International Orthopaedics (SICOT) (2015) 39:27–33
DOI 10.1007/s00264-014-2554-0
ORIGINAL PAPER
Total hip arthroplasty with subtrochanteric
osteotomy in neglected dysplastic hip
Eid Ahmed & El-Ganzoury Ibrahim & Bassiony Ayman
Received: 17 July 2014 / Accepted: 23 September 2014 / Published online: 11 October 2014
# SICOT aisbl 2014
Abstract
Purpose Total hip arthroplasty (THA) in the presence of
developmental dysplasia of the hip (DDH) presents many
challenges to the reconstructive surgeon. The complexity of
femoral and acetabular anatomy in these cases makes standard
reconstruction technically challenging. Restoring the anatom-
ic centre of hip rotation may require femoral osteotomy. The
aim of this study was to determine the rate of union, compli-
cations and functional results in a series of patients with
Crowe IV dysplastic hips who underwent cementless THA
and simultaneous subtrochanteric oblique osteotomy.
Methods A retrospective study was designed in a series of 13
patients (14 hips) with Crowe IV DDH who underwent
cementless THA and simultaneous subtrochanteric oblique
osteotomy at a mean age of 37 years. Patients were reviewed
clinically and radiographically with a minimum follow-up of
two years. Complications were noted. Harris Hip Score (HHS)
was recorded pre-operatively and at six and 12 months
postoperatively.
Results Union occurred in 14 of 14 femora (100 %). The
overall revision rate was 14 % (7 % femoral, 7 % acetabular).
No dislocations necessitated further surgery. No patient had
intraoperative femoral fracture, sciatic nerve injury, infection
or deep venous thrombosis. Mean HHS improved from 42
preoperatively to 79 at 6 months and 86 at 12 months.
Conclusion Combined subtrochanteric femoral osteotomy
and cementless THA is technically demanding and proved
to be safe and effective in femoral shortening for treatment of
Crowe IV DDH.
Keywords Dysplastic hip . Osteotomy . Subtrochanteric .
Arthroplasty . Crowe IV
E. Ahmed (*) : E.<G. Ibrahim : B. Ayman
Orthopaedic Surgery, Ain Shams University, Cairo, Egypt
e-mail: ahmedsalem5474@yahoo.com
Introduction
Developmental dysplasia of the hip (DDH) is a leading cause
of hip arthritis, especially in young adults, and total hip
arthroplasty (THA) remains the gold standard of treatment
when end-stage arthritis leads to significant pain and loss of
function [1]. Performing THA in the presence of severe DDH
is technically demanding and presents many challenges to the
surgeon on both the femoral and acetabular sides. Usually,
there is difficulty in identifying and preparing the true acetab-
ulum, which is characterised by deficiencies both anterolater-
ally and superiorly, with difficulty in achieving stable fixation
of the acetabular component [2–6]. Restoring the anatomical
centre of hip rotation has proved to yield favourable biome-
chanical results in THA for DDH patients [7–10]. In restoring
the centre of hip rotation in cases with high dislocation of the
hip and severe contracture of soft tissue, the leg may be
lengthened by >4 cm [11, 12], leading to difficulty in reducing
the hip and a major risk of neurologic traction injury [2],
particularly where there is scarring from previous surgery,
which increases the risk of direct or indirect neurologic injury
[11].
On the femoral side, computed tomography (CT) studies
have demonstrated that dysplastic femurs had consistently
increased anteversion, shorter necks and decreased
intramedullary canal size than nondysplastic femurs and
straight contour and that the anterior bow of the femur
displaced further distally with increasing degree of dysplasia
[13]. The decreased canal width and thinner cortical diameters
in dysplastic hips also may make them more prone to fracture
[14] and adds to the difficulty of obtaining stable implantation
of an adequately sized femoral component [15–17].
To address these difficulties during THA for severe dys-
plasia, many surgeons advocate performing subtrochanteric
osteotomy, of which different types—either transverse,
oblique chevron or T-shaped—have been well documented
28 International Orthopaedics (SICOT) (2015) 39:27–33

with good clinical results [18–25], but nonunion and com-

plexity in performance remain the major concerns in the
procedure [18, 26]. Progressive osteotomy at the femoral neck
with greater trochanteric osteotomy [27], distal femoral
osteotomy [15] and lesser trochanteric osteotomy has been
reported in previous studies [28].
Most published studies reporting THA combined with
subtrochanteric osteotomy in DDH used cementless femoral
components and reported high rates of union and major im-
provements in the postoperative Harris Hip Score (HHS) [4,
16, 18, 20, 29–35]; cemented femoral components are rarely
used, although similar rates of union and survivorship are
reported compared with cementless components [6, 36–40].
The aim of this study was to determine union rate, compli-
cations and early HHS in a series of cementless THA and
simultaneous subtrochanteric oblique osteotomy in 13 pa-
tients (14 hips) with Crowe IV dysplastic hips.

Patients and methods Fig. 1 a Femoral neck osteotomy; b acetabular component implantation
in true acetabulum and femoral canal preparation; c short oblique
This was a prospective study of 13 patients (14 hips) who subtrochanteric osteotomy is performed, femoral rasp replaced into prox-
imal fragment, which is reduced into the acetabulum, and amount of
underwent primary cementless THA with simultaneous overlap between proximal and distal fragments is determined to identify
subtrochanteric osteotomy between 2006 and 2012. The indi- bone length to be resected; d after bone resection equal in length to
cation for surgery was painful osteoarthritis secondary to amount of overlap, proximal and distal fragments are reduced together
severe DDH (Crowe Grade IV [2]) in all cases. The mean
age at surgery was 37 (range, 27–54) years. All patients were was performed just distal to the lesser trochanter. The rasp was
last followed up between two and eight years after surgery replaced into the proximal fragment only, which was reduced
(mean, 4.75 years). to ensure the abductors allowed normal positioning of the
Subtrochanteric osteotomy was performed to shorten the femoral component. An abductor release or trochanteric slide
femur in all cases; the average length of bone removed was was not required in any case in this series. Traction was
2 cm (range, 1.5–2.5 cm). All operations were performed applied to the distal fragment, and the amount of overlap
using cementless femoral and acetabular components between the proximal and distal fragments was noted,
(Trilogy acetabular system, FMT stem, Zimmer, Warsaw, IN, reflecting the corresponding length of bone to be resected
USA). A posterior approach was used, with distal extension to from the distal fragment to allow reduction of the final con-
access the proximal femoral shaft. The sciatic nerve was struct. After bone resection, the proximal and distal fragments
identified and carefully protected but not formally dissected. were reduced and the appropriate femoral trial introduced
The true acetabulum was identified by following the
ligamentum teres and confirmed by image intensifier; the
acetabulum was then prepared in the standard manner with a
structural femoral head autograft to provide adequate superior
coverage of the cup where necessary, but it was performed
only if 50–70 % of the trial was covered by the acetabulum
[nine hips (64.3 %)]. The acetabular component was then
implanted.
On the femoral side, a total capsulectomy was performed,
the iliopsoas tendon released and the gluteal sling kept intact.
The femoral canal was opened by straight reamer and pre-
pared in the standard manner by rasping. The femoral com-
ponent with the largest offset, which best fit the femur, was
chosen. With the trial rasp in place, traction was then applied
to the femur for trial reduction, which usually proved impos- Fig. 2 After bone resection, proximal and distal fragments are reduced;
sible. The rasp was removed, and a short oblique osteotomy final component with compression of osteotomy site after bone resection
International Orthopaedics (SICOT) (2015) 39:27–33 29

Fig. 3 a Autologous morselised

bone graft; b resected bone is split
longitudinally into two halves and
placed around the osteotomy site
as additional strut bone graft and
fixed with cerclage wires

across the osteotomy, which was compressed with bone-
reduction forceps (Figs. 1 and 2).
Trial reduction into the acetabulum and assessment of
stability was confirmed. The definitive femoral component
was then implanted, the osteotomy site packed with an autol-
ogous morselised bone graft and resected bone from the distal
fragment split longitudinally into two to four fragments and
placed around the osteotomy site as additional strut bone graft
and fixed with cerclage wires (Fig. 3).
Postoperatively, patients were allowed to partially weight
bear for the first six weeks with the aid of a walking frame or
two walking sticks and were reviewed in the outpatient clinic
at six weeks, three months, six months and 12 months after
surgery. HHS was recorded pre-operatively and at six and
12 months postoperatively. At each follow-up visit, the pa-
tients were assessed clinically and radiographically by
anteroposterior (AP) and lateral radiographs. Rate of
osteotomy union and complications were recorded. Union
was defined by the presence of mature bone bridging the
osteotomy on at least three of four cortices as seen on AP
and lateral radiographs (Fig. 4).
Complications were defined as deep infection (requiring
reoperation), dislocation, neurologic injury (temporary or per-
manent), intra-operative fracture, periprosthetic fracture and
revision for any reason.
(7 %) after 1.5 years using a cementless tantalum cup
(Zimmer), with no further revision at last follow-up at
three years. The femoral head was reduced into the true
acetabulum for each hip. There was no sciatic nerve palsy,
either transient or permanent, infection, dislocation or
periprosthetic fracture during the follow-up period. No
patient developed deep venous thrombosis. Mean leg
length discrepancy (LLD) for 12 patients with unilateral
dysplastic hip (12 hips) decreased from 4.25 cm (range,
0–7) pre-operatively to 0.7 cm (range, 0–2.5) postopera-
tively. All patients had positive Trendelenburg signs pre-
operatively. Five hips (35.7 %) became negative for
Trendelenburg sign, which was positive but markedly
reduced in seven hips (50 %), and two hips (14.3 %)
continued to show the sign until the last follow-up. HHS
improved from 42 (range, 24–59) pre-operatively to 79
(range, 62–89) at six months and 86 (range, 68–92) at
12 months (Table 2).

Results

Fourteen primary hips in 13 patients (seven women, six men),

mean age 37 (range 27–54) years, were operated upon. The
mean follow-up period was 4.75 (range, two to eight) years.
No patient was lost to follow-up. All osteotamies united
(100 %); there were two complications (14 %) (Table 1).
Two revisions were necessary for aseptic loosening
(14 %): one for femoral component loosening (7 %) after
two years, which was revised by cementless long-stem Fig. 4 a Pre-operative anteroposterior (AP) radiograph of pelvis in 46-
year-old man with neglected developmental dysplasia of the hip (DDH)
femoral component (Wagner stem, Zimmer) with no fur- Crowe IV; b 6 months postoperative image showing bridging callus at
ther revision at last follow-up at two years after revision; osteotomy site after total hip replacement (THR) with subtrochanteric
the other was revised for acetabular component loosening osteotomy
30 International Orthopaedics (SICOT) (2015) 39:27–33

Table 1 Major its different types, was used to facilitate restoring hip centre
complications Complications Total
and leg length without sciatic nerve compromise.
Infection 0 The purpose of this study was to determine union rate,
Dislocation 0 complications and HHS in a series of patients undergoing
Nonunion of osteotomy 0 cementless THA and simultaneous subtrochanteric short
Sciatic nerve palsy 0 oblique osteotomy for neglected DDH. Our union rate of
Aseptic loosening 2 100 % is similar to reported results [20, 29, 31, 34] and
Intraoperative femoral fracture 0 compare favourably with other studies using THA with
Deep venous thrombosis 0 subtrochanteric osteotomy and cementless stem [4, 16, 18,
30, 32, 33, 35]. Total revision rate in our study was 14 % (two
cases) for aseptic loosening, which compare favourably with
revision rates in other studies [4, 16, 18, 20, 29, 31, 33, 34]
Discussion and inferior to results reported by Sener et al. [30], Onodera
et al. [32], and Nagoya et al. [35]. We had no complications of
Crowe type IV DDH presents a challenge for THA. In dealing dislocation, infection, sciatic nerve palsy, intraoperative fem-
with such cases, the surgeon should anticipate being faced oral fracture or deep vein thrombosis (Table 3).
with problems on both the acetabular and femoral sides. As Absence of dislocation in this series can be explained
regards the acetabulum, there are usually segmental defects by proper component orientation, restoring abductor le-
that might be superior, anterior or posterior. The acetabulum is ver arm by placing the cup in the true acetabulum and
usually excessively anteverted, shallow and small, reflected restoring the anatomical centre of hip rotation. In addi-
by the small distance between the anterior and posterior walls, tion the subtrochanteric osteotomy allowed internal ro-
which presents a difficulty in reaching proper cup size with tation of the proximal fragment, if needed, for stability
adequate bony coverage. On the femoral side, there is usually during trial assessment. Using the posterior approach in
excessive anteversion, and the femoral canal is usually nar- this series may counteract the tendency towards anterior
row, with pencil-like cortices. Another important issue in dislocation due to the excessive femoral anteversion
neglected dysplastic hips is soft-tissue contracture that results found in neglected dysplastic hips. Osteotomy union
from the longstanding pathology. There is shortening of the occurred in all cases, and may be attributed to many
neurovascular bundle, with general decrease in tissue excur- factors: First, oblique osteotomy used in this study has
sion with subsequent difficulty in reducing the head in the true two main advantages: (1) it provides rotational stability
acetabulum and subsequent difficulty in restoring limb length at the osteotomy site, and (2) it increases the surface
without putting the sciatic nerve at risk of injury. In order to area at the osteotomy site, which in turn increases the
address these problems, femoral shortening osteotomy, with union rate. Also, the use of bone grafts at the osteotomy

Table 2 Demography, leg-length discrepancy (LLD), and Harris Hip Score (HHS)

No. Sex Age FU (years) Preop LLD (cm) Postop LLD (cm) Preop HHS HHS 6 months HHS 12 months
postop postop

1 F 29 3 4 0 57 89 92
2 M 27 2 6 1.5 33 73 81
3 F 38 4 7 2.5 24 62 68
4 M 45 5 0 0 33 83 87
5 F 27 8 5 1 54 87 90
6 F 46 7 3 0 56 83 86
7 M 54 4.5 6 1.5 29 68 81
8 F 39 6 – – 33 68 83
9 F 39 6 – – 35 81 87
10 M 37 4.5 3 0 53 86 90
11 M 28 4 5 1 31 73 87
12 F 30 3 5 1 35 76 88
13 M 49 4 3 0 57 88 92
14 F 36 5.5 4 0 59 89 90

FU follow-up, Preop pre-operative, Postop postoperative

International Orthopaedics (SICOT) (2015) 39:27–33 31

femoral fracture
site, both morselised and structural, and absence of
Intraoperative infection are other factors in promoting union. Finally,

3 (13 %)
2 (22 %)

5 (18 %)
6 (43 %)

2 (10 %)
5 (11 %)

4 (6 %)
absence of any retained hardware from previous surger-
(%) ies may be another factor improving the union rate, as

0
0

0
0
retained metalwork has been proved to add specific
injuries (%)
Neurologic

difficulties in performing THA [41]. There was no sci-

3 (11 %)

5 (7 %)
0
atic nerve palsy, either transient or permanent, in our

NS
NS
0

0
0
0

0
0
series. Femoral lengthening by >4 cm increases the
incidence of nerve palsy, and various authors have rec-
infections (%)

ommended lengthening the femur by <4 cm [42, 43].

By shortening the femur during THA of the dysplastic
2 (7 %)
1 (2 %)

hip, the incidence of nerve palsy is probably reduced

Deep

0
0

0
0

0
0

0
0
[44]. There was no intra-operative femoral fracture in
our series. Reported rates of intra-operative femoral
Dislocations

fracture using cementless stems in dysplastic femora

4 (14 %)
3 (14 %)

4 (18 %)
1 (11 %)

3 (4 %)
1 (4 %)
1 (7 %)
2 (4 %)

are as high as 20 % [29, 32, 35]. We did not perform

(%)

prophylactic splitting of the proximal femur, which is

0
0

recommended by some authors [16]. We preferred

Table 3 Overview of previous studies of total hip arthroplasty (THA) with subtrochanteric osteotomy using cementless femoral stem

3 (13 %)

4 (14 %)
2 (10 %)
1 (11 %)
revisions
Femoral

5 (7 %)
2 (7 %)

1 (7 %)
2 (9 %)

1 (7 %)
3 (7 %)

cementless fixation, despite the higher risk of intra-

operative fracture, because patients with DDH require
(%)

arthroplasty at a relatively young age, and early reports

29 (43 %)
2 (22 %)
1 (14 %)

5 (23 %)

4 (17 %)
4 (18 %)

7 (25 %)
2 (10 %)

2 (14 %)
8 (17 %)

of cemented THA in younger patients describe problems

2 (7 %)

1 (7 %)
revisions

with aseptic loosening [45, 46]. Furthermore, some au-

Total

(%)

thors believe cementless femoral components allow

greater control of anteversion, independent of the stabil-
9 (100 %)
7 (100 %)

22 (100 %)

23 (100 %)

14 (100 %)
58 (95 %)
26 (93 %)

13 (93 %)

21 (88 %)

19 (95 %)
26 (93 %)
44 (96 %)

ity of both fragments [32]. The overall revision rate was

Union

14 % at a mean of 4.75 years, which is comparable with the

(%)

published data (Table 3). THAwith subtrochanteric osteotomy

is technically demanding and an infrequently performed pro-
Cementless
Cementless
Cementless
Cementless
Cementless

Cementless
Cementless

Cementless
Cementless
Cementless
cementless
cementless
Stem type

cedure (0.1–0.3 % of all THAs at the Mayo Clinic [18]). Even

in specialist centres, it is associated with increased complica-
tion rates (Table 3).
This study presents a series of 14 cases with neglected
Mean follow-up

DDH operated upon by THA with subtrochanteric oblique

4.7 (0.5–7.2)
4 (0.6–7.7)
2.1 (0.7–7.8)

4.8 (2–13.4)
8.1 (4–11.5)
2.7 (0.3–6)

5 (3–7.9)

4.7 (2–7.6)
3.2 (1–5.9)

12.3 (9–15)

8 (5–14)

osteotomy and suggests that short- to midterm results as

4.75 (2–8)

regards the rates of union, complications and revisions are

(years)

comparable with those for cementless techniques in other

studies.
(years, range)

Our study has some limitations: First, the number of pa-

43 (26–64)
50 (22–78)
61 (48–72)
53 (26–77)

55 (23–80)
55 (44–69)

43 (17–67)
54 (29–74)
49 (20–66)

55 (44–69)
48 (30–72)
37 (27–54)
Mean age

tients was relatively small. Second, the method of assessing

radiographic union was not robust, because there was no
analysis of interobserver reliability; and while healing times
cannot be determined, we believe our final assessment of
patients

union is valid given the radiographic appearances and absence

No.

46

28
22
14
61
24
23
20
28
14
7
9

of symptoms. Third, there is little known regarding long-term

survival of these complex arthroplasties, and further long-term
Paavilainen et al. 1990 [16]

Bernasek et al. 2007 [34]

Carlsson et al. 2003 [31]

follow-up is required.
Onodera et al. 2006 [32]
Eskelinen et al. 2006 [4]

Nagoya et al. 2009 [35]

Becker et al. 1995 [20]

Krych et al. 2009 [18]

Bruce et al. 2000 [29]
Sener et al. 2002 [30]

In conclusion, THA with subtrochanteric oblique

Park et al. 2007 [33]

osteotomy is a challenging procedure for the reconstructive

Current study

hip surgeon. Although the technique is difficult, the compli-

cation rate is low, and results are good and compare
Author

favourably with other results in the literature. We recommend

the technique as an addition to the armamentarium of surgeons
32
operating upon complex cases such as Crowe IV dysplastic
hips.
Conflict of interests None.
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