Early Human Development 90 (2014) 731–734

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Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

Best practice guidelines

Treatment and prevention of hip dysplasia in infants and young children

Julia Judd a,1, Nicholas M.P. Clarke a,b,⁎
a
Child Health, University Hospital Southampton Foundation Trust, Southampton, UK
b
Faculty of Medicine, University of Southampton, Southampton, UK

a r t i c l e i n f o a b s t r a c t

Keywords: The diagnosis and treatment of developmental dysplasia of the hip in the infant are uniform, with consensus that
Developmental dysplasia of the hip diagnostic ultrasound and Pavlik harness management are standard procedures. Sequential procedures for failed
Diagnosis early treatment, residual dysplasia and late diagnosis are dependent on the age and the severity of the dysplasia.
Management 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.
© 2014 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731
2. Incidence and screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 731
3. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
4. Subsequent management and complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
5. Residual hip dysplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733

1. Introduction Risk factors are evident at both pre- and post-natal. In an attempt to
qualify diagnostic criteria for DDH, an international survey of paediatric
Developmental dysplasia of the hip (DDH) is a term used to describe orthopaedic surgeons determined a consensus of relevancy which
a spectrum of the disorder ranging from minor acetabular dysplasia to ‘included the Ortolani/Barlow test, asymmetry in abduction of 20° or
irreducible dislocation of the femoral head, with instability of the hip greater, breech presentation, leg-length discrepancy, and first-degree
being a primary cause. Treatment is dependent on both the age at relative treated for DDH’ [1]. Breech positioning increases the risk of
diagnosis and the severity of the condition. DDH [2] and can also be a contributing factor. In the post-natal period,
cultural preferences such as the encouragement of swaddling, or
strapping the infant to a cradle board with legs in extension, are
2. Incidence and screening recognised predisposing factors. Poor hip positioning in infant carriers
may also contribute to abnormal acetabular development.
An abnormal hip at birth is one that is fixed and irreducible, Post-natal surveillance screening will detect a clinically abnormal
dislocatable, subluxed or dysplastic. The incidence of neonatal hip insta- hip in the hands of trained personnel. The Ortolani manoeuvre will
bility is between 10 and 20 per 1000 live births, whereas the incidence reduce a dislocatable hip in abduction and flexion, and the Barlow test
of established dislocation is 1–2 per 1000. A significant number of cases provokes a dislocation in adduction and flexion of the hip [3].
of new-born instability were resolved by two to three weeks without Ultrasound screening is however the recognised ‘gold standard’. As a
intervention. non-invasive method it allows for accurate assessment of the cartilagi-
nous femoral head and of the morphology of the acetabulum. There is
⁎ Corresponding author: Tel.: +44 23 8120 6140; fax: +44 23 8120 4020
variance in the technique with central Europe preferring the static
E-mail addresses: [email protected] (J. Judd), [email protected] (N.M.P. Clarke). Graf method and the measurement of specific angles to denote acetab-
1
Tel.: + 44 23 8120 4991. ular insufficiency, whilst the dynamic method described by Harcke et al.

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732 J. Judd, N.M.P. Clarke / Early Human Development 90 (2014) 731–734

[4] demonstrates femoral head location and hip instability. Either meth- reduced incidence of acetabular dysplasia, whilst delayed reduction
od needs to be performed accurately to produce true coronal and trans- awaiting the appearance of the ossific nucleus (at an average age of
verse images for correct interpretation to diagnose dysplasia and 11.5 months) increases the incidence of open reduction and require-
instability. Selective versus universal ultrasound hip screening con- ment for reoperation. In a study of 50 hips [28], closed hip reductions
tinues to be debated [5]. In central Europe the latter is advocated, but resulted in 0% AVN, but a secondary procedural rate of 57%, whilst
the evidence to support or reject this is insufficient. Not only are there open hip reductions with intentional delay until appearance of the
significant cost implications to be considered, but the high treatment ossific nucleus showed a 9% AVN rate and a requirement for subsequent
rate raises concern regarding questionable false positive screening re- surgery to augment acetabular development, in 41%. Early closed versus
sults. Overtreatment in this category may risk avascular necrosis delayed open hip reduction, with or without the presence of the ossific
(AVN) in a normal hip [6]. The MRC Hip Trial reported in 2003 [7] dem- nucleus at the time of surgery and whether it positively affects the rate
onstrated the effectiveness of ultrasound imaging in confirming clinical of AVN continues to be debated [25–27] and future research aims to
hip instability and resulted in a reduction of treatment. The timing of determine its significance.
ultrasound screening however is crucial. Performed before two weeks The management of DDH following failed harness treatment or late
of age, the test is oversensitive and the cost of required resources for presentation is age dependent. A closed reduction is more likely to be
global scanning in terms of personnel and facilities is prohibitive. The achieved under the age of eight months and an open reduction required
suggestion that transient hip instability and abnormal sonographic for the older child. The place of pre-operative Gallows traction to reduce
results can resolve spontaneously by eight weeks has resulted in the rate of AVN remains controversial [29]. Surgery includes an open or
varying treatment rates. The incidence of late presentation remains a percutaneous adductor tenotomy and dynamic arthrography to assess
concern and may be due in part to a lack of consensus of the criteria for medial pooling and instability.
for definitive diagnosis [8,9]. Both closed and open hip reductions are immobilised in a hip spica in
the human position within the safe zone of Ramsey (100° flexion, 40–60°
3. Treatment abduction) for an initial six weeks, with subsequent plaster changes.
Single section computed tomographic image, day one post-
Protocols for the treatment of DDH are useful in providing consisten- operatively assesses for maintenance of correct hip positioning follow-
cy and uniformity of treatment. Splintage is used for early management ing hip spica application [28].
and the Pavlik harness is the most frequently used abduction splint
under 3 months of age, with a reported 79% to 96% success rate [9,10].
4. Subsequent management and complications
Flexion and abduction of the hip dynamically reduce it into the acetab-
ulum [11]. Alternative rigid splints have been associated with an in-
The rate of AVN as a consequence of DDH treatment is variable and
creased incidence of AVN, believed to be due to compression of the
dependent on a number of factors, including age at presentation, sever-
retinacular vessels, through excessive hip abduction [12,13]. AVN is a
ity and treatment type [26,30,31]. Lateral growth arrest to the femoral
significant irreversible complication of failed Pavlik harness treatment
physis is a recognised complication. Premature fusion of the lateral
and high rates are reported in the literature [14,15]. Abandoning the
aspect of the femoral head tilts it into a valgus orientation resulting in
harness early is recommended for hips that do not respond to treatment
it being uncovered by the acetabulum. Radiographic monitoring
after a two week trial [16]. Cashman et al. [17] demonstrated the success
is essential for early detection and intervention. Medial screw
of using a standardised protocol for DDH treatment. The prospective
epiphysiodesis will stop the progression of the deformity and improve
study of 546 dysplastic hips highlighted successful outcomes, when
clinical outcome [32,33]. For those infants who present late with
implementing the Pavlik harness early, with close ultrasound and clini-
dislocated hips, treatment is complex and comprises additional femoral
cal monitoring. The AVN rate was reported as 1% in hips that reduced
shortening to facilitate reduction of the hip and prevent vascular injury
with the harness, although higher in failed Pavlik harness treatment
to the femoral head.
(27%). Follow-up radiographic monitoring is recommended until
60 months following completion of harness treatment to assess for
late dysplasia [17]. 5. Residual hip dysplasia
The Pavlik harness protocol involves initial weekly harness checks
supplemented with ultrasound [18]. This facilitates parental compliance Despite early recognition and appropriate treatment, some cases
of the brace and confirms hip reduction. Management of the infant in require secondary procedures to address persistent dysplasia or
the harness requires close observation, with a competent team who
can safely apply and adjust the harness [19]. Incorrect application and
positioning result in failure of the harness [20]. The use of restrictive
clothing over the harness, swaddling and slings which do not support
the hips in flexion, can all contribute to incorrect positioning of the
hips and potentially affect the natural hip development and success of
the harness [21]. Complications of the Pavlik harness are AVN [22]
and femoral nerve palsy when the hip is hyperflexed, or the infant
who is slightly older or larger at the commencement of splintage
[23]. For the latter, parents should be advised to monitor their child's
leg movement within the harness constraints. Failure of concentric
reduction by weeks 2–3, should lead to cessation of harness treat-
ment which does condemn the hip to surgical intervention, the
timing of which is controversial.
The blood supply of the chondroepiphysis is end arteriolar and
therefore susceptible to compression. The appearance of the ossific
nucleus is associated with an anastomotic more mature vasculature.
Vascular injury to the proximal femoral epiphysis caused by the treat-
ment of DDH has been reported between 0 and 73% [24]. It is argued
that early hip reduction promotes joint congruency and results in a Fig. 1. Ultrasound monitoring of DDH treatment in Pavlik harness.
 J. Judd, N.M.P. Clarke / Early Human Development 90 (2014) 731–734 733

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