Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

<6 months of age

1st line – observation

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ONGOING
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<6 months of age
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hip dysplasia
1st line – 

observation

For infants <2 months of age with normal physical exam and mild dysplasia without instability on ultrasound, and normal exam, a repeat ultrasound can be obtained in 3 weeks. A period of observation is recommended and if ultrasound remains abnormal at 6 weeks of age, further treatment is necessary.

2nd line – hip abduction orthosis and further evaluation

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ONGOING
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<6 months of age
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hip dysplasia
2nd line – 

hip abduction orthosis and further evaluation

Following a period of observation, if ultrasound remains abnormal at 6 weeks of age, treatment with a Pavlik harness is typically recommended to enhance optimum hip development.[35] ​Serial follow-up is warranted with ultrasound and plain x-ray evaluation at 6 months of age.

If dysplasia persists or worsens, a rigid abduction brace may be used and has been successful in over 80% of cases that fail a Pavlik harness.[36][37][38]

Less than optimum radiographic findings warrants further evaluation and treatment, which might include exam under anesthesia, arthrogram, and spica casting.[35][39]​​

1st line – observation

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ONGOING
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<6 months of age
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hip subluxation
1st line – 

observation

For neonates with hip subluxation, observation without treatment intervention is recommended for up to 3 weeks because most will experience spontaneous resolution.[28][40]​ ​Although using triple diapering is unlikely to be detrimental to the infant or to its hip development, it has not been shown to provide any added benefit in obtaining hip stability within the first 3 weeks.[28]

After 3 weeks, those with persistent subluxation warrant treatment for a dislocated hip.

1st line – hip abduction orthosis

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ONGOING
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<6 months of age
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nonteratologic hip dislocation
1st line – 

hip abduction orthosis

Pavlik harness can achieve closed reduction of a dislocated hip >90% of the time.[28][41]

Frequent routine clinical follow-up is required over a period of at least 3 months to minimize potential complications and ensure stability and development.

Osteonecrosis and nerve palsy may occur secondary to suboptimal positioning within the brace, forced abduction, and/or excessive flexion. Reported rates of osteonecrosis with Pavlik harness use vary from 0% to more than 7%.[28][41]

If stable reduction of the hip has not been achieved after 3-4 weeks of harness use, the harness must be discontinued to prevent worsening posterolateral acetabular erosion and dysplasia, the phenomenon of Pavlik harness disease.[32][42]​ A more rigid hip abduction splint may be considered, and it can be successful in up to 80% of cases that fail treatment with a Pavlik harness.[36][37][38]​​

2nd line – closed reduction with spica casting

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ONGOING
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<6 months of age
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nonteratologic hip dislocation
2nd line – 

closed reduction with spica casting

Children who have failed splinting need a formal closed reduction under general anesthesia with arthrographic confirmation and placement of a spica cast (a cast that includes the trunk of the body and one or more limbs).[43]

Adductor tenotomy is frequently performed to decrease adduction contracture and allow increased abduction (“safe zone”) and femoral head stability before application of spica cast immobilization.

Cast immobilization is typically continued for 12 weeks or until hip stability has been achieved. Transition from the cast to a splint is commonly practiced thereafter, with discontinuation at the discretion of the orthopedist when it is believed that stability will be maintained unbraced.

3rd line – open reduction with spica casting

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ONGOING
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<6 months of age
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nonteratologic hip dislocation
3rd line – 

open reduction with spica casting

For children in whom attempts at closed reduction have failed, open reduction may be required.[31][37]

The procedure permits the removal of intra-articular obstacles, concentric reduction, and capsulorrhaphy, which will stabilize the joint.[44]​ Cast immobilization depends on the type of open reduction (anterior or medial) and should be continued until hip stability has been achieved.

Transition from the cast to a splint is commonly practiced thereafter, with discontinuation at the discretion of the orthopedist when it is believed that stability will be maintained unbraced.

1st line – open reduction with spica casting

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ONGOING
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<6 months of age
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teratologic hip dislocation
1st line – 

open reduction with spica casting

Teratologic hip dislocation is a fixed dislocation of the hip that occurs prenatally. An open reduction surgery with a spica cast is recommended.

The procedure permits the removal of intra-articular obstacles, concentric reduction, and capsulorrhaphy, which will stabilize the joint.[44]​ Cast immobilization depends on the type of open reduction (anterior or medial) and should be continued until hip stability has been achieved.

Transition from the cast to a splint is commonly practiced thereafter, with discontinuation at the discretion of the orthopedist when it is believed that stability will be maintained unbraced.

6-18 months of age

1st line – closed reduction with spica casting

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ONGOING
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6-18 months of age
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nonteratologic hip dislocation
1st line – 

closed reduction with spica casting

Closed reduction is the recommended treatment for this age group.

General anesthesia is used with arthrographic confirmation and placement of a spica cast (a cast that includes the trunk of the body and one or more limbs).

Adductor tenotomy is frequently performed to decrease adduction contracture and allow increased abduction (“safe zone”) and femoral head stability before application of spica cast immobilization.

Cast immobilization is typically continued for 12 weeks or until hip stability has been achieved. Transition from the cast to a splint is commonly practiced thereafter, with discontinuation at the discretion of the orthopedist when it is believed that stability will be maintained unbraced.

2nd line – open reduction with spica casting

Back
ONGOING
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6-18 months of age
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nonteratologic hip dislocation
2nd line – 

open reduction with spica casting

For children in whom attempts at closed reduction have failed, open reduction may be required.[31][37]

The procedure permits the removal of intra-articular obstacles, concentric reduction, and capsulorrhaphy, which will stabilize the joint.[44]​ Cast immobilization depends on the type of open reduction (anterior or medial) and should be continued until hip stability has been achieved.

Transition from the cast to a splint is commonly practiced thereafter, with discontinuation at the discretion of the orthopedist when it is believed that stability will be maintained unbraced.

1st line – open reduction with spica casting

Back
ONGOING
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6-18 months of age
|
teratologic hip dislocation
1st line – 

open reduction with spica casting

Teratologic hip dislocation is a fixed dislocation of the hip that occurs prenatally. An open reduction surgery with a spica cast is recommended.

The procedure permits the removal of intra-articular obstacles, concentric reduction, and capsulorrhaphy, which will stabilize the joint.[44]​ Cast immobilization depends on the type of open reduction (anterior or medial) and should be continued until hip stability has been achieved.

Transition from the cast to a splint is commonly practiced thereafter, with discontinuation at the discretion of the orthopedist when it is believed that stability will be maintained unbraced.

>18 months to 6 years of age

1st line – open reduction with spica casting

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ONGOING
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>18 months to 6 years of age
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hip dislocation
1st line – 

open reduction with spica casting

This is the recommended treatment for this age group.

The procedure permits the removal of intra-articular obstacles, concentric reduction, and capsulorrhaphy, which will stabilize the joint.[44]​ Cast immobilization depends on the type of open reduction (anterior or medial) and should be continued until hip stability has been achieved.

Transition from the cast to a splint is commonly practiced thereafter, with discontinuation at the discretion of the orthopedist when it is believed that stability will be maintained unbraced.

Surgery in an older child runs the risk of converting an asymptomatic dislocated hip into a symptomatic dysplastic hip. Therefore, the upper age limit for open reduction of asymptomatic, bilateral hip dislocations is about 6 years.[45][46][47]

Consider – femoral or pelvic osteotomy

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ONGOING
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>18 months to 6 years of age
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hip dislocation
Consider – 

femoral or pelvic osteotomy

Treatment recommended for SOME patients in selected patient group

Femoral shortening or derotation osteotomy may be performed at the time of an open reduction to enhance ease of reduction and to help minimize the risk of osteonecrosis by decompressing the soft tissues about the hip.[48][49] ​

Pelvic osteotomy may be required to address instability, inadequacy of femoral head coverage, or residual acetabular dysplasia at the time of surgery.

>6 years of age

1st line – hip reconstruction

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ONGOING
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>6 years of age
1st line – 

hip reconstruction

In children >6 years of age, there is little potential for remodeling. Cases of acetabular dysplasia or subluxation are often treated with hip reconstruction, which consists of pelvic and/or femoral osteotomies and sometimes may necessitate an open reduction. ​In patients >6 years of age with bilateral dislocations or patients >8 years of age with unilateral dislocation, observation could be considered. However, there is limited research and decisions should be made on a case-by-case basis and in a shared manner with the family.

Consider – salvage osteotomies

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ONGOING
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>6 years of age
Consider – 

salvage osteotomies

Treatment recommended for SOME patients in selected patient group

Salvage pelvic osteotomies may be considered in cases where a concentric reduction cannot be achieved. Salvage options are recommended for older children where there is little potential for remodeling and hips are not amenable to open reduction surgery and reconstruction.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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