This paper by Jaiswal et al provides further evidence that the change in terminology from CDH (congenital dislocation or dysplasia of the hip) to DDH (developmental dislocation, displacement or dysplasia of the hip) was correct, as proposed by Klisic in 1989.1 The term congenital implies the pathology is present at birth, while this paper provides a well documented case of normal clinical examination of the hips and normal static ultrasound examination, with later development of a hip dislocation. The case thus provides support for comments in the literature such as : “…not all cases of clinically evident dislocation or subluxation are necessarily preceded by neonatal instability”,2 and “following competent newborn and infant hip examinations, this situation (diagnosis of hip dislocation at a later age) is likely representative of a late-onset dislocation, rather than a “missed” hip dislocation present at birth.”3
Jones et al2 noted that the term “missed dislocation” should be discouraged, and also that late dislocation will never be abolished because of the nature of the condition. Indeed, infant hip screening by experienced surgeons,4,5 as well as more recent studies of ultrasound screening for DDH, with large numbers of patients,6,7 has shown that late-presenting cases of DDH are not eliminated by screening or surveillance programs. The current incidence of late-onset hip dislocation has been estimated at 1 in 5000 children by Schwend et al.3
There has been some controversy about the role of screening for DDH and the benefits of routine clinical and ultrasound examination of infants.2,3 The addition of this case to those reported by Rafique et al8 and Gwynne Jones et al9 provides further support for at least continuing hip examinations through early childhood, as earlier diagnosis of DDH leads to less complicated and more successful treatment. This paper also has important medicolegal implications, as it documents the development of a hip dislocation in a female with no other risk factors and a stable clinical hip examination at multiple time points early in life by experienced examiners, unlike those reported in other cases of late-onset dislocation following normal static ultrasound examinations.8,9 The children reported by those studies either had an unstable clinical hip examination at some time early in life, or had other risk factors for DDH. The addition of a dynamic ultrasound examination would make this report stronger, but was not performed in this case.
Late-onset developmental dislocation of the hip can occur, and can be seen following a stable newborn/infant hip examination and a normal static ultrasound examination.
1. Klisic PJ. Congenital dislocation of the hip--a misleading term: brief report. J Bone Joint Surg [Br] 1989B;71-B:136.
2. Jones D, Dezateux CA, Danielsson LG, Paton RW, Clegg J. At the crossroads--neonatal detection of developmental dysplasia of the hip. J Bone Joint Surg [Br] 2000;82-B:160-4.
3. Schwend RM, Schoenecker P, Richards BS, Flynn JM, Vitale M. Screening the newborn for developmental dysplasia of the hip: now what do we do? J Pediatr Orthop 2007;27:607-10.
4. Gross RH, Wisnefske M, Howard TC, III, Hitch M. The Otto Aufranc Award Paper. Infant hip screening. Hip 1982:50-67.
5. Ilfeld FW, Westin GW, Makin M. Missed or developmental dislocation of the hip. Clin Orthop 1986:276-81.
6. Holen KJ, Tegnander A, Bredland T, Johansen OJ, Saether OD, Eik-Nes SH, Terjesen T. Universal or selective screening of the neonatal hip using ultrasound? A prospective, randomised trial of 15,529 newborn infants. J Bone Joint Surg [Br] 2002;84-B:886-90.
7. Rosendahl K, Markestad T, Lie RT. Ultrasound screening for developmental dysplasia of the hip in the neonate: the effect on treatment rate and prevalence of late cases. Pediatrics 1994;94:47-52.
8. Rafique A, Set P, Berman L. Late presentation of developmental dysplasia of the hip following normal ultrasound examination. Clin Radiol 2007;62:181-4.
9. Gwynne Jones DP, Dunbar JD, Theis JC. Late presenting dislocation of sonographically stable hips. J Pediatr Orthop B 2006;15:257-61.
Frick SL, MD, Residency Program Director
Carolinas Medical Center Department of Orthopaedic Surgery, Charlotte, North Carolina, USA