Features of Secondary OA of the

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Reviewing the characteristic features of secondary OA caused by developmental dislocation of the hip (DDH) or acetabular dysplasia, we can observe the coexistence of two phases, one being wear and the destructive process on the weight-bearing area, and the other the proliferative and reparative process on the peripheral, non-weight-bearing area. The large capital drop that forms on the posteromedial side seems to come from the biological response of the repair process. Even on the weight-bearing area, abundant buds of reparative tissue, so-called chondroid plugs, that seem to have come from the bone marrow can be observed. Thus, the secondary OA can be characterized by the coexistence of two phases, that is, the destructive phase with the devastation of the biomechanical environment, and the pro-liferative and reparative phase that occurs as a result of the biological repair process (Figs. 1, 2).

Hip Arthritis

Fig. 1. Natural course of osteoarthritis (OA) of the hip caused by developmental dislocation of the hip (DDH). Radiologic change of the hip of a 45-year-old woman at the first visit. a April 1991 (45 years old); b April 2001 (55 years old); c April 2005 (59 years old). AP, anteroposterior; Ls, left side

Fig. 1. Natural course of osteoarthritis (OA) of the hip caused by developmental dislocation of the hip (DDH). Radiologic change of the hip of a 45-year-old woman at the first visit. a April 1991 (45 years old); b April 2001 (55 years old); c April 2005 (59 years old). AP, anteroposterior; Ls, left side

Fig. 2. Histological findings of femoral head harvested from terminal-stage OA. a Cross section of the femoral head. ▲, capital drop; ▼, original line of the head. b Magnification of chondroid plugs at weight-bearing area (boxed area in a)

Bombelli used the big capital drop and double floor, formed on the posteromedial side. With applying strong valgus beyond so-called congruency, he destroyed the mechanical environment, and then reduced the anterior quarter of the femoral head, which protruded laterally as a result of the excessive valgus orientation, back into the acetabulum by extension in his VEO [4]. However, if we look closely, we can see that there are cases where the size of the medial capital drop tends to be relatively small.

Fig. 3. Three-dimensional (3-D) computed tomography (CT) findings. The three-dimensional relationship of the capital drop and force S presents an S-curve

There is a corresponding double floor. Three-dimensional computed tomography (3-D CT) shows that the capital drop, in fact, is bigger on the posterior side in most cases. The capital drop is formed in the posteromedial-inferior direction, which is in agreement with the direction of slippage of the femoral head in slipped capital femoral epiphysis. Conversely, the force-S that pushes out the femoral head laterally has a three-dimensional S-curve, going into the anterolateral-superior direction (Fig. 3) [5,6]. The old weight-bearing surface gradually displaces into an anterolateral-supe-rior direction, thereby losing its original function; this has led us to change our procedure from extension to flexion osteotomy [5,6].

The weight-bearing surface is subjected to gradual wear and loss, and the old weight-bearing surface of the femoral head deviates into the anterolateral-superior direction, losing its function. Despite all that, there seems to be some budding of reparative tissues in this environment (see Fig. 2). In the marginal non-weight-bearing area, bony and cartilaginous tissues are regenerated and proliferated in the postero-medial-inferior direction. Assuming that the capital drop and the double floor are serving to form a new joint, then surgery will be needed to induce the natural healing capacity and to promote the regeneration of reparative tissues. This realization led us to combine flexion with valgus osteotomy [5,7,8].

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