Age-Dependent Management | AVN Prevention Critical | Early Diagnosis Essential | 95% Success with Pavlik
AGE-BASED TREATMENT
Critical Must-Knows
- Age determines treatment: 0-6mo = Pavlik, 6-18mo = closed reduction, 18mo-3yr = open reduction, over 3yr = open reduction + osteotomy
- AVN is most devastating complication - always results from treatment, not disease. Prevention: avoid forced abduction over 55°, human position in spica
- Pavlik harness positioning: Flexion 100-110°, abduction 50-70°, wear 23 hours/day, monitor with ultrasound every 3-4 weeks
- Safe zone concept: Range between redislocation and AVN risk positions. Must be at least 25° for closed reduction to succeed
- Graf ultrasound classification: Type I (normal), II (immature/dysplastic), III (subluxed), IV (dislocated)
Clinical Pearls
- "Know age-based treatment algorithm - examiners frequently test this
- "AVN prevention is key - describe human position (100° flexion, 40-50° abduction, neutral rotation)
- "Pavlik harness failure: discontinue if not reduced by 3-4 weeks to prevent AVN
- "Obstacles to reduction: psoas, ligamentum teres, pulvinar, limbus, transverse acetabular ligament, capsule, adductors
Clinical Imaging
Imaging Gallery
Critical DDH Treatment Exam Points
Age Determines Treatment
Treatment is age-dependent. 0-6 months: Pavlik harness (95% success). 6-18 months: Closed reduction + spica. 18 months-3 years: Open reduction. Over 3 years: Open reduction + osteotomy. Never use Pavlik over 6-7 months.
AVN Prevention is Critical
AVN always results from treatment, not disease. Prevention: avoid abduction over 55°, use human position in spica (100° flexion, 40-50° abduction, neutral rotation), discontinue Pavlik if not reduced by 3-4 weeks. AVN rates: Pavlik 5-10%, closed reduction 20%, open reduction 10-20%.
Pavlik Harness Principles
Positioning: Flexion 100-110° (anterior strap), abduction 50-70° (posterior strap). Wear 23 hours/day initially. Monitor with ultrasound every 3-4 weeks. Discontinue if not reduced by 3-4 weeks (AVN risk increases).
Safe Zone Concept
Safe zone: Range between redislocation and AVN risk positions. Must be at least 25° for closed reduction to succeed. Assessed with arthrogram during EUA. Adductor tenotomy widens safe zone if narrow.
DDH Treatment by Age - Quick Reference
| Age Group | Treatment | Key Principles | Success Rate |
|---|---|---|---|
| 0-6 months | Pavlik harness | Flexion 100-110°, abduction 50-70°, monitor with USS | 95% success |
| 6-18 months | Closed reduction + spica | EUA with arthrogram, safe zone over 25 degrees, human position | 80-90% success |
| 18 months-3 years | Open reduction | Medial (under 12mo) or anterior (over 12mo) approach | 85-90% success |
| Over 3 years | Open reduction + osteotomy | Femoral shortening/varus + pelvic osteotomy | 70-80% success |
BREECHDDH Risk Factors
| B | Breech presentation 20% of DDH were breech vs 2% population |
| R | Relaxin sensitivity Females more sensitive (7:1 ratio) |
| E | Ethnicity Caucasian, Lapland, Native American (high risk) |
| E | Extended family history 12% if parents had DDH |
| C | Calcaneovalgus 5% risk of associated DDH |
| H | Hip packaging disorders Torticollis, CTEV, metatarsus adductus |
| B | Breech presentation 20% of DDH were breech vs 2% population | E | Ethnicity Caucasian, Lapland, Native American (high risk) | C | Calcaneovalgus 5% risk of associated DDH |
| R | Relaxin sensitivity Females more sensitive (7:1 ratio) | E | Extended family history 12% if parents had DDH | H | Hip packaging disorders Torticollis, CTEV, metatarsus adductus |
Hook:BREECH babies and females are at highest risk for DDH!
PLACTSObstacles to Reduction
| P | Psoas tendon Tight psoas prevents reduction - release required |
| L | Ligamentum teres Elongated, hypertrophied - excise |
| A | Adductors Tight adductors - tenotomy widens safe zone |
| C | Capsule Inverted, hourglass constriction - incise |
| T | Transverse acetabular ligament Tight inferiorly - release |
| S | Pulvinar (soft tissue) Fibrofatty tissue in acetabulum - excise |
| P | Psoas tendon Tight psoas prevents reduction - release required | A | Adductors Tight adductors - tenotomy widens safe zone | T | Transverse acetabular ligament Tight inferiorly - release |
| L | Ligamentum teres Elongated, hypertrophied - excise | C | Capsule Inverted, hourglass constriction - incise | S | Pulvinar (soft tissue) Fibrofatty tissue in acetabulum - excise |
Hook:PLACTS - all obstacles must be addressed for successful reduction!
FLEX ABDPavlik Harness Positioning
| F | Flexion 100-110° Anterior strap controls flexion |
| L | Limited abduction initially Start 50-70°, adjust based on USS |
| E | Every 3-4 weeks USS Monitor reduction progress |
| X | eXclude if not reduced by 3-4 weeks Discontinue to prevent AVN |
| A | Abduction 50-70° Posterior strap controls abduction |
| B | Brace 23 hours/day Wear continuously initially |
| D | Discontinue if failure Switch to closed reduction if not reduced |
| F | Flexion 100-110° Anterior strap controls flexion | X | eXclude if not reduced by 3-4 weeks Discontinue to prevent AVN | D | Discontinue if failure Switch to closed reduction if not reduced |
| L | Limited abduction initially Start 50-70°, adjust based on USS | A | Abduction 50-70° Posterior strap controls abduction | ||
| E | Every 3-4 weeks USS Monitor reduction progress | B | Brace 23 hours/day Wear continuously initially |
Hook:FLEX ABD - proper positioning prevents AVN and ensures success!
Overview and Epidemiology
Why This Topic Matters
Developmental dysplasia of the hip is the most common hip disorder in infants. Early diagnosis and age-appropriate treatment are essential to prevent long-term disability, AVN, and early osteoarthritis. Understanding the age-based treatment algorithm and AVN prevention strategies is critical for exam success.
Epidemiology
- Incidence: 1 in 1000 live births
- Gender: Female predominance 7:1 (relaxin sensitivity)
- Laterality: Left hip 60% (fetal position), bilateral 20%
- Risk factors: Breech (20% vs 2% population), family history (12%), firstborn, packaging disorders
- Ethnicity: Higher in Caucasian, Lapland, Native American populations
Natural History
- 1 in 60 abnormal at birth but 60% stabilize by 1 week, 88% by 2 months
- Untreated DDH: Leads to abnormal gait, limb shortening, early osteoarthritis
- Early treatment: Excellent outcomes with 95% success in Pavlik harness
- Late treatment: Worse outcomes, higher AVN risk, may require multiple surgeries
Pathophysiology and Mechanisms
Pathoanatomy of DDH
DDH represents a spectrum from mild acetabular dysplasia to complete dislocation. Pathoanatomy includes: shallow acetabulum, labral hypertrophy and inversion, capsular laxity, ligamentum teres elongation, pulvinar (fibrofatty tissue) development in acetabulum, and secondary femoral head changes. Understanding these changes guides treatment approach.
| Structure | Normal | DDH Changes | Clinical Significance |
|---|---|---|---|
| Acetabulum | Deep, covers 50%+ of head | Shallow, covers less than 50% | Reduced coverage, instability |
| Labrum | Normal size, everted | Hypertrophied, inverted | Blocks reduction, requires release |
| Capsule | Normal tension | Lax, hourglass constriction | Prevents reduction, requires release |
| Ligamentum teres | Normal size | Elongated, hypertrophied | Obstacle to reduction, excise |
| Pulvinar | Minimal | Fibrofatty tissue in acetabulum | Obstacle to reduction, excise |
| Femoral head | Spherical, centered | May be flattened, displaced | Secondary changes from dislocation |
Acetabular Development
- Normal: Acetabular index 30° at birth, decreases to 20° by 24 months
- DDH: Elevated acetabular index, shallow acetabulum
- Remodeling potential: Up to 5 years of age
- After 5 years: Limited remodeling, may need osteotomy
Femoral Head Changes
- Early: May be normal if recently dislocated
- Chronic: Flattening, loss of sphericity
- Ossification: Delayed in dislocated hip
- After reduction: May remodel if reduced early
Classification Systems
Graf Classification (Ultrasound)
| Graf Type | Alpha Angle | Beta Angle | Description | Treatment |
|---|---|---|---|---|
| Type I | Over 60° | Under 60° | Normal hip | Observation |
| Type II | 43-60° | 55-77° | Immature or dysplastic | Monitor or Pavlik |
| Type III | Under 43° | Over 77° | Subluxed | Pavlik harness |
| Type IV | Under 43° | Over 77° | Dislocated | Pavlik harness |
Graf Classification Key Points
Alpha angle (bony acetabular coverage): Normal over 60°. Beta angle (cartilaginous coverage): Normal under 60°. Type III and IV require treatment with Pavlik harness. Ultrasound is imaging modality of choice under 4-6 months (cartilaginous head not visible on X-ray).
Clinical Assessment
Neonatal Examination
- Ortolani test: Abduction and gentle pressure over GT - clunk indicates reduction
- Barlow test: Adduction and posterior pressure - clunk indicates subluxation
- Reliability: Unreliable after 2-3 months as soft tissues tighten
- Other signs: Asymmetric creases, limited abduction (under 60°), Galeazzi sign (unilateral only)
Older Infant/Child
- Limited abduction: Primary sign after 3 months
- Limb length discrepancy: Unilateral cases
- Gait abnormality: Waddling gait in bilateral, Trendelenburg in unilateral
- Asymmetric skin creases: May be present but not diagnostic
Clinical Examination Findings
| Age | Key Findings | Tests | Reliability |
|---|---|---|---|
| 0-3 months | Ortolani/Barlow positive | Ortolani, Barlow tests | Reliable |
| 3-12 months | Limited abduction | Abduction ROM, Galeazzi sign | Moderately reliable |
| Over 12 months | Limp, LLD, limited ROM | Gait assessment, ROM | Less reliable - imaging key |
Investigations
Ultrasound (Under 4-6 Months):
- Timing: Most useful from 4-6 weeks until femoral head ossifies
- Graf classification: Alpha angle (bony coverage, normal over 60°), beta angle (cartilaginous, normal under 60°)
- Dynamic assessment: Evaluates stability during movement
- Monitoring: Repeat every 3-4 weeks during Pavlik treatment
Radiographs (Over 4-6 Months):
- AP pelvis: Assess acetabular index, Shenton's line, head position
- Frog-leg lateral: Assess femoral head coverage, version
- Measurements: Acetabular index (normal under 30° at 1 year), center-edge angle (after age 5)
Arthrogram (During EUA for Closed Reduction):
- Normal findings: Sharp labrum (rose thorn sign), minimal medial pooling
- Abnormal findings: Widened medial joint space (pooling over 5mm), blunted labrum, hourglass constriction
- Safe zone assessment: Determines abduction range maintaining reduction without AVN risk
Management Algorithm
Treatment Algorithm by Age
0-6 Months: Pavlik Harness
- First-line treatment for dislocatable/dislocated hips
- Positioning: Flexion 100-110°, abduction 50-70°
- Wear 23 hours/day initially, wean over 2-4 months
- Monitor with ultrasound every 3-4 weeks
- Success rate: 95% for Graf III/IV detected early
- Discontinue if not reduced by 3-4 weeks (AVN risk)
6-18 Months: Closed Reduction
- Examination under anaesthesia with arthrogram
- Assess reduction quality and safe zone
- Adductor tenotomy if safe zone narrow (under 25°)
- Spica cast: 100° flexion, 40-50° abduction, neutral rotation
- Cast for 3 months, change at 6 weeks
- Success rate: 80-90% if adequate safe zone
18 Months-3 Years: Open Reduction
- Indicated when closed reduction fails
- Medial approach (Ludloff, Ferguson) under 12 months
- Anterior approach (Smith-Petersen) over 12 months
- Address obstacles to reduction
- May need femoral shortening if tight
Over 3 Years: Open Reduction + Osteotomy
- Open reduction always required
- Femoral varus and shortening osteotomy
- Pelvic osteotomy for residual dysplasia
- More complex, higher complication risk
This age-based approach ensures optimal outcomes while minimizing complications.
Surgical Technique
Pavlik Harness Application
Indications:
- Graf Type III or IV (subluxed or dislocated)
- Age 0-6 months (maximum 6-7 months)
- Dislocatable hip on examination
Application:
- Chest strap: Around nipple line, snug but not tight
- Anterior strap: Controls flexion 100-110°
- Posterior strap: Controls abduction 50-70°
- Positioning: Hip flexed and abducted, allows active motion
Monitoring:
- Ultrasound every 3-4 weeks
- Check for reduction, assess Graf type improvement
- Adjust straps as needed
Discontinuation:
- If reduced: Gradually wean over 2-4 months
- If not reduced by 3-4 weeks: Discontinue to prevent AVN
- Switch to closed reduction if Pavlik fails
Complications:
- AVN (5-10%): From forced abduction, discontinue if not reduced
- Pavlik disease: Posterolateral acetabular wear from treatment in unreduced position
- Recurrence: ~10% after successful treatment
Proper application and monitoring are essential for success and AVN prevention.
Complications
Avascular Necrosis (Most Devastating)
Incidence:
- Pavlik harness: 5-10%
- Closed reduction: ~20% (Salter type 1)
- Open reduction: 10-20% (medial approach 10%, anterior approach 10-20%)
Causes:
- Always results from treatment, not disease
- Forced abduction over 55°
- Extreme abduction with internal rotation and extension
- Multiple reduction attempts
- Early rigid casting
Kalamchi-MacEwen Classification:
- Class I: Nucleus only - will be normal
- Class II: Lateral physis - coxa valga from lateral physeal fusion
- Class III: Central - moderate deformity
- Class IV: Whole physis - severe deformity, poor outcomes
Prevention:
- Avoid abduction over 55°
- Use human position in spica (100° flexion, 40-50° abduction, neutral rotation)
- Discontinue Pavlik if not reduced by 3-4 weeks
- Gentle reduction technique
- Avoid multiple reduction attempts
Management:
- Established AVN: Containment procedures, may need later salvage
- Monitor for growth disturbance, coxa magna, coxa breva, coxa vara
AVN prevention is the most important principle in DDH treatment.
Postoperative Care
Pavlik Harness:
- Wear 23 hours/day initially
- Gradually wean over 2-4 months as hip stabilizes
- Monitor with ultrasound every 3-4 weeks
- Discontinue if not reduced by 3-4 weeks
- Parent education on application and care
Spica Cast (Closed Reduction):
- Duration: 3 months
- Change cast at 6 weeks
- Immediate MRI in spica to confirm reduction
- Cast care: Keep dry, check for pressure areas
- Monitor for cast problems, skin issues
Open Reduction:
- Spica cast for 3 months postoperatively
- Change cast at 6 weeks
- Monitor for AVN with serial radiographs
- Physiotherapy after cast removal
- Long-term follow-up for residual dysplasia
Long-term Follow-up:
- Serial radiographs: 6 months, 1 year, 2 years, then annually until skeletal maturity
- Monitor for AVN, residual dysplasia, redislocation
- Acetabular index should normalize by age 2-3 years
- Center-edge angle assessment after age 5
Follow-up Key Points
Long-term follow-up is essential to monitor for AVN (may present late), residual dysplasia (may need later osteotomy), and redislocation. Serial radiographs monitor acetabular development and femoral head shape.
Outcomes and Prognosis
Early Treatment Outcomes
- Pavlik harness: 95% success if detected early (under 6 weeks)
- Closed reduction: 80-90% success if adequate safe zone
- Open reduction: 85-90% success
- Key factor: Early diagnosis and treatment
Late Treatment Outcomes
- Over 3 years: 70-80% success, higher complication rates
- Over 5 years: Limited remodeling potential
- Bilateral painless dislocations: May leave alone (controversial)
- Late diagnosis: Correlates with worse outcomes
Outcomes by Treatment Modality
| Treatment | Success Rate | AVN Risk | Key Factors |
|---|---|---|---|
| Pavlik (0-6mo) | 95% | 5-10% | Early detection, proper positioning |
| Closed reduction (6-18mo) | 80-90% | 20% | Adequate safe zone, human position |
| Open reduction (18mo-3yr) | 85-90% | 10-20% | Address all obstacles, gentle technique |
| Open reduction + osteotomy (over 3yr) | 70-80% | 15-25% | Complex, higher risk |
Differential Diagnosis
Distinguishing DDH from Mimics
| Condition | Key Distinguishing Feature | Investigation | Why It Matters |
|---|---|---|---|
| Developmental dysplasia (DDH) | Reducible/dislocatable, shallow acetabulum, no fixed deformity | Ultrasound (Graf), AP pelvis | Index diagnosis - reversible if treated early |
| Teratologic dislocation | Fixed, irreducible at birth; syndromic (arthrogryposis, myelomeningocele) | Exam, screen for neuromuscular cause | Will NOT respond to Pavlik; needs surgery and a different prognosis |
| Proximal focal femoral deficiency | Short femur, abnormal proximal femur, not simply dislocated | Radiograph of whole femur | Limb reconstruction problem, not a reduction problem |
| Septic arthritis / sequelae | Pain, fever, raised inflammatory markers, pseudoparalysis | Aspiration, bloods, ultrasound effusion | Surgical emergency; late sequela can mimic dysplasia |
| Coxa vara (developmental) | Decreased neck-shaft angle, vertical physis, Trendelenburg | AP pelvis (Hilgenreiner-epiphyseal angle) | Femoral-side problem, different osteotomy |
| Neuromuscular hip displacement (CP) | Spasticity, progressive subluxation, GMFCS-related | Hip surveillance radiographs (migration %) | Salter contraindicated; needs Dega-type and soft-tissue surgery |
Do Not Force a Teratologic Hip
A teratologic dislocation is irreducible from birth and is associated with arthrogryposis, myelomeningocele and other syndromes. Attempting Pavlik or forced closed reduction wastes time and risks AVN. Always examine for fixed deformity, contractures and neurological signs before committing to conservative reduction.
Controversies and Areas of Uncertainty
Universal vs Selective Ultrasound
Universal newborn ultrasound reduces late-presenting dislocation and the need for surgery but markedly increases harness treatment (overtreatment of physiologically immature hips). Selective screening avoids overtreatment but depends on reliable clinical examination. No global consensus exists; practice tracks resources and historical programmes.
Static vs Dynamic Pavlik Devices
The Pavlik harness allows active motion within a safe range; rigid abduction braces (von Rosen, Tübingen, Plastazote) provide more fixed control. Evidence does not clearly favour one device, and rigid braces are often used as second-line after Pavlik failure or for non-compliant families rather than as proven superiors.
Timing of Pavlik Discontinuation
The classic teaching is to abandon the harness if the hip is not reduced within 3-4 weeks to limit AVN ("Pavlik disease"). Some series tolerate up to 6 weeks with a gentle progressive protocol. The unifying principle is that a persistently dislocated hip inside a harness causes posterior acetabular wear and must not be left.
Concurrent vs Staged Open Reduction + Osteotomy
For older children, whether to perform pelvic/femoral osteotomy at the same sitting as open reduction or in a staged fashion is debated. Long-term Salter data suggest performing open reduction first and reserving or staging osteotomy improves durability, but single-stage surgery is widely practised to limit anaesthetics.
The Painless Bilateral Dislocation in the Older Child
In a walking child with bilateral, painless, completely dislocated hips presenting late (e.g. over 4-6 years), the morbidity of bilateral open reduction and osteotomy (stiffness, AVN, redislocation) may exceed the natural history of well-tolerated bilateral dislocation for many years. Whether to operate, operate on one side, or observe remains genuinely controversial and is individualised to symptoms, function and family expectations.
Evidence Base
Pavlik Harness Success and Failure Predictors
- Overall Pavlik success 83.4% across all Graf types
- Earlier start (mean 6.7 vs 8.8 weeks) favours success
- Frank dislocation and Graf III/IV independently predict failure
- Femoral nerve palsy is a marker of excessive flexion and impending failure
Pavlik Harness in the Late-Diagnosed Dislocated Hip (6-24 Months)
- Graf III hips can still reduce in older infants (60%)
- Graf IV (frankly dislocated) success was 0% - do not persist
- No AVN in successfully reduced hips with gentle progressive technique
- Abandon the harness if not reduced by ~6 weeks
Risk Factors for Failed Pavlik Reduction
- Higher initial dislocation (small distance A) predicts failure
- Acetabular angle over 36° predicts failure
- Age over 4 months at application predicts failure
- Quantifies the case selection that favours Pavlik success
AVN After Medial Open Reduction - Systematic Review
- Medial open reduction AVN rate ~20% (24% at maturity)
- AVN nearly triples the unsatisfactory outcome rate
- Immobilisation at 60° abduction or more increases AVN
- Surgery under 12 months independently increases AVN risk
Salter Innominate Osteotomy - 26-35 Year Follow-up
- 90% survival of the Salter osteotomy at 35 years
- AVN and residual dysplasia drive long-term failure
- Higher dislocation grade predicts worse outcome
- Stage open reduction before pelvic osteotomy when both needed
Universal vs Selective Ultrasound Screening
- Selective screening did not increase true late diagnoses
- Universal screening increases treatment rate (overtreatment)
- Universal screening shifts treatment earlier and less invasive
- Trade-off between overtreatment and avoiding late surgery
DDH Management - Contemporary Review (AVN Mechanisms)
- ~90% of mild neonatal instability resolves by 8 weeks
- Ortolani-positive hip requires immediate treatment
- AVN linked to excessive abduction and forced reduction
- Acetabular index evolution best predicts residual dysplasia
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Pavlik Harness Management
"A 3-month-old infant presents with Graf Type IV DDH (dislocated hip). You decide to use Pavlik harness. Describe your management approach including positioning, monitoring, and when you would discontinue treatment."
Closed Reduction Decision
"An 8-month-old infant with DDH failed Pavlik harness treatment. You perform examination under anaesthesia with arthrogram. The arthrogram shows medial pooling of 8mm and a safe zone of only 15°. Discuss your management."
Older Child DDH
"A 2.5-year-old child presents with untreated unilateral DDH. The hip is dislocated and irreducible. Discuss your management approach including surgical technique and expected outcomes."
MCQ Practice Points
Pavlik Harness Success Rate
Q: What is the success rate of Pavlik harness for Graf Type III/IV DDH when initiated early (under 6 weeks)? A: 95% - Pavlik harness achieves 95% success rate when initiated early. Success drops to 80% if started after 7 weeks.
Most Devastating Complication
Q: The most devastating complication of DDH treatment is: A: Avascular necrosis (AVN) - AVN is the most devastating complication, causing femoral head deformity and growth disturbance. It always results from treatment, not disease.
Maximum Abduction Angle
Q: What is the maximum abduction angle in spica cast to minimize AVN risk? A: 55° - Abduction over 55° significantly increases AVN risk. Human position uses 40-50° abduction to minimize risk.
Acetabular Remodeling Potential
Q: At what age does acetabular remodeling potential significantly decrease? A: 5 years - Acetabular remodeling potential exists up to 5 years. After this, limited remodeling occurs and osteotomy may be required.
Open Reduction Approach
Q: Which approach is preferred for open reduction of DDH in a 10-month-old child? A: Medial approach (Ludloff/Ferguson) - Preferred under 12 months as it preserves blood supply and has lower AVN risk (10% vs 10-20% for anterior).
Safe Zone for Closed Reduction
Q: What is the minimum safe zone required for successful closed reduction? A: 25° - Safe zone under 25° is associated with high failure and AVN risk. Adductor tenotomy may widen safe zone.
Guidelines, Registries & Global Practice
Global Epidemiology
- Incidence: Wide range (0.06 to 76 per 1000) depending on definition and screening intensity; clinically significant DDH ~1 per 1000
- Highest prevalence: Native American, Lapland/Sami, and other swaddling cultures (tight hip extension)
- Lowest prevalence: Populations carrying infants in abduction (parts of Africa and Asia)
- Consistent risk factors worldwide: Female sex, breech, family history, firstborn, oligohydramnios
Screening Strategy Debate
- Clinical screening: Universal newborn Ortolani/Barlow is endorsed across all major societies
- Selective ultrasound: Risk-factor plus abnormal-exam based - UK NIPE, BOA, and most European programmes
- Universal ultrasound: Standard in Austria and parts of Germany/Switzerland (Graf); reduces late surgery but increases harness treatment
- AAOS (US): Conditional recommendation for imaging surveillance of at-risk infants rather than universal ultrasound
Major Society Guidance - Side by Side
| Body | Imaging Approach | Treatment Emphasis |
|---|---|---|
| AAOS (US) | Selective imaging of at-risk infants; no universal ultrasound | Pavlik or rigid abduction brace first-line under 6 months |
| BOA / NIPE (UK) | Universal clinical exam + selective ultrasound (risk factors, abnormal exam) | Brace under 6 months; closed/open reduction thereafter |
| Graf school (Austria/Germany) | Universal ultrasound screening of all newborns | Early ultrasound-guided abduction treatment, low late-surgery rate |
| EFORT / European consensus | Selective ultrasound with mandatory clinical screening | Avoid forced abduction; staged reduction by age and severity |
Registry and Long-Term Burden
DDH is the single largest cause of hip osteoarthritis requiring total hip arthroplasty in young adults, accounting for roughly 20-30% of THAs in patients under 60 in arthroplasty registry data (e.g. AOANJRR, NJR, Swedish Hip registry contexts). This long-term burden - not short-term reduction success - is the real justification for early diagnosis and AVN-avoiding treatment.
High- vs Limited-Resource Practice Variation
- High-resource settings: Newborn ultrasound capacity, early Pavlik, arthrogram-guided reduction, MRI-confirmed spica position, multidisciplinary follow-up to maturity
- Limited-resource settings: Reliance on clinical exam and late radiographs, higher rate of neglected/late-presenting dislocation, greater use of traction and open reduction with osteotomy
- Universal principle everywhere: Gentle concentric reduction in the human position, avoiding abduction over 55°, remains the AVN-avoidance standard regardless of resources
DDH TREATMENT OPTIONS
Clinical summary
Age-Based Treatment Algorithm
- •0-6 months: Pavlik harness (95% success if early)
- •6-18 months: Closed reduction + spica (80-90% success)
- •18 months-3 years: Open reduction (85-90% success)
- •Over 3 years: Open reduction + osteotomy (70-80% success)
Pavlik Harness Management
- •Positioning: Flexion 100-110°, abduction 50-70°
- •Wear: 23 hours/day initially
- •Monitoring: Ultrasound every 3-4 weeks
- •Discontinue if not reduced by 3-4 weeks (prevents AVN)
- •Success rate: 95% if detected early (under 6 weeks)
AVN Prevention - Critical Principles
- •Human position: 100° flexion, 40-50° abduction, neutral rotation
- •Never exceed 55° abduction (significantly increases AVN risk)
- •Gentle reduction - forced reduction causes AVN
- •Discontinue Pavlik promptly if reduction fails
- •AVN always results from treatment, not disease
Safe Zone and Closed Reduction
- •Safe zone: Range between redislocation and AVN risk
- •Minimum 25° required for closed reduction success
- •Medial pooling over 7mm = poor outcome predictor
- •Adductor tenotomy may widen safe zone
- •If safe zone inadequate after tenotomy → open reduction
Obstacles to Reduction
- •Psoas tendon (release)
- •Ligamentum teres (excise)
- •Pulvinar (excise)
- •Inverted limbus (may need release)
- •Transverse acetabular ligament (release)
- •Capsule hourglass constriction (incise)
- •Adductors (tenotomy)
Graf Classification
- •Type I: Normal (alpha over 60°, beta under 60°)
- •Type II: Immature (may resolve)
- •Type III: Subluxed (needs treatment)
- •Type IV: Dislocated (needs treatment)
- •Ultrasound under 4-6 months (cartilaginous head)
Open Reduction Approaches
- •Medial approach (Ludloff/Ferguson): Under 12 months, 10% AVN risk
- •Anterior approach (Smith-Petersen): Over 12 months, 10-20% AVN risk
- •Medial preserves blood supply better in infants
- •Anterior allows pelvic osteotomy if needed
Pelvic Osteotomies
- •Salter: Redirectional, young children
- •Pemberton: Reshaping, under 8 years
- •PAO (Periacetabular Osteotomy): Adolescent/adult
- •Indicated if acetabular index over 30° or center-edge angle under 20°
AVN Rates by Treatment
- •Pavlik harness: 5-10%
- •Closed reduction: 20%
- •Open reduction: 10-20%
- •Late presentation: Higher complication rates
- •AVN is most devastating complication
Key Principles
- •Early diagnosis and treatment essential
- •95% success with Pavlik if detected early
- •Age-based treatment algorithm critical
- •AVN prevention is paramount
- •Address all obstacles to reduction