What are the treatment options for hip dysplasia in patients of different ages and severity levels?

Treatment of Hip Dysplasia

Treatment of hip dysplasia must be stratified by age, with the Pavlik harness as first-line therapy for infants under 6 months (achieving 70-95% success when started before 7 weeks), progressing to closed reduction with spica casting for ages 6-18 months, open reduction with possible osteotomy for ages 18 months to 3 years, and periacetabular osteotomy or total hip replacement for adolescents and adults with symptomatic disease. 1, 2

Infants (Birth to 6 Months)

Initial Management

• Pavlik harness is the gold standard treatment for infants under 6 months with confirmed hip dysplasia, achieving success rates of 70-95% when initiated before 7 weeks of age 1, 2
• Treatment efficacy decreases significantly with age—start as early as possible, ideally before 6 weeks 1
• The harness maintains hip position at >90° flexion with 45-50° abduction (not exceeding this to prevent avascular necrosis) 1

Monitoring During Harness Treatment

• Use ultrasound as the preferred modality to confirm concentric hip reduction and assess treatment response 1, 2
• Perform serial ultrasound examinations throughout treatment duration 2
• Radiography is suboptimal during harness treatment due to delayed ossification and positioning limitations 2

Predictors of Harness Failure

• Low post-reduction alpha angle 1, 2
• Less than 20% femoral head coverage 2
• Bilateral hip involvement 2
• Graf Type IV hips 2
• Treatment initiation after 7 weeks of age 1
• Nerve palsy or irreducible hips 1

Special Consideration: Graf Type IIa Hips

• No treatment required for infants under 3 months with Graf Type IIa hips (alpha angle 50-59°), as 60-90% resolve spontaneously 1, 2
• All other Graf types (IIb, IIc, IId, III, IV) require immediate Pavlik harness treatment 1

Infants and Toddlers (6-18 Months)

When Pavlik Harness Fails or Age >6 Months

• Closed reduction with spica casting is the preferred treatment for children under 12 months when harness therapy fails 3
• Children aged 12-18 months may require open reduction through medial or anterior approach 3
• The goal is achieving stable concentric reduction while avoiding avascular necrosis of the femoral head 3

Young Children (18 Months to 3 Years)

Combined Surgical Approach

• Open reduction plus femoral or pelvic osteotomy is typically required to correct residual bony deformity 3
• Either femoral osteotomy alone or pelvic osteotomy alone may suffice, depending on the specific deformity pattern 3
• This age group represents a transition where soft tissue release alone is insufficient 3

Children (3-8 Years)

Acetabular Reshaping Procedures

• Acetabular reshaping osteotomy (Pemberton procedure or San Diego osteotomy) is the treatment of choice for residual dysplasia 4
• Surgical intervention at this age can alter the natural history of hip dysplasia and greatly improve hip joint longevity 4
• Residual dysplasia is a major cause of disability and should be corrected surgically at an early age 4

Older Children and Adolescents (8-15 Years)

Triple Innominate Osteotomy

• Children over age 8-10 years are best treated with triple innominate osteotomy 4
• This procedure provides more comprehensive correction than single-plane osteotomies 4

After Triradiate Cartilage Closure (Age 14-15+)

• Ganz periacetabular osteotomy (PAO) provides effective correction of residual dysplasia once the triradiate cartilage is closed 4
• PAO is the treatment of choice for young adults when restoration of hip anatomy as close to normal as possible is needed 5

Complex Deformity or Children >3 Years

Combined Femoral and Pelvic Osteotomies

• Both pelvic and femoral osteotomies are commonly required to stabilize an open reduction in children with complex deformity or those over 3 years of age 3
• This combined approach addresses both acetabular and femoral-sided pathology 3

Adults with Symptomatic Hip Dysplasia

Joint-Preserving Surgery vs. Replacement

• Osteotomy and joint-preserving procedures are useful for younger patients with painful hip dysplasia or deformity for whom total hip replacement (THR) is not yet justified 6
• However, evidence for these procedures is sparse (category III evidence) 6

Total Hip Replacement

• THR must be considered in patients with radiographic evidence of hip osteoarthritis who have refractory pain and disability 6
• THR achieves 43.2% to 84.1% of patients free from pain at long-term follow-up (average 9.4 years) 6
• Revision rates range from 0.18 to 2.04 per 100 person-years 6
• THR is more cost-effective in younger women (e.g., age 60) compared to elderly men (age >85) 6

Critical Pitfalls to Avoid

Overtreatment Risk

• Avoid universal ultrasound screening, which leads to overdiagnosis and unnecessary treatment, increasing avascular necrosis risk 1
• 60-80% of cases identified on physical examination and >90% of cases identified on ultrasound resolve spontaneously 1

Late Diagnosis Consequences

• Late diagnosis is a major negative prognostic factor requiring more complex treatment and surgical intervention 1
• Unrecognized and untreated hip dysplasia inevitably leads to early degenerative joint disease 1, 2
• DDH causes up to one-third of total hip arthroplasties in patients under 60 years of age 1, 2

Avascular Necrosis Prevention

• Do not exceed 45-50° of abduction during Pavlik harness treatment 1
• Excessive abduction is the primary modifiable risk factor for avascular necrosis 1

Long-Term Surveillance

Follow-Up Protocol

• Continue hip examinations at all well-child visits through age 5 years 2
• Perform follow-up radiographs at age 1 and 4 years to assess acetabular development 2
• Serial physical examinations and periodic imaging assessments throughout treatment duration 2