Twelve-week standard of care protocol longer than median time to normalization among IIc hips treated with Pavlik
Reba L Salton1, Patrick Carry1,2, Tyler Freeman2
1Musculoskeletal Research Center, Orthopedics Institute, Children's Hospital Colorado.
Insights
Treatment for developmental dysplasia of the hip (DDH) in infants using the Pavlik harness can be shortened for some patients. Greater femoral head coverage and hip stability at treatment initiation are linked to longer normalization times.
Area of Science:
- Pediatric Orthopedics
- Biomedical Engineering
- Clinical Research
Background:
- Developmental dysplasia of the hip (DDH) treatment protocols, particularly for Graf IIc hips, lack defined optimal durations.
- The Pavlik harness is a common treatment for DDH, but its efficacy and ideal treatment length require further investigation.
Purpose of the Study:
- To estimate the time to normalization for Graf IIc hips treated with the Pavlik harness.
- To identify factors influencing the duration of Pavlik harness treatment for DDH.
Main Methods:
- Retrospective review of 132 Graf IIc hips in 106 infants treated with Pavlik harness between 2009-2018.
- Kaplan-Meier and Cox proportional hazards regression analyses were used to model time to normalization.
- Normalization defined as alpha angle ≥ 60° and femoral head coverage ≥ 50%.
Main Results:
- Median time to normalization was 7.0 weeks, with 85.8% of hips normalizing by 12 weeks.
- Greater initial femoral head coverage (HR 1.03) and hip instability (HR 0.64) were associated with longer normalization times.
- Some stable Graf IIc hips may normalize before 12 weeks, suggesting potential for shorter treatment durations.
Conclusions:
- Shorter Pavlik harness treatment durations may be possible for select infants with DDH without compromising long-term outcomes.
- Femoral head coverage is a critical diagnostic and prognostic factor in DDH.
- Hip instability at presentation is a concerning indicator that warrants close monitoring during treatment.
Abstract:
Best treatment protocols for infants with developmental dysplasia of the hip (DDH) are poorly defined. This study estimates the time to normalization among Graf IIc hips undergoing Pavlik harness treatment. Following institutional review board approval, patients referred for DDH evaluation at a pediatric institution between 2009 and 2018 (n = 1424 hips/712 patients) were identified. We isolated all Graf IIc hips that underwent Pavlik harness treatment (n = 132 hips/n = 106 patients). Demographic and outcome measures were collected. Normalization was defined as alpha angle greater than or equal to 60° and femoral head coverage greater than or equal to 50%. Kaplan-Meier and Cox proportional hazards regression analyses modeled time to normalization and identified factors associated with earlier normalization. Median time to normalization was 7.0 weeks. At 12 weeks standard treatment, 85.8% [95% confidence interval (CI): 80.2-91.9%] had normalized. Greater femoral head coverage [hazard ratio (HR) per 1% increase: 1.03; 95% CI: 1.01-1.05; P = 0.0068] and hip stability at treatment initiation (HR unstable vs. stable: 0.64; 95% CI: 0.44-0.93; P = 0.0192) were associated with longer time to normalization. Some patients may not need 12 weeks of Pavlik bracing, particularly those with stable presentation who normalize before week 12. Shorter treatment lengths offer benefit without sacrificing long-term outcomes. Findings reinforce growing evidence that femoral head coverage should be a more significant consideration during diagnosis and instability is a concerning finding on examination.
