title: Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip.
abstract: BACKGROUND
  Closed reduction and spica casting is the most commonly recommended choice for infants with developmental dysplasia of the hip (DDH) for whom Pavlik harness treatment has failed, but it requires general anesthesia in addition to the challenges of spica cast care. The purposes of this study were to evaluate the effectiveness of Ilfeld bracing for infants for whom Pavlik harness treatment is unsuccessful and to compare these results with those for a similar cohort of patients directly undergoing closed reduction and spica casting.
  
  
  METHODS
  We reviewed the cases of a consecutive series of children with DDH who had failure of Pavlik harness treatment and were subsequently managed with Ilfeld bracing (the BR cohort) and compared this cohort with a similar historical group of infants who had failure of Pavlik harness treatment but had standard closed reduction and spica casting (the CR cohort). The cohorts were compared with respect to clinical and ultrasonographic data at the time of Pavlik discontinuation. At one year, the hip stability and acetabular index were assessed; the presence of osteonecrosis was graded according to the criteria described by Salter et al.
  
  
  RESULTS
  Twenty-eight hips (nineteen infants) made up the BR cohort and twenty-two hips (sixteen infants) made up the CR cohort. Ultrasonographic indices (including the alpha angle and the percentage of femoral head coverage) were comparable between the two cohorts (p=0.66 and 0.19, respectively). Following treatment, a stable reduction was achieved in twenty-three (82%) of twenty-eight hips in the BR cohort compared with twenty (91%) of twenty-two hips in the CR cohort. At one year, acetabular indices were similar between both cohorts (mean and standard deviation, 27°±6° for the BR cohort versus 27°±5° for the CR cohort; p=0.62); however, osteonecrosis developed in three hips in the CR cohort compared with none in the BR cohort.
  
  
  CONCLUSIONS
  In our series of infants with DDH for whom Pavlik harness treatment had failed, Ilfeld bracing had success rates comparable with those for closed reduction and spica cast treatment. With the added advantages of avoiding general anesthesia and spica casting as well as a potentially lower rate of osteonecrosis, rigid abduction bracing should be considered as the next step for infants who have had failed Pavlik harness treatment prior to proceeding with closed reduction and spica casting.
authors.affiliation: Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Wood Building, 2nd Floor, 34th and Civic Center Boulevard, Philadelphia, PA 19104. E-mail address for W.N. Sankar: sankarw@email.chop.edu.
authors.forename: Wudbhav N
authors.initials: WN
authors.lastname: Sankar
authors.affiliation: Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Wood Building, 2nd Floor, 34th and Civic Center Boulevard, Philadelphia, PA 19104. E-mail address for W.N. Sankar: sankarw@email.chop.edu.
authors.forename: Afamefuna
authors.initials: A
authors.lastname: Nduaguba
authors.affiliation: Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Wood Building, 2nd Floor, 34th and Civic Center Boulevard, Philadelphia, PA 19104. E-mail address for W.N. Sankar: sankarw@email.chop.edu.
authors.forename: John M
authors.initials: JM
authors.lastname: Flynn
mesh_terms: D001915:Braces; D002370:Casts, Surgical; D015331:Cohort Studies; D005260:Female; D005270:Femur Head / Q000000981:diagnostic imaging; D005500:Follow-Up Studies; D006618:Hip Dislocation, Congenital / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009989:Orthotic Devices; D011859:Radiography; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome; D014463:Ultrasonography