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Nair A, Yatsonsky D, Liu J. Comparison of outcomes of different Graf grades of developmental dysplasia of the hip in infants treated with Tubingen splint versus Pavlik harness - A systematic review. J Orthop 2024; 49:68-74. [PMID: 38075458 PMCID: PMC10701362 DOI: 10.1016/j.jor.2023.11.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/19/2023] [Accepted: 11/21/2023] [Indexed: 02/29/2024] Open
Abstract
This systematic review was designed to compare the outcomes of the two braces against each other classified by the Graf method. The databases sources included PubMed, Embase, and Google Scholar. The keywords included "DDH Tubingen versus Pavlik" and Tubingen and Pavlik separately. Included papers provided specific data regarding success and failure rate, avascular necrosis (AVN), duration, and age of intervention. The excluded studies discussed surgeries, diagnosis and mechanism, and ones that weren't in English. Total of 20 papers were included, resulting in 1243 Tubingen and 420 Pavlik samples. It was seen that the Tubingen splint had a statistically significant greater success rate and lower failure rate for Graf 2, D, and 3 hips, while both braces were not very successful for Graf 4 at success rates less than 60 %. Tubingen also had a lower incidence of AVN. Both braces shared similar ages of intervention, duration, and time per day. Both braces are very comparable to each other, each having better success rates for lower Graf grades, which points to the importance of bracing earlier to improve the success rates. The Tubingen splint had a higher success rate, lower failure rate, and lower AVN rate compared to the Pavlik harness. This points to the Tubingen splint potentially being the preferred option for bracing in infants.
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Affiliation(s)
- Ajay Nair
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - David Yatsonsky
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
| | - Jiayong Liu
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, United States
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Tomaru Y, Kamegaya M, Saisu T, Murakami R, Sakuma A, Oikawa Y, Kakizaki J, Segawa Y, Tsukagoshi Y, Kamada H, Yamazaki M. Reapplication of the Pavlik Harness for Treatment of Developmental Dysplasia of the Hip After Initial Pavlik Harness Failure. J Pediatr Orthop 2024; 44:69-75. [PMID: 37981894 DOI: 10.1097/bpo.0000000000002572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVE The Pavlik harness (PH) has been widely used as the standard treatment for infants with developmental dysplasia of the hip (DDH). When the initial application of the PH fails, alternative treatments, such as closed reduction, open reduction, and reapplication of the PH will be considered. Compared with other treatments, reapplication of the PH offers certain advantages, including simplicity and reduced physical, and psychological stress, on both infants and caregivers. This study aims to investigate the effectiveness of reapplying the PH in patients with DDH. METHODS This study included patients with DDH (complete dislocation) who were treated by reapplication of PH between 1988 and 2012. Patients who were able to follow-up for more than 5 years were included. We examined the reduction rate and several factors to identify indicators associated with successful reduction during reapplication, including age, sex, side of hip dislocation, and the presence of the Ortolani sign. At the final follow-up, hip development was assessed using the Severin classification, whereas avascular necrosis (AVN) was evaluated using the Kalamchi classification and the Salter criteria. RESULTS A total of 56 patients (48 females and 8 males) and 57 hips were included in this study. The mean age at first and second application of PH was 4.2 months old (range: 0.12 to 6.4), and 5.8 months old (3.0 to 11.4), respectively. The reduction rate was 49% (28 out of 57 hips). Among the successfully reduced hips, the AVN rate was 3.6% (1 out of 28 hips). The Severin classification revealed 27 hips in class I and 1 hip in class III. Statistical analysis indicated a significantly higher proportion of left hip involvement in the reduction group (85% vs 41%, χ 2 test, P < 0.001). Although not statistically significant, the rate of positive Ortolani sign tended to be higher in the reduction group (61% vs 38%, χ 2 test, P = 0.06). CONCLUSION The reapplication method demonstrated a 49% reduction rate and a low AVN rate of 3.6% in our study. It is worth considering for patients who fail the initial PH treatment, particularly in cases of left-side dislocation and a positive Ortolani sign during the initial application.
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Affiliation(s)
- Yohei Tomaru
- Chiba Child & Adult Orthopaedic Clinic, Chiba
- Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba
| | | | | | - Reiko Murakami
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata
| | - Akitoshi Sakuma
- Department of Orthopaedic Surgery, Chiba Children's Hospital, Chiba
| | - Yasuhiro Oikawa
- Department of Orthopaedic Surgery, Chiba Children's Hospital, Chiba
| | - Jun Kakizaki
- Department of Orthopaedic Surgery, Chiba Children's Hospital, Chiba
| | - Yuko Segawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Tsukagoshi
- Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba
| | - Hiroshi Kamada
- Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba
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Aw AAL, Wong KPL, Lee NKL, Mahadev A. The utility of ultrasound and plain radiographs in the management of developmental dysplasia of the hip. J Pediatr Orthop B 2024; 33:9-15. [PMID: 36943691 DOI: 10.1097/bpb.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The purpose of this study is to assess the utility of follow-up radiological imaging in the management of developmental dysplasia of the hip (DDH) in patients successfully treated with the Pavlik harness. A retrospective review was conducted on all children under 6 months diagnosed with DDH at a tertiary pediatric hospital between January 2004 and December 2018. Inclusion criteria included successful Pavlik harness treatment following a standardized protocol with complete radiological documentation at 2 years of age. Ultrasonography was reviewed to measure the α and β angles and Graf classification. Anteroposterior pelvic radiographs were evaluated for the acetabular index and residual acetabular dysplasia. Seventy-eight hips from 57 infants were included in this study. The mean 6-month, 12-month and 2-year acetabular index of Graf I, IIa and IIc hips on ultrasound at 12 weeks were within the normal range according to age. There were no Graf IIb, IId, III and IV hips. All infants had normal radiographs at 2 years follow-up. The 6- and 12-month residual dysplasia rates in patients with DDH normalization at 12 weeks and 6 months range from 2.5 to 8.82%. Regardless of when the acetabular index normalized, all patients eventually had normal hip radiographs at 2 years of age. Following a standardized protocol, patients undergoing Pavlik harness treatment for DDH with Graf I and IIa hips at 12 weeks are likely to have normal plain radiographs at discharge. The incidence of residual dysplasia is very low and hence, radiographic surveillance is probably unnecessary until discharge at 2 years. Level II, retrospective study.
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Affiliation(s)
- Angeline Ai Ling Aw
- Faculty of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University
| | - Kenneth Pak Leung Wong
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Nicole Kim Luan Lee
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Arjandas Mahadev
- Department of Orthopaedic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Abdulla N, Ashoor M, Heinz N, Alexopoulos V, Majid I, Morakis E, Khamis AH, Alshryda S. Prognostic factors for failed Pavlik harness treatment in infants with developmental dysplasia of the hip: a retrospective cohort study. INTERNATIONAL ORTHOPAEDICS 2023; 47:2337-2345. [PMID: 37170027 DOI: 10.1007/s00264-023-05829-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 04/26/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE Pavlik harness treatment is the most common treatment in newborns diagnosed with developmental dysplasia of the hip (DDH). The success rates and predictors for failure have been debated over the last decade. In this study, we explored our treatment failure rate and potential prognostic factors that could predict the failure of Pavlik harness (PH) treatment in patients with DDH. METHODS Two hundred and sixty-five patients were treated with PH based on the Graf hip types of classification. Age, gender, first born status, family history, foot deformity, plagiocephaly, breech presentation, hip abduction, hip stability, Graf hip type, Galeazzi sign, bilateralism, and femoral nerve palsy were tested as predictors for failure in multivariate logistic regression mode. Success and failure were determined by the normalization of the hip based on the Graf hip classification. RESULTS The failure rate of patients treated with Pavlik harness was 16.6% which is within the reported range of failure rate. The mean age of patients who were successfully treated was 6.73 weeks in comparison to 8.84 weeks for those who failed. Age, plagiocephaly, hip instability, Graf classification, and the development of femoral nerve palsy were found to be predictors for failure of PH treatment upon univariate analysis only. However, only the presence of Galeazzi sign, hip instability, high grades of Graf hip classification, and the development of femoral nerve palsy proved to be independent predictors for failed PH treatment upon multivariate logistic regression analysis. CONCLUSIONS Pavlik harness treatment is a successful treatment with an average success of 83.4%. Several independent predictors for failure of PH treatment have been identified. These include a positive Galeazzi sign, a frankly dislocated hip, Graf types III and IV, and the development of femoral nerve palsy.
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Affiliation(s)
- Nada Abdulla
- Medical School, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates
| | - Maryam Ashoor
- Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | | | | | - Ibrar Majid
- Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | | | - Amar Hassan Khamis
- Medical School, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates
| | - Sattar Alshryda
- Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.
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Li Y, Canavese F, Liu Y, Wu J, Li J, Yuan Z, Xu H. Incidence and risk factors for persistent acetabular dysplasia in patients with developmental dislocation of the hip treated by Pavlik Harness. J Pediatr Orthop B 2023; 32:312-317. [PMID: 35703163 DOI: 10.1097/bpb.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Some patients with developmental dysplasia of the hip (DDH) before 6 months of age successfully treated by Pavlik Harness (PH) still had persistent acetabular dysplasia (PAD). This study aimed to investigate the incidence and risk factors for PAD in patients with DDH treated by PH. We retrospectively reviewed the data of 89 patients (109 hips; mean age, 3.2 ± 1.5 months) with DDH treated by PH. Prior to treatment, all patients underwent ultrasound examination and classified according to Graf's method. PH was terminated once the hip achieved imaging recovery criteria. At final follow-up, the acetabular index (AI), center-edge angle (CEA) of Wiberg were measured on radiograph. Overall, 67/109 hips (61.5%) had successful PH treatment. Among these 67 hips, 58 hips (86.6%) achieved satisfactory outcome, nine (13.4%) had PAD. Age of the patients with PAD (4.3 ± 1 months) was significantly higher than those without PAD (2.8 ± 1.5 months) ( P = 0.001). Hips with PAD had higher mean Graf grade than those with satisfactory outcome ( P = 0.014). Logistic regression-confirmed age and Graf classification were risk factors for PAD. Overall, 55/67 (82.1%) met imaging recovery criteria to stop PH treatment, whereas 12/67 hips (17.9%) did not. The rate of PAD at final follow-up in patients achieving recovery criteria (4/55; 7.3%) was significantly lower than those not achieving it (41.7%) ( P = 0.007). In conclusion, age and Graf classification are risk factors for PAD. If hips are not normal at the end of PH treatment, the risk of PAD increases further.
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Affiliation(s)
- YiQiang Li
- GuangZhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - Federico Canavese
- GuangZhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
- Department of Pediatric Orthopedic Surgery, Jeanne de Flandre Hospital, Lille University Centre, Lille, France
| | - YanHan Liu
- GuangZhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - JianPing Wu
- GuangZhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - JingChun Li
- GuangZhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - Zhe Yuan
- GuangZhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - HongWen Xu
- GuangZhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
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Ghanem I, Karam G, Ghanem D, Saliba I. Femoral nerve palsy during Pavlik harness treatment for developmental dysplasia of the hip is not an indication for harness abandonment. J Child Orthop 2023; 17:205-211. [PMID: 37288053 PMCID: PMC10242367 DOI: 10.1177/18632521231172986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/13/2023] [Indexed: 06/09/2023] Open
Abstract
Objectives The aim of this study was to report the incidence of femoral nerve palsy in developmental dysplasia of the hip children treated with Pavlik harness, to identify any possible associated risk factors, and to evaluate its outcome without any specific strap release. Methods A retrospective chart review was conducted on all cases of femoral nerve palsy in a consecutive series of children who underwent Pavlik harness treatment for developmental dysplasia of the hip. In unilateral cases, the developmental dysplasia of the hip was compared to the contralateral side. All hips with femoral nerve palsy were compared to the remaining hips of the series and any possible risk factor for paralysis was recorded. Results In total, 53 cases of femoral nerve palsy of various severity were identified from a group of 473 children with 527 hips treated for developmental dysplasia of the hip at an average age of 3.9 months. However, 93% occurred during the first 2 weeks of treatment. Femoral nerve palsy was more common in older and larger children with the most severe Tonnis type, and a hip flexion angle in the harness above 90° (p < 0.03 for all). All of them resolved spontaneously before completion of treatment without any specific measures. We found no correlation between the presence of femoral nerve palsy or the time taken for spontaneous resolution and treatment failure using the harness. Conclusion Femoral nerve palsy is most observed with higher Tonnis types and high hip flexion angles in the harness, but its presence by itself is not predictive of treatment failure. It resolves spontaneously before completion of treatment and does not require any strap release or harness discontinuation. Level of evidence Level III.
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Affiliation(s)
- Ismat Ghanem
- Department of Orthopedic Surgery, Hôtel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Geoffrey Karam
- Department of Orthopedic Surgery, Hôtel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Diane Ghanem
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ibrahim Saliba
- Department of Orthopedic Surgery, Hôtel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
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Lankinen V, Helminen M, Bakti K, Välipakka J, Laivuori H, Hyvärinen A. Known risk factors of the developmental dysplasia of the hip predicting more severe clinical presentation and failure of Pavlik harness treatment. BMC Pediatr 2023; 23:148. [PMID: 37004001 PMCID: PMC10064754 DOI: 10.1186/s12887-023-03935-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/27/2023] [Indexed: 04/03/2023] Open
Abstract
PURPOSE Developmental dysplasia of the hip (DDH) varies from mild instability of the hip to subluxation or total dislocation of the joint. Well-known risk factors of DDH include pre-natal breech position, female sex, positive family history, hip side, primiparity and the mode of delivery. Aim of the present study was to further evaluate known risk-factors of DDH, find associations with more severe dysplasia (characterized with Ortolani positivity) and find risk factors of failure of the Pavlik harness treatment. MATERIAL AND METHODS All children with the diagnosis of DDH treated in Tampere University hospital in the years 1998-2018 were retrospectively identified for the study and the data was collected from the medical records. Teratological dislocations (n = 3) were excluded from the analysis. Total of 945 patients were included. RESULTS Breech presentation was strongly associated with Ortolani positivity (p < 0.001). Breech presentation was not associated with ending up for spica casting and/or operative treatment (p = 0.291) despite the association with Ortolani positivity. Ortolani positivity (p = 0.002), positive family history (p = 0.013) and girl sex (p = 0.029) were associated with ending up for spica casting and/or operative treatment. CONCLUSION Breech presentation seems to increase the risk of Ortolani positive DDH. However, these infants are likely to recover with initially started Pavlik harness treatment, as it was not associated with elevated risk for undergoing more robust treatments. Positive family history and girl sex are associated with the most severe cases of developmental dysplasia of the hip, and it may predispose to the failure of the Pavlik harness treatment.
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Affiliation(s)
- Vilma Lankinen
- Department of Pediatric Surgery, Turku University Hospital, Turku, Finland.
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Mika Helminen
- Faculty of Social Sciences, Health Sciences, Tampere University, Tampere, Finland
- Tays Research Services, Tampere University Hospital, Tampere, Finland
| | - Karim Bakti
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Hannele Laivuori
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anna Hyvärinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Surgery, Mehiläinen Länsi-Pohja Oy, Kemi, Finland
- Department of Otorhinolaryngology and Head and Neck Surgery, Oulu University Hospital, Oulu, Finland
- Clinical Medicine Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
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Gou P, Li J, Li X, Shi M, Zhang M, Wang P, Liu X. Clinical features and management of the developmental dysplasia of the hip in congenital muscular torticollis. INTERNATIONAL ORTHOPAEDICS 2022; 46:883-887. [PMID: 34997287 DOI: 10.1007/s00264-021-05279-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE A consistent relationship between CMT and DDH has been established. However, whether the presence of CMT has effect on clinical outcomes of DDH remains unanswered. This study aimed to evaluate clinical features and management of DDH in patients with CMT. METHODS We reviewed the medical records of 54 patients (91 hips) simultaneously diagnosed with DDH and CMT and included 54 patients (97 hips) with only DDH by random number method as the control group. Clinical and examination outcomes were recorded and compared, respectively. RESULTS The mean follow-up was 18.1 ± 14.5 months (range, 2 to 72 mo). In the DDH and CMT group, the age of initial treatment was lower (100.8 ± 92.3 vs. 229.0 ± 157.4 d, P < 0.001), and the rate of male significantly increased (42.6% vs. 11.1%, P < 0.001). Before treatment, development degree of hip was better than that of the DDH group. Therefore, patients with CMT had approximately 14 times greater odds of conservative treatment success than children in the DDH group (OR, 13.84; 95% CI, 3.16 to 60.60). CONCLUSION We concluded that CMT was not the risk factor for the failure of treatment. On the contrary, the identification of CMT may be beneficial to early discovery and treatment of DDH when we remain vigilant to perform physical exam and screen imaging of DDH for patients with CMT.
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Affiliation(s)
- Pan Gou
- Department of Orthopedic, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, No. 136 of Zhong Shan Er Lu, Chongqing, 400014, China
| | - Jun Li
- Department of Orthopedic, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, No. 136 of Zhong Shan Er Lu, Chongqing, 400014, China
| | - Xiang Li
- Department of Orthopedic, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, No. 136 of Zhong Shan Er Lu, Chongqing, 400014, China
| | - Mingyan Shi
- Department of Orthopedic, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, No. 136 of Zhong Shan Er Lu, Chongqing, 400014, China
| | - Man Zhang
- Department of Orthopedic, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, No. 136 of Zhong Shan Er Lu, Chongqing, 400014, China
| | - Peikang Wang
- Department of Orthopedic, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, No. 136 of Zhong Shan Er Lu, Chongqing, 400014, China
| | - Xing Liu
- Department of Orthopedic, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, No. 136 of Zhong Shan Er Lu, Chongqing, 400014, China.
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Imerci A, Rogers KJ, Bhattacharjee A, Bowen JR, Thacker MM. Risk Factors for Failure of Pavlik Harness Treatment in Infants With Dislocated Hips That Are Evaluated by Dynamic Sonography. J Pediatr Orthop 2021; 41:e386-e391. [PMID: 34096546 DOI: 10.1097/bpo.0000000000001799] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Frankly dislocated hips occur in ∼1% to 3% of infants with developmental dysplasia of the hip and are often difficult to treat. In the most severely dislocated hips, the femoral head is positioned outside the posterior/lateral rim of the acetabulum and is irreducible, that is, the femoral head will not reduce by positioning the leg. The purpose of this study was to determine risk factors, using univariate and multivariate analyses, for Pavlik harness failure in infants who initially presented with irreducible/dislocated hips (confirmed by dynamic sonography). METHODS Following institutional review board approval, 124 infants (170 hips) with frankly dislocated hips treated using a Pavlik harness between 2000 and 2018 were evaluated. Patients' demographic characteristics, clinical findings, dynamic sonographic findings (dislocated-fixed vs. dislocated-mobile), age at onset of Pavlik harness treatment, duration of harness usage, and follow-up treatments were recorded. Univariate analyses were used to determine risk factors for treatment failure. RESULTS In frankly dislocated hips (confirmed by dynamic sonography to be positioned outside the posterior/lateral rim of the acetabulum), Pavlik harness treatment was successful in 104 of 170 hips (61%) while it failed in 66 hips. Mean follow-up was 4.86±4.20 years. Univariate analysis determined the risk factors to be onset of treatment after the seventh week of age (P=0.049) and initial mobility (dislocated-fixed group) (P<0.001) by dynamic sonography. In addition, multivariate analysis (P=0.007) showed infants of multigravida mothers (non-firstborn) to be another risk factor for failure. Six percent of hips with no risk factors failed Pavlik harness treatment, those with 1 risk factor had 42% failure, 2 risk factors had 69% failure, and all 3 risk factors had 100% failure. CONCLUSIONS In our patients with frankly dislocated irreducible hips, 39% of hip failed Pavlik harness treatment. Independent multivariate, logistic regression analysis, and multivariate analysis determining the risk factors for failure of Pavlik harness treatment were onset of treatment after the seventh week of age, infants of multigravida mothers, and initial hip mobility (fixed-dislocated hips) by dynamic sonography. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ahmet Imerci
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Kenneth J Rogers
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | | | - James Richard Bowen
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Mihir M Thacker
- Department of Orthopaedic Surgery, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
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Sepúlveda MF, Pérez JA, Saban EA, Castañeda LE, Sepúlveda DF, Birrer EAM. Developmental dysplasia of the hip screening programme in Chile. J Child Orthop 2021; 15:35-41. [PMID: 33643456 PMCID: PMC7907761 DOI: 10.1302/1863-2548.15.200240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Developmental dysplasia of the hip (DDH) encompasses a wide pathological spectrum, from mild acetabular dysplasia to complete congenital hip dislocation at birth. Screening policies have been implemented in an effort to effectively identify and treat patients with DDH. Since 2009 there has been a national DDH programme in Chile. The current study evaluates the results of the programme in patients born between 2010 and 2015. METHODS Records of patients hospitalized from 1st January 2010 to 31st December 2019 were retrieved from national databases. Those born from 1st January 2010 to 31st December 2015 who underwent a procedure for DDH under general anaesthesia during their first five years of life were selected. Sex, first surgical procedure and age at first surgical procedure were analyzed. The incidence of DDH that required major surgical treatment was calculated. RESULTS A total of 961 children born from 1st January 2010 to 31st December 2015 underwent a procedure for DDH during their first five years of life. The number of major procedures was significantly lower than the number of minor procedures (269 vs 692). The incidence of major procedures was 0.18 per 1000 live births. Girls underwent a higher number of procedures than boys (831 vs 130), whereas 39.2% of the boys and 26.2% of the girls had major procedures. The mean age at the time of the first procedure was 15.35 months (sd 10.09; range 0.03 to 55.92 months). CONCLUSION The present study suggests that the Chilean National DDH Screening Program is an appropriate programme with substantial benefits with respect to public health. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Matías F. Sepúlveda
- Universidad Austral de Chile, Valdivia, Chile,Hospital Base de Valdivia, Valdivia, Chile,Correspondence should be sent to Matías F. Sepúlveda, Yungay 773, Depto 501, Valdivia, Chile. E-mail:
| | | | | | - Luis E. Castañeda
- Programa de Genética Humana, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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Abstract
The term ‘developmental dysplasia of the hip’ (DDH) includes a wide spectrum of hip alterations: neonatal instability; acetabular dysplasia; hip subluxation; and true dislocation of the hip. DDH alters hip biomechanics, overloading the articular cartilage and leading to early osteoarthritis. DDH is the main cause of total hip replacement in young people (about 21% to 29%). Development of the acetabular cavity is determined by the presence of a concentrically reduced femoral head. Hip subluxation or dislocation in a child will cause an inadequate development of the acetabulum during the remaining growth. Clinical screening (instability manoeuvres) should be done universally as a part of the physical examination of the newborn. After two or three months of life, limited hip abduction is the most important clinical sign. Selective ultrasound screening should be performed in any child with abnormal physical examination or in those with high-risk factors (breech presentation and positive family history). Universal ultrasound screening has not demonstrated its utility in diminishing the incidence of late dysplasia. Almost 90% of patients with mild hip instability at birth are resolved spontaneously within the first eight weeks and 96% of pathologic changes observed in echography are resolved spontaneously within the first six weeks of life. However, an Ortolani-positive hip requires immediate treatment. When the hip is dislocated or subluxated, a concentric and stable reduction without forceful abduction needs to be obtained by closed or open means. Pavlik harness is usually the first line of treatment under the age of six months. Hip arthrogram is useful for guiding the decision of performing a closed or open reduction when needed. Acetabular dysplasia improves in the majority due to the stimulus provoked by hip reduction. The best parameter to predict persistent acetabular dysplasia at maturity is the evolution of the acetabular index. Pelvic or femoral osteotomies should be performed when residual acetabular dysplasia is present or in older children when a spontaneous correction after hip reduction is not expected. Avascular necrosis is the most serious complication and is related to: an excessive abduction of the hip; a force closed reduction when obstacles for reduction are present; a maintained dislocated hip within the harness or spica cast; and a surgical open reduction.
Cite this article: EFORT Open Rev 2019;4:548-556. DOI: 10.1302/2058-5241.4.180019
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Affiliation(s)
| | | | - Enrique Gil Garay
- Department of Orthopedic Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - Luis Moraleda
- Department of Orthopedic Surgery, Hospital Universitario La Paz, Madrid, Spain
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Yang S, Zusman N, Lieberman E, Goldstein RY. Developmental Dysplasia of the Hip. Pediatrics 2019; 143:peds.2018-1147. [PMID: 30587534 DOI: 10.1542/peds.2018-1147] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 11/24/2022] Open
Abstract
Pediatricians are often the first to identify developmental dysplasia of the hip (DDH) and direct subsequent appropriate treatment. The general treatment principle of DDH is to obtain and maintain a concentric reduction of the femoral head in the acetabulum. Achieving this goal can range from less-invasive bracing treatments to more-invasive surgical treatment depending on the age and complexity of the dysplasia. In this review, we summarize the current trends and treatment principles in the diagnosis and treatment of DDH.
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Affiliation(s)
- Scott Yang
- Department of Orthopedics and Rehabilitation, Doernbecher Children's Hospital and Oregon Health and Science University, Portland, Oregon; and
| | - Natalie Zusman
- Department of Orthopedics and Rehabilitation, Doernbecher Children's Hospital and Oregon Health and Science University, Portland, Oregon; and
| | - Elizabeth Lieberman
- Department of Orthopedics and Rehabilitation, Doernbecher Children's Hospital and Oregon Health and Science University, Portland, Oregon; and
| | - Rachel Y Goldstein
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, California
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Abstract
From 2009 to 2015, 15 infants with a congenital dislocation of the hip were treated with closed reduction under anaesthesia, after first being treated with Pavlik bandaging. A retrospective study was carried out with a minimum follow-up of 1 year to assess the success rate of the procedure and predictive factors. Twelve out of 15 (80%) patients achieved successful reduction. In the successful cases, the Barlow test was positive and the safe zone was 20° or more. In the unsuccessful cases, there was a negative Barlow present in the outpatient clinic and the safe zone was less than 20°. These three cases all had teratologic comorbidity, and required additional surgery in the form of open reduction. Avascular necrosis was noted in one out of 15 (6.7%) patients. In nonteratologic hips, a positive Barlow test with a safe zone of 20° is predictive of a successful closed reduction. In these patients, anaesthesia and arthrography might not be necessary.
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Ömeroglu H. Treatment of developmental dysplasia of the hip with the Pavlik harness in children under six months of age: indications, results and failures. J Child Orthop 2018; 12:308-316. [PMID: 30154920 PMCID: PMC6090187 DOI: 10.1302/1863-2548.12.180055] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of this article is to review the current concepts in the indications, results and failure causes of the treatment of developmental dysplasia of the hip (DDH) with the Pavlik harness. METHODS The reported variables influencing the outcome in the Pavlik harness treatment were analyzed. RESULTS Significant discrepancies about the clinical and radiological outcomes, the rates of failure and complications as well as the variables influencing the treatment outcome occur in the published studies due to the heterogeneity of the data and the differences in the methods used. The overall short-, mid- or long-term success rate of the treatment ranges from 45% to 100% and it is commonly over 75%. The rate of osteonecrosis of the femoral head ranges from 1% to 30%. Age, gender, laterality, radiological or clinical severity of the initial hip pathology and parents' compliance are the commonly reported determinants of failure of the treatment. CONCLUSION The failure in treatment with the Pavlik harness is multifactorial, initial type of hip dysplasia being the most prominent followed by the treatment initiation age. This type of treatment cannot be considered as the best option in Graf IV hips (hip ultrasonography) or highly dislocated hips (plain radiography) and in infants older than three months of age, as the risk of failure and development of complications including osteonecrosis and femoral nerve palsy seem to increase in such circumstances. Large-scale, comparative studies including homogenous data are needed to answer the unsolved questions concerning indications.
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Affiliation(s)
- H. Ömeroglu
- Department of Orthopaedics and Traumatology, TOBB University of Economics and Technology, Faculty of Medicine, Ankara, Turkey, Correspondenceshould be sent to H. Ömerog˘lu, TOBB University of Economics and Technology Hospital, Yasam Caddesi No:5, Sögütözü, Ankara, Turkey. E-mail:
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