Results of total hip arthroplasty differ in subtypes of high dislocation

Primary Staged Bilateral Total Hip Arthroplasty in a Patient With Short Stature and Hartofilakidis Type I Developmental Dysplasia of the Hip

Syndromes associated with osteochondrodysplasia, short stature, and DDH are rarely reported in the literature. Total hip arthroplasty (THA) in such cases is a complex procedure with a high rate of complications and difficulties. In this case report, we describe the staged bilateral complex primary THA of a patient with the rare occurrence of a syndrome involving osteochondrodysplasia and DDH, highlighting the surgical challenges and importance of the right prosthesis selection.

Total Hip Arthroplasties for Hartofilakidis Type C1 and C2 High Hip Dislocations Demonstrate Similar Survivorship and Clinical Function at Minimum 10-year Follow-up With Cementless Implants

BACKGROUND

This study aimed to determine the differences in survivorship, clinical function, and complications among patients who have Hartofilakidis Type C1 or C2 developmental dysplasia of the hips and underwent total hip arthroplasty (THA) with cementless implants.

METHODS

This retrospective study identified 84 Hartofilakidis Type C hips that underwent THA between 2002 and 2011 with a minimum 10-year follow-up (mean, 13 years, range, 10 to 19 years). Survivorship, latest Harris Hip Scores and satisfaction levels, radiographic outcomes (eg, implant stability, rate and length of subtrochanteric shortening transverse osteotomy, leg-length discrepancy, cup position, and orientation), as well as complications (eg, dislocation, periprosthetic fracture, periprosthetic joint infection) were compared to analyze the differences between Hartofilakidis C1 and C2 hips.

RESULTS

Between C1 and C2 hips, no difference existed in the 15-year cumulative Kaplan-Meier survivorship, with the endpoint defined as any reoperation (93.1 versus 90.8%), aseptic loosening combined with periprosthetic joint infection (93.1 versus 96.2%), or aseptic loosening (94.8 versus 96.2%), latest Harris Hip Score (87.1 versus 86.1%), vertical (6.1 versus 6.0 mm) and horizontal (11.5 versus 10.3 mm) distance to the anatomic center of rotation, postoperative leg length discrepancy (11.2 versus 15.5 mm), dislocation (5.2 versus 11.5%), stem aseptic loosening (6.9 versus 7.7%), periprosthetic fracture (3.4 versus 7.7%), and intraoperative femoral fracture (32.8 versus 23.1%). However, Type C2 hips demonstrated more severe preoperative leg length discrepancy (66.9 versus 42.5 mm) and required a higher percentage of subtrochanteric shortening transverse osteotomies (84.6 versus 36.2%) that were longer (33.7 versus 26.47 mm) than the Type C1 hips.

CONCLUSION

With cementless cups positioned near the anatomic acetabular center and cementless stems combined with subtrochanteric shortening transverse osteotomies, THAs for the Hartofilakidis Type C1 and C2 hips demonstrated similar survivorship, clinical function, and complications.

[Long-term effectiveness of total hip arthroplasty for Crowe type developmental dysplasia of the hip]

Objective

To investigate the long-term effectiveness of primary total hip arthroplasty (THA) in treatment of Crowe type Ⅳ developmental dysplasia of the hip (DDH).

Methods

A clinical data of Crowe type Ⅳ DDH patients treated with primary THA between January 2002 and August 2008 and followed up more than 13 years was retrospectively analyzed. Forty-two patients (45 hips) met the selection criteria and were enrolled in this study. There were 13 males and 29 females with an average age of 43.5 years (range, 18-65 years). There were 39 patients of unilateral hip and 3 of bilateral hips. The preoperative Harris score was 38.3±10.7 and leg length discrepancy of the patients treated with unilateral THA was (50.52±24.51) mm. During operation, 19 hips underwent subtrochanteric shortening osteotomy, with an average length of 25 mm (range, 15-35 mm). The Harris score, subjective satisfaction, prosthesis survival rate, complications, and related imaging indicators were summarized.

Results

All patients were followed up 13.0-19.6 years (mean, 15.0 years). The complications included 1 hip of femoral nerve palsy, 2 hips of dislocation, 1 hip of periprosthetic fracture, 1 hip of periprosthetic joint infection. At last follow-up, the Harris score was 82.1±9.3, which significantly improved when compared with preoperative one ( t=-21.885, P=0.000). The subjective satisfaction was evaluated as very dissatisfactory in 3 hips, dissatisfactory in 1 hip, generally in 4 hips, satisfactory in 17 hips, and very satisfactory in 20 hips. X-ray films showed that the height of the greater trochanter of affected side was 3.01-51.60 mm (mean, 23.22 mm); the descending distance of greater trochanter was 3.95-98.06 mm (mean, 48.20 mm); the affected limb lengthened 3.95-61.63 mm (mean, 34.92 mm); the leg length discrepancy of patients treated with unilateral THA was (12.61±8.56) mm, which was significantly shorter than that before operation ( t=11.721, P=0.000). The vertical distance between the center of rotation of the affected side and the teardrop line was (14.65±6.16) mm, and the difference was not significant when compared with (15.60±4.99) mm of the healthy side ( t=-0.644, P=0.525); the horizontal distance was (22.21±5.14) mm, and the difference was significant when compared with (34.48±5.63) mm of the healthy side ( t=-12.973, P=0.000). Except for the non-union of 1 hip subtrochanteric shortening osteotomy, the other subtrochanteric osteotomies healed well. During follow-up, all the femoral stems obtained bone ingrowth fixation without radiolucent line or radiopaque line. With any reoperation and aseptic loosening as the endpoint, the prosthetic survival rates were 88.64% [95% CI (63.73%, 96.82%)] and 89.19% [95% CI (65.61%, 96.94%)], respectively.

Conclusion

For Crowe type Ⅳ DDH patients, primary THA combined with subtrochanteric shortening osteotomy if necessary, can obtain satisfactory long-term effectiveness and prosthetic survival rate.

Three-dimensional morphological study of the proximal femur in Crowe type IV developmental dysplasia of the hip

Background

When performing femoral reconstruction in patients with Crowe type IV developmental dysplasia of the hip (DDH), anatomical deformity presents many technical challenges to orthopedic surgeons. The false acetabulum is suggested to influence load transmission and femoral development. The aim of this study was to describe the morphological features of dysplastic femurs in Crowe type IV DDH and further evaluate the potential effect of the false acetabulum on morphological features and medullary canal of Crowe type IV femurs.

Methods

We analyzed preoperative computed tomography scans from 45 patients with 51 hips (25 hips without false acetabulum in the IVa group and 26 hips with false acetabulum in the IVb group) who were diagnosed with Crowe type IV DDH and 30 normal hips in our hospital between January 2009 and January 2019. Three-dimensional reconstruction was performed using Mimics software, and the coronal femoral plane was determined to evaluate the following parameters: dislocation height, dislocation ratio, height of the femoral head (FH), height of the greater trochanter (GT), GT–FH height discrepancy, height of the isthmus, neck-shaft angle, femoral offset and anteversion of the femoral neck. The mediolateral (ML) width, anterolateral (AP) width and diameter of medullary canal of the proximal femur were measured on the axial sections. Further, canal flare index (CFI), metaphyseal-CFI and diaphyseal-CFI were also calculated.

Results

Compared with the normal femurs, the Crowe type IV DDH femurs had a higher femoral head, larger GT–FH height discrepancy, larger femoral neck anteversion, higher isthmus position and smaller femoral offset. Dislocation height and dislocation rate were significantly larger in the IVa DDH group (65.34 ± 9.83 mm vs. 52.24 ± 11.42 mm). Further, the IVb femurs had a significantly lower isthmus position, larger neck-shaft angle and smaller femoral neck anteversion than IVa femurs. The ML, AP canal widths and the diameter of medullary canal in both DDH groups were significantly smaller than the normal group. Dimensional parameters of IVa femurs were also narrower than IVb femurs in most sections, but with no difference at the level of isthmus. According to the CFIs, the variation of proximal medullary canal in IVb femurs was mainly located in the diaphyseal region, while that in IVa femurs was located in the whole proximal femur.

Conclusions

High dislocated femurs are associated with more anteverted femoral neck, smaller femoral offset and narrower medullary canal. Without stimulation of the false acetabulum, IVa DDH femurs were associated with higher dislocation and notably narrower medullary canal, whose variation of medullary canal was located in the whole proximal femur.

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.

Can a surgeon predict the longevity of a total hip replacement?

INTRODUCTION

The purpose of this study was to examine the ability of a surgeon to predict survival of a total hip replacement (THR) based on the patient's diagnosis, demographics, postoperative activity level and the surgical technique.

METHODS

4 experienced hip surgeons were asked to predict the longevity of 131 Charnley THRs, performed by the senior author (GH) 22-35 years ago, by providing them with pre- and postoperative radiographs, and data concerning patient's diagnosis, demographics, postoperative activity level and the surgical technique. This process was repeated 3 months later.

RESULTS

There was only a slight agreement between the majority of the predictions and actual outcome. The inter-observer agreement was also slight and intra-observer agreement ranged from slight to moderate.

CONCLUSION

We confirmed that surgeons are unable to determine the life expectancy of the implants of a THR, based on the aforementioned data, because there are other non-identified factors that affect the survivorship of a THR. For this reason, regular follow-up remains the safest way to evaluate patients' clinical picture and the evolution of radiographic changes, if there are any, in order to accurately advise patients and decide on the appropriate time for revision.

Three-dimensional femoral morphology in Hartofilakidis type C developmental dysplastic hips and the implications for total hip arthroplasty

PURPOSES

The aim of this study was to describe and compare the femoral morphologies of Hartofilakidis types C1 and C2 developmental dysplasia of the hip (DDH), and discuss the potential influence on subsequent total hip arthroplasty (THA).

METHODS

We analyzed preoperative CT data from 81 patients (42 C1 and 39 C2 subtypes) who underwent THA for arthritis secondary to Hartofilakidis type C DDH. The CT data was three-dimensionally reconstructed and measured of following parameters: neck-shaft angle, femoral neck length, anteversion, medial inclination, femoral offset, height of the greater trochanter and femoral head, mediolateral (ML) and anteroposterior (AP) widths of the medullary canal. The canal flare indices and ML-to-AP ratio were further calculated. We also reviewed surgical and follow-up records to compare the different implants utilized and the clinical results between C1 and C2 hips.

RESULTS

The C2 femurs had a significantly lower neck-shaft angle (119.0° vs. 124.0°), shorter femoral neck (37.0 mm vs. 41.2 mm), larger medial cortical inclination (158.8° vs. 149.1°), and higher position of the greater trochanter. The C2 femurs were narrower and had a smaller canal flare index (2.88 ± 0.50) than C1 femurs (3.64 ± 0.69). The ML-to-AP ratio of the proximal femoral medullary canal was significantly smaller in the C2 group. Accordingly, C2 femurs required thinner stems, more non-sprouted sleeves, and had a higher rate and required a longer length of shortening osteotomies. At an average follow-up of 36.0 months, the C1 and C2 groups had a similar Harris Hip Score (83.5 ± 14.3 vs. 84.2 ± 9.8, P = 0.771) and no stem loosening occurred in either group.

CONCLUSION

C1 and C2 proximal femurs have substantial differences in the coronal, sagittal, and axial planes. In the setting of THA, C2 femurs may therefore require thinner stems, more non-sprouted sleeves, and have a higher rate and require a longer length of shortening osteotomies.

Risk of Dislocation After Total Hip Arthroplasty in Patients with Crowe Type IV Developmental Dysplasia of the Hip

Objective

To investigate whether the risk of dislocation after total hip arthroplasty (THA) in patients with Crowe type IV developmental dysplasia of the hip (DDH) is high and to further identify the risk factors for postoperative dislocation in these patients.

Methods

This retrospective cohort study reviewed Crowe type IV DDH patients undergoing THA between January 2009 and December 2017 in our institution. Each Crowe type IV DDH patient was matched with three Crowe type I, II, or III DDH patients according to gender, side and date of operation. The primary outcome of this study was postoperative dislocation after THA. Occurrence, rate, classification, treatment and outcome of dislocation were documented in detail for all patients. The dislocation rates were compared between Crowe type IV DDH patients and Crowe type I, II, or III DDH patients. Demographic data, implant factors, and surgical factors were compared between the dislocation and no dislocation groups. Multiple logistic regression analysis was used to determine the independent risk factors for dislocation in Crowe type IV hips.

Results

A total of 131 Crowe type IV hips were followed up for a mean of 76.5 ± 28.1 months. Three hundred and ninety‐three Crowe type I, II and III hips, including 261 type I hips, 94 type II hips, and 38 type III hips, were identified as controls and followed up for a mean of 76.4 ± 28.2 months. No significant difference was observed in follow‐up time between two groups (P = 0.804). One or more dislocations occurred in 22 of the 524 dysplasia hips (4.20%). Of the 22 dislocated hips, 20 hips (90.9%) were successfully managed with non‐operative treatment. Two patients (9.1%, one Crowe type I and one Crowe type IV) experienced recurrent dislocation and required revision surgery. Crowe type IV hips had a significantly higher postoperative dislocation rate than type I, II, and III hips (11.45% vs 1.78%, P < 0.001). The use of a 22‐mm femoral head (odds ratio [OR] = 23.55, 95% confidence interval [CI] = 1.901–291.788, P = 0.014), older age (OR = 1.128, 95% CI = 1.037–1.275, P = 0.031), and absence of false acetabulum (OR = 12.425, 95% CI = 1.982–77.879, P = 0.007) were identified as independent risk factors for dislocation in Crowe type IV hips.

Conclusions

Crowe type IV DDH patients were at a high risk of dislocation after THA, and using large femoral heads and improving abductor muscle strength may help decrease the rate of postoperative dislocation in such patients.

High congenital hip dislocation in adults - arthroplasty and functional results

Objective

Retrospective case–control study on the authors’ experience regarding arthroplasty in high congenital dislocations of the hip in adults.

Methods

Sample with 11 high congenital hip dislocations (Hartofilakidis type C) that occurred in seven patients, who were submitted to hip arthroplasty by the same surgeon and with the same surgical technique. Mean follow-up period was 4.32 ± 2.67 years (minimum one year) and all patients were evaluated by the same examiner.

Results

All the arthroplasties had cementless fixation, with application of screwed acetabular cups, conical femoral stems, and a metal-polyethylene articular pars. In every patient, shortening femoral osteotomies were performed at subtrochanteric or supracondylar locations. The mean Harris Hip Score at the last evaluation was 88.55 ± 4.50 (range 81–94). The mean time with high dislocation of the hip (42.91 ± 14.59 years, range 19–68) showed a significant inverse correlation with Harris Hip Score (r = 0.80; p = 0.003). All patients reported important relief of pain complaints and are capable of ambulation without any external support. In the unilateral dislocations, leg length discrepancies were fully corrected; in the bilateral cases, isometric limbs were achieved in all patients. All osteotomies consolidated, with a mean interval of 3.27 ± 0.47 months. There were complications in 18.18% of the sample: one iatrogenic intraoperative fracture of the greater trochanter and a transitory sciatic neurapraxia.

Conclusion

Despite being a demanding surgery with a reportedly high complication rate, total hip arthroplasty in high congenital dislocations, when properly indicated and technically correctly performed, allows an improvement in function and quality of life.

Reconstruction of the Acetabulum in Developmental Dysplasia of the Hip in total hip replacement

Developmental dysplasia of the hip (DDH) or congenital hip dysplasia (CDH) is the most prevalent developmental childhood hip disorder. It includes a wide spectrum of hip abnormalities ranging from dysplasia to subluxation and complete dislocation of the hip joint. The natural history of neglected DDH in adults is highly variable. The mean age of onset of symptoms is 34.5 years for dysplastic DDH, 32.5 years for low dislocation, 31.2 years for high dislocation with a false acetabulum, and 46.4 years for high dislocation without a false acetabulum. Thorough understanding of the bony and soft tissue deformities induced by dysplasia is crucial for the success of total hip arthroplasty. It is important to evaluate the existing acetabular deformity three-dimensionally, and customize the correction in accordance with the quantity and location of ace tabular deficiencies. Acetabular reconstruction in patients with DDH is challenging. Interpretation of published data is difficult and should be done with caution because most series include patients with different types of hip disease. In general, the complication rate associated with THA is higher in patients with hip dysplasia than it is in patients with osteoarthritis. Overall, clinical and functional outcomes following THA in patients hip dysplasia (DDH) differ from those treated for primary hip osteoarthritis, possibly due to the lower age and level of activity. Although function scores decline with age, the scores for pain and range of motion presented with a statistically significant improvement in the long-term.