Abstract
Background: The general consensus is that nonoperative treatment of
developmental dysplasia of the hip should not be attempted for patients in
whom previous treatment of the disease has failed, those in whom the disease
was neglected, or those in whom the disease presented late. In such cases, it
is believed that the optimum period for hip remodeling has passed and that
operative methods are preferable. The purpose of the present study was to
report the efficacy of a modified form of the Hoffmann-Daimler method for the
treatment of late-presenting developmental dysplasia of the hip.
Materials: We retrospectively reviewed the records of sixty-nine
patients (ninety-five hips) with neglected developmental dysplasia of the hip
who had been managed nonoperatively with a modification of the
Hoffmann-Daimler method from 1971 to 2000. With this method, the patient wears
a flexion harness (Phase A), during which time the femoral head is gradually
reduced, followed by an abduction splint (Phase B), during which time the
reduced hip remodels. We have modified the original method by introducing new
treatment strategies. The study group included nine boys and sixty girls. The
average age of the patients was sixteen months (range, six to forty-four
months) at the start of treatment and 11.5 years (range, six to twenty-nine
years) at the time of the latest follow-up. Radiographs were assessed to
determine the acetabular index, the Severin classification, and the presence
of evidence of osteonecrosis of the proximal femoral epiphysis. Hips that were
rated as Severin class I or class II were classified as satisfactory, whereas
those that were rated as Severin class III or class IV were classified as
unsatisfactory.
Results: On the basis of the most recent follow-up radiographs,
eighty-eight (93%) of the dislocated hips were classified as satisfactory
(sixty-seven were rated as Severin class I and twenty-one were rated as
Severin class II) and seven were classified as unsatisfactory (six were rated
as Severin class III and one was rated as Severin class IV). No hip was rated
as Severin class V or VI. The average acetabular index was 40° ±
7.4° prior to the onset of treatment and 24° ± 5.7° at the
end of treatment. No redislocations or other complications were noted.
Osteonecrosis was noted in six of the ninety-five hips.
Conclusions: Late-presenting or neglected developmental dysplasia of
the hip can be successfully treated with use of a modified Hoffmann-Daimler
method. The high rate of successful reduction, the low prevalence of
osteonecrosis and residual dysplasia, and the limited complications may make
this modified method a safe alternative to surgical treatment.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
Although the rate of occurrence of developmental dysplasia of the hip has
been substantially reduced as a result of better clinical assessment,
especially with the availability of sonographic hip
screening1,2,
there are still some cases that present in older patients as a result of late
or missed
diagnoses3,4.
The functional methods that have been applied to treat developmental dysplasia
of the hip, such as the use of a Pavlik harness, have been successful, with a
relatively low complication
rate5. However, the
general consensus is that they are not used after the age of six months. The
rate of successful treatment of developmental dysplasia of the hip with use of
the Pavlik harness after the age of six months
decreases6, mainly
because the size and strength of the child do not allow the lower extremities
to be held efficiently in the preferred
positions6-8.
At this older age, it is believed that the optimum period of cartilage
remodeling has passed, and closed reduction and/or surgical procedures are
recommended9,10.
In the present study, we reviewed the outcomes for children with
late-presenting developmental dysplasia of the hip who had been managed
nonoperatively with a modified Hoffmann-Daimler functional method. The
purposes of the study were (1) to describe our modifications of this method,
(2) to determine whether this modified method successfully reduces the hip and
maintains the reduction, (3) to evaluate the prevalence of osteonecrosis of
the femoral head, and (4) to identify any residual subluxation or dysplasia of
the hip.
The medical records of 144 patients with the diagnosis of developmental
dysplasia of the hip who had been managed with the modified Hoffmann-Daimler
method between January 1971 and December 2000 were reviewed. Fifty-nine
patients were excluded because their radiographs or medical records were
inadequate or could not be located. We have not applied this method to
children who were previously operated on, those who were managed with open
reduction, or those in whom the dislocation of the hip was secondary to
neuromuscular disease, arthrogryposis, septic arthritis, or a teratological
condition or was associated with a congenital anomaly or syndrome. Patients
who had been previously managed unsuccessfully with a Pavlik or Freijka
harness were included in this analysis. Eighty-one (85%) of ninety-five hips
treated with the Hoffmann-Daimler method had had no previous treatment and
were diagnosed for the first time at this late stage. Seven patients for whom
other treatment had been selected were excluded. Nine children (thirteen
dislocated hips) who had less than six years of follow-up and all children who
were younger than six years of age at the time of the most recent follow-up
were also excluded.
A total of sixty-nine patients with ninety-five dislocated hips were
available for the study (Table
I). The study group included nine boys and sixty girls. The
average age of the patients was sixteen months (range, six to forty-four
months) at the start of treatment and 11.5 years (range, six to twenty-nine
years) at the time of the most recent follow-up. Forty-three patients had
unilateral involvement (with twenty-five having involvement of the left hip
and eighteen having involvement of the right hip), and twenty-six had
bilateral involvement. For the patients who had bilateral involvement, each
hip was considered separately in the statistical analysis. The duration of
treatment in the Hoffmann-Daimler harness and splint was recorded for each
phase.
The type and severity of subluxation and dislocation were classified on the
basis of anteroposterior pelvic radiographs according to the system presented
by Tönnis11.
All patients were monitored with serial anteroposterior radiographs of the
pelvis and hips from the beginning of treatment with the modified
Hoffmann-Daimler method to the end of treatment and then from the end of
treatment to skeletal maturity. Mose
templates12 were
used to measure the center-edge angle of
Wiberg13. The
lateral end of the
sourcil14 was
selected as the marking point indicating the lateral margin of the middle of
the superior portion of the acetabulum for accurate measurement of the
acetabular index and the center-edge angle in cases in which the osseous
landmarks were indistinct. Acetabular remodeling on radiographs was evaluated
by observing the change in the acetabular index over time with use of serial
measurements. We measured the acetabular index prior to treatment and again
one year after the end of treatment, and we calculated the difference between
these measurements as a quantitative indication of acetabular improvement.
The final results were evaluated according to the Severin classification
system15. Although
controversy16,17
has arisen lately about the reliability and reproducibility of the Severin
system, in the present study, hip deformity was graded with use of this system
at different ages by two independent observers (including one of the authors
[T.B.]) who were experienced pediatric orthopaedic surgeons (k > 0.87).
Radiographs were evaluated for signs of osteonecrosis as described by
Salter et al.18,
and femoral head growth disturbances were classified according to the criteria
described by Bucholz and
Ogden19. The
presence or absence of the ossific nucleus on the radiograph of the hip prior
to the commencement of treatment was also recorded.
Hoffmann-Daimler Method and Modifications
Developmental dysplasia of the hip is a dynamic disorder, and malformations
of the anatomic structures result from the gentle but persistent forces that
are applied on the dislocated
hip20. When the hip
is adducted21 and
the knee is fully
extended22,23,
the muscles around the hip (primarily the adductors, iliopsoas, and
hamstrings) act to dislocate the
hip24. With the hip
in adduction, the dysplastic acetabulum cannot balance the forces acting on
the femoral head (Fig. 1-A). A
dislocating force is produced, which drives the femoral head over the
posterosuperior rim of the acetabulum, resulting in further anatomic changes
to the limbus, capsule, and acetabular rim and leading to a complete
dislocation.
The treatment of developmental dysplasia of the hip with use of the
Hoffmann-Daimler method involves placing the dislocated hip in flexion. The
anatomic changes caused by the dislocation gradually reverse, allowing the
femoral head to gradually move into the acetabulum by the redirected action of
the adductor and flexor muscles of the hip (Phase A)
(Fig. 1-B). This principle is
similar to that used in any functional method of treatment of developmental
dysplasia of the hip. By abducting the reduced hip (Phase B), acetabular
changes correct as a result of the mechanical forces placed on the
acetabulum25-28.
As indicated earlier, there are two phases of treatment with the
Hoffmann-Daimler
method29-32
(Figs. 2-A, 2-B, and 2-C).
During the reduction phase (Phase A) a harness is used with the hips fully
flexed, whereas during the acetabular remodeling phase (Phase B) a splint is
used to abduct the hips.
Phase A (Reduction Phase) for the Original Hoffmann-Daimler
Method
In this phase, the Hoffmann-Daimler flexion harness is applied. If femoral
head reduction is achieved initially or soon after harness placement, Phase B
is begun. More commonly, femoral head reduction is achieved gradually, with
the position of the femoral head being assessed on serial radiographs with use
of four points: the high-riding dislocation position, the ischial tuberosity,
the obturator foramen, and the acetabulum
(Fig. 3).
Once the femoral head is at the ischial tuberosity, hip flexion is reduced
to 110° in the harness. This subphase, when the femoral head moves over
the ischial tuberosity to the obturator foramen, is the most difficult and
lengthy part of the reduction phase. Sometimes, a posterior strap is added to
the flexion harness to increase hip abduction or bilateral thigh skin traction
in abduction is used to facilitate reduction. With the traditional
Hoffmann-Daimler method, failure of the femoral head to reduce in three weeks
from the time of reaching the ischial tuberosity position is an absolute
indication for open reduction of the hip.
If the femoral head remains inferior to the acetabulum (point 3) for more
than three weeks, hip flexion is further reduced to 100° and posterior
abduction straps are used to facilitate femoral head reduction.
With the original method, the reduction phase (Phase A) should never exceed
thirty days. If the femoral head is not reduced by this time, open reduction
should be
performed33.
Modifications of Phase A Used in the Present Study
In our series, hip flexion in the harness did not exceed 120° and
abduction was never forced with the use of posterior straps. We did not follow
the Hoffmann-Daimler method guideline of open reduction or forced reduction by
bilateral thigh traction or other means if the femoral head was not reduced
within thirty days after the initiation of treatment. Instead, in our
patients, open reduction was not done and the harness was used (for as long as
150 days) to allow the femoral head to gradually but spontaneously reduce
(Figs. 4-A through 4-E).
Furthermore, in cases in which the hip reduced easily in fifteen days or less,
a hip spica cast, with the hip flexed 90° and abducted 70°, was used
for six weeks before Phase B was begun.
Phase B (Acetabular Remodeling Phase) for the Original
Hoffmann-Daimler Method
Once the femoral head is reduced, harness flexion is reduced to 90°
while a Hoffmann-Daimler splint in 90° of abduction
(Fig. 2-B) is also worn for one
month. After one month, the harness is discontinued and the abduction splint
is used full time (Fig. 2-C)
(see Appendix). Once the child is walking well, the magnitude of abduction in
the splint is decreased from about 90° to 45° for each hip. For more
severe cases of acetabular dysplasia or for limited femoral head coverage, the
decrease of the amount of hip abduction in the Hoffmann-Daimler splint is
delayed for three months.
Radiographic evaluation is done every two months, with measurement of the
center-edge angle and the acetabular index. Once these measurements are
normal, the splint is discontinued. The duration of Phase B is usually about
one year.
Modifications of Phase B Used in the Present Study
The Hoffmann-Daimler abduction splint was worn with the hips being forced
not to maximum abduction but rather to the abduction that was possible. The
degree of abduction remained the same for as long as was needed for the
acetabular obliquity to be restored radiographically. After that, abduction
was gradually reduced monthly to the level of 45° for each hip. Toward the
end of treatment, hip abduction in the splint was gradually decreased in order
to avoid difficulty in walking after the end of treatment.
Statistical Analysis
The data were analyzed with use of the nonparametric Mann-Whitney test. The
level of significance was set at p < 0.05. All analyzed variables showed a
nonparametric distribution. The chi-square test was used for qualitative data.
The Spearman correlation coefficient was used to examine correlations between
multiple factors. Statistical analysis was performed with use of SPSS software
(version 10.0; SPSS, Chicago, Illinois).
Before treatment, radiographic assessment of the severity of dislocation
with use of the Tönnis classification system demonstrated that forty-five
hips (47%) were grade II, twenty-three (24%) were grade III, and twenty-seven
(28%) were grade IV. The Hoffmann-Daimler method was not used for grade-I
hips.
The mean duration of the reduction phase (Phase A) was forty-seven days
(range, fifteen to 150 days), and the mean duration of the remodeling phase
(Phase B) was thirteen months (range, three to thirty months). On the basis of
the most recent follow-up radiographs that were made after treatment,
eighty-eight (93%) of the dislocated hips were rated as satisfactory
(sixty-seven were rated as Severin class I and twenty-one were rated as
Severin class II) and seven were rated as unsatisfactory (six were rated as
Severin class III and one was rated as Severin class IV). No hip was rated as
Severin class V or VI. Table I
lists the variables that were evaluated. With the numbers available, gender,
the side of involvement, bilateral involvement, the presence or absence of the
ossific nucleus, and the durations of Phases A and B were not found to have a
significant correlation with the final Severin grade. All seven patients who
were classified as having a Severin class-III or IV hip at the time of the
most recent follow-up had started treatment when they were more than twelve
months old, and all of these hips initially had been classified as Tönnis
grade IV.
The prevalence of osteonecrosis was 6% (six of ninety-five hips). One hip
had type-I osteonecrosis, two had type-II osteonecrosis, and three had
type-III osteonecrosis. When type-I changes were excluded, the prevalence of
osteonecrosis (types II, III, and IV) was only 5% (five of ninety-five hips).
One patient with type-III osteonecrosis and two with type-II osteonecrosis had
been managed elsewhere with a Freijka or a Pavlik harness before starting
treatment with the modified Hoffmann-Daimler method. With the numbers
available, the side of involvement, bilateral involvement, the presence or
absence of the ossific nucleus, the age at the onset of treatment, the
durations of Phases A and B, and the degree of displacement of the femoral
head (Tönnis grade) were not significantly associated with the appearance
of osteonecrosis.
The average acetabular index was 40° ± 7.4° (range, 25°
to 57°) prior to the onset of treatment and 24° ± 5.7°
(range, 11° to 40°) following the end of treatment. The mean
improvement in the acetabular index was 16° ± 7.8° (range,
1° to 42°).
Seven hips redislocated during the first months of treatment with the
Hoffmann-Daimler method. In two cases, the flexion harness was removed
mistakenly by the parents, in two cases the femoral ring was accidentally
removed, and in three cases the reduction had been achieved in less than a
week.
The flexion harness was immediately reinstituted in all cases in which
successful re-reduction was achieved. The next step was to apply a hip spica
cast with the hip held in flexion and abduction for six weeks, after which
time Phase B was begun.
Nine hips reduced during Phase A after less than fifteen days of treatment.
All of these hips were considered to be very unstable and were treated with a
hip spica cast for six weeks before Phase B was begun. There were no observed
redislocations following this treatment plan.
No other well-documented complications such as infection, osteochondritis
dissecans, chondrolysis, trochanteric overgrowth, limb-length discrepancy,
subluxation or dislocation of the hip, coxa valga or coxa vara, coxa magna, or
deformity of the femoral head were observed following the treatment of
developmental dysplasia of the hip in our patients.
Complications that occurred in association with the Hoffmann-Daimler
flexion harness and splint included contact dermatitis, especially at the
flexor surfaces of hips in very obese children, and diaper rash in the region
where the skin was continuously moistened by urine. We also saw ulceration of
the skin in the spine area (resulting from pressure exerted by continuous
contact of the straps) and at the thighs (caused by the plastic segment of the
femoral rings). All of these complications were minor and resolved
uneventfully.
For patients with developmental dysplasia of the hip, functional
treatments, such as the Pavlik method, have been used with remarkable success
as the femoral head descends gradually into the
acetabulum34,35.
However, functional treatment of developmental dysplasia of the hip is not
currently considered appropriate for patients over the age of six months. As
the patient with developmental dysplasia of the hip becomes older, the
anatomic changes that ensue become substantial obstacles to closed reduction
(Fig. 4-B). The seemingly
irreparable and irreversible anatomic changes of developmental dysplasia of
the hip (inverted limbus, constriction and narrowing of the hip capsule),
which can hinder reduction, gradually reverse (through hip remodeling) and
allow the femoral head to find its anatomic position
(Fig. 4-C). This occurred even
in the oldest patient with complete (Tönnis grade-IV) subluxation in our
series, something that seems to contradict the general belief that after six
months the anatomic obstacles to reduction usually are insurmountable. Once
concentric reduction is achieved, acetabular remodeling can be surprisingly
good36-38.
The reported prevalence of redislocation after open reduction has ranged
from 0% to
15%39,40
and in this group of patients the prevalence of osteonecrosis was as high as
44%40. Mardam-Bey
and MacEwen reported that 66% of children of walking age with developmental
dysplasia of the hip who had undergone closed reduction required additional
surgery41, and
other investigators have noted a high prevalence of redislocation after open
reduction9,42-44.
In younger children who have been managed with a Pavlik harness, the rate of
redislocation has been reported to be
14%5,45,
which has been attributed mainly to an adduction contracture that limits hip
abduction and prevents reduction of the femoral head. In our series, the hips
that reduced easily were also prone to redislocate easily. Therefore, a hip
spica cast was used for six weeks for hips that redislocated or hips that
reduced in less than fifteen days. The modified Hoffmann-Daimler method
described here is arguably more advantageous because the reduction of the
femoral head was achieved in all cases and none of our patients required
additional surgery.
Inadequate acetabular development may be a common problem after open
reduction of the congenitally dislocated
hip46, and it can
lead to early degenerative joint disease. Tucci et al. reported that 20% of
patients who had been managed successfully with the Pavlik method later had
development of acetabular
dysplasia47.
Acetabular development after closed reduction for the treatment of
developmental dysplasia of the hip has been investigated by numerous authors,
and it has been reported that the lower limit of acetabular remodeling is two
years of age48 and
that the upper limit is eleven years of
age49. The
acetabular remodeling potential continues even as long as eight years after
reduction if the hip is reduced before the fourth year of
age50. In the
present study, once a concentric reduction was achieved by placing the hips in
the abduction splint, the acetabulum continued to remodel, even in children
who were more than 3.5 years of age.
The mean acetabular improvement was greater in patients who started the
treatment when they were more than eighteen months old, perhaps because of the
fact that such children are able to
walk51 while
wearing the abduction splint. The redirected concentric compressive force on
the acetabulum in the splint is generated by the action of the adductor
muscles. When the child walks, weight-bearing is added and may further
stimulate the process of acetabular remodeling.
On the basis of unpublished data, Hoffmann-Daimler reported that at the
outset of applying the method, one child had development of femoral artery
thrombosis due to the extreme flexion of the thighs associated with the use of
the flexion harness. Neither in the international literature nor in our study
did we find femoral artery thrombosis as a complication of the harness or
splint. Femoral nerve palsy also has been reported as a complication of the
Pavlik
harness6,52,
but we did not observe this complication in association with the
Hoffmann-Daimler harness in our study. No other well-documented complications
resulting from the treatment of developmental dysplasia of the hip were
observed in our patients.
The reported prevalence of osteonecrosis has ranged from 2.38% to 16% for
infants managed with a Pavlik
harness5,53
and from 0% to 67% for patients managed operatively for late-presenting
developmental dysplasia of the
hip54-59.
When closed reduction is used, forceful traction and prolonged immobilization
in forced abduction may lead to osteonecrosis rates of as high as
28%60 secondary to
high intra-articular
pressure9,42,
a condition that is avoided with our modified method. A high prevalence (30%
to 65%) of osteonecrosis was also initially reported in association with the
original Hoffmann-Daimler
method61-63;
the previously reported lowest rate associated with the Hoffmann-Daimler
method was 12.7%64.
It was thought that this high rate was due to forced maximum
abduction63. In the
present study, the prevalence of osteonecrosis was 6% and was not related to
the degree of dislocation of the hip or the absence of an ossific nucleus at
the time of reduction.
The general consensus is that hip dislocation in patients who are more than
eighteen months old should be treated primarily surgically. In this age-group,
the highest reported rate of success of operative treatment (as defined as a
Severin class of I or II) has been
75%65, but the rate
of avascular necrosis has been reported to be 20% to 40% in Tönnis
grade-III and IV
hips60,66.
In the present series, twenty Tönnis grade-III and IV hips in patients
who were more than eighteen months old were treated with the modified method
of Hoffmann-Daimler; in this group, the rate of success was 90% and the
prevalence of avascular necrosis was 0%.
We believe that the extreme flexion in the reduction phase (Phase A), the
forcing of the hip into increasing abduction either with use of a posterior
strap or even with the application of lateral traction, the forced maximum
abduction by the abduction splint, and the premature reduction of abduction
during Phase B of the original Hoffmann-Daimler method were perhaps
contributing factors to the high reported prevalence of osteonecrosis. We
believe that an appropriate amount of time during therapy should be allowed
for the soft-tissue structures, the acetabulum, and the femoral head to
accommodate gradually.
The modified Hoffmann-Daimler method does not require in-hospital
treatment. In cases in which the social setting is poor, we prefer to see the
patient every week. In cases in which the parents are not reliable and cannot
comply, especially during the first critical days of reduction, we prefer
in-hospital treatment for better surveillance. Poor applications of the
harness, inadequate supervision, or lack of compliance by the parents are
factors that can lead to failure. Poor harness construction or fit is easily
addressed by careful evaluation of the harness. We minimized poor compliance
over the long duration of treatment by providing better parent education
regarding developmental dysplasia of the hip and use of the harness.
There is general agreement that the best results are achieved if the
treatment of developmental dysplasia of the hip is initiated during the
neonatal period. Patients in whom previous treatment of the disease has
failed, those in whom the disease has been neglected, and those in whom the
disease presented late are thought to be too old for management with
functional methods. The modified Hoffmann-Daimler method, however, appears to
achieve a safe and lasting reduction with a low prevalence of osteonecrosis
and residual acetabular dysplasia.
A table showing details of all of the patients and a video demonstrating
the application of the brace are available with the electronic versions of
this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?
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