High congenital hip dislocation in adults - arthroplasty and functional results

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

High

congenital

hip

dislocation

in

adults

–

arthroplasty

and

functional

results

夽

Diogo

Lino

Moura

∗

,

António

Figueiredo

Servic¸odeOrtopedia,CentroHospitalareUniversitáriodeCoimbra,Coimbra,Portugal

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received13December2016 Accepted21February2017 Availableonline23February2018

Keywords:

Hipcongenitaldislocation Hiparthroplasty

Hipjoint Adult Osteotomy

a

b

s

t

r

a

c

t

Objective:Retrospective case–controlstudyonthe authors’experienceregarding arthro-plastyinhighcongenitaldislocationsofthehipinadults.

Methods:Sample with 11 high congenital hip dislocations (Hartoﬁlakidis type C) that occurredinsevenpatients,whoweresubmittedtohiparthroplastybythesamesurgeonand withthesamesurgicaltechnique.Meanfollow-upperiodwas4.32±2.67years(minimum oneyear)andallpatientswereevaluatedbythesameexaminer.

Results:Allthearthroplastieshadcementlessﬁxation,withapplicationofscrewed acetab-ularcups,conicalfemoralstems,andametal-polyethylenearticularpars.Ineverypatient, shorteningfemoralosteotomieswereperformedatsubtrochantericorsupracondylar loca-tions.ThemeanHarrisHipScoreatthelastevaluationwas88.55±4.50(range81–94).The meantimewithhighdislocationofthehip(42.91±14.59years,range19–68)showeda sig-niﬁcantinversecorrelationwithHarrisHipScore(r=0.80;p=0.003).Allpatientsreported importantreliefofpaincomplaintsandarecapableofambulationwithoutanyexternal support.Intheunilateraldislocations,leglengthdiscrepancieswerefullycorrected;inthe bilateralcases,isometriclimbswereachievedinallpatients.Allosteotomiesconsolidated, withameanintervalof3.27±0.47months.Therewerecomplicationsin18.18%ofthe sam-ple:oneiatrogenicintraoperativefractureofthegreatertrochanterandatransitorysciatic neurapraxia.

Conclusion:Despitebeingademandingsurgerywithareportedlyhighcomplicationrate, totalhiparthroplastyinhighcongenitaldislocations,whenproperlyindicatedand techni-callycorrectlyperformed,allowsanimprovementinfunctionandqualityoflife.

夽_Study_conducted_at_Centro_Hospitalar_e_{Universitário}_de_Coimbra,_Servic¸o_de_Ortopedia,_Coimbra,_Portugal. ∗ _{Corresponding}_author.

E-mail:dﬂ[email protected](D.L.Moura). https://doi.org/10.1016/j.rboe.2017.02.008

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Luxac¸ões

congênitas

altas

da

anca

no

adulto

–

Artroplastia

e

resultados

funcionais

Palavras-chave:

Luxac¸ãocongênitadeanca Artroplastiadeanca Articulac¸ãodaanca Adulto

Osteotomia

r

e

s

u

m

o

Objetivo: Estudoretrospectivosobreaexperiênciadosautoresnousodeartroplastiaspara otratamentodeluxac¸õescongênitasaltasdaanca.

Métodos:Amostracom11luxaçõescongênitasaltasdaanca(HartofilakidistipoC)verificadas emsetepacientes,queforamsubmetidosaartroplastiadaancapelomesmocirurgiãocom amesmatécnicacirúrgica.Otempodeseguimentomédiofoide4,32±2,67anos(mínimo umano)etodosospacientesforamavaliadospelomesmomédico.

Resultados: Todasasprótesestiveramfixaçãonãocimentada,usaram-secúpulas acetabu-laresaparafusadas,hastesfemoraiscônicasepararticularmetal-polietileno.Emtodosos pacientesforamefetuadasosteotomiasdeencurtamentofemoralnonívelsubtrocantérico ousupracondiliano.OHarrisHipScoremédionomomentodaúltimaavaliaçãoclínicafoi de88,55±4,50(intervalo81-94).Otempodeduraçãodaluxaçãoaltadaanca(42,91±14,59 anos,intervalo19-68)demonstrouumacorrelaçãoinversasignificativacomoHarrisHip Score(r=0,80;p=0,003).Todosospacientesrelataramalívioimportantedasqueixasálgicas etodossãocapazesdedeambularsemqualquerapoioexterior.Nasluxaçõesunilaterais, conseguiu-secorreçãocompletadadismetriaenasbilaterais,membrosisométricosem todos ospacientes.Todasasosteotomiasconsolidaramemtempomédiode3,27±0,47 meses.Verificaram-secomplicaçõesem18,18%daamostra:umafraturaiatrogênica intra-operatóriadograndetrocântereumaneuropráxiatransitóriadociático.

Conclusão: Apesar de serumacirurgia exigenteecomelevadoíndicede complicac¸ões relatado,aartroplastiadaancanaluxac¸ãocongênitaalta,quandodevidamenteindicadae tecnicamentebemexecutada,permitemelhorarafuncionalidadeequalidadedevidados pacientes.

Introduction

Highdislocationofthehip,alsodescribedbyHartoﬁlakidis as type 3 or type C dislocation, is a rare clinical entity, representingthe mostseveretype inthespectrumof con-genitalhipdysplasia.Typically,patientspresentafterdecades of evolution and adaptation to the abnormal hip position in the neoacetabulum or false acetabulum, with disabling complaintsofpainandfunctionallimitationduetothe devel-opmentofearlysecondarycoxarthrosis(whosesymptomsare typicallyobservedinthefourthandﬁfthdecadesoflife).1–9

Arthroplastyreconstructionatthecorrectcenterofrotation ofthe hip, atthelevel ofthe true acetabulum or paleoac-etabulum,hasbeenshowntohavesuperiorbiomechanical results(amongwhich,theincreaseintheleverarmandinthe strengthoftheabductormuscles),andsuperiorarthroplasty duration when compared with the more cephalic applica-tion ofthe arthroplasty.6,10–15 _In _order _to _bring _the _femur

intothepaleoacetabulumandpreventorminimizethe occur-renceofneurovascularinjuriesduetoexcessive stretching, afemoralshorteningosteotomyisusuallyrequiredinhigh dislocations.6,15–18_Hip_arthroplasty_in_cases_of_high

disloca-tionisconsidered oneofthemostdemandingsurgeries in orthopedics,mainlydue tothefollowingreasons: needfor reconstructionofthe centerofrotationinthe paleoacetab-ulum,withriskofneurovascularlesionsbystretching;need

forfemoralshorteningosteotomy;distortionofthemuscular, neurovascular,and boneanatomy(reducedpaleoacetabular bonestockand narrowfemoralcanal);andneedtorestore isometryofthelowerlimbs.5,6,15,19,20_The_authors_describe_the

arthroplastictechniquethattheyuseinhighcongenital dislo-cationsofthehipinadults;subsequently,theresultsoftheir experiencearepresented.

Material

and

methods

Theauthorsretrospectivelypresented11casesofhigh con-genital dislocations ofthe hip (Hartoﬁlakidis type C),3,7 _in

sevenpatientswhounderwenthiparthroplastybythesame surgeonusingthesamesurgicaltechniqueovereightyears. Themeanfollow-uptimewas4.32±2.67years(minimumone, range1–8).Dataonthedurationofhighhipdislocation, symp-tomsthatledtoarthroplasty,thetypeofprosthesisapplied, lengthofhospitalstay,complications,andlevelofsatisfaction (scalefrom0to5)werecollected.Aclinicalandradiographic evaluationwas performedatthetimeoffollow-up ofeach patient(1–8yearspostoperatively).Thefunctionalscoreused wastheHarrisHipScore21_;_{Trendelenburg}_sign_was_classiﬁed

inaccordancewithKuhfuss.22_Patients_were_also_assessed_for

improvementinpaincomplaints,gaitfunction,andwhether ornottheywouldundergoanewsurgicalintervention. Radio-graphicevaluationincludedthesearchforsignsofloosening

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andprostheticmigration,aswellasperiarticularheterotopic ossiﬁcation.Regardingthetimeofosteotomyconsolidation,it wasconsideredequaltothedateoftheconsultationinwhich radiologicallyfortheﬁrsttime,thedisappearanceofthe hypo-transparencyoftheosteotomycutandthepresenceofbone calluswasobserved.Thevariableswerestatisticallyanalyzed usingSPSSv_.23_Pearson’s_correlation_test_was_used_for

quan-titativevariables.All patientssignedtheInformedConsent Formandthepresentstudywasapprovedbythisinstitution.

Arthroplastytechniqueinhighcongenitalhipdislocations inadults

Thearthroplastytechniqueusedbytheauthorsaimsat posi-tioningtheacetabularcomponentinthecenterofrotationof thehip,i.e.,inthepaleoacetabulumortrueacetabulum,and atthesametimecorrectingthelowerlimbdysmetria.Inthe preoperativeperiod,ifthedistancebetweenthelocationof thefemoralheadintheneoacetabulumorfalseacetabulum andthepaleoacetabulumisgreaterthan4cm,whichhappens inmostcasesofcongenitalhipdislocation,theauthorsuse femoralshorteningosteotomy(whichcanbeperformedatthe subtrochantericorsupracondylarlevel)tobringthehipinto thepaleoacetabulum,thusreducingtheriskofneurovascular injuriesduetoexcessivestretching.16,17_Careful_preoperative

planningoftheamountoffemoralbonetoberesectedatthe siteoftheosteotomyforshorteningisparamountinorder tocorrectthe dysmetria.Itshould benotedthat, although afemoralshorteningosteotomyisperformed,afterthehip arthroplastyappliedonthepaleoacetabulum,thesepatients becometallerthaninthepreoperativeperiod,asthe dislo-catedfemoralheadinthehighpositionisreducedtoacaudal position;thishipreductiondistancefrom thehighposition correspondsto theamount ofbone thatisresected atthe osteotomy.Thefirstintravenouscefazolin doseis adminis-tered approximately30minpriorto surgery,and continues forthefirst48h.Forthissurgery,theauthorspreferthe pos-terior accessroute, inwhichthe patient ispositionedin a lateraldecubitusposition.Afterremovalofthehypertrophic andredundantjointcapsule,aninsitufemoralneckosteotomy is performed. Subsequently, the femoralhead is extracted andthe paleoacetabulumisexposed;thelattercanbe rec-ognizedthroughtheidentificationofthefollowingreferences: greatersciaticnotch,radiologicalU,anterior/posterior acetab-ularcolumns,andobturatorforamen.Inordertodetermine howfartoadvanceacetabularmillinginthedysplastic pale-oacetabulum,theauthorsprogressivelydrillthecenterofthe acetabularcavitywithafinedrilluntilboneconsistencycan nolongerbefelt.Thelengthofthedrillintheintraosseous positionwillcorrespondtotheremainingbonequantityin theacetabulumtoanintrapelvicposition;themillingshould belessdeep than thismeasured length.Intraoperative flu-oroscopymay beusefultoidentifythe levelofthe femoral neckosteotomyandofthetrueacetabularfundus.Thenext goalistoreconstructacavityinadysplasticacetabulumand atthe same time preserve as muchof the native bone as possible,whichisachievedbyextendedmilling(withsmall mills – 40–44mm) in the thicker posterior acetabular wall andlessmillingintheanterior,dysplasticwall.Theexisting bonebridgebetweentheneoandpaleoacetabulumshouldbe

preserved;althoughfragile,itcorrespondstotheroofofthe paleoacetabulum.Incasesofsevereacetabulardysplasia,in whichmorethanone-thirdoftheacetabulardomeis uncov-ered,afemoralheadgraftisusedtoreconstructtheacetabular wall(acetabuloplasty).Afteradequateacetabularpreparation, the uncemented acetabular component is implanted, and thensecuredwithscrews(usuallytwo)andtheirrespective polyethyleneinserts.

Inhighhipdislocations,softtissuereleaseisoften insuf-ficient to achieve a reduction from the femoral head to thepaleoacetabulum.Thus,inordertoavoidneurovascular lesions due toexcessive stretching,incases ofhigh dislo-cationstheauthorsoptforatransversefemoralshortening osteotomy (whichmay or may notbeassociatedwith soft tissuerelease,includingiliopsoas,rectusfemoris,hamstring andlongadductortenotomies);theseosteotomiescanbe per-formed atasubtrochanteric(Fig.1)or supracondylar level. Apartialcorrectionofthedysmetriaispreferred toa neu-rovascularinjurybyexcessivetension.Currently,theauthors prefersubtrochantericfemoralosteotomiestothedetriment ofthesupracondylartype.Aftertheacetabularcomponentis applied,femoralmillingbegins;specialmillsmayberequired duetothenarrowdysplasticintramedullarycanal.The sur-geonshouldpayspecialattentiontothismilling,duetothe frequentfragilityofthecorticalboneandthehighriskof iatro-genic fracture. Thesubtrochantericosteotomylevel isthen marked with the teststem;the first osteotomy cutis per-formedapproximately1cmdistaltothesmalltrochanter.The remainingmillingofthe proximaland distalfemuris per-formed;then,aclampisappliedonthedistalfemurandthe teststemispassedthroughtheproximalfemur.Thestemin theproximalfemurisreducedtotheacetabularcomponent, and itsdistalportion overlapsthedistalfemur,thus mark-ingtheamountoffemurthatneedstoberemoved(inmost cases, 2–3cm; Fig.1).Thesecondcutofthefemoral short-ening osteotomyisperformed atthesubtrochanteric level, followed bythe applicationofthedefinitive non-cemented conical femoralstemthat passesfirst through thefemoral fragment proximaltothe osteotomyand thenthrough the distalfragment;subsequently,theprosthesisisreduced.The typeofimplantusedandthemethodoffixationdependon the qualityandquantityofbonestock. Sincepatientswith highhipdislocationsaretypicallyyoung,withacceptablebone stock,theprostheticfixationispreferablynon-cemented.The elective implants chosen by the authors for these arthro-plasties are trabecular metalacetabular domes withscrew fixationandconicalfemoralstems.Themainadvantagesof the non-cementedconicalstemsincludetheirbetter adap-tation to the dysplasticfemoral canalsthat these patients typicallypresent,andgreaterstabilityofthesubtrochanteric osteotomyduetotheirdiaphysealfixationcapacityand con-sequenthighercontactstressattheosteotomylevel(aneffect causedbyarotationallystabilizedcenter-medullarystem,due to its porosityand bonecontactstress), which oftensaves fixationmaterial.23–27Incasesofhipabductioninsufficiency andprostheticinstability,theuseofaconstrainedoradual mobilityprosthesisisrecommendedtoensurethestabilityof theneo-articulation.Insituationsofscarceacetabularbone stockorabsentwalls,thecavitycanbeconstructedwithan autograft extracted from the femoralhead; the acetabular

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Fig.1–Subtrochantericosteotomytechnique.(A)Markingtheleveloftheﬁrstcutofthesubtrochantericosteotomywiththe

teststem;(B)ﬁrstcutofthesubtrochantericosteotomy;(C)proximalanddistalfemurmillingandclampingofthedistal

femur;(D)reductionofthestemappliedintheproximalfemurtothepreviouslyappliedacetabularcomponentandits

overlapwiththedistalfemur,markingtheamountoffemurtoberemoved;(E)secondcutofsubtrochantericosteotomy,in

thiscasewithanexcisionofabout3cmoffemurlength(F);(G)applicationofthedeﬁnitiveconicalfemoralstem,passing

ﬁrstthroughthefemoralfragmentproximaltotheosteotomy;(H)applicationofthedeﬁnitiveconicalfemoralstemthrough

thedistalfemoralfragment;subsequently,prosthesisreductionisperformed.

funduscanbereinforcedwithimpactedgranulatedbonegraft, followedbytheapplicationofthenon-cementedacetabular domeorreconstructionringsintheremaininghostbone.In mostsubtrochantericosteotomies, afterthe non-cemented conicalstem isapplied,the osteotomy isstableenough to avoidthe needformoreﬁxation material.However,if this stabilityisnotobserved,particularlyatarotationallevel,the osteotomyshouldbestabilizedwithaplateorsteelcables. Inthesupracondylarosteotomies,plateandscrew stabiliza-tionisalwaysnecessary.Thesurgicaltimeofthis highhip dislocationtotalarthroplastytechniqueisbetweentwoand threehours, withanapproximatebloodlossof600ml.The postoperativeperiodofthesepatientsincludeswalkingwith crutcheswithoutweight-bearingontheoperatedlimbuntil osteotomyconsolidation,followedbyarehabilitation proto-colthatfocusesontheabductorapparatus.Themainstepsof thisinterventionare:ensuringgoodsurgicalexposureinorder torecognizetheanatomicalreferences,adequateacetabular millingatthecenterofrotationofthepaleoacetabulum, ade-quaterestorationofsofttissuetension,stablereconstruction

of the neo-articulation, and adequate rehabilitation of the abductorapparatus.

Results

Thesevenpatients(allfemales)weresubmittedtototalhip arthroplastyafterameanof42.91±14.59years(range19–68) with high congenital hip dislocations classified as Hartofi-lakidistypeC(Table1).Ofthetotal,57%ofthepatientshad bilateralhighdislocations,whiletheremainderhadunilateral highdislocations;onepatient(VAPS)hadaHartofilakidistype 2lowdislocationonthecontralateralside.

In all patients, the complaints that led to arthroplasty werethecombinationofdisablingpainintheaffectedhips and functional limitation,inparticulargaitability(Table2; Fig. 2). The posterior approach of the hip was used in all cases.Femoral shorteningosteotomywasperformedon all hips;theseproceduresweredoneatasubtrochantericlevel in 72.72% of the cases, and at the supracondylar level in

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Table1–Descriptiveanalysisofthesample.

CMPB CMPB RMSA RMSA VAPS

Gender ♀ ♀ ♀ ♀ ♀ Side L(bilateral dislocation) R(bilateral dislocation) R(bilateral dislocation) L(bilateral dislocation)

L(bilateraldislocation,but onlyhighontheleft) Dislocationtime–ageat

surgery(years)

26 27 44 45 19

Follow-uptime(years) 8 7 7 6 7

MHMT MALS MMMM MMMM MFDF MFDF Summary Gender ♀ ♀ ♀ ♀ ♀ ♀ 100%♀ Side R(Unilateral dislocation) L(Unilateral dislocation) L(bilateral dislocation) R(bilateral dislocation) L(bilateral dislocation) R(bilateral dislocation) 54.54%L;45.44%R; 57.14%patientswith bilateralhigh dislocations,42.86% unilateralhigh dislocations Dislocation time–age atsurgery (years) 55 68 40 41 53 54 Mean42.91±14.59 Follow-up time(years) 3 2 3 2 1.5 1 Mean4.32±2.67 R,right;L,left.

theremainingpatients.Allsupracondylarosteotomieswere securedwithplate and screws.Noextra fixationwas used in subtrochanteric osteotomies that remained stable after the application of the femoral stem;this was observed in half ofthese osteotomies. In the other half, due to insuf-ficient stability after placement of the femoral stem, it was reinforced with plate and screws and/or steel cables. No further soft tissue release was required to achieve an arthroplasty with acceptable mobility. All prostheses had non-cemented fixation; acetabular domes with screw fixa-tion and conical femoral stems were used in all patients. Thearticularparsappliedwasthemetal-polyethyleneinall hips.Inonepatient(VAPS),foraccentuatedpaleoacetabular dysplasia and insufficient walls, shelf acetabuloplasty was performedwith autograftextracted fromthe femoralhead itself,inorder toincreasesupralateralacetabularcoverage. None ofthe casesrequiredconstrainedor double mobility prostheses.

Themeanhospitalizationtimeforsurgerywas9.63±2.87 days (range 6–14); in63.63% of the patients, postoperative transfusionoferythrocyteconcentratewasrequired(Table3). ThemeanHarrisHipScoreatthetimeofclinicalevaluation was88.55±4.50(range81–94;Table4).Thedurationofthehigh hipdislocationhadasigniﬁcantinversecorrelationwiththe HarrisHipScore(r=0.80;p=0.003).

Allpatientsarecurrentlyabletowalkwithoutanysupport; 57.14%ofthesamplepresentaslightTrendelenburgsign.All patientsreportedsigniﬁcant relieffrompaincomplaints;in 14.29%ofthepatients,thisreliefwaspartial.

Inunilateraldislocations,acompletecorrectionofthe dys-metriawasachieved;inbilateralcases,isometriclimbswere achievedinallpatients.Allfemoralosteotomiesconsolidated, withameantimeof3.27±0.47months.

Complications were observed in 18.18% of the sample (Table 5), namely: one intraoperative iatrogenic fracture of

thegreattrochanter,whichwassecuredwithKirschnerwires andatensionband;andoneneurapraxiaofthesciaticnerve, whichrevertedcompletelyaftertwomonths.Nocasesof pros-thetic loosening, infection or heterotopic ossiﬁcation were recordeduntilthedateofthisstudy.

Allpatients,includingthosewithcomplications,indicated thattheywouldundergoanewarthroplasty(mean satisfac-tionlevelof4.86±0.3witharangeof4–5,onascaleof0to 5),mainlyduetothereliefofpainfulcomplaints,recoveryof hipmobility,andcorrectionofdysmetria,whichallowedthem tocarryoutactivitiesofdailylivingthatwerepreviouslynot possibleandthussubstantiallyimprovedtheirqualityoflife.

Discussion

Arthroplasty incongenitalhipdislocationsisachallenging andtechnicallydemandingsurgery.Theanatomyisdistorted bydecadesofpossiblemobilizationofthedislocatedhipin theneoacetabulum,andthesofttissuesareretracteddueto jointelevation.Highdislocations(HartoﬁlakidistypeC)arethe mostextremeofthecongenitalhipdislocations,asthereisa long distancefromthehip toits correctcenterofrotation. Inmostcases,therotationcentercanonlybecorrectedby femoralshorteningosteotomy.1–5 _Even _after_osteotomy,_the

necessary stretchingto reconstructthe hipin the paleoac-etabulum maycauseneurovascular injuries,mostofwhich aresciaticneurapraxia.Inthepresentstudy,theauthorsused transverseosteotomiesatthesubtrochantericandalsoatthe supracondylarlevel.However,despitegoodresultswithboth techniques,aimingatreducingsurgicalaggressivenessandto haveonlyoneincision,subtrochantericosteotomiesare cur-rentlypreferred,inlieuofsupracondylarosteotomies.

The functional results (mean Harris Hip Score of 88.555±4.50), gait functionality, and symptomatic relief

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Table2–Surgicalintervention.

CMPB CMPB RMSA RMSA VAPS MHMT

Reasonfor wanting arthro-plasty Hippain, functional limitation Hippain, functional limitation Hippain, functional limitation Hippain, functional limitation Hippain, functional limitation Hippain, functional limitation

Accessroute Posterior Posterior Posterior Posterior Posterior Posterior

Typeof femoral osteotomy Subtrochanteric, securedwith 1plateand2 steelcables Supracondylar, securedwith plateand1 steelcable Supracondylar, securedwith plate Supracondylar, securedwith plate Subtrochanteric, securedwith steelcables Subtrochanteric, noextra fixation Prosthesis Non-cemented, acetabulum withscrew fixation, conicalstem Non-cemented, acetabulum withscrew fixation, conicalstem Non-cemented, acetabulum withscrew fixation, conicalstem Non-cemented, acetabulum withscrew fixation, conicalstem Non-cemented, acetabulum withscrew fixation, conicalstem, shelf acetab-uloplasty Non-cemented, acetabulum withscrew fixation, conicalstem

Articularpars Metal-polyethylene Metal-polyethylene Metal-polyethylene Metal-polyethylene Metal-polyethylene Metal-polyethylene

MALS MMMM(Fig.2) MMMM(Fig.2) MFDF MFDF Summary

Reasonfor wanting arthro-plasty Hippain, functional limitation Hippain, functional limitation Hippain, functional limitation Hippain, functional limitation Hippain, functional limitation 100% Pain+Functional limitationin ADLs

Accessroute Posterior Posterior Posterior Posterior Posterior 100%

Posterior Typeof femoral osteotomy Subtrochanteric, securedwith steelcables Subtrochanteric, noextra fixation Subtrochanteric, securedwith steelcables andcortical autograft Subtrochanteric, noextra fixation Subtrochanteric, noextra fixation 72.72% sub-trochanteric; 27.27% supracondylar Prosthesis Non-cemented, acetabulum withscrew fixation, conicalstem Non-cemented, acetabulum withscrew fixation, conicalstem Non-cemented, acetabulum withscrew fixation, conicalstem Non-cemented, acetabulum withscrew fixation, conicalstem Non-cemented, acetabulum withscrew fixation, conicalstem 100% non-cemented, acetabulum withscrew fixation,and conicalstems Articularpars

Metal-polyethylene Metal-polyethylene Metal-polyethylene Metal-polyethylene Metal-polyethylene 100% metal-polyethylene AVDs,activitiesofdailyliving.

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Table3–Postoperativeperiod.

CMPB CMPB RMSA RMSA VAPS MHMT MALS MMMM MMMM MFDF MFDF Summary

Lengthofstay(days) 11 11 13 12 7 7 14 6 7 7 11 Mean9.63±2.87

Transfusionof erythrocyte concentrate(EC)

Yes Yes No Yes No Yes Yes Yes No No Yes 63.63%yes

observedinthepatientsinthepresentsamplearein agree-mentwiththoseinthescientiﬁcliterature;inmajorstudies onarthroplastiesinhigh hipdislocations,the meanHarris HipScorerangesbetween83and95.5,6,20,27–32_Although

sat-isfactoryfunctionalresultshavebeenobserved,theliterature reportsimportantsurgicalcomplicationratesinhighhip dis-locations(between9%and 43%);thesevaluesaregenerally higher than those foundin the present sample (complica-tion rate of18.18%). The main complications reported are prostheticasepticloosening,whichrangesfrom4.7%to16%, andismorefrequentforacetabulardomesthanforfemoral stems,intraoperativefracture,neurovascularlesions, disloca-tion,infection,heterotopicossiﬁcation,non-consolidationof theosteotomy,andabductorapparatusinsufﬁciency,among others.5,6,20,28–32_The_two_{complications}_observed_in_the

sam-plewereduetotractionmovementsorexcessivetractionof softtissuesduringsurgery,resultinginintraoperativefracture andneurapraxia.Nocasesofprostheticloosening,infection, heterotopicossiﬁcation,ornon-consolidationofthefemoral osteotomywereobservedinthe presentsample.Asa con-sequence, whileinthe literaturethe revisionrate ofthese arthroplastyrangesupto26%,inthepresentsamplenoneof theprosthesesrequiredrevisiontodate.5,20,28–32_In_turn,_the

caretakenduringsurgerynottoinjuretheretractedabductors (inparticulargluteusmedius,avoidingdirectdivulsionoverit) andadequaterehabilitationoftheabductormusclesallowed animportantdegreeoffunctionalrecovery;italsocausedthe Trendelenburgsignrecordedinthissampletobeonlyslight, andlikelyrecoverableafteraperiodofprogressive rehabilita-tion,whichisinagreementwithothersimilarstudies.6,23,28_In

addition,thisstudystatisticallydemonstratedthatthelonger thedurationofthehipdislocation,thelowerthefunctional indexesoftheHarrisHipScoreafterthemeanfollow-uptime ofthisstudy(4.32±2.67years),whichisprobablyduetothe greateratrophyandretractionoftheabductormusclesina hipdislocatedforalongertimeandconsequentgreater dif-ﬁcultyinitsrehabilitationwhencomparedwithdislocations withlowerevolutiontime.

Long-termstudiesonarthroplastiesincongenitalhip dis-locationsusingnon-cementedprosthesesarescarce;someof themaresummarizedbelow.Reikeråsetal.,20_in_a

prospec-tive study over a mean follow-up time of 13 years (range 8–18)in65non-cementedarthroplastiesinhighhip disloca-tionsusingasubtrochantericshorteningfemoralosteotomy, observedameanHarrisHipScoreof87andacomplicationrate ofonly9%.Complicationsincluded10acetabulardome revi-sionsduetoasepticloosening(thatwasnotobservedinany ofthefemoralstems),onecaseofrecurrentdislocation,two casesofcommonﬁbularnerveneurapraxia,andonecaseof non-consolidationoftheosteotomy.Inturn,Ollivieretal.,5_in

theirretrospectivestudywithameanfollow-uptimeoften years (range0.8–14.5)with28 non-cemented arthroplasties

performedinhighhipdislocations,concludedthatalthough somecomplicationswereobserved(29%complicationrate), long-termoutcomesweresatisfactory(astatistically signiﬁ-cantimprovementinthemeanHarrisHipScorefrom43in thepreoperativeperiodto87),achievinga10-yeararthroplasty survivalrateof89%.Similarly,Eskelinenetal.27_{retrospectively}

studied64high dislocationsthatunderwent non-cemented arthroplasties,withameanfollow-uptimeof12.3years,and obtainedastatisticallysignificantimprovementinthemean HarrisHipScorefrom54.2inthepreoperativeperiodto83.9 attheendofthefollow-uptime.Two-thirdsofthepatients intheirsamplepresentedtotal relieffrompaincomplaints and only8% of the patients had a positive Trendelenburg sign (compared to84% preoperatively). Therate of periop-erative complicationswas19%and includedthree casesof commonfibularnerveneurapraxia,oneofthefemoralnerve, and one ofthe glutealnerve, four intraoperativefractures, onepoorlypositionedstem,onesuperficialinfection,andtwo early dislocations.The10-year survivalrate ofthefemoral stems was 93.7% and ofthe acetabulardomes,87.8%.The authorsidentifiedsignificantlyhigherasepticlooseningrates inthenon-cemented acetabulardomeswithscrewfixation whencomparedwithcompareddomeswithporouscoating; the10-yearsurvivalrateofthelatterwas94.9%.Onlythree casesofheterotopicossificationwereobserved.

Somestudiesreportcasesofnon-consolidationof trans-verse osteotomies, probably due to insufﬁcient rotational stability,andthereforerecommendobliqueratherthan trans-verse osteotomies and some form of ﬁxation.5,18,20,30,33 _In

thepresentstudy,allosteotomiesweretransverseand con-solidated in a mean time of 3.27±0.47 months. This rate is probably due to the quality ofthe stability achieved in osteotomies,eitherwiththenon-cementedconicalstem (con-sideredbytheauthorsthestabilizationofchoiceinosteotomy, withouttheneedforosteosynthesismaterialduetoits char-acteristics,whichhavealreadybeendescribedinthesurgical technique),orwiththeuseofﬁxationmaterial;therateisalso probablyduetotheappropriateintervaluntilweight-bearing ontheoperatedlimbwasauthorized,whichhappenedonly afterconsolidationoftheosteotomy.

Themainlimitations ofthe present study are its retro-spectivenature,whichdidnotallowarigorouspreoperative functional evaluation,thesmall samplesize,and theshort follow-uptime.Inturn,thefactthatthearthroplastieswere allperformedbythesame surgeonusingthesamesurgical techniquedecreasessomebiasesdependentonthesefactors. Adequateindication,atechnicallywell-performedsurgery, withoutinjurytotheabductors,andthecorrectapplication ofnon-cementedprostheticcomponentstoachieveastable arthroplastyandobtainisometryofthelowerlimbs,aswell asanadequaterehabilitationfocusedontheabductor appara-tus,maybesomefactorsthatexplainthesatisfactoryresults

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r e v b r a s o r t o p . 2 0 1 8; 5 3(2) :226–235

233

HarrisHip Score 94 91 85 87 93 83

Gait Yes,withoutsupport Yes,withoutsupport,slightTrendelenburgsign Yes,without support Yes,without support, slight Trende-lenburg sign PainRelief Yes,complete Yes,incomplete Yes,complete Yes,complete Satisfaction index(1–5) 5 5 5 5 Osteotomy consolida-tion

Yes,3months Yes,3months Yes,4months Yes,3months Yes,3months Yes,4months

MALS MMMM MMMM MFDF MFDF Summary

HarrisHip Score

81 93 91 85 91 Mean

88.55±4.50 Gait Yes,without

support, slight Trende-lenburg sign Yes,without support

Yes,withoutsupport,slightTrendelenburgsign 100%withoutsupport;57.14%slightTrendelenburgsign

Painrelief Yes,complete Yes,complete Yes,complete 100%yes,85.71%completeand14.29%incomplete Satisfaction index(1–5) 5 5 4 Mean4.86±0.3 Osteotomy consolida-tion

Yes,3months Yes,3months Yes,3months Yes,4months Yes,3months 100%yes, mean 3.27±0.47

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Table5–Complications.

CMPB CMPB RMSA RMSA VAPS MHMT MALS MMMM MMMM MFDF MFDF Summary

No No Intraoperative fractureof thegreat trochanter, ﬁxationwith K-wireand tensionband No No No No Sciatic neurapraxia (painand paresthesias that disappeared withintwo months) No No No 18.18% com-plications: 9.09% iatrogenic fractureof thegreat trochanter; 9.09%sciatic neurapraxia

obtainedinthisseries.Themainsurgicalchallengesincases ofhighhipdislocationaretheidentiﬁcationandcreationof theacetabularcavityatthecenterofhiprotation(inthe pale-oacetabulum)andthefemoralshorteningosteotomyrequired toreducethehiptothepaleoacetabulum,whilethegreatest challengeinthepostoperativeperiodistherehabilitationof abductormusclesthathaveatrophied,retracted,and weak-enedfordecadesduetothedislocatedhip.6

Conclusion

Despitebeingademandingsurgerywithareportedhighrate ofcomplications,hiparthroplastyinhighcongenital disloca-tion,whencorrectlyindicatedandtechnicallywellperformed, allowsanimprovementinthefunctionalityandqualityoflife ofthesepatients.

Conﬂicts

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Theauthorsdeclarenoconﬂictsofinterest.

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