Management of irreducible hip dislocations in infants with developmental dysplasia of the hip diagnosed below 6 months of age.

Aarvold A, Schaeffer EK, Kelley S, Clarke NMP, Herrera-Soto JA, Price CT, Mulpuri K, IHDI Study Group. Management of irreducible hip dislocations in infants with developmental dysplasia of the hip diagnosed below 6 months of age. J Pediatr Orthop. January 2018.  DOI: 10.1097/BPO.0000000000001205.

Abstract

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.