Evolution of Surgical Techniques for the Treatment of Angular and Torsional Deviation in DDH: 20 Years Experience

Abstract

The anatomical abnormalities associated with developmental dysplasia of the hip (DDH) increase the complexity of hip arthroplasty In addition, previous femoral osteotomy can deform the proximal femur. Noncemented cups and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe grade IV and sometimes Crowe grade III; additional surgical procedures are required. The purpose of the study was to analyse the surgical procedure and then the reconstructive options in DDH. From 1984 until now, total arthroplasty has been performed, on dysplastic hips, in 2,101 patients for 2,308 hips (207 patients bilateral 9% rate). All the procedures were perfomed by the senior authors (LS, GG) at the same hospital specialised in elective hip surgery. More than 80% of patients came from Northern Italy. The average age was 51 (range 32–83), 565 cases had involved a previous femoral osteotomy. Out of these 2,308 cases, 128 cases needed treatment for corrections of femoral side deformity; 64 cases were subjected to a greater trochanter osteotomy. In 12 cases, proximal femur shortening was involved. In 9 cases, rotational abnormality and shortening were controlled with a distal femur osteotomy. Fifty-five cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only noncemented stems were used. Long-term results in these patients are consistently inferior (70% survival rate at 15 years) compared to those in the non-DDH population (97.7% survival at 15 years). On the femoral side, early failures are the reflection of a learning curve and are due to insufficient fixation of the osteotomy. The more promising outcomes are those involving a shortening subtrochanteric osteotomy.

An Attempt to Throw Light on Congenital Hip Disease Terminology and Anticipation of Clinical Outcomes when Treated with Total Hip Arthroplasty

“…Total hip arthroplasty in congenital hip disease is generally considered as having higher failure rates (19). It seems also that these patients score rather less in objective rating scales (such as Harris Hip Score) compared to those with primary osteoarthritis, while similar data derived from subjective rating scales are lacking (20). It has to be stressed that the interpretation of results is difficult because in the majority of the studies all types of the disease are included, to a varying degree.…”

Congenital hip disease in adults

“…It has been suggested that this technique gives satisfactory results when at least 70% of the acetabular component is supported by the host bone. 29 High placement of the component in the region of the false acetabulum has also been proposed. 27,30 The problem with this technique is that with the acetabular component at this level, the lever arm for the body-weight is much longer than that of the abductors, and causes excessive loading of the hip.…”

“…It seems that detachment of the trochanter with shortening of the proximal metaphysis is indicated for proximal malformations which are difficult to treat; a middiaphyseal osteotomy is indicated when there is a concomitant severe valgus deformity of the knee, while a subtrochanteric shortening osteotomy has broader indications. 29 When planning a shortening osteotomy, a CT of the pelvis and lower limbs is essential to measure the femora accurately and thus the true leg-length discrepancy. It has been found that in up to 30% of cases of low and high dislocation the affected femur is longer than that on the opposite side.…”

“…The young age of the patients combined with the altered morphology of the hip, and consequent lack of bone stock may result in a higher rate of a failure 39 and a worse functional outcome. 29 It should be stressed that the interpretation of the published results is difficult because most series include patients with many different types of hip disease.…”

The Trabecular Metal Monoblock acetabular component in patients with high congenital hip dislocation

“…Various classifications for congenital dysplasia and dislocation have been described, 4,[8][9][10][11][12] the most commonly used being those of Hartofilakidis et al 4,11 or Crowe et al, 9 the inter-and intraobserver reliabilities of which were recently examined by Decking et al 13 Good results have been reported using both cemented and uncemented implants. [14][15][16] The surgical technique used for high hip dislocation is different from that for simple acetabular dysplasia. An osteotomy for femoral shortening is frequently needed.…”