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

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.

The tension of the iliopsoas tendon more than doubles during extension of the dysplastic hip in open reduction

The role of the iliopsoas as an obstructing and re-dislocating factor in developmentally dislocated hips is unclear. The purpose of this article is to determine the change in the iliopsoas' tension during flexion and extension when performing an open reduction. We evaluated 34 hips undergoing an anterior open reduction for a developmental dislocation. At the time of surgery, we identified the iliopsoas, and before sectioning it as part of the open reduction, we measured the tension while cycling the reduced hip through flexion and extension. We performed statistical analysis using Pearson and Spearman correlation tests. We created an initial tension artificially at 20 N with the hip held in 90º of flexion, which then doubled to a mean of 42 N when placed in extension. We found a significant increase in tension when the hip went below 20º of flexion. We also found the correlation between the angle of the hip and the force of tension to be statistically significant ( P  = 0.003). This study provides quantitative support that the tension of the iliopsoas tendon increases significantly in extension when performing an open reduction of a developmentally dislocated hip.

Progress in screening strategies for neonatal developmental dysplasia of the hip

Developmental dysplasia of the hip (DDH) is the most common congenital disease of the musculoskeletal system in newborns and encompasses a disease spectrum ranging from a stable hip with a mildly dysplastic acetabulum to complete hip dislocation. Systematic screening for infant DDH has been performed for several decades all over the world and has contributed greatly to the early detection, diagnosis and treatment of DDH. However, some cases of delayed diagnosis still occur among the screened population, or conversely, overdiagnosis or overtreatment occasionally occurs. Furthermore, screening strategies for DDH are still controversial. The aim of our study was to analyze the current literature on DDH screening, paying particular attention to DDH screening strategies and their effectiveness. We searched the DDH screening literature from 1958 to 2021 in MEDLINE and other databases using PubMed. In this study, we reviewed the history of DDH screening and the progress of screening strategies and discussed the controversies regarding clinical and ultrasound screening methods with particular emphasis on the current opinions. Given the existing scientific evidence and changes in newborn DDH screening practices, universal ultrasound screening seems to be the best option for preventing late-detected cases and can be recommended as a favorable prevention strategy.

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.

Developmental Dysplasia of the Hip: Controversies in Management

PURPOSE OF REVIEW

Many aspects of developmental hip dysplasia (DDH) care and evaluation are still active areas of debate. Recent studies have provided more insight into these topics such as strategies for reducing osteonecrosis, assessing hip reduction after closed and open reduction, and the management of residual acetabular dysplasia.

RECENT FINDINGS

The presence of the ossific nucleus at the time of reduction does not alter the risk of osteonecrosis. The risk of osteonecrosis may be higher when hips are immobilized in excessive abduction. Limited sequence MRI may be the best choice for assessing hip reduction after closed and open reduction; however, new technologies are emerging such as 3D fluoroscopy and perfusion MRI. The treatment of residual acetabular dysplasia with bracing has been shown to be effective and the decision to perform a pelvic osteotomy is based on patient-specific factors. The spectrum of DDH treatment has evolved over the past several decades. Recent studies have provided insights into strategies for osteonecrosis prevention, hip evaluation during after reduction, and the management of residual acetabular dysplasia. However, there is ample room for additional and more rigorous studies guiding advanced imaging for assessing hip reduction such as 3D fluoroscopy and perfusion MRI, as well as the management of residual acetabular dysplasia.

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.

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.

Narrative Review of Complications Following DDH Treatment

BACKGROUND

The purpose of this narrative review was to survey the literature for common complications following treatment of DDH in children less than 4 years old.

METHODS

The Pubmed database was queried. Search result titles were reviewed to identify papers that were pertinent to the topic. Abstracts for these papers were obtained and read, and a subset of these were selected for review of the complete manuscript.

RESULTS

92 manuscripts were reviewed. Residual dysplasia, redislocation, and osteonecrosis are the primary complications of treatment in this age group. In the long term, hips without complications related to DDH treatment tend to do well, although a significant percentage of them will inevitably require joint replacement surgery.

CONCLUSION

Although there is excellent potential for a good outcome when DDH is diagnosed and treated under age 4 years, osteonecrosis continues to be a concern with all treatment methods. A subset of patients from this young cohort will continue to have residual dysplasia or recurrent dislocation requiring return to the operating room.

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.

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.

Efficacy of closed reduction for developmental dysplasia of the hip: midterm outcomes and risk factors associated with treatment failure and avascular necrosis

BACKGROUND

The purpose of this study was to evaluate the efficacy of closed reduction (CR) in the treatment of developmental dysplasia of the hip (DDH) and to investigate risk factors associated with CR failure and avascular necrosis (AVN) occurrence in follow-ups.

METHODS

The study retrospectively included 110 patients and 138 hips with DDH diagnosis that underwent closed reduction between February 2012 and November 2015 in our single tertiary medical institution. The failure rate of CR and the underlying risk factors were evaluated. Meanwhile, the incidence of AVN and the related risk factors among the successful CR cases were assessed.

RESULTS

The overall failure rate of DDH treated by CR in the present study was 31.16% (43/138). Risk factors for the CR failure were older age at the time of CR (≥ 18.35 month), large medical interval before CR (≥ 35.35 mm), and severer dislocation of the affected hip (IDHI grades III and IV). The incidence of AVN was 8.33% (6/72) in patients with successful CR at the last follow-up. No significant risk factors had been established in the present study that associated with the AVN occurrence.

CONCLUSIONS

For the treatment of DDH with CR, patients with younger age might achieve better outcomes; early diagnosis and early treatment might be the key point in the DDH treatment.

Neonatal hip ultrasound: tangent to lateral roof angle correlates better with stability than alpha angle according to Graf or percentage femoral head coverage

The aim of this study was to determine the relationship of tangent to the lateral roof angle (TLRA), Graf's alpha angle and percentage femoral head cover (PHC) and to observed stability, and to establish intraobserver and interobserver errors for measurement of alpha angle and TLRA. In total, 2235 babies referred to the hip review clinic over a period of 8  years. Intraobserver and interobserver errors were calculated from readings of 383 hip images by an experienced paediatric radiologist and a trainee. Taking TLRA <70° as abnormal resulted in sensitivity for unstable right hips of 88% compared with 77% for alpha angle <60° (P  =  0.002) and 81% for PHC <60% (P  =  0.028) and specificity of TLRA 89%, alpha angle 90% (P  =  0.07) and PHC 83% (P  <  0.001). Corresponding figures for left hips are sensitivity of TLRA 99%, alpha angle 91% (P  <  0.001) and PHC 96% (P  =  0.013), and specificity TLRA 86%, alpha angle 83% (P  =  0.001) and PHC 67% (P  <  0.001). Mean intraobserver errors for alpha angle were 1.85° and 1.81° for consultant and trainee compared to 2.54 and 2.55 for TLRA. Mean interobserver errors were 2.22 for alpha angle and 3.42 for TLRA. TLRA, a new parameter, correlated better with observed stability with significant improvement in sensitivity in both hips and specificity in left hips compared with Graf's alpha angle, and significantly improved sensitivity and specificity in both hips compared with percentage femoral head cover.

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

PURPOSE

The aim of this article is to review the current concepts in the indications, results and failure causes of the treatment of developmental dysplasia of the hip (DDH) with the Pavlik harness.

METHODS

The reported variables influencing the outcome in the Pavlik harness treatment were analyzed.

RESULTS

Significant discrepancies about the clinical and radiological outcomes, the rates of failure and complications as well as the variables influencing the treatment outcome occur in the published studies due to the heterogeneity of the data and the differences in the methods used. The overall short-, mid- or long-term success rate of the treatment ranges from 45% to 100% and it is commonly over 75%. The rate of osteonecrosis of the femoral head ranges from 1% to 30%. Age, gender, laterality, radiological or clinical severity of the initial hip pathology and parents' compliance are the commonly reported determinants of failure of the treatment.

CONCLUSION

The failure in treatment with the Pavlik harness is multifactorial, initial type of hip dysplasia being the most prominent followed by the treatment initiation age. This type of treatment cannot be considered as the best option in Graf IV hips (hip ultrasonography) or highly dislocated hips (plain radiography) and in infants older than three months of age, as the risk of failure and development of complications including osteonecrosis and femoral nerve palsy seem to increase in such circumstances. Large-scale, comparative studies including homogenous data are needed to answer the unsolved questions concerning indications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV-retrospective case series.

An improved method for measuring hip abduction in spica after surgical reduction for developmental dysplasia of the hip

PURPOSE

Excessive in-spica abduction is a risk factor for oste-onecrosis after surgical reduction for developmental dysplasia of the hip (DDH). The traditional method for radiographically measuring hip abduction using axial imaging does not reflect the true angle, which usually lies in an oblique plane. The purpose of this study was to describe a novel method for measuring true hip position using advanced imaging.

METHODS

A trigonometric model was derived to define hip position based upon the femoral axis angular deviation from midline as measured on axial and coronal sequences of MRI studies. In-spica MRIs of 28 hips having undergone surgery for DDH were reviewed. On two separate occasions, the same three raters measured the femoral axis deviation from mid-line on axial and coronal imaging. Abduction was estimated using the traditional method of measurement and our novel method. Intra- and inter-rater reliability were assessed.

RESULTS

The methods yielded different estimates (p < 0.001). Inter- and intra-rater reliability were excellent for both methods (inter-rater ICC > 0.922, intra-rater ICC > 0.919). The traditional method is accurate at 90° of flexion, but it increasingly overestimates abduction as hip flexion decreases. All cases where hip flexion was ≤ 40° exhibited ≥ 10° of error.

CONCLUSIONS

Decreasing hip flexion in spica modifies the perceived angle of abduction as measured using axial imaging. This inaccuracy can be overcome through assessment of orthogonal views using our new approach, which is accurate and reliable. It should be considered for future research investigating the effects of in-spica hip position on outcomes of DDH treatment.

Utilization of ultrasonography to detect developmental dysplasia of the hip: when reality turns selective screening into universal use

Background

Developmental dysplasia of the hip (DDH) occurs in 3–5 of 1000 live births and is associated with known risk factors. In most countries, formal practice for early detection of DDH entails the combination of risk factor identification and physical examination of the hip, while the golden standard diagnostic instrument is hip ultrasonography (US). This practice is commonly referred to as selective screening. Infants with positive US findings are treated with a Pavlik harness, a dynamic abduction splint.

The objective of our study was to evaluate hip US utilization patterns in Maccabi Healthcare Services (MHS), a large health plan.

Methods

Study population: All MHS members, born between June 2011 and October 2014, who underwent at least one US before the age of 15 months. Study variables: Practice specialty and number of enrolled infants. Positive US result was defined as referral to an abduction splint. Cost was based on Ministry of Health price list. Chi square and correlation coefficients were employed in the statistical analysis.

Results

Of the 115,918 infants born during the study period, 67,491 underwent at least one hip US. Of these, 60.6% were female, mean age at performance: 2.2 months. Of those who underwent US, 625 (0.93%) were treated with a Pavlik harness: 0.24% of the male infants and 1.60% of the female infants (p < 0.001). Analysis of physician practice characteristics revealed that referral to US was significantly higher among pediatricians as compared with general practitioners (60% and 35%, respectively). Practice volume had no influence on referral rate. Direct medical costs of the 107 hip US examinations performed that led to detection of one positive case (treated by Pavlik): US$10,000.

Conclusions

Current pattern of hip US utilization for early detection of DDH resembles universal screening more closely than selective screening. This can inform policy decisions as to whether a stricter selective screening or a formal move to universal screening is appropriate in Israel.

DEVELOPMENTAL DYSPLASIA OF THE HIP: DO THE RESPONSIBLE FOR SCREENING KNOW WHAT TO DO?

Objective:

To evaluate the knowledge on developmental dysplasia of the hip (DDH) by professionals involved in its diagnosis.

Methods:

This is a cross-sectional study using questionnaires to assess the knowledge about DDH. Orthopedic surgeons and pediatricians, residents and medical students from a tertiary teaching hospital were included in the study.

Results:

We evaluated 142 medical students, eight orthopedic residents, ten pediatric residents, seven pediatricians, and nine orthopedic surgeons; 50% declared not having examined any DDH case in the last year and only three had diagnosed more than 10 cases during their career. Regarding self-assessed knowledge (0-10), the average score was 4.25 [n=186; SD=2.43]. Nineteen percent of the participants ignored semiological tests and 26.1% of pediatricians (specialists and residents), were unaware of how to perform them. The most acknowledged and neglected risk factor was pelvic presentation (68%) and CMT (9.3%), respectively. None of the participants were able to identify all the risk factors. The average number of risk factors identified was two (n=186; SD=1.58). Forty seven point three percent of the participants failed to recognize the time of birth as the ideal moment for diagnosis; 17% reported it was after the first month. Regarding neglected severe DDH, 45.3% failed to recognize its natural history.

Conclusion:

Knowledge on DDH among health professionals who are involved in screening is flawed. Level of Evidence IV, Developing a Decision Model.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, therapeutic study.

Long-term outcome following medial open reduction in developmental dysplasia of the hip: a retrospective cohort study

INTRODUCTION

Avascular necrosis (AVN) is a serious complication of treatment for developmental dysplasia of the hip. There is ongoing controversy regarding AVN and its influence on hip development following medial open reduction (MOR).

PURPOSE

The aim of our study was to (1) determine the long-term prevalence of AVN following MOR, (2) evaluate hip development after MOR, and (3) identify predictors of AVN and radiographic outcome at skeletal maturity after MOR.

METHODS

A retrospective cohort analysis of 60 patients (70 hips) who underwent MOR with a mean follow-up of 10.83 years (5.23-16.74) was conducted. AVN was recorded according to Bucholz and Ogden classification and radiographic outcome based on Severin grading. AVN and hip morphology related to length of follow-up were evaluated. Chi-squared and t-tests were used to identify relationships between AVN and other variables. Logistic regression was used to assess predictors of AVN and Severin outcome.

RESULTS

The rate of clinically significant AVN (types 2-4) following MOR was 32.9 % with type 2 accounting for 82.6 % of these cases. While early acetabular development was satisfactory, long-term outcome was unsatisfactory in 26 % of cases with AVN (vs 8.7 % of cases without AVN). A higher rate of AVN was identified when hips were immobilized in ≥60° of abduction postoperatively. A higher rate of poor Severin outcome was identified in hips with AVN.

CONCLUSIONS

Our findings suggest that there is a high rate of AVN and unsatisfactory long-term outcome following MOR. AVN remains a significant concern following MOR surgery for developmental dysplasia of the hip that may not be apparent until long-term evaluation.

Acetabuloplasties at Open Reduction Prevent Acetabular Dysplasia in Intentionally Delayed Developmental Dysplasia of the Hip: A Case-control Study

BACKGROUND

Avascular necrosis (AVN) and residual acetabular dysplasia are the two main complications of developmental dysplasia of the hip (DDH) treatment. Although early reduction of the hip may decrease the incidence of residual dysplasia, it may increase the incidence of AVN and vice versa. However, we do not know if changes in surgical technique may lead to a modification in these outcomes.

QUESTIONS/PURPOSES

Does an incomplete periacetabular acetabuloplasty, as an added step to delayed open reduction, (1) diminish the risk of developing acetabular dysplasia; or (2) increase the rate of AVN compared with patients treated with open reduction alone?

METHODS

We conducted a retrospective matched case-control study comparing 22 patients (27 hips) with early isolated DDH who underwent intentionally delayed open reduction and acetabuloplasty from 2004 to 2010 and followed up > 4 years (88% of the cohort) with early historic controls treated with delayed open reduction alone. Of 53 patients available for matching, 45 (85%) had enough followup (> 10 years) to be considered. They were matched one to one for age at presentation and bilaterality (fuzz 45, 0). This generated a control group of 25 patients (27 hips). The mean followup was different between the groups (p < 0.001). Residual dysplasia considered when center-edge angle < 15° (6-13 years old) or < 20° (≥ 14 years old) or as a nonevolving acetabular index > 30° and pelvic osteotomies were used as our primary outcomes. The proportion of patients with AVN was also compared.

RESULTS

Patients treated with open reduction and an incomplete periacetabular acetabuloplasty were less likely to develop acetabular dysplasia and undergo pelvic osteotomies than were patients in the control group (0% [zero of 27] versus 37% [10 of 27]; odds ratio [OR], 11; 95% confidence interval [CI], 2-80; p = 0.02 and 0% [zero of 27] versus 26% [seven of 27]; OR, 8; 95% CI, 1-60; p = 0.025, respectively). With the available numbers, there was no difference in terms of the proportion of patients who developed AVN (11 of 27 [41%] both groups; OR, 1; 95% CI, 1-2; p = 1).

CONCLUSIONS

The addition of an incomplete periacetabular acetabuloplasty to all hips undergoing open reduction eliminated residual acetabular dysplasia, whereas it did not appear to have deleterious effects as evidenced by the similar AVN proportion.

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.