Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
Surgical Research Society, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Clin Orthop Relat Res. 2024 Jun 1;482(6):1038-1047. doi: 10.1097/CORR.0000000000002900. Epub 2023 Oct 27.
Performing THA in patients with high-riding developmental dysplasia of the hip (DDH) is associated with serious complications and technical challenges. Various methods of shortening osteotomy are available to facilitate femoral head reduction during THA in patients with high-riding hips; subtrochanteric shortening osteotomy and trochanteric slide osteotomy plus proximal shortening are the most common techniques. However, which approach is superior remains a topic of controversy.
QUESTIONS/PURPOSES: (1) Is there any difference in clinical outcomes (defined as the Harris Hip Score [HHS] and residual limb length discrepancy) at a minimum of 3 years between subtrochanteric shortening osteotomy and trochanteric slide osteotomy in patients with Crowe Type IV DDH who underwent THA? (2) Is there any difference in the risk or type of complications between the two approaches?
We performed a retrospective, comparative study of two groups (subtrochanteric shortening osteotomy versus trochanteric slide osteotomy) matched for sex and preoperative HHS at a minimum of 3 years of follow-up. Between 2010 and 2018, we performed 67 THAs in patients with unilateral Crowe Type IV DDH. During that time, we generally used a trochanteric slide osteotomy for THA in all patients with Crowe Type IV hips and performed subtrochanteric shortening osteotomy when a conical stem was not available. A total of 42% (28) had THA with subtrochanteric shortening osteotomy, and 58% (39) had THA with trochanteric slide osteotomy. Of those, 89% (25) and 74% (29), respectively, were accounted for with complete datasets for possible matching at a minimum of 3 years of follow-up. Patients were matched for gender and preoperative HSS (within 10 points), leaving 22 patients in each group (79% of the subtrochanteric shortening osteotomy group and 56% of the trochanteric slide osteotomy group) for evaluation and analysis. Age (42 versus 46 years), gender (female: 73% versus 73%), preoperative HSS (40 versus 40), and preoperative leg length discrepancy (5.9 versus 5.3 cm) were comparable between the two groups (p > 0.05). The trochanteric slide osteotomy group exclusively received Cone Wagner (Zimmer) implants (100%), while Corail (DePuy Synthes) implants (77%) were the most commonly used in the subtrochanteric shortening osteotomy group. HHS at a minimum of 3 years as well as the presence or absence of a limp and Trendelenburg sign, functional leg length discrepancy, nonunion, nerve palsy, and other surgical complications were recorded and compared between the groups based on data drawn from a longitudinally maintained institutional database.
At a mean follow-up of 73 months, improvement in HHS was greater in the subtrochanteric shortening osteotomy group than in the trochanteric slide osteotomy group (48 ± 4 points versus 36 ± 11 points, mean difference 12 points [95% CI 7 to 17 points]; p < 0.001). Although the preoperative leg length discrepancy was similar between the groups, there was a greater postoperative improvement in the subtrochanteric shortening osteotomy group (44 ± 8 mm and 38 ± 8 mm in the subtrochanteric shortening osteotomy and trochanteric slide osteotomy groups, respectively; p = 0.02). The risk of nonunion was higher with a trochanteric slide osteotomy than with a subtrochanteric shortening osteotomy (23% [5 of 22] versus 0% [0 of 22]; p = 0.048). Other complications, including intraoperative periprosthetic fractures, nerve palsy, heterotopic ossification, revision surgery, and dislocation, did not differ between the groups.
In patients with Crowe Type IV hips undergoing THA, surgeons might consider subtrochanteric shortening osteotomy rather than trochanteric slide osteotomy to minimize the risk of nonunion and achieve superior hip function. Better correction of leg length discrepancy may also be possible with subtrochanteric shortening osteotomy. The long-term survivorship of hips after these two techniques, as well as the influence of the specific anatomy of the proximal femur on the choice of technique, remain to be explored in future studies.
Level III, therapeutic study.
在患有高位发育性髋关节发育不良（DDH）的患者中进行全髋关节置换术（THA）与严重并发症和技术挑战相关。为了在高位髋关节患者中进行 THA 时便于股骨头复位，有各种缩短截骨术方法可用；转子下缩短截骨术和转子间滑动截骨术加近端缩短术是最常见的技术。然而，哪种方法更优仍然存在争议。
问题/目的：（1）在 Crowe Ⅳ型 DDH 患者中，行 THA 后至少 3 年，转子下缩短截骨术与转子间滑动截骨术在临床结果（定义为 Harris 髋关节评分[HHS]和残余肢体长度差异）方面是否存在差异？（2）两种方法的并发症风险或类型是否存在差异？
我们对两组（转子下缩短截骨术与转子间滑动截骨术）进行了回顾性、对照研究，两组在至少 3 年的随访时按性别和术前 HHS 进行匹配。2010 年至 2018 年期间，我们对 67 例单侧 Crowe Ⅳ型 DDH 患者进行了 THA。在此期间，我们通常在所有 Crowe Ⅳ型髋关节患者中使用转子间滑动截骨术进行 THA，当无法使用锥形柄时则采用转子下缩短截骨术。共有 42%（28 例）采用转子下缩短截骨术进行 THA，58%（39 例）采用转子间滑动截骨术进行 THA。其中，分别有 89%（25 例）和 74%（29 例）的患者具有完整的数据集，可进行至少 3 年的随访匹配。患者按性别和术前 HHS（相差 10 分以内）进行匹配，每组各有 22 例患者（转子下缩短截骨术组 79%，转子间滑动截骨术组 56%）进行评估和分析。两组患者的年龄（42 岁与 46 岁）、性别（女性：73%与 73%）、术前 HHS（40 与 40）和术前肢体长度差异（5.9 与 5.3 cm）相当（p > 0.05）。转子间滑动截骨术组仅接受 Cone Wagner（Zimmer）植入物（100%），而转子下缩短截骨术组中 Corail（DePuy Synthes）植入物（77%）更为常用。两组患者在至少 3 年的随访中，HHS 以及跛行和 Trendelenburg 征的存在或不存在、功能肢体长度差异、骨不连、神经麻痹和其他手术并发症等方面的情况，均基于从纵向维护的机构数据库中提取的数据进行记录和比较。
平均随访 73 个月时，转子下缩短截骨术组的 HHS 改善优于转子间滑动截骨术组（48 ± 4 分与 36 ± 11 分，平均差异 12 分[95%CI 7 至 17 分]；p < 0.001）。尽管两组患者术前肢体长度差异相似，但转子下缩短截骨术组术后改善更大（转子下缩短截骨术组和转子间滑动截骨术组分别为 44 ± 8 mm 和 38 ± 8 mm；p = 0.02）。转子间滑动截骨术的骨不连风险高于转子下缩短截骨术（23%[5/22]与 0%[0/22]；p = 0.048）。其他并发症，包括术中假体周围骨折、神经麻痹、异位骨化、翻修手术和脱位，两组之间无差异。
在 Crowe Ⅳ型髋关节患者中进行 THA 时，外科医生可能会考虑采用转子下缩短截骨术而非转子间滑动截骨术，以降低骨不连的风险并获得更好的髋关节功能。转子下缩短截骨术也可能更好地纠正肢体长度差异。这两种技术的长期髋关节生存率以及股骨近端特定解剖结构对技术选择的影响，有待未来研究进一步探讨。
III 级，治疗性研究。
