title: What Risk Factors and Characteristics Are Associated With Late-presenting Dislocations of the Hip in Infants?
abstract: BACKGROUND
  Most infants with developmental dysplasia of the hip (DDH) are diagnosed within the first 3 months of life. However, late-presenting DDH (defined as a diagnosis after 3 months of age) does occur and often results in more complex treatment and increased long-term complications. Specific risk factors involved in late-presenting DDH are poorly understood, and clearly defining an associated set of factors will aid in screening, detection, and prevention of this condition.
  
  
  OBJECTIVE
  Using a multicenter database of patients with DDH, we sought to determine whether there were differences in (1) risk factors or (2) the nature of the dislocation (laterality and joint laxity) when comparing patients with early versus late presentation.
  
  
  METHODS
  A retrospective review of prospectively collected data from a multicenter database of patients with dislocated hips was conducted from 2010 to 2014. Baseline demographics for fetal presentation (cephalic/breech), birth presentation (vaginal/cesarean), birth weight, maternal age, maternal parity, gestational age, family history, and swaddling history of patients were compared among nine different sites for patients who were enrolled at age younger than 3 months and those enrolled between 3 and 18 months of age. A total of 392 patients were enrolled at baseline between 0 and 18 months of age with at least one dislocated hip. Of that group, 259 patients were younger than 3 months of age and 133 were 3 to 18 months of age. The proportion of patients with DDH who were enrolled and followed at the nine participating centers was 98%.
  
  
  RESULTS
  A univariate/multivariate analysis was performed comparing key baseline demographics between early- and late-presenting patients. After controlling for relevant confounding variables, two variables were identified as risk factors for late-presenting DDH as compared with early-presenting: cephalic presentation at birth and swaddling history. Late-presenting patients were more likely to have had a cephalic presentation than early-presenting patients (88% [117 of 133] versus 65% [169 or 259]; odds ratio [OR], 5.366; 95% confidence interval [CI], 2.44-11.78; p < 0.001). Additionally, late-presenting patients were more likely to have had a history of swaddling (40% [53 of 133] versus 25% [64 of 259]; OR, 2.053; 95% CI, 1.22-3.45; p = 0.0016). No difference was seen for sex (p = 0.63), birth presentation (p = 0.088), birth weight (p = 0.90), maternal age (p = 0.39), maternal parity (p = 0.54), gestational age (p = 0.42), or family history (p = 0.11) between the two groups. Late presenters were more likely to present with an irreducible dislocation than early presenters (56% [82 of 147 hips] versus 19% [63 of 333 hips]; OR, 5.407; 95% CI, 3.532-8.275; p < 0.001) and were less likely to have a bilateral dislocation (11% [14 of 133] versus 28% [73 of 259]; OR, 0.300; 95% CI, 0.162-0.555; p = 0.002).
  
  
  CONCLUSIONS
  Those presenting with DDH after 3 months of age have fewer of the traditional risk factors for DDH (such as breech birth), which may explain the reason for a missed diagnosis at a younger age. In addition, swaddling history was more common in late-presenting infants. A high index of suspicion for DDH should be maintained for all infants, not just those with traditional risk factors for DDH. Further investigation is required to determine if swaddling is a risk factor for the development of hip dislocations in older infants. More rigorous examination into traditional screening methods should also be performed to determine whether current screening is sufficient and whether late-presenting dislocations are present early and missed or whether they develop over time.
  
  
  METHODS
  Level III, retrospective study.
authors.affiliation: Department of Orthopaedics, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada. kmulpuri@cw.bc.ca.|Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, BC, Canada. kmulpuri@cw.bc.ca.
authors.forename: Kishore
authors.initials: K
authors.lastname: Mulpuri
authors.affiliation: Department of Orthopaedics, University of British Columbia, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada.|Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, BC, Canada.
authors.forename: Emily K
authors.initials: EK
authors.lastname: Schaeffer
authors.affiliation: Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, BC, Canada.
authors.forename: Janice
authors.initials: J
authors.lastname: Andrade
authors.affiliation: Children's Hospital of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Wudbhav N
authors.initials: WN
authors.lastname: Sankar
authors.affiliation: Women's and Children's Hospital, North Adelaide, Australia.|Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, Australia.
authors.forename: Nicole
authors.initials: N
authors.lastname: Williams
authors.affiliation: Boston Children's Hospital, Boston, MA, USA.
authors.forename: Travis H
authors.initials: TH
authors.lastname: Matheney
authors.affiliation: Rady Children's Hospital, San Diego, CA, USA.
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Mubarak
authors.affiliation: Women's and Children's Hospital, North Adelaide, Australia.|Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, Australia.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Cundy
authors.affiliation: Arnold Palmer Medical Center, Orlando, FL, USA.
authors.forename: Charles T
authors.initials: CT
authors.lastname: Price
mesh_terms: D000367:Age Factors; D001512:Bedding and Linens; D016208:Databases, Factual; D057210:Delayed Diagnosis; D005260:Female; D006618:Hip Dislocation, Congenital / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D006621:Hip Joint / Q000503:physiopathology*; D006801:Humans; D007223:Infant; D007224:Infant Care / Q000379:methods; D007746:Labor Presentation; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011247:Pregnancy; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors