Aim
To obtain and maintain a concentric reduction without complication
0 - 6 /12 is the best time for treatment
- splint in flexion and abduction
- reduce the hip
- maintain reduction of head & allow normal acetabular development
Indication
Dislocated hip
Unstable hip (can wait 6 weeks to see if hip stabilizes itself)
Graf 2a and higher / alpha angle < 60°
Splint options
Pavlik Harness Von Rosen splint
Pavlik harness
Von Rosen Splint
Rigid abduction brace
Hip spica
Pavlik Harness
Design
Most commonly used
- holds hips flexed and abducted
- allows dynamic reduction of the hip joint
- can ultrasound with the harness on
Application
Chest strap at nipple level with boots
- anterior straps for hip flexion
- posterior straps for abduction
Avoid AVN / femoral nerve palsy
- limit excessive flexion and abduction
- anterior straps 100o-110o flexion
- posterior straps abduction between 30 - 50o
Management
Review every two weeks
- confirm safe zones of flexion and abduction
- review for pressure sores / femoral nerve palsy
- ultrasound 2/52 to confirm head reduced
- discontinue splint if no reduction by 4 weeks
6 week ultrasound
- alpha angle > 60° / Graf I / discontinue splint
- alpha angle < 60° / splint for further 6 weeks
Xray at 6 months
- monitor for subuxation / residual dysplasia
Results
Kitoh et al J Pediatr Orthop 2009
- 210 patients treated with Pavlik Harness
- success in 82%
- AVN 9%
- failure in bilateral and adduction contractures
- 137 patients treated with Pavlik Harness
- failure in 27% of dislocated hips
- highest risk in males with Graf IV
Novais et al J Pediatr Orthop 2018
- 134 hips successfully treated in Pavlik Harness
- incidence of acetabular dysplasia at 12 months 12%
- most common with initial Graf IV
Von Rosen splint
Complications
AVN
Not part of natural history of DDH
Avoid excessive abduction
Femoral nerve palsy
Avoid excessive flexion
Suspect in persistently crying baby
- review of 30 babies with femoral nerve palsy from Pavlik harness
- 87% presented in first week of treatment
- more likely in larger babies with more severe DDH
- femoral nerve palsy strongly predictive of treatment failure
Failure treatment
Indication
No reduction by 4 weeks on ultrasound
Options
Closed +/- open reduction after 6 months of age
Rigid abduction bracing
Rigid abduction bracing
Broomstick casting
Ilfeld abduction orthosis
Results
- failed Pavlik harness treated with Ilfeld brace (28) versus closed reduction / hip spica (22)
- Ilfeld Brace: 85% stable reduction
- closed reduction / hip spica: 92% stable reduction
- AVN: 0% Ilfeld brace, 14% closed reduction