Soft tissue balancing in total hip arthroplasty for patients with adult dysplasia of the hip.
ABSTRACT To summarize our surgical experience of release and balance of soft tissues around the hip in total hip arthroplasty (THA) for patients with adult dysplasia of the hip (ADH).
From January 2001 to January 2006, 29 adult patients with dysplastic hips (31 hips) were included in this study. Among them, there were 19 women and 10 men, aged from 38 to 65 years. According to the Crowe classification system, there were 8 type I, 12 type II, 6 type III and 5 type IV. THA was performed via a lateral approach. All acetabular cups were reconstructed at the original anatomic location through soft tissue releasing around the hip to restore limb length, and techniques of balance of soft tissue were applied to extend the strength of the hip abductor and improve its function.
All patients had restoration of limb length (range, 1.5-4.5 cm). One postoperative dislocation occurred due to slight enlargement of the angle of abduction of the acetabulum. At 1.5-year follow-up (mean, 3.2 years) in 29 patients, the Harris score had increased from 42.6 preoperatively to 85.4. All hips were pain free with good function.
In order to restore the anatomic structure and physiologic function of the affected hip, the technique of release and balance of soft tissues around the hip should be applied cautiously in arthroplasty of ADH.
- SourceAvailable from: ncbi.nlm.nih.gov[Show abstract] [Hide abstract]
ABSTRACT: The gluteus medius muscle is essential for gait and hip stability. Changes that occur in the gluteus medius muscles in patients with developmental dysplasia of the hip (DDH) are not well understood. A better understanding of DDH related changes will have positive repercussions toward hip soft tissue reconstruction. 19 adult patients with unilateral DDH scheduled for total hip arthroplasty were assessed for: cross-sectional area (CSA), radiological density (RD) and the length of gluteus medius using computed tomograhpy(CT) (scanned before THA). Hip abductor moment arm and gluteus medius activation angle were also measured via hip anteroposterior radiographs. Both CSA and RD of gluteus medius muscle were significantly reduced (p < 0.05) in the affected hip compared to the control. In the affected hip, the length of the gluteus medius muscle was reduced by 8-11% (p < 0.05) while the gluteus medius activation angle was significantly increased (p < 0.05) and the hip abductor moment arm was decreased (p < 0.05). The gluteus medius showed substantial loss of CSA, RD as well as decreased length in patients with DDH in the affected hip. These changes should be considered in both hip reconstruction and postoperative rehabilitation training in patients with DDH.BMC Musculoskeletal Disorders 06/2012; 13:101. · 1.88 Impact Factor
Soft tissue balancing in total hip arthroplasty for
patients with adult dysplasia of the hipos4_034212..215
Xing Wu MD, Lie-ming Lou MD, Shao-hua Li MD, Wei-ping Wu MD, Zheng-dong Cai MD
Department of Orthopaedics, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China
Objective: To summarize our surgical experience of release and balance of soft tissues around the hip in total hip
arthroplasty (THA) for patients with adult dysplasia of the hip (ADH).
Methods: From January 2001 to January 2006, 29 adult patients with dysplastic hips (31 hips) were included in this
study. Among them, there were 19 women and 10 men, aged from 38 to 65 years. According to the Crowe classification
system,there were 8 type I,12 type II,6 type III and 5 type IV.THA was performed via a lateral approach.All acetabular
cups were reconstructed at the original anatomic location through soft tissue releasing around the hip to restore limb
length, and techniques of balance of soft tissue were applied to extend the strength of the hip abductor and improve its
Results: All patients had restoration of limb length (range, 1.5–4.5 cm). One postoperative dislocation occurred due
to slight enlargement of the angle of abduction of the acetabulum.At 1.5-year follow-up (mean,3.2 years) in 29 patients,
the Harris score had increased from 42.6 preoperatively to 85.4. All hips were pain free with good function.
Conclusion: In order to restore the anatomic structure and physiologic function of the affected hip, the technique of
release and balance of soft tissues around the hip should be applied cautiously in arthroplasty of ADH.
Key words: Arthroplasty, replacement, hip; Hip dislocation, congenital; Orthopedic procedures
Adult dysplasia of the hip (ADH) is a common joint
disease, the symptoms of which often include arthralgia,
an effective procedure for hip dysplasia, but it is some-
times difficult to complete because of femoral head dis-
location, dysplasia of the acetabulum and the femur,
disparity in limb length, soft tissue contraction, and mus-
cular atrophy1. For the past few years, we have obtained
good results with THA in ADH using techniques of effec-
tive release and balance of soft tissue in order to recon-
struct the true socket, partly recover the abductor and
prevent resection of the femur.
Materials and methods
From January 2001 to January 2006, 29 adult patients
with dysplastic hips (31 hips) were included in this study.
Among them, there were 19 women and 10 men, aged
from 38 to 65 years. Preoperative anteroposterior radio-
graphs of the pelvis and anteroposterior and lateral radio-
graphs of the affected hip joint were taken to assess the
severity of hip dysplasia and anatomic variations of the
acetabulum and proximal femur. A computed tomogra-
phy (CT) scan was routinely taken to identify the quality
of bone around the true and the fake sockets and the
shape of the proximal femoral cavity. According to the
Crowe classification system2, there were 8 type I, 12 type
II, 6 type III and 5 type IV hips.
Initial surgical technique
approach began from 5 cm proximal to the apex of the
greater trochanter and paralleled the longitudinal axis of
the thigh. Skin and subcutaneous tissue were slit and the
fascia lata incised lengthwise slightly posteriorly.Then the
gluteus medius was exposed and separated from its one
third anterior–middle parts. Parts of the sheath of the
vastus lateralis were incised distally. Continuity of the
aponeurosis of the gluteus medius and the sheath of
the vastus lateralis were retained and repaired afterwards.
The gluteus minimus was dissected from its attachment
Address for correspondence Lie-ming Lou, MD, Department of
Orthopaedics, Shanghai Tenth People’s Hospital, Tongji University,
Shanghai 200072, China Tel: 0086-21-66307308; Fax: 0086-21-
66307308; Email: firstname.lastname@example.org
Received 24 January 2009; accepted 24 February 2009.
Orthopaedic Surgery (2009), Volume 1, No. 3, 212–215
© 2009 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd
and anterior parts of the articular capsule were exposed
and incised in a ‘T’ shape to explore the femoral head.
Technique of soft tissue release and balance
Thickening and contractures of the articular capsule,
fibrosis, scar tissue and hyperplastic osteophytes were
removed thoroughly during the operation. For patients
with Crowe type I or II, it was not very difficult to reduce
the femoral head. At most the adductor and parts of the
Crowe type III or IV, in whom the femoral head had
dislocated entirely and did not connect to the true
acetabulum, the femoral heads were difficult to reduce
and it was necessary to extensively release periacetabular
The four processes utilized were as follows: Firstly, the
adductor and parts of the iliotibial tract were split and
the superior attachment of the gluteus maximus to the
femoral crest was released. Secondly, if reduction was still
difficult, the iliopsoas muscle’s attachment at the lesser
trochanter was released but not abscised, and the attach-
ments of the rectus femoris and sartorius muscles to the
anterior superior iliac were released or even transsected.
ments of the piriformis and hamstring muscles,including
the gracilis and biceps femoris, to the ischial tuberosity.
Eventually, osteotomy and migration of the greater
gluteus medius fixation distally. Four hips with Crowe
type IV and limb shortening of more than 4 cm were
release or osteotomy of the greater tubercle, preventing
subtrochanteric osteotomy and resulting in no impair-
ment of the sciatic nerve. Restoration and reconstruction
of the anatomic structure of the gluteus medius and
vastus lateralis were carried out at the end of operation.
Reconstruction of the acetabulum
Reconstruction of the acetabulum was achieved in
place of the true socket in all cases. A regular size of
biotype socket prosthesis could be placed in the true
socket once it had been deepened and increased in cases
IV, the true socket was deepened backwards and inwards
by a small arthroplasty reamer, retaining a thin layer of
cortical bone. Then small amounts of spongy bone from
the femoral head were implanted and compacted with an
inversely rotating reamer.At last,a small socket prosthesis
with an outer diameter of less than 44 mm and a femoral
head prosthesis with a diameter of 22 mm were fixed.
Good coverage of the socket prosthesis could be achieved
by techniques of true socket ingression,thus bone graft of
the lateral acetabulum was avoided. A small non-cement
slim shaft of prosthesis was inserted into the femoral
bone. If anteversion of proximal femur was such as to
render this unsuitable, rectification was made with a
cement shaft prosthesis. A prosthesis with offset (LIMA-
LTO,Udine,Italy) could be applied according to abductor
tension to improve abductor strength and joint stability.
Postoperative rehabilitation and follow-up
The affected limb was placed in an abducted and
neutral position with 70° hip flexion and 90° knee flexion.
Rehabilitation of active flexion and extension of the hip
joint began seven days postoperatively. Patients were gen-
erally encouraged to walk initially with crutches and other
ambulation aids, with a stick six to eight weeks after
surgery and eventually to give up the stick aid twelve
weeks after surgery. Delay of walking time to six weeks
after operation was recommended for patients with
osteotomy of the greater trochanter.Twenty-nine patients
(31 hips) were followed up for 1–5 years (mean, 3.2).
Evaluations were made by hip joint function scores
(Harris scores) and X-ray films.
Noearlycomplicationsof palsyof thesciaticorfemoral
nerves, deep vein embolism, incision infection or fracture
occurred. One case of femoral head dislocation occurred
abduction angle (50°) when the patient was transported
carelessly, and this was successfully treated by closed
reduction. Limb lengthening of 1.5–4.5 cm was achieved
in the treatment group. No cases of loosening of prosthe-
sis,penetration,subsidence or dislocation occurred up till
final follow-up. Harris scores increased from 42.6 preop-
eratively to 85.4 postoperatively. Arthralgia was relieved
and gaits were obviously improved.
Pathology of soft tissue in ADH
In ADH a series of pathologic changes develop in the
soft tissue around the hip joint owing to dislocation and
movement upwards of the femoral head. These changes
display as thickening of the capsule extending it outwards
and upwards in a choanoid shape, its coherence to the lip
of the dysplastic acetabulum with its narrow end, extend-
ing gradually in the direction of the femoral head and
adhering to the abductor. Dysfunction of the transverse
abductor leads to gait instability. Other manifestations
Orthopaedic Surgery (2009), Volume 1, No. 3, 212–215 213
© 2009 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd
include pachynsis of the iliopsoas, contracture of the
hamstring, adductor and rectus femoris muscles, crispa-
tion of the sciatic nerve and deep femoral artery and ever-
sion of the outlet of the femoral nerve at the pelvis.
extension is over 4 cm during arthroplasty3.
mechanisms, the purposes of reconstruction of soft tissue
in arthroplasty for patients with ADH are as follows: (i)
limb extension and acetabulum reconstruction at the level
of the true acetabulum are achieved by release of soft
functional impairment while avoiding injury to the sciatic
nerve; and (ii) the force arm of the abductor lengthens
and the tension of the adductor decreases to increase
abductor strength and ameliorate claudication as much as
Contribution of soft tissue release to
reconstruction of the acetabulum
Up to now, most surgeons recommend prosthetic
replacement in the position of the true acetabulum to
recover the normal anatomic relationships of the acetabu-
lum,preventing rapid wearing out of the prosthesis under
non-physiological conditions4, and to lengthen the
extremity so as to improve abductor function. According
to the report of Linde et al.5, the data from 15 years of
follow-up reveal that the loosening ratio of socket pros-
thesis in the position of the true acetabulum and the
pseudo-acetabulum is 13% and 42% respectively.
The main characteristics of patients with Crowe type
IV are complete dislocation of the hip joint and severe
crispation of more than 3 cm in the affected limb. When
THA is performed there is a risk of injury to the sciatic
nerve with limb lengthening. Therefore, some surgeons
do not recommend complete recovery of limb length but
rather to utilize artificial reconstruction with mortar,
with which there are obvious shortcomings6. Other
surgeons accept subtrochanteric osteotomy for limb
shortening of between 1 and 3 cm while applying a non-
cement long prosthetic shaft, which can lead to difficul-
ties in implantation, rotational displacement of the
femoral shaft, nonunion of fracture and loosening of the
prosthesis7. Kerboull et al. insist that there is not genuine
shortening but rather a change in the pathway of the
sciatic nerve in patients with Crowe type IV, and safe
lengthening of the lower limb of more than 7 cm can be
achieved by thorough release of soft tissue8. In this study,
THA was performed on 30 patients with Crowe type IV
and limb shortening of more than 4 cm, and the affected
limb lengths were recovered by techniques of release of
soft tissue without injury to the sciatic nerve. Sener et al.
propose that for severe dislocation of the hip joint, entire
excision of the joint capsule and scar tissue is a priority,
then loosening of the superior parts of the gluteus
maximus, adductor, rectus
In our opinion, limb lengthening in patients with
Crowe type IV can be achieved by the technique of careful
and effective soft tissue release: thickening and contrac-
ture of the articular capsule, fibrous and scar tissue and
hyperplastic osteophytes should routinely be cleaned up.
Then muscle groups around the hip joint can be released
by four procedures: Firstly, the adductor is cut down, and
parts of the iliotibial tract transected or released by a ‘Z’
shaped extension, then the superior attachment of the
gluteus maximus to the femoral crest is released. Next, if
reduction is still difficult, the iliopsoas muscle’s attach-
ment to the lesser trochanter is released but not abscised,
and the attachments of rectus femoris and sartorius
muscles to the anterior superior iliac released or even
transected.Then,release can be performed with respect to
the attachments of the piriformis and hamstring muscles,
including the gracilis and biceps femoris muscles at the
ischiac tuberosity. Eventually osteotomy and migration of
greater tubercle may need to be performed which helps
reduction and extends the offset to improve abductor
muscle strength by moving the greater tubercle combined
with shifting the fixation of gluteus medius distally. Four
cases with Crowe type IV and limb shortening of more
than 4 cm were reduced to the level of the true acetabu-
lum by the technique of soft tissue releasing with a knee
flexion position. After the operation, the affected limb is
set in an abducted and neutral position with 90° flexion of
the knee and 70° flexion of the hip.
Balance of soft tissue in THA for ADH
hip and disparity in limb length but also by pathology of
the abductor resulting in muscular atrophy and dysfunc-
tion. Dysplasia of the femoral head causes maldevelop-
ment and augmentation of the greater trochanter whose
topmost extent becomes higher than that of the femoral
head. In addition, upward and outward dislocation of the
femoral head results in transverse tension on the abductor
which aggravates muscular weakness. Although the pro-
cedure of THA is of definite assistance in improving mus-
cular strength and rectifying lameness, amelioration of
gait and muscle strength can be achieved by balancing of
regard to improving muscular strength and function of
the affected hip: (i) operative approach. We believe that a
214X Wu et al., Soft tissue balancing in THA for ADH
© 2009 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd
lateral approach can meet the requirements of exposure
and successful completion of the operation, though some
exposure of the acetabulum.For patients with Crowe type
IV, greater trochanter osteotomy can be utilized to expose
the operative area clearly. Damage to the extortor is
avoided via a lateral approach compared with a post-
lateral approach. Thus muscle strength is protected and
the incidence of postoperative dislocation is lower. The
gluteus medius should be protected from too much injury
and repaired together with the gluteus minimus during
the operation; (ii) release of contractured muscle groups
of the anterior-medial parts of the hip joint such as the
adductor, iliopsoas and rectus femoris is helpful in recov-
ery of abductor function; (iii) restoration of the anatomy
of the acetabulum and reconstruction of the true socket.
the socket prosthesis in place of lateral bone implantation
can be achieved with the techniques of rotator centre
ingression and inner wall of acetabulum osteotomy10; (iv)
the technique of trochanter migration can be performed
in patients with Crowe type IV. This was introduced by
Paavilainen et al.11and is achieved by greater trochanter
osteotomy, then shifting and fixation of the greater tro-
chanter distally and laterally to extend the strength of the
abductor and improve its function; (v) an eccentric
femoral prosthesis is utilized to extend the arm of the
muscle, enhance the strength of the abductor and contri-
bute to stability of the hip joint; and (vi) training of active
abduction of the affected hip should be emphasized after
On the whole, satisfactory clinical results can be
achieved for patients with severe ADH as follows: precise
evaluation of extremity crispation and force of abductor
before operation, effective procedures for release of soft
tissue around the hip to extend the limb and reconstruct
the true socket, restoration of the anatomic course of the
abductor and balance of its muscular strength and correct
postoperative rehabilitation regimes to improve the func-
tion of the affected joint.
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© 2009 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd