Total Hip Arthroplasty for Crowe III/IV Hip Dysplasia With Oblique Subtrochanteric Shortening Osteotomy and S-ROM-A Modular Stem: 10-Year Outcomes

Abstract

Background: High dislocation due to developmental dysplasia of the hip (DDH), classified as Crowe type III or IV, presents significant challenges in total hip arthroplasty (THA), particularly in preventing nerve complications while restoring leg length.

Aim: This study aimed to evaluate the clinical and radiographic outcomes of primary THA using an S-ROM-A modular stem with oblique subtrochanteric shortening osteotomy in patients with high hip dislocation; to identify the advantages, limitations, and possible countermeasures of this surgical approach.

Patients and methods: Subjects were 45 hips (37 patients) with high hip dislocation (Crowe III/IV) treated by primary THA using an S-ROM-A stem, with femoral shortening osteotomy performed at our institution. Outcomes 3 years after surgery were examined in 100% of the subjects. Postoperative complications and functional and radiographic outcomes were investigated.

Results: The mean age at surgery was 65 years and the mean duration of postoperative follow-up was 10.7 ± 3.4 years. There were no cases of postoperative infection, symptomatic pulmonary embolism, or neurological complications in the legs. Early postoperative dislocation occurred in two hips (4%, resolved conservatively) and osteotomy site nonunion in one hip (2%). Repeat surgery was required in only this case of nonunion (2%). The hip function score was significantly improved postoperatively. Leg lengthening after surgery was 0-56 mm (mean, 28 mm). Examination of radiographs revealed that it took 12 weeks for bone union at the osteotomy site in all hips except for the one hip with nonunion. No stem subsidence was found postoperatively, and "fixation by bone ingrowth" was achieved at the final follow-up examination in all hips (100%), including the one that required repeat surgery.

Conclusion: THA using an S-ROM-A modular stem with oblique subtrochanteric shortening osteotomy provided favorable mid-term outcomes in patients with Crowe III/IV DDH. No neurological complications occurred, and functional and radiographic improvements were substantial. Our method, which emphasizes intraoperative sciatic nerve palpation for individualized leg lengthening, may serve as a practical and safe alternative to more complex monitoring systems. Further research incorporating objective intraoperative monitoring may help standardize this approach.

Keywords: Crowe classification; S‐ROM‐A stem; high hip dislocation; modular stem; oblique subtrochanteric shortening osteotomy; sciatic nerve palsy; total hip arthroplasty.

FIGURE 1

Types of subtrochanteric osteotomy: (A) transverse, (B) oblique, (C) step‐cut, and (d) double‐chevron. Among these, we initially adopted the step‐cut technique but later transitioned to the oblique type due to its technical simplicity and superior rotational stability in Crowe III/IV hips. This figure serves to illustrate the rationale for our final choice of the oblique technique in this study.

FIGURE 2

The S‐ROM‐A modular stem used in this study. (A) Sleeve, stem, and head; (B) stem; (C) sleeve.

FIGURE 3

Examination of the sciatic nerve tension by palpation and measurement of bone shortening length (A). Bone shortening length (A): The leg was pulled manually and the length of the overlapping portion of the distal bone segment with the proximal bone segment was measured just before the point where the sciatic nerve tension became excessive (defined as “a rod‐like palpation, with no elasticity or mobility”).

FIGURE 4

Determination of bone shortening length.

FIGURE 5

Radiographs of a 68‐year‐old woman with bilateral Crowe IV DDH. (A) Preoperative anterior–posterior plain radiograph of both hips. (B) Postoperative anterior–posterior image. Right THA, and then left THA, were performed in the two‐stage fashion. The cup was placed at the true acetabulum, oblique shortening osteotomy was performed, and the S‐ROM‐A was used for THA on both sides. (C) Anterior–posterior radiograph of the left hip 3 month after surgery. Shift of the stem in the distal bone segment was confirmed. (D) After repeat THA. The standard stem was replaced with a long stem, but the original sleeve that obtained bone ingrowth was preserved: Autologous bone grafting resulted in successful bone union.