To the Editor: We read with interest the review by Farrell et al1 regarding modifications to paediatric orthopaedic practice which may be necessary in the context of the COVID-19 pandemic. We particularly wish to focus on their comments regarding developmental dysplasia of the hip (DDH).
We write on behalf of the International Interdisciplinary Consensus Committee on DDH Evaluation, a recently formed organisation of specialists concerned with the early detection and treatment of DDH, and the promotion and teaching of the Graf method of infant hip ultrasonography.2,3
We note that our colleagues in Australia and Canada propose to “postpone assessment and treatment of DDH for the next 2 to 4 months.” We fully understand and share the concerns that lie behind this proposal. Indeed some of our own members are located in some of the centers in Europe which have been worst affected by the pandemic.
However, we feel some points are worthy of note.
First, as of now, we do not know if circumstances will be any more favorable in 2 to 4 months' time. Indeed, some point out that the COVID-19 event still has a long way to run, and restrictions may have to continue for many months and/or until a vaccine is developed.4
Although good outcomes can of course be achieved for children who present late with DDH, early treatment is associated with the best results, including the avoidance of late and often complex surgery.5,6 Even in the context of early, closed treatment, time is of the essence. Pavlik harness treatment for example, has been shown to be less effective over the age of 4 months.7 Therefore, a decision to defer the treatment of 2 to 4 months, let alone a longer period of time, cannot be taken lightly.
The authors rightly raise concerns about the dangers involved in bringing small children into the acute hospital setting at this time. In the case of some of our own members, assessment and early closed treatment of DDH occurs outside such settings, for example, in community-based clinics; in the cases of others, the process has been moved out of the acute hospital to a community setting for the duration of the crisis. In any case, however, only a single parent/legal guardian/accompanying person should be allowed along with the child. We suggest that this may provide an answer to this concern; of course, all necessary precautions must be observed.
We realise that circumstances in every centre are different, and at this time, it behoves all of us to be mutually helpful. We hope our comments will encourage colleagues, where local circumstances permit, to continue efforts as far as possible in detection and treatment of DDH.
Finally, we agree with the authors that at a later stage there will be a need for research into the impact which the pandemic has had on paediatric orthopaedic outcomes—which of course includes DDH.
References printed in bold type are those published within the past 5 years.
1. Farrell S, Schaeffer EK, Mulpuri K: Recommendations for the care of pediatric orthopaedic patients during the COVID-19 pandemic. J Am Acad Orthop Surg 2020;28:e477-e486.
2. Graf R: Hip sonography: Background; technique and common mistakes; result; debate and politics; challenges. Hip Int 2017;27:215-219.
3. O'Beirne J, Chlapoutakis K, Alshryda S, et al.: International interdisciplinary consensus meeting on the evaluation of developmental dysplasia of the hip. Ultraschall Med 2019;40:1-11.
4. Hanage W. “No matter how you crunch the numbers, this pandemic is only just getting started”. The Guardian, 2020. Available at: https://www.theguardian.com/commentisfree/2020/apr/16/number-coronavirus-pandemic
. Accessed Apr 27 2020.
5. Biedermann R, Riccabona J, Giesinger JM, et al.: Results of universal ultrasound screening for developmental dysplasia of the hip: A prospective follow-up of 28,192 consecutive cases. Bone Joint J 2018;110-B:1399-1404.
6. Thalinger C, Pospischill R, Ganger R, Radler C, Krall C, Grill F: Long-term results of a nationwide general ultrasound screening system for developlental disorders of the hip: The Austrian hip screening program. J Child Orthop 2014;8:3-10.
7. Omeroglu H, Kose N, Akceylan A: Success of pavlik harness treatment decreases in patients ≥ 4 months and in ultrasonographically dislocated hips in developmental dysplasia of the hip. Clin Orthop Relat Res 2016;474:1146-1152.