Shortening subtrochanteric osteotomy and cup placement at true acetabulum in total hip arthroplasty of Crowe III-IV developmental dysplasia: results of midterm follow-up

Clinical efficacy of greater trochanter osteotomy with tension wire fixation in total hip arthroplasty for Crowe type IV developmental dysplasia of the hip

OBJECTIVE

The choice of osteotomy in joint replacement surgery for Crowe type IV developmental dysplasia of the hip (DDH) is a challenging and controversial procedure. In this study, we compared the clinical efficacy of a combination of greater trochanter osteotomy and tension wire fixation with that of subtrochanteric osteotomy.

METHODS

We performed 15 primary total hip arthroplasty (THA) procedures between January 2016 and July 2020 on 13 patients with a combination of greater trochanter osteotomy and tension wire fixation (the GTT group) and 12 THA procedures in 11 patients using subtrochanteric osteotomy (the STO group). The mean follow-up was 2.8 years (range 2.2-4.5 years) in the GTT group and 2.6 years (range 2.5-4.3 years) in the STO group. Clinical scores and radiographic results were evaluated during the final follow-up for the 15 hips in the GTT group and 12 hips in the STO group.

RESULTS

Postoperative Harris hip scores, implant position, and the surgery time did not differ between the treatment groups. There were no differences in preoperative leg length discrepancy LLD (P = 0.46) and postoperative LLD (P = 0.56) between the two groups. Bone union occurred within 6 months after surgery in 12 hips in the GTT group (92.3%) and in 9 hips (81.8%) in the STO group. One case in the GTT group and two cases in the STO group had nonunion, and additionally, there was one case of postoperative nerve injury in the STO group, while no symptoms of nerve damage were observed in the GTT group.

CONCLUSION

The GTT method demonstrated many advantages and reliable clinical results for Crowe type IV DDH patients undergoing THA. This is a surgical method that warrants further development and promotion clinically.

Mid-Term Outcomes of Cemented Stem and Subtrochanteric Shortening Derotational Osteotomy in Total Hip Arthroplasty for Crowe IV Developmental Dysplasia

OBJECTIVE

Performing subtrochanteric osteotomy with cemented components in patients with Crowe IV developmental dysplasia of the hip (DDH) is technically challenging and not widely reported. This study aimed to evaluate the mid-term outcomes of cemented stem total hip arthroplasty (THA) with subtrochanteric femoral shortening and transverse derotational osteotomy in patients with Crowe IV DDH.

METHODS

Data collected from patients with Crowe IV DDH who underwent cemented stem THA with subtrochanteric femoral shortening and transverse derotational osteotomy between 2010 and 2018 were retrospectively evaluated. The cemented Lubinus SP II femoral component and the cementless CombiCup acetabular component were used together in all cases. These data, including Harris hip scores, limb length discrepancy (LLD), severity of limp, Trendelenburg test, bone union, length of the resected femur, limb lengthening, level of the osteotomy site, and length bridging the osteotomy site, as well as complications, were analyzed. A paired Student t-test was used to analyze continuous variables, categorical data were compared using Fisher's exact probability test, and correlation analysis was performed using Spearman's rank correlation coefficient.

RESULTS

Among 14 included patients (10 females and four males), the mean age was 60.4 years (range, 47-73). The mean follow-up period was 49.1 months, and no patient was lost to follow-up. The mean Harris hip score improved from 40.7 to 87.7. The mean LLD decreased from 52 to 12.7 mm. The mean length of the excised femoral segment was 38.4 mm, and the mean length of limb lengthening was 27.1 mm. The mean distance between the osteotomy site and the lesser trochanter was 21.1 mm after surgery. The mean length of the femoral stem bridging the osteotomy site was 97.6 mm. Finally, the mean osteotomy union time was 10.6 months. No statistically significant correlation was found between the osteotomy union time and these factors. No neurological deficits were noted. Delayed union was observed in one patient, and postoperative dislocation was observed in two patients. Cement leakage into the osteotomy gap was observed in one patient, however, no revisions were required, and no signs of loosening or migration were observed.

CONCLUSIONS

Cemented stem THA combined with subtrochanteric femoral shortening and transverse derotational osteotomy is safe and effective in treating patients with Crowe IV DDH. Rather than leading to nonunion, cement leakage may negatively affect bone healing.

Total Hip Arthroplasty With Subtrochanteric Osteotomy for Developmental Hip Dysplasia: A Long-term Follow-up Study

Background

Total hip arthroplasty (THA) for developmental hip dysplasia (DDH) often requires a subtrochanteric shortening derotational osteotomy (SDO) to limit leg lengthening, mitigate risk of peripheral nerve palsy, and reduce excessive femoral anteversion. Few studies exist detailing long-term clinical outcomes and survivorship. The aim of this study is to analyze the long-term outcomes and survivorship of an SDO-THA cohort.

Methods

We retrospectively reviewed all patients who underwent cementless THA with femoral osteotomy due to Crowe I-IV DDH between 1991 and 2001. Primary outcome measures included revision surgery for any reason and functional outcome measures using modified Harris Hip scores. Secondary outcome measures included mode of implant failure and radiographic assessment for osteotomy union, polyethylene wear, osteolysis, and implant loosening.

Results

Our review resulted in 24 SDO-THA cases in 20 patients with a mean follow-up of 19 years (range, 8-27 years). Overall survivorship was 67%. All 8 failures were treated with acetabular revision at a mean time to revision of 11 years (range, 1-25 years). Of the failures, there were 5 cases due to polyethylene wear (62.5%), 2 cases due to acetabular loosening (25%), and 1 case due to recurrent instability (12.5%). The mean postoperative modified Harris Hip score was 76 (range, 52-91) with long-term improvement of 43 points maintained (P < .001).

Conclusions

THA with SDO can produce durable long-term outcomes for the patient with DDH. It is important to consider some common reasons for revision, namely polyethylene wear and osteolysis, acetabular loosening, and recurrent acetabular dislocations.

Cementless modular total hip arthroplasty with subtrochanteric transverse shortening osteotomy for high hip dislocations

Background

Performing a total hip arthroplasty for a high hip dislocation is technically demanding and presents several challenges, with appropriate evaluation of the bone morphology of the hip and proper implant selection being critical for successful outcomes.

Objective

The purpose of our study was to evaluate the clinical and radiographic outcomes of cementless modular total hip arthroplasty for the treatment of high hip dislocations with sub-trochanteric transverse shortening osteotomy.

Methods

Sixty-eight hips with a high hip dislocation, were treated using a sub-trochanteric transverse shortening osteotomy and cementless modular total hip arthroplasty, retrospectively reviewed. Hip function was assessed using the Harris hip score, with hip abduction strength evaluated using the Trendelenburg test. Radiographic assessment included the measurement of leg length discrepancy, identification of implant loosening, localization of the hip center, and union at the osteotomy site.

Results

The mean follow-up period was 12.9 (range 5.2–16.8) years. The mean Harris hip score improved from a pre-operative score of 48.6 ± 3.6 to 82.4 ± 4.2 (p < 0.05). The hip was within the true acetabulum in all patients, postoperatively. Osteotomy union was achieved in 67 of the 68 hips (98.5%) in a mean latency of 12.5 ± 0.6 weeks. The mean length of femoral shortening was 66.5 ± 4.5 mm, with a mean pull-down length of the proximal part of 35.5 ± 3.5 mm.

Conclusion

For the treatment of high hip dislocations with satisfactory clinical outcomes, the modular stem offers an adjustable anteversion angle to restore sufficient rotational stability and the transverse osteotomy provides sufficient compression pressure across the osteotomy site to facilitate union.

Trial registration It was a retrospective study and approved by Istanbul Research and Training Hospital institutional Ethics Review Board (772-05/02/2016).

Restoring Rotation Center in Total Hip Arthroplasty for Developmental Dysplasia of the Hip with the Assistance of Three Dimensional Printing Technology: A Pilot Study

Objective

To develop a new method to restore hip rotation center exactly and rapidly in total hip arthroplasty (THA) with the assistance of three dimensional (3D) printing technology and evaluate its clinical and radiological outcomes.

Methods

From March 2014 to July 2018, a total of 17 patients (five hips of four men and 16 hips of 13 women) with end‐stage osteoarthritis secondary to developmental dysplasia of the hip who underwent THA were analyzed and followed up retrospectively. The average age is 58.00 ± 8.12 years (range from 45 to 71 years). Simulated operations were performed on 3D printed hip models for preoperative planning. The morphology of Harris fossa and acetabular notches were recognized and restored to locate the acetabular center. The size of bone defect was measured by the bone wax method. The agreement on the size of acetabular cup and bone defect between simulated operations and actual operations were analyzed. Harris Hip Score (HHS) was used to evaluate the recovery of hip joint function. The vertical distance and horizontal distance of the rotation center on the pelvis plain radiograph were measured, which were used to assess the efficacy of restoring hip rotation center and acetabular cup migration.

Results

The mean sizes of bone defect in simulated operations and THA were 4.58 ± 2.47 cm² and 4.55 ± 2.57 cm² respectively. There was no significant difference statistically between the sizes of bone defect in simulated operations and the actual sizes of bone defect in THA (t = 0.03, P = 0.97). The sizes of the acetabular cup of simulated operations on 3D print models showed a high rate of coincidence with the actual sizes in the operations (ICC = 0.93). All 17 patients were available for clinical and radiological follow‐up. The average follow‐up time was 18.35 ± 6.86 months (range, 12–36 months. The average HHS of the patients was improved from (38.33 ± 6.07) preoperatively to the last follow‐up (88.61 ± 3.44) postoperatively. The mean vertical and horizontal distances of hip rotation center on the pelvic radiographs were restored to 15.12 ± 1.25 mm and 32.49 ± 2.83 mm respectively. No case presented dislocation or radiological signs of loosening until last follow‐up.

Conclusions

The application of 3D printing technology facilitates orthopedists to recognize the morphology of Harris fossa and acetabular notches, locate the acetabular center and restore the hip rotation center rapidly and accurately.

The Influence of Femoral Proximal Medullary Morphology on Subtrochanteric Osteotomy in Total Hip Arthroplasty for Unilateral High Dislocated Hips

Objective

To evaluate the predictive values of femoral proximal medullary morphology for the use of subtrochanteric osteotomy (STO) in unilateral Crowe IV developmental dysplasia of the hip (DDH).

Methods

Ninety four patients with unilateral Crowe type IV DDH (59 hips in STO group and 35 hips in the non‐STO group) between April 2008 and June 2019 were enrolled. All patients underwent THA using the Pinnacle acetabular shell, ceramic liner and femoral head, the S‐ROM stem with proximal sleeve. Three parameters on the standard anteroposterior hip radiographs were measured: the widths of medullary canals at 20 mm above the center of lesser trochanter (CLT)，20 mm below the CLT and the isthmus. Canal flare index (CFI), metaphyseal canal flare index (MCFI), diaphyseal canal flare index (DCFI) were calculated. A S‐ROM femoral stem was used in all patients during total hip arthroplasty (THA).

Results

The CFI and DCFI in the STO group were lower than those in the non‐STO group. However, there was no statistical difference in MCFI between the two groups. The receiver operating characteristic (ROC) curves shown that DCFI had the highest area under the curve (AUC), at 0.885. This was followed by the CFI, which had an AUC of 0.847. The AUC of MCFI was 0.579. The optimal threshold for DCFI was 1.44, which lead to a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 0.771, 0.898, 0.869, and 0.818, respectively. For CFI, the optimal threshold was 3.28, resulting in a sensitivity, specificity, PPV, and NPV of 0.829, 0.729, 0.878, and 0.644, respectively.

Conclusions

The DCFI and CFI may be potent indicators in predicting the use of STO in unilateral Crowe IV DDH. The optimal threshold for CFI and DCFI were 3.28 and 1.44 and had good sensitivity and specificity for predicting the use of STO during THA.

Total Hip Replacement in Developmental Hip Dysplasia: A Narrative Review

The reconstruction of the hip joint in patients suffering from developmental hip dysplasia (DDH) is a demanding procedure and presents many challenges to the reconstructive surgeon. Higher rates of mechanical complications are present in this group of patients. The results of cemented and uncemented implants used in DDH patients are very promising, according to recent outcomes. However, the surgeon has to be aware of several complications, in order to establish an uneventful surgical management of DDH. The specific article investigates the technical challenges and clinical results of total hip arthroplasty in patients with DDH.

Novel 3D printed integral customized acetabular prosthesis for anatomical rotation center restoration in hip arthroplasty for developmental dysplasia of the hip crowe type III: A Case Report

RATIONALE

Exact restoration of the rotation center in total hip arthroplasty (THA) is technically challenging in patients with end-stage osteoarthritis due to developmental dysplasia of the hip (DDH), especially in the Crowe type II and III procedures. The technical difficulty is attributable to the complex acetabular changes. In this study, a novel 3-dimensional (3D) printed integral customized acetabular prosthesis for anatomical rotation restoration in THA for DDH Crowe type III was developed using patient-specific Computer-aided design and additive manufacturing (AM) methods.

PATIENT CONCERNS

A 69-year-old female patient had developed left hip joint pain and restricted movement for 40 years; the symptoms had increased in the past 5 months. Pain, limited motion of the left hip joint, and lower limb length discrepancy were noted during physical examination.

DIAGNOSIS

The patient was diagnosed with left hip end-stage osteoarthritis secondary to DDH (Crowe type III).

INTERVENTION

A 3D printed acetabulum model was manufactured and a simulated operation was performed to improve the accuracy of reconstruction of the rotation center and bone defect. A 3D printed titanium alloy integral customized acetabular prosthesis was designed according to the result of simulated operation. The integral customized prothesis was implanted subsequently via the posterolateral approach. Radiography of the pelvis and Harris score assessment were performed during the perioperative period as well as at the 6- and 12-month follow-up.

OUTCOMES

The 3D printed integral customized acetabular prosthesis matched precisely with the reamed acetabulum. The rotation center was restored and the bone defect was exactly reconstructed. There were no signs of prosthetic loosening at the 12-month follow-up. The Harris score gradually improved during the follow-up period.

LESSONS

Satisfactory results of hip rotation restoration and bone defect reconstruction could be achieved by using 3D printed integral customized acetabular prosthesis, which provides a promising way to reconstruct the acetabulum in patients with DDH anatomically and rapidly for THA.

Long-term results of total hip arthroplasty in developmental dysplasia of hip patients

Objectives

This study aims to report the physiological and radiological long-term results of total hip arthroplasty (THA) combined with or without subtrochanteric osteotomy in a group of developmental dysplasia of hip (DDH) patients.

Patients and methods

This retrospective study included 90 hips of 59 patients (3 males, 56 females; mean age 45.7±10.9 years; range, 24 to 67 years) who underwent THA between January 1979 and March 2006. Thirteen patients needed subtrochanteric shortening. The evaluation was performed through Harris hip scores, physical examination, and radiological imaging.

Results

The follow-up period ranged from 5 to 32 years, and the mean follow-up period was 10.3±6.4 years. Revision was required in 17 hips out of 90. Twelve revisions were needed because of aseptic loosening of femoral or acetabular component, three were for fracture of the femoral stem, and two for protrusio acetabuli. Four patients had transient nerve palsy, and one had permanent nerve function loss. In one patient, nonunion was observed around the femoral osteotomy site. Harris hip score was remarkably improved compared to top preoperative values (48 vs. 88.2, p<0.01).

Conclusion

Although revision rates tend to increase in long-term follow-up, THA is one of the best treatment options in DDH patients to relieve pain, improve daily activity levels, and minimize the damage of the knee and lumbar region.

Leg Length Balance in Total Hip Arthroplasty for Patients with Unilateral Crowe Type IV Developmental Dysplasia of the Hip

Objective

To explore the leg length balance in total hip arthroplasty (THA) with shortening subtrochanteric osteotomy (SSTO) or not for unilateral Crowe type IV developmental dysplasia of the hip (DDH) through the evaluation of postoperative full‐length anteroposterior radiographs.

Methods

The postoperative radiographs of 60 patients with unilateral Crowe type IV DDH from July 2012 to May 2019 were retrospectively reviewed. All patients underwent THA using the Pinnacle Acetabular Cup system, a ceramic liner and femoral head, and the S‐ROM stem with a proximal sleeve or cone. Patients with leg length discrepancy (LLD) < 10 mm were defined as the non‐LLD group. To identify differences associated with SSTO, the group was further divided into two groups based on whether the patient underwent SSTO. A total of 48 patients (26 for SSTO and 22 for non‐SSTO) were in the non‐LLD group. There were 3 male and 45 female patients. The mean age of the patients in the non‐LLD group was 39 years. These data, including leg length, femoral length, the height of center of rotation (COR) of the hip, the depth of the sleeve or cone in the femoral medullary canal and the height of the greater trochanter, were measured.

Results

In the non‐LLD group, the femoral lengths in both SSTO and non‐SSTO groups were significantly shorter on the operated side compared with the contralateral side, and the mean discrepancy in the SSTO group was approximately equal to the mean length of the SSTO. The mean height of the COR of the hip on the operated sides in both SSTO and non‐SSTO groups was 13.2 mm, and the contralateral sides were 15.2 and 15.5 mm, respectively. The depth of the sleeve or cone in the femoral medullary canal between SSTO and non‐SSTO groups was 21.7 and 30.6 mm, respectively. The depth of the sleeve or cone in the SSTO group was negatively correlated with the length of SSTO. The heights of the greater trochanter in the operated and contralateral sides were 5.3 and 16.6 mm in the SSTO group, and 13.2 and 17.2 mm in the non‐SSTO group, respectively.

Conclusions

Shortening subtrochanteric osteotomy led to femoral shortening on the operated side for patients with unilateral Crowe type IV DDH. The position of the sleeve or cone should be close to the apex of the greater trochanter to compensate the length of the SSTO. The position of the sleeve or cone without SSTO should be adjusted to make sure that the height of the greater trochanter on the operated side is close to that on the contralateral side.

Total Hip Arthroplasty for Crowe Type IV Hip Dysplasia: Surgical Techniques and Postoperative Complications

Total hip arthroplasty (THA) of Crowe type IV developmental dysplasia of the hip (DDH) is challenging. Although traditional (lateral, posterolateral, and posterior) THA approaches have been used with great anatomic success, they damage periarticular muscles, which are already quite weak in type IV DDH. The recently developed direct anterior approach (DAA) can provide an inter‐nerve and inter‐muscle approach for THA of type IV dysplasia hips. However, femur exposure with the DAA could be difficult during surgery and it is hard to apply femoral shortening osteotomy. THA techniques used for type IV DDH include anatomic hip center techniques (true acetabular reconstruction) and high hip center techniques, wherein an acetabulum is reconstructed above the original one. Although anatomic construction of the hip center is considered “the gold standard” treatment, it is impossible if the anatomical acetabular is too small and shallow. Procedures used to support type IV DDH reduction with anatomic hip center techniques include greater trochanter osteotomy, lesser trochanter osteotomy, and subtrochanteric osteotomy. However, these techniques have yet to be standardized, and it is unclear which is best for type IV DDH. One‐state and two‐state non‐osteotomy reduction techniques have also been introduced to treat type IV DDH. Potential complications of THA performed in patients with type IV DDH include leg length discrepancy (LLD), peri‐operative femur fracture, nonunion of the osteotomy site, and nerve injury. It is worth noting that nowadays an increasing number of Crowe type IV DDH patients are more sensitive to postoperative LLD.

Primary Total Hip Arthroplasty in Severe Dysplastic Hip Osteoarthritis With a Far Proximal Cup Position

BACKGROUND

Developmental hip dysplasia is the most common cause of secondary hip osteoarthritis. Due to severe acetabular bone deficiency, cup positioning in total hip arthroplasty (THA) of dysplastic hips remains a surgical challenge. The aim was to analyze the functional outcome of far proximal cup positions in primary THA.

METHODS

Fifty patients (61 hips) with THA for severe dysplastic osteoarthritis and a far proximal cup position were included. Patients were divided according to the heights of the implanted cups with increasing vertical distance from the interteardrop line (group A: 55-65 mm, group B: 65-75 mm, group C: >75 mm). Functional outcome was assessed at latest follow-up (38 ± 16 months) by Lower Extremity Functional Score, Tegner Activity Score, and Harris Hip Score (HHS). Patients answered a Patient Satisfaction Questionnaire. Leg length discrepancy was estimated radiographically.

RESULTS

The Lower Extremity Functional Score significantly decreased in C (45.3 ± 25) compared to A (66.7 ± 15.3) and B (67.9 ± 9.9). The Tegner Activity Score significantly increased in all subgroups from preoperative to postoperative (2.2 ± 1.3 to 4.1 ± 1.4; P < .05). The mean overall HHS was 89.3 ± 14.7 (A: 89.5 ± 14.3, B: 94.3 ± 6.5, C: 78.3 ± 22.1). The HHS domains of activity of daily life and gait were significantly reduced in C (P < .05). Patients described a high satisfaction level with the surgery. No significant differences were found with regard to preoperative and postoperative leg lengthening (P = .881). Neither dislocations, impingement problems nor neurologic complications were observed.

CONCLUSION

Primary THA without any concomitant surgical interventions with a far proximal cup position offers a safe and effective treatment option in severe dysplastic hip osteoarthritis.

[Challenges of primary hip arthroplasty with high hip dislocation]

BACKGROUND

Endoprosthetic care of high hip dislocation is a surgical challenge. The hip anatomy is greatly altered in these patients, including a rather flat and small acetabulum with impaired bone quality and a relevant chance of a bony defect of the acetabular roof. Additionally, the front coverage and in some cases even the dorsal coverage of the hip are missing. The proximal femur is characterized with an increased antetorsion, a coxa valga position and an enlarged greater trochanter. The medullary cavity is narrowed, the offset is reduced, and the absolut leg length can be enlarged. Further anatomic variations can have been caused by previous surgeries.

AIM OF THE TREATMENT

The goal of the endoprosthetic care is the re-creation of a hip with an anatomic center of rotation, an anatomic offset and equal leg length.

TREATMENT

This can be achieved by a medial shift of the acetabular cup. An acetabular osteotomy including central cancellous bone graft or a bony graft to reinforce the acetabular roof might be necessary. In cases in which an anatomic acetabular cup placement is not possible, a more cranial placement can be done. Further strategies that are essential in several cases are shortening or re-orientation osteotomies of the femur, reaming of the medullary cavity and correct implant selection. Additionally, thorough soft tissue management is of main importance. Generally, the surgery should be well prepared preoperatively.