Subtrochanteric femoral shortening osteotomy combined with cementless total hip replacement for Crowe type IV developmental dysplasia: a retrospective study

Background

Total hip replacement for high dislocation of the hip presents some difficulties, considering patients’ young ages, the abnormal hip anatomy and the high rate of complications. In this study, we present our experience in terms of clinical and radiological results in the treatment of Crowe type IV hips with subtrochanteric femoral shortening osteotomy and cementless total hip replacement.

Materials and Methods

We retrospectively reviewed 15 patients with Crowe type IV hip dysplasia (two bilateral cases for a total of 17 hips) treated with cementless total hip replacement associated with shortening subtrochanteric osteotomies (nine transversal and eight Z-shape osteotomies) between March 2000 to February 2006. The mean follow-up was 88 months (range 63–133). Harris hip score, leg length discrepancy, neurological status, union status of the osteotomy and the component stability were the criteria of the evaluation. All complications were noted.

Results

The mean HHS improved from 38.3 (range 32–52) to 85.6 (range 69–90). The mean preoperative leg length discrepancy was of 45 mm (range 38–70) and reduced to a mean of 12 mm (range 9–1.6) postoperatively. All osteotomies resulted healed at an average of 12.3 weeks (range 10–15). No cases of delayed union or nonunion were detected. Two patients (11%) showed early symptoms of sciatic nerve palsy which resolved uneventfully in 6 months. There was no migrations and none of the implants required revision.

Conclusions

Cementless THA with shortening subtrochanteric osteotomy is an effective method in the treatment of patients with Crowe type IV development dysplasia of the hip.

Level of evidence

IV.

     

Subtrochanteric shortening with overlapping femoral resection in total hip arthroplasty for Crowe type IV adult dislocation of the hip

Objective: To summarize the surgical technique and clinical outcomes of subtrochanteric shortening with overlapping femoral resection in primary total hip arthroplasty (THA) for Crowe type IV adult dislocation of the hip (ADH). Methods: From January 2000 to December 2005, 12 patients with ADH (15 hips) were treated with primary cementless hip arthroplasty using the method of subtrochanteric shortening with overlapping femoral resection. There were three male and nine female patients (nine unilateral and three bilateral hips) with an average age of 56 years (range, 41–75). Subtrochanteric shortening with overlapping femoral resection and ‘V’ shaped derotational osteotomy were performed in all cases without soft tissue cutting release. Proximal femoral shaft splitting was performed as an adjunct in 10 hips. Results: The mean follow‐up time was 6 years (range, 3–8). There were no infections, nonunion, malunion, dislocation or nerve injury of traction. Postoperative X‐ray films showed that the acetabular cups were placed in anatomical position with 95% coverage of the acetabulum. Furthermore, initial stability of the femoral stem fixation was satisfactory and all osteotomies healed in 10–15 weeks. The Harris hip score had improved from 25–32 to 88–98 at one year after surgery (P < 0.01). All acetabular and femoral components were judged to be osteointegrated and well‐fixed during follow‐up. No components have needed revision. Conclusions: Subtrochanteric shortening osteotomy is a safe and predictable method for restoring the anatomic hip center in Crowe type IV ADH. The clinical outcomes of treating Crowe type IV ADH with THA were satisfactory.     

股骨转子下叠加缩短截骨在CroweⅣ型成人髋脱位全髋置换术的应用

目的总结CroweⅣ型成人髋脱位采用股骨转子下叠加缩短截骨行全髋置换术的方法与疗效。方法2000年1月至2003年12月，收治8例（11髋）CroweⅣ型成人髋脱位患者，男3例，女5例；年龄40-57岁，平均48岁；单髋5例，双髋3例；先天性发育不良7例，陈旧性髋关节结核1例。假体臼杯为金属杯＋聚乙烯内衬设计，其中Duraloc（Depuy，Warsaw，USA）8髋，Pressfit SⅡ（LINK，Ger-many）3髋。股骨柄假体采用AML（Depuy，Warsaw，USA）4髋，Summit（Depuy，Warsaw，USA）4髋，Ribbed（LINK，Germany）3髋。假体均采用生物学固定。手术均采用股骨转子下叠加缩短截骨，并附加断端“V”形截骨，其中6髋因最小号股骨柄假体置 入困难，而附加股骨劈开成形术。结果无一例发生感染、脱位等并发症，无一例行臀大肌或臀中、小肌等短肌松解。转子下平均缩短截骨长度为4．5cm（4～6cm），无一例因截骨过短，导致股骨头假体复位困难或坐骨神经牵伸伤；也无一例因截骨过长，导致股骨头假体松弛性脱位。术后X线片示臼杯均位于真臼区，股骨柄假体的初始固定均优良，截骨断端在3～6个月后均骨性愈合。测量显示患肢平均延长3cm（2．5～3．5cm）。随访3～7年，髋关节Harris评分从术前的25～32分改善至1年后的90～98分。无一髋假体显示有X线松动和邻近骨溶解。结论股骨转子下叠加缩短截骨术可用于CroweⅣ型成人髋脱位的全髋置换术治疗。     

Leg length change in total hip arthroplasty with subtrochanteric femoral shortening osteotomy for Crowe type IV developmental hip dysplasia

Primary total hip arthroplasties were performed in 70 hips for the treatment of Crowe type IV developmental dysplasia of the hip. The patients were subdivided into 2 groups with or without iliofemoral osteoarthritis. Leg length change was measured radiographically. Preoperative hip motion was reviewed from medical records and defined as either higher or lower motion groups. The leg length change in patients without iliofemoral osteoarthritis was significantly greater than that in patients with iliofemoral osteoarthritis, and the higher hip motion group had greater leg length change in total hip arthroplasty than the lower motion group. The current study identifies several features that might help predict leg length change during the preoperative planning of total hip arthroplasty for Crowe type IV developmental hip dysplasia.     

Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip

A surgical technique, which uses a transverse osteotomy, for subtrochanteric femoral shortening and derotation in total hip arthroplasty for high-riding developmental dislocation of the hip is described. Anteversion is set by rotating the osteotomy fragments, and torsional stability is augmented with allograft struts and cables when indicated. Eight patients with 9 total hip arthroplasties were followed for an average of 43 months (range, 24–84 months). Good to excellent results were obtained in 87% of patients (7 of 8). Eight of 9 osteotomies (89%) demonstrated radiographic evidence of healing at an average of 5 months. One patient had an asymptomatic nonunion of the osteotomy site but still had a good overall clinical result. Another patient suffered fatigue failure of a distally ingrown porous device, which necessitated revision total hip arthroplasty 18 months after surgery. Subtrochanteric osteotomy in total hip arthroplasty for developmental dislocation of the hip allows for acetabular exposure and diaphyseal shortening while facilitating femoral derotation. Furthermore, proximal femoral bone stock is maintained and some of the potential complications of greater trochanteric osteotomy may be avoided.     

Results on total hip arthroplasties with femoral shortening for Crowe's group IV dislocated hips

We performed total hip arthroplasties in 11 women with Crowe's group IV completely dislocated hips, with a mean age at surgery of 59.6 years and a mean follow-up of 65 months. In all cases, femoral shortening was achieved using step-cut osteotomy. All acetabular cups were placed in their anatomical locations. The mean Merle d'Aubigne hip score improved from 10.9 points to 16.9. There was no case of nonunion or malunion in the osteotomized site. Temporary numbness was observed in 2 hips, which subsided within 3 weeks without any treatment. One hip had to be revised 8 years after surgery because of aseptic loosening of the stem. Our study shows that total hip arthroplasty, incorporating step-cut femoral shortening, provides acceptable results for completely dislocated hip.     

Subtrochanteric transverse shortening osteotomy in cementless total hip arthroplasty achieved using a modular stem

It is challenging to reconstruct normal hip motion after a high hip dislocation. Although total hip arthroplasty (THA) with shortening osteotomy is a solution for high hip dislocation, osteotomy nonunion is a major complication. To improve the rate of osteotomy union, subtrochanteric transverse shortening osteotomy was performed using a modular-type stem, S-ROM, that can be fixed to both the proximal and distal parts of the femur individually with a stepped proximal sleeve and polished distal flutes with fins, respectively. The stem can facilitate union of the osteotomy by maintaining rigid rotational stability and generating compression pressure between bone parts of the femur even in simple transverse osteotomy. Moreover, transverse osteotomy is technically simple and minimizes the damage of the periosteum at the osteotomy. In our series, this procedure was performed on 6 hips in 6 patients with high hip dislocation. The mean follow-up period was 8.1 years. Osteotomy union was achieved in all patients for a mean of 8.8 weeks. This procedure is a good option for surgical treatment of high hip dislocation.     

Treatment of Crowe IV high hip dysplasia with total hip replacement using the Exeter stem and shortening derotational subtrochanteric osteotomy

We evaluated all cases involving the combined use of a subtrochanteric derotational femoral shortening osteotomy with a cemented Exeter stem performed at our institution. With severe developmental dysplasia of the hip an osteotomy is often necessary to achieve shortening and derotation of the proximal femur. Reduction can be maintained with a 3.5 mm compression plate while the implant is cemented into place. Such a plate was used to stabilise the osteotomy in all cases. Intramedullary autograft helps to prevent cement interposition at the osteotomy site and promotes healing. There were 15 female patients (18 hips) with a mean age of 51 years (33 to 75) who had a Crowe IV dysplasia of the hip and were followed up for a mean of 114 months (52 to 168). None was lost to follow-up. All clinical scores were collected prospectively. The Charnley modification of the Merle D'Aubigné-Postel scores for pain, function and range of movement showed a statistically significant improvement from a mean of 2.4 (1 to 4), 2.3 (1 to 4), 3.4 (1 to 6) to 5.2 (3 to 6), 4.4 (3 to 6), 5.2 (4 to 6), respectively. Three acetabular revisions were required for aseptic loosening; one required femoral revision for access. One osteotomy failed to unite at 14 months and was revised successfully. No other case required a femoral revision. No postoperative sciatic nerve palsy was observed. Cemented Exeter femoral components perform well in the treatment of Crowe IV dysplasia with this procedure.     

Transverse subtrochanteric shortening osteotomy in primary total hip arthroplasty for patients with severe hip developmental dysplasia

Twenty-four total hip arthroplasties were performed on patients with Crowe grade 3 or 4 hip dysplasia using subtrochanteric shortening osteotomy with 2 kinds of femoral stems. The average age of the patients was 44.8 years, and their average length of follow-up was 4.7 years. Acetabular reconstruction with structural autograft was used in 11 hips. Radiologically, hip centers were nearly normalized by a vertical height of 10.6-mm elevation and a horizontal length of 1.7 mm as compared with uninvolved sites. Three osteotomy nonunions required revisions with bone graft. One acetabular revision was performed for migration. One postoperative dislocation was managed successfully with closed reduction and an abduction brace. However, no neurologic complication was noticed. The Harris hip score improved from 35.6 to 81.7. A cementless modular distal fluted femoral stem is a useful device in these patients.     

Cementless arthroplasty with a distal femoral shortening for the treatment of Crowe type IV developmental hip dysplasia

Background:Severe developmental dysplasia of the hip is a surgical challenge. The purpose of this study is to describe the cementless arthroplasty with a distal femoral shortening osteotomy for Crowe type IV developmental hip dysplasia and to report the results of this technique.Results:The mean followup for the 12 hips was 52 months (range 36-82 months). The mean Harris hip score improved from 41 points (range 28-54) preoperatively to 85 points (range 79-92) at the final followup. The mean length of bone removed was 30 mm (range 25-40 mm). All the osteotomies healed in a mean time of 13 weeks (range 10-16 weeks). There were no neurovascular injuries, pulmonary embolism or no infections.Conclusion:Our study suggests that cementless arthroplasty with a distal femoral shortening is a safe and effective procedure for severe developmental dysplasia of the hip.     

Total hip replacement for high dislocated hips without femoral shortening osteotomy

When performing total hip replacement (THR) in high dislocated hips, the presence of soft-tissue contractures means that most surgeons prefer to use a femoral shortening osteotomy in order to avoid the risk of neurovascular damage. However, this technique will sacrifice femoral length and reduce the extent of any leg-length equalisation. We report our experience of 74 THRs performed between 2000 and 2008 in 65 patients with a high dislocated hip without a femoral shortening osteotomy. The mean age of the patients was 55 years (46 to 72) and the mean follow-up was 42 months (12 to 78). All implants were cementless except for one resurfacing hip implant. We attempted to place the acetabular component in the anatomical position in each hip. The mean Harris hip score improved from 53 points (34 to 74) pre-operatively to 86 points (78 to 95) at final follow-up. The mean radiologically determined leg lengthening was 42 mm (30 to 66), and the mean leg-length discrepancy decreased from 36 mm (5 to 56) pre-operatively to 8.5 mm (0 to 18) postoperatively. Although there were four (5%) post-operative femoral nerve palsies, three had fully resolved by six months after the operation. No loosening of the implant was observed, and no dislocations or infections were encountered. Total hip replacement without a femoral shortening osteotomy proved to be a safe and effective surgical treatment for high dislocated hips.     

Bilateral synchronous total hip arthroplasty for ankylosed hips

Purpose  

We investigated the effect of bilateral total hip replacement (THR) for patients with ankylosed hip joints caused by late ankylosing spondylitis (AS) and to discuss its related pre- and postoperative problems.     

The methods of shorting proximal femoral and total hip arthroplasty for Crowe IV dysplastic hip of adults

OBJECTIVES: To discuss the methods and outcome of shorting proximal femoral and total hip arthroplasy for Crowe IV dysplastic hip of adults. METHODS: From July 2000 to February 2006, 13 cases of osteoarthritis secondary to severe development dysplastic hip were treated by total hip replacement and the shorting proximal femoral. RESULTS: The duration of follow-up ranged from 4 months to 55 months. The average score increased from 36.9 to 84.1 points after the surgery according to Harris. All the patients could walk independently. Their paces were improved obviously and the function of their hips was satisfactory. CONCLUSIONS: The treatment by total hip arthroplasy and the shorting of posterior femoral is effective and efficient for osteoarthritis secondary to Crowe IV development dysplastic hip in adults. The long-term followup is necessary for further study.     

Cemented total hip arthroplasty with subtrochanteric femoral shortening transverse osteotomy for severely dislocated hips: outcome with a 3- to 10-year follow-up period

Background  

Total hip arthroplasty (THA) for the treatment of severe dislocation of the hip is a technically demanding procedure. In most previous reports, techniques and clinical outcomes using cementless prostheses are widely reported, but there have been few reports on the technique and outcomes using cemented prostheses. The purpose of this study was to evaluate the outcomes of a cemented THA with a simultaneous subtrochanteric femoral shortening transverse osteotomy in patients with Crowe type III or IV developmental dysplasia of the hip.     

Total hip arthroplasty (S-ROM stem) and subtrochanteric osteotomy for Crowe type IV developmental dysplasia of the hip

Background:

Developmental dysplasia of the hip (DDH) in adults with severe pain and disability is best treated by total hip arthroplasty (THA). The purpose of this study was to retrospectively evaluate the outcomes of subtrochanteric shortening osteotomy combined with THA using S-ROM stem for those severe patients with a special focus on the effect of two shapes in the subtrochanteric osteotomy ends: Oblique and transverse.

Materials and Methods:

Twenty one cases with mean age of 43.6 years who met inclusion criteria and were operated between February 2007 and February 2012 were included in the study. Those cases had been divided into two groups (oblique vs. transverse) and all records between the two groups were analyzed.

Results:

The Harris hip score significantly improved from 30.6 (range 18–59) preoperatively to 91.2 (range 87–98) postoperatively by the latest followup. Complications including one deep venous thrombosis, one intraoperative fracture of femur and two dislocations occurred while they were addressed properly afterward. The oblique group showed significant advantages in operative time, union time and additional fixation in comparison with the transverse group.

Conclusions:

In the primary THA for the treatment of irreducible DDH, subtrochanteric oblique osteotomy combined with the freely-rotatable S-ROM stem provided favorable short term outcomes by affording both morphological and functional advantages.     

骨水泥型与非骨水泥型人工全髋关节置换术的比较

目的评价骨水泥型和非骨水泥型人工全髋关节置换术的术中、术后临床效果。方法对52例患者(54髋)进行人工髋关节置换治疗,其中骨水泥组20例(20髋),非骨水泥组32例(34髋)。术后随访进行髋关节Harris评分、自主功能恢复Parker评分,并观察术后死亡率、假体翻修率及其他并发症的发生情况。结果与骨水泥型组相比,非骨水泥型组术中手术时间短、失血量少,两组差异有显著性(P0.05)。骨水泥组1例患者住院时出现深静脉血栓形成,非骨水泥组有3例住院时出现深静脉血栓形成。骨水泥组置换后3个月,14例患者可独立行走,5例需助步器辅助行走,1例仅能活动(卧床活动);非骨水泥组23例患者可独立行走,9例需助步器辅助行走。置换后1年,在患者髋关节Harris评分和患者自主功能恢复Parker评分方面,两组之间均无显著差异。置换后3年,骨水泥组有4例翻修(均为假体松动),翻修率20%。而非骨水泥组仅有3例翻修(均为假体松动),翻修率9.37%,但两组之间差异无显著性(P0.05)。另外,随访期间骨水泥组有1例患者死亡。结论应用非骨水泥假体可明显降低全髋关节置换术的手术时间和失血量。随访期内骨水泥型和非骨水泥型双动头假体置换术的临床疗效无显著差异。     

转子下截骨短缩全髋关节置换治疗髋关节发育不良

目的探讨股骨转子下截骨短缩人工髋关节置换治疗成人CroweIV型髋关节发育不良的临床疗效。方法CroweIV型髋关节发育不良患者18例24髋，均为女性，平均年龄46．8岁（38-55岁）。采用S-ROM或AML假体结合股骨转子下横断截骨短缩行人工关节置换术，按术前计划、股骨重叠情况及软组织和坐骨神经张力截除相应长度股骨。术前、术后行Harris评分及功能评价。结果全部病例随访9-72个月，平均29个月。Harris评分由术前41分增加到术后89分，优良率83．3％。髋旋转中心平均下降56mm，平均截骨短缩长度为31mm。截骨平均愈合时间为8个月。1髋术中、2髋术后并发股骨骨折，发生率12．5％，用加压钢板及钢丝固定，平均10个月后骨折愈合。术前Trendelenburg征均为阳性，术后15例阴性、3例阳性，转阴时间平均为13个月。单侧患者肢体不等长发生率为25％。无一例出现关节感染、假体松动、脱位、神经功能损伤等并发症。结论股骨转子下截骨短缩人工髋关节置换治疗髋关节发育不良高位脱位可避免坐骨神经损伤，单侧患者易形成肢体不等长，软组织平衡及肌力恢复需要一定时间，Trendelenburg征转阴时间长，易并发术中及术后股骨骨折，需用钢丝环扎预防。     

A new device for a V-shaped subtrochanteric osteotomy combined with total hip arthroplasty

Subtrochanteric femoral shortening and a corrective osteotomy are considered to be an integral part of total hip arthroplasty for a completely dislocated hip or a severe deformity of the proximal femur. A precise subtrochanteric osteotomy is mandatory to achieve good results for such cases. We herein describe a new simple device for accurately performing precise subtrochanteric V-shaped osteotomy.