro, BSN, RN, who spends a lot of time with families explaining practical issues like clothing, fitting a child with a spica cast into the car seat, and connecting new parents with others who have gone through DDH surgery and casting. This kind of personalized support can only be offered at a center with a very high volume of patients.
Q: How is CHOP’s surgical treatment for DDH unique?
A: Due to our lengthy experience treating infant hip dysplasia, we offer several specialized services that have improved surgical outcomes and patient/family satisfaction. These include:
- Spinal anesthesia for patients younger than 6 months who are undergoing DDH surgery. This reduces the risk of complications in very young children.
- Experienced cast technicians who put on the spica. Our techs apply one of these specialized casts every week – unlike other facilities that may only apply it 1-4 times a year.
- Standardized use of MRI after surgery to confirm blood flow to the hip is adequate for growth and healing. If blood flow is impeded, imaging can be used to guide adjustments to the hip joint in the spica cast post-op. CHOP is one of the few centers in the country that offers state-of-the-art perfusion MRI imaging after cast placement. This has drastically reduced the risk of avascular necrosis, the most concerning complication of DDH treatment.
- A dedicated post-op pathway that allows our team to ensure consistency. This pathway includes:
- A comprehensive pre-surgical counseling session with a nurse specialist
- Advanced imaging immediately after surgery
- Specialized car seat rental program
- One night in the hospital
- Imaging at 3 weeks post-surgery
- Cast removal at 6-8 weeks
- Range of motion assessment 6 weeks after cast removal
Contact us
If you have additional questions about infant hip dysplasia, want a second opinion or to refer a patient to CHOP, please contact our dedicated referral nurse navigator, Maribeth Magarity, MSN, RN, or complete our Orthopedic Center Referral Nurse Navigator form.
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Children’s Hospital of Philadelphia (CHOP) is proud to offer a dedicated Hip Disorders Program that specializes in diagnosing and treating all pediatric hip disorders. One of the most common disorders is developmental dysplasia of the hip (DDH) – also known as infant hip dysplasia – which occurs once in every 1,000 births.
Wudbhav N. Sankar, MD, a nationally recognized leader in pediatric hip disorders, recently sat down to discuss which factors increase a child’s risk of infant hip dysplasia, how best to diagnose the disorder, bracing options, when surgery is needed and how CHOP can collaborate with pediatricians on care. Dr. Sankar heads up CHOP’s Hip Disorder Program and is Director of the Young Adult Hip Preservation Program.
Question: How is DDH screened in the U.S.?
Answer: Neither the U.S. Preventive Services Task Force nor the American Academy of Pediatrics (AAP) recommend universal ultrasound screening for hip dysplasia for all babies. Instead, the recommendation is for physicians to perform careful clinical exams with selective ultrasound screening.
What this means is that at every well-child visit for the first year – including in the newborn nursery – the hips should be felt by the pediatrician and assessed to determine:
- Whether the hip is dislocatable, i.e., sliding out (Barlow test)
- Whether the hip is dislocated but clunks back in with abduction (Ortolani test)
Essentially, both tests assess the stability of the hip. But this is a flawed assessment because if the hip is not moving in and out of the joint (because it is irreducible), it is not going to be felt by the pediatrician. It’s important to note that a physical exam is not going to catch everything – even experienced hip surgeons can miss DDH. I published a paper a few years ago looking at 500 hips (known to be dislocated, based on ultrasound) from 10 centers around the world. Hip experts missed 13% of these dislocations based solely on the physical exam.
Our recommendation at CHOP is to perform physical exams on all babies. If instability is found or suspected, or if there are risk factors in the patient’s history (i.e., the child has parents or siblings with hip dysplasia), we recommend an ultrasound – regardless of what the physical exam shows.
Q: Are breech babies more at risk for hip dysplasia?
A: Babies born in the breech position or who were breech for a significant portion of the pregnancy should be screened for hip dysplasia. That’s because the forces put on the hips in utero in breech kids are different than those in cephalic presentation – and that increases the stress on their hip and increases the risk of hip dysplasia.
Q: When should you send a patient for an ultrasound?
A: The classic reasons to send a patient suspected of having infant hip dysplasia for an ultrasound include:
- An abnormal exam
- An abnormal assessment from the Barlow or Ortolani test
- A feeling of instability in the hip
- A family history of hip dysplasia
- Any history of breech positioning in utero
There are other reasons a pediatrician may request a hip ultrasound, such as:
- Asymmetric thigh creases – or asymmetry in the baby fat in the legs. While most asymmetries in the buttocks and thigh creases have little to do with hip dysplasia (there are several studies on this topic), there is a slight increase of mild hip dysplasia caught in patients sent for ultrasound based on this indication.
- Hip clicks. There is one study that suggests there is a higher incidence of hip dysplasia in patients who have hip clicks. A little click or pop or noise when the hip moves is usually benign, but probably does warrant an ultrasound to be sure.
Q: Is there any new screening information for 2025?
A: One newer piece of DDH screening information that often catches pediatricians a little off guard is what to do with breech kids after the first ultrasound. There are two studies out – one CHOP published and one out of San Diego – showing a 10-30% risk of shallowness in the hip of babies who were breech. While not the most severe forms of hip dysplasia, these mild forms of dysplasia were found in older babies, even after a normal ultrasound at birth.
So, our recommendation is to get a follow-up X-ray at 6 months of age even if the baby has a normal ultrasound at 6 weeks old. Local pediatricians have caught on to our practice and I see this happening all the time now. While it’s not a published recommendation from the AAP, it is a trend now in most orthopedic communities.
Q: What bracing options are available for DDH at CHOP?
A: The Pavlik harness is the most widely used non-surgical treatment for infants with DDH in this country, but doesn’t always work. At CHOP, we have been very successful at taking care of patients who have failed the Pavlik harness. Our goal is to rescue the hip before it must go to surgery. We use three primary alternate braces:
- Ilfeld brace (dynamic Ilfeld hip abduction splint), which we’ve published quite a few papers on. Some other institutions use it, but very infrequently. I’ve found it to be a very useful second-line tool because it’s adjustable and you can ultrasound the patient in it to confirm the hip structure is in the correct position.
- Tubingen splint (Tubingen hip flexion and abduction orthosis), which is a commonly used brace in Germany.
- Rhino or “bucket” brace (hip abduction brace), which is a plastic brace that most orthopedic specialists are familiar with, but don’t use as widely as the Pavlik harness.
Q: How is bracing for DDH different at CHOP?
A: We offer a wider range of devices than most centers and can avoid surgery in a significant number of patients. While it’s not totally unique to use such a wide variety of braces, it’s certainly less common. Another one of the unique things about our practice is that we offer ultrasound in our clinics. So, in real-time, we fine-tune brace adjustments under ultrasound – which increases our success rate. Our non-operative approach is varied, experienced and flexible.
Q: What are CHOP’s surgical patient volumes for DDH?
A: CHOP is arguably the busiest program in the United States for DDH. Hundreds of babies are referred to us each year and we treat patients from every region of the U.S. While bracing is successful in more than 75 percent of these patients, sometimes it’s simply not enough. In these cases, we offer surgical treatment to place the femoral head more deeply into the acetabulum or to repair the angle of the hip socket. One in every 1,000 babies with DDH will require surgical correction. We used to do 5-6 open reductions for dislocated hips a year. Now we perform 45-50 of these surgeries every year.
Q: What drives CHOP’s surgical outcomes?
A: We now have very high surgical volumes for DDH, and that increase in volume drives better results for our patients. Another driving factor behind our success is that we have a dedicated hip dysplasia nurse, Meg Morro, BSN, RN, who spends a lot of time with families explaining practical issues like clothing, fitting a child with a spica cast into the car seat, and connecting new parents with others who have gone through DDH surgery and casting. This kind of personalized support can only be offered at a center with a very high volume of patients.
Q: How is CHOP’s surgical treatment for DDH unique?
A: Due to our lengthy experience treating infant hip dysplasia, we offer several specialized services that have improved surgical outcomes and patient/family satisfaction. These include:
- Spinal anesthesia for patients younger than 6 months who are undergoing DDH surgery. This reduces the risk of complications in very young children.
- Experienced cast technicians who put on the spica. Our techs apply one of these specialized casts every week – unlike other facilities that may only apply it 1-4 times a year.
- Standardized use of MRI after surgery to confirm blood flow to the hip is adequate for growth and healing. If blood flow is impeded, imaging can be used to guide adjustments to the hip joint in the spica cast post-op. CHOP is one of the few centers in the country that offers state-of-the-art perfusion MRI imaging after cast placement. This has drastically reduced the risk of avascular necrosis, the most concerning complication of DDH treatment.
- A dedicated post-op pathway that allows our team to ensure consistency. This pathway includes:
- A comprehensive pre-surgical counseling session with a nurse specialist
- Advanced imaging immediately after surgery
- Specialized car seat rental program
- One night in the hospital
- Imaging at 3 weeks post-surgery
- Cast removal at 6-8 weeks
- Range of motion assessment 6 weeks after cast removal
Contact us
If you have additional questions about infant hip dysplasia, want a second opinion or to refer a patient to CHOP, please contact our dedicated referral nurse navigator, Maribeth Magarity, MSN, RN, or complete our Orthopedic Center Referral Nurse Navigator form.
Contact us
Hip Disorders Program