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Treatment of DDH: New born (birth to 6 months)

- Discussion:
    - treatment is directed at stabilizing hip that has positive Ortolani or Barlow test or to reducing dislocated hip w/ mild to moderate adduction contracture;
    - implications of positive Ortolani & Barlow's Test are different;
          - Barlow's Test identifies unstable hip that requires dynamic positioning w/ Pavlik harness to ensure that hip does not dislocate;
         - Ortolani test identifies an early dislocated hip which still can be reduced;
                 - positive test requires early aggressive treatment w/ proof of reduction;
                 - w/ a positive Ortolani test, the Pavlik harness will usually be sufficient but closed reduction & spica casting may be necessary in some cases;
    - early treatment of the displaced or unstable hip is based on principle of concentric reduction in position of abduction & flexion of hip;
    - as child ages and soft tissue contractures develop, along w/ secondary changes in acetabulum, the success rate of the Pavlik harness decreases;
          - w/ pts w/ frank dislocation, Pavlik harness fails to reduce hip in 25%;

- Treatment:
    - Pavlik Harness:
          - Pavlik harness is method of choice for DDH up to age 4 to 6 months;
          - relative contra-indications for use of the Pavlik harness is DDH w/ a negative Ortolani test, in which case, closed reduction and spica casting is considered;
          - it should be worn full time until stability is attained, as seen by a negative Barlow test;
          - Pavlik Harness Failure:
                - Patterns of Dislocation following Pavlik harness;
                       - superior dislocation: - additional flexion of the hip is indicated;
                       - lateral dislocation:
                             - should be observed initially;
                             - as long as the femoral neck is directed toward the triradiate cartilage, the head should gradually reduce into the acetabulum;
                       - posterior dislocation:
                             - results from tight hip adductor muscles
                             - may be diagnosed by palpation of greater trochanter posteriorly;
                - when persistent dislocation or subluxation persist for > 4 weeks, treatment in Pavlik harness should be discontinued;
                - consider traction, arthrogram & closed reduction & application of spica;
                - rarely open reduction will be required in this age group;
                - references:
                       - Use of the Pavlik harness for hip displacements. When to abandon treatment.
                       - Use of the Pavlik harness in congenital dislocation of the hip. An analysis of failures of treatment.

- Evaluation of Reduction:
    - X-ray:
           - radiograph should confirm adequate hip flexion & that femoral head is directed toward the triradiate cartilage;
           - if femoral neck does not point toward triradiate cartilage, further flexion to maximum of 110 deg should be achieved;
     - Ultrasound:
     - CT scan:
           - indicated if a spica cast is applied;

- Post Reduction Care:
     - since growth is rapid at this age, infant should be examined frequently so that anterior straps do not become overly tight & cause hyperflexion

Teratologic dislocation of the hip.

Damage to the capital femoral epiphysis due to Frejka pillow treatment.

Morphology of the acetabulum in congenital dislocation of the hip. Gross, histological and roentgenographic studies.

Acetabular development in the infant's dislocated hips.

Diagnosis by ultrasound of congenital dislocation of the hip joint.

Neonatal screening and staggered early treatment for congenital dislocation or dysplasia of the hip.

Primary anterior congenital dislocation of the hip in infancy.

Acetabular development after closed reduction of congenital dislocation of the hip.

Closed reduction for congenital dysplasia of the hip. Functional and radiographic results after an average of thirty years.

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