The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 19

Current Concepts Review | October 03, 2012

Total Hip Arthroplasty for Adult Hip Dysplasia

Benedict A. Rogers, MA, MSc, DipSEM, FRCS(Orth)¹; Shawn Garbedian, MD, FRCSC¹; Raul A. Kuchinad, MD, FRCSC¹; David Backstein, MD, FRCSC¹; Oleg Safir, MD, FRCSC¹; Allan E. Gross, MD, FRCSC¹

¹ Division of Orthopaedic Surgery, Mount Sinai Hospital, 600 University Avenue, Suite 476 (A), Toronto, ON, Canada M5G 1X5. E-mail address for A.E. Gross: agross@mtsinai.on.ca. E-mail address for B.A. Rogers: benedictrogers@hotmail.com

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Investigation performed at the Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada

J Bone Joint Surg Am, 2012 Oct 03;94(19):1809-1821. doi: 10.2106/JBJS.K.00779

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Abstract

Preoperative planning is essential to define anatomy, clarify the operative approach and exposure, and ensure that suitable implants are available.

Concerns exist regarding the long-term effectiveness and safety of hip resurfacing arthroplasty for the young dysplastic hip.

In light of current evidence, concerns exist regarding the use of metal-on-metal articulations for hip arthroplasty in the young dysplastic hip.

The ideal bearing surface is not known, although the longest data available support the use of metal-on-polyethylene.

Figures in this Article

Introduction and Etiology

Developmental dysplasia of the hip (DDH) presents as hip incongruence secondary to low or high dislocation¹. Pathological changes include flattening or inversion of the labrum and capsular structures (limbus) in association with hypoplasia of the capital femoral ossific nucleus and abnormal acetabular development with a high inclination and reduced femoral head coverage. The increasing use of ultrasound has produced earlier diagnosis to allow earlier treatment and a resultant improved prognosis².

The term dysplasia fails to convey the varied underlying pathology, and the term congenital hip disease has been advocated^3-5. The term developmental dysplasia of the hip (DDH) is used worldwide and shall be used in this article, although it fails to convey the often congenital etiology of this condition^4,6.

Incidence

The incidence of established neonatal hip dislocation in untreated populations is approximately one to two per 1000, and that of neonatal hip instability is between fifteen and twenty per 1000⁷. Thus, a large proportion of cases of neonatal instability resolve in the first few weeks of life without treatment. Substantial geographical and ethnic variations exist, with a high incidence reported in northern Scandinavia⁸.

DDH provides a large caseload for the orthopaedic surgeon^7,9,10. Lloyd-Roberts et al. reported that hip dysplasia was attributable to one-third of cases of osteoarthritis, with relative acetabular retroversion being a common associated factor^11,12. Wroblewski noted that an in-turned acetabular labrum was a common feature of hips that had osteoarthritis secondary to dysplasia¹³.

Diagnosis

Adult patients with DDH sequelae typically report groin pain that is exacerbated with physical activity. Young adults may report lateral hip pain, exacerbated by crossing the affected leg over and stretching the hip abductors¹⁴. Labral tears or chondral pathology may present with locking, catching, or giving way^14,15. Painless clicking can result from the iliopsoas tendon snapping over the uncovered anterior aspect of the femoral head¹⁶.

Hip range of motion is generally preserved unless severe subluxation or secondary osteoarthritis is present¹⁴. Young adults with hip dysplasia may exhibit increased internal rotation due to greater femoral anteversion. Decreased internal rotation of the hip may be a sign of secondary osteoarthritis. The impingement test, with hip flexion, adduction, and internal rotation, is sensitive for detection of labral pathology or impingement of the femoral head-neck junction against the anterior acetabulum. Physical examination of the hip, in particular assessment of extension, abduction, and external rotation, may reveal instability¹⁴. An accurate measurement of limb lengths with use of clinical examination and radiographs, and a detailed neurovascular examination of the lower extremities, is essential for all patients.

Initial radiographs should include a lateral radiograph of the hip and a standing anteroposterior radiograph of the pelvis for assessment of the Tönnis angle and lateral center-edge angle of Wiberg (Fig. 1-A). A lateral center-edge angle of >25° is considered normal, 20° to 25° is considered borderline normal, and <20° indicates dysplasia and is pathological¹⁷. The association between DDH and osteoarthritis of the hip was confirmed by Murphy et al., who demonstrated that osteoarthritis of the hip developed by the seventh decade of life in all patients who had moderate to severe dysplasia (lateral center-edge angle <15°)¹⁸.

Fig. 1-A

Radiograph showing lateral center-edge angle of Wiberg.

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Fig. 1-B

Radiograph showing the Tönnis angle.

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The Tönnis angle measures the inclination of the weight-bearing zone of the acetabulum, (normal, <10°; Fig. 1-B). The ventral center-edge angle is measured in a manner similar to the lateral center-edge angle and should be 20° to 25° or greater on the false-profile view; measurements of <20° suggests deficiency in anterior acetabular coverage of the femoral head¹⁴.

The role for computed tomography is limited to planning for acetabular re-directional osteotomy. Magnetic resonance imaging is useful for the assessment of symptomatic hips (e.g., hips with disorders such as a labral tear or chondral defect) that show no signs of structural abnormality on radiographs. Hip arthroscopy should be reserved for hips that have minimal radiographic abnormalities but in which intra-articular pathology is suspected¹⁵.

Classifications

Numerous classification systems have been described for DDH^19,20 although those described by Hartofilakidis et al.^4,5,21 and Crowe et al.²² are the ones that are most commonly used (Table I).

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TABLE I Principal Classification Systems of Hip Dysplasia

Classification	Type	Description	Acetabular Anatomy During Surgery
Crowe et al.²²	I	Proximal displacement <0.10 of pelvic height or less than 50% subluxation
	II	Displacement of 0.10 to 0.15 or subluxation 50% to 74%
	III	Displacement of 0.16 to 0.20 or subluxation 75% to 100%
	IV	Displacement >0.20 or subluxation >100%
Hartofilakidis et al.^4,5,21	Dysplasia (Type A)	The femoral head is contained within the original acetabulum despite the degree of subluxation	Segmental deficiency of the superior wall
		Secondary shallowness due to fossa-covering osteophyte
	Low dislocation (Type B)	The femoral head articulates with a false acetabulum, which partially covers the true acetabulum to a varying degree	Complete absence of the superior wall
		Anterior and posterior segmental deficiency
		Narrow opening and inadequate depth of the true acetabulum
	High dislocation (Type C)	The femoral head is completely out of the true acetabulum and migrated superiorly and posteriorly to a varying degree	Segmental deficiency of the entire acetabulum with narrow opening
		Inadequate depth
		Excessive anteversion
		Abnormal distribution of bone stock, mainly located superoposteriorly in relation to the true acetabulum

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TABLE I Principal Classification Systems of Hip Dysplasia

Classification	Type	Description	Acetabular Anatomy During Surgery
Crowe et al.²²	I	Proximal displacement <0.10 of pelvic height or less than 50% subluxation
	II	Displacement of 0.10 to 0.15 or subluxation 50% to 74%
	III	Displacement of 0.16 to 0.20 or subluxation 75% to 100%
	IV	Displacement >0.20 or subluxation >100%
Hartofilakidis et al.^4,5,21	Dysplasia (Type A)	The femoral head is contained within the original acetabulum despite the degree of subluxation	Segmental deficiency of the superior wall
		Secondary shallowness due to fossa-covering osteophyte
	Low dislocation (Type B)	The femoral head articulates with a false acetabulum, which partially covers the true acetabulum to a varying degree	Complete absence of the superior wall
		Anterior and posterior segmental deficiency
		Narrow opening and inadequate depth of the true acetabulum
	High dislocation (Type C)	The femoral head is completely out of the true acetabulum and migrated superiorly and posteriorly to a varying degree	Segmental deficiency of the entire acetabulum with narrow opening
		Inadequate depth
		Excessive anteversion
		Abnormal distribution of bone stock, mainly located superoposteriorly in relation to the true acetabulum

The classification system of Hartofilakidis et al.^4,5,21 describes the anatomical abnormalities in DDH: mild dysplasia (Type A) (Fig. 2-A), low dislocation (Type B) (Fig. 2-B), and high dislocation (Type C) (Fig. 2-C). The classification system of Crowe et al.²² can be quantified in one of two ways: first, on the extent of proximal migration of the femoral head as compared with the height of the undeformed femoral head (i.e., Type-I hips have migrated <50% of the height of the undeformed femoral head; Type-II, 50% to 74%; Type-III, 75% to 100%; and Type-IV, >100%), and second, by dividing the vertical distance between the interteardrop line and the femoral head-neck junction by the vertical distance between the line connecting the ischial tuberosities and the line connecting the iliac crests (Type I, <0.10; Type II, 0.10 to 0.15; Type III, 0.16 to 0.20; and Type IV, >0.20) (Fig. 3).

The classification system of Hartofilakidis et al. for hip dysplasia.

Fig. 2-A

shows mild dysplasia (Type A); the hip has a flattenedfemoral head (coxa plana) and a Töonnis angle of >10°, and the femoral head remains within the true acetabulum.

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Fig. 2-B

shows low dislocation (Type B); the false acetabulum is continuous with the true acetabulum.

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Fig. 2-C

shows high dislocation (Type C); the falseacetabulum is noncontinuous with the true acetabulum.

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Fig. 3

Radiograph showing measurements for the classification of Crowe et al. Vertical distance between the reference interteardrop line (line 1) and the femoral head-neck junction (line 2). Vertical distance between the line connecting the ischial tuberosities (line 3) and the line connecting the iliac crests (line 4).

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Both classification systems have been demonstrated to be reliable and reproducible^23-25. In a study in which 145 radiographs were assessed by three experienced surgeons working in different units, the range of kappa values for the interobserver error was 0.90 to 0.92 and 0.85 to 0.93 for the classification systems of Crowe et al. and Hartofilakidis et al., respectively²³. Similar ranges of kappa values were obtained for intraobserver error. However, the need for a whole pelvic radiograph, the variability of the location of the femoral head-neck junction, and the assumption that proximal migration is directly proportional to severity are drawbacks of the classification of Crowe et al. Similarly, when using the classification system of Hartofilakidis et al., although it is difficult to differentiate borderline cases, the system does have the advantage of providing insight into the structural anatomical changes to be encountered at the time of hip surgery.

In summary, these two classification systems assess the hip from different perspectives: Crowe et al. is quantitative and Hartofilakidis et al. is qualitative, and both can be used for clinical or research purposes.

Treatment Options

Nonoperative treatment for hip dysplasia includes nonsteroidal anti-inflammatory drugs, which are known to have improved efficacy when combined with other treatments such as physiotherapy, activity modification, and patient education^26,27.

Joint-Preserving Surgery

While this review focuses on arthroplasty techniques for the dysplastic hip, periacetabular osteotomy and femoral osteotomies may be considered if minimal articular cartilage degeneration has occurred^15,28-30.

Realignment of the congruous dysplastic acetabulum with a periacetabular osteotomy can reduce symptoms for some years, even if a degree of osteoarthritis exists^31,32. Beneficial outcomes have been reported for patients with Tönnis grade-3 or 4 radiographic osteoarthritis, providing that an improvement in the cartilage-space interval is achieved³³. However, there is a substantial learning curve for the periacetabular osteotomy surgery and a complication rate of as much as 15%^34,35. Evidence suggests that periacetabular osteotomy affords a good outcome for patients who are less than thirty years old and have good-to-excellent hip-joint congruency at the time of the operation³⁶.

Total hip arthroplasty is possible after a periacetabular osteotomy. Parvizi et al. analyzed forty-one patients with this condition, and their results demonstrated a reduction in pain and good bone stock after implantation of the acetabular component. However, following a periacetabular osteotomy, the acetabulum had a tendency to be retroverted in twenty-three of the forty-one hips³⁷.

Arthroplasty

Preoperative Planning

Thorough preoperative planning is essential to clarify the operative technique and surgical approach, assess available bone stock, and determine the position and choice of the femoral and acetabular implants.

Good-quality, calibrated radiographs are needed to size and correctly plan the position of the components, which can be done digitally or with traditional acetate templates. Decisions should be made regarding the approach, type, and length of any proximal femoral osteotomy; the approximate size and type of implants to be used; the need for bone graft (autologous, allograft, or bone substitutes); and the possibility of a wake-up test if substantial limb-lengthening (i.e., >3 cm) is expected.

Operative Approach

A trochanteric osteotomy or slide provides superior access to the hip joint and also the capability to restore abductor biomechanics by advancing the trochanter distally³⁸. Copious irrigation minimizes the risk of thermal necrosis during a proximal femoral osteotomy. At our institution, reduction of the trochanteric osteotomy is achieved with use of cerclage wires and the placement of autologous bone graft, especially distally. Excessive soft-tissue dissection from osseous fragments is avoided to minimize the risk of osteonecrosis.

Use of a modification of the trochanteric slide, so as to maintain the integrity of the external rotators and the posterior capsule, will reduce the risk of dislocation while preserving the continuity of the vastus lateralis muscle with the osteotomized trochanter and the hip abductors³⁹. If performed carefully, a trochanteric slide can be repeated on a previously osteotomized greater trochanter with good results⁴⁰. The posterior approach is also commonly used and provides good exposure in less severely dysplastic hips; in addition, with careful repair of the short external rotator muscles, the risk of dislocation should be similar to a transgluteal or trochanteric slide approach^41-43.

If a subtrochanteric shortening derotational osteotomy is required, the use of a trochanteric osteotomy may compromise the fixation of the proximal sleeve of the femoral component. Furthermore, the subtrochanteric derotational osteotomy allows correction of the posterior position of the greater trochanter at the time of the insertion of the femoral component, further stabilizing the subtrochanteric osteotomy.

An excellent exposure was described after using the Smith-Petersen approach for severely dysplastic hips, but that approach was associated with a high reported rate of femoral nerve palsy⁴⁴. The iliofemoral approach provides excellent extensive exposure, although a large-muscle dissection is required with no benefit demonstrated over other approaches⁴⁵.

A large iliac-crest muscle release to lower the hip center has been described⁴⁶. However, it is not clear how much soft-tissue release is required before the trial components are inserted, and such a soft-tissue release increases the risk of weakness and instability.

Acetabular Reconstruction

Acetabular reconstruction is critical. The acetabular cup is ideally placed at the site of the true acetabulum; however, a high—but not lateral—position may be acceptable^47-52.

A high hip center utilizes live host bone, thus reducing the requirement for bone graft, and is technically easier than determining the level of the true acetabulum. However, there are several disadvantages of a cup positioned in the ilium, including a persisting limp and high dislocation rate^44,51. Excessive shear stresses and a high rate of component loosening are seen in hips that have a high hip center⁵¹. The main predictors of loosening are a lack of lateral osseous support, the degree of preoperative dislocation, and the height of the acetabular component relative to the true acetabulum⁴⁹. If there is adequate bone stock on the anterior and posterior aspects of the acetabular component, 75% to 80% coverage of the acetabular cup is adequate^53,54.

In a recent study of fifty-three cementless cups inserted in dysplastic hips, with a minimum follow-up of ten years, the polyethylene wear rate was significantly greater when the cup was positioned in >45° of inclination (p = 0.045) or if the cup was placed lateral to the acetabular teardrop by >25 mm (p = 0.001)⁵⁵. In addition, aseptic loosening of the femoral component was significantly greater when the cup was placed >25 mm superior to the teardrop (p = 0.049).

An acetabular component should ideally achieve 75% to 80% bone coverage, and a suboptimal small cup size is frequently required due to the relative lack of available bone to stabilize a high-center cup. The small cup size results in a reduced femoral head-neck ratio and inferior wear properties. A high hip center does not allow for anatomical limb lengthening, and further revision surgery is difficult due to the lack of bone stock. A combination of a suboptimal head-neck ratio, the high shear stresses, and the limited limb-lengthening correction results in a high dislocation rate, as the lesser trochanter may impinge on the ischium.

The intraoperative identification of the true acetabulum can be difficult due to the abnormal anatomy. The confluence of the ischium and the pubis identifies the true level, and the surgical exposure should be adequate to visualize these landmarks. The fovea should be cleared of residual soft tissue to evaluate acetabular depth, and intraoperative radiographs may be used to confirm acetabular height and depth.

Achieving optimal medialization of the cup can be difficult while avoiding overreaming, producing a reduction in bone stock, and risking medial migration of the cup, loss of position, and fatigue fractures of the acetabulum²². If the correct anatomical height of the true acetabulum has been identified, the degree of medialization can be determined after initial reaming by drilling and measuring the depth of a small hole in the floor of the acetabulum⁵⁶. Reaming should continue to approximately 3 to 4 mm from the inner cortex, thus leaving sufficient bone stock for future revision surgery. A trial cup should be used to ensure coverage of at least 70% and, if this is not achieved, then bone-grafting should be considered.

Cementless acetabular components afford bone ingrowth and enhance longevity by resisting tensile and shear stresses at the host-prosthesis interface^57-60. Modern acetabular components, with porous metal backing, have shown enhanced ingrowth and may reduce the amount of host-bone coverage that is necessary^61,62.

Restoration of Bone Stock

Anterolateral acetabular bone deficiency poses an important problem in total hip arthroplasty for dysplasia. Several surgical options exist, including a high hip center⁵², placement of the acetabular component in a medialized or protruded position⁵, or structural bone-grafting to the superolateral aspect of the acetabulum (also known as a shelf graft)⁶⁰.

Shelf Graft

A shelf graft provides osteoconductive lateral support with the potential for enhanced bone stock for revision surgery⁶³. This technique provides reliable early clinical results⁶⁴ with encouraging long-term results^60,63,65-67.

The operative technique has been described^56,60. Femoral head autograft (or rarely allograft) can be used to construct a shelf graft⁶⁸. Residual cartilage is reamed away to expose subchondral bone. The graft is placed at, or just within, the superior edge of the acetabulum (Figs. 4-A and 4-B) and initially secured with 3.2-mm drill bits placed in an oblique-to-vertical direction through the graft into the pelvis, with each drill bit subsequently replaced with Arbeitsgemeinschaft für Osteosynthesefragen (AO) 4.5-mm cancellous screws. An acetabular reamer is used to ream the graft until congruent with the previously reamed host acetabulum. After the cup is inserted, morselized autograft is placed at the graft-host junction (also known as a flying-buttress graft) to promote union.

Preoperative (Fig. 4-A) and postoperative (Fig. 4-B) radiographs of a dysplastic hip that received acetabular reconstruction with autologous shelf graft supported superiorly by autologous morselized bone graft (also known as the flying-buttress graft).

Fig. 4-A

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Fig. 4-B

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Morsi et al. reported on thirty-three cementless cups that were inserted with structural allograft or autograft⁶⁰. A 94% success rate was demonstrated (mean follow-up, 6.6 years), with all grafts united to the host bone. Those authors advocated the use of cementless cups with structural autografts, provided that the graft supported less than 50% of the cup. This same series was updated at a mean follow-up time of fourteen years, with graft-host bone union achieved in 93% and with ten patients requiring revision for loosening of the acetabular component⁶³. Only two of these revisions required further structural allograft for inadequate bone stock, indicating that the initial autografts restored bone stock for revision surgery⁶³. Similar results have been replicated by other authors⁶⁹.

Bone-Cement Augmentation and Reinforcement Rings

Encouraging early results have been reported with bone cement that was used to fill superior acetabular defects^48,70,71. Gill et al. reported on two series of reconstructions in which reinforcement rings or cages were used⁷². In the initial series, a Müller reinforcement ring (also known as a roof ring) was used in eighty-seven consecutive patients with severe dysplasia, more than forty of whom received a morselized autologous femoral-head graft. The authors advocated restoration of the anatomical hip center with use of an acetabular roof reinforcement ring; bone graft was used medially and superiorly to augment bone stock. Gill et al. recommended that bone cement should not replace bone stock, as the authors believed that it contributed to aseptic loosening⁷².

Subsequently, Gill et al., in a series of thirty-three hips (two of which were revised as a result of aseptic loosening), reported on the use of a Ganz ring and used an inferior hook position in the obturator foramen to provide further stability⁷³.

In summary, for patients with DDH, it is preferable to place the cup at the level of the true acetabulum, at an appropriate inclination, rather than in the superior, lateral, and vertical position of the false acetabulum. Structural bone graft, bone cement augmentation, and reinforcement rings are possible options when a large portion of the acetabular component remains uncovered.

Femoral Reconstruction

A small femoral intramedullary canal, femoral hypoplasia, marked femoral anteversion, a posterior position of the greater trochanter, and previous osteotomies are possible problems during femoral component insertion^74,75. If the hip center is lowered, a femoral shortening osteotomy may be necessary to avoid excessive tension on neurovascular structures, in particular the sciatic nerve^76,77. Careful femoral canal preparation minimizes the risk of cortical perforation with a guidewire, as does the use of intraoperative radiographs, which ensures the accurate passage of the intramedullary guidewire²².

For mild dysplasia, a small-size conventional femoral component can be considered. For severe dysplasia, a straight and narrow stem with limited medial curvature is beneficial, since there is frequently little remaining calcar following the femoral neck osteotomy. A derotational femoral osteotomy may be required for femoral anteversion of >40°, and a custom or modular implant allowing version adjustment of the femoral neck will be needed^78,79. Modern, small, straight taper-stemmed implants can be rotated to neutralize femoral anteversion and mitigate the need for a derotational femoral osteotomy.

The importance of femoral component modularity was highlighted by Silber and Engh, who reported that sixteen of nineteen patients required modular components due to variation in femoral size and shape and the loss of the metaphyseal flare⁸⁰.

When a subtrochanteric osteotomy is performed, cementless components are commonly used to avoid cement leakage and resultant nonunion at the osteotomy site^74,76,81. However, Charity et al. reported good results from their series of fifteen patients with severe dysplasia who underwent subtrochanteric osteotomy and subsequent insertion of a polished, smooth, cemented femoral component⁸².

Femoral Osteotomy

When the hip center is reconstructed at the level of the true acetabulum, lengthening the lower limb by >4 cm carries the risk of sciatic nerve palsy^83,84. A number of intraoperative methods of measuring limb length have been described; however, to date, none have been demonstrated to be superior⁸⁵. The amount of femoral shortening that will be required can be determined intraoperatively and compared with the preoperative determination of limb lengths through the use of templates and radiographs.

Proximal or subtrochanteric osteotomies have been described for femoral shortening. Subtrochanteric osteotomies performed with transverse, step, oblique, or double-chevron cuts allow for both angular and rotational correction in addition to shortening, and the results of several clinical studies support their use^{74,77,81,86-88}.

In summary, anatomical variations may be encountered when preparing for femoral-component insertion in patients with hip dysplasia. The modularity of modern revision components is greatly beneficial; however, a femoral osteotomy may be required and thorough preoperative planning will aid decision-making regarding femoral reconstruction.

Resurfacing Arthroplasty

The third generation of hip resurfacing arthroplasty implants have a cemented femoral component and a press-fit acetabular component⁸⁹. The advantages of this technique include the conservation of the femoral neck, minimal wear, and a reduced risk of dislocation due to the large diameter of both components^90-93. Such advantages would be of benefit to the young patient with DDH. However, concerns exist regarding the failure rates of first and second-generation implants^94,95, the rate of femoral neck fracture⁹⁶, metal hypersensitivity, and increased serum levels of metal ions^97-100.

Few studies specifically address metal-on-metal hip resurfacing arthroplasty for DDH patients who have arthritic changes. Early techniques and hip-resurfacing implants were associated with high rates of femoral neck fractures and femoral-side loosening for mild dysplasia¹⁰¹. Amstutz et al. addressed previous failures of hip resurfacing in patients with mild dysplasia by using new techniques for femoral component fixation and meticulous bone preparation and demonstrated that the short-term results for mildly dysplastic hips are similar to the survivorship of hip resurfacing arthroplasty in nondysplastic hips¹⁰². Furthermore, the acetabular components in the series of Amstutz et al. remained well fixed at follow-up times of two to eleven years. However, long-term studies of resurfacing for DDH are needed to address specific patient selection criteria, long-term complications and survivorship, and metal ion release.

In consideration of the use of hip resurfacing arthroplasty in general, a recent systematic review of the literature showed that none of the hip-resurfacing arthroplasty implants met full ten-year benchmark implant survival and only thirteen studies demonstrated satisfactory three-year survival¹⁰³. This study concludes that, until longer-term data are available, concerns remain regarding the effectiveness and safety of hip resurfacing arthroplasty. While the most common mode of failure was aseptic loosening, there is large variation in the rate of femoral neck fracture, the principal cause of which is not fully understood. In addition, a meta-analysis of forty-six studies comparing hip resurfacing arthroplasty with total hip arthroplasty and published in 2010 concluded that, although the functional outcomes associated with hip resurfacing arthroplasty are better or the same as those associated with total hip arthroplasty, there is an increased risk of heterotopic ossification and aseptic loosening after hip resurfacing arthroplasty and the revision rate of hip resurfacing arthroplasty is twice that of total hip arthroplasty¹⁰⁴.

Metal-on-Metal Arthroplasty

The use of metal-on-metal articulation in both total hip arthroplasty and resurfacing arthroplasty remains controversial, with growing concern regarding the incidence of symptomatic periprosthetic inflammatory reactions^105-107. A high inclination angle of the acetabular component risks edge-loading and subsequent increased component wear and an elevated serum metal-ion concentration^{97-100,108-110}. This process has also been associated with periprosthetic inflammatory masses¹¹¹.

Recent retrieval analysis suggests that the problems related to high wear rate in metal-on-metal hip resurfacing arthroplasty are likely to be similar for all types of metal-on-metal hip arthroplasty¹¹². Edge-loading occurred more often in hip resurfacing arthroplasty due to the retention of the femoral neck, which caused impingement-type edge-loading, particularly when the acetabular component had been implanted with a low inclination and either excessive or insufficient version. However, acetabular version in isolation has not been shown to influence the rate of wear in retrieved metal-on-metal hip resurfacing components¹¹³.

Considering the recent evidence regarding the safety and effectiveness of metal-on-metal articulations for both hip resurfacing arthroplasty and total hip arthroplasty, metal-on-metal articulations cannot be advocated for the young DDH patient. Indeed, as a result of concerns, in April 2010 the United Kingdom Medicines and Healthcare Products Regulatory Agency issued a medical device alert regarding the safety of all types of metal-on-metal hips¹¹⁴.

Outcomes and Complications

The complication rate associated with arthroplasty surgery is higher in patients with hip dysplasia than it is in patients who have osteoarthritis, and this difference cannot be accounted for by the younger age at which dysplastic patients present for arthroplasty^{48,49,72,84,115}.

The rate of sciatic nerve palsy following total hip arthroplasty in patients with dysplastic hips has been reported as being higher by ten times or more as compared with the rate seen in patients with nondysplastic hips^{22,45,64,70,83}. Garvin et al. suggested that 2 cm is the safe limit of limb-lengthening⁸⁴. Edwards et al. proposed that the risk of sciatic nerve palsy is greatly increased with lengthening of >4 cm¹¹⁶. Suggested precautions include the use of electromyographic monitoring and the use of a wake-up test similar to that used in scoliosis surgery^79,117. It is suggested that if limb-lengthening occurs, the sciatic nerve should be exposed and palpated intraoperatively with the knee in flexion and extension to assess the degree of tension. If there is any suggestion of too much tension in the nerve, then a wake-up test should be performed. This test involves reducing the level of anesthesia to allow the patient, while on the operating table, to respond to command—specifically, ankle dorsiflexion to confirm sciatic-nerve motor function¹¹⁷. This procedure needs to be fully explained to the patient prior to surgery and patient consent must be obtained, and the anesthetist must also be aware of the potential need to perform this test. Furthermore, if limb-lengthening is done, the ipsilateral knee should be kept flexed immediately following surgery to reduce tension on the sciatic nerve.

The highest rates of hip dislocation have been reported following arthroplasty for dysplasia^64,70,84. It is thought that the risk of dislocation may result from trochanteric nonunion (so-called trochanteric escape) or the impingement of the femoral component on the anterior acetabular column with the hip in flexion and internal rotation. The risk of impingement is greatest with a high hip center and a medialized cup and can be partially resolved by using a femoral component with an increased offset.

The femoral deformities inherent in patients with severe hip dysplasia increase the risk of intraoperative femoral fracture^118,119. Thus, as highlighted before, much care must be taken when preparing the femoral canal so as to avoid cortical perforation, and the use of a guidewire to ensure intramedullary position is highly recommended. If a cortical perforation is identified intraoperatively, the femoral component used must then bypass the perforation by at least two cortical diameters and the use of a cortical onlay allograft should also be considered.

Obesity is an increasingly common coexisting problem for young adult patients who present for joint replacement¹²⁰. Recent data support hip arthroplasty in the presence of morbid obesity because the postoperative outcome was not affected and thus the withholding of surgery on the basis of body mass index was considered unjustified¹²¹. However, this study and others have also reported that obesity is a risk factor for prosthetic infection^121-123.

There is a higher infection rate reported for total hip arthroplasty performed for dysplasia as compared with total hip arthroplasty performed for osteoarthritis^70,124,125. The cause is probably multifactorial, including the complexity and duration of the operations, the large exposure and extensive dissection, soft-tissue stripping, and the frequent use of bone graft.

Summary

The anatomical features of hip dysplasia necessitate thorough preoperative planning to ensure that the most appropriate implants, surgical approach, and bone-restoration techniques are used. Currently, long-term clinical data support the use of a metal-on-polyethylene bearing; however, clinicians and patients alike should be aware of the increased complication rate that has been associated with total hip arthroplasty when performed for the treatment of adult hip dysplasia.

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

femur ; hip dislocation, congenital ; hip joint ; hip replacement arthroplasty ; dysplasia ; hip joint prosthesis, acetabular component

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Evert Smith BSc MBBCh FRCS, Anthony Ward BMedSci BMBS FRCS, Konstantinos Zahos MD, Sanchit Mehendale MS(Orthopaedics) FRCS

Posted on October 28, 2012

The 15° face-changing (15°FC) cementless acetabular cup: an alternative treatment for dysplastic and low dislocation cases

North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, UK; evert@evertsmith.com

The authors have omitted to recognise in their paper the potential use of a unique cementless shell with a ceramic bearing surface. The 15° face-changing (15°FC) cementless acetabular cup (1, 2) was specifically designed for use in dysplastic and low dislocation cases according to Hartofilakidis classification system.(3) It is an alternative treatment to the ‘normal’ cementless acetabular component. The technique for insertion is distinctly different from a standard cementless hemispherical component as it is designed to position the bearing surface at the optimal angle of inclination without compromising shell cover, by maximizing host bone to porous surface contact. Modification of the standard hemispherical cementless acetabular component design to that of a 15°FC component permits the entire porous surface to make contact with the host bone. As a result additional screw fixation is not always necessary. The liner can be inclined to the optimal position of <45°. It allows for a more anatomical reconstruction of the center of rotation of the hip. Compared with standard components, this acetabular implant has more contact surface between host bone and component because virtually all the porous surface is in contact with the host bone. We perceive that this is a major advantage.

References
1. Journal of Bone and Joint Surgery (Br) 2012, 94-B, No.2, 163-6
2. Reconstructive Review, Journal of Joint Implant Surgery and Research Foundation (JISRF), Aug 2012 2, No. 2: 32-39
3. Hartofilakidis G, Stamos K, Karachalios T, Ioannidis TT, Zacharakis N. Congenital hip disease in adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty. J Bone Joint Surg Am. 1996 May;78(5):683-92

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Benedict A. Rogers, Shawn Garbedian, Raul A. Kuchinad, David Backstein, Oleg Safir, Allan E. Gross; Total Hip Arthroplasty for Adult Hip Dysplasia. The Journal of Bone & Joint Surgery. 2012 Oct;94(19):1809-1821.

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