Letter to the Editor: “Developmental dysplasia of the hip in the context of the COVID-19 pandemic”
by Joseph O’Beirne, Maurizio De Pellegrin, Carolina Casini, Kostantinos Chlapoutakis, Ustun Aydingoz, Beat Dubs, Apostolos Karantanas (email@example.com)
We write on behalf of the International Interdisciplinary Consensus Committee on DDH Evaluation (ICODE), a recently formed organisation of specialists concerned with the early detection and treatment of DDH, and the promotion and teaching of Graf’s sonographic technique, for the diagnosis and guidance of treatment of DDH [1, 2].
In the context of the COVID-19 pandemic, we understand and share the concerns which lie behind temporary postponement of assessment and treatment of DDH, as has been published recently  or has been proposed by National/Local Health Authorities. However, despite the fact that some of our own members are located in the European centres which have been worst affected by the pandemic, we fear that discontinuation of existing DDH screening policies, and deferral of early treatment of DDH, could be catastrophic and with unpredictable consequences.
Firstly, as of now, we do not know if circumstances will be any more favourable within a reasonable time frame. 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 .
While good outcomes may, of course, still be achieved for children who present late with DDH, early detection – leading to early treatment – is associated with the best results, including the avoidance of late, and often complex surgery [5, 6]. 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 , and Tübinger harness treatment, is very effective when applied during early infancy . Therefore, a decision to defer treatment for a few weeks or months, should not be taken lightly.
Considering concerns about the dangers involved in bringing small children into the acute hospital setting at this time, an effective solution might be offered by the assessment and early closed treatment of DDH outside such settings, e.g. in community-based clinics or outpatient settings; the process might also be moved out of the acute hospital to a community setting for the duration of the crisis. There might be other more practical solutions, depending on the local circumstances and facilities. In any case, however, all necessary precautions must be observed, in accordance with the local guidance or international scientific recommendations.
According to the currently available evidence  and recommendations [10, 11], specific precautions should be taken when performing sonographic examinations. Special precautions for the planning, preparation and performance of hip sonographic examination should include:
• Careful screening for clinical symptoms/history of COVID-19 using standardized checklists, both before arrival to the ultrasound unit (telephone) and at arrival, by trained personnel.
• Careful scheduling of the scans, with widened scan intervals, aiming to receive the next scan, after the previous has departed the waiting room.
• Only one parent/legal guardian/relative is allowed to enter the examination room with the baby.
• Thorough cleaning of the examination cradle, the probe handle and the baby changing table each morning and after each scan.
• Use of disposable cradle and changing table covers, which should be removed with gloved hands, folded and disposed of, immediately at the end of each examination.
• Use of PPE according to local/national guidelines.
• The use of at least a surgical mask, both for the examiner and the parent/legal guardian/accompanying relative, is strongly recommended. The examiner should also wear an apron, disposable examination gloves and goggles for any patient contact closer than 1 metre.
• Strict hand hygiene, and the use of disposable examination gloves, is mandatory.
We realise that local circumstances may differ significantly, 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.
We agree with the proposal that, at a later stage, there will be a need for research into the impact which the pandemic has had on pediatric orthopedic outcomes . However, in the case of DDH, it is preferable to intervene early, than to harvest the consequences of non-intervention (which may include permanent disability, with heavy social impact).