Cementless total hip arthroplasty for patients with Crowe type III or IV developmental dysplasia of the hip: two-stage total hip arthroplasty following skeletal traction after soft tissue release for irreducible hips

Abstract

Background: Total hip arthroplasty (THA) for severe developmental dysplasia of the hip (DDH) is a technically demanding procedure for arthroplasty surgeons, and it is often difficult to reduce the hip joint without soft tissue release due to severe flexion contracture. We performed two-stage THAs in irreducible hips with expected lengthening of the affected limb after THA of over 2.5 cm or with flexion contractures of greater than 30 degrees in order to place the acetabular cup in the true acetabulum and to prevent neurologic deficits associated with acute elongation of the limb. The purpose of this study is to evaluate the outcomes of cementless THA in patients with severe DDH with a special focus on the results of two-stage THA.

Methods: Retrospective clinical and radiological evaluations were done on 17 patients with Crowe type III or IV developmental DDH treated by THA. There were 14 women and 3 men with a mean age of 52.3 years. Follow-ups averaged 52 months. Six cases were treated with two-stage THA followed by surgical hip liberalization and skeletal traction for 2 weeks.

Results: The mean Harris hip score improved from 40.9 to 89.1, and mean leg length discrepancy (LLD) in 13 unilateral cases was reduced from 2.95 to 0.8 cm. In the patients who underwent two-stage surgery, no nerve palsy was observed, and the single one-stage patient with incomplete peroneal nerve palsy recovered fully 4 weeks postoperatively.

Conclusions: The short-term clinical and radiographic outcomes of primary cementless THA for patients with Crowe type III or IV DDH were encouraging. Two-stage THA followed by skeletal traction after soft tissue release could provide alternative solutions to the minimization of limb shortenings or LLD without neurologic deficits in highly selected patients.

Keywords: Congenital hip dysplasia; Total hip arthroplasty.

Fig. 1

A curvilinear incision over the iliac crest was used to elevate abductor muscles off the ilium subperiosteally (A). The hip was exposed through a modified Hardinge's approach (B).

Fig. 2

Preoperative plain radiograph showing Crowe type IV developmental dysplasia of the hip (A). During the first stage, surgical hip liberalization with abductor slide and skeletal traction for 2 weeks were performed (B, C). During the second stage, a total hip arthroplasty and subtrochanteric shortening osteotomy were performed due to difficult reduction (D).

Fig. 3

Preoperative radiograph showing Crowe type III developmental dysplasia of the hip (A). One-stage total hip arthroplasty was performed and the superolateral aspect of the acetabulum was augmented with an autogenous femoral head bone graft (arrow, B). Solid union was confirmed by plain radiography at 3 years after surgery (arrowhead, C).

Fig. 4

In cases of unilateral developmental dysplasia of the hip, leg length discrepancy was defined as the difference between the distances from the interteardrop line and the greater trochanter tip in the affected and contralateral hips on anteroposterior hip radiographs and was measured before and after surgery (b - a).

Fig. 5

Postoperative plain radiograph taken at 2 years after surgery showing a diffuse radiolucent line of less than 2 mm in Gruen zones 1 and 7 (A). This was considered to indicate stable fibrous fixation because no change was observed 1 year later (B).

Fig. 6

Incongruence between canal diameters of apposed fragments after subtrochanteric shortening is exacerbated by excessive resection of the diaphyseal segment.