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

Child Opportunity Index and Diagnosis of Developmental Dysplasia of the Hip: Insights From a Children's Hospital Serving Disadvantaged Communities

INTRODUCTION

Initiation of Pavlik harness treatment for developmental dysplasia of the hip (DDH) by 6 to 7 weeks of age predicts a higher rate of success. Child Opportunity Index (COI) 2.0 is a single metric designed to measure resources and conditions affecting children's healthy development. This study investigates COI in relation to the timing of DDH diagnosis.

METHODS

This is a retrospective cohort study on patients younger than 4 years diagnosed with DDH between 2016 and 2023, treated with a Pavlik harness, rigid hip abduction orthosis, and/or surgery. Demographic and clinical data were recorded, including date of first diagnostic imaging. Patients with syndromes, congenital anomalies, or neuromuscular disorders and those referred with an unknown date of first diagnostic imaging were excluded. A subgroup analysis of patients diagnosed at ≤6 weeks ("early") and >6 weeks ("late") was conducted. Statewide COI scores (total, three domains) and categorical quintile scores (very low, low, moderate, high, and very high) were recorded.

RESULTS

A total of 115 patients were included: 90 female infants (78%), with a median age of 32 days at diagnostic imaging. No notable difference was observed between median age at diagnosis for study patients in low or very low quintiles and those in moderate, high, or very high quintiles for COI total or domains. "Early" and "late" diagnosis subgroups did not differ markedly by COI total or domains, nor insurance type, race, or ethnicity. Subgroups differed markedly by race and insurance status.

DISCUSSION

In an urban children's hospital, COI did not differ markedly between patients diagnosed with DDH by ≤6 weeks and >6 weeks. This is the first study to pose this question on DDH in a population with predominantly low/very low COI scores and public insurance, which may lead to unexpected results. Replicating the study in a different setting could yield different results.

LEVEL OF EVIDENCE

III.

Outcomes of treatment for developmental dislocation of the hip when the Pavlik method has failed

OBJECTIVES

Despite the success rate of the Pavlik method in the treatment of developmental dislocation of the hip, there is a subset of hips that do not reduce with harness use. The purpose of this study was to determine the outcomes after closed reduction (CR), open reduction (OR) and combined open reduction and pelvic osteotomy (OR+PO) in patients with infantile hip dislocations who initially failed the Pavlik method.

METHODS

This was a retrospective cohort study of patients with infantile hip dislocations who failed the Pavlik method and subsequently underwent a secondary procedure for persistent hip dislocation. The primary outcome measure was the Severin classification of the involved hip 3 years after the secondary procedure. Other outcomes assessed included rates of redislocation, residual acetabular dysplasia and proximal femoral growth disturbance.

RESULTS

Twenty-three patients were included; seven subsequently underwent CR, three underwent isolated OR and 13 proceeded directly to OR+PO. The overall successful outcome rate at final follow-up (as determined by radiographic Severin class I or II) was 11/23 (48%). However, patients undergoing OR+PO had significantly higher rates of successful outcomes (77%) compared with CR (15%) and OR (0%), P  < 0.05. The rate of residual acetabular dysplasia and proximal femoral growth disturbance was significantly lower in patients treated with OR+PO compared with CR and isolated OR, P  < 0.05.

CONCLUSION

Patients with dislocated hips who failed Pavlik harness treatment had better radiographic outcomes 3 years after OR+PO in comparison to patients undergoing CR or isolated OR.

Prevalence of Acetabular Dysplasia at a Mean age of 18 Years After Treatment for Neonatal hip Instability

BACKGROUND

The long-term radiological outcomes after the treatment of neonatal hip instability (NHI) in developmental dysplasia of the hip are unclear. Therefore, the prevalence of acetabular dysplasia at a mean age of 18 years after treatment was investigated. The relationship between acetabular dysplasia and hip discomfort has also been poorly established. Therefore, the differences in pain, hip-related quality of life (QOL), and hip impingement tests in hips with and without acetabular dysplasia were assessed.

METHODS

All 127 patients treated for NHI from 1995 to 2001 at the study hospital and meeting the inclusion criteria were invited to participate in this population-based follow-up. Of these individuals, 88 (69.3%) participated. The lateral center-edge angle (LCEA), Sharp's angle (SA), and acetabular head index (AHI) were calculated for both hips from pelvic anterior-posterior radiographs. The Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire was completed for both hips separately; the total score, pain, and QOL subscores were calculated; and the impingement test was performed.

RESULTS

The prevalence of acetabular dysplasia, defined as an LCEA <20°, was 3.4%. Only the mean AHI (81.1%, SD 5.3) differed (-5.08, 95% CI -5.77 to -4.38, P <0.001) from previously described gender-specific and side-specific means, whereas the mean LCEA and SA did not. The odds ratio for a positive hip impingement test was 2.8 (95% CI: 1.11-7.05, P = 0.029) for hips with an LCEA <25° compared to hips with LCEA ≥25°. The hips with an SA ≥45° had a mean of 7.8 points lower for the HAGOS pain subscore (95% CI: 4.2-11.4, P <0.001) and a mean of 6.1 points lower for the HAGOS QOL subscore (95% CI: 2.1-10.2, P = 0.003) compared with hips with an SA <45°.

CONCLUSIONS

The prevalence of acetabular dysplasia was low after treatment for NHI. Acetabular dysplasia seems to be as common in the general population as for those treated for NHI based on the LCEA. Only an SA ≥45° resulted in slightly more pain and lower hip-related QOL.

Study on the efficacy of brace therapy for developmental dysplasia of the hip with Graf IIc and greater severity

To assess changes in the α and β angle with brace treatment in DDH classified as Type Graf IIc, D, III, and IV; to study the α angle threshold that can predict the treatment effect; to analyze the effective rate in different groups. A retrospective study was conducted on children from 2013 to 2018 with Graf type IIc and greater diagnosed with ultrasound (US). Brace therapy was applied to 356 patients, with 423 affected hips (Graf IIc: 202 hips; Graf D: 17 hips; Graf III: 118 hips; and Graf IV: 86 hips). For follow-up efficacy analyses using US, X-ray and clinical examination, based on the success of early treatment of the brace, the outcomes were divided into 'effective' and 'noneffective' groups. The statistical results showed that the α angle increased ( P  < 0.05) and the β angle decreased ( P  < 0.05). When α≥43°, the accuracy of success with early treatment was 95.95%. The overall effective rate of bracing treatment was 74.70%. Children with α ≥ 43° are recommended to receive brace therapy as soon as possible and demonstrate the best effects. The effective rate varies across different Graf types and the age at treatment initiation. Brace therapy is more effective for Graf IIc and D hips compared to Graf III and IV.

Does This Infant Have a Dislocated Hip?: The Rational Clinical Examination Systematic Review

Importance

Delayed diagnosis of a dislocated hip in infants can lead to complex childhood surgery, interruption to family life, and premature osteoarthritis.

Objective

To evaluate the diagnostic accuracy of clinical examination in identifying dislocated hips in infants.

Data Sources

Systematic search of CINAHL, Embase, MEDLINE, and the Cochrane Library from the inception of each database until October 31, 2023.

Study Selection

The 9 included studies reported the diagnostic accuracy of the clinical examination (index test) in infants aged 3 months or younger and a diagnostic hip ultrasound (reference test). The Graf method of ultrasound assessment was used to classify hip abnormalities.

Data Extraction and Synthesis

The Rational Clinical Examination scale was used to assign levels of evidence and the Quality Assessment of Diagnostic Accuracy Studies tool was used to assess bias. Data were extracted using the individual hip as the unit of analysis; the data were pooled when the clinical examinations were evaluated by 3 or more of the included studies.

Main Outcomes and Measures

Sensitivity, specificity, and likelihood ratios (LRs) of identifying a dislocated hip were calculated.

Results

Among infants screened with a clinical examination and a diagnostic ultrasound in 5 studies, the prevalence of a dislocated hip (n = 37 859 hips) was 0.94% (95% CI, 0.28%-2.0%). There were 8 studies (n = 44 827 hips) that evaluated use of the Barlow maneuver and the Ortolani maneuver (dislocate and relocate an unstable hip); the maneuvers had a sensitivity of 46% (95% CI, 26%-67%), a specificity of 99.1% (95% CI, 97.9%-99.6%), a positive LR of 52 (95% CI, 21-127), and a negative LR of 0.55 (95% CI, 0.37-0.82). There were 3 studies (n = 22 472 hips) that evaluated limited hip abduction and had a sensitivity of 13% (95% CI, 3.3%-37%), a specificity of 97% (95% CI, 87%-99%), a positive LR of 3.6 (95% CI, 0.72-18), and a negative LR of 0.91 (95% CI, 0.76-1.1). One study (n = 13 096 hips) evaluated a clicking sound and had a sensitivity of 13% (95% CI, 6.4%-21%), a specificity of 92% (95% CI, 92%-93%), a positive LR of 1.6 (95% CI, 0.91-2.8), and a negative LR of 0.95 (95% CI, 0.88-1.0).

Conclusions and Relevance

In studies in which all infant hips were screened for developmental dysplasia of the hip, the prevalence of a dislocated hip was 0.94%. A positive LR for the Barlow and Ortolani maneuvers was the finding most associated with an increased likelihood of a dislocated hip. Limited hip abduction or a clicking sound had no clear diagnostic utility.

Incidence of Nerve Palsies During Pavlik Harness Treatment for Developmental Dysplasia of the Hip: A Retrospective Cohort Study

BACKGROUND

The Pavlik harness has been used for approximately a century to treat developmental dysplasia of the hip (DDH). Femoral nerve palsy is a documented complication of Pavlik harness use, with an incidence ranging from 2.5% to 11.2%. Rare reports of brachial plexus palsy have also been documented. The primary purpose of the current study was to evaluate the incidence of various nerve palsies in patients undergoing Pavlik harness treatment for DDH. Secondary aims were to identify patient demographic or hip characteristics associated with nerve palsy.

METHODS

We performed a retrospective review of patients diagnosed with DDH and treated with a Pavlik harness from February 1, 2016, to April 1, 2023, at a single tertiary care orthopaedic hospital. Hip laterality, use of a subsequent rigid abduction orthosis, birth order, breech positioning, weight, and family history were collected. The median (and interquartile range [IQR]) or mean (and standard deviation [SD]) were reported for all continuous variables. Independent 2-sample t tests and Mann-Whitney U tests were conducted to identify associations between the variables collected at the initiation of Pavlik harness treatment and the occurrence of nerve palsy.

RESULTS

Three hundred and fifty-one patients (547 hips) were included. Twenty-two cases of femoral nerve palsy (4% of all treated hips), 1 case of inferior gluteal nerve palsy (0.18%), and 2 cases of brachial plexus palsy (0.37%) were diagnosed. Patients with nerve palsy had more severe DDH as measured by the Graf classification (p < 0.001) and more severe DDH as measured on physical examination via the Barlow and Ortolani maneuvers (p = 0.003).

CONCLUSIONS

Nerve palsies were associated with more severe DDH at the initiation of Pavlik harness use. Upper and lower-extremity neurological status should be scrutinized at initiation and throughout treatment to assess for nerve palsies. The potential for femoral, gluteal, and brachial plexus palsies should be included in the discussion of risks at the beginning of treatment. Families may be reassured that nerve palsies associated with Pavlik harness can be expected to resolve with a short break from treatment.

LEVEL OF EVIDENCE

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

Comparison of outcomes of different Graf grades of developmental dysplasia of the hip in infants treated with Tubingen splint versus Pavlik harness - A systematic review

This systematic review was designed to compare the outcomes of the two braces against each other classified by the Graf method. The databases sources included PubMed, Embase, and Google Scholar. The keywords included "DDH Tubingen versus Pavlik" and Tubingen and Pavlik separately. Included papers provided specific data regarding success and failure rate, avascular necrosis (AVN), duration, and age of intervention. The excluded studies discussed surgeries, diagnosis and mechanism, and ones that weren't in English. Total of 20 papers were included, resulting in 1243 Tubingen and 420 Pavlik samples. It was seen that the Tubingen splint had a statistically significant greater success rate and lower failure rate for Graf 2, D, and 3 hips, while both braces were not very successful for Graf 4 at success rates less than 60 %. Tubingen also had a lower incidence of AVN. Both braces shared similar ages of intervention, duration, and time per day. Both braces are very comparable to each other, each having better success rates for lower Graf grades, which points to the importance of bracing earlier to improve the success rates. The Tubingen splint had a higher success rate, lower failure rate, and lower AVN rate compared to the Pavlik harness. This points to the Tubingen splint potentially being the preferred option for bracing in infants.

Length of treatment and ultrasound timing in infants with developmental dysplasia of the hip

PURPOSE

Developmental dysplasia of the hip (DDH) joint is a complex condition that may lead to severe problems. Ultrasound scan (USS) in the first four-to-six weeks of life is considered the gold-standard for diagnosis while the Pavlik harness (PH) is a widely utilized method as first-line treatment. The purpose of this study is to compare clinical outcomes of infants with DDH in relation to the timing and frequency of USS following application of the PH.

METHODS

Retrospective data were collected over a 5-year period from February 2017 to February 2022. We included patients who underwent the first USS post-diagnosis and PH application in two, three, four and six weeks. Two-hundred-twenty-five patients were included and divided in four groups according to timing of the first follow-up: week-2, n = 13; week-3, n = 66; week-4, n = 95; and week-6, n = 51. For every patient Graf classification, treatment length and number of follow-ups were documented.

RESULTS

Week-3 and week-4 groups displayed a statistically significant shorter treatment length compared to week-6 group (p value < 0.001), while also demonstrating a lower number of sonographic follow-ups per patient compared to both week-6 (p value < 0.001) and week-2 (p value = 0.002 vs week-3; p value < 0.001 vs week 4). Week-4 group presented the highest treatment completion (56%) on first visit post-diagnosis. Conservative treatment with PH failed in 1.8% (4/225) and displayed no significant difference among all subgroups.

CONCLUSIONS

Differences in timing of first USS post-DDH diagnosis and initiation of treatment can lead to discrete outcomes with implications to the clinical outcome and cost effectiveness.

Acetabular index as an indicator of Pavlik harness success in grade I developmental dysplasia of the hip: A retrospective study

Purpose

Some articles have focused on the effectiveness of the Pavlik harness treatment for unstable and dislocated hips, yet data on monitoring its effectiveness with the acetabular index remains elusive. Therefore, this study aimed to assess Pavlik harness effectiveness in infants ≤6 months diagnosed with grade I developmental dysplasia of the hip using acetabular index improvement and identify the possible predictors of successful Pavlik harness treatment.

Methods

A retrospective review of infants with grade I acetabular dysplasia treated with a Pavlik harness and monitored with anteroposterior pelvis X-rays at presentation and follow-up. Successful treatment was defined as achieving an acetabular index <30°.

Results

A total of 231 infants with acetabular dysplasia were treated with a Pavlik harness. A successful outcome was achieved in 135 infants (58.4%). Younger age, lower initial acetabular index, and patients with unilateral developmental dysplasia of the hip were significant predictors of a successful outcome. An age of 4.5 months or older was found to be the threshold for an unsuccessful result following Pavlik harness treatment, with a sensitivity of 65.2% and specificity of 57.3%. An initial acetabular index of 35.5° was found to be the threshold for an unsuccessful result, with a sensitivity of 83.7% and specificity of 61.5%.

Conclusion

Pavlik Harness's success in correcting the acetabular index in acetabular dysplasia patients was related to unilateral cases, a younger age at presentation, and a lower initial acetabular index. The thresholds for unsuccessful treatment were an age of 4.5 months or greater and an acetabular index of 35.5° or higher.

Neonatal clinical examination and selective ultrasound screening are not reliable for the early diagnosis of hip dysplasia: A retrospective cohort study

AIM

To compare the incidence, clinical features and timing of initial treatment of early- and later-presenting developmental dysplasia of the hip (DDH) in infancy in the context of a risk-based selective ultrasound screening programme.

METHODS

We conducted a retrospective observational study of infants born at a tertiary perinatal centre in Melbourne, Australia, between July 2016 and June 2020 and treated for DDH up to 18 months of age at a tertiary paediatric centre. The incidence of DDH was calculated for early- and later-presenting cases. Clinical features and ultrasound indications were analysed using multivariate logistic regression.

RESULTS

There were 192 infants with DDH requiring treatment, 100 (52%) of which were not detected by universal neonatal hip examination and selective ultrasound screening based on risk factors (overall incidence 6.3 per 1000 livebirths). The median age at which treatment was commenced was delayed by 8 weeks for the later-presenting group compared to those detected through screening (16.7 vs. 7.9 weeks, P < 0.001). Skin crease asymmetry was associated with later presentation (adjusted odds ratio (aOR) 44.03, 95% confidence interval (CI) 9.99-333), whilst breech presentation (aOR 0.08, 95% CI 0.02-0.26) and Barlow/Ortolani test positivity (aOR 0.06, 95% CI 0.01-0.25) were associated with early presentation. Only 39 (1.45%) infants receiving a screening ultrasound had DDH.

CONCLUSION

Approximately half of all infants with DDH were not detected by combining risk-based selective ultrasound screening with neonatal clinical findings, highlighting the failure of this screening method to reliably detect a significant proportion of dysplastic infant hips.

Prognostic factors for failed Pavlik harness treatment in infants with developmental dysplasia of the hip: a retrospective cohort study

PURPOSE

Pavlik harness treatment is the most common treatment in newborns diagnosed with developmental dysplasia of the hip (DDH). The success rates and predictors for failure have been debated over the last decade. In this study, we explored our treatment failure rate and potential prognostic factors that could predict the failure of Pavlik harness (PH) treatment in patients with DDH.

METHODS

Two hundred and sixty-five patients were treated with PH based on the Graf hip types of classification. Age, gender, first born status, family history, foot deformity, plagiocephaly, breech presentation, hip abduction, hip stability, Graf hip type, Galeazzi sign, bilateralism, and femoral nerve palsy were tested as predictors for failure in multivariate logistic regression mode. Success and failure were determined by the normalization of the hip based on the Graf hip classification.

RESULTS

The failure rate of patients treated with Pavlik harness was 16.6% which is within the reported range of failure rate. The mean age of patients who were successfully treated was 6.73 weeks in comparison to 8.84 weeks for those who failed. Age, plagiocephaly, hip instability, Graf classification, and the development of femoral nerve palsy were found to be predictors for failure of PH treatment upon univariate analysis only. However, only the presence of Galeazzi sign, hip instability, high grades of Graf hip classification, and the development of femoral nerve palsy proved to be independent predictors for failed PH treatment upon multivariate logistic regression analysis.

CONCLUSIONS

Pavlik harness treatment is a successful treatment with an average success of 83.4%. Several independent predictors for failure of PH treatment have been identified. These include a positive Galeazzi sign, a frankly dislocated hip, Graf types III and IV, and the development of femoral nerve palsy.

The impact of the introduction of selective screening in the UK on the epidemiology, presentation, and treatment outcomes of developmental dysplasia of the hip

Aims

Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population.

Methods

We conducted a systematic review and meta-analysis of the epidemiological literature from the last 25 years in the UK. Articles were selected from databases searches using MEDLINE, EMBASE, OVID, and Cochrane; 13 papers met the inclusion criteria.

Results

The incidence of DDH within the UK over the last 25 years is 7.3/1,000 live births with females making up 86% of the DDH population (odds ratio 6.14 (95% confidence interval 3.3 to 11.5); p < 0.001). The incidence of DDH significantly increased following the change in the Newborn and Infant Physical Examination (NIPE) guidance from 6.5/1,000 to 9.4/1,000 live births (p < 0.001). The rate of late presentation also increased following the changes to the NIPE guidance, rising from 0.7/1,000 to 1.2/1,000 live births (p < 0.001). However, despite this increase in late-presenting cases, there was no change in the rates of surgical intervention (0.8/1,000 live births; p = 0.940).

Conclusion

The literature demonstrates that the implementation of a selective screening programme increased the incidence of DDH diagnosis in the UK while subsequently increasing the rates of late presentation and failing in its goal of reducing the rates of surgical intervention for DDH.

Residual acetabular dysplasia after Pavlik harness treatment for Graf type II hips

Purpose

To evaluate the residual acetabular dysplasia in Graf type II hips after Pavlik harness treatment with a radiographic follow-up at 2 years of age.

Methods

We retrospectively reviewed the developmental dysplasia of the hip patients who were treated with the Pavlik harness between March 2018 and February 2022. Patients with Graf type II hip dysplasia who had at least one radiographic follow-up after 2 years of age were included. The following information, sex, laterality, affected side, age at harness initiation, treatment duration, α angle, and the morphology of bony roof, was collected and studied. We evaluated the radiographic acetabular index at the last follow-up and defined the value of greater than 2 standard deviations as residual acetabular dysplasia.

Results

A total of 33 patients (53 hips) met the criteria. The mean initial α angle was 53.4°; the mean age at Pavlik harness initiation was 10.9 weeks. The mean treatment duration was 10 weeks. The mean α angle at the last ultrasound follow-up was 64.9°. The mean age of the last radiographic follow-up was 2.6 years, and 26 hips had a residual acetabular dysplasia with acetabular indexes greater than 2 standard deviations above the mean. The morphology of the acetabular bony rim (odds ratio = 4.333, P = 0.029) and age of initial treatment <12 weeks (odds ratio = 7.113, P = 0.014) were seen as significant predictors for a higher acetabular index more than 2 years of age.

Conclusions

A notable incidence of residual acetabular dysplasia after Pavlik harness treatment in Graf type II hips, wherein the acetabular bony roof with a blunt rim at the end of treatment and initial age after 12 weeks were independent predictors associated with residual acetabular dysplasia.

Levels of evidence

Therapeutic studies, IV.

The Significance of Isolated Hip Click as a Sign of DDH: Implications on Referral Guidelines

BACKGROUND

The clinical significance of an isolated hip click remains unclear. The rates of developmental dysplasia of the hip (DDH) in those referred for hip click vary from 0% to 28%. The purpose of this study was to evaluate the rate of DDH in patients prospectively referred for isolated hip click.

METHODS

We prospectively enrolled patients referred to a single pediatric orthopaedic center with concern for DDH secondary to isolated hip click felt by the pediatrician on examination. Patients with known sonographic abnormalities or risk factors for DDH (breech presentation or positive family history) were excluded. Ultrasounds were obtained upon initial presentation and defined as abnormal if alpha angle <60 degrees and/or femoral head coverage (FHC) <50%. Mild dysplasia, analogous to Graf IIa physiological immaturity, was defined as alpha angle 50<α<60 and/or <50% FHC in a patient <3 months age. Severe dysplasia was defined as ≤33% FHC, which has been proposed to be sonographically consistent with a hip dislocation.

RESULTS

Two hundred fifty-five children were referred for isolated hip click. One hundred eighty-nine patients (74%) had normal ultrasound whereas 66 patients (26%) had sonographic abnormalities (mean age 6.5±6.2 wk at initial ultrasound). Fifty patients (19.6%) demonstrated physiological immaturity, 3 patients (1.2%) demonstrated moderate sonographic dysplasia, and 13 patients (5.1%) had sonographic findings consistent with severe dysplasia or dislocated hip. Hips with severe dysplasia were younger than the remaining population (2.8±2.4 wk vs. 6.6±6.2 wk, P <0.001) with no difference in sex distribution ( P =0.07) or first-born birth order ( P =0.36). For those with sonographic abnormality, 18 (27%) patients were treated with Pavlik harness, 1 (2%) was treated with abduction orthosis, and the remainder (71%) were observed for resolution of physiological immaturity.

CONCLUSIONS

Infants with isolated hip click identified by their pediatrician may have higher rates of dysplasia than previously reported. We recommend screening ultrasound and/or orthopaedic referral for all infants with isolated hip click.

LEVEL OF EVIDENCE

Level II-prospective prognostic study.

Femoral nerve palsy during Pavlik harness treatment for developmental dysplasia of the hip is not an indication for harness abandonment

Objectives

The aim of this study was to report the incidence of femoral nerve palsy in developmental dysplasia of the hip children treated with Pavlik harness, to identify any possible associated risk factors, and to evaluate its outcome without any specific strap release.

Methods

A retrospective chart review was conducted on all cases of femoral nerve palsy in a consecutive series of children who underwent Pavlik harness treatment for developmental dysplasia of the hip. In unilateral cases, the developmental dysplasia of the hip was compared to the contralateral side. All hips with femoral nerve palsy were compared to the remaining hips of the series and any possible risk factor for paralysis was recorded.

Results

In total, 53 cases of femoral nerve palsy of various severity were identified from a group of 473 children with 527 hips treated for developmental dysplasia of the hip at an average age of 3.9 months. However, 93% occurred during the first 2 weeks of treatment. Femoral nerve palsy was more common in older and larger children with the most severe Tonnis type, and a hip flexion angle in the harness above 90° (p < 0.03 for all). All of them resolved spontaneously before completion of treatment without any specific measures. We found no correlation between the presence of femoral nerve palsy or the time taken for spontaneous resolution and treatment failure using the harness.

Conclusion

Femoral nerve palsy is most observed with higher Tonnis types and high hip flexion angles in the harness, but its presence by itself is not predictive of treatment failure. It resolves spontaneously before completion of treatment and does not require any strap release or harness discontinuation.

Level of evidence

Level III.

Active monitoring versus an abduction device for treatment of infants with centered dysplastic hips: study protocol for a randomized controlled trial (TReatment with Active Monitoring (TRAM)-Trial)

BACKGROUND

Developmental Dysplasia of the Hip (DDH) is one of the most common pediatric orthopedic disorders, affecting 1-3% of all newborns. The optimal treatment of centered DDH is currently under debate. This randomized controlled trial aims to study the (cost-)effectiveness of active monitoring versus abduction treatment for infants with centered DDH.

METHODS

This is a multicenter, parallel-group, open-label, non-inferiority randomized controlled trial studying the (cost-)effectiveness of active monitoring versus abduction treatment for infants with centered DDH in fourteen hospitals in the Netherlands. In total, 800 infants with centered DDH (Graf IIa-/IIb/IIc), aged 10-16 weeks, will be randomly allocated to the active monitoring or abduction treatment group. Infants will be followed up until the age of 24 months. The primary outcome is the rate of normal hips, defined as an acetabular index lower than 25 degrees on an antero-posterior radiograph, at the age of 12 months. Secondary outcomes are the rate of normal hips at the age of 24 months, complications, time to hip normalization, the relation between baseline patient characteristics and the rate of normal hips, compliance, costs, cost-effectiveness, budget impact, health-related quality of life (HRQoL) of the infant, HRQoL of the parents/caregivers, and parent/caregiver satisfaction with the treatment protocol.

DISCUSSION

The outcomes of this randomized controlled trial will contribute to improving current care-as-usual for infants with centered DDH.

TRIAL REGISTRATION

Dutch Trial Register, NL9714, registered September 6, 2021. https://clinicaltrialregister.nl/en/trial/29596.

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.

Intra- and interobserver variability of novel magnetic resonance imaging parameters for hip screening and treatment outcomes at age 5 years

BACKGROUND

The outcome measure of neonatal hip screening is usually the radiographic acetabular index.

OBJECTIVE

To assess the feasibility of magnetic resonance imaging (MRI) without sedation and compare the utility of outcome parameters measured from MRI images.

MATERIALS AND METHODS

The invitation for MRI scanning at 5 years of age was incorporated into follow-up for babies who had more than one ultrasound examination during treatment or surveillance.

RESULTS

Diagnostic images were obtained in 132 of 134 children. The mean osseous acetabular index (standard deviation [SD]) was 16.6 (3.3) degrees for the right hip and 17.8 (3.2) for the left; the values for the cartilaginous acetabular index were 3.1 (3) and 3.4 (3.2). The mean downslope of a tangent to the lateral bony acetabular roof was 10.4 (4.5) and 9.0 (4.3) with respect to Hilgenreiner's line and that of a line drawn through the apex to the margin of the acetabulum was 3.7 (4.6) and 3.9 (4.7). Intra- and interobserver variation was greater for measures specific to the lateral acetabular roof than for ossific and cartilaginous indices. There was significant negative correlation between the downslope of the tangent to the lateral roof index and the age at onset of treatment on both sides, but no significant correlation for ossific or cartilaginous acetabular indices or apex-marginal index.

CONCLUSION

MRI without sedation at 5 years of age is feasible as an outcome measure for hip screening programmes. Parameters specific to the lateral acetabulum may better reflect acetabular sufficiency, despite having greater observer variation than cartilaginous and ossific acetabular indices.

Developmental retardation of femoral head size and femoral head ossification in mild and severe developmental dysplasia of the hip in infants: a preliminary cross-sectional study based on ultrasound images

Background

For infants up to 6 months, ultrasound (US) screening of developmental dysplasia of the hip (DDH) is recommended. This cross-sectional study investigated the developmental data of femoral head size and femoral head ossification in mature infant hips and the impact of mild and severe DDH on femoral head development based on US images.

Methods

We reviewed all hip US studies performed from January 2018 to December 2019 to evaluate DDH in infants younger than 6 months at West China Hospital, Sichuan University. The femoral head diameter (FHD) and femoral head ossification center type of each hip were recorded. A total of 1,037 normal participants with 2,074 mature hips and 367 DDH participants with 456 dysplastic hips were included in this study.

Results

For normal mature hips (Graf I), the FHD of mature male hips was significantly larger than that of female hips from the age of 2 months to 6 months (all P values <0.01), and the femoral head ossification center of males occurred significantly later than that of females at the same age from 3 months to 6 months (all P values <0.05). Compared with the matched mature hips, the FHDs of Graf IIa (-), IIb, IIc, and D, III or IV hips were significantly smaller (1.64 vs. 1.72 cm, 1.75 vs. 1.79 cm, 1.65 vs. 1.73 cm, 1.51 vs. 1.71 cm, respectively; all P values <0.05), and the occurrence of the femoral head ossification center was delayed in Graf IIa (-) and D, III or IV hips (both P values <0.05). However, no significant developmental retardation of the femoral head was observed in Graf IIa (+) hips.

Conclusions

We identified a relatively normal range for the development of infants' hips from 1 month old to 6 months old and found significant developmental retardation of the femoral head in Graf IIa (-), IIb, IIc, and D, III or IV hips. This is a preliminary study of the developmental impact of DDH on the femoral head, and we will continue the follow-up study after treatment.

Clinical and sonographic improvement of developmental dysplasia of the hip: analysis of 948 patients

BACKGROUND

Developmental dysplasia of the hip is a common condition, which varies in severity. Abduction treatment is widely used to correct the development of the hips, but mild forms of DDH can also recover spontaneously. The purpose of this study was to evaluate factors affecting the rate of improvement of developmental dysplasia of the hip, and evaluate any risk factors slowing the process.

MATERIAL AND METHODS

The study population consisted of patients diagnosed with DDH in Tampere University hospital in the years 1998-2018. Data were retrospectively collected, and associations between clinical variables and rate of improvement were analyzed. Alpha angles were assessed monthly, and associations between risk factors and improvement of alpha angles were studied. A total of 948 patients were included in the analysis.

RESULTS

More severe first status of the hips was associated with faster improvement in dynamic ultrasound compared to milder DDH in univariate design in first 3 months of age; in the multivariable design, Ortolani positivity was conversely associated with lower alpha angles in 1-month follow-up. Immediate abduction treatment was associated with faster recovery rate compared to delayed abduction or watchful waiting. Female sex and positive family history were associated with slower rate of improvement and lower alpha angles. In multivariable design, female sex, positive family history and treatment strategy remained statistically significant as initiation time of the treatment explained the first found association of clinical hip status and the recovery rate after 2 months of age.

CONCLUSION

Female sex and positive family history might be independent risk factors for slower recovery in DDH before 6 months of age. These children might need special attention in their follow-up plans and abduction treatment.

Knowledge and Practices Related to Hip-Healthy Swaddling for Newborns Among Maternity Nurses

OBJECTIVE

To assess the self-reported knowledge, education, and practices related to hip-healthy swaddling of newborns among nurses, how they teach this technique to parents, and the relationships among these factors.

DESIGN

Descriptive cross-sectional exploratory survey.

SETTING

Academic women and children's hospital with an average of 4,500 annual births.

PARTICIPANTS

One hundred four registered maternity nurses who work primarily in the maternity unit.

METHODS

At three staff meetings, we surveyed maternity nurses to determine their knowledge, education, and practices related to hip-healthy swaddling and how they teach this technique to parents. We analyzed results using descriptive statistics and chi-square and Fisher's exact tests.

RESULTS

Of the 156 nurses in the maternity unit, 104 attended three staff meetings and completed the survey. Among the participants, 18.9% (18/95; 9 participants did not respond) were unable to identify the correct hip swaddling position. Overall, 64.2% (61/95; 9 participants did not respond) reported that they received education on general swaddling technique, yet 14.8% (9/61) of these participants were unable to identify the correct hip-healthy swaddling position. Among the participants, 99.0% (103/104) reported that nurses teach parents how to swaddle infants rather than other health care providers; 12.5% (13/104) of participants responded that medical doctors provide training as well. Overall, 67.0% (69/103; 1 participant did not respond) reported that they taught parents in >75% of parent interactions.

CONCLUSION

Our results illustrate a gap in knowledge about hip-healthy swaddling among the maternity nurses who participated in this survey and a need for further education.

Radiological predictors associated with success of treatment for developmental dysplasia of hip using the Pavlik harness: A retrospective study

BACKGROUND

While various predictors of treatment outcome of Pavlik harness have been reported, appropriate indications for treatment and relationships between patient characteristics and outcome are unclear. The present study aimed to identify radiological predictors for successful Pavlik harness treatment of DDH at the initiation of treatment and investigate the progression of radiological characteristics after successful treatment.

METHODS

One-hundred-forty-two of 527 infants who visited our hospital for secondary screening of DDH were treated with the Pavlik harness. One-hundred-eight hips of 108 infants experienced successful treatment and could be followed up until 3 years of age (group S); treatment was unsuccessful within the first 2 weeks for 22 hips of 21 infants (group F). We investigated the Graf classification and radiological parameters.

RESULTS

We observed the ipsilateral-side measurements of distance A and B as defined by Yamamuro and Chene's method to be significantly smaller and greater, respectively, in group F compared with those of group S. Group F tended to exhibit the smaller distance A and larger distance B compared to the group S among the same Graf type. The cut-off values for successful treatment at were >7.4 mm at initiation of treatment for distance A and <11.2 mm for distance B. The acetabular index (AI) of the ipsilateral side at the initiation of treatment was significantly correlated with that at 1 and 3 years of age. Patients with an AI of >32° at the initiation of harness treatment were more likely to exhibit hip dysplasia at 3 years of age.

CONCLUSIONS

Radiographic parameters prior to the Pavlik harness could be predictors of treatment failure and DDH in the future. This study showed that AI at the initiation of treatment is associated with residual acetabular dysplasia, suggesting that radiographic assessment may be useful even considering the risks associated with radiation exposure.

Impact of Multiple Factors on the Incidence of Developmental Dysplasia of the Hip: Risk Assessment Tool

Background and Objectives: Developmental dysplasia of the hip (DDH) is one of the most common musculoskeletal conditions in children. If not treated, it leads to disability, gait abnormalities, limb shortening, and chronic pain. Our study aims to determine the impact of multiple risk factors on the incidence of DDH and to develop an interactive risk assessment tool. Materials and Methods: We conducted a retrospective cohort study in the Outpatient Clinic for Children of the Medical University of Warsaw Hospital. The Graf classification system was used for universal ultrasonographic screening. In total, 3102 infants met the eligibility criteria. Results: The incidence of DDH in the study group was 4.45%. The incidence of DDH in the Warsaw population, Poland, during the study period was 3.73 to 5.17 (95% CI). According to the multivariate analysis, the risk factors for DDH were birth weight (OR = 2.17 (1.41−3.32)), week of delivery (OR = 1.18 (1.00−1.37)), female sex (OR = 8.16 (4.86−13.71)), breech presentation (OR = 5.92 (3.37−10.40)), physical signs of DDH (25.28 (8.77−72.83)) and positive family history in siblings (5.74 (2.68−12.31)). Our results support the recent hypothesis that preterm infants (<37 weeks) have a lower rate of DDH. Conclusions: A multivariate logistic regression predictive model was used to build the risk calculator. The DDH risk calculator will be evaluated in a prospective validation study.

Twelve-week standard of care protocol longer than median time to normalization among IIc hips treated with Pavlik harness

Best treatment protocols for infants with developmental dysplasia of the hip (DDH) are poorly defined. This study estimates the time to normalization among Graf IIc hips undergoing Pavlik harness treatment. Following institutional review board approval, patients referred for DDH evaluation at a pediatric institution between 2009 and 2018 (n = 1424 hips/712 patients) were identified. We isolated all Graf IIc hips that underwent Pavlik harness treatment (n = 132 hips/n = 106 patients). Demographic and outcome measures were collected. Normalization was defined as alpha angle greater than or equal to 60° and femoral head coverage greater than or equal to 50%. Kaplan-Meier and Cox proportional hazards regression analyses modeled time to normalization and identified factors associated with earlier normalization. Median time to normalization was 7.0 weeks. At 12 weeks standard treatment, 85.8% [95% confidence interval (CI): 80.2-91.9%] had normalized. Greater femoral head coverage [hazard ratio (HR) per 1% increase: 1.03; 95% CI: 1.01-1.05; P = 0.0068] and hip stability at treatment initiation (HR unstable vs. stable: 0.64; 95% CI: 0.44-0.93; P = 0.0192) were associated with longer time to normalization. Some patients may not need 12 weeks of Pavlik bracing, particularly those with stable presentation who normalize before week 12. Shorter treatment lengths offer benefit without sacrificing long-term outcomes. Findings reinforce growing evidence that femoral head coverage should be a more significant consideration during diagnosis and instability is a concerning finding on examination.

An evaluation of clinical and ultrasound results of Pavlik harness treatment for developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) is the instability or dislocation of the hip joint at birth that may occur in utero, during infancy, and childhood. This condition was identified as an important challenge. This study aimed to determine the clinical and ultrasound results of Pavlik harness treatment for DDH in patients referred to the pediatric clinic of Imam Khomeini Hospital in Ahvaz. This is a descriptive cross-sectional study in which 100 newborns aged 15 to 30 days were included by the census method after obtaining parental consent. Follow-up of the infants was performed at 3 and 6 months after treatment. All analyzes were performed using SPSS version 22 at a significance level of 0.05. The results showed that the mean age of the infants was 23.46±2.12 days, of which 33 infants were boys and 67 girls. The involvement on the right and left sides was 39% and 50%, respectively, and 11% of the infants had bilateral involvement. The mean value of acetabular index before placement was 25.48±6.509 and 26.38±3.866 on the right and left sides, which after 3 months of placement, was reduced to 21.62±2.578 and 21.57±2.839, respectively. Pavlik harness treatment was associated with acceptable radiological results in infants. This technique seems to be a suitable and applicable attempt to treat this problem and prevent serious and irreversible complications of late diagnosis.

Does a Graf Type-I Hip Justify the Discontinuation of Pavlik Harness Treatment in Patients with Developmental Dislocation of the Hip?

Background: To analyze the clinical data of patients aged < 6 months with developmental dislocation of the hip (DDH) treated with Pavlik Harness (PH) in order to identify the best time to terminate PH treatment. Method: Fifty-four patients (47 females, 7 males; 63 hips) met the inclusion criteria and were included in the study; there were 33 (61.1%) left, 12 (22.2%) right and 9 (16.7%) bilateral DDH. The mean age at diagnosis was 11.8 ± 5.9 weeks (range, 1.4−25.5). All patients underwent fulltime PH treatment for about three months. At completion of PH treatment, patients were then divided into Group A, including patients with clinically stable hip joint and Graf type-I hip on ultrasound (US), and Group B, including patients with clinically stable hip joint and well-reduced hip on anterior-posterior (AP) radiographs without acetabular dysplasia. Six months after completion of PH treatment, the presence/absence of residual acetabular dysplasia (RAD) was evaluated on AP pelvis radiographs. The t-test and chi-square test were used to compare the differences in age, gender, side, Graf classification and RAD rate between the two groups of patients. Results: At completion of PH treatment, 45 hips were in Group A and 18 in Group B. There were no significant differences in age, gender, side, preoperative alpha angle and Graf classification between the two groups. Six months after discontinuation of PH, the AI in Group A (27.1° ± 6.8°) was significantly higher than that in Group B (21.9° ± 3.5°; p = 0.001); moreover 23 hips (51.1%) in Group A developed RAD compared to one hip in Group B (5.6%; p = 0.001). Among Group A patients, those with RAD were significantly older (13.7 ± 4.9 weeks) than those with normal hips (7.6 ± 3.8 weeks; p < 0.001); the incidence of RAD was significantly lower in patients with Graf type-II D hips (22.2%) than in patients with Graf type-III (70%) and type-IV hips (71.4%; p = 0.006). However, logistic regression analysis identified age as the only risk factor for RAD. All 24 hips with RAD (24/63, 38.1%) were treated with abduction braces. At final follow-up, AI in Group A (20.5° ± 3.3°) was not significantly different from that in Group B (21.9° ± 3.3°; p = 0.132). At the last follow-up visit, five hips (11.1%) in Group A still had RAD, compared to none in Group B (p = 0.31). Conclusions: In patients with DDH treated by PH, Graf type-I on US is not an absolute timing to terminate PH treatment. In addition, patients ≥ 13 weeks had a high risk of RAD despite PH treatment as 51.1% of infants developed RAD during follow up. Follow-up radiographs should be requested in all patients achieving Graf type-I hips at completion of PH treatment.

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.

The Evolution of DDH Management in India

BACKGROUND

Developmental dysplasia of hip (DDH) is a relatively common disorder of the paediatric age group and can have a significant impact on the quality of life, if left untreated. Some research has been done in this field from India over the past many decades, thereby helping to attain the present state of knowledge about DDH. Through this review, an attempt was made to identify and acknowledge important contributions in this field from India.

PURPOSE

To provide some historical aspects and summarise the evidence developed in India concerning different facets of DDH since 1920.

METHODS

Information about the evolution of DDH management in India was collated from recollections of the senior author (ANJ), from existing records, and contributions from senior Paediatric Orthopaedic surgeons of the country. The Medline database was searched for Indian literature concerning different aspects of DDH. All studies published in English language were included. Included studies were categorised into original studies, reviews, book chapters, case series and case reports, and their contribution to the understanding of DDH was highlighted.

RESULTS

The analysis showed 63 published studies on DDH from India. The majority of publications occurred between 2011 and 2020. Retrospective cohort studies and reviews comprised 46% of the published literature.

CONCLUSION

There is a scarcity of research on DDH from India, with many knowledge gaps still prevalent. The overall quality of published literature is poor, with very few good quality original research. However, an increasing trend for research on different aspects of DDH was observed.

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.

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.

What is the Interobserver Reliability of an Ultrasound-enhanced Physical Examination of the Hip in Infants? A Prospective Study on the Ease of Acquiring Skills to Diagnose Hip Dysplasia

BACKGROUND

Developmental dysplasia of the hip (DDH) is the most common disorder found in newborns. The consequences of DDH can be mitigated with early diagnosis and nonoperative treatment, but existing approaches do not address the current training deficit in making an early diagnosis.

QUESTION/PURPOSE

Can ultrasound be taught to and used reliably by different providers to identify DDH in neonates?

METHODS

This was a prospective observational study of a series of neonates referred for an evaluation of their hips. An experienced clinician trained three second examiners (a pediatric orthopaedic surgeon, an orthopaedic resident, and a pediatrician) in performing an ultrasound-enhanced physical examination. The 2-hour training process included video and clinical didactic sessions aimed to teach examiners to differentiate between stable and unstable hips in newborns using ultrasound. The experienced clinician was a pediatric orthopaedic surgeon who uses ultrasound regularly in clinical practice. Materials required for training include one ultrasound device. A total of 227 infants (454 hips) were examined by one of the three second examiners and the experienced clinician (gold standard) to assess reliability. Of the 454 hips reviewed, there were 18 dislocations, 24 unstable hips, and 63 dysplastic hips, and the remainder had normal findings. The cohort was composed of a series of patients younger than 6 months referred to a specialty pediatric orthopaedic practice.

RESULTS

Ultrasound-enhanced physical examination of the hip was easily taught, and the results were reliable among different levels of providers. The intraclass correlation coefficient between the gold-standard examiner and the other examiners for all hips was 0.915 (p = 0.001). When adjusting for only the binary outcome of normal versus abnormal hips, the intraclass correlation coefficient was 0.97 (p = 0.001). Thus, the agreement between learners and the experienced examiner was very high after learners completed the course.

CONCLUSION

After a 2-hour course, physicians were able to understand and reliably examine neonatal children using ultrasound to assess for DDH. The success of the didactic approach outlined in this study supports the need for ultrasound-enhanced examination training for the diagnosis of DDH in orthopaedic surgery and pediatric residency core curriculums. Training programs would best be supported through established residency programs. Expansion of training more residents in the use of ultrasound-enhanced physical examinations would require a study to determine its efficacy. This finding highlights the need for further research in implementing ultrasound-enhanced physical examinations on a broader scale.

LEVEL OF EVIDENCE

Level II, diagnostic study.

Team Approach: Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of hip disorders, including neonatal instability, acetabular dysplasia, hip subluxation, and frank dislocation of the hip. It is a common disorder, with a reported incidence of between 0.1% and >10% of live births. Coordinated, interdisciplinary care is important to achieving successful outcomes. This starts with accurate assessment of risk factors in the prenatal period, thorough clinical examination by the primary care provider at all well-child visits, and early referral to a pediatric orthopaedic surgeon for prompt diagnosis and treatment. Early diagnosis and prompt treatment is critical for an excellent outcome. Ongoing, open communication between clinicians is essential for the effective coordination of care. Treatment options vary depending on the age of presentation. A Pavlik harness (dynamic hip abduction orthosis) is used for children up to 6 months of age. A more rigid abduction orthosis may be used if treatment with a Pavlik harness is unsuccessful, with a closed reduction and spica cast being the next step if needed for children up to 18 months of age. Finally, open reduction with possible concomitant femoral and/or pelvic osteotomies is the surgical option in an older child, when necessary. In general, the later the child is diagnosed with and treated for DDH, the greater the risk of a nonoptimal outcome. Depending on the severity of the condition, children with DDH may need to be followed closely until skeletal maturity so as not to miss the diagnosis of asymptomatic residual hip dysplasia, which can predispose patients to early hip arthritis.

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.

A Global Survey of Patient and Caregiver Experiences Throughout Care for Developmental Dysplasia of the Hip

BACKGROUND

Diagnosis and treatment for developmental dysplasia of the hip (DDH) varies greatly depending on condition severity, age at diagnosis, and professional opinion. Little is known about patient experiences across the globe. We aimed to characterize global patient and caregiver experiences during DDH care and to highlight patient-identified priorities.

METHODS

We developed a cross-sectional survey in collaboration with 7 DDH outreach organizations. DDH patients and/or their caregivers (above 18 y old) were invited to complete an international online survey about their experiences. Participants were recruited through web media of all collaborating organizations. Data collection took place over 3 months. Descriptive statistics were used to analyze quantitative results. Qualitative content analysis was used to categorize open-ended responses.

RESULTS

A total of 739 participants completed the survey, representing 638 (86.3%) parents/guardians of DDH patients, and 101 (13.7%) patients. Three hundred eighty-six (52.2%) participants received diagnosis by 3 months of age; mean age of diagnosis was 15.96 months (90% confidence interval=12.04, 19.91). Of 211 participants with family history of DDH, 68 (32.3%) did not receive DDH screening. Of 187 patients born breech, 82 (43.9%) did not receive DDH screening. In total, 36/94 (38.3%) participants with both family history and breech birth did not receive DDH screening. Most participants reported treatment (696/730, 95.3%), including bracing (n=461) surgery (n=364), and/or closed reduction (n=141). A total of 144 patients reported >1 surgery; 82 reported >3 surgeries. Participants reported a range of 1 to 400 visits to health care professionals for DDH care across 1 to 66 years. Lack of information and resources on treatment practicalities and timelines, along with emotional burden of diagnosis, were greatest challenges reported.

CONCLUSION

Results demonstrate that DDH diagnosis and treatment can pose significant burden on patients and caregivers. Reliable public information is needed to support those affected. Global educational efforts are needed to raise awareness of DDH risk factors, signs, and symptoms among care providers, to increase awareness and improve identification, screening, and monitoring of at-risk children.

The incidence of avascular necrosis following a cohort of treated developmental dysplasia of the hip in a single tertiary centre

PURPOSE

Avascular necrosis (AVN) may occur following treatment for developmental dysplasia of the hip (DDH). The primary aim of this study was to identify the incidence of AVN in a cohort of patients treated for DDH. Secondary aims were to classify AVN using available classification systems, analyze the correlation between the systems and investigate their relationship with the age at diagnosis of DDH.

METHODS

An 11-year retrospective study was carried out at a single tertiary centre, using data from the clinical portal (patient records database) and IMPAX (system used to store plain radiographic images). Clinical details (patient demographics and outcomes) and plain radiographic images were used to identify cases of DDH and categorize cases of AVN using available classification systems: Tonnis and Kuhlmann, Kalamchi and McEwen, Bucholz and Ogden and Salter. Severin was used to assess final clinical outcome.

RESULTS

In total, 405 (522 hips) cases of DDH were identified, of which 213 resolved without treatment, 93 were treated conservatively and 99 surgically. Only treated cases were included in the analysis (n = 192). AVN (45/99; 45.5%) was found to occur only postoperatively. A positive correlation was present between age at presentation and severity of AVN as classified according to Salter's criteria (chi-squared p value < 0.01).

CONCLUSION

AVN incidence was 23.4% (45/192) and only occurred in surgically treated patients. Older age at diagnosis was associated with a higher incidence of AVN, as defined according to Salter's criteria. The classification systems appeared to show no correlation amongst each other (p-value < 0.01).

LEVEL OF EVIDENCE

III - Retrospective cohort study.

Is There a Benefit to Weaning Pavlik Harness Treatment in Infantile DDH?

BACKGROUND

Following successful treatment of developmental hip dysplasia with a Pavlik harness, controversy exists over the benefit of continued harness use for an additional "weaning" period beyond ultrasonographic normalization versus simply terminating treatment. Although practitioners are often dogmatic in their beliefs, there is little literature to support the superiority of 1 protocol over the other. The purpose of this study was to compare the radiographic outcomes of 2 cohorts of infants with developmental hip dysplasia treated with Pavlik harness, 1 with a weaning protocol and 1 without.

METHODS

This was a comparative review of patients with dislocated/reducible hips and stable dysplasia from 2 centers. All patients had pretreatment ultrasounds, and all started harness treatment before 3 months of age. On the basis of power analysis, a sufficient cohort of hips were matched based on clinical examination, age at initiation, initial α angle, and initial percent femoral head coverage. Patients from institution W (weaned) were weaned following ultrasonographic normalization, whereas those from institution NW (not weaned) immediately ceased treatment. The primary outcome was the acetabular index at 1 year of age.

RESULTS

In total, 16 dislocated/reducible and 16 stable dysplastic hips were matched at each center (64 total hips in 53 patients). Initial α angle and initial femoral head coverage were not different between cohorts for either stable dysplasia (P=0.59, 0.81) or dislocated/reducible hips (P=0.67, 0.70), respectively. As expected, weaned hips were treated for significantly longer in both the stable dysplasia (1540.4 vs. 1066.3 h, P<0.01), and dislocated/reducible cohorts (1596.6 vs. 1362.5 h, P=0.01). Despite this, we found no significant difference in the acetabular index at 1 year in either cohort (22.8 vs. 23.1 degrees, P=0.84 for stable dysplasia; 23.9 vs. 24.8 degrees, P=0.32 for Ortolani positive).

CONCLUSIONS

Despite greater total harness time, infants treated with additional Pavlik weaning did not demonstrate significantly different radiographic results at 1 year of age compared with those who were not weaned. However, differences in follow-up protocols between centers support the need for a more rigorous randomized controlled trial.

LEVEL OF EVIDENCE

Level III.

Double Diapering Ineffectiveness in Avoiding Adduction and Extension in Newborns Hips

Hip flexion and abduction is fundamental for developmental dysplasia of the hip (DDH) treatment. At present, double diaper treatment has been inappropriately adopted when DDH is suspected. The aim of this study was to verify whether double diapers influence a newborn’s hip position. Here, we studied 50 children (23 female; 27 male; average age 62.33 ± 20.50 days; average birth weight 3230 ± 447 g) with type I hips according to Graf. At the same time of the ultrasound (US) examination, the following hip positions were measured using a manual protractor: (1) spontaneous position, supine on the outpatient bed without a diaper; (2) spontaneous position, with a double diaper; and (3) squatting position on the caretakers’ side. Statistical analysis was performed with a t-test to compare between (1) the spontaneous position without a diaper and with double diapers; (2) the spontaneous position with double diapers as well as the squatting position on the caretakers’ side with a diaper. The comparison between the hip position without diaper and with double diapers was statistically not significant for all measurements, i.e., right hip flexion (p < 0.33), left hip flexion (p < 0.34), and right and left hip abduction (p < 0.87). The comparison between the hip position with double diapers and on the caretakers’ side was statistically significant for all measurements, i.e., right hip flexion (p < 0.001), left hip flexion (p < 0.001) and right and left hip abduction (p < 0.001). We found that the use of double diapers did not affect hip position, while the position formed on the caretaker’s side shows favorable influence.

Estimated effect of secondary screening for hip dislocation

OBJECTIVES

To quantify the effect of secondary screening for hip dislocations.

DESIGN

Retrospective analysis of hospital files from participants in a prospectively collected nationwide registry.

SETTING

Child healthcare centres and orthopaedic departments in Sweden.

PARTICIPANTS

Of 126 children with hip dislocation diagnosed later than 14 days age in the 2000-2009 birth cohort, 101 had complete data and were included in the study.

INTERVENTIONS

The entire birth cohort was subject to clinical screening for hip instability at 6-8 weeks, 6 months and 10-12 months age. Children diagnosed through this screening were compared with children presenting due to symptoms, which was used as a surrogate variable representing a situation without secondary screening.

MAIN OUTCOME MEASURES

Age at diagnosis and disease severity of late presenting hip dislocations.

RESULTS

Children diagnosed through secondary screening were 11 months younger (median: 47 weeks) compared with those presenting with symptoms (p<0.001). Children diagnosed through secondary screening had 11% risk of having a high (severe) dislocation, compared with 38% for those diagnosed due to symptoms; absolute risk reduction 27% (95% CI: 9.7% to 45%), relative risk 0.28 (95% CI: 0.11 to 0.70). Children presenting due to symptoms had OR 5.1 (95% CI: 1.7 to 15) of having a high dislocation, and OR 11 (95% CI: 4.1 to 31) of presenting at age 1 year or older, compared with the secondary screening group. The secondary screening was able to identify half of the children (55%, 95% CI: 45% to 66%) not diagnosed through primary screening.

CONCLUSIONS

Secondary screening at child healthcare centres may have substantially lowered the age at diagnosis in half of all children with late presenting hip dislocation not diagnosed through primary screening, with the risk of having a high dislocation decreased almost to one-quarter in such cases.

Discrepancy between ultrasonographic and radiographic findings in patients treated for developmental dysplasia of the hip; hip maturation on ultrasonography may not be consistent with radiographic hip maturation

Currently, hip sonography is used for early diagnosis and for monitoring developmental dysplasia of the hip (DDH) treatment in many countries. An early pioneer of ultrasonography for early diagnosis of DDH was Graf. Based on the Graf approach, hip ultrasonography is more sensitive and specific than radiography for the diagnosis of DDH, because of its capability to show cartilaginous structures of the hip joint. The aim of this study was to compare radiographic and ultrasonographic findings in patients treated for DDH. This study included 88 infants (98hips) treated for DDH. Radiography was simultaneously used for treatment and follow-up evaluation in addition to ultrasonography after six months of age. A retrospective evaluation was made of the ultrasonographs and radiographs of these infants. Of the total 98 hips, 28 were normal both ultrasonographically and radiographically, and a pathologic hip was demonstrated in 32 hips both sonographically and radiographically. Hip ultrasonography showed abnormal development in 32 hips, while radiography showed abnormal development in 70 hips. In 38 hips, the findings were normal according to ultrasonography but pathological according to radiography. There were no hips that were normal radiographically but pathological sonographically. When radiography is accepted as the standard imaging method in our study patients, the sensitivity and specificity of hip ultrasonography were determined as 45.7% [95% confidence interval (CI): 41.5-45.7] and 100% (95% CI: 89.4-100), respectively. These findings suggest that hip maturation apparent on ultrasonography may not be consistent with radiographic hip development in infants treated for DDH.

Associations between risk factors and developmental dysplasia of the hip and ultrasonographic hip type: a retrospective case control study

PURPOSE

We aimed to revisit the correlation between the previously defined risk factors and the occurrence of developmental dysplasia of the hip (DDH) and to assess the influence of these factors on the ultrasonographic type of hip dysplasia according to the Graf's classification in patients with DDH.

METHODS

Data of healthy infants (mean age 33 days) who had bilateral mature (normal) hips (Graf type I) were compared with the data of infants (mean age 105 days) who were treated by abduction brace due to unilateral or bilateral DDH (Graf type IIa- and worse hips).

RESULTS

Infants with at least one risk factor had a significantly higher rate of DDH than those with no risk factors (p < 0.001). Likewise, infants with more than one risk factor had a significantly higher rate of DDH than those with only one risk factor (p = 0.008). Family history, breech presentation and swaddling were found to be the three significant risk factors related to the development of DDH. Family history, swaddling and oligohydramnios were found to be the three significant risk factors correlated with a higher rate of unstable/decentred hip(s) (Graf types D/III/IV) in patients with DDH.

CONCLUSION

The risk of DDH significantly increases in infants who have more than one risk factor for DDH. Positive family history and postnatal traditional swaddling are the two main factors both in the aetiology of DDH and in development of a more severe hip dysplasia in patients with DDH. Besides, breech presentation increases the risk of development of DDH and oligohydramnios leads to development of a more severe hip dysplasia in patients with DDH. By introducing these four variables as 'absolute risk factors for DDH' to the selective newborn hip screening programmes, the sensitivity and specificity of these programmes may be optimized and the risk of delayed diagnosis may be lessened.

LEVEL OF EVIDENCE

Level III prognostic study.

Developmental Dysplasia of the Hip

Pediatricians are often the first to identify developmental dysplasia of the hip (DDH) and direct subsequent appropriate treatment. The general treatment principle of DDH is to obtain and maintain a concentric reduction of the femoral head in the acetabulum. Achieving this goal can range from less-invasive bracing treatments to more-invasive surgical treatment depending on the age and complexity of the dysplasia. In this review, we summarize the current trends and treatment principles in the diagnosis and treatment of DDH.

Enhanced detection services for developmental dysplasia of the hip in Scottish children, 1997-2013

BACKGROUND

Developmental dysplasia of the hip (DDH) remains common. If detected early, DDH can usually be corrected with conservative management. Late presentations often require surgery and have worse outcomes.

OBJECTIVE

We estimated the risk of undergoing surgery for DDH by age 3 years before and after the introduction of enhanced DDH detection services.

DESIGN

Retrospective cohort study.

SETTING

Scotland, 1997/98-2010/11.

PATIENTS

All children.

METHODS

Using routinely collected national hospital discharge records, we examined rates of first surgery for DDH by age 3 by March 2014. Using a difference in difference analysis, we compared rates in two areas of Scotland before (to April 2002) and after (from April 2005) implementation of enhanced DDH detection services to those seen in the rest of Scotland.

RESULTS

For children born in the study period, the risk of first surgery for DDH by age 3 was 1.18 (95% CI 1.11 to 1.26) per 1000 live births (918/777 375).Prior to April 2002, the risk of surgery was 1.13 (95% CI 0.88 to 1.42) and 1.31 (95% CI 1.16 to 1.46) per 1000 live births in the intervention and non-intervention areas, respectively. In the intervention areas, from April 2005, this risk halved (RR 0.47; 95% CI 0.32 to 0.68). The risk remained unchanged in other areas (RR 1.01; 95% CI 0.86 to 1.18). The ratio for the difference in change of risk was 0.46 (95% CI 0.31 to 0.70).

CONCLUSIONS

The implementation of enhanced DDH detection services can produce substantial reductions in the number of children having surgical correction for DDH.

Clinical study of anterior hip ultrasound (van Douveren's method)-assisted Pavlik harness

PURPOSE

To investigate the use of anterior hip ultrasound (van Douveren's method)-assisted Pavlik harness in developmental dysplasia of the hip (DDH).

METHODS

Weekly anterior hip ultrasound scanning was performed in children with fixed Pavlik harness to detect whether hip reduction was achieved with the help of harness (the superior ramus of the pubis, the acetabulum, the femoral head, and the femoral neck being depicted in one plane indicated concentric reduction of the hip), and the stability of the reduction was checked by ultrasonography.

RESULTS

A total of 39 child patients and 51 dysplastic hips were successfully detected by anterior ultrasound, and stable reduction was achieved in 37 hips (15 Graf type D and 22 type III) right after the help of Pavlik harness, in seven hips (6 type III and 1 type IV) two weeks after the help of Pavlik harness; the remaining seven hips (2 type III and 5 type IV) failed to reach stable reduction after two weeks.

CONCLUSION

The anterior hip ultrasound (van Douveren's method) can be used to detect the reduction and stability of hip after Pavlik harness treatment in children with DDH. The majority of Graf type D and III hips can achieve a stable concentric reduction right after the help of Pavlik harness, while severely dislocated type IV hips have a low success rate for harness treatment, and abandonment of harness therapy should be considered in early stage.

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.

What's New in Pediatric Hip?

BACKGROUND

Developmental dysplasia of the hip (DDH), which encompasses a wide spectrum of disease from mild dysplasia to frank dislocation, is one of the most common developmental deformities of the lower extremities and one of the leading causes of future osteoarthritis and hip arthroplasty. Legg-Calvé-Perthes disease (LCPD) results from a vascular insult to the growing femoral epiphysis, which in turn can create permanent morphologic changes to the hip joint. Slipped capital femoral epiphysis (SCFE) occurs when the proximal femoral physis fails allowing the epiphysis to displace in relation to the metaphysis. Infections about the hip also create significant morbidity in the pediatric hip.

METHODS

We searched the PubMed database for all studies related to DDH, LCPD, SCFE, and pediatric hip infections that were published between July 1, 2014 and August 31, 2017. The search was limited to English articles and yielded 839 papers. This project was initiated by the Pediatric Orthopaedic Society of North America Publications Committee and was reviewed and approved by the Pediatric Orthopaedic Society of North America Presidential Line.

RESULTS

A total of 40 papers were selected for review based upon new and significant findings. Select historical manuscripts are also included to provide sufficient background information.

CONCLUSIONS

DDH, LCPD, SCFE, and infections about the hip continue to be important topics in pediatric orthopaedics and areas of vital research. This manuscript reviews the most important recent literature on the diagnosis and treatment of these pediatric hip conditions.

LEVEL OF EVIDENCE

Level V.