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Ultrasound Evaluation of Pavlik Harness in
Treatment of Infants with Developmental
Dysplasia of the Hip: Prone Axial Approach to
Harness in Situ
C Fernández, MD; M Guasp, MD; J Gómez Fernández-Montes, MD
Department of Radiology , Pediatric Imaging Section
Hospital Universitario y Politécnico la Fe, Valencia, Spain
Purpose
• To describe a practical guideline for the
performance of the ultrasound (US) in prone
position for the control of Pavlik Harness (PH)
in monitoring the treatment of developmental
dysplasia of the hip (DDH) .
Introduction
• In DDH, the epiphysis is displaced posteriorly in relation to
the acetabulum.
• The PH is the first-choice non-invasive treatment of infants
with DDH, keeping the epiphysis within the acetabulum,
allowing some movement and a good perfusion, to avoid
the avascular necrosis of femoral head.
• Over the past five years, we have used US in prone
position to monitor the treatment when PH is in place to
define intraarticular position of the femoral head.
Pavlik Harness
The PH is a reduction harness which keeps the hips in a fetal position
(flexion, abduction and external rotation) in order to get the relaxation of
psoas and to reduce progressively the posterior dislocated femoral head.
It is a chest halter with two
straps around the shoulders
and four straps for the legs.
Once put the harness, should not be remove, even during US..
Technique
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Equipment specification
Cautions
Position of the patient
Imaging of the Hip
Clinical cases
Follow-up
Equipment specification
• For newborns and infants up to 6 months old,
it is recommended a real-time linear array
transducer from 4 to 9 MHz.
Cautions
• During the scanning, the infant should be
relaxed.
• A quiet environment and a parent in contact
with the infant are helpful.
• The upper body can remain clothed.
• A well-fed infant, having been fed just prior to
the examination, might also be more relaxed
and cooperative.
Position of the Patient
The examination must be performed with
the infant in the harness and prone
position.
This position favors the intraarticular
situation of the femoral head, so that if we
see the epiphysis backwards displaced in
this position, it will be the same in any
other position.
This photo illustrates the position of the
transducer in order to obtain the axial
view.
Imaging of the hip
Only the axial plane with respect to the pelvis is obtained .For teaching
purposes, transverse images are similar to axial cross-sectional imaging.
I
T
E
P
I
T
P E
SS
P
T : Greater Trochanter, E : Epiphysis, I : Ischium, P : Pubis, SS: Sonic shadow
Prone Picture View:
normal and pathologic findings
In the normal hip, we can see all
the acetabulum from ischium to
pubis, with the epiphysis centered
on it .
In the posterior dislocation, the
epiphysis will be uncovered and
closer to transducer than the ischium.
Transverse View:
anatomy and ultrasound correlation
SS
P
The posterior margin of the acetabulum (ischium) should be closer to the
transducer than the not-ossified femoral epiphisis and should cover it.
Transverse View:
normal and pathologic ultrasound findings
We must compare the healthy side (left) with pathological one (right), moving the
transducer from one buttock to the other, what allows us to see clearly the differences.
P
LEFT
In the normal hip, we can see all the
acetabulum, from the ischium (red arrow) to
the pubis, with the epiphysis (white arrow)
centered on it .
RIGHT
In posterior dislocation, the epiphysis will be closer
to the transducer that the ischium and uncovered.
The trochanter compresses the soft tissues of the
buttock.
Transverse View:
Bilateral pathologic ultrasound findings
RIGHT
LEFT
In cases of bilateral DDH, the comparison is even more necessary, because sometimes
one hip is reduced and the other is not. US in prone position shows a patient with PH
placed and both dislocated hips (the femoral epiphysis are displaced posteriorly respect
to the ischiums).
Case 1: Example of response to the
treatment
RIGHT
17/11/08
LEFT
The ultrasound by posterior approach with Pavlik harness placed shows both
hips centered and covered. These findings were confirmed in the following
ultrasound control.
Case 1
10/02/09
X-ray three months later, shows a good
development of the left acetabulum, with the
epiphysis covered but smaller than the right
one.
12/02/10
X-ray obtained 1 year later, shows the
effectiveness of the treatment with both
normal hips.
Case 2: Example of failure to the
treatment
T
T
I
E
E
I
RIGHT
LEFT
The US control of a patient with harness at second and third week of
treatment shows that the left hip remains dislocated, requiring the removal of
the harness and a surgical procedure.
Case 2
Postoperative X-Ray which assesses the orientation of the operated hip with a plaster
placed (if there is any doubt, we must do a low dose CT). Currently, we are testing the
ultrasound in prone position through the hip spica cast to evaluate the situation of the
intraarticular operated hip using a technique similar to the described for the harness, in
order to avoid radiation by X-ray or CT.
Follow-up
PAVLIK HARNES
First control
US at 1-2 weeks
Response to treatment
Failure to treatment
2nd US at 1 month
PH adjustment
Remain with PH for 1
month
3nd US after removing PH
First X-ray at 4 months old
2nd X-ray at walking age
2nd US 1 week later
Persistent dislocation
Early surgery to prevent
the erosion of the labrum
and an avascular necrosis
(“Pavlik disease”)
Conclusion
In DDH, the ultrasound evaluation of
Pavlik harness in situ by prone axial
approach is a simple, safe and
reproducible technique to monitor the
intra-articular situation and the acetabular
coverage of the femoral epiphysis.
References
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Ladino Torres M, DiPietro M. Developmental Dysplasia of the Hip. Ultrasound Clin 2009; 4:445–455.
ACR–AIUM Practice guideline for the performance of the ultrasound examination for detection and
assessment of developmental dysplasia of the hip. Revised 2008
Atalar H, Sayli U, Yavuz Y, Uraş I, Dogruel H. Indicators of successful use of the Pavlik harness in
infants with developmental dysplasia of the hip. International Orthopaedics (SICOT) 2007; 31: 145–150.
Taylor G, Clarke N. Monitoring the treatment of developmental dysplasia of the hip with the pavlik
harness. The journal of bone and joint surgery 1997; vol. 79-b, No. 5.
Kelly D. Carmichael, MD; Anthony Longo, MD; David Yngve, MD; Jose Alberto Hernandez, MD;
Leonard Swischuk, MD. The Use of Ultrasound to Determine Timing of Pavlik Harness
Discontinuation in Treatment of Developmental Dysplasia of the Hip Orthopedics October 2008; Volume
31: Issue 10
Lerman JA, Emans JB, Millis MB, Share J, Zurakowski D, Kasser JR.Earlyfailure of Pavlik harness
treatment for developmental hip dysplasia: clinical and ultrasound predictors. J Pediatr Orthop 2001 ;
21(3):348-353.
Carmichael K, Longo A, Yngve D, Hernandez J, Swischuk L. The Use of Ultrasound to Determine
Timing of Pavlik Harness Discontinuation in Treatment of Developmental Dysplasia of the Hip.
Orthopedics. October 2008 ;Vol31: Issue 10.