Total Hip Arthroplasty for DDH (Crowe type III and IV)

Dept. Orthopaedic SurgeryKyoto City Hospital, Kyoto, Japan

Chiaki TANAKA, Minoru IKENAGA, Hiroshi KANOE, Makoto SHIMIZU, Koujirou TANAKA

A 5- to 12-year follow-up study : Japanese experience

Purpose

After my study in Cochin Hospital, I began to operate on the DDH patients in Japan.

Especially, THA for DDH (Crowe type III and IV) patients is a technically demanding operation.

We report our 5- to 12- year clinical results and technical problems in THA for difficult DDH patients.

Case K.K. 62yr-old F : 134.5 cm 54.3 kg Crowe IV

88/10/22

88/11/10

89/3/8

93/2/2

The most difficult case in my experience

Case K.K. 62yr-old F : Crowe IV

93/12/24

94/1/14

94/9/29

95/4/6

Case K.K. 62yr-old F : Crowe IV

95/4/6 04/10/08 9yr 5mo

PATIENTS - 1

32 hips (27 women, 1 man)

Average age at operation 58.5 y.o. ( 44-78 )

Follow-up period 8 yr. 3 mo. ( 5-12 y )

Body weight 49.3 kg ( 35.7 – 67.0 )

Height 148.5cm ( 134.5 – 167.2)

PATIENTS - 2

Crowe type III 14 IV 18

Previous Operations none 25

femoral osteotomy 7

pelvic osteotomy 1

RECONSTRUCTIVE METHOD-1

Lateral transtrochanteric approach 32

Total capsulectomy 32

Muscle release 0

Bone grafting acetabular 32 femoral 1

THA device Charnley LFA 8 Kyocera PHS 19 CMK 5 32

RECONSTRUNTIVE METHOD-2

Cup diameter 37 1 38 6 38.5 3 40 15 42 2 44 3 46 2

Fixation of greater trochanter

Ortron wire 　　 　　 27Dall-Miles Cable Grip 　 　 3Titanium wire 　　　　　 　 2

Clinical and Radiographical Evaluation

Japanese Orthopaedic Association (JOA) Hip Score System Pain 40, ROM 20, Walking ability 20, ADL 20 Radiolucency : DeLee – Charnley zoneMigration > 3mm or > 3degreesPosition of hip center : distance from teardropBone graft coverage : % of the cupBone grafts : union, resorption, collapse

RESULTSRevision : (acetabular loosening) 1Reoperation : trochanter reattach 1 abductor advancement 1 32 Complications Dislocation 0 Trochanteric nonunion 4 Infection 0 Nerve palsy 0 32

JOA Hip Score

　　　　　 Preop Last FU

Pain 16.7 39.1

ROM 9.7 16.1

Walk 5.0 12.1

ADL 8.5 14.6

Total 39.8 81.9

Radiographic Evaluation - 1

Migration (Cup) 1 (Rev)Radiolucency Acetabular none 25 partial 6 (osteolysis 1) 32 Acetab. Loosening 1 / 32 ( 6.3%)

PE Wear 2mm< 1

Radiographic Evaluation - 2

Stem sinking 0

Radiolucency partial 1

Osteolysis severe 2 mild 2

Radiographic Evaluation - 3

Rotational hip center horizontal distance av. 29.7mm vertical distance av. 22.4mm

Bone graft coverage B / A av. 38% ( 24 ~ 54 ) 50%< 5 hips

collapse 1 hip (Rev. at 18 mo)

AB

Survivorship

Endpoint : Revision 10 years

Acetabular component 96.9%

Femoral component 100%

THA for DDHMackenzie JR 1996 59 hips (II:22,III:18,IV:19) Surv(Rev) 85% at 15y Surv(Rad.loose) 68%Numair J 1997 46 hips (IV) Surv(Rev) 68% at 15y

Shinar AA 1977 70 hips Rev 36% Rev+Rad loose 60% at 16.5y

Bobak P 2000 45 hips (I:4,II:17,III:13,IV:11) Rev 0% Rad loose 12% at 11y (10-15) Kerboull M 2001 118 hips (IV) Surv 78% at 20 y

Kobayashi S 2003 37 hips (II:16,III:17,IV:4) Rev 0% Rad Loose 0% at 19 y (10-26)Hartofilakidis G 2004 84 hips (high disl) Surv(Rev) 76.4% at 15 y

Case K.K. 60yr-old F : Crowe III

Pre-op 2mo 10yr 12.5yr JOA score 83 p. Wear < 2mm Osteolysis

Case M.K. 50yr-old F : Crowe IV

Pre-op 1 mo 11 yrs

JOA score 92 p.

Case S.I. 55yr-old F : Crowe IV

Pre-op 2mo 8mo 9mo 12yr JOA s. 78 p.Nonunion Gr.Tr.

Titanium wireNonunion of Gr.Tr.

Troch. Rev.

Case T.H. 78yr-old F : Crowe III

Preop 2 mo 7 yr 9 moJOA score 94 p.

Case Y.S. 80yr-old F : Crowe IV

Pre-op 2 mo 6 yr 3 mo

JOA score 76 p.

Case M.I. 53yr-old F : Crowe IV

Preop 9 y 10 mo 9 y 5 moJOA score 81 p.

Case F.M. 57yr-old F : Crowe III

Preop

3w

Advancem.1w

8yr8mo

Abduction contracture 25 deg. Trendelenbourg (-)JOA score 74 p.

Problems and my solutions1) Acetabulum Small and shallow acet. thin walls　　　　 CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft

Case K.K. 62yr-old F : Crowe IV Small Acetabulum

True acetabulum is the best position !!

40 mm

Though the true acetabulum is the best position, the AP diameter is small.

Problems and my solutions1) Acetabulum Small and shallow acet. thin walls　　　　 CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide ‘Asagao’ Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft

Morning Glory : ‘Asagao’

Joint capsule : the best guide to obturator foramen

It looks like a Morning Glory :‘Asagao’ in japanese

Greater TrochFemurExternal obturator

Problems and my solutions1) Acetabulum Small and shallow acet. thin walls　　　　 CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft

Case K.K. 62yr-old F : Crowe IV Post. Wall Deficiency

40mm

Problems and my solutions1) Acetabulum Small and shallow acet. thin walls　　　　 CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘Column Horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft

Case M.K. 50yr-old F : Crowe IV 3D-CT Image

Preservation of ant. and post. ‘Column Horn’

Problems and my solutions1) Acetabulum Small and shallow acet. thin walls　　　　 CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft

Bone Graft : Shaping Method

＊ ＊

Problems and my solutions1) Acetabulum Small and shallow acet. thin walls　　　　 CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft

Case T.I. 60yr-old F : Crowe IV Extra-series

2) Femoral side Narrow canal, strong anteversion straight stem Respect the greater trochanteric bone bed when the femoral neck is cut stem design is very important !! Subtrochanteric shortening osteotomy is a useful technique when the reduction seems very difficult or when the femoral neck needs to be cut too much　　　　　　　　 or in previously osteotomized cases

Problems and my solutions

Preservation of Trochanter Bed

Kyocera PHS CMK

＊

2) Femoral side Narrow canal, strong anteversion straight stem Respect the greater trochanteric bone bed when the femoral neck is cut stem design is very important !! Subtrochanteric shortening osteotomy is a useful technique when the reduction seems very difficult or when the femoral neck needs to be cut too much　　　　　　　　 or in previously osteotomized cases

Problems and my solutions

Case T.S. 70yr-old F : Crowe IV Case S.K. 56yr-old F : Crowe IVExtra-series

3) Limb lengthening If the range of motion is good, lengthening is easy. If not, removal of the scar tissue is necessary. Principles of Prof. Kerboull Respect the periarticular muscles as possible. The best method to avoid nerve palsy !! Reduction mild flexion and adduction of the hip with mild flexion of the knee pushing the stem head directly into the cup Never pull the limb !!

Problems and my solutions

4) Trochanter fixation In severely contracted hips, lowering the greater trochanter is difficult. Detachment of gluteal muscle origin upwards from ilium Option : advancement of gluteal muscles through the iliac rest incision Fixation with stainless monofilament wires Attention to titanium wires and Dall-Miles cables !!

Problems and my solutions

Lowering of Greator Trochanter

M. Kerboull EMC R.C. Kingsley JBJS

Detachment upwards from ilium Advancement

4) Trochanter fixation In severely contracted hips, lowering the greater trochanter is difficult. Detachment of gluteal muscle origin from ilium upward direction from inside Option : advancement of gluteal muscles through the iliac rest incision Fixation with stainless monofilament wires Attention to titanium wires and Dall-Miles cables !!

Problems and my solutions

Fixation of Greator Trochanter

Titanium wire Dall-Miles Cable Grip

Attention to Titanium wires and Dall-Miles Cables

Conclusions

THA for DDH (Crowe type III and IV) patients is a technically demanding operation.

5- to 12- year clinical results of our series were satisfactory.

Main techinical problems are reconstruction of very small dysplastic acetabuli and solid fixation of greater trochanter.