Aim
To obtain and maintain a concentric reduction without complication
Timing
0 - 6 /12
- best time for treatment
- maintain reduction of head & allow normal acetabular development
Equivocal Hip
Obtain ultrasound
Graaf 2A and 2B
- Alpha angle 50 - 59o range
- many will resolve without treatment
- reassess at 3/12 with ultrasound and 6/12 with xray
Graaf 2C or more / Alpha angle < 49o
- manage as below
Algorithm
1. Hips subluxed or dislocated but reducible
Splint 6/52
- ultrasound 2/52 to confirm head enlocated
- check splint every 2 weeks (pressure sores / fitting correctly / femoral nerve / safe zone)
Ultrasound at 6/52
- alpha angle > 60° / no further splint
- alpha angle < 60° / 3/12 treatment in total
Results
- very successful in Graaf 2C / D and 3
- 50% successful in Graaf 4
Follow up
- xray at 6/12 until 2 years
- final assessment 12 years
Hips dislocated & irreducible
Management
- trial Pavlik harness 4/52
Failure treatement
- closed reduction +/- open reduction after 6/12
Hips locatable, but unstable in safe range abduction
Management
- trial harness only in safe range
Failure treatment
- closed reduction +/- open reduction after 6/12 age
Treatment Options
A. Pavlik harness
- most common in world
B. Von Rosen Splint
C. MUA / Spica
Pavlik Harness
Advantage
- can reduce dislocated hip
- able to clinically check reduction with harness on
- can ultrasound with harness on to check is reduced
Contraindication
Muscle imbalance / spina bifida
Stiffness / arthrogrypotic
Age over 8/12
Technique
Chest strap - at or slighly below nipple line
Shoulder straps
Boots attached to chest strap
Anterior straps located in anterior axillary line
- tightened to achieve 100o-110o flexion
- no more or risk femoral nerve palsy
Posterior straps lightly tightened
- allow adduction to within 7 cm of knees touching
- maximum abduction 30 - 50o to reduce risk AVN
Follow up
Review 1 week
- ensure enlocated with US
- ensure no femoral nerve palsy
Repeat US at 6/52 and 3/12
Results
Mostert et al J Paediatr Orthop 2000
- prospective study of 41 hips treated with Pavlik harness
- 97% success in 29 Graaf type III
- 50% success in 12 Graaf type IV
Complications
1. Failure to achieve reduction
Require closed +/- open reduction at 6/12
2. AVN
Very low if safe ranges respected
Peled et al CORR 2008
- pavlik harness used in 78 Graaf 3 or 4 hips
- no AVN in any patient
3. Femoral nerve palsy
Probably due to very chubby thighs / excessive flexion
- suspect in persistently crying baby
Murnaghan et al JBJS Am 2011
- review of 30 babies with femoral nerve palsy from Pavlik harness
- 87% presented in first week
- more likely in larger babies with more severe DDH
- femoral nerve palsy strongly predictive of treatment failure
Von Rosen Splint
Indications
Best suited to newborn
Disadvantages
Non dynamic
- hip must be reduced / reducible
Cannot ultrasound with splint on
- must be removed
Technique
Padded malleable aluminium splint
- 2 shoulder uprights
- 2 legs for thighs
- 2 wings for torso
Different sizes depending on weight
Hips in 60-90° flexion & 45° abduction (safe zone)
Parents don't adjust
Results
Wilkinson et al JBJS Br 2000
- suggested better outcomes than Pavlik harness
- fewer required operative reduction
Complications
Skin irritation
AVN 2%
Treatment failure