Total hip arthroplasty in dysplasia and dislocation of the hip

  • John Vlamis
Keywords: total hip arthroplasty in developmental dysplasia of the hip, terminology of developmental dysplasia of the hip, classification of developmental dysplasia of the hip, reconstruction of the acetabulum, reconstruction of the femur


Developmental dysplasia of the hip encompasses a wide spectrum of hip pathology ranging from a shallow acetabulum to a completely dislocated “high-riding” hip. It is a common cause of secondary osteoarthritis and is the underlying diagnosis in the majority of young adults requiring total hip arthroplasty (THA) for coxarthrosis. It is clear we still do not have an agreed and correct terminology covering the entire pathology of congenital deformities of the hip. We recommend the use of the term “Dysplasia and Dislocation of the Hip (DDH)” that is by definition the most suitable term to describe the total spectrum of related deformities in adults. Various systems of classification of DDH in the adults are in use. The most practical classification seems to be that of Hartofilakidis et al. We propose a classification system of DDH in adults based on the CT of the pelvis to supplement the existing classification systems and to be used in the preoperative planning of a THA. The acetabular deficiency is classified, according to Crowe or Hartofilakidis classification, in the frontal plane based on a plain AP radiograph, and then further classified as “neutral”, “anteverted” or “retroverted” in the transverse plane based on the CT scan of the pelvis. Careful attention to the morphology of the acetabulum, femur, pelvis, lumbar spine and knee in plain radiographs and CT scans in patients with DDH, is necessary, primarily to accurately classify the deformity and predict the bone deficiencies that will be encountered during THA. This will facilitate the selection of the proper reconstruction method and implants. In the present article useful surgical techniques and implants are presented for the management of these patients with a THA that presents difficulties because the majority of them are young with a considerable demand on their implants and they may require complex reconstruction on both sides of the joint.


Download data is not yet available.

Author Biography

John Vlamis

3rd Orthopaedic Department, Medical School, National and Kapodistrian University of Athens, General Hospital of Athens KAT, Greece


1. Dupuytren G. Original or congenital displacement of the heads OF THIGH-bones. Clin Orthop Relat Res 1964; 33:3-8.
2. Howorth MB. Congenital Dislocation of the Hip. Ann Surg 1947; 125(2):216-36.
3. Stanisavljevic S, Mitchell CL. Congenital Dysplasia, Subluxation, and Dislocation of the Hip in Stillborn and Newborn Infants. J Bone Joint Surg Am 1963; 45:1147-58.
4. Klisic PJ. Congenital dislocation of the hip--a misleading term: brief report. J Bone Joint Surg Br 1989; 71(1):136.
5. Hartofilakidis G, Babis GC. Congenital disease of the hip. Clin Orthop Relat Res 2009; 467(2):578-9; discussion 80-1.
6. Wedge JH, Wasylenko MJ. The natural history of congenital disease of the hip. J Bone Joint Surg Br 1979; 61-B(3):334-8.
7. Weinstein SL. Natural history of congenital hip dislocation (CDH) and hip dysplasia. Clin Orthop Relat Res 1987; (225):62-76.
8. Hartofilakidis G. Developmental dysplasia of the hip: An unsuitable term. J Bone Joint Surg [Internet]. 2004.
9. Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am 1979; 61(1):15-23.
10. Eftekar NS. Variations in technique and specific considerations. In: Eftekar NS, editor. Principles of total hip arthroplasty. St. Louis: CV Mosby; 1978. p. 1-440.
11. Eftekhar NS. Congenital displasia and dislocation. Summary of essentials. In: Eftekhar NS, editor. Total hip arthroplasty. II. St. Louis, Mssouri: Mosby; 1993. p. 977.
12. Kerboul M, Mathieu M, Sauzieres P. Total hip replacement for congenital dislocation of the hip. In: Postel M, Kerboul M, Evrard J, Courpied JP, editors. Total hip replacement. New York: Springer; 1987. p. 51–66.
13. Mendes DG, Said MS, Aslan K. Classification of adult congenital hip dysplasia for total hip arthroplasty. Orthopedics 1996; 19(10):881-7; quiz 8-9.
14. Gaston MS, Gaston P, Donaldson P, et al. A new classification system for the adult dysplastic hip requiring total hip arthroplasty: a reliability study. Hip Int 2009; 19(2):96-101.
15. Hartofilakidis G, Stamos K, Ioannidis TT. Low friction arthroplasty for old untreated congenital dislocation of the hip. J Bone Joint Surg Br 1988; 70(2):182-6.
16. Hartofilakidis G, Stamos K, Karachalios T, et al. Congenital hip disease in adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty. J Bone Joint Surg Am 1996; 78(5):683-92.
17. Vlamis J, Kavroudakis E, Karabinas P, et al. Classification of DDH in adults using CT imaging. In: Macheras GA, editor. 9th Domestic Meeting of the EUROPEAN HIP SOCIETY; Athens, Greece, 2010; 20(03):p. 367.
18. Hartofilakidis G, Babis GC, Lampropoulou-Adamidou K. Congenital Hip Disease: General Aspects, Terminology and Classification. Congenital Hip Disease in Adults: Springer-Verlag Italia; 2014. p. 11-27.
19. Karachalios T, Hartofilakidis G. Congenital hip disease in adults: terminology, classification, pre-operative planning and management. J Bone Joint Surg Br 2010; 92(7):914-21.
20. Browning WH, Rosenkrantz H, Tarquinio T. Computed tomography in congenital hip dislocation. The role of acetabular anteversion. J Bone Joint Surg Am 1982; 64(1):27-31.
21. Buckley SL, Sponseller PD, Magid D. The acetabulum in congenital and neuromuscular hip instability. J Pediatr Orthop 1991; 11(4):498-501.
22. Kim SS, Frick SL, Wenger DR. Anteversion of the acetabulum in developmental dysplasia of the hip: analysis with computed tomography. J Pediatr Orthop 1999; 19(4):438-42.
23. Edelson JG, Hirsch M, Weinberg H, et al. Congenital dislocation of the hip and computerised axial tomography. J Bone Joint Surg Br 1984; 66(4):472-8.
24. Gugenheim JJ, Gerson LP, Sadler C, et al. Pathologic morphology of the acetabulum in paralytic and congenital hip instability. J Pediatr Orthop 1982; 2(4):397-400.
25. Murphy SB, Kijewski PK, Millis MB, et al. Acetabular dysplasia in the adolescent and young adult. Clin Orthop Relat Res 1990; (261):214-23.
26. Johnston CE, 2nd, Wenger DR, Roberts JM, et al. Acetabular coverage: three-dimensional anatomy and radiographic evaluation. J Pediatr Orthop 1986; 6(5):548-58.
27. Crockarell J, Jr., Trousdale RT, Cabanela ME, et al. Early experience and results with the periacetabular osteotomy. The Mayo Clinic experience. Clin Orthop Relat Res 1999; (363):45-53.
28. Ganz R, Klaue K, Vinh TS, et al. A new periacetabular osteotomy for the treatment of hip dysplasias. Technique and preliminary results. Clin Orthop Relat Res 1988; (232):26-36.
29. Hussell JG, Rodriguez JA, Ganz R. Technical complications of the Bernese periacetabular osteotomy. Clin Orthop Relat Res 1999; (363):81-92.
30. Myers SR, Eijer H, Ganz R. Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop Relat Res 1999; (363):93-9.
31. Rab GT. Biomechanical aspects of Salter osteotomy. Clin Orthop Relat Res 1978; (132):82-7.
32. Rab GT. Containment of the hip: a theoretical comparison of osteotomies. Clin Orthop Relat Res 1981; (154):191-6.
33. Salter RB. Role of innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip in the older child. J Bone Joint Surg Am 1966; 48(7):1413-39.
34. Tachdjian MO. Salter’s innominate osteotomy to detorate the maldirected acetabulum. In: Tachdjian MO, editor. Congenital dislocation of the hip: New York: Churchill Livingstone; 1982. p. 525-41.
35. Dora C, Mascard E, Mladenov K, et al. Retroversion of the acetabular dome after Salter and triple pelvic osteotomy for congenital dislocation of the hip. J Pediatr Orthop B 2002; 11(1):34-40.
36. Sugano N, Noble PC, Kamaric E, et al. The morphology of the femur in developmental dysplasia of the hip. J Bone Joint Surg Br 1998; 80(4):711-9.
37. Liu S, Zuo J, Li Z, et al. Study of three-dimensional morphology of the proximal femur in developmental adult dysplasia of the hip suggests that the on-shelf modular prosthesis may not be an ideal choice for patients with Crowe type IV hips. Int Orthop 2017; 41(4):707-13.
38. Xu H, Zhou Y, Liu Q, et al. Femoral morphologic differences in subtypes of high developmental dislocation of the hip. Clin Orthop Relat Res 2010; 468(12):3371-6.
39. Sanchez-Sotelo J, Trousdale RT, Berry DJ, et al. Surgical treatment of developmental dysplasia of the hip in adults: I. Nonarthroplasty options. J Am Acad Orthop Surg 2002; 10(5):321-33.
40. Ganz R, Klaue K, Vinh TS, et al. A new periacetabular osteotomy for the treatment of hip dysplasias: technique and preliminary results. 1988. Clin Orthop Relat Res 2004; (418):3-8.
41. Hartofilakidis G, Babis GC, Georgiades G, et al. Trochanteric osteotomy in total hip replacement for congenital hip disease. J Bone Joint Surg Br 2011; 93(5):601-7.
42. Lakstein D, Backstein DJ, Safir O, et al. Modified trochanteric slide for complex hip arthroplasty: clinical outcomes and complication rates. J Arthroplasty 2010; 25(3):363-8.
43. Ollivier M, Abdel MP, Krych AJ, et al. Long-Term Results of Total Hip Arthroplasty With Shortening Subtrochanteric Osteotomy in Crowe IV Developmental Dysplasia. J Arthroplasty 2016; 31(8):1756-60.
44. Mu W, Yang D, Xu B, et al. Midterm Outcome of Cementless Total Hip Arthroplasty in Crowe IV-Hartofilakidis Type III Developmental Dysplasia of the Hip. J Arthroplasty 2016; 31(3):668-75.
45. Karachalios T, Roidis N, Lampropoulou-Adamidou K, et al. Acetabular reconstruction in patients with low and high dislocation: 20- to 32-year survival of an impaction grafting technique (named cotyloplasty). Bone Joint J 2013; 95-B(7):887-92.
46. Hartofilakidis G, Georgiades G, Babis GC, et al. Evaluation of two surgical techniques for acetabular reconstruction in total hip replacement for congenital hip disease: results after a minimum ten-year follow-up. J Bone Joint Surg Br 2008; 90(6):724-30.
47. Malizos KN, Bargiotas K, Papatheodorou L, et al. Survivorship of monoblock trabecular metal cups in primary THA : midterm results. Clin Orthop Relat Res 2008; 466(1):159-66.
48. Dorr LD, Tawakkol S, Moorthy M, et al. Medial protrusio technique for placement of a porous-coated, hemispherical acetabular component without cement in a total hip arthroplasty in patients who have acetabular dysplasia. J Bone Joint Surg Am 1999; 81(1):83-92.
49. Jasty M, Anderson MJ, Harris WH. Total hip replacement for developmental dysplasia of the hip. Clin Orthop Relat Res 1995; (311):40-5.
50. Hampton BJ, Harris WH. Primary cementless acetabular components in hips with severe developmental dysplasia or total dislocation. A concise follow-up, at an average of sixteen years, of a previous report. J Bone Joint Surg Am 2006; 88(7):1549-52.
51. Harris WH, Crothers O, Oh I. Total hip replacement and femoral-head bone-grafting for severe acetabular deficiency in adults. J Bone Joint Surg Am 1977; 59(6):752-9.
52. Jaroszynski G, Woodgate IG, Saleh KJ, et al. Total hip replacement for the dislocated hip. Instr Course Lect 2001; 50:307-16.
53. Morsi E, Garbuz D, Stockley I, et al. Total hip replacement in dysplastic hips using femoral head shelf autografts. Clin Orthop Relat Res 1996; (324):164-8.
54. Russotti GM, Harris WH. Proximal placement of the acetabular component in total hip arthroplasty. A long-term follow-up study. J Bone Joint Surg Am 1991; 73(4):587-92.
55. Bal BS, Maurer T, Harris WH. Revision of the acetabular component without cement after a previous acetabular reconstruction with use of a bulk femoral head graft in patients who had congenital dislocation or dysplasia. A follow-up note. J Bone Joint Surg Am 1999; 81(12):1703-6.
56. Gross AE, Catre MG. The use of femoral head autograft shelf reconstruction and cemented acetabular components in the dysplastic hip. Clin Orthop Relat Res 1994; (298):60-6.
57. Inao S, Gotoh E, Ando M. Total hip replacement using femoral neck bone to graft the dysplastic acetabulum. Follow-up study of 18 patients with old congenital dislocation of the hip. J Bone Joint Surg Br 1994; 76(5):735-9.
58. Marti RK, Schuller HM, van Steijn MJ. Superolateral bone grafting for acetabular deficiency in primary total hip replacement and revision. J Bone Joint Surg Br 1994; 76(5):728-34.
59. Rodriguez JA, Huk OL, Pellicci PM, et al. Autogenous bone grafts from the femoral head for the treatment of acetabular deficiency in primary total hip arthroplasty with cement. Long-term results. J Bone Joint Surg Am 1995; 77(8):1227-33.
60. Raut VV, Stone MH, Siney PD, et al. Bulk autograft for a deficient acetabulum in Charnley low-friction arthroplasty. A 2-9-year follow-up study. J Arthroplasty 1994; 9(4):393-8.
61. Hartwig CH, Beele B, Kusswetter W. Femoral head bone grafting for reconstruction of the acetabular wall in dysplastic hip replacement. Arch Orthop Trauma Surg 1995; 114(5):269-73.
62. Mulroy RD, Jr., Harris WH. Failure of acetabular autogenous grafts in total hip arthroplasty. Increasing incidence: a follow-up note. J Bone Joint Surg Am 1990; 72(10):1536-40.
63. MacKenzie JR, Kelley SS, Johnston RC. Total hip replacement for coxarthrosis secondary to congenital dysplasia and dislocation of the hip. Long-term results. J Bone Joint Surg Am 1996; 78(1):55-61.
64. Jasty M, Freiberg AA. The use of a high-hip center in revision total hip arthroplasty. Semin Arthroplasty 1995; 6(2):103-8.
65. Jensen JS, Retpen JB, Arnoldi CC. Arthroplasty for congenital hip dislocation. Techniques for acetabular reconstruction. Acta Orthop Scand 1989; 60(1):86-92.
66. Kelley SS. High hip center in revision arthroplasty. J Arthroplasty 1994; 9(5):503-10.
67. Pagnano W, Hanssen AD, Lewallen DG, et al. The effect of superior placement of the acetabular component on the rate of loosening after total hip arthroplasty. J Bone Joint Surg Am 1996; 78(7):1004-14.
68. Yoder SA, Brand RA, Pedersen DR, et al. Total hip acetabular component position affects component loosening rates. Clin Orthop Relat Res 1988; (228):79-87.
69. Schmitz M, Hannink G, Gardeniers JWM, et al. Acetabular Reconstructions with Impaction Bone-Grafting and a Cemented Cup in Patients Younger Than 50 Years of Age: A Concise Follow-up, at 27 to 35 Years, of a Previous Report. J Bone Joint Surg Am 2017; 99(19):1640-6.
70. Petheram TG, Howell JR. The Exeter method-acetabular impaction grafting with cemented reimplantation. Oper Orthop Traumatol 2014; 26(2):114-25.
71. Te Stroet MA, Keurentjes JC, Rijnen WH, et al. Acetabular revision with impaction bone grafting and a cemented polyethylene acetabular component: comparison of the Kaplan-Meier analysis to the competing risk analysis in 62 revisions with 25 to 30 years follow-up. Bone Joint J 2015; 97-B(10):1338-44.
72. DeBoer DK, Christie MJ. Reconstruction of the deficient acetabulum with an oblong prosthesis: three- to seven-year results. J Arthroplasty 1998; 13(6):674-80.
73. Herrera A, Martinez AA, Cuenca J, et al. Management of types III and IV acetabular deficiencies with the longitudinal oblong revision cup. J Arthroplasty 2006; 21(6):857-64.
74. Desai AS, Dramis A, Board TN, et al. Acetabular revision surgery with the uncemented oblong BOFOR Cup--early to midterm results. Hip Int 2012; 22(3):280-5.
75. Gill TJ, Sledge JB, Muller ME. Total hip arthroplasty with use of an acetabular reinforcement ring in patients who have congenital dysplasia of the hip. Results at five to fifteen years. J Bone Joint Surg Am 1998; 80(7):969-79.
76. Berry DJ, Muller ME. Revision arthroplasty using an anti-protrusio cage for massive acetabular bone deficiency. J Bone Joint Surg Br 1992; 74(5):711-5.
77. Bohm P, Banzhaf S. Acetabular revision with allograft bone. 103 revisions with 3 reconstruction alternatives, followed for 0.3-13 years. Acta Orthop Scand 1999; 70(3):240-9.
78. Peters CL, Curtain M, Samuelson KM. Acetabular revision with the Burch-Schnieder antiprotrusio cage and cancellous allograft bone. J Arthroplasty 1995; 10(3):307-12.
79. Zehntner MK, Ganz R. Midterm results (5.5-10 years) of acetabular allograft reconstruction with the acetabular reinforcement ring during total hip revision. J Arthroplasty 1994; 9(5):469-79.
80. Ewers A, Spross C, Ebneter L, et al. 10-Year Survival of Acetabular Reinforcement Rings/Cages for Complex Hip Arthroplasty. Open Orthop J 2015; 9:163-7.
81. Ahmad AQ, Schwarzkopf R. Clinical evaluation and surgical options in acetabular reconstruction: A literature review. J Orthop 2015; 12(Suppl 2):S238-43.
82. Hartofilakidis G, Lampropoulou-Adamidou K. Lessons learned from study of congenital hip disease in adults. World J Orthop 2016; 7(12):785-92.
83. Koulouvaris P, Stafylas K, Sculco T, et al. Distal femoral shortening in total hip arthroplasty for complex primary hip reconstruction. A new surgical technique. J Arthroplasty 2008; 23(7):992-8.
84. Muratli KS, Karatosun V, Uzun B, et al. Subtrochanteric shortening in total hip arthroplasty: biomechanical comparison of four techniques. J Arthroplasty 2014; 29(4):836-42.
85. Becker DA, Gustilo RB. 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. J Arthroplasty 1995; 10(3):313-8.
86. Paavilainen T, Hoikka V, Paavolainen P. Cementless total hip arthroplasty for congenitally dislocated or dysplastic hips. Technique for replacement with a straight femoral component. Clin Orthop Relat Res 1993; (297):71-81.
87. Papagelopoulos PJ, Trousdale RT, Lewallen DG. Total hip arthroplasty with femoral osteotomy for proximal femoral deformity. Clin Orthop Relat Res 1996; (332):151-62.
88. Symeonides PP, Pournaras J, Petsatodes G, et al. Total hip arthroplasty in neglected congenital dislocation of the hip. Clin Orthop Relat Res 1997; (341):55-61.
89. Yasgur DJ, Stuchin SA, Adler EM, et al. Subtrochanteric femoral shortening osteotomy in total hip arthroplasty for high-riding developmental dislocation of the hip. J Arthroplasty 1997; 12(8):880-8.
90. Bicanic G, Barbaric K, Bohacek I, et al. Current concept in dysplastic hip arthroplasty: Techniques for acetabular and femoral reconstruction. World J Orthop 2014; 5(4):412-24.
91. Eggli S, Hankemayer S, Muller ME. Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. J Bone Joint Surg Br 1999; 81(5):843-5.
92. Hartofilakidis G, Babis GC, Lampropoulou-Adamidou K, et al. Results of total hip arthroplasty differ in subtypes of high dislocation. Clin Orthop Relat Res 2013; 471(9):2972-9.
93. Chen KH, Wang HY, Sung CS, et al. Wake-up test in total hip arthroplasty with high-riding developmental dysplasia. Orthopedics 2014; 37(7):e625-30.
94. Chen D, Xu Z, Shi D, et al. Clinical outcome of Zweymuller total hip arthroplasty for patients with high congenital hip dislocation. Hip Int 2011; 21(1):71-5.