Introduction

Among patients with osteoarthritis secondary to congenital dislocation of the hip, those with high dislocations show poor ambulation with severe limping and usually experience a dull pain at the lumbar and pelvic region rather than pain of the hip joint itself. However, it is a known fact that symptoms and functional impairments caused by high dislocations increase with age and that conservative treatment alone is insufficient for middle-aged or older patients.

In high congenital dislocation of the hip, Crowe group III or IV [2], the femoral head is entirely outside the original acetabulum. A joint-preserving procedure is not recommended for patients with this condition. However, recent techniques of total hip arthroplasty have been established, and a certain degree of confidence has been acquired with regard to the lasting effectiveness of these techniques. Thus, painless-ness, ability for weight-bearing, and mobility can be regained simultaneously by

1 Department of Orthopaedic Surgery, Nakajo Central Hospital, 12-1 Nishihoncho, Tainai, Niigata 959-2656, Japan

2 Division of Orthopaedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata 951-8510, Japan appropriate surgery, and such treatments are the most suitable for responding to the needs of the present-day patient.

In most cases of high dislocation, the true acetabulum is usually small, porotic, and triangularly shaped. The upwardly displaced femur is also dysplastic with a narrow medullary canal, a small head, and an anteverted neck, but of normal length (Fig. 1).

Initial attempts to reconstruct a high dislocation Crowe group III or IV [2], using a secondary acetabulum with formed osteophytes, have been performed in two cases. In these patients, however, poor ambulation persisted and a biomechanically stable joint could not be obtained, resulting in loosening of the acetabular cup at an early postoperative stage.

Figure 2A-C shows a case with these processes. These experiences suggest a necessity to improve the biomechanical relationship between the femoral head and the pelvis by implanting the artificial joint at the level of the original acetabulum. This necessity has also been stated in the literature by Eftekhar [4], Arcq [5], Azuma [6], and Yamamuro [7]. A second attempt to reconstruct the high dislocation, using a small-sized cup in the true acetabulum, had been performed, but this technique had a risk of abrasion of the high density polyethylene (HDP) and breakage of the component. Figure 2D-F shows a case in which the small-cup component was used, which

Fig. 1. A 62-year-old woman: three-dimensional (3D) computed tomography (CT) findings of right hip, Crowe group IV. A Anteroposterior (ap): left normal femur (arrows). B Posteroante-rior (pa): right upper displaced slender femur (arrows). C Right lateral: narrow true acetabulum and pressure mark of the femoral head on iliac bone wall (double-headed arrow)

Fig. 1. A 62-year-old woman: three-dimensional (3D) computed tomography (CT) findings of right hip, Crowe group IV. A Anteroposterior (ap): left normal femur (arrows). B Posteroante-rior (pa): right upper displaced slender femur (arrows). C Right lateral: narrow true acetabulum and pressure mark of the femoral head on iliac bone wall (double-headed arrow)

Fig. 2. A-C Upper case. A A 69-year-old woman with Crowe group III [2]. B Total hip replacement (THR) in the secondary acetabulum. C Upward migration (arrow) of the cup in a short period (2 years) after surgery. D-F Lower case. D A 52-year-old woman with left Crowe group IV [2]. E THR using a small cup. F Breakdown of the cup (arrow) in a short period (2 years) after surgery

Fig. 2. A-C Upper case. A A 69-year-old woman with Crowe group III [2]. B Total hip replacement (THR) in the secondary acetabulum. C Upward migration (arrow) of the cup in a short period (2 years) after surgery. D-F Lower case. D A 52-year-old woman with left Crowe group IV [2]. E THR using a small cup. F Breakdown of the cup (arrow) in a short period (2 years) after surgery resulted in a breakdown of the cup in a short period after surgery. If at all possible, a normal-sized component should be used.

These failures taught us that we should reconstruct a biomechanically stable condition around the hip by implanting the component in an anatomically correct position and keep in mind that using a normal-sized component is also of importance.

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