Developmental Dysplasia of the Hip (DDH) is the most common orthopaedic disorder in newborns. Whilst the Pavlik harness is one of the most frequently used treatments for DDH, there is immense variability in treatment parameters reported in the literature and in clinical practice, leading to difficulties in standardising teaching and comparing outcomes. In the absence of definitive quantitative evidence for the optimal Pavlik harness management strategy in DDH, we addressed this problem by scientifically obtaining international expert-based consensus on the same. An initial list of items relevant to Pavlik harness treatment was derived by systematic review of the literature according to PRISMA criteria and reviewed by two expert clinicians in DDH management. Delphi methodology was used to guide serial rounds of surveying and feedback to content matter experts from the International Hip Dysplasia Institute (IHDI), a collaborative group of paediatric orthopaedic surgeons with expertise in the management of DDH. Rounds of surveying continued in the same manner until consensus was reached. Importance ratings were derived from each round of surveying by calculating median score responses on the 5-point Likert scale for each item. Items requiring clarification or those with a median score of below 4 (“agree”) were modified as needed prior to each subsequent round. Consensus was considered reached when 90% or more of the items had an interquartile range (IQR) of ≤ 1. This value indicates low sample deviation and is accepted as having achieved consensus. This was followed by a corroboration of face validity to derive the final set of management principles. The literature search and expert review identified an initial list of 66 items in 8 categories relevant to Pavlik harness management. Four rounds of structured surveying were required to reach consensus. Following a final round of face validity, a definitive list of 33 items in 8 categories met consensus by the experts. These items were tabulated and presented as “General Principles of Pavlik Harness Treatment for DDH” and “Pavlik Harness Treatment by Severity of Hip Dysplasia”. Furthermore, highly contentious items were identified as important future areas of study and will be discussed. We have developed a comprehensive set of principles derived by expert consensus to assist clinicians, and for use as a teaching resource, in the non-operative management of DDH using the Pavlik harness. We have gained consensus on both the general principles of Pavlik harness treatment as well as the detailed treatment of hip subtypes seen across the spectrum of pathology of DDH. Furthermore, this study has also served to generate a list of the most controversial areas in the non-operative management of DDH which should be considered high priority for future study to further refine and optimise the outcomes of children with developmental hip dysplasia

Simulated learning is increasingly prevalent in many surgical training programs as medical education moves towards competency based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated diagnosis where the standard of care in patients less than six months of age is an orthotic device such as the Pavlik Harness. However, despite widespread use of the Pavlik Harness and the potential complications that may arise from inappropriate application, no formal educational methods exist. A video and model based simulated learning module for Pavlik Harness application was developed. Two novice groups (residents and allied health professionals) were exposed to the module and at pre-intervention, post-intervention and retention testing were evaluated on their ability to apply a Pavlik Harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skill (OSATS) and a Global Rating Scale (GRS) specific to Pavlik Harness application. A control group who did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik Harness alone would affect ability. All groups were compared to a group of clinical experts who were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t-tests and ANOVA. Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik Harness (p<0.05) to the level of expert clinicians and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve nor did they achieve competency. The simulated learning module has been shown to be an effective tool for teaching the application of a Pavlik Harness and learners demonstrated retainable skills post intervention. This learning module will form the cornerstone of formal teaching for Pavlik Harness application in developmental dysplasia of the hip

There is no consensus regarding the optimum frequency of ultrasound for monitoring the response to Pavlik harness (PH) treatment in developmental dysplasia of hip (DDH). The purpose of our study was to determine if a limited-frequency hip ultrasound (USS) assessment in children undergoing PH treatment for DDH had an adverse effect on treatment outcomes when compared to traditional comprehensive ultrasound monitoring. This study was a single-center non-inferiority randomized controlled trial. Children aged less than six months of age with dislocated, dislocatable and stable dysplastic hips undergoing a standardized treatment program with a PH were randomized, once stability had been achieved, to our current standard USS monitoring protocol (every clinic visit) or to a limited-frequency ultrasound protocol (USS only until hip stability and then end of treatment). Groups were compared based on alpha angle at the end of treatment, acetabular indices (AI) and IHDI grade on follow up radiographs at one-year post harness and complication rates. The premise was that if there were no differences in these outcomes, either protocol could be deemed safe and effective. One hundred patients were recruited to the study; after exclusions, 42 patients completed the standard protocol (SP) and 36 completed the limited protocol (LP). There was no significant difference between the mean age between both groups at follow up x-ray (SP: 17.8 months; LP: 16.6 months; p=0.26). There was no difference between the groups in mean alpha angle at the end of treatment (SP: 69°; LP: 68.1°: p=0.25). There was no significant difference in the mean right AI at follow up (SP: 23.1°; LP: 22.0°; p=0.26), nor on the left (SP:23.3°; LP 22.8°; p=0.59). All hips in both groups were IHDI grade 1 at follow up. The only complication was one femoral nerve palsy in the SP group. In addition, the LP group underwent a 60% reduction in USS use once stable. We found that once dysplastic or dislocated hips were reduced and stable on USS, a limited- frequency ultrasound protocol was not associated with an inferior complication or radiographic outcome profile compared to a standardized PH treatment pathway. Our study supports reducing the frequency of ultrasound assessment during PH treatment of hip dysplasia. Minimizing the need for expensive, time-consuming and in-person health care interventions is critical to reducing health care costs, improving patient experience and assists the move to remote care. Removing the need for USS assessment at every PH check will expand care to centers where USS is not routinely available and will facilitate the establishment of virtual care clinics where clinical examination may be performed remotely

Debate currently exists regarding the economic viability for screening for developmental dysplasia of the hip in infants. A retrospective study of infant hip dysplasia over the period of 1998–2008 (36,960 live births) was performed to determine treatment complexity and associated costs of disease detection and hospital treatment, related to the age at presentation and treatment modality. 179 infants (4.8/1000) presented with hip dysplasia. 34 infants presented late (>3 months of age) and required closed or open reduction. 145 infants presented at <3 months of age, 14 of whom failed early pavlik harness treatment. A detailed cost analysis revealed:. 131 early presenters with successful management in a pavlik harness at a cost of £601/child. 34 late presenters who required surgery (36 hips, 19 closed/ 17 open reductions, 1 revision procedure) at a cost of £4352/child. 14 early presenters with failed management in a pavlik harness requiring more protracted surgery (18 hips, 4 closed/ 14 open reductions, 7 revision procedures) at a cost of £7052/ child. Late detection causes increased treatment complexity and a seven-fold increase in the short-term costs of treatment, compared to early detection and successful management in a pavlik harness. However improved strategies are needed for the 10% of early presenting infants who fail pavlik harness treatment and require the most complex and costly interventions

Introduction. The standard plane imaging of Graf and the dynamic methods of Harcke are well established methods in assessing hip dysplasia but give limited information in the flexed-abducted treatment position used in the Pavlik harness. The femoral head may sit on the edge of the acetabulum in a flexed position and only reduce when the hips are abducted. This may mean that hips, which reduce when abducted in the Pavlik harness, appear subluxed when scanned in neutral abduction. Harness treatment may thereby be abandoned prematurely due to the failure to confirm reduction. This study identifies ultrasound landmarks on an anterior hip scan which could be used to confirm reduction of the hip in Pavlik Harness. Materials and method. Hips of a newborn piglet were scanned, imaged with magnetic resonance and x-rayed both before and after anatomical dissection. Radiographic markers delineated the position of the tri-radiate cartilage and potential ultrasound landmarks identified to help confirm hip reduction in the flexed-abducted position. Porcine imaging was then compared with that of a human newborn. Results. The porcine model corresponded well to human imaging and we were able to establish a landmark, the ‘Ischial Limb’, which corresponds to the ossification front delineating the posterior ischial edge of the tri-radiate cartilage. This could clearly be seen on anterior hip ultrasound of both the porcine and human hip. This landmark can be used to confirm the hip is reduced by reference to the centre of the femoral head. Discussion and conclusion. We would recommend anterior hip scanning using the ‘Ischial Limb’ as a reference point to confirm hip reduction in Pavlik harness. This simple method is a useful adjunct to conventional ultrasound scanning in the harness treatment of hip instability

Aims. Use of videos for patient education has grown in popularity. Literature promotes the use of videos to provide clearer information to patients and families. Information to patients are often provided via leaflets. In our regional (Cwm Taf Morgannwg University Health board- CTM UHB) one stop clinic, we aimed to pilot the use of an educational video on developmental dysplasia of the hip (DDH) for parents and guardians and assess its usefulness. Methods. Parents and guardians of children being treated for DDH with Pavlick harness were invited to the partake in the pilot scheme. A short video provided by the ‘What? Why? Children in Hospital’ (WWCIH) organisation was shown on a tablet to parents and guardians. A ten question questionnaire was then provided post watching the video. The questionnaire consisted of short answer, multiple choice, and rating scale (1-10) questions. Results. 23 parents/guardians participated. All participants stated the video was of the right duration. Participants of all stages in the Pavlik harness journey found the videos helpful. All participants responded that they would recommend the video to other parents and guardians. 52%(n=12) suggested that the video would be most useful to watch after DDH is diagnosed but before starting treatment. Participants also provided feedback on how to improve the videos such as inclusion of detailed explanations about the harness. Conclusion. The use of an educational video for parents/guardians with children diagnosed with DDH is beneficial, with all participants finding it useful. Other centres could adopt the use of educational videos for newly diagnosed DDH children's families, prior to starting treatment with the Pavlick harness

The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. Variability exists in the duration of brace treatment after successful reduction of the dislocated hip. In this study we evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database. We retrospectively studied prospectively enrolled infants with at least one dislocated hip that were initially treated with a PH and had a recorded AI at two-year follow-up. Subjects were treated at one of two institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured 12-week brace treatment protocol. Hip dislocation was defined as less than 30% femoral head coverage at rest on the pre-treatment ultrasound or IHDI grade III or IV on the pre-treatment radiograph. Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace 3x longer than hips from institution 2 (adjusted mean 8.9±1.3 months vs 2.6±0.2 months)(p < 0 .001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (p=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9˚) compared to Institution 2 (adjusted mean 23.5±0.8˚) (p=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age- and sex- matched AI normal data (p=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia, compared to a 22% (6/27) from Institution 2 (p=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (p=0.071). Our findings suggest that prolonged brace treatment does not result in improved acetabular index at age two years. Hips treated at Institution 1 had the same AI at age two years as hips treated at Institution 2, while spending about 1/3 the amount of time in a brace. We recommend close follow-up for all children treated for dislocated hips, as ~1/4 of infants had acetabular index measurements at or above the 90th percentile of normal. Continued follow-up of this prospective cohort will be critical to determine how many children require acetabular procedures during childhood. The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at two-year follow-up

The purposes of this study were to investigate whether twins and multiple births have a higher incidence of Developmental Dysplasia of the Hip (DDH), and whether universal ultrasound scanning would be beneficial in this population. Methods. Records of all twin and multiple births between 1st January 2004 and 31st December 2008 at Addenbrooke's Hospital were obtained. Information regarding sex, gestation, birth weight, DDH risk factors, results of the neonatal hip examination and of any ultrasound scans were analysed. The incidence of DDH in singletons born during the same period was calculated from birth records and the DDH database. Results. Of the 990 twin and multiple births, 267 had ultrasound scans. Of those scanned, over 92% had a normal (bilateral Graf I) scan initially. Within the study cohort there was one case of DDH diagnosed on ultrasound and successfully treated with Pavlik harness. There were two cases of late presenting DDH, one at 8 months and one at 14 months old. Both had no risk factors, a normal neonatal examination and consequently had not had an ultrasound scan. Conclusion. In our study, twins did not have a significantly higher incidence of DDH compared to singletons. However, ultrasound screening of twins would have detected the two late presenting cases of DDH earlier. It remains to be seen whether universal scanning would be cost-effective

Ultrasound (US) is the standard imaging modality used to screen for developmental dysplasia of the hip in infants. Currently, radiologists or orthopaedic surgeons review scan images and judge them to be adequate or inadequate for interpretation. If considered adequate, diagnostic dysplasia metrics are determined; however, there is no standardised method for this process. There is significant inter-observer variability in this manual process which can affect misdiagnosis rates. To eliminate this subjectivity, we developed an automatic method to identify adequate US images and extract dysplasia metrics. The purpose of this study was to validate the efficacy of this automatic method by comparing results with observer-determined dysplasia metrics on a set of US images. A total of 693 US images from scans of 35 infants were analysed. Trained clinicians at a single institution labeled each image as adequate or inadequate, and subsequently measured alpha and beta angles on adequate images to diagnose dysplasia. We trained our image classifier on random sets of 415 images and used it to assess the remaining 278 images. Alpha and beta angles were automatically estimated on all adequate images. We compared the manual and automatic methods for discrepancies in adequacy determination, metric variability and incidences of missed early diagnosis or over-treatment. There was excellent agreement between the automatic and manual methods in image adequacy classification (Kappa coefficient = 0.912). On each adequate US image, alpha and beta angle measurements were compared, producing mixed levels of agreement between methods. Mean discrepancies of 1.78°±4.72° and 8.91°±6.437° were seen for alpha and beta angles, respectively. Standard deviations of the angle measures across multiple images from a single patient scan were significantly reduced by the automatic method for both alpha (p<0.05) and beta (p<0.01) angles. Additionally, the automatic method classified three hips (two patients) as Graf type II and two hips (two patients) as type III, while the manual method classified them as type I and II, respectively. Both cases flagged as type III patients by the automatic system subsequently failed Pavlik harness treatment and were booked for surgery. The automatic method produced excellent agreement with radiologists in scan adequacy classification and significantly reduced measurement variability. Good agreement between methods was found in Graf classification. In instances of disagreement, subsequent clinical findings seemed to support the classification of the automatic method. This proposed method presents an alternative automatic, near-real-time analysis for US images that may potentially significantly improve dysplasia metric reliability and reduce missed early diagnoses without increasing over-treatment