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Total Hip Arthroplasty with Subtrochanteric Femoral Shortening Osteotomy for Crowe Type IV Post-Dysplastic Hip
Marek Rovnak1,2, Marian Melisik1,2, Maros Hrubina1,2
1Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, 036 59 Martin, Slovakia.
Insights
Total hip arthroplasty with femoral shortening osteotomy effectively treats Crowe type IV hip dysplasia, significantly improving limb length and function. This procedure offers sustained functional gains and acceptable implant survival in experienced centers.
Area of Science:
- Orthopedic Surgery
- Hip Reconstruction
- Arthroplasty
Background:
- Post-dysplastic coxarthrosis, particularly Crowe type IV high iliac dislocation, presents surgical challenges for total hip arthroplasty (THA).
- Restoring the hip center often necessitates femoral shortening osteotomy, but long-term functional and survival data are limited.
Purpose of the Study:
- To evaluate the long-term functional outcomes and prosthesis survival of THA combined with subtrochanteric femoral shortening osteotomy in Crowe type IV hip osteoarthritis.
- To assess the achievement of biomechanical restoration and identify potential predictors for osteotomy length.
Main Methods:
- Retrospective cohort study of 19 patients (22 hips) with Crowe type IV hip osteoarthritis undergoing uncemented THA and transverse subtrochanteric femoral shortening osteotomy.
- Serial clinical follow-up included range of motion, limb-length discrepancy, Harris Hip Score, and WOMAC questionnaire.
- Radiological assessment evaluated osteotomy union, implant positioning, osteolysis, and measured key anatomical distances (CR, GT, LT) relative to reference lines (ischial line, teardrop line).
Main Results:
- All osteotomies achieved union by a mean of 5.57 months, with a mean follow-up of 129 months.
- Significant improvements were observed in limb-length discrepancy (5.27 cm to 1.5 cm) and hip flexion (82.9° to 106°).
- Functional scores improved significantly (WOMAC: 55.4 to 80.1; Harris Hip Score: 49.8 to 84.66). Implant survival was 81.3% long-term. Distal femoral fissure (27.3%) and revision (18%) were noted complications.
Conclusions:
- THA combined with subtrochanteric femoral shortening osteotomy is a feasible and effective procedure for Crowe type IV hip osteoarthritis in experienced centers.
- The technique provides reliable osteotomy healing, sustained functional improvement, reduced limb-length discrepancy, and satisfactory biomechanical restoration.
- The lesser trochanter-teardrop (LT-TD) distance may predict osteotomy length, but further validation is required due to sample size limitations.
Abstract:
Background: Surgical management of adult patients with post-dysplastic coxarthrosis using total hip arthroplasty is technically demanding and carries an increased risk of complications. In cases of high iliac dislocation classified as Crowe type IV, restoring the acetabular component to the anatomical hip centre often requires femoral shortening osteotomy to enable safe reduction in the prosthetic joint. Nevertheless, long-term evidence on functional outcomes and prosthesis survival with this approach is limited. Methods: A retrospective cohort study included 19 patients with 22 cases of Crowe type IV post-dysplastic hip osteoarthritis treated with uncemented total hip arthroplasty (Pinnacle/S-ROM, DePuy, Warsaw, IN, USA) combined with transverse subtrochanteric femoral shortening osteotomy. Patients underwent serial clinical follow-up, including assessment of range of motion, measurement of limb-length discrepancy, and functional evaluation using the Harris Hip Score and the WOMAC questionnaire. Radiological assessment included evaluation of osteotomy union, implant positioning, and osteolysis on standardized radiographs. Vertical distances of the centre of rotation (CR), the tip of the greater trochanter (GT), and the tip of the lesser trochanter (LT) from both reference lines were measured bilaterally, and inter-side differences were calculated. The reference lines consisted of the line connecting the inferior margins of the ischial bones and the teardrop (TD) line. Results: All osteotomies united at a mean of 5.57 months, with a mean follow-up of 129 months. Mean limb-length discrepancy decreased from 5.27 cm to 1.5 cm, and mean hip flexion improved from 82.9° to 106°. Functional outcomes improved significantly, with mean WOMAC increasing from 55.4 to 80.1 (p < 0.001) and mean Harris Hip Score from 49.8 to 84.66 at up to 3 years of follow-up (p < 0.001). Osteotomy length correlated strongly with lesser trochanter-teardrop distance (p = 0.00000048). Complications included distal femoral fissure (27.3%) and revision (18%), with no infection or permanent neurological deficit. Conclusions: Total hip arthroplasty combined with subtrochanteric femoral shortening osteotomy for Crowe type IV post-dysplastic hip osteoarthritis appears to be a feasible and effective procedure in an experienced centre, providing reliable osteotomy healing and significant early functional improvement that is sustained over time. Limb-length discrepancy was reduced and satisfactory biomechanical restoration was achieved, with an acceptable complication profile and implant survival of 81.3% at long-term follow-up. The LT-TD parameter was identified as a potential predictor of osteotomy length, enabling the proposal of a preoperative planning equation. However, given the limited sample size and lack of validation, these findings should be interpreted cautiously. Further studies are needed to confirm their broader applicability.
