Trochanteric osteotomy in total hip replacement for congenital hip disease

Surgical Outcomes of Total Hip Arthroplasty with Paavilainen Osteotomy in Patients Who Have High Developmental Hip Dislocation: Mean 4.4 Year Follow-Up

BACKGROUND

Although subtrochanteric osteotomy is a common procedure, the use of Paavilainen osteotomy combined with total hip arthroplasty (THA) for high developmental hip dislocation is less documented. This study assessed the efficacy and complications of this approach, with a particular focus on the risk factors for nonunion post-osteotomy.

METHODS

All patients who had high dislocated hip dysplasia who underwent combined THA and Paavilainen osteotomy, were retrospectively reviewed with over one year of follow-up. A total of 44 patients (51 hips) were included, with an average follow-up period of 4.4 years (range, 1.97 to 6.94). Anatomical data of the hip joints were measured on pre- and postoperative radiographs. Demographic data, Trendelenburg sign, complications related to this procedure, Harris Hip Score (HHS), and EuroQoL-5-Dimension 5-Level (EQ-5D-5L) health questionnaire were collected from the medical chart. Binary logistic regression analysis was used to identify predictors for bone nonunion.

RESULTS

Out of the 51 hips, eight displayed a positive Trendelenburg sign. Patients' HHS saw an improvement from 43.8 ± 11.8 preoperatively to 85.7 ± 11.1 at the latest follow-up (P < 0.001), accompanied by a substantial enhancement in the average EQ-5D-5L score from 0.38 ± 0.15 to 0.87 ± 0.13 (P < 0.001). Nonunion, as the most concerning complication, occurred in 12% (seven of 56) of osteotomy cases. The contact length between the osteotomy block and femoral cortex was a key risk factor for nonunion. The Receiver operating characteristic (ROC) analysis identified 2.15 centimeters (cm) as the critical bone contact length for healing.

CONCLUSIONS

Paavilainen osteotomy combined with THA and subtrochanteric osteotomy proved effective and less complex than other techniques for high-dislocation hip dysplasia. A bone contact length between the greater trochanteric fragment and the femoral cortex of less than 2.15 cm is a risk factor for nonunion.

Cementless Total Hip Arthroplasty With Paavilainen Femoral Shortening Osteotomy Can Provide Good Results at 10 Years in Patients Who Have Crowe IV Developmental Dysplasia of the Hip

BACKGROUND

The aim of this study was to present the clinical and radiologic results of primary total hip arthroplasty (THA) using the femoral shortening osteotomy technique described by Paavilainen in patients who have Crowe IV developmental dysplasia of the hip.

METHODS

We retrospectively analyzed the results of primary THA using the Paavilainen technique in 335 hips. The mean follow-up was 10.2 years. The degree of limp, leg-length discrepancy, and patient satisfaction were assessed. The Oxford Hip Score was used to examine functional outcomes. A number of radiographic parameters were also assessed.

RESULTS

The most common reason for revision surgery was nonunion of the distally advanced greater trochanter. This complication was observed in 22 hips (6.5%). The 10-year survival for acetabular components, it was 97.3%, and for femoral components was 98.7% with aseptic loosening as the end point, and 85.9% with reoperation for any reason as the end point. Patients demonstrated improved functional outcomes. The mean limb lengthening was 27.8 mm. Nonunion was more common if the contact length of the proximal femoral fragment with the lateral surface of the distal femoral fragment was less than 35 mm.

CONCLUSIONS

Cementless primary THA using the femoral shortening osteotomy technique described by Paavilainen in patients who have Crowe IV dysplasia of the hip demonstrates good clinical and radiologic postoperative results. If the contact between the fragments after osteotomy is less than 35 mm, there is a high risk of nonunion, and supplemental fixation may be warranted.

Subtrochanteric Shortening Osteotomy Provides Superior Function to Trochanter Slide Osteotomy in THA for Patients With Unilateral Crowe Type IV Dysplasia at a Minimum of 3 Years

BACKGROUND

Performing THA in patients with high-riding developmental dysplasia of the hip (DDH) is associated with serious complications and technical challenges. Various methods of shortening osteotomy are available to facilitate femoral head reduction during THA in patients with high-riding hips; subtrochanteric shortening osteotomy and trochanteric slide osteotomy plus proximal shortening are the most common techniques. However, which approach is superior remains a topic of controversy.

QUESTIONS/PURPOSES

(1) Is there any difference in clinical outcomes (defined as the Harris Hip Score [HHS] and residual limb length discrepancy) at a minimum of 3 years between subtrochanteric shortening osteotomy and trochanteric slide osteotomy in patients with Crowe Type IV DDH who underwent THA? (2) Is there any difference in the risk or type of complications between the two approaches?

METHODS

We performed a retrospective, comparative study of two groups (subtrochanteric shortening osteotomy versus trochanteric slide osteotomy) matched for sex and preoperative HHS at a minimum of 3 years of follow-up. Between 2010 and 2018, we performed 67 THAs in patients with unilateral Crowe Type IV DDH. During that time, we generally used a trochanteric slide osteotomy for THA in all patients with Crowe Type IV hips and performed subtrochanteric shortening osteotomy when a conical stem was not available. A total of 42% (28) had THA with subtrochanteric shortening osteotomy, and 58% (39) had THA with trochanteric slide osteotomy. Of those, 89% (25) and 74% (29), respectively, were accounted for with complete datasets for possible matching at a minimum of 3 years of follow-up. Patients were matched for gender and preoperative HSS (within 10 points), leaving 22 patients in each group (79% of the subtrochanteric shortening osteotomy group and 56% of the trochanteric slide osteotomy group) for evaluation and analysis. Age (42 versus 46 years), gender (female: 73% versus 73%), preoperative HSS (40 versus 40), and preoperative leg length discrepancy (5.9 versus 5.3 cm) were comparable between the two groups (p > 0.05). The trochanteric slide osteotomy group exclusively received Cone Wagner (Zimmer) implants (100%), while Corail (DePuy Synthes) implants (77%) were the most commonly used in the subtrochanteric shortening osteotomy group. HHS at a minimum of 3 years as well as the presence or absence of a limp and Trendelenburg sign, functional leg length discrepancy, nonunion, nerve palsy, and other surgical complications were recorded and compared between the groups based on data drawn from a longitudinally maintained institutional database.

RESULTS

At a mean follow-up of 73 months, improvement in HHS was greater in the subtrochanteric shortening osteotomy group than in the trochanteric slide osteotomy group (48 ± 4 points versus 36 ± 11 points, mean difference 12 points [95% CI 7 to 17 points]; p < 0.001). Although the preoperative leg length discrepancy was similar between the groups, there was a greater postoperative improvement in the subtrochanteric shortening osteotomy group (44 ± 8 mm and 38 ± 8 mm in the subtrochanteric shortening osteotomy and trochanteric slide osteotomy groups, respectively; p = 0.02). The risk of nonunion was higher with a trochanteric slide osteotomy than with a subtrochanteric shortening osteotomy (23% [5 of 22] versus 0% [0 of 22]; p = 0.048). Other complications, including intraoperative periprosthetic fractures, nerve palsy, heterotopic ossification, revision surgery, and dislocation, did not differ between the groups.

CONCLUSION

In patients with Crowe Type IV hips undergoing THA, surgeons might consider subtrochanteric shortening osteotomy rather than trochanteric slide osteotomy to minimize the risk of nonunion and achieve superior hip function. Better correction of leg length discrepancy may also be possible with subtrochanteric shortening osteotomy. The long-term survivorship of hips after these two techniques, as well as the influence of the specific anatomy of the proximal femur on the choice of technique, remain to be explored in future studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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.

Transverse subtrochanteric shortening osteotomy with double tension-band fixation during THA for Crowe III-IV developmental dysplasia: 12-year outcomes

BACKGROUND

When performing total hip arthroplasty in patients with severe developmental dysplasia, shortening the femur facilitates reduction while also preventing sciatic or crural nerve injury and excessive length of the operated limb. No consensus exists about the optimal type of implant and best internal fixation procedure, two parameters that directly govern the risk of the most common intraoperative and postoperative complications (diaphyseal fractures, dislocation, non-union). To minimise these risks, we developed a technique combining a transverse subtrochanteric shortening osteotomy, a long ovoid-profiled, cementless stem anchored in the metaphysis, and double tension-band wiring for internal fixation. The primary objective of this study was to evaluate the outcomes of this technique with emphasis on (i) complications and femoral implant survival, (ii) clinical outcomes (functional scores and lower-limb length inequality [LLLI]), and time to healing.

HYPOTHESIS

Our technique is associated with low rates of intraoperative and postoperative complications.

MATERIAL AND METHODS

This single-centre retrospective cohort study included patients who underwent THA with a transverse subtrochanteric shortening osteotomy and fixation using double tension-band wiring to treat severe (Crowe III or IV) developmental hip dysplasia. The femoral implant was a long, ovoid, cementless stem fully coated with hydroxyapatite. We collected the intraoperative and postoperative complications, survival, LLLI, functional scores (Harris Hip Score [HHS] and Forgotten Joint Score [FJS]), patient satisfaction, and radiographic outcomes.

RESULTS

The study included 31 hips in 25 patients. Two patients (2/31 hips, 6.5%) were lost to follow-up, leaving 29 hips for the analysis of postoperative outcomes. Mean follow-up was 13.7±4.2 years (range, 5.8-18.3 years). The four intraoperative complications (4/31, 12.9%) consisted fracture of the diaphysis (2/31, 6.5%), fracture of the greater trochanter (1/31, 3.2%), and sciatic nerve injury followed by a full recovery (1/29, 3.4%). The 8 (8/29, 27.5%) postoperative complications consisted of dislocation (2/29, 6.9%), stem subsidence (2/29, 6.9%), and non-union (4/29, 13.8%). Femoral implant survival at last follow-up was 87.1% (95% CI, 76.1-99.7). The mean HHS increased from 39.6±12.0 (range, 14-61) before surgery to 81.7±13.2 (range, 48-100) at last follow-up (p<0.01). The FJS at last follow-up indicated that the joint was forgotten in 14/29 (48.2%) cases and caused only acceptable symptoms in 9/29 (31.0%) of cases. Clinically significant (≥ 1cm) LLLI was present in 8/29 (27.6%) patients postoperatively compared to 19/29 (65.5%) preoperatively. The mean LLLI decreased from 20.8±19.7mm (range, 0-60mm) to 5.0±7.3mm (range, 0-30mm). Mean time to healing was 4.3±2.4 months (range, 2-11 months).

CONCLUSION

Regarding these complex procedures, this technique was associated with low rates of intraoperative fractures and early postoperative complications. However, femoral stem survival was shorter than in earlier studies and the non-union rate was high, despite satisfactory functional and clinical outcomes.

LEVEL OF EVIDENCE IV

Cerclage wire fixation of trochanteric osteotomies in complex hip revision: our experience and comparison with cable-plate fixation

INTRODUCTION

Osteotomy of the greater trochanter is a commonly used procedure in complex revision hip arthroplasty in order to achieve a wide exposure to the femoral stem and acetabular components. There is no clinical evidence in favour of a specific fixation method. The aim of this study was to compare cable-plate with figure-of-eight cerclage wire fixation in patients requiring a trochanteric "slide" osteotomy.

MATERIAL AND METHODS

In a retrospective study, 51 greater trochanteric "slide" osteotomies in complex acetabular revision arthroplasties were included. Patients were divided into 2 groups: 28 hips were fixed with 1 of 2 cable-plate systems (Dall-Miles staple, Stryker or Cable-Ready plate, Zimmer) and 23 with a figure-of-eight cerclage wire.Consolidation, osteolysis, migration of greater trochanter, bursitis of the trochanteric area, Trendelenburg gait and removal of osteosynthesis material were studied at 6 months follow-up.

RESULTS

Both groups showed good union rates. The lysis rate was similar with 32% in the cable-plate group versus 29% in the cerclage wire group (p = 0.084). 43% of the hips with cable-plate and 22% of the cerclage wire had trochanteric migration (p = 0.297). Pain at the greater trochanter was less frequent in the cerclage wire group (9%) as compared to the cable-plate group (43%) (p = 0.007). Implant removal was more frequent in the cable-plate group (4 vs. 0 patients). Trendelenburg gait was found in 3 patients in the cerclage wire group as compared to 10 in the cable-plate group (p = 0.054).

CONCLUSIONS

The cerclage wiring had superior clinical outcomes with similar radiographic results. The authors recommend the use of figure-of-eight cerclage wire when fixing a greater trochanteric "slide" osteotomy in complex revision hip arthroplasty.

Minimum 10-Year Results of Cementless Ceramic-On-Ceramic Total Hip Arthroplasty Performed With Transverse Subtrochanteric Osteotomy in Crowe Type IV Hips

BACKGROUND

Total hip arthroplasty (THA) performed for developmental dysplasia of the hip is a technically difficult procedure with a high complication rate, especially in the presence of completely dislocated hips. This study aimed to evaluate at least 10 years of follow-up results of cementless, ceramic-on-ceramic (CoC) THA performed with transverse subtrochanteric osteotomy in Crowe type IV hips.

METHODS

We retrospectively reviewed 50 patients' 67 hips that underwent CoC, cementless THA with transverse subtrochanteric osteotomy between 2008 and 2011. Clinical and radiological data of the hips were examined. Clinical results were evaluated using the Harris Hip Score and the Western Ontario and McMaster Universities Osteoarthritis Index.

RESULTS

The mean Harris Hip Score improved from 22.9 ± 9.9 preoperatively to 94.1 ± 8.1 at the final follow-up (P < 0.001). The median Western Ontario and McMaster Universities Osteoarthritis Index score improved from 72 (interquartile range: 17) preoperatively to 2 (interquartile range: 17) postoperatively (P < 0.001). The preoperative mean leg length discrepancy was improved from 4.9 ± 1 cm to 1.5 ± 1 cm in unilateral cases at the last follow-up (P < 0.001). Revision surgery was required because of nonunion in two patients, prosthetic infection in one patient, and aseptic femoral loosening in the other patient. The overall ten-year survival rate was 94% for femoral stems and 98.5% for acetabular components as per Kaplan-Meier survival analysis.

CONCLUSION

Transverse subtrochanteric shortening osteotomy combined with using cementless acetabular and femoral components with a CoC bearing surface promises successful clinical results and high prosthesis survival in the treatment of Crowe IV hips at long-term follow-up.

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.

Two-stage total hip arthroplasty following skeletal traction after extensive soft tissue release for severe limb-length discrepancy

INTRODUCTION

To maximise limb-length discrepancy (LLD) resolution during total hip arthroplasty (THA) for untreated developmental hip dysplasia or septic hip sequelae, THA following limb lengthening was introduced using different methods. We aimed to evaluate 2-stage THA results following limb lengthening via skeletal traction after extensive soft tissue release.

METHOD

In total, 24 hips with severe LLD in 10 men and 14 women (mean age, 49.6 ± 15.2 years) underwent 2-stage THA and were followed thereafter (mean 6.3 ± 3.7 years). The entire abductor muscle origin was subperiosteally released from the ilium, and the soft tissue around the hip joint, including the psoas tendon, short external rotator, joint capsule, and adductor tendon, was extensively released. 2-stage THA was performed after 2-week skeletal traction using proximal tibial pins. During the final THA, 7 hips necessitated subtrochanteric shortening osteotomy (STO) for hip joint reduction. We evaluated the clinical and radiological results and especially focused on LLD and neurological complications.

RESULTS

The Harris Hip Score improved from 57.1 ± 9.6 to 88.3 ± 6.3 points. No patients showed worse abductor power. LLD improved from 5.0 ± 2.0 to 1.4 ± 1.0 cm. No permanent neurological complications occurred except for 1 transient peroneal nerve palsy during traction, which resolved fully after cessation of traction. There were 2 hips with STO nonunion treated with osteosynthesis and stem revision.

CONCLUSION

2-stage THA following skeletal traction after extensive soft tissue release showed favourable results in terms of neurologic complication prevention and LLD resolution. However, a large proportion of patients still necessitated shortening osteotomy with a risk for nonunion at the osteotomy site. Though surgical procedures might be complicated and necessitate longer hospital stays, 2-stage THA with extensive soft tissue release might be an alternative treatment option for patients with severe LLD willing to resolve their limb length discrepancy.

Comparison of Trochanteric Slide and Subtrochanteric Shortening Osteotomy in the Treatment of Severe Hip Dysplasia: Mid-Term Clinical Outcomes of Cementless Total Hip Arthroplasty

BACKGROUND

The aim of this study is to compare clinical results of Crowe type III-IV developmental dysplasia of the hip (DDH) patients who underwent total hip arthroplasty with either trochanteric slide osteotomy (TSO) or subtrochanteric shortening osteotomy (SSO).

METHODS

The patients who underwent cementless total hip arthroplasty with femoral shortening osteotomy due to Crowe type III/IV DDH between 2004 and 2014 and completed at least 5 years of follow-up were retrospectively analyzed. The patients were grouped according to the type of shortening osteotomy as either TSO or SSO. Preoperative and postoperative clinical evaluation included Harris Hip Score, Visual Analogue Scale pain, leg length discrepancy, and the presence of Trendelenburg sign. The clinical outcome measures and complication rates were compared in terms of osteotomy type.

RESULTS

The TSO group consisted of 34 patients (43 hips) and the SSO group consisted of 40 patients (51 hips). The SSO group (96.1%) had a slightly higher 5-year survival of the implant compared to TSO (93%) without statistical significance (P = .18). No significant difference was detected between the groups in terms of clinical outcomes. Complication rates did not significantly differ between the groups except for the lack of bony union which was significantly higher in TSO (P = .006) but this difference did not transform into clinical significance since 5 of 6 patients who did not have a bony union in the TSO group were symptom-free with a fibrous union.

CONCLUSION

TSO and SSO provide similar clinical outcomes at mid-term follow-up in the management of Crowe III-IV DDH by cementless total hip arthroplasty. Both techniques can be used safely depending on the surgeon's preference.

LEVEL OF EVIDENCE

Level III, Therapeutic, Case-control study.

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.

Prediction of time to prosthesis implantation as a function of joint anatomy in patients with developmental dysplasia of the hip

Background

Developmental dysplasia of the hip (DDH) can lead to pain and premature secondary osteoarthritis at an early stage. Joint-preserving osteotomy is an established solution to this problem. In contrast, a conservative approach would result in pain persistence, ultimately raising the patients question for a possible date of expected prosthesis implantation.

The aim of the study was to identify the relationship between the dysplastic hip anatomy and the time of prosthesis implantation in order to enable prognostic predictions in younger patients with symptomatic DDH.

Materials and methods

Data from 129 hips who received THA due to secondary DDH osteoarthritis were evaluated. The preoperative hip anatomy was evaluated for AI and LCE angle. Multiple linear regression analyses were then used to correlate the influence of these parameters with the patient’s age at the time of surgery. In addition, a graphical relationship was derived by the method of power least squares curve fitting with second-degree polynomials.

Results

The mean age for THA was 54.3 ± 11 years. The time of surgery correlated significantly with LCE (0.37) and AI (− 0.3) (p < 0.001). The mean age of patients with LCE angle ≤ 10° was 41.9 ± 14.0 years, for LCE 11–20° 52.7 ± 9.5 years, and for LCE 21–30° 57.0 ± 10.3 years. The following formula could then be determined for the calculation of the potential patient age at the time of THA as a function of LCE angle: age pTHA = 40.2 + 0.8 × LCE angle − 0.01 × (LCE angle)².

Conclusion

A significant correlation between the extent of dysplasia and the time of prosthesis implantation was identified. In particular, the LCE and the AI correlated strongly with the time of implantation. The more dysplastic the angles were, the sooner the THA was necessary. Using the calculations presented in this study, the probable age of prosthesis implantation can be prognosticated and included in a counseling session about treatment options for DDH.

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.

Fixation Options Following Greater Trochanteric Osteotomies and Fractures in Total Hip Arthroplasty: A Systematic Review

BACKGROUND

The optimal system for greater trochanteric fixation following osteotomy or fracture remains unknown. This systematic review aims to synthesize the available English-language literature on 5 commonly reported trochanteric fixation methods to quantify and compare rates of complications and reoperation.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 1946 to June 2017 was performed for articles in English describing fixation of trochanteric osteotomies and fractures using wires, cables, cable-plate devices, claw or locking plates, and trochanteric bolts. Pooled mean rates of complications and reoperation with 95% confidence intervals (CIs) were analyzed using a random-effects model.

RESULTS

Fifty-seven studies involving 10,956 hips were eligible for inclusion. Five studies had Level-III evidence and 52 had Level-IV evidence. The pooled mean rate of nonunion was 4.17% (95% CI, 3.21% to 5.13%; I = 79%) for wires, 5.07% (95% CI, 0.37% to 9.77%; I = 74%) for cables, 16.11% (95% CI, 10.85% to 21.37%; I = 89%) for cable-plate systems, 9.60% (95% CI, 2.23% to 16.97%; I = 59%) for claw or locking plates, and 12.42% (95% CI, 3.41% to 21.43%; I = 75%) for trochanteric bolts. Substantial heterogeneity in the data precluded formal statistical comparison of outcomes and complications between implants.

CONCLUSIONS

Available literature on the various trochanteric fixation implants is heterogeneous and consists primarily of retrospective case series. Based on the current literature, it is difficult to support the use of one implant over another. Despite superior mechanical properties, rates of complication and reoperation following cable-plate fixation remains suboptimal, especially in complex revision scenarios. Additional rigorous prospective randomized and cohort studies are needed to make definitive recommendations regarding the most reliable method of trochanteric fixation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does Trochanteric Osteotomy Length Affect the Amount of Proximal Trochanteric Migration During Revision Total Hip Arthroplasty?

BACKGROUND

Nonunion and proximal trochanteric migration is a known complication of trochanteric osteotomy. This study examines the effect of osteotomy length on proximal greater trochanter (GT) migration.

METHODS

We analyzed 113 modified trochanteric slide osteotomies and 73 extended trochanteric osteotomies performed between 2008 and 2016. All osteotomies were fixed using cerclage wires and had minimum 6-month radiographic follow-up. Spearman correlations were used to assess association between osteotomy length and GT migration distance. Chi-squared test and logistic regression were used to assess association between patient and surgical factors and GT migration >1 cm. Receiver operating characteristic curves were constructed to determine the optimal cutoff osteotomy length for predicting GT migration >1cm.

RESULTS

Mean osteotomy length was 6.1 cm (range 3-12) for modified trochanteric slide osteotomies and 14.8 cm (range 8-23) for extended trochanteric osteotomies. Osteotomy length was negatively correlated (r = -0.340, P < .001) with GT migration distance. Longer osteotomy length was protective against GT migration >1 cm (odds ratio 0.67, P = .002). Receiver operating characteristic curve analysis demonstrated an optimal cutoff osteotomy length of 9.8 cm for predicting GT migration >1 cm (sensitivity 0.971, specificity 0.461). Among osteotomies <10 cm, those fixed using at least one distal wire below the lesser trochanter and vastus ridge demonstrated less mean GT migration (3.86 vs 7.12 mm, P = .009) and higher mean union rate (68.8% vs 31.2%, P < .001).

CONCLUSION

Osteotomies shorter than 10 cm are at higher risk of developing proximal GT migration >1 cm. A distal cerclage wire below the lesser trochanter and vastus ridge may help decrease the amount of GT migration.

LEVEL OF EVIDENCE

Prognostic Level IV.

Comparison of the long-term outcome of cemented Charnley low-friction arthroplasty with hybrid arthroplasty in patients with congenital hip disease

AIMS

To our knowledge, no study has compared the long-term results of cemented and hybrid total hip arthroplasty (THA) in patients with osteoarthritis (OA) secondary to congenital hip disease (CHD). This is a demanding procedure that may require special techniques and implants. Our aim was to compare the long-term outcome of cemented low-friction arthroplasty (LFA) and hybrid THA performed by one surgeon.

PATIENTS AND METHODS

Between January 1989 and December 1997, 58 hips (44 patients; one man, 43 woman; mean age 56.6 years (25 to 77)) with OA secondary to CHD were treated with a cemented Charnley LFA (group A), and 55 hips (39 patients; two men, 37 women; mean age 49.1 years (27 to 70)) were treated with a hybrid THA (group B), by the senior author (GH). The clinical outcome and survivorship were compared.

RESULTS

At all timepoints, group A hips had slightly better survivorship than those in group B without a statistically significant difference, except for the 24-year survival of acetabular components with revision for aseptic loosening as the endpoint, which was slightly worse. The survivorship was only significantly better in group A compared with group B when considering reoperation for any indication as the endpoint, 15 years postoperatively (74% vs 52%, p = 0.018).

CONCLUSION

We concluded that there was not a substantial difference at almost any time in the outcome of cemented Charnley LFAs compared with hybrid THAs when treating patients with OA of the hip secondary to CHD. We believe, however, that after improvements in the design of components used in hybrid THA, this could be the method of choice, as it is technically easier with a shorter operating time. Cite this article: Bone Joint J 2019;101-B:1050-1057.

Current concepts in developmental dysplasia of the hip and Total hip arthroplasty

Developmental dysplasia of the hip (DDH) is a spectrum of pathology that involves dysplasia of both the acetabulum and the femur. If left untreated, it can develop to hip pain and osteoarthritis, which eventually require total hip arthroplasty (THA). A broad array of anatomical abnormalities of the acetabulum and femur, plus the younger age of DDH patients make THA a great challenge. Meticulous operation planning with various options is one of the most important prerequisites of a successful THA. This review presents the current concepts of acetabular and femoral reconstruction in THA for DDH, including high hip center, acetabular bone deficiency, highly porous metal, correction of femoral anteversion, femoral shortening osteotomy, stem selection, among others.

Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review

BACKGROUND

The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome.

METHODS

A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories.

RESULTS

Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures.

CONCLUSIONS

The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cementless total hip arthroplasty with extended sliding trochanteric osteotomy for high congenital hip dislocation: A retrospective study

Total hip arthroplasty (THA) for high congenital hip dislocation (CHD) is technically demanding. The purpose of this retrospective study was to evaluate the results of cementless THA combined with extended sliding trochanteric osteotomy. We also assessed whether chronic low back pain was relieved after surgery.The study included 19 patients (23 hips) with high CHD treated with cementless THA using extended sliding trochanteric osteotomy technique. Clinical and radiographic outcomes were evaluated.Harris Hip Score, WOMAC score, visual analog scale for low back pain and Trendelenburg sign were significantly improved (P < 0.01) compared with the preoperative. Average limb-length discrepancy in the 15 unilateral hips was reduced from 38.2 ± 7.9 mm to 6.7 ± 4.1 mm (P < 0.01). No dislocation, deep vein thrombosis, or infection occurred. Two patients (8.7%) developed sciatic nerve palsy. One (4.3%) developed symptomatic greater trochanteric bursitis. Two (8.7%) sustained proximal femur shaft fracture during implantation of the femoral component. All femoral components showed successful bony ingrowth at the final follow-up. No stem subsidence was detected. There was no acetabular loosening. Bony union of the reattached greater trochanter was obtained in all hips. Wire breakage occurred in 3 hips (13%).Cementless THA with extended sliding trochanteric osteotomy may be appropriate options for patients with high CHD.

Cementless Total Hip Arthroplasty Involving Trochanteric Osteotomy without Subtrochanteric Shortening for High Hip Dislocation

BACKGROUND

Total hip arthroplasty with subtrochanteric shortening osteotomy is widely performed for high hip dislocation. However, suboptimal leg length discrepancy correction and nonunion of the osteotomy site remain concerns. Although total hip arthroplasty using trochanteric osteotomy without subtrochanteric osteotomy was introduced, cemented implants have been more commonly used than contemporary cementless implants in this procedure. We evaluated the long-term results of cementless total hip arthroplasty with trochanteric osteotomy without subtrochanteric osteotomy for high hip dislocation.

METHODS

From 1990 to 2002, 27 cementless total hip arthroplasties using trochanteric osteotomy without subtrochanteric osteotomy were performed in 26 patients with Crowe III or IV high hip dislocation and a mean age of 36.4 ± 12.9 years. Seven ceramic-on-ceramic, 8 ceramic-on-polyethylene, 10 metal-on-polyethylene, and 2 metal-on-metal bearings were inserted. Mean follow-up was 15.1 ± 3.7 years. We retrospectively reviewed medical records and radiographic data and evaluated the clinical and radiological results including the Harris hip score, implant survival, correction of leg length discrepancy, and occurrence of complications.

RESULTS

The mean Harris hip score and leg length discrepancy improved significantly from 73.3 to 94.9 points and from 4.3 cm to 1.0 cm, respectively. With revision for loosening set as the end point, implant survival rates at 10 and 15 years postoperatively were 96.0% and 90.9% for stems and 74.1% and 52.3% for cups. In 8 of 10 hips with the metal-on-polyethylene bearing and 4 of 8 hips with the ceramic-on-polyethylene bearing, revision surgery was performed for aseptic loosening. However, no revision was performed in hips with the ceramic-on-ceramic bearing or the metal-on-metal bearing. Implant survival was significantly different by the type of bearing surface. Two permanent neurologic complications occurred in patients with a limb lengthening over 3.5 cm.

CONCLUSIONS

With proper selection of the bearing surface coupled with adjustment of lengthening, cementless total hip arthroplasty using trochanteric osteotomy without subtrochanteric osteotomy might be a favorable treatment option for high hip dislocation.

Lessons learned from study of congenital hip disease in adults

Orthopaedic surgeons specialising in adult hip reconstruction surgery often face the problem of osteoarthritis secondary to congenital hip disease (CHD). To achieve better communication among physicians, better treatment planning and evaluation of the results of various treatment options, an agreed terminology is needed to describe the entire pathology. Furthermore, a generally accepted classification of the deformities is necessary. Herein, the authors propose the use of the term “congenital hip disease” and its classification as dysplasia, low dislocation and high dislocation. Knowledge of the CHD natural history facilitates comprehension of the potential development and progression of the disease, which differs among the aforementioned types. This can lead to better understanding of the anatomical abnormalities found in the different CHD types and thus facilitate preoperative planning and choice of the most appropriate management for adult patients. The basic principles for improved results of total hip replacement in patients with CHD, especially those with low and high dislocation, are: Wide exposure, restoration of the normal centre of rotation and the use of special techniques and implants for the reconstruction of the acetabulum and femur. Application of these principles during total hip replacement in young female patients born with severe deformities of the hip joint has led to radical improvement of their quality of life.

Biomechanical Comparison of 2 Different Femoral Stems in the Shortening Osteotomy of the High-Riding Hip

BACKGROUND

We hypothesized that a rectangular cross-sectional femoral stem may produce more initial stability of the transverse subtrochanteric femoral shortening osteotomy rather than a circular cross-sectional stem.

METHODS

Twenty, fourth-generation, synthetic femur models were inserted with either circular or rectangular cross-sectional femoral stems after 3 cm of transverse subtrochanteric shortening. Half of the models were tested with axial bending and the other half with torsional loads. After the femora underwent cyclic loading, they were loaded until failure. Outcome parameters were stiffness values before and after cyclical loading, failure loads/torques, and displacements at the osteotomy sites.

RESULTS

In axial bending tests, the results were not significantly different between the groups. Under rotational forces, the mean stiffness value before cyclical loading and failure torque of the cylindrical stems was significantly higher than that of rectangular cross-sectional stems (11.8 ± 1.2 vs 7.1 ± 2.8 Nm/degree; P = .009 and 136.9 ± 60.2 vs 27.1 ± 17.5 Nm; P = .027 Nm, respectively). The mean amounts of displacements at the osteotomy sites were not significantly different between the groups in any direction in both axial and rotational tests.

CONCLUSIONS

According to the results of the study, using straight, cylindrical femoral stems can increase rotational stability of the transverse osteotomy more than the rectangular cross-sectional stems although the latter one has the advantages of rectangular geometrical design.

Small diameter acetabulum and femoral head in total hip arthroplasty for developmental dysplasia of the hip, with no femoral osteotomy

We present the results of 66 total hip arthroplasties in 62 patients of mean age 46 years (24-74 years), with developmental dysplasia of the hip. In all cases the centre of rotation of the new hip was positioned at the site of the true acetabulum. In all patients cementless press fit acetabular components of small diameter (42-44 mm) were used, articulating exclusively with a 22.25 mm modular metal femoral head, without the use of bone grafts or shortening osteotomies of the femur. Despite the use of small diameter femoral heads the rate of dislocation was 3%. After an average follow-up period of 9 years (4-18 years), no revisions were required for infection, loosening or wear or implant migration. Osteolytic lesions were seen in the periacetabular region in 3 patients who were symptom free. A total of 2 revisions were required for instability and 2 patients had the wires of their trochanteric osteotomy removed because of bursitis. Leg length inequality was improved in 55% of the patients and one postoperative transient sciatic nerve lesion settled within 4 months. We believe that in patients with painful dysplastic hips, the use of small diameter implants with the centre of rotation at the true acetabulum, can give very satisfactory results, without any supplementary procedures.

Two Different Total Hip Arthroplasties for Hartofilakidis Type C1 Developmental Dysplasia of Hip in Adults

Background:

Total hip arthroplasty (THA) in developmental dysplasia of the hip (DDH) is more complex than the normal hip, with large replacement risks and many complications. Although nonosteotomy THA is convenient to perform, femoral osteotomy shortening can avoid blood vessel and nerve traction injuries. This study aimed to compare osteotomy THA with nonosteotomy to determine reasonable options for operative management of DDH.

Methods:

Data on 48 DDH patients who underwent THA were analyzed retrospectively. The patients were divided into two groups: Group A 29 cases (nonosteotomy), and group B 19 cases (osteotomy). Harris and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, limb length discrepancy (LLD), radiological data on the hip, and claudication were evaluated. Data were analyzed by using paired-sample Student's t-test, independent-sample Student's t-test, and Pearson's Chi-square test; the test level was α =0.05.

Results:

Postoperative Harris (90.7 ± 5.1) and WOMAC scores (88.0 ± 10.6) were significantly improved compared with preoperative Harris (44.8 ± 5.7) and WOMAC scores (42.0 ± 5.3) in group A (P < 0.05). Postoperative Harris (90.4 ± 2.8) and WOMAC scores (88.2 ± 5.9) were significantly improved compared with preoperative Harris (44.4 ± 4.2) and WOMAC scores (43.2 ± 4.3) in group B (P < 0.05). One case of dislocation occurred in group A; after closed reduction, dislocation did not recur. In group A, 2 patients developed cutaneous branch injury of the femoral nerve, which spontaneously recovered without treatment. Postoperative LLD >2 cm was seen in one case in group A and five cases in group B. Postoperative claudication showed no significant difference between the two groups (P > 0.05). No patients developed infection; postoperative X-rays showed that the location of the prosthesis was satisfactory, and the surrounding bone was not dissolved.

Conclusions:

THA is effective and safe for DDH. For unilateral high dislocation DDH patients with limb lengthening ≤4 cm and good tissue conditions, THA without femoral osteotomy may be considered.

Combined Anterior and Posterior Approach in Total Hip Arthroplasty for Crowe IV Dysplasia or Ankylosed Hips

We evaluated 70 patients (71 hips) who underwent complex total hip arthroplasty (THA) through the combined anterior and posterior approach. Sixty-five patients (32 dislocated hips and 34 ankylosed hips) were followed-up at a minimum of 3 years (median, 6 years; range, 3-10 years). Seven patients (10.6%), who had transient paresthesia on the anterior thigh, recovered within 3 months. All patients had a good clinical outcome in terms of range of motion, pain and recovery of walking. At the latest follow-up, all prostheses had bone-ingrown stability without any detectable wear or osteolysis. The combined approach allows an excellent exposure of the acetabulum for accurate cup alignment, leg lengthening and mobilization of joint in complex THA without trochanteric osteotomy, excessive abductor release and femoral shortening osteotomy.

Total hip arthroplasty with a non-modular conical stem and transverse subtrochanteric osteotomy in treatment of high dislocated hips

Conventional stems may be unsuitable for hypoplastic femurs associated with severe dysplasia, meanwhile, custom-made or modular stems in total hip arthroplasty are often complex and expensive. This series included 21 Crowe type IV dysplastic hips in which a non-modular cementless conical stem was implanted with transverse subtrochanteric femoral osteotomy. Follow up averaged 40months. Twenty hips survived with mean Harris hip score improved from 52 to 90. One hip failed for stem loosening. The average leg lengthening was 3.8cm with transient sciatic nerve palsy occurring in three hips. Femoral offset averaged 3.3cm postoperatively. The non-modular conical stem not only obviated the complexities, high medical cost and potential risk at the neck-stem interface associated with stem modularity, but also simplified surgical technique.

Results of total hip arthroplasty differ in subtypes of high dislocation

BACKGROUND

In a previous study, we described two subtypes of high dislocation of the hip depending on the presence (C1) or absence (C2) of a false acetabulum, yet we have already presented the concise followup of total hip arthroplasty (THA) in these patients as a group at a minimum of 15 years.

QUESTIONS/PURPOSES

In this retrospective study, we investigated differences in the results of THA in the C1 and C2 subtypes of high dislocation such as (1) survivorship of the reconstructions; (2) Merle d'Aubigné-Postel clinical scores; (3) leg lengthening and femoral shortening; and (4) site of reattachment and union rate of the greater trochanter.

METHODS

We included 49 hips of the C1 subtype and 30 hips of the C2 subtype operated on from 1976 to 1994. We evaluated survivorship (using reoperation for any reason as the end point) and performed chart and radiographic reviews.

RESULTS

The 15-year survival was 84% (± 10% [95% CI]) for the C1 subtype and 60% (± 17% [95% CI]) for the C2 subtype (p = 0.001). Cox regression analysis, after adjustment for confounding factors, showed also statistically significantly worse survivorship in the C2 subtype (p = 0.021) and, after adjustment for possible predictive factors, found a statistically significant relationship of high dislocation subtype (p = 0.018) and trochanteric union (p = 0.005) with survival of THAs. Pain, function, and mobility scores improved from preoperative to last followup in C1 and C2 groups but they did not differ between C1 and C2 hips. C2 hips were lengthened more (p < 0.001) despite greater amounts of femoral shortening (p = 0.006). Site of reattachment and the risk of greater trochanter nonunion were not different between the groups.

CONCLUSIONS

We found important differences in fundamental parameters after THA in the high-dislocation subtypes, including the risk of revision, which was higher in patients whose hips did not have a false acetabulum. These findings indicate that while reporting THA results in patients with high dislocation, mixing results of the two subtypes may lead to statistical bias.

Comparison of the outcome following the fixation of osteotomies or fractures associated with total hip replacement using cables or wires: the results at five years

There are no recent studies comparing cable with wire for the fixation of osteotomies or fractures in total hip replacement (THR). Our objective was to evaluate the five-year clinical and radiological outcomes and complication rates of the two techniques. We undertook a review including all primary and revision THRs performed in one hospital between 1996 and 2005 using cable or wire fixation. Clinical and radiological evaluation was performed five years post-operatively. Cables were used in 51 THRs and wires in 126, and of these, 36 THRs with cable (71%) and 101 with wire (80%) were evaluated at follow-up. The five-year radiographs available for 33 cable and 91 wire THRs revealed rates of breakage of fixation of 12 of 33 (36%) and 42 of 91 (46%), respectively. With cable there was a significantly higher risk of metal debris (68% vs. 9%; adjusted relative risk (RR) 6.6; 95% confidence interval (CI) 3.0 to 14.1), nonunion (36% vs. 21%; adjusted RR 2.0; 95% CI 1.0 to 3.9) and osteolysis around the material, acetabulum or femur (61% vs 19%; adjusted RR 3.9; 95% CI 2.3 to 6.5). Cable breakage increased the risk of osteolysis to 83%. There was a trend towards foreign-body reaction and increased infection with cables. Clinical results did not differ between the groups. In conclusion, we found a higher incidence of complications and a trend towards increased infection and foreign-body reaction with the use of cables.

Trochanteric osteotomy in primary and revision total hip arthroplasty: risk factors for non-union

BACKGROUND

Trochanteric osteotomies (TO) facilitate exposure and "true hip reconstruction" in complex primary and revision total hip arthroplasty (THA). However, non-union represents a clinically relevant complication. The purpose of the present study was to identify risk factors for trochanteric non-union.

METHODS

All cases of THA approached by TO during the past 10 years were analyzed with respect to potential risk factors for non-union.

RESULTS

In 298 cases complete data were available for analysis. Trochanteric union occurred in 80.5%, fibrous union in 5.4% and non-union 14.1%. Risk factor analysis revealed a four times higher risk for non-union in anterior trochanteric slide osteotomies compared to extended trochanteric osteotomies and a three times higher risk in cemented versus non-cemented stems. Multiple logistic regression analysis revealed patient's age and use of cement to be independent risk factors for non-union.

CONCLUSIONS

Femoral cementation and increasing age negatively influence the union of trochanteric osteotomies.