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Children's Orthopaedics: J. Nakamura, M. Kamegaya, T. Saisu, M. Someya, W. Koizumi, and H. Moriya Treatment for developmental dysplasia of the hip using the Pavlik harness: LONG-TERM RESULTS J Bone Joint Surg Br 2007; 89-B: 230-235 [Abstract] [Full text] [PDF]

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Junichi Nakamura, Kamegaya M   (30 May 2007)

Treatment for developmental dysplasia of the hip using the Pavlik harness

Ismet Gavrankapetanovic, Zoran vukasinovic, Insitute for Orthopedic diseases Banjica Belgrade   (20 April 2007)

Authors' reply: 30 May 2007
Junichi Nakamura, MD Department of Orthopaedic Surgery, Graduate School of Medicine,Chiba University, Kamegaya M Send letter to journal: Re: Authors' reply: njonedr{at}yahoo.co.jp Junichi Nakamura, et al.	Sir, We thank Drs Gavrankapetanovic and Vukasinovic for their correspondence and we appreciate their interest in our paper. We applied the Pavlik harness as a therapeutic screening measure to every DDH patient seen in our clinic, regardless of whether the Ortolani sign was positive or negative. Of the 191 dislocations eligible for inclusion in our study, we had complete records about reducibility for only 108 hips. Our results suggested that reducibility was not a prognostic factor for the success of harness treatment, as we failed to identify any statistically significant difference between the Ortolani positive and Ortolani negative subjects with respect to Severin classification or avascular necrosis (AVN) incidence. As the doctors mention in their letter, examining patients on the first day after harness application is extremely important. In our current protocol, during the first two weeks after applying the harness, we confirm every few days whether parents cradle their baby in their arms whenever the baby cries and whether the dislocation is reduced. Since spontaneous reduction rarely happens after two weeks, we discontinue use of the harness after two weeks in patients whose hip dislocations do not reduce and employ alternative methods of joint reduction. We initially apply the harness loosely (70° of flexion) to accustom the baby to the therapeutic position and then gradually increase the degree of flexion. After reduction is achieved and stabilised, we gradually begin to reduce flexion. Spontaneous movement of the lower extremity usually disappeared within a few days after reduction. Iwasaki1 reported a reduction rate of 100% in a series of hospitalised patients who were tied to the bed in a supine position, but also encountered a high incidence of AVN (28%). These findings suggest that too lengthy a period of immobilisation may increase the risk of AVN. Consequently, we established a safe zone for abduction by placing small pillows under the knees. Currently, we routinely follow patients with ultrasonography, using the anterior approach reported by Suzuki.2 We have found that the Graf method, which employs a lateral approach, is useful for initial diagnosis but is difficult to employ during follow-up examination in patients wearing a harness because the adduction position of the Graf method entails an increased risk of re-dislocation. In the more than 100 cases we have followed ultrasonographically by an anterior approach, we have observed that the initial reduced position of the femoral head is anterior and lateral to the normal position and that concentricity is achieved during the following months or years.3,4 The full papers have not yet been published, but we have published preliminary results in abstract form. We would be pleased to send you these references by fax or email. J. Nakamura, MD, M. Kamegaya, MD, Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba City, Japan. 1. Iwasaki K. Treatment of congenital dislocation of the hip by the Pavlik harness. Mechanism of reduction and usage. J Bone Joint Surg [Am] 1983;65-A:760-7. 2. Suzuki S. Ultrasound and the Pavlik harness in CDH. J Bone Joint Surg [Br] 1993;75-B:483-7. 3. Kamegaya M, Shinohara Y, Tsukeoka T. Anterior Approach in Ultrasonic Scanning for Congenital Dislocation of the Hip Treated with Pavlik Harness [abstract]. 4th Congress of the International Society for Musculoskeletal Sonography, 1998. 4. Ochiai N, Kamegaya M, Saisu T, Moriya H. Is anterior ultrasound technique useful for predicting the prognosis of developmental dysplasia of hip [abstract]? 14th Triennial Congress of the Asia Pacific Orthopaedic Association, 2004.
Treatment for developmental dysplasia of the hip using the Pavlik harness 20 April 2007
Ismet Gavrankapetanovic, orthoopedic surgeon University Clinical Center Sarajevo, Clinic for orthopedics and traumatology, Zoran vukasinovic, Insitute for Orthopedic diseases Banjica Belgrade Send letter to journal: Re: Treatment for developmental dysplasia of the hip using the Pavlik harness ismetcap{at}ortotrauma.com.ba Ismet Gavrankapetanovic, et al.	Sir, We read this article with great interest and we congratulate the authors on the good results published in this paper. Our institutions, the Orthopedic clinic at University Clinical Center Sarajevo, and the Institute for Orthopedic Disease Banjica, Belgrade, in past decades have accumulated a vast amount of experience in treatment of developmental dysplasia of the hip (DDH). In the Balkan regions the incidence of this condition is 29 per 1000 newborns.2,3 We kindly ask the authors to explain the following: of the 79 hips reduced by harness, 66 were reducible and 13 were irreducible (Ortolani negative). We would like to know whether the patients went home after harness application, in cases of irreducible hip, and if the position of the harness was checked the next day. Our experience and protocol is for a reduced hip to be followed every day.1 An irreducible hip is admitted until reduction is achieved and stabilised. We think it is very important to maintain close observation of a child in a harness because the position of the hip can easily change due to the movements of the child or parental negligence. The incidence of avascular necrosis (AVN) after the application of a Pavlik harness for an irreducible hip is high. We routinely follow hip reduction with ultrasonic examination according to Graf, always using the lateral approach which we find ideal for visualisation of the labrum, triradiate cartilage and iliac bone. In our protocol, we conduct ultrasonic examination every day until reduction is achieved. I. Gavrankapetanovic, Orthopaedic Surgeon, University Clinical Center Sarajevo, Sarajevo, Bosnia. Z. Vukasinovic, Institute for Orthopedic Diseases, Banjica, Belgrade, Serbia. 1. Tachdjian MO. Paediatric Orthopedics. Second ed. Philadelphia: W.B.Saunders, 1990. 2. Vukasinovic Z i saradnici. Decja ortopedija. Beograd: Institut za ortopedsko-hirurske bolesti 'Banjica', 1999. 3. Gavrankapetanovic I i suradnici. Osnovi djecije ortopedije. Sarajevo:I.P.'Svjetlost', 2001.