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Cementless Total Hip Arthroplasty in Patients with High Congenital Hip Dislocation
Antti Eskelinen, MD1; Ilkka Helenius, MD, PhD2; Ville Remes, MD, PhD2; Pekka Ylinen, MD2; Kaj Tallroth, MD, PhD2; Timo Paavilainen, MD, PhD2
1 Koivuviita 12 B 6, Espoo FIN-02130, Finland. E-mail address: antti.eskelinen@fimnet.fi
2 ORTON Orthopedic Hospital, Invalid Foundation, Tenholantie 10, Helsinki FIN-00280, Finland
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from Orion Research Foundation, Research Foundation of Orthopaedics and Traumatology, Pär Slätis Joint Surgery Research Foundation, and Duodecim Research Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at ORTON Orthopedic Hospital, Invalid Foundation, Helsinki, Finland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Jan 01;88(1):80-91. doi: 10.2106/JBJS.E.00037
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Abstract

Background: The optimal surgical treatment for patients with high congenital dislocation of the hip remains controversial. The purpose of our study was to evaluate the mid-term to long-term results of cementless total hip arthroplasty in such patients.

Methods: The study included sixty-eight total hip replacements performed between 1989 and 1994 in fifty-six consecutive patients with high congenital hip dislocation at our hospital. The cup was placed at the level of the true acetabulum, and a shortening osteotomy of the proximal part of the femur and distal advancement of the greater trochanter were performed in 90% of the hips. At the time of final follow-up, at a mean of 12.3 years postoperatively, fifty-two patients (sixty-four hips) were evaluated by us with a physical examination, determination of Harris hip scores, and radiographs.

Results: The mean Harris hip score increased from 54 points preoperatively to 84 points at the time of final follow-up (p < 0.001). There was a negative Trendelenburg sign in fifty-nine (92%) of the sixty-four hips. There were thirteen perioperative complications (19%): three peroneal nerve palsies, one femoral nerve palsy, one superior gluteal nerve palsy, four nondisplaced fractures of the proximal part of the femur, one malpositioned stem perforating the posteromedial cortex of the femur, one superficial wound infection, and two early dislocations. With revision because of aseptic loosening as the end point, the ten-year survival rate for press-fit, porous-coated acetabular components was 94.9% (95% confidence interval, 89.3% to 100%). Eight of nine threaded acetabular components were revised, and the ninth was radiographically loose at the time of the last follow-up examination. The rate of survival for the CDH femoral components, with revision because of aseptic loosening as the end point, was 98.4% (95% confidence interval, 96.8% to 100%) at ten years.

Conclusions: Total hip arthroplasty, with placement of the cup at the level of the true acetabulum, distal advancement of the greater trochanter, and femoral shortening osteotomy, can be recommended for patients with high congenital hip dislocation. Complications such as wear, osteolysis, and cup revision were secondary to the suboptimal design of the acetabular components used in this series.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Omur Caglar, M.D.
    Posted on November 14, 2006
    Total Hip Arthroplasty For High Dislocation Of The Hip: The Femoral Side
    Hacettepe University, Faculty of Medicine, Dept. of Orthopaedics, Sihhiye/Ankara/TURKEY

    To The Editor:

    In the article, “Cementless total hip arthroplasty in patients with high congenital hip dislocation”(1) The authors are to be complimented for their classification of the different deformities and proposed management strategy for each. However,we are concerned about some of their surgical techniques.

    Since 1999, we have used a proximally hydroxyapatite coated cementless stem; (Osteonics, Securfit Plus®) for these patients. Our surgical technique on the femoral side includes a short oblique subtrochanteric osteotomy and excision of a segment of femur sufficient to allow for a safe reduction. Safe reduction usually requires extensive soft tissue releases of the pelvifemoral muscles. The gluteus maximus, tensor fascia latae and adductors are routinely released, but we limit the extent of these releases as much as possible because preserving the attachment of the abductors and iliopsoas are important to optimize the functional outcome. We never resect or osteotomize the trochanters and, if a release is unavoidable, it is performed proximally. Thus, it is possible to preserve a complete segment of the proximal femur with a soft tissue envelope. This segment allows for better bone stock, prompt healing, reliable proximal fixation through the intact medial calcar, and avoids the complications of trochanteric osteotomy. With this technique we have not performed a femoral revision for any reason in 85 high dislocated hips since 1999.

    In the current article(1), the authors prefer to resect the medial calcar with the lesser trochanter and they perform a greater trochanteric osteotomy. This approach destroys the proximal femur; thus distal fixation with a calcar replacement femoral stem remains the only option. Resecting the iliopsoas insertion and reattachment of the abductors may cause gait abnormalities and fixation failures. The reported femoral revision rate of 7% can be attributed to this technique.

    We would ask the authors to comment on whether their technique results in deficiency of proximal bone support and motor power, as these may lead to limping, difficulty in stair climbing, early fixation failures and difficulty in performing subsequent revisions.

    The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

    Reference:

    1. Eskelinen A, Helenius I, Remes V, Ylinen P, Tallroth K, Paavilainen T. Cementless total hip arthroplasty in patients with high congenital hip dislocation. J Bone Joint Surg Am 2006;88:80-91.

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