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OBJECTIVE The aim of this study was to investigate the effects of the developmental dysplasia of the hip screening program on the treatment procedures in a tertiary health care center. METHODS We retrospectively reviewed all the DDH patients between 2012 and 2019 from the operating theatre records. The patients were separated based on the year of treatment. The rates of each treatment modality were determined respectively from 2012 to 2019, and Pavlik harness usage of the patients were queried. The changes in the rates of several surgical interventions after the start of screening program were identified. RESULTS Between 2012 and 2019, 831 interventions were applied to 711 DDH patients. Closed Reduction (CR) is the least invasive treatment method, and it increased significantly from 20% to 46%. The rate of Open Reductions (OR) also increased from 3% to 9% at this time period, but it was statistically insignificant. Conversely, Pemberton-Salter Osteotomy (PSO) and Dega-Chiari Osteotomy (DCO) rates decreased significantly (41% to 28% and 9% to 0%, respectively). The rate of Pemberton- Salter osteotomy with femoral shortening (PSO-FS) rate decreased insignificantly from 27% to 20%. In patients that used Pavlik harness, the most common intervention was CR (83%). In CR group, the screened newborn rate increased more than two times from 2012 to 2019. CONCLUSION The results of this study have shown that after the initiation of the screening program for DDH, less invasive treatment modalities such as CR and OR interventions increased, and major bony procedures such as PSO, PSO-FS and DCO interventions decreased. Furthermore, as the screening program advanced, CR rate and the use of Pavlik harness rate in CR interventions increased. LEVEL OF EVIDENCE Level IV, Therapeutic Study.

BACKGROUND: Little was known about developmental dysplasia of the hip (DDH) in the early historical era. Symptoms such as limping were caused by a variety of disease processes, many of which were life threatening. It was not until the discovery of X-ray in 1896 that clear understanding of childhood hip conditions, including DDH, could evolve. METHODS: We reviewed available literature and distilled it into this summary of the history of our understanding of DDH. RESULTS: The development of non-operative methods relied on plaster of Paris cast reductions and later splints and harness systems leading to the Pavlik harness (1950’s). The development of ultrasound as a diagnostic technique made early diagnosis and treatment possible. Surgical approaches to DDH treatment required several key discoveries: invention of general anesthesia (1840s); development of sterilization techniques (1860–1880); discovery of X-ray (1890s); development of stainless steel (1920s); and the discovery of antibiotics (1930s). These surgical advances allowed the development of a remarkable variety of operations to treat DDH including open reduction techniques, and osteotomies of the acetabulum and proximal femur. CONCLUSION: The path to accurate diagnosis and predictable treatment of DDH parallels the many advances that application of the scientific method has allowed in the specialty of orthopedic surgery. The development of academic centers that focus on research and education in childhood hip disorders, as well as a growing number of centers that focus on hip problems in adolescents and young adults, assure a continuous and changing “history” of this common childhood hip condition.

Aims To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures. Methods Data was obtained from the Northern Ireland DDH database. All children who underwent an attempted closed reduction between 2011 and 2016 were identified. Children with a dislocated hip that failed Pavlik harness treatment were included in the study. Successful closed reduction was defined as a hip that reduced in theatre and remained reduced. Most recent imaging was assessed for the presence of AVN using the Kalamchi and MacEwen classification. Results There were 644 dislocated hips in 543 patients initially treated in Pavlik harness. In all, 67 hips failed Pavlik harness treatment and proceeded to arthrogram (CR) under general anaesthetic at an average age of 180 days. The number of hips that were deemed reduced in theatre was 46 of the 67 (69%). A total of 11 hips re-dislocated and underwent open reduction, giving a true successful CR rate of 52%. For the total cohort of 67 hips that went to theatre for arthrogram and attempted CR, five (7%) developed clinically significant AVN at an average follow-up of four years and one month, while none of the 35 hips whose reduction was truly successful developed clinically significant AVN. Conclusion The likelihood of a successful closed reduction of a dislocated hip in the Northern Ireland population, which has failed Pavlik harness treatment, is 52% with a clinically significant AVN rate of 7%. As such, we continue to advocate closed reduction under general anaesthetic for the hip that has failed Pavlik harness. Cite this article: Bone Jt Open 2021;2(8):594–598.

Aims The objective of this study was to evaluate the clinical and radiological outcomes of patients younger than six months of age with developmental dysplasia of the hip (DDH) managed by either a Pavlik harness or Tübingen hip flexion splint. Methods Records of 251 consecutive infants with a mean age of 89 days (SD 47), diagnosed with DDH between January 2015 and December 2018, were retrospectively reviewed. Inclusion criteria for patients with DDH were: younger than 180 days at the time of diagnosis; ultrasound Graf classification of IIc or greater; treatment by Pavlik harness or Tübingen splint; and no prior treatment history. All patients underwent hip ultrasound every seven days during the first three weeks of treatment and subsequently every three to four weeks until completion of treatment. If no signs of improvement were found after three weeks, the Pavlik harness or Tübingen splint was discontinued. Statistical analysis was performed. Results The study included 251 patients with Graf grades IIc to IV in 18 males and 233 females with DDH. Mean follow-up time was 22 months (SD 10). A total of 116 hips were graded as Graf IIc (39.1%), nine as grade D (3.0%), 100 as grade III (33.7%), and 72 as grade IV (24.2%). There were 109 patients (128 hips) in the Pavlik group and 142 patients (169 hips) in the Tübingen group (p = 0.227). The Tübingen group showed a 69.8% success rate in Graf III and Graf IV hips while the success rate was significantly lower in the Pavlik group, 53.9% (p = 0.033). For infants older than three months of age, the Tübingen group showed a 71.4% success rate, and the Pavlik group a 54.4% success rate (p = 0.047). Conclusion The Tübingen splint should be the preferred treatment option for children older than three months, and for those with severe forms of DDH such as Graf grade III and IV, who are younger than six months at time of diagnosis. The Tübingen hip flexion splint is a valid alternative to the Pavlik harness for older infants and those with more severe DDH. Cite this article: Bone Joint J 2021;103-B(5):991–998.

Background: Worldwide a wide variation exists in duration of Pavlik harness treatment for infants up to 6 months with stable developmental dysplasia of the hip (DDH). The purpose of this study was to evaluate whether shortening the time to first routine follow-up ultrasound after initiation of Pavlik harness treatment would reduce treatment duration and whether this influenced radiologic outcome at 1 year of age. Furthermore, predictors of higher acetabular index (AI) at 1 year of age were investigated. Methods: A retrospective study was conducted in infants with stable DDH (Graf IIb and IIc) diagnosed and treated between 2015 and 2017. Two groups were identified: first routine follow-up ultrasound at 12 weeks after Pavlik harness initiation (group I) and first routine follow-up ultrasound at 6 weeks after Pavlik harness initiation (group II). In both groups, treatment was continued until repeat ultrasound measurements (every 6 wk) showed a normalized hip. Radiologic outcome at 1 year of age was defined as residual dysplasia measured on an anteroposterior hip radiograph according to the Tönnis table. Results: A total of 222 infants were included. The median time of Pavlik harness treatment was 12 weeks (interquartile range, 11.9 to 12.3) in group I compared with 6.1 weeks (interquartile range, 6.0 to 7.5) in group II (P

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

Purpose To understand the variation in the management of hip dysplasia identified from the United Kingdom neonatal selective screening programme. Methods Having been designed and tested by the research committee of the British Society for Children's Orthopaedic Surgery (BSCOS), a nationwide online survey was conducted of BSCOS members to ascertain their treatment strategies for neonatal hip dysplasia. Results There were 111 responses (60% of members), which illustrated wide variation in care. In all, 91 (over 80%) of respondents treat more than ten cases per year, yet only 61 (55%) work to an agreed protocol. A total of 90 (81%) use the Graf classification and 103 (93%) use the Pavlik harness initially. Consensus is lacking in key areas including duration of harness use, hours per day, clothing and weaning. Importantly, notable differences of opinion even exist regarding which hip pathologies need treatment. Conclusion This study quantifies the wide variation in many key elements of the initial treatment of neonatal hip dysplasia in the United Kingdom. This variation appears unnecessary and unacceptable as the Getting It Right First Time programme seeks to standardize care pathways. The charitable sector has called for consensus to mitigate parental anxiety, and it has been suggested that this could allow better integration of hip dysplasia into national screening pathways. Standardized care benefits patients and represents the platform from which we can begin understanding effectiveness and optimizing outcomes. Level of Evidence Level V

Casts are commonly used for fracture management and postoperative immobilization in pediatric patients. However, cast immobilization is not without complications (eg, thermal injuries, pressure sores, infection, and neurovascular injury) and may be associated with additional costs and increased loss of school/work days for cast removal or other complications. The disadvantages of traditional casting can be minimized by alternative management strategies: waterproof casts to facilitate bathing and swimming; a Pavlik harness in infants, a single-leg spica cast, or flexible intramedullary nails to avoid complications with double-leg spica casts for femur fractures; and braces or splints to manage buckle and minimally displaced distal radius fractures, toddler's fractures, and stable foot/ankle fractures.

Objective: To analyze and follow-up patients previously selected by pediatricians at the time of birth who presented altered initial physical examination results to identify the pathological changes in their hips. Methods: A prospective cohort study was conducted involving 34 newborns (68 hips) out of a total of 1273 live births; these infants were assessed within the first days of life as altered findings were noted in the initial examination by the pediatrician. The results of clinical and ultrasonographic examination performed using the GRAF method and of specific treatments were analyzed. Results: Of the 68 hips in 34 patients, 2 hips in 2 patients required intervention using the Pavlik harness for 8 weeks; a satisfactory treatment outcome was obtained in both cases. Conclusions: Despite the low orthopedic workload in medical courses, it was possible to identify data consistent with the literature, both in the presentation of clinical findings and in those that required treatment, indicating that an initial evaluation of all newborns is mandatory, especially those with risk factors. Level of evidence IV, case series. RESUMO Objetivo: Analisar e acompanhar os pacientes previamente selecionados por pediatras desde o nascimento, em busca de alterações patológicas nos quadris, naqueles considerados com exame físico inicial alterado. Métodos: Estudo de coorte prospectivo, iniciado nos primeiros dias de vida, em 68 quadris de 34 recém-nascidos, de um total de 1.273 nascidos vivos no ano da pesquisa, devido a alguma alteração no exame inicial do pediatra. Primeiramente, foram utilizados exame clínico e ultrassonográfico, com o método de Graf, tendo sido instituído tratamento específico naqueles que se fizeram necessários. Resultados: Dos 68 quadris em 34 pacientes, dois quadris em dois pacientes distintos necessitaram de intervenção com uso do suspensório de Pavlik por 8 semanas, obtendo resultado satisfatório em ambos após o término do tratamento. Conclusão: Apesar da baixa carga horária da Ortopedia nos cursos de medicina, podem-se observar dados condizentes com a literatura, tanto na apresentação de achados clínicos, quanto nos que se fez necessário o tratamento, de forma que se mostra necessária a realização de avaliação inicial adequada de todos os recém-nascidos, em especial naqueles que possuem fatores de risco. Nível de evidência IV, Série de casos.

Variation exists in the Pavlik harness (PH) treatment regimen for infantile developmental dysplasia of the hip (DDH). The purpose of this study was to determine if the daily PH wear duration (23 vs. 24 h) and frequency of follow-up visits affect the clinical and radiographic outcomes of infants with dislocated but reducible (Ortolani+) hips.This study reviewed prospectively enrolled patients with DDH in a single center who presented at age6 months with Ortolani+ hips and were treated with PH. Recommended daily PH wear duration (23 vs. 24 h) and the frequency of clinic visits in first 4 weeks after the initiation of PH treatment were analyzed. The clinical success (stable hip that did not require closed or open reduction or the use of an abduction orthosis) and radiographic success based on the acetabular index at 2-year follow-up were compared between different PH regimen groups.Sixty-two patients (74 hips, 53 females) with Ortolani+ hips had a mean age of presentation of 23±28 days (range, 4 to 128 d) and mean follow-up of 33.2±18.4 months (range, 8 to 85 mo). Overall clinical success rate of PH for Ortolani+ hips was 93% (69/74 hips) and radiographic success rate at 2 years was 84% (48/57 hips). There was no difference in clinical or radiographic success rate between the 23- and 24-hour wear groups (P0.99, 0.73) or between hips assessed almost weekly compared with once or twice during the first 4 weeks of PH treatment (P0.99 for both).The 23- versus 24-hour PH regimen and frequency of clinic visits in the first 4 weeks of PH treatment did not affect the clinical or radiographic success rate of Ortolani+ hips in infantile DDH. A strict weekly clinic visit and 24-hour PH regimen may not be necessary to obtain stable reduced hips in infants presenting6 months of age with Ortolani+ hips.Level III-therapeutic.

Background Pavlik harness (PH) treatment is successful in treating over 90% of newborns with developmental dysplasia of the hip (DDH). There is a need for close supervision, frequent adjustments, size changes, and monitoring of complications. This paper aims to provide a safe criterion for remote follow-up of DDH patients treated in a PH to reduce the risk of COVID-19 (coronavirus disease 2019) exposure to patients, parents, and health practitioners. Methods All infants with stable hips (Graf I, IIa/b/c/d, treated III/IV) with consenting parents after appropriate counseling were enrolled in a virtual clinic. Clinics were conducted using the NHS "Attend anywhere" virtual link service by an extended scope practitioner-specialist physiotherapist and a clinical nurse specialist. The virtual clinic group was compared with a matched cohort of patients from 2018/2019. Results A total of 141 patients were referred to the neonatal hip clinic; 45 patients were eligible for harness treatment and 20 patients were selected for virtual clinics. In total, there were 35 virtual clinic appointments. Each of the patients had an average of 1.7 virtual appointments ranging from 1 to 3 (26.3% of total number of clinics). Age at presentation of the treated group was 7±4.2 weeks and control group 5.7±5.5 weeks (P=0.59). PH duration of the study group was 9±2.6 weeks and the control group, 7.8±2.5 weeks (P=0.12). There were no missed complications at the follow-up face-to-face appointment. Patients saved an average of 76 km total travel distance. Conclusions This study demonstrates adequate evidence that children requiring routine follow-up appointments involving PH adjustment, skincare, and identification of clinical anomalies, can be treated and followed up safely using virtual clinics. Clinical triage of suitable patients for virtual clinic provision must always be made by experienced clinicians. Children presenting with Graf IIa, IIb, IIc, IId, as well as those with stable and improving Graf III at initial diagnoses, had successful treatment with virtual clinic follow-up appointments in this study. Level of evidence Level IV.

CASE In this report, we present an infant who was diagnosed with femoral nerve palsy (FNP) and developmental dysplasia of the hip (DDH) on the same side after delivery. The patient was treated with hip alternative abduction orthosis, which did not force hip flexion with satisfactory results. CONCLUSION FNP in newborns with DDH is usually described as a possible complication of the Pavlik harness treatment. However, there is only one report that presents 2 cases. Our objective is to raise awareness of this very rare condition because performing an early intervention is vital to achieving an optimal therapeutic result.

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.

INTRODUCTION The failure rate of Pavlik harness treatment for developmental dysplasia of the hip (DDH) has been reported as high as 55%. The purpose of this study is to investigate the effect of an inverted acetabular labrum on outcomes of Pavlik harness treatment for DDH. METHODS A retrospective review was conducted on DDH patients at a tertiary care pediatric hospital from 2004 to 2016. DDH patients that underwent index treatment with Pavlik harness and had minimum 12 months follow-up were included. Medical charts were reviewed for demographics, treatment, and outcomes. Outcomes were compared between patients with an inverted labrum versus those without an inverted labrum. RESULTS A total of 156 patients with 229 dysplastic hips were included. The mean age at initiation of Pavlik harness treatment was 1.9±1.4 months and mean follow-up was 37.7±23.0 months. Bilateral DDH was diagnosed in 46% (73/156) of patients. In all, 37% (75/229) of hips failed Pavlik harness index treatment. Second-line treatment was rigid hip abduction bracing in 91% (68/75) of hips, closed reduction in 5% (4/75) of hips, and open reduction in 4% (3/75) of hips. An inverted labrum was present in 10% (22/229) of all hips. The incidence of Pavlik harness treatment failure was 91% (20/22) in the inverted labrum group compared with 27% (55/207) in the control group (P

Objective: To investigate the effectiveness of the Pavlik harness (PH) in the treatment of patients who were diagnosed with unstable hips aged between three and six months. Material and Method: We retrospectively reviewed patients aged three to six months who were diagnosed with unstable hips and treated with the PH. The patients were treated using PH and were closely followed by a weekly clinical examination. The primary outcome was to assess the success rate of PH treatment in children with unstable hips (Graf Type IID, III, IV). A successful outcome as a result of PH treatment was defined as either obtaining a Type I hip based on Graf’s method of hip ultrasonography or a concentric reduction based on hip radiography. Results: Thirty-three patients’ 34 hips were included in this study with a diagnosis of DDH based on hip sonography performed according to the Graf’s method at the time of initial admission to our department. The mean age of the children in the beginning of the PH treatment was 17 weeks (range, 14–22); the mean follow-up was 48 months (range, 24–84). On admission, the mean alpha angle was 46 (range, 35–58). According to the Graf classification, DDH was determined as Type D in 18 hips (52%), Type IIIa in 5 hips, Type IIIB in 3 (24%) and Type IV in 8 (24%). Of these 34 hips, 28 (82%) were treated successfully using PH, with a mean application time of 11.24 weeks (range, 4–20). The success rate of PH treatment was determined as 82% (28/34 hips). Conclusions: Favorable outcomes can be expected from PH treatment in patients with unstable hips (Graf Type IID, III, IV) who are diagnosed between the age of three and six months.

BACKGROUND For 0- to 6-month-old patients with developmental dislocation of the hip, the likelihood of Pavlik harness treatment failure may be increased. The human position brace is an available option. We aimed to compare therapeutic efficacy between the Pavlik harness and human position brace. METHODS We included 87 patients (106 hips) in the human position brace group and 47 patients (62 hips) in the Pavlik harness group. Clinical and radiologic outcomes were recorded and compared, respectively. RESULTS The mean follow-up was 17.73±14.56 months (range, 5 to 56 mo). Human position brace produced higher success rates (65.1% vs. 43.5%; P=0.006) and had significant advantages in the 4 to 6 months group (P

INTRODUCTION The success of Pavlik harness therapy is based, among other things, upon the correct reapplication by parents. This prospective study assesses the effectiveness of a validated Objective Structured Assessment of Technical Skill (OSATS) educational module for Pavlik harness application among Greek parents. METHODS Forty consecutive parents of newborns with developmental dysplasia of the hip (DDH), who were treated with Pavlik harness, were divided into two groups. Twenty parents (group 1) were educated with the Greek OSATS version, while the rest (group 2) served as the control. The OSATS score, quality of the final product (Global Rating Scale - GRS) and sonographic imaging of the hips were evaluated during follow-up. RESULTS Post-intervention evaluation revealed significant higher means of OSATS score (p

We investigated if infants with a Barlow positive hip(s) have natural hip stabilization and can thus avoid Pavlik Harness (PH) treatment. We conducted a chart review for infants who presented within two weeks of life, had a Barlow positive hip, and were deferred treatment. Of the thirty infants, eighteen were treated with PH at 4-6 weeks or 12 weeks due to persistent dysplasia. Twelve infants avoided PH entirely. There were zero cases of PH failure. Parents can be counseled that deferring treatment until at least 4-6 weeks of age might avoid treatment altogether without an increased risk of harness failure.

Background Developmental dysplasia of the hip is effectively treated with a Pavlik harness (PH) within the first 6 months of life. Over 80% of unstable hips in the newborn period will naturally stabilize by 2 months of age. If there is no difference in the effectiveness of initiating PH treatment at 1 week compared with 4 weeks of age, waiting may allow the hips to naturally stabilize and avoid treatment. The purpose of this study is to evaluate whether the timing of PH implementation influences its effectiveness in the treatment of developmental dysplasia of the hip. Methods A retrospective review was conducted between 2004 and 2010. Patients were included if PH therapy was prescribed for hip instability or dislocation at or before 6 months of age. PH failure was defined as requiring any operative procedure for definitive management. Groups were divided based on the age at which the PH was initiated-group1= 60 days. Results A total of 176 children were included with 38 (21.6%) failing PH treatment. The mean age at PH initiation was 1.3 months (SD=1.3) in the successfully treated children and 1.4 months (SD=1.2) in the failures (P=0.77). There was no difference in the failure rates by age with group 1=19.1% (18/94), group 2=22.5% (9/40), and group 3=26.2% (11/42) (P=0.87). There was no statistical difference with respect to sex or breech positioning in the success or failure groups; however, there was a higher percentage of bilateral involvement in the failure group (P=0.04). Conclusions Patients who had PH initiation before 30 days of age were no more or less likely to fail than when PH was initiated after 30 days of age. Parents can be counseled that waiting until after 30 days of age is appropriate before PH implementation. By avoiding swaddling during this period, the hips may stabilize without treatment and allow for more parental-infant bonding before implementation of PH. Level of evidence Level III-therapeutic, case control study.

In dysplastic infant hips undergoing abduction harness treatment, cartilage contact pressure is believed to have a role in therapeutic cartilage remodeling and also in the complication of femoral head avascular necrosis. To improve our understanding of the role of contact pressure in the remodeling and the complication, we modeled cartilage contact pressure in cartilaginous infant hips undergoing Pavlik harness treatment. In subject-specific finite element modeling, we simulated contact pressure of normal and dysplastic hips in Pavlik harness at 90° flexion and gravity-induced abduction angles of 40°, 60° and 80°. We demonstrated that morphologies of acetabulum and femoral head both affected contact pressure distributions. The simulations showed that in Pavlik harness, contact pressure was mainly distributed along anterior and posterior acetabulum, leaving the acetabular roof only lightly loaded (normal hip) or unloaded (dysplastic hip). From a mechanobiological perspective, these conditions may contribute to therapeutic remodeling of the joint in Pavlik harness. Furthermore, contact pressure increased with the angle of abduction, until at the extreme abduction angle (80°), the lateral femoral head also contacted the posterior acetabular edge. Contact pressure in this area could contribute to femoral head avascular necrosis by reducing flow in femoral head blood vessels. The contact pressure we simulated can plausibly account for both the therapeutic effects and main adverse effect of abduction harness treatment for developmental dysplasia of the hip. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Background Infants with dislocated irreducible (D/I) hips can be substantially harder to treat than infants with dislocated but reducible hips. The purpose of this study was to compare treatment methods and outcomes for infants with D/I hips in order to optimize management of this difficult patient cohort. Methods A multicenter prospective hip dysplasia study database was analyzed from 2010 to 2016. Infants aged below 6 months with clinically and radiologically confirmed D/I hips were included in the study. Teratological hips (syndromic/neuromuscular) were excluded. Results In total, 59 hips in 52 patients were included. All hips were clinically Ortolani negative and radiologically dislocated but irreducible on presentation and had at least 20 months of follow-up. Mean age at diagnosis was 1.9 months (range, 0.1 to 5.9 mo). There were 33 left hips, 12 right hips, and 14 bilateral hips (7 patients). In total, 48 of 59 hips were treated in Pavlik harness. The remainder were treated by alternative braces or primary closed or open reductions. Pavlik treatment was successful in 27 of 48 hips. Pavlik treatment was abandoned in 21 D/I hips, 3 due to femoral nerve palsy and the remainder due to failure to achieve reduction. There was no statistical correlation between Pavlik success and age at diagnosis (P=0.22), patient sex (P=0.61), or bilateral compared with unilateral D/I hips (P=0.07). Left hips were more likely to be successfully reduced in Pavlik harness than right hips (P=0.01). Five complications occurred: 3 patients developed femoral nerve palsy in Pavlik harness, while 2 patients developed avascular necrosis, both after failed Pavlik treatment and subsequent surgery. Conclusions Pavlik harness treatment has been demonstrated to be a safe and sensible first-line treatment for infants with D/I hips. Left hips were more likely to be successfully reduced in Pavlik harness than right hips, but age, sex, and bilaterality were not correlated. The outcomes demonstrated from this multicentre prospective database inform management of this complex patient cohort. Level of evidence Level II-prognostic study: less-quality prospective study.

BACKGROUND We asked whether patient-specific factors and ultrasound (US) measurements of hip dysplasia severity at initial examination influence short-term residual acetabular dysplasia in patients successfully treated with Pavlik harness for developmental hip dysplasia. METHODS After IRB approval, 134 hips (84 patients) successfully treated by the Pavlik method between August 2011 and October 2014 with follow-up at 12 months of age were identified. Early successful treatment was defined as normal examination and US after approximately 12 weeks of Pavlik treatment. Multivariate linear and logistic regression models were used to identify factors associated with acetabular index (AI) measurements at 12 months as well as factors associated with an increase in AI between the 6- and 12-month timepoints (dysplastic progression). RESULTS The study consisted of 134 hips (84 patients). The distribution of dysplastic, Barlow, and Ortolani hips was 44.8% (N=60), 30.6% (N=41), and 24.6% (N=33), respectively. The crude incidence of residual dysplasia at the 6-month visit (AI>30 degrees) was 11.7% (12/102). The incidence of residual dysplasia at the 12-month visit (AI>28 degrees) was 11.8% (13/111). Graf type was the only variable associated with AI values at the 12-month visit (mean difference: Graf type-IV-Other, 2.6; 95% confidence interval, 0.3-4.9; P=0.026). CONCLUSIONS The risk of residual acetabular dysplasia after normal hip US following Pavlik treatment is not negligible. Radiographic surveillance is warranted to monitor and screen for dysplasia progression. Patients with dislocated Graf type-IV hips at diagnosis are at increased risk of residual acetabular dysplasia at 1 year after successful treatment with the Pavlik method. LEVEL OF EVIDENCE Level III-therapeutic study.

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.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.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 were7.4 mm at initiation of treatment for distance A and11.2 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 of32° at the initiation of harness treatment were more likely to exhibit hip dysplasia at 3 years of age.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.

In this thesis, we showed that the incidence of (late) DDH increases in regions such as the province of Manitoba (Canada), where there is no screening programme in place, as (selective) ultrasound programmes in other countries have shown to decrease the rate of late presenting DDH. Improved access to health care and well baby clinics in rural areas, including clinical assessment of the hips beyond walking age, can improve diagnosis and overall outcome. It is unclear from our study if the late DDH is due to family predisposition and inbreeding or mechanically induced due to swaddling/restricted hip movements, a regional custom. Screening should also take into consideration risk factors for the province such as first female, breech and presence of clubfoot deformity. The latter is somewhat controversial, and could again be a regional entity, as current screening programmes no longer include clubfoot as a risk factor.(18,19) On the other hand, ultrasound has also its limitations in identifying relevant DDH. Despite abnormal findings on ultrasound suggestive for DDH within the first 6 months of life, many of these abnormalities will improve over time without treatment. Furthermore, abduction treatment of stable well-centered hips in 3 to 4 months old will not alter acetabular development, as 80% will become normal without treatment. Again, this questions the specificity of US as diagnostic tool to identify true hip disease based on Graf Classification alone. The role of Pavlik harness treatment over 6 months of age is questionable but can still be successful in 60% of the cases in moderate dislocation (≤ Graf type III). Prolongation of the Pavlik harness beyond 6 weeks of treatment did not alter the success rate. After failed Pavlik harness, medial approach lead to poor results in 20% of the patients for both radiographic and functional outcomes. The medial approach in patients younger than 6 months showed better results. Thus, the medial approach should probably be reserved to this age group. AVN rate was high, with almost 1/2 showing some changes during growth but eventually only 1/6 developed more severe proximal growth disturbance. The patient's observed outcome was not linked to the type of AVN but the severity of residual dysplasia. Finally, shape varian978-94-6419-087-8ts of AVN hips using SSM can identify early radiographic changes linked to poor outcome. This has the potential to develop as a tool for decision-making process at already a very young age and therefore improving the outcome.

The classic Ortolani and Barlow signs are routinely used to diagnose hip instability secondary to severe acetabular dysplasia in the newborn. However, eliciting a positive sign depends largely on the experience of the examiner and the subjective amount of manual pressure the examiner applies on the baby's hips. Furthermore, these signs do not give a clue for the selection of a maturation or immobilization device after reduction of an unstable hip: below-knee hip spica, above-knee hip spica or a Pavlik harness. The aim of this study is to describe a clinical sign that could be useful in detecting hip instability of the newborn and to decide the proper treatment in a more objective manner: knee extension provokes dislocation of the ipsilateral unstable hip.

CASE A 2.5-month-old girl with bilateral hip dysplasia presented for orthopaedic evaluation and began treatment with a Pavlik harness. One month after the initiation of treatment, decreased use of the left upper extremity was noted, which was consistent with a brachial plexus palsy. The Pavlik harness was discontinued, and upper extremity function fully recovered within 8 weeks. CONCLUSIONS The Pavlik harness is an effective treatment for hip dysplasia with a low-risk profile. This case serves to remind clinicians of the risk for upper extremity traction injury when a Pavlik harness is used in patients who are large for their chronological age.

BACKGROUND The treatment protocol for children with developmental dysplasia of the hip (DDH) is routinely adjusted by assessing the hip reduction after 3 weeks of Pavlik harness treatment. However, there is a high risk of failure and complications in the treatment adjustment. The aim of this study was to explore the value of ultrasound features in predicting the treatment outcome of Pavlik harness after 3 weeks in DDH children. METHODS A total of 215 DDH children were recruited and the demographics and the changes of ultrasound features [α and β angle and femoral head coverage (FHC)] during the Pavlik harness treatment were recorded. The children were divided into the success group and the failure group according to the reduction outcome after 3 weeks. Univariate and multivariate analyses were performed to analyze the independent predictors for the treatment outcome. Repeated-measures analysis of variance was used to compare the changes of ultrasound features between the two groups during the treatment. Receiver operating characteristic (ROC) curves were plotted to analyze the predictive accuracy of the ultrasound features. RESULTS Graf type III (P=0.036), bilateral dislocation (P=0.031), and age at diagnosis (P=0.021) were associated with an increased risk of Pavlik harness failure in the multivariate analysis. The changes in α and β angle and FHC were generally greater in the success group than in the failure group. The α angle and FHC were larger in the success group, while the β angle was larger in the failure group (P

Introduction In 2014 our centre started a dedicated clinic for developmental dysplasia of the hip (DDH). The aim of the clinic was to streamline DDH referrals, enabling timely review, imaging and multidisciplinary treatment. Ongoing audit has been carried out based on the UK National Screening Committee newborn and infant physical examination (NIPE) guidelines, first published in 2008. Methods A three-year prospective audit was undertaken between 2014 and 2016 assessing compliance with NIPE standards (ST2b and ST2d) relating to timeliness of expert consultation following positive ultrasonography findings of DDH with positive examination or risk factors. Results A total of 257 babies born between January 2014 and December 2016 were seen in our dedicated DDH clinic, with 106 with abnormalities on ultrasonography and 54 requiring treatment. Compliance with ‘expert consultation within 4 weeks of age for babies with an abnormality detected on clinical examination and positive ultrasonography’ improved from 50% in 2014 to 53% in 2015 and 71% in 2016. Compliance with ‘expert consultation within 8 weeks of age for babies with positive risk factors, negative examination and positive ultrasonography’ improved from 65% in 2014 to 93% in 2015 and 100% in 2016. Conclusions This prospective audit assessing timeliness of expert consultation has demonstrated ongoing improvements between 2014 and 2016. A greater proportion of babies with ultrasonography evidence of DDH have been seen at the appropriate time. In the majority of cases, this has enabled timely non-invasive treatment with a Pavlik harness rather than surgery.

To investigate the use of anterior hip ultrasound (van Douveren’s method)-assisted Pavlik harness in developmental dysplasia of the hip (DDH). Weekly anterior hip ultrasound scanning was performed in children with fixed Pavlik harness to detect whether hip reduction was achieved with the help of harness (the superior ramus of the pubis, the acetabulum, the femoral head, and the femoral neck being depicted in one plane indicated concentric reduction of the hip), and the stability of the reduction was checked by ultrasonography. A total of 39 child patients and 51 dysplastic hips were successfully detected by anterior ultrasound, and stable reduction was achieved in 37 hips (15 Graf type D and 22 type III) right after the help of Pavlik harness, in seven hips (6 type III and 1 type IV) two weeks after the help of Pavlik harness; the remaining seven hips (2 type III and 5 type IV) failed to reach stable reduction after two weeks. The anterior hip ultrasound (van Douveren’s method) can be used to detect the reduction and stability of hip after Pavlik harness treatment in children with DDH. The majority of Graf type D and III hips can achieve a stable concentric reduction right after the help of Pavlik harness, while severely dislocated type IV hips have a low success rate for harness treatment, and abandonment of harness therapy should be considered in early stage.

Pavlik harness is the initial treatment for the infants with developmental dysplasia of the hip who have not yet begun walking.The present study evaluates the variables which affect the duration of PH treatment for patients successfully treated.Cross-sectional study.Pavlik harness was employed for 140 hips of 87 patients with developmental dysplasia of the hip in our institution between 2010 and 2013. In all, 55 hips of 46 patients who were treated successfully with Pavlik harness were included in this study. According to Graf's sonographic classification, 23 hips were Type IIC, 26 were Type IID, and 6 were Type III. The studied variables were (1) alpha angle, (2) age at the start of treatment, (3) laterality, and (4) gender. The variables were compared with the duration of Pavlik harness treatment.A highly significant inverse correlation was observed between Pavlik harness application time and alpha angle at the start of the treatment ( r = -0.050; p 0.001). Bilateral involvement has statistically longer duration, when compared with unilateral involvement ( r = 0.28; p = 0.036). No statistically significant difference was present between duration of treatment and age at the start of Pavlik harness treatment ( r = -0.034; p = 0.804). There was no statistical significance between gender and duration of Pavlik harness ( r = 0.201; p 0.05).The duration of treatment was negatively correlated with the initial alpha angle. A change of 1 degree in alpha angle may alter the duration of treatment as 0.89 week calculated by the formula (Application time (Week) = 56.6 - 0.89 × alpha angle). Bilateral involvement may need longer Pavlik harness treatment. Clinical relevance Pavlik harnes generally is the first treatment method for the infants with DDH. This study suggest conclutions about how long time is the Pavlik harness should be kept on the infants? The main indicator is initial alfa angle which is negatively correlated with the duration of treatment.

Pediatric femoral shaft fractures present many challenging patient care decisions. Nonoperative treatment approaches still dominate care of the youngest age groups while surgical intervention is commonplace in virtually all older children. Treatment is determined primarily by patient age as modified by clinical factors including mechanism of injury, weight, and skeletal maturity. Infants can be successfully treated by placement into a Pavlik harness, whereas children younger than 5 years are most commonly treated by early reduction and spica cast immobilization. Children aged up to 11 years are most commonly treated by flexible intramedullary nailing, whereas older children and adolescents, particularly with length unstable fractures should be treated with more rigid fixation such as lateral entry locked nails or submuscular plating.

Hip dysplasia is one of the most common skeletal disorders. As a late consequence 20–25% of the patients are at risk to develop secondary osteoarthritis and may require total hip replacement early in life. The treatment principles of hip dislocation are (1) concentric reposition, (2) retention, i.e., plaster in human post or Pavlik harness and (3) maturation in abduction flexion orthesis. The Tubingen splint was introduced as a further development of abduction devices for the treatment of (residual) hip dysplasia with stable hips. The advantages are easy handling, adjustment according to growth and safe limitation of abduction. The aim of this study was to determine the success of treatment of unstable hips with use of the Tubingen splint from early diagnosis until final end of therapy hence normal ultrasound findings. From January 2003 to August 2016 79 children with 109 sonographic unstable hips were treated with the Tubingen splint initially consequently 24 h/day. Inclusion criteria were diagnosis of type D, type III a/b or type IV hips according to Graf and beginning of treatment at an age of less or equal 6 weeks, without limitation of abduction on clinical examination. At the time of diagnosis 51 type D (46.8%), 46 type III (42.2%) and 12 type IV (11.0%) hips were noticed. In 30 patients (38.0%) bilateral hip dysplasia (type D–IV) was diagnosed. 104 of 109 hips (95.4%) treated with the Tubingen splint could be transferred in a type I hip after a mean treatment period of 88.9 days (SD ± 26.0). In 5 cases (4.6%, 1 type III and 4 type IV hips) the treatment failed. Our data show, that successful treatment of unstable hips in neonates with the Tubingen splint is a comparably successful treatment modality relative to the Pavlik harness and Fettweis plaster.

Background Management of developmental dysplasia of the hip (DDH) with a Pavlik harness is a well-known treatment.Follow-up until skeletal maturity is recommended as long-term studies mention late sequelae.The purpose of this study was to determine whether such a follow-up is necessary in patients treated successfully under a strict protocol. Methods A retrospective review of a consecutive series of normal infants treated for DDH between January 1995 and July 2004 was undertaken.Only normal infants with frankly pathologic hips treated successfully with a Pavlik harness were included, and with a normal anteroposterior (AP) pelvis x-ray at the age of 2 years.All infants with any type of neurological disease, syndrome, other form of treatment for DDH, and failure of the Pavlik harness were excluded.At the last follow-up, a clinical examination and a standing AP pelvis x-ray were performed. Results A total of 109 hips in 83 children were available for review. The mean follow-up was of 10 years and 2 months. All 109 hips had a normal clinical examination and a normal AP pelvis x-ray: a mean center-edge angle (CEA) of 29.5 degrees, SD±4.1 degrees, a mean acetabular index (AI) of 1457±3.74 degrees, a mean Sharp's angle of 41.92±3.42 degrees, a Seringe-Severin score of IA, a normal teardrop figure, no signs of avascular necrosis, and Moses circles Conclusion This study strongly suggests that in a selected group of patients treated for DDH with a Pavlik harness, under a strict protocol, and a normal x-ray at 2 years of age, a long-term follow-up is not necessary. Level of evidence Level III-therapeutic.

In the UK, the Pavlik harness is generally the accepted treatment technique for the treatment of neonatal and infant pathological developmental dysplasia of the hip. In 2013, the success rate of the Pavlik harness became an outcome measure from the British Society of Children's Orthopaedic Surgery for appraisal and revalidation with the GMC for paediatric orthopaedic surgery. The standard set requires an 80% success rate, with less than 20% requiring surgery. This study evaluated the outcomes of Pavlik harness treatment in neonates/infants with 'pathological hips' diagnosed by ultrasound imaging in a district general hospital setting. In a 10-year prospective observational longitudinal cohort study, modified Graf type III and IV hips (excluding those presenting with irreducible hip dislocation) were classified as pathological and splinted. A total of 2826 neonates/infants underwent ultrasound assessment in the paediatric orthopaedic 'screening clinic'. Neonates and infants were referred as 'at-risk' or as clinically unstable by the Paediatric Department and by general practitioners. Thirty-one Graf type III and 95 Graf type IV hips were identified and treated with a Pavlik harness. One Graf type III (30/31=success rate 96.8%) and three clinically unstable Graf type IV hips progressed to irreducible hip dislocations (92/95=96.8%). The success rate of the Pavlik harness in Graf type III and IV dysplasia was 96.8%, with 3.2% requiring surgery because of progression of the condition, confirming acceptable results for this technique in a district general hospital setting.

The Pavlik harness and the Tubingen hip flexion splint (Tubingen hip flexion splint) are two effective options for the early management of patients younger than 6 months of age with developmental dysplasia of the hip (DDH). The main objective of this study was to evaluate the clinical and radiological outcomes of patients younger than 6 months of age with type IIb to IV DDH managed by Pavlik harness or Tubingen hip flexion splint. The Pavlik harness and Tubingen hip flexion splint groups were comparable regarding the affected side (P = 0.09), Graf grade (P = 0.635), and age at initial treatment (P = 0.77). Overall, failure rates were 12 and 33% in Pavlik harness (4/33 hips) and Tubingen hip flexion splint groups (14/43 hips), respectively (P = 0.038). No cases of avascular necrosis (AVN) were found in either group. In the Tubingen hip flexion splint group, the failure rate was significantly higher in bilateral cases (66.6%; P = 0.004), in severe forms (Graf grade IV hips; P ≤ 0.0001), and in patients with lower age at initial treatment (67.7 ± 39.3 days; P = 0.005). The average follow-up time was 30.35 ± 3.58 months (range: 24-36). At the last follow-up visit, no statistically significant differences were found between the Pavlik harness and Tubingen hip flexion splint groups regarding the acetabular index (t = 0.632; P = 0.53) or center-edge angle (Z = -0.303; P = 0.762). Our study showed that both the brace treatments for DDH in children younger than 6 months of age were effective and well tolerated. However, Tubingen hip flexion splint should not be used in patients with severe forms of DDH (Graf grade IV hips).

OBJECTIVE: Although the Pavlik Harness (PH) is the most utilized treatment for developmental dysplasia of the hip (DDH), the ideal treatment protocol (frequency of clinic visits in the first month and daily wear duration) for Barlow ​+ ​hips (reduced but dislocatable) has yet to be defined. METHODS: This study compared DDH patients with Barlow hips who were treated with 23 vs 24 h per day PH wear and weekly vs every other week visits. Clinical success was defined as a stable hip that did not require closed or open reduction, or the use of an abduction orthosis prior to achieving clinical stability. Radiographic success was based on the acetabular index at 2-year follow up. RESULTS: Sixty-five patients (75 hips/58 females) with Barlow hips had a mean age of presentation of 15 ± 12 days (range 4–70) and mean follow-up of 33 ± 17 months (range 6–90). There was no difference in clinical or radiographic success rate between 23 h vs 24 h wear groups (p > 0.99 both) or the Frequently vs Infrequent visit groups (p = 0.49 both). Overall clinical success rate was 97% (73/75 hips) and radiographic success rate at 2 years was 97% (58/60 hips). CONCLUSION: A strict, weekly clinic visit and 24-h PH regimen may not be necessary to obtain good clinical and radiographic outcomes in infants presenting

OBJECTIVES This study aims to evaluate the effectiveness of full-time bracing in residual acetabular dysplasia (RAD) and the effect of previous Pavlik harness usage on the results of treatment with abduction orthosis. PATIENTS AND METHODS We retrospectively reviewed 80 patients (9 males, 71 females; mean age 6±0.8 months; range, 5 to 7 months) with developmental dysplasia of the hip (119 dysplastic hips) treated with hip abduction orthosis. Patients with an acetabular index (AI) measurement of 30° and over who used full-time hip abduction brace for six months were included in the study. Acetabular index values were measured at the initiation, third, and sixth months of treatment and the effectiveness of abduction orthosis was evaluated. The patients were analyzed for the effect of prior Pavlik harness application on abduction orthosis treatment. RESULTS Mean AI value of the dysplastic hips (n=119) was 33.4°±2.6°, which decreased to 28.5°±2.6° after treatment (p

Background Earlier clinical reports have identified femoral anteversion as a factor associated with developmental dysplasia of the hip. This study investigates the biomechanical influence of femoral anteversion on severe dislocations and its effect on hip reduction using the Pavlik harness. Methods A computational model of an infant lower-extremity, representing a ten-week old female was used to analyze the biomechanics of anteversion angles ranging from 30° to 70° when severe dislocation was being treated with the Pavlik harness. Specifically, the effects and relationships between muscle passive response and femoral anteversion angle were investigated over a range of hip abduction and external rotation. Findings Results of this study suggest that increased femoral anteversion may decrease the success rate for treatment of high-grade developmental dysplasia of the hip when using the Pavlik harness. However, hip external rotation and decreased abduction in the harness may facilitate initial reduction in these cases. Interpretation This biomechanical study may help explain why dissections of newborn specimen with developmental dysplasia of the hip have shown normal distribution of femoral anteversion in contrast to studies of patients requiring surgery where greater frequency of increased femoral anteversion has been reported. This study also suggests that adjusting the Pavlik harness to increase external hip rotation and decrease hip abduction may facilitate initial reduction for severe dislocations with increased femoral anteversion.

Outpatient treatment of hip dysplasia in newborns has excellent results. A combination of general screening with early treatment with a functional abduction device works well. Treatment with the Frejka pillow and the Pavlik harness is frequently used in our region. The aim of the study is to compare efficiency and treatment duration, related to the brace used, and to prove that the choice of an abduction device implies parental compliance with the treatment protocol. Data of 286 treated children were analyzed. The diagnosis was made in the first weeks of life by clinical and sonographic examinations during general screening. The choice of treatment device was expert dependent and was involved by many variables. The experience, type of clinical finding and sonographic pathology according to Graf, availability of a treating facility, and the potential cooperation of individual parents were major parameters. The Frejka pillow was used to treat 145 children and the Pavlik harness was used in 137 children. The treatment duration and percentage of infants lost from follow-up in relation to the device used was documented. The success rate of outpatient treatment was 98.6%. In six patients, the type of device had to be changed during the treatment period. Physiological sonographic findings were achieved in all hips by the end of the treatment. The Frejka pillow was used as the preferred device in milder stable dysplastic hips, while unstable and decentered hips were treated more frequently with the Pavlik harness. Treatment lasted, on average, 95 days and 119 days in the Frejka and in the Pavlik group, respectively; there was no statistical significance in treatment duration of comparable sonographic pathologies. We observed statistically greater parental non-compliance with the treatment protocol in the Pavlik harness group (p = 0.0279; OR 2.7; 95% CI 1.07; 8.5). Neither of the abduction devices was inferior with regard to treatment efficiency. We found that parental cooperation was an important factor during screening and treatment. The treatment decision and the choice of the brace must be made with full consent of the parents, keeping in mind that comfort during the nursing care may have a significant influence on compliance with the treatment protocol.

Background The use of competency-based training is increasing in medical education as it offers individualized learning opportunities to master required skills. Inherent to this method of teaching is the need for standardized and objective assessments of skill mastery. In orthopaedic surgery, educational programs have focused on surgical skills with lesser emphasis on nonoperative techniques. Accordingly, formal evaluation tools specific to Pavlik Harness application do not exist, despite its widespread use and potential complications from inappropriate application. This study sought to develop a reliable and valid evaluation tool based on international expert consensus to standardize and evaluate Pavlik Harness application for developmental dysplasia of the hip. Methods Consensus was sought from 10 content experts using Delphi methodology. Resulting items formed the Objective Structured Assessment of Technical Skill (OSATS). Thirty-five participants were selected into 3 a priori groups (expert, intermediate and novice) based on Pavlik Harness experience. On 2 occasions, 3 content experts assessed randomized and deidentified videotapes of each participant applying a Pavlik Harness to an infant model using the OSATS and global rating scales (GRS). The reliability and validity of the OSATS was determined with intraclass (ICC) and Pearson correlations and analysis of variance (ANOVA). Results Consensus was obtained after 2 rounds of structured surveying and resulted in a 25-item OSATS. The reliability of the OSATS was excellent with an ICC of 0.96 for interrater and 0.98 for test-retest reliability. Construct validity was excellent with high correlations between OSATS and GRS (>0.90). In addition, the OSATS discriminated between expert, intermediate, and novice users. Conclusions We have developed a competency-based evaluation tool for Pavlik Harness application based on consensus from international experts. The OSATS has been shown to be a reliable and valid method for assessing Pavlik Harness application that can discriminate between expert, intermediate, and novice users. Level of evidence Level II.

Background The Pavlik harness is the most common initial treatment for developmental dysplasia of the hip worldwide. During treatment, parents are required to re-apply the harness at home. Teaching parents how to apply the harness is therefore paramount to success. While simulated learning for medical training is commonplace, it has not yet been trialed in teaching parents how to apply a Pavlik harness. Methods A group of parents underwent a simulated learning module for Pavlik harness application. Parents were evaluated pre- and post-exposure and at one month after testing. A validated objective structured assessment of technical skill (OSATS) and a global rating scale (GRS) specific to Pavlik harness application were used for evaluation. A control group of parents was also tested at both time points. A clinical expert group was used to determine competency. ANOVA and t tests were used to assess differences between groups and over time. Results Parent scores on the OSATS improved to the level of expert clinicians both immediately post-intervention and at retention testing. However, on the GRS, only half were considered competent due to their inability to achieve the required hip positions. The control group did not improve nor were they considered competent. Conclusions The use of a simulated learning module improves both the confidence and skill level of parents in the application of the Pavlik harness. However, the challenges parents face in understanding the more detailed subtleties of medical care suggest that they still require an appropriate level of supervision by clinicians to ensure effective treatment.

Background: Simulation-based learning is increasingly prevalent in many surgical training programs, as medical education moves toward competency-based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated condition, where the standard of care for patients less than six months of age is an orthotic device such as the Pavlik harness. However, despite widespread use of the Pavlik harness and the potential complications that may arise from inappropriate application, we know of no previously described formal training curriculum for Pavlik harness application. Methods: We developed a video and model-based simulation learning module for Pavlik harness application. Two novice groups (residents and allied health professionals) were exposed to the module and, at pre-intervention, post-intervention, and retention testing, were evaluated on their ability to apply a Pavlik harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skills (OSATS) and a global rating scale (GRS) specific to Pavlik harness application. A control group that did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik harness alone would affect skill acquisition. All groups were compared with a group of clinical experts, whose scores were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t tests and analysis of variance (ANOVA). Results: Exposure to the learning module improved resident and allied health professionals’ competency in applying a Pavlik harness (p < 0.05) to the level of the expert clinicians, and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve, nor did they achieve competency. Conclusions: The simulation-based learning module was shown to be an effective tool for teaching the application of a Pavlik harness, and learners demonstrated retainable skills post-intervention. This learning module can form the cornerstone of formal teaching of Pavlik harness application for developmental dysplasia of the hip.

Background The purpose of this single-examination pilot study was to confirm the ability to perform hip sonography while swaddled and to ascertain whether the various swaddling techniques influenced hip position and dynamics. Methods Dynamic sonography was used to evaluate 30 infants in both swaddled and unswaddled positions who were being seen in clinic for suspected or documented developmental dysplasia of the hip. A "treatment group" of 16 infants (32 hips) treated in a Pavlik harness and a "nontreatment group" of 14 untreated infants (28 hips) were studied.Criteria for comparing sonographic results between swaddled and unswaddled hip positions included femoral head position, instability, and range-of-motion restriction. Results Tight swaddling with a blanket was applied in 11 "nontreatment group" cases (20 hips; in 2 cases, only 1 hip studied) and produced limited flexion and abduction. One unstable left hip dislocated when tightly swaddled. Safe swaddling technique in 12 cases (24 hips) showed no limitation of flexion and abduction of the legs and no change in stability by sonography. Commercial swaddling products appeared to mildly restrict leg motion in 14 hips, but there was no change in hip position in the "nontreatment group." However, the commercial swaddling products changed the hip position in 3 Pavlik harness cases. Conclusions Swaddling techniques that allow a free range of leg motion may not affect hip stability in normal infants or those being treated with Pavlik harness. Swaddling with restricted leg motion increases potential for hip instability. Tight swaddling dislocated 1 unstable hip, and commercial swaddling products judged to apply only mild restriction of leg motion negatively impacted 3 cases being treated for developmental dysplasia of the hip with Pavlik harness. On the basis of this pilot study, we advise caution when swaddling infants, especially with techniques that restrict leg motion. Further study of the long-term effects of swaddling is warranted. Level of evidence Level II.

Case A 1-week-old female patient presented to our clinic with bilateral dislocated hips and was subsequently treated in a Pavlik harness. Harness treatment failed requiring a closed reduction and spica cast application. In the Post-Anesthesia Care Unit (PACU), the patient was found to have a right humerus fracture. Six weeks after cast application, the patient was found to have nondisplaced bilateral femur fractures prompting a genetics evaluation. The patient was subsequently found to have osteogenesis imperfecta type 3. Conclusion Perioperative fractures in pediatric patients should raise suspicion for osteogenesis imperfecta. Early diagnosis can improve the management of hip dysplasia and allow for early bisphosphonate therapy.

Introduction No clear practice guideline exists for the management of stable hip with ultrasonic dysplasia (UD). This study assessed the treatment patterns for stable UD and determined the outcomes of Pavlik harness (PH) treatment or observation (OB). Methods This is a prospective study of 80 infants (107 hips) aged ≤12 weeks at presentation diagnosed with stable UD. Results Sixty-five hips were treated with PH, whereas 42 hips were observed. Patients who were older at the time of initial sonogram and those with lower head coverage were more likely to be treated with PH. The mean head coverage was lower in the PH group, indicating more severe UD. At a 2-year follow-up period, 93% of patients in the OB group and 87% in the PH group had a good radiographic outcome. Discussion Head coverage and age at first sonogram had a significant influence on the treatment decision for PH. A milder ultrasonic hip dysplasia can be observed because 93% of the patients who were observed had a good outcome. Level of evidence Level II: prospective cohort study.