Treatment of Infant Hip Dysplasia
For infants diagnosed with hip dysplasia, the Pavlik harness is the first-line treatment for those under 6 months of age, with 70-95% success rates when initiated early, ideally before 7 weeks of age. 1, 2, 3
Age-Based Treatment Algorithm
Birth to 6 Months: Pavlik Harness Protocol
The Pavlik harness should be applied as soon as DDH is confirmed in infants with unstable hips or significant dysplasia on ultrasound, maintaining the hip in >90° flexion with 45-50° abduction to achieve concentric reduction while avoiding avascular necrosis. 2, 4, 5
- Treatment is most effective when started before 6 weeks of age, with efficacy decreasing as age increases 1
- The harness can be used up to 6 months of age with overall success rates of 67-83% 1
- Continue treatment until the hip is stable and shows concentric reduction on imaging 2, 5
Monitoring During Harness Treatment
Ultrasound is the preferred modality for monitoring harness treatment, performed to confirm concentric hip reduction, assess treatment response, and identify early signs of failure. 1
- Predictors of harness failure include: low post-reduction alpha angle, <20% femoral head coverage, femoral nerve palsy, irreducible hips, initiation after 7 weeks, right hip dislocation, Graf Type IV hips, and male sex 1, 3
- If stable reduction cannot be obtained after 2 weeks of Pavlik harness treatment, alternative treatment is indicated 4
When Conservative Treatment Fails
If the Pavlik harness fails after 2 weeks or the hip remains irreducible, proceed to examination under general anesthesia with possible closed reduction. 4, 3
- Closed reduction is indicated after failed bracing 3
- If concentric reduction cannot be obtained with closed methods, open surgical reduction is the next step 4, 6
Special Considerations by Hip Classification
Graf Type IIa (Immature Hip)
- No treatment required for infants <3 months with alpha angle 50-59°, as 60-90% resolve spontaneously 1, 2
- Follow-up imaging is advised due to small risk of delayed displacement or acetabular dysplasia 1
Graf Type IIb, IIc, IId, III, and IV
- All require immediate referral for treatment with Pavlik harness 1
- Type III (low displacement) and Type IV (high displacement) hips require immediate treatment 1
Critical Pitfalls to Avoid
The most serious complication of treatment is avascular necrosis of the femoral head, which occurs with overtreatment or excessive abduction beyond 50°. 1, 2
- Universal ultrasound screening leads to overdiagnosis and unnecessary treatment, increasing iatrogenic AVN risk 1
- Do not perform ultrasound before 2 weeks of age due to high false-positive rates from physiologic laxity 2, 7
- Avoid treating Graf Type IIa hips in infants <3 months, as most normalize spontaneously 1, 2
Age-Specific Treatment Transitions
Infants diagnosed after 6 months often require surgical correction rather than harness treatment, as the ability to stand and progressive soft-tissue contractures preclude harness use. 1, 4, 5
- Children aged 12-18 months requiring open reduction face longer recovery, with walking typically resuming 4-6 months after cast removal 8
- Late diagnosis is a major negative prognostic factor, requiring more complex treatment and increasing risk of long-term complications 1
Long-Term Outcomes
Early diagnosis and treatment with Pavlik harness demonstrates very good therapeutic success with low rates of residual dysplasia (2.81%) and excellent clinical outcomes at 20+ year follow-up. 9
- Unrecognized and untreated DDH inevitably leads to early degenerative joint disease, causing up to one-third of total hip arthroplasties in patients <60 years 1
- Serial physical examinations should continue at all well-child visits through age 5, with follow-up radiographs at ages 1 and 4 years to assess acetabular development and detect AVN 8