Jan 27, 2012 - 1Faculty of Medicine, University of Belgrade, Belgrade ... Developmental disorder of the hip (DDH) is the most frequent disease of this joint. ..... Femoral abbreviation osteotomies in total arthroplasty of the hip, particularly when .
hip to total hip arthroplasty have been reported in the literature as have .... Resection arthroplasty (Girdlestone Proceedure), nerve palsies, limb length inequality ...
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and the types of arthroplasty performed are shown in Tables. II and ... arthroplasties performed. Number of ..... in all 12 a Girdlestone arthroplasty was performed.
Gonzalez Della Valle A, Serota A, Go G, Sorriaux G, Sculco TP, Sharrock NE, et al. Venous thromboembolism .... Yu HT, Dylan ML, Lin J, Dubois RW. Hospitals' ...
Abstract: Instability after total hip arthroplasty (THA) is not a rare occurrence. Numerous factors have been associated with dislocation including surgical approach, implant design, failure to restore proper hip mechanics and soft tissue restraints,
V early osteointegration. On-growth of bone to porous coated prostheses is ... rich femoral component or with the ce- ... total hip arthroplasty in dogs (1, 2). Loo-.
Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem ... following total joint replacement.12 A retrospec- tive study by ...
Total hip replacement (THR) is a very common procedure undertaken in up to 285 000 .... diagnosis can include activity-related pain, aseptic loosening,.
an ideal total hip replacement with a large femoral head and a high head-neck ratio. B: Cam-type impingement in the native hip caused by a reduced femoral head-neck offset and similar impingement in a prosthetic hip with a small femoral head and a sk
575. INTRODUCTION. Total hip replacement (THR) provides a very effective ... arthroplasty, bilateral arthroplasty; those transferred or initially treated at other ...
90% (Schulte et al 1993; Neumann, Freund and SÃËrenson. 1994). Since its ..... Fowler JL, Gie GA, Lee AJC, Ling RSM. .... Clin On/top l993;292: 191-201. VOL.
Jun 13, 2018 - Abstract -- Introduction: Total hip replacement (THR) surgery is still evolving in Nigeria with .... Excision arthroplasty hips (Girdlestone). 4. 6.8%.
May 30, 2016 - introduction: In the Middle East, severe developmental dysplasia of the hip with subsequent high dislocation is often seen. We assessed the ...
Jan 1, 1984 - vitallium mesh. B shows lateralization and distalization of the acetabular component, no lucent lines, and homogeneous structure of the graft.
Acetabular and femoral loosening ... hybrid THR with a cementless acetabular com- ponent and cemented .... 2), revision surgery, stiff hips, protrusio acetabuli ...
developed a femoral device which differed in concept from the traditional ..... parameters on calcar stresses following femoral head arthroplasty. J. Biomed Mater ...
The complications of trochanteric osteotomy include nonunion, fibrous union, chronic bursitis and broken wires. For revision cases, osteoporosis, osteolysis, and.
5, SEPTEMBER. 1991. Table. I. Pain before operation and at follow-up, five hips with a. Girdlestone procedure at review are excluded. Grade. Description ofpain.
putting on shoes and socks or stockings. Functional limita- tions are usually ... Elderly patients undergoing elective hip replacement for either osteoarthritis or ...
arthroplasty of the hip for infection using an interim articulated Prostalac hip spacer: a 10- to 15-year follow-up study. J Bone Joint Surg [Br] 2009;91-B:1431-7.
Bearings can be broadly divided into hard-on-soft (e.g. metal or ceramic on ... Newer more corrosion resistant stainless steel alloys are now available, and the use ... Titanium alloys are more vulnerable to abrasion than cobalt- ... combined with he
The results of primary total hip arthroplasty for sub-capital femoral neck fracture in previously normal hips are reported. Thirty-seven patients aged 70 or less at ...
Dec 7, 2016 - (low friction arthroplasty principles stated by Charnley ) and a large ... complex primary or revision hip replacement for different etiologies in ...
Total hip replacement for high dislocated hips without femoral shortening osteotomy
X. Zhao, Z.-A. Zhu, Y.-Z. Xie, B. Yu, D.-G. Yu From Department of Orthopaedic Surgery, Ninth People’s Hospital, Shanghai, China
When performing total hip replacement (THR) in high dislocated hips, the presence of softtissue 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.
Total hip replacement (THR) may be required for patients with a high dislocated hip as a consequence of severe developmental dysplasia of the hip (DDH),1 and occasionally following other conditions such as slipped upper femoral epiphysis and tuberculosis. For biomechanical reasons, it has been recommended that the acetabular component should be placed in the true acetabulum.2,3 However, soft-tissue contractures can make reduction of the hip difficult because of the potential risk of neurovascular damage. This problem has been resolved by the use of various techniques of femoral shortening osteotomy when leg lengthening might exceed 4 cm.4-8 A femoral shortening osteotomy may be preferred because of the danger of neurological complications, but these techniques are usually complex and timeconsuming. Patients with a unilateral high dislocated hip always have marked leg-length discrepancy, and shortening the femur will limit any restoration of leg length, which for young patients is an important consideration. The purpose of this study was to review the clinical and radiological results of THR in patients with high dislocation, and assess the safety of THR without a femoral shortening osteotomy.
VOL. 93-B, No. 9, SEPTEMBER 2011
Patients and Methods We retrospectively reviewed 65 patients (74 hips) with high dislocated hips articulating in a false acetabulum who underwent THR between November 2000 and June 2008 in our hospital. The high dislocated hip was judged according the Hartofilakidis classification.9 The indications for THR were severe hip pain or limited mobility. Patients who had undergone a previous Schanz osteotomy with resulting severe curvature of the proximal femur, which would preclude THR without a further femoral osteotomy, were excluded. In all, 65 patients, 15 men and 50 women (74 hips), met the criteria for inclusion in the study. Of these, nine patients had high dislocation of the hip bilaterally and underwent staged bilateral THR. In addition, 14 patients had a low dislocation and nine had dysplasia in the contralateral hip according to the Hartofilakidis classification.9 Bilateral THRs were also performed in these patients either under the same anaesthetic or on a different occasion, depending on their physical condition. The mean age of the patients at the time of the operation was 55 years (46 to 72), and the mean follow-up was 42 months (12 to 78). There were 69 hips with a high dislocation 1189
X. ZHAO, Z.-A. ZHU, Y.-Z. XIE, B. YU, D.-G. YU
due to DDH, four due to a slipped capital femoral epiphysis and one due to tuberculosis. Permission to conduct this review was granted by the local ethics committee. Implants. All implants except one resurfacing implant were cementless. A total of 68 hips were managed with a straight Secur-Fit hydroxyapatite-coated stem (Stryker, Mahwah, New Jersey) and either an Osteonics Crossfire highly crosslinked polyethylene or a ceramic acetabular insert (Stryker). A straight modular S-ROM stem (Depuy, Warsaw, Indiana) with either a Bantam polyethylene or a Duraloc Option ceramic acetabular component (both DePuy) was used in five hips. Both acetabular components were inserted into a Duraloc Acetabular Cup (Depuy). In one hip a resurfacing was undertaken with the Conserve Plus implant (Wright Medical Technologies, Arlington, Tennessee). Surgical techniques. Pre-operative templating was undertaken to ensure that the femur was sufficiently straight to accept a commercial stem.10 The patient was placed in the lateral position and the hip and proximal femur were exposed through a standard posterolateral approach. Dissection of the inferior part of the elongated capsule permitted exposure of the true acetabulum. All osteophytes and hypertrophied soft tissue around the true acetabulum were removed to provide a complete view of the true acetabulum. The soft-tissue release is important for the reduction of the hip. If necessary, an iliopsoas and subcutaneous adductor tenotomy were performed. The acetabular component was placed at the level of the reamed anatomical location. When the coverage was < 80%, superolateral screws were placed in the roof of the component to enhance stability, and bone defects were filled with impacted morsellised autogenous bone graft taken from the resected femoral head. The femoral neck was divided more distally than in a standard THR, at the upper margin of the lesser trochanter, in order to lessen the tension when the hip was reduced. The femoral component which was selected was the one that best matched the broached intramedullary canal with the anteversion carefully controlled. For the patient who was treated with resurfacing replacement, the standard surgical technique was performed to implant the femoral component. A trial reduction was attempted, which was usually tight and difficult. Initially the limb was held in adduction and internal rotation as distal traction was applied to the femur by an assistant. If this was insufficient to reduce the hip, direct leverage was applied to the greater trochanter using an elevator, which obtained purchase on the bone below the acetabulum. When the modular femoral head reached the level of the acetabular component, the reduction was achieved by externally rotating the leg. During the procedure, the hip and knee were always held in flexion to relax the sciatic nerve and reduce the tension on the soft tissues. This position was maintained post-operatively for several days to avoid damage to the nerve.
Post-operative rehabilitation. In addition to protecting the nerve, this posture was sometimes required because the soft tissue was tight after the leg lengthening. The joints were gradually extended over the course of two to three weeks, by which time full hip and knee extension was obtained without any nerve palsy. Patients were allowed to sit on a chair and mobilise with partial weight-bearing using crutches during this period. When they had regained full extension, walking exercises with crutches and full weightbearing were initiated. The ipsilateral crutch was discarded six weeks post-operatively, but the contralateral one was used for three months. Radiological evaluation. Standard anteroposterior (AP) and lateral radiographs of the pelvis were taken pre-operatively, post-operatively and at follow-up examinations. The vertical distance from the tip of the greater trochanter to the inter-teardrop line was measured on both sets of radiographs. For the pre-operative leg-length discrepancy the difference in this distance between both hips was recorded. The extent of the lengthening obtained in the affected limb was determined by the difference of the values on pre- and post-operative radiographs. Subsidence was measured using the method of Heekin et al.11 It was measured by determining the change in distance from the superomedial tip of the stem to the most proximal point on the lesser trochanter. Subsidence of the femoral component > 5 mm was considered significant.12 Progressive radiolucencies were recorded and measured around the acetabular component in the three zones according to DeLee and Charnley.13 If the acetabular component had progressive radiolucencies in more than one zone, or migration, it was defined as loose. Any change of the position of the acetabular component by > 5 mm was considered to be migration, with the pelvic teardrops used as reference points. Clinical examination. A physical examination was conducted pre-operatively, at three and six months postoperatively, and once yearly thereafter until the latest follow-up. Abduction strength was assessed with the Trendelenburg test.5 All patients also underwent a detailed clinical neurological examination, focusing on sciatic and femoral nerve function but not including routine electrophysiological testing. The outcome was assessed using the Harris hip score (HSS).14
Results No patients required revision during the follow-up period. The mean HHS score improved from 53 points (34 to 74) pre-operatively to 86 (78 to 95) at the final follow-up. The pre-operative Trendelenburg sign was positive in all 74 hips, but at the time of final follow-up was positive in only five (6.7%). From radiological measurements, the mean limb-length discrepancy decreased from 36 mm (5 to 56) preoperatively to 8.5 mm (0 to 18) at final review. The mean leg lengthening achieved was 42 mm (30 to 66). In THE JOURNAL OF BONE AND JOINT SURGERY
TOTAL HIP REPLACEMENT FOR HIGH DISLOCATED HIPS WITHOUT FEMORAL SHORTENING OSTEOTOMY
Radiographs of a patient with developmental dysplasia of the hip a) pre-operatively, showing a low dislocation of the right hip and a high dislocation of the left, according to the Hartofilakidis classification,9 and b) 12 months post-operatively after staged bilateral total hip replacements performed without femoral shortening osteotomy. The leg lengthening in the left hip was 66 mm on radiological measurement.
Radiographs of a patient with developmental dysplasia of the hip a) pre-operatively, showing bilateral high dislocated hips, and b) six months post-operatively after bilateral S-ROM total hip replacement without femoral shortening osteotomy. The radiological leg lengthening of the right and left hips was 37 mm and 40 mm respectively.
five patients the leg lengthening ranged from 50 mm to 66 mm. No loosening of a component was observed in any patient at the last follow-up. There were four (5%) femoral nerve palsies with numbness of the thigh and/or weakness of knee extension, all of which were observed immediately after the operation and treated conservatively. Three had resolved completely after six months. One patient had a permanent femoral palsy, with weakness of knee extension. In five hips (6.7%) there was a peri-operative longitudinal fissure femoral fracture which was secured with cables. No dislocation or wound infection was encountered (Figs 1, 2 and 3). VOL. 93-B, No. 9, SEPTEMBER 2011
Discussion In our series of 74 THRs performed for high dislocation of the hip without a femoral shortening osteotomy, a mean leg lengthening of 42 mm was obtained. One patient had permanent damage to the femoral nerve. Satisfactory clinical results were achieved with a mean HHS of 86 points at the latest visit. In this series, the principle of reconstruction involved placing the acetabular component at the level of the anatomical acetabulum. We used a cementless component with a small external diameter and a ceramic liner to reduce wear. Although the proximal femur was extremely narrow in some patients, narrow commercially available
X. ZHAO, Z.-A. ZHU, Y.-Z. XIE, B. YU, D.-G. YU
Radiographs of a patient who had tuberculosis of the left hip in infancy, a) pre-operatively, showing a high dislocation, and b) 12 months post-operatively after total hip replacement without femoral shortening osteotomy, achieving a radiological leg lengthening of 60 mm.
stems were used. Nevertheless, intra-operative femoral fracture was a risk and occurred in five hips. These fractures were longitudinal fissures without significant displacement; they could be secured using cables and without compromising the stability of the implant. The literature on THR in high dislocated hips in the presence of a femoral shortening osteotomy reports an intra-operative fracture rate between 7% and 10%.5,6 In THR for high DDH, restoration of the anatomical hip centre reduces the reaction force of the hip joint and creates an improved lever arm for the abductor musculature, and is considered to improve the longevity of the THR.15,16 However, this method renders the reduction of the femoral component difficult because of the soft-tissue contractures, and leaves the nerves vulnerable to injury. Various femoral shortening osteotomies have been used, with good results. However, these techniques are complex and time-consuming, and reduce the capacity to restore the length of the leg, which may reduce abductor strength. There is also a risk of nonunion of the osteotomy, and instability of the osteotomy may result in early femoral loosening.7,17 Furthermore, resection of the proximal femur sacrifices the bone stock suitable for cementless fixation,18 and incongruency between the diameters of the proximal and distal canals after shortening can cause problems in achieving secure fixation of the femoral component.4 There are few reports of THR in patients with a high dislocated hip without femoral shorting osteotomy.19,20 This matter has been addressed twice by the same group, who felt that femoral osteotomy was not necessary.19,20 Of 84 THRs for high dislocated hips in that study,20 13 (15%) had 5 cm or more of leg lengthening without neurological complications. The two patients who had neurapraxia had 3 cm and 3.5 cm of lengthening, respectively, and both recovered fully. There were two major points in our THR technique for high DDH: the reduction of the hip and the protection of
the nerves. In our experience, the difficulty of the reduction was related to the degree of pre-operative stiffness of the hip. This must be addressed as described in our operative technique and managed post-operatively by a gradual reestablishment of extension. Although four patients presented with severe femoral nerve palsies in the early stage, three had recovered fully by six months after the operation. It has been suggested that the nerve damage in THR is not related to the amount of lengthening but to the difficulty of the surgery itself.21 We used a posterolateral approach in which the sciatic nerve was retracted directly during the procedure, but, interestingly, all nerve palsies related to the femoral nerve. We are unable to explain this. The disadvantage of this technique was the difficulty in obtaining the correct anteversion of the femoral component in every hip owing to the presence of excessive femoral anteversion deformity. In these patients, modular stems were used to achieve the best correction. In this study there were no dislocations and no loosening of the components. Although THR without a femoral shortening osteotomy in high dislocated hips has been described previously, the technique was different in requiring an osteotomy of the greater trochanter to improve the exposure via a lateral approach.19,20 This facilitated the reduction of the replaced hip owing to the reduction in tension around the joint, but reattachment of the greater trochanter was a problem. Fibrous union of the greater trochanter occurred in 22% of hips.19 Nonunion and migration of the greater trochanter was observed in one hip (1%). Iliofemoral distraction with external fixators before THR has been described as an alternative technique to femoral shortening osteotomy.22,23 One report using this technique describes achieving a mean lengthening after THR of 46 mm.23 However, this technique was uncomfortable for patients and had the potential for pinsite infection. THE JOURNAL OF BONE AND JOINT SURGERY
TOTAL HIP REPLACEMENT FOR HIGH DISLOCATED HIPS WITHOUT FEMORAL SHORTENING OSTEOTOMY
We performed THR for patients with a high dislocated hip without femoral shortening osteotomy. This is a relatively easy procedure that can provide more initial stability for the femoral component and does not sacrifice leg length. Our results indicate that it is a safe method of treatment in THR for high dislocated hips.
Listen live Listen to the abstract of this article at www.jbjs.org.uk/interactive/audio The study was supported by a grant from Shanghai Key Laboratory of Orthopaedic Implant and the Fund for Key Disciplines of the Shanghai Municipal Education Commission (J50206). No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
References 1. Karachalios T, Hartofilakidis G. Congenital hip disease in adults: terminology, classification, pre-operative planning and management. J Bone Joint Surg [Br] 2010;92-B:914–921. 2. Bicanic G, Delimar D, Delimar M, Pecina M. Influence of the acetabular cup position on hip load during arthroplasty in hip dysplasia. Int Orthop 2009;33:397–402. 3. Sanchez-Sotelo J, Berry DJ, Trousdale RT, Cabanela ME. Surgical treatment of developmental dysplasia of the hip in adults: II: arthroplasty options. J Am Acad Orthop Surg 2002;10:334–344. 4. Togrul E, Ozkan C, Kalaci A, Gülşen M. A new technique of subtrochanteric shortening in total hip replacement for Crowe type 3 to 4 dysplasia of the hip. J Arthroplasty 2010;25:465–470. 5. Eskelinen A, Helenius I, Remes V, et al. Cementless total hip arthroplasty in patients with high congenital hip dislocation. J Bone Joint Surg [Am] 2006;88-A:80– 91. 6. Nagoya S, Kaya M, Sasaki M, et al. Cementless total hip replacement with subtrochanteric femoral shortening for severe developmental dysplasia of the hip. J Bone Joint Surg [Br] 2009;91-B:1142–1147 7. Krych AJ, Howard JL, Trousdale RT, Cabanela ME, Berry DJ. Total hip arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV developmental dysplasia. J Bone Joint Surg [Am] 2009;91-A:2213–2221 8. Reikerås O, Haaland JE, Lereim P. Femoral shortening in total hip arthroplasty for high developmental dysplasia of the hip. Clin Orthop 2010;468:1949–1955.
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9. Hartofilakidis G, Stamos K, Karachalios T, Ioannidis TT, Zacharakis N. Congenital hip disease in adults: classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty. J Bone Joint Surg [Am] 1996;78-A:683–692. 10. Zhao X, Zhu ZA, Zhao J, et al. The utility of digital templating in total hip arthroplasty with Crowe type II and III dysplastic hips. Int Orthop 2011;35:631–638. 11. Heekin RD, Callaghan JJ, Hopkinson WJ, Savory CG, Xenos JS. The porous coated anatomic total hip prosthesis, inserted without cement: results after five to seven years in a prospective study. J Bone Joint Surg [Am] 1993;75-A:77–91. 12. Malchau H, Kärrholm J, Wang YX, Herberts P. Accuracy of migration analysis in hip arthroplasty: digitized and conventional radiography, compared to radiostereometry in 51 patients. Acta Orthop Scand 1995;66:418–424. 13. DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop 1976;121:20–32. 14. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty: an end-result study using a new method of result evaluation. J Bone Joint Surg [Am] 1969;51-A:737–755. 15. Pagnano MW, Hanssen AD, Lewallen DG, Shaughnessy WJ. The effect of superior placement of the acetabular component on the rate of loosening after total hip arthroplasty. J Bone Joint Surg [Am] 1996;78-A:1004–1014. 16. Yoder SA, Brand RA, Pederson DR, O’Gorman TW. Total hip acetabular component position affects acetabular loosening rates. Clin Orthop 1988;228:79–87. 17. Park MS, Kim KH, Jeong WC. Transverse subtrochanteric shortening osteotomy in primary total hip arthroplasty for patients with severe hip developmental dysplasia. J Arthroplasty 2007;22:1031–1036. 18. Bruce WJ, Rizkallah SM, Kwon YM, Goldberg JA, Walsh WR. A new technique of subtrochanteric shortening in total hip arthroplasty: surgical technique and results of 9 cases. J Arthroplasty 2000;15:617–626. 19. Hartofilakidis G, Karachalios T. Total hip arthroplasty for congenital hip disease. J Bone Joint Surg [Am] 2004;86-A:242–250. 20. Hartofilakidis G, Stamos K, Karachalios T. Treatment of high dislocation of the hip in adults with total hip arthroplasty: operative technique and long-term results. J Bone Joint Surg [Am] 1998;80-A:510–517. 21. Eggli S, Hankemayer S, Müller ME. Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. J Bone Joint Surg [Br] 1999;81-B:843–845. 22. Holinka J, Pfeiffer M, Hofstaetter JG, et al. Total hip replacement in congenital high hip dislocation following iliofemoral monotube distraction. Int Orthop 2011;35:639–645. 23. Lai KA, Shen WJ, Huang LW, Chen MY. Cementless total hip arthroplasty and limb-length equalization in patients with unilateral Crowe type-IV hip dislocation. J Bone Joint Surg [Am] 2005;87-A:339–345.