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Treatment of High Dislocation of the Hip in Adults with Total Hip Arthroplasty. Operative Technique and Long-Term Clinical Results*

GEORGE HARTOFILAKIDIS, M.D., KONSTANTINOS STAMOS, M.D. and THEOFILOS KARACHALIOS, M.D., ATHENS, GREECE

Investigation performed at the Orthopaedic Department, Athens University, K.A.T. Hospital, Athens

	Abstract

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The clinical results of eighty-four total hip arthroplasties performed through a transtrochanteric approach in sixty-seven patients who had a high dislocation of the hip (the femoral head completely out of the acetabulum), from 1976 to 1994, were reviewed. The acetabular component was placed in the true acetabulum and the femur was shortened at the level of the femoral neck, along with release of the psoas tendon and the small external rotators, in order to facilitate reduction of the components and to avoid neurovascular complications. Eleven hip prostheses (13 per cent) failed at a mean of 6.4 years (range, two months to sixteen years) postoperatively; the failure was due to aseptic loosening of both components in four hips, aseptic loosening of the stem only in three, late infection in three, and malpositioning of the acetabular component that caused recurrent dislocations in one. The other seventy-three hips were functioning well at the latest follow-up examination, two to twenty years (mean, 7.1 years) postoperatively. The overall cumulative rate of success was 92.4 per cent (95 per cent confidence interval, 89.5 to 95.3 per cent) at five years and 88.0 per cent (95 per cent confidence interval, 82.2 to 93.8 per cent) at ten years. We believe that this operative technique of total hip arthroplasty is effective for the treatment of the difficult condition of high dislocation of the hip.

	Introduction

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We have previously described three distinct types of congenital hip disease in adults^11,12. The first type is dysplasia, in which the femoral head articulates with the original (true) acetabulum, despite some degree of subluxation. The second type is low dislocation, in which the femoral head articulates with a false acetabulum that partially covers the true acetabulum. The third type is high dislocation, in which the femoral head migrates superiorly and posteriorly in relation to the hypoplastic true acetabulum and may articulate with a hollow in the iliac wing that resembles a false acetabulum. The considerable variation in anatomical abnormalities associated with these three types of the disease makes reconstruction with a total hip arthroplasty difficult. The identification and preparation of the true acetabulum, the preparation of the femoral canal, and the reduction of the components pose several important technical problems, especially in hips with a high dislocation.

Most studies of total hip arthroplasty in patients who had congenital hip disease have included all three types of the disease^{6,7,9,10,17,18,22}. This has caused confusion in the evaluation of the results.

The purpose of the present study was to review the long-term clinical and radiographic results of total hip arthroplasty in sixty-seven patients (eighty-four hips) who had a high dislocation.

	Materials and Methods

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Sixty-seven patients (eighty-four hips) who had a high dislocation (Figs. 1-A and 1-B) were managed with a total hip arthroplasty in our department from 1976 to 1994. Fifteen patients (twenty hips) were followed for ten to twenty years; forty-seven patients (fifty-nine hips), for three to ten years; and five patients (five hips), for two to three years. All of the patients were female. The mean age at the time of the operation was 49.5 years (range, twenty-three to seventy years). Fifty-two left and thirty-two right hips were treated. Eighteen (27 per cent) of the sixty-seven patients had bilateral high dislocation, but one of the eighteen had operative treatment of only one hip. Sixteen patients (24 per cent) had a low dislocation of the contralateral hip, fifteen (22 per cent) had a dysplastic contralateral hip, and eighteen (27 per cent) had a normal contralateral hip. All of the contralateral hips that were dysplastic or had a low dislocation were treated with a total hip arthroplasty at a different time.

View larger version (143K): [in this window] [in a new window]   Figs. 1-A and 1-B: Three-dimensional computerized tomography scans of a patient who had a high dislocation of the left hip. Fig. 1-A: Lateral oblique view of the hip. The hypoplastic true acetabulum, triangular in shape, has segmental deficiency of the entire acetabular rim, a narrow opening, and inadequate depth. The femoral head is small, there is increased anteversion of the femoral neck, and the diaphysis has a thin cortex and a narrow canal.

View larger version (158K): [in this window] [in a new window]   Fig. 1-B: Lateral oblique view of the defective acetabulum after removal of the femoral head. Bone stock at the level of the true acetabulum is mainly superoposterior. The anterior acetabular wall is defective. The entire iliac bone is in increased anteversion. The hollow in the iliac wing represents the false articulation of the dislocated femoral head.

Clinical and radiographic data were obtained for all patients preoperatively and at yearly intervals postoperatively. The system of Merle d'Aubigné and Postel, as modified by Charnley³, was used for the clinical evaluation. The height of the dislocation on the preoperative radiographs, as recorded with the method described by Crowe et al., ranged from 2.7 to 9.2 centimeters (mean, six centimeters). The length of the lower limb was recorded as the distance between the anterior superior iliac spine and the medial malleolus.

Arthroplasties with a Charnley low-friction implant and technique were performed between 1976 and 1990 (sixty-five hips), and since then (from 1990 to 1994) so-called hybrid total hip arthroplasties (insertion of the acetabular component without cement and insertion of the femoral component with cement) have been done (eighteen hips) (Table I). Only one total hip arthroplasty was performed without cementing of either component. All of the bilateral arthroplasties were done as two separate procedures.

Operative Technique
The procedure is always performed through a lateral approach to the hip joint and with use of a trochanteric osteotomy for better exposure and reconstruction of both the acetabular and the femoral side. A provisional osteotomy is performed at the middle of the femoral neck or at a level predetermined on the preoperative radiographs with use of templates. A final adjustment is made during the trial reduction of the components.

When the area has been adequately exposed, the acetabulum is widened and deepened with curved osteotomes and with reamers with a small (thirty-eight to forty-millimeter) diameter. Care is taken to avoid fracture of the anterior wall, with the reaming done mainly in a superior and posterior direction, where bone stock typically is adequate^12,24. After preparation of the true acetabulum, either a thirty-five millimeter, fully covered, offset-bore Charnley cup (DePuy, Warsaw, Indiana) is inserted with cement or a forty to forty-two-millimeter cup is press-fit without cement when the remaining osseous cavity can provide at least 80 per cent coverage of the cup with bone. When these options are not possible, the acetabulum is reconstructed with the cotyloplasty technique, as described by one of us (K. S.), and the acetabular component is implanted with cement^11,12,20.

The femoral canal is prepared with hand-powered reamers, since power reamers may fracture the thin cortex. A trial reduction of the femoral component, at the correct degree of anteversion, is attempted after release of the psoas tendon and the small external rotators. Insertion of the component in excess anteversion or in a position of varus or valgus must be avoided. If the reduction is not possible, additional shortening of the femur is performed with progressive resection of the femoral neck. Care is taken to keep the resection proximal to the lesser trochanter; otherwise, the narrow diameter of the femoral canal more distally becomes a major problem. The prosthesis is then implanted with use of so-called modern cementing techniques.

After the final reduction, reattachment of the greater trochanter is often difficult and it may be necessary to release the gluteus medius and the remnants of the joint capsule.

Two to three weeks of bed rest postoperatively is recommended to allow for better adjustment and balance of the soft tissues, and full weight-bearing is usually permitted three to four months postoperatively.

	Results

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The prosthesis failed in eleven (13 per cent) of the eighty-four hips, at a mean of 6.4 years (range, two months to sixteen years) postoperatively. In seven of these hips, the implant failed, at a mean of 8.6 years (range, two to sixteen years) postoperatively, because of aseptic loosening; both components were revised in four hips, and only the femoral component was revised in three. In one hip, the acetabular component was revised at two months postoperatively because it had been inserted in an extreme vertical position (80 degrees), resulting in an irreducible dislocation. In the remaining three hips (4 per cent), the prosthesis failed, between the second and third postoperative years, because of late infection. Two of these three hips were treated with excision (Girdlestone) arthroplasty, and the third was revised in one stage.

Seventy-three prostheses had survived at a mean of 7.1 years (range, two to twenty years) postoperatively (Figs. 2-A, 2-B, 3-A and 3-B). One patient (two hips) was lost to follow-up at five years and three patients (four hips) died, at a mean of ten years (six, seven, and seventeen years) postoperatively, from causes unrelated to the procedure. For these patients, the last follow-up records were used for the final evaluation.

View larger version (130K): [in this window] [in a new window]   Figs. 2-A and 2-B: Anteroposterior radiographs of a forty-seven-year-old woman who had bilateral high dislocation of the hip. Fig. 2-A: According to the method of Crowe et al., the height of the dislocation of the right hip is seven centimeters and that of the left hip is 8.2 centimeters.

View larger version (107K): [in this window] [in a new window]   Fig. 2-B Eight years after bilateral total hip arthroplasty with offset-bore acetabular components, inserted after cotyloplasty, and Harris CDH stems. The length of the right lower limb increased from seventy-one to seventy-five centimeters and that of the left increased from seventy to seventy-five centimeters. The patient's height increased from 152 to 155 centimeters.

View larger version (149K): [in this window] [in a new window]   Figs. 3-A and 3-B: Anteroposterior radiographs of a thirty-three-year-old woman who had bilateral high dislocation of the hip. Fig. 3-A: The height of the dislocation of each hip5 is nine centimeters.

View larger version (152K): [in this window] [in a new window]   Fig. 3-B Six years after bilateral hybrid total hip arthroplasty with forty-two-millimeter Harris-Galante sockets inserted without cement and Harris CDH stems inserted with cement. The length of the lower limbs increased from seventy-one to seventy-four centimeters, and the patient's height increased from 150 to 153 centimeters.

View larger version (21K): [in this window] [in a new window]   Fig. 4 Bar graphs representing the preoperative clinical scores for the eighty-four hips with a high dislocation treated with total hip arthroplasty compared with the postoperative scores for the seventy-three hips in which the prosthesis survived.

The overall survivorship analysis showed a cumulative rate of success of 92.4 per cent (standard error, 1.5 per cent; 95 per cent confidence interval, 89.5 to 95.3 per cent) at five years and 88.0 per cent (standard error, 2.9 per cent; 95 per cent confidence interval, 82.2 to 93.8 per cent) at ten years (Fig. 5). Revision (planned or performed) of one component or both, or removal of the components as part of an excision arthroplasty, was considered a failure. The cumulative rate of survival of the acetabular components was 95.0 per cent (standard error, 1.9 per cent; 95 per cent confidence interval, 91.3 to 98.7 per cent) at five years and 90.4 per cent (standard error, 3.0 per cent; 95 per cent confidence interval, 84.5 to 96.3 per cent) at ten years (Fig. 5), and that of the femoral stems was 93.6 per cent (standard error, 1.5 per cent; 95 per cent confidence interval, 90.7 to 96.5 per cent) at five years and 89.1 per cent (standard error, 3.0 per cent; 95 per cent confidence interval, 83.2 to 95.0 per cent) at ten years (Fig. 5).

View larger version (20K): [in this window] [in a new window]   Fig. 5 Survivorship curves showing the cumulative rates of success (solid lines) and the 95 per cent confidence intervals (dotted lines) of (a) both components (17.5 cases at risk at ten years), (b) the femoral components, and (c) the acetabular components. Revision (planned or performed) of either component or removal of the components as part of an excision (Girdlestone) procedure was considered a failure.

As a result of the operation, the limb length increased by a mean of 3.5 centimeters (range, one to seven centimeters). The patients who had a bilateral procedure became a mean of five centimeters (range, two to seven centimeters) taller. The patients who had a unilateral procedure had improvement of the limb-length discrepancy from a preoperative mean of 5.1 centimeters to a postoperative mean of 1.4 centimeters.

All patients had had a positive Trendelenburg sign preoperatively. After the operation, the sign became negative in forty-one patients (61 per cent) and it was still positive but markedly less prominent than preoperatively in twenty-six patients (39 per cent). Only one patient (one hip) had a trochanteric non-union, which resulted in a mild limp.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Early in the development of total hip arthroplasty, attempts to reconstruct the hips of adults who had congenital dislocation proved unsuccessful and the initial impression was that such hips should not be operated on⁴. The acetabular and femoral abnormalities found in such hips seemed to pose major obstacles to reconstruction. In our department, we started performing total hip arthroplasties in adults who had congenital hip disease as early as 1976. We soon realized that our knowledge of acetabular and femoral abnormalities in such patients was lacking and that the development of special reconstruction techniques was necessary. Later, while trying to compare our results with the clinical experience at other centers, we realized that this was not feasible because of the lack of a uniform terminology to describe the different types of congenital hip disease and the inclusion of dissimilar cases within the same series. For these reasons, we conducted a prospective, clinical evaluation of patients with all types of congenital hip disease and we recently described the anatomical abnormalities of the acetabulum found in the three types (dysplasia, low dislocation, and high dislocation)¹². Each type is a distinct abnormal anatomical entity, with high dislocation being the most severe.

The three major areas of difficulty encountered when a high dislocation of the hip is treated with total hip arthroplasty are acetabular reconstruction, preparation of the femoral canal, and reduction of the components with overall improvement of the limb length.

The advantage of placement of the acetabular component in the area of the true acetabulum^13,15,16 and the technical difficulties associated with acetabular reconstruction in congenital hip disease, including high dislocation, were described in previous reports on our series^11,12.

As for preparation of the femoral canal, careful and slow preparation with hand reamers ensures that the thin cortex of the femur is not fractured. The surgeon must be prepared to use a straight and thin prosthesis and must leave adequate space for a cement mantle of sufficient thickness. Special care must be taken to avoid insertion of the stem with excess anteversion or in a varus or valgus position.

Reduction of the prosthesis is often difficult, and shortening by resection of part or all of the femoral neck combined with soft-tissue release may be necessary. Shortening at the level of the femoral neck is simple and uneventful, and therefore we do not favor shortening of the femoral diaphysis, as has been suggested by others^19,21. Despite shortening of the femoral neck, the overall limb length increases. It has been suggested⁷ that limb-lengthening of more than two centimeters should be avoided, mainly because of the danger of neurological complications. In the present study, the mean of 3.5 centimeters of lengthening was achieved without major complications. The two patients who had neurapraxia had 3.0 and 3.5 centimeters of lengthening, and both recovered fully. No neurological complications were observed in the twelve patients (thirteen hips) who had five centimeters of lengthening or more (range, five to seven centimeters). Therefore, we considered the lengthening technique that we used to be safe.

Postoperative dislocations were related to the improper placement of cups inserted without cement. Proper orientation of the cup and two to three weeks of bed rest postoperatively (for better soft-tissue readjustment) prevented this complication.

We favor the insertion of prostheses with cement, as do other authors^1,11,12,14; few authors have suggested the insertion of devices without cement^19,23. The use of hybrid arthroplasties is currently being investigated¹⁸. The principles and goals of fixation of the stem without cement (optimum canal fit and fill, initial stability of the implant, and adequate bone ingrowth) are not easily achieved in a narrow femoral canal with such a thin cortex. Although we currently insert hemispherical cups without cement, their clinical efficacy must be tested and shown to be comparable with the long-term results achieved with small Charnley cups inserted with cement in this series. The results (a cumulative rate of success of 88.0 per cent [95 per cent confidence interval, 82.2 to 93.8 per cent] at ten years) in this series of hips with the most severe type of congenital hip disease are not easily comparable with those of other series, which included patients who had various types of congenital hip disease. In the only two series (of which we are aware) that included only completely dislocated hips, the rate of failure was 25 per cent in 100 patients at a mean of ten years¹⁴ and the rate of success was 71 per cent in twenty-eight patients (thirty-four hips) at a mean of 9.4 years¹.

The favorable clinical results and the low rate of complications in the present study of treatment of high dislocation of the hip indicate that a thorough understanding of anatomical abnormalities and the use of proper reconstruction techniques and implants make total hip arthroplasty feasible in patients who have such complex congenital hip disease.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

21 Photiou Patriarnhou Street, Athens 11471, Greece. Please address requests for reprints to Professor Hartofilakidis.

Orthopaedic Department, Athens University, K.A.T. Hospital, 10 Athinas Street, Athens 14561, Greece.

	References

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