Difficult-to-treat Ortolani-positive hip: improved success with new treatment protocol

Defining the Incidence of Residual Acetabular Dysplasia After Successful Reduction With a Harness

BACKGROUND

The purpose of this study was to evaluate the rate of residual acetabular dysplasia (RAD), defined as an acetabular index (AI) of >90th percentile of age and sex-matched controls, in a cohort of infants successfully treated with the Pavlik harness (PH).

METHODS

We retrospectively studied typically developing infants at a single center, with at least 1 dislocated hip, that was successfully treated with a PH and had a minimum of 48 months follow-up. Hip dislocation was defined as <30% femoral head coverage at rest on pretreatment ultrasound or IHDI grade 3 or 4 on the pretreatment radiograph.

RESULTS

Forty-six dislocated hips (41 infants) were studied (4 males and 37 females). Brace treatment was initiated at an average age of 1.8 months (range: 2 d to 9.3 mo) and was maintained for an average of 10.2 months (range: 2.3 to 24.9 mo). All hips achieved IHDI grade 1 reduction. Five of 46 hips (11%) had an AI >90th percentile at the conclusion of bracing. Average follow-up was 6.5 years (range: 4.0 to 15.2 y). We found a 30% incidence of RAD (14/46 hips) on final follow-up radiographs. Of these hips, 13/14 (93%) had AI <90th percentile at the end of brace treatment. Comparing children with and without RAD, there were no differences in age at the initial visit or brace initiation, total follow-up, femoral head coverage at the initial visit, alpha angle at the initial visit, or total time in the brace (P > 0.09).

CONCLUSION

In a single-center cohort of infants with dislocated hips treated successfully with a PH, we observed a 30% incidence of RAD at a minimum 4.0-year follow-up. Normal acetabular morphology at the end of brace treatment did not result in normal acetabular morphology at the final follow-up in 13/41 hips (32%). We recommend that surgeons should pay close attention to the year-over-year change in both the AI and AI percentile.

LEVEL OF EVIDENCE

Level IV: case series.

Closed reduction and plaster immobilization: an alternative solution for patients with developmental dysplasia of the hip who failed Pavlik harness treatment

BACKGROUND

The current study aims to investigate the clinical efficacy of closed reduction and cast immobilization for patients with developmental dysplasia of the hip (DDH) who failed Pavlik harness treatment.

METHODS

Patients with DDH who underwent cast immobilization under general anaesthesia after the failure of the Pavlik harness or Tübingen brace treatment between January 2015 and December 2020 were retrospectively recruited. General information, including Graf classification of initial diagnosis, initial treatment, age of cast immobilization, IHDI classification, AI index, avascular necrosis (AVN), and residual dysplasia, was collected. The incidence of AVN and late acetabular dysplasia (LACD) was also estimated. Moreover, factors related to AVN and LACD were investigated by multiple logistic regression analysis.

RESULTS

Thirty-four patients (47 hips) were finally included in the current study. Of these patients, 31 hips (66.0%) were successfully treated with closed reduction and cast immobilization. Open reduction was successfully performed in 16 hips (34.0%). Till the latest follow-up, LACD and AVN were found in 13 (27.7%) and 10 (21.3%) hips, respectively. In the open reduction group, type III and IV of the IHDI classification and type IV of the Ultrasound Graf classification were significantly higher when compared with the closed reduction group. Multiple logistic regression showed that failure of closed reduction was related to the initial types of the Ultrasound Graf and IHDI classifications.

CONCLUSIONS

Although the success rate of closed reduction after early harness failure in DDH is only 66%, we still advocate closed reduction as a first-line treatment for children who have failed sling treatment. Even if closed reduction fails, open reduction can still achieve acceptable results.

Prediction of Late Dysplasia Based on Ultrasound and Plain X-Ray at 6 Months

BACKGROUND

Developmental dysplasia of the hip represents a spectrum of deformity. Residual dysplasia at 2 years of age is associated with an increased risk for osteoarthritis and functional limitations. We compared the prognostic value of 6-month imaging modalities and aimed to identify optimal diagnostic metrics for the prediction of residual dysplasia.

METHODS

After IRB approval, patients who underwent Pavlik treatment between 2009 and 2018 with 2-year follow-up were identified. Sonographs [ultrasound (US)] and radiographs (x-ray) were obtained at 6-month and 2-year-old visits. Dysplasia at 2 years was defined as an acetabular index (AI) >24 degrees. Receiver operating characteristic curves were constructed to quantitatively compare the prognostic ability of US and x-ray-based measures at 6 months. Youden's index [(YI) (values range from 0 (poor test) to 1 (perfect test)] was used to evaluate existing cutoffs at 6 months of age (normal measurements: alpha angle (AA) ≥60 degrees, femoral head coverage (FHC) ≥50%, and AI <30 degrees) relative to newly proposed limits.

RESULTS

Fifty-nine patients were included, of which 28.8% of patients (95% CI: 17.3 to 40.4%) had acetabular dysplasia at 2 years. After adjusting for sex, AA [Area under the Curve (AUC): 80] and AI (AUC: 79) at 6 months of age were better tests than FHC (AUC: 0.77). Current diagnostic cutoffs for AA (YI: 0.08), AI (YI: 0.0), and FHC (YI: 0.06) at 6 months had poor ability to predict dysplasia at 2 years. A composite test of all measures based on proposed cutoffs (AA ≥73 degrees, FHC > 62% and AI ≤24 degrees) was a better predictor of dysplasia at 2 years (Youden's index (YI): 0.63) than any single metric.

CONCLUSIONS

The rate of residual dysplasia remains concerning. The 6-month x-ray and US both play a role in the ongoing management of the developmental dysplasia of the hip. The prediction of dysplasia is maximized when all metrics are considered collectively. Existing parameters were not accurate; We recommend the following cutoffs: AA ≥73 degrees, FHC > 62%, and AI ≤24 degrees. These cutoffs must be validated.

LEVEL OF EVIDENCE

Prognostic Level II.

Testing of an Ultrasound-Limited Imaging Protocol for Pavlik harness Supervision (TULIPPS) in developmental dysplasia of the hip: a randomized controlled trial

AIMS

There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring.

METHODS

This study was a single-centre noninferiority randomized controlled trial. Infants aged under six months whose hips were reduced and centred in the harness at initiation of treatment (stable dysplastic or subluxable), or initially decentred (subluxated or dislocated) but reduced and centred within four weeks of PH treatment, were randomized to our current standard US monitoring protocol (every clinic visit) or to a limited-frequency US protocol (US only at end of treatment). Groups were compared based on α angle and femoral head coverage at the end of PH treatment, acetabular indices, and International Hip Dysplasia Institute (IHDI) grade on one-year follow-up radiographs.

RESULTS

Overall, 100 patients were included; 42 patients completed the standard protocol (SP) and 40 completed the limited protocol (LP). There was no significant difference in mean right α angle at the end of treatment (SP 70.0° (SD 3.2°) ; LP 68.7° (SD 2.9°); p = 0.033), nor on the left (SP 69.0° (SD 3.5°); LP 68.1° (SD 3.3°); p = 0.128). There was no significant difference in mean right acetabular index at follow-up (SP 23.1° (SD 4.3°); LP 22.0° (SD 4.1°); p = 0.129), nor on the left (SP 23.3° (SD 4.2°); LP 22.8° (SD 3.9°); p = 0.284). All hips had femoral head coverage of > 50% at end of treatment, and all were IHDI grade 1 at follow-up. In addition, the LP group underwent a 60% reduction in US use once stable.

CONCLUSION

Our study supports reducing the frequency of US assessment during PH treatment of DDH once a hip is reduced and centred.Cite this article: Bone Joint J 2022;104-B(9):1081-1088.

Prolonged Brace Treatment Does Not Result in Improved Acetabular Indices in Infantile Dislocated Hips

BACKGROUND

The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. However, significant variability exists in the duration of brace treatment after successful reduction of the dislocated hip. The purpose of this study was to evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database.

METHODS

We retrospectively studied prospectively enrolled infants with at least 1 dislocated hip that were initially treated with a PH and had a recorded AI at 2-year follow-up. Subjects were treated at 1 of 2 institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured shorter brace treatment protocol. Hip dislocation was defined as <30% femoral head coverage at rest on the pretreatment ultrasound or International Hip Dysplasia Institute (IHDI) grade III or IV on the pretreatment radiograph.

RESULTS

Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace ×3 longer than hips from institution 2 (adjusted mean 8.9±1.3 vs. 2.6±0.2 mo) (P<0.001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (P=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9 degrees) compared with Institution 2 (adjusted mean 23.5±0.8 degrees) (P=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age-matched and sex-matched AI normal data (P=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia (more than 2 SD from the mean), compared with a 22% (6/27) from Institution 2 (P=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (P=0.071).

CONCLUSIONS

The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at 2-year follow-up.

LEVEL OF EVIDENCE

Level III.

Clinical features and management of the developmental dysplasia of the hip in congenital muscular torticollis

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.

Principles of Bracing in the Early Management of Developmental Dysplasia of the Hip

Bracing is considered a gold standard in treating Developmental Dysplasia of the Hip (DDH) in infants under 6 months of age with reducible hips. A variety of braces are available that work on similar principles of limiting hip adduction and extension. This paper summarises the current evidence regarding bracing in DDH. Most of the literature pertains to the Pavlik harness (PH) and there are few studies for other brace types. Bracing eliminates dislocating forces from the hamstrings, the block to reduction of the psoas and improves the muscle line of pull to stabilise the hip joint. Recent studies have shown no benefit in bracing for stable dysplasia. The rates of PH treatment failure in Ortolani-positive hips have been reported to be high. Barlow positive hips have lower Graf grades and are more amenable to PH treatment. There is consensus that the earlier the diagnosis of DDH and initiation of PH treatment, the better the outcome. Failure rates due to unsuccessful reduction and AVN are higher with treatment initiated after age 4-6 months. Studies have shown no benefits of staged weaning of braces. While there is no maximum time in brace, current consensus suggests a minimum of 6 weeks. The key to successful bracing lies in education and communication with the family.

Tübingen hip flexion splint for the treatment of developmental dysplasia of the hip in children younger than six months age: a meta-analysis

PURPOSE

To investigate the success rate of the Tübingen hip flexion splint (THFS) for the treatment of developmental dysplasia of the hip (DDH), of different severity as per the Graf classification, among infants younger than six months of age. The type and incidence rate of complications associated with THFS treatment were also evaluated.

METHODS

The following databases were searched using keywords and limited for age less than six months: PubMed, Embase, Web of Science, Cochrane Library, and SinoMed, between inception and July 2020. Articles were screened and extracted by two researchers, and the quality of the included literature was evaluated (methodological index for non-randomized studies criteria). R studio 1.3 was used for statistical analysis. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

After screening, eight articles were included in the analysis, contributing 1211 hips (875 patients). The overall success rate of THFS treatment is 91% (95% confidence interval (CI) 0.82 to 0.95). The success rate by Graf type is as follows: type-II, 98% (95% CI 0.94 to 1.00); type-III, 96% (95% CI 0.88 to 1.00); and type-IV, 32% (95% CI 0.18 to 0.47). Complications (24/1211, 2%) included transient femoral nerve palsy (n = 1); avascular necrosis of the femoral head (n = 9) and residual acetabular dysplasia (n = 14).

CONCLUSION

THFS treatment is successful for Graf type-II and -III, but low for type-IV, with a low rate of complication. THFS may be an effective treatment option for DDH among infants less than six months of age. However, those with Graf type-IV require close monitoring.

LEVEL OF EVIDENCE

III.

Risk Factors for Failure of Pavlik Harness Treatment in Infants With Dislocated Hips That Are Evaluated by Dynamic Sonography

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.

Dynamic and Static Splinting for Treatment of Developmental Dysplasia of the Hip: A Systematic Review

BACKGROUND

Developmental dysplasia of the hip (DDH) is one of the most common pediatric conditions. The current gold-standard treatment for children under six months of age with a reducible hip is bracing, but the orthopedic literature features several splint options, and each one has many advantages and disadvantages. The aim of this review is to analyze the available literature to document the up-to-date evidence on DDH conservative treatment.

METHODS

A systematic review of PubMed and Science Direct databases was performed by two independent authors (C.d.C. and A.V.) using the keywords "developmental dysplasia hip", "brace", "harness", "splint", "abduction brace" to evaluate studies of any level of evidence that reported clinical or preclinical results and dealt with conservative DDH treatment. The result of every stage was reviewed and approved by the senior investigators (V.P. and G.T.).

RESULTS

A total of 1411 articles were found. After the exclusion of duplicates, 367 articles were selected. At the end of the first screening, following the previously described selection criteria, we selected 29 articles eligible for full text reading. The included articles mainly focus on the Pavlik harness, Frejka, and Tubingen among the dynamic splint applications as well as the rhino-style brace, Ilfeld and generic abduction brace among the static splint applications. The main findings of the included articles were summarized.

CONCLUSIONS

Dynamic splinting for DDH represents a valid therapeutic option in cases of instability and dislocation, especially if applied within 4-5 months of life. Dynamic splinting has a low contraindication. Static bracing is an effective option too, but only for stable hips or residual acetabular dysplasia.

A Comparison of Pavlik Harness Treatment Regimens for Dislocated But Reducible (Ortolani+) Hips in Infantile Developmental Dysplasia of the Hip

BACKGROUND

Variation exists in the Pavlik harness (PH) treatment regimen for infantile developmental dysplasia of the hip (DDH). The purpose of this study was to determine if the daily PH wear duration (23 vs. 24 h) and frequency of follow-up visits affect the clinical and radiographic outcomes of infants with dislocated but reducible (Ortolani+) hips.

METHODS

This study reviewed prospectively enrolled patients with DDH in a single center who presented at age <6 months with Ortolani+ hips and were treated with PH. Recommended daily PH wear duration (23 vs. 24 h) and the frequency of clinic visits in first 4 weeks after the initiation of PH treatment were analyzed. The clinical success (stable hip that did not require closed or open reduction or the use of an abduction orthosis) and radiographic success based on the acetabular index at 2-year follow-up were compared between different PH regimen groups.

RESULTS

Sixty-two patients (74 hips, 53 females) with Ortolani+ hips had a mean age of presentation of 23±28 days (range, 4 to 128 d) and mean follow-up of 33.2±18.4 months (range, 8 to 85 mo). Overall clinical success rate of PH for Ortolani+ hips was 93% (69/74 hips) and radiographic success rate at 2 years was 84% (48/57 hips). There was no difference in clinical or radiographic success rate between the 23- and 24-hour wear groups (P>0.99, 0.73) or between hips assessed almost weekly compared with once or twice during the first 4 weeks of PH treatment (P>0.99 for both).

CONCLUSIONS

The 23- versus 24-hour PH regimen and frequency of clinic visits in the first 4 weeks of PH treatment did not affect the clinical or radiographic success rate of Ortolani+ hips in infantile DDH. A strict weekly clinic visit and 24-hour PH regimen may not be necessary to obtain stable reduced hips in infants presenting <6 months of age with Ortolani+ hips.

LEVEL OF EVIDENCE

Level III-therapeutic.

Developmental Dysplasia of the Hip with Concurrent Legg-Calvé-Perthes Disease in the Contralateral Hip

Developmental dysplasia of the hip (DDH) is a common hip disorder in pediatrics; about one in 100 newborns has it due to dysplasia and one to two per 1000 have it due to dislocation. Some factors are responsible for the disease, and breech presentation has been identified as a major risk factor. It might be associated with other conditions too. Patients with Legg-Calvé-Perthes disease present with painless limping gait with idiopathic etiology; it is unilateral in most of the cases. This paper reported a rare scenario of DDH associated with concurrent contralateral Legg-Calvé-Perthes disease.

A 5-year-old Saudi male patient, known case of developmental dysplasia of the right hip, which was managed operatively at a different hospital, presented in our outpatients clinic for right hip dysplasia and was found incidentally as having a limping gait due to left hip limited range of motion, following clinical assessment, pelvic radiographs demonstrated presence of subluxation at the right hip in addition to sclerosis, and irregularity of the left femoral head epiphysis. Right pelvic Dega osteotomy, femoral derotation osteotomy, varus osteotomy, and left hip arthrogram was examined under anesthesia with the positioning of the left hip at 45 degrees of abduction and 30 degrees of flexion to achieve the best coverage. Hip spica application was performed to correct DDH of the right hip. Repeated radiography at the subsequent visits showed better coverage of the femoral head on the right side. During a routine follow-up, there were also some osteonecrotic changes of the left femoral head that confirmed the diagnosis of left Legg-Calvé-Perthes disease.

Ultrasound Characteristics of Clinically Dislocated But Reducible Hips With DDH

BACKGROUND

Although ultrasound (US) is frequently used in diagnosis and management of infantile developmental dysplasia of the hip, precise ultrasonographic parameters of what constitutes a dislocation, subluxation etc remain poorly defined. The purpose of this study was (1) to describe the ultrasonographic characteristics of a large cohort of clinically dislocated but reducible hips and (2) to begin to develop ultrasonographic definitions for what constitutes a hip dislocation.

METHODS

A retrospective review of prospectively collected data from an international multicenter study group on developmental dysplasia of the hip was conducted on all patients under 6 months of age with hip(s) that were dislocated at rest but reducible based on initial physical examination (ie, Ortolani positive). Femoral head coverage (FHC), alpha angle (α), and beta angle (β) were measured on pretreatment US by the individual treating surgeon, and were recorded directly into the database.

RESULTS

Based on 325 Ortolani positive hips, the median FHC on presentation was 10% with an interquartile range of 0% to 23%. A total of 126 of the 327 hips (39%) demonstrated 0% FHC. The 90th percentile was found to be at 33% FHC. Of 264 hips with sufficient α data, the median α was 43 degrees with an interquartile range from 37 to 49 degrees. The 90th percentile for α was at 54 degrees. A total of 164 hips had documented β with a median of 66 degrees and an interquartile range of 57 to 79 degrees; the 90th percentile was at 94 degrees.

CONCLUSIONS

Analysis of a large cohort of patients with dislocated but reducible hips reveals a median percent FHC of 10%, a median α of 43 degrees, and a median β of 66 degrees on initial US. Using a threshold at the 90th percentile, a sensible ultrasonographic definition of a dislocated hip seems to be FHC≤33%, implying that FHC between 34% and 50% may be reasonably termed a subluxation. Although these findings are consistent with previous, smaller reports, further prospective research is necessary to validate these thresholds.

LEVEL OF EVIDENCE

Level IV-diagnostic study.

Expert-Based Consensus on the Principles of Pavlik Harness Management of Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) is the most common orthopaedic disorder in newborns. While the Pavlik harness is one of the most frequently used treatments for DDH, there is immense variability in treatment parameters reported in the literature and in clinical practice, leading to difficulties in standardizing teaching and comparing outcomes. In the absence of definitive quantitative evidence for the optimal Pavlik harness management strategy for DDH, we addressed this problem by obtaining international expert-based consensus on the subject.

METHODS

An initial list of items relevant to Pavlik harness treatment was derived by a review of the literature. Delphi methodology was used to guide serial rounds of surveying and obtaining feedback from content matter experts from the International Hip Dysplasia Institute (IHDI), which continued in the same manner until consensus based on standard statistical analysis was reached. This was followed by a corroboration of face validity to derive the final set of management principles.

RESULTS

Four rounds of structured surveying were required to reach consensus. Following 2 rounds of peer review, and from an initial list of 66 items in 8 categories, we were able to derive 2 simplified, yet comprehensive, print-friendly tables consisting of 28 items in 8 categories to assist clinicians in managing DDH with a Pavlik harness. The tables contain principles of treatment initiation, application and follow-up of the harness, complications, weaning, and end-of-treatment decision-making as well as specific criteria based on the severity of the DDH. Furthermore, highly contentious items were identified as important areas of future study.

CONCLUSIONS

We developed a comprehensive set of principles based on expert consensus to assist clinicians in the management of DDH using the Pavlik harness. This study also generated a list of the most controversial areas in the nonoperative management of DDH, which should be considered high priority for future study to further refine and optimize outcomes.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Is male gender a prognostic factor for developmental dysplasia of the hip? Mid-long-term results of posteromedial limited surgery

Objective

The aim of this study was to determine if male sex is a poor prognostic factor for developmental dysplasia of the hip (DDH) and to determine the mid-long-term radiological and clinical results of male patients in comparison with female patients following an open reduction with posteromedial limited approach.

Methods

We examined 54 hips of 41 male patients (12.38 ± 4.82 months) and 96 hips of 82 female patients (11.11 ± 4.93 months) with DDH. All the patients underwent open reduction with posteromedial limited approach. The average follow-up time was 108 months for the male patients and 110 months for the female patients. The Tönnis grade, acetabular index, Kalamchi and MacEwen classification, and Severin classifications were determined for all patients. The Mc Kay classification system was used to evaluate the functional results.

Results

From the total, 25 (60%) male and 70 (85%) female patients had satisfactory radiographic outcomes (Severin Ia, Ib, or II) according to the Severin classification. There was a significant difference between the two groups in terms of the Severin classification (P = 0.04). Residual acetabular dysplasia (RAD) was observed in 12 (15%) female and 17 (41%) male patients (P = 0.001). Grade 2 or higher osteonecrosis was observed in 7 (9%) patients in female and 6 (15%) patients in male group. The clinical outcomes in terms of the Mc Kay classification showed satisfactory outcomes in 72 (87%) female and 34 (82%) male patients. Further, 8 (9.7%) female patients and 6 (14.6%) male patients underwent a second operation. However, there was no difference between the two groups in terms of postoperative osteonecrosis presence (P = 0.982), functional outcomes (P = 0.571), and secondary operation rates (P = 0.298). Male sex was associated with poor outcomes in terms of the Severin classification (P = 0.04) and RAD (P = 0.001).

Conclusion

Although our results indicated that male sex is a poor prognostic factor for radiological results and RAD, there was no difference between male and female patients in terms of osteonecrosis, redislocations, and functional outcomes. Secondary surgical interventions should not be delayed in the absence of the spontaneous development of acetabulum.

Level of evidence

Level III, prognostic study.

Timing of Pavlik Harness Initiation: Can We Wait?

BACKGROUND

Developmental dysplasia of the hip is effectively treated with a Pavlik harness (PH) within the first 6 months of life. Over 80% of unstable hips in the newborn period will naturally stabilize by 2 months of age. If there is no difference in the effectiveness of initiating PH treatment at 1 week compared with 4 weeks of age, waiting may allow the hips to naturally stabilize and avoid treatment. The purpose of this study is to evaluate whether the timing of PH implementation influences its effectiveness in the treatment of developmental dysplasia of the hip.

METHODS

A retrospective review was conducted between 2004 and 2010. Patients were included if PH therapy was prescribed for hip instability or dislocation at or before 6 months of age. PH failure was defined as requiring any operative procedure for definitive management. Groups were divided based on the age at which the PH was initiated-group1=<30 days, group 2=30 to 60 days, group 3=>60 days.

RESULTS

A total of 176 children were included with 38 (21.6%) failing PH treatment. The mean age at PH initiation was 1.3 months (SD=1.3) in the successfully treated children and 1.4 months (SD=1.2) in the failures (P=0.77). There was no difference in the failure rates by age with group 1=19.1% (18/94), group 2=22.5% (9/40), and group 3=26.2% (11/42) (P=0.87). There was no statistical difference with respect to sex or breech positioning in the success or failure groups; however, there was a higher percentage of bilateral involvement in the failure group (P=0.04).

CONCLUSIONS

Patients who had PH initiation before 30 days of age were no more or less likely to fail than when PH was initiated after 30 days of age. Parents can be counseled that waiting until after 30 days of age is appropriate before PH implementation. By avoiding swaddling during this period, the hips may stabilize without treatment and allow for more parental-infant bonding before implementation of PH.

LEVEL OF EVIDENCE

Level III-therapeutic, case control study.

Developmental dysplasia of the hip: addressing evidence gaps with a multicentre prospective international study

There is a lack of high quality evidence available to guide clinical practice in the treatment and management of developmental dysplasia of the hip (DDH). Evidence has been limited by persistent confusion on diagnostic and classification terminology, variability in surgeon decision making and a reliance on single centre, retrospective studies with small patient numbers. To address gaps in knowledge regarding screening, diagnosis and management of DDH, the International Hip Dysplasia Institute began a multicentre, international prospective study on infants with hips dislocated at rest. This review discusses the current state of screening, diagnostic and management practices in DDH and addresses important unanswered questions that will be critical in identifying best practices and optimising patient outcomes. There is insufficient evidence to support universal ultrasound screening; instead, selective screening should be performed by 6-8 weeks of age on infants with risk factors of breech presentation, family history, or history of clinical hip instability. Follow-up of infants with risk factors and normal initial screening should be considered to at least 6 months of age. Brace treatment is a sensible first-line treatment for management of dislocated hips at rest in infants < 6 months of age. Early operative reduction may be considered as there is insufficient evidence to support a protective role for the ossific nucleus in the development of avascular necrosis.

Treatment of developmental dysplasia of the hip with the Pavlik harness in children under six months of age: indications, results and failures

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.

Pavlik Harness Disease Revisited: Does Prolonged Treatment of a Dislocated Hip in a Harness Adversely Affect the α Angle?

BACKGROUND

Current dogma contends that prolonged treatment of a dislocated hip in Pavlik harness beyond 3 weeks will cause "Pavlik harness disease." To our knowledge, however, no previous studies have documented objective morphologic changes to the acetabulum from continued treatment of a persistently dislocated hip.

METHODS

We retrospectively reviewed a consecutive series of infants with developmental dysplasia of the hip, below 6 months old, who failed Pavlik treatment from a single, tertiary-care pediatric hospital and a multicenter, international study group. Inclusion criteria were dislocated hips confirmed by ultrasound (both initially and at Pavlik termination) and a minimum of 2 ultrasounds during harness treatment at least 3 weeks apart. As a global measure of acetabular morphology, α angle (AA) was compared between initial and final ultrasound. The final means of obtaining successful hip reduction was recorded from the medical records.

RESULTS

Forty-nine hips in 38 patients were identified. Median age at Pavlik initiation was 4 weeks (range, 0 to 18 wk); median time in harness was 6 weeks (range, 3 to 14 wk). Surprisingly, a mean of 4 degrees improvement in AA (95% CI, 2-6 degrees; P=0.001) was observed between first and final ultrasound. We found no difference in AA change between those in harness 3 to 5 weeks and those with prolonged wear >5 weeks (P=0.817). There was no significant association between change in AA and time in harness (P=0.545), age at Pavlik initiation (P=0.199), clinical reducibility of the hip (P=0.202), or initial percent femoral head coverage (P=0.956). Following harness failure, 22/49 hips (45%) were successfully treated with rigid abduction bracing, 16 (33%) by closed reduction/spica casting, and 10 (20%) by open reduction; 1 hip (2%) spontaneously reduced and required no further treatment.

CONCLUSIONS

On the basis of the lengths of harness treatment in our series, most hips did not exhibit negative changes in the acetabular AA in response to prolonged treatment of a dislocated hip in harness. Furthermore, 80% of hips failing Pavlik treatment were successfully reduced through closed means, indicating that subsequent treatment was not compromised.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Use of inlet radiographs in the assessment of reduction after the surgical treatment of developmental dysplasia of the hip

AIMS

This pilot study aimed to evaluate prospectively the use of inlet radiographs of the hip as an alternative method of the assessment of reduction after the surgical treatment of developmental dysplasia of the hip (DDH).

PATIENTS AND METHODS

The children in this study underwent surgery between January 2013 and January 2015. All had inlet radiographs and CT scans post-operatively. Data were analysed by determining inter-observer reliability and intra-observer reproducibility, using the kappa value (K). Differences were settled by discussion between the two observers until a consensus was reached. The sensitivity and specificity of the radiographic and CT results were compared. A total of 26 radiographs were obtained from 23 children, with a mean age of 2.38 years (one to five).

RESULTS

Similar high levels of intra- and inter-observer agreement were observed (K = 0.834, 95% confidence interval (CI)). There was a high agreement between the radiographic and CT results (K = 0.834, 5% CI), with excellent sensitivity and a specificity of 95.5%.

CONCLUSION

These results suggest that inlet radiographs may be a reliable method of assessing the reduction of the hip after the surgical treatment of DDH. Cite this article: Bone Joint J 2017;99-B:697-701.

Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure

BACKGROUND

The use of a brace has been shown to be an effective treatment for hip dislocation in infants; however, previous studies of such treatment have been single-center or retrospective. The purpose of the current study was to evaluate the success rate for brace use in the treatment of infant hip dislocation in an international, multicenter, prospective cohort, and to identify the variables associated with brace failure.

METHODS

All dislocations were verified with use of ultrasound or radiography prior to the initiation of treatment, and patients were followed prospectively for a minimum of 18 months. Successful treatment was defined as the use of a brace that resulted in a clinically and radiographically reduced hip, without surgical intervention. The Mann-Whitney test, chi-square analysis, and Fisher exact test were used to identify risk factors for brace failure. A multivariate logistic regression model was used to determine the probability of brace failure according to the risk factors identified.

RESULTS

Brace treatment was successful in 162 (79%) of the 204 dislocated hips in this series. Six variables were found to be significant risk factors for failure: developing femoral nerve palsy during brace treatment (p = 0.001), treatment with a static brace (p < 0.001), an initially irreducible hip (p < 0.001), treatment initiated after the age of 7 weeks (p = 0.005), a right hip dislocation (p = 0.006), and a Graf-IV hip (p = 0.02). Hips with no risk factors had a 3% probability of failure, whereas hips with 4 or 5 risk factors had a 100% probability of failure.

CONCLUSIONS

These data provide valuable information for patient families and their providers regarding the important variables that influence successful brace treatment for dislocated hips in infants.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Association between open or closed reduction and avascular necrosis in developmental dysplasia of the hip: A PRISMA-compliant meta-analysis of observational studies

BACKGROUND

The risk of avascular necrosis of the femoral head (AVN) after treatment of developmental dysplasia of the hip is associated with the method of reduction. Some authors have suggested that open reduction is a risk factor for AVN; however, this is controversial. To our knowledge, a quantitative comparison of the incidence of AVN between closed and open reduction has not been conducted.

METHODS

Published studies were identified by searching PubMed, EMBASE, and the Cochrane Library up to May, 2015, focusing on the incidence of AVN after closed or open reduction for developmental dysplasia of the hip in children aged <3 years. Patients were age-matched who were treated by either closed or open reduction, but without pelvic or femoral osteotomy. Two authors independently assessed eligibility and abstracted data. Discrepancies were discussed and resolved by consensus. We pooled the odds ratios (ORs) and 95% confidence intervals (95%CIs) from individual studies using a random-effects model and evaluated heterogeneity and publication bias.

RESULTS

Nine retrospective studies were included in this analysis. The pooled OR for comparing open reduction with closed reduction for all grades of AVN was 2.26 (95%CI = 1.21-4.22), with moderate heterogeneity (I = 44.7%, P = 0.107). The pooled OR for grades II to IV AVN was 2.46 (95%CI = 0.93-6.51), with high heterogeneity (I = 69.6%, P = 0.003). A significant association was also found for the further surgery between open and closed reduction, with a pooled OR of 0.30 (95%CI = 0.15-0.60) and moderate heterogeneity (I = 46.4%, P = 0.133). No evidence of publication bias or significant heterogeneity between subgroups was detected by meta-regression analyses.

CONCLUSION

Findings from this meta-analysis suggest that open reduction is a risk factor for the development of AVN compared with closed treatment. Future studies are warranted to investigate how open reduction combined with pelvis and/or femoral osteotomy affects the incidence of AVN.

Developmental dysplasia of the hip: What has changed in the last 20 years?

Developmental dysplasia of the hip (DDH) describes the spectrum of structural abnormalities that involve the growing hip. Early diagnosis and treatment is critical to provide the best possible functional outcome. Persistence of hip dysplasia into adolescence and adulthood may result in abnormal gait, decreased strength and increased rate of degenerative hip and knee joint disease. Despite efforts to recognize and treat all cases of DDH soon after birth, diagnosis is delayed in some children, and outcomes deteriorate with increasing delay of presentation. Different screening programs for DDH were implicated. The suspicion is raised based on a physical examination soon after birth. Radiography and ultrasonography are used to confirm the diagnosis. The role of other imaging modalities, such as magnetic resonance imaging, is still undetermined; however, extensive research is underway on this subject. Treatment depends on the age of the patient and the reducibility of the hip joint. At an early age and up to 6 mo, the main treatment is an abduction brace like the Pavlik harness. If this fails, closed reduction and spica casting is usually done. After the age of 18 mo, treatment usually consists of open reduction and hip reconstruction surgery. Various treatment protocols have been proposed. We summarize the current practice for detection and treatment of DDH, emphasizing updates in screening and treatment during the last two decades.

Results of the Pavlik harness when treating Ortolani-positive hips: predictors of failure and arthrographic findings

BACKGROUND

Predictors of failure of the Pavlik harness in reducing and stabilizing an Ortolani-positive hip remain 'unclear'. The purpose of this study is to investigate the success of the Pavlik harness when treating Ortolani-positive hips, to look for predictors of failure of the harness and to analyze the arthrographic findings among these failures.

MATERIALS AND METHODS

The medical records of 39 consecutive patients with an Ortolani-positive hip treated initially with a Pavlik harness were reviewed. Data regarding birth order, problems during pregnancy, presentation at birth, delivery, family history of DDH, gender, side involved, bilaterality, onset of treatment, problems related to use of the harness, and time until the harness reduced and stabilized the hip or was abandoned because of a failure were recorded. The presence of plagiocephaly, torticollis or foot deformity was also noted. We looked for predictors of failure among these aspects and report the arthrographic findings of the failures.

RESULTS

The mean age when the harness was started was 16.7 days. The mean time until success or failure of the harness in reducing and stabilize the hip was 18.5 days. There were 8 (20.5 %) failures. Multigravida (p = 0.026) and foot deformity (p = 0.023) were associated with failure of the harness. On the other hand, problems during pregnancy (p = 1), presentation at birth (p = 0.078), c-section (p = 0.394), family history of DDH (p = 1), gender (0.313), torticollis (p = 1), bilaterality (p = 1) and onset of treatment (p = 0.485) were not associated. Arthrographic abnormalities were found in all failures.

CONCLUSION

The Pavlik harness failed to reduce and stabilize the hip in 20.5 % of the newborns with an Ortolani-positive hip. Multigravida and foot deformity were statistically associated with failure of the harness. An anatomical obstacle for reduction was found in all hips with a harness failure. A more teratological than mechanical hip dislocation could be the reason for failure of the Pavlik harness.

LEVEL OF EVIDENCE

IV, Retrospective case series.

[Incidence and duration of therapy of pathological hip findings in U2 and U3 examinations (SNiP study)]

INTRODUCTION AND OBJECTIVES

Determination of the efficacy of an early ultrasound examination followed by immediate treatment of hip joint dysplasia as well as measuring the therapeutic success in a population-based cohort study of neonates.

MATERIAL AND METHODS

The Survey of Neonates in Pomerania (SNiP) study included 4,093 neonates which represents 95.1 % of the total neonatal population. Of these children 2,534 (61.9 %) underwent ultrasound examination of the hip joint during the U2 stage (3-10 days after birth). The mean gestational age was 38.9 weeks. The sonographic classification was performed according to Graf.

RESULTS

Initially (U2 stage) 42 (1.66 %) children were reported to be in need of therapy (stage IIc or higher according to Graf). The analysis showed a significantly higher incidence in girls (32 girls vs. 10 boys, p < 0.023, χ(2) test) and in children who had a breech birth (116, 4.6 %). A genetic predisposition was ascertained in 180 (7.1 %) children. The children could be subdivided into two groups: 1) children who underwent hip joint ultrasound during both U2 and U3 and 2) children who were first screened at the U3 stage. Of the 49 out of 54 neonates where the ultrasound findings were positive at the U2 examination the hip joint was matured in 32 children at U3 (4-8 weeks), 11 children had to be treated for 8-12 weeks 5 children were treated for over 3 months and1 child needed surgical correction.

CONCLUSION

The early diagnosis of hip maturation disorders and joint dysplasia facilitates early implementation of effective treatment. At our clinic over 60 % of the infants underwent the U2 check up and, given a pathological finding, could undergo early treatment. It was possible to successfully treat 78 % of these children with a Tübingen hip flexion splint in just 4-8 weeks. In contrast, infants who were first examined at the U3 stage needed treatment for 4-12 months. In our opinion, early diagnosis at the age of 3-10 days should be carried out for all newborns.

Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip

BACKGROUND

Closed reduction and spica casting is the most commonly recommended choice for infants with developmental dysplasia of the hip (DDH) for whom Pavlik harness treatment has failed, but it requires general anesthesia in addition to the challenges of spica cast care. The purposes of this study were to evaluate the effectiveness of Ilfeld bracing for infants for whom Pavlik harness treatment is unsuccessful and to compare these results with those for a similar cohort of patients directly undergoing closed reduction and spica casting.

METHODS

We reviewed the cases of a consecutive series of children with DDH who had failure of Pavlik harness treatment and were subsequently managed with Ilfeld bracing (the BR cohort) and compared this cohort with a similar historical group of infants who had failure of Pavlik harness treatment but had standard closed reduction and spica casting (the CR cohort). The cohorts were compared with respect to clinical and ultrasonographic data at the time of Pavlik discontinuation. At one year, the hip stability and acetabular index were assessed; the presence of osteonecrosis was graded according to the criteria described by Salter et al.

RESULTS

Twenty-eight hips (nineteen infants) made up the BR cohort and twenty-two hips (sixteen infants) made up the CR cohort. Ultrasonographic indices (including the alpha angle and the percentage of femoral head coverage) were comparable between the two cohorts (p=0.66 and 0.19, respectively). Following treatment, a stable reduction was achieved in twenty-three (82%) of twenty-eight hips in the BR cohort compared with twenty (91%) of twenty-two hips in the CR cohort. At one year, acetabular indices were similar between both cohorts (mean and standard deviation, 27°±6° for the BR cohort versus 27°±5° for the CR cohort; p=0.62); however, osteonecrosis developed in three hips in the CR cohort compared with none in the BR cohort.

CONCLUSIONS

In our series of infants with DDH for whom Pavlik harness treatment had failed, Ilfeld bracing had success rates comparable with those for closed reduction and spica cast treatment. With the added advantages of avoiding general anesthesia and spica casting as well as a potentially lower rate of osteonecrosis, rigid abduction bracing should be considered as the next step for infants who have had failed Pavlik harness treatment prior to proceeding with closed reduction and spica casting.

Abduction bracing after Pavlik harness failure: an effective alternative to closed reduction and spica casting?

BACKGROUND

Previous studies have reported that the use of abduction bracing after Pavlik harness failure in patients with developmental dysplasia of the hip (DDH) is often effective in achieving hip reduction.

METHODS

This is a retrospective study of consecutive patients with DDH at a single institution between 2006 and 2011. Patients in this study met all 4 inclusion criteria: (1) DDH, (2) a dislocated or dislocatable hip, (3) unsuccessful treatment with a Pavlik harness, and (4) subsequent treatment with abduction bracing. Exclusion criteria were dislocated hips associated with neurological, teratologic, syndromic, or other nonidiopathic conditions.

RESULTS

Seven hips met inclusion criteria. Mean age at Pavlik harness initiation was 2.1 months (range, 1 d to 6 mo) and patients spent an average of 1.2 months (range, 0.4 to 2.7 mo) in the harness. After ultrasound demonstrated a persistently dislocated hip, patients were transitioned to an abduction brace and spent an average of 1.3 months (range, 0.1 to 3 mo) in the brace. One hundred percent (7/7) of hips treated with an abduction orthosis failed to reduce and required further treatment; 4 with closed reduction and spica casting, and 3 with open reduction. Patients were followed for an average of 33.6 months (range, 10 to 60 mo), and all patients had stable hips at latest follow-up.

CONCLUSIONS

In this series of 7 patients with developmentally dislocated hips who failed Pavlik harness treatment, subsequent abduction bracing provided no benefit, in contrast to previous studies. All patients who failed Pavlik harness treatment went on to require closed or open reduction of the hip. Abduction bracing may unnecessarily prolong the time to definitive treatment.

LEVEL OF EVIDENCE

Case series, level 4.

Musculoskeletal screening: developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) is common because it is present in 1 of 100 newborns. Failure to diagnose DDH and treat in infancy can result in significant long-term disability. Early diagnosis can be accomplished through a quick but careful physical examination of all newborns. Further selective screening by ultrasound is indicated for those children with risk factors for DDH, which include family history, breech presentation, and unstable hip examination at the initial newborn examination. Continued examination of the hip at all routine well-child checkups is mandatory through the first year of life because late presenting DDH may occur. Treatment with a Pavlik harness is not typically instituted in the neonate because many unstable hips stabilize without intervention, but it is indicated in children older than 2 weeks with hip instability. Ultrasound screening for infants with risk factors for DDH is recommended at age 6 weeks. Pavlik harness treatment for children with unstable hips or significant dysplasia on ultrasound is continued until the hips stabilize and show concentric reduction on imaging. With time, diagnosis and treatment evolve to accommodate the growing child. Infants who fail to respond to nonoperative management may require more extensive interventions. At any time when treatment is initiated, a DDH specialist should be involved in the patient's care. If DDH is recognized early, treatment is less invasive, and long-term effects are minimized.

Developmental dysplasia of the hip in the newborn: A systematic review

Developmental dysplasia of the hip (DDH) denotes a wide spectrum of conditions ranging from subtle acetabular dysplasia to irreducible hip dislocations. Clinical diagnostic tests complement ultrasound imaging in allowing diagnosis, classification and monitoring of this condition. Classification systems relate to the alpha and beta angles in addition to the dynamic coverage index (DCI). Screening programmes for DDH show considerable geographic variation; certain risk factors have been identified which necessitate ultrasound assessment of the newborn. The treatment of DDH has undergone significant evolution, but the current gold standard is still the Pavlik harness. Duration of Pavlik harness treatment has been reported to range from 3 to 9.3 mo. The beta angle, DCI and the superior/lateral femoral head displacement can be assessed via ultrasound to estimate the likelihood of success. Success rates of between 7% and 99% have been reported when using the harness to treat DDH. Avascular necrosis remains the most devastating complication of harness usage with a reported rate of between 0% and 28%. Alternative non-surgical treatment methods used for DDH include devices proposed by LeDamany, Frejka, Lorenz and Ortolani. The Rosen splint and Wagner stocking have also been used for DDH treatment. Surgical treatment for DDH comprises open reduction alongside a combination of femoral or pelvic osteotomies. Femoral osteotomies are carried out in cases of excessive anteversion or valgus deformity of the femoral neck. The two principal pelvic osteotomies most commonly performed are the Salter osteotomy and Pemberton acetabuloplasty. Serious surgical complications include epiphyseal damage, sciatic nerve damage and femoral neck fracture.

[Dysplasia in the development of the hip]

Developmental dysplasia of the hip (DDH) causes anatomical changes that cause early coxarthrosis. Although risf factors have been determined, the aetiology and physiopathology remains exactly unknown. Neonatal screening with physical examination and ultrasound have been stablished in order to diagnose this disease early in life. A diagnosis in the first months of life is essential as it enables a normal hip to form and prevent the appearance of early coxarthrosis. Treatment principles are to be able to reduce the hip without provoking avascular necrosis of the femoral head, and to normalize the acetabular development. Knowledge of the orthopaedic and surgical options is essential in order to achieve success in the treatment.

Ultrasonographic findings in hips with a positive Ortolani sign and their relationship to Pavlik harness failure

BACKGROUND

In developmental dysplasia, Pavlik harness treatment of hips with a positive Ortolani sign fails in up to 40% of such patients; however, no study has described factors for failure associated with ultrasonographic parameters. The goal of this study was to describe unique ultrasonographic markers in hips with a positive Ortolani sign that are associated with Pavlik harness failure.

METHODS

A retrospective review was performed of all patients less than six months old who were treated for developmental dysplasia of the hip with a Pavlik harness from 1991 to 2005 at a single institution. Inclusion criteria for this study were patients with a hip that was dislocated but reducible (a positive Ortolani sign), treatment with a Pavlik harness, and an ultrasound examination performed within four weeks after the initiation of treatment. The initial coronal ultrasound studies were graded with use of the Graf classification, the percentage of femoral head coverage, labral morphology, and two new measurements: superior femoral head displacement relative to the labrum and total femoral head displacement.

RESULTS

Eighty-five patients with 115 hips fitting the inclusion criteria were identified. Pavlik harness treatment was successful in seventy-two hips (63%) and failed in forty-three hips (37%). Increased beta angle, decreased femoral head coverage, an inverted labrum, decreased superior femoral head displacement relative to the labrum, and decreased total femoral head displacement were significantly correlated with Pavlik harness failure (p < 0.001 for all). A finding of 0 degrees of superior femoral head displacement relative to the labrum was seen in 98% of the hips with successful Pavlik harness treatment. Total femoral head displacement of less than -30 degrees was found in 89% of the hips with a failure of Pavlik harness treatment.

CONCLUSIONS

We identified two new objective measurements on static ultrasound examinations of the hip that are associated with the outcome of Pavlik harness treatment in patients with developmental dysplasia and a positive Ortolani sign. A femoral head positioned below the labrum is strongly associated with success of the Pavlik harness treatment, whereas a hip with a femoral head that is located substantially superior and lateral to the labrum is associated with Pavlik harness treatment failure. The presence of a deficient cartilaginous anlage and an inverted labrum may provide a pathoanatomical explanation for Pavlik harness treatment failure.