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Developmental dysplasia of the hip: a history of innovation

Tarpada, Sandip P.; Girdler, Steven J.; Morris, Matthew T.

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Journal of Pediatric Orthopaedics B: May 2018 - Volume 27 - Issue 3 - p 271-273
doi: 10.1097/BPB.0000000000000463
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Abstract

Introduction

Developmental dysplasia of the hip (DDH) describes a wide spectrum of hip disorders. The common etiology along this spectrum is an inability of the femoral head to maintain the proper position within the acetabulum, causing permanent disability over time 1. An awareness of congenital hip defects has long been known since the days of Hippocrates 2. In medieval London the disease was common, with an incidence of 2.7 per 1000 3. One of the earliest modern descriptions of this condition was made by Palletta, a Milanese physician in 1820 4. However, the most prominent early description of the DDH was made by Dupuytren in 1826 5. It was Dupuytren who first systematically considered the etiology of the condition alongside anatomy, pathology, and clinical presentation 6,7. In the USA, a notable early description of the disease was made by A. M. Phelps in 1891. He later went on to report that the disease could be hereditary in nature, citing Ambrose Paré: ‘It is that crooked, not necessarily, but oftentimes, are generated by crooked, and lame by lame’ 8. Currently, treatment for DDH relies on reduction of the femoral head in the acetabulum, by closed or open means 9,10. Here, we cover three treatment methods for DDH: the Pavlik harness, traction, and casting as well as other names and practices that historically have changed the way the condition is managed.

A note on terminology

Until relatively recently, DDH was most commonly known in the Anglophone world as congenital dislocation of the hip, or simply hip dysplasia. The term ‘developmental dysplasia of the hip’ is now preferred, although ‘congenital dislocation of the hip’ is also used to a lesser extent. This disagreement of terminology relates to controversy over whether the disorder is congenital or developmental in nature 11. In 1970, Ruth Wynne-Davies introduced the concept of a spectrum of hip dislocation characterizing the disorder, with genetic and developmental causes leading to early and late presentation, respectively 12. In 1958, Massie proposed a combined etiology, hypothesizing that a congenital laxity of the joint capsule was coupled with pathological developmental 13. Synder and colleagues first used the term ‘developmental dysplasia of the hip’ in 1992, formulating the disorder as a developmental condition in which subluxation and dislocation were secondary 14,15.

Treatment techniques for developmental dysplasia of the hip

Early treatment techniques were largely ineffective, and sometimes utilized physically brutal manipulations 3. In 1896, Lorenz 16 recommended closed reduction followed by immobilization with a plaster cast in a maximally abducted position. At that time, DDH was frequently unrecognized until after the child began to walk, but treatment after infancy often failed because of small size and diminished plasticity of the acetabulum 16. In addition, this method of forced abduction and immobilization was associated with avascular necrosis (AVN).

The Pavlik harness

During the mid-twentieth century, the focus of treatment strategies shifted from manipulation and cast immobilization to one of harnessing with free movement within a protected range of motion. In 1939, Pavlik became head of the orthopedic clinic in Olomouc, Czechoslovakia, and began developing a harness that brought about a ground-breaking conceptual shift in the treatment of DDH 17,18. Pavlik’s device consists of a thoracic harness and bilateral stirrups that guide the infant’s movements, producing natural hip and knee flexion that gently reduces the hip deformity over time 17,19. This method has resulted in significantly lower rates of AVN and even today is considered the standard of care.

Although the Pavlik harness is associated with adverse effects such as inferior dislocation, brachial plexus palsy, and femoral nerve palsy, careful follow-up and parental education can minimize the incidence of complications 18,21. Problems arising from the use of the Pavlik harness can frequently be attributed to compliance issues, either due to poor education by physicians or misunderstanding by guardians 22. In the 1970s, Ramsay, Lasser, and MacEwen experimented with Pavlik harnesses that used webbing instead of leather. They also developed the concept of the ‘safe zone’: the angle between comfortable abduction and potential hip redislocation. This concept is still used today as a guideline for treatment of DDH as well as positioning the hip following closed reduction 20.

Ortolani’s ‘click’

Marino Ortolani was another pioneer in the treatment of DDH. In 1937, he recognized that a characteristic clicking sound and tactile sensation could be used to detect prodromal hip dysplasia 23. The simplicity of the Ortolani test allowed it to be carried out by any healthcare provider without imaging. Ortolani not only developed a screening method for DDH but also a child-centered, inexpensive treatment method consisting of early intervention. Specifically, he promoted dressing affected infants in three diapers to maintain chronic hip abduction, finding that this makeshift harness could keep most children from progressing to a state of permanent dislocation.

The Frejka pillow

Although the Frejka pillow is technically a splinting method and not a harness, it serves as a useful example of the history of modern DDH treatment. Similarly to Pavlik, Bedrich Frejka sought to improve the high rate of AVN associated with the forceful abduction and immobilization method. In 1941, he developed the Frejka pillow, which holds the infant’s hips in a position of abduction, but allows the infant to easily counteract the pressure with their own movements. Although rarely used in North America, it is commonly used in some parts of Europe, reportedly with positive results 24. A study carried out in Norway in 2005 found that the Frejka pillow is comparable with the Pavlik harness in terms of safety and reliability 25.

Traction

By the late 1980s, traction was commonly used as a precursor to other interventions for DDH. Longitudinal traction is applied through small boards under the soles of the feet, with elastic adhesive tape extending alongside the lateral side of the infant’s leg. Traction maintains the infant’s legs in a position of abduction and medial rotation, sometimes referred to as the Lange position. Overhead traction in a flexed position is also used, particularly in children who were too old to be treated with the Pavlik harness 23. Suzuki et al.26 considered that use of immobilization techniques may lead to AVN, but that traction is essential in preventing this complication by relaxing surrounding muscles and preventing femoral head compression. However, Kutlu and colleagues found no connection between preliminary traction and AVN, citing a lack of well-controlled trials.

Management of developmental dysplasia of the hip with casting and surgery

Before the Pavlik harness and the Frejka pillow, casting was the predominant noninvasive method for the treatment of DDH, but the results were frequently unsatisfactory. Lorenz’s technique involved forceful hip manipulation, involving an avulsion of the adductor longus tendon created by applying pressure to the hip joint, followed by casting with 90° flexion and abduction 27. By the 1960s, Salter acknowledged that this position likely contributed to the high rate of AVN and resultant degenerative arthritis in many children who underwent treatment for DDH 28.

Before the 1950s, surgical treatment of DDH often led to outcomes worse than the untreated condition. However, the technique developed by Robert Salter introduced a safe surgical option with positive outcomes. Salter is widely known for the innominate osteotomy as well as the fracture classification system he developed with Robert Harris. Salter additionally developed a concept of continuous passive movement with regard to the hip joint, asserting that synovial joints must move to recover and regenerate 29. Modern casting methods for DDH generally involve closed reduction and immobilization with a hip spica cast. Recently, open reduction has come to be preferred over forced, closed reduction 30,31. When children are diagnosed with DDH after 6 months, or after failed treatment with noninvasive methods, surgery with subsequent casting is recommended. This alone may contribute to the fact that treatment of DDH with closed reduction and a hip spica cast is considered only relatively effective 32. Dislocation and subluxation of the hip in children older than 18 months is generally treated using innominate osteotomy 33.

Unanswered questions

Unanswered questions exist regarding DDH screening. For example, estimates of the incidence of DDH vary widely owing to varying methods of diagnosis 22. In the late 1960s, newborn screenings changed the way DDH was detected. Wynne-Davies noted that introduction of ultrasound screening brought a four-fold increase in the number of cases presenting for treatment compared with the previous decade. By this time in Scotland, the majority of cases were diagnosed within the first week of life 12. However, in developing countries, the disease is often diagnosed later because of screening difficulties 33. With the exception of Beukes familial dysplasia, a 4q35 mutation, which occurs only in a single family in South Africa, most etiologies of DDH are multifactorial 34. In 2006, the USPSTF found no direct link between DDH screening and better outcomes 35. Therefore, room exists for improvement in the methodology surrounding current screening practices.

Conclusion

Many of the unanswered questions surrounding DDH concern ambiguity: interventions favored in one country or region are often dismissed or regarded poorly in another. In order to ensure the best treatment for patients in the future, more research is needed to categorize the etiologies of DDH. Future treatment options should be tailored in concert with these advances.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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Keywords:

developmental dysplasia of the hip; harness; history of developmental dysplasia of the hip; traction

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