This study attempts to assess the effects of using the Pavlik Harness and spica cast for treatment of Developmental dysplasia of hip in children. Does early diagnosis of DDH lead to early intervention, and does early intervention reduce the need for surgery or improve functional outcomes. Moreover, to retrospectively review the results of closed reduction (spica cast) and Pavlik harness for developmental dysplasia of the hip (DDH), and what is the best treatment for DDH in children?
Introduction:
Development Dysplasia of the Hip (DDH) was previously known as Congenital Hip Dislocation. It is a combination of hip disorders which are related to pediatric word missing here. It also combines hip clinical instability (neonatal and early post-natal) having or not having subluxation (dislocation) and anatomical dysplasia (fig 1). This is what gave birth to the term developmental rather than congenital. In most of the cases, the hips are found not to have dislocated whereas in all the cases of pathological hips are found to be having dysplasia and in rare cases are dislocated. This means that the term dysplasia is considered to have a better meaning than dislocation. Development Dysplasia of the Hip (DDH) refers to the whole of word missing spectrum that is associated with the problems of the hip joint developing abnormalities. In the recent cases, those disorders are diagnosed after birth though the situation is likely to worsen in future. Since late 1970, Ultrasound has been used as the investigation method of infant hip (Alexiebv et al).
The exact cause of DDH is unknown. In the general population, the overall incidence of DDH is approximately 3-4 per 1000 live births, this can be due to various factors such as; A family history of hip problems (genetic), breech position in the last three months of pregnancy, breech birth, lack of fluid surrounding the baby in the womb and girls are more often affected than boys, particularly the first born.
Fig(1) Hip Joint (www.zadeh.co.uk)
Pavlik Harness (fig 2) is a sensitive method used to detect hip pathology in the early days of life. It is also an important diagnostic orthotic tool used in evaluating development of acetabular, for following the progress of treatment and for recognizing reduction after initiating treatment. If it is used improperly, it is likely to cause a high overtreatment level. According to Alexiebv, et al , the overall DDH successful treatment is early initiation. This implies that, screening becomes successful if only it is followed by early treatment that is correct. Different devices have been used in DDH treatment but they have been replaced by the Pavlik method. The method was discovered as a result of disappointments in the increasing rate of femoral head Avascular Necrosis (AVN) and lack of successful congenital dislocation of hip conservative treatment. During the early stages, Pavlik was use to help children in achieving active movement of dysplastic or dislocated hip joint.
Fig (2) The Pavlik Harness (wheatonbrace.com)
Closed reduction in developmental dysplasia of the hip treatment is the one of the standardized methods of treatment for the DDH which is followed by Spica cast hip immobilization (Fig 3). The treatment is performed prior to independent walking achievement under arthrographic and anesthesia control. During the procedure, forced reductions avoidance as well as hip having extreme positions immobilization is of greanecessity. Femoral head Development of Avascular Necrosis (AVN) is the major parameter which affects the procedure of late outcome. All factors that are modifiable are supposed to be influenced in the patient's favor in order to avoid AVN. Where this method is applied by pediatric orthopaedic surgeons that are experienced and having the AVN acceptable rates, the method is considered as satisfying (Aksoy).
Fig (3) spica casting from www.orthobullets.co
Regardless of the age of the patient, the objective remains the same in DDH treatment. This objective is necessary in providing the anatomic as well as stable reduction, achieved reduction maintenance and capturing of normal course of hip development. The essential target of this objective is to achieve a long lasting and if necessary, life time fully functioned, pain free and stable hip. While treating those patients, the orthotist should select the method that gives optimum results. In the recent days, treatment algorithms are articulated with the aim of reducing DDH treatment complexity. Other than the today's algorithms being limited used compared to the past usage, closed reduction is considered as one of the major DDH treatment indispensable methods. (Aksoy).
Methods:
Perform a systematic review of the literature by using a best evidence approach. The review focused on screening relevant to primary care and treatment for children with DDH.
By identifying studies published from 1981 to 2009, using the electronic databases such as RECAL Legacy database search, Science Direct, pubmed (PubMed is a service of the U.S. National Library of Medicine and the National Institutes of Health); and Suprimo the Strathclyde university search service.
After the quality appraisal, studies were included or excluded and the result and data analysis were reviewed for conclusion.
Result and discussions:
According to Balik et al, since 1992, all the newborns at Rambam Medical Center have been sonographically examined in the 24 hours after birth by pediatric orthopaedic surgeon that is experienced. This is done in order to check any symptoms of hip pathology by use of the Graf method. Through the sonographic examination event which reveals the hip pathology, clinical investigation is also performed by the orthopaedic surgeon. Independently, every newborn is examined twice by neonatologist. Examination that is carried out includes searching hip instability. In order to avoid over treatment that is unnecessary, treatment algorithm or neonates follow up is carried out (Bialik et al). According to the study, every baby that is treated is considered as bearing true DDH. Since January 1992 up to December 2001, a number of 45404 newborns that is 98808 hips were examined using this way. The children that were served in all the outpatient clinics were treated using the Pavlik's method. In order to exclude problems that were connected to the learning curve, assessment of results of the babies that were treated was done on 5 years period, from 1996. Out of the 127 hips that were treated belonging to 75 babies (69 girls and 6 boys), 116 hips belonged to girls and 11 to boys. During the same period, (1681 hips) were diagnosed having different sonographic pathology. The hips that were left untreated were considered as radiologically normal by age of one year and clinically balanced sonographically. I cannot elicit what the results were from this study
Developmental dysplasia of hip treatment using closed reduction and hip Spica Cast immobilization. From the research that was done, 200 hips for 129 patients were evaluated with DDH diagnosis where they were treated using the closed reduction as well as spica cast. 153 hips belonged to females while 47 belonged to males in the selected group. The patients' mean age was six (2-13 range) months and 51 (16-240 range) months mean follow-up. Those patients that were treated using the closed reductions were then immobilized to hip Spica Cast. The mean time used to immobilize the cast was 102 (49-190 range) days. It was observed that avascular necrosis in hips was 15 %. The patients 'radiological and clinical ends results were evaluated using Severin classification and McKay criteria modification. 82 % of the patients portrayed satisfactory results in regard to McKay criteria modification. On the other hand, 76% were in accordance to Severin classification. The end results were affected by pre-reduction hip location, avascular necrosis and acetabalur index values. This reveals that DDH treatment using hip Spica Cast closed reduction is an effective and relatively safe method (Aksoy).
According to Bian et al, the results of the closed reduction treatment of DDH hip were reviewed and then analyzed in order to get the causes of unsatisfying radiology results. The results of closed reduction were obtained from the case study (methods) (1997 to 2005) for 60 children (77 hips). The radiological final results were evaluated using Severin classification. (Results): 73% of the patients had satisfying results in accordance to Severin classification. 21 hips that were classified Severin 3-5; seventeen of them were having reconstructions. 29 of the hips were observed as having avascular necrosis. The factors that affected the results were discovered to be avascular necrosis and age during reduction. Conclusion that was arrived at is that, in order to attain radiological and clinical better results, infants that are suffering from DDH should receive treatments at an early age. Where avascular necrosis establishes itself for long, it results to poor prognosis (Bian et al). there is no detail on the age range of the subjects, intervention
Under DDH general anesthesia treatment, closed reduction can be referred to as application of Spica Cast. This is in the line of providing reduction of subluxated or dislocated hip or maintenance reduction achievement. This method in the recent years is applied to 12months or less patients (Tezeren et al). The other methods are applicable in general to the patients that are more than 1 years old in order to reduce rates of complications. Pavlik Harness should be applied to children of less than 4 months and if it fails, closed treatment should be used as the otherwise. It should also be applied if the bandage use cannot be applied due social reasons, family compliance, etc. whereas Pavlik Harness is applied as the initial method for the patients diagnosed prior to six months of age, plaster cast or closed reduction immobilization is applied as the standard method when the Pavlik Harness fails. Traction (house or hospital, skin or skeleton) is the most method of closed reduction that has been used over the years in providing avascular necrosis reduction rates of AVN. However, in the recent years traction method is not considered as an effective method. The reason for this is due to the facts that affect application of traction particularly the rates of avascular necrosis could not portray positive results in terms of science (Tezeren et al).
In addition to the research that was conducted by the Pediatric Orthopedic Society of North America (POSNA), it was discovered that the members who used the traction prior to reduction were only 5 percent (Aksoy ). Even though the traction method has been applied as method of standardized treatment, it was discovered that there existed no vital difference between the results where traction method had been applied and where it had not been applied in relation to rates of avascular necrosis. This implies that traction was not applied before application of reduction. Closed Reduction is executed in the operating room where general anesthesia is applied. No force should be applied while trying reduction. It is achieved generally in abduction or flexion hip position. Therefore, there is requirement for arthrography in order to determine the quality of reduction. The arthrography reduction controlled way that is acceptable is the anatomic reduction. The safe zone of the hip (motion range of adduction-abduction in maintenance of reduction) is supposed to be determined. Where the range remains narrow, it has to be widened by closed or open adductor tenotomy. In this procedure, there is also need to reduce the AVN frequency. The most important decision which the surgeon should make is determination of the power to be applied during reduction. After provision for reduction, surgeon should not use such force in the maintenance of reduction (Aksoy et al).
According to Tezeren et al, excessive positions should also not be applied during the maintenance of reduction. It is supposed to be maintained using human position. It is termed as restricted abduction and hyperflexion. In the clinical application, 90 degrees position flexion is given to the hip and at the same time abduction position is avoided more than 50 degrees. Where movement of inner rotation as well as excess abduction is required in order to maintain reduction, it implies that the method is not recommendable for that patient. Inner rotation and excess abduction should be avoided at all costs. The reduction quality is also an important consideration to be made. Reduction that is acceptable is anatomic reduction that is arthrography controlled. After providing reduction within the limits that are acceptable and anatomically and the case is shown arthrographically, Spica cast has to be applied for the reduction maintenance (Tezeren et al).
Plaster cast is preferred to be extended to the two ankles in babies. One of the most vital advantages of plaster casts that are standardized is the ability to shape them. However, plaster casts that are synthetic are lighter, durable and permit radiology control imaging after the plaster cast. It also facilitates application. Even though the author recommends synthetic materials, surgeons should use the method that they are familiar with. While the plaster cast is being applied, the hip is put in the position that is requested and it should not be changed while casting. The amount of abduction should be increased relatively to the reduction loss and exhaustion during the process. In order to prevent losses of reduction, the plaster cast has to be shaped professionally in gluteal region. Control of radiological reduction should be made after finishing the casting procedure (Van der Sluijs, et al).
If there is a suspected situation and full image cannot be captured as a result of the cast, CT (Computerized Tomology) or MRI (Magnetic Resonance Imaging) should be used in checking of reduction quality (Shipman et al). The period of immobilization during the cast is not standardized. The differences can be noted between surgeons and clinics. The general application involves patient immobilization after 3 months. Checkups should commence after the end of sixth week and where the cast is destroyed it should be replaced. There are those surgeons that prefer using the device up to when the hip totally recovers while others use the device for a given period. When the device is being applied to the patients, there should be avoidance of excess positions. From the study, there is no scientific efficiency for the application of the device and it has been applied traditionally in most of the clinics (Shipman et al).
Complications
Complications that arise after DDH closed reduction treatment can be divided into two groups; that is late and early complications. Early complications are associated with arthrography and cast. Late complications are proximal femur growth disturbances which basically appear in the AVN and late period. They are the complications that in most cases affect the hip. The situation is termed as "proximal femoral growth disturbance". According to Nakamura et al, the AVN findings have been defined as; Non-appearance ossific nucleus femoral head after 1 year reduction. The second is after 1 year reduction femoral head ossific nucleus lack of growth. The third is after 1 year reduction femoral neck thickening. The fourth is increased femoral head density and fragmentation. The fifth is deformity in neck and femoral head after the femoral head completion reossification: coxa plana, coxa magna, coxa vara, thick and short femur neck. The AVN has no classification that is ideal although no clear definition has been arrived at present.
The method of closed reduction is often applied during treatment of DDH and it is recognized as simple procedure. On the other hand, by considering the age of patient and the situation that is likely to cause those complications in future, it is discovered that closed reduction is the best intervention than any other orthopaedic procedure. This implies that, the procedure has to be carried out in maximum attention and at the same time ample time should be dedicated while dealing with the procedure. There are those situations mistake that have been regarded as increasing the rates complications. Family has to be adequately informed regarding when to go for patient's closed reduction. Procedures to be applied should be prioritized according to the early hours of the day (Shipman et al).
Results analysis
Spica cast in closed reduction
No of hips tested
McKay criteria modification
Severin Classification
AVN
End results
Effects
200 (129 patients)
82%
76%
15%
Hip location, acetabalur index values and AVN.
77 (60 patients)
73%
22%
Age reduction and AVN.
Pavlik's Harness Hesults
1424
17.9% Supplementary
patients.
AVN had 0% effects on those treated.
This reveals that DDH treatment using hip spica cast closed reduction is an effective and relatively safe method.
Pavlik Harness is one of the attractive recognized methods of DDH treatment due to its design simplicity as well as application. Through the Pavlik harness use, femoral head spontaneous centralization, spontaneous repositioning and proper functional and anatomical healing is highly achievable (Alexiebv et al). The Pavlik harness reduction mechanism consists of the femoral head shift to the acetabulum posterior aspect. In addition, where an assumption on abducted position is made, lower extremity carries more weight in playing most of the adductor muscle stretching role. Consequently, this allows femoral head that has been dislocated to slide into acetabelum anteriorly on top of acetabular rim. This implies that, the direction of acting power during the reduction is equal to the one acting in manual reduction (Hedequist et al,). The use of Spica Cast in closed reduction stands eligible to the patients that are having satisfactory DDH treatment results over the years. If the procedure is carried out by orthopedic surgeons that are experienced, it gives positive results with low rates of complications.
By considering the whole population that was treated using the method, it implies that, 0.98 percent AVN method was used. It was noted that the AVN rate was 0 percent for subluxation and dysplasia and 17.9 percent for dislocation. Those results were similar to those that were conducted in Germany. In the opinion of study, the results are influenced where treatment starts late especially for hip with full dislocation. Where treatment started before 14 weeks of age, favorable results are likely to be attributed to this ground. According to the assumptions, there are hips that are not due to improve normally. It is believed that the results are a true reflection of the Pavlik's method of treatment. Through the practice, 0 percent AVN of the whole treated population there was only 1 child that was having transient type 1 ANV. This lies in hand with the MacEwen as well as the others where DDH key treatment management is on the early detection (Bian et al).
Treatment failure is likely to be attributed to first sonographic pathology severity combined with instability of the clinic. This means that the problem is as a result of combined severe hip joint anatomical disturbance and capsule's failure to contract. In the short period, unstable hips clinical treatment was surprising; this indicated a correlation to Barlow's study and the 90 percent experience throughout the study. This indicated that hips were normal at the range of 2 months age. The observation that was made concerning the time required for treatment gives support to this theory. This implies that, the age when treatment is due to be started is not considered as influential on treatment duration, ANV outcome and rate of success. This is due to the fact that all the hips treatment started when the babies were less than 14 weeks of age. Sex was also found not to have treatment influence (Bialik).
Methods that were used in the initial reduction phase of DDH treatment were usually repositioning done manually then followed by mechanical devices that are passive for the retention purposes. The new device that was discovered was used in most of the reduction stages which patients performed for themselves and portrayed no violence. From the experience of most of the authors, the basic difference that was noted in the approach was considered as significant reduction of AVN rate. According to Pavlik, treatment should be started before 2 months of age, from the study; the method is also discovered to be applicable. The results which are arrived at after treatment of hips using true DDH, that are based on combination of clinical sonographic and neonatal screening are comparable to the results of the study. This acts as a justification of hip development starting from the period of newborn to the point which involves decision making on treatment to undertake. By following the rules of Pavlik's method, stirrups are considered as an aid rather than principle. When the method is used appropriately, it gives a successful early DDH stage treatment (Borowski et al).
Conclusion
The aim of those DDH treatments is to obtain concentric reduction and at the same time avoid avascular necrosis. However, Pavlik Harness is considered as the best and applicable treatment for the babies that are less than 3 months. If the method is properly applied and monitored using ultrasounds, it becomes an excellent form of treatment. The method portrays simple, comfortable, safe and successful even in the situations of bilateral cases. This implies that, Pavlik Harness is the recommendable for the treatment of initial bilaterally hips that have been dislocated. This should involve patients starting from neonatal period to 3 months of age. This is according to the results that have been attained in the study which shows that a child who is having hips that are bilaterally dislocated is at a lower risk. This is in comparison to the Pavlik Harness treatment of a child that is having unilaterally dislocated hip. Where the method fails for both the bilateral and unilateral dislocated hips, the patient is vulnerable to higher risks.
During my placement at Yorkhill hospital I found that they using a Pavlik Harness first for treatment DDH for babies before walking, then spica cast when they start walking, which work very good with good result.
Summary
Pavlik harness
Spica cast
This has been the best method for treating DDH in children, and especially with early diagnosis and intervention
This is not the best with children below six months. Most of studies showed that it is the best with grownups and older babies. It is expensive
Best for children below six months
Best for older children and beyond
Best method of treatment with early diagnosis and intervention
Best when DDH has been diagnosed later in life of a child
Most effective, easy to use
Expensive and challenging
Need the family understand and support.
Need support from the family
