Pavlik Harness Treatment Versus Monitoring for Treatment of Graf Type 2b and 2c Hip Developmental Dysplasia of the Hip (DDH)

Developmental dysplasia of the hip (DDH) is a common cause of childhood disability, and diagnosis after 3 months may lead to the need for surgery and long-term complications. The incidence in the UK before ultrasound (US) screening became available was 1-2 per 1000. Since the advent of selective US screening, estimates in the UK incidence range from 5-30 per 1000. In terms of criteria for screening, there is consensus that a family history of DDH, female gender, breech presentation, primiparity and oligohydramnios increase the risk of DDH, although screening criteria vary amongst centres. There is a lack of evidence to support birth weight, prematurity, multiple pregnancy, mode of delivery or the presence of foot deformity as increased risk-factors for DDH.

Radiographic depiction of the hip is difficult in the first few months of life, due to the absence of the ossific nucleus. The advent of ultrasound (US) has significantly impacted these challenges, and this method has become popular since the first paper describing it by Graf in 1980. The Graf method has been accepted as the Gold Standard in Ultrasound analysis.

Differences in image acquisition and interobserver variation can significantly influence the diagnosis in the border zones between the different categories of the classifications. Reviews conclude that diagnosis by US is 'highly sensitive but poorly specific', and it is not clear how much unnecessary treatment is instituted due to the lack of a benchmark for diagnosis. It is unclear in well centered, stable hip dysplasia, whether treatment alters the natural history of the development of the hip. Randomised trials of abduction treatment of dysplastic hips according to the existing classification systems have failed to show a difference between the treatment and non-treatment groups between six weeks and three months, and between three months and six months .

While low risk, the Pavlik harness is not entirely benign. The rate of avascular necrosis (AVN) varies widely according to application , and has been associated with a longer duration of treatment.

While other complications from a correctly applied harness are rare, it may cause skin crease dermatitis and femoral nerve palsy (which has been linked with treatment failure). It is therefore beneficial to keep time spent in a harness to a minimum, and initiate treatment only when necessary.