The Journal of Arthroplasty 32 (2017) S38eS44

Contents lists available at ScienceDirect

The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

AAHKS Symposium

Challenges in Total Hip Arthroplasty in the Setting of Developmental

Dysplasia of the Hip
Eric M. Greber, MD, Christopher E. Pelt, MD *, Jeremy M. Gililland, MD,
Mike B. Anderson, MSc, Jill A. Erickson, BSc, PA-C, Christopher L. Peters, MD
Department of Orthopaedics, University of Utah, Salt Lake City, Utah

a r t i c l e i n f o a b s t r a c t

Article history: Background: Developmental dysplasia of the hip (DDH) is a recognized cause of secondary arthritis,
Received 8 February 2017 which may eventually lead to total hip arthroplasty (THA). An understanding of the common acetabular
Accepted 9 February 2017 and femoral morphologic abnormalities will aid the surgeon in preparing for the complexity of the
Available online 22 February 2017
surgical case.
Methods: We present the challenges associated with acetabular and femoral morphologies that may be
Keywords:
present in the dysplastic hip and discuss surgical options to consider when performing THA. In addition,
developmental dysplasia of the hip
common complications associated with this population are reviewed.
total hip arthroplasty
modular stems
Results: The complexity of THA in the DDH patient is due to a broad range of pathomorphologic changes
complications of the acetabulum and femur, as well as the diverse and often younger age of these patients. As such, THA
subtrochanteric osteotomy in the DDH patient may offer a typical primary hip arthroplasty or be a highly complex reconstruction. It
is important to be familiar with all the subtleties associated with DDH in the THA population. The
surgeon must be prepared for bone deficiency when reconstructing the acetabulum and should place the
component low and medial (at the anatomic hip center), and avoid oversizing the acetabular component.
Femoral dysplasia is also complex and variable, and the surgeon must be prepared for different stem
choices that allow for decoupling of the metaphyseal stem fit from the implanted stem version. In Crowe
III and IV dysplasia, femoral derotation/shortening osteotomy may be required. Many complications
associated with THA in the DDH patient may be mitigated with careful planning and surgical technique.
Conclusion: Performed correctly, THA can yield excellent results in this complex patient population.
© 2017 Elsevier Inc. All rights reserved.

Developmental Dysplasia of the Hip
Developmental dysplasia of the hip (DDH) is a recognized cause
of secondary arthritis which may lead to eventual total hip
arthroplasty (THA) to relieve pain and improve function [1e3]. THA
for the dysplastic hip has been shown to result in excellent out-
comes. However, given the variety of morphologies present, this
population requires special attention and may be at a higher risk for
complications [4e6]. Aside from the morphologic challenges, sur-
geons must also consider the age of the patient, as this population
One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.02.024.
* Reprint requests: Christopher L. Peters, MD, Department of Orthopaedics,
University of Utah, 590 Wakara Way, Salt Lake City, UT 84108.
may present earlier in life (Fig. 1) and as a result may require
subsequent revision surgeries [4e6]. Given these challenges, the
appropriate evaluation of bony morphologies and implant selection
is imperative to a successful THA in patients with DDH.
Bony morphologies associated with DDH have been classified
using several methods including the Crowe classification and the
Hartofilakidis method [6,7]. Along with the acetabular variations,
different femoral morphologies also contribute to the complexity of
the cases. These morphologies include excessive femoral ante-
version and coxa valga, which may necessitate the need for
modular femoral implants. An understanding of the common
acetabular and femoral morphologic abnormalities will aid the
surgeon in preparing for the complexity of the surgical case.
Herein, we (1) present the challenges associated with the vari-
ety of morphologies that may be present in the dysplastic hip, (2)
discuss surgical options to consider when performing THA on the
DDH patient population, and (3) report the common complications
associated with this population.

http://dx.doi.org/10.1016/j.arth.2017.02.024
0883-5403/© 2017 Elsevier Inc. All rights reserved.
 E.M. Greber et al. / The Journal of Arthroplasty 32 (2017) S38eS44
Fig. 1. This histogram demonstrates the wide age distribution in our cohort of patients
who have undergone total hip arthroplasty (THA) due to developmental dysplasia of
the hip (DDH). The mean age for our population was 42 years (range, 17-77 years).
Acetabular Challenges
There are many challenges to consider when planning for THA in
a patient with DDH. Owing to the deficient bone stock often
encountered in DDH, the most troublesome issues often lie with the
acetabular reconstruction. These challenges include a small-
diameter native acetabulum, deficient bony architecture, and a
high-riding or even chronically dislocated femoral head. It is
important to understand that not every patient with DDH has the
same acetabular morphology, and therefore, preoperative planning,
including classification of the morphology, is necessary. Crowe et al
[6] described a classification system from grades I to IV demon-
strating the percent of subluxation of the femur from the acetab-
ulum (Fig. 2). The Hartofilakidis method categorizes dysplasia into
types A, B, and C (Fig. 3) when describing both the acetabular
changes and femoral subluxation in the dysplastic hip [7]. Both
Fig. 2. This figure demonstrates the 4 grades of severity in the Crowe classification of hip dysplasia [6]. The grades are defined as grade I <50% subluxation of the femoral head,
grade II between 50% and 75% subluxation of the femoral head, grade III between 75% and 100% subluxation of the femoral head, and grade IV >100% subluxation/dislocation of the
femoral head.
S39
these classification systems are useful in understanding the bony
anatomy of the acetabular side and may help guide the surgeon as
they seek to establish the true acetabulum.
A smaller native acetabulum is often present because of the lack
of forces in the developing cartilaginous acetabulum from the
subluxated/dislocated head which does not allow the acetabulum
to form appropriately. Adding to the poor development of the ac-
etabulum from early development is the superolateral bony wear
from the high-riding, subluxated femoral head. The small diameter
of the femoral head and bony acetabulum typically dictate the use
of a smaller acetabular component when compared with patients
undergoing THA for primary osteoarthritis. Acetabular components
with outer diameters of 38-50 mm are commonly used in this
patient population. The necessary smaller acetabular components
have implications for preoperative inventory planning, intra-
operative preparation, and choice of femoral head size.
Consistent with the theme of variable morphology in DDH,
deficient bony architecture around the acetabulum can be found
lateral, anterior, or posterior. There is no reliable trend that can be
used for planning, but instead, the surgeon has to be prepared for
all the possibilities found with bone deficiency intraoperatively.
Nonetheless, isolated posterosuperior deficiency is usually seen in
neuromuscular disorders that can be associated with DDH.
Furthermore, patients with Crowe III-IV dysplasia typically have
superior or anterosuperior bony deficiency. Global deficiency is rare
but can be seen as well and is usually associated with more severe
dysplasia including a dislocated femoral head (Crowe IV) [8,9].
When considering placement of the acetabular component in
the patient with DDH, a common mistake occurs when the surgeon
chases the pseudoacetabulum, often resulting in a cup placed high,
lateral, and oversized. This mistake often leads to problems with
fixation, stability, and the restoration of appropriate hip biome-
chanics. Bringing the hip center back down to the true acetabulum
is imperative, and although this is not possible in all situations, it is
biomechanically superior [7,10,11]. When establishing the true ac-
etabulum, the most important step is finding the cotyloid fossa and
the inferior aspect of teardrop. It is only after these anatomic lo-
cations are found and dissected that the true acetabulum can be
evaluated. However, exposure of the true acetabulum can be
challenging owing to soft-tissue contractures and extensive
covering of the cotyloid fossa with soft tissue secondary to the
femoral head being positioned higher than this location. Following
the capsule down to the inferior aspect of the acetabulum can
be helpful to locate the true acetabulum intraoperatively in
S40 E.M. Greber et al. / The Journal of Arthroplasty 32 (2017) S38eS44

Fig. 3. This figure demonstrates the 3 types of severity in the Hartofilakidis method for categorizing hip dysplasia [7]. Type A occurs when the femoral head remains within the
acetabulum with minimal subluxation, and there is also some deficiency in the superior wall with a shallow acetabulum. In Type B, the femoral head creates a pseudoacetabulum
superior to the true acetabulum, and there is complete absence of the superior wall with a shallow acetabulum. Finally, Type C is seen when the femoral head is completely
uncovered and has position superiorly and posteriorly. The true acetabulum is completely deficient and excessive anteversion may be present.

more severe cases. Once identified, bone deficiency of the true
acetabulum can then be determined.
Reaming should commence in a medial direction (Fig. 4A and B)
to the base of the cotyloid fossa or, in some situations, slightly medial
to the base as described by Dorr et al [12] to maximize bony coverage
of the acetabular component. Often, the initial reamer will be
extremely smalldin the range of 38-44 mm. Reaming should pro-
ceed in the anatomic (approximately 40 degrees of abduction and
20-25 degrees of anteversion) position with care to not over-ream
the anterior and posterior walls. Dunn and Hess [13] described a
medial wall breakthrough technique to further medialize the
component and gain superior bony coverage. It is not uncommon to
have some lateral uncovering of the component owing to the
common superolateral bony deficiency (Fig. 4C). It has been re-
ported that 20%-50% of lateral uncovering may be acceptable
[14e17]. When excessive lateral undercoverage is encountered,
femoral head autograft or modular porous metal augments may be
placed superolaterally to help support the uncovered cup (Fig. 4D).
The use of the just-removed femoral head as autograft has
demonstrated good results with 10-year survivorship being
reported at 94% [18]. In more extreme cases, when there is global
bony deficiency, elevating the hip center to gain bony support is
acceptable, with medialization, but should only be used if necessary
(Fig. 4E and F) [19,20]. Chen et al [19] reported a 5-year survivorship
of 90.3% for all-cause revisions when using a high hip center during
THA in DDH patients with Hartofilakidis type B changes.
Along with understanding the type of morphologic changes to
the acetabulum, proper selection of the acetabular component is
also important and unique in these patients. Higher rates of loos-
ening and acetabular failure with cemented acetabular components
in patients with DDH have been reported [20]. This is likely sec-
ondary to a combination of young age, increased activity, and
deficient bony support. As such, cementless acetabular recon-
struction is the most frequently used technique in these patients. If
needed, supplemental screws can aid in early cup stability until
ingrowth occurs. Since the native acetabulum is usually small in
diameter, it is important to understand that the appropriate size of
the acetabular component should be small in patients with DDH
(usually in the range of 38-52 mm).
A common mistake is to begin reaming with an oversized reamer
after measuring the excised dysplastic femoral head. Although the
authors typically use a rule of thumb for acetabular size to be 4-6
mm larger than the native femoral head, this rule does not apply in
the setting of DDH. The dysplastic femoral head, often articulating in
a large, shallow, lateralized pseudoacetabulum, is not a good pre-
dictor of the proper implant size. In addition to needing to stay
smaller in the size range to restore the hip center, the main size
constraint of the acetabular size is the anterior to posterior dimen-
sion of the native acetabular walls and distance between the ante-
rior and posterior columns. Failure to understand this principle can
lead the surgeon down the road of starting with an oversized reamer
and staying lateral. The coverage is often inadequate, and the
acetabular component can fail to get a good “scratch fit.” This is often
followed by an effort to medialize with larger sized reamers and
often results in reaming away of the anterior and/or posterior col-
umns. We cannot overstate the importance of understanding the
individualized anatomic size considerations, often with the neces-
sary size being much smaller than may seem apparent at first glance.
Furthermore, attention must be taken to not oversize the compo-
nent in these unique patients, as an oversized acetabular component
can lead to iliopsoas pain, rectus femoris pain, and capsular pain
from tension over the prominent anterior or anterior-lateral edge of
the implant. Ultimately, efforts should be made to place the cup in
the anatomic hip center, which is often achieved by keeping the cup
low, medial, and small.
Femoral Challenges
On the femoral side, increased anteversion and high valgus neck-
shaft angles can create nuanced challenges. The most notable of
these morphologic variants is the increased likelihood to have
excessive femoral anteversion. Sugano et al [21] found that patients
with DDH had an average increase of 10-14 degrees of anteversion of
the native femoral neck. In their study, they reported the incidence of
anteversion >40 degrees to be 23% in DDH, whereas only 7% in age-
matched controls with no DDH diagnosis. Similar results were found
by Noble et al [22] who determined femoral anteversion was increased
in patients with DDH on average by 5-16 degrees in their cohort. The
 E.M. Greber et al. / The Journal of Arthroplasty 32 (2017) S38eS44 S41

Fig. 4. This figure contains the before and after views demonstrating medial wall breakthrough (A and B), anatomic position with bone graft augmentations (C and D), and placing
the cup in a high hip center using the existing bone stock (E and F).
S42 E.M. Greber et al. / The Journal of Arthroplasty 32 (2017) S38eS44
Fig. 5. The 4 common methods for performing a subtrochanteric osteotomy are displayed in the figure.
anteversion increased with increased subluxation of the hip. However,
even in mild DDH cases (eg, Crowe I), there was a significant increase
in anteversion. An understanding of the increased anteversion will
help the surgeon in determining the optimal femoral stem choice in
these patients. To address these morphologic challenges, primary and
even modular stem designs may aid in the correction and restoration
of appropriate hip mechanics.
Modular stems that can essentially decouple the metaphyseal/
diaphyseal fit from the version of the stem will be necessary in some
cases with excessive anteversion. At our institution, a modular
metaphyseal sleeve femoral stem is used if the anteversion is
determined to be in excess of 25 degrees intraoperatively. Other
Fig. 6. A Kaplan-Meier survival curve for THA in a cohort of DDH patients from our
institution. CI, confidence interval.
stem options include modular or nonmodular, splined, tapered
stems as these stem designs can engage the distal diaphysis,
bypassing the proximal femoral morphology. However, owing to the
distal fixation and risk of proximal stress shielding, the authors
attempt to avoid these designs in primary THA, unless necessary. In
femora with excessive anteversion, tapered nonmodular femoral
stems are at risk of being undersized, or placed in malalignment or
malrotation, and may even increase the risk of intraoperative
femoral fracture. In an attempt to assist in preoperative stem
selection, our group [23] retrospectively studied DDH patients un-
dergoing THA and compared patients who received a modular
metaphyseal sleeve stem with those who received a tapered non-
modular stem. The purpose of that study was to identify preopera-
tive radiographic variables that would predict the use of modular
femoral stem designs as opposed to our typical double-tapered,
wedge, primary stem designs. In this study, the best preoperative
radiographic predicators for using a modular femoral stem included
an AP neck-shaft angle
142 degrees, a lateral neck-shaft angle
153 degrees, and a femoral anteversion >32 degrees.
With increased anteversion, the dysplastic femur can often have
an appearance of coxa valga; however, this valgus neck-shaft may
actually be a result of the increased anteversion of the neck seen on
AP radiographs. Both Sugano et al [21] and Noble et al [22] have
shown that although there are some patients with DDH that have
coxa valga, it is likely that the dysplastic femur can have a normal
neck-shaft angle. Sugano et al [21] also reported that with severe
dysplasia, there is a higher likelihood of encountering a varus neck-
shaft angle, as opposed to coxa valga. Regardless, there is a higher
rate of variability of the neck-shaft angle (both coxa vara and valgus)
in patients with DDH compared with that of normal cohorts [21,22].
The morphologic changes of the femur are not limited to ante-
version or neck-shaft angles, as many dysplastic femurs also have a
small diaphyseal diameter that can also affect stem selection. Often,
neither the AP nor the lateral radiograph can accurately depict the
diameter of the canal. The AP radiograph often overestimates and
the lateral radiograph underestimates the diameter because of the
rotational mismatch of the metaphysis and diaphysis, as well as the
radiographic position of the femur because of the excessive femoral
anteversion [22]. The narrow diaphyseal canal may push the lower
limits of diaphyseal diameter for many implants, and as a result,
 E.M. Greber et al. / The Journal of Arthroplasty 32 (2017) S38eS44
stem selection may need to be altered to account for this with the
use of reduced distal diameter stems, or rarely, even the use of
custom stems in extremely small patients. Here again, the authors
have found the use of modular metaphyseal sleeve femoral stems to
be helpful, as the modularity allows for a more customized fit in
both the femoral metaphysis and diaphysis.
Subtrochanteric Osteotomy
In the setting of more severe dysplasia (Crowe III or IV), with high-
riding hip centers or significant subluxation, femoral shortening may
be necessary to safely reduce the hip to the anatomic hip center. One
method for accomplishing this is the use of a subtrochanteric osteot-
omy. This can facilitate restoration of the true acetabulum, mitigate
soft-tissue contractions, and protect the neurovascular structures in
the setting of severe preoperative limb shortening.
Subtrochanteric osteotomy, at the time of THA in the DDH
population, has demonstrated effective results, with survivorship
reported around 75% at 14 years [24e27]. The subtrochanteric
osteotomy can be performed using a variety of techniques including
transverse, oblique, z-shaped, or the double chevron osteotomy
(Fig. 5) [26,28e30]. Muratli et al [30] assessed the stability of the 4
techniques, during load testing in a biomechanical laboratory
setting and found no differences in the stability of the techniques.
Regardless of the method used, the limiting factor in determining
the amount of shortening is often dependent on the soft-tissue
structures around the hip, and special attention should be
directed to the sciatic nerve [13].
The authors' preferred technique for subtrochanteric femoral
shortening for severe dysplasia is based on the principles of ensuring
adequate femoral fixation, maintenance of the abductor mechanism,
and preserving intraoperative flexibility in determination of the
appropriate amount of shortening (femoral shaft resection).
Generally, a posterior approach is used with release of the short
external rotators and posterior capsule. Acetabular preparation and
component placement is performed to allow for appropriate posi-
tioning in the true acetabulum. An oblique or transverse sub-
trochanteric osteotomy is performed and the desired amount of
femoral shaft is removed. Next, a modular stem is used such that the
proximal femoral metaphysis can be prepared independent of the
diaphysis. Final implant placement achieves proximal fixation via a
porous-coated sleeve and distal fixation with a fluted stem.
Achievement of rotational stability is paramount, and bone graft,
from the resected diaphyseal segment, can be secured around the
osteotomy for additional support. Final reduction can then be per-
formed, and assessment of the soft tissue and sciatic nerve tensions
should be completed. If excellent femoral fixation is achieved,
postoperative management is similar to uncomplicated THA.
Bearing Surface Options
As described by Heisel et al [31], the goal of bearing surfaces is to
reduce wear and the associated complications. Given the wide age
spectrum and morphologic changes associated with the DDH
population, the surgeon must decide which bearing surface would
provide the greatest longevity with the fewest complications for
each individual patient. This is of greater concern in the younger
THA population, as studies have demonstrated increased wear in
this population [31,32]. Contemporary bearing surface options
include metal-on-highly cross-linked polyethylene (MoP), ceramic-
on-highly cross-linked polyethylene (CoP), and ceramic-on-
ceramic (CoC). For the purposes of this discussion, the authors
have omitted the discussion of metal-on-metal (MOM) bearings
because of the significantly increased risk of complication associ-
ated with this articulation [33e35].
S43
Although MoP is one of the most common bearing surface
options, studies have demonstrated increased rates of revision,
osteolysis, and aseptic loosening compared with those of CoC im-
plants [36]. Furthermore, recently, the issues of trunnionosis in
MoP because of the modular head-neck interface have become
recognized. These factors become more problematic in the
extremely young patient who will hopefully have the implants in
place for a much longer period than the standard patient with
osteoarthritis. CoC bearings have shown some promise by
demonstrating lower rates of wear than MoP [37e40]. Despite re-
ports of survivorship of CoC bearings reported as high as 99.3% at
short-term to midterm follow-up [41], CoC bearings are at risk for
fracture of the bearing surfaces, squeaking, or other mechanical
symptoms, which may result in the need for revision of THA.
However, the rate of fractures in contemporary ceramic bearings is
extremely low (rates <1%), yet, further studies may be needed to
understand the wear products, wear and failure potentials, and
wear monitoring of these articulations [42,43].
Perhaps, the most promising option, when weighing the risks of
wear vs the risks of complications, is CoP. CoP has demonstrated a
similar low risk of ceramic head fracture, decreased polyethylene
wear compared with that of MoP, and even decreased risk of
trunnionosis [44,45]. Thus, CoP bearings have become the bearing
option of choice at our institution for these complex patients.
Complications
The long-term survival of THA in general has been reported to be
as high as 90% at 10 years and 80% at 25 years [46,47]. However,
implant survival in younger populations is reported to be as low as
70% at 10 years and 55% at 20 years in the young dysplastic hip
[48,49]. In our own cohort of DDH THA patients (n ¼ 134 patients;
n ¼ 164 THAs), our current survival is 76% at 5 years (Fig. 6). However,
a majority of our failures were due to MOM bearings (46%).
When considering both the age-related concerns and morpho-
logic challenges in these cases, it is not surprising that complica-
tions exist. The most common complications have included aseptic
loosening, postoperative dislocations, polyethylene wear, intra-
operative femoral fractures, nerve palsy, distal femur perforation,
and nonunion of the femoral osteotomy [6,24,25,50e53]. In our
own patient population, we have experienced similar complica-
tions including dislocation and aseptic loosening. Aseptic loosening
has been shown to be one of the leading causes of revision in the
younger population and has been attributed to increased activity
levels [48,51,53]. Of note, many of these reports include historic
bearing options, including, most commonly, metal-on-nonecross-
linked polyethylene. Owing to this concern, our institution had
tried to move toward MOM as a potential low wear bearing option
in this young, active, patient cohort. When combining all bearing
options over the last decade, only 8% of our cases were revised for
aseptic loosening as compared with 46% for metallosis and 31% for
dislocations. Although we have since abandoned the use of MOM
articulations, dislocation still remains a concerning complication
after THA in the DDH patient. Given the pathomorphology
described previously in this population, it is perhaps not surprising
that the DDH patient is at high risk for dislocation after THA, with
rates reported from 1.6% to 16.6% [6,25,50,52]. However, many of
these complications may be mitigated with careful planning and
appropriate surgical techniques.
Summary
The complexity of THA in the DDH patient is due to a broad range of
pathomorphologic changes of the acetabulum and femur, as well as
the diverse and often younger age of these patients. As such, THA in the
S44 E.M. Greber et al. / The Journal of Arthroplasty 32 (2017) S38eS44
DDH patient may offer a typical primary hip arthroplasty or be a highly
complex reconstruction. It is important to be familiar with all the
subtleties associated with DDH in the THA population. The surgeon
must be prepared for bone deficiency when reconstructing the ace-
tabulum and should place the component low and medial (at the
anatomic hip center), and avoid oversizing the acetabular component.
Femoral dysplasia is also complex and variable, and the surgeon must
be prepared for different stem choices that allow for decoupling of the
metaphyseal stem fit from the implanted stem version. In Crowe III
and IV dysplasia, femoral derotation/shortening osteotomy may be
required. Performed correctly, THA can yield excellent results in this
complex patient population.
References
[1] Harris WH. Etiology of osteoarthritis of the hip. Clin Orthop Relat Res 1986:20e33.
[2] Cooperman DR, Wallensten R, Stulberg SD. Acetabular dysplasia in the adult.
Clin Orthop Relat Res 1983:79e85.
[3] Lloyd-Roberts GC. Osteoarthritis of the hip; a study of the clinical pathology.
J Bone Joint Surg Br 1955;37-B:8e47.
[4] Biant LC, Bruce WJ, Assini JB, Walker PM, Walsh WR. Primary total hip
arthroplasty in severe developmental dysplasia of the hip. Ten-year results
using a cementless modular stem. J Arthroplasty 2009;24:27e32.
[5] Faldini C, Nanni M, Leonetti D, Miscione MT, Acri F, Giannini S. Total hip
arthroplasty in developmental hip dysplasia using cementless tapered stem.
Results after a minimum 10-year follow-up. Hip international. J Clin Exp Res
Hip Pathol Ther 2011;21:415e20.
[6] Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital disloca-
tion and dysplasia of the hip. J Bone Joint Surg Am 1979;61:15e23.
[7] Hartofilakidis G, Stamos K, Ioannidis TT. Low friction arthroplasty for old un-
treated congenital dislocation of the hip. J Bone Joint Surg Br 1988;70:182e6.
[8] Edelson JG, Hirsch M, Weinberg H, Attar D, Barmeir E. Congenital dislocation of the
hip and computerised axial tomography. J Bone Joint Surg Br 1984;66:472e8.
[9] Kim HT, Wenger DR. The morphology of residual acetabular deficiency in
childhood hip dysplasia: three-dimensional computed tomographic analysis.
J Pediatr Orthop 1997;17:637e47.
[10] Johnston RC, Brand RA, Crowninshield RD. Reconstruction of the hip. A
mathematical approach to determine optimum geometric relationships.
J Bone Joint Surg Am 1979;61:639e52.
[11] Hartofilakidis G, Karachalios T. Total hip arthroplasty for congenital hip
disease. J Bone Joint Surg Am 2004;86-A:242e50.
[12] Dorr LD, Tawakkol S, Moorthy M, Long W, Wan Z. 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;81:83e92.
[13] Dunn HK, Hess WE. Total hip reconstruction in chronically dislocated hips.
J Bone Joint Surg Am 1976;58:838e45.
[14] Garvin KL, Bowen MK, Salvati EA, Ranawat CS. Long-term results of total hip
arthroplasty in congenital dislocation and dysplasia of the hip. A follow-up
note. J Bone Joint Surg Am 1991;73:1348e54.
[15] Li H, Mao Y, Oni JK, Dai K, Zhu Z. Total hip replacement for developmental
dysplasia of the hip with more than 30% lateral uncoverage of uncemented
acetabular components. Bone Joint J 2013;95-B:1178e83.
[16] Jasty M, Anderson MJ, Harris WH. Total hip replacement for developmental
dysplasia of the hip. Clin Orthop Relat Res 1995:40e5.
[17] Kim YH, Kim JS. Total hip arthroplasty in adult patients who had develop-
mental dysplasia of the hip. J Arthroplasty 2005;20:1029e36.
[18] Kim M, Kadowaki T. High long-term survival of bulk femoral head autograft
for acetabular reconstruction in cementless THA for developmental hip
dysplasia. Clin Orthop Relat Res 2010;468:1611e20.
[19] Chen M, Luo ZL, Wu KR, Zhang XQ, Ling XD, Shang XF. Cementless total hip
arthroplasty with a high hip center for Hartofilakidis type B developmental
dysplasia of the hip: results of midterm follow-up. J Arthroplasty 2016;31:1027e34.
[20] Yang S, Cui Q. Total hip arthroplasty in developmental dysplasia of the hip:
review of anatomy, techniques and outcomes. World J Orthop 2012;3:42e8.
[21] Sugano N, Noble PC, Kamaric E, Salama JK, Ochi T, Tullos HS. The morphology of the
femur in developmental dysplasia of the hip. J Bone Joint Surg Br 1998;80:711e9.
[22] Noble PC, Kamaric E, Sugano N, Matsubara M, Harada Y, Ohzono K, et al.
Three-dimensional shape of the dysplastic femur: implications for THR. Clin
Orthop Relat Res 2003:27e40.
[23] Peters CL, Chrastil J, Stoddard GJ, Erickson JA, Anderson MB, Pelt CE. Can
radiographs predict the use of modular stems in developmental dysplasia of
the hip? Clin Orthop Relat Res 2016;474:423e9.
[24] Bernasek TL, Haidukewych GJ, Gustke KA, Hill O, Levering M. Total hip
arthroplasty requiring subtrochanteric osteotomy for developmental hip
dysplasia: 5- to 14-year results. J Arthroplasty 2007;22(6 Suppl 2):145e50.
[25] Krych AJ, Howard JL, Trousdale RT, Cabanela ME, Berry DJ. Total hip arthroplasty
with shortening subtrochanteric osteotomy in Crowe type-IV developmental
dysplasia: surgical technique. J Bone Joint Surg Am 2010;92(Suppl 1 Pt 2):176e87.
[26] Li X, Sun J, Lin X, Xu S, Tang T. Cementless total hip arthroplasty with a double
chevron subtrochanteric shortening osteotomy in patients with Crowe type-
IV hip dysplasia. Acta Orthop Belg 2013;79:287e92.
[27] Sofu H, Kockara N, Gursu S, Issin A, Oner A, Sahin V. Transverse sub-
trochanteric shortening osteotomy during cementless total hip arthroplasty in
Crowe type-III or IV developmental dysplasia. J Arthroplasty 2015;30:
1019e23.
[28] Li X, Lu Y, Sun J, Lin X, Tang T. Treatment of Crowe type-IV hip dysplasia using
cementless total hip arthroplasty and double chevron subtrochanteric
shortening osteotomy: a 5- to 10-year follow-up study. J Arthroplasty
2017;32:475e9.
[29] Linde F, Jensen J, Pilgaard S. Charnley arthroplasty in osteoarthritis secondary
to congenital dislocation or subluxation of the hip. Clin Orthop Relat Res
1988;227:164e71.
[30] Muratli KS, Karatosun V, Uzun B, Celik S. Subtrochanteric shortening in total
hip arthroplasty: biomechanical comparison of four techniques. J Arthroplasty
2014;29:836e42.
[31] Heisel C, Silva M, Schmalzried TP. Bearing surface options for total hip
replacement in young patients. Instr Course Lect 2004;53:49e65.
[32] Kim YH, Oh SH, Kim JS. Primary total hip arthroplasty with a second-
generation cementless total hip prosthesis in patients younger than fifty
years of age. J Bone Joint Surg Am 2003;85-A:109e14.
[33] Fehring KA, Fehring TK. Modes of failure in metal-on-metal total hip arthro-
plasty. Orthop Clin North Am 2015;46:185e92.
[34] Gililland JM, Anderson LA, Erickson J, Pelt CE, Peters CL. Mean 5-year clinical
and radiographic outcomes of cementless total hip arthroplasty in patients
under the age of 30. Biomed Res Int 2013;2013:649506.
[35] Pijls BG, Meessen JM, Schoones JW, Fiocco M, van der Heide HJ, Sedrakyan A,
et al. Increased mortality in metal-on-metal versus non-metal-on-metal pri-
mary total hip arthroplasty at 10 Years and longer follow-up: a systematic
review and meta-analysis. PLoS One 2016;11:e0156051.
[36] Hu D, Tie K, Yang X, Tan Y, Alaidaros M, Chen L. Comparison of ceramic-on-
ceramic to metal-on-polyethylene bearing surfaces in total hip arthro-
plasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res
2015;10:22.
[37] Dorlot JM, Christel P, Meunier A. Wear analysis of retrieved alumina heads and
sockets of hip prostheses. J Biomed Mater Res 1989;23(A3 Suppl):299e310.
[38] Urban JA, Garvin KL, Boese CK, Bryson L, Pedersen DR, Callaghan JJ, et al.
Ceramic-on-polyethylene bearing surfaces in total hip arthroplasty. Seven-
teen to twenty-one-year results. J Bone Joint Surg Am 2001;83-A:1688e94.
[39] Wroblewski BM, Siney PD, Dowson D, Collins SN. Prospective clinical and joint
simulator studies of a new total hip arthroplasty using alumina ceramic heads
and cross-linked polyethylene cups. J Bone Joint Surg Br 1996;78:280e5.
[40] Zichner LP, Willert HG. Comparison of alumina-polyethylene and metal-
polyethylene in clinical trials. Clin Orthop Relat Res 1992:86e94.
[41] Buttaro MA, Zanotti G, Comba FM, Piccaluga F. Primary total hip arthroplasty
with fourth-generation ceramic-on-ceramic: analysis of complications in 939
consecutive cases followed for 2-10 years. J Arthroplasty 2017;32:480e6.
[42] D'Antonio JA, Sutton K. Ceramic materials as bearing surfaces for total hip
arthroplasty. J Am Acad Orthop Surg 2009;17:63e8.
[43] Huet R, Sakona A, Kurtz SM. Strength and reliability of alumina ceramic
femoral heads: review of design, testing, and retrieval analysis. J Mech Behav
Biomed Mater 2011;4:476e83.
[44] So K, Goto K, Kuroda Y, Matsuda S. Minimum 10-year wear analysis of highly
cross-linked polyethylene in cementless total hip arthroplasty. J Arthroplasty
2015;30:2224e6.
[45] Stambough JB, Pashos G, Wu N, Haynes JA, Martell JM, Clohisy JC. Gender
differences in wear rates for 28- vs 32-mm ceramic femoral heads on modern
highly cross-linked polyethylene at midterm follow-up in young patients
undergoing total hip arthroplasty. J Arthroplasty 2016;31:899e905.
[46] Haraguchi A, Nakashima Y, Miyahara H, Esaki Y, Okazaki K, Fukushi JI, et al.
Minimum 10-year results of cementless total hip arthroplasty in patients with
rheumatoid arthritis. Mod Rheumatol 2016:1e7.
[47] Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five-year survivor-
ship of two thousand consecutive primary Charnley total hip replacements:
factors affecting survivorship of acetabular and femoral components. J Bone
Joint Surg Am 2002;84-A:171e7.
[48] Tsukanaka M, Halvorsen V, Nordsletten L, EngesaeTer IO, EngesaeTer LB,
Marie Fenstad A, et al. Implant survival and radiographic outcome of total hip
replacement in patients less than 20 years old. Acta Orthop 2016;87:479e84.
[49] Swarup I, Marshall AC, Lee YY, Figgie MP. Implant survival and patient-
reported outcomes after total hip arthroplasty in young patients with
developmental dysplasia of the hip. Hip Int 2016;26:367e73.
[50] Wang D, Li LL, Wang HY, Pei FX, Zhou ZK. Long-term results of cementless
total hip arthroplasty with subtrochanteric shortening osteotomy in Crowe
type IV developmental dysplasia. J Arthroplasty 2016:1e9.
[51] Dudkiewicz I, Salai M, Ganel A, Blankstein A, Chechik A. Total hip arthroplasty
in patients younger than 30 years of age following developmental dysplasia of
hip (DDH) in infancy. Arch Orthop Trauma Surg 2002;122:139e42.
[52] Howie CR, Ohly NE, Miller B. Cemented total hip arthroplasty with
subtrochanteric osteotomy in dysplastic hips. Clin Orthop Relat Res 2010;468:
3240e7.
[53] Munger P, Roder C, Ackermann-Liebrich U, Busato A. Patient-related risk
factors leading to aseptic stem loosening in total hip arthroplasty: a case-
control study of 5,035 patients. Acta Orthop 2006;77:567e74.