Frequently Asked Questions: Independent Audit on Hip Surgery Thresholds for Children with Developmental Dysplasia of the Hip(DDH)

The DDH Parent Information Line is open for families who have queries following this audit’s publication: 

Freephone 1800 807 050 (or call 00 353 1 240 8706 from outside Ireland).

• Open Monday to Friday 8am – 8pm
• Open Saturday and Sunday 9am – 5pm

• Why did this audit happen?

The audit was prompted following a protected disclosure, which raised concerns that CHI at Crumlin, CHI at Temple Street and NOHC may have used differing criteria to determine whether DDH surgery was required.

In July 2024, CHI and NOHC confirmed they would undertake a joint clinical audit to examine a random and anonymised sample of DDH surgeries performed between 2021 and 2023. The clinical audit was conducted by a UK paediatric orthopaedic consultant with specialist expertise in this area and is now complete.

• What did the audit find?

The audit reviewed 147 random and anonymous cases across the three hospitals. Based on criteria that had been retrospectively applied for the purpose of the audit, it found:

• Thresholds for recommending pelvic osteotomy procedures varied between CHI at Crumlin, CHI at Temple Street and The National Orthopaedic Hospital in Cappagh. Based on the criteria that had been retrospectively applied for the purpose of the audit, the auditor raised concerns about the indications for surgery in many cases in CHI at Temple Street and NOHC. 

This group of patients will be contacted directly to explain what this means and the next steps for them.

• Children who had surgery at CHI at Crumlin were found to have been appropriately selected for surgery based on the current international standards used by the auditor.
• Regrettably the audit identified one case from the review sample where a child experienced complications due to the surgical approach recommended to them. This family has been contacted and supported through an open disclosure process. 
• What does “thresholds for surgery” mean?

A “threshold” refers to the clinical criteria or a set of standards and medical tests used to decide whether surgery is needed. This includes X-ray findings, the child’s symptoms, age, and overall hip development.

• Why would thresholds be different at different hospitals?

Differences in decision-making may arise from a surgeon's clinical judgement, local practices, surgical education and experience.

Surgeons in CHI at Temple Street and NOHC were using a less-invasive DDH surgical technique, when compared to traditional methods, and were using different thresholds for DDH surgery based on this.

It is important now that we align surgical decision-making across all sites.

• Does this variation mean that some surgeries were unnecessary? 

This is not directly answered in the audit. However, As the reviewer indicates in the report (page 15), the high percentage of pelvic osteotomies that do not reach the criteria he used in the review at CHI at Temple Street and NOHC mandates further enquiry.  All patients will be reviewed and followed up as per the recommendations (outlined in Question 11).

• What are the consequences of a child having unnecessary DDH surgery?

This depends on an individual patient’s circumstance. The routine reviews will establish more information for your child and will continue intermittent reviews until your child’s bones are fully developed (skeletal maturity). If you have concerns about your child in this regard, please speak to your medical team about them.

• What is skeletal maturity?

Skeletal Maturity is a measure of bone development. It is an approximation, but girls tend to reach skeletal maturity at 12 years old, and boys at 14 years old. For the purpose this follow-up review to skeletal maturity, these age groups will be used as the framework.

• Did the audit find that any of the audited surgeries were wrong or harmful?
  

Regrettably, the audit identified one case from the review sample where a child experienced complications due to the surgical approach recommended to them. This family has been contacted and supported through an open disclosure process.

• My child had DDH surgery in CHI at Crumlin, was their surgery necessary?

Children who had surgery in CHI at Crumlin were found to have been appropriately selected for surgery based on the current standards used by the auditor. Children's Health Ireland will write to these families to confirm this information. These children will then continue in their normal follow up processes, including follow up to skeletal maturity.

• My child had DDH surgery in CHI at Temple Street or National Orthopaedic Hospital Cappagh, was their surgery necessary? 

The HSE will commission a review, which will be undertaken by an external panel of experts, to examine patients who underwent DDH surgery to determine if their surgery was necessary. This will be offered on an opt-in basis, and parents of patients who do not opt-in will have the offer of a HSE-funded appointment with an alternative expert.

• My child is due to have DDH surgery soon, will they be safe?

All patients who require DDH surgery currently and in the future will be discussed at a cross-hospital, pre-operative, multidisciplinary team meeting. Experts at this meeting will decide on the best course of treatment for your child.

• What happens next?

The auditor made a number of recommendations, which are fully accepted and will be implemented across CHI and NOHC:

• All patients in all three hospitals will receive periodic appointments to attend the hospital for assessment until your child’s bones are fully developed.
• A multidisciplinary team is being established to review the relevant cohorts of patients who underwent surgery in CHI at Temple St and NOHC. This will include radiological assessment with oversight from independent Consultant Orthopaedic Surgeons. We will contact families to arrange an appointment. The purpose of this review is to ensure patients are doing well following surgery.  Should any concerns be identified during this appointment, we will discuss them with you and recommend a suitable course of action.
• The HSE will commission a review, which will be undertaken by an external panel of experts, to examine patients who underwent DDH surgery to determine if their surgery was necessary. This will be offered on an opt-in basis, and parents of patients who do not opt-in will have the offer of a HSE-funded appointment with an alternative expert.
• Any complications identified during the follow-up reviews will be acknowledged, discussed with families, and appropriate action will be taken. Families will be involved in a thorough and transparent discussion of decision making, including risks and benefits, in order to make informed decisions for their child.
• Surgeons across all sites will work together and make decisions using shared, evidence-based criteria. External experts have been appointed to guide this work, and cross-site multidisciplinary meetings are in place.

Will my child’s surgery be reviewed?

• All patients in all three hospitals will receive periodic appointments to attend the hospital for assessment until your child’s bones are fully developed.
• A multidisciplinary team is being established to review the relevant cohorts of patients who underwent surgery in CHI at Temple St and NOHC. This will include radiological assessment with oversight from independent Consultant Orthopaedic Surgeons. We will contact families to arrange an appointment. The purpose of this review is to ensure patients are doing well following surgery.  Should any concerns be identified during this appointment, we will discuss them with you and recommend a suitable course of action.
• The HSE will commission a review, which will be undertaken by an external panel of experts, to examine patients who underwent DDH surgery to determine if their surgery was necessary. This will be offered on an opt-in basis, and parents of patients who do not opt-in will have the offer of a HSE-funded appointment with an alternative expert.

You will be contacted by the relevant hospital in the coming days in relation to scheduling your child’s follow-up appointment(s). However, if you would like further information, please do not hesitate to use the DDH Parent Information Line.

• What should I do if I’m worried about my child’s care?

The DDH Parent Information Line is open for families who have queries following this audit’s publication:

Freephone 1800 807 050 (or call 00 353 1 240 8706 from outside Ireland).

Open Monday to Friday 8am to 8pm and Saturday and Sunday 9am to 5pm.

If you have clinical concerns about your child, please contact your GP or medical team directly.

• Can my child be seen soon?

In addition to your intermittent follow-up, you will receive a letter for a multidisciplinary assessment with oversight from an independent orthopaedic surgeon to ensure your child is doing well.

• Can I see a different surgeon at my child’s next appointment?

Yes, the option for a second opinion is available to you. You will need to request this when we contact you with your appointment.

• Will CHI change how DDH is treated going forward?

There are different types of DDH and different types of treatment. You can find more information and guides to DDH, non-operative treatments, and surgical treatments on www.childrenshealthireland.ie/DDH .

Surgery is one type of treatment. A key recommendation (which we accept and are progressing) is that there should be a cross-hospital, pre-operative, multidisciplinary team meeting where each DDH surgical case is discussed. We are working with national and international experts to help guide this process and our continued improvement.

• What is CHI doing to prevent varying practices in other areas?

We are working to unify care standards and strengthen clinical governance as part of our full integration into the new national children’s hospital. This includes regular multidisciplinary meetings, shared decision-making tools, and transparent processes across all hospital sites.

• I have questions regarding how CHI processes my child’s personal data. Where can I find information? 

Please see the information provided in the CHI Privacy Policy. Any data protection related queries can be submitted to the DPO via DPO@childrenshealthireland.ie.

For NOHC patients, please see www.nohc.ie.

• How can I request a copy of my child’s medical files?

Please see: Healthcare record and personal data requests | Children's Health Ireland.

For NOHC patients, please see www.nohc.ie .