Surgical Treatment of Developmental Dysplasia of the

Hip in Adults: II. Arthroplasty Options

Joaquin Sanchez-Sotelo, MD, Daniel J. Berry, MD,

Robert T. Trousdale, MD, and Miguel E. Cabanela, MD

Abstract

Total hip arthroplasty is the procedure of choice for most patients with sympto- as comparison of results using dif-
matic end-stage coxarthrosis secondary to hip dysplasia. The anatomic abnormal- ferent treatments.
ities associated with the dysplastic hip increase the complexity of hip arthroplasty. The classification of Crowe et al2
When pelvic bone stock allows, it is desirable to reconstruct the socket at or near is widely accepted as a method to
the normal anatomic acetabular location. To obtain sufficient bony coverage of categorize the degree of dysplasia.
the acetabular component, the socket can be medialized or elevated, or a lateral The authors divided dysplastic hips
bone graft can be applied. Uncemented acetabular components allow biologic fix- radiographically into four cate-
ation with potentially improved results compared with cemented cups, especially gories based on the extent of proxi-
in young patients. The location of the acetabular reconstruction and the desired mal migration of the femoral head.
leg length influence the type of femoral reconstruction. Cemented and uncemented The migration is calculated on an
implants can be used in femoral reconstruction, depending on the clinical situa- anteroposterior radiograph of the
tion. Femoral shortening is required in some cases and can be performed by meta- pelvis by measuring the vertical dis-
physeal resection with a greater trochanteric osteotomy and advancement or by a tance between the inter-teardrop
shortening subtrochanteric osteotomy. The results of total hip arthroplasty line and the junction between the
demonstrate a high rate of pain relief and functional improvement. The long-term femoral head and medial edge of
durability of cemented total hip arthroplasty reconstruction in these patients is the neck (Fig. 1). The amount of
inferior to that in the general population. The results of uncemented implants are subluxation is the ratio between this
promising, but only limited early and midterm data are available. distance and the vertical diameter
J Am Acad Orthop Surg 2002;10:334-344 of the undeformed femoral head.

Dr. Sanchez-Sotelo is Special Fellow, Adult

In spite of the availability of several
nonarthroplasty alternatives, many
patients with hip dysplasia require
hip replacement surgery. Total hip
arthroplasty has a higher failure
rate for patients with dysplasia
than for the general population.
This is probably because of the
anatomic abnormalities of hip dys-
plasia and the younger mean age of
patients with this diagnosis who
require arthroplasty.1
The surgical planning of hip
reconstruction in dysplastic hips is
based on each individual’s anatomic
abnormalities (Table 1). The acetab-
ulum usually is deficient anteriorly,
laterally, and superiorly; the femur
commonly has excessive antever-
sion and a valgus neck-shaft angle;
and the leg frequently is shortened.
The location of the placement of the
acetabular component defines the
new center of hip rotation, which in
turn influences leg length, the need
for femoral shortening procedures,
and the optimal type of femoral
reconstruction.
Classification
Dysplastic hips can be characterized
by the severity of anatomic abnor-
malities. Classification systems are
useful for patient assessment as well
Reconstruction, Department of Orthopaedic
Surgery, Mayo Clinic, Rochester, MN. Dr.
Berry is Consultant, Department of Orthopae-
dic Surgery, Mayo Clinic, and Associate
Professor, Department of Orthopaedic Surgery,
Mayo Medical School. Dr. Trousdale is
Consultant, Department of Orthopaedic Sur-
gery, Mayo Clinic, and Associate Professor,
Department of Orthopaedic Surgery, Mayo
Medical School. Dr. Cabanela is Consultant,
Department of Orthopaedic Surgery, Mayo
Clinic, and Professor, Department of Orthopae-
dic Surgery, Mayo Medical School.
Reprint requests: Dr. Berry, 200 First Street
SW, Rochester, MN 55905.
Copyright 2002 by the American Academy of
Orthopaedic Surgeons.

334 Journal of the American Academy of Orthopaedic Surgeons


Table 1
Reconstruction Options Based on Severity of Hip Dysplasia*
Crowe Type2 Acetabulum
I Uncemented component
in true acetabular region
with slight medialization
II or III Uncemented component
at or near true acetabular
region, if necessary with
autograft augmentation;
or high hip center; or
medialization
IV Extra-small uncemented
acetabular component in
true acetabular region
* Anatomic variations and previous surgery may require changes in surgical technique.
Thus, if the distance between the
head-neck junction and the teardrop
is half the vertical diameter of the
femoral head, the hip is subluxated
50%. When the femoral head is
deformed, the predicted vertical
diameter of the femoral head was
found to be 20% of the height of the
pelvis as measured from the highest
point on the iliac crest to the inferior
margin of the ischial tuberosity.
Type I represents proximal migra-
tion of the head-neck junction from
the inter-teardrop line of <50% of
the vertical diameter of the femoral
head (<10% of the vertical height of
the pelvis) (Fig. 2). Type II repre-
sents proximal migration of 50% to
75% of the femoral head diameter
(10% to 15% of the pelvic height).
Type III has 75% to 100% proximal
migration (15% to 20% of the pelvic
height). Type IV has >100% proxi-
mal migration (>20% of the pelvic
height). Other classification systems
also are used, including that of
Hartofilakidis et al,3 which divides
congenital hip disease in adults into
three categories: dysplasia, low dis-
location, and high dislocation.
Vol 10, No 5, September/October 2002
Femur
Cemented or uncemented stem
based on patient age, bone
quality, and bone geometry
Cemented or uncemented stem
based on patient age and
bone geometry
Greater trochanteric osteotomy
with sequential proximal shortening
and cemented “DDH stem,” or
shortening subtrochanteric osteotomy
and uncemented stem
Proximal migration of the fem-
oral head can be accompanied by
soft-tissue changes. The abductor
muscles may become oriented more
transversely and therefore function
less efficiently. There is capsular
Pelvic vertical height
Head-neck
junction
Inter-teardrop line
Figure 1 Radiographic references used to determine the severity of hip dysplasia accord-
ing to the system of Crowe et al.2 (By permission of Mayo Foundation.)
Joaquin Sanchez-Sotelo, MD, et al
Approach
Anterolateral or posterolateral
based on surgeon preference
Anterolateral, posterolateral,
transtrochanteric, or
subtrochanteric approach based
on reconstructive technique and
need for femoral shortening
Transtrochanteric or posterior
approach with shortening
subtrochanteric osteotomy
thickening, psoas tendon hypertro-
phy, and shortening of the ham-
string, adductor, and rectus femoris
muscles. The femoral nerve exits
the pelvis more laterally and superi-
orly, and the sciatic nerve becomes
Femoral head
diameter
Inferior margin
of the ischial
tuberosity
335
Surgical Treatment of Developmental Dysplasia of the Hip: II. Arthroplasty Options
A B
C D
Figure 2 Anteroposterior radiographs of hips showing degrees of dysplasia according to
the classification of Crowe et al.2 A, Type I. B, Type II. C, Type III. D, Type IV.
shortened over time and therefore is
vulnerable to injury if the limb is
lengthened more than 3 cm when
the hip is reconstructed.
Surgical Technique
Approach
Moderately dysplastic hips can
be reconstructed through a conven-
tional anterolateral or posterolateral
approach according to the prefer-
ence of the surgeon. Extensile expo-
sure of the acetabulum for certain
difficult reconstructions may re-
quire one of the variations of the
transtrochanteric approach. A variety
of techniques is available to prevent
trochanteric nonunion after a trans-
trochanteric approach. Depending
on the size and shape of the tro-
chanter, a flat or chevron osteotomy
may provide the best bony apposi-
336
tion and stability. Although cable
fixation may be used, wires allow a
stable trochanteric reattachment and
are less likely to produce local dis-
comfort or metallic debris. Pro-
tected weight-bearing, as well as
restriction of active abduction and
passive adduction, decreases tension
through the osteotomy site and may
facilitate union of the trochanteric
fragment. When femoral shortening
is needed, a transfemoral approach
via subtrochanteric osteotomy is a
consideration.
Acetabular Reconstruction
Choosing the optimal anatomic
level of acetabular reconstruction
represents a series of compromises.
The practical and biomechanical
advantages of hip reconstruction at
a normal anatomic location must be
balanced with the need to provide
sufficient acetabular implant cover-
Journal of the American Academy of Orthopaedic Surgeons
age. When possible, acetabular
reconstruction should seek normal-
ization of the hip center of rotation.4
Because of the anatomic abnormali-
ties, placement of standard-size
acetabular components in a dysplas-
tic acetabulum may leave part of the
component unsupported by native
bone. Lack of support increases the
stresses at the bone-implant (or
bone-cement) interface and thus the
probability of mechanical failure.
However, the minimum surface
area of component that needs to be
supported by native bone has not
been determined and may differ
depending on the type of fixation
used. When sufficient coverage of
the implant by native bone cannot
be achieved with standard acetabu-
lar implant placement, an alterna-
tive reconstructive technique should
be considered.
Acetabular reconstruction in
patients with hip dysplasia often
requires extra-small acetabular im-
plant sizes. As a consequence, small
femoral head sizes are needed to
preserve adequate polyethylene
thickness. Some of the very small
cemented acetabular components
have the cavity for the femoral head
placed eccentrically, thus providing
greater polyethylene thickness
superiorly in spite of the small exter-
nal diameter. These so-called offset-
bore components have been used
mainly in patients with hip dyspla-
sia. 5 With press-fit uncemented
sockets, poor bone quality or incom-
plete coverage of the socket by native
bone may necessitate the use of aug-
mented socket fixation with screws.
The Crowe classification method
(Figs. 1 and 2) provides a useful
means of subdividing dysplastic
hips by the level of hip subluxation.
Although there are many individual
variations, typical acetabular and
femoral deformities are present for
each level of hip subluxation and
dislocation. The suggested method
of reconstruction is directly related to
the type of bony deformity (Table 1).
 Joaquin Sanchez-Sotelo, MD, et al

Crowe Type I Hips

Mildly dysplastic hips typically
have a less pronounced acetabular
bony deformity and relatively good
bone quality. Most can be recon-
structed with a standard acetabular
component placed in the true ace-
tabular region. The component may
be safely medialized to the inner
acetabular wall to provide satisfac-
tory coverage of the implant.

Crowe Type II and III Hips

Subluxation of the femoral head
without complete dislocation usually
results in lateral acetabular bone de-
ficiency because of developmental
deficiency, with subsequent erosion
by the femoral head. This leaves
less bone to support a socket that is
placed in the normal position. Ace-
tabular deformities present in the
Crowe type II or III hip are the most
difficult to reconstruct, and their
management is the most controver-
sial subject in acetabular reconstruc-
tion for hip dysplasia. In some
cases, sufficient lateral coverage of
the socket can be obtained at or near
the normal anatomic position by
deepening the socket with reaming
to the medial wall (Fig. 3). When
this is not feasible, three alternative
methods of reconstruction can be
used: acetabular augmentation with
superior lateral bone grafting, re-
A B
Figure 3 A, Preoperative anteroposterior radiograph of Crow type II hip. B, Acetabular
reconstruction with medialization of the component to but not through the medial wall of
the acetabulum.
construction of the acetabulum in a increase bone stock, which in turn
superior location (high hip center), may facilitate revision surgery 6,7
or medialization of the cup (Fig. 4). (Fig. 5) There are also disadvan-
Acetabular augmentation by tages: bone grafting increases the
structural grafting of the deficient technical complexity of the proce-
acetabulum in combination with dure, and when a large amount of
placement of the component in its the component is supported by graft,
anatomic position has some desir- there is a risk of long-term graft
able features. Autograft bone is resorption and collapse, leading to
available by using the patient’s own socket failure.8
femoral head; the hip center can be A second alternative is to place
restored to a biomechanically nor- the acetabular component superior
mal position; and bone grafting can to its true anatomic location, at a

A B C D

Figure 4 Three alternative methods to reconstruct (A) Crowe type II and III dysplastic acetabuli: B, augmentation with bone grafting,
C, high hip center, and D, medialization of the cup. (By permission of Mayo Foundation.)

Vol 10, No 5, September/October 2002 337

Surgical Treatment of Developmental Dysplasia of the Hip: II. Arthroplasty Options

Crowe Type IV Hips

When a high dislocation is pres-
ent, there is often quite good lateral
bone over a small hypoplastic native
hip socket because the femoral head,
which lies more superiorly, has not
eroded the bone near the anatomic
socket. In most cases, the acetabu-
lum can be reconstructed with an
extra-small acetabular component at
the anatomic hip center without
bone grafting. Several points of sur-
A B gical technique facilitate the recon-
struction. The acetabular rim can be
Figure 5 Preoperative (A) and postoperative (B) anteroposterior radiographs demonstrat-
ing reconstruction of the acetabulum with structural augmentation and an uncemented
overgrown by bone and may be
component in Crowe type III hips. opened with a burr. The acetabular
fovea and teardrop can be used as
internal landmarks during the ream-
ing process. Most socket coverage is
so-called high hip center9,10 (Fig. 6). tive forces through medialization of gained from the posterior column;
Placing the component superiorly the hip center of rotation. Its main special caution is required to avoid
allows the component to be covered disadvantages are the loss of medial overreaming the anterior and medial
more completely by native bone, bone stock—which may compro- walls. The bone usually is quite soft,
which facilitates biologic fixation mise future revision surgery—and and using the last reamers in a re-
and avoids the need for bone graft- the risk of early catastrophic acetab- verse mode preserves bone stock by
ing. In some cases, it also decreases ular component migration into the expanding the acetabulum and com-
the need for a concomitant shorten- pelvis. pacting rather than removing bone.
ing femoral osteotomy. A high hip
center also has disadvantages: it re-
quires very small acetabular compo-
nents with thin polyethylene, does
not increase acetabular bone stock,
affords a limited amount of leg
lengthening, and leads to abnormal
hip biomechanics. Careful assess-
ment with trial components should
be done to ensure that there is no
impingement with flexion on the
anterior inferior iliac spine or with
extension on the ischial tuberosity.
Concomitant lateralization of the hip
center of rotation should be avoided
when this technique is used.4
The third alternative for acetabu-
lar reconstruction in Crowe type II
or III hips is socket medialization
by intentional overreaming or even
deliberate fracture of the medial
wall of the acetabulum. 3,11 This
technique, termed acetabuloplasty
A B
by some authors, provides in-
creased lateral coverage of the Figure 6 Preoperative (A) and postoperative (B) anteroposterior radiographs demonstrat-
acetabular component by native ing acetabular reconstruction at a high hip center in a Crowe type III hip.
iliac bone and decreases joint reac-

338 Journal of the American Academy of Orthopaedic Surgeons


Femoral Reconstruction
The abnormal anatomy of the
dysplastic femur, with its excessive
anteversion and coxa valga, presents
several reconstructive problems.
The medullary canal often is small
and can be unusually shaped, with a
much smaller medial-lateral than
anterior-posterior diameter. The
greater trochanter is located posteri-
orly and may need to be moved to a
more anatomic position. The charac-
teristics and severity of the femoral
deformity and the level of the associ-
ated acetabular reconstruction must
be taken into consideration when
planning femoral reconstruction.
The anteversion of the implanted
acetabular component will influence
how much anteversion can be ac-
cepted on the femoral side without
compromising hip stability. Femoral
shortening may be needed to avoid
excessively lengthening the lower
extremity and stretching the sciatic
nerve.12
Crowe Type I and II Hips
Because the acetabular recon-
struction usually changes the hip
center of rotation relatively little,
length is not a major problem and
femoral shortening generally is not
needed. The type of implant used is
based on patient demographic fea-
tures, bone quality, bone geometry,
and surgeon preference. The com-
ponent should not be placed in ex-
cessive anteversion, which can occur
if the patient’s excessively anteverted
native femoral neck is used as a ref-
erence. Excessive femoral compo-
nent anteversion can lead to anterior
hip instability and can compromise
external rotation of the hip.
Crowe type I and II femurs can
be reconstructed with either cement-
ed or uncemented components.
Cemented implants allow the sur-
geon to deal with moderate degrees
of deformity, especially excessive
anteversion.1 So-called DDH stems
are smaller and have a minimal
metaphyseal flare, which allows the
Vol 10, No 5, September/October 2002
stem to be oriented independent of
the patient’s anteversion and avoids
insertion of the femoral component
in varus even when there is coxa
valga. Uncemented femoral compo-
nents are appealing because many
patients with dysplastic hips are
young.13 Nonmodular, proximally
porous-coated, metaphyseal-filling
implants can be used when anatomic
abnormalities are mild, but they
have a limited role when the proxi-
mal anatomic abnormalities are
marked. Extensively porous-coated
implants can bypass the metaphy-
seal abnormalities and gain distal
fixation, and therefore are versatile
even in the presence of substantial
deformity. Extensively coated im-
plants with reduced metaphyseal
cross-sections allow the surgeon to
compensate for mild to moderate
anteversion abnormalities. However,
they cannot be used when the canal
is very small because of the risk of
fatigue failure with very-small-diam-
eter, porous-coated stems. Modular
femoral implants allow the surgeon
to fill the metaphysis with an unce-
mented, proximally porous-coated
implant and still orient the implant
anteversion independent of the pa-
tient’s anatomy. Implants with mod-
ular bodies also allow the surgeon to
mix and match metaphyseal shapes
and diaphyseal sizes to match a val-
gus femoral neck or other anatomic
abnormalities.
Crowe Type III and IV Hips
When the center of hip rotation is
brought from a markedly elevated
position down to a normal or nearly
normal position, femoral shortening
usually is required. Without fem-
oral shortening, soft-tissue contrac-
tures make it difficult to reduce the
prosthetic femoral head into the ace-
tabular component, and leg-length
discrepancy may result. The exact
amount of lengthening that will
result in the occurrence of sciatic
nerve dysfunction is not known.
Acute limb lengthening of more
Joaquin Sanchez-Sotelo, MD, et al
than 2 to 4 cm during arthroplasty
has been associated with an in-
creased risk of neural injury.12 As a
general rule, the leg should be
lengthened the minimum amount
required to reestablish reasonable
function and hip stability.
Shortening can be done either by
sequentially resecting the proximal
femur or by performing a shortening
subtrochanteric osteotomy. The com-
bination of greater trochanteric os-
teotomy, sequential proximal femoral
resection, and insertion of a cement-
ed stem is the technically easier of the
two (Fig. 7), but it has several disad-
vantages. The osteotomized greater
trochanteric fragment is advanced
onto a tube of cortical bone and may
fail to unite. In addition, the resultant
shape of the femur is abnormal: a
straight tube with a small metaphy-
seal flare. The small straight tube of
remaining femur usually is unsuit-
able for uncemented implants and
typically necessitates use of a small,
cemented DDH stem with a straight
proximal medial geometry without a
metaphyseal flare. Finally, if the
osteotomy reaches the level of the
lesser trochanter, the psoas tendon
has to be released, and hip flexion
strength may be compromised.
A subtrochanteric shortening
osteotomy is more attractive from a
theoretic point of view: it preserves
the metaphyseal femoral region
(which provides most of the rotation-
al stability of the implant), obviates
the need for a greater trochanteric
osteotomy, and allows concomitant
correction of angular and antever-
sion deformities 14-16 (Fig. 7). Its
main disadvantages are the techni-
cal difficulty of the procedure and
the risk of nonunion.
Subtrochanteric osteotomy allows
the proximal fragment to be rotated
superiorly on its abductor pedicle,
thus providing exposure to the ace-
tabulum. However, this requires ex-
tensive soft-tissue stripping and
devascularization of the proximal
fragment. An alternative method is
339
Surgical Treatment of Developmental Dysplasia of the Hip: II. Arthroplasty Options
A B
Figure 7 Preoperative (A) and postoperative (B) anteroposterior radiographs of a patient
with Crowe type IV hip dislocation treated with femoral shortening by proximal resection
and greater trochanteric osteotomy.
a posterior approach to the hip fol-
lowed by anterior displacement of
the proximal femur, preserving as
much soft-tissue attachment and
vascularity as possible. Once the ace-
tabular reconstruction is completed,
the femoral canal can be provisionally
prepared. The subtrochanteric os-
teotomy is then performed, a trial
femoral component is placed into
the proximal fragment, the hip is
reduced, and the required amount
of femoral shortening is determined
by judging the amount of overlap
between the distal femur and proxi-
mal fragment, with a moderate
amount of longitudinal traction on
the leg. Both angular and rotational
correction can be determined. The
resected subtrochanteric section of
the femur can be split longitudinally
and placed around the osteotomy
site as onlay autogenous grafts (Fig. 8).
340
Different subtrochanteric osteoto-
my geometries, including trans-
verse, oblique, stepcut, and chevron
shapes, can be used; the more com-
plex osteotomy shapes provide
more inherent rotational stability.
When good fixation of the proximal
and distal fragments can be obtained
with the implant itself, a transverse
osteotomy is easiest and allows cor-
rection of rotational abnormalities.
Although cemented stems can be
implanted in conjunction with sub-
trochanteric osteotomy, uncemented
stems with extensive porous coating
or other design features (such as dis-
tal flutes) that allow fixation of both
the proximal and distal fragments
are usually preferable for several
reasons. Uncemented stems can
provide excellent stability of the
osteotomy site, acting as press-fit in-
tramedullary rods. They also avoid
Journal of the American Academy of Orthopaedic Surgeons
the potential interference of acrylic
cement with union of the osteotomy
site and may provide a more durable
result in young patients (although
no published evidence substantiates
this speculation) (Fig. 9).
Results
Pain relief in patients with hip dys-
plasia after total hip arthroplasty
parallels the excellent results of
total hip arthroplasty in the general
population.1 Notable overall im-
provements in hip scores also are
reported in most series. 1,3,4,17,18
Patients with very stiff hips preop-
eratively may have some residual
postoperative stiffness. Historic-
ally, functional results have tended
to be excellent in patients with
Crowe type I and II dysplasia but
not as good in patients with Crowe
type III and IV hip disease, who
have had more tendency for persis-
tent limp with a waddling gait.
The poorer functional results in
patients with the most severe bony
abnormalities have been attributed
to longstanding abductor muscle
deconditioning and longstanding
gait abnormalities. Current meth-
ods of reconstructing high disloca-
A B C D
Figure 8 Subtrochanteric osteotomy
allows both shortening (A) and correction
of rotational abnormalities (C) while pre-
serving the metaphysis. The resected bone
(B) may be used as an onlay autograft (D).
(By permission of Mayo Foundation.)

A B
Figure 9 Preoperative (A) and postoperative (B) anteroposterior radiographs of a patient
with a Crowe type IV high dislocation treated with femoral reconstruction using shorten-
ing subtrochanteric osteotomy and implantation of an uncemented, fully coated stem.
tions that provide more nearly
normal hip anatomy and biome-
chanics may improve the function-
al results.
Acetabular Reconstruction
Standard Reconstruction
High long-term mechanical fail-
ure rates have been reported for
cemented acetabular components
implanted without structural aug-
mentation or intentional elevation
or medialization. Reported failure
rates have varied from 16% to 52% at
a mean follow-up of approximately
10 to 20 years.1,4,17,18 Younger age
at surgery, extensive preoperative
proximal migration of the hip center
of rotation, and nonanatomic place-
ment of the acetabular component
correlated with a poor outcome in
these studies. Others have reported
low wear, revision, and loosening
rates resulting from the use of ce-
Vol 10, No 5, September/October 2002
mented Charnley offset-bore com-
ponents5 (Table 2).
Uncemented acetabular compo-
nents may provide more long-last-
ing reconstructions in patients with
hip dysplasia, but published infor-
mation is still limited. Anderson
and Harris19 reported on 20 dysplas-
tic hips reconstructed with an unce-
mented hemispheric cup and fol-
lowed for a mean of 6.9 years.
Native bone covered 75% to 100% of
the components, which were placed
an average of 28 mm (range, 5 to 66
mm) proximal to the inter-teardrop
line. None of the sockets had been
revised and none had loosening,
migration, osteolysis, or a complete
radiolucent line. These results are
promising, but longer follow-up of a
greater number of patients is re-
quired before uncemented sockets
can definitively be said to outper-
form cemented cups in dysplastic
hips (Table 2).
Joaquin Sanchez-Sotelo, MD, et al
Acetabular Augmentation
Autogenous bone graft augmen-
tation in association with cemented
acetabular components for hip dys-
plasia has provided satisfactory
early clinical results but a higher rate
of failure with longer follow-up,
particularly when a large amount of
the socket is supported by graft. At
10 to 11 years, about 40% of cement-
ed acetabular components partly
supported by autograft show radio-
graphic signs of loosening, and 10%
to 20% have been revised.6,8 Better
results have been reported when the
hip center initially is restored to its
anatomic position,20 when the graft
supports less than 30% to 40% of the
component, and when posterior as
well as superior support is provid-
ed.6,8 Large bone grafts in associa-
tion with cemented sockets have not
provided optimal long-term dura-
bility; however, when the recon-
struction fails, the bone graft usually
provides additional bone stock res-
toration and facilitates subsequent
revision surgery.
Published experience with lateral
bone graft augmentation in associa-
tion with uncemented acetabular
components is limited to small series
of patients with a short follow-up.
All the failures in one series13 used
threaded acetabular components.
However, none of the porous-coated
components in either series had
failed at a mean follow-up of 3 to 6.6
years. 13,21 Although these short-
term results are promising, longer
follow-up is required to prove the
durability of uncemented compo-
nents supported by structural auto-
graft in dysplastic hips (Table 2).
High Hip Center
Intentional proximal placement
of the acetabular component was rec-
ommended by Russotti and Harris9
for cases in which placement of the
acetabular component in the true
anatomic position would otherwise
require grafts to provide most of the
socket’s structural support. They
341
Surgical Treatment of Developmental Dysplasia of the Hip: II. Arthroplasty Options

Table 2
Results of Acetabular Reconstruction in Hip Dysplasia

Total No. of Mean Patient Age Mean Follow-up Revision for Mechanical
Study Hips in Study* in Years (Range) in Years (Range) Aseptic Loosening Failure†

Cemented without acetabular augmentation

Numair et al17 182 45.2 (19.5-76.5) 9.9 (3.1-22.8) 10% 16%
Pagnano et al4 145 51 (15-76) 14 (2-22) 12% 52%
MacKenzie et al18 59 53 (23-73) 16 (10-21) 7% 39%
Sochart and Porter1 60 32.4 (17-39) 20.3 (7.3-30) 37% 37%
Cementless without acetabular augmentation
Anderson and Harris19 20 52 (25-87) 6.9 (5.3-8.5) 0% 0%
Cemented with acetabular augmentation
Mulroy and Harris8 46 46.5 (14-69) 11.8 (10-15.9) 20% 46%
Rodriguez et al6 29 49 (20-78) 11 (7-17) 10% 38%
Lee et al7 36 (102) 51 (21-78)‡ 10.2 (4-18.6)‡ 35%§ 38%§
Cementless with acetabular augmentation
Silber and Engh13 19 45 (NR) 3 (2-6.3) 5% 26%
Morsi et al21 17 (33) 50.3 (36-65)‡ 6.6 (5.1-9.8)‡ 0% 0%
High hip center
Russotti and Harris9 19 (37) 51 (16-73)‡ 11 (7-17)‡ 2.7%‡ 16%‡
Schutzer and Harris10 5 (56) 51 (26-81)‡ 3.3 (2-5.3)‡ 0% 0%
Medialization
Hartofilakidis et al3 86 47 (23-70) 7 (2-15) 2% NRll
Dorr et al11 24 45 (22-69) 7 (5-13) 0% 0%

* Total number of patients with dysplasia and other diagnosis included in the study.
† Mechanical failure, including revision and radiographic loosening.
‡ Data for the total number of patients included in the study, not for only those with hip dysplasia.
§ Probability of revision and loosening at 12 years for patients with dysplasia.
ll 12% incidence of complete radiolucent lines.
NR = not reported

reported revision and loosening
rates of 2.7% and 16%, respectively,
in a group of complex cemented
total hip replacements that included
19 dysplastic hips. Schutzer and
Harris10 later reported the results of
superiorly placed uncemented com-
ponents in a mixed group of 56 hips
that included only 5 primary arthro-
plasties on dysplastic hips. At a
mean follow-up of 3.3 years, no
acetabular component had been
revised for loosening. These two
studies suggest that proximal place-
ment of both cemented and unce-
mented acetabular components did
not negatively affect the outcome of
acetabular reconstruction provided
that the component was not lateral-
ized.
However, other reports support
placement of the acetabular compo-
nents in the true acetabular region.
Higher loosening and revision rates
for both femoral and acetabular com-
ponents have been reported in sever-
al series when cemented acetabular
cups are initially placed superior or
lateral to the anatomic position.4,20
Proximal placement of the acetabular
component probably should be
reserved for cases in which acetabu-
lar reconstruction in the anatomic
position would leave more than 40%
to 50% of the socket surface uncov-
ered or covered by bone graft.
Medialization of the Component
Intentional medialization of the
acetabular component through the
medial wall by reaming or creating a
controlled comminuted fracture has
been reported to provide reasonable
midterm results. Low revision rates
have been published combining this
technique with both cemented3 and
uncemented11 components followed
for an average of 7 years. However,
nonprogressive but complete radio-
lucent lines >1 mm wide were found
around 18% of the cemented acetab-
ular cups.3 In reviewing their results
with press-fit uncemented acetabu-
lar components inserted after ream-
ing the medial acetabular wall, Dorr

342 Journal of the American Academy of Orthopaedic Surgeons


et al11 recommend creating a medial
wall defect of about 25% of the
acetabular area. Of 24 hips followed
for a mean of 7 years, 2 required
polyethylene exchange, but none of
the metal shells were revised or
found radiographically to be loose.
The average medialization of the hip
center was 12.7 mm, and supple-
mental structural bone graft cover-
ing 15% to 30% of the component
was used in only six hips. Longer-
term follow-up of the durability of
this form of reconstruction in con-
junction with uncemented cups is
needed to demonstrate whether its
advantages (technical simplicity and
good lateral support of the cup on
native bone) will outweigh the un-
desirable loss of remaining medial
acetabular bone stock.
Femoral Reconstruction
Cemented femoral components
have provided more satisfactory
long-term results than have cemented
acetabular components in hip dys-
plasia. Numair et al17 reported a 3%
revision rate in a series of 182 dys-
plastic hips followed for a mean of
9.9 years. In the series of McKenzie
et al18 of 59 hips followed for a mean
of 16 years, 3.4% of the femoral com-
ponents required revision, and an
additional 5% were considered
loose. Sochart and Porter1 reported
rates of femoral revision and aseptic
loosening of 10% each in 60 cemented
replacements of dysplastic hips per-
formed at a young age and followed
for a mean of 20.3 years. The proba-
bility of survival of the femoral com-
ponent at 25 years in their series was
81%. The use of uncemented fem-
oral components in hip dysplasia is
based on the hope that uncemented
fixation will outperform cemented
fixation in young, active patients.
However, limited information is
available on the results of uncemented
Vol 10, No 5, September/October 2002
femoral components specifically in
hip dysplasia.13
The results of total hip arthro-
plasty for hip dysplasia with differ-
ent forms of femoral osteotomy have
been reported with short-term to
midterm follow-up. Reikeraas et al14
reported on 25 dislocated hips that
were treated with femoral shorten-
ing through a subtrochanteric trans-
verse osteotomy with an uncement-
ed stem. After follow-up of 3 to 7
years, one delayed union and one
malunion were reported but no
mechanical failures. Yasgur et al15
reported on a series of eight patients
with Crowe type IV hips who had
replacement with fully coated (six
hips), modular (one hip), or cemented
(two hips) stems combined with a
transverse subtrochanteric osteotomy
for shortening and retroversion. At a
mean follow-up of 3.6 years (range, 2
to 7 years), one hip required revision
and an asymptomatic patient devel-
oped radiographic nonunion. The
rate of satisfactory results was 87%.
Chareancholvanich et al16 reported
on 15 dislocated hips that were treated
with a double chevron subtrochan-
teric osteotomy and insertion of a
stem that was uncemented in all but
one case. All osteotomies united,
and the rate of satisfactory results
was 80%. The Mayo Clinic series22
included 14 primary hip replace-
ments in patients with hip dysplasia,
8 of them with previous failed proxi-
mal femoral osteotomy. Shortening
and correction of angular and rota-
tional deformities were performed
at the osteotomy site. Two of the
four patients treated with femoral
shortening required revision surgery
for osteotomy nonunion and aseptic
loosening of the femoral component.
Overall, subtrochanteric osteotomy
has provided satisfactory results in
at least 80% of cases.14-16 However,
malunion and nonunion occasionally
Joaquin Sanchez-Sotelo, MD, et al
occur and can be associated with
fatigue failure of the stem15 or asep-
tic loosening.22
Summary
The wide range of anatomic abnor-
malities that characterize hip dyspla-
sia dictate the need for different re-
constructive techniques when hip
replacement is required. The age and
activity level of this patient popula-
tion, coupled with the increased com-
plexity of surgery, explain the some-
what elevated historical failure rate of
hip replacement in dysplasia and em-
phasize the need for careful analysis
of each case and selection of the most
appropriate reconstruction options.
In regard to the acetabular cup,
deficient bone stock may limit the
ability to place the component fully
on native bone at the true acetabular
region. When standard techniques
of reconstruction leave a significant
portion of the component uncov-
ered, the alternatives include acetab-
ular augmentation with bone auto-
graft, intentional high placement of
the component, or medialization of
the component. Uncemented sock-
ets have provided promising mid-
term results with and without sup-
plemental bone augmentation.
Either cemented or uncemented
femoral components may be used
depending on patient age and bone
quality. Although proximally coated
monolithic stems may be used in
mild dysplasia, they are less versatile
in the presence of significant meta-
physeal abnormalities. For more
marked deformities, extensively
coated and modular uncemented
stems offer technical advantages.
Subtrochanteric or metaphyseal
osteotomy may be required for
shortening or the correction of rota-
tional deformities.
343
Surgical Treatment of Developmental Dysplasia of the Hip: II. Arthroplasty Options
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