Total Hip Arthroplasty for DDH (Crowe type III and IV) Dept. Orthopaedic Surgery Kyoto City...
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Transcript of Total Hip Arthroplasty for DDH (Crowe type III and IV) Dept. Orthopaedic Surgery Kyoto City...
Total Hip Arthroplasty for DDH (Crowe type III and IV)
Dept. Orthopaedic SurgeryKyoto City Hospital, Kyoto, Japan
Chiaki TANAKA, Minoru IKENAGA, Hiroshi KANOE, Makoto SHIMIZU, Koujirou TANAKA
A 5- to 12-year follow-up study : Japanese experience
Purpose
After my study in Cochin Hospital, I began to operate on the DDH patients in Japan.
Especially, THA for DDH (Crowe type III and IV) patients is a technically demanding operation.
We report our 5- to 12- year clinical results and technical problems in THA for difficult DDH patients.
Case K.K. 62yr-old F : 134.5 cm 54.3 kg Crowe IV
88/10/22
88/11/10
89/3/8
93/2/2
The most difficult case in my experience
Case K.K. 62yr-old F : Crowe IV
93/12/24
94/1/14
94/9/29
95/4/6
Case K.K. 62yr-old F : Crowe IV
95/4/6 04/10/08 9yr 5mo
PATIENTS - 1
32 hips (27 women, 1 man)
Average age at operation 58.5 y.o. ( 44-78 )
Follow-up period 8 yr. 3 mo. ( 5-12 y )
Body weight 49.3 kg ( 35.7 – 67.0 )
Height 148.5cm ( 134.5 – 167.2)
PATIENTS - 2
Crowe type III 14 IV 18
Previous Operations none 25
femoral osteotomy 7
pelvic osteotomy 1
RECONSTRUCTIVE METHOD-1
Lateral transtrochanteric approach 32
Total capsulectomy 32
Muscle release 0
Bone grafting acetabular 32 femoral 1
THA device Charnley LFA 8 Kyocera PHS 19 CMK 5 32
RECONSTRUNTIVE METHOD-2
Cup diameter 37 1 38 6 38.5 3 40 15 42 2 44 3 46 2
Fixation of greater trochanter
Ortron wire 27Dall-Miles Cable Grip 3Titanium wire 2
Clinical and Radiographical Evaluation
Japanese Orthopaedic Association (JOA) Hip Score System Pain 40, ROM 20, Walking ability 20, ADL 20 Radiolucency : DeLee – Charnley zoneMigration > 3mm or > 3degreesPosition of hip center : distance from teardropBone graft coverage : % of the cupBone grafts : union, resorption, collapse
RESULTSRevision : (acetabular loosening) 1Reoperation : trochanter reattach 1 abductor advancement 1 32 Complications Dislocation 0 Trochanteric nonunion 4 Infection 0 Nerve palsy 0 32
JOA Hip Score
Preop Last FU
Pain 16.7 39.1
ROM 9.7 16.1
Walk 5.0 12.1
ADL 8.5 14.6
Total 39.8 81.9
Radiographic Evaluation - 1
Migration (Cup) 1 (Rev)Radiolucency Acetabular none 25 partial 6 (osteolysis 1) 32 Acetab. Loosening 1 / 32 ( 6.3%)
PE Wear 2mm< 1
Radiographic Evaluation - 2
Stem sinking 0
Radiolucency partial 1
Osteolysis severe 2 mild 2
Radiographic Evaluation - 3
Rotational hip center horizontal distance av. 29.7mm vertical distance av. 22.4mm
Bone graft coverage B / A av. 38% ( 24 ~ 54 ) 50%< 5 hips
collapse 1 hip (Rev. at 18 mo)
AB
Survivorship
Endpoint : Revision 10 years
Acetabular component 96.9%
Femoral component 100%
THA for DDHMackenzie JR 1996 59 hips (II:22,III:18,IV:19) Surv(Rev) 85% at 15y Surv(Rad.loose) 68%Numair J 1997 46 hips (IV) Surv(Rev) 68% at 15y
Shinar AA 1977 70 hips Rev 36% Rev+Rad loose 60% at 16.5y
Bobak P 2000 45 hips (I:4,II:17,III:13,IV:11) Rev 0% Rad loose 12% at 11y (10-15) Kerboull M 2001 118 hips (IV) Surv 78% at 20 y
Kobayashi S 2003 37 hips (II:16,III:17,IV:4) Rev 0% Rad Loose 0% at 19 y (10-26)Hartofilakidis G 2004 84 hips (high disl) Surv(Rev) 76.4% at 15 y
Case K.K. 60yr-old F : Crowe III
Pre-op 2mo 10yr 12.5yr JOA score 83 p. Wear < 2mm Osteolysis
Case M.K. 50yr-old F : Crowe IV
Pre-op 1 mo 11 yrs
JOA score 92 p.
Case S.I. 55yr-old F : Crowe IV
Pre-op 2mo 8mo 9mo 12yr JOA s. 78 p.Nonunion Gr.Tr.
Titanium wireNonunion of Gr.Tr.
Troch. Rev.
Case T.H. 78yr-old F : Crowe III
Preop 2 mo 7 yr 9 moJOA score 94 p.
Case Y.S. 80yr-old F : Crowe IV
Pre-op 2 mo 6 yr 3 mo
JOA score 76 p.
Case M.I. 53yr-old F : Crowe IV
Preop 9 y 10 mo 9 y 5 moJOA score 81 p.
Case F.M. 57yr-old F : Crowe III
Preop
3w
Advancem.1w
8yr8mo
Abduction contracture 25 deg. Trendelenbourg (-)JOA score 74 p.
Problems and my solutions1) Acetabulum Small and shallow acet. thin walls CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft
Case K.K. 62yr-old F : Crowe IV Small Acetabulum
True acetabulum is the best position !!
40 mm
Though the true acetabulum is the best position, the AP diameter is small.
Problems and my solutions1) Acetabulum Small and shallow acet. thin walls CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide ‘Asagao’ Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft
Morning Glory : ‘Asagao’
Joint capsule : the best guide to obturator foramen
It looks like a Morning Glory :‘Asagao’ in japanese
Greater TrochFemurExternal obturator
Problems and my solutions1) Acetabulum Small and shallow acet. thin walls CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft
Case K.K. 62yr-old F : Crowe IV Post. Wall Deficiency
40mm
Problems and my solutions1) Acetabulum Small and shallow acet. thin walls CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘Column Horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft
Case M.K. 50yr-old F : Crowe IV 3D-CT Image
Preservation of ant. and post. ‘Column Horn’
Problems and my solutions1) Acetabulum Small and shallow acet. thin walls CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft
Bone Graft : Shaping Method
* *
Problems and my solutions1) Acetabulum Small and shallow acet. thin walls CT scan is useful Difficult exposure of the true acetabulum Joint capsule is the excellent guide Bone grafting Deficient superior and posterior wall Preservation of ant. and post. ‘column horn’ Small and atrophic femoral head graft shaping method option: harvesting the cortical bone by shortening the femoral shaft
Case T.I. 60yr-old F : Crowe IV Extra-series
2) Femoral side Narrow canal, strong anteversion straight stem Respect the greater trochanteric bone bed when the femoral neck is cut stem design is very important !! Subtrochanteric shortening osteotomy is a useful technique when the reduction seems very difficult or when the femoral neck needs to be cut too much or in previously osteotomized cases
Problems and my solutions
Preservation of Trochanter Bed
Kyocera PHS CMK
*
2) Femoral side Narrow canal, strong anteversion straight stem Respect the greater trochanteric bone bed when the femoral neck is cut stem design is very important !! Subtrochanteric shortening osteotomy is a useful technique when the reduction seems very difficult or when the femoral neck needs to be cut too much or in previously osteotomized cases
Problems and my solutions
Case T.S. 70yr-old F : Crowe IV Case S.K. 56yr-old F : Crowe IVExtra-series
3) Limb lengthening If the range of motion is good, lengthening is easy. If not, removal of the scar tissue is necessary. Principles of Prof. Kerboull Respect the periarticular muscles as possible. The best method to avoid nerve palsy !! Reduction mild flexion and adduction of the hip with mild flexion of the knee pushing the stem head directly into the cup Never pull the limb !!
Problems and my solutions
4) Trochanter fixation In severely contracted hips, lowering the greater trochanter is difficult. Detachment of gluteal muscle origin upwards from ilium Option : advancement of gluteal muscles through the iliac rest incision Fixation with stainless monofilament wires Attention to titanium wires and Dall-Miles cables !!
Problems and my solutions
Lowering of Greator Trochanter
M. Kerboull EMC R.C. Kingsley JBJS
Detachment upwards from ilium Advancement
4) Trochanter fixation In severely contracted hips, lowering the greater trochanter is difficult. Detachment of gluteal muscle origin from ilium upward direction from inside Option : advancement of gluteal muscles through the iliac rest incision Fixation with stainless monofilament wires Attention to titanium wires and Dall-Miles cables !!
Problems and my solutions
Fixation of Greator Trochanter
Titanium wire Dall-Miles Cable Grip
Attention to Titanium wires and Dall-Miles Cables
Conclusions
THA for DDH (Crowe type III and IV) patients is a technically demanding operation.
5- to 12- year clinical results of our series were satisfactory.
Main techinical problems are reconstruction of very small dysplastic acetabuli and solid fixation of greater trochanter.