1. Technique and long term outcome
THR ON DDH CROWE IV
Technique and long term outcome
M. KERBOULL

2. Luxation intermédiaire ou postérieure
Class IV of Crowe
Type C or D of Eftekhar
Total dislocation of Hartofilakidis or Harris

3. In complete congenital dislocation of the hip, the femoral head lies entirely outside of the true acetabulum, whether the hip was treated in childhood or not, and articulates with the iliac wing above the true acetabulum or above and behind it. In this second case the false acetabulum may be absent.
The true acetabulum is small, porotic with a triangular cavity usually filled with fat and fibrous tissue, its anterior wall is very thin, the posterior ischiatic wall thick. The femur is also dysplastic with a narrow medullary canal, a small head, an anteverted neck, but its length is normal.

4. This distorted anatomy may be worsened by previous operations,
especially by diaphyseal valgus osteotomy.

5. There are also many secondary anatomical abnormalities
There are also many secondary anatomical abnormalities. The capsule is elongated, extending from the rim of the true acetabulum to the femoral head and sometimes surrounding it.
Because of the high and posterior riding head, the course of nerves and arteries is altered, but they are not actually shortened. When the hip was never operated, the muscles are not substantially contracted. Some, such as external rotators, are even elongated, but their courses are also altered.

6. The abnormal location of the hip and the frequent asymmetry of the dislocation result in several anatomical and physiological changes: leg length discrepancy, pelvic tilt, structural changes in the lumbo-sacral spine, malalignment of the ipsi lateral knee.

7. NUMEROUS VARIETIES
OF DDH CROWE IV

8. Unilateral dislocation with contro lateral hip normal or dysplastic
Shortening = leg length discrepancy
Pelvis horizontal
Lumbar spine vertical

9. Bilateral symmetrical dislocation
Relatively rare
No leg length discrepancy
Pelvis horizontal
Lumbar spine vertical

10. Asymmetric bilateral dislocation
Much more frequent
Leg length discrepancy
Pelvic tilt
Lateral bend of the lumbar spine
Compensating for pelvic tilt

11. Pelvic tilt increased by the femoral
abduction osteotomy

12. Swing-front of the pelvis compensated for hyperlordosis of
the lumbar spine

13. Frontal asymmetry of the pelvis in unilateral or bilateral
asymmetrical dislocations

14. Lateral bend of the lumbar spine with arthrosis

15. Anatomic genu valgum increased by sequelae of ostechondritis or femoral proximal angulation

16. 3 GOALS THA in this field aims at:
Providing the patient with 1 or 2 pain free, mobile and stable hips
Equalizing the leg length
Relieving the low back pain and knee pain through improving of the static body balance

17. SURGICAL TECHNIQUE

19. SURGICAL TECHNIQUE Measure of the leg shortening
OPERATIVE PLANNING
Measure of the leg shortening
Choice of the prosthetic components
Implantation seats of the components
Possible necessity of an alignment osteotomy

20. Measure of leg shortening due to hip dislocation
On a radiograph of the lower part of a body without magnification taking on a single film pelvis and lower limbs on a standing position.
2) On AP x-rays of the hip taking into account magnification coefficient
R = H x 0,85
A = h x 0,85

21. Beside the components most used in primary osteoarthritis
The smallest components of standard and dysplastic ranges

22. Preoperative planning with component seats

23. This femoral angulation will need an alignment osteotomy

24. OPERATIVE TECHNIQUE MAIN POINTS
Lateral transtrochanteric approach
Complete excision of the capsule, scar fibrous tissue, osteophytes, shelf.
Neither muscle nor tendon section
Acetabular reconstruction in anatomic position
Femoral component implantation at the level of the lesser trochanter to avoid any difficulties due to excessive anteversion
Reduction on a limb in adduction, the hip slightly flexed, knee flexed at 90°, by direct thrust on the neck

25. Bilateral dislocation
Bilateral THR with reconstruction of the acetabuli augmented by autograft in anatomic position.
Insertion of a femoral component at the lesser trochanter level.

26. MAIN STEPS OF THE OPERATION

27. Lateral decubitus position
Lateral transtrochanteric approach
Excision of the superior and lateral capsule

28. Section of the neck
Dissection and excision of the inferior and medial capsule

29. Deepening and widening of the true acetubulum at the expenses of ischiatic wall
Augmentation of the deficient acetabulum with a structural autograft secured with 2 screws

30. Cementation of the acetabular component

31. A diaphyseal femoral angulation may complicate the operation

32. The alignment osteotomy is done
at the top of the femoral angulation.
Pure alignment osteotomy.

33. Alignment osteotomy associated with shortening.
Trapezoïdal resection of the femur

34. Stair-step osteotomy to block fragments rotation for alignment of the
femur with resection

35. Left femoral angulation aligned with osteotomy.
The result 18 years PO

36. Inter trochanteric angulation.
Implantation of the femoral component in the focus of angulation and remodelling of the proximal femur, by removing a triangular grey bone fragment, to give it a normal anatomy.

37. SOME EXAMPLES
WITH LONG TERM RESULTS

38. Bilateral dislocation
44 years
Pre op.
16 y. PO

39. 54 years
Unilateral dislocation
21 y. PO

40. 42 years
Unilateral dislocation
22 y. PO

41. Posterior dislocation 18 y. PO 5 y. PO
48 years

42. 19 y. PO
3 years after reoperation

43. 41 years

44. 14 y. PO

45. 16 y. PO

46. 18 y. PO

47. RH: 3 years after reoperation
LH: 21 y. PO

48. RH: 6 years after reoperation
Break of the screws
LH: 24 y. PO

49. RH: 1 year after second reoperation
LH: 25 y. PO

50. On an one surgeon series of 535 THA on DDH with 352 on Crowe IV, operated on between 1969 and 2004, the first 118 on Crowe IV were many times studied and published in Journal of Arthroplasty.

52. MATERIAL 89 PATIENTS (8 Men, 81 women) Average age 52 years (29-78)
119 HIGH DISLOCATIONS
30 bilateral
59 unilateral, with a contro lateral hip
- Crowe II and III (15)
- dysplastic (23)
- normal (21)

53. MATERIAL 118 THA Carried out between 1970 and 1986
10 Original Charnley (narrow stem)
108 Charnley-Kerboull
CONTINUOUS SERIES
ONE SURGEON

54. MATERIAL 39 patients no previous operation
59 previous operation (average 2,22)
- Attempt of closed reduction 27
- Attempt of open reduction 11
- Shelf operation
- femoral osteotomy 23
- Girdlestone
- Arthrodesis
- Arthroplasties (cup, acrylic …)
BUT IN NO INSTANCE WAS THE FEMORAL HEAD REPLACED INTO THE TRUE ACETABULUM

55. MATERIAL
Pain in hip with stiffness and limitation in activity was the main indication for surgery
For 11 patients (12.35 %) back or knee pain was the chief complaint

56. METHOD PRE OPERATIVELY :
A thorough assessment of the patient was made, including
- the dislocated hip, the controlateral hip, knees and lumbo-sacral spine
- noting : pelvic tilt, fixed deformities, lumbo-sacral residual flexibility, leg shortening, true and apparent leg length discrepancy, knee malalignment and skeletal disorders due to previous operations.
X-Rays :
Routinely and AP and lateral X-rays of the lumbar spine in a standing position
AP radiograph of the lower part of the body, taking on a single film pelvis and lower limbs in a standing position
Classical AP and lateral X-rays of pelvis, hips and upper part of the femur
Clinically the hip was assessed according to the d’Aubigné six digit scale evaluating pain, motion, stability and gait, global function and the average value of each criterion.

57. METHOD POSTOPERATIVELY
The same clinical assessment of operated hip was made at each examination
And on an AP X-rays of the pelvis were noted:
- for the acetabular component
- position of the socket relative to usual reference marks and lines, radiolucent lines, linear wear
- for the femoral component were recorded
- position, radiolucent lines, debonding and subsidence
- osteolysis
- heterotopic bone

58. METHOD EVALUATION OF LOOSENING
Was made according to Harris and Johnston in
Definite, probable, possible

59. 1 YEAR POSTOPERATIVELY
A radiograph of the lower part of the body in a frontal view was taken to assess:
- The result of the unilateral or bilateral hip replacement on:
- Pelvic tilt
- Leg lengthening
- Residual leg length discrepancy
On AP and lateral radiograph of the lumbar spine was evaluated the correction of lordosis and lateral curve

60. COMPLICATIONS 1 intra operative femoral fracture (cerclage)
1 peroneal nerve palsy (recovered in a few days)
2 trochanteric non unions (united after revision)
1 dislocation
4 heterotopic ossifications
2 Brooker II
1 Brooker III
- 1 Brooker IV
No infection
Both revised

61. FOLLOW UP Deceased: 41 patients (48 hips)
At each examination 6 weeks, 3 months, 6 months, 1 year, every year until 5 years and then every 2 or 3 years
Lost: 7 patients (9 hips)
2 between 1 and 10 years and 5 between 10 and 20 years
Deceased: 41 patients (48 hips)
12 between 1 and 10 years and 29 between 10 and 27 years
Still alive and regularly seen: 40 patients (61 hips)
Average follow up: 22 years (18 to 32)
Average follow up of the whole series: 16.9 years

62. CLINICAL RESULTS ON THE HIP At the last examination:
CLINICAL RESULTS ON THE HIP At the last examination: before lost to follow up before death before reoperation Mean functional value before operation and y. later
EXCELLENT (18) %
VERY GOOD (17) % 75.4 %
GOOD (16) %
FAIR (15 or 14) %
POOR (13) %
BAD (12) %
When a major femoral angulation needed an alignment osteotomy (19) the functional result were slightly less good (73 % excellent or good, mean postoperative functional value 16.9)

63. CLINICAL RESULTS 40 still alive, 61 hips followed up 18 to 32 y.
Before reoperation
Ex. + VG + G %
After reoperation
Ex. + VG + G 95 %

64. RADIOLOGICAL RESULTS AT LONG TERM
Polyethylene wear
Not measurable: 58 hips (48 %)
Between 1 mm and 7 mm: 60 hips (52 %)
Loosenings
Femoral: 1
Acetabular (definite + probable): 22
2 before they get lost (elsewhere reoperated?)
17 (3 of them were recurrent and reoperated on)

65. REOPERATIONS: (19.5 %)
Loosenings femoral:
acetabular: 20
Heterotopic ossifications: 2
SURVIVORSHIP AT 25 YEARS
Cemented fixation of the femoral component 99 %
Cemented fixation of the acetabular component 79 %
Of the prosthesis %

66. EQUALIZATION OF THE LEG LENGTH
SHORTENING 4.84 cm (3 to 8 cm)
Accurate correction 63
Within 1 cm 42
LENGTHENING 3.8 cm (2 to 7 cm)
AVERAGE LEG LENGTH DISCREPANCY
Preoperatively cm
Postoperatively cm
2 patients needed a shortening of the long femur to get equality

67. RESULTS ON THE IPSI LATERAL KNEE
On the 18 preoperative painful knees:
10 were greatly improved
8 needed an operation
(4 osteotomies and 4 prostheses)

68. This old woman suffered only in the knees (the right in varus the left in valgus). After bilateral THR with bilateral femoral osteotomy the knees were aligned and became painless.

69. RESULTS ON THE LUMBAR SPINE
Reconstruction of the hip and equalization of the leg length have led to many improvements on pelvis and lumbo-sacral spine.
Lateral pelvic tilt was corrected in more than 50 %
21 postoperative versus 47 before THR
Pelvic frontal asymmetry has often been corrected at least partially
and also lordosis and lateral curve of the lumbar spine.
So low-back pain has been relieved in 40 patients but 2 required a laminectomy for lumbar canal stenosis

70. CONCLUSION

71. Total hip arthroplasty on high riding hips may be a wonderful operation, able to greatly improve not only the hip function, but also lumbo-sacral spine and knee thanks to a dramatic improvement of the static body balance. Yet, this operation, full of pitfalls, poses a wide spectrum of difficulties and represents a serious risk of complication.
A successful result depends on a complete preoperative assessment of the patient, a perfect carrying out of the surgical procedure with a suitable prosthesis and a reasonable selection of its indications.