I did several such THR in adults and in all cases but one the fixation of the cup was in primary anatomical acetabulum. The are a lot of pitfalls First CT scan has to be performed and anatomical acetabulum assessed, (especially antero-posterior diameter is very limited), so sometimes very small cup has to be fixed. Quality of bone in anatomical acetabulum is poor. Also in some cases the femoral medullary canal is very narrow, sometimes specially-designed stems have to be used. Reposition of the hip joint to anatomical position usually is difficult and requires even 4-5 cm distal transfer of a leg - there is risk  of peroneal nerve palsy. If reposition is impossible or very forcefull one can try to fix stem dipper or temporarly detach greater trochanter. Another way is to make shortening subtrochanteric osteotomy of the femur - but I do not recommend this method. Although surgery is difficult, results after long rehabilitation are good. Patients are very satisfied although objective results are not excellent. With this method even equalization of the legs is possible. In the literature one can find some instructional lectures concerning this problem.

Thank you, Wieslaw, for your proper response. I agree entirely with the difficulties you mention. It is well that such cases are getting rarer and rarer.

I also have several similar cases. I use a two-staged surgery. At first I resect the head and neck of the luxated hip and put the patient on direct skeletal extension for 2 weeks controlling the neurologic state and the descensus radiologically. In the second stage I implant the endoprosthesis (cup in the primary acetabulum). Here one have to face the small room for implanting the cup (sometimes head diameter 22 mm). The risk of dislocation exists for the reason of small head diameter, and of course in case where  the implantation deviates from the neutral position (big anteversion or retroversion !).

I had a 50-year old patient with bilateral high hip luxation. This is a special challenge. By now (3 years postop.) he is doing well.  I do not know how long ?!

I have done quite a few of high (Crowe IV) dislocations.  Here is what I have learned:

1.  Anatomic location of acetabular prosthesis is mandatory.  You can always find the transverse ligament as an anatomic guide, and if necessary,, obtain an intraoperative X-ray to confirm location.

2.  The resected head/neck fragment is an excellent source of bone graft for the superior/anterior sector of the native acetabulum.  The younger the patient, the more aggressive to be with autogenous graft.

3.  I believe a subtrochanteric osteotomy is essential to minimize sciatic palsy risk.

4.  The use of a proximally modular femoral stem will allow avoidance of excessive anteversion of the stem, and obviate the need for trochanteric osteotomy in most cases (the sub trochanteric osteotomy allows anterior translation of the greater trochanter, thus avoiding troch osteotomy.  An oblique osteotomy will produce rotational stability at the osteotomy site.)

5.  Even with a subtroch osteotomy, I adopted the practice of routinely nursing the patient the first post-op night with the operative extremity abducted off the edge of the bed, allowing the knee to flex, and thus reduce tension on the sciatic nerve.  Support the foot with a bedside chair or stool, to maintain the knee in 45 degrees of flexion.

I have had no non-unions of the subtroch osteotomies.  Good luck!

You mean DDH Crowe IV?

There are quite a bit of these cases in our department. Because screen program for earlier DDH is lack in our country, patients present severe type (when admitted in the hospital), always Crowe III and IV. It seems that the THR is the mainstream choice for those patients, however, some doctor like me prefer another one. You can find details and some useful methods in my recent article published in India journal of orthopaedics.

Dr. Jun, could you, please give some more information about your approach to adult patients with Crowe III and IV DDH ? Unfortunately, I do not have access to IJO. Some link, abstract or just short description would be appreciated.

Panayot,

You are getting some good advise especially from John Cuckler who has significant experience in this area. I had the opportunity recently to co-author a review paper on this subject with Evert Smith from the U.K. and I will attach for your review.

Total Hip Arthroplasty for dysplasia or congenital disease of the hip is technically demanding surgery that requires an in-depth understanding of the complex techniques required to solve the problems of both the pelvis and the femur. It also requires the ability to perform an experienced evaluation of the patient. The ‘high dislocation’ is the extreme example in this range of surgery. Patients are often young or middle aged; their hip pain and functional disability has so adversely affected their quality of life, they are more often than not keen for surgical intervention. A careful consent pertaining to specific complications related to each individual patient’s pathology is essential, as the surgical solution is not likely to rest with a total hip arthroplasty alone. In the majority of cases, there is often a requirement for treatment of the knees and the thoracolumbar spine as well. Emphasis should be directed toward nerve palsies and the fact that, in the majority of cases, revision surgery will be required.

Article Total Hip Arthroplasty for 'Dysplasia 'and Congenital Diseas...

Thank you, Timothy.

Surgery for "high congenital hip dislocation" in adults is really problematic. We might only hope that early prophylaxis and treatment of DDH will solve the problem in time and that such difficult - to- treat patients will be less and less in the future. 

Subtrochanteric osteotomy of the femur and shortening in combination with exact orientation of femoral component are very important moments.

Often the design features of the S-Rom proximal modular stem can reduce the need of osteotomy.

Dear Panayot,

I did several cases of Crowe IV high dislocation. As you said are rare but still present. Usually the acetabulum is very small but still present and you will find the transverse ligament and the pulvinar, I use uncemented press fit cup with two screws. For the femoral side shortening osteotomy usually removal of a segment of 2-3 cm below the lesser trocanter is necessary to reduce the prosthesis and to avoid sciatic palsy. I have no cases of non union. In the beghinning I  used S-Rom prosthesis but I had some problem of stability of the distal femoral segment so I switched to a conical stem with modular neck. You can have a very stable osteotomy, control the femoral version an adjust muscular tension and limb length. In bilateral cases it is important to inform the patinets that she(usally are female) will have a longer limb after the first operation which will be equalized after the second one.

Orthopedics. 2011 Aug 8;34(8):e328-33.

Total hip arthroplasty with shortening osteotomy in congenital major hip dislocation sequelae.

Dallari D1, Pignatti G, Stagni C, Giavaresi G, Del Piccolo N, Rani N.

Best regards.

Dear Giovanni,

I am totally agree with your nice explanation for Crown IV high doslocation.

Best regards. 

Thank you Bytyqi

Best regards

Giovanni