Pitfalls in the Use of the Pavlik
Harness for Treatment of Congenital
Dysplasia, Subluxation, and
Dislocation of the Hip
Scott Mubarak, M.D.
Steven Garfin, M.D.
Raymond Vance, M.D.
Bert McKinnon, M.D.
David Sutherland, M.D.
(Reprinted
from J o u r n a l of Bone and Joint Survery Vol. 63-A, No. 8, pp. 1239-1248,
October
1981.) Copyrighted
1981 by the Journal of Bone and Joint Surgery, Inc. Printed in U.S.A.
Abstract: W e reviewed the records of
treatment of eighteen infants with con­
genital dysplasia, subluxation, o r disloca­
tion of the hip w h o h a d problems with the
involved hip following treatment with the
Pavlik harness. The most c o m m o n prob­
l e m ( s e e n in t w e l v e p a t i e n t s w i t h a dislo­
c a t e d h i p ) w a s failure t o o b t a i n r e d u c t i o n .
This failure w a s attributed primarily to
improper use of the harness by the physi­
c i a n . I n s o m e p a t i e n t s , t h r e e to five m o n t h s
elapsed before the physician recognized
the lack of reduction. In nine patients, a
Pavlik harness of poor quality and con­
struction added to both the physician's and
t h e p a t i e n t ' s p r o b l e m s , a n d in six p a t i e n t s ,
p o o r p a t i e n t c o m p l i a n c e w i t h t h e u s e o f the
h a r n e s s w a s p a r t i a l l y r e s p o n s i b l e for t h e
f a i l u r e . I n t h r e e p a t i e n t s w h o w e r e ini­
tially t r e a t e d in t h e P a v l i k h a r n e s s , a v a s ­
cular necrosis of the hip subsequently de­
v e l o p e d , in t w o f o l l o w i n g o p e n r e d u c t i o n
a n d in o n e after c l o s e d r e d u c t i o n a n d c a s t
application.
T h e p h y s i c i a n ' s i n d i c a t i o n s for u s e a n d
application of the harness must be appro­
p r i a t e . T h e c h i l d m u s t b e e x a m i n e d fre­
q u e n t l y o u t o f t h e h a r n e s s b o t h clinically
a n d r o e n t g e n o g r a p h i c a l l y . F a i l u r e to
achieve reduction or adductor relaxation
m u s t b e r e c o g n i z e d p r o m p t l y a n d dealt
with immediately.
In t h e t w e n t y - f o u r y e a r s s i n c e Pavlik first
r e p o r t e d its u s e in 1,912 p a t i e n t s , t h e P a v ­
lik h a r n e s s h a s b e e n u s e d w i d e l y a s an
o r t h o t i c d e v i c e for t h e m a n a g e m e n t o f c o n ­
genital dislocation of t h e h i p .
W h e n appropriately applied, the har­
ness prevents adduction a n d extension of
t h e hip w h i l e a l l o w i n g f u r t h e r flexion, a b ­
d u c t i o n , a n d r o t a t i o n . This p o s i t i o n a n d
m o t i o n a r e d e s i g n e d to aid t h e gentle,
s p o n t a n e o u s r e d u c t i o n o f t h e dislocated
h i p a n d a c e t a b u l a r d e v e l o p m e n t of t h e
d y s p l a s t i c h i p , . T h e p u r p o s e o f this
s t u d y w a s to r e v i e w t h e u s e of t h e Pavlik
h a r n e s s b y p h y s i c i a n s in o u r c o m m u n i t y
2
4,6
a n d to i d e n t i f y t h e c o m p l i c a t i o n s a n d p i t ­
falls e n c o u n t e r e d i n i t s u s e .
clinics, and hospitals w h o either supplied
or c o n s t r u c t e d t h e i r o w n P a v l i k h a r n e s s e s
for d i s t r i b u t i o n to p a t i e n t s .
MATERIAL AND METHODS
T h e records and roentgenograms of 110
patients were reviewed. Eighteen patients
with congenital dysplasia, subluxation, or
dislocation of the hip in w h o m problems
d e v e l o p e d r e l a t e d to t h e P a v l i k h a r n e s s a n d
its proper use were identified. T h e s e pa­
tients were divided into two groups based
o n t h e i r a g e s at t h e t i m e o f d i a g n o s i s . In
Group I the diagnosis was made in the
newborn period. T h e problem hip was
classified as dislocatable or dislocated
b a s e d on the treating orthopaedist's clini­
cal e x a m i n a t i o n o f t h e p a t i e n t . I n G r o u p II
T h i s r e v i e w is a r e p o r t o f t h e e x p e r i e n c e
of t h e o r t h o p a e d i c s u r g e o n s at t h e U n i v e r ­
s i t y o f C a l i f o r n i a at S a n D i e g o affiliated
hospitals in the use o f the Pavlik harness in
treating congenital dislocation o f the hip.
T h e n a m e s o f t h e p a t i e n t s to w h o m P a v ­
lik h a r n e s s e s h a d b e e n prescribed during
t h e p e r i o d o f 1975 t h r o u g h 1979 w e r e o b ­
tained from t h e orthotic agencies in t h e
San D i e g o area. Additionally n a m e s also
were o b t a i n e d from o r t h o p a e d i c surgeons,
TABLE I
Group-I Patients
t h e d i a g n o s i s w a s m a d e after t h e a g e o f o n e
m o n t h ( r a n g e , o n e to t e n m o n t h s ) . T h e s e
p r o b l e m h i p s w e r e c l a s s i f i e d as h a v i n g
acetabular dysplasia, subluxation, or dis­
location, depending on the appearance o f
the patient's initial roentgenograms.
T h e major p r o b l e m s that h a v e b e e n re­
ported to occur w i t h the use of this device
for t h e t r e a t m e n t o f c o n g e n i t a l d i s l o c a t i o n
o f t h e h i p a r e failure to a c h i e v e a c o n c e n t r i c
reduction a n d avascular n e c r o s i s , . O t h e r
problems that w e encountered were de­
l a y e d a c e t a b u l a r d e v e l o p m e n t , f a i l u r e to
stretch the h i p adductors, femoral-nerve
palsy, and inferior dislocation. T h e reasons
for t h e s e p r o b l e m s w e r e d e t e r m i n e d a n d
classified as b e i n g d u e to:
1. T h e p h y s i c i a n — T h e p h y s i c i a n ' s i n ­
d i c a t i o n s for t h e u s e o r a p p l i c a t i o n o f t h e
h a r n e s s w e r e i n a p p r o p r i a t e . In s o m e c a s e s
the Pavlik harness used w a s of poorquality design and allowed inadequate
control of hip position.
2 . T h e p a r e n t s — T h e p a r e n t s f a i l e d to
h a v e t h e c h i l d w e a r t h e h a r n e s s o r u s e it
properly.
3. I d i o p a t h i c — N o p h y s i c i a n o r p a r e n t a l
fault w a s e v i d e n t , a n d o t h e r r e a s o n s c o u l d
not b e identified.
3
5,79
RESULTS
E i g h t e e n p a t i e n t s w e r e i d e n t i f i e d as
h a v i n g failures o f treatment following use
of the Pavlik harness.
Group I
In G r o u p I t h e r e w e r e n i n e p a t i e n t s w h o
w e r e diagnosed as having dislocatable or
d i s l o c a t e d h i p s at b i r t h ( T a b l e I ) . I n n o i n ­
stance did the treating orthopaedist's ini­
tial r e c o r d e d e x a m i n a t i o n i n d i c a t e w h e t h e r
a dislocated h i p was reducible or not. T w o
of the n i n e patients had bilateral dislocated
hips, a n d o n e had bilateral dislocatable
hips. Following application of the harness,
r o e n t g e n o g r a m s w e r e m a d e for e i g h t o f t h e
n i n e patients. Failure to achieve concentric
reduction with the harness was the major
p r o b l e m i n all n i n e p a t i e n t s . O n e p a t i e n t
( C a s e 1) a l s o h a d a t r a n s i e n t f e m o r a l - n e r v e
palsy.
In s i x o f t h e s e p a t i e n t s , t h e a m o u n t o f h i p
flexion o b t a i n e d in the harness as deter­
mined on the roentgenogram never was
sufficient t o direct t h e f e m o r a l h e a d to­
ward the triradiate cartilage. In five pa­
tients a Pavlik harness of poor-quality con­
structed was used, which allowed adduc­
tion and internal rotation o f the hip.
F u t h e r m o r e , i n all n i n e p a t i e n t s t h r e e to
five m o n t h s p a s s e d b e f o r e t h e p h y s i c i a n
recognized that the h i p w a s not reduced.
All o f t h e s e n i n e p a t i e n t s s u b s e q u e n t l y r e ­
quired traction, general anesthesia, reduc­
tion, a n d a spica cast. S i x of the n i n e pa­
t i e n t s e v e n t u a l l y r e q u i r e d an o p e n r e d u c ­
t i o n . In t h r e e p a t i e n t s a v a s c u l a r n e c r o s i s
subsequently developed, following open
r e d u c t i o n i n t w o a n d after c l o s e d r e d u c ­
tion in o n e .
Group II
I n G r o u p I I , failure t o o b t a i n r e d u c t i o n
w a s t h e p r o b l e m i n four o f n i n e p a t i e n t s for
r e a s o n s similar to t h o s e in G r o u p I
( T a b l e I I ) . I n C a s e 17, a t e n - m o n t h - o l d
boy, attempted reduction of bilateral dis­
l o c a t i o n failed. T h i s p a t i e n t d i d n o t o b t a i n
adequate hip flexion in the harness and
w a s at t h e u p p e r l i m i t o f t h e a g e r e c o m ­
m e n d e d for u s e o f t h e h a r n e s s . F u r t h e r ­
m o r e , t h e s i x - w e e k trial o f s p o n t a n e o u s r e ­
duction in the harness w a s too long. In
Case 16, the proper degree of hip flexion
first a c h i e v e d r e d u c t i o n , b u t e x c e s s i v e
flexion t h e n p r o d u c e d a n i n f e r i o r ( o b ­
t u r a t o r ) d i s l o c a t i o n . In t h r e e o t h e r p a t i e n t s
the hip adductors remained contracted.
O n e o f t h e s e patients (Case 14) w a s in a
poor-quality harness which allowed hip
adduction. T h e other two were in a well
m a d e harness that was properly posi­
t i o n e d , a n d n o s p e c i f i c r e a s o n for t h e t i g h t
hip adductors was found. There were no
patients with avascular necrosis in Group
II.
4
Other
Five other patients with instability or
dislocation of the hip w h o had problems
with the Pavlik harness were encountered.
TABLE I I
Group-II Patients
T h e y were not included in this review b e ­
cause of their diagnoses: myelodysplasia
(two), Ehler-Danlos Syndrome (one),
teratogenesis (one), and sepsis (one).
DISCUSSION
T h e construction, application, and use of
the Pavlik h a r n e s s is g u i d e d b y a few sim­
ple p r i n c i p l e s a n d p r a c t i c a l t e c h n i q u e s
( F i g s . 1-A t h r o u g h 1 - D ) . W i t h c o m m e r c i a l
production o f the Pavlik harness, some o f
the principles of construction have b e e n
violated, w h i c h in s o m e cases has resulted
in an i n a d e q u a t e h a r n e s s . A few important
points in harness construction must b e
noted. First, the shoulder straps on the
h a l t e r ( c h e s t - s t r a p ) s h o u l d cross i n t h e b a c k
to p r e v e n t t h e m from s l i d i n g o v e r a n d
d o w n the child's shoulders. S e c o n d , the
b u c k l e s for t h e a n t e r i o r (flexor) s t i r r u p s t r a p s s h o u l d b e l o c a t e d at t h e c h i l d ' s a n ­
t e r i o r a x i l l a r y l i n e . I f t h e y are p l a c e d too far
medially, tightening the anterior stirrups t r a p w i l l c a u s e n o t o n l y f l e x i o n b u t also
a d d u c t i o n o f t h e h i p . T h i r d , t h e b u c k l e s for
the posterior (abduction) stirrup-straps
should b e located over the scapula. Fourth,
t h e V e l c r o s t r a p for t h e p r o x i m a l p a r t o f t h e
Fig. 1-A: Step A. The chest halter is positioned at the
nipple line and fastened with the Velcro® closure.
The crossed shoulder straps then stablilize the halter
at this position.
Fig. 1-B: Step B. The leg and foot are set back into the
stirrups and fastened with the Velcro® straps. Care
must be taken to ensure that the flexor and abduc­
tion straps are oriented anteriorly and posteriorly
with respect to the child's knee.
Fig. 1-C: Step C. The anterior (flexor) stirrup-straps
are connected to the halter. The straps are adjusted so
that hip flexion is between 100 and 110 degrees to
achieve optimum position of the femoral head rela­
tive to the acetabulum. Occasionally, more flexion
will be necessary initially to achieve reduction. It is
important that the insertion of the anterior stirrupstraps on the halter be at the child's anterior axillary
line.
Fig. l-D: Step D. Lastly, posterior (abduction)
stirrup-straps are attached to the halter. The insertion
point of these straps on the halter should be located
over the child's scapula. The posterior stirrup-straps
should be adjusted so that there is approximately five
to eight centimeters between the knees when both
hips are abducted and the hips have free abduction.
Figs. 1-A through l-D:
Application of the Pavlik Harness
Fig. 2-A. If the Velcro® straps are too far distal, the
anterior and posterior stirrup-straps will bowstring
behind the knee axis. Further tightening of these
straps will cause increased knee flexion and rela­
tively poor control of hip position. Abduction and
internal rotation of the hip is possible.
Fig. 2-B. With a properly positioned proximal Vel­
cro® strap just distal to the popliteal fossa, there is
better control of hip flexion and abduction and less
flextion of the knee.
leg should b e located just b e l o w the child's
popliteal fossa (Figs. 2 - A and 2 - B ) . T h i s
strap stabilizes and controls the k n e e and
prevents bowstringing o f the anterior and
posterior stirrup-straps. With bowstring­
ing o f the stirrup-straps, internal rotation
a n d a d d u c t i o n o f t h e h i p c a n o c c u r as t h e
p o s t e r i o r s t i r r u p - s t r a p is t i g h t e n e d (Fig. 3 ) .
T h e P a v l i k h a r n e s s is i n d i c a t e d i n the
treatment of hip dysplasia or subluxation
i n c h i l d r e n from b i r t h t o a b o u t t h e a g e o f
ten m o n t h s . A s t h e c h i l d a p p r o a c h e s t h e
a g e o f o n e y e a r , i t u s u a l l y b e c o m e s too dif­
ficult to h o l d t h e p a t i e n t in t h e h a r n e s s , a n d
a more conventional fixed-position brace
will b e necessary.
T h e h a r n e s s m a y b e u s e d to reduce a c o n ­
genital dislocation o f the h i p in a child w h o
is less than eight m o n t h s old if the criteria
o f R a m s e y et al. a r e m e t . T h e y n o t e d t h a t
adequate h i p flexion m u s t b e o b t a i n a b l e so
that the femoral head is directed toward
t h e triradiate c a r t i l a g e , a n d m a d e a r o ­
e n t g e n o g r a m o f t h e h i p s i n flexion p r i o r t o
application of the harness. T h e harness is
not indicated in patients in w h o m the
d i s l o c a t e d h i p is n o t c e n t e r e d t o w a r d t h e
acetabulum in flexion or in infants w h o
are m o r e t h a n e i g h t m o n t h s o l d w i t h a
congenital dislocation of the hip. We have
f o u n d it m o r e p r a c t i c a l t o a p p l y t h e h a r ­
ness on the child and then make the
r o e n t g e n o g r a m . In d i s o r d e r s s u c h a s m y ­
e l o d y s p l a s i a ( s e c o n d t o fourth
lumbar
functional level), teratogenic dislocation,
and arthrogryposis, either muscle imbal­
ance or stiffness, or b o t h , m a k e s applica­
tion of the harness nearly impossible.
F u r t h e r m o r e , i t a l s o u s u a l l y is i n a p p r o ­
p r i a t e for u s e i n i n f a n t s w i t h c o n n e c t i v e tissue disorders or as a m e a n s of posi­
t i o n i n g a s e p t i c h i p after d r a i n a g e . T h e
generalized capsular laxity found in these
conditions m a y cause inferior dislocation
of the hip.
Fig. 3. This infant is wearing a commercially avail­
able Pavlik harness. Note that the insertion points of
the anterior (flexor) stirrup-straps are placed me­
dially. Further tightening of these straps will cause
not only flexion, but also abduction, of the hips. Also
note that the Velcro® leg straps are located too far
distally. There is bowstringing of both the anterior
and the posterior stirrup-straps behind the knee.
There is poor knee and hip control for this reason.
To achieve spontaneous reduction o f a
congenital dislocation of the hip in an in­
fant w h o i s l e s s t h a n e i g h t m o n t h s o l d , t h e
harness is applied and a roentgenogram
w i t h t h e c h i l d i n t h e h a r n e s s is m a d e to
confirm a d e q u a t e flexion (Fig. 4 ) . T h e h a r ­
n e s s is w o r n c o n s t a n t l y u n t i l h i p s t a b i l i t y is
a c h i e v e d . T h e p a t i e n t is e x a m i n e d c l i n i ­
c a l l y , o u t o f t h e h a r n e s s , at w e e k l y i n t e r ­
v a l s . B y t w o o r t h r e e w e e k s after h a r n e s s
application, both clinical and roentgeno-
Fig. 4. Plan of use of the Pavlik harness in the treatment of congenital dislocation of the hip in an infant less than
eight months old.
Fig. 5-A. This child was diagnosed at birth as having bilateral dislocated hips. This
roentgenogram, made at the age of three months in the Pavlik harness, demonstrates as­
symetry of the distance from the femoral metaphysis to the triradiate cartilage. The left hip is
abnormal and the Pavlik harness is maintaining the hip dislocated, posterior to the
acetabulum. Note that the acetabular margins look quite good because of the outlet-type view
of the pelvis when roentgenograms are made with the child in the Pavlik harness. The
obturator foramen is visualized poorly and the sciatic notch is well demarcated.
Fig. 5-B. Because of the clinical examination and the ambiguous roentgenogram shown in Fig.
5-A, a second roentgenogram was made with the child out of the harness with the femora in 45
degrees of abduction. This clearly demonstrates the dislocation of the left hip and more
accurately demonstrates a true view of the pelvis, showing the acetabular dysplasia which is
greater on the left than on the right. This child subsequently underwent a period of skin
traction and required an open reduction of the left hip at the age of three months. Subse­
quently, avascular necrosis developed in the left capital femoral epiphysis.
graphic examination must confirm reduc­
t i o n o f t h e h i p . If t h e h i p is n o t r e d u c e d
d u r i n g t h e t h r e e - w e e k trial o f h a r n e s s u s e ,
t h e m o r e c o n v e n t i o n a l a p p r o a c h o f trac­
tion, general anesthesia, closed reduction,
arthrography, and a spica cast should b e
instituted Fig. 4 ) . As roentgenograms
m a d e w i t h t h e c h i l d i n t h e h a r n e s s are dif­
ficult t o i n t e r p r e t , w e p r e f e r t o m a k e a
4 5 - d e g r e e a b d u c t i o n (frog-leg lateral) ro­
entgenogram of the h i p s out of the har­
n e s s to c o n f i r m t h e i r p o s i t i o n at t h e
three-week visit. Furthermore, evaluation
o f a c e t a b u l a r d e v e l o p m e n t is e a s i e r w h e n
r o e n t g e n o g r a m s are m a d e w i t h t h e c h i l d
out of the harness. A roentgenogram in the
h a r n e s s p r o d u c e s a n outlet v i e w o f t h e p e l ­
vis because of the loss of lumbar lordosis
a n d pelvic tilt (Figs. 5 - A a n d 5 - B ) . I f t h e
t r e a t i n g p h y s i c i a n i s still i n d o u b t as to t h e
hip's position, arthrography under general
a n e s t h e s i a s h o u l d b e p e r f o r m e d to c o n f i r m
a c o n c e n t r i c reduction (Fig. 4 ) . If the fem­
oral h e a d is i n t h e a c e t a b u l u m , t h e pa­
t i e n t i s f o l l o w e d at t w o t o f o u r - w e e k i n t e r ­
vals u n t i l t h e c l i n i c a l a n d r o e n t g e n o g r a p h i c
e x a m i n a t i o n s are n o r m a l . A g a i n , t h e s e
should b e performed with the patient out
of the harness. Generally, w e have w e a n e d
a c h i l d f r o m t h e h a r n e s s a c c o r d i n g to t h e
p l a n o f R a m s e y et at.
T h e two major problems previously re­
ported with the use of the Pavlik harness
a r e failure to o b t a i n r e d u c t i o n o f t h e d i s l o ­
cated hip and vascular necrosis o f the cap­
ital f e m o r a l e p i p h y s i s . F a i l u r e to o b t a i n
spontaneous reduction of the congenitally
dislocated hip with the harness has occur­
r e d i n 19 p e r c e n t o f p r e v i o u s l y r e p o r t e d
cases - . Pavlik reported a failure in reduc­
t i o n of 16 p e r c e n t , w h i l e o t h e r s h a v e r e ­
ported a range of 2 to 92 per cent - . In the
treatment of subluxation and acetabular
dysplasia, however, g o o d results have
been reported in 98 per cent of the pub­
lished series - .
T h e m o s t c o m m o n p r o b l e m w a s t h e fail­
u r e to m a i n t a i n r e d u c t i o n o r to a c h i e v e
spontaneous reduction of a dislocated hip.
T h e treating orthopaedist did not observe
t h e p r o p e r i n d i c a t i o n s for t h e u s e o f t h e
Pavlik h a r n e s s , and either applied the har­
1
7
1
2,4
6
7
ness improperly or used a harness of poor
quality construction, or both. T h e most
c o m m o n e r r o r w a s a failure t o o b t a i n
e n o u g h h i p flexion in the h a r n e s s to
achieve reduction (Tables I and II).
Moreover, in most cases the orthopaedist
failed to r e c o g n i z e t h e l a c k o f r e d u c t i o n for
a n a v e r a g e o f t h r e e a n d a h a l f m o n t h s after
application of the harness. This delay,
m o r e t h a n a n y o t h e r factor, p r o b a b l y a c ­
c o u n t e d for t h e n e c e s s i t y o f o p e n r e d u c t i o n
in six of the patients in this series and may
b e a contributing factor in t h e cases o f av­
ascular n e c r o s i s (Figs. 5 - A a n d 5 - B ) .
A s noted in the literature, the incidence
of avascular necrosis w a s higher w h e n the
h a r n e s s w a s u s e d t o treat c o n g e n i t a l d i s l o ­
cation of the hip rather than subluxation or
acetabular dysplasia
. Pavlik, in treating
6 3 2 d i s l o c a t e d h i p s , r e p o r t e d an i n c i d e n c e
of avascular necrosis of 2.8 per cent, al­
t h o u g h it o n l y o c c u r e d i n h i p s r e q u i r i n g
m a n u a l r e d u c t i o n after failure o f s p o n t a n e ­
ous reduction in the harness. Tonnis re­
p o r t e d a 15 p e r c e n t r a t e o f a v a s c u l a r n e ­
crosis in a multicenter study o f 4 , 0 4 6 h i p s .
Others have reported rates of 4 p e r cent , 5
per cent , and 9 per cent . More recently,
K a l a m c h i et al. h a v e r e p o r t e d n o i n c i d e n c e
of avascular necrosis with use of the har­
n e s s in the treatment o f seventy-seven
dislocated hips, 141 subluxated hips, and
105 h i p s w i t h acetabular dysplasia.
In this series there w e r e three patients
w i t h avascular necrosis (Table I ) . In t h e s e
p a t i e n t s t h e failure o f s p o n t a n e o u s r e d u c ­
tion in the harness necessitated traction,
c l o s e d r e d u c t i o n ( o n e p a t i e n t ) o r o p e n re­
duction (two patients), and spica-cast ap­
p l i c a t i o n . A l t h o u g h it i s difficult t o i n ­
c r i m i n a t e a n y specific procedure, it s e e m s
likely that t h e avascular necrosis resulted
from surgical intervention or the cast rather
t h a n t h e h a r n e s s . H o w e v e r , as n o t e d i n t h e
European literature , overly vigorous
tightening o f the a b d u c t i o n strap m a y re­
sult i n a v a s c u l a r n e c r o s i s .
Although sufficient h i p flexion in the
harness to direct the femoral h e a d toward
t h e t r i r a d i a t e c a r t i l a g e i s n e c e s s a r y to
achieve spontaneous reduction, excessive
flexion m a y produce p r o b l e m s . In C a s e 16,
5 , 8 , 9
9
3
7
1 0
8,9
first t h e p r o p e r h i p f l e x i o n a c h i e v e d r e ­
duction a n d then excessive flexion pro­
duced an inferior (obturator) dislocation.
Another problem noted with overly vigor­
ous h i p flexion w a s a transient femoralnerve palsy (Case 1). T h i s complication has
b e e n reported b y o t h e r s . H i p flexion o f
more than 120 degrees should b e main­
t a i n e d o n l y for t h e t w o t o t h r e e - w e e k trial
o f s p o n t a n e o u s r e d u c t i o n . I f r e d u c t i o n is
o b t a i n e d , t h e f l e x i o n is r e d u c e d to 9 0 t o
100 d e g r e e s .
In t w o o t h e r p a t i e n t s t h e h i p a d d u c t o r s
r e m a i n e d contracted in spite of a well made
h a r n e s s a n d its p r o p e r u s e ( C a s e 1 2 a n d 1 5 ) .
Adductor tenotomy was necessary before
acetabular development could proceed. In
hip dysplasia, the adductors usually have
s t r e t c h e d i n o n e to t w o w e e k s after a p p l i ­
c a t i o n o f t h e h a r n e s s . If t h e y r e m a i n t i g h t at
four to six w e e k s , percutaneous adductor
tenotomy under general anesthesia and
p o s s i b l y an a r t h r o g r a m m a y b e n e c e s s a r y .
T h e final p r o b l e m e v i d e n t from t h i s
series was poor compliance of the parents
in maintaining the harness on the child. In
t w o c a s e s ( C a s e s 15 a n d 1 8 ) t h e p a r e n t s
d i s c o n t i n u e d use of the h a r n e s s a n d re­
f u s e d f u r t h e r t r e a t m e n t . I n four p a t i e n t s
( C a s e s 2 , 3 , 1 1 , a n d 1 3 ) , a n o t h e r b r a c e alter­
native was necessary because of poor ac­
ceptance b y the parents. Better parental
education b y the orthopaedist as to the dis­
ease process b e i n g treated and the use of
t h e h a r n e s s m i g h t h a v e o b v i a t e d t h e s e dif­
ficulties.
patient with congenital dislocation of the
hip does not guarantee reduction of the
h i p . T h e important aspects in the use of the
h a r n e s s i n c l u d e : (1) a p p r o p r i a t e i n d i c a ­
t i o n s , (2) a d e q u a t e h i p f l e x i o n i n t h e h a r ­
n e s s a s v e r i f i e d b y r o e n t g e n o g r a m s , (3) u s e
o f a g o o d - q u a l i t y h a r n e s s , (4) c o n f i r m a t i o n
o f c o n c e n t r i c r e d u c t i o n after t h r e e w e e k s o f
h a r n e s s u s e , (5) m a i n t e n a n c e o f t h e p a ­
tient in the harness until a normal clini­
cal a n d r o e n t g e n o g r a p h i c e x a m i n a t i o n is
a c h i e v e d , a n d (6) e d u c a t i o n o f t h e p a r e n t s .
4,6
NOTES
1Dorr, W.M.: Erfahrungen mit dem Riemenbugel n a c h Pavlik in der
Behandlung der sog a n g e b o r e n e n Huftgelenks luxation u n d ihrer
2
E r l a c h e r , P.J.: Early Treatment of Dysplasia of the H i p J . I n t e m a t .
Coll. Surg., 38: 3 4 8 - 3 5 4 , 1962
F r i e d , A m n o n , and Seelenfreund, M.: The Treatment of Congenital
Dislocation o f the Hip by the Pavlik Strap Brace Bull H o s p Joint Dis.,
30: 1 5 3 - 1 6 3 , 1969.
K a l a m c h i , A.; O ' C o n n o r , J . ; a n d M c E w e n , G.D.: Evaluation of the
Pavlik H a r n e s s in the Treatment of Congenital Dislocation of the H i p .
Read at the Annual Meeting of T h e A m e r i c a n A c a d e m y of O r t h o p a e d i c
Surgeons, Dallas, Texas, F e b . 1978.
P a v l i k , Arnold: Die funktionelle B e h a n d l u n g s m e t h o d e mittels
Riemenbugel als Prinzip der konservativen Therapie bei a n g e b o r e n e n
Huftgelenksverrenkungen d e r Sauglinge Zeitschr O r t h o p . , 8 9 : 3 4 1 352, 1957
3
4
s
6
R a m s e y , P.; Lasser, Stephen; a n d M a c E w e n , G.D.: Congenital Dislo­
cation of the Hip. U s e of the Pavlik Harness in the Child during the
First Six Months of Life. J . Bone a n d Joint Surg., 5 8 - A : 1 0 0 0 - 1 0 0 4 , Oct.
1976.
Suzuki, R.: S o m e Complications of Pavlik Method for the Treatment
of C D H . In Proceedings of the Fourteenth World C o n g r e s s of the
S o c i e t e I n t e r n a t i o n a l e d e C h i r u r g i e O r t h o p e d i q u e et d e
T r a u m a t o l o g i c p 1 0 0 . Japan, 1 9 7 8 .
7
8 T o n n i s , D.: An Evaluation of C o n s e r v a t i v e and Operative Methods in
the Treatment of Congenital Hip Dislocation Clin O r t h o p . , 119:
7 6 - 8 8 , 1976.
9 T o n n i s , D.: Investigation o n the C a u s e of Frequency of Avascular
Necrosis in Different Closed Reductions, Primary and Secondary O p e n
Reductions of C D H . In P r o c e e d i n g s of the Fourteenth World Congress
of the Societe Internationale de C h i r u r g i e O r t h o p e d i q u e et de
Traumatologie, p . 107. Japan, 1978
1 0
CONCLUSIONS
T h e p r i m a r y difficulty a s s o c i a t e d w i t h
the use o f the Pavlik harness in this series
w a s failure to a c h i e v e r e d u c t i o n o f t h e d i s ­
location. T h e orthopaedist must realize
that merely applying the harness on the
U e n o , R.; F u n a u c h i , M.; Kura, K.; Tamai, A.; and Nagatsuru, Y . : Die
Behandlung der a n g e b o r e n e n Huftgelenksluxation durch die PavlikBandage Zeitschr O r t h o p . , 113: 1 0 9 0 - 1 0 9 5 , 1975
Dr. Mubarak is with the Division of Orthopedics and Rehabilitation,
University of California, San Diego University Hospital, 225 West Dickinson
Street, San Diego, California 92103 Please address reprint requests to Dr.
Mubarak,
Vorstufe