Orthopaedic Surgery Hip


Transverse Subtrochanteric Shortening Osteotomy in Total Hip Arthroplasty for Severe Hip Developmental Dysplasia


Myung-Sik Park Professor, Department of Orthopaedic Surgery, Chonbuk National University Hospital, Jeonju


Abstract


Thirty-five total hip arthroplasties (33 patients) were performed in cases of Crowe grade III or IV hip dysplasia using subtrochanteric shortening osteotomy with two kinds of femoral stem: monoblock and modular type. All acetabular components were used with a cementless cup. The average patient age was 47.8 years, and the average follow-up time was 5.1 years. Acetabular reconstruction was performed using autogenous femoral head in 11 hips. Radiologically, hip centres were nearly normalised with vertical heights of 10.6mm elevation and horizontal lengths of 1.7mm compared with uninvolved sites. Leg length discrepancies were improved from 4.7 to 1.5cm. Early post-operative complications included two non-unions at the osteotomy site, one dislocation after monoblock stem, one case of peroneal nerve palsy and one subsidence occurring after modular stem placement. The non-union fractures were managed with bone grafts and modular stems. The dislocation was managed with closed reduction and an abduction brace. The peroneal nerve patient was managed with an ankle stop brace. Late complications included cup loosening, but there was no loosening in the femoral stem. The average Harris Hip Score was improved from 36 to 82.4. These data demonstrate that a cementless modular femoral stem is the more useful device for treating hip dysplasia patients.


Keywords Total hip arthroplasty, developmental dysplasia, modular femoral stem


Disclosure: This paper was supported by funding from Chonbuk National University Hospital Research Institute of Clinical Medicine and partially supported by sanofi-aventis Co. Received: 20 September 2010 Accepted: 24 January 2011 Citation: European Musculoskeletal Review, 2011;6(1):55–9 Correspondence: Myung-Sik Park, 561-712, Department of Orthopaedic Surgery, Chonbuk National University Hospital, Jeonju, Korea. E: mspark@jbnu.ac.kr


The high developmentally dislocated hip involves one of the most challenging reconstructive surgical procedures in total hip arthroplasty. There are many anatomical deformities that contribute to the complexity of arthroplasty. Poor acetabular bone stock, high dislocation of the proximal femur and narrowness of the femoral canal cause technical difficulties during surgery. Soft tissues surrounding the hip joint are frequently contracted because of the chronicity of dislocation.1


The longevity of hip arthroplasty in these


patients has improved through restoration of the anatomical hip centre, which decreases the hip joint reaction force and creates an improved lever arm for the abductor musculature.1–3


Restoration of


the anatomical hip centre frequently requires limb lengthening in excess of 4cm and increases the risk of neurological traction injury.1,4,5 Surgical techniques used for high-riding dislocations of the hip are different from those used to correct simple acetabular dysplasia. If shortening of the femur is not performed, reduction of the femoral head into the true acetabulum is impossible, and there is the risk of excessive lengthening of the neurovascular structures. One option for restoring the anatomical hip centre is subtrochanteric femoral shortening osteotomy. Various techniques for shortening osteotomies have been described.6–9


Bruce et al. recently reported on five cases


using a modular cementless femoral system combined with a transverse osteotomy for femoral shortening.7


The risk of surgical complications associated with total hip arthroplasty increases as the extent of dislocation according to the


© TOUCH BRIEFINGS 2011


Crowe classification1


becomes more severe, depending on the degree


of developmental dysplasia of the hip joint. Major complication rates reported in the literature for total hip arthroplasty treatment of severe acetabular dysplasia using shortening femoral osteotomy range from 12 to 41%.1,7–12


Patients with untreated high developmental


hip dislocations frequently develop symptoms of secondary arthritis during the fourth and fifth decades of life.1,10,13


These patients


presented myriad challenges for total hip arthroplasties. The dysplastic acetabulum is hypoplastic and its bone density is often low because of lack of stress remodelling. The femur is small and often exhibits an excessive neck–shaft angle and increased anteversion, which shifts the greater trochanter to a more posterior position. Femoral shortening osteotomy was described by Klisic and Jankovic6 for high dislocations and was adapted by Crowe et al.1


to include


simultaneous hip arthroplasty. The two largest series reported in the literature include a study of 28 hips treated with a step-cut shortening osteotomy based on pre-operative radiographic templating,8


and a


report on 25 hips treated with a transverse shortening osteotomy based on intra-operative femoral length.11


The purpose of our study is


to present a transverse osteotomy technique and complications related to the femoral stem.


Materials and Methods From November 1998 to February 2003, we performed 76 total hip arthroplasties for cases of arthritis secondary to hip dysplasia. Of these, 35 hips (in 33 patients) were managed with transverse femoral


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