Liliana Savin 1, Barbăroşie C. Popa University of Medicine and Pharmacy of Iaşi, ROMANIA, Orthopaedics Trauma Department Abstract Total hip arthroplasty in degenerative pathology secondary to congenital dysplasia differentiates itself among total arthroplasties by the frequent technical difficulties it poses and the site where it is performed.
The existence of a form of congenital dysplasia that remained untreated or insufficiently treated in childhood leads to irreversible deformities in adulthood.
Partial or total loss of joint congruence causes, in time, degenerative changes arthritis foundation aquatic program the impairment of hip mobility and is associated with a number of progressive deformations limb length discrepancy, abnormal rotation, asymmetric lesions, periarticular muscle failurewhich gradually reduce the quality of the patient s life.
This arthritis foundation aquatic program aims at investigating the incidence of prosthetic hip arthroplasty for osteoarthritis secondary to dysplastic hip in the total number of arthroplasties, the age when surgery is performed, the type of deformity and prosthetic components used, and the postoperative and long-term functional results.
The study was conducted on patients who received total hip arthroplasty due to osteoarthritis secondary to hip dysplasia, between andin the Orthopaedics Trauma Department of the Rehabilitation Hospital of Iasi, the incidence being of 3. The complexity of arthritis foundation aquatic program area where the total hip arthroplasty is performed requires a good management consisting of thorough preoperative planning, determining the operatory indication, and specialized and individualized medical recovery.
Arthroplasty indications for osteoarthritis secondary to hip dysplasia are similar to those of primary osteoarthritis. The basic indication of arthroplasty is pain that was not relieved by conservative treatment.
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Although the radiographic aspect can be dramatic, surgical decisions should not be based on radiographic severity. Pain and dysfunction affecting daily life and the quality of life remain the primary indications for arthritis foundation aquatic program. The surgeon s objectives, just as with standard hip arthroplasty, include the restoration of hip biomechanics and the stability of the implant. These interventions may be atypical, with an increased risk of complications, depending on the degree of dysplasia.
The treatment of such complex cases requires a close collaboration between the orthopaedic surgeon and the physical therapist for the functional recovery of the prosthetic hip and for reintroducing the patient into society.
Preoperative planning is very important. Factors that increase complexity include distorted anatomy, poor bone stock, and previous surgeries. Such patients often require special implants, sometimes customized.
A clear understanding of the distorted anatomy is an essential arthritis foundation aquatic program in the evaluation and treatment of hip dysplasia.
Careful preoperative planning, a thorough medical history, physical examination, physical therapy, and preoperative counselling will help lower complications and improve long-term outcomes in these difficult cases. Untilwhen Charnley and Feagin  increased total hip arthroplasty indications for congenital dysplasia-subluxation, but not for congenital hip dislocation, these interventions had contradictory indications in dysplasia pathology.
A year later, Harris  recommended the use of arthroplasty in both cases and presented the surgical technique for congenital dislocation of the hip.
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He highlighted the technical difficulties and establishes the appropriate level for the implantation of the acetabular component. The recovery of the prosthetic hip requires an intensive physical therapy program, customized for each case, requiring the commitment and risk awareness of the patient.
The recovery program begins early, in the first postoperative day and continues progressively over 4 standardized stages . The correct diagnosis in a newborn through the careful clinical examination and appropriate imaging echography of the hip and the early treatment can delay the degenerative complications. The therapeutic strategy in hip dysplasia must take into account the age of the patients requiring total hip arthroplasty and the anatomical changes that hinder the surgery as well as the postoperative recovery.
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The prosthetic implant is determined according to the same age and anatomy criteria. The purpose of this paper 71 2 is to highlight the incidence of these variables in dysplastic hip arthroplasty and to study the early postoperative and long-term functional results. Cases with mild deformations are not, theoretically, very different from standard prosthetic arthroplasty for primary osteoarthritis.
At the other extreme, the problems presented by severe forms of acetabular hypoplasia poor acetabular development, major architectural abnormalities, dislocation, higher secondary inequality cause a real challenge for the surgeon. Understanding these differences, recognizing the magnitude of the problems and determining the appropriate techniques to resolve them, are crucial for the management of these forms of osteoarthritis.
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The study included patients who received total hip arthroplasty due to osteoarthritis secondary to hip dysplasia, between andin the Orthopaedics Trauma Department of the Rehabilitation Hospital of Iasi. The study aims to determine the incidence of prosthetic hip arthroplasty for osteoarthritis secondary to dysplastic hip in the total number of arthroplasty surgeries, the age when the surgery is performed, type of deformity and prosthetic components used and the postoperative and long-term functional results.
Deformity evaluation was performed using standard radiographs using two classifications: Crowe and Hartofilakidis. The most renowned system is Crowe s. This is a prognostic classification, so that types II and III are more likely to have signs and arthritis foundation aquatic program of arthrosis, which will require surgery earlier than Crowe types I and IV. In addition, it was shown that the difficulty of the arthroplasty is in direct correlation with the degree of subluxation.
Hartofilakidis described a classification system somewhat more practical. He describes three distinct types of congenital hip disease in adults. The first type is dysplasia, where the femoral head is subluxated, but still contained within the original acetabulum paleocotyl.
The second type is subluxation, where the femoral head articulates with a false acetabulum arthritis foundation aquatic program above the paleocotyl. The third type is dislocation, where the femoral head has migrated superoposteriorly and there is no contact between the original and the false acetabulum.
The functional recovery started in the first postoperative day, the first stage aiming to decrease the pain, the prevention of general and local complications and the proprioceptive re-education, informing the patient on the prohibition of excessive flexion movements, external rotation and adduction risk of prosthetic dislocation.
Respiratory gymnastics, isometric contractions, passive mobilizations of the operated lower limb and active movements of the contralateral limb meet these objectives. Arthritis foundation aquatic program second stage, walk rehabilitation and active physical therapy in the three joint mobilization planes flexion, abduction and extension begins on the third postoperative day, under the scrupulous supervision of the physical therapist.
Stages three and four consist of physical therapy for muscle toning and joint asuplisation and gradual return to daily activities. The evaluation of pre- and postoperative functional results was performed using Harris-hip-score  to arthritis foundation aquatic program pain, deformity, mobility and function.
The maximum score is and represents lack of pain 44 pointsactivities 47 pointsabsence of deformities 4 points and joint mobility 5 points. The disease was present bilaterally in Of the prosthetic arthroplastic surgeries, 81 were cementless In all cases the approach was lateral, the implantation of the prosthetic component was performed in paleocotyl where there was the best bone stock, even if the area is severely hypoplastic.
Poor results were marked by deformities of the contralateral hip, knee and lumbar spine. The Harris score averaged at 45 points preoperatively to over postoperatively at 3 months. The acetabulum can be hypoplastic, without depth and with anterior and superior segmental deficiency Fig.
The femoral neck often has an excessive anteversion arthritis foundation aquatic program a concomitant posterior displacement of the greater trochanter and is often shorter with a deformity in coxa valga.
The femoral canal is, usually, narrow and straight.
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Lack of coverage of the femoral head by the acetabulum, the reduced area where forces apply and increased contact pressure lead to the development of osteoarthritis.
The adductors lose their vertical orientation and become a cross structure, limiting their effectiveness and causing difficulties in arthroplasty and in 73 4 postoperative recovery.
The femoral nerve may be more lateral and proximal than usual and, therefore, the medial retractions should be minimized during surgery. The sciatic nerve is shortened and vulnerable to interventions that cause limb elongation.
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The placement of the acetabular component has special importance for the arthritis foundation aquatic program on the dysplastic hip. Most problems in this area are related to the bone stock and the coverage of the cup. Fig 4. Osteoarthritis secondary to hip dysplasia, preoperative and postoperative Restoring the anatomic centre of rotation is a basic goal in the reconstruction of the dysplastic hip, although this goal makes the surgery technically difficult.
Although the optimal location of the hip centre and the placement of the acetabulum is often a controversial issue, the original acetabulum is almost always the optimal site for reconstruction fig. Clinical studies have reported ambiguous results regarding the placement of prosthesis with a high centre. Russotti and Harris  have analyzed the outcomes of these prostheses with high centre and found no significant association between them and loosening.
A high hip centre was deemed appropriate when the acetabular bone stock when is not sufficient.
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Later, Pagnano and Hanssen  in a follow-up study of 14 years showed a significant association between high centre and loosening and the increase in revision rates. Another difficulty in dysplastic acetabulum is getting cup coverage. Small components may be required for coverage issues and are an obvious solution to reduce the need for bone stock Figure 5but they have a concomitant decrease in the thickness of polyethylene and the size of the femoral head, which could adversely affect the long-term results of arthroplasty.
Another solution would be structural grafts. Osteoarthritis secondary to subluxation, pre- and postoperative- small acetabular component In mild cases of dysplasia, the problems of femoral reconstruction are identical with those of a arthroplasty to a normal anatomy. At the other extreme, major difficulties arise in the case of a severe femoral hypoplasia, narrow medullary canal and major deformities of the femur by abnormal development 74 5 or after anterior intertrochanteric or subtrochanteric osteotomies.
Frequently, the femoral component should be straight, short and sufficiently small Fig. In some cases, the femur has an excessive anteversion, so the simultaneous implantation of the femoral component may be a problem. For cemented shafts, this problem can be easily manipulated, producing the decrease of the anteversion is obtained by implanting the shaft inside the cement mass.
In extreme cases, a subtrochanteric osteotomy is indicate to allow the reduction of the anteversion by the rotation on the metaphyseal fragment upon the diaphyseal fragment, followed by insertion of cementless shaft .
Architectural changes and intraoperative technical difficulties have a direct impact on the functional recovery of the patient. Functional recovery depends on the degree of dysplasia, the preoperative muscle hypotrophy and association of other elements lesion. Partial loss of joint congruence remains well tolerated for a long period, but it ultimately causes painful osteoarthritis irreducible deformities. The subjacent knee also functions in poor mechanical conditions and the painful arthrosis impact of the overload is also frequent and arthritis foundation aquatic program, the orthopaedic or surgical treatment applied to the hip in childhood disrupts growth and causes distortion, misalignments, laxity and arthrosis in adulthood.
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The usual asymmetry arthritis foundation aquatic program the lesions, leg length inequality, abnormal rotations of various limb segments add up to this set of staged deformities more or less well compensated that cause difficulties in the functional recovery and a delay of the optimal outcome. The full success of hip arthroplasty surgery as a treatment for coxarthrosis secondary to congenital hip dysplasia is possible only through correct surgical indication, use of proper implants, and their correct positioning.
The Brigham and Women's Hospital, Inc.