Long-term results of congenital dislocation of the hip treated with the Pavlik harness

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.

Long-term Results of Developmental Hip Dysplasia Under Therapy With Pavlik Harness

INTRODUCTION

The Pavlik harness is a commonly used treatment for developmental dysplasia of the hip (DDH) of types IIc or worse, based on the Graf classification. This study aimed to assess the long-term follow-up outcomes after treating DDH with the Pavlik harness.

METHODS

Between 1995 and 2006, ultrasound screening was conducted on 7372 newborns within the first days of life. Among them, 203 dysplastic hips in 152 patients, whose sonograms were Graf type IIc or worse, were treated with Pavlik harness. Treatment was discontinued if the measurement indicated Graf type Ia/b. More than 20 years later (mean: 20.46 y), patients were invited for clinical evaluation (Oxford Hips Score, Schulthess Hip Score, Harris Hip Score) and radiologic examination (center-edge angle according to Wiberg and the Severis classification, the rate of roofing of the femoral head via the Reimers migration percentage, and the Sharp angle).

RESULTS

Of the 152 patients, 60 (39.5%) participants with 80 (39.4%) affected hips (57.7% type IIc, 7.9% type D, and 15.6% type IIIa/b) were reexamined. The average follow-up duration was 20.5 years, with a maximum of 25.9 years. According to the Severin's classification, only 2 (3.77%) patients, each with one affected hip, showed slight residual dysplasia. The Reimer's migration percentage indicated an average of almost 90% canopy cover in the patient collective studied. No avascular necrosis was found, and the Sharp angle showed an average of almost 38 degrees. Only 4 participants with each one affected hip showed residual dysplasia according to the Sharp angle. The clinical results were quite satisfying, as none of the patients experienced hip pain that significantly limited their everyday activities or sports engagement, requiring medical attention before this study.Conclusions:Conservative therapy of DDH (Graf type IIc, D, III) with the Pavlik harness has demonstrated very good therapeutic success and a very low rate of residual dysplasia (2.81%). Both the radiologic and clinical outcomes were highly satisfactory.

LEVEL OF EVIDENCE

Level IV.

Reapplication of the Pavlik Harness for Treatment of Developmental Dysplasia of the Hip After Initial Pavlik Harness Failure

OBJECTIVE

The Pavlik harness (PH) has been widely used as the standard treatment for infants with developmental dysplasia of the hip (DDH). When the initial application of the PH fails, alternative treatments, such as closed reduction, open reduction, and reapplication of the PH will be considered. Compared with other treatments, reapplication of the PH offers certain advantages, including simplicity and reduced physical, and psychological stress, on both infants and caregivers. This study aims to investigate the effectiveness of reapplying the PH in patients with DDH.

METHODS

This study included patients with DDH (complete dislocation) who were treated by reapplication of PH between 1988 and 2012. Patients who were able to follow-up for more than 5 years were included. We examined the reduction rate and several factors to identify indicators associated with successful reduction during reapplication, including age, sex, side of hip dislocation, and the presence of the Ortolani sign. At the final follow-up, hip development was assessed using the Severin classification, whereas avascular necrosis (AVN) was evaluated using the Kalamchi classification and the Salter criteria.

RESULTS

A total of 56 patients (48 females and 8 males) and 57 hips were included in this study. The mean age at first and second application of PH was 4.2 months old (range: 0.12 to 6.4), and 5.8 months old (3.0 to 11.4), respectively. The reduction rate was 49% (28 out of 57 hips). Among the successfully reduced hips, the AVN rate was 3.6% (1 out of 28 hips). The Severin classification revealed 27 hips in class I and 1 hip in class III. Statistical analysis indicated a significantly higher proportion of left hip involvement in the reduction group (85% vs 41%, χ 2 test, P < 0.001). Although not statistically significant, the rate of positive Ortolani sign tended to be higher in the reduction group (61% vs 38%, χ 2 test, P = 0.06).

CONCLUSION

The reapplication method demonstrated a 49% reduction rate and a low AVN rate of 3.6% in our study. It is worth considering for patients who fail the initial PH treatment, particularly in cases of left-side dislocation and a positive Ortolani sign during the initial application.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

Graf Type-IV Hips Have a Higher Risk of Residual Acetabular Dysplasia at 1 Year of Age Following Successful Pavlik Harness Treatment for Developmental Hip Dysplasia

BACKGROUND

We asked whether patient-specific factors and ultrasound (US) measurements of hip dysplasia severity at initial examination influence short-term residual acetabular dysplasia in patients successfully treated with Pavlik harness for developmental hip dysplasia.

METHODS

After IRB approval, 134 hips (84 patients) successfully treated by the Pavlik method between August 2011 and October 2014 with follow-up at 12 months of age were identified. Early successful treatment was defined as normal examination and US after approximately 12 weeks of Pavlik treatment. Multivariate linear and logistic regression models were used to identify factors associated with acetabular index (AI) measurements at 12 months as well as factors associated with an increase in AI between the 6- and 12-month timepoints (dysplastic progression).

RESULTS

The study consisted of 134 hips (84 patients). The distribution of dysplastic, Barlow, and Ortolani hips was 44.8% (N=60), 30.6% (N=41), and 24.6% (N=33), respectively. The crude incidence of residual dysplasia at the 6-month visit (AI>30 degrees) was 11.7% (12/102). The incidence of residual dysplasia at the 12-month visit (AI>28 degrees) was 11.8% (13/111). Graf type was the only variable associated with AI values at the 12-month visit (mean difference: Graf type-IV-Other, 2.6; 95% confidence interval, 0.3-4.9; P=0.026).

CONCLUSIONS

The risk of residual acetabular dysplasia after normal hip US following Pavlik treatment is not negligible. Radiographic surveillance is warranted to monitor and screen for dysplasia progression. Patients with dislocated Graf type-IV hips at diagnosis are at increased risk of residual acetabular dysplasia at 1 year after successful treatment with the Pavlik method.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Late acetabular dysplasia after successful treatment for developmental dysplasia of the hip using the Pavlik method: A systematic literature review

The Pavlik method is the most common method used for treatment of developmental dysplasia of the hip (DDH). Late acetabular dysplasia despite successful treatment, however, has had varied reporting. A systematic review was performed, investigating the long-term outcomes of DDH treated with the Pavlik method. Seventeen studies met inclusionary criteria, including 6029 hips treated with an average of 5.29 years follow-up. Radiographic evidence of late dysplasia was present in 280 hips, with 109 hips requiring additional surgery. A specified treatment algorithm had significantly decreased rates of radiographic dysplasia (3.8% vs 17.6%, p = 0.004).

Level of evidence

IV.

Successful Pavlik Harness Treatment for Developmental Dysplasia of the Hip and Normal X-Ray at the Age of 2 Years: Is a Longer Follow-up Necessary?

BACKGROUND

Management of developmental dysplasia of the hip (DDH) with a Pavlik harness is a well-known treatment.Follow-up until skeletal maturity is recommended as long-term studies mention late sequelae.The purpose of this study was to determine whether such a follow-up is necessary in patients treated successfully under a strict protocol.

METHODS

A retrospective review of a consecutive series of normal infants treated for DDH between January 1995 and July 2004 was undertaken.Only normal infants with frankly pathologic hips treated successfully with a Pavlik harness were included, and with a normal anteroposterior (AP) pelvis x-ray at the age of 2 years.All infants with any type of neurological disease, syndrome, other form of treatment for DDH, and failure of the Pavlik harness were excluded.At the last follow-up, a clinical examination and a standing AP pelvis x-ray were performed.

RESULTS

A total of 109 hips in 83 children were available for review. The mean follow-up was of 10 years and 2 months. All 109 hips had a normal clinical examination and a normal AP pelvis x-ray: a mean center-edge angle (CEA) of 29.5 degrees, SD±4.1 degrees, a mean acetabular index (AI) of 1457±3.74 degrees, a mean Sharp's angle of 41.92±3.42 degrees, a Seringe-Severin score of IA, a normal teardrop figure, no signs of avascular necrosis, and Moses circles <2.

CONCLUSION

This study strongly suggests that in a selected group of patients treated for DDH with a Pavlik harness, under a strict protocol, and a normal x-ray at 2 years of age, a long-term follow-up is not necessary.

LEVEL OF EVIDENCE

Level III-therapeutic.

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: What has changed in the last 20 years?

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

Failed Pavlik harness treatment for DDH as a risk factor for avascular necrosis

BACKGROUND

Avascular necrosis (AVN) of the femoral head is an irreversible complication seen in the treatment of developmental dysplasia of hip (DDH) with the Pavlik harness. Its incidence is reported to be low after successful reduction of the hip but high if the hip is not concentrically relocated. We aim to investigate its incidence after failed Pavlik harness treatment.

METHODS

We prospectively followed up a group of children who failed Pavlik harness treatment for DDH treated at our institution by the senior author between 1988 and 2001 and compared their rates of AVN with a group of children who presented late and hence were treated surgically. AVN was graded as described by Kalamchi and MacEwen and only grade 2 to 4 AVN was considered significant and included in the analysis.

RESULTS

Thirty-seven hips were included in the failed Pavlik group (group 1) and 86 hips in the no Pavlik group (group 2). Ten hips in group 1 developed AVN (27%), whereas only 7 hips in group 2 (8%) developed AVN; the odds of developing AVN after failed Pavlik treatment was 4.7 (95% confidence interval, 1.3-14.1) (P=0.009) with a relative risk of 3.32 (range, 1.37 to 8.05).

CONCLUSIONS

There was no statistically significant association observed with duration of splintage and severity of AVN (Spearman's correlation, -0.46; P=0.18). However, there was a positive correlation noted with age at presentation and severity of AVN. Therefore, we advise close monitoring of hips in the Pavlik harness and discontinue its use if the hips are not reduced within 3 weeks.

LEVEL OF EVIDENCE

Level III.

Back-carrying infants to prevent developmental hip dysplasia and its sequelae: is a new public health initiative needed?

BACKGROUND

Developmental dysplasia of the hip (DDH) is rarely encountered in the native sub-Saharan African population. We present a retrospective review of the incidence of symptomatic DDH in Malawi and a systematic review of the role of back-carrying as a potential influence of prevalence in this population group.

METHODS

We retrospectively reviewed the diagnosis and management of all infants seen at the Beit CURE International Hospital, Malawi and its mobile clinics, from November 2002 to September 2012. In addition, methodical review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist and algorithm was performed.

RESULTS

A total of 40,683 children aged less than 16 years were managed at our institute over a 10-year period, of which 9842 children underwent surgery. No infant presented with, or underwent surgical intervention, for symptomatic DDH.

CONCLUSIONS

The majority of mothers in Malawi back-carry their infants during the first 2 to 24 months of life, in a position that is similar to that of the Pavlik harness. We believe this to be the prime reason for the low incidence of DDH in the country. In addition, there is established evidence indicating that swaddling, the opposite position to back-carrying, causes an increase in the incidence of DDH. There is a need for the establishment of a large clinical trial into back-carrying and prevention of DDH in non-African population groups.

LEVEL OF EVIDENCE

Level II.

Treatment and prevention of hip dysplasia in infants and young children

The diagnosis and treatment of developmental dysplasia of the hip in the infant are uniform, with consensus that diagnostic ultrasound and Pavlik harness management are standard procedures. Sequential procedures for failed early treatment, residual dysplasia and late diagnosis are dependent on the age and the severity of the dysplasia. This paper reviews the treatment of developmental dysplasia of the hip from birth to subsequent follow-up procedures, with particular reference to some of the senior authors' research and the Southampton approach to the management of hip dysplasia.

Evidence-based management of developmental dysplasia of the hip

Developmental Dysplasia of the Hip (DDH) refers to a spectrum of abnormalities involving the developing hip. These abnormalities range from mild instability to frank dislocation of the joint. It is important to treat the condition effectively in order to encourage the hip to develop normally and produce good long-term results. This article reviews the evidence related to the treatment of DDH. The quality of evidence for DDH management remains low, with little uniformity in terminology and most studies being retrospective in nature. Given this, it is not possible to recommend or reject most treatment modalities based on existing studies.

Developmental dysplasia of the hip in neonates: evolution of acetabular dysplasia after hip stabilization by brief Pavlik harness treatment

BACKGROUND

The recommended treatment duration in neonates with developmental dysplasia of the hip (DDH) varies depending on whether prolonged Pavlik harness therapy is believed to favourably affect the course of the acetabular dysplasia. According to one theory, several months of additional Pavlik harness therapy after achieving hip reduction contributes to correct the acetabular dysplasia. Another theory holds that hip dislocation induces the acetabular dysplasia, which corrects spontaneously once the femoral head is properly seated in the acetabulum. Here, we evaluated this second theory by studying outcomes after early brief Pavlik harness therapy.

HYPOTHESIS

Acetabular dysplasia associated with neonatal hip instability undergoes self-correction provided stable hip reduction is achieved very early after birth. Therefore, the duration of Pavlik harness therapy can be substantially shortened.

MATERIALS AND METHODS

We defined hip instability as either reducible hip dislocation or a very easily dislocatable hip with a soft clunk precluding determination of spontaneous hip position as dislocated or reduced. Static and dynamic ultrasound scans were obtained. Patients with ultrasonographic instability (pubo-femoral distance>5mm with less than 50% of coverage) underwent a second physical examination and received treatment. We re-evaluated 42 abnormal hips in 30 patients after a mean follow-up of 6.7 years (range, 5-14 years). Mean age at treatment initiation was 5 days (range, 1-15 days) and mean treatment duration was 34 days (range, 15-75 days).

RESULTS

Mean acetabular angle was 20° (range, 12°-30°) and mean Wiberg's lateral centre-edge angle was 30° (range, 22°-35°). Blunting of the lateral angle of the bony roof was noted in 8 hips at last follow-up. In 1 patient whose hip was stable clinically but unstable by ultrasonography at 21 days of age, recurrent dislocation occurred at 5 months of age. The Severin class was 1a in all patients.

DISCUSSION

Despite continuing controversy about whether hip dislocation induces dysplasia or vice versa, the need for early treatment is universally recognised. The optimal treatment duration, however, remains debated. Proponents of the familial determinism of DDH consider that acetabular shaping is genetically programmed when the femoral head is centred in the acetabular socket. Others advocate routine prolongation of Pavlik harness therapy for 2 months or longer, based on the opinion that this strategy decreases the dislocation recurrence rate and that mechanical hip unloading may promote correction of the dysplasia. Mean treatment duration in our population was 34 days and our sole objective was to treat the instability. The hip was reduced and held in its proper position long enough to allow sufficient capsule and ligament tightening to stabilise the hip. Under these conditions, the acetabular dysplasia underwent self-correction that was not related to treatment duration.

CONCLUSION

Very early Pavlik harness therapy to ensure rapid hip reduction and stabilisation optimises the potential of the acetabulum for spontaneous remodelling.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Selective epiphysiodesis of the triradiate cartilage for treatment of residual experimental acetabular dysplasia

BACKGROUND

The purpose of the study is to evaluate the effect of a selective epiphysiodesis of the ilioischial limb of the triradiate cartilage (TC) in an experimental dysplastic hip.

MATERIALS AND METHODS

A hip dysplasia was obtained in 23 New Zealand rabbits 3 weeks old by immobilizing the knee in extension with a K-wire, in 4 groups: (1) control group; (2) K-wire maintained until sacrifice; (3) K-wire removed 1 week later without epiphysiodesis; and (4) K-wire removed 1 week later with selective epiphysiodesis of the ilioischial limb of the TC. Radiographic evaluation was performed previous to knee immobilization, after K-wire removal and after sacrifice. Acetabular index (AI), Sharp's angle, ACM angle, acetabular floor thickness ratio (AFTR) were measured and presence of dysplasia, subluxation, or dislocation was noted. The acetabular version, the acetabular sector angles, and the pelvis rotation were obtained using CT evaluation. A morphology score was developed and a morphometric study of both proximal femur and acetabulum was performed.

RESULTS

No differences between groups in the radiographic assessment before immobilization or K-wire removal were found. All cases in group 2 showed dysplasia, subluxation, or dislocation of the hip. The radiographic assessment of group 4, compared with group 3, showed a lower AI (P=0.027), Sharp's angle (P=0.005), ACM angle (0.049), and AFTR (P=0.017). No differences between groups 1 and 4 regarding AI (P=0.08), Sharp's angle (P=0.484), and AFTR (P=0.639) were obtained. The morphology score was lower in group 4 than in groups 2 and 3. Group 4 showed a deeper acetabulum than group 2 (P=0.008) and group 3 (P=0.033), while it was similar to group 1 (P=0.364).

CONCLUSIONS

A selective epiphysiodesis of the ilioischial limb of the TC in a dysplastic hip normalized the radiographic measurements of the acetabulum and the acetabular deepness, and it improved the previous gross morphology of the capsule, labrum, and ligamentum teres in rabbits.

LEVEL OF EVIDENCE

Level II-therapeutic study.

The Pavlik method: a systematic review of current concepts

We present a systematic review of the use of the Pavlik method in developmental dysplasia of the hip. Our aims were to evaluate treatment protocols, reported results and factors associated with successful outcomes. We found 218 relevant citations, of which 62 fulfilled our inclusion criteria. Our results have shown satisfactory clinical and radiological outcomes with the use of the harness at long-term follow-up. However, failures of harness use have been reported along with episodes of avascular necrosis. Ultrasound plays a key role in the early detection of such cases. Alternative methods of splintage have been described but larger comparative studies are required to change current practice.

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

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

Screening and treatment in developmental dysplasia of the hip-where do we go from here?

PURPOSE

Developmental dysplasia of the hip (DDH) is a leading cause of disability in childhood and early adult life. Clinical and sonographic screening programmes have been used to facilitate early detection but the effectiveness of both screening strategies is unproven. This article discusses the role for screening in DDH and provides an evidence-based review for early management of cases detected by such screening programmes.

METHODS

We performed a literature review using the key words 'hip dysplasia,' 'screening,' 'ultrasound,' and 'treatment.'

RESULTS

The screening method of choice and its effectiveness in DDH still needs to be established although it seems essential that screening tests are performed by trained and competent examiners. There is no level 1 evidence to advise on the role of abduction splinting in DDH although clinicians feel strongly that hip instability does improve with such a treatment regime. The definition of what constitutes a pathological dysplasia and when this requires treatment is also poorly understood.

CONCLUSION

Further research needs to establish whether early splintage of clinically stable but sonographically dysplastic hips affects future risk of late-presenting dysplasia/dislocation and osteoarthritis. There is a need for high quality studies in the future if these questions are to be answered.

Predictive factors for unsuccessful treatment of developmental dysplasia of the hip by the Pavlik harness

BACKGROUND

The Pavlik harness is a widely used and effective means of initial treatment of developmental dysplasia of the hip (DDH), but some hips fail to stabilize with the use of harness and avascular necrosis (AVN) of the femoral head can occur. Predictive factors for unsuccessful Pavlik harness treatment should be determined for appropriate indication of the treatment and prevention of AVN.

METHODS

The outcome of Pavlik harness treatment for DDH was retrospectively examined in 221 hips of 210 patients who were treated initially at our institution and followed up for at least 1 year after the application of the harness. Univariate analysis was performed to determine predictors for failure of reduction and for the incidence of AVN by using the Mann-Whitney U test for continuous variables and the Fisher exact test or the Pearson test for categorical variables. Next, independent multivariate predictors for the failure of reduction and the incidence of AVN were identified using logistic regression analysis.

RESULTS

One hundred and eighty-one hips were reduced and the overall rate of reduction was 81.9%. AVN that was diagnosed according to the criteria of Salter et al was identified in 16 of the 181 reduced hips and the rate of incidence of AVN was 8.8%. Bilaterality and decreased distance "a," as defined by Yamamuro and Chene, were statistically significant univariate and multivariate risk factors for the failure of reduction. Between them, distance a was the most powerful predictor. Adduction contracture of the hip (abduction with the hips flexed to 90 degrees <60 degrees) was the only significant univariate and multivariate predictor for the incidence of AVN.

CONCLUSIONS

Distance a and adduction contracture of the hip were important predictors for the outcome of Pavlik harness treatment. We concluded that the Pavlik harness is a very safe and effective means of DDH treatment for the hips with abduction > or = 60 degrees and distance a > or = 6 mm.

LEVEL OF EVIDENCE

Therapeutic studies, level III (retrospective study).

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

BACKGROUND

The aim of this paper was to review the outcomes of treatment of dislocated but reducible (Ortolani-positive) hips.

METHODS

A comparative retrospective review was conducted of all patients aged younger than 6 months who presented for treatment of developmental dysplasia of the hip for two 10-year periods. The inclusion criteria consisted of a clinical evaluation documenting Ortolani-positive examination, no previous treatment, and an initial treatment with Pavlik harness only. Patients with insufficient follow-up, neuromuscular disease, provocative dislocatable hips, or dislocated but not reducible hips were excluded. In group 1 (1984-1994), treatment involved initiation of Pavlik harness and parental education at the time of initial diagnosis. Group 2 (1997-2007) was treated the same as group 1 with the addition of serial orthopaedic office-based ultrasound examinations and use of a hip abduction orthosis in hips remaining unstable after 3 weeks in the Pavlik harness. Records were assessed for successful achievement and maintenance of hip reduction, need for and type of further treatment, and development of avascular necrosis.

RESULTS

In group 1, the mean time of follow-up was 28 months. Forty-four (85%) of 52 hips were treated successfully. Eight patients required further operative treatment. In group 2, the mean follow-up to the final evaluation was 34 months. Forty-one (93%) of 44 hips were treated successfully. Three hips required further treatment. There were no documented cases of avascular necrosis in patients treated for orthoses only in either group.

CONCLUSIONS

In 1994, we presented a series of 52 Ortolani-positive hips (group 1) with a success rate of reduction of 85%. Now, our protocol for treating Ortolani-positive hips has evolved to include serial orthopaedic office-based ultrasound in all patients and use of a hip abduction orthosis in hips remaining unstable after 3 weeks in a Pavlik harness. Three previous studies at major centers reported successful reduction in only 63% to 71%. In group 2, our current success rate of 93% exceeds that previously reported by us and is significantly greater than these 3 previous studies (all P < 0.006). Furthermore, our current treatment module has decreased our rate of open reduction from 10% in group 1 to 5% in group 2. LEVEL OF RELEVANCE: Therapeutic study, level 3.

Avascular necrosis rate in early reduction after failed Pavlik harness treatment of developmental dysplasia of the hip

Our hypothesis is that hips with developmental dysplasia (DDH), which fail Pavlik harness treatment and are reduced within 3 months of age, have a low rate of avascular necrosis (AVN). Inclusion criteria are as follows: diagnosis of DDH within 2 months of birth, failure of reduction or stabilization by Pavlik harness treatment, surgical reduction of the hip advised to be performed within 3 months of age, and follow-up for Salter criteria of AVN. Twenty-one consecutive cases (35 hips) met the inclusion criteria. Nineteen cases (31 hips) were initially reduced within 3 months of age, and none of these cases developed AVN. After Pavlik harness failure, initial closed reduction was achieved in 33 (94%) of 35 hips, and open reduction required in 2 (6%) of 35 hips. At latest follow-up, one (3%) of 35 hips had AVN. At the time of reporting, 1 (3%) of the 35 hips has required an additional procedure (Pemberton osteotomy) for residual dysplasia. There were 2 outlier cases (4 hips) in which the parents delayed the reduction and 1 case developed unilateral AVN, which was reduced after the proximal femoral ossification center developed at 7 months of age. The data presented in the current study support our hypothesis.

Treatment for developmental dysplasia of the hip using the Pavlik harness

We reviewed the medical records of 115 patients with 130 hips with developmental dysplasia with complete dislocation in the absence of a neuromuscular disorder, spontaneous reduction with a Pavlik harness, and a minimum of 14 years’ follow-up. The mean age at the time of harness application was 4.8 months (1 to 12) and the mean time spent in the harness was 6.1 months (3 to 12). A total of 108 hips (83.1%) were treated with the harness alone and supplementary surgery for residual acetabular dysplasia, as defined by an acetabular index > 30°, was performed in 22 hips (16.9%).

An overall satisfactory outcome (Severin grade I or II) was achieved in 119 hips (91.5%) at a mean follow-up of 16 years (14 to 32) with a follow-up rate of 75%. Avascular necrosis of the femoral head was noted in 16 hips (12.3%), seven of which (44%) underwent supplementary surgery and nine (56%) of which were classified as satisfactory. The acetabular index was the most reliable predictor of residual acetabular dysplasia.

Prediction of acetabular development after closed reduction by overhead traction in developmental dysplasia of the hip

BACKGROUND

The prediction of acetabular development after reduction of developmental dysplasia of the hip (DDH) is important to ensure optimal timing of acetabuloplasty and to avoid unnecessary surgery. The objective of this study was to find early and reliable predictors of future acetabular dysplasia in the hips reduced by overhead traction (OHT).

METHODS

We retrospectively reviewed 45 hips in 40 patients treated by OHT for DDH without additional procedures. The average age at the time of closed reduction was 9.3 months, and the average age at the latest examination was 17.3 years. Residual hip dysplasia at skeletal maturity was defined according to Severin's classification. The following variables were evaluated as possible predictors of the final outcome: age at reduction, severity of the dislocation, serial measurements of acetabular index (AI), center-edge angle of Wiberg (CE), and the center-head discrepancy distance (CHDD).

RESULTS

Sixty-two percent of the hips had satisfactory results in Severin I/II and 38% had unsatisfactory results in Severin III. Bilateral DDH showed significantly poorer outcome than unilateral DDH. The average AI of the unsatisfactory group was significantly greater than that of the satisfactory group at 4 years or more after reduction. Similarly, the average CE of the satisfactory group was greater than that of the unsatisfactory group at 5 years or more after reduction. In unilateral cases, the AI and the CE of the uninvolved hip at 1 year after reduction also correlated with the final outcome of the involved hip.

CONCLUSIONS

The AI of 4 years and the CE of 5 years after reduction were the earliest predictors of the final outcome. Careful consideration for the need of acetabuloplasty would be given at 4 or 5 years after reduction by OHT. Bilateral DDH and poor acetabular coverage of the uninvolved hip in unilateral DDH were the prognostic factors of unfavorable acetabular development of the dislocated hip.

Residual dysplasia after successful Pavlik harness treatment: early ultrasound predictors

The purpose of this study was to evaluate a group of children treated with Pavlik harness for developmental dysplasia of the hip (DDH) to determine early ultrasound characteristics that predict poor acetabular development after walking age. From a group of 487 infants with DDH, 55 met inclusion criteria of (1) ultrasound documentation of major neonatal hip instability, (2) treatment with Pavlik harness, and (3) a minimum of 4 years of follow-up. These 55 infants had 100 abnormal hips. Harness treatment alone was successful in treating 87 of 100 hips. Persistent or late acetabular dysplasia was defined from serial radiographs. At a mean follow-up of 5.3 years, 5 of the 87 (6%) were found to have sequelae (late acetabular dysplasia, avascular necrosis of the femoral head, or both). Three sonographic findings present on the initial ultrasound predicted late sequelae: (1) dynamic coverage index of 22% or less, (2) alpha angle less than 43 degrees, and (3) abnormal echogenicity of the cartilaginous roof on initial ultrasound. Abnormal echogenicity was the most specific single predictor of residual dysplasia (sensitivity 100% and specificity 88%). The structurally normal cartilaginous roof is non-echogenic except for a short triangular fibrous tip (the labrum). Pathologic cartilage becomes echogenic beyond the tip as hyaline cartilage becomes fibrous and deformed. In unstable hips that respond well to Pavlik harness treatment, it would appear that midterm acetabular development can be affected when early transformation of roof cartilage accompanies displacement and instability.

Long-term result of combination of open reduction and femoral derotation varus osteotomy with shortening for developmental dislocation of the hip

This study examined femoral derotation varus osteotomy with shortening performed on children with developmental dislocation of the hip. Each patient reached 14 years of age. Surgical outcomes were evaluated clinically and roentgenographically. We studied nine patients with 11 joints undergoing surgical repair. Age at the time of operation averaged 2 years and 1 month; the period of observation averaged 15 years and 7 months; and age at final investigation averaged 17 years and 8 months. Each patient underwent the study operation as an initial treatment. Salter pelvic osteotomy was reserved as a second treatment for those patients whose acetabular development proved inadequate during post-surgical observation. The evaluation method established by McKay was utilized to determine clinical results at the time of final investigation; 73% of the study group were established as having good results. Severin's evaluation method was used to assess roentgenographical results; 45% of the study group were determined to have good results. Kalamchi's evaluation method allowed six joints to be diagnosed with avascular necrosis of the femoral head; however, in all cases but one, necrosis had been present prior to surgery. Those six joints that did not have necrosis of the femoral head prior to surgery developed only one mild necrosis subsequent to surgery. Achieving a stable reduced position by femoral derotation varus osteotomy, as well as sufficient decompression of the femoral head by shortening osteotomy, are considered to have played very important roles in preventing the femoral head from developing necrosis.

Plastazote abduction orthosis in the management of neonatal hip instability

Since 1987, 113 consecutive newborns with either Ortolani-positive or provocative-positive hip examinations in the newborn nursery have been treated with a Plastazote hip abduction orthosis when diagnosed and followed to determine if the method was safe, effective, and easy to use. Ortolani-positive hips often had bilateral abnormalities in the hip examination, were frequently associated with breech position, and were anatomically more dysplastic than those hips that were unstable by provocative testing. No patient developed ischemic necrosis during follow-up. Only two had additional treatment of their unstable hips. The rest had excellent results. Parents and caregivers found the device easy to use. The orthosis is recommended as the primary method for managing newborns with clinical instability to either the provocative or Ortolani test as being safe, effective, and easy to use across all skill levels.

Paediatric hip--ultrasound screening for developmental dysplasia of the hip: a review

This paper will try to deal with the following questions: Which is the correct screening model for the developmental dysplasia of the hip (DDH)? What is the clinical significance of "sonographic" DDH? Can overtreatment produced by ultrasound (US) screening cause a waste of resources and eventually morbidity? We reviewed the literature since January, 1996 through December, 2000. To compare our experience with the literature, we analysed the results of the US examinations of the hip performed in our Institute. Over 4 years of US screening 11326 infants (22652 hips), aged 3 days to 4 months, were examined consecutively. Sonographic hip findings were abnormal in 531 infants (4.7%). The screening showed 381 subjects (3.36% of the population) with a type IIa hip (bilateral or unilateral); 65% of these infants were normal at follow up and only 35% worsened. On the whole we treated 282 infants (2.5%). No open reduction was performed. Avascular necrosis appeared in 2/282 treated cases (1.06%). We support the routine generalised US screening of neonatal hips. The excess of doubtful cases and, consequently, of the extra referrals may be limited, and the overtreatment decreased to the lowest rates reported by optimisation of everyone's approach.

Early failure of Pavlik harness treatment for developmental hip dysplasia: clinical and ultrasound predictors. J Pediatr Orthop. 2001;21:348-353. [PMID: 11371819 DOI: 10.1097/01241398-200105000-00017]

A cohort of 93 patients with developmental dysplasia of the hip (DDH) treated with a Pavlik harness were evaluated to determine predictors of treatment failure. Failure was defined as failure to achieve or maintain hip reduction in the Pavlik harness. Of 93 patients (137 hips), 17 (26 hips) failed Pavlik harness treatment. Univariate risk factors for failure included bilaterality, initial clinical exam, and initial ultrasound (US) percent coverage. Clinical exam and initial percent coverage were multivariate risk factors for failure. Among initially clinically dislocatable hips, a low initial US alpha angle correlated with an increased likelihood of failure. All (6/6) patients with an initially irreducible hip and an initial coverage of <20% by US eventually failed treatment. Gender, side of pathology, and age at diagnosis and initiation of treatment did not correlate with failure. Irreducibility by physical exam combined with US coverage of <20% identified a patient group that uniformly failed Pavlik harness treatment. These patients may be candidates for alternative bracing, traction, or closed or open reduction.

Early failure of Pavlik harness treatment for developmental hip dysplasia: clinical and ultrasound predictors

A cohort of 93 patients with developmental dysplasia of the hip (DDH) treated with a Pavlik harness were evaluated to determine predictors of treatment failure. Failure was defined as failure to achieve or maintain hip reduction in the Pavlik harness. Of 93 patients (137 hips), 17 (26 hips) failed Pavlik harness treatment. Univariate risk factors for failure included bilaterality, initial clinical exam, and initial ultrasound (US) percent coverage. Clinical exam and initial percent coverage were multivariate risk factors for failure. Among initially clinically dislocatable hips, a low initial US alpha angle correlated with an increased likelihood of failure. All (6/6) patients with an initially irreducible hip and an initial coverage of <20% by US eventually failed treatment. Gender, side of pathology, and age at diagnosis and initiation of treatment did not correlate with failure. Irreducibility by physical exam combined with US coverage of <20% identified a patient group that uniformly failed Pavlik harness treatment. These patients may be candidates for alternative bracing, traction, or closed or open reduction.

Untreated acetabular dysplasia of the hip in the Navajo. A 34 year case series followup

Patients born in the Many Farms District of the Navajo Indian Reservation from 1955 to 1961 were studied. Five hundred forty-eight of the 628 infants born (87%) received clinical examinations and pelvic radiographs at some time during the first 4 years of their lives. Eighteen (3.3%) of the 548 infants examined had acetabular dysplasia. Because of traditional cultural beliefs, none of these children received medical treatment. Followup evaluations and radiographs were obtained in these 18 patients during early adolescence. In 10 of the original 18 patients followup evaluations and radiographs were obtained at an average age of 35 years. None of the dysplastic hips progressed to frank dislocation. The mean center edge angle improved from 7 degrees when the patients were 1 year of age, to 29 degrees when the patients were 12 years of age, to 30 degrees when the patients were 35 years of age. Despite overall improvement of hip measurements with maturity, eight hips in five of the 10 patients who were in their fourth decade of life and who were available for examination, had radiographic evidence of residual abnormalities. The hips in patients with subluxation during infancy were less likely to be normal as adults. The results of this 34-year followup study of untreated developmental hip dysplasia showed marked radiographic improvement in all patients during childhood; however, subtle abnormalities persisted in the radiographs of 40% of the hips.

Outpatient pediatric orthopedics. Common and important conditions

Many common pediatric orthopedic conditions can be managed by the pediatrician who has a knowledge of the natural history of these conditions. An accurate diagnosis is necessary to provide proper treatment, give advice to patients, or make referrals to the proper specialist. The authors' find that in approximately 95% of cases, a specific diagnosis can be made and that 40% of patient referrals for orthopedic problems could have been managed by the primary care physician. This article discusses some of the more common pediatric orthopedic problems often encountered by primary care physicians.