Primary THA in DDH

Shay Daji, PGY-1

Dr. Montijo Sr., MD

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
DDH Background

Shallow acetabulum with lack

of anterior and lateral coverage

Incidence: 3-5% in the US

Risk factors: breech position,

female sex, family history

Estimated 10% of THAs are

performed for DDH

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Pathophysiology
• Abnormal movement of the
femoral head within the
acetabulum due to both
osseous and soft tissue
abnormalities

• Overload of the acetabular

rim leads to secondary OA

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Abnormal Anatomy
• Abnormal Acetabulum
o Shallow
o Hypoplastic
o Excessive anteversion
o Thick medial wall
o Deficient anterior-superior

• Abnormal Femur
o Coxa valga
o Excessive anteversion
o Narrow femoral canal

• Abnormally tight soft tissue/musculature

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Presentation
• Hip or groin pain with insidious onset
• Exacerbating by hip flexion or external rotation in
weight bearing stance
Physical Exam:
• Inspection
• Evaluation of gait; abductor fatigue or Trendelenburg sign
• Overall ligamentous laxity; Beighton score

• Motion
• Increased internal rotation with the hip in flexion (increased
femoral anteversion)

• Provocative tests
• Anterior apprehension sign
• Prone external rotation tests

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Diagnosis made with plain radiographs
• Lateral Center Edge Angle (LCEA)
• assesses superolateral coverage of the femoral head on the AP view
• angle between a vertical line through the center of the femoral head and
the acetabular edge

• 25-39° :: Normal
• 20-25° :: Borderline
• <20° :: Dysplastic

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Diagnosis made with plain radiographs
• Tonnis Angle
o inclination of the weight bearing portion
of the acetabulum
o angle formed between the horizontal
and a line along the superior
acetabulum
o evaluated on the AP view

• Normal: <10°
• Dysplastic: >10°

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Diagnosis made with plain radiographs
• Anterior center-edge angle
(ACEA)
o assesses anterior coverage of the femoral
head
o angle created between a vertical line through
the center of the femoral head and the
anterior acetabulum
o evaluated on the false-profile view

• Dysplastic: <20°
• Dormal 25-40°
• >40° indicative of
femoroacetabular impingement
(FAI)
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Classification Systems

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Crowe Classification

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affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Crowe Classification

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Hartofilakidis Classification

Type A

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affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Hartofilakidis Classification

Type B Type C

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affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
THA in DDH
• Preoperative planning is essential (CT)
o Implanting acetabular component is difficult given abnormal anatomic landmarks
o Adequate assessment of acetabular and proximal femoral osseous morphology including
▪ distal femur should be included in CT in patients with clinical signs of femoral anteversion
▪ diameter of femoral canal may be over-estimated on AP radiographs and underestimated on
lateral radiographs due to rotational mismatch of the metaphysis and diaphysis

▪ Ranawat’s Triangle
▪ True acetabular area
▪ A :: 5mm lateral to teardrop
▪ AB and BC is 20% of pelvic height
▪Approach
▪ Anterior, lateral or posterior based approaches
may be used

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
 THA in DDH
• Technique
• Trochanteric osteotomy may be needed to improve visualization,
especially in Crowe type III or IV dysplastic hips
• Goal is to place the acetabular component in the true acetabulum
to restore normal hip center of rotation and biomechanics
• This may cause significant leg lengthening, which would
subsequently require femoral shortening (trochanteric or
subtrochanteric)
• Components may need to be medialized or used with augments to
gain adequate coverage and stability of the acetabulum
• Can use uncemented cup if there is less than 30% uncoverage
• A high hip center can be used to gain adequate bony stability, but
is less ideal biomechanically
• Modular femoral components allow for correction of rotational
deformities
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Outcomes following THA
• Improves Harris Hip scores and pain

• Outcomes for Crowe I and II patients are in similar to

those of THA for primary OA in the short term
• Revision rates for Crowe III and IV are higher than non-dysplastic hips

• Higher revision rate compared to THA for OA

• Higher complication rate

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Complications
• Increased risk of infection and neurovascular injury
• Sciatic nerve palsies
• 10x increased incidence of sciatic nerve palsy (5-15%)
• Lengthening of greater than 4 cm can lead to sciatic nerve palsy (presents clinically as a foot
drop)

• Nonunion
• 29% nonunion with greater trochanter osteotomy
• Subtrochanteric osteotomy and trochanter advancement lowers nonunion rate

• Hip Dislocation
• Increased risks of hip dislocation after arthroplasty (5-10%), especially when high hip center is
used

• Component loosening
• Placement of the acetabular component in a high hip position associated with increased risk of
loosening
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare
affiliated entity. The views expressed in this publication represent those of the author(s) and do
not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.