High failure rate of the Pavlik harness in dislocated hips: is it bilaterality?

Developmental Dysplasia of the Hip and Laterality: The Importance of Graded Severity of the Contralateral Hip

Background

Laterality and bilaterality have been reported as prognostic variables in developmental dysplasia of the hip (DDH) outcomes. However, there is little clarity across the literature on the reporting of laterality in developmental dysplasia of the hip (DDH) due to the variability in severity of the condition. It is widely accepted that the left hip is most frequently affected; however, the true incidence of unilateral left, unilateral right and bilateral cases can be hard to quantify and compare across studies. The purpose of this study was to examine laterality accounting for graded severity in a multi-centre, international prospective observational study of infants with hip dysplasia to demonstrate the complexity of this issue.

Methods

A multi-centre, prospective hip dysplasia database was analyzed from 2010 to April 2015. Baseline diagnosis was used to classify patients into a graded laterality category accounting for hip status within the DDH spectrum.

Results

A total of 496 patients were included in the analysis; 328 were <6 months old at diagnosis and 168 were between 6 and 18 months old. Of these patients, 421 had at least one frankly dislocated hip. Unilateral left hip dislocations were most common, with 223 patients, followed by unilateral right and bilateral dislocations with 106 and 92 respectively. Stratifying these patients based on status of the contralateral hip, 54 unilateral left and 31 unilateral right dislocated patients also had a dysplastic or unstable contralateral hip. There were significantly fewer bilateral patients in the 6 to 18-month group (p = 0.0005). When classifying laterality by affected hip, bilaterality became the predominant finding, comprising 42% of all patients.

Conclusions

Findings from this multi-centre prospective study demonstrate the necessity to account for the graded severity in hip status when reporting DDH laterality. To accurately compare laterality across studies, a standardized, comprehensive classification should be established, as contralateral hip status may impact prognosis and treatment outcomes.

Level of Evidence

Level II Prognostic Study.

Known risk factors of the developmental dysplasia of the hip predicting more severe clinical presentation and failure of Pavlik harness treatment

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.

Can Medialization of Acetabular Rim Be a Prognostic Factor in Treatment of Developmental Dysplasia of Hip?

OBJECTIVES

To investigate if acetabular rim medialization (ARM) can be used as a new parameter in determining the treatment choice and duration in Graf type III and IV hips.

METHODS

Among the 12,300 infants who underwent hip ultrasound (US) according to Graf's method between 2015 and 2019, 26 infants (9 had bilateral pathology hence 35 hips) with type III and IV hips, whose follow-up data could be obtained were included in the study. Age of the infants at the initial diagnosis, ARM measurement, the duration of harness treatment, and the treatment results were noted. To determine the extent of ARM, distance between a line that is drawn tangential to the iliac wing and acetabular rim was measured.

RESULTS

In cases with poor prognosis, ARM measurement was 6 to 8.5 mm on the right hip and 4 to 9 mm on the left hip. Bilaterality or unilaterality, left or right pathology, and gender did not have a significant effect on the prognosis (P >.05). Age at the initial diagnosis and ARM had significant effects on treatment success (P = .04, P = .00, respectively). In predicting the prognosis, ARM was found to be more successful than age (AUC = 0.95 versus AUC = 0.68). When these two variables were evaluated together, the success in predicting the prognosis significantly increased (AUC = 0.98).

CONCLUSIONS

ARM measurement may have an important role in determining the treatment method and duration in Graf type III and IV hips. It can be used as a prognostic factor alone or in combination with treatment initiation time. When the two factors are combined, prognostic value significantly increases.

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.

The nomogram predicting the early failure rate of the Pavlik harness for developmental dysplasia of the hip in infants under 6 months of age

BACKGROUND

The aim of our study was to develop a nomogram predicting the early failure rate of Pavlik harness in infants under 6 months of age with developmental dysplasia of the hip (DDH).

METHODS

We retrospectively analyzed the clinical data of 227 patients (372 hips) with DDH who were treated with Pavlik harness at our institution from August 2019 to January 2022. Fifty-eight patients (102 hips) failed the Pavlik harness treatment, and 169 patients (270 hips) were successfully treated. Then, the independent risk factors for treatment failure were determined via univariate and multivariate logistic regression and used to generate the nomogram predicting the failure rate of the Pavlik harness.

RESULTS

It was found that age at initial treatment (OR 1.031, 95% CI 1.022-1.040, P < 0.001), angle α (OR 0.723, 95% CI 0.671-0.779, P < 0.001), and concomitant deformity (OR 0.129, 95% CI 0.036-0.459, p = 0.002) were independent risk factors for treatment failure. The nomogram showed good discrimination [the area under the curve (AUC): 0.862], good calibration, and a net benefit in the range of probabilities between 5 and 90% according to the decision curve analysis.

CONCLUSION

This study successfully established the nomogram prediction model based on three independent risk factors. Due to the high level of predicting accuracy, this nomogram could be a useful resource for pediatric orthopedic surgeons to identify patients at major risk of Pavlik harness failure who might need more reliable treatments.

Comparison of treatment outcomes of stable and unstable developmental dysplasia of the hip with the Tübingen splint

BACKGROUND

The Tübingen splint was initially developed for the treatment of stable developmental hip dysplasia (DDH). Later on, some authors expanded its include for the treatment of unstable DDH, but there remain some controversies in the literature. This study aims to compare the outcome between stable and unstable DDH treated with a Tübingen splint.

METHODS

Epidemiological data and ultrasonographic data of all infants diagnosed with DDH and initially treated with a Tübingen splint at our institution between May 2017 and February 2020 were assessed retrospectively. We divided the population into stable and unstable hips using the Graf classification. Age at treatment initiation, duration of treatment, complications, and radiological outcome between 12 and 24 months were investigated.

RESULTS

We included a total of 45 patients (57 hips) affected by DDH treated with the Tübingen splint. Treatment has been successful in 93% of stable hips and only 40% of unstable hips. Radiological outcome at 1-year follow-up significantly correlated with initial Graf classification (p < 0.001).

CONCLUSION

The Tübingen splint is a safe and effective treatment for stable hips, nevertheless, for unstable hips, closed reduction, and spica cast remains the gold standard.

Outcomes of ultrasound-monitored treatment of divelopmental dysplasia of the hip graf type II

Introduction: The management of developmental dysplasia of the hips (DDH) type Graf IIa is still controversial. This study aims to examine the outcomes of ultrasound-monitored Pavlik harness treatment, as well as the effects of associated factors, such as gender, side of DDH, the age at the treatment start, and laterality on the treatment outcomes in different Graf type II subtypes. Methods: A cohort retrospective investigation was performed on 88 ultrasound-screened infants or 125 hips diagnosed with Graf type II dysplasia during a six-month period at a single institution, the University Clinic for Orthopedic Surgery, Skopje. Subsequently, 47 infants (18 boys, 29 girls) or 73 hips who underwent Pavlik harness treatment with at least one follow-up throughout treatment monitoring were included in this study. Results: The treatment success rate of the right DDH Graf type IIa (-) was higher (70.8%) compared to the rate of success (50%) in the treatment of left Graf type IIa (-) hips. The mean age of the infants at the treatment start in successfully treated Graf type IIa (-) hips was lower (9.12 ± 2.27 weeks) compared to the age of the infants with treatment failure at the last follow-up (11.33 ± 3.06 weeks), P = 0.04. Conclusion: The age of treatment initiation and the side of DDH were the most relevant factors related to the treatment outcome. Infants with maturational deficit hips, Graf type IIa (-), should undergo early initiated, carefully guided, and monitored Pavlik harness treatment.

Prevalence of Developmental Dysplasia of the Hip in a Maternity Hospital in São Paulo, Brazil

Objective  To evaluate the prevalence of developmental dysplasia of the hip (DDH), that is, hips classified as Graf type-IIc or higher, among a sample of the population of newborns aged from 0 to 3 days of life, and to correlate the findings with the main risk factors described in the literature. Methods  An observational, cross-sectional, prospective study on a sample of newborns at a Maternity Hospital School in the city of São Paulo, Brazil, to assess the prevalence of DDH diagnosed by the Graf method and verify its correlation with the risk factors. Results  A total of 678 newborns underwent hip ultrasound (1,356 hips). The prevalence of DDH was of 5.46%. The logistic regression analysis showed odds ratios (ORs) with statistical significance for the following parameters: white ethnicity (OR = 2.561; 95% confidence interval [95%CI]: 1.07 to 6.11); multiparity (OR = 3.50; 95%CI: 1.62 to 7.38), female gender (OR = 4.95; 95%CI: 1.86 to 13.13); and breech presentation (OR = 2.03; 95%CI: 1,01 to 4.11). Conclusion  The prevalence of DDH in the sample was of 5.45% using ultrasound as a diagnostic method. This result is different from that of studies that assessed prevalence exclusively through physical examination (Ortolani maneuver). The main risk factors associated with a higher risk of developing DDH were newborns of the female gender, with breech presentation, firstborns, and of white ethnicity.

What Are the Rate and Risk Factors for Developing a Complication With the Pavlik Method for the Treatment of Hip Dysplasia?

BACKGROUND

The Pavlik method for the treatment of developmental dysplasia of the hip (DDH) has been proven successful for over 85 years. The high success rate and reproducibility have made it the mainstay of treatment.

METHODS

We performed a retrospective cohort study of patients with DDH treated with the Pavlik method between September 2016 and August 2018 with at least 24 months of follow up in a single academic center. We excluded patients with neuromuscular conditions, teratologic dislocations, and arthrogryposis. We identified and included a total of 307 patients in the analysis. There were 66 patients with dysplasia, 97 with instability, and 144 with a dislocation. Data collected included age at initiation of the Pavlik method, diagnosis (isolated dysplasia, subluxation, or dislocation), duration of treatment, follow up duration and any complication. At final follow up, anteroposterior radiographs of the pelvis were used to determine the Severin classification.

RESULTS

Major complications were proximal femoral growth disturbance (5.8%) and femoral nerve palsy (0.98%). Multivariate analysis showed that an initial diagnosis of a dislocated hip (odds ratio, 2.20; P<0.01), was significantly associated with developing a complication. At final follow up, we found Severin type I or II radiographic findings in 100% of patients with dysplasia, 95% of patients with instability and 54% of patients with dislocation (P=0.001).

CONCLUSIONS

Complications are not entirely uncommon when the Pavlik method is used for the treatment of DDH. The overall rate of major complications was 7%. The Pavlik method is safe, and independent risk factors for complications were being over 5 months of age and having a dislocated hip at initial presentation.

LEVEL OF EVIDENCE

Level IV-cohort study.

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.

Comparison between the Pavlik harness and the Tübingen hip flexion splint for the early treatment of developmental dysplasia of the hip

The Pavlik harness and the Tübingen hip flexion splint (Tübingen hip flexion splint) are two effective options for the early management of patients younger than 6 months of age with developmental dysplasia of the hip (DDH). The main objective of this study was to evaluate the clinical and radiological outcomes of patients younger than 6 months of age with type IIb to IV DDH managed by Pavlik harness or Tübingen hip flexion splint. The Pavlik harness and Tübingen hip flexion splint groups were comparable regarding the affected side (P = 0.09), Graf grade (P = 0.635), and age at initial treatment (P = 0.77). Overall, failure rates were 12 and 33% in Pavlik harness (4/33 hips) and Tübingen hip flexion splint groups (14/43 hips), respectively (P = 0.038). No cases of avascular necrosis (AVN) were found in either group. In the Tübingen hip flexion splint group, the failure rate was significantly higher in bilateral cases (66.6%; P = 0.004), in severe forms (Graf grade IV hips; P ≤ 0.0001), and in patients with lower age at initial treatment (67.7 ± 39.3 days; P = 0.005). The average follow-up time was 30.35 ± 3.58 months (range: 24-36). At the last follow-up visit, no statistically significant differences were found between the Pavlik harness and Tübingen hip flexion splint groups regarding the acetabular index (t = 0.632; P = 0.53) or center-edge angle (Z = -0.303; P = 0.762). Our study showed that both the brace treatments for DDH in children younger than 6 months of age were effective and well tolerated. However, Tübingen hip flexion splint should not be used in patients with severe forms of DDH (Graf grade IV hips).

Instability Testing for Congenital Hip Dislocation: Knee Extension Provokes Hip Dislocation

The classic Ortolani and Barlow signs are routinely used to diagnose hip instability secondary to severe acetabular dysplasia in the newborn. However, eliciting a positive sign depends largely on the experience of the examiner and the subjective amount of manual pressure the examiner applies on the baby's hips. Furthermore, these signs do not give a clue for the selection of a maturation or immobilization device after reduction of an unstable hip: below-knee hip spica, above-knee hip spica or a Pavlik harness. The aim of this study is to describe a clinical sign that could be useful in detecting hip instability of the newborn and to decide the proper treatment in a more objective manner: knee extension provokes dislocation of the ipsilateral unstable hip.

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.

Management of Irreducible Hip Dislocations in Infants With Developmental Dysplasia of the Hip Diagnosed Below 6 Months of Age

BACKGROUND

Infants with dislocated irreducible (D/I) hips can be substantially harder to treat than infants with dislocated but reducible hips. The purpose of this study was to compare treatment methods and outcomes for infants with D/I hips in order to optimize management of this difficult patient cohort.

METHODS

A multicenter prospective hip dysplasia study database was analyzed from 2010 to 2016. Infants aged below 6 months with clinically and radiologically confirmed D/I hips were included in the study. Teratological hips (syndromic/neuromuscular) were excluded.

RESULTS

In total, 59 hips in 52 patients were included. All hips were clinically Ortolani negative and radiologically dislocated but irreducible on presentation and had at least 20 months of follow-up. Mean age at diagnosis was 1.9 months (range, 0.1 to 5.9 mo). There were 33 left hips, 12 right hips, and 14 bilateral hips (7 patients). In total, 48 of 59 hips were treated in Pavlik harness. The remainder were treated by alternative braces or primary closed or open reductions. Pavlik treatment was successful in 27 of 48 hips. Pavlik treatment was abandoned in 21 D/I hips, 3 due to femoral nerve palsy and the remainder due to failure to achieve reduction. There was no statistical correlation between Pavlik success and age at diagnosis (P=0.22), patient sex (P=0.61), or bilateral compared with unilateral D/I hips (P=0.07). Left hips were more likely to be successfully reduced in Pavlik harness than right hips (P=0.01). Five complications occurred: 3 patients developed femoral nerve palsy in Pavlik harness, while 2 patients developed avascular necrosis, both after failed Pavlik treatment and subsequent surgery.

CONCLUSIONS

Pavlik harness treatment has been demonstrated to be a safe and sensible first-line treatment for infants with D/I hips. Left hips were more likely to be successfully reduced in Pavlik harness than right hips, but age, sex, and bilaterality were not correlated. The outcomes demonstrated from this multicentre prospective database inform management of this complex patient cohort.

LEVEL OF EVIDENCE

Level II-prognostic study: less-quality prospective study.

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.

Higher Pavlik Harness Treatment Failure Is Seen in Graf Type IV Ortolani-positive Hips in Males

BACKGROUND

Patients with developmental dysplasia of the hip (DDH) whose hips are dislocated but reducible (Ortolani positive) are more likely to experience Pavlik harness treatment failure than are patients with dysplastic and reduced but dislocatable (Barlow positive) hips. However, data regarding factors associated with failure are limited and conflicting.

QUESTIONS/PURPOSES

We asked: (1) What is the frequency of Pavlik harness treatment failure among Ortolani-positive hips, Barlow-positive hips, and dysplastic hips? (2) What are the factors predictive of failure of Pavlik harness treatment for Ortolani-positive hips?

METHODS

In this retrospective study we identified 150 patients who underwent the Pavlik harness method for treatment of DDH between August 2011 and July 2015. Six patients initially treated at an outside facility, four patients with associated conditions, and three who pursued treatment elsewhere were excluded. A total of 137 patients (215 hips) with a median age at the time of Pavlik placement of 30 days (range, 4-155 days) were included. Of the 215 hips, 78 (36.3%) were Ortolani positive, 60 (27.9%) were Barlow positive, and 77 (35.8%) were stable, with the diagnosis of dysplasia made on ultrasound. All patients were treated with the Pavlik harness method. The primary outcome was failure of the Pavlik harness to achieve and maintain concentric hip reduction assessed by examination and ultrasound. All patients were followed after completion of Pavlik treatment for a minimum of 2 months (mean, 3 months; range, 2-4 months). In addition, 90% (122 of 137) of the patients were followed for a minimum of 6 months. Patient-specific data including family history, breech versus cephalic presentation at birth, age, sex, laterality, and hip abduction were recorded. Ultrasound data at the time of diagnosis included Graf classification, alpha angle, and percentage of femoral head coverage.

RESULTS

The Pavlik harness method failed in 27% (21 of 78) of hips that were Ortolani positive, 8% (six of 77) with dysplasia, and 5% (three of 60) that were Barlow positive. After controlling for potential confounding variables, such as range of hip abduction, male sex (adjusted odds ratio [OR], 6.9; 95% CI, 2.0-24.2; p = 0.002) and Graf Type IV ultrasound classification (dislocated hip with alpha angle less than 43° and labrum displaced downward) (OR, 4.4; 95% CI, 1.3-15.4; p = 0.019) were identified as independent predictors of failure of Pavlik treatment among Ortolani-positive hips.

CONCLUSIONS

Ultrasound imaging of the hip should be part of the initial assessment for Ortolani-positive hips, as the ultrasound classification was found to have prognostic implications. Parents of male infants with Graf Type IV hips should be counseled regarding the higher risk of Pavlik failure. Future well-designed prospective controlled studies are necessary to establish whether alternative strategies to the Pavlik harness might improve the early outcomes of DDH in males with Graf Type IV hips.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.

Success of Pavlik Harness Treatment Decreases in Patients ≥ 4 Months and in Ultrasonographically Dislocated Hips in Developmental Dysplasia of the Hip

BACKGROUND

Treatment of developmental dysplasia of the hip (DDH) using the Pavlik harness has been a widely used method in patients between 0 and 6 months of age for many years. However, the factors influencing the success rate of this treatment modality have still not exactly been determined as a result of the limited number of clinical studies with higher level of evidence.

QUESTIONS/PURPOSES

We, therefore, asked whether (1) patient-related variables such as age, gender, and laterality; coexisting risk factors including family history, breech presentation, intrauterine packing, first-born girl, oligohydroamnios, and swaddling; and (2) the severity of hip dysplasia, defined by ultrasonography, are associated with differences in the success rate of Pavlik harness treatment in infants with DDH.

METHODS

Between 2012 and 2014, we treated 153 children (≤ 6 months of age) with DDH using the Pavlik harness. Hip dysplasia apart from coexisting neuromuscular disorders, congenital abnormalities, or syndromes was our inclusion criteria. Of patients thus treated, 130 (85%) were available for the evaluation of patient- and hip-related variables against the success of Pavlik harness treatment. Mean age of these patients on day of diagnosis and initiation of treatment was 108 days. The diagnostic and followup examinations of the hips were made by ultrasonography using Graf's method. Pavlik harness treatment was initiated in Graf Type IIa- and worse hips and treatment was considered "successful" when a Graf Type I hip was achieved. Pavlik harness treatment was successful in 92 (71%) patients (130 of 181 hips [72%]).

RESULTS

Age was the only patient-related variable influencing the success rate of the treatment; the mean age of children in whom Pavlik harness treatment succeeded (97 ± 38 days; 95% confidence interval [CI], 90-112) was lower than the age of those who failed (135 ± 37 days; 95% CI, 123-147; p < 0.001). The highest success rate was obtained in children younger than age 3 months (37 of 40 [93%]) and the lowest one older than age 5 months (nine of 24 [37%]) (p < 0.001). The threshold age value related to an increased risk of failure was found to be 4 months and older, which had a sensitivity of 66% and a specificity of 77% (p < 0.001). A higher initial α angle was observed in the hips in which the treatment succeeded (53° ± 6°; 95% CI, 51°-53°) than in those that failed (47° ± 7°; 95% CI, 45°-50°; p < 0.001). The threshold α angle value related to an increased risk of treatment failure was 46° and less, which had a sensitivity of 47% and a specificity of 86% (p < 0.001). Dislocated hips (Graf Type III and IV hips) had the lowest rate of treatment success (five of 19 [26%] and two of four [50%], respectively), whereas Graf Type IIa- hips had the highest (27 of 29 [93%]) (p < 0.001).

CONCLUSIONS

We conclude that Pavlik harness treatment is less effective in children at and over the age of 4 months at the time the harness is first applied as well as in hips with complete dislocations and hips with severely deficient acetabular bony roofs. In such older patients and worse hip types, the use of initial Pavlik harness treatment needs to be revisited. Future studies, comparing the outcomes of the Pavlik harness treatment and other types of interventions in such patients and hip types, are needed.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Developmental dysplasia of the hip in children with a psychomotor disorder. A risk factor for a poor outcome?]

INTRODUCTION

Orthopaedic treatment of developmental dysplasia of the hip (DDH) has a high success rate in cases that are diagnosed early. However, the outcomes of these patients are not really known when they are subsequently diagnosed with some type of cerebral impairment.

MATERIALS AND METHODS

A retrospective observational study was conducted on cases of DDH with a poor outcome after orthopaedic treatment, being unknown if they had any type of psychomotor disorder. The patients were clinically and radiologically assessed, and afterwards received neurological valuation by the Child Neurology Unit.

RESULTS

Of the 325 cases of DDH diagnosed in 293 patients, 10 patients (3%) with 16 hips with DDH were diagnosed of any cerebral impairment. All them were initially treated orthopedically. Clinical and radiologically evolution was succesful only in 4 cases (25%) being necessary any surgical procedure in the remaining 12 cases. After surgical treatment we got an improvement in the Acetabular Index (p=0.005) and Reimers Extrusion Index (p=0.042). Neck-shaft angle and Wiberg CE angle also improved but this difference was not statically significant. Cerebral impairment was diagnosed at 2,5 years of age and the begining of walking was delayed at 2.4 years of age.

CONCLUSIONS

Cerebral impairment can lead to an unfavourable outcome in the treatment of DDH, with the relative risk of a poor outcome being 7.2 times higher in these patients. An unfavourable outcome with conventional treatment of DDH must make us suspect the presence of some type of neurological disorder, particularly if there is a delay in walking.