The treatment for Hip Dysplasia may not be as straight forward as one may think. In this section we will talk about how a treatment plan develops and give a very broad, very general guide as to what treatment methods are generally preferred in different stages of a baby’s development. Treatment depends on the age of the child and the amount of hip displacement. The information here applies mainly to complete hip dislocation. We’ve listed some general treatment choices as first line of treatment for children with dislocated hips. If the first line of treatment is not successful, then the next step is usually performed regardless of age.
Primer
The purpose of treatment is to hold the hip in the socket until the ligaments go back to normal and to allow time for the socket and bone to grow to their proper shape.
When hip dislocation occurs at the time of birth, the ligaments are stretched and the socket is shallow. The ligaments of a baby are very loose and the edges of the socket are made of cartilage that is soft and flexible. The hips will usually go back to normal if they can be held in the sockets until they become stable.
After several months, there are greater changes in the soft tissues and ligaments. The soft tissues become tighter and stiffer. More force is needed to get the hips in the right position and more time is needed after reduction for the hip to recover its shape.
If the hip has been displaced for a longer period of time, there are changes in the underlying bone that need to be corrected with surgery to re-align the bones in addition to putting the hip back into the socket. Older children require longer for the socket and bone to develop more support.
Newborns
Primary Treatment(s): Pavlik Harness
Often the dislocated hip of a newborn baby goes back into the socket very easily because the mother’s hormones that relax ligaments are still in the baby. Dislocated or unstable hips in newborn infants can usually be held in place by a brace or harness that holds the legs in a position while the socket and ligaments become more stable.
There are a wide variety of holding devices available, but the most common ones are the Pavlik Harness, or various types of devices called fixed abduction braces. The choice of method depends on the needs of the family and the experience of the treating doctor.
Most doctors recommend full-time wear for 6-12 weeks but some doctors allow removal for bathing and diaper changes as long as the legs are kept apart to keep the hips pointed at the socket. After the hips become stable, the brace is worn part time, usually at night, for another 4-6 weeks.
1 to 6 Months of Age (Infants)
Primary Treatment(s): Pavlik Harness
Treatment is similar to treatment in newborn infants in this age group. A fixed abduction brace can be used when the hip is mildly unstable or when it can easily go back into the socket.
If the hip is completely dislocated and stuck in a dislocated position, then the Pavlik Harness can sometimes put the hip back in the socket over a period of 2-4 weeks. This period of time allows the muscles and tendons gradually relax so the hip can slip back into the socket. It is important to use the Pavlik Harness throughout the day and night for this to be successful.
Once the harness is fitted properly, it is necessary to have follow-up visits every week or two to adjust the harness and check the progress of the reduction. This is evaluated by the doctor when he checks the baby’s hip, and also by ultrasound in most cases. Occasionally, x-rays will be used to help decide whether the treatment is working or not.
After the hip is reduced into the socket, the Pavlik Harness is continued until the ligaments become stable. This is usually takes another 6-12 weeks in the harness. Even after that, the baby may need to sleep in the harness or another brace for a few weeks as a safety measure. Sometimes the treatment is changed to a fixed-abduction brace after a few weeks.
Treatment with the Pavlik Harness should be successful within four weeks or another form of treatment is usually recommended. Prolonged treatment with a Pavlik Harness while the hip remains dislocated may damage the wall of the socket.
6 to 18 Months of Age
Primary Treatment(s): Closed Reduction and Spica Cast
Possible Alternative Treatment(s):
- Open Reduction, Medial or Anterior surgical approach.
- Pavlik harness in carefully selected patients.
- IHDI Protocol for Papadimitriou Method.
Summary:
- Manual closed reduction under general anesthesia is typical for this age group. (Sometimes this can also be tried after the age of 18 months and up to two years old).
- Puncture release of tight groin muscle is often done at the time of the closed reduction.
- A needle may be inserted into the joint to inject x-ray dye for an arthrogram.
- Some doctors prefer traction before doing the closed reduction.
- Three months in a cast is fairly standard, but older children may need longer time. This also lets the hip grow and become more stable.
- If closed reduction is unsuccessful and the child is less than 12 months old an open reduction may be performed through a medial approach or through an anterior approach, but the anterior approach is more standard after one year of age.
- The Pavlik harness may be attempted for less severe dislocations in infants between the ages of 6 months and 12 months.
- The Papadimitriou method of harness and brace treatment has been successfully used in this age group but has not been widely adopted. The IHDI developed a protocol for investigation of this innovative method that could avoid casts or surgery.
This age group is a period of transition when non-operative treatment may work, or there may be a need for surgery. Treatment in this age group depends on the severity of the dysplasia and the experience of the doctor. The Pavlik Harness is rarely successful after age 6 months. However, there are published reports of successful use of the Pavlik harness between the ages of six months and twelve months for Grade II or Grade III dislocations, but not with more severe dislocations. Up to six weeks of treatment may be needed before determining success or failure. Prolonged wear beyond three weeks is acceptable in this older age group even when the hip fails to go back into the socket. (V Pollet, JPO 2010;30(5):437-42) (MAJ van de Sande, Intl. Orthop. 2012;36:1661)
The most common treatment for this age group is for the surgeon to manipulate the hip back into the socket under general anesthesia and then apply a body cast called a spica cast to hold the hip in position for several months while it heals and becomes more stable. This is called “closed reduction.” Sometimes preliminary traction is used to help stretch the hip and its muscles before trying to put the hip back into place.
The Papadimitriou method of harness and brace treatment has been successfully used in this age group but has not been widely adopted. The IHDI has developed a protocol for investigation of this innovative method that could avoid casts or surgery.
Occasionally, surgery is recommended without trying “closed reduction” because the dislocation is more severe or because bone changes have already occurred. During surgery, the abnormal tissue that is keeping the hip out of the socket is removed and the joint is inspected. Loose ligaments are tightened and tight muscles are loosened. This part is called an “open reduction.“
Surgical reduction in children less than one year of age this may be performed through a medial approach, but after one year of age the anterior approach is generally recommended. One reason for choosing the anterior approach is that any abnormality in the pelvis can be corrected at the same time with a “pelvic osteotomy”. Also, the thigh bone often needs to be shortened and tilted towards the joint to relieve pressure on the hip, to improve stability, and to reduce the risk of later problems. Surprisingly, shortening the bone actually stimulates growth of the leg so the shortening is almost always temporary as long as the hip stays in the socket and does not develop AVN. Prior to one year of age, bone procedures are often unnecessary, so the obstacles to reduction can be cleared from the medial approach. Even when bone procedures are unnecessary, the anterior approach is successfully used by many surgeons.
18 Months to 6 Years of Age
Primary Treatment(s): Anterior open reduction of the joint with additional bone surgery and ligament tightening as needed.
Closed reduction is possible in older children, but a longer time in the cast is normally needed for the hip to grow back into a normal shape. Open reduction accomplishes this more quickly and more reliably in most cases. Although successful closed treatment has been reported up to the age of four years. There are usually bone changes at this age that are best treated by open reduction combined with bone re-modeling to repair any deformity of the femur or pelvis.
In this age group, open reduction surgery is almost always performed through an anterior approach to put the hip back into the joint, repair the ligaments, and to realign the bones. An arthrogram under anesthesia can be performed in the operating room to decide if there is still the possibility of success with closed treatment in a cast. The arthrogram will also help determine how much bone deformity is present so the surgeon can decide whether the pelvis and femur need to be re-shaped at the time of open reduction of the joint.
Summary:
- Anterior open reduction of the joint with additional bone surgery and ligament tightening as needed.
- A body cast is used for 6-8 weeks after surgery.
- Pelvic osteotomy is often performed to re-shape the socket.
- Femoral shortening and VDO (Varus Derotational Osteotomy means tipping the bone towards the socket) is often performed to improve joint stability.
6 Years of Age and Older
Reduction is rarely recommended in older children with completely dislocated hips because the bone changes are permanent by this age. Hip dysplasia with partially displaced hips can still be treated in older children and adolescents. This can delay the onset of arthritis in many cases.
