Impact of Prosthetic Angle Variations in Combined Anteversion Technique on Surgical Failure Rates in Developmental Dysplasia of the Hip: A 12-Year Follow-Up Study

Abstract

Objectives: The combined anteversion technique was introduced to guide prosthesis orientation in patients with developmental dysplasia of the hip and has achieved favorable short-term results in a previously published series. However, excessive variations in implant orientation may increase the risk of accelerated polyethylene wear and lead to revision THA. This study aimed to report whether the variation in implant orientation caused by the combined anteversion technique would result in an increased surgical failure rate and the mid- to long-term clinical outcome in total hip arthroplasty for patients with hip dysplasia.

Materials and Methods: This retrospective study reviewed patients with hip dysplasia who underwent total hip arthroplasty with the combined anteversion technique between 2007 and 2012 at our center. The surgical protocol prioritized the combined anteversion principle, requiring maintenance of the combined anteversion within the 25°–50° range while permitting physiological variation in individual femoral or acetabular component positioning. In total, 55 patients (80 hips) were included, with an average follow-up period of 12.7 years (range, 11 to 16). Ceramic fragmentation, periprosthetic radiolucencies, and osteolysis around the cup and stem were evaluated based on the immediate postoperative pelvic anteroposterior radiographs and the last follow-up. Femoral, acetabular, and combined anteversions pre-and postoperatively were measured using CT-based models. The Harris hip score at the latest follow-up was used for comparison with the score before surgery.

Results: The average Harris hip score increased from 28.3 ± 10.1 preoperatively to 91.2 ± 6.7 (p < 0.01) at the last follow-up. The mean femoral, acetabular, and combined anteversions were 25.6° ± 11.1° and 23.7° ± 10.6°, 23.2° ± 7.4° and 19.8° ± 8.3°, and 48.7° ± 12.9° and 43.1° ± 6.8° preoperatively and postoperatively, respectively. By the last follow-up, one patient developed periprosthetic osteolysis 11 years after primary surgery without obvious periprosthetic loosening and migration of the femoral head rotation center. Two patients experienced prosthesis dislocation, one of whom received a revision 4 years after primary surgery, and the other underwent manual reduction under anesthesia 8 years after primary surgery. Two patients underwent revision and internal fixation due to prosthesis loosening caused by a periprosthetic fracture 10 years and 12 years after primary surgery.

Conclusion: The combined anteversion technique in total hip arthroplasty for patients with hip dysplasia yielded reliable mid-to-long-term results. This technique's changes in prosthesis angle did not significantly increase the surgical failure rate.

Keywords

combined anteversion / developmental dysplasia of the hip / surgical technique / total hip arthroplasty

References

[1] E. M. Greber, C. E. Pelt, J. M. Gililland, M. B. Anderson, J. A. Erickson, and C. L. Peters, “Challenges in Total Hip Arthroplasty in the Setting of Developmental Dysplasia of the Hip,” Journal of Arthroplasty 32, no. 9S (2017): S38-S44, https://doi.org/10.1016/j.arth.2017.02.024.

[2] J. Zhang, L. Wang, Y. Mao, H. Li, H. Ding, and Z. Zhu, “The Use of Combined Anteversion in Total Hip Arthroplasty for Patients With Developmental Dysplasia of the Hip,” Journal of Arthroplasty 29, no. 3 (2014): 621-625, https://doi.org/10.1016/j.arth.2013.08.004.

[3] L. Wang, R. T. Trousdale, S. Ai, K.-N. An, K. Dai, and B. F. Morrey, “Dislocation After Total Hip Arthroplasty Among Patients With Developmental Dysplasia of the Hip,” Journal of Arthroplasty 27, no. 5 (2012): 764-769, https://doi.org/10.1016/j.arth.2011.08.021.

[4] C. Dezateux and K. Rosendahl, “Developmental Dysplasia of the Hip,” Lancet 369, no. 9572 (2007): 1541-1552, https://doi.org/10.1016/S0140-6736(07)60710-7.

[5] J. F. Crowe, V. J. Mani, and C. S. Ranawat, “Total Hip Replacement in Congenital Dislocation and Dysplasia of the Hip,” Journal of Bone and Joint Surgery. American Volume 61, no. 1 (1979): 15-23.

[6] X.-T. Shi, C.-F. Li, C.-M. Cheng, C.-Y. Feng, S.-X. Li, and J.-G. Liu, “Preoperative Planning for Total Hip Arthroplasty for Neglected Developmental Dysplasia of the Hip,” Orthopedics 11, no. 3 (2019): 348-355, https://doi.org/10.1111/os.12472.

[7] J. Zhang, J. Wei, Y. Mao, H. Li, Y. Xie, and Z. Zhu, “Range of Hip Joint Motion in Developmental Dysplasia of the Hip Patients Following Total Hip Arthroplasty With the Surgical Technique Using the Concept of Combined Anteversion: A Study of Crowe I and II Patients,” Journal of Arthroplasty 30, no. 12 (2015): 2248-2255, https://doi.org/10.1016/j.arth.2015.06.056.

[8] M. Fujii, Y. Nakashima, T. Sato, M. Akiyama, and Y. Iwamoto, “Pelvic Deformity Influences Acetabular Version and Coverage in Hip Dysplasia,” Clinical Orthopaedics and Related Research 469, no. 6 (2011): 1735-1742, https://doi.org/10.1007/s11999-010-1746-1.

[9] B. Zhu, C. Su, Y. He, et al., “Combined Anteversion Technique in Total Hip Arthroplasty for Crowe IV Developmental Dysplasia of the Hip,” Hip International 27, no. 6 (2017): 589-594, https://doi.org/10.5301/hipint.5000498.

[10] L. D. Dorr, A. Malik, M. Dastane, and Z. Wan, “Combined Anteversion Technique for Total Hip Arthroplasty,” Clinical Orthopaedics and Related Research 467, no. 1 (2009): 119-127, https://doi.org/10.1007/s11999-008-0598-4.

[11] C. Amuwa and L. D. Dorr, “The Combined Anteversion Technique for Acetabular Component Anteversion,” Journal of Arthroplasty 23, no. 7 (2008): 1068-1070, https://doi.org/10.1016/j.arth.2008.04.025.

[12] T. Ohmori, T. Kabata, Y. Kajino, et al., “Differences in Range of Motion With the Same Combined Anteversion After Total Hip Arthroplasty,” International Orthopaedics 42, no. 5 (2018): 1021-1028, https://doi.org/10.1007/s00264-017-3653-5.

[13] B. M. Jolles, P. Zangger, and P. F. Leyvraz, “Factors Predisposing to Dislocation After Primary Total Hip Arthroplasty: A Multivariate Analysis,” Journal of Arthroplasty 17, no. 3 (2002): 282-288, https://doi.org/10.1054/arth.2002.30286.

[14] J. H. J. van Erp, T. E. Snijders, H. Weinans, R. M. Castelein, T. P. C. Schlösser, and A. de Gast, “The Role of the Femoral Component Orientation on Dislocations in THA: A Systematic Review,” Archives of Orthopaedic and Trauma Surgery 142, no. 6 (2022): 1253-1264, https://doi.org/10.1007/s00402-021-03982-1.

[15] R. Biedermann, A. Tonin, M. Krismer, F. Rachbauer, G. Eibl, and B. Stöckl, “Reducing the Risk of Dislocation After Total Hip Arthroplasty: The Effect of Orientation of the Acetabular Component,” Journal of Bone and Joint Surgery (British Volume) 87, no. 6 (2005): 762-769, https://doi.org/10.1302/0301-620X.87B6.14745.

[16] T. Fujishiro, T. Hiranaka, S. Hashimoto, et al., “The Effect of Acetabular and Femoral Component Version on Dislocation in Primary Total Hip Arthroplasty,” International Orthopaedics 40, no. 4 (2016): 697-702, https://doi.org/10.1007/s00264-015-2924-2.

[17] W. S. Murphy, H. H. Yun, B. Hayden, J. H. Kowal, and S. B. Murphy, “The Safe Zone Range for Cup Anteversion Is Narrower Than for Inclination in THA,” Clinical Orthopaedics and Related Research 476, no. 2 (2018): 325-335, https://doi.org/10.1007/s11999.0000000000000051.

[18] B. F. Mayeda, J. G. Haw, A. K. Battenberg, and T. P. Schmalzried, “Femoral-Acetabular Mating: The Effect of Femoral and Combined Anteversion on Cross-Linked Polyethylene Wear,” Journal of Arthroplasty 33, no. 10 (2018): 3320-3324, https://doi.org/10.1016/j.arth.2018.06.003.

[19] S. Bergiers, H. Hothi, J. Henckel, et al., “The In Vivo Location of Edge-Wear in Hip Arthroplasties: Combining Pre-Revision 3D CT Imaging With Retrieval Analysis,” Bone Joint Research 10, no. 10 (2021): 639-649, https://doi.org/10.1302/2046-3758.1010.BJR-2021-0132.R1.

[20] Y. T. Lin, J. S. Wu, and J. H. Chen, “The Study of Wear Behaviors on Abducted Hip Joint Prostheses by an Alternate Finite Element Approach,” Computers in Biology and Medicine 131 (2016): 143-155, https://doi.org/10.1016/j.cmpb.2016.04.015.

[21] C.-K. Liaw, S.-M. Hou, R.-S. Yang, T.-Y. Wu, and C.-S. Fuh, “A New Tool for Measuring Cup Orientation in Total Hip Arthroplasties From Plain Radiographs,” Clinical Orthopaedics and Related Research 451 (2006): 134-139, https://doi.org/10.1097/01.blo.0000223988.41776.fa.

[22] M. Dastane, L. D. Dorr, R. Tarwala, and Z. Wan, “Hip Offset in Total Hip Arthroplasty: Quantitative Measurement With Navigation,” Clinical Orthopaedics and Related Research 469, no. 2 (2011): 429-436, https://doi.org/10.1007/s11999-010-1554-7.

[23] P. Massin, L. Schmidt, and C. A. Engh, “Evaluation of Cementless Acetabular Component Migration. An Experimental Study,” Journal of Arthroplasty 4, no. 3 (1989): 245-251, https://doi.org/10.1016/s0883-5403(89)80020-8.

[24] F. Pierchon, G. Pasquier, A. Cotten, C. Fontaine, J. Clarisse, and A. Duquennoy, “Causes of Dislocation of Total Hip Arthroplasty. CT Study of Component Alignment,” Journal of Bone and Joint Surgery (British Volume) 76, no. 1 (1994): 45-48.

[25] D. W. Murray, “The Definition and Measurement of Acetabular Orientation,” Journal of Bone and Joint Surgery (British Volume) 75, no. 2 (1993): 228-232, https://doi.org/10.1302/0301-620X.75B2.8444942.

[26] W. H. Harris, O. Crothers, and I. Oh, “Total Hip Replacement and Femoral-Head Bone-Grafting for Severe Acetabular Deficiency in Adults,” Journal of Bone and Joint Surgery. American Volume 59, no. 6 (1977): 752-759.

[27] L. J. Seo, J. Gabor, D. Novikov, J. E. Feng, R. Schwarzkopf, and J. M. Vigdorchik, “Outcomes in 385 Developmental Dysplastic Hips Requiring Total Hip Arthroplasty,” Archives of Orthopaedic and Trauma Surgery 139, no. 5 (2019): 723-728, https://doi.org/10.1007/s00402-019-03143-5.

[28] N. Sugano, P. C. Noble, E. Kamaric, J. K. Salama, T. Ochi, and H. S. Tullos, “The Morphology of the Femur in Developmental Dysplasia of the Hip,” Journal of Bone and Joint Surgery (British Volume) 80, no. 4 (1998): 711-719, https://doi.org/10.1302/0301-620x.80b4.8319.

[29] P. C. Noble, E. Kamaric, N. Sugano, et al., “Three-Dimensional Shape of the Dysplastic Femur: Implications for THR,” Clinical Orthopaedics and Related Research 417 (2003): 27-40.

[30] W. N. Sankar, C. O. Neubuerger, and C. F. Moseley, “Femoral Anteversion in Developmental Dysplasia of the Hip,” Journal of Pediatric Orthopedics 29, no. 8 (2009): 885-888, 888, https://doi.org/10.1097/BPO.0b013e3181c1e961.

[31] H. Fahlbusch, M. Budin, A. Volk, et al., “Long-Term Outcomes of Total Hip Arthroplasty in Patients With Developmental Dysplasia of the Hip: A Minimum 21-Year Follow-Up,” Archives of Orthopaedic and Trauma Surgery 143, no. 11 (2023): 6609-6616, https://doi.org/10.1007/s00402-023-04970-3.

[32] M. Ollivier, M. P. Abdel, A. J. Krych, R. T. Trousdale, and D. J. Berry, “Long-Term Results of Total Hip Arthroplasty With Shortening Subtrochanteric Osteotomy in Crowe IV Developmental Dysplasia,” Journal of Arthroplasty 31, no. 8 (2016): 1756-1760, https://doi.org/10.1016/j.arth.2016.01.049.

[33] J. H. J. Van Erp, T. P. C. Schlösser, A. W. Baijense, et al., “Calculation of the 3-D Femoral Component's Orientation in Total Hip Arthroplasty Using a Trigonometric Algorithm,” Scientific Reports 12, no. 1 (2022): 3499, https://doi.org/10.1038/s41598-022-07331-z.

[34] J. M. Elkins, J. J. Callaghan, and T. D. Brown, “The 2014 Frank Stinchfield Award: The ‘Landing Zone’ for Wear and Stability in Total Hip Arthroplasty Is Smaller Than We Thought: A Computational Analysis,” Clinical Orthopaedics and Related Research 473, no. 2 (2015): 441-452, https://doi.org/10.1007/s11999-014-3818-0.

[35] Y. Nakashima, M. Hirata, M. Akiyama, et al., “Combined Anteversion Technique Reduced the Dislocation in Cementless Total Hip Arthroplasty,” International Orthopaedics 38, no. 1 (2014): 27-32, https://doi.org/10.1007/s00264-013-2091-2.

[36] L. Wang, G. Isaac, R. Wilcox, A. Jones, and J. Thompson, “Finite Element Analysis of Polyethylene Wear in Total Hip Replacement: A Literature Review,” Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 233, no. 11 (2019): 1067-1088, https://doi.org/10.1177/0954411919872630.

[37] N. Kaku, A. Tanaka, H. Tagomori, and H. Tsumura, “Finite Element Analysis of Stress Distribution in Flat and Elevated-Rim Polyethylene Acetabular Liners,” Clinical Orthopaedics and Related Research 12, no. 3 (2020): 291-297, https://doi.org/10.4055/cios19145.

[38] S. Glyn-Jones, G. E. R. Thomas, P. Garfjeld-Roberts, et al., “The John Charnley Award: Highly Crosslinked Polyethylene in Total Hip Arthroplasty Decreases Long-Term Wear: A Double-Blind Randomized Trial,” Clinical Orthopaedics and Related Research 473, no. 2 (2015): 432-438, https://doi.org/10.1007/s11999-014-3735-2.

[39] W. H. Harris, “Traumatic Arthritis of the Hip After Dislocation and Acetabular Fractures: Treatment by Mold Arthroplasty. An End-Result Study Using a New Method of Result Evaluation,” Journal of Bone and Joint Surgery. American Volume 51, no. 4 (1969): 737-755.

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