Aims. Complex total hip arthroplasty (THA) with subtrochanteric shortening osteotomy is necessary in conditions other than developmental dysplasia of the hip (DDH) and septic arthritis sequelae with significant proximal femur migration. Our aim was to evaluate the hip centre restoration with THAs in these hips. Methods. In all, 27 THAs in 25 patients requiring THA with femoral shortening between 2012 and 2019 were assessed. Bilateral shortening was required in two patients. Subtrochanteric shortening was required in 14 out of 27 hips (51.9%) with aetiology other than DDH or septic arthritis. Vertical centre of rotation (VCOR), horizontal centre of rotation, offset, and functional outcome was calculated. The mean followup was 24.4 months (5 to 92 months). Results. The mean VCOR was 17.43 mm (9.5 to 27 mm) and horizontal centre of rotation (HCOR) was 24.79 mm (17.2 to 37.6 mm). Dislocation at three months following acetabulum reconstruction required femoral shortening for offset correction and hip centre restoration in one hip. Mean horizontal offset was 39.72 (32.7 to 48.2 mm) compared to 42.89 (26.7 to 50.6 mm) on the normal side. Mean Harris Hip Score (HHS) of 22.64 (14 to 35) improved to 79.43 (68 to 92). Mean pre-operative shortening was 3.95 cm (2 to 8 cm). Residual limb length discrepancy was 1.5 cm (0 to 2 cm). Sciatic neuropraxia in two patients recovered by six months, and femoral neuropraxia in one hip recovered by 12 months. Mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 13.92 (9 to 19). Mean 12-item short form survey (SF-12) physical scores of 50.6 and mental of 60.12 were obtained. Conclusion. THA with subtrochanteric shortening is valuable in complex hips with high dislocation. The restoration of the hip centre of rotation and offset is important in these hips. Level of evidence IV. Femoral shortening useful in conditions other than DDH and septic sequelae. Restoration of hip centre combined with offset to be planned and ensured

Introduction. Femoral-shortening osteotomy for the treatment of leg length discrepancy is demanding technique. Many surgical technique and orthopaedic devises have been suggested to perform this procedure. Herein, we describe modified femoral shortening osteotomy over a nail, using a percutaneous multiple drill-hole osteotomy technique. Materials and Methods. We operated on six patients with LLD. Mean femoral shortening was 4.2 cm. Osteotomy was performed using a multiple drill-hole technique, and bone was stabilized using an intramedullary nail. Post-operative clinical and radiological data were reported. Results. Shortening was achieved, with a final LLD of < 1 cm in all patients. All patients considered the lengths of the lower limbs to be equal. No special surgical skills or instrumentation were needed. Intraoperative and post-operative complications were not recorded. Conclusions. Percutaneous femoral-shortening osteotomy over a nail using multiple drill-hole osteotomy technique was effective and safe in treating LLD

Purpose: To compare the incidence of avascular necrosis, and radiological outcomes between groups treated by closed reduction, open reduction, and open reduction + femoral shortening, under the care of a single surgeon, with open reductions performed through an anterior approach, uninfluenced by the appearance of the ossific nucleus. Methods: Between Sept 1991 and Dec 2003 we retrospectively studied 66 patients (3 bilateral; 10 males, 53 females) who had undergone reduction under anaesthesia. Of these 34 hips were reduced closed with adductor release (average 0.7 yrs, range 0.2–1.7), 11 reduced open (average age 1.0; 0.4–3.3) and 24 reduced open with femoral shortening (average age 2.4; 0.9–7.8). Follow up radiographs were graded for the presence of AVN by the Bucholz and Ogden method. Radiological outcome was graded by the Severin score. Average follow up was up to the age of 6.6 years (SD 2.9) for the closed reduction group, open reduction group 8.0 (SD 3.6) and femoral shortening group 9.0 (SD 3.9). Results:. AVN scores. Closed Reduction (n=34) : Grade 1 : 5. Open Reduction (n= 11) : Grade 1: 2, Grade 2: 1, Grade 3: 1. Open, with shortening (n=24): Grade 1: 5, Grade 2: 1. Severin Scores:. Closed I: 22 II:3 III:8 IV:0. Open I:6 II:1 III:2 IV:2. Shortening I: 8 II:8 III:3 IV:2. Conclusions: The group with the highest incidence of AVN & worse Severin grades was the group (average age-1.0) who had open reduction without femoral shortening. The open reduction & shortening group had a higher proportion of good radiological results despite treatment being given at a older age. Concentric closed reduction, where possible, gave the best results. Significance: Any child presenting with DDH at walking age (over 1) who requires open reduction should also have a femoral shortening. This gives the best chance of avoiding high grade AVN and achieving a good radiological result. Results might improve if open reductions without shortening were discontinued

Purpose: Total hip arthroplasty in high riding congenital dislocation of the hip is a challenging procedure. In order to position the cup in the true acetabulum, femoral shortening osteotomy is often needed. The purpose of our study was to evaluate the results of two different methods of femoral shortening osteotomy. Method: Thirty-one total hip arthroplasties were performed in 29 cases with high congenital hip dislocation. The acetabular cups were placed at true acetabulum and femoral shortening osteotomies of the femur were performed at proximal (14 hips, group 1) or distal femur (17 hips, group 2). After a mean follow up of 4.2 years, all 31 hips were evaluated with Harris Hip Scores and X-rays. Technical difficulties and complications were also reported. Results: The mean increase in Harris Hip Score was 51 in group one and 52 in group two. There was one peroneal nerve palsy and one early dislocation in group 1, while there was no such perioperative complications in group 2. One acetabular cup and femoral stem were revised in group 1. Non-union happened in two cases of group 2. Special shape (cylindrical, non-tapered and longer than standard) femoral stems were needed for most proximal osteotomy patients. Conclusion: Hip arthroplasty, with insertion of cup at true acetabulum and femoral shortening osteotomy in patients with high congenital dislocation, can produce good results. Either proximal or distal femoral shortening osteotomy could have advantages and disadvantages. Proximal shortening osteotomy is a more challenging procedure, may need special stem design, and could compromise stem fixation

Objectives: We evaluated the results of a femoral shortening z-osteotomy in patients who underwent THA due to high dislocation of the hip. Methods: From 8/1997 until 11/2003 we performed THA in combination with a z-shaped subtrochanteric shortening osteotomy in 6 patients (4 females, 2 males) with high dislocation of the hip. In all cases for the reconstruction of the acetabulum a cementless press fit component was implanted, in 5 cases in combination with an acetabular roof reconstruction by autograft. For the femoral component we used standard titanium cementless stems in 5 cases, in one case a revision model. The z-shaped shortening osteotomy was fixed by titanium cerclages in all cases. Results: Postoperative complications (nerve lesions, THA dislocations, non union) could not be observed in the clinical and radiological follow up examinations 6 to 72 months postoperatively. In all cases femoral union at the area of the shortening osteotomy could be observed 3 months postoperatively. Conclusion: Femoral shortening z-osteotomy in THR is a safe technique in patients with high total dislocation of the hip, leading to satisfactory postoperative results

Purpose: To compare the radiological and functional results of Developmental Dysplasia of the Hip (DDH) patients who received Pemberton Pericapsular Osteotomy (PPO) with femoral shortening (FS) and those who did not. Material and Method: Between the years 2001–2006 of 12 DDH patients 14 hips (7 female unilateral, 2 female bilateral, 3 male) received treatment. 5 patients (6 hips) received PPO and/or open reduction (OR) (group 1), and 7 patients (8 hips) received OR+PPO+FS (group 2). The average age of group 1 was 2.06, and group 2 was 5.08 years. All patients received one stage surgery. According to the Tönnis the grade of displacement and the acetabular index (AI) was determined preop and postop. Clinical evaluations were made with McKay, radiological with Severin and femoral head avascular necrosis measurements were taken with Kalamchi-MacEwen. The average follow up period was 5.8 ±1.6 for group 1 and 6.67 ±1.4 years for group 2. Results: AI for group 1 was 40.12°±4.09 preop and 16.88°±6.45 (p=0.012) postop, group 2 was 44.33°±7.31 preop, and 30°±5.66 (p=0.009) postop. Both groups showed a significant correction (p< 0.05). According to Severin classification group 1 was 87.5% Ia, 12.5% III, group 2 was 75% Ia, 12.5% Ib, 12.5% II. According to Kalamchi-McEven measurements group 1 was 75% Type I, 25% Type II. Functional results of group 1 were 87% I (very good), 12.5% II (good), group 2 100% I (very good). For each group no significant difference was found in terms of clinical and radiological results (p> 0.05). Conclusion: Functional and radiological mid term results of DDH patients who received PPO with or without FS could be classified as very good

Total hip arthroplasty is a challenging problem in case of high hip dislocation. In order to reduce the hip, a femoral shortening osteotomy is necessary to prevent damage to the neurovascular structures. In this study we present the mid-term results of a simple technique of simultaneous derotating and shortening osteotomy of the femur without the necessity of additional osteosynthesis. In this retrospective study we included 28 patients with high hip dislocation. In these patients 30 consecutive cementless primary total hip arthroplasties with femoral shortening osteotomy were performed. 20 cases were previously operated. All patients were clinically and radiologically followed up after a mean of 4.5 years (range 2 – 5.7 years). Time point of consolidation was determined on consecutive radiographs for each patient. The average operative time was 116 minutes (range 65 to 150 minutes). There were no intraoperative complications. Postoperatively no femur fractures, no pseudarthroses and no pareses were observed. The mean consolidation time of the osteotomy was 4.4 months. At the time of follow-up, one aseptic loosening had been verified. In this case a very small stem (size 03) had been used. The mean Merle d’Aubigne score for the unrevised hips improved from 8.2 points preoperatively to 15.1 points at follow-up. In conclusion the presented technique allowed an easy and fast implantation of total hip arthroplasty in patients with high hip dislocation. The Zweymueller stem design with its rectangular cross-section seems responsible for the sufficient stability of the osteotomy resulting in a short consolidation time. Any additional osteosynthesis is obsolete. This leads to additional advantages including a short duration of surgery and a low complication rate. The good clinical results are attributable to the fact, that by shortening the femur, the physiological hip joint biomechanics could be approximated. The mid-term results of the described technique are very promising

Background. Total hip arthroplasty for Crowe type IV developmental dysplasia of the hip is a technically demanding procedure. Restoration of the anatomical hip center frequently requires limb lengthening in excess of 4 cm and increases the risk of neurologic traction injury. However, it can be difficult to predict potential leg length change, especially in total hip arthroplasty for Crowe type IV developmental hip dysplasia. The purpose of the present study was to better define features that might aid in the preoperative prediction of leg length change in THAs with subtrochanteric femoral shortening osteotomy for Crowe type IV developmental dysplasia of the hip. Patients and Methods. Primary total hip arthroplasties with subtrochanteric femoral shortening osteotomy were performed in 70 hips for the treatment of Crowe type IV developmental hip dysplasia. The patients were subdivided into two groups with or without iliofemoral osteoarthritis. Leg length change after surgery was measured radiographically by subtracting the amount of resection of the femur from the amount of distraction of the greater trochanter. Preoperative passive hip motion was retrospectively reviewed from medical records and defined as either higher or lower motion groups. Results. The preoperative flexion of patients without iliofemoral osteoarthritis was significantly higher than for patients with iliofemoral osteoarthritis. All hips without iliofemoral OA had higher motion. The preoperative flexion in the higher motion group both with and without iliofemoral OA was significantly greater than in the lower group with iliofemoral OA (Figure 1). Leg length change in patients without iliofemoral osteoarthritis was significantly greater than with iliofemoral osteoarthritis (Figure 2), and the higher hip motion group had greater leg length change in THA than the lower motion group. No clinical evidence of postoperative neurologic injury was observed in patients with iliofemoral OA. Postoperative transient calf numbness in the distribution of the sciatic nerve was observed in 2 of 25 hips without iliofemoral OA (8.0%), however, no sensory and motor nerve deficit was observed. Discussion. The authors hypothesized that preoperative hip motion could affect soft tissue contractures, and our findings suggest that the soft tissues surrounding the hip joint with iliofemoral OA should be more contracted than the hip without OA. We also found leg length change in the higher motion group was greater than in the lower motion group. Previous studies reported limb lengthening in excess of 4 cm could increase the risk of nerve palsy. Transient calf numbness in the distribution of the sciatic nerve was observed in 2 hips without iliofemoral OA and their leg length change was not greater than 4 cm. Our findings suggest that hips without iliofemoral OA should be paid attention to protect the nerves from excessive elongation. The current study identifies several features that might help predict leg length change during the preoperative planning of total hip arthroplasty for Crowe type IV developmental hip dysplasia

Background:. Closed femoral shortening (CFS) is a recognised procedure for managing leg length discrepancy (LLD). Method:. We report twenty-nine consecutive patients with LLD who underwent CFS using an intramedullary saw and nail. Mean age was 29.2 years (16.1–65.8). The primary outcome was accuracy of correction. Secondary outcomes were complications, union, ASAMI score and re-operation, alongside Patient Reported Outcome Measures (PROMs), using EQ5D-5L and GROC. Results:. Mean pre-operative limb length discrepancy was 3.4 cm (1.5–6.5). Mean planned and achieved shortening was 2.9 cm (1.7–5.0). Mean follow-up was 2.0 years (0.2–8.4). Minimal access surgery was possible in all cases but careful technique is essential. All patients achieved a correction within 5mm of the planned shortening (range 0–5mm). 28 patients (97%) achieved uncomplicated union. One patient had a non-union requiring exchange nailing and subsequent compression plating. 13 patients had nail removal at a mean of 1.7 years and 3 had locking screw removal. Patients had an overall positive experience with 81% reporting high PROM scores. Discussion:. This technique offered accurate limb length correction with few complications. Patients rehabilitated well with good functional outcomes. Conclusion;. CFS with an intramedullary saw is a well-tolerated and effective technique when managing LLD up to 5cm

Treating Crowe type 3 or 4 of hips tends to be technically difficult when performing total hip arthroplasty (THA) due to the severely dysplastic acetabulum and proximal femur in addition to a high dislocation of the hip. Since the socket is limited to being placed at the original hip center, a femoral shortening osteotomy is often required in order to prevent neurovascular problems. This osteotomy will need the stability of the femoral stem with both the proximal and the distal femoral bones. We used the modular S-ROM stem, which has a valuable proximal structure and a distal flute structure to stabilize the stem with the proximal and distal femoral fragments. The purpose of this study was to report the clinical and radiographic results of the primary THA with a shortening osteotomy while also using the S-ROM prosthesis. Between 1994 and 2004, primary THA using the S-ROM prosthesis was performed on 7 hips in 6 cases (1 male, 5 females). Crowe type 3 or 4 was observed in one and 6 hips, respectively. The mean age at operation was 56 years old (range 51~60). The mean follow-up period was 41 months (range 24~56 months). Four hips had previously undergone a subtrochanteric valgus osteotomy. All hips underwent a step-cut femoral osteotomy at the proximal metaphysis for the shortening and/or correction of angulations with on-lay chip bone grafts. All of the used stems were straight type. The clinical outcome was evaluated using the clinical scoring system of hip joints established by the Japanese Orthopaedic Association (JOA). According to a 100 point scale, pain was determined to be 40, ROM was 20, gait was 20 and ADL was 20. No hips had undergone any revision surgery as of the most recent follow-up. Union was achieved at the osteotomy site in all hips. Neither osteolysis nor a loosening of the implant was radiographically observed. The mean JOA score before THA and at the last follow-up was 41 (31–48) and 81 (62–91) points, respectively. The mean postoperative days to start full weight bearing was 53 days (range 49~70). In two cases (28%), a procedure using circular wiring was performed to treat a crack in the proximal femur. The S-ROM prosthesis was thus found to be useful for primary THA with a shortening metaphyseal femoral osteotomy for hips in patients with Crowe type 3 or 4 developmental dysplasia

Introduction

Limb Length discrepancy after total hip replacement has been reported to happen in 1–27% of cases with differences up to 70mm. Occasionally revision THR has been used to achieve limb length equalisation, especially when patients are symptomatic with hip/back pain, neurologic symptoms or instability. However, in presence of a well-functioning, pain free hip without hip symptoms, revision THR for shortening can lead to problems with decrease in offset or stability. An option in these cases would be a distal shortening osteotomy of femur.

Hip dysplasia in cerebral palsy (CP) poses technical challenges because of the need to produce large corrections in the face of soft tissue contractures, and extreme distortion of the femur and acetabulum. In addition to adductor and flexor lengthenings, bony surgery may be required in the older child. We have developed an inter-trochanteric shortening osteotomy which allows a major varus realignment without resulting in an adducted leg. Medial displacement of the lower femoral shaft is carried out. The osteotomy is fixed using a Richards Intermediate Hip Screw, whose lag screw and barrel are inserted into the upper face of the osteotomy (not through the lateral cortex as in the standard technique). The plate is attached to the femur below in the normal way. The plate is not prominent laterally because of the medial displacement.

We have performed 37 such osteotomies in 29 patients.19 were male, 18 were female. Age range 3–12 years, mean 8 years. Mean time since operation 5.8 years. Additional procedures were carried out in 16 patients. The mean neck shaft angle pre-operatively was 159 degrees, post-operatively it was 118 degrees. The mean change was 41 degrees. The mean migration percentage pre-operatively was 56.8%, post-operatively it was 15.7%. The mean change was 41.1%. We found the technique to be easier, more stable, and obtained better correction screw did not seem to be a problem, we think because the osteotomy is above the than conventional femoral osteotomy. Rotation of the upper segment around the psoas attachment, and psoas is released.

Introduction. The anatomic abnormalities are observed in developmental dysplasia of the hip (DDH) and it is challenging to perform the total hip arthroplasty (THA) for some DDH patients. If acetabular cup was placed at the original acetabular position in patients with high hip dislocation, it may be difficult to perform reduction of hip prosthesis because of soft tissue contracture. The procedures resolving this problem were to use femoral shortening osteotomy, or to place the acetabular cup at a higher cup position than the original hip center. Femoral shortening osteotomy has some concerns about its complicated procedure, time consuming, and risk of non-union. Conversely, implantation of the acetabular cup at the higher cup position may eliminate these shortcomings and this procedure is considered to be preferred if possible. However, the criteria of cases without femoral shortening osteotomy are not clear. In this study, we retrospectively analysed the clinical outcomes of patients performed THAs for high hip dislocation, and clarified the adaptation of THA with or without femoral shortening osteotomy. Methods. We included a total of 65 hip joints from 57 patients who underwent primary THA using Modulus stem for high hip dislocation from November 2007 to December 2015 at our institution. The mean follow up period was 5.2 years (2 – 10 years). The mean age at surgery was 65.4 years (Table 1). Thirty seven hips were classified as Crowe III, and twenty eight hips as Crowe IV based on Crowe classification. We classified patients into two groups based on the use of femoral osteotomy. Then, we compared the surgical time, blood loss, Japanese Orthopaedic Association (JOA) Score as clinical outcomes, preoperative position of the greater trochanter, the cup position, and complications between two groups. The position of the greater trochanter was measured the height of the tip of greater trochanter from the inter teardrop line. The cup center position was assessed by measuring the distance between the cup center and ipsilateral tear drop. Receiver operating characteristic (ROC) curves were plotted for deciding the cut-off value for the height of the greater trochanter. The cut-off value presented the maximum sensitivity and specificity was determined. Results and Discussion. Fifty three THAs were operated without femoral shortening osteotomy, and twelve THAs were performed with femoral shortening osteotomy. The surgical time was significantly longer in the osteotomy group than the non-osteotomy group. The mean height of the tip of the greater trochanter were 53.2±11.4mm in the non-osteotomy group and 92.2±19.7 mm in the osteotomy group (Table 2). The cut-off value of the height of greater trochanter evaluated from the ROC curve analysis was 69.5mm (Fig.1). There were no significant differences in clinical score between two groups. More ratio of revisions and fractures were observed in the osteotomy group with significant differences. Conclusion. There were significant differences in postoperative complications in osteotomy group compare to non-osteotomy group. In cases with a greater trochanter tip height of 69.5 mm or less, it may be considered to avoid femoral shortening osteotomy

Unrecognised DDH may present late in older children. The problems lie in reducing the femoral head into the acetabulum, obtaining concentric reduction and obtaining a functional hip. The aim of this paper is to describe our early results with operative reduction, femoral shortening and derotation in older children with DDH. Ten hips in 9 girls, aged 3–9 years, with DDH, seen over a 10 year period, underwent operative treatment. Pre-operative traction was not used. The femoral head was exposed through an anterior oblique incision, and femoral shortening and varus derotation osteotomy was performed through a separate lateral approach. The hip was fixed with a plate (6 cases) and cross K wires (4 cases) and immobilized in a spica cast for 6 weeks. A neck shaft angle of 90. 0. –130. 0. was obtained. The osteotomies healed in all hips. Minor skin problems were pin tract sepsis and pressure effects from the cast in 2 patients. Follow up ranged from 6 months to 5 years. Functional and radiological assessment was done to assess the outcome. Pain with avascular necrosis occurred in one patient and another had subluxation of the hip. The CE angle ranged from 0. 0. –30. 0. , neck shaft angle 90. 0. –130. 0. , leg length discrepancy from 1cm 2.5cm. The results were good in 6, satisfactory in 2 and poor in 2 children. Remodeling of the neck shaft and acetabulum was seen in the majority. Although the follow up period is short, the results of open reduction and femoral shortening in late DDH is encouraging. The author concludes that the combination of open reduction, femoral shortening and varus derotation osteotomy gave good to satisfactory results in the majority of patients

Purpose. Crowe IV complete dislocated hips were thought to be difficult for primary THA. Correction for leg length discrepancy associated with nerve palsy or tough to reduction during surgery. Purpose of this study was to evaluate 3.5cm total leg length correction for any type of Crowe IV patients setting in anatomical positioning of acetabular cup with femoral shortening osteotomy. Materials & Methods. 24 hips were evaluated averaged 28 months after primary THA. Correction length of center of rotation, amount of femoral shortening, Harris hip score, and abductor muscle power recovery with MicroFet 2 caluculator. Bilateral cases were preformed with 6 months interval. Length of femur and tibia compared to contralateral normal side were evaluated from plain radiograms. Results. Average LLD before surgery was 7.3 (5 to 8.5) cm, but recovered within 3.5 cm (0.8 to 2.9) after surgery. One cm longer of femur in 9 patients, one cm longer of tibia in 12 patients, and 1cm longer both of femur and tibia in 5 patients compared to contralateral side before surgery. Average OR time was 92 minutes. All patients were women averaged age was 60 (34 to 75). Harris hip score improved from 45 to 92 before and latest follow-up. All patients did not need t-cane 2 years after surgery. Center of rotation was averaged 6.8 (5.2 to 8.1) cm reducted to anatomical position. Femoral shortening averaged 3.3 (1.7 to 4.5) cm, so total correction was 3.5cm (3.1–4.2). No nerve palsy and had good muscle recovery without T-cane. Patients with normal contra lateral side had averaged 2 cm (1.5∼3) heel up orthosis after surgery, but had no complaint about heel up situation in activity of daily living. Discussion & Conclusion. Amount of correction with leg length discrepancy during THA had controvertial issues especially in cases of completed dislocated hip joint. Several authors demonstrated that muscle-evoked potentials elicited by brain electric stimulation monitoring, but problems was occurred during epidural or spinal anesthesia. Averaged 3.5cm Total correction of leg length was very safe and satisfactory results for all Crowe IV patients

Introduction. The project of a modular, double-conicity stem is born from the need to obtain primary stability and correct osseointegration in patients with developmental hip dysplasia, or proximal femoral dysmorphisms requiring a femoral shortening osteotomy or presenting characteristics of non-adaptability to single-conicity or straight stems. Such an implant could also be employed in femoral nail failures, or lateral femoral neck fractures requiring prosthetic substitution. Aim of the study. To assess implantability of the new double-conicity stem in cadaver femurs, determining “fit and fill” and the behaviour of femoral cortical bone by means of Rx, CT and pre- and post-implantation mechanical testing. Methods. Seven double-conicity stems with anti-rotation fins were implanted in cadaver femurs of various sizes. All femurs underwent pre- and post-implantation radiological assessment for evaluation of fit and fill at the 2 levels corresponding to the 2 conicities, fins penetration, possible microfractures and stem positioning. Prior to implantation, templating was carried out to define the correct size of the stem to be implanted. Modular necks with cervico-diaphyseal angle of 125° or 135° (short or long) were implanted, to preserve the correct rotation center and femoral offset. In 2 femurs, mechanical testing was performed before and after implantation, in order to assess, by means of strain gauges, the variation of the tensional state of cortical bone under dynamic loading (gait cycle simulation). In 2 femurs, 3 cm chevron shortening osteotomies were performed and stabilized with the stem alone. Results. Implanted stems respected pre-operative planning. In the 2 cases in which shortening osteotomies were performed, the stem allowed for good meta-diaphyseal stability without the employment of fixation devices. Radiographic assessment evidenced a valid “fit and fill”. In 4 cases the stem was correctly aligned; in 2 cases it was positioned in 1° varus and in 1 case in 1° valgus. In the 2 osteotomy cases, penetration of the fins was good at the proximal level and slight distally. In the remaining 4 cases penetration at both levels ranged from slight to good. No microfractures, either intraoperative or following stress testing, were evidenced. Mechanical tests showed that stem implantation reduced deformation of the femoral cortical bone undergoing cyclic loading, in comparison with the pre-implantation situation. Conclusions. The double-conicity prosthetic stem showed good implantability, with the capacity to allow for stability in case of femoral shortening osteotomies without the use of plates or cerclage fixation. Mechanical testing also showed a correct load distribution, and a reduction of stress on femoral cortical bone in comparison with the state before implantation. Prospective clinical studies are necessary to assess efficacy and dependability from a clinical and radiographic viewpoint

Background. There are many difficulties during performing total hip replacement in high riding DDH. These difficulties include:. In Acetabular part: bony defect in antero lateral acetabular wall/finding true centre of rotation/shallowness of true acetabulum/hypertrophied and thick capsular obstacle between true and false acetabulum. In Femoral part: small diameter femoral shaft/excessive ante version/posterior placement of greater trochanter. anatomic changes in soft tissue & neurovascular around the hip including: adductor muscle contracture/shortening of abductor muscles/risk of sciatic nerve injury following lengthening of the limb after reduction in true acetabulum/vascular injury. The purpose of this lecture is how to manage above problems with using reinforcement ring (ARR) for reconstruction of true acetabulum and step cut L fashion proximal femoral neck shortening osteotomy in a single stage operation. Method. 23 surgeries in 19 patients, including 18 female and one male were performed by me from Jan. 1997 till Dec. 2009. Six patients had bilateral hip dislocation, but till now only four of them had bilateral stepped operation. Left hip was involved in 15 cases (65.2%). The average age was 40 years old. All hips were high riding DDH according to both hartofillokides and crowe classification. Reconstruction of true acetabulum was performed with aid of reinforcement ring and bone graft from femoral head in all cases. Trochantric osteotomy was done in all, followed by fixation with wire in 22 cases which needed two revisions due to symptomatic non union (9%). Hooked plate was use in one case for trochantric fixation. Due to high riding femur, it was necessary to performed femoral shortening in neck area as a step cut L fashion. In two patient, one with bilateral involvement, after excessive limb lengthening following trial reduction, it was necessary to performed concomitant supracondylar femoral shortening. (3 cases = 13%). 22 mm cup & miniature muller DDH stem were used in 18 cases (78.26%). In 5 cases, one bilaterally, non cemented stem and 28 mm cemented cup in ring were used. Primary adductor tenotomy was performed in 9 cases. Secondary adductor tenotomy needed in 2 cases (totally = 47.82%). Repair of iatrogenic femoral artery tear after traction injury with retractor, occurred in 2 cases (8.69%). All patients evaluate retrospectively. Average follow up month is 68.7. Results. One case of left acetabular component revision due to painful bony absorption in infero medial part of ring with poor inclination wad done, after 2 years of primary operation. Know after 13 years she has had early signs of stem loosening in the same side. Another acetabular component revision following traumatic dislodgment of cup and cement from ring was performed after 13 months from primary operation. Again she had poor implant inclination. So revision rate is 8.69%. (One case will need revision in near future, so the revision rate will increase to 13%) Radiological wires breakage which were used for greater trochanteric fixation, could be seen in 11 cases (47.82%), but only two of them with functional impairment needed to re-fixation with Menen plate(18.18% of trochanteric non union). Average limb lengthening after operation is 4.3 Cm (2-7 Cm). Only one case of transient Sciatic nerve paresis had happened for 2 months followed by complete recovery. Two case of secondary adductor tenotomy wre done, one after traumatic dislocation of prosthesis with pubic fracture, and the other one after restriction of hip abduction. The average Harris hip score from 23 pre -operatively has been increase to 85.38. (The pre op. scores were 12.625 – 40.775/The post op. scores were 64.92 – 96). No post operative infection was seen. Discussion. This is a midterm follow up survey, but 7 cases have more than 9 years follow up with only one stem loosening (11% long term loosening rate). It is a challenging procedure for performing joint replacement in high riding DDH, if so using reinforcement ring with graft for true acetabulum reconstruction and getting primary proximal femoral shortening in a step cut L fashion around the lesser trochanteric region would be a worthy procedure. In high riding DDH due to hypoplasia of lesser trochanter, there is not a significant difference in bone resistance and it is possible to get shortening in this area without fearing of deco promising bony stability. The average shortening is 3 Cm. In specific cases with more severe contracture for preventing neuro-vascular complication, concomitant shortening osteotomy in supracondylar area is recommended. Although greater trochanter fibrous union has produced less functional impairment, but a better technique should be considered. Distal and lateral advancement of osteotomised greater trochanter lead to better abductor muscle performance and less limp. Adductor tenotmy has a great importance in contracted soft tissue, so in any case with abduction limitation it should be performed

Purpose of the study: Generally, hip prosthesis implantation for congenital hip dysplasia is a routine procedure. Material and methods: We compared preliminary results between two surgical techniques. On one hand, hip prostheses were implanted via trochanterotomy with femoral shortening osteotomy for cemented insertion and trochanteroplasty. On the other, access was achieved via a triple infratrochanteric osteotomy for shortening, correction of valgum and derotation followed by implantation of a press-fit prosthesis without osteosynthesis. Results:. Between 1993 and 2001, 61 patients underwent surgery for Crowe III or Eftekhar grade C hips (n=45) and Crowe IV or Eftekhar grade D hips (n=16). Mean patient age was 42 years. Prostheses inserted via the trans-trochanteric approach with femoral shortening osteotomy and cementing developed complications related to the trochanteroplasty: nonunion of the greater trochanter (n=6), functional impairment (n=2), infection after bursitis on suture and secondary necrosis (n=1). Because of these complications we adopted the triple femoral osteotomy technique for shortening, derotation and press-fit femoral implants. Between 2001 and 2005, eight Eftekhar D hips were treated with this technique. Locked non-cemented femoral prostheses were inserted. Pre- and postoperative clinical assessment was based on the Postel-Merle-d’Aubigné score. For the cup, the technique remained unchanged, with cemented implants. The lengthening obtaine varied from 3.5 to 5.5 cm with no cases of sciatic palsy. There has been no case of prosthesis dislocation. Conclusion: These preliminary results concern non-cemented femoral prosthesis with insufficient follow-up. We nevertheless have found this an attractive technique free of femoral complications

Introduction: Angular and torsional deviations of femur are usually combined with Congenital Dislocation of the Hip (CDH) and increase the complications of hip arthroplasty. The aim of this study is to evaluate surgical and reconstructive options for the treatment of CDH. Material and Methods: In this retrospective study, we evaluated the results and complications of 55 primary cementless total hip arthroplasties, all of whom had Crowe type-IV developmental dysplasia of the hip. The arthroplasty was performed in combination with a subtrochanteric shortening osteotomy and with placement of the acetabular component at the level of the anatomic hip center. The patients were evaluated at a mean of 8,1 years postoperatively. Results: From 1984, more than 2000 cases of arthroplasty have been performed in dysplastic hip, 565 cases had a previous femoral osteotomy; 128 cases needed correction of femoral side deformity; 64 had a greater trochanteric osteotomy. In 9 cases rotational abnormality and shortening were controlled with plate and distal femur osteotomy. 55 cases were treated by a shortening subtrochanteric osteotomy. Only non-cemented stems were used. 4 failures occurred for the incorrect fixation of the metaphysis. The fixation can be obtained only by prosthetic press-fit, but it is preferable to use metal wires. There was no sciatic injury; indeed shortening osteotomy provides an easy control of deformity and lengthening, with a maximum of 4 cm. One case was reviewed for heterotopic calcification (grade 4). One infection of the soft tissue was medically cured. There were two revisions for polyethylene failure at 8 and 12 years postoperative. Discussion: The anatomic abnormalities associated with CDH and previous femoral osteotomy increase the complexity of hip arthroplasty. We had best results with the femoral shortening subtrochanteric osteotomy where a rapid consolidation was obtained. Moreover, the functional result was better for the management of the insertion of the muscle tendons in particular the mediogluteus and also for the relatively correct positioning in favour of the reciprocal relationship of the pelvic-trochanter. The detachment of the greater trochanter associated with a metaphyseal proximal shortening, remains an effective technique for the treatment of malformations that are difficult to treat, but there is a high risk of pseudarthrosis of greater trochanter. Conclusion: Femoral shortening subtrochanteric osteotomy preserves the proximal femoral anatomy, avoids the problems associated with reattachment of the greater trochanter, and facilitating a cementless femoral reconstruction in relatively young patients

Background. Subtrochanteric femoral shortening and corrective osteotomy are considered to be an integral part of total hip arthroplasty for a completely dislocated hip or severe deformity of the proximal femur. A number of alternative femoral osteotomy techniques, transverse, oblique, step-cut, and V-shaped, have been described. Becker and Gustilo reported the “double-chevron subtrochanteric shortening derotational femoral osteotomy,” which is reasonable in that the osteotomy site is torsionally more stable and can be stabilized with a shorter stem. We have simplified this procedure, and performed it without a trochanteric osteotomy. We describe a simplified double-chevron osteotomy and provide the clinical results from a series of 22 successful procedures. Methods. In this series, we performed 22 cementless total hip arthroplasties combined with double-chevron subtrochanteric osteotomies between 1997 and 2002. There were 17 females and 2 males. Their average age at the time of the operation was 59 years old (range, 41–74 years old). Thirteen of these hips were congenitally dislocated hips (Crowe IV), and 8 hips were after proximal femoral osteotomies using a procedure described by Schanz or valgus osteotomy, and 1 hip was an ankylosed hip in malposition. Results. The mean length of the operation was 128 minutes (range, 80–215 minutes). The mean total blood loss was 1442 g (range, 809–2007 g), which included both the intraoperative blood loss and postoperative blood loss. After an average of 7.6 years of follow-up, the Japanese Orthopaedic Association Hip Score improved from 48 to 79. The mean amount of intraoperative femoral resection was 29 mm (range, 10–45 mm). The postoperative highest point of the greater trochanter was lowered by a mean of 50 mm (range, 6–74 mm) compared with its preoperative point on the radiograph. The calculated measurement (lowered greater trochanter minus intraoperative femoral resection) of leg lengthening was a mean 21 mm (range, −4–51 mm). Two acetabular component migrated, and one case required revision surgery. The other components showed no evidence of migration or loosening. There were radiolucent lines of less than 2 mm thickness in zones 1, 2, and 3 in one acetabular as previously mentioned revision case. One femoral component had subsidence 3 mm. Four femoral components had radiolucencies. One osteotomy site failed union and was varus deformity. After 6 years after the operation, the case required revision using cementless long stem. All femoral components achieved fixation with an optimal interface at the latest follow-up. Three types of complications were observed. There were no cases of neurologic abnormality, infection. There were 4 early dislocations, 3 proximal splits, and 1 nonunion at the osteotomy site. All femoral fragment fractures during the operation and all dislocations after the operation were in the Crowe IV group. Conclusions. Our study shows that double-chevron subtrochanteric osteotomy provided acceptable results for subtrochanteric femoral shortening and corrective osteotomy. The operation procedure is simple and the operation time is much shorter. However, THA combined with subtrochanteric osteotomy is a technically demanding treatment option