[A study of total hip arthroplasty with subtrochanteric osteotomy in Crowe type developmental dysplasia of hip]

[Revision reasons and prosthesis selection of Crowe developmental dysplasia of hip after total hip arthroplasty]

OBJECTIVE

To investigate revision reasons and prosthesis selection of Crowe Ⅳ developmental dysplasia of the hip (DDH) after total hip arthroplasty (THA).

METHODS

A clinical data of 14 patients (15 hips) with Crowe Ⅳ DDH, who underwent a revision hip arthroplasty between January 2008 and May 2018, was retrospectively reviewed. There were 1 male (1 hip) and 13 females (14 hips). The age ranged from 27 to 63 years (mean, 45.0 years). There were 7 cases of left hip, 6 cases of right hip, and 1 case of bilateral hips. The prosthetic interfaces of primary THA were metal-on-polyethylene (MOP) in 9 hips, ceramic-on-ceramic (COC) in 4 hips, ceramic-on-polyethylene (COP) in 1 hip, and ceramic-on-metal in 1 hip. The time from primary THA to revision was 3-204 months (mean, 65.0 months). The causes of revision included aseptic loosening in 7 hips, dislocation in 3 hips, periprosthetic joint infection in 2 hips, osteolysis in 1 hip, nonunion of osteotomy in 1 hip, and a small-angle of femoral anteversion in 1 hip. Preoperative Harris score was 54.1±17.8 and the range of motion (ROM) of flexion was (92.7±20.2)°. Preoperative X-ray films showed the acetabular bone defect in 11 hips and osteolysis of femoral side in 4 hips. During the revision, the prostheses with COP and COC interfaces were used in 5 hips and 10 hips, respectively. Both acetabular and femoral revisions were performed in 11 hips and only femoral revision was performed in 4 hips.

RESULTS

The mean operation time was 3.7 hours (range, 1.5-6.0 hours). The mean intraoperative blood loss was 940.0 mL (range, 200-2 000 mL). All patients were followed up 16-142 months (mean, 73.9 months). Postoperative X-ray films showed no difference in inclination and anteversion between primary THA and revision ( P>0.05). The height of rotation center and offset after revision were higher than those after primary THA, and the difference in offset was significant ( P<0.05). At last follow-up, the Harris score and ROM of flexion were 85.0±7.3 and (115.0±17.0)°, respectively, which were significantly higher when compared with those before revision ( t=8.909, P=0.000; t=4.911, P=0.000). Three hips underwent a re-revision operation. All protheses were fixed well and no radiolucent line, loosening, or subsidence was observed at last follow-up.

CONCLUSION

The most common reason for revision in patients with Crowe Ⅳ DDH after THA was aseptic loosening. Due to high activity demand of this population, the prosthesis with MOP interface should be prevented and the prosthesis with COC interface could be alternative. Metal block, cup-cage, and reinforcement ring were reasonable solutions for reconstruction of acetabulum with severe bone defects and have satisfactory effectiveness. S-ROM prosthesis should be the preferred stem for neither primary THA or revision.

[Safety and efficacy of total hip arthroplasty following failed internal fixation of intertrochanteric fractures]

Objective

To evaluate the safety and efficacy of total hip arthroplasty (THA) following failed internal fixation of intertrochanteric fractures.

Methods

Between January 2007 and January 2016, THAs were performed in 32 patients (33 hips) for failed internal fixation of intertrochanteric fractures. There were 15 males and 17 females, with mean age of 74.0 years old (range, 65-87 years). There were 3 hips of Evans-Jensen type Ⅱ, 10 hips of type Ⅲ, 8 hips of type Ⅳ, and 12 hips of type Ⅴ. The fractures were fixed with dynamic hip screw in 18 hips, proximal femoral nail antirotation in 9 hips, locking plate in 5 hips, and hollow screw in 1 hip. The internal fixation failure caused by fracture displacement and nonunion in 22 patients, traumatic arthritis in 6 patients, fracture nonunion and infection in 3 patients, and avascular necrosis of the femoral head in 2 patients. The mean interval from initial fracture fixation to THA was 20 months (range, 2-48 months). The safety evaluation indicators included operation time, amount of operative bleeding and postoperative drainage, blood transfusion, and perioperative complications. The efficacy indexes included the hip Harris score, the range of motion (ROM), visual analogue scale (VAS) score, and the length difference between both legs; the X- ray films were taken to assess the prosthesis survival condition.

Results

The average operation time was 92 minutes (range, 55-135 minutes). The average amount of operative bleeding and postoperative drainage were 480 mL (range, 360-620 mL) and 350 mL (range, 220-520 mL), respectively. Intraoperative proximal femur fissure fracture occurred in 2 hips. After operation, 10 cases received allogeneic blood transfusion, 1 case occurred cerebral infarction, 2 hips experienced dislocation, 1 hip occurred greater trochanter re-fracture and dislocation because of spraining, and 1 case died of myocardial infarction. Twenty-nine patients (30 hips) were followed up 2-10 years (mean, 4.9 years). At last follow-up, there was no infection recurrence in 3 infected hips, and there was no prosthesis loosening, subsidence, or rupture in all cases. The Harris score, ROM, VAS score, and the length difference between both legs were significantly superior to preoperative ones ( P<0.05).

Conclusion

THA is an effective salvage procedure after failed internal fixation of intertrochanteric fracture. But its perioperative risks and complications are pretty high. Adequate preoperative evaluation, elaborate and individualized perioperative management are keys to make sure the patient can safely survive the perioperative period.