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Pavlik Harness

- Discussion:
    - Pavlik harness is a dynamic flexion abduction orthosis used to treat DDH in infants up to 6 months of age;
    - harness usually leads to stability of reduced hip w/ in 4 wks, but its use should  be continued until clinical exam & x-rays
          of hip are normal;
    - patient's should expect a 85-95% success rate if the diagnosis is made in the newborn nursery;
           - clearly, a lower success rate would be expected w/ a teratologic dislocation;
    - indications and contra-indications:
           - indicated for infants w/ DDH & who are younger than six months;
           - not indicated for infants w/ a "hip click" but a normal physical exam (Barlow's test and Ortolani's test);
           - if teratologic dislocation is present, Pavlik harness is not used;
    - cautions:
           - note that continued dislocation of a hip while in Pavlik harness stretches the posterior capsule and reduces chances of
                     maintaining good reduction later;
           - note that male patients and patients w/ bilateral dislocations may have worse results w/ the Pavlik harness than females;
           - it is difficult to determine the true success rate for patients w/ clear cut DDH, since results published from tertiary care centers
                   will be biased due to the large number of referred cases (referred because of treatment failures);
           - other negative risk factors include: DDH in children older than 7 weeks, and hips which are not initially reducible;
           - age greater than 6 mo is a contraindication due to worsening of impediments to reduction;
                   - in these pts, harness may not produce reliabe reduction;
           - ref: Success of Pavlik Harness Treatment Decreases in Patients ≥ 4 Months and in Ultrasonographically Dislocated Hips in Developmental Dysplasia of the Hip.   

- Technique of Application:
    - position for reduction & safe zone:
    - harness consists of chest strap, 2 shoulder straps, & 2 stirrups;
    - each stirrup has an anteromedial flexion strap & posterolateral abduction strap;
    - harness is applied with the child supine;
    - chest straps:
          - chest strap is applied first, allowing enough room for hand to be placed between the chest and the harness;
          - shoulder straps are buckled to maintain chest straps at nipple line;
          - these should not be applied distal to nipple line;
    - stirrups: feet are then placed in the stirrups one at a time;
    - anterior strap: hip is reduced in flexion (90 to 120 deg), & anterior flexion strap is tightened to maintain this position;
          - transient femoral nerve palsy has been reported w/ hip flexion greater than 120 deg; 
          - ref:  Femoral Nerve Palsy in Pavlik Harness Treatment for Developmental Dysplasia of the Hip
    - lateral strap: lateral strap is loosely fastened to limit adduction, not to force abduction (knees should be 3-5 cm apart at full
          adduction in harness);
    - posterior strap:
          - will maintain hip in safe zone but must not to force hip into abduction (to avoid the rare complication of AVN);
          - posterior straps should not be overtightened;
          - knees should be able to come together to w/ in 3 fingers width or should come to within 3-5 deg of the midline;

- Post Application Evaluation:
    - Barlow test should be performed w/ in limits of harness to assure adequate stability;
    - child is then placed in the prone position, & greater trochanters are palpated;
          - if an asymmetry is noted, a persistent dislocation is present;
    - radiographs:
          - at 4 wees post harness application, it is necessary to document the reduction (w/ x-rays taken in harness);
          - femoral head should point to the triradiate cartilage with the hips held in flexion and abduction;
          - MRI: may be indicated for infants between the ages of 4-6 months;
          - ref: Radiographic Follow-up of DDH in Infants: Are X-rays Necessary After a Normalized Ultrasound
    - ultrasound:
          - in the report by Song KM, et al (2000), 14 children treated for DDH with a Pavlik harness were evaluated at the time of harness
                  application with clinical examination, hip ultrasonography, and AP radiography;
                  - clinical exam agreed with hip US for hip position in 100% of hips;
                  - interpretation of radiographs agreed with US in only 49% of cases in which the hip was judged to be dislocated and in 82%
                           of cases in which the hip was judged to be reduced;
                  - US was superior to anteroposterior radiography for assessing hip position.
    - generally the patient is left in the pavlic harness for a few weeks after the hip has stabilized in a reduced position, and subsequently
            part time abduction bracing should be used for several more weeks;
    - references:
            - Prediction of reduction in developmental dysplasia of the hip by magnetic resonance imaging
            - Ultrasound and the Pavlik harness in CDH.   
            - Determination of hip position in the Pavlik harness.   

- Treatment Failures:
    - impediments to reduction in DDH 
    - if reduction is questionable after 4-5 wks in harness, then consider traction, adductor tenotomy, or closed reduction,
            arthrogram, and casting; 
    - w/ persistent hip dislocation after 2 weeks,  the harness should be discontinued;
          - further use of the Pavlik harness may contribute to a posterolateral acetabular deficiency, which will further complicate
                   attempts at reduction;
    - spica cast:
          - may be used when reduction has narrow stable zone or when non-compliance w/ harness has been a problem

Inferior (obturator) dislocation of the hip in neonates. A complication of treatment by the Pavlik harness.

Use of the Pavlik harness for hip displacements. When to abandon treatment.

Congenital dislocation of the hip. Use of the Pavlik harness in the child during the first six months of life.

Pitfalls in the use of the Pavlik harness for treatment of congenital dysplasia, subluxation, and dislocation of the hip.

Treatment of congenital dislocation of the hip by the Pavlik harness. Mechanism of reduction and usage.

Use of the Pavlik harness in congenital dislocation of the hip. An analysis of failures of treatment.

Reduction of CDH by the Pavlik harness. Spontaneous reduction observed by ultrasound.

Avascular necrosis in patients treated with the Pavlik harness for congenital dislocation of the hip.

Splintage in developmental dysplasia of the hip: how low can we go?

Treatment of true developmental dysplasia of the hip using Pavlik's method.

Treatment for developmental dysplasia of the hip using the Pavlik harness: long-term results.

Results of Pavlik Harness Treatment in Children With Dislocated Hips Between the age of six and Twenty-four Months