Dr. Rubin performs the following hip treatments:
- Congenital Hip Dysplasia
- Slipped Capital Femoral Epiphysis
- Hip Replacement
Pavlik harness is used as treatment for infants with hip dysplasia. It is usually suggested as the first stage in treatment. The Pavlik harness is fit to the baby and holds his or her hips in proper position. By flexing up the legs, and allowing the knees to fall outwards, the hips are held in proper position (approximately 100 degrees of flexion and 45 degrees of abduction). By doing so, this position maintains the proper position of the femoral head and allows for ‘tightening up’ of the ligamentous structures as well as for stimulation of normal formation and deepening of the hip socket. In turn the hip joint is properly reduced, and the hips will form normally.
The Pavlik harness is successful in approximately 90-95% of infants with hip dysplasia. The Pavlik harness is usually needed for approximately 6-12 weeks, as long as there is continued improvement seen on serial hip ultrasounds. If there is no improvement seen, the Pavlik harness will be discontinued, and it will be necessary to proceed with closed reduction and spica body casting (done in the operating room). Pavlik harnesses are ordinarily the first line of treatment for DDH in newborns and infants under six months of age.
The Pavlik harness is made of canvas straps, velcro and buckles. The harness is fitted and checked regularly by us and we also do a series of ultrasounds to track correction of the hip. Dr. Rubin is seen here holding Baby Kolby whom we are treating for hip dysplasia. Kolby is wearing the harness and has tolerated this very well. Behind Dr. Rubin and Kolby is our ultrasound machine that we use to monitor and assess the position of the hip in relation to the socket. One of the many benefits to ultrasound is that it uses soundwaves to effectively detect anatomical structures, therefore causing no exposure of radiation to your baby.
Developmental dysplasia of the hip is a condition seen in newborns. It affects approximately 1 in 1,000 newborn babies. Baby girls are more likely to be affected than baby boys. Babies who have a family member who had hip dysplasia are also more likely to have hip dysplasia. Also, babies who were breech during the pregnancy are more likely to have hip dysplasia.
Hip dysplasia is very important to catch as early as possible in life. If it is treated early, it is much easier to treat and the treatment is much more successful. If it is caught in the first six months of life it can be treated with a Pavlik Harness.
I usually give the Pavlik Harness 3 weeks to get the hip back in the correct position. I check to see if the Pavlik is working with weekly or every other week physical exams and ultrasounds and an occasional x-ray. If the Pavlik is successful (it is 90% of the time) then I leave it on for an additional 3 months. Then all that is needed is regular follow-up, which includes a periodic physical exam and an x-ray approximately every 3 months, for the next few years to make sure the hip continues to develop normally, which it usually does.
If the Pavlik does not get the hip reduced within 3 weeks, then I remove the Pavlik Harness and go to Plan B. Plan B is an arthrogram and closed reduction in the operating room under general anesthesia. An arthrogram is a procedure where I inject the hip with dye and move the hip under a ‘live’ x-ray machine. You may ask ‘Why do you need to inject the hip with dye?’ The reason is that most of the hip in a newborn is made of cartilage, and cartilage does not show up on an x-ray. So the dye, which does show up on an x-ray, outlines the cartilage and allows me to see where the hip is and whether it is in the right place, and whether it can be manipulated into the correct position. After the hip is manipulated into position, my assistant holds the hip in that position while I place a spica cast. A spica cast is a full body cast from the chest down to the ankles.
If I am not able to manipulate the hip into the correct position, then I need to open the hip. This requires an incision in the groin. By the way, the groin incision usually ends up being very cosmetic. In most cases you cannot even notice this incision after a few months. After opening the hip up, I remove several obstacles which are blocking the ball from getting in the right position next to the socket. Once these obstacles are removed I can put the ball in the socket and close the soft tissues and the skin and then put a spica cast on.
Please see our section on Spica Cast Care if your baby is going to have a spica cast after surgery.
Slipped Capital Femoral Epiphysis
Slipped Capital Femoral Epiphysis (SCFE for short, pronounced “skiffy”) is an uncommon condition where the ball of the hip joint falls off the femur, or thigh bone. It can cause hip or knee pain and can cause a limp. In chronic cases the foot will point outward while the patient is walking. It usually happens in adolescents between the ages of 10 and 16 years old. When one hip is affected by slipped capital femoral epiphysis, almost half the time the other hip will eventually be affected. It happens more commonly in males than females, and is more common in adolescents who are overweight.
SCFE is diagnosed with x-rays. If I suspect this condition, I will order AP and frog lateral x-rays of both hips. I describe the condition to my patients and their parents in the following way: think of the hip joint as a ball and socket. The ball part sits on the thigh bone like a scoop of ice cream sits on an ice cream cone. In a SCFE, the scoop of ice cream is falling off the cone. Once the condition is diagnosed, it is important that the child use crutches immediately and does not put weight on that leg.
This condition requires surgery. If surgery is not performed, the deformity can progess and the ball part of the hip joint can die. I have performed many of these surgeries. In the surgery I will place a screw across the growth plate which prevents the ball from falling off the thigh bone (prevents the scoop of ice cream from falling off the cone) any further. This also causes the growth plate to close down in the hip joint, a desired effect since that ensures that there will be no further slippage of the ball. I usually recommend to parents that I also do the same surgery on the other hip, even if there is no SCFE there, because of the significant chance it will develop on the other side. I can do both sides at the same time while the child is under one anesthetic. The procedure usually takes me about 20 minutes on each side, and the incision is only about a quarter of an inch long. The child gets to go home from the hospital the same day as the surgery in most cases. I like for the child to use crutches for about 6 weeks after surgery. As with any surgery, complications can occur but are uncommon. They include infection and problems with the ball part of the hip joint.
Most kids feel better than they did before surgery within about a week after surgery.
Dr. Rubin does hip replacement surgery. We evaluate patients with hip pain. This typically includes getting x-rays. If the pain is severe and there is arthritis seen on the x-rays, the patient may be a candidate for a hip replacement. Most patients are extremely happy with their hip replacement.
I enjoy hip replacement surgery because of the difference it can make in people’s lives. For my hip replacements, I use the Depuy metal on metal hips as I believe these last longer than the metal-plastic-metal hips. The day after surgery, a physical therapist in the hospital helps the patient walk. I give my patients a machine called a PCA, which is a pain pump. Every time the patient pushes a button, they get a shot of pain medicine which goes into their vein through the IV. Usually patients have the PCA for about 2 or 3 days after surgery in the hospital then get converted to oral pain medicines. By the time the patients leave the hospital, which is usually 4 days after surgery, they are able to walk on their own and do stairs. They have staples over the incision which are removed in my office about 2 weeks after surgery. I like my patients to keep their incisions dry for about 2 weeks after surgery, usually until the staples come out. I encourage my patients to walk as soon as they get home. For my hip replacement patients, they are instructed to avoid certain extreme positions. I allow my patients to go back to light to moderate sports about four months after hip replacement surgery.
SPICA Cast Care
Keeping the cast dry is very important. It prevents skin irritation and breakdown. It also prevents the cast from smelling. These steps and supplies have proven to be effective in preventing urine and stool from staining the cast.
- Place a maxi pad up under the cast, both front and back.
- Next fit a newborn diaper under the cast, tucked in the front, back and the sides.
- Place a larger sized diaper over top of the cast (Size #6).
It is very important to change the maxi pad and the inside diaper very frequently. They must be changed much more frequently than normal diapers must be changed. Do not allow them to go more than 2 hours at one sitting during the day without a change.