Developmental Dysplasia of the Hip: An Examination of Care Practices of Orthopaedic Surgeons in India

Abstract

Background

We evaluated screening, referral and treatment practices for developmental dysplasia of the hip (DDH) in India by surveying Orthopaedic surgeons who treat patients with DDH. The survey assessed the timing of DDH presentation, resource availability, and current state of screening and diagnosis, which would help in the development of a DDH care pathway for India.

Methods

An online survey was distributed to Orthopaedic surgeons practicing in India via email and administered onsite to those attending the annual conference of the Pediatric Orthopaedic Society of India in 2019.

Results

173 completed surveys were received from surgeons practicing in a predominantly urban setting. 68.8% of respondents had performed initial evaluations on children with DDH aged over 1 year in the past 12 months, and 49.1% had assessed children with DDH aged > 2 years on initial presentation. There was no consistent use of established guidelines, with only 30% of respondents stating that a care pathway was in place at their institution. However, 91.9% would support the implementation of a care pathway developed in India, to decrease the incidence of delayed diagnosis and facilitate earlier intervention. 85% of respondents had ready access to ultrasound scans and 95.4% had access to X-rays.

Conclusions

In India, there is still a large number of late-presenting cases of DDH, which could be improved with effective screening. The development of a care pathway for DDH in India is well-supported by Orthopaedic surgeons and may help decrease the incidence of late presenting cases; potentially improving outcomes, decreasing morbidity, and upskilling local practitioners.

Electronic supplementary material

The online version of this article (10.1007/s43465-020-00233-0) contains supplementary material, which is available to authorized users.

Introduction

Developmental dysplasia of the Hip (DDH) is a common pediatric musculoskeletal condition, affecting 1–2% of all newborns worldwide [1, 2]. The incidence in India is estimated to range from 1.0 to 9.2 per 1000 live births, depending upon the definition used [3–5]. DDH encompasses a wide spectrum; with more severe forms and late presentation being associated with significant morbidity and a higher rate of surgical intervention [6–8]. Untreated DDH may also cause problems such as limp, limb length inequality and premature degenerative arthritis persisting into adulthood, necessitating complex hip reconstructive procedures or replacement at a young age [9]. These surgical procedures are largely preventable with adequate screening and early intervention; yet controversy remains surrounding screening recommendations worldwide due to lack of consensus [9, 10].

There are very few studies from India regarding the incidence [3–5], screening recommendations [11–13] or treatment practices for newborns with DDH. Late presentation of DDH beyond the walking age has been reported [6–8], and the lack of a uniform infant hip screening programme in India has been highlighted in some studies [11–13]. While countries like Austria and Germany have instituted universal ultrasound hip screening in an attempt to reduce the incidence of late-diagnosed cases [14], others like the UK and USA utilize selective ultrasound screening so as to avoid over-treatment of mild cases which may resolve spontaneously [15]. The American Academy of Orthopaedic Surgeons (AAOS) [16] and the American Academy of Pediatrics (AAP) [17] have published guidelines detailing best practices for DDH screening and treatment based on available evidence from the literature. However, the evidence is limited in strength and the guidelines are more relevant to high-income countries. These guidelines may not be applicable to other parts of the world where efficient access to imaging, clinical expertise, and treatment may be more limited [18].

In the absence of uniform and standardized screening guidelines for DDH in India, it was hypothesized that there would be a wide variation in screening, referral and treatment practices for DDH in India. The purpose of this study was to evaluate DDH treatment practices within India by surveying Orthopaedic surgeons who treat children with DDH. The aim of the survey was to assess the timing of DDH presentation, resource availability, the current state of screening and diagnosis across the country, and to determine whether there was any variance between clinical practice and established guidelines. Understanding current screening practices and resource availability in our country would help in the development of evidence-based clinical practice guidelines and a consensus-based uniform DDH care pathway that would be contextually relevant to a resource-limited country like India.

Materials and Methods

An online survey was developed in consultation with Pediatric Orthopaedic surgeons practicing in North America and India, based upon current evidence and recommendations in literature (Online Appendix 1). Similar surveys have been administered in North America, China, and Ecuador; with results from the North American study published recently [19]. The online survey was distributed to members of the Paediatric Orthopaedic Society of India (POSI) via email or administered on-site to those attending the Silver Jubilee Conference of the Pediatric Orthopaedic Society of India in January 2019 (POSICON 2019). Respondents working outside of India or those solely in adult practice were excluded. Study data were collected and managed using the online Research Electronic Data Capture (REDCap) platform hosted at a Canadian hospital-affiliated research institute. Ethics approval was obtained from this institution’s affiliated Research Ethics Board prior to commencement of the study.

The survey comprised of nine main sections: physician demographics; scope of DDH practice; DDH referrals from primary care physicians; awareness and use of existing DDH guidelines; DDH screening practices; utilization of DDH care pathways; availability and utilization of imaging; clinical examples of infant hip abnormalities; and treatment approaches for DDH in infancy. Survey questions aimed to identify existing practice patterns, patient population characteristics, and resource availability for screening and treatment. Additionally, we sought to clarify perceptions regarding the need for the development of a region-specific care pathway to optimize screening, diagnosis, and treatment of DDH. Descriptive statistics were used to analyze survey data using Microsoft Excel (MS Office Version 16.3) software. Categorical variables were reported as frequencies and percentages while continuous data were reported as median (interquartile range).

Results

Physician demographics

From the surveys distributed at POSICON 2019 and via email to POSI members, 173 complete responses were obtained out of 453 potential respondents (38%). Demographics have been summarized in Table 1. Notably, 85.5% (148/173) of respondents practiced in an urban setting and two-thirds were fellowship-trained Orthopaedic surgeons; 79% (93/118) of whom had completed Pediatric Orthopaedic fellowship training. Respondents practiced in a wide range of different facilities—from small centres with no inpatient services to large hospitals with over 1000 beds. Pediatric patients comprised more than 75% of the surgeon’s practice in 35.8% (62/173) of respondents but only up to 20% of a surgeon’s practice in 29.5% (51/173) of respondents. Most respondents were relatively senior with a median of 13 years (IQR 1–53) in practice and two-thirds of the respondents (115/173, 66.5%) managed DDH cases at least monthly.

Table 1.

Demographic attributes of survey respondents

	N (%)
Fellowship trained
Yes	118 (68.2)
No	55 (31.8)
Fellowship
Pediatrics	93 (78.8)
Deformity correction	8 (6.8)
Other	17 (14.4)
Practice setting
Urban	148 (85.5)
Rural	21 (12.1)
Other	4 (2.3)
Median years in practice
Years	13 years [IQR 1, 53]
Total number of beds in facility
< 100	78 (45.1)
100–499	61 (35.2)
500–1000	31 (17.9)
> 1000	9 (5.2)
Unanswered	1 (0.5)
What percentage of your practice is Pediatrics?
0–20	51 (29.5)
21–50	49 (28.3)
51–75	10 (5.8)
76–100	62 (35.8)
How often do you treat patients with DDH?
Once a year	5 (2.9)
Twice a year	44 (25.4)
Once per 2–3 months	1 (0.6)
Once per month	70 (40.5)
Once per week	44 (25.4)
3 times per week	1 (0.6)
Rarely	7 (4)
Unanswered	1 (0.6)

DDH Diagnosis and Referrals

Diagnosis and referral practices are summarized in Table 2. The vast majority of respondents (153/173, 88.4%) diagnosed up to 25 new cases of DDH in the preceding 12 months, while a small number (11, 6.4%) diagnosed greater than 50 cases. In the past 12 months, 68.8% (119/173) of surgeons performed initial evaluations on children with DDH over 1 year of age, and nearly half (85/173, 49.1%) performed an initial DDH assessment for children greater than 2 years of age. More than half the respondents (56.1%, 96/173) believed that primary care physicians (PCPs) were not referring patients with DDH appropriately, with an overwhelming majority (93.8%) reporting under-referral. Two-thirds of the respondents also believed that PCPs were not ordering imaging studies appropriately, with 82.6% of these stating that imaging studies were not ordered frequently enough.

Table 2.

Diagnosis and referral practices among survey respondents

	N (%)
In the past 12 months how many children have you diagnosed with DDH?
< 10	97 (56)
10–25	56 (32.4)
25–30	9 (5.2)
30–50	0 (0)
> 50	11 (6.4)
At what age have you seen patients for an initial DDH referral?*
0–6 weeks	73 (42.2)
6 weeks–3 months	67 (38.7)
3–6 months	48 (27.7)
6–12 months	71 (41)
12–24 months	86 (49.7)
2–5 years	78 (45)
5–10 years	32 (18.5)
Older than 10 years	17 (9.8)
Average patient percentage divided by age
0–6 weeks	27.8
6 weeks–3 months	25.7
3–6 months	24.5
6 months–1 year	26
1–2 years	36.8
2–5 years	31.7
5–10 years	18.2
> 10 years	20.4
Are PCPs referring patients appropriately?
Yes	75 (43.8)
No	96 (56.1)
Why are referrals inappropriate?
Over-referral	6 (6.3)
Under-referral	90 (93.8)
What percent of referred patients are actually diagnosed with DDH?
0–10%	16 (9.2)
11–25%	16 (9.2)
26–50%	36 (20.8)
51–75%	51 (29.5)
76–90%	24 (13.9)
> 90%	27 (15.6)
Unanswered	3 (1.7)
Do you believe PCPs are ordering imaging studies appropriately?
Yes	56 (32.4)
No	115 (66.5)
Unanswered	2 (1.2)
Why are imaging studies inappropriate?
Ordered too frequently	20 (17.4)
Not ordered frequently enough	95 (82.6)

*Physicians were able to select more than one option, resulting in total percentage > 100

PCPs Primary Care Physicians

DDH Screening

Clinical examination was the preferred screening tool by 82.7% of respondents (143/173) as seen in Table 3. A little more than half the respondents (55%, 96/173) utilized USS for screening. The majority of respondents (84.4%, 146/173) believed that clinical screening using the Ortolani and Barlow maneuvers should be performed at each well-baby check, up to 3 months of age. 90% of the respondents were familiar with the Ortolani and Barlow tests and were comfortable performing them.

Table 3.

Attitudes towards screening among survey respondents

	N (%)
Do you screen for risk factors in children < 3 months?
Yes	120 (69.4)
No	48 (27.7)
Unanswered	5 (2.9)
What screening tool do you use?a
Clinical exam	143 (82.7)
Radiographs	63 (36.4)
USS  Other (History)	96 (55.5) 1 (0.6)
Should infants be screened with Ortolani and Barlow maneuvers at each well child check up to 3 months?
Yes	146 (84.4)
No	12 (6.9)
Not sure	8 (4.6)
Unanswered	7 (4)
How familiar are you with Ortolani/Barlow?
Extremely	128 (74)
Moderately	29 (16.8)
Somewhat	6 (3.5)
Slightly	4 (2.3)
Not at all	6 (3.5)
How comfortable are you performing Ortolani/Barlow?
Extremely	117 (67.6)
Moderately	38 (21.9)
Somewhat	8 (4.6)
Slightly	2 (1.2)
Not at all	6 (3.5)
Should infants be screened with hip abduction at each well child from newborn up to walking age?
Yes	146 (84.4)
No	10 (5.8)
Not sure  Unanswered	11 (6.4) 6 (3.5)
Does limited abduction alone warrant further action?
Yes	147 (85)
No	15 (8.7)
Not sure  Unanswered	5 (2.9) 6 (3.5)

^aPhysicians were able to select more than one option, resulting in total percentage > 100

Imaging studies

The availability and interpretation of imaging studies are summarized in Table 4. The majority of respondents (85%, 147/173) had ready access to ultrasound scans (USS), either in their own facility (49.7%) or a short distance away. However, 19% were not confident about the reliability of USS reporting and 38.2% were not comfortable interpreting US scans themselves. The majority of respondents (95.4%, 165/173) had ready access to reliable X-ray imaging and reporting. Two-thirds of the respondents (66%, 114/173) would recommend an X-ray for diagnosis of DDH after the age of 3 months.

Table 4.

Survey respondents’ perspectives regarding availability and use of ultrasound scans (USS) and X-rays for DDH screening

	N (%)
Do you have access to ultrasound scans (USS)?
Yes	147 (85)
No	21 (12.1)
Unanswered	5 (2.9)
Where is the USS?
Own practice	73 (49.7)
Different facility	74 (50.3)
<1 h away	65 (87.8)
1–2 h away	7 (9.5)
> 2 h away	2 (2.7)
Please rate the quality of USS reporting
Very reliable	57 (38.8)
Moderately reliable	62 (42.2)
Somewhat reliable	27 (18.4)
Not reliable	1 (0.7)
How comfortable are you with interpreting USS?
Extremely	35 (20.2)
Moderately	72 (41.6)
Somewhat	33 (19.1)
Slightly	16 (9.2)
Not at all	11 (6.4)
Unanswered	6 (3.5)
What is the earliest age you would perform an X-ray?
< 1 month	16 (9.2)
1–2 months	10 (5.8)
2–3 months	26 (15)
3–4 months	25 (14.5)
4–5 months	29 (16.8)
> 6 months	60 (34.7)
Unanswered	7 (4)
Where is your X-ray access?
Own practice	134 (77.5)
Different facility	32 (18.5)
< 1 h away	24 (75)
1–2 h away	5 (15.6)
> 2 h away	3 (9.4)
Unanswered	7 (4)
Do you have a musculoskeletal radiologist to read the X-ray?
Yes	139 (80.3)
Own Practice Setting	90
Different Facility	49
No	26 (15)
Unanswered	8 (4.6)

DDH Management Guidelines

DDH management responses are summarized in Table 5 and demonstrate that the majority of respondents are aware of the AAOS [16] (135/173, 78.9%) and AAP [17] (96/173, 56.1%) clinical practice guidelines for screening and non-operative management of DDH. However, only 30% (52/173) of surgeons currently have a standard care pathway for DDH in their institution. There was overwhelming support (159/173, 91.9%) for developing screening guidelines and a DDH care pathway specifically for India. Attitudes about screening for DDH based on risk factors varied, but in the setting of a normal clinical exam, 69% (120) of respondents stated that risk factors alone were enough to screen children less than 3 months of age.

Table 5.

Survey respondents’ perspectives regarding DDH management

	N (%)
Do you follow DDH guidelines?a
AAOS#
Aware of	135 (78.9)
Follow	69 (51)
Partially follow	42 (31.1)
AAP#
Aware of	96 (56.1)
Follow	54 (56.3)
Partially follow	28 (29.2)
Does your region/hospital have a standardized care pathway/evaluation protocol?
Yes	52 (30)
No	116 (67.1)
Not Sure	5 (2.9)
Do you think there is a need for a DDH pathway and early screening in India?
Yes	159 (91.9)
No	7 (4)
Not answered	6 (3.5)
What risk factors would warrant radiologic investigations?a
Breech Presentation	154 (89)
Family History of DDH/Hip Instability	113 (65.3)
Incorrect swaddling	64 (37)
Female	82 (47.4)
First Born	67 (38.7)
Otherb	15 (8.7)

^#AAOS American Academy of Orthopaedic Surgeons [16], AAP American Academy of Pediatrics [17]

^aPhysicians were able to select more than one option, resulting in total percentage > 100

^bPhysicians cited: positive clinical findings, hyperlaxity, torticollis, clubfoot, twin births, other associated congenital abnormality/syndrome, calcaneovalgus, metatarsus adductus

Clinical management of DDH

Surgeons were presented with six different clinical scenarios of DDH presentation and were asked to choose the next step(s) they would take (Table 6). 59.5% (103/173) of the respondents would recommend an ultrasound scan and 29.4% (51/173) would elect to start abduction bracing for an isolated Barlow positive hip in a child under 4 weeks of age. Similarly, 39.3% (68/173) of physicians would begin bracing treatment for a 3-month-old patient with mild dysplasia on ultrasound without physical exam findings. Only 11.5% (20/173) of respondents selected the AAOS [16] recommendation of giving a Pavlik harness trial for not more than 3 weeks for an irreducible dislocation.

Table 6.

Clinical management: survey participants were asked to select the next best step(s) in managing patients with various hip abnormalities

	N (%)	AAOS/AAPa recommendation
Positive Barlow, age < 4 weeks*
Continue wellness checks	67 (38.7)	✔
Order an Ultrasound	103 (59.5)	X
Order a pelvic radiograph	16 (9.2)	X
Start conservative hip abduction: e.g. double nappy	37 (21.4)	X
Initiate brace treatment	51 (29.5)	X
Recommend Surgery	0 (0)	X
Refer	2 (1.2)
Positive Ortolani, age < 4 weeks*
Continue wellness checks	66 (38.1)	✔
Order an Ultrasound	110 (63.6)	✔
Order a pelvic radiograph	18 (10.4)	X
Start conservative hip abduction: e.g. double nappy	34 (19.7)	✔
Initiate brace treatment	58 (33.5)	X
Recommend Surgery	0 (0)
Refer	2 (1.2)
Limited Hip Abduction, age < 4 months*
Continue wellness checks	62 (35.8)	✔
Order an Ultrasound	112 (64.7)	✔
Order a pelvic radiograph	46 (26.6)	X
Start conservative hip abduction: e.g. double nappy	22 (12.7)
Initiate brace treatment	32 (18.5)	X
Recommend Surgery	1 (0.6)
Refer	2 (1.2)
Limited Hip Abduction, age > 4 months*
Continue wellness checks	50 (28.9)	✔
Order an Ultrasound	80 (46.2)	X
Order a pelvic radiograph	91 (52.6)	✔
Start conservative hip abduction: e.g. double nappy	25 (14.5)
Initiate brace treatment	40 (23.1)	X
Recommend Surgeryb	6 (34.7)
Mild dysplasia on US without physical exam findings, age = 3 months*
Continue wellness checks	81 (46.8)	✔
Order an Ultrasound	25 (14.5)
Order a pelvic radiograph	35 (20.2)
Start conservative hip abduction: e.g. double nappy	38 (22)
Initiate brace treatment	68 (39.3)	X
Recommend Surgery	0 (0)
Refer	2 (1.2)
How long to use a Pavlik harness or similar device before discontinuing due to failure to reduce?
1 week	7 (4.0)
2 weeks	16 (9.2)
3 weeks	20 (11.5)	✔
4 weeks	30 (17.3)
5 weeks	2 (1.1)
6 weeks	46 (26.5)
3 months	40 (23.1)
4–6 months	4 (2.3)
1 year	2 (1.1)
Unanswered	6 (3.4)

*Physicians were able to select more than one option, resulting in total percentage > 100

^aAAOS American Academy of Orthopaedic Surgeons [16], AAP American Academy of Pediatrics [17]

^bSurgery may be recommended if over age 18 months in the setting of advanced disease

✔: The AAOS and AAP recommend following this course of action, X: The AAOS and AAP recommend against this course of action, Blank spaces: There are no guidelines specifically addressing this option

Discussion

This study clearly supports the premise that there exists a large variability in the diagnosis and management of DDH throughout different healthcare institutions in our country. It also indicates that it would be beneficial to create a standardized care pathway that is specifically sensitive to resource availability in India. While a uniform national hip screening programme is lacking in India, DDH is included among 30 selected health conditions that children between birth to 18 years of age are screened for under the Rashtriya Bal Swasthya Karyakram (RBSK) or National Child Health Program launched in 2013 under the National Health Mission, Ministry of Health and Family Welfare, Government of India [20]. Under this scheme, nine common birth defects, including DDH, are screened at the time of delivery by an auxiliary nurse midwife or medical officer attending the delivery; during post-natal community visits by Accredited Social Health Activist (ASHA) till 6 weeks of age; by mobile block health teams at Anganwadi centres from 6 weeks to 6 years of age; and at Govt. aided schools from 6 to 18 years of age. Referral to the district hospital (DH) or District Early Intervention Centre (DEIC) is recommended for any infant who is positive for two or more of the following risk factors: female, breech presentation at birth, positive family history of DDH, or an abnormal physical exam [20]. Despite this laudable Government initiative, it is uncertain what proportion of India’s infant population actually gets screened as there are currently no uniform clinical practice guidelines or care pathways for DDH screening in India. Furthermore, only 50% of the rural population and just over one-third of the urban population utilize government healthcare services and potentially have access to the RBSK screening initiative [21]. The remaining population is uninsured or serviced by the private healthcare sector, where there is even less uniformity in guidelines for DDH screening.

Currently, there is still a significant number of late-presenting cases of DDH in India that can be minimized with periodic screening [6]. Within the past 12 months, 41% of Orthopaedic surgeons in our survey reported diagnosing DDH in patients between 6 and 12 months of age. More worryingly, over two-thirds of the respondents initially assessed children older than 12 months of age, and about half of the respondents assessed children greater than 2 years of age with DDH. A similar survey of Orthopaedic surgeons practicing in North America showed that this was an issue there too, with 57% having performed an initial assessment for DDH on children older than 12 months; however, their volume of patients at this age tends to be far lower [19]. Our survey respondents indicated their largest volume of DDH patients were in the 1–5 years age range, who are more likely to require extensive surgical procedures and experience long-term morbidity. Our survey also indicates that 56% of Orthopaedic surgeons feel that primary care physicians (PCPs) often under-refer patients with suspected DDH, and when referral does occur, it is frequently without adequate imaging. This finding is in contrast to Orthopaedic surgeons in North America, where 93% of respondents felt PCPs were either referring appropriately or over-referring, and often ordering imaging too frequently [19]. This under-referral in India could be responsible for a proportion of the late-presenting cases and may be due to limited knowledge or restricted access to imaging for some PCPs, particularly those practicing in rural areas.

We hypothesized that the access and quality of ultrasound scans (USS) with skilled reporting would be variable throughout India, considering limited resource availability. However, the majority of respondents (83.8%) had ready access to USS within 2 h of their facility, and half reported access to USS at their own facility. As most respondents reported working in an urban environment (85.5%), it is possible that access to USS in rural areas is not accurately captured by our survey. Interestingly, despite this ready availability of USS, a little more than half the respondents (55%) utilized USS as a screening tool for DDH. Routine ultrasound screening is controversial worldwide, with concern for potential over-diagnosis of DDH due to hip immaturity, leading some to question the efficacy of early USS screening [22]. Multiple studies have suggested that between 6 weeks and 3 months of age, 60–80% of clinically-detected hip abnormalities spontaneously resolve at follow up [23, 24]. Similarly, up to 90% of USS-detected hip abnormalities (Graf IIa) may spontaneously resolve, suggesting treatment at this age may be unnecessary [25–27]. In contrast, other authors have reported an overall reduction in cost and rates of surgical reduction for dislocations when universal USS screening is available [28, 29]. A retrospective review of universal versus selective USS from the United Kingdom showed higher rates of intervention with the universal screening protocol but lower rates of surgery [30]. Similarly, a decision-analysis study [9] comparing (1) no screening, (2) routine screening with USS, and (3) routine screening with clinical examination and selective USS, with the goal of preventing hip arthritis at age 60 years, reported that routine screening with clinical examination and selective USS is the optimum strategy. A recent Turkish study suggests that USS at 8 weeks of age is an ideal time to accurately predict DDH while reducing the risk of false positives, subsequent unnecessary interventions, and parental anxiety [31]. This could represent one approach to cost-effective USS timing in the setting of a normal clinical examination in India.

A normal pelvic radiograph at 4 months of age can reliably exclude DDH and reduce the need for unnecessary treatment [32]. The American College of Radiology has published Appropriate Use Criteria on DDH screening [33], which are in line with AAP recommendations [17] and would support the approach of age-stratified imaging: the use of selective USS from age 4 weeks–4 months, followed by selective radiographic screening in children aged 4 months and older. This would likely be a reliable and accessible screening tool for DDH in India, given that 91% of respondents have easy access to quality radiographs and reporting. Importantly, DDH diagnosed by radiographs at 4 months of age can still be treated with closed reduction and spica casting in the majority of cases, with a decreased need for more invasive procedures such as open reduction and osteotomies which are often required when the diagnosis is delayed to an older age [34].

This survey identified several key findings regarding the variable approach to clinical management of DDH among Orthopaedic surgeons in India. It is estimated that 15–25% of infants with DDH have known risk factors; of which breech presentation, positive family history and female sex have the strongest association [2, 16, 35]. Incorrect hip swaddling, with the hips in adduction and extension, is a lesser-known but important risk factor especially in countries which practice traditional straight-leg swaddling [17, 36]. While the majority of respondents correctly identified breech presentation (89%) and family history (65.3%) as important risk factors for DDH, only 37% were aware of the role of incorrect swaddling as a risk factor for DDH. Despite being aware of the AAOS and AAP clinical practice guidelines for DDH [16, 17], when presented with various clinical scenarios, survey respondents frequently chose responses which were at variance with the accepted recommendations. According to AAOS and AAP guidelines [16, 17], infants < 4 weeks of age with clinically unstable (Barlow positive) hips, and those with mild ultrasound abnormalities but normal physical examination can be safely observed with serial checks and delayed bracing. From the survey responses, there appears to be a tendency to over-treat neonatal hip instability (Barlow positive hips) and infants with mild ultrasound dysplasia but absent physical exam findings with abduction bracing in 29.4% and 39.3% of surgeons respectively. However, 110/173 respondents recommended an ultrasound and 58/173 would initiate brace treatment for a neonate with an Ortolani positive hip, which are correct decisions within current guidelines [16, 17].

Results from this survey of Indian Orthopaedic surgeons further suggest that there is great support amongst surgeons for the development of a DDH care pathway relevant to India, to better facilitate DDH screening and early management. While there appears to be reasonable access to USS and X-ray screening and moderately reliable reporting, there are still a number of late-presenting DDH cases in children who would benefit from early intervention [6]. Efforts are currently underway to bring together Paediatric Orthopaedic surgeons and Primary Care Physicians (PCPs) practicing in India to establish guidelines for a standardized DDH care pathway that can be tailored to the specific availability of resources within the existing healthcare system. This involves bringing together key stakeholders from organizations such as the Paediatric Orthopaedic Society of India (POSI) and the Indian Academy of Pediatrics (IAP), to begin the process of developing screening guidelines and a DDH Care Pathway.

Limitations of this study include potential recall bias, which is inherent to survey-based studies. The majority of respondents practice in an urban setting, while 70% of India’s population lives in rural areas, so the study sample may not be fully representative of Orthopaedic surgeons across all of India. The low rate of respondents from rural areas may have skewed these results, and accessibility in more resource-limited areas of India may be worse than our survey predicts. This may explain why a large number of late-presenting DDH cases are still being diagnosed, despite the majority of survey respondents claiming good access to USS.

Conclusions

In India, there is still a large number of late-presenting cases of DDH, which could be improved with early intervention. The development of a care pathway for DDH in India is well-supported by pediatric orthopaedic surgeons and may help decrease the incidence of late presenting cases—potentially improving outcomes, decreasing morbidity, and upskilling local practitioners.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author Contributions

EKS developed the study, analyzed the data and edited the manuscript. EH and JKW aided in the development of the study. NK and AA aided in data interpretation and manuscript drafting. AA and RN helped adapt the survey for an Indian population and developed the study. EH, JKW, IKT, JFB, and AA aided in data collection, analysis, and manuscript revisions. KS and KM oversaw study completion and data interpretation and advised on the writing of the manuscript.

Funding

This work was partially funded by I’m a HIPpy Foundation, BC Children’s Hospital Research Institute, Pediatric Orthopaedic Society of North America (POSNA), and International Hip Dysplasia Institute (IHDI).

Compliance with Ethical Standards

Conflicts of interest

KM has received research support from Allergan, Pega Medical and Depuy Synthes (Johnson and Johnson). None are directly relevant to the research in this paper. For the remaining authors none were declared.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors

Informed consent

For this type of study informed consent is not required.