The Authors' Reply: We thank these readers for their thoughtful response to our recent publication1 regarding modifications to pediatric orthopaedic practice that may be necessary to balance the health and safety of patients, families, and healthcare providers during the coronavirus disease 2019 (COVID-19) pandemic.
We appreciate the thorough review and points of discussion these readers raised and would like to address their concerns with specific regard to our recommendations involving the management of patients with developmental dysplasia of the hip (DDH).
At the outset of the pandemic in North America, our tertiary pediatric care center, similar to several centers in Australia, made the decision to defer all appointments for DDH in the Orthopaedic Clinic for an estimated 2 to 3 months. This decision was made based on both observations and advice from orthopaedic surgeons practicing in locations impacted early by COVID-19, including Italy and Singapore, as well as a modeling study assessing the potential for viral transmission between patients and families and healthcare providers should continue treatment.2
These readers justifiably raise concerns about delaying DDH treatment, particularly in the case of complete dislocations. They posit that we are likely to be continuing to battle COVID-19, to some extent, for many months to come. We recognize these valid concerns, especially as it is known that early detection and treatment of DDH is important for optimal outcomes. However, findings from the International Hip Dysplasia Institute (IHDI) have demonstrated a 79% success rate with Pavlik harness in infants up to 6 months of age3 as well as a 91% success rate of closed reduction in infants at a median 8 months of age.4 These findings do not refute the importance of early detection and treatment, but they do suggest that harness or closed reduction can still be successful in many children under 1 year of age.
Our recommendations were formed in the early stages of the pandemic when the world was observing the devastation COVID-19 was wreaking on the Italian healthcare system. Potential shortage of adequate personal protective equipment was also of global concern as centers in yet-to-be heavily impacted regions rushed to prepare. In that context, taken with the IHDI findings, we felt it reasonable to suggest a deferral of these patients for a temporary period at the height of the first COVID-19 wave.
We agree with the concern that continuing to defer treatment beyond that initial period of delay would likely cause the risks of long-term impact on the patient's quality of life to outweigh the benefits of reducing potential viral transmission. Every effort should be made to resume at limited capacity, detection, and treatment of DDH once the height of the first wave subsides. The readers make excellent suggestions regarding shifting the initial assessment for DDH from acute hospital settings to community settings where possible. We agree that this could present a potential solution in certain locations but may not be possible depending upon individual local resources and capacity.
Again, we wish to thank these readers for their important addition to this discourse. Approaches to care and management of pediatric orthopaedic patients will need to be adaptable throughout different phases of the pandemic, and the global pediatric orthopaedic community can come together to continue to support each other and provide creative and flexible solutions to confront these extraordinary challenges.
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. Schaeffer EK, Bone JN, Mulpuri K: Do no harm: Considerations for pediatric orthopaedic practice during the coronavirus pandemic. JAAOS Glob 2020;4:e20.
3. Upasani VV, Bomar JD, Matheney TH, et al.: Evaluation of brace treatment for infant hip dislocation in a prospective cohort. J Bone Joint Surg Am 2016;98:1215-1221.
4. Sankar WN, Gornitzky AL, Clarke NM, et al.: Closed reduction for developmental dysplasia of the hip. J Pediatr Orthop 2019;39:111-118.