JBJS Classics: Congenital Dislocation of the Hip

OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Having passed the half-century mark with continued relevance, this classic JBJS article by T.G. Barlow, published in the British volume in 1962, rewards the reader with pearls and insights that can still help us make good decisions about treatment of infants with hip dysplasia. Exploring new approaches always pays rich dividends, and this report details Barlow’s observations from a five-year study (1957­­-1962) in which he examined all newborns at his hospital and followed them up at one year of age. This effort was undertaken at a time before the emerging field of pediatric orthopaedics had many full-time adherents.

Barlow studied nearly 10,000 newborns at the Hope Hospital in Manchester, England. He conducted the first examinations during the first week of life, in an era when newborns in the UK stayed in the hospital for at least one week. He carefully recorded his findings and made observations on incidence of hip dislocation, natural history, and treatment.

His first contribution, for which he is still remembered, was to show that in newborns, with their low resting muscle and tissue tension, the Ortolani test is often subtle, and a dislocated hip may escape notice. The Ortolani test was often impressive in older babies, but less so in newborns. Therefore, Barlow devised his eponymous test, which increases the proprioceptive feedback by applying axial pressure and provoking subluxation or dislocation. Simply put, it is often easier to feel the hip displacing with pressure than to feel it slip back in.  The number of babies who have benefited from this method of early detection is too numerous to count!

Barlow’s other observations are equally relevant and useful. He observed that many babies with dislocatable but non-dislocated hips will stabilize naturally. He showed that only one-eighth of unstable hips will have a persistent dislocation, which is why we now only treat dislocated hips immediately upon detection.  Recent articles¹ have added further insights in this regard.

Barlow also showed that with a program of screening and treatment, no patient in his experience presented at a year of age with a hip dislocation. We still debate the proper method of early detection, but he properly targeted the neonatal period as the time that instability usually begins. Barlow also demonstrated a simple abduction splint made of aluminum and leather that holds the hips in flexion and abduction. Although the Pavlik harness has become more popular as an initial treatment, experts have recently come to realize that a fixed-angle brace can benefit some children who do not stabilize in a Pavlik.²

This classic article was fun to re-read and remains useful to general and pediatric orthopaedic surgeons. Barlow’s disciplined undertaking has shaped our understanding of this important disorder. The man and his insights are remembered for good reason.

Paul D. Sponseller, MD
JBJS Deputy Editor

References

1. Upasani VV, Bomar JD, Matheney TH, Sankar WN, Mulpuri K, Price CT, Moseley CF, Kelley SP, Narayanan U, Clarke NM, Wedge JH, Castañeda P, Kasser JR, Foster BK, Herrera-Soto JA, Cundy PJ, Williams N, Mubarak SJ. Evaluation of Brace Treatment for Infant Hip Dislocation in a Prospective Cohort: Defining the Success Rate and Variables Associated with Failure. J Bone Joint Surg Am. 2016 Jul 20;98(14):1215-21

2. Sankar WN, Nduaguba A, Flynn JM. Ilfeld abduction orthosis is an effective second-line treatment after failure of Pavlik harness for infants with developmental dysplasia of the hip. J Bone Joint Surg Am. 2015 Feb 18;97(4):292-7.