Rev. bras. ortop. vol.49 número1

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Technical

Note

Total

arthroplasty

in

displaced

dysplastic

hips

with

acetabular

reconstruction

and

femoral

shortening

–

technical

note

夽

,

夽夽

Paulo

Silva

_,

_Leandro

_Alves

_de

_Oliveira

_,

_Danilo

_Lopes

_Coelho

_,

Rogério

Andrade

do

Amaral

_,

_Percival

_Rosa

_Rebello

_,

_Frederico

_Barra

_de

_Moraes

a_{HospitalGeraldeGoiânia,Goiânia,GO,Brazil}

b_{ClínicadeOrtopediaeTraumatologia,Goiânia,GO,Brazil}

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Articlehistory:

Received3April2013 Accepted13May2013

Keywords:

Arthroplasty,replacement,hip Bonediseases,developmental Osteotomy

Transplantation,autologous

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Todescribeanewprocedureoftotalhipreplacementinpatientwithsevere developmen-taldysplasiaofthelefthip,usingtechniqueofacetabularreconstructionwithautogenous bonegraftsandsubtrochantericshorteningfemoralosteotomy.Totalhipreplacementdone inJanuaryof2003.TheEftekhar’sclassificationwasusedandincludedtypeD,neglected dislocations.Bonegraftincorporatedinacetabularshelfandfemoralosteotomy.Our con-tributionistheuseofanAllisplatetobetterfixacetabulargrafts,avoidingloosening,and cerclagearoundbonegraftinfemoralosteotomysite,whichdiminishpseudoarthrosisrisk. Thistechniqueshowsefficiency,allowingimmediatelyresolutionforthiscasewithpainand rangeofmotionofhipimprovement.Italsoallowstheacetabulardysplasiareconstruction, equalizationofthelimblength(withoutelevatedriskofneurovascularlesion)andrepairs thenormalhipbiomechanicsduetothecorrectionofthehip’scenterofrotation.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Artroplastia

total

em

quadris

displásicos

luxados

com

reconstruc¸ão

acetabular

e

encurtamento

femoral

Palavras-chave:

Artroplastiadequadril

Doenc¸asdodesenvolvimentoósseo Osteotomia

Transplanteautólogo

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e

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o

Descrevercontribuic¸õesàtécnicadacirurgiadeartroplastiatotalemdisplasiasdo desen-volvimentodoquadrilgrave,pormeiodareconstruc¸ãoacetabularcomousodeenxerto autólogoeencurtamentofemoralfeitocomosteotomiasubtrocantéricaem Vinvertido. Pacientesubmetidoaartroplastiatotaldoquadrilesquerdoemjaneirode2003.Foiusadaa classificac¸ãodeEftekhareopacienteeradotipoD,luxac¸ãoinveterada.Incorporac¸ãodo enx-ertonotetoacetabulareosteotomiafemoral.Acrescentamosafixac¸ãodoenxertodacabec¸a femoralnoacetábulocomplacadotipoAllis,quecontribuiparamaiorresistênciado sis-tema,eacerclagemcomfiodeac¸onoenxertoósseojuntoàosteotomiasubtrocantérica,que

夽

Pleasecitethisarticleas:SilvaP,deOliveiraLA,CoelhoDL,doAmaralRA,RebelloPR,deMoraesFB.Artroplastiatotalemquadris displ´sicosluxadoscomreconstruc¸ãoacetabulareencurtamentofemoral.RevBrasOrtop.2014;49:69–73.

夽夽

StudyconductedatDepartmentofHipSurgery,HospitalGeraldeGoiânia,ClínicadeOrtopediaeTraumatologiadeGoiânia,GO,Brazil.

∗ _{Correspondingauthor.}

E-mail:fredericobarra@yahoo.com.br(F.B.deMoraes).

2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

tambémareconstruc¸ãododéficitósseoacetabular,arecomposic¸ãodocomprimentodo membro(semriscoaumentadodelesãoneurovascular)earecuperac¸ãodabiomecânicado quadrilcomareparac¸ãodocentroderotac¸ãonormal.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Sincetheemergenceofthemoderntechniquesofprosthetic reconstruction ofthe hip using the principles ofCharnley etal,1 _{adiseasecontinuestochallengehip orthopedic} sur-geons: developmental dysplasia of the hip (DDH). In DDH the anatomy is altered. The dysplastic acetabulum is ver-tical, shallow and with proximal migration, and has poor bone quality and superolateral coverage deficit. The prox-imal femur is narrow, with small femoral head; and the shortneckand trochanter are locatedposteriorly.Changes inthesoftpartsalsooccur,withflatteningoftheabductor muscles, joint capsule thickening and redundant, hyper-trophy of iliopsoas muscle and shortening of the sciatic nerve.2

Because of these changes, Charnley et al. and Feagin etal.discouragedthepracticeoftotalhiparthroplasty(THA) in patients with DDH.3 _{Subsequently, other authors have} publishedstudiesusing bonegraft,withthegoal of recon-structingtheacetabulum andpromotinganincreaseinthe coverage of the prosthetic component. Hasting et al. and Parkeretal.,4 _{in1975,werethefirst touseautograftofthe} femoral head, with good results. Harris, in 1977, demon-strated the incorporation ofcortico-cancellous grafts,5 _and Azumaet al.,6 _{in1994,reviewedthe graft incorporationby} radiographicstudies.Thesestudiesencouragedthepractice ofacetabularreconstructionandadoptedtheincorporation of the graft into the acetabular bed with increased bone stock,whichresultsinincreasedsurvivalofthehip arthro-plasty.

Apartfromthedifficultiesimposedbyacetabular dyspla-sia,otherimportantobstaclesarethechangesoftheproximal femurandthelower limbdysmetria. Inthesepatients,the ectopyofthefemoralhead,moreproximally located,leads totheformation ofafalseacetabulumand tothe soft tis-sue changes already mentioned.In patients with bilateral involvement,the twosurgeries should be made withlittle delay between the procedures, so there is no detrimental effectonthepatient’sgaitrehabilitation.2_{Inthosepeoplein} whomtheaffectionisunilateral,oneshouldtrytorestorethe limblength.Thefemoralshorteningshouldbemadetoavoid anexaggeratedlimblengtheningand toprotectthe sciatic nerve.

Theaimofthisstudywastodescribethesurgicalstepsof atotalhiparthroplastyinpatientswithDDHwithdislocated hip,throughanacetabularreconstructionwithbonegrafting ofthefemoralheadandfixationwithplateforaddedstrength, andfemoralshorteningwithosteotomyininverted-V,with additionofbonegraftcerclageintotheosteotomy,toprevent nonunion.

Technical

note

Femalepatient,44yearsold,submittedtoTHAinJanuary2003, withclinicalpresentationofDDHandstubborndislocationof lefthip.Thepatientwasoperatedbyagroupofhipsurgeons intheGeneralHospitalofGoiânia(GO).Theclassificationof DDHofEftekhar7_{wasused:typeD(stubborndislocation),in} which,besidestheneedforacetabularreconstruction,femoral shorteningosteotomywasalsomade.

Inthepreoperativeplanning,werequestedAPradiographs ofthepelvis,includingtheproximalthirdoffemur,hipprofile, andorthoradiographicprofileofthelowerlimbs.An assess-mentwiththeuseoftemplateswasperformed.Thegoalwas thenormalbiomechanicsofthehiptobeoperated(Fig.1).

The patient underwent spinal anesthesia and was pos-itioned in lateral recumbency. The procedure started with anextensiveposterolateralapproachandposterior capsulec-tomy(viaKocher-Langenbeck).Followingtheosteotomyofthe femoralneck,thefemoralheadisreservedtobeusedasa graft totheacetabulum.Afterlocatingthetrueacetabulum (torestore thebiomechanics ofthe hipand givedurability totheimplant;onemustbecarefulnottoputthe implant into the false acetabulum), this structure was preparedto receivethegraftoffemoralheadfragment,andanosteotomy ofthefemoralneckwasperformed.Thefemoralheadiskept tobe usedasgraft oftheacetabulum,which ispositioned soastoincreasethesuperolateralcoverage ofacetabulum, and for correction of dysplasia. To obtain a good integra-tion,therecipientbedwasscarifiedtillbleedingandthegraft isfixedwithanAllisplateandscrewsforsmallfragments,

Fig.1– Radiographyofpelvisintheanteroposteriorviewin thepreoperativeplanningthathighlightsthe

Fig.2–RigidfixationoftheautograftforacetabularreconstructionwithAllisplate,showingintraoperativeimage(A)and pelvicX-rayinpost-operativeanteroposteriorview,showingacetabularreconstruction(B).

providing rigid stability to the system. Following that, the reamingoftheacetabularbedwasmade,andtheprosthetic componentwasapplied,nowunderanappropriatecoverage (Fig.2).

Thenext stepistopreparethefemoralcanal.Wemust becarefulwiththefemoralanteversionandanterior angu-lationofthefemur. Afterthereamingofthefemoralcanal, thesubtrochantericosteotomyofthefemurinan inverted-Vwasmade,withshorteningofthebone.Theosteotomyin Vfacilitatesthe reduction,increasesthecontactsurfaceof theosteotomyanddecreasesthepercentageof pseudoarthro-sis(Fig. 3).Withthe osteotomyreductiondone, weapplied animplant-testintothefemoralcanalanddidthefixation withDCPforlittlefragments,avoidingthefemoralcanal.After this,anautograftwithsteelwirecerclageatthe osteotomy sitewiththeosteotomizedboneitselfwasdone,alsoto pre-ventnonunion.Then,definitiveimplantandinterchangeable femoralheadwereapplied,andthehipreductionwasdone (Fig.4).Afterstabilitytestingofthehipandlowerlimblength hasbeenmade,weproceededwiththepercutaneousadductor tenotomy.

Inthepost-operativefollow-up, orthoradiographyor tel-eradiographyoflowerlimbswastaken,toassesslimblength discrepancy.APandlateralradiographsoftheoperatedhips were also obtained, to assess the osteointegration of the graftintheacetabularbedandtheconsolidationoffemoral osteotomy(Fig.5).

Againinlengthoftheoperatedlimbwasobtained,inspite ofthefemoralshortening,becausetheacetabularimplantis alwayspositionedinthetrueacetabulum,totherestorationof thepropercenterofrotationanditshipbiomechanics.Thus, femoralshorteningwasessentialforthenon-occurrenceof vascular complications and especially of any neurological injury postoperatively. The consolidationof the osteotomy occurredinsixmonthsaftersurgery.

Theresultsofpost-operativeorthoradiography or telera-diographyalsoshowedequalizationofthelowerlimbs.This fact,togetherwiththeretensioningoftheabductormuscles caused bythe correctionofthehip centerofrotation, was responsibleforimprovinggaitandqualityoflifeofthepatient. Therewasalsoimprovementinpainandinrangeofmotion intheoperatedhip.

Discussion

PatientswithsequelaeofDDHhave,asanoptionin adult-hood,theprosthetichipreconstructiontoimprovegaitand qualityoflife.Wemustrememberthattheseareyoungand autonomous patients. Thearthroplasty forhips with stub-borndislocationpresentsaspecialproblem,becauseofthe peculiarsurgicaltechnique;itspracticewasevendiscouraged byCharnleyandFeagin3_{Morerecently,studieshave} demon-strated the effectiveincorporation ofthe bonegraft in the

Fig.4–Intraoperativeimageinwhichfemoralosteotomyininverted-VandrigidfixationwithDCPplate(A)wereperformed andpelvicX-rayinanteroposteriorviewshowingtheattachmentaftershorteningandapplicationofgraftcerclageintothe osteotomy(B).

Fig.5–Radiographiccontrolinthepostoperativeperiodoflengthdiscrepancythroughorthoradiographyofthelowerlimbs (A);X-rayshowingautologousbonegrafttakenfromtheosteotomyfragmentplacedinthesubtrochantericregionwith cerclagebysteelwire(arrow)(B).

acetabularroof, withmidterm resultsthat encouraged the procedure.4–8

Thefirst obstacletogoodfunctional outcomeofTHAin casesofDDHis:loweringofthecenterofrotation,remaking oftheacetabularcoverageandcorrectionofthedysplasia.The implantationoftheacetabulardomeintothefalseacetabulum isassociatedwithshortersurvivaloftheimplant.Lindeetal.9 reported42%oflooseningwhenthedomewasplacedinthe falseacetabulum;andStansetal.10_{demonstratedanindexof} acetabularlooseningof83%inafollow-upof16years.

For the reconstructionofthe acetabularroofthe use of autologousfemoralheadis recommended, asdescribed by

Harrisetal.5_{in1977.Intheirstudy,theseauthorsguidethe} graftfixationontheacetabularroofwithscrews.Buttheyhad 20%oflooseninginsevenyears.5_{Webelievethat,togetagood} resultintheconsolidationofthegraftsothere’sno reabsorp-tion,thereisneedforaproperpreparationofthehostbed (whichiscritical),asdescribedbyChandlerandPennenberg,11 andastablefixation.

concludedthat the best methodfor the evaluation ofthis incorporationisthehistologicalone;however,theprocedure isdifficultandcausesmorbidityforthepatient.Hence, radio-graphyisthetechniquemostused.

Thesecondobstacle istheshorteningofthe limbtobe operated.Incasesofstubborndislocationandhighposition, correctionoflowerlimbdysmetriaisthegoaltobeachieved, sinceitscorrectionwillbenefitthegaitandqualityoflifeof thepatient.Asinthesecasesthecenterofrotationofthehipis high,thefemoralreductioninthetrueacetabulummaycause excessiveprolongation ofthemember,and hence,possible neurologicaldamage.

Thus, we made a femoral shortening subtrochanteric osteotomy in inverted-V, as described by Becker and Gustilo,13 _{with fixationwithDCP forsmall fragments. This} osteotomyfacilitates reduction,promotes rotational stabil-ityandincreasesthecontactsurface.Ourcontributiontothe existingtechniquesistheuseofbonegraftgeneratedbythe osteotomyitselfaroundtheinverted-V,withasteelwire cer-clage,whichreducestheriskoffemurnonunion.

Conclusion

Thetechniqueofacetabularreconstructionandfemoral short-eninginpatientswithDDHclassifiedasEftekhartypeDwas veryefficient, withimmediateresolutionofthe defectand pain.Fixationofthefemoralheadgraftintotheacetabulum withplateAlliswasdone,whichcontributestogreater resis-tanceofthesystem,andcerclagewithsteelwireinthebone graftnext tothe subtrochantericosteotomy, whichreduces theriskofnonunion.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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