O3259: Utility of “Pavlik Holiday” for Infantile Hip Dysplasia Following Failure of Pavlik Harness Treatment

Background: The Pavlik harness is 90% successful in treating developmental dysplasia of the hip (DDH). We present a case series of infantile dysplastic hips that initially failed Pavlik treatment but went on to successful reduction with a second round of brace treatment after a harness-free interval – a “Pavlik holiday”.

Methods: We retrospectively identified patients with non-teratologic, dislocated hips that underwent a Pavlik holiday in a pediatric orthopaedic tertiary care center. Hip dislocation was defined as a positive Ortolani sign and/or reduced femoral head coverage (FHC) ( < 30%) on ultrasound. Hips that did not reduce after 3 to 4 weeks of full-time Pavlik treatment were instructed to discontinue the Pavlik harness for a time period, a “Pavlik holiday”, after which it was re-instituted full-time. Hips were reassessed clinically and radiographically every 2 to 3 weeks during the second trial of bracing prior to considering reduction of the hip in the operating room. Success was defined as hips that reduced with a second round of Pavlik harness treatment and did not require closed or open reduction in the operating room. Mann-Whitney and Fisher’s exact tests compared age, clinical features, ultrasound measurements, and length of time in-harness or on Pavlik holiday between successful and unsuccessful patients.

Results: Twenty-one hips from 16 patients (13 female, 3 male) were given a Pavlik holiday after initial harness treatment failed to reduce the hip. Eleven (52%) hips successfully reduced during a second round of Pavlik treatment following the holiday. Median age at initial Pavlik application was 5.9 weeks (range 0.9-13.9). All hips were dislocated on initial ultrasound with the median percentage of femoral head coverage (%FHC) of 15 and median alpha angle of 49. Thirteen hips were Ortolani-positive. The first round of Pavlik treatment lasted for a median of 22 days in the successful group and 27.5 days for the unsuccessful group (p=0.096). Median holiday duration was 28 days (range 8-67). Median duration of the second Pavlik treatment was 65 days in the successful group with final %FHC of 60.

Conclusion: A “Pavlik holiday” rescued approximately half of dislocated hips that failed a first round of treatment. This can be implemented while patients wait until they are large enough to undergo spica casting and therefore has the potential to avoid more invasive intervention without delaying care. Future investigations will focus on risk factors for failing Pavlik treatment and predictive factors for success of the “Pavlik holiday”.