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

Abstract

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 (B 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 a 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°-

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

“…In our study, the overall proportion of patients experiencing Pavlik harness failure was 14% (30 of 215 hips), 27% (21 of 78 hips) for patients with Ortolani-positive hips, 5% (three of 60 hips) for patients with Barlow-positive hips, and 5% (four of 77 hips) for patients with stable ultrasound-dysplastic hips. Our findings were similar to those of previous studies indicating that a high proportion of Barlow-positive hips and stable ultrasounddysplastic hips can be treated successfully with the Pavlik harness [6,8,12,14,19,25,31]. Despite our strict protocol, the rate of failure in Ortolani-positive hips was similar to those of previous studies reporting a 30% to 60% incidence of treatment failure in dislocated hips [2,16,19,20,24,31,32].…”

“…Although the incidence and risk factors associated with Pavlik harness failure have been reported, previous studies may have been limited by lack of complete assessment of patient factors such as clinical examination [14,19,20,24,31,32] and failure to review ultrasound findings at the time of diagnosis [13,31,32]. We found that failure of Pavlik harness treatment was greatest among patients with Ortolani-positive hips and that male sex and Graf classification were associated with failure of treatment.…”

“…Greater than 90% success may be expected in hips that are stable on examination but dysplastic on ultrasound images [8] and for those dislocatable with the Barlow [3] maneuver [6,12,14,25]. However, treatment failures of 30% to 60% have been reported in dislocated reducible Ortolani-positive hips [2,14,16,19,20,24,[30][31][32]. Failure of the Pavlik harness method has been associated with an increased risk of osteonecrosis of the femoral head [29].…”

“…Previous studies have described clinical and ultrasound parameters that define failure of the Pavlik harness treatment method of Ortolani-positive hips [13,14,18,19,27]. However, there are conflicting results regarding age [13,14,31,32], sex [4,13,14,31,32], bilaterality [10,14,20,31], and ultrasound findings at initial examination [10,16,19,24,28,30,32].…”

“…However, there are conflicting results regarding age [13,14,31,32], sex [4,13,14,31,32], bilaterality [10,14,20,31], and ultrasound findings at initial examination [10,16,19,24,28,30,32]. Methods of data collection in these previous retrospective studies have varied, and they did not address the full spectrum of potential factors that may lead to failure such as detailed patient and family history, physical examination, and ultrasound findings.…”