Children’s Hospital of Philadelphia (CHOP) is proud to offer a dedicated Hip Disorders Program that specializes in diagnosing and treating all pediatric hip disorders. While many programs across the country can help patients with mild developmental dysplasia of the hip (DDH), CHOP’s program offers support to orthopedic specialists around the country and a full range of advanced treatment options for your most complex DDH patients.
Wudbhav N. Sankar, MD, a nationally recognized leader in pediatric hip disorders, recently sat down to discuss the advanced diagnostic testing available at CHOP that can help chart the best treatment approach for each child with DDH, four bracing options that avoid the need for surgery in more than 75% of patients, as well as determining when surgery is the best option,. Dr. Sankar heads up the Hip Disorders Program and is Director of the Young Adult Hip Preservation Program at CHOP.
Question: What bracing options are available for DDH at CHOP?
Answer: The Pavlik harness is the most widely used non-surgical treatment for infants with DDH in this country, but it doesn’t always work. At CHOP, we have been very successful at taking care of patients who have failed the Pavlik harness. Our goal is to rescue the hip before it has to go to surgery. We use three primary alternate braces within my practice:
- Ilfeld brace (dynamic Ilfeld hip abduction splint), which we’ve published quite a few papers on. Some other institutions use it, but very infrequently. I’ve found it to be a very useful second-line tool because it’s adjustable and you can ultrasound the patient in it to confirm the hip structure is in the correct position.
- Tubingen splint (Tubingen hip flexion and abduction orthosis), which is a commonly used brace in Germany.
- Rhino or “bucket” brace (hip abduction brace), which is a plastic brace that most specialists are familiar with, but don’t use as widely as the Pavlik harness.
Q: How is bracing for DDH different at CHOP?
A: We offer a wider range of devices than most centers and can avoid surgery in many patients. While it’s not totally unique to use such a wide variety of braces, it’s certainly less common. I had a patient about 6 weeks ago who had tried the Pavlik harness for 3 weeks, then quit. We were able to find another brace that worked better for this patient and their family – thus avoiding the need for surgery.
One of the unique things about our practice is that we offer ultrasound in our clinics. So, in real-time, we fine-tune brace adjustments under ultrasound which increases our success rate. Our non-operative approach is more varied, experienced and flexible.
Q: What are CHOP’s surgical patient volumes for DDH?
A: CHOP is the busiest program in the United States treating DDH. Hundreds of babies are referred to us each year and we treat patients from every region of the U.S.
While bracing is successful in more than 75 percent of these patients, sometimes it’s simply not enough. In these cases, we offer surgical treatment to place the femoral head more deeply into the acetabulum or to repair the angle of the hip socket.
One in every 1,000 babies with DDH will require surgical correction. We used to do 5-6 open reductions for dislocated hips a year. Today, we perform 45-50 of these surgeries. This doesn’t include the older patients we take case of who have shallow hip sockets but not dislocated hips.
Q: What drives CHOP’s positive surgical outcomes?
A: We have a very high surgical volumes for DDH, and that increase in volume drives better results for our patients.
One of the driving factors behind our success is that we have a dedicated hip dysplasia nurse, Meg Morro, BSN, RN, who spends a lot of time with families – both when they are getting fit for their harness or brace, and when they are going into surgery and will be fitted with a spica body cast post-op.
She does an immense amount of teaching and counseling in terms of practical issues like clothing and fitting the child with a spica cast into the car seat. She does a great job connecting new parents with others who have already gone through DDH surgery and post-op casting. This kind of personalized support can only be offered at a center with a very high volume of patients.
Q: How is CHOP’s surgical treatment for DDH unique?
A: Due to our lengthy experience treating infants with DDH, we offer several specialized services that have improved surgical outcomes and patient/family satisfaction.
These include:
- Spinal anesthesia for patients younger than 6 months who are undergoing DDH surgery. Spinal anesthesia has proven effective and reduces the risk of complications in very young children. However, the procedure must be completed more quickly, which is only possible with an experienced surgical team. General anesthesia is used for older children who have more developed lungs, and it is more versatile for patients with complex medical histories.
- Experienced cast technicians who put on the spica. Our techs apply one of these specialized casts every week – unlike other facilities that may only apply it 1-4 times a year.
- Standardized use of MRI after surgery to confirm blood flow to the hip is adequate for growth and healing. If blood flow is impeded, imaging can be used to guide adjustments to the hip joint in the spica cast post-op. CHOP is one of the few centers in the country that offers state-of-the-art perfusion MRI imaging after cast placement. This has drastically reduced the risk of avascular necrosis, the most concerning complication of DDH treatment.
- A dedicated post-op pathway that allows our team to ensure consistency. This pathway includes:
- One night in the hospital
- Imaging on the day of surgery
- Imaging at 3 weeks post-surgery
- Cast removal at 6-8 weeks
- Range of motion assessment 6 weeks after cast removal
Q: What DDH research is CHOP participating in?
A: Surgeons and researchers on our team are key members of several multi-center research groups investigating the cause of hip disorders and optimal outcomes. These groups include the International Hip Dysplasia Institute, the Academic Network of Conservational Hip Outcomes Research and the International Perthes Study Group.
Please reach out to me at SankarW@chop.edu if you would like to discuss a challenging case or have an interest in learning more about CHOP’s hip research with any of the organizations listed above.
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Children’s Hospital of Philadelphia (CHOP) is proud to offer a dedicated Hip Disorders Program that specializes in diagnosing and treating all pediatric hip disorders. While many programs across the country can help patients with mild developmental dysplasia of the hip (DDH), CHOP’s program offers support to orthopedic specialists around the country and a full range of advanced treatment options for your most complex DDH patients.
Wudbhav N. Sankar, MD, a nationally recognized leader in pediatric hip disorders, recently sat down to discuss the advanced diagnostic testing available at CHOP that can help chart the best treatment approach for each child with DDH, four bracing options that avoid the need for surgery in more than 75% of patients, as well as determining when surgery is the best option,. Dr. Sankar heads up the Hip Disorders Program and is Director of the Young Adult Hip Preservation Program at CHOP.
Question: What bracing options are available for DDH at CHOP?
Answer: The Pavlik harness is the most widely used non-surgical treatment for infants with DDH in this country, but it doesn’t always work. At CHOP, we have been very successful at taking care of patients who have failed the Pavlik harness. Our goal is to rescue the hip before it has to go to surgery. We use three primary alternate braces within my practice:
- Ilfeld brace (dynamic Ilfeld hip abduction splint), which we’ve published quite a few papers on. Some other institutions use it, but very infrequently. I’ve found it to be a very useful second-line tool because it’s adjustable and you can ultrasound the patient in it to confirm the hip structure is in the correct position.
- Tubingen splint (Tubingen hip flexion and abduction orthosis), which is a commonly used brace in Germany.
- Rhino or “bucket” brace (hip abduction brace), which is a plastic brace that most specialists are familiar with, but don’t use as widely as the Pavlik harness.
Q: How is bracing for DDH different at CHOP?
A: We offer a wider range of devices than most centers and can avoid surgery in many patients. While it’s not totally unique to use such a wide variety of braces, it’s certainly less common. I had a patient about 6 weeks ago who had tried the Pavlik harness for 3 weeks, then quit. We were able to find another brace that worked better for this patient and their family – thus avoiding the need for surgery.
One of the unique things about our practice is that we offer ultrasound in our clinics. So, in real-time, we fine-tune brace adjustments under ultrasound which increases our success rate. Our non-operative approach is more varied, experienced and flexible.
Q: What are CHOP’s surgical patient volumes for DDH?
A: CHOP is the busiest program in the United States treating DDH. Hundreds of babies are referred to us each year and we treat patients from every region of the U.S.
While bracing is successful in more than 75 percent of these patients, sometimes it’s simply not enough. In these cases, we offer surgical treatment to place the femoral head more deeply into the acetabulum or to repair the angle of the hip socket.
One in every 1,000 babies with DDH will require surgical correction. We used to do 5-6 open reductions for dislocated hips a year. Today, we perform 45-50 of these surgeries. This doesn’t include the older patients we take case of who have shallow hip sockets but not dislocated hips.
Q: What drives CHOP’s positive surgical outcomes?
A: We have a very high surgical volumes for DDH, and that increase in volume drives better results for our patients.
One of the driving factors behind our success is that we have a dedicated hip dysplasia nurse, Meg Morro, BSN, RN, who spends a lot of time with families – both when they are getting fit for their harness or brace, and when they are going into surgery and will be fitted with a spica body cast post-op.
She does an immense amount of teaching and counseling in terms of practical issues like clothing and fitting the child with a spica cast into the car seat. She does a great job connecting new parents with others who have already gone through DDH surgery and post-op casting. This kind of personalized support can only be offered at a center with a very high volume of patients.
Q: How is CHOP’s surgical treatment for DDH unique?
A: Due to our lengthy experience treating infants with DDH, we offer several specialized services that have improved surgical outcomes and patient/family satisfaction.
These include:
- Spinal anesthesia for patients younger than 6 months who are undergoing DDH surgery. Spinal anesthesia has proven effective and reduces the risk of complications in very young children. However, the procedure must be completed more quickly, which is only possible with an experienced surgical team. General anesthesia is used for older children who have more developed lungs, and it is more versatile for patients with complex medical histories.
- Experienced cast technicians who put on the spica. Our techs apply one of these specialized casts every week – unlike other facilities that may only apply it 1-4 times a year.
- Standardized use of MRI after surgery to confirm blood flow to the hip is adequate for growth and healing. If blood flow is impeded, imaging can be used to guide adjustments to the hip joint in the spica cast post-op. CHOP is one of the few centers in the country that offers state-of-the-art perfusion MRI imaging after cast placement. This has drastically reduced the risk of avascular necrosis, the most concerning complication of DDH treatment.
- A dedicated post-op pathway that allows our team to ensure consistency. This pathway includes:
- One night in the hospital
- Imaging on the day of surgery
- Imaging at 3 weeks post-surgery
- Cast removal at 6-8 weeks
- Range of motion assessment 6 weeks after cast removal
Q: What DDH research is CHOP participating in?
A: Surgeons and researchers on our team are key members of several multi-center research groups investigating the cause of hip disorders and optimal outcomes. These groups include the International Hip Dysplasia Institute, the Academic Network of Conservational Hip Outcomes Research and the International Perthes Study Group.
Please reach out to me at SankarW@chop.edu if you would like to discuss a challenging case or have an interest in learning more about CHOP’s hip research with any of the organizations listed above.
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