Cementless total hip arthroplasty in developmental dysplasia of the hip with end stage osteoarthritis: 2-7 years' clinical results

Subtrochanteric Osteotomy in Direct Anterior Approach Total Hip Arthroplasty for Crowe IV Dysplasia-Surgical Technique and Literature Review

For Crowe IV dysplasia, the clinical efficacy and surgical technique of subtrochanteric osteotomy (SO) within the direct anterior approach total hip arthroplasty (DAA-THA) was a subject of debate. This study aimed to describe the surgical technique and clinical outcomes in 11 cases of SO in DAA-THA and to summarize the relevant literature on this topic. Between June 2016 and June 2023, we retrospectively evaluated patients diagnosed with Crowe IV hip dysplasia at our institution. Criteria identified 11 patients who underwent SO during DAA-THA. Comprehensive data encompassing demographic information, radiological data, prosthetic implant type, and surgical intricacies were collected. In addition, an exhaustive review of existing case series literature was undertaken utilizing the PubMed databases. There were no revisions, deaths, dislocations, or infections. One hip (9.09%) had an intraoperative proximal split fracture, two hips (18.2%) had lower limb deep vein thrombosis, and one hip (9.09%) had symptoms of femoral nerve injury. Radiological data showed improved bilateral femoral offset, leg length discrepancy, and anatomical acetabular. During the mean follow-up of 2.18(1.06-2.46) years, patients demonstrated enhanced functional outcomes, with average changes of 25.2 in the Harris hip score and 47 in the WOMAC score. Reviewing the literature, most studies have favored S-ROM prostheses and transverse osteotomy techniques. Intraoperative fractures were notably frequent, with rates peaking at 25%. Nonunion and nerve injury were secondary common complications. SO via DAA-THA may offer satisfactory clinical and radiographic outcomes, but the literature review underscores the need for heightened awareness of intraoperative fracture risk. Proximal detachment of the vastus intermedius plays a pivotal role in SO exposure through the DAA.

Non-coding RNAs and exosomal non-coding RNAs in pituitary adenoma

Pituitary adenoma (PA) is the third most common primary intracranial tumor in terms of overall disease incidence. Although they are benign tumors, they can have a variety of clinical symptoms, but are mostly asymptomatic, which often leads to diagnosis at an advanced stage when surgical intervention is ineffective. Earlier identification of PA could reduce morbidity and allow better clinical management of the affected patients. Non-coding RNAs (ncRNAs) do not generally code for proteins, but can modulate biological processes at the post-transcriptional level through a variety of molecular mechanisms. An increased number of ncRNA expression profiles have been found in PAs. Therefore, understanding the expression patterns of different ncRNAs could be a promising method for developing non-invasive biomarkers. This review summarizes the expression patterns of dysregulated ncRNAs (microRNAs, long non-coding RNAs, and circular RNAs) involved in PA, which could one day serve as innovative biomarkers or therapeutic targets for the treatment of this neoplasia. We also discuss the potential molecular pathways by which the dysregulated ncRNAs could cause PA and affect its progression.

Femoral Head Autograft to Manage Acetabular Bone Loss Defects in THA for Crowe III Hips by DAA: Retrospective Study and Surgical Technique

Introduction: The pathologic anatomy of Crowe III is characterized by the erosion of the superior rim of acetabulum, with a typical bone defect in its supero-lateral portion. The performance of a total hip arthroplasty requires the management of the acetabular bone defect, and femoral head autograft can be a valid option to optimize implant coverage. Material and Methods: In all, eight Crowe III patients (nine hips), seven of which having unilateral hip affected, and one with bilateral involvement by secondary osteoarthritis in DDH; maximum limb length discrepancy (LLD) of 3.5 cm in unilateral patients. All were operated on by direct anterior approach. Patients were evaluated in terms of clinical, surgical, and radiological (center-edge, horizontal coverage, cup inclination) parameters. Results: Cup placement was implanted with a mean of 39.5 ± 7.5°. Stem alignment showed average 1.5 ± 2.3° in valgus. LLD showed an overall average preoperative of -29.5 ± 10.5 mm at the affected side, with a significant improvement to -2.5 ± 6.4 mm (p = 0.023). The mean initial coverage evaluated like a percentage of the horizontal bone host was 52.1 ± 7.1%, while the mean final coverage at the last post-operative X-ray from femoral autograft bone was 97.0 ± 4.5% with an average improvement of 44.5%. Average CE improved from -9.5 ± 5.2° (CE I) to the immediate post-operative (CE II) of 40.6 ± 8.2°. At the final follow up, CE III showed a mean of 38.6 ± 6.2°, with an average decrease of 2.0°. Discussion: Acetabular bone defect in Crowe III DDH patients undergoing THA by DAA, can be efficiently managed by massive autograft femoral head, which allowed an adequate and long-lasting coverage of the implant, with cup positioning at the native acetabulum.

Risk factors of dislocation after total hip arthroplasty in patients with developmental dysplasia of the hip

PURPOSE

Dislocation following total hip arthroplasty (THA) is a well-known complication. However, there is little data on its rate and predictors in patients with developmental dysplasia of the hip (DDH). The current study is aimed to determine the rate and specific risk factors of dislocation following THA in DDH patients.

METHODS

All the medico-surgical records of primary THAs from January 2014 to January 2019 were retrospectively reviewed. They were categorized into three main groups: primary OA, DDH, and others. Pre-operative and post-operative radiographs, past medical and surgical history, and surgical notes were reviewed in DDH cases.

RESULTS

In a total of 171 patients with DDH, 21 suffered from dislocation after THA (12%) which was significantly more frequent than those with primary OA. In univariate analysis, higher grade of dysplasia, smaller head size, intra-operative fracture, Wagner Cone stem, failure of offset restoration, and implanting the cup outside the Lewinnek's safe zone were identified as predictors of dislocation. In multiple regression analysis, however, only higher Crowe grade, intra-operative fracture, and post-operative acetabular offset less than 16 mm were independent predictors of dislocation.

CONCLUSION

Dysplastic hips can be more prone to post-THA dislocation than those with primary OA. Higher grades of dysplasia, failure of offset restoration, and intra-operative fracture can increase the rate of dislocation in this group of patients.

Up-regulation of the expressions of MiR-149-5p and MiR-99a-3p in exosome inhibits the progress of pituitary adenomas

This study explored the function of microRNAs (miRNAs) in invasive pituitary adenomas (IPA), and developed a microRNA-exosome strategy for the disease treatment. Differentially expressed miRNAs and tumor-associated markers in IPA, non-invasive pituitary adenoma (NIPA), and rat pituitary adenoma cells were identified by bioinformatics analysis and qRT-PCR. Then, the cells were treated by miR-149-5p and miR-99a-3p mimics or inhibitors, or incubated with modified exosome with overexpressed or silenced miRNAs. The cell behaviors were analyzed by molecular experiments. Xenograft assays were constructed by injection of pituitary adenoma cells and exosome into NU/NU nude mice. Tumor size, weight, and expressions of markers related to miRNAs and angiogenesis were determined. Target genes for miR-99a-3p and miR-149 were predicted and verified by bioinformatics analysis and molecular experiments. Twenty differentially expressed miRNAs were identified, among which miR-99a-3p and miR-149 were inhibited in both pituitary adenoma cells and tissues significantly. Expressions of E-cadherin and p53 were down-regulated, while those of MMP-2, MMP-9, N-cadherin, Vimentin, and VEGF were up-regulated in pituitary adenoma cells and tissues, especially in IPA. Further experiments revealed that overexpressed miR-149 and miR-99a-3p inhibited the growth and metastasis of pituitary adenoma cells and tube formation of endothelial cells. MiR-149 and miR-99a-3p overexpressed by exosome showed similar suppressive effects on cell viability, metastasis, tube formation ability, in vivo tumor growth, and expressions of angiogenesis-related markers. Further analysis showed that NOVA1, DTL, and RAB27B were targeted by miR-99a-3p. This study found that overexpressed miR-149-5p and miR-99a-3p induced by exosome could suppress the progression of IPA. 1. MiR-149-5p and miR-99a-3p affect the expression of EMT- and ECM-related markers and tumor-related genes in rat pituitary adenoma cells treated with exosomes. 2. Exosome inhibited the tumor growth. 3. Overexpressed miR-149-5p and miR-99a-3p induced by exosome.

An Analysis of the Potential Relationship between Crowe Type and Lower Extremity Morphology in Patients with Developmental Dysplasia of the Hip

Purpose

To test whether Crowe type is related to femoral alignment and leg length discrepancy by evaluating the preoperative lengths and coronal alignment of femurs, pelvic parameters and hip morphology of patients who underwent primary hip arthroplasty due to coxarthrosis secondary to developmental dysplasia of the hip (DDH).

Materials and Methods

Medical records of patients with coxarthrosis secondary to DDH who were treated with total hip arthroplasty at Department of Orthopaedics and Traumatology, Istanbul University Faculty of Medicine between 2008 and 2017 were reviewed. The mechanical axis of lower limbs was analyzed; pelvic height and femoral and tibial lengths were measured. All femurs were classified according to the Dorr classification.

Results

A total of 97 patients were eligible for analysis and were diagnosed with unilateral DDH (n=51) or bilateral DDH (n=46). In those diagnosed with unilateral DDH, the affected pelvis, femur, and tibia were often shorter than the unaffected side. In those diagnosed with bilateral DDH, femoral and pelvic lengths were unpredictable. In the femoral coronal alignment test, data varied widely but were within normal limits. The difference in the Dorr types of femurs was significant between dysplastic and normal sides of patients with unilateral DDH (P=0.001) but not those with bilateral DDH.

Conclusion

Especially in patients with unilateral DDH, pelvic heights and femoral and tibial lengths on the affected side may be shorter compared with unaffected side regardless of the Crowe type. Femoral coronal alignment is unpredictable for both groups. Careful preoperative analyses of femoral coronal alignment and pelvic length are advised.

The Direct Anterior Approach for Total Hip Arthroplasty for Severe Dysplasia (Crowe III and IV) Provides Satisfactory Medium to Long-Term Outcomes

BACKGROUND

The direct anterior approach (DAA) is increasingly used for total hip arthroplasty (THA). Although the DAA can reduce pain, recovery time, and dislocations in nondysplastic hips, few studies report its results in patients with severe dysplasia. We aimed to evaluate outcomes of primary THA through the DAA with cup placement at the true acetabulum in hips with severe dysplasia.

METHODS

We retrospectively evaluated 23 consecutive patients (29 hips) who underwent THA by DAA for osteoarthritis secondary to Crowe III-IV dysplasia. Surgical procedures were performed on a traction table, and the acetabular cup was placed in the true acetabulum. Patients were assessed clinically (complications, modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Hip Score) and radiographically (radiolucencies, subsidence, leg length discrepancies, cup inclination, and cup coverage) at a minimum of 2 years.

RESULTS

One patient (2 hips) died with original implants (at 13 and 14 years), 3 patients (3 hips) were revised due to wear-induced loosening (at 14, 16, and 18 years), and there were no dislocations or infections. The remaining 19 patients (24 hips) were assessed at 8.4 ± 4.7 years (range 2-20); 2 patients (2 hips) had complications that required reoperation without implant removal. The modified Harris Hip Score improved from 32 ± 9 to 94 ± 7, Western Ontario and McMaster Universities Osteoarthritis Index from 46 ± 18 to 90 ± 7, and Oxford Hip Score was 56 ± 4. Patients were very satisfied (90%) or satisfied (10%). Limb length discrepancy was 2.5 ± 9.0 mm.

CONCLUSION

THA through the DAA with cup placement at the true acetabulum provides satisfactory mid to long-term clinical and radiographic outcomes compared to other approaches for hips with severe dysplasia.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Morphological Analysis of True Acetabulum in Hip Dysplasia (Crowe Classes I-IV) Via 3-D Implantation Simulation

BACKGROUND

The purpose of this study was to investigate the 3-dimensional (3D) morphological features of the true acetabulum in patients with developmental dysplasia of the hip (DDH).

METHODS

Seventy-nine hips-53 in patients with developmental dysplasia of the hip (DDH) and 36 normal hips-were included in the present study. According to the Crowe classification, 26 hips were graded as Class I, 31 were Class II or III, and 22 were Class IV. The anterior pelvic plane was defined to standardize the measurements in the study. A selected virtual cup component was implanted into the true acetabulum of a 3D pelvic model of each hip. The acetabular anteversion angle, effective center-edge (CE) angle, effective Sharp angle, and thickness of the medial wall were measured to provide morphological indices of the true acetabulum. Acetabular sector angles and the component coverage ratio were measured to provide coverage indices.

RESULTS

The acetabular anteversion angle increased with the severity of the DDH. Crowe-II/III hips had the smallest effective CE angle and the largest effective Sharp angle. The mean medial wall thickness was greatest in the Crowe-II/III hips (8.72 mm; 95% confidence interval [CI] = 7.52 to 9.92 mm), intermediate in the Crowe-I hips (7.17 mm; 95% CI = 6.24 to 8.11 mm), and smallest in the Crowe-IV hips (6.05 mm; 95% CI = 4.78 to 7.32 mm). The integrated coverage ratio of the Crowe-II/III hips was significantly less than that of the Crowe-I and IV hips.

CONCLUSIONS

The morphological features of the true acetabulum in patients with DDH can be evaluated comprehensively by using 3D implantation simulation. Segmental bone deficiency was prevalent in the dysplastic hips, especially those in the Crowe-II/III group. Both the severity and the individual morphology of the acetabular dysplasia should be carefully considered in preoperative planning.

The radiological research for pelvis asymmetry of unilateral developmental dysplasia of the hip in adult

Objectives

To investigate whether adult patients with unilateral developmental dysplasia of the hip (UDDH) have pelvic asymmetry and what correlation existing between them.

Methods

A total of 100 adult patients with UDDH were enrolled in the retrospective observational study in Shanghai Jiaotong University Affiliated Sixth People’s Hospital, Shanghai, China, between January 2012 and February 2014. The anteroposterior pelvic radiographs were reviewed and the pelvic heights and ischium heights were measured and compared between the affected and non-affected sides to find out the relationship between the pelvic morphology and hip dysplasia.

Results

The pelvic heights demonstrated significant differences between the non-affected side and the affected side in patients with Crowe type II-IV UDDH (p<0.05), but not in patients with Crowe type I UDDH (p=0.09). There were significant differences in the bilateral ischium heights in patients with Crowe type III and IV UDDH (p<0.05), but not in patients with Crowe type I and II UDDH (p=0.78, p=0.055). In addition, the degree of hip dysplasia was positively associated with the degrees of asymmetry of pelvis (r=0.78, p<0.001) and ischium (r=0.72, p<0.001) in UDDH patients.

Conclusion

The pelvic asymmetry exists in adult patients with UDDH. In addition, the degree of asymmetry has correlation with the degree of hip dysplasia. We recommend that it should be taken more cautions to use teardrops and ischial tuberosity as anatomy landmarks to balance leg-length discrepancy for unilateral DDH patients in preoperative planning and total hip arthroplasty.