Total Hip Arthroplasty for Crowe III/IV Hip Dysplasia With Oblique Subtrochanteric Shortening Osteotomy and S-ROM-A Modular Stem: 10-Year Outcomes

Abstract

Background: High dislocation due to developmental dysplasia of the hip (DDH), classified as Crowe type III or IV, presents significant challenges in total hip arthroplasty (THA), particularly in preventing nerve complications while restoring leg length.

Aim: This study aimed to evaluate the clinical and radiographic outcomes of primary THA using an S-ROM-A modular stem with oblique subtrochanteric shortening osteotomy in patients with high hip dislocation; to identify the advantages, limitations, and possible countermeasures of this surgical approach.

Patients and Methods: Subjects were 45 hips (37 patients) with high hip dislocation (Crowe III/IV) treated by primary THA using an S-ROM-A stem, with femoral shortening osteotomy performed at our institution. Outcomes 3 years after surgery were examined in 100% of the subjects. Postoperative complications and functional and radiographic outcomes were investigated.

Results: The mean age at surgery was 65 years and the mean duration of postoperative follow-up was 10.7 ± 3.4 years. There were no cases of postoperative infection, symptomatic pulmonary embolism, or neurological complications in the legs. Early postoperative dislocation occurred in two hips (4%, resolved conservatively) and osteotomy site nonunion in one hip (2%). Repeat surgery was required in only this case of nonunion (2%). The hip function score was significantly improved postoperatively. Leg lengthening after surgery was 0–56 mm (mean, 28 mm). Examination of radiographs revealed that it took 12 weeks for bone union at the osteotomy site in all hips except for the one hip with nonunion. No stem subsidence was found postoperatively, and “fixation by bone ingrowth” was achieved at the final follow-up examination in all hips (100%), including the one that required repeat surgery.

Conclusion: THA using an S-ROM-A modular stem with oblique subtrochanteric shortening osteotomy provided favorable mid-term outcomes in patients with Crowe III/IV DDH. No neurological complications occurred, and functional and radiographic improvements were substantial. Our method, which emphasizes intraoperative sciatic nerve palpation for individualized leg lengthening, may serve as a practical and safe alternative to more complex monitoring systems. Further research incorporating objective intraoperative monitoring may help standardize this approach.

Keywords

Crowe classification / high hip dislocation / modular stem / oblique subtrochanteric shortening osteotomy / sciatic nerve palsy / S-ROM-A stem / total hip arthroplasty

References

[1] 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 (1979): 15-23.

[2] T. Paavilainen, V. Hoikka, and K. A. Solonen, “Cementless Total Replacement for Severely Dysplastic or Dislocated Hips,” Journal of Bone and Joint Surgery. British Volume 72, no. 2 (1990): 205-211.

[3] V. E. Ozden, G. Dikmen, B. Beksac, and I. R. Tözün, “Tapered Stems One-Third Proximally Coated Have Higher Complication Rates Than Cylindrical Two-Third Coated Stem in Patients With High Hip Dislocation Undergoing Total Hip Arthroplasty With Step-Cut Shortening Osteotomy,” Orthopaedics & Traumatology, Surgery & Research 103 (2017): 569-577.

[4] G. Grappiolo, F. La Camera, A. Della Rocca, G. Mazziotta, G. Santoro, and M. Loppini, “Total Hip Arthroplasty With a Monoblock Conical Stem and Subtrochanteric Transverse Shortening Osteotomy in Crowe Type IV Dysplastic Hip,” International Orthopaedics 43 (2019): 77-83.

[5] M. Takao, K. Ohzono, T. Nishii, H. Miki, N. Nakamura, and N. Sugano, “Cementless Modular Total Hip Arthroplasty With Subtrochanteric Shortening Osteotomy for Hips With Developmental Dysplasia,” Journal of Bone and Joint Surgery. American Volume 93 (2011): 548-555.

[6] P. Koczewski and M. Shadi, “Lower Limb Inequality Treatment With Subtrochanteric Femoral Shortening Osteotomy Fixed With Intramedullary Nail,” Polish Orthopedics and Traumatology 77 (2012): 65-71.

[7] T. Kawai, C. Tanaka, and M. Ikenaga, “Cemented Total Hip Arthroplasty With Transverse Subtrochanteric Shortening Osteotomy for Crowe Group IV Dislocated Hip,” Journal of Arthroplasty 26 (2011): 229-235.

[8] D. A. Becker and R. B. Gustilo, “Double-Chevron Subtrochanteric Shortening Derotational Femoral Osteotomy Combined With Total Hip Arthroplasty for the Treatment of Complete Congenital Dislocation of the Hip in the Adult: Preliminary Report and Description of a New Surgical Technique,” Journal of Arthroplasty 10 (1995): 313-318.

[9] M. H. Huo, L. E. Zatorski, and K. J. Keggi, “Oblique Femoral Osteotomy in Cementless Total Hip Arthroplasty. Prospective Consecutive Series With a 3-Year Minimum Follow-Up Period,” Journal of Arthroplasty 10 (1995): 319-327.

[10] O. Reikeraas, P. Lereim, I. Gabor, R. Gunderson, and I. Bjerkreim, “Femoral Shortening in Total Arthroplasty for Completely Dislocated Hips: 3-7 Year Results in 25 Cases,” Acta Orthopaedica Scandinavica 67 (1996): 33-36.

[11] N. Sener, I. R. Tözün, and M. Aşik, “Femoral Shortening and Cementless Arthroplasty in High Congenital Dislocation of the Hip,” Journal of Arthroplasty 17 (2002): 41-48.

[12] B. N. Edwards, H. S. Tullos, and P. C. Noble, “Contributory Factors and Etiology of Sciatic Nerve Palsy in Total Hip Arthroplasty,” Clinical Orthopaedics and Related Research 218 (1987): 136-141.

[13] P. W. Yoon, J. I. Kim, D. O. Kim, et al., “Cementless Total Hip Arthroplasty for Patients With Crowe Type III or IV Developmental Dysplasia of the Hip: Two-Stage Total Hip Arthroplasty Following Skeletal Traction After Soft Tissue Release for Irreducible Hips,” Clinics in Orthopedic Surgery 5 (2013): 167-173.

[14] O. A. Nercessian, F. Piccoluga, and N. S. Eftekhar, “Postoperative Sciatic and Femoral Nerve Palsy With Reference to Leg Lengthening and Medialization/Lateralization of the Hip Joint Following Total Hip Arthroplasty,” Clinical Orthopaedics and Related Research 304 (1994): 165-171.

[15] W. F. Kennedy, T. F. Byrne, H. A. Majid, and L. L. Pavlak, “Sciatic Nerve Monitoring During Revision Total Hip Arthroplasty,” Clinical Orthopaedics and Related Research 264 (1991): 223-227.

[16] H. Tamegai, T. Otani, H. Fujii, Y. Kawaguchi, T. Hayama, and K. Marumo, “A Modified S-ROM Stem in Primary Total Hip Arthroplasty for Developmental Dysplasia of the Hip,” Journal of Arthroplasty 28 (2013): 1741-1745.

[17] Y. Matsushita, T. Otani, T. Hayama, H. Fujii, Y. Kawaguchi, and M. Saito, “A Modified Modular Stem in Primary Total Hip Arthroplasty for Developmental Dysplasia of the Hip: Average 11-Year Follow-Up in Cases With Previously Reported 3-Year Clinical Results,” Journal of Arthroplasty 37 (2022): 1832-1838.

[18] R. Ogawa and S. Imura, “Evaluation Chart of Hip Joint Functions,” Nippon Seikeigeka Gakkai Zasshi 69 (1995): 860-867.

[19] C. A. Engh, J. D. Bobyn, and A. H. Glassman, “Porous-Coated Hip Replacement. The Factors Governing Bone Ingrowth, Stress Shielding, and Clinical Results,” Journal of Bone and Joint Surgery. British Volume 69 (1987): 45-55.

[20] T. Liu, S. Wang, G. Huang, and W. Wang, “Treatment of Crowe IV Developmental Dysplasia of the Hip With Cementless Total Hip Arthroplasty and Shortening Subtrochanteric Osteotomy,” Journal of International Medical Research 47 (2019): 3223-3233.

[21] X. T. Shi, C. F. Li, Y. Han, Y. Song, S. X. Li, and J. G. Liu, “Total Hip Arthroplasty for Crowe Type IV Hip Dysplasia: Surgical Techniques and Postoperative Complications,” Orthopaedic Surgery 11 (2019): 966-973.

[22] Z. Lu, Q. Chen, Y. Lan, S. Xie, F. Lin, and E. Feng, “Subtrochanteric Osteotomy in Direct Anterior Approach Total Hip Arthroplasty for Crowe IV Dysplasia-Surgical Technique and Literature Review,” Orthopaedic Surgery 16 (2024): 766-774.

[23] J. B. Masson, C. Foissey, A. Bertani, V. Pibarot, and F. Rongieras, “Transverse Subtrochanteric Shortening Osteotomy With Double Tension-Band Fixation During THA for Crowe III-IV Developmental Dysplasia: 12-Year Outcomes,” Orthopaedics & Traumatology, Surgery & Research 109 (2023): 103684.

[24] H. Ravanbod, K. Gharanizadeh, P. Mirghaderi, A. Hassan, and M. Abolghasemian, “Subtrochanteric Shortening Osteotomy Provides Superior Function to Trochanter Slide Osteotomy in THA for Patients With Unilateral Crowe Type IV Dysplasia at a Minimum of 3 Years,” Clinical Orthopaedics and Related Research 482 (2024): 1038-1047.

[25] I. Mimendia, K. Lakhani, J. H. Núñez, et al., “Total Hip Arthroplasty Associated With Transverse Subtrochanteric Shortening Osteotomy and Conical Stem Fixation in Crowe Type IV Hip Dysplasia,” Musculoskeletal Surgery 107 (2023): 367-372.

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