25-χρονη εμπειρία στην ολική αρθροπλαστική ισχίου σε συγγενή υψηλά εξαρθρήματα.
25 Jahre Erfahrung mit totalen Hόftgelenkersatz bei hohen congennitalen Hόftluxation.
A 25 years period experiene of total hip arthroplasties in high congenital hip dislocations.
INTRODUCTION:
We seldom see high Congenital Dislocation of the Hip in adults. In the majority of them they are not neglected undiagnosed dislocations but not satisfactory initial management. The hypoplastic femoral head migrates high and creates secondary acetabulum. According to Prof. G. Hartofilakidis the classification is as follows. Dyplastic, low and high dislocation. This classification accordingand to Mr. Harris has the importance to locate the anatomical (true) acetabulum. Total Hip Replasment is a demanding operation in these cases with hypoplasia of the femoral head and acetabulum. Degenerative arthritis appears early, especially in unilateral involvement with lumbosacral findings. The unsuccesful initial management make these patients less cooperative.
MATERIAL:
The study is a retrospective one and is refered to 54 patients with CDH in adults.THR was done between 1971-1996. Men were 4 and women 50. The mean age for men was 62 (59-65) and for women 51,5 (31-82) years. A.High CDH: 6 bilateral and 18 unilateral (8 right side and 10 left side) B.Low CDH: 2 bilateral and 10 unilateral (2 right side and 10 left side) C.Dysplastic: 2 bilateral and 10 unilateral (2 right side and 8 left side). D.Combination: High in one side and low in the other side 4 cases. Low in one side and dysplastic in the other side 2 cases. Previous operation was done in 20 patients:14 osteotomies 4 open reductions 2 chiari operations In 34 patients no operative management was done. PATHOLOGY:The pathological findings are: The acetabulum is shallow with oval shape The femoral head is behind the ilium,small,oval shape with tiny cartilage.The capsule is hypertrophic. The neck is hypopplastic, narrow, in anteversion and valgus position.The part of the femur in trochanteric regions is also hypoplastic with narrow canal. All these anatomical variations must be carefully studied before THR artthroplasty.
SURGICAL TECHNIQUE:
Adductor tenotomy (closed) is the first step. We prefer the anterolateral approach.The osteotomy is done at the region of lesser trochanter. Location of true acetabulum and reaming with small reamers. Breakage of the acetabular floor is done.If the remaining acetabulum is shallow then we use the head and neck as allograft after shaving it.It is stabilized by cortical screws and then we do the final reaming.The application of the acetabular part of the prosthesis is done in a press fit manner (one size bigger than the reaming ). In thiw stage, with traction we attempt reduction. If not succesfull,osteotomy goes distally.In reaming the femoral canal we usually use flexible reamers. We seldom do the osteotomy lower to lesser trochanter. The femoral stem is narrow. In the last 10 years we prefer the cementless fixation.Between 1971-1977 the cemented Mc Kee-Farrar and Charnley-Muller implants, the cementless Mittelmeier was used until 1986 and in the last 10 years the Zweymuller implants. In the last two years metal-metal Allo-pro is our preference. The mobilization starts in the next day and full weight bearing after three weeks.
RESULTS:
In one case of unilateral CDH revision was done for deep infection. In one case of a lady of 70 years old with bilateral CDH one mpnth after the second operation after an accident she sustained dislocation and during the open reduction we had a diaphyseal fracture which was united succesfully. In an other case of a 48 year old lady with bilateral CDH which was operated in 1991 with partcipation of professor Peter Bosch in our clinic, with elongation of 7 cm without paresis, she had fall 3 months postoperatively.Intraoperative finding was loosening of acetabulum, femoral head osteointegrated. We changed the acetabular component (one size bigger) with satisfactory result. 5 years later she had had another accident with avulsion of the trochanter which was stabilized operativelly. In all our cases the reduction was achieved in the anatomical acetabbulum. The range of elongation was between 3-7cms. 2 pareses of femoral nerve returned back to normal within 3 months and one of sciatic nerve within the first 6 months. All our patients are happy.Their life-style changed, some of them married with normal sexual life and improvement of their walking.
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