Objective To review research advances of revision surgery after primary total hip arthroplasty (THA) for patients with Crowe type Ⅳ developmental dysplasia of the hip (DDH). Methods The recent literature on revision surgery after primary THA in patients with Crowe type Ⅳ DDH was reviewed. The reasons for revision surgery were analyzed and the difficulties of revision surgery, the management methods, and the related prosthesis choices were summarized. Results Patients with Crowe type Ⅳ DDH have small anteroposterior diameter of the acetabulum, large variation in acetabular and femoral anteversion angles, severe soft tissue contractures, which make both THA and revision surgery more difficult. There are many reasons for patients undergoing revision surgery after primary THA, mainly due to aseptic loosening of the prosthesis. Therefore, it is necessary to restore anatomical structures in primary THA, as much as possible and reduce the generation of wear particles to avoid postoperative loosening of the prosthesis. Due to the anatomical characteristics of Crowe type Ⅳ DDH, the patients have acetabular and femoral bone defects, and the repair and reconstruction of bone defects become the key to revision surgery. The acetabular side is usually reconstructed with the appropriate acetabular cup or combined metal block, Cage, or custom component depending on the extent of the bone defect, while the femoral side is preferred to the S-ROM prosthesis. In addition, the prosthetic interface should be ceramic-ceramic or ceramic-highly cross-linked polyethylene wherever possible. Conclusion The reasons leading to revision surgery after primary THA in patients with Crowe type Ⅳ DDH and the surgical difficulties have been clarified, and a large number of clinical studies have proposed corresponding revision modalities based on which good early- and mid-term outcomes have been obtained, but further follow-up is needed to clarify the long-term outcomes. With technological advances and the development of new materials, personalized prostheses for these patients are expected to become a reality.
Objective To investigate the morphological changes of the proximalfemur and their implication to the total hip arthroplasty in patients with Crowe Ⅱ/Ⅲ developmental dysplasia of the hip (DDH). Methods The experimental gr oup was composed of 15 hips in 14 patients (Crowe Ⅱ, 9 hips; Crowe Ⅲ, 6 hips ) with osteoarthritis secondary to Crowe Ⅱ/Ⅲ DDH (2 males, 12 females; age, 35-61 years). None of the patients had accepted any osteotomy treatment. The control group was composed of 15 normal hips in 15 patients with unilateral DDH (3 males, 12 females; age, 35-57 years). Twelve hips came from the experimental group and the other 3 came from the patients with unilateral Crowe Ⅰ DDH. The femurswere examined with the CT scanning. The following parameters were measured: theheight of the center of the femoral head (HCFH), the isthmus position (IP), theneckshaft angle(NS), the anteversion angle, the canal flare index, and the canal width. Then, the analysis of the data was conducted. Results HCFH and IP in theexperimental group and the control group were 50.1±6.7 mm, 50.1±7.4 mm, and 107.4±21.5 mm, 108.7±18.1 mm，respectively, which had no significant differencebetween the two groups（Pgt;0.05）. In the experimental group and the control group, the NS were 138.3±10.0° and 126.7±5.7°，the anteversion angles were 36.5±15.9° and 18.8±5.4°, and the canal flare indexes were 4.47±0.40and 5.01±0.43. There was a significant difference between the two groups in the above 3 parameters （Plt;0.05）. As for the canal width of the femur, therewasa significant difference in the interior/exterior widths and the anterior/posterior widths at the level of 2 cm above the lesser trochanter and 4 cm belowthe lesser trochanter between the two groups （Plt;0.05）; however, there was nosignificant difference in the canal width of the femur at the isthmus between the two groups（P＞0.05）. Conclusion It is necessary to evaluate the morphology of the proximal femur before the total hip arthroplasty performed in patients with Crowe Ⅱ/Ⅲ DDH. The straight and smaller femoral prosthesis should be chosen and implanted in the proper anteversion position duringoperation.
ObjectiveTo review the imaging evaluation, treatment progress, and controversy related to developmental dysplasia of the hip (DDH) in adolescents and adults. Methods The domestic and abroad hot issues related to adolescents and adults with DDH in recent years, including new imaging techniques for assessing cartilage, controversies over the diagnosis and treatment of borderline DDH (BDDH), and the improvement and prospect of peracetabular osteotomy (PAO) were summarized and analyzed. ResultsDDH is one of the main factors leading to hip osteoarthritis. As the understanding of the pathological changes of DDH continues to deepen, the use of delayed gadolinium-enhanced MRI of cartilage can further evaluate the progress of osteoarthritis and predict the prognosis after hip preservation. There are still controversies about the diagnosis and treatment of BDDH. At the same time, PAO technology and concepts are still being improved. ConclusionCartilage injury and bony structure determine the choice of surgical methods and postoperative prognosis of hip preservation surgery. The hip preservation of adolescent and adult DDH patients will move towards the goal of individualization and accuracy.
Objective To explore the surgical technique and effectiveness of autologous femoral head bone graft in total hip arthroplasty (THA) for Crowe type Ⅲ developmental dysplasia of the hip (DDH) with acetabular bone defect. Methods Between July 2012 and September 2015, 12 cases (12 hips) of Crowe type Ⅲ DDH with acetabular bone defect were included. Of the 12 patients, 2 were male and 10 were female, with an average age of 54.3 years (range, 37-75 years). The Harris score before operation was 41.08±7.90. The preoperative leg length discrepancy was 0.53-4.28 cm, with an average of 2.47 cm. Autologous femoral head bone graft and cancellous screw fixation were used in all cases to reconstruct acetabula in THA. Four cases were performed with subtrochanteric shortening osteotomy at the same time. Results All incisions healed by first intention. Twelve cases were followed up 1 year and 10 months to 5 years, with an average of 3.0 years. X-ray films showed that bone healing was observed in all cases at 6 months to 1 year after operation. There was no bone graft osteolysis, absorption, bone graft collapse, and acetabular prosthesis loosening. At last follow-up, the Harris score was 89.50±2.78, showing significant difference when compared with preoperative value (t=–25.743, P=0.003). The length discrepancy was 0-1.81 cm at last follow-up with an average of 0.76 cm. Conclusion Autologous femoral head bone graft is effective for Crowe type Ⅲ DDH with acetabular bone defect, which has advantages of restoring pelvic bone stock, obtaining satisfied prosthetic stability and mid-term effectiveness.
Objective To investigate the effectiveness of Salter osteotomy combined with subtrochanteric shortening and derotational osteotomy in treating Tönnis type Ⅲ and Ⅳ developmental dysplasia of the hip (DDH) in children and explore the urgical timing. Methods A retrospective collection was performed for 74 children with Tönnis type Ⅲ and Ⅳ DDH who were admitted between January 2018 and January 2020 and met the selection criteria, all of whom were treated with Salter osteotomy combined with subtrochanteric shortening and derotational osteotomy. Among them, there were 38 cases in the toddler group (age, 18-36 months) and 36 cases in the preschool group (age, 36-72 months). There was a significant difference in age between the two groups (P<0.05), and there was no significant difference in gender, side, Tönnis typing, and preoperative acetabular index (AI) (P>0.05). During follow-up, hip function was assessed according to the Mckay grade criteria; X-ray films were taken to observe the healing of osteotomy, measure the AI, evaluate the hip imaging morphology according to Severin classification, and assess the occurrence of osteonecrosis of the femoral head (ONFH) according to Kalamchi-MacEwen (K&M) classification criteria. Results All operations of both groups were successfully completed, and the incisions healed by first intention. All children were followed up 14-53 months, with an average of 27.9 months. There was no significant difference in the follow-up time between the two groups (P>0.05). At last follow-up, the excellent and good rates according to the Mckay grading were 94.73% (36/38) in the toddler group and 83.33% (30/36) in the preschool group, and the difference between the two groups was significant (P<0.05). The imaging reexamination showed that all osteotomies healed with no significant difference in the healing time between the two groups (P>0.05). There was no significant difference in AI between the two groups at each time point after operation (P>0.05), and the AI in the two groups showed a significant decreasing trend with time extension (P<0.05). The result of Severin classification in the toddler group was better than that in the preschool group at last follow-up (P<0.05). There was no significant difference in the incidence of ONFH between the two groups (P>0.05). In the toddler group, 2 cases were K&M type Ⅰ; in the preschool group, 3 were type Ⅰ, and 1 type Ⅱ. There was no dislocation after operation.ConclusionSalter osteotomy combined with subtrochanteric shortening and derotational osteotomy is an effective way to treat Tönnis type Ⅲ and Ⅳ DDH in children, and surgical interventions for children aged 18-36 months can achieve better results.
ObjectiveTo evaluate the effectiveness of total hip arthroplasty (THA) combined with subtrochanteric osteotomy in the treatment of Crowe type Ⅳdevelopmental dysplasia of the hip (DDH).MethodsBetween April 2008 and June 2016, 71 patients with unilateral Crowe type Ⅳ DDH were treated with THA. Of 71 cases, 44 were performed with subtrochanteric osteotomy (osteotomy group) and 27 were performed without subtrochanteric osteotomy (non-osteotomy group). There was no significant difference in gender, age, body mass, height, body mass index, affected side, and preoperative Harris score between 2 groups (P>0.05). The complications were recorded and the effectiveness was assessed by Harris score. Besides, the femoral dislocation height and the settling depth of sleeve were measured in the pelvic anteroposterior X-ray film pre- and post-operatively.ResultsOsteotomy group was followed up 12-90 months (mean. 34.77 months), and non-osteotomy group was followed up 12-79 months (mean, 34.33 months). There was no significant difference in follow-up time between 2 groups (t=–0.088, P=0.930). There was 11 cases of intraoperative or postoperative complications in osteotomy group, and 3 cases of postoperative complications in non-osteotomy group. Among the osteotomy group, 1 case had nonunion due to infection and received revision after 20 months. No loosening or dislocation of the implant occurred in both 2 groups. Significant differences were found in femoral dislocation height and settling depth of sleeve between 2 groups (t=–8.452, P=0.000; t=6.783, P=0.000). Moreover, the osteotomy length was not correlated with the settling depth of sleeve (r=–0.038, P=0.806). At last follow-up, there was no significant difference in Harris score between 2 groups (t=–1.160, P=0.254).ConclusionTHA combined with subtrochanteric osteotomy can provide a favorable outcome for treating Crowe type Ⅳ DDH. Furthermore, patients with higher femoral dislocation and severely narrow femoral proximal canals are prone to be peformed with subtrochanteric osteotomy.
ObjectiveTo investigate the early effectiveness of proximal femur reconstruction combined with total hip arthroplasty (THA) in the treatment of adult Crowe type Ⅳ developmental dysplasia of the hip (DDH).MethodsBetween May 2015 and March 2018, 29 cases (33 hips) suffering from Crowe type Ⅳ DDH were treated with proximal femur reconstruction combined with THA. Of the 29 cases, there were 6 males (7 hips) and 23 females (26 hips), aged from 24 to 74 years with an average age of 44.9 years. The preoperative Harris hip score was 44.0±12.0. Gait abnormalities were found in all of the 33 hips with positive Trendelenburg sign, and the lower limb discrepancy was (3.8±1.6) cm. Preoperative X-ray films and CT both indicated serious anatomical abnormalities, including complete dislocation of the affected hip with significant move-up of the greater trochanter, abnormal development of the femoral neck, abnormal anterversion angle and neck-shaft angle, dysplasia of proximal femur and dysplasia of medullary cavity. The operation time, intraoperative blood loss, transfusion rate, and complications were recorded. The Gruen and DeLee-Charnley zoning methods were used to evaluate the aseptic loosening of the prosthesis on X-ray films. The Harris score was used to evaluate hip function. The lower limb discrepancy was calculated and compared with the preoperative value.ResultsThe operation time ranged from 80 to 240 minutes, with an average of 124.8 minutes. The intraoperative blood loss ranged from 165 to 1 300 mL, with an average of 568.4 mL. Seventeen patients (51.5%) received blood transfusion treatment. All the incisions healed by first intention without infection or deep vein thrombosis. All patients were followed up 19-53 months, with an average of 33 months. One patient had posterior hip dislocation because of falling from the bed at 4 weeks after operation, and was treated with manual reduction and fixation with abduction brace for 4 weeks, and no dislocation occurred during next 12-month follow-up. Two patients developed sciatic nerve palsy of the affected limbs after operation and were treated with mecobalamin, and recovered completely at 12 weeks later. Trendelenburg sign was positive in 3 patients and mild claudication occurred in 4 patients after operation. X-ray films showed that all the osteotomy sites healed at 3-6 months after operation, and no wire fracture was observed during the follow-up. The Harris score was 89.8±2.8 and lower limb discrepancy was (0.6±0.4) cm at last follow-up, both improved significantly (t=–22.917, P=0.000; t=11.958, P=0.000). The prosthesis of femur and acetabulum showed no obvious loosening and displacement, and achieved good bone ingrowth except 2 patients who had local osteolysis in the area of Gruen 1 and 7 around the femoral prosthesis, but no sign of loosening and sinking was observed.ConclusionThe treatment of Crowe Ⅳ DDH with proximal femur reconstruction and THA was satisfactory in the early postoperative period. The reconstruction technique of proximal femur can effectively restore the anatomical structure of proximal femur, which is one of the effective methods to deal with the deformity of proximal femur.
ObjectiveTo investigate the influence of the degree of acetabular deformity and the learning-curve on the acetabular cup positions in total hip arthroplasty (THA) for adults with developmental dysplasia of hip (DDH). MethodsBetween January 2008 and December 2015, 130 patients (144 hips) with DDH underwent primary THA, and the clinical data were analyzed retrospectively. Fifty-three patients (59 hips) were admitted before 2012, and 77 patients (85 hips) were treated after 2012. There were 32 males and 98 females, aged from 31 to 83 years (mean, 61). Unilateral replacement was performed in 116 cases and bilateral replacement in 14 cases. Of 144 hips, 48 hips were rated as Crowe type I, 57 hips as type II, and 39 hips as type of III/IV. The standard pelvic radiograph was taken within 1 week after operation. The mediCAD software was adopted to measure the angle of anteversion and abduction, bony coverage, and the distance between true rotating center and optimal rotating center to the connection of teardrops and the horizontal distance between two centers to evaluate the qualified rate of acetabular cup positions. ResultsCompared with the patients with the same type in 2013-2015 group, the anteversion angle and qualified rate of acetabular cup position significantly decreased in patients with Crowe I (P < 0.05); the horizontal distance significantly increased and qualified rate of acetabular cup position significantly decreased in patients with Crowe II (P < 0.05); and the anteversion angle significantly decreased and the horizontal distance significantly increased in patients with Crowe III/IV (P < 0.05) in 2008-2012 group. But no significant difference was shown in the other indexes (P > 0.05). In all Crowe types, the vertical distance between the true rotating center and the optimal rotating center increased with the degree of acetabular deformity in both 2008-2012 group and 2013-2015 group, showing significant difference (P < 0.05), but no significant difference was found in the other indexes (P > 0.05). ConclusionFor adults with acetabular dysplasia, there are high potential risks for unsatisfactory acetabular cup positions during primary THA. So it is necessary to evaluate acetabular deformities and to sum up operative experience so as to improve the accuracy of cups installation.
ObjectiveTo explore the surgical technique and the effectiveness of reconstructing the hip center in total hip arthroplasty (THA) for developmental dysplasia of hip (DDH). MethodsBetween January 2004 and January 2010, 29 patients (32 hips) with DDH underwent THA. There were 6 males (6 hips) and 23 females (26 hips), aged 45-67 years (mean, 50.6 years). The locations were left side in 22 hips and right side in 10 hips. According to Crowe classification, 12 hips were rated as Crowe I and 20 hips as Crowe II. The patients had limb length discrepancy of 1.9-4.4 cm. The Harris score was 50.7 ± 8.6. ResultsAll incisions healed by first intension. Posterior hip dislocation occurred in 1 case (1 hip) after operation. All patients were followed up 2 years-4 years and 6 months (mean, 2.3 years). The lower limbs were lengthened by 0.5-5.8 cm (mean, 2.5 cm). The Harris score was 87.7 ± 5.9 at 1 year after operation, showing significant difference when compared with preoperative score (t=21.77, P=0.00). X-ray films showed loosening of acetabular component in 1 case (1 hip) and displacement of acetabular component with too large abduction angle in 1 case (1 hip); no loosening and subsidence of acetabular or femoral components occurred in the other patients during follow-up. The horizontal location of hip center, the vertical distance between teardrop and the hip center, the vertical acetabular abduction angle, and the femoral offset were better than those before operation (P lt; 0.05). ConclusionFor DDH patients, reconstructing the hip center in THA can lengthen the limb, improve the joint function, and reduce the failure rate of joint replacement.
ObjectiveTo investigate the clinical characteristic differences of cementless total hip arthroplasty (THA) between with and without subtrochanteric femoral shortening osteostomy in Crowe type IV developmental dysplasia of the hip (DDH). MethodsBetween January 2006 and March 2012, 21 patients (21 hips) with Crowe type IV DDH who underwent primary THA were enrolled according to inclusion criteria. According to whether subtrochanteric femoral shortening osteostomy was performed during THA or not, the patients were divided into 2 groups: THA with osteostomy group (n=9) and THA without osteotomy group (n=12). There was no significant difference in gender, age, body mass index, and hip Harris score between 2 groups (P>0.05) except leg length discrepancy (t=-3.170, P=0.005). The operation time, blood loss, postoperative drainage, complications, and radiography data were compared to evaluate the clinical characteristics. ResultsThe operation time, blood loss, and postoperative drainage of osteotomy group were all significantly greater than those of no osteotomy group (P<0.05). All patients achieved primary healing of incision; 1 patient (1 hip) had transient sciatic nerve symptom in osteotomy group. The average follow-up time was 53 months (range, 28-88 months). The X-ray films showed good fracture healing at 3-6 months after operation in osteostomy group. No prosthetic loosening or dislocation was found. The hip Harris score was 90.67±4.06 in osteostomy group and 92.17±3.27 in no osteostomy group, showing no significant difference between 2 groups (t=-0.938, P=0.360). The leg length discrepancy was (0.22±0.26) cm in osteostomy group and (0.18±0.27) cm in no osteostomy group, showing no significant difference (t=107.000, P=0.546). The leg length discrepancy was found in 6 patients of osteotomy group and 5 patients of no osteotomy group. One patient complained of thigh pain in osteotomy group; 2 patients had slight limp (Trendelenburg +) in no osteotomy group. ConclusionTHA can improve joint function and increase limb length in the treatment of Crowe type IV DDH. Subtrochanteric shortening osteotomy is an effective treatment which can be performed according to preoperative template measurement, leg length shortening, and the soft tissue tension.