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Boston Children’s Hospital hip sub-specialists provide comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care. How we’ll treat your child’s DDH depends on the complexity and severity of her condition—as well as her age, overall health, medical history and the expectations for the course of her condition as she grows.
The goal of all treatments for DDH is to put the femoral head back into the hip socket, so that the hip can develop normally. Treatment options may include:
If the socket of a child 6 months of age or younger is only slightly shallow and the instability is minor, the doctor will just follow the hip closely, since often the joint will form normally on its own.
A Pavlik harness is used on babies up to 4 months of age to hold the hip in place, while allowing the legs to move a little. Your baby's doctor puts the harness on; the baby usually wears it full-time for at least six weeks, then part-time (12 hours per day) for another six weeks.
During this time the doctor will see your baby frequently, to examine her hip and check the harness for proper fit. At the end of the treatment, x-rays (or an ultrasound) will check hip placement.
The baby’s hip is usually successfully treated with the Pavlik harness, but sometimes it may continue to be partially or completely dislocated.
If the hip continues to be partially or completely dislocated, traction or casting may be used. Traction—consisting of pulleys, strings, weights and a metal frame attached over or on the bed—applies force to stretch certain parts of the body in a specific direction.
The purpose of traction is to stretch the soft tissues around the hip and allow the femoral head to move back into the hip socket. Traction can be set up either at home or in the hospital and is usually used for about 10 to 14 days.
• Keep your child’s cast clean and dry
• Check for cracks or breaks in the cast
• Put pads on rough edges to protect the skin from scratches
• Don’t scratch the skin under the cast by inserting objects inside the cast
• Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow
warm or hot air into the cast
• Cover the cast while your child is eating to prevent food spills and crumbs from entering the cast
• Prevent small toys or objects from being put inside the cast
• Elevate the cast above the level of the heart to decrease swelling
• Encourage your child to move her toes to promote circulation
• Don’t use the abduction straps on a Pavlik harness to lift or carry your child
If the other methods aren’t successful—or if DDH is diagnosed after the child is 2 – closed reduction surgery may be needed to put the hip back into place manually. After surgery, a spica cast (a cast that extends from the nipple line to the legs) is put on the baby to hold the hip in place.
The baby wears the spica cast for about three to six months. The cast is changed from time to time to accommodate the baby's growth and to ensure the cast's rigidity (it may soften with daily wear). The cast remains on the hip until the hip achieves normal placement. Following casting, the baby may need a special brace and physical therapy exercises to strengthen the muscles around the hip and in the legs.
Non-surgical treatment is generally ineffective for a child older than walking age (especially if her hip isn’t developing properly or is dislocated). Open reduction surgery (in which the hip is repaired through an incision into the body) is usually needed, since by this time the child’s bones are usually enough “off-track” that they need to be re-positioned in order for the hip to grow and function normally.
The type of procedure for children of walking age (and older) depends on the problem that the surgery is treating, such as:
Surgery can reshape and re-direct the hip socket if it’s too shallow, or is pointed in the wrong direction. This is done by cutting above or around the socket to re-direct it within the pelvis.
Surgery can re-direct the ball (femoral head) if it’s pointing in the wrong direction. The surgeon cuts the femur, points the femoral head in the correct position, and reconstructs the cut pieces with plates and screws until they heal.
With a complete dislocation,
• the ball is put back into the socket
• tight muscles (and/or obstructive fatty tissue) that are preventing the ball from going into the socket
(“obstacles to reduction”) are cut away
• ligaments to hold the ball in the socket are reconstructed
• a cast keeps the ball in place in the socket during healing
If the ball is out of the socket in a child older than 18 months, the socket is usually extremely shallow and hasn’t developed well. And the longer the ball stays out of the socket, the shallower the socket gets. In this situation, the surgeon will almost always need to:
• put the ball into the socket
• deepen the socket
• re-orient the socket so it’s more stable
• tighten the ligament
By this age the joint’s tissues (muscles and ligaments) are usually very tight, so in addition to the above, surgeons must also shorten the thigh bone (femur) to loosen the tissues. Loosening the tissues allows the ball to go into the socket, and relieves pressure on the cartilage and the small blood vessels that go to the ball.
At Boston Children's, we’ve performed over 1,400 Bernese periacetabular osteotomies to correct dysplastic hips in teens and adults, whose hip sockets have finished growing.
The PAO is the most complex and powerful procedure for repositioning the hip socket. Children’s is the most experienced center in the United States for the procedure – and the second-most experienced in the world. It’s our standard treatment for a hip socket that’s too shallow in a patient whose socket has finished growing – typically at ages 13 or 14 through adult – and whose hip is still viable enough to be repaired rather than replaced.
The PAO involves rotating the shallow, dysplastic socket (acetabulum) by cutting it free enough from its attachments within the pelvis to be repositioned into a more stable alignment on the top of the head of the femur. In this new alignment, excessive pressure from the femoral head is more evenly distributed away from the sensitive rim area.
The great majority of non-surgical and surgical treatments of DDH at Boston Children’s occur without complications. But if left untreated, the condition will eventually become painful, and a limp and/or differences in leg length may develop.
The maldevelopment in hip dysplasia usually causes the head of the thigh bone (femoral head) to put too much pressure on the rim of the hip socket. Over time, this can damage cartilage and is the most common cause of premature arthritis (and its attendant disability) in young adults.
Boston Children’s research into bone problems means that we can provide your child with the most innovative care available. As a result, the great majority of children treated for DDH at Boston Children’s have corrections that enable their bones to grow normally—so they can walk, play, grow and live active lives.
Success rates are high for hip dysplasia treatments at Boston Children’s. Even so, any child who’s been treated for hip dysplasia must still be followed periodically by her orthopedist until her skeletal growth is complete. The doctor will monitor the repaired hip, since it needs to grow normally through the whole growth period in order to be durable for a lifetime.
We are grateful to have been ranked #1 on U.S. News & World Report's list of the best children's hospitals in the nation for the third year in a row, an honor we could not have achieved without the patients and families who inspire us to do our very best for them. Thanks to you, Boston Children's is a place where we can write the greatest children's stories ever told.”