5. Acetabular alterations in CHD (3D) (*) ischiatic prevalence ischiatic overload bone stock increase @ posterior column (*) anterior column deficit ischiopubic branch ipoplasia secondary to loss of charge

6. Proximal Femoral Deformities • increase in antiversion angle • G.T. posterior displacement • L.T. anterior displacement • diafiseal diameter reduction • ipoplasia of metaphisys

7. 1970 Surgical technique evolution Cemented stem Proximal osteotomy and lowering of GT 70 ’s

8. Surgical technique evolutions 1970 1980 Distal shortening Osteotomy and femoral derotation 80 ’s

9. • cemented stem implant according to CHD anteversion • distal femur shortening & derotation (according to preoperative planning) Surgical technique: shortening osteotomy and distal derotation

10. 18 y f-up i.d. 12575

14. The Surgeon has to keep in mind the local and peripheral abnormal anatomy of CDH A B C C B A E E’ D and try to restore the normal hip biomechanics A = gluteus maior B = gluteus medius C = gluteus minor D = ileopsoas E = short adductor E’= long adductor A B C C B A D

15. in Crowe IV CHD it’s possible to perform THA with a sub troch femoral shortening osteotomy at same time

17. CHD patients Crowe grade 1 to 3 Crowe grade 4 THA performed 2.308 1367 376 565 21.538 1984 - 2009 osteotomies sequelae Santa Corona Hospital, Pietra Ligure Humanitas Clinical Institute, Milano

18. our surgical technique: PLANNING IS THE KEY

21. Restore anatomic rotational center I.D. 7367

24. 28 hips in 24 patients in 13 years (about 9000 THA in same period) mean follow up 4.8 years (2 – 13 years) Good clinical results but a complication rate about 43 %

26. from 1990 to 2000 in 2 centres 214 hips in 153 patients operated with the same tecnique (planning, posterolateral approach, uncemented implant, no additional fixation) with a minimum follow up of 10 years mean age 37.6 years (range, 26 to 64 ) HHS moved from a mean of 43 to 89 limb-length discrepancy moved from a mean of 43 mm (range 25-60) to be inferior than 10 mm in all cases (lateral position during surgery)

27. RESULTS Survival curve is working progress and is considerably worse than THA (age at operation – different needs ?) 0 2 4 6 8 10 12 14 16 Years 376 Cases 27 # Events 349 # Censored 18 20 22 2006 Conus stem survivorship study 92 % Kaplan-Meier Cum. Survival Plot for DELTA G Censor Variable: CENSOR G 94 % 0 0.2 0.4 0.6 0.8 1.0

28. Intra op complications are very rare: No femoral fractures, only 2 GT fractures 3 neurologic injuries (pre op discrepancy > than 50 mm ) Rate of overall complications is 22,3 % in ’90 serie The procedure is very safe after a learning curve

30. I.D. 7823 9/4/1995 22/2/1996

31. I.D. 7823 18/6/1996

32. I.D. 7823 10 ys F. up

33. 16679

35. 17230 3 ys F-up

36. 9882 4 ys F. up 8 ys F. up 9 ys F. up

37. 6911 Conclusions In Crowe 1 / 2 survival of last uncemented stem designs is comparable to standard stems

38. post-op i.d. 14416 ...but Crowe 3 / 4 treatment, specially in association with torsional deviation, is complex and technically demanding, with considerable influence on implant survival

39. in Crowe IV patients THA with a femoral shortening sub troch osteotomy at the same time is a reasonable option with encouraging results also if worse than primary THA in same age group

40. 1970 1980 1990 THANK YOU VERY MUCH FOR YOUR ATTENTION