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Leczenie szelkami Pavlika nie zawsze jest skuteczne, powinno być dobrane do wieku dziecka i rodzaju wady, ponieważ nieprawidłowo zastosowane powoduje martwice głowy kości udowej - u 7do 14% niemowląt(nawet do 30% jeżeli leczymy w warunkach szpitalnych).

Szelki Pavlika są również bardzo nieskuteczne w leczeniu większych wad w co najmniej 15.2% przypadków zwichnięć stawów biodrowych ( rozpoznanych nawet tuż po urodzeniu) do 40%(5) i 3.3% dysplazji stawów biodrowych , dlatego w niektórych krajach stosowany jest przed nimi wyciąg typu" over head" w celu zmniejszenia liczby komplikacji .

Szelki Pavlika u niemowlaków do 3 miesiąca życia mogą powodować pogorszenie wady biodra, ponieważ w tym wieku kości a zwłaszcza chrząstka szklista z której zbudowana jest głowa ,szyja i krętarz kości udowej są bardziej miękkie i delikatne niż siła wiązadeł i mięśni,podczas każdego prostowania nóg niemowlaka dochodzi do ucisku głowy na panewkę ,taki ucisk nie występuje fizjologicznie.

Amerykanie nie badają i nie publikują wyników rozpoznania i leczenia dysplazji czy zwichnięcia stawów biodrowych ,nie wiadomo ile dzieci operują rocznie w swoim kraju. Wiadomo jedynie że około 50 tys dorosłych rocznie ma wymieniany staw z powodu DDH w dzieciństwie ,co daje ok 2% DDH rocznie wymagających leczenia w latach 40 ubiegłego wieku i tak jest pewnie do dzisiaj,bo częstotliwość występowania DDH w populacji jest stała i nie uległa zmianie wraz z rozwojem ludzkości.

Amerykańskie metody diagnostyki nie zmieniły się, badanie kliniczne jest ich podstawą,ale posiadają obecnie niższy standard.Nie wykonują ich ortopedzi ale przeszkolone pielęgniarki a badanie usg wykonują technicy rtg, zgodnie z najnowszymi zaleceniami Amerykańskiego Stowarzyszenia Ortopedów Dziecięcych.


1) 1: Acta Orthop Belg. 1990;56(1 Pt A):195-206. Links
Ischemic necrosis as a complication of treatment of C.D.H
.
Tönnis D.
University Hospital, Orthopedic Department, Dortmund, Germany.
Ischemic necrosis is seen after both closed and open reduction. Its causes have been clarified during the last two decades. The position of the immobilized hip after reduction is an important factor; the method of reduction is another. There are other factors such as development of the epiphyseal nucleus and the degree of dislocation. In a collective series of 20 hospitals our study group on hip dysplasia investigated 3316 hip joints reduced by different techniques. It was shown that methods working with the Lorenz position of immobilization have an average rate of 27% ischemic necrosis. Lange's position of abduction with internal rotation, without flexion of the hip joint, has a 17% necrosis rate. Pavlik's harness, as a more functional method, had a 7% rate. Methods reducing bij increased flexion and less abduction, such as that of Fettweis, Hanausek and Krämer, had 2% on the average. The percentage of necrosis was increased with the degree of dislocation. The length of time of immobilization had no influence. These findings correspond with the investigations on the femoral blood circulation in different positions of the femoral head and under pressure that have been published by Schoenecker et al. and Law et al. The cartilaginous epiphysis may be squeezed so much that the circulation is interrupted. Another cause is direct pressure to epiphyseal vessels in extreme Lorenz and Lange positions (Ogden and others). There has been a question as to what degree the reduction itself is the cause of ischemic necrosis. The method of reduction was determined by arthrography. If it seemed possible, a cast in squatting position according to the method of Fettweis was applied immediately. In the beginning we even allowed the joints to reduce themselves slowly against a narrow introitus of the joint. In other joints traction was applied first, and in a few older patients open reduction was performed immediately. A total of 388 joints was evaluated. There was an increasing rate of ischemic necrosis from open acetabular inlets (3.6% necrosis) to constricted joints (8.5%) and those with an inverted upperlabrum (31%). The width of the acetabular introitus, as measured between the upper and lower labrum (ligamentum transversum), also showed a correlation with ischemic necrosis. When the degree of reduction is classified as "deeply seated", there is a definite correlation with ischemic necrosis. Also when the distance of the femoral head from the acetabular floor is measured, the same increase in incidence of necrosis is noted.(ABSTRACT TRUNCATED AT 400 WORDS)

 

2) The natural history of developmentaldysplasia of the hip after early supervised treatment in the Pavlik harness
A PROSPECTIVE, LONGITUDINAL FOLLOW-UPJ. P. Cashman, J. Round, G. Taylor, N. M. P. Clarke
From Southampton General Hospital, England
Between June 1988 and December 1997, we treated332 babies with 546 dysplastic hips in a Pavlik
harness for primary developmental dysplasia of the hip as detected by the selective screening programmein Southampton. Each was managed by a strict protocol including ultrasonic monitoring of treatmentin the harness. The group was prospectively studied during a mean period of 6.5 ± 2.7 years with follow-up of 89.9%. The acetabular index (AI) and centre-edgeangle of Wiberg (CEA) were measured on an nualradiographs to determine the development of the hip after treatment and were compared with publishednormal values.
The harness failed to reduce 18 hips in 16 patients(15.2% of dislocations, 3.3% of DDH.(Uprząż była nieskuteczna u 18 bioder u 16 pacjentów(15.2%z zwichnięciem i 3.3% z dysplazja)(mk) These requiredsurgical treatment. The development of those hips which were successfully treated in the harness showed no significant difference from the normal values of theAI for the left hips of girls after 18 months of age. Ofthose dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA <20°) and 0.2% persistent severe late dysplasia (CEA <15°). All could be identified by anabnormal CEA (<20°) at five years of age, and many from the progression of the AI by 18 months.Dysplasia was considered to be sufficient to requireinnominate osteotomy in five (0.9%). Avascular necrosis was noted in 1% of hips treated in theharness.( wg Saltera i tylko wieksze martwiceIIIi IV st,,mniejszych nie uwzględniono (mk) )

 

3.)Preliminary traction and the use of under-thigh pillows to prevent avascular necrosis of the femoral head in Pavlik harness treatment of evelopmental dysplasia of the hip
Shigeo Suzuki, Yoichi Seto, Tohru Futami, and Naoya Kashiwagi Department of Orthopaedic Surgery, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, Shiga 524-0022, Japan
At the Shiga Medical Center for Children, the Pavlik harness had been used in the outpatient clinic between 1980 and 1987. In 1988, according to Iwasaki’s s uggestion,6 we introduced two measures in order to reduce avascular necrosis; preliminary skin traction and the use of pillows placed under the thighs during application of the harness to prevent extreme abduction. We compared the results of the treatment used during the period between 1980 and 1987 and that in the period 1988 to 1992.Patients and methods between 1980 and 1992, 161 hips in 145 patients (13
boys and 132 girls) were treated with the Pavlik harness at Shiga Medical Center for Children, and these patients were followed-up for at least 1 year after application of the harness. Patients who had had p revious treatment elsewhere or who were treated initially with a different method were excluded from the study.A dislocation was diagnosed when the hip was felt to have relocated with abduction, as described by Ortolani. If the hip could not be reduced but there was limited abduction, asymmetry of the thigh folds, or shortening of the affected extremity, a dislocation was
suspected. The diagnosis was made radiographically.The radiograph was taken with the infant in the supine position, with both lower extremities maintained in a n eutral position. The focus of the tube was adjusted to the center of the triangle that is formed bilaterally by the iliac crests and the symphysis, and the focal distance as 1m. The diagnosis was established when there was lateral and cephalad displacement of the proximal
end of the femur accompanied by interruption of the Shenton line.The amount of dislocation was measured on anteroposterior radiographs according to the method of Abstract One hundred and sixty-one hips of 145 patients were treated with the Pavlik harness for developmental dysplasia of the hip. The patients were divided into two groups. Group A consisted of 65 patients (70 hips) who were treated between 1980 and 1987. The harness was applied immediately after the diagnosis. Group B consisted of 80 patients (91 hips) who were treated between 1988 and 1992. These patients received preliminary traction, and small pillows supported the lower extremities from just above the knee to the foot to prevent extreme abduction when the
harness was applied. When the distance from the middle point of the proximal metaphyseal border of the femur to the Y-line distance “a”) was 8 mm or more on the initial X-ray picture,the rate of avascular necrosis in group A was 11% and that in group B was 0%; the difference was significant. However,
when distance “a” was less than 8 mm, the rate of avascular necrosis in group A was 13% and that in group B was 12%, and there was no significant difference. Thus, we suggest that the Pavlik harness is indicated for developmental dysplasia of t he hip in which distance “a” is 8 mm or more. Traction should precede application of the harness, and pillows placed under the thigh must be used during application.

 

4.)Copyright 983 by The Journal of Bone and Joint Surgery. Incorporated 760 THE JOURNAL OF BONE AND JOINT SURGERY
Treatment of Congenital Dislocation of the Hip by the Pavlik Harness
MECHANISM OF REDUCTION AND USAGE bY KATSURO IWASAKI, M.D.*, NAGASAKI CITY, JAPAN
From the Department of Orthopaedic Surgery, Nagasaki University School of Medicine, Nagasaki City

ABSTRACT: The Pavlik harness was used in the treatment of complete congenital dislocation of one or both hips in a series of infants, on either an outpatient or an inpatient basis. The results in the two groups were compared. For the children treated as outpatients the incidence of avascular necrosis of the femoral head was 7.2 per cent and for the group treated as inpatients the rate was 28 per cent. Application of the Pavlik harness allowed reduction of the hip by shifting the femoral head first to the posterior part of the acetabulum through fiexion of the hip, followed by
movement of the femoral head anteriorly into the acetabulum through abduction of the hip, which is possible because of stretching of the adductor muscles by the weight of the lower extremity. When the reduction i s obtained by forced abduction there is a greater danger of avascular necrosis of the femoral head.

5)

Failure of the Pavlik Harness

The Pavlik Harness fails in approximately 40% of "Ortolani Positive" hip dislocations. These are hips that are dislocated at birth but can be put back into the socket during examination. The Pavlik Harness is used instead of a cast or more rigid immobilization in an attempt to hold the hip in the joint until the hip becomes stable. A recent scientific publication by KK White, et.al. have identified a possible ultrasound finding that may predict failure of the Pavlik Harness. Such a finding would allow earlier change to a different, and hopefully more successful, form of treatment.[9]

 
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