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Hip resurfacing after iliofemoral distraction for type IV developmental dysplasia of the hip a case report. Osteoarthritis secondary to developmental dysplasia of the hip is a surgical challenge because of the modified anatomy of the acetabulum which is deficient in its shape with poor bone quality, torsional deformities of the femur and the altered morphology of femoral head.
Particularly in Crowe type III and IV, additional surgical challenges are present, such as limb-length discrepancy and adductor muscle contractures.
This is a bilateral hip dysplasia case where bilateral hip replacement was indicated, on the left side with a resurfacing one and on the other side a two stage procedure using a iliofemoral external fixator to restore equal leg length with a lower risk of complications.
This case report shows both the negative clinical outcome of the left and the excellent one of the right hip where the dysplasia was much more severe. Patient selection and implant positioning are crucial in determining long-term results. Resurfacing, hip, dysplasia, congenital, bilateral. Osteoarthritis secondary to developmental dysplasia of the hip DDH is a surgical challenge because of the modified anatomy of the acetabulum, which is deficient in its shape, with poor bone quality, torsional deformities of the femur and the altered morphology of the femoral head.
Moreover, particularly in Crowe type III and IV, 2 additional surgical challenges are present, such as limb-length discrepancy and adductor muscle contractures.
When restoring limb-length discrepancy greater than four centimeters, the risk of nerve palsy should be considered. In order to minimize this complication, different surgical techniques, such as femoral shortening with subtrochanteric osteotomy or cup positioning with a high center of rotation, have been proposed for one-stage treatment.
However, these procedures are inadequate to restore limb-length discrepancy.
Hip resurfacing HR has gained popularity during the past 15 years as a suitable solution for young and active patients affected by hip disease. However, HR introduced new mechanisms of failure, such as femoral neck fracture and increased serum concentrations of metal ions that may lead to either local effects pseudo-tumor, osteolysis, ALVAL or may theoretically produce systemic effects renal failure, carcinogenity, cobaltism.
In Octobera year-old female with severe hip pain affected by bilateral DDH type I in the left hip and type IV in the right hip according to the Crowe classification came to our institute for clinical examination.
The patient had a positive bilateral Trendelemburg sign and her hips were highly limited in their range of motion. Particularly, the right hip was limited to 60 o in flexion and to 5 o in internal and external rotations. A mm limb-length discrepancy was measured on anteroposterior preoperative radiographs Figura 1.
The acetabular shell was positioned with an inclination of 67 o Figura 2. Due to the resurfaced left hip, limb-length discrepancy increased to 57 mm.
Espesor del catílago acetabular en pacientes con displasia de cadera. (Inglés) – Sogacot
Considering the positive clinical outcome, the patient wanted to receive the same treatment in the contralateral hip. Since the right limb was 57 mm shorter than the left one, an external iliofemoral fixator was used for soft-tissue distraction to reduce the risk of nerve palsy and to be able to implant the acetabular cup into the true acetabulum. In October a capsulotomy through lateral approach was performed and an iliofemoral external fixator Orthofix, Bussolengo, Verona, Italy was implanted using three hydroxyapatite coated pins 16 on the lateral aspect of the iliac wing and two pins inserted into the femoral diaphysis with no distraction at the time of surgery.
Percutaneous adductor tenotomy was performed to achieve further soft-tissue distraction. Postoperatively, progressive one displadia distraction per day was planned, until the tip of the greater trochanter reached the upper border of the native acetabulum Figura 3.
External fixator was well tolerated by the patient, aceabular no signs of pin tract infection. After 55 days, the external fixator was removed, and through the same lateral cadefa, a HR was implanted mm cemented femoral head, mm uncemented acetabular cup. The acetabular shell was positioned with an inclination of 47 o. The limb-length discrepancy was completely adetabular.
Six months after the second HR, the patient’s aetabular outcome was excellent, with HHS of 95 for the right hip and 91 for the left one.
Figura 1 – Displasia acetabular (A), Subluxación de la cadera (B) y Luxación de la cadera (C)
Annually scheduled follow-up for clinical and radiographical examinations showed excellent outcome until Aprilwhen the patient started complaining of groin pain on the left side HHS was Radiographs showed severe osteolysis of both the acetabular and femoral sides with extensive neck narrowing Figura 4. A good implant stability was achieved using autologous bone graft and two screws Figura 5. One year after revision surgery, the patient is doing well; hip pain has disappeared on the left side HHS 95while the right one has still an excellent clinical outcome HHS 98with radiographs showing a complete osteointegration of the implant.
Nevertheless, these patients are usually younger than those affected by primary osteoarthritis of the hip; therefore, long-term implant survival still remains a concern. Excluding large-diameter metal-on-metal THA, which recently experienced a high revision rate, a similar good survival for stemmed prostheses and the BHR resurfacing system has been reported in young patients affected by low grade DDH. BHR prostheses, either implanted in primary osteoarthritis or secondary to DDH, have been reported to have a similar positive survivorship.
HR is a bone-preserving solution suitable for young and active patients with a long life expectancy where revision surgery is more probable to become necessary. However, it may not be possible to restore severe limb-length discrepancy nor to correct important deformities on the femoral side, which characterize high-grade DDH.
In this patient, since the deformities of the left hip were minimal, a HR was implanted. At the time of the first operation, the edge wear phenomenon was not completely known; therefore, the steep cup inclination 67 o due to the high stability provided by the large-diameter femoral head was not considered a major concern.
Now, it is well known that metal-on-metal coupling does not tolerate cup malpositioning, which must have an inclination between 40 o and 50 o and an anteversion from 10 to 20 o. We believe that in our patient, incorrect cup orientation was been the main cause of implant failure.
Considering the patient’s characteristics and the radiological features of both of the acetabular and the femoral sides, severe limb-length discrepancy represented the major limitation to perform a HR.
The two-stage procedure using an iliofemoral external fixator to distract soft tissue before the THA is indicated in Crowe type III and IV to restore equal leg length with a lower risk of complications. By using this technique, the hip center of rotation can be restored to a more anatomical position and may lead to improve hip biomechanics, avoiding excessive joint reaction forces.
The use of a small-sized iliofemoral distractor with hydroxyapatite coated pins provides a stable and, at the same time, non-cumbersome system which allows discharging the patients, permitted non-weight bearing walking on the affected side, between the first and the second stage. In our patient, we performed this two-stage procedure combined with a HR, thus achieving a good clinical outcome and an excellent implant survival.
By using a HR instead of THA, the infection risk may be eventually reduced due to the higher distance between the femoral component and the pin tracts. This case report shows both the negative clinical outcome of the left hip and the excellent one of the right one, hip where the dysplasia was much more severe.
In our patient, affected by grade IV DDH after restoring limb-length discrepancy using external fixator, HR allowed to obtain excellent results in terms of functional improvement and implant survival.
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Results cadear the Birmingham Hip Resurfacing dysplasia component in severe acetabular insufficiency: J Bone Joint Surgy Br. Treatment of the casera active patient with osteoarthritis of the hip: Survivorship, patient reported outcome and satisfaction following resurfacing and total hip arthroplasty.
Outcome of hip resurfacing arthroplasty in patients with developmental hip dysplasia. Indications sisplasia results of hip resurfacing. Metal-on-metal hip resurfacing in developmental dysplasia: Failure rates of metal-on-metal hip resurfacings: Introduction Osteoarthritis secondary to developmental dysplasia of the hip DDH is a surgical challenge because of the modified anatomy of the acetabulum, which is deficient dis;lasia its shape, with poor bone quality, torsional deformities of the femur and the altered morphology of the femoral head.
Case report In Octobera year-old female with severe hip pain affected by bilateral DDH type I in the left hip and type IV in the right hip according to the Crowe classification came to our institute for clinical examination.
Conclusion In our patient, affected by grade IV DDH after restoring limb-length discrepancy using acegabular fixator, HR allowed to obtain excellent results in terms of functional improvement and implant survival.